 As I said, slight change in the agenda. We'll have Dr. Rahsaan come in and do talk about the localized management. I'd like to just introduce by saying, it's very confusing the number of people involved in providing care. So there are surgeons, and that's the urologists who take care of patients with kidney cancer. I'm a medical oncologist, mostly doing medical therapy. We have radiation oncologists, so it's important for us to sort of understand who the players are. Dr. Rahsaan is going to talk about surgical management and feel free to have any questions that you might have for him either during his talk or at the end. Thank you, Sandy. And again, just to reiterate, please don't hesitate to stop, raise your hand, ask a question at any point throughout this, throughout the talk if you want some more clarification on anything we're mentioning. So we have a nice background set up about kidney cancer, kidney cancer diagnosis. And one of the interesting things that has been happening over the last 20, 30 years is there's been a slow and consistent rise in new diagnoses from kidney cancer, about three to 4% each year since the 1980s. This is in part related to some of the risk factors. It looks like one of them has disappeared, but so the primary risk factors would be obesity, smoking, genetic predisposition, so people with family histories are at an increased risk of kidney cancer, as well as imaging. So just more use of CAT scans, ultrasound, MRI, incidentally finding renal masses. So it used to be that the most, what we call the classic triad, the way kidney cancer was diagnosed was based on three things. One, blood in the urine, two, pain, and three, a palpable abdominal mass. So you see somebody in clinic and you examine their abdomen and you can actually feel these masses. Now that triad is relatively uncommon. So fewer than 10% of patients initially diagnosed with kidney cancer will have that. Much more commonly now is the incidental renal mass. Again, someone that's getting an ultrasound for abdominal pain from a gallstone, say, but low and behold, has a mass in the kidney as well. That's reflected in this graph here where we look at, this is by year here on the X axis, 1993 here up to 2004. And the proportion of these, stage one is the blue and then stage two is green, yellow, red. So in general, what we see is that stage three, stage four has been pretty consistent new cases over time, but stage one has been steadily increasing. So the vast majority of this increase in kidney cancer diagnosis is in this stage one, localized, smaller masses confined to the kidney. And this is great because the survival with these smaller masses confined to the kidney is much better than the patient presenting with a metastatic kidney cancer. So we see the chance of being alive five years later related to the kidney cancer is more than 90% with these stage one smaller masses compared to the stage four metastatic kidney cancer where the chance of being alive in five years can be less than 10%. So finding these things early when they're small is critical in terms of the chance for cure. So what do we do about these things? Up until the, prior to the 1960s, there wasn't really much we could do in terms of options. But in the 1960s, the radical nephrectomy was initially described. Radical nephrectomy meaning surgery to remove the entire kidney, the adrenal gland, the fat around the kidney, as well as lymph nodes in that area. With this operation, they saw that about half of people then would be alive five years later. So this was a significant improvement over previously when there was really nothing to offer these patients. There was a significant mortality rate, so a 3% chance of having this operation and dying related to the surgery. But because of the improvement in survival, this really became the standard of care management of kidney cancer for decades. Fortunately now, more recently, there are a variety of new options that we have to treat kidney cancer from a surgical standpoint. And the goal behind this, as is the goal behind treatment of all different types of cancers, is to initially we kind of throw everything at a patient and then we figure out, well, what can we take back? How can we do this in a way that's less invasive, less painful, less recovery time? So again, the goal specifically, we wanna reduce the risk from surgery, reduce pain, reduce bleeding, reduce recovery time while at the same time preserving or even improving upon the benefit related to surgery. So what are the options that we have for patients initially coming in with small masses in the kidney? So surveillance is one, ablation, surgery, whether that be with an open operation or minimally invasive surgery or removal of the entire kidney, the radical nephrectomy removal of just the tumor partial nephrectomy. And we'll talk about all of these things in a minute. When you look at what's been done over time, what we see again here on the X axis, we're seeing in 2001, 2002, up to 2009, and the proportion of patients treated with these different options. So blue is radical nephrectomy, green partial nephrectomy, red is nonsurgical management or surveillance, monitoring these without treatment, and then the purple is ablation. And so what we notice just in general with trends over time, as time has gone along, we're seeing more patients treated with ablation, more patients treated with partial nephrectomy, and fewer with radical nephrectomy. So the goal is becoming more, let's try to treat this cancer with an operation, but also try to preserve kidney function as much as we can. So then how do we decide what to do for these patients? So there are a number of different ways, things that I look at when I see a new