 All right, let's move on to another case. This is a 74-year-old who presented with abdominal pain. And again, a CAT scan that was obtained because of this abdominal pain demonstrated an incidental right renal mass, which is one of the most common presentations we're seeing nowadays. Past medical history is significant for hypertension, diabetes, and also inflammatory bowel disease. And the patient currently is taking steroids for it. Also history pulmonary fibrosis, and the patient is morbidly obese. He's had numerous back surgeries and currently gets around in a wheelchair. And you can see here in the right kidney. And again, for those of you that have not seen CAT scans before, basically this is like looking from the feet upwards. So this is the right. This is the left. Here's the liver. Here's the gallbladder. Here's the spine. This is the left kidney. This is the right kidney. And you can see in the right kidney, there's a mass posteriorly present in the right kidney. So I'll throw this one to Dr. Karam. Dr. Karam, how would you manage this patient? I would check with his internist first to see what his prognosis is from the pulmonary fibrosis standpoint. These could be either stable or it could be progressive disease. So if the patient is progressing with the pulmonary fibrosis, then active surveillance would be really the only realistic option to discuss with the patient or to recommend. Otherwise, we can offer other therapies such as ablation or surgery. But surgery would be the lowest on the recommendation list. So for this patient, I would choose or recommend active surveillance first. And if the patient would like active therapy or insists on active therapy, I think this is probably a good position for ablation therapy given the posterior location, although it is close to the hyalum. Let's just assume that her pulmonary fibrosis is stable on steroids. So your recommending? So you're recommending ablation. Cameron, what do you think about ablating this thing? I think, again, the size is reasonable. It's probably at the upper limit of what I consider ideal. The location is a little tricky, kind of like the last case. Would be on a scale of 1 to 10 and degree of difficulty would be a 7 or 8, probably not the most difficult case we have ever done, but it can be done. Dr. Chapin, do you agree with that? Would you recommend ablation or what would you recommend for this patient? In the medical communities, I don't think it's unreasonable to consider a period of active surveillance. However, one question that comes up a lot when you're looking at active surveillance, and I know with Dr. Reteen's protocol here, we offer patients the possibility of a biopsy to get a diagnosis prior to doing active surveillance. And I don't know what the finding would change unless it was benign, in which case you'd feel a lot more comfortable with active surveillance, but I don't know if there'd be a finding that would cause you to act, but that is a possibility and I would probably recommend active surveillance for a period of time. So active surveillance for a period of time, who would do a biopsy? Of all the panel members, raise your hand, who would do a biopsy of the lesion? So we've got two people for biopsy. Dr. Reteen, why would you do a biopsy? What would you learn from that and how would it help your management? So I think there's two issues with that. One is you're looking for reasons to justify not doing something aggressive and potentially unnecessary surgery for someone who may have very little to gain from it. So if we do a biopsy and show that it's benign, then really there's no need to do anything. And you can even make an argument to not follow it, but we do. Because even if they're benign, they can grow. But they're probably not going to cause any harm for the most part. Now there are some cases where it shows the likelihood is that it's cancer. I'm not sure we need to go over that with you all. But if we just look at a mass like this, depending on the age of the patient and their gender, there's anywhere between a 60% to 80% chance of it actually being kidney cancer. So there's a chance it could be benign. But even within the realm of kidney cancer, there's different types of behavior. So if the biopsy shows that it's a chromophobe kidney cancer, for example, those are what I tell patients are reluctant cancers in some ways. In the sense that they sometimes will grow, but their ability to invade or spread and actually cause demise in the patient is very unlikely. They can get huge and not spread. So I think it does help, even for patients where we know we won't make a difference, we've decided on surveillance, my justification for recommending a biopsy is that you have a right to know what you have. You have a right to know if you have cancer or not. And I think it allows us to be proactive so that when we're watching it and it grows in ways that we don't expect, we know what we're dealing with. And I think it's better for me because then I can have a plan in mind. And I think for the patient, the worst thing is the fear of the unknown. And so when you know what it is and you know what's happening and you know that some decisions will be based on that, I just think psychologically it's much easier to deal with. All right, so let's say we went ahead and did a biopsy and the biopsy came back as clear cell, renal cell carcinoma, Furman's Grade 2. So the medical oncologist on the panel get to be surgeons for a day, you lucky guys. Let's go ahead and vote. Who would do partial nephrectomy? What do we say our kidney function was? Her EGFR is about 60. So you want to explain what kind of- You. So that's basically a global measure of the function