 All right, we're going to go ahead and get started again. Do some more cases, and this is again in the locally advanced setting, and then this afternoon we'll be devoted entirely to cases about patients with metastatic disease to cover the spectrum. So this next patient is a 78-year-old white female who presents with an incidental renal mass. She has a history of breast cancer, and it was discovered during surveillance for her breast cancer. She does have some medical problems, hypertension, diabetes, hypothyroidism, atrial fibrillation, history of depression. She takes aspirin, diltiasm, metformin for diabetes, thyroid replacement, divan for blood pressure, effects her for her depression. Her metastatic evaluation is negative. Her labs are within normal limits, except for her GFR, which is measured to be 50 CCs. Now, normal GFR for someone with two normal kidneys, male is about 100 to 120. So she's got compromised renal function, and would be classified as having chronic kidney disease. She's got a mass sitting right here in her right kidney. Dr. Mateen, how would you evaluate and manage this patient and why? Can you go back to the previous slide for a minute? I was busy sipping my coffee. OK, thanks. What are you looking for? No, just the medical history and everything. Yeah, so it's a small mass. It looks like about 2 centimeters, roughly. And the breast cancer is actively being treated now? Breast cancer, she's just taking Tamoxifen. Reasonable to watch it for a while. It's small, and I think that would probably be my primary recommendation for the time being, unless she really did not want to have any more scans than she just wanted it treated fully. So your recommendation would be active surveillance. How often would you follow her? What would you follow her with? And what would be the trigger to intervene? Thank you. So if this is the first scan that we have, everybody is worried about maybe it's rapidly growing. And most of them do not, but there are maybe a small percentage that do. So what I do is get another scan in about three or four months. That's fairly short term. And almost always, they're unchanged. And if that's the case, then we get scans every six months. I think a CT scan is fine. And it just would be a CT of the abdomen every six months. Alternatively, we could do an MRI. But it is harder for the patient, as Cameron was saying, just because you have to lay still on the MRI machine, much more than on a CT. And for older patients, that's harder to do holding one's breath for 30 seconds or 45 seconds each time. So CT is a little bit easier. And what did I say? Every six months, did I answer your questions? What would be the reason to intervene? So generally, greater than 0.5 centimeters growth per year is the guideline we use. And then in addition, over the course of years, it could, of course, keep growing little by little. And if it gets to be three centimeters, then we get a little bit more serious about acting on it. The other thing I would talk to her about is the possibility of doing biopsy. And we kind of covered all those issues earlier about that. Dr. Karam, how would you manage this patient? I would agree with Dr. Matin. I would recommend active surveillance as the first treatment option. Dr. Chapin? Yeah, I mean, I would agree based on our ageing comorbidities. I'm not really sure why she got a CAT scan, because they don't do those for follow-up for breast cancer. Presumably, she hasn't had any additional imaging before, so we don't really have a starting point that's happened between the last scan and this scan if there was a last scan. But I would agree active surveillance would be an option. And then I'd give her the option, like we talked about before, of biopsy or not biopsy. A lot of times patients feel very strongly one way or the other, and I just go along with theirs. But I wouldn't necessarily request that they have a biopsy. She says, Dr. Chapin, I want to do whatever you want to do. What do you want to do? I would surveil her. I'd follow her up in three months with repeat imaging, probably a CAT scan at that time. And if it hasn't changed much, whatever size criteria you want to determine, Dr. Matin talks about less than 0.5 centimeters. I mean, if it hasn't grown or it has grown very little, I would still consider watching her. And I'd probably would image her every six months beyond that. So you'd get a scan three months from her. Correct. Dr. Arar, what are your thoughts? Well, I think the AUA guidelines suggested in 2009 when patients present, you know, the urologists are encouraged to give them all the options. A patient like this here would be seen, I'm sure, to be advised that these are the options, essentially partial nephrectomy versus observation versus thermal operation. A lot of patients come actually prepared and they have kind of tendencies towards leaning one way or another. So in this particular patient, considering those three options, I think all three options are available to her, whatever she wants. And thermal operation would definitely be an option for her. So of all the panel members, who would do a biopsy in this lady? Two for biopsy and everyone else no. All right, Serena, defend it. Well, I already did. I think, I mean, you don't have to. But I think, you know, a well-informed patient and physician just sort of tends to make a little bit better of a smooth course over time. Truth is the results will not really alter the immediate plan. But again, I think we kind of go into it more proactively and rather than being reactionary down the line. On the other hand, I actually could make a difference. If we biopsy it and it showed oncocytoma or oncocytic cells even, you know, we would be even less concerned in terms of its potential to harm her long-term. So this is not an uncommon problem that we see in the clinic every day where you have older patient comorbidities, they have a tumor and the $64,000 question is are they gonna die with this thing or of this thing? And in the overwhelming majority of cases they're probably going to die with it rather than of it. And it becomes a struggle as to how intensive our intervention needs to be. And there are other issues that involve some people who are very cancer-phobic and the idea of harboring a cancer and just walking around with it is very uncomfortable for them. So we struggle against these issues all the time. So the biopsy was obtained at the time it was ablated in the patient. It did undergo ablation and the biopsy showed it to be a benign oncocytoma, although they did not know that obviously at the time they did the ablation.