 Alright, 53-year-old black female presents with chest pain, shortness of graft, previous history of diabetes and glaucoma, never had surgery, takes metformin, CT of the chest, no pulmonary nodules, MRI of the brain bone scan is negative, she's got a BMP of 141 that just measures heart strain, and she's slightly anemic. And you can see from her CT of the chest, these black areas right here are sitting in the pulmonary artery, leaving the heart. So she's had massive bilateral pulmonary emboli, and that's why she's short of breath and has chest pain. And you can see she has a locally advanced tumor involving her left kidney, with a tumor thrombus that extends into the vena cava, and up the vena cava, you can see here the tumor thrombus sitting inside the vena cava right here, here's the locally advanced tumor involving the left kidney. Dr. Mateen, what would you recommend to this patient? These are just guides, you don't have to necessarily pick one if you don't want to. Yes, I mean you're left to wonder whether the pulmonary emboli are from the tumor that's broken off, or whether they're just what we call a bland thrombus, meaning just blood clot. But if she's a candidate for surgery, I would just proceed with a left radical nephrectomy and IVC thrombectomy for the time being, and observe her assuming she's doing well from a cardiopulmonary perspective. That raises the issue, how long would you wait before doing that? She's short of breath sitting there, she's panting. Yeah, yeah, so we'd anticoagulate on the assumption that it's a bland thrombus, due to scans of her legs and upper extremities, because the clot could have come from there. Assuming that's all negative, you wait about, I think the safety time is about a month on anticoagulation, and then after that, but obviously it just depends also on how well she's breathing at that point. Dr. Karam, do you have any thoughts on this? I would agree with Dr. Mateen, as initially I would start anticoagulation, get the patient to be less symptomatic, so she needs to be breathing better before she undergoes a major operation. But I would repeat the imaging right before surgery to make sure that the thrombus hasn't progressed just because it might change surgical planning, or from your colleagues to involve such as vascular surgeons or what not. So how long would you wait? At least two weeks, probably two to six, there is no magical number, but at least I want to make sure the patient is less symptomatic or feeling better before we proceed. Well, what's your magical number? Four weeks. Four weeks. Doctor, I have cancer, won't it spread? I would explain to the patient that it might in that four weeks, but that the more acute life-threatening event is the pulmonary embolus or the blood clot in the lungs on both sides. So that's the more dangerous immediate threat. Any role to send her to Michael, sitting on your left there for targeted therapy to keep this thing under control while she's getting better from her pulmonary embolism? Michael, you want to comment on that? I would say no. I mean, again, we've talked about kind of neo-adjuvant and adjuvant, and this would be, I guess, neo-adjuvant. But there's really no role for using a targeted therapy in this setting. We don't have great data with how the targeted therapies work when the tumor is intravascular. But, I mean, certainly she's very sick and has other problems we need to address. Yeah, it's not uncommon in my practice, I'll get patients from the outside that have an IVC thrombus, and they're started on targeted agents by their oncologists, well-meaning oncologists in the community who tell them, basically, this will keep it under control, this will shrink the thrombus, this will make your surgery easier, and the vast majority of cases, and perhaps Dr. Delacroix, you actually did a research project on this, the vast majority of cases, they're wrong. I'm seeing this now that I'm back in New Orleans. I'm seeing people who are trying to downstage patients with IVC as an inferior vena cava, biggest vein in your body. And these tumors that are in the kidney sometimes can grow into the vasculature and sort of be free-floating, sitting in the inferior vena cava, which goes all the way to the heart. Sometimes these tumor thrombus can grow all the way to the heart. So it's a big surgery, depending upon if they're all the way up in the heart, it requires, it can require a chest to be open as well as the abs, I mean patients to go on bypass, and it requires a surgical team with not only a urologic oncologist, but a lot of times with a cardiac surgeon. So I see people that put patients on targeted therapy in the hopes that the tumor will shrink and the tumor thrombus will shrink and make the surgery less extensive. But when we looked at our institution here as well as from Dallas, we looked at all the patients who had tumor thrombus and were started on targeted therapy. Now these were all metastatic patients. And more commonly, the tumor thrombus actually grew in size rather than shrinking. So this lady has, this female has no evidence of metastatic disease. She needs to go to the operating room and be cured, attempted to cure with a knife. I guess that my only caveat to that, I wouldn't say no evidence of metastatic disease. We really don't know what these tumor thrombi are. What about embolectomy? Any role for that? Would you go after these pulmonary emboliac? Con, that's where you put the surgery team together. It's beyond our expertise. I talked to the vascular surgeon. Now you've done that, right? Not you alone, but you were the cardiac surgeon. Embolectomy? Yeah. And what case was that? That was an acute embolus. These chronic, so these, you know, she embolized and has gone many days with these embolized. She's actually lucky she's not dead. I mean, she had bilateral saddle embolized. She's lucky to be walking. There's really no role for embolectomy. They're really, at this point, socked in and scarred in. They'd have to do bilateral pneumonectomies to get them out.