 Okay, so again, I think this you know We sort of gave you an overview of where things stand in 2017 for the management of patients Who present with kidney cancer both localized locally advanced and metastatic disease and now? We're going to sort of sort of put those principles into practice with some case presentations First if anyone has any questions about the lectures now would be a good time if you had wanted to ask a question Feel free and if you have any questions about the cases or want to get a better understanding of Why they do what they do, please don't hesitate to interrupt and ask a question So gentlemen, these are the ground rules you can mention clinical trials, but your ultimate recommendation should be the standard of care No whining about the radiology. There are no tricks Please tell us what you would do not what you could do Explain the reasoning behind your recommendation and brevity is a must no babbling. We have a lot of people to help here today So the first patient is a 57 year old African-American male who presents with a history of hepatitis C and a history of renal cysts His doctor ordered imaging to follow up on this history of renal cysts Again, his past medical history is significant for hepatitis C and esophageal reflux Previous surgeries include appendectomy and laminectomy and his CT of the chest demonstrates small basically indeterminate pulmonary nodules And you could see he has this lesion present in his left or sorry his right kidney so Let me go back here. Hold on so Serena, why don't you tell me what you see? There's a normal left kidney first of all, but on the right side there is a Multicistic sort of a complex solid mass upper pole of the kidney based on what I can tell maybe to the mid portion Okay, so what's what's your differential in this? Not having seen anything else. It could be cysts that have hemorrhaged. He's had a history of cysts by itself It could be that it's a mass So this this area right here isn't it is enhancing with the administration of contrast. You can see the brightness there Yeah, so it's let's assume. That's a solid mass. Yep So again your differential diagnosis is what? Well, I would be concerned with that you're concerned about a renal cell carcinoma He's African-American, so you always want to think about potential for medullary RCC and see if they have sickle cell trait And also I would think transitional cell carcinoma because it could be a dilated renal pelvis and could be sitting in the renal Maybe I haven't seen the other images. Sure. There are no other images All right So we did cystoscopy with a retrograde pylogram which showed a UPJ obstruction So an obstruction at the year where the ureter joins the renal pelvis And there was a mass extending from the 8th atrophied renal parenchyma into the collecting system We could not pass a ureteroscope because the UPJ obstruction Avoided urine cytology and washings of the ureter were negative. So what now? Nazar, what are your thoughts? Okay, so you need diagnosis not it's good that he doesn't have metastatic disease so I Would biopsy the mass that solid Area that if you are not able to get through it retrograde So you do needle biopsy the mass well, I I let you or Jose or Surena handle it, but I think He does have a mass that enhances and there is obstruction and It is tumor As far as I'm concerned. There is no metastasis, which is good. So that the only thing You could proceed as is and do surgery and not get a biopsy Because he doesn't have metastatic disease And I don't have the indeterminate pulmonary nodules which but again, I think those they could be they are indeterminate So they may not be metastatic JJ, what are your thoughts? I think we would do a biopsy. So you do a biopsy case you got one biopsy We got Nazar biopsy Serena. I would do surgery take it out get a frozen section If it by chance is urethalial, then we get the rest of the ureter and the bladder cuff at that time It's an atrophied kidney. So I don't think you have anything to lose by doing that. Okay, and Eric What about you and what do you think? So you said the urethalium, sorry the the urethalium was normal in the pelvis No, you couldn't see inside the pelvis because of the UPG obstruction. I do a biopsy So, okay, so the medical oncologist want to do a biopsy and the surgeons want to do surgery make sense So we did surgery and it turned out to be a T4 collecting duck carcinoma It was invasive into the overlying peritoneum margins were negative So Nazar you're our guru on weird variants of kidney cancer What are your thoughts about this? How would you manage this patient? He's at high risk for recurrence because of T4 and collecting duck carcinoma is a virulent disease. It's like RMC and Obviously because he's African-American and the diagnosis histologically is You know collecting duct I would get a hemoglobin electrophoresis or The check ask if he has history of sickle cell trait as Surinam mentioned because he could have RMC instead of collecting duct although for an adjuvant I still There is no data with high level of Evidence to strongly recommend any adjuvant therapy So would you recommend any adjuvant therapy? No, okay, would you recommend adjuvant therapy? So this is this is similar To bladder cancer. So in bladder cancer if we have T4 disease we would And with the therapy was chemo therapy. So I would favor adjuvant therapy. What therapy would you give him? Likely, you know a gem site being cisplanned gem sis. Okay, Serena. What are your thoughts? No adjuvant. No adjuvant. Okay, Eric close surveillance. Oh So I'm glad we're all united in our opinions. Okay, so Basically the patient was followed with close surveillance and he was NED for five years actually And he moved to Korea And he basically got tired of flying back to the US for his checkups and he came back one last time in 2016 again, his CT chest demonstrated those indeterminate pulmonary nodules that had not changed so they're likely benign and JJ tell me what you see it looks like in the Resection bed on the right side. There is a mass there. Okay, and what what is that mass doing? So it has some contrasting it. It looks like a tumor recurrence to me Right, and it's I'm basically trying to get you to say that it's invading into the vena cava and actually extending almost into the Left renal vein over here. That's correct. And there's some nodules here and here that would suggest lymph adenopathy So the patient now has a local look five years out from surgery and I'd say that to you patients who after five years get tired of coming back for follow-up Five years out from surgery now has a local recurrence invading the vena cava with lymph adenopathy So very quickly down the line. How will we manage this dr. Gal? I would you know, this is although this is a Parent cancer recurrence. I would get a biopsy for a couple of reasons one is for definitive diagnosis to as I can you know send the tissues for To my Genomic profiling study to see whether there are talking about mutations in the future to to direct Both treatment and also clinical trials. Okay, so you do a biopsy followed by what? I Would look at the biopsy first. Okay, and the biopsy comes back collecting that now what if it's collecting duct so it looks like This