 So this is a part of the conference that may we've gotten a lot of positive feedback on because it shows you that medicine is Indeed an art and not a science That there's not only is not always is one correct answer and they're offering often as differences of opinion But what we hope to illustrate through these case presentations is to reiterate some of the points that have been made today and Also try to cover points that we didn't have time to cover during the didactic sessions So if I can have the first slide, okay Yeah, so before I begin many of you have approached me a little bit concerned about my health So I'm a little bit red in the face wondering whether I might have high blood pressure. Are you sure you that's not the case? This is what I've been doing the last couple of days. I was in at the master's tournament in Augusta, Georgia with my son a Unbelievable experience. I know he is That's okay, I just say sit down so I can slap you Okay, so let's begin So we have a 68 year old white female who presents with right-sided abdominal pain She has a past medical history significant for hypertension Past surgical history is significant for a hysterectomy. She has a bone scan MRI of the brain, which is negative She has some anemia, but otherwise her labs are within normal limits And you can see here she has a locally advanced tumor involving the right kidney There's evidence of a renal vein an IBC thrombus so the tumor is growing out of the renal vein into the inferior vena cava and She has bilateral pulmonary nodules. There's one there. It's one there one there So now just a little bit about the rules. I know you there are a lot of things you could do I want to know what you would do specifically for each case So let's start. Let's see. Dr. Karam What would you recommend for this patient and why? Reason to get an MRI brain or bone scan or assume that's negative So I think the patient needs surgery The question is should she also enroll in a clinical trial? And so that's something we would discuss with the patient assuming that these Deletions and the longer metastatic and you know measurable and She would ultimately need the radical nephrectomy and IVC thrombectomy. So that would be your upfront maneuver You would offer this patient right radical nephrectomy with IVC thrombectomy. Yes, okay And then then what well the patients on a certain trial. She will get the drug for that trial If not, then oh, she's not on a clinical trial. What would you do? I would refer to dr. Gau dr. Tenir or dr Yonez Okay, what time would you refer at? At about four to six weeks after I've seen the patient after the patients recovered from surgery If she did not go on a clinical trial, okay, and I suppose dr. Gau dr. Tenir and dr. Yonez are unavailable What treatment would you recommend? Soon it's enough or is open Okay, you're enough If assuming this is clear cell and all the other stuff Dr. Dr. Gau What would you recommend and why? so you know Dr. Graham actually mentioned clinical trial. Can you guys hear me now speak up bring them closer? So I don't know how big the lung lesions are if they are over one centimeter This patient can be a good candidate for for the clinical trial. I just talked about So they are they are over one centimeter. So you would enroll the patient in clinical trial Yeah, so this patient can clearly get, you know, either Nevalumab or Nevalumab plus epilumab or Nevalumab plus Bevacizumab and if he and if she hadn't response Has the stable disease before surgery after that you can continue Nevalumab as medicine and therapy So that will be one option if if she's a candidate for okay So you would recommend pre-surgical therapy with the immune checkpoint inhibitors that we're saying Yeah, I think that's a reasonable choice. That would be your first choice In the I mean if we want to learn about the biology of this patient and her cancer So I think that will be my first choice. Okay And suppose the biopsy didn't come back as came back as non-clear self came back as what's a papillary What would you recommend if it's papillary? Unfortunately, she will not be qualified for for that clinical trial, right? So what would you recommend? So I would go with doc doc what dr. Graham said We'll do surgery first So you'd advocate so to reductive nephrectomy for non-clear cell histology I I think that the data for non-clear cell is not that clear-cut so but for a patient with with you know with symptoms and also with With thrombosis was anemia. So I think you know if you take out the primary tumor potentially this patient can benefit clinically So that just for the audience is sake There's a controversy in the literature about whether or not patients who have non-clear cell histology should undergo site-reductive nephrectomy There are conflicting reports in the literature some say benefits some say it does not benefit And so it's always an issue that we go round and round about whether or not patients with non-clear cell histology should have that surgery Because you can see from the slides that the vast majority of the tumor burden would be removed by taking out the patient's kidney in the IBC thrombus that said patients with non-clear cell histology who have evidence of venous involvement It's almost uniformly fatal So this patient if that were non-clear cell is not going to do very well Eric give anything Dan? No, just if if this is papillary I then The idea of trying a met inhibitor sooner rather than later and especially on a clinical trial We're about to open a papillary renal cell carcinoma trial with a met inhibitor that would be an ideal venue for this individual So the patient ultimately under one site-reductive nephrectomy and we included this patient in the ADAPT trial That was a trial that I showed during my site-reductive nephrectomy talk where patients are randomized to a Autologous then dirt Excel based vaccine plus synidinib versus synidinib alone. You can see the pathology from the resection All right, let's move on. So this is a 23 year old African-American Male who presents with gross hematuria and flank pain has no past medical or past surgical history The pain was alleviated with non-steroidals like Motrin or Advil or one of those As a side note, he just graduated from Yale University with a degree in business All of his labs are within normal limits except for some mild anemia And so the presumptive diagnosis by the emergency room is that he has a kidney stone And they do a stone protocol CT which they tell him is negative So dr. Mateen If you were to see this patient with this imaging and this story, what would you recommend and why? So for the purposes of the audience a stone protocol CT means that there is no contrast given there's no intravenous contrast There's no oral contrast So doesn't take a trained eye to look at the scan to see that everything's sort of gray and fuzzy You can't really make out much. You know the only thing you can really tell is that there's no kidney stone So with with the gross hematuria meaning that there's visible blood in the urine He needs a contrast enhanced study CT of the abdomen and pelvis Okay, anything else Would you do cystoscopy? Yeah, I would I would do a Workup for hematuria, which includes looking in the bladder, but that's Likely to be higher up after crime give anything down. No, just agree to that from a team on this one Okay, so the pain persisted as did intermittent gross hematuria and the patient sought numerous medical Consultations and as a consequence of those consultations. It was found out that he's sickle cell trait positive And a CT with IV contrast was finally obtained five months from his initial presentation all this went on outside MD Anderson by the way and he had a CT chest bone scan MRI the brain all of which was negative and Here's the scan so Dr. Taneer, what's your presumptive diagnosis and what would you recommend for this patient? I think this patient fits the criteria for the diagnosis of renal medullary carcinoma these are patients who are young African American and have sickle cell trait and Invariably the vast majority 95% of them present with either metastatic disease or locally advanced disease Unfortunately, this is a disease that the drugs I talked about today the target therapies don't work and therefore This patient should have a biopsy to confirm the diagnosis and in our opinion Patients with this diagnosis, even if they don't have metastatic disease to visceral organs When they present with local region disease like this patient has with bulky lymph nodes in the retroperitoneum they should receive systemic therapy the only therapy that we have noted that helps Control the disease for a while is cytotoxic chemotherapy. So this patient would have a biopsy to confirm it This is renal medullary carcinoma. I would treat them with cytotoxic chemotherapy up front Hopefully the patient will respond and then I will refer him to you or to Jose or sure enough for Cytoductive nephrectomy and Removing all visible disease with the hope that if we can convert them into no evidence of disease status We will continue chemotherapy postoperatively and hopefully there is a chance that this patient could survive Past two years just to show the audience the x-ray. So this is the tumor is sort of an infiltrative tumor involving the right kidney And then these big lumps here. There's one here and There's one here. This is all lymph in large lymph nodes that are involved by the cancer And so would you buy see the lymph node or the primary tumor? I think either one There is you could get the diagnosis with either one, whichever is amenable to surgery I think the lymph nodes are big enough to stick a needle there, but I think the kidney is fine Would anybody on the panel advocate upfront surgery? No So biopsy didn't deed reveal that it was a real medullary carcinoma Poorly differentiated patient went on to receive five cycles of chemotherapy with pachylatoxyl and carboplatin So there's already want to come in on that ridgeline. Yeah, I think we are still treating these patients with cytotoxics Using the same regimens we use for bladder cancer basically or transition sarcosinoma of the upper tract so this is a regimen that the Advantage of using this combination is that we know if the patient is going to have surgery They're going to lose their kidney. So it is important