of both her kidneys. And as you can see, the left kidney doesn't look very healthy. It's kind of small compared to the right one. So it's likely that we're looking at her one good kidney. So her total function of 60 is right borderline of what we consider normal. So less than that is 59 would be considered chronic kidney disease. Meaning her kidneys are not functioning properly. Which you expect in a 74 year old with all those medical issues also. And so that's something to keep in mind. Probably the worst thing we could do for this patient is risk dialysis. So that's just an important thing to kind of keep in mind. Because as probably many of you all know, everything we decide, decisions we make jointly, there's a trade off. So even doing nothing has a trade off, right? So that's an important consideration in terms of the kidney function. And it's something you'll hear us asking frequently for these cases. So her EGFR is 60. So who would recommend active surveillance? It's because you guys looked at the slides. Who would recommend partial nephrectomy? Who would recommend ablation? The loan. The loan ablation. Okay, so Cameron, why would you recommend ablation? Well, like, I think it's the least invasive. And as Dr. Metin said, you worry about kidney function. And studies have shown that ablation, everything we do to the kidney has a side effect and causes some deterioration of the kidney function. But ablation has been shown the least problematic or caused the least amount of decline in the kidney function. Compared to nephrectomy, partial nephrectomy and other. So if we decided to do something actively, other than surveillance, then I would recommend starting with ablation. Okay, so the patient did undergo a biopsy. And the biopsy did show clear cell renal cell carcinoma, nuclear grade two. And the patient and her doctor elected to pursue active surveillance because of her comorbidities. And then she comes back one year later for imaging. And you can see that the tumor has increased in size. Now, Serena, you published significant material in the active surveillance literature. Is this increase in size consistent with what's published in the literature with regards to growth of a tumor? Yeah, I didn't get a size measurement from you, but it's. It's bigger. It's bigger. But so generally, if it's a half centimeter. It's six millimeters bigger. Yeah, so I was going to say, it looks a little bit more than that. So, you know, that's a bit of a concern. It's not based on anything really scientific in the sense that we think that that behavior, it's just basically somewhat arbitrary. But it is whatever, it is the information we have. So, yeah, it is a concern that it's grown. And I would be uncomfortable with continued active surveillance, assuming there's been no other changes in her other. Everything's pretty much stable. Right. So what would you do? Yeah, so I would have a talk with her about treating it with either. She'd say, whatever you say, Dr. Matisse. Of course, of course, yeah. And I, you know, the options are just like before, a partial versus ablation. I would ask Cameron to take a look at the films and see how comfortable he would be with the blade of therapy because it's gotten a little bit harder now than before. Luckily, Cameron's sitting right next to you. Cameron, take a look at the films. What do you think? So, you know, you have to realize when we measure tumors on a two-dimensional CT scan, we're measuring diameters of the tumor. So this tumor has grown from, let's say, a diameter of 3 centimeter to 4 centimeter. But the volume of it has dramatically larger to a factor of 3. So the volume that we have to treat, to treat this kind of central tumor abutting the hyalum would become very difficult. In our experience, most of the patients that we have observed, and occasionally, their tumor has grown. We have been able to do appellation. But this is one that I would hesitate to say that I can easily get margin at this point. So there comes a point where just watching and waiting, there comes a point where you cross that bridge and you say, well, you know, I'm not as confident now that I can do as good a job as I could have done about a year ago. Okay. So... Can I ask you a question? If you can ask me anything you want. Would one year be the period of time that you would follow up someone who writes with surveillance, typically? No, typically we'd see it every six months. We would see her every six months, but she was lost the follow-up and came back to the year. Dr. Delacroix, this patient shows up in New Orleans. What are you gonna offer him? A open, right partial nephrectomy. Okay, you would not consider ablation? My intervention, I don't have Cameron. My intervention of radiologist, that's a difficult ablation. So I think it would be a right open partial nephrectomy. All right, so let's take a poll. Who would recommend active surveillance? Continued? Who would recommend partial nephrectomy? Because you've all seen the slides. Honestly, I don't remember the cases because you have so many, that guy just... Who would recommend ablation? Okay, so the patient undergoes partial nephrectomy and it's a T1A, N0, M0. Ferman's grade three, clear cell renal cell carcinoma. So T1A just means four centimeters or less confined to the kidney. So it's a localized tumor. So Dr.... Chris, can I point out something? Absolutely. To the point that Serena brought up about biopsy, this is a tumor that's nuclear grade three. Hardly ever you see nuclear grade one or two grow this fast. So if you had a biopsy ahead of time when we were observing this patient, you'd be a little bit more careful probably about following this. If somebody had a grade