is you know that the tumor invests into the inferior vena cava. So I would consult my Urology colleagues to see whether this is resect resectable if it's not we can offer near-endument treatment Okay, dr. Tenor. What would you do? Agree, I think if there is no evidence of metastasis, and you think this is a resectable since it's been five years from the initial nephrectomy And we know this is collecting duct. It's not Anything that we know how to treat or there is effective systemic therapy for it. I would do surgery I would go and resect it. Okay, dr. Mateen And dr. Yonash surgery wow we're united, okay? So we did take the patient for surgery. I can ask a quick question. Yeah scan six months ago were negative So the patient underwent exploratory laparotomy he had resection of the mask with with a resection of the vena cava RPL and D we had to patch the IVC with pericardium And also we removed the adrenal you can see the pathology there showed poorly differentiated carcinoma consistent with collecting duct Margins are negative two out of nine lymph nodes are positive the mass was six centimeters in size Dr. Gal what's next I? Would I would steal a favor a favor? Agilement therapy so you'd favorite Agilement therapy with I Mean he has disease in the lymph nodes So that means the future recurrence rate is almost 100% so I would give him chemotherapy Again with gem side things his plan gem sis. Okay. Dr. Turner. I Would follow him close surveillance close surveillance dr. Mateen. I think JJ makes a really interesting point about these collecting duct tumors being What is thought to be you know similar to your thelial so? but I Think the current standard would be close surveillance. So Dr. Yonash surveillance so one chemo three watch Okay, well ultimately we did watch this patient and he did recur in the superclinic alert lymph nodes And he was referred to dr. Tenir for further systemic therapy, and I guess currently is doing okay Let's move on So 51-year-old Jehovah's Witness presents with elevated LFTs past surgical history and remarkable past medical history is Hypertension and cholesterol labs are within normal limits CT chest is negative and And just for the uninitiated Jehovah's Witness people Typically don't allow blood transfusions. They don't allow their blood to be outside of the body It has to always be connected through some sort of circuit And makes for some challenging times during surgery. So dr. Mateen tell me what you say so there appears to be a locally Advanced tumor in the right kidney. I think there's a tumor thrombus also That kidney does not appear to be salvageable based on those images on the left side There is a exophytic tumor in the medial upper pole Okay, so again just to show the audience there's a Locally advanced tumor involving the right kidney with extension into the renal vein and into the IVC There's a tumor thrombus right there and then on the left side There's a tumor sticking out of the upper portion medially of the left kidney So Serena give me some give me your thoughts. How would you manage this patient? What would your counseling be and and how would you take this patient to the operating room? So between the two lesions the right side is the one that's more immediately threatening both in terms of you know potential for progression locally and metastatic my experience with Jehovah's Witnesses is that they come in different flavors so to speak and Sometimes they are very prone to societal Pressures in terms of their own Society so I try to have a private conversation with them about how strict of a Jehovah's Witness They really are because sometimes they will say if push comes to shove and it's life-threatening and they need blood They'll actually will accept it if they don't have That societal pressure Immediately next to them. So I think that's an important conversation to have but either way Surgery is really the primary It's the only potential for cure so we would talk to them about that if they still don't accept blood transfusions There are some measures we can take including using a cell saver Which means this blood we suction up Remains in circuit and then get and get filtered and be given back to the patient And there would be a high risk for needing blood transfusion with that right-sided Procedure so my recommendation ultimately would be you know taking all those steps ahead of time But doing a staged procedure with the right radical nephrectomy IVC tumor thrombectomy See the patient back probably you know a month maybe even a three months to restage them And if there's no evidence of metastatic disease do a left partial nephrectomy no role for doing both at the same time Do not like to generally not unless the other side is also highly threatening I think the the risk of renal failure is very high in those cases Okay, anyone have any different thoughts about that? Is there anything in that liver there? You know there is little no So her LFT is elevated because of the tumor in the kidney so basically Yeah Probably they're elevated because of the anti-cholesterol drug but in any event anybody have any different thoughts about this So right side first Which we did we use cell saver we had a hundred CC blood loss And then in delayed fashion, we did a left partial nephrectomy 50 CC blood loss cell saver was used both times Any rule for adjuvant therapy in this patient? Is there any medicine that we can give him to decrease his risk of recurrence? I'm assuming by silence. That means no. No, no, I mean unless a trial She can he or she can participate in trial clinical trial. Okay, which can be Which can be a challenge as well It can be what I'm sorry a challenge as well as well because because of Jehovah Would anyone have considered neal adjuvant therapy to try and shrink the tumor and make the surgery easier? No, I would not Serena No, I don't think so. No, okay All right, let's move on Who night to one 91 year old African-American gentlemen presents with lower urinary tract symptoms in dysuria Past history of hypertension a remote history of seizures You can see the medicines he's taking Good performance status He's young he's younger looks much younger than a stated age eGFR of 70 So that's the his basically his kidney function is good for someone 91 years of age CT chest is negative And you can see he's got this rather large cyst in the left kidney that does not enhance There's also a hyper dense cyst, which is a cyst filled with protein or old blood that does not enhance And then he's got this lesion present in the lower portion of his right kidney. You can see it a little bit better here again very large cyst present in the In the left kidney So 91 year old guy looks younger than a stated age got a mass in the lower pole of his right kidney and a huge cyst in the left kidney Who wants to take this on is our what would you do? 91 I think I would Observe you'd observe him Any role for biopsy? Perhaps if you're gonna do something, you know If you're not gonna operate on 91 year old You could observe him for a short time and see if this grows Increases in size. What what is the estimation of the size of this four centimeters for it's the size is a border line where you consider a small real mass and management of a small real mass