 Morning. Thank you for to the KCA and the committee for giving me this chance to discuss this burning topic Admittedly it's a topic with a limited amount of data So I'll do my part for keeping us on time of course and have a chance to show some CT scans and talk You know tell some anecdotes and see if we can actually Answer any questions. I don't have any disclosures to Give And just to clarify at the beginning here that this is not a discussion of the role of lymph adenectomy for somebody who has bulky nodal disease in the absence of systemic or distant sites Some people lump those together because those patients often have a very poor prognosis But as was discussed yesterday, some of these patients do Do well with lymph adenectomy, so we're not going to discuss them We're going to discuss only patients with clinical node positive or negative disease in the setting of Distant sites of metastasis So first Discussing the situation when you have what appears to be nodal involvement on staging imaging. So clinical node positive disease There is some data, of course The group at UCLA Showed about a decade ago that patients who underwent lymph adenectomy in the setting of metastatic disease do better Than patients who do not have lymph node dissection at the time of nephrectomy Now this was retrospective, but nevertheless there was a substantial Survival benefit and even on multivariate analysis. They consistently found that lymph node dissection did offer a survival advantage Other reasons to do a lymph node dissection besides a possible survival benefit. Well, it's fairly easy to do Complication rate is low in the single digits. It's definitely prognostic patients with nodal disease true nodal involvement in With distant sites of disease do very poorly There's also some Thought that perhaps perhaps patients with nodal involvement are not good candidates for immunotherapy in that paper by Pantuck as well As by Faisali In a couple years prior to that or they did not see a very good response of immunotherapy to patients who had nodal involvement Admittedly the numbers were low But also something that maybe it doesn't show very often, but there is a possibility of progressive Or a morbidity from progressive adenopathy of a couple of CT scans admitted that these are relatively unusual Situations, but they do come up if you look here This is a CT scan of a patient who had the primary tumor in place as bulky adenopathy here in the inner adocable region and a tumor thrombus But if you look at a slightly different slice, you'll see the renal vein is clear In fact at the time of nephrectomy and cable thrombectomy and no dissection all of the or the the thrombus was actually coming from the nodal disease and that I've seen that a couple of times now The this is another patient who just saw very recently a 30 year old who had had a nephrectomy On an outside institution about four or five months prior was transferred to our institution with a bowel obstruction and What we saw on CT is that he had very large nodal burden Essentially obstructing his duodenum and he couldn't even receive any Oral therapy so he had to actually go undergo a decompressive g-tube and a feeding j-tube to allow the initiation of systemic therapy And this is a patient who had on your gun the sort of node plucking that dr. Margulis referred to yesterday, so he had a no dissection which was actually negative But it was just a hyaluridic section But there are potentially reasons to not do a lymph node dissection even when there is clinical node involvement Reasons for that well the data supporting the role of lymph node dissection is limited It was the study the UCLA study was retrospective and probably subjected quite a bit of selection bias if Patients who did not undergo a lymph node dissection probably had higher burdens of systemic disease or perhaps poor performance status and this is also a report that came in the immunotherapy era and Again now that were you more often than not using targeted agents perhaps those those sites of disease those nodal Deposits do respond better to targeted therapy Another reason is well. It's easier to do an effrectomy laparoscopically if you're not going to do a node dissection You certainly can do it, but it's certainly a lot harder takes longer and As been shown by dr. Studer and others a lot of those clinically positive nodes are actually negative Perhaps at least in the setting of localized disease greater than 50% of those nodes are actually negative There is of course the risk of kyla societies greater blood loss potentially and even something we often forget in this population though with Be some my experience seeing more and more young patients with RCC you can Cause an ejaculation did have a patient who was most bothered by this after an extensive load node dissection And of course you have one case of Recalcitrant kyla societies, and you won't soon forget it nor will the patient And I just want to show you some examples of some what appear to be these are all patients with distant disease at the time of presentation And they had what appeared to be no positive disease some of them are less impressive than others of course here We have a nodal deposit here. You have some Interactive cable disease This here you can see actually quite an enhancing node, which again was negative and this one was most surprised by had fairly large Clinically no positive disease or See here in our area of cablee and even behind the Renault Highland and these are all negative So again, you can't be fooled by imaging Thinking that of course that they have Nodal disease and potentially even necessitating an open approach to try to dig out some of those inner area to cable the deposit so But I also want to touch on maybe some of the stuff that was just discussed There's there's a reason to not do with no dissection or a set of reductant effect me in these settings And when you have a node positive disease as you've already mentioned No positive patients with metastatic diseases do have a very poor prognosis the worst of the worst you might say And are they even benefiting from surgery of any sort? And that's of course debatable as we just heard That report that was mentioned by Dr. Bartosz Bartoszowski from MD Anderson they looked at seven preoperative variables that could be identified Of course before surgery that would help guide you in selecting patients who are going to benefit or not from set of reductant nephrectomy and one of those Variables was the presence of retroperitoneal lymph adenopathy. So of course, I don't have an answer Whether that should exclude them But certainly when you see a patient who has a metastatic renal cell with the primary in place and you see retroperitoneal lymph adenopathy Should alert kind of your antenna should go up thinking well This patient may have a poor prognosis and may in fact better be served with at least upfront systemic therapy Again, that's debatable But at least and again a lot of these patients often have Sarcoma to ethystology it's been shown by in that Pantuck report that If you have nodal involvement at the time of nephrectomy you have three times higher likelihood of having sarcoma to ethystology And again, many of those patients don't benefit from surgery In the setting when you have clinical node negative disease Honestly, there's really no data in this in this space I'm sure I can offer some opinions though here The role of lymph adenopathy in that setting there really isn't any specific data But if you're going to be doing a complete metastasectomy It certainly behooves you to at least consider lymph node dissection It would be a shame to go to that extent to render somebody disease-free and not remove their lymph nodes The likelihood of nodal involvement All-comers is greater than 25 percent in patients with metastatic renal cell Whether that holds true with patients who have clinical node negative disease It's hard to say but certainly they have a higher rate than that maybe the three to six percent we think of in patients with localized disease and And I can think of a case where I did do a complete metastasectomy guy deliver lesion and I did a lymph node dissection But of course what was not as extensive as I needed to be in about two years later He was any D except for a lymph node behind the adrenal gland and that's I was kicking myself for that So but on a more philosophical note if I may By doing a lymph node dissection at the time of us and a freck me or there I mean doesn't add that much time to your surgery and likelihood of complications is low and I think again, maybe not Currently but in the coming years as our agents are more effective and patients do live longer Individual sites of disease. I think are going to be more important If somebody lives for three four or five years that one spot that node that you didn't remove that now becomes You know has an unresponsive clone does become more important psychologically if not physically with potential symptoms so again I think if you're Gonna be optimistic and I think as a surgeon you kind of have to be optimistic That's what we're doing surgery at the time anyway the I think that cleaning up the nodes at the time of the freck to me It certainly makes sense And then if I may just on a slightly unrelated note I think it's lymph node involvement has been used as a Least a reason to to not use immunotherapy or at least some evidence points in that direction I want to having had two Patients recently referred who actually has had essentially complete responses to IL-2. I'm very optimistic on that at this time And I want to point out a patient who was 66 year old who had clear cell metastatic clear cell that developed Or her metastatic disease developed at about a year after surgery And it was primarily nodal recurrence. You had an iterated cable lymph node doesn't project real well, but trust me It's it's a real node. I didn't remove that lymph node I did her nephrectomy laparoscopic link took out her peria cable nodes I didn't do it in her cable dissection and she also had Pulmonary hyalurus disease in the nodes and she did push for IL-2 and she got it and she had essentially complete response So I don't think that I think the limited evidence that suggests that it's not effective against little diseases Probably partly selected So anyway, thank you for your attention and I don't know if anybody's heard about the Phil Knight's promise to the OHSU Cancer Center $500 million if it's matched by a similar amount in two years, so I will be a Out-front collecting spare change towards that effort Just to summarize I'm sorry again clinical node positive disease probably should do it possibly therapeutic definitely prognostic occasional complications maybe have to use a more invasive approach, but these patients may not be benefiting from surgery at all truly As far as clinical no negative. It's Definitely prognostic Very question be therapeutic, but of course get home later if you do it But let's and we have to remember time is money But that is never more true than in the OR or every minute is hundreds of dollars. So anyway, thank you