patient in clinic to decide what's gonna be the best option. So we look at the patient's age, someone who's 40 may have a different recommendation for treatment that someone who's 90. Medical problems, so you're very healthy or a number of other medical problems, heart disease, diabetes, et cetera. What's the size of the mass? So that will impact what we do, as well as what is the location within the kidney, and I'll show some sample CAT scan images to illustrate that. What is the kidney function? So someone who has very poor kidney function may be close to dialysis, we may be, we wanna push more to preserve as much kidney function as we can than someone who has perfect kidney function. Personal preferences, so sometimes the patients will express very strong opinion about I want everything removed or let's try to save as much kidney function as possible. And then finally, and I italicize this, the biopsy result, and I'll mention this quickly, the use of biopsy of these renal masses to help decide what to do. So when I see a patient in clinic, the primary components, the way we gather the information that I mentioned in the previous slide is through a comprehensive history and physical examination, spend a lot of time reviewing the prior imaging or obtaining new imaging, either with CAT scans, MRI, or ultrasound. When kidney cancer spreads, one of the more common spots it can go to is to the lungs, and so we'll do some form of chest imaging, whether it be a chest X-ray or a CAT scan, to help differentiate the mass that's confined to the kidney from the one that may have spread elsewhere. And then finally, blood tests, and in large part looking at the kidney function, because again, that can help us decide what we want to do for treatment. So just one slide on renal mass biopsy. It had been until recently that we really never biopsy. So we're talking about needle biopsies taking a small needle under imaging guidance through the skin to take a little sample of these tumors. Until recently, we had not been doing this at all, but a number of things have helped kind of push us into reconsidering and saying, well, maybe some of these things should be biopsy to help us decide what to do from a treatment standpoint. And a couple of those things, and one in particular is the fact that we have learned that for masses, solid masses involving the kidney that are less than four centimeters in size, and that's usually the cutoff for what we refer to as a small renal mass, that about 20% of those are actually not cancers. There are maybe benign tumors, but not cancers. So if we are operating on everybody that has a mass less than four centimeters in size, we're going to be removing, we're gonna be operating on 20% of people that maybe didn't actually need surgery. And on top of that, even when some of these are cancerous, so some of the 80% that are, many of these small ones are slow-growing and not particularly aggressive. So perhaps we could get away with not operating on some patients in that group as well. The renal mass biopsy is actually pretty safe. There's only about a 1% chance that we'll do a biopsy or the interventional radiologists in this case will do a biopsy and say this is not cancer, we'll find out later that it is. There's a chance of bleeding, but that's pretty small, less than 2% chance of significant bleeding. The chance of spreading the tumor, patients often will ask about that. What is the chance of spreading the tumor by putting a needle into it? That's less than one in 10,000. So that has been described to have happened, but very, very, very rare. And there is though a chance that we may not get enough tissue with the biopsy and not get an answer. And in that situation, sometimes we could repeat the biopsy or often what we'll say is okay, let's just go on and treat the way we see fit. So what about surveillance? So I mentioned that briefly. So this is one option that I will mention to patients that I see with a newly diagnosed small mass in the kidney. And what we've learned and the way we've learned this is that many patients, so say you'll take someone who's 90 years old has a lot of medical problems and is found to have a small mass in the kidney and may say, well, I have a lot of other things to worry about. Let's not do anything about the kidney cancer. And what we've learned over time is that these grow very slowly. So the average growth rate for a small mass in the kidney that's not being treated is about in the range of two to three millimeters per year. So they don't change all that quickly. Some of these don't grow at all. Some will grow more quickly than that. And we know that if we follow these, again, with no treatment, the chance of that patient within the next couple of years going on to develop metastatic kidney cancer is less than 1%. It's not zero, but it's low. Yep. This is stage one. So these are gonna be people with smaller masses in the kidney with no obvious signs of spread elsewhere. Yeah. So again, I think this is a great option for patients with a shorter life expectancy or because of medical problems or other reasons can't tolerate surgery. And I have a lot of patients that I follow with small renal masses without treatment, just keeping track periodically with imaging to make sure that they're not growing rapidly. Question? Yep. Not necessarily. Yeah, so great question. So this is an overall average of growth rate. And so we see some of the patients that I'm following with surveillance, you'll do a scan one year and the next year you come back and the thing's exactly the same size. And other ones can grow a centimeter a year. So this is an average, so patients will often ask that of have a big mass, how long has this been there? And unless