 Good morning, everybody. Thank you for coming. I'm setting a timer. I wasn't playing with my telephone Just I want to make sure we stay on time and there leave plenty of time for questions So what I thought I'd do over the next 25 minutes or so is that go over the evaluation and management of a small renal mass? This may not apply to Many of you who are here as survivors, but yet now you are The facto source of information for your family and friends also who may come to you with their own personal Dilemmas if they're diagnosed with a tumor in their kidneys. So hopefully this will provide some background information for you I'll spend a little bit of time on evaluation and really focus on Manage management aspects so in terms of evaluation briefly what we as a Standard baseline like to do is get a history and physical talk to patients We want to look for other signs and symptoms that may need additional workup In terms of a small renal mass. They are invariably nearly all Silent they're usually caught incidentally. So really what we're also trying to look for with the history and physical is to assess overall health What we call competing risks. I'll tell you what that means and tolerance for anesthesia and surgery If you mind don't mind. I'm just going to check one thing here to make the pointer more friendly We'd like to get a scan of the abdomen. That's where the kidney is So if there's not one if there's for example, just a simple ultrasound We'd like to get something more detailed with a contrast enhanced CT or MRI We don't really have to cover the pelvic portion in many cases and in fact insurance will refuse to pay for it Or if what was done sometimes they'll not reimburse that so in today's age of much more attention to Cost that is just one little detail to point out And then we'd like to look at the chest either with a simple chest x-ray or if indicated a CT scan Because kidney cancer as many of you might know it likes to go to the lung more so than anywhere else Very unlikely to do that in the case of a small tumor in the kidney But still it's just the baseline evaluation and the chest x-ray pretty simple thing fairly low radiation exposure and then we get blood work Primarily to look at the metabolic profile and more importantly to let get the serum creatinine level which we can use to calculate Kidney function which we call the estimated glomerular filtration rate or GFR Which gives us an idea of what the overall kidney function is So I mentioned this idea of competing risks and it's something that we're much more aware of now than we were Let's say 20 years ago where we sort of had a one-size-fits-all approach to people with two patients with kidney cancer And the idea here is that there are a variety of factors out there trying to kill patients One of them is the tumor and if it's cancer it could grow Worst case scenario it can spread and become incurable of course That's part of our goal is to try to avoid that and in the process of growing. Maybe it would destroy more kidney and Patients would lose more kidney function on the other hand. What's pulling on your life are these comorbidities? diabetes high blood pressure heart disease strokes etc and So with that there is a risk of us intervening because maybe there's silent heart disease that's on diagnosed We don't want to go in and treat something and have you risk getting a heart attack because we didn't think thoroughly enough about that there's the idea that Maybe what we're gonna do isn't really gonna help you from a cancer perspective because there's so many other medical conditions that that's really what's gonna Be the end of life and then secondly the issue of things like diabetes or kidney stones harming kidney function already and on top of that if We're going to intervene then we may Cause more loss of kidney function So these are some of a few of the competing risks that we consider when we're seeing patients So how does that translate to real life? Here's a study that looked at patients who were treated for a small tumor and then looked at their comorbidity status So how sick were they so a Charleston zero means they're pretty healthy a Charleston three plus means you know what? They've got a lot of medical conditions. So what's their survival of these different groups like I'm not gonna look at the bigger tumors Let's just focus on this row and what you're gonna see is blue and red blue means the risk of dying from non kidney cancer causes Look at how overwhelming that blue is compared to the red the red is the risk of dying from Treated kidney cancer not that they watched it, but they got treated But the point is that once it's treated the risk of dying of kidney cancer is so incredibly small compared to the overall overall other risk and it makes you wonder that maybe some of these patients did not necessarily have to have treatment for this Especially once you get to these issues to these patients who have many more comorbidities and have such a much higher risk of dying Now if you look down here with a smaller tumor in a healthy patient You can see that the risk of dying of kidney cancer is almost equal to dying from non Kidney cancer causes so obviously the risk-benefit ratio there is different But again, we're just focusing on the small tumor mass which we define