three or four, nuclear grade. That's a good point actually. Dr. Crum, why don't you explain for the audience what we mean by nuclear grade? What does it add to the equation? Sir, Furman grading basically the pathologist who devised the system. His last name is Furman. The grading system is based on how the cells look under the microscope. So there's grades one, two, three, four. One being the lowest grade and four being the highest. So if the cells look almost normal or barely cancerous, that would be a grade one. If they look very unusual or very abnormal, that would be a grade four. And the higher the grade, the more aggressive the tumor is as far as how quickly it grows, how quickly it metastasizes or how quickly it invades other structures. So that's what Dr. Arar was mentioning. If we know it's a grade three or four, we have to be very careful and maybe follow the patient much more closely because of the higher risk of quick growth. So Dr. Chapin, since you made a recommendation regarding follow-up practice, surveillance perhaps you'd like to make a recommendation for follow-up after surgery? In this case or in any case? In this case. In this case, I typically would, I'd follow up with a CT scan imaging about six months post-op. I would do a CT abdomen pelvis and then laboratory work. I'd do a complete metabolic panel and LDH. And I've been getting urine protein-cranate ratios, but that's basically because of your recommendation. And I haven't really seen that they've directed my post-op management at all. Would you get any chest imaging of any kind? I mean, I probably initially would get a chest x-ray the first time around and then I wouldn't follow up any further with the chest beyond that. All right, so you're saying you would see this patient every six months with a CT scan and labs? Is that what you're saying? For the first two years, yeah. For the first two years? And then probably yearly thereafter. Yearly thereafter. Dr. Karam, do you agree with that strategy? I think that's a bit too aggressive to follow up for a stage one renal cell. I would agree with Dr. Chapin as far as getting something at six months, including a CT scan, chest x-ray, and labs. But as far as abdominal imaging, I think we can get another one about one year or two years after the initial one. And I think the chest x-ray is the one that needs to be more frequently done maybe every six to 12 months, given that this is the more common place it would go. And it's comforting to know that the margins were negative and it's a stage one. So I would be less worried about a local recurrence in that kidney. So Dr. Delacroix, the patient comes to you and they have Time Magazine in their hand and they've showed you the article that says that they're gonna glow in the dark from so many CAT scans that Dr. Chapin wants to order. So what would be your recommendation? I disagree with the guy on my left. Am I right? Not surprising, yeah. At six months, I'd get cross-sectional imaging. I'd get a CT scan, just to reestablish a baseline, look what the defect was. You have negative margins. And I'd also get a chest x-ray. And after that, I'd just follow the patient with renalutrosams and no other imaging. Dr. Matin, how would you follow this patient? I disagree with all three of them. You can see this, this is an art, not a science. Yeah, and so I think one thing, I'd just take a more global view on this. You're gonna hopefully hear us disagree on a number of items and we usually do. And I think, hopefully it'll give you a sense for how much, there's a lot of gray zones in medicine and specifically in urology, as far as today goes in kidney cancer. But this issue of follow-up and how we follow-up is really an area of need that we have in terms of getting it more standardized. The AUA is actually coming up with a set of recommendations and I had the opportunity to review them. I could not disagree with them more. Because unfortunately it's just expert opinion and not really based on evidence as much. So if we look at the evidence, the likelihood of abdominal recurrence, so anywhere in the abdomen, kidney, liver, lymph nodes, anything like that, for something like this is less than five percent. Basically, her overall risk of recurrence is less than five percent. Within that five percent, the greatest risk, as Dr. Karan pointed out, is in the chest. So the place you wanna look is the chest and the chest x-ray is minimal dosage of radiation compared to a CT scan and no evidence that doing a CT of the chest leads to better outcomes than a chest x-ray. We do tend to be more aggressive in patients who we think are gonna have more aggressive cancer, but the truth is that's never been shown. So you're getting about 200 times more radiation dose for a CT of the chest. In terms of the CT of the abdomen, when you're looking at one percent or less likelihood of recurrence and doing that, for my practice, this patient would get a CT scan. Actually, now I'm doing it at one year only because I get the pressure from everybody saying that, oh my God, you have to have one. But the truth is, up until a few years ago, I was ordering them maybe two or three years later. They can get a baseline then because the likelihood of any recurrence being there is almost nil. And in the rare cases where you see a recurrence at three years, I never think, oh my gosh, wish we had a baseline. So this whole concept of having a baseline CT makes no sense to me. And unfortunately, I think it's one of the many things that we default on because we're insecure. We're insecure about a variety of factors, some of them about feeling like we're short changing the patient, some of them because of liability concerns. And so, and