 I'd like to thank the meeting organizers for asking me to do this. This is sort of the fun job amongst everybody in the panel because I get to tweak every single one of these people now for 24 minutes and 46 seconds. So I would like to recognize the fact that there is a tremendous amount of expertise out in the audience and there's not a big enough panel podium space to get all of you up here to comment but there are microphones back there and we're going to have some audience response questions and if you have a difference of opinion or you just like to make a point please move to the microphone quickly I have six cases I don't expect to get through all six but I'd like to get through as many as we can. So I have nothing to disclose and we'll get right into the first case this is a 67 year old male who's been followed for an abdominal aortic aneurysm and he's got a little bit of comorbid disease he's got aphid he's on Coumadin he's still smoking and on his routine follow-up imaging for his AAA which he's neglected for a while he has a new problem identified. So there's some stuff in the bottom of the lungs and there's something in his kidney and if you look closely there's something in his renal vein going into his vena cava and a dedicated chest CT this is the scout film from the dedicated chest CT I think you can see all the cannonballs and this is a few selected cuts from his chest CT. So to summarize what we've seen he's got about a 10 centimeter renal mass he's got an infrahepatic IVC tumor thrombus he's got pretty significant pulmonary metastatic disease one of which has been biopsied and read as clear cell renal cell carcinoma he did have a bone scan he did have an MRI of his head both of which were negative he's anemic he's got thrombocytosis so I'll put it to the panel and I'll start off with Gennady so everybody should have a cytoreductin effect to me as the first step correct. Yeah so while I'm recovering for my loss which I calculated was statistically not significant I would like to state that this is discontinuum that this patient does not belong in the box of absolutely and it certainly doesn't belong in the box where I never but again we just don't have the time to play with these patients they are dying in the 8 to 14 months so I understand that this is a moderate amount of disease I wish I had the interval scans and to see how fast this disease came on and I understand that his prognostic factors are not perfect. Nevertheless it is somebody I've discussed a cytoreductin effect to me with and I would be willing to proceed and this is a case the IVC involvement is not bad this is a I hate to say it's a quick robotic reticle with the IVC thrombectomy robotically and this patient goes home and my last one went home in 18 hours so bottom line is you can certainly perform and debulk him quite a bit. Tom do you agree with that? Yeah I guess I guess I do I mean he's not terribly well he's got quite aggressive disease and it seems somewhat counterintuitive to go through a major it would be a major operation with the IVC involvement as opposed to starting systemic therapy and seeing what happens so I probably would I agree with that we probably wouldn't go in and do an effect to me up front on this guy right now. Okay so I'd like you to use your audience oh sorry Tony please. Brad I want to say yes the performance status comorbidities should drive this but did you look closely with the platelet number and the hemoglobin if you look at the hang IMDC risk criteria this is very likely a poor risk disease so an honest approach and a discussion with the patient is necessary here. Honest meaning you're gonna recommend against surgery? Not not necessarily not necessarily. Okay so do we have an audience response for this? Everybody's playing nice we're not in Minnesota anymore so okay so the vast majority want upfront systemic therapy with possible cytoreduction can we go back to the slide so we can see what happened so you know there's nothing more distressing as a surgeon than operating on somebody and then watching them progress rapidly before they can get systemic therapy and you know this is a paper by Alex Kudakov and Steve when Steve was at Fox Chase looking at the fact that 30% of their cytoreductin of rectumese didn't get postoperative systemic therapy and most often it was due to rapid progression of disease and my concern with this patient was that he had relatively high volume pulmonary metastatic disease and had a little shortness of breath so what we did was what the vast majority of the audience wanted us to do he was started on Sunit Nib he had one cycle of Sunit Nib and actually had an encouraging response so Tom we're gonna use this approach in this patient now how long before we consider doing something more so my sir we've done probably I guess about 150 patients using this approach one way or another in the trials we've done one of the things that my surgeons my surgeons the surgeons I work with they come back they come back and say after about three cycles they're noticing quite a lot of fibrosis a lot of necrosis and actually the surgery is becoming more difficult and so they're encouraging us to try and give a shorter period of upfront therapy of about 12 weeks and we're doing a scan about 12 weeks and if they're responding and things are going well then we would then