as those being less than four centimeters So the other factor is that we're born with a tremendous amount more kidney function when we're infants and toddlers and teenagers But we lose it over time as we get older just aging processes And then if you add to that diabetes and high blood pressure, then you lose it even more quickly And unfortunately unlike the liver and lizard tails We don't regenerate kidneys. Okay, that would be a huge advance if somebody figured that out Kidneys don't really regenerate. So once it's gone, it's gone The other question that we get is, you know, why do I have to have this injection during my scan? Do we really need it? And here's to give you a couple of examples of how big of a difference it can make Here's a patient actually saw just recently and initially they thought the patient had a kidney stone So they got a scan what they see is a cyst in the kidney. No big deal. We don't really worry about those There's a little something here But this is a non-contrast study It's basically like going in a dark room and trying to make things out when it's sort of everything's kind of dark when we give contrast the lights up the blood vessels and lights up portions of the kidney and Tumors tend to light up either more slowly or more quickly than the rest of the kidney so then we can tell what's going on So suddenly you see that there's something here The cyst is there. It's much more pronounced. We don't really not really worried about the cyst But now we see this tumor and To just get a little bit more Detailed with you. It's not just even about giving contrast But it's about doing the scan in a proper way so that the timing is done well So that's why sometimes when patients come see us we emphasize look we want to get a scan here Or we have to repeat your scan or your scan wasn't quite what we needed when they're done elsewhere and it has to do with these Important details where the devil lives because then if you skip it then you may miss something and so here's another example Here's a non-contrast study. You see a couple of little things going on here, but overall the kidney looks kind of normal When we give contrast that you know there you see this black spot You see this looks a little funny and this is done in an earlier phase after the contrast has given Maybe this is done about four or five minutes after the injection But then if you give it a little bit more time and let that contrast circulate and just sort of Equally distribute through the tissues then we get a better picture of what's going on and suddenly this was nothing This is just some fat inside the kidney But lo and behold there's a tumor there in the kidney that was completely not seen and not really well So this could have easily been skipped the radiologists easily could have missed it any of us could have missed it But now it's really well-defined where it is okay, and the other thing I wanted to show you is that the scans don't really help us differentiate between kidney cancers the most common being clear cell or papillary and They don't really help us distinguish that from benign tumors such as oncocytoma or metanefric adenoma Which is an unusual one that we sometimes see they all pretty much look the same on CT scan With some rare exceptions for example, sometimes we can kind of guess semi in educated fashion that it's a papillary kidney cancer So just to give you some of that baseline So we talked about considerations kidney function patients health and vitality competing risks And then we'll talk about treatment options and some of the clinical guidelines that are out there And then I'm going to close up with surveillance after treatment So we have certain guidelines from societies. There's the American Urological Association AUA There's the National Comprehensive Cancer Network NCCN, and then there's the European Association of Urology the EU the point I want to make about this is that the guidelines that they used to have These groups have proposed you'll see a lot of similarity. There's some subtle differences. They're not based on hard evidence They're based on a group of people coming together in a room and its consensus because we don't have Great high-quality scientific evidence and what I mean by high quality is like a ton of randomized studies for example We have very few of these in kidney cancer actually especially surgical management So a lot of times it's based on the strongest personality of in the room or the most senior person and How those discussions go and that's what we call consensus So in terms of the American Urological Association guidelines that I was a part of and helped develop in 2009 at the time We considered partial nephrectomy a standard approach, which means this is pretty much You know top-tier choice Radical nephrectomy was also standard because we couldn't achieve Agreement on whether it should be maybe a level lower Because we lose much more kidney function with that and then active surveillance or ablation Was given as a recommendation, which is yet a step lower of Guideline and then an option is really like bottom. It's like yeah, you have this option But you know kind of really can you please think about it is what that means. There's all euphemisms in terms of providing guidance to the urologist The NCCN