even in younger people includes active surveillance and If you want to do a biopsy could do biopsy and do it, you know ablation or you can do partial nephrectomy But somebody who is 91? I think any of those interventions are not without their complications and I'm not sure this is going to Increase his survival so you know feeling and yeah four centimeter. I would observe how often would you get scans? No, six months every year. Okay, JJ. What are you about? What is the cause for the dysuria? Is it caused by the upstream? Masses or this is just, you know Infection or anything? No, it's just he's got a big prostate. Okay. Yeah in that case I would agree with snooze are You know at age 91 if you do anything you potentially can cause more harm than benefit So you would observe right? Okay, dr. Mateen when I was a fellow at the clinic we actually looked at the issue of age and use the large database and Basically, the only thing that age predicted by itself was a longer hospital stay And that's probably related to support Their ability to get support at home What the issue with being older is that that you the older you get the more comorbidities or coexistent medical conditions you have And what really determines the likelihood of complications are the comorbidities not age And actually there's been several other studies and other Specialties that have looked at this and with the same conclusions so I think the issue of physiologic age is important and And this patient physiologically probably is younger Better kidney function than I have And with a four centimeter tumor I would actually give him the option of definitive treatment with either like a robotic partial or possibly biopsy followed by ablation if by chance he Wasn't interested in surgery then I would at least try to do a biopsy before making a determination It's fairly hypervascular Heterogeneous in its appearance, so I would be concerned about a clear cell Possibly a clear cell type which would be more aggressive. So he says whatever you say doc. It's that that's what I'll do Yeah, I would offer him treatment. So you'd offer him treatment and when that treatment would be partial partially correct me Okay, Eric, I do differential renal function to see how much the left contributes. I would offer him a biopsy perhaps to confirm what this is and think about perhaps thermal ablation versus partial You know this guy The alternative would be to a shorter to do a short interval follow-up imaging study to see whether this thing's changing at any reasonable rate Of growth and and that would also partly define whether or not this you know the aggressivity You could do a short interval follow-up scan and if the think doesn't budge Then then that would actually decrease the risk of this actually being something something dangerous. So what would you do? I? Would do differential renal function and I would suggest to him that we would intervene. Okay So we did do a biopsy and the biopsy came back as clear cell kidney cancer Four centimeter mass again. Does that change anyone's mind? Dr. Gao said change your mind still want to watch it Well, of course, you know, I will have a very candid discussion with him You know patient preference, especially at his age is very important You know, some people will say I don't want to do anything. So if it's up to me You know if I were at his age, I probably will still I will be leaning toward doing nothing at this time except you know getting Close imaging at this time maybe in three months instead of in six months to see how fast this tumor grows All right, so in three months the tumor hasn't changed. What are you going to do? I would continue to observe Every three months. Yep. So basically you're treating the tumor with radiation from CAT scans Where the cat scan is not that high you can I mean after two or three City scans if everything is stable, then you can you know, you can expand to every six months instead of every three months All right, Dr. Tuneer. We are with this change anything in your thoughts. No, but obviously, I mean We live in a society where patients Make a decision as well. So if the patient wants Intervention then obviously the what Serena mentioned Now that we know it is clear cell not say oncocytoma or some other benign etiology Then the option would be partial or ablation and both intervention modalities are appropriate So it's the patient will drive the decision if the patient as JJ mentioned does not want to You know operate on or have any procedure. I think it's it's reasonable to follow them You know nine to one Again, even if we did surgery, are we increasing up substantially the survival? I don't know if we intervene. Are we going to make him live to be a hundred? I don't know. So that's why I think I'm fine with observation if it's okay with the patient the family He says whatever you want to do so you'd observe Okay, so any already tell me you take it out Well, I think you know percutaneous ablation is not unreasonable either the thing is with that size and the fact that they looked a bit central The results with that are not quite as good But I think it's still a reasonable option The only thing and I think you know Eric made some good points The only thing about a nuclear renogram is with a distorted kidney like what you have on the left side The reading can be very skewed. So it's it's not a bad option But you just have to look at the results with a grain of salt Eric does this change your mind? So you still observe or you do some you do some I'd want to I'd want to okay, you know 91 when we're 91 we're gonna probably think differently about being 91. That's true My only issue with ablation here is that with these lower pole tumors that are you know medial is your rederal injury? You know because the ablation zone has to go out beyond the confines of the tumor and and sitting right here next to the Tumor is the year sometimes you can put up a catheter and irrigate cold saline to prevent it from getting injured But I've had a couple of patients that have had your rederal injuries as a consequence of getting ablated in the Lord with a lower pole tumor But anyway, what we did was we did do a partial nephrectomy What I did note was that even though the guy was younger than a state-of-age as kidney was definitely 91 years old Tissue was very very friable very difficult to sew but ultimately we were successful It was a t1b grade 3 and he had a post-op review on leak that was managed conservatively and ultimately resolved Okay, let's move on. Can you give us a follow-up? Is he still alive? Yes. How many how old is he now? I think he's like 93 For 94 Thanks me every time he comes to the clinic for saving his life There is obviously you're showing success story if he had Some complication not that you have ever have had any complications it would be different discussion That's true But that's I mean he actually was very pro do something No, no, obviously, I mean it's like I said the decisions are driven by patients if he wanted intervention You would intervene well, I mean I'm not sure I agree complete with that I mean certainly you take the patient's wishes into consideration, but you don't offer them something That's not indicated just because they want right All