 Welcome, good morning. Thanks for the invitation, half hour to educate you on a very complex topic. When I rehearsed this in New Haven two weeks ago, it took about 10 minutes. But moving to the West Coast now, it's probably about an hour talk with that type of change in speed. So I'm gonna educate you on the renal mass. The incidental detection of the renal mass is kind of a new problem in this era. Prior to the 1980s, these patients would present, we'd have a large abdominal mass, blood in the urine, or pain. And there'd be sometimes these subtle symptoms where the internist would try to figure out what's going on with when patients had fevers, chills, a high red blood cell count. But 1980s onwards, there's been a shift to what we call incidental detected tumors. And these are usually asymptomatic tumors. And why is that happening? Well, the widespread availability of cross-sectional imaging has been just, there are a number of scans done each year now has quadrupled since the 1980s. You go to the ER, you cough, and they give you a CT scan. I had a patient who got bit by a spider, had a panic attack, and she was found with a small renal mass. So there's been increased cost and radiation from a lot of these scans, but we've also found a lot of these small incidental renal tumors. And when we call, you know, there's four times more kidney cancer today than there were about 40, 30, 40 years ago. And if you look at the size, there's been a really dramatic shift where we have tons of new small tumors, two to four centimeters, which generally are very, they're likely to be asymptomatic. And this has led to the field really having to shift really, you know, the expectations and the management, where now about 70% of new diagnoses today that we see are really stage one. Okay, so it's really what we call a stage migration. But we still see large tumors. This is the same day in the OR for me where we have this 20-something centimeter kidney tumor. But these are few and far between now. For every five of these we see, we see ones on the right, which are these small, tiny tumors which have a lot more treatment options available to them. And the goals in management of these small or incidental renal tumors that are asymptomatic are number one, to minimize long-term harm, you know, trying to give cancer control, but two, maximize functional benefit, try to preserve other organs which are important, such as, you know, trying to preserve kidney function, trying to limit, you know, collateral damage to things like the adrenal gland, trying to not remove someone's rib and give them a flank hernia on try to minimize convalescence, try to minimize the amount of time they're off of work so they can return to lifestyle as quickly as possible. So the focus on this talk is really the more early stage, stage one, stage two, which are more commonly the incidental detected renal tumors. Other people will talk about the other types of tumors. So in 2018, you know, you're trying to think, well, what are my options for these incidental or smaller renal tumors? Well, we have surveillance, we have partial nephrectomy, radical nephrectomy, or ablation. And you say, oh, I have all these treatment options available for my renal mass, but hold on a second, is this really cancer? So the first things people will ask, well, how do you know? How do you know this is cancer? Well, I will tell you that we don't know and a lot of times we remove tumors and they turn out to be benign. So people always say, well, what about a biopsy? Well, there has been somewhat of a paradigm shift into considering biopsy, but historically in kidney tumors, we have skipped biopsy except when we have considered patients having suspicion for metastasis to the kidney or what we call lymphoma. And some of the concerns has been that we have had a difficult time distinguishing between benign versus cancer. We've had difficulty, you know, we've had concerns about seeding, putting a needle in and spreading a cancer or bleeding. Well, those are really overstated. So the performance of a biopsy is improved. If you detect cancer in a biopsy, it's gonna be cancer when you remove it over 99% of the time. But there are 15% of tumors that are non-diagnostic. So the AUA, our governing body for urology, really has statements where you would never biopsy a patient. If it's not gonna change management, if someone's unwilling to accept there's gonna be some uncertainty and you always wanna biopsy a patient when you actually are suspected that this could be infection, inflammatory or metastatic. But there's this huge gray area where you really have to counsel the patient. And the AUA is pretty clear that as of 2018, you at least wanna counsel the patients regarding the rationale of a biopsy, some of the benefits, some of the risks. And you know, if it's not gonna change management, if you're a 40 year old gentleman with a three centimeter renal mass, by question really that will ultimately change the management knowing the uncertainty. But if you have the ability to influence patient or physicians' characteristics, a biopsy is safe and can be done as an outpatient with minimal risks. So moving back then, again, counseling the patient of these four options, they're all good options in the right patients. Now, I think we're stuck a little bit, okay? So for radical nephrectomy, when you're thinking about that, that has historically been the mainstay of therapy. It's radical, you remove the whole entire kidney and the surrounding adrenal and lymph nodes. Basically, a tumor is completely removed encased in a surrounding fat. You don't even get to see the kidney tumor, it's just contained. Well, we have evolved in recent years where we've tried to be less radical, we're still radical, but we've tried to spare that adrenal gland, we've tried to admit lymph node dissection, which lymph nodes are drainage sites around the area of the kidney. If we see nodes that are involved, clearly we're not gonna do surgery and leave suspected cancer behind, but we tried to minimize things. We've tried to minimize resection of the rib, which some of my older professors used to do routinely and it