is a little bit more clear They prefer a partial nephrectomy for a small kidney tumor a radical nephrectomy only if a partial is not feasible Surveillance in selected patients and ablation and patients who aren't surgical candidates and somewhat similar for the European guidelines So those are some of the options that we're going to talk about next We're not really gonna at the very end. I'll talk about radical nephrectomy very briefly We remove the whole tumor and it's still an option for very big tumors or people with multiple tumors in a kidney But I'll talk about open partial nephrectomy Robotic partial nephrectomy, which we're doing more and more often a blade of therapy and also Active surveillance. We'll actually go in this order So that's a lot of options and so hopefully I haven't lost you and if I have I'll make it clear by the time We're done before we get to those the other question that comes up is what's the role of biopsy that frequently comes up patients who have dealt with cancer before frequently ask for Patients who haven't and it's their first exposure to Medicine they they're worried that maybe the biopsy is going to spread cancer and we have to allay those fears Traditionally what we have done biopsy for is to rule out maybe spread to the kidney from something else like lymphoma Or if the patient for example has another cancer and now that we find something in the kidney We worry maybe it's spread to the kidney so biopsy in that setting is pretty good and for decades We had considered that an option To use it to diagnose what the actual tumor of the kidney is it's not something that we've felt confident with until the past few years Because techniques have gotten better both the biopsy techniques have gotten better, but it's also on the other side sort of in the back door Behind the back door where the pathologists are working They've gotten better at being able to tell what these different tumors are because not only do they look the same on CT scan and they look Very similar when we cut into them and look at them Even under the microscope sometimes they can look similar and again that devil is in the details for them to be able to pick apart those specific Factors which identify them as cancers or benign tumors So things have gotten much better over the past I would say within the past 10 years You may be even a little bit less I think your accuracy is probably around 90% depending which institution you look at a little bit higher a little lower Occasionally still get a non-diagnosis from a biopsy but much less frequently than we used to and of course with contemporary techniques We really don't see this issue of it spreading any cancer. There is some risk of bleeding that risk is pretty low in good hands The other little important detail is that there's a couple of different biopsy types in Areas where not they're not very comfortable with doing this all they do is basically an aspiration Which means all they're doing is sucking out some fluid from inside the tumor because this way they can use a tiny little needle And the risk of bleeding is less and they're less nervous about it The problem with that is is that it gives the pathologist who is then has the obligation of trying to diagnose this very little tissue to go with and So with that you it's not unusual to get a non-diagnostic result. They say well the cancers look blue So it could be cancer. It could be not cancer So it's hard for them to tell with a larger needle. They can actually get some more tissue And so not only does a pathologist have more tissue at that point, but they can actually do these new chemical stains That color different molecules different colors and those molecules are associated with either cancer or benign tumors and they can actually do panels or six or eight of Them and then based on the combination of those they can actually with pretty good confidence say hey, this is cancer This is not cancer So biopsies pretty good for certain things they can tell us for example Clear cell type versus the non-clear cell type of kidney cancer It's not quite as good for telling high versus low grade and then if you want the exact grade like one two three four And that gets pretty bad and then if you want to look for the rare very aggressive variant like what we call sarcomatoid It's really not good for that So you have to think about what you're looking for and order it appropriately and there are we don't do it in every patient But sometimes we consider it when we think it makes a difference and here's an example. Here's an elderly patient that I saw Very poor kidney function Patients usually think of GFR as a percentage. It's really not But it helps to think of it that way if you want to it's reasonable to say that Patient has about 30% kidney function compared to normal And it's a tumor that we found incidentally that really is a size where we're not too comfortable watching it So we discovered we discussed doing a biopsy and it was done under MRI You don't really see the metal because it doesn't show up on MRI But they did both an FNA an aspiration and again We don't did not get a diagnostic result from that But they also did a biopsy where they got tissue and they did multiple stains and What they're favoring is an oncocytoma it looked like an oncocytoma