right, so 43 year old white male with right flank pain and he and grossing materia or blood in the urine Also as fatigue and weight loss No significant past medical or surgical history chest CT shows bilateral pulmonary nodules Bone scan and MRI the brain are negative got some anemia low blood count LDH is normal calcium is normal platelets and white blood cell counter normal So you can see here the is the lung CT. Here's a nodule right here in the left lung Here's a rather large nodule here in the right lung also a nodule here Couple of nodules here and then he's got this locally advanced tumor involving his right kidney With extension into the renal pelvis you can see again. This is another picture of it here locally advanced tumor So let's start with Eric. How would you manage this patient? I would do biopsy and I would send them to JJ's Trial to do if it's clear cell so biopsy to demonstrate clear cell and you put them on a clinical trial and if you were Practicing on the community. How would you treat him? Probably send him for nephrectomy probably let's see It's a bit of a weird-looking mass So I would probably still biopsy at first because I want to I want to exclude some sort of a variant histology And if the biopsy showed let's say clear cell you'd send him for surgery this surgery Yeah, surgery first side right doctor. Interferes me followed by systemic therapy. I suppose it showed papillar I would then have a conversation with the patient and say we're it's not as clear whether the Nephrectomy would prolong survival and we could initiate systemic therapy first because it's not a particularly large renal mass Okay, and if it were clear cell you did the biopsy they had their surgery What systemic therapy would you offer? Well, if it's in the community the standards of care would be Synet nebropizopinib as a front line set in the front line setting, okay? Serena what are your thoughts? I think clinical trial is a always a good option to offer We do have one that regardless of histology. He'd be a candidate for which is the cryoblation or the Tremi lemma map with or without Cryo, could you just just briefly describe the theory behind that? Yeah, so basically we have this clinical trial It's actually a pilot trial because it's never been done in the setting of kidney cancer but the idea here is to Patients like this who have a metastasis that we can ablate do or do percutaneous cryoblation We do the percutaneous cryoblation and then follow it up with Immunotherapy checkpoint blockade the idea there is and it's based on several lines of Research that have been done when we do cryoblation. We're basically revving up the immune system But and then with the addition of the immune checkpoint blockade you're essentially releasing the brakes on that immune system So the idea is to really rev up the body's ability to fight the cancer. So we're testing that with this clinical trial and She he has one of the smaller the smaller metastasis and along is amenable I think to cryo And the good thing about that trial is that it's two months of treatment And then they still go to surgery for side-reductive nephrectomy, which I think the patient Whatever they do. They should have that done at some point. So Okay, is our Yeah, I like the idea of a Babsi if it's clear cell enrollment on check on the trial JJ is leading the 13-07-15 which is Randomization to one of three arms either new volume up alone or new volume up plus be a business map or new volume up plus epilomap as he showed if it is a Variant histology since he has flank pain and gross immaturia. I would not treat him with systemic therapy I would send him to you or serenade to do the surgery And then postoperatively will treat him with systemic therapy. What would that be? I mean if he's pepillary we have a trial that's coming up It's an international study with Savoli team as he met inhibitor pure cement inhibitor versus Sunita in it So I encourage him to enroll on a clinical trial because there's really no established therapy for variant histologies RCC And if you're in the community, what would you offer Sunita, okay? How about I'll too? Well, I'm talking about non-clear cell Hidals are two is not therapy for no, so I'm sorry, so if it's clear cell If it's good, right to me, would you offer a mile to yes? Yes, he's since he's 43 obviously Yeah, if he doesn't have access to enrolling on the trial of JJ Though the one with the immune checkpoint inhibitor pre-surgery, you know before the nephrectomy Then we'll do the nephrectomy and then postoperatively after recovery. I can discuss with I'll discuss with him Hidals are two and Nizar just out of curiosity. What do you tell patients the mortality rate is associated with hydro cell to? Close to zero percent now in the past. It used to be up to four percent But now it's close to zero percent. We have not lost any patient in more than 12 13 years. Okay, JJ any different thoughts? Apparently he's very young so Despite the fact There is lots of in-situ mechanism about target therapy immune checkpoint therapy We cannot forget about high dose IO2 because If you treat 100 patients six or seven of them can be cured So that's actually a very high percentage, especially in younger patients with younger children so I will definitely talk to him about that and It appears, you know if he has good organ function that would be something to consider otherwise You know all the other therapies discussed by Nizar Serena and Eric will be will be good as well. Okay, so just to summarize in the community Probably upfront nephrectomy plus or minus a biopsy beforehand followed by synitinib or pizopinib Here at MD Anderson, we also have the luxury of several clinical trials that potentially could be offered to this patient So he underwent sederatective nephrectomy It was clear cell with focal rabdoid differentiation He shows modest progression on postoperative films. What would you do now? Nizar you want to comment on rabdoid, what does that mean? Now all this means is that it's a high-grade disease Doesn't mean anything. It's focal. So it doesn't really change. It's still clear cell So it's the most common histology since you elected to do up front side to reductive nephrectomy and he has You know as anticipated some progression and the lungs I believe so if he's performs that is still good I would offer him high dose I'll too because we're talking about you know in the community now or at MD Anderson now if He declines to have high dose I'll too or Then I think you know he can be treated in the community Let's say he wants to go back home and be treated locally Doesn't want participation in a clinical trial then I think soon it will be options Which one would you choose? I? Think soon it in a two weeks one week off as Eric mentioned earlier or positive on him. I you know look at the other things if he There are some places where I would choose maybe Sunita nib over positive for him and there will be some place where I would choose Paz opening over Sunita without going into the details right now. I think we can discuss that later Later when I Mean with the patient and look at the list of medsies on and I think you know it will be some nuances that can be that can sway one person one One drug or the other? JJ Yeah, I mean other than what Nizar talked about if he has measurable tumors he can be He can be a good candidate for clinical trials as well Okay, let's move on So a part of my geriatric practice 82 year old physics professor presents with right flank pain and grossing materia He's got some medical problems hypertension coronary artery disease carotid stenosis hypercholesterolemia aortic stenosis Hypothyroidism and complete heart block with a left bundle branch block. He has a pacemaker He takes aspirin and some other medications CT of the chest is negative so To move along here this he's got a locally advanced tumor involving his right kidney here. You can see it in cross section So 82 years old multiple medical problems has a pacemaker How would you manage this? Let's start off with Eric? Get him off his Anticoagulants for a moment and do a biopsy to figure out what this thing is because it's very it's a rather unusual looking tumor So you get him off his anticoagulation and biopsy. Okay, dr. Mateen There's chest imaging is negative negative. I'd Get him medically cleared and do an effect me do an effect me. Would you do it open laugh? You know, it's a little hard to tell like doesn't look like it's invading the bowel at all because there's not much of a plane visible there I mean, I would look at that But it's not being the ball. Yeah, so I would do a laparoscopic laparoscopic nephrectomy. Okay. Would you do another deception? Again, can't tell what's above the vena cava there Yeah, if I don't see anything abnormal. No, I wouldn't do it. Okay, dr. Tenir Nephrectomy, okay We do it open her lap I'll send him to you that you decide Yeah, well, he has pain apparently the tumor is causing symptoms and also hematuria So surgery will solve both problems. So I would go for surgery. So we go one biopsy and three surgeries Patient under one radical nephrectomy with RPL and E He had T3A disease with invasion into the renal vein as well as into the sinus fat We recommended surveillance post op and he was without evidence of disease for two years His CT of the chest remains negative, but two years out from surgery. He comes in and he has this And you can see it here too, so Dr. Mateen, what are your thoughts? Did you save the adrenal you preserved the adrenal at the time of surgery we did yeah We left the adrenal in place. Yeah, so yeah, I'm guessing it's a Adrenal metastasis presenting two years later Okay, what do you want to do if he has no other evidence of metastatic disease? I would do surgery had do a laparoscopic adrenal ectomy laparoscopic adrenal ectomy after a laparoscopic nephrectomy Yeah, I've done several. Okay, would you approach it trans abdominally or go through the retroperitoneal approach? You go trans. There's really at that point the retroperitoneum is obliterated. So you go trans. Okay Anyone have any other ideas when anyone do a biopsy? Adrenal ectomy. Adrenal ectomy. Dr. Gal You agree, okay, Dr. Jonas I'd also have a conversation with my interventional radiologist to see whether or not this could be thermally ablated thermal ablation versus Okay, everyone agrees that needs to go Any role for systemic therapy either before or after surgery? No, no Okay So he had a right radical adrenal ectomy which showed metastatic renal cell carcinoma. What now? Surveillance surveillance, how often would you surveil them? Four to six months every four to six months everyone agree with that. Yes Okay He was surveilled over time and then he comes back eight months later CT scan of the chest again remains negative Dr. Mateen what do you see? Looks like he's got a contralateral adrenal metastasis there So he's got a lesion present in the left adrenal gland. All right, let's go down the line. Dr. Gao. How would you manage this? He's now like 83 or 84 He has done quite well with the previous surgery. So how do you know? well I Think you guys did a good job on him. No sucking up if it if something Worked for him quite well before so I would still do the same thing. So you'd offer him surgery Yeah, okay, and then he'd have to be on lifelong adrenal replacement. Yes, okay, which is what? You know the adrenal cotygoid hormones so prednisone in Florida, right? Okay. Dr. Yes, I think the third is the charm. Hopefully this is the third and the last surgery you'll have Yes Left adrenalectomy and hydrocortisone 20 milligram in the morning 10 milligram in the afternoon. Okay Dr. Mateen, you know, maybe overthinking this a little bit But just to look at the timeline of things it took two years for us first met took eight months for the second Met and I do get a little bit concerned the one issue with doing an adrenalectomy now and You know with the age going on steroid replacements, it's not terrible It's not great But you are burning a bridge in the sense that if this is by chance an acceleration of his disease He really won't be eligible for clinical trials once he's Adrenali dependent usually he will be usually not no no He is if it is physiologic replacement So that's new so that's been accounted for yes That's the case then I think adrenalectomy would be reasonable So you do adrenalectomy, but I yeah, but I would be I am a little bit concerned about acceleration of his disease Okay, open or laparoscopic laparoscopic. Okay. Dr. Young once again consult my interventional radiology colleagues And they say no Then I would have it surgically removed. So you do it and you're like me Okay, so we underwent a left radical adrenalectomy Metastatic renal cell parsonoma. They're actually two tumors in the adrenal So what's next? Surveillance everyone agrees no role for adjuvant therapy. Nope. Okay So just to give you a follow-up on that one on that case he ultimately developed lung metastases and I think Dr. Teniers treating them there. Okay Okay, so 44 year old white male the history of renal cell carcinoma presents with abdominal pain He had a previous right radical nephrectomy back in 2003. There's his pathology Then he had a hand assisted laparoscopic left partial nephrectomy in 2008 for T1 a tumor It's got some minor medical comorbidities. These are the medicines. He's taking Again, those dreaded bilateral indeterminate pulmonary nodules brain and bone scan are negative He's got some renal insufficiency with an EGFR of 42 so Just to help with to help the crowd understand so he's got here's his kidney and There's a tumor involving the upper pole of the of the left kidney with extension into the renal vein and into the vena cava That's also shown here. Here's another view again locally advanced tumor involving the Left kidney very central Extending into the renal vein and ultimately into the vena cava so This guy's got troubles Dr. Yonez, how would you approach this patient? I would biopsy it so you'd biopsy this kidney. Okay, and the differential you're looking for is what? TCC versus yet more RCC and I'd also do a good family history Figure out why this person who so he was 20 something or 30 something when he had his first renal cell carcinoma So just sort of I would I would also just make sure we we figure out whether or not he has a syndrome or not Okay, so you look for genetic syndromes, and you do a biopsy Dr. Mateen what are your thoughts? Yeah, I mean, I think it's recurrent RCC and I'd need