plan surgery over the next four week period that's what we did okay so it wouldn't have made it into a presentation if there wasn't something interesting about it he actually did extremely well and we offered him surgery in six months but he wanted to quit smoking before he had an operation so we were pleased to hear that this is his imaging at nine months so pre is on the left side posts is on the right side primary tumor and nothing in the renal vein or vena cava anymore so after nine months he's had some response in the primary tumor near complete resolution of his pulmonary metastatic disease tumor thrombus is gone or nearly gone his performance status is great he's quit smoking Gennady does he have to have his primary tumor removed now I'm afraid of the audience one thing I still don't know is if we did the site or a doctor in the factory first and that would have given them a systemic therapy now wouldn't have this dilemma but since we have the tumor in place I'd still clean them up you would take it out so very quickly audience response does he have surgery does he have more systemic therapy or do we do something else okay so next slide everybody wants us to take out the tumor that's what he did he went ahead and had his surgery he had negative lymph nodes he was a t1b grade two with necrosis which I don't know if that means anything John and the post-treatment setting does not no sarcomatoid features so Tom does he need ongoing therapy so that's now become a very difficult question that's why we're asking and I am during this treatment break you've been off therapy for about I guess four to six weeks and we would probably scan at this point to see if there's a rebound and certainly if there has been progression we would definitely restart therapy I mean we are restarting therapy in all of our patients but this obviously has now been quite a long period of time and there's a little bit of data which is obviously retrospective and all the shortcomings associated with that about cessation of targeted therapy in individuals who have had a spectacularly good response and they are having a treatment break but and there are one or two studies looking at this treatment break issue but I mean we're not keen on pursuing that outside of a clinical trial so we would start systemic therapy particularly if there's a rebound the tumor so he does resume Sunit Nib and this is now quite a ways out he remains NED should he continue his therapy he's still on Sunit Nib Tom oh so I mean we would keep going but sometimes patients come back to me and say I've had enough I want some time off and you kind of have to respect that a little bit so but we wouldn't stop in the first year after a year of therapy we would we reluctant to stop but you know there are some some retrospective data out there suggesting it may be safer so it may be safe so it would be reasonable but we wouldn't recommend it it's patient driven to some extent yeah I just worry that the the excellent case presentation that you just made is gonna maybe make people change their practice pattern and unfortunately I think millions of people play the lottery every day without winning with the hopes of winning and appropriately selected patients with clinical pathologic and molecular profiling that it puts them in an appropriately selected group have the chance to win the lottery about 8% of the time with side reductance refracted me and high dosal 2 for instance so I just don't want us to forget about those people duly noted so this is an extreme example obviously I think maybe you'll be more satisfied with some of the next ones so the next case is a 44 year old male who complained of some shoulder pain his local doc injected his shoulder but decided we'll just get an x-ray they saw a sternal mass this was biopsied read as clear cell RCC in the bone and he was referred for an opinion on cider reduction after he had received some radiotherapy and he's basically asymptomatic now so you can see this destructive lesion in the bone he's got some things that the radiologist called micro nodules which I had to spend some time to find and then you can see there's something in both the right kidney and the left kidney and he's got another bone lesion in his iliac bone so panel this is a 44 year old male with metastatic renal cell carcinoma he's got sternal and iliac bone Mets bone scan shows nothing anyplace else he's got bilateral renal masses he's medically reasonably healthy and all of his other labs are normal with a serum creatinine of 0.9 Jose does this patient deserve complete resection of two bone lesions and his primary tumors I'm not sure about deserving or not but I wouldn't remove that initially I mean that he's a very young patient which is a good thing but having two large bony Mets that will probably sway me away from doing even a side-reducted nephrectomy of print considering that he has bilateral renal tumors as well so if we do a left nephrectomy what do we do about the right one do we just keep it there or ablate it and the iliac bone looks like it's going to need some treatment at some point as well but the bulk of the disease outside of the kidney is worrisome so I would probably not do a side-reducted nephrectomy or metastasectomy as of yet so you're gonna recommend upfront systemic therapy yes okay Gennady yes you're reaching yeah hi