to use combinations that Have less toxicity on the kidney so avoiding cisplatin And that's why I think you know the pachylatoxyl and carboplatin would be a good regimen and we have Seen many patients have actually I would say are probably around 50% 40 or 50% of these patients will respond to this regimen How common is it? How common is this cancer? This is a very very very rare cancer. In fact, I think In the literature there are fewer than 50 Patients diagnosed, but I have to say that it's probably a lot of it is not talked about because There is a lack of awareness people don't think about This disease they think it's just kidney cancer and they'll treat like any kidney cancer I think the important thing here for patients their families as well as providers surgeons nurses and medical oncologists Is when they see a patient who has who is african-american who is young and the 95% of these patients are african-americans Or africans who are in the u.s. But this is a diagnosis that is common actually in large countries with large african Descent patients so I think with More awareness and we've seen that when we started To get interested in doing research on this aggressive disease That's rare that all of a sudden we have we are Hearing more and more about it from different states different cities with large african-american populations where you know patients are diagnosed, so I think We don't nobody knows the exact incidence because again, it's a lot of it is Put in the column of kidney cancer, but I think you know if we Go back and look at all patients, you know who had kidney cancer who were african-american young And had sickle cell trait that the incidence Would be higher than it's been reported. So we were able to Compile a series of about 50 patients now over the past 10 years Mostly treated here at md. Anderson and and I would say probably half of those We have seen over the last two or three years here at md. Anderson I think this remains a Uniformly fatal disease unfortunately with a median survival of only one year despite initial response in many of these patients with cytotoxics We are conducting molecular Research on these tumors as well as immune research and this is a disease where if you harvest the kidney Whether it's before or after cytotoxics you'll find immune infiltrates So that suggests that there is an attempt by the tumor by the body to mount an immune response So an exciting thing would be to treat these patients in the very near future with the immune checkpoint inhibitors Which hopefully will add to the Very modest benefit of cytotoxic chemotherapy One of the other benefits is that as a consequence of Doing cytoreductive surgery on these patients. We've been able to establish a model in the laboratory Which will again further allow us to evaluate different therapies that might be effective in the setting But the challenge has been because it is such a rare disease In african-americans that you know to try and develop a standard therapy has been a real challenge Chris if you don't mind before we move on this case i'd like to acknowledge the presence of two ladies who are Mounting a very Noble campaign to try to raise the level of awareness of this disease Uh, mrs. Uh Richie and uh, mrs. Uh, kora Connor Mrs. Richie johnson lost her son unfortunately a few years ago to this disease after a valiant fight of 15 months and kora We're happy that her her brother is a cancer survivor and he's three years Out from the initial diagnosis with a complete response. I think they're doing great work in if you're interested Mrs. Johnson has a pamphlet. She established a foundation. Both of them are patient advocates. That's why i'm Uh, i don't think i'm identifying them in the audience so that Um, people will know about the great job. They're doing so hopefully we will we are in the process of forming an alliance arena medullary carcinoma alliance for patients and patient advocates to try to Uh, increase the level of awareness of this and of obviously also to try to increase funding for this very aggressive cancer That's extremely unfunded where industry. Unfortunately Is not, uh, uh, doesn't have trials for these patients with these very rare tumors Okay So serena here's the response after five cycles of chemotherapy. What would you recommend at this point? Yeah, that's a great response, you know, and it's um, can you talk to the microphone? That's a great response. You know, you get very excited and I think he's a young patient. Yeah, I would offer surgery um, you know, you still You try to withhold your excitement a little bit based on what nizar said, but that's what we have to offer Would you do it open or laparoscopic? I would do it open. Uh, there's probably likely going to be a fairly heavy reaction after all that regression And the short-term benefit of a minimally invasive approach. I think is heavily outweighed by Wanting to do us thorough and careful job as possible. So I do it open So does anyone disagree with the idea of doing surgery at this point? Dr. Karam, would you do it open or laparoscopic? Do it open so you wouldn't break out the robot Okay So the patient underwent a right radical nephrectomy with rp lnd the pathology demonstrated no evidence of viable tumor patient had some kyla societies postoperatively kyla societies just means the leakage of lymphatic fluid into the abdomen Um, it was managed conservatively. I won't go into details about that So assuming the postoperative studies are negative for evidence of recurrence. Eric, what would you recommend at that point? Yeah, so obviously this the textbook on this has not been written yet So the temptation would be to then give some consolidative treatment. You had a really nice response before with this therapy You worry about cells that are lurking So maybe giving similar therapies for several cycles afterwards to make sure that any residual cells are killed Is attractive again, but it's not based on on large amounts of evidence. So you but you're saying you'd recommend adjuvant there Yes, okay, and how many cycles? four And that number comes from Denier Medicine is an art not a science. Um, Dr. Tenir, what would you recommend? Yeah, we we followed up on this patient with more chemotherapy and he was eager to go back to work and life and He wants to go back actually to You said he was from he graduated from Yale. So he was living in Connecticut So we stopped so we gave him five before five after so he's finished his chemo The latest scans when we saw him were negative. So we wish him well, but I think You know, we are nervous. He is nervous. His family is nervous about, you know They they're they're willing to continue chemotherapy indefinitely, but I told them, you know at this point We need to balance Benefit there's no clear evidence that continuing beyond what we did is beneficial and probably going to be just Giving him toxicity. So we stopped we stopped. I hope he will be another Long-term survivor like, you know, Herman Kora's brother Okay, let's move on This is a 39 year old white male who presented initially with grossing materia He had no significant past medical or past surgical history He underwent a hand assisted laparoscopic right radical nephrectomy at an outside institution You can see his pathology is stage three With evidence of renal sinus invasion Firmans grade four the firm's grade just refers to how aggressive the cells look like under the microscope on a scale of one to four One being good for being bad. His is a four He also has evidence of extensive necrosis And lymphovascular invasion meaning that they see cancer cells inside the lymphatics and the blood vessels of the tumor Suggesting that the cells are trying to leave So the patient presents them to enter sent for a discussion of adjuvant therapy postoperatively Dr. Karam Patient presents in your clinic and wants a discussion of adjuvant therapy postoperatively. What would you recommend? Here we don't have any open trials for adjuvant therapy. There is one that is open Nationally the everest trial using everolimus versus placebo for such a scenario The patient should qualify for the trial given the high grade and stage of the tumor So I would tell them there are trials that are open here But we don't have them at md. Anderson at this point. We did have the a short trial that you mentioned the Sunatina versus seraphina versus placebo which is closed And we did have the pisopina trial and that has closed to accrual at present But one thing before Deciding on the trial as well as I would like to restage him if that hasn't been done yet Just to be sure the patient's free of disease Okay, but in the absence of a clinical trial and for some reason this patient wants to stay with you What would you recommend? Just observation with imaging and laboratory studies. So even if he wanted to be treated you wouldn't recommend any treatment. No Does anyone differ with that? Wow, everyone's in agreement today. Okay So patient undergoes a repeat baseline staging evaluation after his surgery. It's now six weeks out And we see Evidence of something going on here And something going on here so um Dr. Mateen You can see the scans. What would you recommend based on those scans? So what uh, dr. Wood is pointing out is what appears to be some enlarged lymph nodes their Number and size of them indicates that they're likely to be metastatic disease from the patient's uh, kidney cancer and so Uh, usually with clear cell renal cell carcinoma if there is cancer in the lymph nodes It's a sign that the disease is probably metastatic elsewhere also. It's rarely Just in the lymph nodes um Rare situation being if there's a single lymph node and it's not very large and um point being It'd be important for the patient to understand that Even though we see these discrete areas going in and removing them Which would be a fairly moderately aggressive operation Is unlikely to render him without disease for any period of time so my my approach for these is And notwithstanding some of the work that's been done with lymph node removal on this and and you've done a large part of it, you know, my My uh inclination is to get one of the medical oncologists involved And to figure out a strategy where we combine treatments Surgery may be as part of the plan But I would not be eager to have surgery be the initial part