and the stains confirmed that this was consistent with one So we got a pretty confident diagnosis. This is a benign tumor. It's not going to spread It's not going to harm the patient except that it may grow over time it may so we kind of want to keep an eye on it But the bottom line was that we will felt very comfortable telling the patient, you know, what I Don't think you need to have anything done. Why don't you come back in a year? And we'll take a look at it and make sure that it's not going to harm your kidney function So it can make a difference depending on the right setting So it goes to this idea of active surveillance for certain patients now That was a benign tumor not a cancer and so when we do active surveillance quite frequently we're doing it either for known or presumed kids small kidney cancers and This was something that started to be popularized in the late 90s We did not have much information before then because basically somebody showed up with a tumor in the kidney It didn't matter how big it was that kidney was out And so we learned over the time that you know Maybe we don't have to remove all of these and maybe we're harming more patients by destroying their kidney function when we do That and in fact multiple multiple studies have been published even more than what I show you on the slide And what these slopes show was the rate of growth of these tumors and on average what we see is about a point two five to point four five centimeter Growth per year So we take that upper limit of that point five centimeters as sort of the maximum we're willing to accept when we're watching these tumors The other piece of information that I'm not showing you is server certain several studies that show that when cancers are less than three centimeters their likelihood of spread is exceedingly low It doesn't mean it doesn't happen. It just means that the likelihood is so low. It's probably less than 1% And so for these smaller tumors We're fairly confident that we can usually watch them at least for some time depending on the patient's scenario if we need to And so generally and if you if we look at the overall Publications a 2% rate of metastatic disease But then if you look at these cases, they are all you know, most of them are bigger tumors They weren't exactly less than three centimeters and some other factors And of course it's associated again larger tumors and those that grew more quickly were the ones that were bad players So you do have to keep an eye on it This is our own data is somewhere around 2006 2007 We started a registry for patients that we put on active surveillance and this shows actually the growth of tumors over the Course of two years each little column here is a tumor single tumor and how much it grew over the course of two Years you can see that the overwhelming majority Grew one centimeter or less within the course of two years There are a few bad players that we caught along the way and we had to intervene You can see that it's some of them even shrink for reasons that we don't fully understand So the other question that comes up is is it is it risky to delay management and again? Metastatic disease at least in our situations exceedingly unlikely and if we do have to intervene We usually haven't burned a bridge We still have all these options available and whether it grows or not doesn't tell you if it's cancer We see cancers not grow and we have benign tumors that we biopsied that we know are benign and those will grow So the fact that it doesn't grow or does grow doesn't tell you much about what it is So it's a pretty reasonable treatment options for very select patients if either they're unfit for surgery There's competing risks. We have a few that just flat out refuse surgery. So we watch it It does require personalization and the patients do have to agree to come back to get it followed up Want to spend a couple of minutes talking about ablation and with that I mean either freezing the tumor with cryoblation or heating it to very high degrees using radio frequencies Cryoblation has been around much longer and the idea there is that basically we can puncture the tumor with a specialized probe This shows it being done laparoscopically although the majority of these we now do percutaneously and interventional radiologists Our collaborator Puts it through the skin while the patients asleep under MRI or CT and can guide it right into the tumor and basically what you get Is an ice ball that essentially destroys all that tissue and then we leave everything there And then what we have to do is basically get scans over about three of them or the over the course of the first year This shows the tumor beforehand at one month. You see how the kidney is white There's contrast, but there's no white in the area that we treated meaning there's no blood flow no blood flow no life So that's good in this case and over time what we'd like to see is that the area? Not only does it have no blood flow that but that it shrinks and that gives us confidence that it's fully treated Radio frequencies ablation is the same idea except it heats the tissue and this is This shows these this umbrella shaped wires or what actually We withdraws in this we we put the probe in and then we Expose those wires and that what's that's what causes