 I'm going to talk about the management of renal cell cancer with venous thrombus. So we know up to 10% of patients with renal cell cancer may have an invasion of the venous system. It definitely makes surgery more complex and increases the risk for morbidity and for perioperative mortality. The thrombus may be confined to the renal vein or it may extend into the IVC and up into the patient's right heart. Sometimes the thrombus is mobile which makes surgery a lot easier and sometimes it invades into the actual wall of the IVC and patients may require resection and grafting in this case. So when patients present, they usually come in with some constellation of lower extremity edema, right-sided varicoseal, pulmonary embolus, capid medusa, sometimes protein in the urine, cardiac or lung systems if the thrombus is higher level or non-functioning renal units. A lot of patients surprisingly have a few symptoms. This is a patient we saw just a little while ago and he had a higher level IVC thrombus and his only symptom was some dilated superficial scrotal veins. So when we look at surgery for patients with venous thrombus, the first surgery was reported in the early 20th century and the rationale at that time was if you could do surgery in these patients who didn't have metastasis, it could be curative and this rationale remains today. We see 45 to 70 percent of patients without metastatic disease can be cured with surgery alone and the second half is that in patients who have an IVC thrombus that extends into the hepatic or cardiac circulation, patients may have hepatic or cardiac failure down the line and surgery may prevent this. Imaging is very important in patients that you suspect a thrombus. The MRI or a high quality CT scan is essential. We also use transesophageal echocardiography at the time of surgery to monitor the thrombus height. There's several different systems which have been devised to classify tumor thrombus. Probably the most widely used is the Mayo system with zero being in the renal vein and level four being above the diaphragm. So the principles for surgery for level or one for the low level thrombus include early control of the renal artery, ligation of the lumbar veins, placing clamps on the large veins draining into the IVC, and sizing the IVC and removing the kidney and the thrombus on block. Patients with a thrombus above the hepatic veins may require a pringle maneuver including the hepatic blood supply. We know when this is prolonged patients may have hepatic failure and poor outcomes and the highest level IVC thrombus these are the thrombi that invade into the right heart circulation may require in sizing the pericardium from below or sternotomy and cardiopulmonary bypass taking things out from above and below. We know this increased the patient's risk for bleeding, stroke, and cardiac dysfunction. So in the remaining time this morning I'm going to talk really just about newer articles and newer themes in patients with venous thrombus. We know that some patients who have a venous thrombus present with pulmonary embolism this is maybe five percent of patients. It's very difficult to tell whether or not this is tumor embolized from the thrombus or whether or not this is a more global hyperquaggable state that we see in other types of cancer. The thought is that maybe some of these patients have worse outcomes the patients with pulmonary emboli and so surgery may have less benefit in these patients and certainly this belief some patients with renal cell cancer and pulmonary emboli are not offered surgery up front and I know our anesthesia team always reminds us that the 90-day mortality rates for patients again non kidney cancer patients who have acute pulmonary embolism is about 15 percent. So to answer these questions we used a collaborative effort between Wisconsin UT Southwestern and MD Anderson. We looked at 782 patients who had venous thrombus who underwent surgery from 2000 to 2011 and we identified 35 patients who had a pulmonary embolism diagnosed prior to surgery. What we found is there was no difference in perioperative mortality this is mortality out to 90 days it was actually lower than the patients who had PE even though they were more likely to have a higher level thrombus and after we did multi variable analysis there was no difference in cancer specific survival for the patients and there was no difference in recurrence free survival for the patients who did not have metastasis. This was very interesting even in the patients who had PE preoperatively they were no more likely to develop pulmonary metastasis so just if the tumor is embolizing just because it ends up in the pulmonary circulation does not mean it can grow in the circulation and produce metastasis. Again you can see here the there's no difference in cancer specific survival or recurrence free survival on about 63 percent of the patients who did not have metastasis did not have disease recurrence after surgery. So neo neoazurine targeted therapy to shrink the thrombus prior to surgery is certainly a hot topic in literature. There's a theoretical advantage as you can do less invasive surgery in these patients and there's certainly some dramatic responses reported in the tumor thrombus. However when considering neoazurine therapy for these patients we need to know several things how often does the thrombus respond and when it does respond how often does that change the surgical approach. Our patients able to tolerate systemic therapy we've seen this in adjuvant trials where patients without metastasis tolerate this systemic therapy worse than patients with metastasis. And really the ultimate question is is the risk of surgery outweighed by the risk of thrombus extension causing hepatic or cardiac failure. Among the the case reports there's us two studies which are larger of 25 and 14 patients and they found only the minority of patients did the thrombus actually shrink while in targeted therapy. Few patients less than 10 percent changed the surgical approach and some patients actually did have an increase in the height of thrombus while on targeted therapy. So for purposes of shrinking the thrombus the majority of patients with IBC thrombus should not receive neoazurine therapy. However there may be some patients who would benefit from neoazurine therapy and to identify these really the theoretical benefit is best in patients with the highest level thrombus because we can avoid cardio pulmonary bypass in these patients. When we look at patients with upper level IBC thrombus we know this is rare less than one percent of patients. It's the most technically complex surgery with renal cell cancer with an increased risk for morbidity and early mortality. But what we really don't know is what are the risks. There's really a lack of high quality contemporary data in patients with upper level thrombus. If we look at just the series of morbidity and early death with patients with upper level thrombus you can see that many of these studies span decades. They have low patient numbers overall. The way that complications or morbidity or mortality was defined is very variable and just the rate of periodic mortality is anywhere between 2 and 22 percent. So it's hard to know what to tell patients. So again going back to collaborative data with this. This time we have a collaborative study between the Mayo Clinic, MD Anderson, UT Southwestern and University of Wisconsin. We had 162 patients consecutive using only contemporary patients from 2000 and 2012. We defined complications using the clavian scale and death was recorded within 90 days. What we found is one in three patients had a major complication after surgery. Independent preoperative predictors of this were a level fourth thrombus or the presence of systemic symptoms being fatigue or weight loss. Ten percent of patients had mortality in 90 days. It was about five percent in 30 days and about 10 percent in 90 days. The preoperative predictors of this were ECOG performance status greater than one and albumin less than the lower limits of normal. Both of these increased the patient's risk about four fold and so these may be the patients that will be most suited for neo-adjuvant clinical trials. So in conclusion patients with venous extension increases the complexity of surgery. There's certainly a risk for morbidity or mortality. However it may provide a durable cure in the majority of non-menostatic patients. Upfront surgery is certainly the standard of care for most patients with venous thrombus. Many patients who present with PE have similar outcomes to patients with without PE and neo-adjuvant clinical trials in renal cell cancer with thrombus should really consider patients individually for the theoretical benefit which does not appear to be high versus the risk individually for that patient and focus on the patient with high risk features including thrombus above the diaphragm, systemic symptoms, poor performance status, or low serum albumin. Thank you.