of the plan All right. Well, we had just happened to have some medical oncologists here. So let's get them involved. JJ. What would you recommend for this patient? so, um Of course, I will discuss with uh with one of your surgeons To see, you know, whether surgery is an option. Uh, if we agree That, um, you know surgery at this short interval after the last surgery is not a good option Certainly we can we can start this patient on some target agents such as suit and a presumptive And uh, if the patient has good response, uh We can discuss about uh further surgery again So you would recommend upfront systemic therapy followed by surgery. Is that what you're saying? No, I uh, I mean it really depends upon if if you guys want to do surgery Of course, you know surgery is an option However, if we all agree that surgery is not a good option at this time Certainly this patient can be treated with some target agents. All right. Well, let's just say surgery clearly is an option I mean, that's that would be not a difficult rp lnd Would you prefer to do the lymph node dissection first or would you prefer to give systemic therapy first? Which would you prefer patient sitting right in front of you? Whatever you say doc Um, well, I mean first of all, uh, we need to restate the patients to make sure There is no disease Elsewhere, okay So they've got a ct the chest an MRI the brain and a bone scan all of which are negative In that case, I think it's not unreasonable to treat the patients first With what with uh, you know either a suit and a presumptive. So you would recommend systemic therapy first Yes, yes, okay Eric, what do you think what would you do? Yeah, well since I'm a medical oncologist and I can't operate No, I think, you know, you could you could argue that in this individual We actually have some some pretty exciting trials. This is metastatic disease This patient would be eligible for the uh checkpoint 2 1 4 study I believe because this is clear cell the patient has metastatic disease This wouldn't be an opportunity for this individual then to try a trial that randomizes individuals between upfront sunit and versus Epidemumab plus nevolumab I would offer that to the patient and we could then treat Uh, and if we have a good response or we have some minimal residual disease at some point in time This does not preclude consolidative surgery later on I notice no one's recommended a biopsy would anybody biopsies notes before doing anything Is that an option? I was going to ask you you uh, uh, this patient had surgery elsewhere Do we have the scans from when he had the surgery at baseline before the nephrectomy? We did these nodes where there was a hint of these nodes being there Uh, in other words, he had already locally advanced disease with nodal metastasis And these things just grew a little bit post operatively. It's not like he didn't have them and now they he has metastasis Right, I agree We don't have those films, but that would be my assessment of this that it's not like there were nothing there And all of a sudden they grew I you know in regard to your question about biopsy I usually leave it up to the medical oncologists I I can't really tell when they want it and when they won't when they don't But I have stranger things seen stranger things happen So where we think it's disease and we biopsy and we find something else or just inflammation So I think it's a reasonable thing to do. Eric. Did you biopsy it or no? Would you treat without biopsy? I guess is the question Yeah, no, I think it's reasonable reasonable to say this is the first how many weeks after six weeks It would be reasonable to do one other scan To see what direction these things are going, you know, are they are they getting a little bit bigger? They're leading to get smaller I really would Need to defer to my surgical colleagues whether or not this could be reactive You know Serena made the comment. Oh, this doesn't look like reactive. This looks like Metastatic disease But I think it'd be reasonable to to wait a little bit Make sure that we are moving in the right in the right or wrong direction here And if we're quite concerned that this is metastatic disease if it's growing if they're increasing in size I don't think you need to biopsy If they decrease in size again, I think you don't need to biopsy because it could be reactive So when you say wait a little bit, what do you mean by that? Another six to eight weeks So wait another six to eight weeks and then re-image And if those show enlargement of the nodes, you wouldn't recommend a biopsy to start treatment If it shows anything other than that you would just observe At the moment yes, okay Dr. Crom what are your thoughts? So if this is truly newly metastatic disease that popped in a matter of six weeks I mean that would make me nervous to go directly and do an operation on this patient. I would definitely Wait a little bit before deciding on that. So I agree with Eric You scan at about six to eight weeks and see how the tumor is behaving if the tumor is rapidly growing in that six-week period I don't think surgeries Should be the next best step. I think you might benefit from uh systemic therapy first And then if the patient remains free of disease elsewhere, then do a consolidated surgery So you're advocating waiting six to eight weeks getting another set of scans to see which directions these nodes are going Yeah, and to check the other areas as well to make sure the liver You know bankrails all those other places are fine, too Okay, Nazar, what are your thoughts? I would get the scans from uh baseline from the other hospital If there was a hint that these were there then he had already to begin with Nodal metastasis and they just grew a little bit and if he's fit and is You know willing to have surgery. I would not do a biopsy. I would send him to one of you guys for rpl And the render him an ed then follow him post operatively And if he has then metastatic disease then we will offer him treatment on the immune checkpoint phase three trial So I'd like to point something out for the audience Do you notice that the medical oncologists are recommending surgery and the surgeons are recommending systemic therapy? Very good. Actually there is a can I make a comment as well? So if you know after rescanning after and we decided this is Uh, this is clear sale uh metastasis. You know this guy is only Um 39 years old, you know, it's not unreasonable to to offer him high dose io2 therapy at least, you know for um You know at least send send him to the melanoma department as we do here for a evaluation of that because if he responds well To high dose io2 therapy, uh, maybe there is a cure for him. Would that be your first choice? Uh After much discussion, you know, if we agree this is metastasis. This is This is uh Clear sale cause normal. I would that would be my first recommendation. Of course in the meantime, you know, he Can also be a clinical trial candidate So so the comment I would make to that is although the data are retrospective looking at what ucla and other places have Determined intra abdominal lymphadenopathy from renal cell carcinoma is one of the negative predictors for benefit to il2 So I'd be a little concerned about il2 being one of the top options It doesn't mean that this patient wouldn't respond, but it has been associated with that less lower likelihood of response Chris I just want to add that if he did not have metastatic disease elsewhere I think this patient can have a good durable disease free Survival with just rpl and d surgery. I've had many of those patients You know clear cell or papillary and I think you know I think you said clear cell. This is the pathogen. Okay Obviously clear cell will be associated with a much higher incidence of relapse post rpl and d But I think you know papillary especially that we do not have effective therapy For these these non clear cell installages. I think surgery remains an option And now it would be my first option in this patient. Yeah, I don't I don't fully agree with that I mean, there definitely is a difference between papillary and clear cell papillary When it goes in the lymph nodes, it just likes to stay there And while we've done when we looked at our data, there's about a 60 5 year survival In patients who have lymph node metastatic disease that's removed by surgery And and so as long as there's no other metastases anywhere else Clear cell does not even get close to those numbers and the the one lesson that we've learned with clear cell and relearned and relearned And many times Unfortunately over the complications of patients who've had surgery Is that we're not very likely to cure them at all with with Overly aggressive surgery well when when clear cell rcc is in the lymph nodes It is a signal That there are likely cancer cells elsewhere hibernating. We may not be seeing them, but they're there There's the very rare patient who may be we may be able to help But we can't treat the majority based on those rare situations So there is this agreement and then we don't know what the right answer is but we've gone down that road before and Have to do that very carefully. So this patient was actually first seen by a medical oncologist. So obviously surgery was recommended And the patient underwent that surgery And here's the pathology. You can see that it showed Evidence of metastatic renal cell carcinoma in six of 30 lymph nodes removed And then post operative changes So dr. Tenir you talked me into doing surgery Oh, I sent him to you What's that you built you agreed with me tonight, of course I always agree with you. What do you want to do now? I mean again, we can offer him adjuvant Enrollment on an adjuvant trial. He will qualify But in the absence of a clinical trial for him. I think you know surveillance You know scans every three months Close surveillance because again, we know that these patients are at high risk of recurrence And as Surya mentioned, you know, this is higher much higher with clear cell than with this with papillary. So close close follow-up If no trials are available for enrollment. So scans every three months. I would Does anyone disagree with that? Okay, so interestingly, I don't I don't think yeah, there's no So what can you give us a follow-up? What's that? Can you give us a follow-up? Yes, I can So I actually uh, we did the