to look at some more images Usually in these cases you have to do a radical nephrectomy You could consider systemic therapy to try to downsize it That work in your experience. What's that does that work in your no not great not reliably the other thing We've done not many patients. In fact, I have a fellow looking at our experience here, but I have done Partial nephrectomy with tumor thrombectomy When the anatomy looks favorable to do that? You know exceedingly rare indication for it But as long as you think that there is some venous anatomy that you can preserve or do venous reconstruction Which we have not yet had to do Then you could potentially do that I can't tell it's not favorable. No doctor. So again, tell me one more time. So I know what would you do? Oh Surgery analysis you'd take it out. Okay, Dr. Taneer. What do you thought? Unfortunately, yes, he will be doing dialysis. So surgery surgery and dr. Gal. I would like to Take a look at the tumor like what dr. Yonash said I would like, you know to see what it is So you do a biopsy? Yes. Okay. So the biopsy comes back as clear cell kidney cancer. What are you gonna do now, Eric? Put them on exit. Okay in the hopes of hopes of changing hopefully Qualitatively or quantitatively changing the surgical approach because data from wood and karam suggests that Significant shrinkage can occur with that agent Okay, so you put them on exit name. How long I'd rescan him in three months three months. Okay JJ clear cell. What are you gonna do? I would put him on my trial. You put him on your trial. Yeah So a little bit of self-promotion there Well, it's a there's no metastatic disease So originally the plan was for him to go on JJ's trial actually He had a biopsy that showed clear cell renal cell carcinoma, but then after the biopsy he went into renal failure As cranting rose to 3.5 his EGFR was down to 20 and he required dialysis So at that point we figured there was no point He wasn't eligible for the trial because of his renal failure And we felt that there was no point in even attempting any nephron sparing approaches So we took him to the OR and did the radical nephrectomy and also place the dialysis catheter so Just very quickly JJ any role for additional treatment after the nephrectomy No, okay, anyone. Let me put it this way anyone want to give him additional treatment. No, okay, and Serena in your experience when would this patient be eligible for a renal transplant? There's a lot of people a lot of family that want to give my kidney Yeah, so generally depends on each transplant center because they have their own all their own criteria But generally for a locally advanced tumor such as this it's a five-year wait For low-stage tumors usually they'll wait one maybe two years But for something like this, I think it would be a five-year wait before he's eligible for transplantation So five years, okay Just to give you follow-up on this patient actually This happened about two years ago and just recently he presented with a urethral metastasis which was resected and Currently he's NED I Think it was I think it was probably a drop metastasis Okay How are we doing? Okay, so 23 year old African-American who presents with gross hematuria and flank pain No previous past medical or surgical history. The pain was alleviated with non-steroidals like Motrin He just graduated from Yale University with a degree in business He's got some mild anemia, but otherwise his labs are within normal limits They think it's a kidney stone, so they do a stone protocol CT And he is told that it is negative Dr. Mateen you agree with that radiographic assessment Well, you know, I mean we're doing patient kidney cancer conference So either the right kidney appears somewhat more asymmetrical than the left side, but there's not much more you can say All right, so what would you do? Contrast enhanced CT or you'd get a contrast CT for sure. Okay, and well with a group with For the audience with the gross hematubus visible blood in the urine. There's no question that a enhanced Contrast enhanced studies indicated That's that's standard. Yeah, I mean the message should be gross hematuria is cancer till proven otherwise And you need to get an enhanced CT to be able to them because that that right kidney does not look normal at all There's some fullness here that it's not you know if you look at the other kidney You don't see that you can see some fullness here So they didn't do that And the pain persisted as did the intermittent gross hematuria And he sought numerous medical consultations until someone had the bright idea of doing a sickle cell test And he turned out to be sickle cell trait positive Five months after the initial presentation somebody finally got a CT with IV contrast CT the chest bone scan and brain MRI are negative so Dr. Tenir, what do you see? I mean he has a Centrel located the right renal mass. He has bulky adenopathy in the retroperitoneum Retrocaval inter-hour to cable This is renal medullary carcinoma Is there any need for biopsy? sure, but I Think yes, you need to do a biopsy, but an African-American With sickle cell trait a mass in the kidney renal medullary carcinoma Until proven otherwise, so it is you would you would get a renal biopsy a renal mass biopsy or an Biopsy of one of those lymph nodes to confirm the diagnosis because I think that could impact or influence the approach to treatment whether we go with surgery upfront Radical nephrectomy and retroperitoneal dissection with the dissection of all visible disease and then adjuvant therapy post-surgery or pre-surgical Therapy followed by surgery if the patient responds to therapy and if it is renal medullary carcinoma Which I suspect this patient has when you do the biopsy then out in this patient with bulky nodes I would do systemic therapy upfront and then do the surgery. All right So the biopsy does come back as renal medullary. What systemic therapy would you offer? the only therapy that Outside the context of a clinical trial obviously so in the community as well as at Henry Anderson Unless we have a clinical trial for these patients the therapy the mainstay of therapy is cytotoxic chemotherapy and Peckley-Tuxel plus carbo-platin Or those that's mVAC any of those cytotoxic chemotherapy regimens that we have we treat our patients with produce around 30 percent response rate And it's the only thing that has really produced long-term You know survival in a very small fraction of the patients unfortunately This is a disease as I was saying in my my presentation that really needs requires concerted efforts to really do research to try to really and you know have insights gain insights into the biology and identified some targets and Develop some effective therapies more than just what we do. So as you know in our Paper that we published last year in British Journal of Urology The median survival of patients with advanced RCC Which is this patient is 13 months. So this is a really a very very aggressive cancer 13% survived two years and Less than 5% survived five years. In fact out of more than 50 patients in that study Only two are now five years a lot of five years and ed only two out of 52 patients. So that's less than 5% So this is really very aggressive disease and I think we are