we can go back and look at prior imaging and comparing, usually there's really no way of saying because it's fairly variable. The more aggressive tumor may grow faster, the less aggressive tumor may grow almost imperceptibly. So ablation. So this is another very interesting option that can be a great answer for many patients. So ablation means usually taking a needle, putting it in a tumor, either through an open surgery, laparoscopic surgery or more commonly just through the skin, put a needle in the tumor and then either freezing it or burning it and killing it that way. With the goal of killing the cancer but trying to preserve the rest of the kidney in the least invasive way possible. So this is a good option for small masses of the kidney, meaning say less than four centimeters would be ideal. It's good for patients who can't tolerate a more invasive operation, although that doesn't necessarily have to be the case. It can often be done with a small needle again through the skin. So this is a sample case with a patient, this is a CAT scan, patients laying on their belly. A needle is placed under imaging guidance, you put it right in the middle of the tumor and then here in this case, this is radiofrequency ablation. So there are a couple of different energy technologies that can then can be used to try to destroy the tumor this way. Yeah. Is ablation a technology? Usually not. So these are more likely to be the stage one tumors that are confined to the kidney itself. So without signs of spread to the lymph nodes or elsewhere. So how well does this work? There was a recent study, this was just last month I believe, from the Mayo Clinic where they compared the results from partial nephrectomy surgery to the cryoablation for masses less than seven centimeters in size. In 1400 patients all treated at the Mayo Clinic, so a single center. And what they found is that the chance of that cancer coming back was very similar, whether you had surgery or whether you had ablation. So what this shows is that ablation is a very, can be a very reasonable option for many patients. Now that hasn't necessarily been the case elsewhere from some of the other areas in the literature. So what I have seen previously is that the chance of tumor coming back in that kidney with partial nephrectomy is about 1%. The chance of it coming back with the ablation may be as high as 10% depending on the size and the complexity. So it varies. It may be that at the Mayo Clinic they're selecting patients better. They may be very skilled in the ablation technology. But all in all, I think that this can be fairly comparable when done well. And it is somewhat less invasive than the surgery. Usually just a night in the hospital as opposed to two to three nights in the hospital. Yeah? Right, you're right. So this is very interesting because this is awfully large for ablation. So for example, if we're using cryoablation you can only treat a certain amount of tissue. So when you get a bigger mass then they're putting multiple needles in there to try to cover the whole area and then having kind of overlapping freezing zones which can put you at higher risk for having some area that doesn't get adequately treated within there. So this in my mind is really pushing the envelope in terms of what's possible with ablation. And what I think it probably shows is that with a very skilled interventional radiologist who at the Mayo Clinic they have high volumes who are going to be doing lots and lots and lots of these may be able to treat these successfully up to a fairly large size. Exactly what's going to be treated now. Right. If you're looking for kind of a boxed answer on exactly this is what the standard of care is going to be for all cases. The surgeon gets tested for a lot of local variability. Right. Exactly. I mean you may have in one place a very skilled interventional radiologist who's going to be the one doing the ablation who's willing to try this. While another center you may show this to them and say what do you think? And they say you got to be kidding me. There's no way I'm willing to do that. So yeah, there is going to be a lot of institutional dependence depending on who's available at that particular place. Yeah. Yeah. So it looks like cryo's probably a little better than RFA. There was some RFA that was in here and actually the cryo ended up being better than that. So I think when given both options again this may be something some institutions may favor cryo some favor RFA and it's hard to compare necessarily you know kind of apples to apples but in general my impression of the literature has been that cryo's probably a little bit better. So then how about surgery? So I think when I think about surgery they're really two quick two key questions. So one is how do we get there? Meaning how do we get to the kidney? And the second is what do we do once we get to the kidney? So how do we get there? So first of all this audience is familiar with the general anatomy of the kidney but just to reiterate the kidneys are paired structures deep in the abdomen or what the area would call a retroperitoneum meaning in the cavity or behind the cavity that contains our intestines. This is the aorta the major blood vessel that carries all the blood from the heart to the rest of the body. This is the vena cava the blood vessel that carries all the blood back to the heart. The kidney's job is filtering our blood so they get a tremendous amount of blood supply and each kidney has at least one major artery to it and at least one major vein to drain the blood back to the level of the heart. So how do we get there? So traditionally what this has been done with open surgery there are a couple of different incisions that can be