surgery the patient remained disease free for two years And then at the two-year mark he so when we did the node dissection We removed the nodes next to the vena cava Under the vena cava in between the vena cava and the aorta And also the nodes underneath the aorta. So the only nodes that we left behind were the nodes that were on the left side of the aorta He went did well for two years and then developed recurrence in one node on the left side of the aorta And we took him to surgery. I think it was about six weeks ago to resect that and now we're going to follow him up again So how typical is how typical is that situation chris? Oh, it's real. I agree. I agree. But I mean it also The implication is that our systemic therapies are so great as well I mean, I think that you know localized disease young guy aggressive approach Surgeon, you know, we wouldn't I wouldn't argue with giving systemic therapy first followed by Followed by uh surgical resection The only concern I would have with that approach would be that if this patient's tumor was not responsive to the systemic therapy You could potentially be losing a window of curability Using your approach, which I'm not saying is wrong because you could argue maybe isn't curable But you know, so I guess in a young guy like this, I'm going to swing for the fences I would say exactly the same thing except swinging for the for the fence for the fences for me It would mean multi modality there Anybody else have comment? All right, let's talk about this one 43 year old white female presents with back pain The back pain has been increasing over the last three months She's requiring narcotics to alleviate. She's had a 30 pound weight loss CT chest bone scan is negative all labs within normal limits except for an elevated alkaline phosphatase so Dr. Karam, you want to take me through this scan? What do you see? Well based on these two pictures as you always like to show one or two pictures stop whining There is a lesion on the left side of the abdomen The pictures aren't enough to tell me if it's coming from the adrenal gland or from the pancreas for all that matters Or from the left kidney, but whatever that lesion is. It's probably invading stomach pancreas and spleen among others At the kidney cancer association. Where do you think it's coming from? Well with you on the podium I don't know. So that's why I'm just covering all basis But let's assume it's a left kidney mass with invasion of the adrenal diaphragm spleen Pancreas and maybe stomach as well Okay, so you see a locally advanced tumor from the left kidney involving the back posterior wall of the stomach So for that's right here Involving the spleen which is right here Involving the posterior musculature and ribs which are here And here's more again more involvement of the spleen and also the diaphragm. This is the diaphragm right here There's two more pictures just for you So locally advanced tumor here And here this is the pancreas. So it's involving the tail of the pancreas You can see that right here. So again, just a review possibly posterior wall of the stomach the spleen the pancreas the muscles of the back Doctor, let's see doctor Tenir, what would you recommend for this patient and why? You know the this is a t4 disease t4 invading surrounding structures prognosis is Same like we were talking about a patient having metastasitolymph nodes that they're likely to have recurrence and Long-term poor outcome same thing here a t4 disease is associated with higher recurrence so in in the absence of a clinical trial and in the absence of metastatic disease and if You or serena or jose say I think we can Resect this then I think If you if you can resect it then I think Surgery is is one option if it is going to be as you say We're frequently a big whack and she's going to lose the spleen the tail of the pancreas muscle. I mean the stomach part of the stomach And you may not render her an ed with despite all this Then I think some debulking with medications with systemic therapy upfront would be the way to go Hopefully to do two things Render her render her disease resectable and second to give her Give us time to see how this disease is going to behave over the next say 12 weeks with systemic therapy If she responds and there is no evidence of metastatic disease elsewhere Then I think surgery will be the next thing to do if she does not respond and there is metastasis Then obviously we spared her the surgery So just to summarize your view in an ideal world if the surgeon said yes You'd send her for surgery if they said no you'd give her systemic therapy and then hope that the surgeons reconsider Depends on what the surgeon is going to tell me is going to she's going to require I mean if as I said she's going to require all those things spleenctomy Resection of the part of the pancreas Then I think systemic therapy upfront is necessary to try to String the tumors to make it You know more resectable with less morbidity post-operative. Okay, and what systemic therapy would you choose? I think you know you've upset her this looks like clear cell And I think you know again just because of the size and it's locally advanced involvement posterior abdominal wall And the pancreas and spleen and stomach. I suspect that she may have sarcoma to it So I would say this is a clear cell RCC with sarcoma to it features Um, what systemic therapy would you choose? Target therapy, uh, which one? Sunitinib would be an option What would you choose? Sunitinib. I mentioned it. Sunitinib. Okay. We keep saying it's an option Um, you happen to be sitting next to a surgeon perhaps that surgeon could weigh in without whining about the limited number of scans On whether or not this is resectable Uh, I mean it is resectable, but there's going to be a lot of organs coming out with it So I wouldn't really go for surgery as the initial step. I would agree with nizar I would get a biopsy first if it's clear cell Uh, I would You know, of course, my colleagues would treat the patient with targeted therapy I don't know if I would choose sunitinib first from the data that's been published It doesn't have as much of a primary tumor response to compared to other agents For example, such as exitinib or even as bezopenib. So I would choose one of those two instead Which one would you choose? Exitinib just because of our own personal experience here The response rates were close to 45 percent In a you know limited trial, but um, that's what I would go for So suppose the insurance company because exitinib as you know is only improved in second line Suppose the insurance company said no We'll start with bezopenib and Then if bezopenib fails, then we can go with exitinib as a second line. Okay If bezopenib works then it works and then we can deal with it. Does anyone disagree with that? No, I would just add that I am concerned that this is sarcomatoid renal cell carcinoma I would be concerned that this would be the sort of individual that a surgery Even if it's technically possible would result in rapid local regional disease regrowth I would want a biopsy and I would probably give this person a combination And I'm assuming that this is going to be clear cell renal cell carcinoma with sarcomatoid features And if that were the case, I would give a combination of gem cytobine plus an anti angiogenic agent Just parenthetically Exitinib or inlida is now on the nccn compendia as a category two in the front line setting So it is something that insurance company to do reimburse in the front line setting now So a combination of gem cytobine plus exitinib or gem cytobine plus bezopenib would be what I would give Okay, so the patient did undergo biopsy and it did demonstrate clear cell renal cell carcinoma high grade. They did not mention sarcomatoid de-differentiation Uh, the patient was treated with 12 weeks of neoadjuvant exitinib with a dose escalation up to 10 milligrams vid She had some significant toxicities including hypertension gi symptoms rash There was no dose reduction or drug holidays required to manage those toxicities. They were all well managed So here's the response Dr. Um, Karam, you want to wind through these factories too? So using the two CT scans that dr. Woods showing me I could see that the tumor has regressed some You could see the tumor on especially on the right side has moved away from the Spleen it's moved away from the vessels that you could see on a little bit on the left side of the tumor So looks like there has been some response And even a more obvious response in here I still don't see any enlarged lymph nodes Liver the the section i'm looking at looks good It seems to be to have moved away from the pancreas as well. Okay. So what would you recommend? Surgery, so you would take it a surgery? Yeah, it's 12 weeks. This is what we see that the response is going to be probably at the maximum If not if it hasn't happened already And if the patient still does not have any metastatic disease on the repeat restaging This is what we should do. So you take the surgery. Okay. And when you consented the patient, what would you consent them for? For left nephrectomy and adrenalectomy and lymph node dissection and possible partial gastrectomy Spleenectomy and partial Distal pancreasctomy And possible colectomy just it's close. It'll be fine. But just to be more upfront. Serena. Do you agree? Yeah, look, this is a great response. I mean it may not qualify as a Partial response technically but it's still from a surgical perspective. It's a great response. Does anyone disagree? We're taking this patient a surgery at this time Is there any point in giving more therapy? A little is good. More is better I don't think we know the timing when is the most optimal timing for surgery But we know if she does not have metastatic disease as you showed, you know There is you know evidence to suggest that Surgery is good in these patients with metastatic disease. So for people who don't have metas, but have a t4 disease There is even more, uh, you know A stronger case to be made to do surgery at some point. So I think we demonstrated her tumor is sensitive I think She's young and healthy and the resectable and then surgery is is that I think to do So the patient was taken for surgery They had resection of the left kidney the left adrenal The periodic lymph nodes the spleen and a portion