would lead to sometimes disfigurement and some patients. So we've tried to get less radical and we can do multiple types of incisions. Historically, the open approach, we had multiple ways to get to the kidney, okay? From the flank, from the center, from underneath the rib and those are all viable options. However, in recent years, most practitioners have felt very comfortable taking out a whole kidney through tiny incisions and we're not magicians, we can't say abracadabra and boom, it comes out. Generally, we make a small incision, we put it in a bag and we really kind of crank it, trying to get out through the smallest incision possible, but generally very small incisions and you can remove tumors. Again, if a tumor is huge, you still need to make a moderate size incision, but we make these incisions at the least painful part of the body where things could be removed. But the kidney is an important organ and removal can lower kidney function and we know kidney function is important. So in some patients, when you lower their kidney function, it may predispose them through some harms, cardiovascular, increase in admissions to the hospital, related to chronic kidney disease. There is some debate in our literature whether surgical related chronic kidney disease is different than medically induced kidney disease, but we do know the kidney is an important organ, we like to preserve it. So we really reserve the radical nephrectomy when there is concern, yeah, at the end. So we only should, you know, we consider it when there's increased oncologic risk. We want to maybe not see the tumor, not get close to the edges if we were gonna do a partial nephrectomy. If somebody really has a very high risk of tumor complexity, then maybe we'd want to try to stick to the radical nephrectomy if it'll be a lot easier for the patient. And of course, patients must have a normal contralateral kidney. We'd like to obviously not try to make a patient a nephric. And then when needed, we try to do a minimally invasive approach. And about 95% of those with a T1 lesion who needs a radical nephrectomy, the seven centimeter or less, we can generally handle it with a minimally invasive approach. When we're talking about T2 or grade or huge tumors, there's some diminishing return of doing that minimally invasively. So moving on to, you know, going from more invasive to less invasive, the partial nephrectomy. This is similar to in breast cancer where people just remove the lump rather than the whole breast. And removing the tumor and sparing the kidney, you know, has historically been performed for if you had a single kidney, you had bilateral kidney tumors, a hereditary condition, or had really bad kidney function. These were what we called imperative partial nephrectomies where really you really have to preserve the kidney. But in the last two decades from work from multiple investigators, we've really showed that it can be more elective and it really does have benefits for some patients to preserve kidney functions when feasible. So the partial nephrectomy, again, you see the tumor, you cut the tumor out, making sure you don't leave anything behind, and then you repair the kidney or close it, okay? Well, partial nephrectomy is safe and we've done a very good job with modern techniques. There are some additional risks which are seen when you leave a kidney in. The kidney is a very vascular organ, receives a lot of blood flow, so if you leave a kidney in, well, urine could come out from that kidney and blood can come out from that kidney. Well, we have done a very good job at minimizing the risks of complications, but there are some complications that do exist when you are sparing an organ. But the oncologic outcomes appear at least equivalent from randomized trials or databases and the functional outcomes are likely at least superior in terms of the maintenance of kidney function. So what you may hear in the literature or from your doctor talking, but when you do a partial nephrectomy, it's like stabbing the kidney. You can't just stab the kidney and walk away. So you generally, if the kidney is a very vascular organ, sometimes you want to minimize the amount of bleeding when you're making an incision into the kidney. So we do things like place a tourniquet, we try to place a clamp. Sometimes we place ice on the kidney to try to minimize the amount of damage. You know, if you fall into a water body after five minutes, your brain's not gonna be happy. But you know, there's some stories where it's like negative 10 degrees and someone gets pulled out of the water miraculously, their brain is preserved. So we try to preserve as much kidney function as possible and sometimes we do things like icing the kidney. And now the partial nephrectomy, there is a chance of local recurrence because we're not removing the whole kidney. But the local recurrence rate historically has been very low, two to 5%. But as our field is pushing the envelope, larger and larger tumor, more and more aggressive tumors, we are probably going to start seeing a higher rate of local recurrences. There are some series when you really try to do these heroic partial nephrectomies that the local recurrence rate, meaning a tumor will remain in that bed where that tumor was, could be as high as 20%. The amount of tissue removed also is an area in our field where we're debating. In the past, used to take a huge margin around the tumor, but that devascularizes or limits the amount of viable tissue. So now we're getting closer and closer and closer to the edge, which a lot of people argue is safe, other people argue is it potentially puts the patient at risk. And we can generally do this through a flank approach off the tip of the 11th rib. Okay, it's not necessary to take the whole rib, some people have done in the past, but we have now adopted some minimally invasive techniques where we try to use tiny instruments and their oncological outcome is the same as the open approach. But laparoscopy is challenging. I try to tell my patients, I can eat sushi with chopsticks, but I can't sew a button back on a blouse with chopsticks. So the laparoscopic technique really didn't