 لقد نرى أن نرى الى التالي هذا هو قبل مخلوق 59 سنة الذي قام بخطف ذلك وقد قام بخطف ذلك لمدة 6 سنة فتيق وخطف ذلك ونائد سوات وقام بخطف ذلك في الخارج منه وما قمنا بخطف ذلك وحك這一 صفحة وخائق كبري وصنع جيداً هنا are the two views of his left renal mass and you can see that it's a large mass rising from the left kidney and I believe there is compression here of the left renal vein you see another view here Doctor Wood would you like to comment on the left- very-cocele يجب أن ي ув唻 احمد القديم في مقايا لديك هذا وصف الحية او جديد من كثير من الجنس نعم، باهم فاقه قديم منه اسبحه من جديد من صاحبهم أن هناك كثير من يارغا سيل أفداعنا الاستعمال لأنها إتباه انما اتباه الرينو مع فاقه القديم يتباهات رينو فاقه قديم يعني أن هناك قداء في صوتها مدينة وانتبقها لتستخدمها وانتبقها لتزال على إطار مادة بلافتادي لذا يجب أن يكونوا مادة بلافتادي إذا كانوا حدثين أو ينفعوا على نفس مواجهة وفي شرطة هذا السبب، كيف سأفتح لممعات تصوير مدينة سأفعله بما يفعله بجانب سأفعله بسعر رضي رضاً في ذلك، مواجهة كبيرة تحتاج إلى أن تفعل مصالح وأنها مباشة خلال تتحمل وأنه كانت خطوة في تلك المساعدة, ولكن I'd also want to make sure that I do an adequate node dissection of this patient. Dr. Batim, is there a size cutoff where you would not recommend the laparoscopic robotic approach? It varies a little bit on the configuration. Once you get to above 10, 11, 12 cm, you know the benefit goes down pretty quickly like Chris said. وكما تفعله باستخدام كيف يبدو كبير وكيف يبدو كبير ولكن بسرعة أكثر من مرحباً على حوالي تتواجد من الوضع وكما تفعله ببناء. وكما تفعله ببسرعة أكثر من 10. حسنا. والأخر أمر أكثر من هذا المكتب هو أن المجموعة ستقول لماذا لم تقوم بجيب من ذلك المدينة التي تقوم بجيب هذه المجموعة من المجموعة والأجهر هو again أنه في المجموعة من حجم التحقيق أنه ليست نظام على حجم التحقيق حتى نقوم بعمل جيدًا كيف تعمل هذه الأجيزة؟ عندما تستطيع المستخدمين لتستخدمهم؟ المستخدمين المستخدمين still remains a standard of care. لذا ستفعل لديك نفرق لديك هنا؟ هل ستفعل أدريانغ لان؟ أو تقديم نفرق أدريانغ لان؟ لذا you can see in the picture, and Nazar if you can point out with the arrow, the left adrenal gland phenotypically is normal on the scan. And I couldn't argue against taking out that adrenal, but you know with locally advanced disease, particularly since the, on the left side, the adrenal vein empties into the left renal vein, you actually have to go out of your way to try and save the adrenal as opposed to on the right side where you have to, where the venous drainage is right into the vena cava. So I probably would take the adrenal gland with this just because of the locally advanced nature of the tumor. Okay. All right. So the patient underwent a left reticum infractomy with a resection of the visible lymph nodes and the adrenal gland was removed with the kidney. The pathology as you see here, clear cell kidney cancer, fermonucleic grade 2, T3A and 0M0. The nodes were all negative. Now what would you offer this patient, Dr. Harrison? Would you offer the patient any adjuvant therapy? So as we discussed this morning, this is another case of a patient who's at high risk for recurrence. However, adjuvant therapy is not standard of care off of a trial. So I would try to talk to the patient about possibly enrolling in an adjuvant clinical trial. So as we discussed this morning about, you know, the surveillance studies, the interval. How often do we do scans and imaging studies? Do we do an ultrasound as we discussed in Europe? That's what they're doing. Or do we use an MRI or we use a CAT scan? How often do we do a CAT scan on the chest? Or do we just do a plain chest x-ray? So the patient was followed with serial imaging. He was without evidence of disease. That's the NED, no evidence of disease until 22 months after surgery. And he presented with, you know, what you see here, a tiny pulmonary nodule. You see it here. And 28 months later after surgery, he has these few pulmonary nodules, a sub-synometer in size in the left lung. Dr. Pili, what would you do? Would you offer him systemic therapy, metastasectomy? You continue to follow. The patient is completely asymptomatic. He is healthy otherwise, except for essential hypertension that's well-controlled with blood pressure medicine. And this would be a compelling case to consider the removal of the lung nodules to send a thoracic surgery. It took two years to show up, this solitary lesion. So if it's only the only spot, maybe it's not. But I think with two years interval you can make the case. So I think definitely I would discuss with the patient the option for surgery. Dr. Harrison, would you recommend systemic therapy? No, I would not. And I think this is a patient where maybe we could avoid the chronic toxicity of targeted therapy. The patient has some features that Roberto pointed out. So two years since