of the diaphragm. We're able to spare the pancreas Uh patient had kidney cancer renal cell carcinoma clear cell type with extensive necrosis and therapy related changes for a nuclear grade three Invasion into the sinus adipose tissue perinephric adipose tissue diaphragm and spleen There was evidence of metastasis to let's see four out of 15 lymph nodes Dr. Karam, what are your thoughts? Um, still the pathology is very impressive. The patient does have uh pathological t4 And that puts the patient at stage four basically just the same category as metastatic patients And uh right now we just need to Let the patient heal from surgery and then if there is no I don't think the patient will qualify for adjuvant trials because she's already received Therapy, so I would just observe so you would observe after surgery. How frequently? At least every three months. Okay, anyone disagree with that? So patient's post-operative course was unremarkable discharged after seven days She comes back to clinic six weeks post-operatively complaining of increasing abdominal pain Her labs are within normal limits except for an alkaline phosphatase that's elevated and some anemia CT chest bone scan are both negative And this is her CT scan. You don't really have to be a radiologist to realize that this probably doesn't belong here or this So this is a classic appearance of a liver metastasis Um for this patient. She had multiple lesions present within her liver That were consistent with metastatic disease So dr. Gao I call you on the phone and say hey look. This is what happened. What would you recommend? So this is uh, this happens in you know, quite a population of patients after surgery So, uh, the theory behind this is you know, uh after removing the The tumor you can release some tumor cells and then can cause what's called the cytokine stone Which can actually serve as a growth factors for For kidney cancer. So, um, this is uh, clearly metastasis I don't think we need a biopsy to prove this. So and uh, so what would you recommend? So again, you know, um This is a young patient. Um, so, um I know with liver metastasis high dose i o 2 may be not a good option, but uh, but I at least you know For systemic therapy, I would refer the patient for for consideration of high dose i o 2 alternatively, um, you know A target agent such as suit and oposal can be used as well So what would be your primary recommendation if I we had to you had to put your neck on the block? What's it going to be? Really, I actually had patients like this in the past You know, I have a 40 year old Female patient who came in once she learned about high dose i o 2 therapy And she has she was uh, she's a nurse and then she has three younger kids She said I will go for high dose i o 2 therapy. So is that your recommendation? Um You're waffling come on come in. I yes. Yes, okay Dr. Tenir, do you agree with that? I would Enroll her on an anti pd1 or anti pdl1 trials immune checkpoint inhibitors. Okay in the absence of that. What would you recommend? I'm very tenacious. I'm going to get her on one of those trials or come talk to the company To her insurance company to allow to give it these these drugs are on the market I am very concerned that she did not really have a good response To an anti vgf agent within six weeks after 12 weeks of therapy with accident if she had She developed liver metastasis. So i'm not confident. I'm not Comfortable to treat her with another tki at this point I doubt that the mtor inhibitors are going to make any impact here in her disease So really in my view her only hope is Immune checkpoint inhibitors suppose you're in a place where there are no clinical trials available What would you recommend? It's Maybe then I will treat her with an mtor inhibitor everolimus with the hope that She may have her tumor. I mean obviously if we are We have access to study her tumor like we were talking earlier in the morning taken the nephrectomy specimen and doing a exome Sequencing or at least some target gene Mutational analysis, you know, whether you use the md. Anderson or the foundation one from Boston if she has a mutation in the tsc1 tsc2 mtor pathway Any of those genes mutated then I think she has she has a chance of having a gratifying response to an mtor inhibitor so off Without the access to this Molecular characterization and absence of immune checkpoints then I would treat her with Empirically with everolimus everolimus would be your choice in the absence of a clinical trial Can I add something here? By all means so if exotinib worked the first time on whatever at least was present at the time Why can't you try the same drug again and see if it works again the second time? I mean you can try it's just I think Uh It's disconcerting that She has an explosive disease within six weeks from therapy unless you believe in the notion that Exotinib given only for a short period of time, you know 12 weeks is not Very long time by any stretch of the imagination not short but not long and then with added storm of surgery Maybe we have contributed somehow With the to the fuel and made her disease angry and progressed so quickly We could not I mean I sort of agree with hosea Couldn't this represent that the exotinib actually controlled this metastatic disease and it didn't progress While she was receiving that therapy and that we're actually seeing the impact of vegf rebound I mean that is That's what i'm saying basically a short time of vegf blockade and then Followed by surgery may be one of the hazards of this approach of just a short time Followed by surgery in some patients with tumors like this having rebound Perfect storm surgery and vegf rebound of You know after you stop the drug I still Would be surprised if this lady did well with the target agents quote unquote That we have available dr. Yonesh. What are your thoughts? So obviously a serious situation we knew that from the beginning this patient's disease was locally very aggressive Which means that it's going to be aggressive Uh, she did I think respond quite well to the anti angiogenic therapy Ideally you'd want to give her something Better than what she was on before and if there was a checkpoint trial that was available I would certainly try to get her on that in the absence of that I don't think that anti angi re initiating anti angiogenic therapy would be a bad idea here And I think she is your patient or I think that's exactly what you did you restart her on exitinib Okay, so how did she do and we she was restarted on exitinib and Yeah disease disease has has stabilized for for a period of time and now Now other options are being explored Okay, let's see um Dr. Gao 15 year old white male presents with fever night sweats 20 pound weight loss and abdominal pain Symptoms have been progressing over the last six months performance status is one There is a family history of renal cell carcinoma and the patient's grandfather All labs are within normal limits chest x-ray is negative Here's the scan What would you recommend? So just for the audience there's a appears to be a lesion involving the right kidney here Yeah, so this is a very young patient with a right kidney mass so Normally, you know for kidney cancer that happens in younger patients. Uh, normally they they They could be clear sale, but normally they can be uh, it's very often their translocation renal cell carcinoma So, um, I think I would at least uh, biopsy this patient and see Um, see, you know the the the pathology of of the tumor. Okay, so you would recommend the biopsy Though you say If Let me take it back So, uh, of course also refer the patient to surgery to see whether nephrectomy is an option So, okay, so the patients referred to dr. Matin is surgery an option dr. Matin He has no disease anywhere else. No disease anywhere else. Yeah doing a frectomy So you would just doing a frectomy you would not do a biopsy Okay, dr. Cron. Do you agree with that? I I don't know that the the way the tumor looks like and the fever Makes me want to be sure before I take this guy's kidney out I would I would do a biopsy just the the fuzziness on the left side and just the location of that lesion Um, the fuzziness on the right side Or on the left picture. Oh of the right kidney. So So I would do a biopsy Yeah, just that just doesn't look right. Dr. Unesh, what are your thoughts? Biopsy Dr. Tonya So do we have blood cultures on this gentleman? This sounds like it could be an infection here abscess Uh, do we have I mean acting like now? New England general medicine cpc conference here, but uh, I think it's important to know White cells, you know urine culture. There is any infection of some sort All normal blood cultures normal urine culture chest x-ray no pneumonia nothing Yeah, I would biopsy because I think I agree with Jose This is uh It does not clear to me that this is renal. I mean renal cell Cancer, although, you know, obviously it could be Wilms. You mean, this is an age another the tumor in this young age group will be Wilms You know Lymphoma peanut, etc. You know, which is a Ewing sarcoma family of tumor, but I would think that this is an infection First we need to make sure it's not Definitely biopsy with cultures at the time of biopsy for pathology before nephrectomy If this were Wilms tumor, what are the implications of doing a biopsy? No, I mean You know, you may If it's Wilms tumor we treat them with depending on the histology They get treated with systemic therapy first chemotherapy is one and then they get surgery and then radiation So it's a trimodality therapy for this rare tumor Wilms tumor that's mostly in in adolescence But again, I would want to rule out here an infection As this abscess With the fever at night's Western, you know, I've seen the Wilms tumors sort of frowned upon correct? Not really It is no I mean the tumor and seed the tract and change the state so it changes the stage But I mean the nwts here they don't do that They just give the chemo and then hope it's or not hope but assume it's Wilms But the siop they just do it the other way I think they just do a biopsy first on everyone It like you said, I agree with you up stages the tumor But then they give chemotherapy knowing for sure it's Wilms So the audience the implication that if this patient has Wilms tumor you do a biopsy you change their stage You make them more advanced