done but in general what we do is we cut either through the front or through the side to go back we cut through the muscles of the abdominal wall of the flank to get down to the level of the kidney and do the operation that way. And the alternative that's emerged and is really taken over is minimally invasive surgery either with a surgical robot or just straight laparoscopic surgery. And the reason why this is taken over is that instead of making one big incision now we can make several small incisions and by doing that we're able to have do the operation successfully but with less pain, less bleeding and shorter hospitals stay quicker recovery overall. So this is really taken over laparoscopic or robotic surgery is taken over as the new standard for radical and when possible partial nephrectomy for kidney cancer surgery. And then the second question beyond kind of how do we get there is what are we gonna do when we get there? And there are two major categories. So one radical nephrectomy meaning removing the entire kidney and the second partial nephrectomy meaning cutting out the tumor plus a little bit of normal kidney around it but preserve kidney function in that kidney. So what is the benefit of radical nephrectomy? Well actually it's technically easier to remove the whole kidney than it is to remove part of the kidney and you don't have to worry about the chance of cancer returning in that kidney. Cancer still could return elsewhere but it's not gonna return in that kidney because the whole thing is gone. The downside is that you will lose some kidney function because often what we have is a normal functional kidney which just happens to have a tumor growing on it. And what we've seen is that loss of kidney function may contribute to an increased risk for heart disease or other medical problems and may lead to that patient down the line needing dialysis which we always try to avoid. Yeah, you mean like. So normally the kidney on the side of the tumor continues to work pretty well unless that tumor gets very, very large eventually they can kind of lose function in that kidney but largely it continues to work fine. After a radical nephrectomy remove the whole kidney normally the other kidney can compensate fine. There are times when the other kidney is just struggling along on its own and you remove one and then you end up getting much worse or even going on dialysis but for the most part it does a pretty good job of compensating even if it's the only one left. Yeah. You can take periodic tests for example creatinine. Right, right and that is part of the follow up care afterwards just to continue to monitor kidney function exactly. What is the limit on creatinine for when going dialysis? So normally by the time we get to that point the patient will be seeing a nephrologist. It's not so much the creatinine level that indicates that it's more like is your blood getting too acidic are you getting kind of fluid overloaded? Too much fluid in the body and the kidney is just not able to eliminate that. And a couple of other things the level of potassium there are a number of different factors that the nephrologist will look at to help decide when does a particular patient need to go on dialysis and when is the kidney just hanging in there and not quite need to do that yet. And then partial nephrectomy again the pro is to try to remove the tumor but preserve kidney function. It is more technically difficult and there is a somewhat increased chance of complications with that approach. So one thing I wanna focus on a bit is the robotic partial nephrectomy. So this is kind of what I would consider to be the gold standard in a young and healthy patient who has a small mass in the kidney when this is possible. So this is technically challenging. There are chance of complications. The two primary ones we worry most about is either bleeding because again the kidneys filter a lot of blood and so there's a chance of bleeding with the surgery or urine leakage. So the kidneys filter our blood, they make urine, the urine is supposed to pass down in the bladder. If you're removing a large mass there's a chance that that urine then could leak out of the kidney. But with both of these we're talking about single digit percent chances of this. Most patients will do great without these potential complications. And again a greater short term complications related to removal of the whole kidney but long term once the kidney recovers then we do have that remaining kidney function. So I wanted to go through just for curiosity not that you will be doing these operations but just in case that people are curious to see well how do we actually go about doing this? Once we make a decision to remove part of a kidney what are the technical steps of this surgery? So a patient will go to the operating room, will be put to sleep by our anesthesiologists and then will be moved laying on the side. So if the mass is on the right side we have the patient on the left side down. We make several small holes in the belly. This is an example of an image of laparoscopic surgery where we make several small holes again kidney sitting right here. And with laparoscopic surgery it's the surgeons that are actually holding the instruments outside of the body. In this case with the surgical robot the difference being the robot holds the instruments outside the body and the surgeon will sit in kind of a video game console in the room, in the same room a few feet away. And the initial part of the operation is removing things out of the way in order to get to the kidney. So the colon for example sits right in front of the kidney we have to remove the colon out of the way in order to get down to as I mentioned the major blood