I think, again, taking a global view, this is one of the many little things that adds up to the, what is it, $2 billion care for kidney cancer that we have. And then on top of that, you add to the total issue in terms of cost of medicine. So I've gone from 30,000 feet down to one-inch view. But my point being, I think, if you look at the data, all really she needs is a chest x-ray. I would say maybe every six months in the first year because it's a grade three. After that, once a year, and I'd get a CT scan of two or three years. Yeah, in my practice, basically at one year, I get a CT and chest x-ray and follow them yearly. I don't see them every six months. Cameron, since you're here and are an expert radiologist, maybe you could comment on the value of ultrasound versus CT scan versus MRI for imaging the abdomen, imaging the kidney, looking for evidence of recurrence. As you know, in Europe, ultrasound is largely, primarily used as a man in follow-up for patients. Correct, so there are some limitations. We have grade imaging compared to 20, 30 years ago where we had only x-ray. We have grade imaging. Diagnostic imaging has made great progress. We have CT, we have MRI, and we have ultrasound. And all of them are good. None of them, not a single modality is perfect. So every time you decide that I want to image something, you have to decide, okay, what are the pros and cons of imaging something? In a thin individual, you can do ultrasound. Ultrasound is great for individuals that are thin. You can see the kidney. If a person is larger body habitus, has a larger body habitus, ultrasound becomes very difficult. CT is great because it's easy to perform. MRI is a bit more difficult and varies. The quality of MRI varies from institution to institution. And from the equipment that an institution may have. So for the most part, most of the time we do CT scan. The downside of CT is radiation and also iodine. Iodine is not really friendly to kidneys. And there is a point where the kidney function goes lower than certain limit and we really dislike or do not like to give iodine. So at that point, MRI becomes a good option, a second option. So, and recently you've seen the Time Magazine and other articles that have been out about the risks of radiation over long term. Yes, those risks are real, although still very low. And I think the benefits that we get from appropriately sanctioned imaging is much better, much higher than the risk of cancer that they cause. I think those are all good considerations. If you have good imaging, good MRI imaging, I think MRI is a good way to go. In Europe, ultrasound has made headways and they use ultrasound quite a bit. In the Far East also they use ultrasound a lot, but they have other things that we don't have available. For example, contrast enhanced ultrasound is a technology that's available in Europe, but FDA has not approved it in this country so we don't have contrast enhanced ultrasound. It will come eventually. So 30 months later, she presents for her annual follow-up. She's now 78 years old, no significant complaints. She's still in her wheelchair. Pulmonary fibrosis is still stable and a CT is obtained and you can see that now she has a tumor in her atrophic left kidney. Dr. Karam, what are you gonna do for this patient? I would check renal function of this patient with a nuclear scan to see how much the left kidney is contributing. Like Dr. Mateen mentioned earlier, it looks like the left kidney is much smaller. So I would like to know that information before deciding. Ultimately, the realistic option would be either surveillance or partial nephrectomy or radical nephrectomy. I don't think this is a good position for ablation, but Dr. Arar might wanna comment on that. So the renal scan is gonna tell you what and how are you gonna use that information? So if the renal scan tells me the left kidney is contributing about 10 or 15% of the total kidney function of this patient, we can do a left radical nephrectomy. If the left kidney is contributing more than 20 or 30% of the global function, I think we need to do a kidney sparing approach. So that would be a left partial nephrectomy. Okay, let's say it's contributing 25%. We just got the renal scan, results are in. So active surveillance or partial nephrectomy. If the patient tells me whatever you think, Doc, then we would go for a left open partial nephrectomy or left robotic partial nephrectomy. Who else would consider active surveillance in this patient? What's the size of it now? Let's say it's about three centimeters. Anyone else? Dr. Karam, you're the lone wolf that would consider active surveillance. You wanna defend yourself? Well, if the patient, I mean, it's at the upper limit, but if the patient is willing to do it, I think we can watch it, but we would have to do it more closely, not to bring her back in a year. Probably repeat the scan in four to six months and see if the mass has grown. Just wondering maybe for their purposes, you wanna explain what you mean by the three being at the upper limit. So there is a loose definition of small renal masses. It's basically any mass in the kidney that is less than three or four centimeters. So anything less than three or four centimeters, we would call it a small renal mass. So if the mass is five centimeters, we typically do not observe it. If it's one or two, we would definitely consider it. Three or four is at the upper limit, so we're not as comfortable offering that to the patient as far as the treatment option. And this patient falls in that category of the gray zone of the observation category. I guess my concern about this is that, so this woman has been followed for 30 months since surgery. So