perhaps when you've got a hammer everything's a nail this is a relatively straightforward case to me I think the age and the age of this patient dictates what I'm gonna do I'm gonna give this very patient as I tried to do to most of the patients a benefit of a doubt this is a patient that I would debulk and this is a patient that I would actually strongly recommend metastasectomy understanding that he may actually fail but I at this point this patient has a ligament aesthetic disease there is an angel health data that clearly shows that even when you resect more than one side of disease these patients do better and I think just because it's a bone and it's a bulky disease I think this is a resectable disease and I would absolutely recommend metastasectomy with the primary tumor debalken removal as well I think bone lesions we can't treat them all the same I mean if somebody has a skull met we can't you know consider that as just a simple bone lesion most of the studies with bone metastasectomy are spine which you can resect a portion of it and replace humerus or femur and not as much the manubrium which he will basically need resection of his chest wall with plastic surgery reconstruction which will delay his healing which means he won't be able to receive targeted therapy in time so yeah I agree that that's what I would want to see some blood on the stage but I do think that this patient is too young and I would go over the wall closure and the resection of the iliac bone with aggressive orthopedic surgeons so we have an opportunity to break up the fight and I think I must be missing something because people are concentrating on the bone and what would worry me about this patient is his kidneys and actually trying to get local control there to prevent him progressing there and going on dialysis in other words I'd like to see more of the pictures of his kidney and sort out what we're going to do about that first and then return to the issue of the bone so I'll put it to the other surgeons on the panel other than Jose and Gennady what do you think about doing one kidney the other or neither kidney as the beginning of this person's therapy Brian Steve Jeff I would just also comment this patient is 44 years old has bilateral multifocal disease I would definitely refer this patient to a genetic counselor for genetic testing panel based testing now but we can't assume that both sides one tumor has metastasized to the other side this could easily be an aggressive you know left sided primary and just a de novo new lesion on the right side but you know you would probably an 44 year old man if you're going to go after the tumors you know you'd probably go after both of them but you know the one on the you could consider maybe biopsying both sides and seeing you know with this disconcordance I mean you can't rely on a biopsy to necessarily grade to his accurately but it may give you better insight into the biology both sides rush I'm not sure which side I would fall on in this case but I would remind the audience that in the days and age of excellent probe ablation therapy some of these lesions whether they're in the kidney or even in some of these bones maybe not the manubrium but certainly in the ilac there might be an integration of surgery as well as probe ablation therapy so don't forget about that so we remember it all that and this was made relatively easy for us but before I get to what actually happened let's go to the audience response systemic therapy no surgery systemic therapy with surgery based on response to systemic therapy surgery then systemic therapy or something else so 56% want some upfront therapy and the majority the rest want to start off with cytoreduction okay can we go back to the slides so this was made easy because it was relatively recent and we discussed with him all of the things that have been discussed so far but when we mentioned clinical trial he bit at that so just in August I did bilateral partial nephrectomy is in the same setting perhaps indicating as Brian said that as Brian said these are two different tumors he had a grade 4 clear cell on the left the nastier looking tumor in a grade 2 on the right so the tumor collection was from the left-sided tumor he was randomized to the control arm and unfortunately he's progressing in his hip so he's NED in his abdomen but you can see that iliac bone is getting worse so I'll update you in a future meeting on that one let's try to get through one more this is a 63 year old male with a six-week history of mid-abegastric pain he's had no radiation of his pain nothing makes it better nothing makes it worse and otherwise he's doing fine he's got a large primary tumor 12 centimeter enhancing solid mass there's no adenopathy seen his chest is negative his labs are normal so let's go straight to the audience what do we do with this do we take out his kidney and his adrenal do we take out his kidney his adrenal and his lymph nodes or does he not have his adrenal removed without and with lymph nodes so the vast majority want maximal surgery okay Gennady shaking his head already Jeff let's start with you do you agree that this patient should have a lymph anectomy in the absence of clinically evident disease in the retroperitoneum not necessarily honestly I frankly I think that could be done laparoscopically I mean it's not with a hand in