vessels that go to the kidney because to do the partial nephrectomy surgery we have to temporarily block off the blood supply to the kidney, cut out the tumor, sew up the kidney and then allow the blood to get back to the kidney. So that's the initial part of the surgery. Once we have done that and things are kind of prepared we'll use ultrasound interoperatively through with a laparoscopic or robotic probe and I'll show you a little video of this in a minute to show exactly where the edge of the tumor is so we know how far out we need to cut to remove the whole kidney while minimizing damage to the normal kidney. Once we've decided where we're gonna cut we'll take these little clips and we'll block off the blood vessels. So temporarily, okay they squeeze on there so the blood can't get beyond here but then when we're done we just open these up and then the blood goes right back into the kidney. So once these are temporarily occluded we then go in we can cut out the tumor cut out a little bit of normal kidney and then go back and sew up the kidney over the top of this area that will then allow us to open the blood supply back to the kidney without bleeding from this area. So this is a short surgical video from one of the operations that I had done not too long ago just as an example of what we're looking at here. So this is an image that we're seeing here we're seeing a two dimensional image actually during the operation itself the camera has two different eyes on it so just the way that we have three dimensional vision by having two different eyes that are slightly offset same thing with the robot so we can see this in three dimensional view during the surgery. I'll play this in a minute but what we're looking at here this is gonna be the ultrasound probe that we're gonna use to find where exactly we wanna cut. This is the tumor down here. This is the kidney up here without ultrasound we can't tell exactly if the tumor stops here or does it kind of dive deeper up into here so that's what the ultrasound is used for and what I've already done by this point is I've scored or kind of make it a mark for myself where I think I wanna cut here and I'm just gonna play this so and then the other thing that we're looking at this is gonna be the ultrasound image so this probe will generate an ultrasound image and it's kind of a picture in picture view in the robotic console so I can see what that image is gonna be oops let me just play this here so as we're starting here again this is with the robotic instruments moving this ultrasound probe around you can see this image is changing at the time to figure out where this is gonna go and again I'm looking back at where I've scored out and I'm happy that we marked the right spot so this is where we're blocking off I previously dissected out this is the main artery that feeds that kidney and what we're doing at this point in the operation is temporarily blocking the blood supply to the kidney so that it's not gonna bleed and now once we've done that we can go up to this tumor and we can cut this out so this is cutting some normal kidney again the tumor is down here this is magnified 10 times so this is actually in reality is much smaller than this the amount of bleeding that we're looking at here is only a few millimeters so very very small amount of bleeding here and what we- do you see it 10 times larger? we do no we see it 10 times larger during the operation itself yeah so this is going kind of deep down into the kidney where the major blood vessels are gonna go to this portion as well as what we call collecting system so this is the area where the urine is collected in the kidney before it passes down so now I've cut out the tumor I look at it quickly to make sure that I don't see any signs of the tumor on the edge and then what we do is with needle and thread going in and sewing these blood vessels and again the area where the urine collects and we'll run this along to sew this area down this is robotic this is the robotic surgery right so this is sped up a little bit yeah this is a this is a two times the natural speed it's off to the side so in a minute once we sew this up and get the blood back into it we put in a plastic bag and then pull it out later and then what we do here with some reinforcing sutures we can snug this down very tightly on the outside so that when we then go back and I'm not gonna show that part when we actually take the clips off so that the blood will go back into the kidney there's no bleeding and then what we can do is we can kind of tack the fat back over the top of the kidney and so this is the after image here where we can see that you can't even see the kidney anymore because previously early in the operation what we've done is we open the fat kind of like a book we do the operation and flip it back over the top to kind of tuck it away from everything else in the abdomen so with this operation we wanna get patients up walking actually even the same day as the surgery we usually the hospital stay is about two to three days so not a long time in the hospital recovery time is variable depending on how quickly the or what the patient wants to get back to doing if they're a power lifter it takes longer than if it's somebody that leads a more sedentary lifestyle I usually tell people that they should be about 80% by two weeks about 90% by a month I'll see patients back somewhere between two to four weeks later to make sure everything is healing up okay return to work depends on what kind of work but it could be as early as a week afterwards it could be as long as a month again just depending on how rigorous the work is and then I'll continue to see those patients for a number of years afterwards with periodic