 All right, we'll move on to another case. This is a 66-year-old male who presented with hemoptysis that he coughed up some blood while traveling. And past history, he has high blood pressure, on therapy control, high cholesterol. And he was evaluated because of the hemoptysis. And they did a CAT scan of the chest. They were concerned more about his lungs because of the scoffing up of blood. And the lungs were OK. There was nothing obvious in the chest by CAT scan. But incidentally, they discovered a mass in the left kidney and a benign-looking cyst in the right kidney. And again, on examination, similar to the patient we presented before, he had the left varicoseal. Again, to drive the point that a left varicoseal in a middle age and an elderly male should trigger a further evaluation. It should not be just left alone. The patient should be evaluated for something happening in the area where the left kidney is. And so this should be a bell for the patient, as well as for a primary physician and urologist. The labs were all normal. And he had this mass in the left kidney here, but no metastatic disease. Dr. Karam, how would you approach this patient? No metastasis. And he has this mass in the left kidney? So the chest is clear? Yes. No, we don't know why he was coughing blood. No metastasis. And that's all the films you're going to show me, right? Yes. So no hidden agenda. So for this patient, I would do a left radical nephrectomy and no dissection. You could see some probably enlarged lymph nodes there. Yep, that's what I would do. I would do it open myself just because of the nose being in a tricky location. Would you also take the left adrenal gland with the kidney? I don't know, because I can't see it on the film. So if it's not enlarged, do you take it out? If it's normal, I would not remove it, because the chance of metastasizing to the adrenal, it can happen to both sides. So direct extension of the tumor to the adrenal gland, you can usually see it on the CT scan or during surgery. And what we're worried about is metastasis from the kidney to the adrenal gland, which could happen both to the left or to the right side in, I think, almost equal frequency. So if it looks normal during surgery and on imaging, even on the left, I would personally keep it. OK, Dr. Mati, how would you approach this patient? I agree completely. I do the same thing. I would open radical lymph node dissection, preserve the adrenal. OK, Dr. Wood, different? I mean, I would probably remove the adrenal. It's just my sort of policy on locally advanced disease, particularly, again, on the left-hand side, where they share the same venous drainage. Certainly it could show up in the right adrenal as well. But I think in these more locally advanced tumors where the risk of metastasis is higher, that I would probably go ahead and remove the adrenal. I would do it open. I would do a lymph node dissection. It is interesting, though, in a sense. If you have a lot more cases, we don't have to spend a lot of time with this. But we spent a lot of time talking about neo-agipent therapy in the first part. And in a case like this, when there's so much disease in the lymph nodes, and those are truly positive, they're not reactionary. Where are you guys seeing lymph nodes? I'm assuming those are nodes, unless they're big veins on the other side. Is this the genital vein or what? The aorta on the other panel. That's bowel, isn't it? No, no, the other panel. Behind the aorta? Where? That's bowel. It's contrast. This is bowel here. Behind the aorta. Aorta, IVC. And bowel. Yeah, but between the spine and the aorta. It's not lymph nodes. This? Yeah. Well, it's not bowel. I'll show you guys how to read this later. It's not bowel. I'll have to. No, bowel doesn't live better. Those are not lymph nodes. These are opacified bowel looms. Behind the aorta? Behind the aorta? That could be a retroaortic renal vein. It's not a lymph node, for sure. That's why more films, yeah, but yeah. But I think the CT is calling your decision to do open because you want to remove the lymph nodes. But you could have lymph nodes. On the basis that we thought those were, because there should only be two circles above the spine, and there's four, five. So, all right. Well here, the patient underwent, and it's interesting you all decided to do open. And the patient did undergo, in fact, laparoscopic. Not open, laparoscopic nephrectomy. And sparing the left adrenal gland because it did not look enlarged by CAT scan or at the time of surgery by inspection. The lymph nodes were all negative. And here is the pathology, T3A, N0, no lymph node metasis, and no metasis. So we discussed this morning what would be the role of any therapy in the patient where you resect completely the disease. But he has local advanced disease. This is the T3A. So as we discussed, not to belabor the point too much, but off protocol, if there are no clinical trials available to the patient, or the patient declines participation in the clinical trial in this setting to prevent or reduce the probability of recurrence of the disease of the cancer after surgery, you observe them. And the frequency of scans, we discussed that this morning. If the patient is interested, very interested to participate in