the radio frequencies You see a bunch of steam being generated because it's heating up the tumor to very high degrees And then that said once we think we've gotten the whole thing again We actually this shows it being done percutaneously through the skin without even any surgery And then same thing no blood flow and over time we'd like to see it shrink So we have to get scans afterward. That's one downside of doing this procedure The other downside is that even though the results are pretty good These numbers are not quite as good a surgery as I'm going to show you But that's also in the short term because when we did these analyses We did not have long-term follow-up like we had with surgery So the techniques have gotten better also over time So we reserve this for that reason for elderly patients or who those who are higher risk And maybe we have to intervene a lot of times I'm treating patients who have we're on active surveillance and the tumors are growing and Patients are nervous and they say you know what I think I want to get it treated And we're still kind of worried about their medical situation. So then we fall back on this option and There has to be a verbal agreement to all of these factors with the patient in terms of the biopsy before possibly after And then making sure they come back for follow-up The one thing that does not relate to small kidney tumors And you may hear about it later today from one of our medical oncologists and what we're very excited about This idea that we can kill the tumor and keep it in place What happens is you're creating this tremendous inflammation and an opportunity for immune system To maybe start recognizing that there's a cancer there because up until that point the cancer has been able to create this Immunogenic wall where it doesn't allow the body to recognize it So we actually have this clinical trial that just opened and the idea was fairly novel although Novel in that we were able to get it approved and done But it's something we a lot of people have been trying to do But the idea that patients with metastatic disease We can actually perform ablation in one area where the tumor is and then give them these new this new generation of Immune compounds that basically allows the immune system to unleash its force against the rest of the cancers And so we have this trial that's opening up and it's basically after the treatment is done We go in and remove the primary kidney tumor and then we continue the treatment with the immunogenic compound afterward if we see that there's a benefit Want to spend the next couple minutes talking about partial nephrectomy? It's a very good option and it's we could what we consider the reference This is an example of a patient with a essentially solitary functioning kidney the other kidney was shrunken down not working well was sent to me with this large tumor and In cases like this we can really do a complex but quite effective partial removal be able to preserve the majority of the kidney And as it turns out actually that was a benign tumor the patient's kidney function was totally unchanged Here's another situation of a tumor that's deep inside the kidney surrounded by critical structures This is where the urine's collecting the blue arrows show where the tumor is Here's again the tumor a different view This is the urinary collecting system, and then there's also in these red arrows point out all the blood vessels surrounding the tumor So that patient was given the option of attempting a complicated partial removal versus removing the whole kidney And patient wanted to have the kidney try to be preserved, and that's what we did It's a fairly complex approach We have to do ultrasound to see exactly where the tumor is because we don't see any surface landmarks We then have to start doing this micro dissection of the blood vessels and the collecting system away from the tumor And then we actually stop the blood supply to the kidney. That's why the kidney looks pale here And then this way we can work in a bloodless field where we're cutting through the kidney and make sure with every cut That we're not getting into tumor And here it is you didn't even see any cancer because it's all surrounded by normal tissue And what we can do is preserve the majority of the kidney This shows that kidney after the tumors been removed blood vessels that are tied off and then we reconstructed Reestablished the blood flow. You can see the pink kidneys nice and pink. This is what the cancer looked like It was a clear cell renal cell carcinoma, and you say, yeah, that's all fine and good. How does this patient do? Well, this is the CT scan six years later. It's doing great Okay, no evidence of recurrence of the kidney or anywhere else And we can do this for very complex cases solitary kidney with very big tumors if the anatomy is appropriate Or in cases of genetic syndromes where there's multiple bilateral tumors and and try to do these complex resections So it is the reference standard and we have very good data showing that it's extremely effective and it's a good cancer operation In the old days we used to make these huge incisions not necessary most days Most of the time we can really do these through fairly small incisions truth is It's still you know an incision that is probably not the