imaging tests to make sure that there's no sign of the tumor coming back and then the only other thing is that most of these patients are not gonna need any additional treatment with the small mass that's fully removed but if there are particularly aggressive features there are sometimes clinical trials that patients will sign up for as a way to try to take a medicine to reduce the chance of the tumor coming back over time and that's something that we can get an indication of based on the pathology result from the surgery to decide do we need to do any sort of additional treatment or not but again the majority of these patients are will be cured with surgery alone and not need anything else no chemo, no radiation, no anything else and just to quickly run through a couple of sample images of cases largely that we've done the robotic partial nephrectomy the tumors can be located anywhere really within the kidney so here's a CAT scan image this is an axial image so meaning a slice through the body kind of like this this is what we call a coronal image meaning the imaging plane is now up and down right here right kidney is here left kidney is here again right kidney here left kidney here what we see here is a tumor that's what we refer to as endophytic meaning it's not kind of growing outside the kidney it's deep down in the kidney which can make this more difficult but with the use of ultrasound we can still figure out exactly where it is to cut it out safely and this is a patient we're able to do a robotic partial nephrectomy on another example of an endophytic tumor another axial image this is the kidney here tumor here and the other thing this patient had this is the adrenal gland on this side also had a mass in the adrenal gland so we're able to do the robotic partial nephrectomy and remove the adrenal gland at the same time this was a kidney cancer and this actually was a benign non-cancerous lesion another example of a tumor this time it's an MRI instead of a CAT scan tumor is located here in this case so this is more exo-fitted some of it sticks down into the kidney but a lot of it sticks out which makes it a little bit easier and it's on the anterior kind of the front side of the kidney compared to in this case what we see is a tumor on the posterior so the back side of the kidney so actually in this case we can do a robotic surgery where we go in more through the side to come straight back on the back side of the kidney sometimes they're either on the front nor the back they can be more laterally so more on the outside of the kidney you can see exo-fitic and again a mass sticking out of the kidney depending on where they are on the kidney can make it either possible or impossible to preserve some of the kidney function so this was an operation we just did a couple of weeks ago with a pretty large tumor but it's on the lower portion of the kidney kind of hanging off in the bottom and as you can see on this axial image on the level, normal left kidney and right kidney we don't see any of because this is mostly tumor but this was a patient who had some medical problems diabetes, kidney function not very good so we wanted to try to preserve as much kidney function as possible even though it was a bigger tumor and we were able to do this successfully to cut off the lower portion of the kidney but still preserve the normal upper portion of this kidney sometimes though these masses get big enough and replace enough kidney you can see here this is all tumor on the right side normal left kidney, all tumor on the right all tumor over here so when we get a big enough tumor with only a small amount of normal kidney then we do do the radical nephrectomy so this was a 10 centimeter tumor so in this case we did a robotic radical nephrectomy so there wasn't enough normal kidney worth preserving yeah, yeah good question so what we do we make small incisions and then once that kidney is free we put in a pretty strong plastic bag so we can insert a plastic bag, put it in there and then we'll make an incision that's maybe about yay big but within in a bag you can actually pull on it fairly hard without rupture in the kidney without spilling anything and you can actually get these things out of a pretty small incision still but if you end up with one like this and this was a case from a few weeks ago also so sometimes these get really big and this used to be more often what we would end up seeing when we initially found these before the beginning of imaging this is a patient who even though she had a very large mass it had not spread it was confined to the kidney and was one too when we did the operation laying on the bed you could actually see this bulging up through the abdomen visibly before doing the surgery once they get this big you can see it essentially fills half the body cavity at this point we can't really do these minimally invasively anymore here you would need a very big incision to get it out to begin with this is too big to even fit in any of the plastic bags that we've done so in this case we do still have to have the ability to do open surgery to make a bigger incision to take this tumor out safely and we did and she did very well but it was a couple of additional days in the hospital beyond what we can normally do by doing the minimally invasive small incision surgery so as a final slide just in summary so kidney cancer is found earlier nowadays due to increased use of imaging ultrasound, CAT scan, MRI there's been a transition to less invasive surgery so trying to minimize the number of large incisions we're making as well as a transition to kidney preservation so we don't have to do it that way but when possible when it's feasible we will often try to spare kidney function