a clinical trial that offers adjuvant therapy, these adjuvant therapies are all with placebo control. I think this is important for the audience to really know that these trials have a placebo control. So the patient, it's double blind. The patient, as well as the team treating the patient, the physician and the nurse, do not know what the patient is actually taking. The patient could be taking a placebo or a drug. And it's given for a finite time, the majority of these adjuvant trials are one year. So would you, we all agree, if the patient is interested, enroll them on an adjuvant trial? Yes. Yes. So the patient was offered to enroll on a trial that's called the Ashur trial. It's a one year of adjuvant therapy with one of two drugs versus placebo, sunitinib, surafinib, or placebo for one year. And the patient didn't know what he was taking and that he had toxicity that led to interruption of therapy. And in fact, it took him because of the interruption 14 months instead of one year to finish the therapy. But he did finish it, he did receive the therapy, didn't know what he was getting. And 16 months later, after surgery, we have the scan here. Dr. Karam, would you like to comment on the scan? What do you see here? I mean, this is a benign right renal cyst for the audience. This is a benign. But is there anything that catches your attention? Are you worried about anything here? Like in that adreno you left behind? There's a one centimeter left adrenal mass that looks suspicious from a testotic disease that's presented two and a half years after surgery. Okay, would you have done anything at this stage of the game here? What's that? Would you have done anything at this stage of the 16 months after surgery? Would you do anything? I would have obtained imaging more frequently, maybe six months later rather than a year later. If it looks suspicious at that time. And if it is something that can be biopsy that would biopsy that too. But other than that, I think surgery would be what I would recommend if the patient has no metastatic disease. Okay, Dr. Ramatheed, any? Yeah, actually I have a fear. It's a sneaking suspicion. This is one of my patients looks very familiar. So yeah, I would do a laparoscopic nephrectomy. I can't recall if we did a biopsy or not. I think it's reasonable, but the suspicion is pretty high there. What did I say? Adrenalectomy. Adrenalectomy, what did I say? Nephrectomy. Oh yeah, forget it, yeah. Adrenalectomy. And I think the images we were seeing before, I think the patient probably had a vein coursing back there, which is what threw Dr. Karim and I off. We were thinking they were looking like lymph nodes in that one slide. But either way. Whatever. Yeah. Michael, Roberto, would anybody consider systemic therapy or left adrenalectomy? Surgery, surgery, yeah. All right. So he had a biopsy first and that confirmed that this is metastatic disease. There was no disease elsewhere and he underwent unblinding of his therapy and that he received before for one year on that trial and he was receiving synitinine and the side effects he experienced while receiving this drug were consistent with the toxicity of this agent. What would you offer now? They said it would be like this. Okay. He underwent a left adrenalectomy, negative margins, and the pathology is one centimeter metastatic RCC. Patient was observed after surgery. Three years after metastatectomy, surveillance films show a lesion in the left seven thrib. Reminder of metastatic evaluation is negative. And here, further evaluation of this. On the bone scan, he has a hot spot here. And on the CAT scan, there is this tumor here that corresponds to this. So he has metastatic disease to that left seven thrib. Dr. Pile, what would you do? I think I remember what I, you know, the case, but I read the case, but I think in this case, really three years, single metastasis means in the rib, I would make sure that that's the only site, but I would send it for surgery again, because, you know, it's been shown that probably that's, probably maybe it's the best option this patient has. I have a few cases when I was a Hopkins that, exactly the same. Even after therapy, that is the sanctuary in the bones and in the ribs, I just take the rib out and I ask the surgeon to take the rib out and the patient did find some. I would, if there is disease elsewhere, would then... Different story, but depends on where it is. But three years out, single met in the rib. Could the medical oncologist comment on the value of PET scanning in this circumstance? Michael, go ahead. Sure, yeah. You know, there's limited data and there is some data, but there's really not a good role for PET scan. Again, we talked in the earlier session that the most common PET scan uses FDG PET, and so really that's what I'm talking about. That's the labeled sugar. There are other types that, you know, might be more informative, but I would say at least if we're talking about the common type of PET FDG, it's probably not that useful. There's limited data that may be useful for following treatment response and advanced disease, but probably not for staging, so I wouldn't recommend that. I think you brought an important issue. I mean, nuclear imaging, I think, is a functional imaging, is