nicest for the patient And so what's happened over the past several years is these minimally invasive approaches laparoscopy initially now robotic Laparoscopic surgery where we can actually perform a lot of these Through smaller incisions. This is done with the machine that allows us to do the surgery in a more effective and simpler fashion The surgeon sits separately while an assistant helps at the bedside the surgeons looking at this three-dimensional view and with these controls Has an ability to manipulate these micro-wristed instruments that are attached to this part of the machine and that they're inserted through these punctures into the body This machine does not operate independently. So the surgeon on the other side really needs to know what they're doing And it's I in fact a little bit more complex than do an open surgery and requires more training I'm gonna skip over this video because I have a couple of others But we can also do some of these complicated approaches with the micro dissection Here's a tumor that's in close proximity to the blood vessels of the kidney This video is sped up. So it looks like I'm working super fast. I don't work that fast Chris would might work that fast. I don't But basically what it's showing is dissection of these blood vessels Away from the tumor you don't even see it because it's cut we kept keep the fat covering it and then we can basically over time When with additional dissection Essentially then remove just that disease part of the kidney have minimal blood loss and feel very confident about the resection And we've done this many many times very complicated cases patients are sent to us So they come to us saying they can't save my kidney You think you can remove the tumor and quite frequently we can and sometimes we can do this robotically even So all cases that we've done robotic partial removal with negative margins and very good outcomes So so far we think that a replicates open partial nephrectomy. It's a good minimally invasive option Surgeon experience again is much more important than the machine. That's used. Okay. That's the machine is just an enabling tool To finish up as you know radical nephrectomy not really a role for small renal tumors In fact, they're one of the few randomized studies done in this disease Was looking at doing a radical versus partial nephrectomy for tumors less than five centimeters. This was done in Europe They only accrued 541 patients out of the 1300 that they were supposed to enroll the problem was that very few patients actually died of kidney cancer over the course of nine years Most patients died of cardiovascular disease And there was a lot of limitations from this study. So basically after all of this work and all of this effort There's unfortunately not much we can get away with in terms of information with this except to say that we think they're about the same So why aren't we saving more kidneys? We did a patient reported outcomes study here. It's one of the largest ones done the point I want to make about that so what's unique about this is that we actually asked patients about how things went and not Just asked them in clinic, but we did have these standardized questionnaires And the point I want to make is that what patients really worry about most Is really after one year? They don't care about the scar so much. They really worry about cancer recurrence and so the minimally invasive options are great options for the short term and You know for the long term We just need to think a little bit more globally and it's important for us to think about that because sometimes We sometimes put maybe put too much value on how much you how much you care about your scars or some of the pain after surgery But really maybe what we need to consider is what happens one year later or three years later There's really no role for removal of lymph nodes after in terms of small renal tumors I'm going to skip over this if you have questions about it. We can go over the Q&A portion Surveillance I'm going to skip also because I'm at 30 minutes actually and I don't want to go over But basically it's based on the theory that if we catch Recurrence of cancer early that maybe patients will do better believe it or not We don't really have any studies that prove that but in our heart of hearts We feel that it does make a difference and I know you do too But actually there's not not much scientific literature for that So bottom line is that what we want to do is do a risk-adapted approach patients who are low risk try to minimize the burden of radiation and cost and time But for those who have higher risk try to catch the recurrences early And so there's a way guidelines that make recommendations. They're not perfect We may be missing up to 30% of recurrences But many of us feel that maybe they're also misguided because they're way too many scans for the low-risk patients And not enough for the high-risk patients, and then there's the cost issue So I'm going to finish Just to tell you that basically the idea with all these options is that we can really individualized care Whereas 15 years ago we didn't it was a one-size-approach one one-size-fits-all approach And so we think we're delivering better care and really approach this in a much more global way for the patient Thank you