we'll consider surveillance for some patients typically the elderly the person with medical many medical problems with a short life expectancy ablation is a great option in select patients and with the advent of robotic surgery we're now able to perform increasingly difficult operations with less morbidity shorter time in the hospital quicker recovery time and that's all I have and I'd be happy to take any other questions you mentioned chemo and radiation it has a follow on but you didn't mention it was an initial treatment so why was it so the traditional radiation is typically not part of treatment on any step for kidney cancer unless it's metastasized say to bone somewhere for example chemotherapy same sort of deal and Sandy will talk in a minute about some of the medical therapies right so sometimes there have been cases with use of some of these targeted agents that Dr. Srinivas will be talking about done prior to surgery to try to shrink down the tumors to make what would otherwise be an impossible surgery possible and there are reports of that working they're not all that reliable and many times it can help with the metastatic sites but it doesn't shrink down the primary tumor in the kidney itself enough that it significantly changes the operation and it can impair wound healing and things like that so for that reason that's typically not part of what we do unless we see someone who has metastatic cancer we can try some of these systemic drugs if a patient has a great response to it and the vast majority of the disease is only in the kidney in those cases we will sometimes do surgery to get the bulk of the tumor out and then go back on the medical treatments yeah I'd like to go back to the rising incidence you said there was a three to four percent increase incidence inside the kidney right and I would assume that because of better imaging more cancer something of all sorts is there any differential between kidney cancer and all forms of cancer and rising incidence yeah so some are going up some are going down and some are staying level and kidney cancer really is kind of apart from many other malignancies is going up I mean you're right we do type tend to see more masses by doing more imaging but the interesting thing here and the thing that makes us think that it's not just imaging the answer here is that you would expect if you're finding more of these cancers with imaging when they're small that at some point the large masses should start going down but that hasn't been the case those have been relatively level so there's probably something else at play too that's for whatever reason making the incidence of kidney cancer going up slowly each year yeah so most major well I would say basically all major cancer centers nowadays will have access to a robot the company that makes the robot does an incredible job with marketing and selling these places and they probably exist in more places than they should and this the robot is just a tool it's an outstanding tool but it has to have trained hands and know what to do with it so I think in general if you go to a major cancer institute you can get an excellent robotic surgery you don't want to just go specifically seek out the robot you want to seek out the surgeon who has the ability to use the robot well yeah okay right and so I think we're going to talk a little bit about imaging later today and I'll briefly mention so you're right that PET in general we don't use much for kidney cancer because it's pretty unreliable some cases they do light up really nicely and other times they don't so that really isn't for right yeah so again my focus is just looking in the kidney itself that's an unusual case to not see anything at all and then that quickly afterwards to have a mass that's that big but really the CAT scan and MRI are what we consider gold standard imaging for masses confined to the kidney yeah what do you mean by that oh it's as I say why kidney is going to occur for whatever reason genetics or obesity or whatever why didn't it attack our kidney versus our other organs do you have any idea of that? well I think so I mean cancer can affect any organ in the body essentially and some of the risk factors for kidney cancer say smoking is an example so smokers are going to be more likely to get kidney cancer more likely to get lung cancer more likely to get bladder cancer so there's a lot of overlap between risk factors for one type of cancer and risk factors for another type of cancer so good question it's not necessarily standardized what I will do is for the larger more aggressive tumors I'll see patients a little bit more frequently for ones who have a small two centimeter mass fully removed less frequently in general what we'll often do is every six months say for the first couple of years do an imaging test and then once a year out to about four or five years again largely driven on what is my suspicion or worry about this maybe coming back in the future yep mm-hmm so just to clarify imaging is separate from that in the sense that imaging is not a risk factor per se it's not a cause of these things it just so happens that it's incidentally picked up by using more imaging and there's a whole variety of different things reasons-wise so a lot of people get back pain right I mean almost all of us at some point in our life will have some back pain and many people will go on and get an MRI of their spine and you can just catch a little you see a little bit of the kidney with an MRI of the spine and they may see we'll see masses in the kidney for that situation gallbladder problems is another one if you get gallstones you get an ultrasound they also will take a quick glance at the kidney we'll find a little mass in