 Okay, let's move on. 51-year-old Hispanic male presents with gross hematuria. He's got a past medical history significant for diabetes, hypertension, gout, and kidney stones. He has a past surgical history only significant for fixing an inguinal hernia. He takes metformin for his diabetes, lysinepril, and sertraline for his blood pressure, and symphastatin for his hypercholesterolemia. His mother, his father, and his brother all had kidney cancer. And his father died from metastatic disease. He doesn't drink, he doesn't smoke, he has two kids. His chest is negative and his labs are within normal limits. Now you can see here he's got this very, very large tumor involving his right kidney, and in addition he has a smaller tumor involving his left kidney. Here's another view. Again, large tumor involving the right kidney, small tumor involving the left kidney. Here's a coronal view. Well, you guys are looking at that? Smaller. Smaller. Smaller. That's still a big tumor. Just so you don't think Dr. Wood is saying that it grosses him out, but the gross is a term we use in terms of visible, meaning you don't need my cross. So I don't know how many of you guys are familiar with that terminology. He's not saying he's grossed out by it. All right. So let's see. Dr. Chapin, this patient comes to you. So large tumor, right kidney. Smaller tumor, left kidney. No metastatic disease. Mother, father, brother have had kidney cancer. Father died of kidney cancer. What are you going to do? I think based on the size of the right tumor and the risk for that becoming metastatic or the source of metastases, I would probably do the right kidney first, followed by a left partial nephrectomy. Why not do both? At the same time? Yeah, why not do both at the same time? I just think it's a lot for the patient to handle at having both at the same time. If you have the contralateral kidney, the left kidney is still in site too, then you can hope that postoperatively he'll recover faster than if you took both kidneys out and put them on dialysis or renal replacement therapy. Jose, do you agree with that? I would choose number one too, but I think on the left side we should definitely try to do a partial nephrectomy, but what Dr. Chapin mentioned is dialysis, temporary dialysis in case you do a partial nephrectomy and you've lost kidney function on the same day from the right side. But I agree with Dr. Chapin, I would do a right nephrectomy first because of the higher risk of metastasis or spread from the right side, and then about six to eight weeks later follow that with a left partial nephrectomy. Scott, what do you think? We talk about this a lot, but I don't think there's a right answer here. Actually what I would do would be an open left partial nephrectomy first because that right kidney, if the right kidney was entirely tumor, when you look at the coronals there, there's actually some normal prankima a little bit at the top and the bottom, so I'd do the big open left partial nephrectomy, salvage that kidney and then have my right kidney there to, I know it's got a large tumor in it, but have the right kidney there to back me up as the patient recovers. And within eight weeks I'm going to be taking out the right kidney, so within eight weeks he's going to get both of them treated. Would anyone consider biopsy? Would that help in any way? I don't think it's going to change the management whatsoever. Not unless it's a protocol. Michael, do you want to comment on the role of targeted therapy in this setting? Would anyone consider giving this patient targeted therapy to try and shrink the tumors or eliminate metastatic disease or... of metastatic disease, I do not recommend systemic therapy upfront. Only if the patient has metastasis or if after surgery the patient develops recurrence. I think a comment to be made here, this is a patient with three bloodlines having RCC, one has to consider this being an inherited syndrome. So, by laterality father, mother and brother had rena to be evaluated at the genetic clinic to rule out this being a VHL disease, VHL, you know, Von Hippel-Lindau inherited syndrome. In terms of approaches I agree, I think the one that's most threatening is the right side. So, one would take care of that first and then the left partial, although there are surgeons, urologists at the Mayo Clinic who have done or still advocate doing both surgeries at the same time. Yeah, I think conventional wisdom in urology is to do stage procedures and then it becomes a real controversy in terms of how you stage it. So, you know, both of the arguments are valid. On the right side there's a locally advanced tumor, you worry about it metastasizing, but on the left side there's a fairly large tumor that's not going to be a chip shot partial and you're concerned that if you take out the right kidney and then do the left kidney that if the left kidney goes into shutdown the patient ends up on dialysis. Conversely, you could do a partial nephrectomy on the left side, but if they have a complication or something that delays their subsequent surgery they could metastasize on the right side. So, you can see it's not no easy answers and can sometimes be really challenging to make those decisions. Well, ultimately I can tell you that the patient underwent a left partial nephrectomy turned out to be a clear cell renal cell carcinoma T1B and then a right radical nephrectomy turned out to be a T3A meaning it was invading into the renal sinus and the perinephric fat clear cell renal cell carcinoma Grade 3. So then, Michael or Nazar would you like to comment on the role of adjuvant therapy meaning that after completing these two surgeries the patient comes to you and says my father died of kidney cancer. Is there any medicine that you can give me that can make sure that I don't die of kidney cancer? Sure. I can take that one. So my answer to the patient would be off of a protocol. There's really no role for adjuvant therapy. Now, this patient is high risk and we know that we have lots of active targeted therapies. We have seven FDA approved agents in the last six, seven years now. So we know that we have active agents, but it's really not clear off of a protocol what the role of that is. So I would encourage that patient if they were eligible to enroll on a clinical trial protocol that was appropriate. Do you know the clinical trials that are available currently in the United States? Yeah, I mean, there are several that in the past several years. I'm not sure what you all have here. We have a protect study. It's looking at adjuvant Pazopinib. There has been a Shur that's looked at Sunitinib or Seraphinib. There's been S-track. There's been Everest looking at Everolimus. Yeah, the two currently open trials in the United States are the Everest trial, which is sponsored by SWAG, which has randomized patients to Everolimus versus placebo, and then the Protect trial, which is sponsored by GSK and randomizes patients to Pazopinib versus placebo. Question. There is one adjuvant study that has shown to be a benefit and it's never been replicated. It was a tumor-derived vaccine from Germany. So would you have enrolled this gentleman on a vaccine trial before you took out his kidney? If one existed, but as you're well aware that there's controversy surrounding that study because the intent to treat analysis was negative. It was only when they looked at patients who actually got the vaccine and the trial was empowered to show that. But you're right. There is a vaccine preparation in Germany that potentially could decrease the risk of recurrence, but I don't think that's going anywhere as I understand it. Just to comment on the concept of randomized. So when we say randomized, basically we randomly choose there is a certain computerized process that tells us if the patient is going to take the medication or the placebo or otherwise known as a sugar pill for example. So the doctor or the patient, we don't choose what medication the patient is going to receive. So the patient needs to know that they could be on a non-active medication or on the active medication and it's completely random process. Thank you.