really take up that much adoption until the DaVinci robot came along where you actually can have your hands inside and the laparoscopic equipment can mimic the rotation of your wrist. So this is a really an enabling technology which has really revolutionized how we do partial nephrectomies when instead of only several people using chopsticks, now we have this fancy machine to allow us to cut and sew very quickly. And partial nephrectomy in 2018, it can preserve renal function, it can limit some of the long-term renal harms. It is still underutilized, but it is starting to increase and increase in the community. And now about 75% of stage one renal tumors in academic centers are really tackled minimally-invasively. Open surgery still has a role and there are definitely patient and tumor factors which do limit the ability to do things minimally-invasively. Now moving towards an ablation. Ablation is kind of the new kid on the block the past 15 years. Basically, ablation, just like if you have a wart and you wanna have it ablated, this is a way to focally destroy a renal tumor, okay? And you're basically using extreme temperatures, whether it be cold, which is cryo, or whether it be heat, which can be microwave or radio frequency. Basically, the tumor is not removed, it is killed in place. Similar to when someone goes for radiation, the radiation zaps and kills a tumor. This is a little bit more invasive because you have to stick a needle into the area, but you do kill it in place. And the definition of success is very different than when we do surgery. When we do surgery, we come out of the OR and we say we got what we came in for, we removed it, all the edges look good. This is basically, the way we know it works is over time the tumor doesn't grow and when you give IV contrast into someone's vein, that tumor does not become bright, meaning it does not have a blood supply. So it's a little bit different in what we define as success. And this can be performed via laparoscopy, going to sleep, having small incisions and placing needles, but the percutaneous approach is generally what's done. That's usually a small needle guided under imaging into the tumor. It depends on the location and physician comfort, but the percutaneous approach has much less morbidity and there's generally not much role for laparoscopy unless the tumor is situated at a very difficult place. So the radio frequency basically there is ionized, there's agitated ions that leads to friction and basically it tries to cover the whole entire area of the tumor to destroy it. Not many tumors could live in that extreme environment. Sometimes if things fail, it's basically not targeting the whole entire region where the tumor is, maybe leaving a little bit not at the right temperature. And that's just, it's called the levine needle. Now I prefer cryoblation and I do these with our interventional radiologists and this is what you use liquid argon to rapidly cool. Helium, it depends on the system, but there's actually a national helium shortage and helium has been going up and up and up in price so the companies have tried to eliminate helium and we had a funny story at Yale where they had an event for children and they ran out of helium. So the next day we went to do a cryo and there was no helium left over because they went into the radiology suite and they used our medical grade helium for balloons for the kids, okay? So you cool the temperature to minus 190 degrees. Again, not many things can live in that temperature but if something lives, it's generally due to failure to completely cover that tumor and cells die at minus 20. This is a patient with a larger tumor. You know, the larger and larger tumors you get, the more difficult it is to kill something with one needle, okay? And you need to overlap the ice ball. The more needles you put in, the higher chance of bleeding. You need to obviously cover a whole entire area with multiple things. You can just imagine you put five needle or lollipops in. You need to make sure you cover every single area perfectly for a large tumor and that's why the rate of recurrence is much higher for a larger tumor. So the cryo and RFA take home, they have lower success than surgery but it's still fairly successful. For large tumors that success rate is gonna drop off significantly and 50% of the failures may be retreated with another needle but the ones that aren't, you just have to understand that you put yourself in a challenging situation because salvage after an ablation becomes much more challenging. It may not make a difference if you're 85 and you're trying to get treated but if you're 40 and you have 30 years to have a tumor come back, it just becomes a little bit more challenging. So we employ patient and tumor characteristics in trying to make these decisions. It's better when the tumors are very small. The cryo and RFA have about five to 10 year data which is good. We don't know 20, 30 year data like surgery and you must know what you kill. If you don't get a piece of tissue, you really don't know what you actually killed and if the tumor was benign and it comes back and obviously it may influence your decision. And again, the percutaneous approach is increasing. I haven't done a laparoscopic cryo in years and only 14% of ablations actually have urology involvement. So a lot of times the interventional radiologists do this on their own but I try to push my urology colleagues we need to stay involved in this procedure. Cryo is performed more common than RFA and 75% of these cases are done in the outpatient setting. Now what about active surveillance? Well we know renal tumors have dramatically increased due to detection but the number of deaths each year in kidney cancer has stayed the same and this has led epidemiologists to say we are over treating a lot of these small renal tumors and this is from autopsy studies. We have removed all these small tumors so when pathologists look at an autopsy from a patient dying of something else they used to be surprised three to 4% of the time and say, huh, this patient was living with a small renal tumor which was cancer. Now since we're removing all these