there of course I cheat and put my hand in there to wrestle with the thing and I certainly doing an effective me I certainly would have moved nodes at some level I would definitely take the pair of cable nodes I'd pluck off sorry to use that word the least is the superficial inter aortic cable lymph nodes and I would leave the adrenal frankly there I'd fight saw that correctly there was no evidence of adrenal involvement it was a I think a lower or mid to lower pole tumor and while I know that he has some degree of risk of adrenal involvement honestly in my own experience I've seen people develop contralateral adrenal lesions just as often as ipsilateral adrenal lesions in a you know in a mtacrosan mtacronous fashion so I'm my my tendency is to leave the adrenal gland in should he develop contralateral adrenal disease he's still got his ipsilateral adrenal in place so I I swear this isn't a setup these guys I've not seen these cases so actually there's some data on that and it turns out that if you look at patients that have adrenalectomy in patients that don't have adrenalectomy at the time of taking care of their primary tumor in patients that have the adrenal left in sight to their risk is equal and the lip ipsilateral and contralateral adrenal gland and ipsilateral adrenalectomy doesn't make a difference in terms of the likelihood of developing a subsequent adrenal metastasis in the contralateral side so you know we actually would advocate against adrenalectomy so he did have a lap radical nephrectomy it was a pt2 supposedly John without necrosis without sarcomatoid features and then he comes back with this an ipsilateral adrenal met so he had it and then a pulmonary met so Jose is this patient a good candidate for metastasectomy three and a half years out and this is the only sites of metastatic disease you found right that's right and they're both biopsied is renal cell carcinoma yes he's a healthy gentleman otherwise with good econk performance status of less than 70 years of age more than two years disease free interval with two resectable lesions he could qualify for that so it doesn't matter to you that there's two lesions at the same time in two different organs no Steve do you have a comment on that yeah no I would agree with Jose I think that this is an appropriate candidate for metastasectomy and I think that you know we often see as Jose brought up people who have come to us who haven't been considered for metastasectomy because they have you know for example multiple metastatic lesions and I think it should be guided a lot more by the comorbidity status the patient and the receptability lesions rather than the number so I would recommend metastasectomy for this gentleman so I know come on there's room for both of you there's room for both of you age before beauty dr. okay first dr. figlin I'm not sure who's more aged I'm not going to get in the middle of that one you're both beautiful thank you Brad you're welcome so I think that it would be important for you to at least have a conversation about the role of non-surgical metastasctomies using SBRT and other modalities to approach these two lesions which are becoming much more common data's not as mature but at least enter the conversation about whether you think these two lesions can approach be approached non-surgically can we get the audience response going to get a vote on dr. figlin's comment because it's sort of in here and similar to dr. figlin I there's something that hasn't been mentioned at all by anybody on the panel and that is a trial of time before you go for metastasectomy so this is a real classic you don't know whether the sudden development of metastases in this patient in two sites is a harbinger a very aggressive metastatic disease in this setting so we would never in my institution go immediately to metastasectomy in these patients we would repeat the scan in somewhere between six eight maybe ten weeks time just to double check the pace of disease before sending in one of my surgeons they're my surgeons Tom since I have pointed out so the comment about trial of time because nobody's mentioned it I'm a little bit surprised I think that's a good point and that was sort of the point behind option three here is do you watch it for a bit of time to see if this is a disease that's about to explode and I'd like to ask anybody on the panel does the three year disease free three and a half year disease free interval sway you in that regard absolutely I mean this is oligo metastatic disease of course he could explode with disease he just as easily not time to development of systemic disease is the consistent variable that's been predicting a good response to metastasectomy and so yes perhaps it's been quiescent for three and a half years and all of a sudden it's going to overrun him but that seems unlikely frankly I think that doing a laparoscopic adrenalectomy and you could even do an RFA of that pulmonary lesion with minimal morbidity so the idea that you're going to subject somebody to a some you know barbaric procedure to render him any these I think false and that being optimistic as I'm fortunately very prone to doing I think is very reasonable this time so actually both of those lesions are treatable with a percutaneous ablation you could ablate the lung mass and the adrenal mass without making an incision at all