 All right, let's move on. 50-year-old white male presents with right-sided flank pain, no urologic symptoms, excellent performance status, CT chest MRI, the brain and bone scan are negative, and a biopsy of this primary tumor here reveals it to be clear cell renal cell carcinoma. What are your thoughts? Dr. Chapin. Do we have any other imaging work up, or is this? Nope, that's it. So you've got a locally advanced tumor clearly involving the renal sinus and collecting system of the left kidney extending very centrally? Yeah. No events of any metastatic disease? So I think in this setting, here we try to go to the clinical trial first, if one's available. In the absence of a clinical trial, I would offer this patient a left laparoscopic nepharctomy. And based on your imaging, I mean you're telling me it's invasive of the renal sinus there, in a single image, taking your word for it for T3 disease, I would do a lymph node dissection with my nepharctomy. So laparoscopic radical nepharctomy with a lymph node dissection? Yes. Dr. Karan, your thoughts? I think that's a reasonable option, but like Dr. Chapin asked for more images just to make sure how resectable the tumor is, I mean another option would be to do a partial nepharctomy, especially if the patient does not have good kidney function, which just another consideration. And sometimes I tell the patient, we will try to do a partial nepharctomy, but there is a high risk of ending up with a radical nepharctomy. But the only downside to that, or the main downside is that we will have to do it open, or I would do an open partial if I can, converting it to a radical through the open incision if I cannot achieve good margins. Dr. Delacroix? I would offer this patient an open, attempted left partial, again. What do you think the odds of success are? I don't have all the images here. You stop whining, you guys are whining. I know. I know. Probably, I'd tell them 40, 50% chance I'm gonna have to take out the kidney. Tumor goes almost to the other side of the sinus. Yeah, but I look at this image down here, really this is when we need more images. But if I look at the images and I think it's, if I have a 50% chance that I can do a partial effect to me, that'd be what I did. This picture almost begs the question if this is the same tumor or not. It looks so nicely encapsulated on the right side and it just looks much different on the left side. It's a lobulated tumor that extends centrally. This cut over here is lower. I would have chosen some better pictures. Oh. Oh. I don't know. So can I ask Chris? Yeah, why? You're presenting all these patients who have pain that doesn't really, is not explained by their tumors. Right side of the flank pain here is the tumor on the left. The other several patients had abdominal pain or left flank pain when the tumor is on the right. What's going on here? I mean, it's a very common presentation. They present with symptoms that are completely unrelated to their renal tumor, often contralateral, and yet they have these findings. I mean, these are all real patients, all real history and physicals. Well, it's also the CAT scan when you walk into an emergency room. Exactly. People have back pain, people have flank pain, people have history, kiddie stones. Any trigger gets a CAT scan now when you walk into ER. Not that it's correct, and most times it's not, but it's what happens, and then they show up in our office with this history. So not to belabor the point, but basically this patient was enrolled in our neo-adjuvant excitinib trial, and received three months of neo-adjuvant excitinib. Excitinib is a new targeted agent from Pfizer, escalated to 10 milligrams BID. It was relatively well tolerated, grade two hypertension and fatigue, hypothyroidism, and stomatitis. And these are the follow-up images. I trust these images are adequate for your use. Those are adequate. And that definitely appears to be a much easier partial nephrectomy. You could even attempt that robotically. You can see that the tumors regress dramatically, and plus also in addition to shrinking in size, there's a central necrosis where the inside of the tumor is basically dead, and that's related to the anti-angiogenic effect of the medicine to cause the blood vessels to regress. And this patient underwent a partial nephrectomy with interpretive ultrasound, and it turned out to be a T1A from a grade three. So it shrank the tumor dramatically. And this may be the wave of the future. I think neo-adjuvant therapy, particularly with these new targeted agents, may be the wave of the future to try and decrease the size of the primary tumor to either make surgery easier, make nephron sparing more feasible. But obviously, all of this needs to be studied in the context of a clinical trial. Okay, I think that's very important, just go ahead. Can I just ask a question to Dr. Mateen and Dr. Wood, what have you found intra-operatively? Do you find that the tissue planes are any different, especially robotically, after targeted therapy? I think that you can get this reactive rind around it. Other than that, I'm not sure it's that much more difficult. Yeah, I haven't noticed any dramatic changes, I mean, which is actually very fortunate. You'd expect, many times, like for instance, with testicular cancer patients, after getting chemotherapy, there can be this tremendous reaction around what's left over because of the dying tumor and your body's immune system attacking it. And that was a concern here. Could this actually make the surgery harder? But that has not been our experience. And in many patients where it was either a borderline partial or partial was not possible, we were able to shrink the tumor using this drug and perform partial nephrectomy with good outcomes. I would just wanna stress the importance that this is on a clinical trial basis and that this would not be considered something that would be standard. And we've made point of that several times today of not giving TKIs with the hope of downsizing or downstaging a tumor. Although, we see a lot of anecdotal cases in the literature and I think that it tends to falsify kind of what people think of this. I know your experience so far with Exitim has been different and when that's published, it can be something that we evaluate further. But at this point, this is only in the context of a clinical trial and would not have been standard of care therapy. Okay.