Conducting in collaboration with you all Research to really gain insights into the biology of this disease and we have actually two clinical trials we have three clinical trials we finished one with an Inhibitor of the easy H2 pathway, which is upregulated in this disease as a result of a gene Smart P1 loss for this disease which defines this disease and we have a trial with Pembrolizumab APD1 antibody And a trial that we've soon Open in our department JJ alluded to it with nevolumab plus epilumab in this disease for real medical Okay, so again the biopsy shows renal medullary anyone have anything different from the czar anyone want to do up on surgery Take that as a no, okay So biopsy revealed renal medullary you get five cycles of chemotherapy with pachylataxyl and carpal platin There's the response You can see that the tumor in the kidney is regressed significantly as has the retropertenial adenopathy So what would you recommend Eric? Eric wants to do surgery. Okay, Serena Okay Dr. Tim, of course, okay, I'm gonna ask you JJ All right, so the patient underwent a right radical nephrectomy with RPL and D There was minimal residual tumor in the primary and the nodes. So basically there was a significant amount of treatment effect Patient did develop Kylo societies postoperatively dr. Mateen. I know you never have this problem But when you're managing my patients, how do you manage Kylo societies? I Usually start with changing diet a low-fat or non-fat diet that doesn't work TPN So Matt a statin you could try I don't think it works great It's super expensive and patients have side effects But those those would be the three three things we do. Okay, and of course drainage Dr. Yonez assuming postoperative scan studies are negative. What would you recommend at this point close observation? We had a few words dr. Tenir, I mean that's again, there is no data to guide us in a High-level way, but my approach is because these patients as I said their survival is so poor and this is an unusual gratifying response Since you had only five cycles if you didn't really have a whole lot of toxicity from those five cycles I would continue with what worked and this is similar to the experience say with ovarian cancer And you know, I would keep giving him treatment until tolerance with the hope that he'll be one of those five percent who will survive five years So I would give him more of the same chemo Dr. Guy so you shaking your head. Yes, you would do I actually I I agree with dr. Tenir So apparently he's he responded very well to chemotherapy, but he's still had some residual tumor Which means it's possible that And also with the lymph nodes That has treatment effects that means Inside the lymph nodes actually he already had tumor cells before chemotherapy and the surgery Which also means he probably has microscopic disease in other parts of his body. So in that setting Considering most of these patients don't survive beyond two years. So I I would give anguine chemotherapy What would you give him the same stuff or different? Same stuff. It you know with five cycles of chemotherapy. There was dramatic reduction of tumor That means this type of chemotherapy actually worked very well For the small residual tumor It's probably just you know inside the tumor that the chemotherapy just didn't penetrate very well Well, it could be devil's advocate Could you all couldn't you also explain that as the residual tumor that was left was the resistant clones? It could be but you know normally in our experience if you especially for bladder cancer If you give full cycles of chemotherapy very rarely you can you can achieve complete response. So So I would I would you know, I would do the the same type of chemotherapy if You switch to another chemotherapy regimen that that's fine But in this setting I will I will continue because it he just had five cycles if he had six or seven cycles I would switch to something else. Okay. We have we have time for one more case. I think So 57 year old African-American female presents with abdominal pain History of hypertension. She also had an MI back in 2012 my party a heart attack These are the medications she's taking CT chest is negative labs are within normal limits Everyone gets to be a surgeon today So here's her scans You can see there's a tumor here in the right kidney. That's largely inside the kidney and then another tumor here in the left kidney another view So So what would you recommend? So let me go back dr. Start up with dr. Gal. How would you treat this patient? I don't say send us it looks like you already give the answer But anyway, how would you how would you measure? You know, I'm always curious about what's going on there. So as a medical oncologist, I think we always Not always, but I I favor a biopsy first So you do a biopsy. Okay. Dr. Teneir. What would you do two partials two partials? Which one first? The right you do the right side first. I mean I Which is the easiest of the two? The left the left. Okay. The left is easiest. So maybe do the left then To make sure that if I'm gonna end up with a right radical effect to me I have at least a remnant of the left so she don't the patient doesn't end up on down so if it's if you say the The easier of the two is to do the left. I'll do the left first Okay, fair enough. Dr. Mateen. What are you? Yeah, I agree I would do the we do staged bilateral robotic partial nephrectomy do the left side first It's not easy on the left side. It goes all the way to the vein actually in the deportion But it's easier than the right side also note that they have two different characteristics on scan So it's possible and you certainly see that not that it would change management, but just any rules in my opinion No, I don't think so and she's got some comorbidities, but I think she's you know, she's a surgical candidate Yeah, Dr. Yonez. Yeah, I wouldn't do anything different in this case Actually, these are I think typical looking enough that I would want to I would forego a biopsy And I would recommend I would send into my surgical colleagues Okay, so as you are well aware from me flipping the slide the wrong way She actually went to an outside hospital did not come to MD Anderson And she was counseled to undergo a robotic assisted laparoscopic left partial nephrectomy the quote-unquote easy side And this would be followed by an attempted robotic partial on the right Per her surgeon the left tumor was found to be quote more complex and quotes And they actually took nine hours to do the surgery with the robot Pathology revealed unclassified renal cell carcinoma and All of the margins were positive. Basically. They just hacked through tumor to get this thing out And after the case was over and she'd recovered She was advised to have a period of observation for the right-sided tumor Which by definition was the harder side so the patient wasn't happy with that So she comes to MD Anderson for second opinion regarding management about four months after her left-sided surgery There's no interval change in her medical condition and her skin's CT chest is normal is negative and labs are within normal limits So dr. Mateen, what do you see? there appears to be a little bit of progression in the right-sided tumor and That you can see