potentially you alter their prognosis By the same token if you just take their kidney out and it's you're wrong and it's not Wilms tumor Then you've taken out a kidney and a 15 year old who probably needs that kidney for the rest of his life Now Wilms tumor it he's not in the age Typical age group from Wilms. That's the only other thing to consider. So That's something that I was considered Adolescence 15 17 years of age. It's possible. You can see very rarely see it in adults But that's uncommon usually much younger. So a biopsy was done Which demonstrated acute and chronic inflammation with foamy histiocytes micro absceses reactive stromal changes and a biopsy culture Was performed which revealed ectinomyces, which is a fungus And the patient was treated with Ciprofloxacin metronidazole Returns completely asymptomatic There's an MRI doctor Mateen good job You would have had it in the bucket, man. So how did he get that patient that ectinomyces? You tell me Anybody have any comments? Would you do anything especially in the kidney? A great case a great case. I would write a case report All right Everyone hanging in there getting tired or no. We're good All right, we'll keep going So this is a 46 year old hispanic female who presented with vague abdominal complaints. She had no previous surgery. She's a hospital administrator CT chest bone scan negative Dr. Karam, would you like to whine about these films for us, please? So on the limited films that I see there is a mass present in the upper pole of the left kidney Okay, so there's a mass present in the upper pole of the left kidney See it here And based on these limited films that no one's going to hold you to what would you recommend? Seeing more of the films. Okay, and you've seen more of the films and they're not revealing in any way Laboratory studies metastatic workup. Metastatic workup is negative laboratory studies are within normal limits um I don't know what else to look. I mean, there is no More films to look at so I assume we can do a partial nephrectomy, but you would recommend a partial nephrectomy Would you do it open or robotically? Robotically You would do it robotically. Okay. Dr. Mateen. What are your thoughts? Yeah, that's fine any thoughts for neoadjuvant therapy in the setting maybe downstage improve your ability to do the partial or no No I assume she has a right kidney. Correct. She does. Okay So she underwent a robotic-assisted laparoscopic left partial nephrectomy at an outside institution the procedure was quote-unquote complicated It took them over 10 hours to do the procedure The patient was discharged at post op day five And then she returns on post op day 30 with abdominal pain and hematuria Dr. Mateen, what would you recommend at this point? Yeah, so, you know when jose and I answered we left a lot out because you know, we're getting we're getting clobbered here And you know, we're getting verbally assaulted by this moderator So he is mostly but um, no look, uh, it's a difficult location. So in terms of a, you know Jose and I are saying yeah, we'll do it But that's because we've got a lot of experience doing it and we also know that that's a bit of a more of a tricky spot So there's uh in the community There are a lot of people starting to do robotic partials, which is in some ways good because they're doing that instead of taking out whole kidneys But on the other hand, there may not be the realization that some cases are tougher than others And i'm afraid that this represents one of those scenarios Yeah, I mean would you actually sit at a console for 10 hours or would you no no enough? You know, I've you know, we've all learned the hard way or sometimes the easy way But I set time limits for myself and we always tell patients look at there's a chance we may convert But if I struggle within the first hour or two and we don't think it's it You know, it's going to take a while We just convert and do it open and try to do a good job that way Okay, but 10 hours is is alarming So the patient presents with abdominal pain and hematuria. What do you recommend? Yeah, I mean I would I would restager I would get a chest x-ray at the very minimum and also a CT scan and labs What are you looking for? Well, I'm worried about a complication But I'm also there's alarm bells going off about the 10 hour operation the fact that it was you know complicated I'd want to look at the operative note and So you you you worry about The typical things and then in the back of your mind you're also thinking about maybe even Atypical things that you would rather Not be the case, but I think it is the case here. What's the typical thing? Um, you know, there may be maybe like an arterial venous fistula Um, so basically abnormal connection with the blood vessels at the time of the partial nephrectomy That might explain the blood in the urine that might explain the abdominal pain What you really were in the back of your head if there was tumor spread at the time of the case and and and on In inexperienced hands That can happen and unfortunately all of us here have have seen patients refer to us in those scenarios So I'm I'm concerned this may be the case here. So you're going to get abdominal imaging chest x-ray and labs Okay, anyone different from that Uh, could we have the path report? It's coming it's faxing right now as we speak Okay, so the patient underwent imaging and it revealed evidence of A pseudo aneurysm, which is a dilation of the blood vessel or communication between the venous and arterial systems usually caused by Surgery partial nephrectomy. So how would you treat this? Yeah, so They're right there doing angio so they what they can do is thread a little thing up there and basically embolize um that area And in almost all cases they're able to control it that way and and stop the bleeding and still save the kidney So it's actually quite rare that for bleeding to have to take one of these patients back Typically the interventional radiologists They've gotten so good that virtually all these problems with bleeding after surgery unless it's you know emergent and life threatening They can manage with interventional radiology and avoid having to go back to surgery So patient undergoes embolization Uh, character is your pathology report t1b clear cell ferments grade 2 Margins negative although if you read the fine print The gross report says that the specimen was received in five pieces And initial post operative imaging is performed Here's your limited imaging Dr. Tenir. What are your thoughts? So the concern is uh, whether she has because of the uh Peace meal Surgery that there is tumor spillage and Concern about but the potential local recurrence in the left remnant in the left renal remnant So what would you recommend? I think it is She probably is going to end up with i'm send send her back to the to you or to ausia and serena She may end up having to have an infractomy So you're advocating doing an infractomy now or what? No, i'm i'm i'm concerned that she has recurrence because of the surgical mishap and that there is tumor in the Kidney you could Follow her after the embolization You know six weeks later two three months later See what happens post embolization if the bleeding stopped get get another set of scan I wouldn't rush into surgery because she doesn't have metastatic disease But i am concerned you would rush or you would not rush. I would not rush because you already the ir Physician did selective embolization stopped the bleeding. I would get another set of scan but Soon after the embolization maybe six weeks six so you'd wait six weeks and get another set of scans I would but i am concerned as i said that she may have recurrence Uh in the kidney because of the surgical mishap, okay, dr Karam, what would you recommend for this patient? I would definitely wait. I would not take this patient back to surgery. I think that's probably the worst thing We can do at this point is make a bad situation worse Uh, I would scan the patient every three months And even if I see something that's even suspicious. I want to see how that develops over time. So if I see a One centimeter or half centimeter lesion in the kidney or around the kidney I wouldn't necessarily rush the patient to surgery right away. I would wait because probably there's going to be more things that will Develop over time. So that way you can wait until all that is mature and then you can go and Do surgery to clean out that whole area? Okay, so you're saying wait and wait for evidence of recurrence and even at that recurrence not necessarily jump in With both feet just continue to observe it to let it declare its biology. Is that what you're saying? Yeah for a short time after we declare that there is now we're sure there is a recurrence. I would Um, you know be more careful and keep watching and then decide at that time if we should go back to surgery or not Okay, anyone disagree with that plan? No one would go in right now and do an impractical Yep, okay So observation was recommended the patient returns in six months with repeat imaging ct chest is within normal limits patient has No complaints Dr. Karam Six months have passed There's your ct scan You can see that there's Subtle evidence of something growing right there Basically in the same spot that the old tumor was What do you recommend and why? So, uh, I assume this is the only lesion that we see in the You assume correctly Okay, so this looks like a two centimeter recurrence at the area like you said of the old tumor So this is tumor that basically is residual that has had the chance to grow And this had grown relatively quickly in that six months period I mean the options would be number one to observe which I don't recommend at this point Looks like it's already grown big enough And then we've had six months to watch it number two would be to do ablation therapy Which should be relatively easy to access because of the posterior location and Number three would be to do surgery which could be either an attempt attempt at partial nephrectomy With a high possibility of doing a radical or just a straight Radical nephrectomy. So what would you recommend ablation? You would recommend ablation. Yeah radio frequency or crime I would let the radiologist choose honestly, but I think both are equally effective in this specific size and location It's far