the kidney that prompts additional imaging so there's a ton of different reasons why people will get an imaging test that just so happens to show a mass in the kidney patients unfortunately don't get blood in the urine and then it just continues to grow and that's and most people have no symptoms at all in the beginning and that's why I think if you have blood that might actually be a good thing because it will bring you to medical attention sooner rather than later so there can be a variety of things I mean that's a good example there can be a blood test we don't screen for these things so it's more just picked up in terms of in the course of routine normal medical care but probably the most common patient that I see nowadays is someone that had an imaging test for an unrelated reason yeah like left versus right no they tend to both be kind of equally involved yeah the robotic partial nephrectomy I mean so no it won't replace it just depends so I do both operations when possible I try to spare some kidney but when not possible remove the whole kidney so if some point in the future we're able to find these things when they're all small and they never get big enough then sure then maybe we would never need to remove the entire kidney but for the time being they will both be part of the treatment options that sometimes we need to use yep yeah and by traditional do you mean like the open surgery or the laparoscopic small incision surgery with the surgeon holding the instruments okay so the robot has a number of key advantages in this ultimately what it allows us to do is more complicated surgery minimally invasively then it's possible with the traditional laparoscopic surgery there are a couple of things so one is we do have the three-dimensional vision which we don't have with traditional laparoscopic surgery it's more magnified so again we get a nicer that ten times magnification is available for that you have wrists on the robotic instruments okay so you imagine trying to do something that's very you know that's technically tedious and if you had to hold your hands like this and your wrists didn't move and they had to be straight versus with the robot you actually have wrists and you can kind of work around corners and things like that so you're able to do much more difficult operations with the robot than the traditional laparoscopic surgery right right so that's heavily dependent on how what is the pathology from the surgery how big was it does it look like it was invading into the fat around the kidney or was it confined to the kidney and that can be a few percentage points or it can be much much higher what you're looking for is spread elsewhere in the body so you're right the kidney is gone it's not going to recur in that kidney but it could go to the lymph nodes it could go to the adrenal gland it could go to the other kidney it could go to the lung there are a number of different places so and what's happened is normally before surgery we'll do imaging we'll look to make sure that there's no sign of anything spread the reason why we follow up afterwards is that there's a chance that the tumor cells may have escaped prior to the operation and been sitting there microscopically too small to see and that over time they gradually grow up and that's what we're picking up with the imaging in the future not necessarily kidney cancer is very strange kidney cancer can come back 20 years later in really weird spots so that's why we follow for a while often we stop but it can behave very very bizarrely we know where it more likely comes back okay but we can't say for sure where it's going to because sometimes it comes back in places that we're just very surprised to see right I mean at some point there's only so much we're not going to do an entire body imaging you know every six months for the rest of every patient's life but you're right I mean sometimes you'll find something else that comes up in the skin for example years later that you just notice yourself my question is as far as chemicals going into the body the the stuff that you drink and the dye that goes in is there anything new out there that's not as toxic yes the contrast the contrast for the scans that we're getting with this correct there are so yes so the concerns with contrast is some people are allergic to them they can impact kidney function so sometimes people can't get a CAT scan can get an MRI because the contrast is easier on them the other concern that patients will often express is with radiation exposure with a CAT scan if you're going to be getting lots and lots of CAT scans so in those situations when we're worried about that sometimes we'll switch and we'll do MRIs which don't have any radiation exposure but yeah there are some newer contrast agents that are a little bit easier on the kidneys and other parts of the body do you my second question is do you have a website or is there any website that shows the symptoms of like if you have the bone cancer or you have brain cancer or you you know it's gone to your your brain or your bones or you know your liver or wherever well the National Cancer Institute is a good website to go to it sort of just illustrates what can happen with kidney cancer what symptoms you can have and what you can watch out for so definitely use that as a source like every six months every year or does it depend on each individual yeah so it depends in part about how bad the cancer is how big it is does it look more aggressive or less aggressive so if we're more worried about it we'll do more imaging less worried about not as much but in general for most patients I'll see them every six months for a couple of years and then once a year after that thank you so much just thank you