that on the panel to the right or to the left And then on the other panel there may be some local progression within the central portion of the left kidney Maybe there's a lot of post-operative changes to and fat stranding which is hard to discern Yeah, that's what I was talking about. There's appears to be something actually you're in league. Oh Yeah contain you're in league. Yeah, no big deal So what would you do? I would There's another view Yeah, is there is there recurrence in the left side center? I just kidding. What's that? I don't know is there? I I don't know and if that's the best we can tell I would actually proceed with the right partial So you would proceed with the right partial? I would because it appears to be progressing. I am concerned about her recurrence risk on the left side With unclassified RCC. She also has a metastatic risk Okay, I don't think we can quantify it But you know I am really concerned about the fact that ultimately she may be looking at the right side being her only kidney So I'd want to salvage that now while it's still as easy as it could be okay, and would you do it robotically or open? you know My gut instinct initially was to do it robotically we can do more complex tumors like this but with someone who presents like this You know that could be the planetary Cycles telling you something bad, so I would actually consider it open one, too So what would you do open you do it open? Yeah, Dr. Yonesh, how would you manage this patient? I agree with us right now I'm really worried about that that the left kidney I've had some individuals where you know you have these these less classified or higher grade tumors where you Have an incomplete partial, and then you have an explosion on that side So trying to get this right-sided lesion that's increasing in size out of the way Hopefully can set the stage for some sort of a completion resection to the left And what would trigger you to do a completion resection on the left? See that's the thing I Would I would do very at this point in time. I think it would do very close surveillance Hoping that if you do see bona fide progression in that side that that you're not losing a window of opportunity Okay, I would have a discussion of the patient I think we'd have to do the first right first see what the renal function is and then have a Conversation about maybe doing that preemptively, okay So what we ended up doing was we did a right radical. Oh, sorry, that's a different case. What we ended up doing was We did the right partial nefractomy did it open and we're just observing the left side Unclassified on both sides both sides were unclassified and You know my thought process behind that is you know, even though the margins were positive and she's at big risk for recurrence in that kidney Hacking through the tumor doesn't change the stage or the biology of the tumor And so if it's still a stage one tumor, it's going to behave like a stage one tumor So I think the risk is relatively low regarding losing track of it and having metastatic progression But it certainly could recur locally you have a follow-up on her after the so far any day any day How many years from the first I think it's about a couple years couple years from the left partial Yeah, I think but Chris makes a good point You know that the one thing we have to keep in mind with positive margins as you know Everybody gets very anxious and concerned when you first hear about it But especially for stage one tumor the real risk is not when everybody's all excited about it The real risk is when you start forgetting about it Meaning that if you look at the recurrence risk in those with positive margins It occurs three to seven years after which is just when everybody starts getting tired of all the follow-up And you start letting your guard down So that's what I emphasize to patients when I tell them is I know you're anxious and very concerned But the real thing to think about is three five seven years potentially afterward when you know the That that's the behavior of these it's much more indolent than that And so you have to reset your brain a little bit in terms of that anxiety and concern Both both as a physician and the patient. So do you continue with imaging studies for surveillance for past five years? Yeah, you would yeah every year or past five years once a year pretty much Yeah, but I think the thing to do is to temper it initially you get a baseline study Make sure it's okay. You follow them a little bit more closely, but not as You know not as Anxiously as some people do where they're scanning patients like every three months Because again in the first two or three years that that is not the behavior of these so that it's it's the idea is to not be unreasonably aggressive initially, but then to continue Keeping your sort of radar signal higher for longer than they normally would About with this nine-hour surgery be that there may have been tumor spillage Absolutely, and they and so the nature of the nature of the recurrence might actually be outside the kidney itself Which sort of baby partly taking back what I said before about the Completion of rectum that that may not actually take care of that problem and of itself So so you have to sort of gain what what kind of recurrence this patient's gonna have no that's correct And I mean I but real quick But that's why we don't jump in and do it for that exact I think you've said it really well because you don't know what you're if what you're taking out is where did this? Microscopic disease is located or not Because the last thing you want to do is subject them to what's going to be very difficult surgery and then years later They have a recurrence right outside that area that you did surgery so in many ways you have to let the disease declare itself and then Is that does that verbalize sort of our strategy? Yes, we are concerned when there is you know, what I quote surgical mishap you know Since two years now past and she hasn't had any recurrence it's unlikely there was spillage in The abdominal cavity because usually my experience at least has been that those patients who had surgical mishaps Rupture, you know some mishandling of the tumor intraoperatively They recurred within the first year in fact the first six nine months with abdominal carcinomatosis So yes, she's she may still be at recurrence and I agree with her You know five six seven years you need to follow them But it's unlikely that she's gonna come with this abdominal carcinomatosis or a site is In the future if it hasn't happened by now I mean I'm sorry I've seen lower lower-grade tumors where you end up getting these slow growth of Nodules kind of in and around the the prior the partial nephrectomy So I think it's a question of how aggressive if it's I agree with you completely if this is a high-grade tumor That has this inherent Properties that's when you get that that pasting of disease in the peritoneum, but with the lower-grade Tumors you'll you'll end up getting these slowly growing nodules that are perinephric Okay, and I think with that will adjourn I want to thank you all for coming. It's been our pleasure Thank my esteem panel and hopefully we'll see you again same time next year. Thank you. Thank you very much