do the math, she got a CAT scan once a year, so this is her second CAT scan. And presumably we looked at the first CAT scan and didn't have a tumor and now we're looking at the CAT scan and we get a three centimeter tumor. Does that bother you at all? Well, there's a lot of assumptions there, but yes, it does bother me if this has grown in one year. There's also something in the liver. I don't know if that's anything real, but I'm assuming that you're discussing here, that's the only site of disease. In that case, if it's grown in a year, I'd recommend partial nephrectomy. Okay, so let's survey the panel. I think we beat this one to death. Who would recommend partial nephrectomy? Depending, yeah. Who would recommend ablation? Who would recommend active surveillance? Who would recommend we move on? Chris, can we have the medical oncology? By all means. Medical oncologist, the view on this. Way in. First, I think for the panelists who recommended Babsi for this lady at the initial time with a mass and the right kidney, and if this will guide you to decide whether you're gonna intervene with surgery or not based on the FNA, final aspiration or Babsi, there is discordance between the final aspiration Babsi and the final pathology from nephrectomy. So while there is a good concordance with a type benign or malignant and the type clear cell or none, but I think to decide on the grade, there is discordance. Will you like to comment on that? I think you may get a firm and nuclear grade two thinking this is low grade on the Babsi and then it'll be grade three or twice versa. So that's a point I think to be made. That's why I do not think I was of the opinion to observe this lady initially and therefore I would not have done the Babsi anyway. The second point about the follow-ups. I am a minimalist so in terms of doing surveillance studies and I agree totally with Dr. Mateen and the reason the medical oncologist's viewpoint here is that you're doing those surveillance studies with scans whether you decide to do them yearly or every six months is if you find something you're gonna do something about it, right? So if you're gonna intervene, I think the question is what are the systemic therapy options for this lady who is 74, who is on steroids who has pulmonary fibrosis, who is wheelchair bound? And so I think in my view, I would be minimalist in the testing because I do not think this lady if she developed lung metastasis, I'm going to jump quickly and treat her with systemic therapy. In my view with her lung disease, she would not be a candidate for metastasectomy if she had lung metastasis and we know that this is the most common site for metastasis. So and we have many patients with systemic disease with metastasis to lungs or lymph nodes that we observe. So I think observing patients with active disease is still an option. And therefore, if I do not think we're gonna intervene treating this lady, I would minimize the testing. So. Sure enough. Serena, a common question that we always get and you know this is after partial infractomy, patients say, what's the likelihood my tumor is gonna come back in that kidney and what's the likelihood that I'm gonna get a tumor in my other kidney? So what do you tell your patients? Well, I thought I kind of went over that a little bit but in terms of the likelihood of recurrence and the abdomen because of the first cancer in terms of it having spread is really very low. Now the risk of developing bilateral disease is still pretty low single digit percentages. Typically you see it more with the papillary type but it depends on how you look at it. The papillary subtype of kidney cancer is much more frequent than the others to be multifocal multiple places in the same kidney as well as being bilateral. But the fact is clear cell is so common. It's 80% of all kidney cancers that because even though the bilaterality occurs somewhere around five to 8% you just see that more often. So I mean it's pretty uncommon. Now having said that to clarify a little bit about what I said before in terms of the CT imaging if there is something that is kind of funny on this initial scans then you should do it a little bit more frequently and in fact we go back and look at her imaging study. She did have something that was a little bit abnormal in that left kidney and so it's likely that this was probably there. It was just small and not quite like that. And so does that answer your question? Yeah, I mean I think the issues are after partial nephrectomy the risk of recurrence in the same kidney is it less than 5%? Oh yeah, I'm sorry. The risk of bilateral disease is 5% or less. And suppose they have a, let's say let's change this a little bit. Let's say they have a chromophobe kidney cancer on the right kidney. What do you tell patients the likelihood is that the contralateral tumor is gonna be a chromophobe? Yeah, so I think the concordance is pretty high. About 70%. Yeah, so it's likely to be whatever it was on the other side. Occasionally it's not. I think it's important also for the audience to really know this because they ask this question all the time. Sometimes we cannot really be certain whether the tumor on the other side, especially if it's small, whether it is metastasis from the original tumor or whether it's a de novo tumor arising in the remaining kidney. So I think often we may not be able to tell unless it's a big size tumor favoring that this is a de novo tumor. But if it's a small two, three centimeter, it could still be metastasis from the original tumor. Very rare though, that's really rare. I'm sorry? That's really rare. Okay, yeah. Okay, let's move on. 51 year old Hispanic male presents with gross hemorrhage.