surgery, it's a solitary metastasis in the lung. So there's some retrospective studies showing those maybe factors indicating that they could benefit from surgery. So I would recommend the surgery and try to avoid systemic therapy. No. No, at this point. So the patient was sent to thoracic surgery and had a left thoracotomy and resection of these pulmonary nodules. That's what this medical term means. Metastasectomy. A total of six nodules were removed from the left lung, two of which had metastasis. So there were tumors, two out of the six. But the margins were clear. So he is again without evidence of disease. Is there anything we will do? Dr. Pili now, would you do anything after the complete resection? So the standard care is observation. So just have the patient recover from surgery and watch him. Okay. There is an ongoing trial. I think it's already open through ECOG where they're going to offer I think it's going to be randomized placebo versus passapate. So what's the role of this agent that blocked the blood supply to prevent further metastasis? So I think if that study is available to the patient I would refer to that trial. Otherwise observation. Okay. So eight months after the resection of these lung nodules you could see he was being followed but now you can see there's some nodules appearing again. You see here. So there are small lung nodules appearing in both lungs now. He has bilateral lung nodules. This is 11 months now after he had resection of these lung nodules from the left lung. What do you recommend, Dr. Harrison? Would you continue to observe? He's asymptomatic. Would you send him for systemic therapy or would you do another metastasectomy this time? Bilateral lung nodules. Bilateral thoracotomies. Yeah, I think the fact that the timeframe from his last metastasectomy being so short and the bilateral nodules that kind of rules out another metastasectomy or in other words resecting nodules from both sides. So I think that this patient is going to need systemic therapy and then this is similar to one of the cases we discussed prior. Is it wrong to maybe watch for a couple of months and see what happens? It's probably not. But on the other hand, we hate to miss a window. And this is another patient where the patient is young. I would be thinking about high-dose interleukin 2 based on the patient's wishes. And of course there would be other systemic therapy options too. Dr. Pili, you agree? Yeah, I agree. I'm always reluctant to start treatment if the tumor is very small. So this patient would not qualify probably for a clinical trials because we need to have a certain dimension at least one centimeter in dimension of these nodules. So if it doesn't fit the criteria for a clinical trial probably we'll still not start systemic therapy. But I would agree without the reason that eventually he will need it. Dr. Wood? I mean, call me surgeon mentality but I think that this guy would be perfect for high-dose IL-2 and that's where I'd refer him. I think it's clear he's got metastatic progression. He's got small volume disease. He's in excellent health. He's got a zero performance status. This is the classic candidate for high-dose IL-2. Admittedly there's toxicity but if he's going to be cured that's his only shot and if it were me or my father that's what I would do. So the patient we discussed I would do the same, Dr. Wood. But I was, you know again waiting sometimes even for immunotherapy at that stage probably it's not going to be harmful. I think the patient eventually will need to be to have a systemic therapy but I'm a strong believer high-dose into looking too and that's why we have also a clinical trial with IL-2 and Tino start but you know again unfortunately the complete response rate is still very low. And so it's a lot of toxicity. And sometimes the patient is a patient that go and get it you know a type of mentality you jump on the treatment so another patient might be a little bit more laid back but at the end I think the IL-2 if he's a candidate I think is the best option for him right now. And I think for the people in the audience this is a decision that's always made you know with the physician and the patient and the family. So obviously we present all the options high dose into looking too target therapy on protocol off protocol we discuss all the side effects and I think ultimately the patient and the family will come together with the physician and decide what they want how aggressive they want are they willing to go through the risks of high dose IL-2 and I think it's it's a personal decision I think we discuss these options with the patient and jointly we made the decision to treat him with high dose IL-2 and that's what he's getting next week.