improving. There is this notion that FDG PET does not work in clear cells, although there are some experience from Memorial. We had a couple of trials, Hopkins with PET and kidney cancer, every patient actually light up. So I would say probably if it's covered, in this case, maybe we're not a better idea to do a PET. If it helps you, if that's lesion lies up and nothing else lies up, yes. It might be negative. If the lesion is negative, of course it's not gonna help you. So what you're looking for though is other lesions, right? Yeah, just to be clear. But if the PET is negative, completely negative, it doesn't help, because you know that, like, yes, disease in the web. Okay, so he underwent a left rib resection and the pathology consisted with metastasis of the kidney cancer. Postoperatively, he had fluid buildup in the left chest, we call pleural effusion, and had a catheter to drain that effusion, the fluid. The fluid was sent for cytology, sent to the lab to test for malignant cells and there were no malignant cells. So it was a reactive postoperative complication and it's not malignant pleural effusion. So no cancer in the chest, other than the rib that was resected. He returns for repeat staging, and now the radiologist and your radiologist looking at the scans says, well, there looks like some spots in the pancreas, which in retrospect were there a year before on a prior CAT scan, but now are more visible, more obvious that they are consistent with metastasis to the pancreas. But there's no disease elsewhere. Now, what would you do, what would you offer him? Dr. Pili? Well, it is a challenging case because, you know, it is not the usual patient with kidney cancer we see in the clinic. But, and of course it would be compelling, intriguing to think about, you know, another surgery. Of course, the timing of this new legion is getting shorter and shorter, so you're wondering. And of course, when we do see disease in the pancreas, you're reluctant to send a patient for a WIPO procedure, for example, where is a pretty extensive disease, surgery. So I would, you know, I would discuss maybe with the surgical oncologist whether there is any role for removal of the, but depending how safe can be done the surgery and whether that truly is the only site. Dr. Harrison, would you go with total pancreatectomy? He has multiple lesions in the pancreas. It's not an option for a laparoscopic resection of the tail of the pancreas. This is the whole pancreas, multiple lesions. Would you do total pancreatectomy or systemic therapy? If the only option was total pancreatectomy, I would not do it, I would do systemic therapy. Systemic therapy, okay. What systemic therapy? So, would you go back, let me ask the question in a different way. Would you go back to Sunitinim, which he received years ago as adjuvant therapy? Would you go with a different tyrosine kinase inhibitor? Would you go with an amtore inhibitor? Would you go with high dose altitude? Or would you, obviously there is always the option of a clinical trial. What would you do? So, in this patient I'd probably think about oxytinib. I think a clinical trial would be a good option too. Certainly Sunitinib retreatment would be a good option. There's some limited data that if we treat patients and they progress on Sunitinib, which this is a little bit different of a scenario. But anyway, if they do progress we can retreat them. There's the dose escalation evidence. But I would have considered this patient to have had a good run at Sunitinib and then think about a more potent VEGF receptor TKI like oxytinib in this case. Dr. Wood, would you talk to your surgical oncologist colleagues for a total pancreatectomy? I mean, to be honest though, I think that this guy has definitely demonstrated that his disease is systemic. It's also very indolent, but it's systemic. And I think it starts to get ridiculous when you're just doing serial sectioning of the patient to try and take the cancer out. I think he's proved to me that he has systemic disease. And I think that the good news is that metastases to the pancreas usually behave very indolently. They're not very aggressive, they don't grow fast. So of all the patients that we've talked about today, this would be the guy that I actually would observe for a period of time for two reasons. Number one, because the pancreas mets usually don't grow at a very rapid rate. They're very indolent. But also, look to see if he crops up somewhere else to see if his disease shows up in another organ system. And then at that point, consider instituting therapy. You talk like a medical oncologist now. Actually, I was gonna make- I think I just got insulted, but no. Actually, I'm glad you brought that up because my thought, for some, and again, it's one of these things about kidney cancer we don't fully understand. There's clearly a seed and soil phenomenon. The cancers that go to the pancreas tend to behave generally much more favorably than, for example, those that go to the liver. So, and it's not clear to me why that happens and smart people like Dr. Karam maybe can figure this out over the next few years. But yeah, I would observe, I think, for those reasons that were mentioned. He may do very well for a while without any therapy.