from the hyalum. It's not close to the collecting system. So either would be just fine. Okay, dr. Mateen, what do you recommend? Yeah, I like the idea of ablation Only because i'm still worried about microscopic disease elsewhere And I think this we see first only probably because it was the larger piece that was left behind So at least with ablation, you haven't burned any bridges. You can still treat what you see But still able to observe the rest of the abdomen and make sure that nothing pops up there I think it's okay to wait a little while longer just to see if anything develops But otherwise, I think it's okay to pull the trigger So, yeah, I mean otherwise, you know, basically agree with Jose, I think it's fine if the patient really just wants surgery done But there's going to have to be an understanding that it's going to be a higher risk operation. It's going to be very scarred Uh, the spleen is right there. It could be at risk Um, it may not be possible to salvage the kidney. I think probably could But you know the risk of bleeding and things like that would be a little bit higher Aren't you concerned? I mean so you the one of the points you brought up is that things are going to be really Socked in which I agree with Aren't you concerned with radio frequency ablation or cryo ablation that there's a significantly high potential for injuring the spleen? Um, it's close or inadequately treating the tumor. Yeah, no, I think in good hands. It should be okay There's enough of a margin there where you could still treat the margin and and spare the spleen A little extra burn on the surface of the spleen wouldn't be it shouldn't be a big deal And then in terms of it shouldn't really make subsequent surgery that much more difficult We've got a fair amount of experience with that and if the treatment is done percutaneously You do get a reaction, but you really get that reaction to localize to the area of the tumor Anyone differ on that? No one would recommend upfront surgery I mean would you know talking to the patient Obviously it's a very important Uh, you know thing we need to do And you'd give her an options you could do rfa or cryo or partial or radical I think you know The patient is going to have to weigh in also what she prefers Haven't had that bad Complication happen and the mishap, you know initially Bleeding an aneurysm, etc. And now recurrence of the tumor because of Inadequate surgery upfront. So my if she was my wife My sister I would probably say, you know if It would be best to do the redo or completion nephrectomy Will do completion nephrectomy rather than rfa and potential. I've seen they don't they're not luckily They're not common. They're rare, but I've seen so many complications with rfa and cryo That I'm Yes I mean not that I've done them other people have done them, but I've seen them Uh, and in those are the ones that you remember. I mean if there are only three cases Uh, and you remember those three cases vividly Then I think the option of rfa cryo would be the lowest on my list of uh, recommendations and I would do a Uh completion nephrectomy in this lady So hosay you looked at our data with with radio frequency ablation a few years ago Do you remember roughly what the? Complication outcomes were Uh, I mean the major complications were quite minimal And I know the cases that the czar is talking about and that's pretty much it I mean the three to four cases. So we looked at our x one hundred and fifty So the major complication rate requiring further procedures is typically less than five percent. So it's really Unusual, but when they do happen They are memorable But the same thing could happen with surgery as well. So surgery is not without its own complications And um, I think it all comes down to patient selection. This tumor is posterior. It's far from the hyalum It is close to the spleen, but I think the chance of any Major complications such as injury to the whole kidney or to the spleen or to the colon Is extremely low in this scenario. So I think this is a good patient for ablation if the patient chooses to do so So again, I want to point out the irony the surgeons are saying don't do surgery and the medical oncologists are saying do surgery Um, we actually took the patient to surgery for an attempted partial nephrectomy. Everything was stuck to everything We actually ended up having to resect a portion of the diaphragm She kept her spleen, but we didn't end up Doing a radical nephrectomy because partial wasn't possible Can you tell us why didn't you, uh, do what your colleagues, uh Ablation you know quite honestly, I have the sort of same attitude as you do and I vaguely remember talking with some of the Interventional radiologists and they were concerned about getting A proper zone of ablation because of things being so scarred in from the embolization of previous surgery Okay, um, this is a 78-year-old white female. She has an incidental renal mass that was discovered during surveillance for her breast cancer She has a few medical problems hypertension diabetes atrial fibrillation depression She these are the medicines she takes metastatic evaluation otherwise negative Her labs are within normal limits except she does have renal insufficiency. So normal gfr should be around 100 hers is 50 There's the mass right here in the right kidney doctor, um Tenir, what would you recommend? We can observe it. This is a small mass. She has comorbid illnesses Uh, I think if she would qualify to be enrolled on Surena's protocol of active surveillance It is uh, it is likely that she may not require To have anything done for this in her lifetime But it we will observe her and I think we do scans every six months And look at the rate of growth maybe one centimeter or less per year is is not bad and maybe we can spare her surgery Um And again, it we talk to the patient and see what the level of anxiety and whether they want to intervene or they're happy To follow this with active surveillance. So you'd recommend active surveillance I see just a small renal mass. That's cortical and uh, yes, I think she's elderly. She has comorbid illnesses I mean you could argue what she had. Didn't you say she had breast cancer before? You know, uh, is this a second primary? Uh, most likely it is It's unusual to have breast cancer metal slides to just like this Cortical uh one kidney without disease elsewhere. So it is unlikely extremely unlikely that this is breast cancer Um, so you could biopsy it if but if I like to offer surveillance anyway, so I biopsy I would say This is not breast cancer. This is Reinal cell, but it's small and I would I would follow it without a biopsy Okay, so you'd recommend active surveillance. I would okay Dr. Karam. What would you recommend? I would recommend active surveillance with possible delayed intervention if the tumor is growing fast. Okay. Would you do a biopsy or no? Um, I would talk to the patient about it, but I wouldn't do it. You would not do it. Okay. Dr. Mateen. What would you recommend and why? I think surveillance is fine. Do we don't have non-contra do we have non-contrast phase? In other words, it's not an angiomyelipoma. No, it's not could look like that. So No, I think active surveillance is a reasonable initial option unless she was very eager to just have it out You know the other scenario we get into these days Is insurance issues, you know patients may have insurance for a while. They're not sure what's going to happen a couple of years from now That's the one problem with surveillance is that you kind of assume That your scans are going to get paid for years down the line when this is still being surveyed But I've had patients being tenuous situations in that regard where they don't know if they'll have insurance a year or two from now And they just want it out and taking care of so You know, that's what drives Patients decisions sometimes even though we don't like to think that it's an influence It is so what would you recommend? Um, no, but I think in my initial suggestion would be active surveillance I do I offer all patients biopsies. It gives us an opportunity to be informed And to be proactive about any changes that occur. So you would recommend a biopsy. I would recommend it. Yeah, okay. Eric, what do you think? The patient's on warfarin I think it ends up creating a whole bunch of logistical challenges and having been there Unfortunately with some of my patients where well-intentioned Crossing the t's and dot in the i's results and other complications. I would not biopsy. I would observe Okay Patient was biopsied ultimately demonstrated on quesitoma Which is a benign tumor by the way You guys doing all right So the implications of that are that Basically, it's a non cancerous tumor And what we've learned from the biopsy is that we don't really you could say she doesn't need any follow-up But we do know that these grow Um, truth is even if they grow, I'm not sure we do anything unless they get really big But the risk of it becoming metastatic or causing the patient harm is really quite low So in those cases, I still follow them, but I follow them much less intensively right Okay Uh 59 year old white male presents with a palpable abdominal mass no urologic symptoms Performance status zero eight pound weight loss over the last three months all labs are normal MRI the brain is negative bone scan is negative So here's a locally advanced tumor Involving the left kidney Again involving maybe the posterior psoas muscle possibly And Evidence of disease in the lungs So, um, just go down the line. I want a yes or no. I don't want a speech. I don't want Blossophizing would you offer this patient cytoreductive nephrectomy? What's the performance status? zero Eric yes or no three you would offer three. Okay Uh sarana Yes, yes number one. Okay crumb Yes, I would have done three if it was on a clinical trial, but off trial I would go for surgery Okay, so you were only in the context of a clinical trial Would you consider pre-surgical therapy because I think he's resectable at this point. So okay. All right bizarre one. Yes Okay, and yes. Yes. So we have one pre-surgical and everyone else is take the kidney out And um, eric just to clarify would you do pre-surgical even if you didn't have a clinical trial or would you put them on a clinical trial? Yeah, I think this is a case where you