small tumors and patients are dying of other things the pathologists are not having these findings so we've really eliminated the reservoir of these people who've been walking around and we're gonna die of something else. Now when you have a small renal mask there's all these fancy algorithms to really say are you really, if you're 80 and you're in oxygen and you're in a wheelchair were you really gonna die of a small renal tumor? You can look and really what's your chance this patient African-American male 68 with a small renal mask who has comorbidities they're much more likely to die in five years of something else than their kidney tumor. So that really has led people to reconsider. Now if all you have is a hammer everything looks like a nail but maybe we should reconsider this paradigm this is just a cartoon that you don't need to treat everything with the weapon of mass destruction. So we do know there are non-treatment strategies where patients with Gleason 6 prostate cancer or CLL they do not necessarily need to have treatment and what happens if we don't treat patients with small renal masses we do know in patients who are too sick to have anything done we've called that watchful waiting and for many years we offered watchful waiting to unhealthy individuals which is different than active surveillance meaning we're gonna actively watch it and if we get concerned we're going to hit it with a sledgehammer rather than right from the beginning. So this is a series from Canada where when they followed patients who were unhealthy most of these grew at a very small rate two millimeters a year and if you follow someone the rate of local progression towards what they would say need for treatment is low and the rate of metastasis is very low. So we do know there are some tumors that if you observe they're gonna act very ugly and others they're going to act at a much more kind of slow growth trajectory and if you were 80 and you started following someone and the tumor started to grow very rapidly you have your answer it needs treatment unless there's some significant competing risk. So active surveillance I would explain is that you need to have close surveillance you can't ignore it you need to watch things with frequent imaging and then the trigger for intervention is really unclear some individuals use a size threshold some people use a rate of change or maximal rate of growth biopsy could be employed if you wanna have additional risk stratification. So the AUA does discuss that there is supporting language in the guidelines now that it can be an option for anyone not just a sick unhealthy person with a small renal mass and if you have a patient where the treatment risk really outweighs the oncologic risk even for larger tumors you could consider active surveillance. So if you have someone who's had a heart attack is bed bound and they have a five centimeter renal mass and the cardiologist says the risk of having problems is very high I would do active surveillance and something like that and then the oncologic risk could be great if it's greater than the treatment risk it doesn't matter the age or comorbidities you would consider intervention. So how do you come up with what to do? Well you can go to Google there's a lot of bad information okay this is you know the Simpson episode where Homer went online he figured out he had leprosy and in reality he just hadn't showered okay we have guidelines for the clinician where we have all these fancy things and they tell us you know you should do this you should do that but a lot of this is based on the clinician and it's also by tumor characteristics clearly a small renal mass like this is gonna be treated differently than this 35 centimeter renal tumor okay now patient characteristics if you see someone like that who's saying bolt you're gonna say and he is a small tumor you're gonna say okay you're a candidate for partial nephrectomy but this other woman who's bed bound who's in her 90's who's on hospice for lung cancer well clearly you're gonna do active surveillance what about this guy this guy just set the world record for the 200 meter dash for someone who's 90 he comes into your office and says well my father's 103 what do I do? So clearly there's gonna be some gray areas where you need to kind of discuss things very closely go over all the risk benefits and then the clinician must be flexible okay you know you need to have a lot of tools in your tool belt okay you can't just say I only do robotics or I only do ablation I only do active surveillance now this unfortunately you know there's a study from David Miller and Mark Litwin who did show that really for many patients it's really the clinicians influence and the clinicians come practice style which unfortunately influences decisions so I would say that this is from the agency for healthcare research and quality really it needs to be shared decision making where the doctor and the patient need to go over all the options to understand there are many ways to skin a cat and there's different ways to focus on shared decision making and there is data that if you explain to the patient they are an active partner they're your passenger and you're driving the car together patients are very happy and willing to participate in the care so in the last two slides there are multiple treatment options available most options will be curative for this stage one or two patient all treatments do have potential short and long term side effects there's not one size fits all therapy and that must be recognized and the clinician and patient must determine the individual strategy and again there's been a dramatic shift in how we treat patients or actually evaluate patients due to incidental detection we want to manage the management has changed due to try to minimize collateral damage you can consider biopsy if it's going to influence your treatment and then over treatment does remain a major problem today and we try to talk to patients about the option to do active surveillance and again shared decision making and also taking it to patient and tumor characteristics are very important into making decisions thank you