perhaps would end up making the surgery a little bit less And we've got pretty good evidence that you can shrink it down. So I I see very little downside to choosing three So the patient was enrolled in the synanib pre-surgical trial He had a biopsy of his lung lesion which demonstrated metastatic clear cell kidney cancer He received two courses of synanib and then was referred for surgery Here's the response Still maybe a little bit of invasion of the psoas muscle But overall fairly satisfying response within the primary tumor with regards to central necrosis not a lot of shrinkage to the primary tumor And the lung disease basically looks relatively stable. Certainly no dramatic regression No dramatic progression um, so Let's go down the other way jj. What would you recommend? So in this setting you can you can do two options one Apparently you can continue to treat the patient, but the patient didn't respond that much in the primary tumor It's also reasonable to watch the patient. So what would you recommend? so you know often If a patient is on already on a tki such as Sooner to me sooner to me if you if you stop the treatment you can have this rebound phenomenon Okay, so in that case tumor tumors can grow very rampantly. Okay. So would you recommend? I would I would recommend a continuous internet. So you'd say continue synanib. Okay Dr. Tania, what would you recommend? So, I mean since the patient is already already enrolled on a clinical trial and the trial, uh, if I recall does Uh, you know encourage patients to stay on trial and if they have stable disease like this gentleman has Or if they had a better response more tumor shrinkage Then they'll go for their cytoreductive nephrectomy and then resume their systemic therapy with synanib postoperatively So I think to follow the the spiritual trial the patient enrolled on the trial with the hope that we learned something Uh, and I think uh the patient Uh, and we behooves us all to follow the spiritual trial and go with uh two option number two So you choose two. Okay. Jose just number two number two So today I would offer actually, uh Six it's two or six is fine Two three months from now when we have our immunoblation trial the patient would actually be a candidate for that Now we talked to him about it and what that would entail is Ablation of one of the lung tumors One of the lung lesions starting ctla4 or being yeah starting ctla4 and then doing a Psyderductive nephrectomy three months later. Okay So the overall assessment of the disease was I didn't think you'd say much different Overall assessment was progression of disease in both the lung and primary But still an excellent performance status and as part of the protocol he was taken to the operating room For cytoreductive nephrectomy. Here's his pathology Locally advanced tumor nuclear grade three invasive into the renal vein renal sinus perinephrogatopost tissue We found a nodule on the diaphragm which revealed metastatic renal cell carcinoma And also we took out a right adrenal mass. I don't think I showed that which showed Let me go back Yeah, there was a small mass here Okay, so did you take both adrenal glands? No, we left the left adrenal. Okay Um Actually, no it says I think we took the mass out of the adrenal left the right adrenal That's what it was because the adrenal gland was present in the left So postoperatively the patient had a superficial wound infection a psoas abscess that required drainage and antibiotics Unfortunately as a consequence of cytoreductive nephrectomy and the complications associated with it systemic therapy was delayed by four months His disease progressed slowly as he recovered. He was started on everlimus And his disease was stable at last follow-up And I'm actually happy to tell you that this patient is in this audience and it's unbelievable To me that he's Here and doing well congratulations all right We'll do one more and then we'll call it a call it a day. I think 47 year old black male With supraclavicular adenopathy. So lymph nodes that around the collarbone on the left side performed status one No comorbid conditions brain The MRI brain negative bone scan negative Biopsy of the supraclavicular lymph node reveals type 2 papillary renal cell carcinoma So here's a picture of his scans. You can see a very large tumor involving the left kidney With bulky lymph nodes present in the periordic enterotic cable space Shown there And also evidence of disease present in the hyalum of the lung So these are the this is a lung CT and you can see there's some enlarged lymph nodes present here in the hyalum So what would you recommend? Let's go down the line. Eric Would you do an upfront set of reductive nephrectomy? If so, would you do a node dissection and how complete would it be? I would not operate on I would not operate on this patient I would start a mone systemic therapy and I would papillary type 2 Can have met up regulation like type 1 Although it's less common. I would try to get awfully well. Cabal zantinib or put the patient on a clinical trial Okay, and if you couldn't get the cabal zantinib what would be the standard of care treatment? The really for papillary the standard of care is essentially Whatever we you know would be an anti angiogenic agent or an mTOR inhibitor and I would probably choose an anti angiogenic agent I would start him on soon as you know Okay, um Serena systemic therapy. Which systemic therapy would you choose? I don't know Well, you know, that's what these guys do. I mean and you know for papillary type 2 it's You know, we're still figuring it out. Do you have an opinion? No, excellent. Dr. Cron. What would you do? To give you the short version. I probably wouldn't operate on this patient. I would do I would refer to our to my colleagues in the medical oncology for systemic therapy So you refer for systemic therapy and what if you had to you know, give your two cents Which you always seem to be happy to do what would be your choice of systemic therapy? Cabal zantinib like Eric said, uh, if that is available, we know the other The therapies don't really work very well from nazar's trial the espn trial the synatinib versus everlimus The results the results aren't that different But that would be the alternative if cabal zantinib or metinibiters are not available What would be the alternative synatinib or everlimus? Okay, which one would you choose? synatinib, okay I agree with what's been said already. Uh, I would recommend systemic therapy. Not that we have effective Uh, therapies, but I think Surgery is with this patients disease and the supraclav lymph nodes and the lungs It's unlikely that uh, surgery is going to serve him well up front I agree with cabal zantinib And but I would try to Enroll the patient on a clinical trial and as we mentioned earlier. There is a trial that we're going to open here Hopefully in the next few weeks With a simet inhibitor from astrazeneca. So I think that would be my first choice. Okay, dr. Uh, now So I think a couple of zantinib or simet inhibitor will be a Reasonable option, but in the meantime, I would send the patient tissue For a genomic sequencing. Uh, just try to see whether we can figure out any targetable mutations Um, if this patient has, you know, some targetable mutations, I would refer him to phase one The clinical trial group For possible target therapy Okay So let's just assume for a minute. Just let's pretend that's not pretend. It's actually real. This case is actually an old case It was uh, the guy presented like 2004 Okay, so 2004 we have no targeted agents of any kind Let's come back down this way. Dr. Gal. What would you recommend it in 2004? Uh, so 2004 that's uh, you were what in high school? Yeah, I uh, I was still in medical school at that time, sorry But at that time, I think uh, saranthinib was not even available. So um, so the only two therapies available at that time was uh, Io2 and interferon. So, um I mean, it's not unreasonable to to try interfering on on this patient. So you would try interferon. Okay. Nazar, what would you recommend? Did you say that the patient was symptomatic from his primary? Yes, sir. Grassy materia. Yes, sir. Yeah If he's symptomatic and we're in 2004 no trials. No system. No FD approved target agents then I would send him to you for surgery. Okay, dr. Uh, karam Looks like you're describing the dark ages. But yes, we'll I think at that point in 2004 Without any Advances, I think surge would be the the first option. Okay Yeah, I remember those days, um You know, I'd been in practice about three or four years And you know, we we did we did surgery. We didn't have anything We were just coming off of the reports of of side reductive nephrectomy providing a benefit and clear cell patients But we were we're riding that wave because we really had nothing else to do I mean that report came out in 2001, right? So, uh, you know, it was soon after so that that's what we did That's all that's all patients and us Really had available. So yeah, we'd have done surgery. But the symptoms are a good point And that's another major driver of doing surgery Eric, what do you think? I think back then we were getting our hands on bevacism up Already for because it was approved for I would I would Consider surgery or also we were giving our lot in them, which is that Plus bevacism up, which is an egf receptor inhibitor plus a vgf antibody Okay So the patient actually was taken for surgery And had a lymph node dissection as well as the resection of the primary tumor and then Was referred over to you guys and I think they started I think you started them on something like for a lot No, as I recall Um It's two o'clock I think maybe Because first of all, do any of the patients or caregivers in the room have any questions? You have a trapped audience. I'd please don't make it specific about your case But if you have any questions now would be the time to ask anyone Okay, it's all clear All right. Well, listen, thank you very much for attending this conference. It was our pleasure to uh to Provide this educational experience It's a it's really great to see a lot of you that uh, you know, we have come with us on this journey And we look forward to seeing you at our next conference next year Special thanks to my assistant carol who without her help. This would not ever happen Thanks and have a great afternoon