 58-year-old white female, history of melanoma, incidental renal mass identified on staging evaluation, history of hypertension, hepatitis B, had a cholecystectomy, a hysterectomy, and a CT chest was performed, which was negative. It's too bad, Chapin left, this is his case. Here's the mass, Dr. Delacroix. That is an atypical appearing mass in the left kidney. You can see that it looks different than a lot of the other masses that we've seen today. It's not round. It almost looks like you've poured water into the kidney, and it's just sitting there. You see it? Yeah. So on this, I would definitely do a biopsy to help guide what I was going to do. So my first step, because I think it's atypical, is I would biopsy this mass. Dr. Koran, what are your thoughts? I agree with Dr. Delacroix. 100%. I would do a biopsy. This does not look like a regular, so to speak, kidney cancer. Dr. Mateen. I think it's fine. She has no disease elsewhere, right? Correct. Yeah, so the concern is maybe that it's the melanoma, and melanoma can't do this. I guess I would talk to the person who treated her for it to see that if it was melanoma, if it would make a difference or not. Because typically, those aren't managed by surgery anyway, unless they're metastatic. So I would consider maybe just doing the ultimate biopsy and putting that in a bucket. Yeah, I think, actually, I agree with you. Because if she has no other evidence of metastatic disease, regardless of what this is, melanoma or renal cell carcinoma, the primary treatment would be surgery. Just like Dr. Mateen mentioned, the key is to talk to the melanoma doctor, not just to take the patient on our own without discussing this with the primary oncologist who treated the patient for melanoma. Sometimes they can use the tumor to make vaccines from it for melanoma. So it's always good to coordinate efforts with our colleagues who treat the main primary disease. So the patient underwent a biopsy of the renal mass, and it turned out to be clear cell renal cell carcinoma. They underwent a left radical nephrectomy, spared the left adrenal gland. You can see the pathology was T3A, Furman's grade four. Postoperative recovery is uneventful. She returned six weeks post-op with imaging. And now the imaging, unfortunately, these images are not that great. But basically what it shows is she has new tumors present. Here's one very central. New tumors present in the right kidney. This is also thought to be an enhancing mass here. And there's also an enhancing mass associated with this cyst. So three different masses that are all intraparenchymal associated with the right kidney. And some very tiny indeterminate nodules present in the chest. Dr. Mateen, what do you want to do? I'd call up one of these two guys, but only because I think just to have a discussion, that the problem with these findings in the lung is that it's this quandary we're in between with CT scans that we see when lesions are that small. They're too small to do anything about. I'm guessing that's about half a centimeter. Oh, yeah. They're too small to biopsy. They're too small to biopsy. But you know there's something there, and patients always want to do something. But there's really nothing you can do except the risk of a needle in the lung. So basically, I would just, a short answer is I would probably look at her, do another set of scans in two or three months. Not three, probably two. What about the lesions in a right kidney? Yeah, I mean, the problem with that is that if she's developing metastatic disease and we're overly aggressive with those lesions in the kidney, it's what we talked about. God forbid she has a bad complication. Meantime, she's sitting in the ICU in a rehab facility recovering from those complications and the metastatic sites are growing and we can't do anything about it. So that's where we run the risk of causing harm, which is. The only challenge is that the radiologist is saying that these lesions appeared in this kidney over the last, basically, two months. So if you wait another two months, are you going to have a kidney? You know, and you will have a kidney and the treatment may be more difficult. And I think it's balancing those different risks. The same could be said about her metastatic disease in terms of things rapidly progressing. If it's metastatic. So I think it's difficult to have a pure win-win situation here. Dr. Crum, what are your thoughts? I would follow the patient for more time in a few weeks. If the patient has more metastatic disease, then that tells me that we shouldn't really operate on the right kidney at all. Dr. Delacro? I agree. If you had a gerontuximab trial, this may be a role, a place where you could utilize it to characterize those lesions in the lung rather than sticking a needle in them. Would you like to elaborate that for us? Everyone knows about PET scans. It's advertised. Well, most PET scans are based on something called FDG, which is where we radio label a glucose. There are other ways to do a PET scan that are not FDG. And there's one marker that's specific to clear cell renal cell carcinoma actually associated with a tumor marker, carbonic anhydrase 9. It's something that's not currently approved in the United States, but it may be something that will allow us in the future to determine if suspicious lesions in the lung or even primary tumors are actually clear cell rather than sticking needles in them. So when we look at these very small renal masses, I mean, these very small lung masses, the interventional radiologists here are good, but those are very, very small to be sticking needles into. So if potentially the gerontuximab scan was approved, you may be a role for it. And if it was positive, you'd know that this patient has metastatic disease, and the patient could go ahead and start systemic therapy. I don't think that it'd be any role in treating the primary tumor here. You would just start systemic therapy. So in the absence of that, so without the... In the absence of that, I'm ready to throw that in there, I would re-scan this patient in six to eight weeks. I would not go, unless you had a clinical trial, I would not do anything else. Okay, I would agree. And just so you know that that gerontuximab, the company, it's been made by a company called Wilex and the FDA has mandated that they have to do another clinical trial before it can get approved. So it's probably many years down the line before we're gonna have that. All right, one more case. So what happened? Update on that patient. I wish Dr. Chapin were here because he asked me to put that case in. He's currently debating what he's going to do. What would you do? I'm sorry? What would you do? I told him to wait. I said wait six to eight weeks and get another scan. And if those nodules in the lung are bigger, you have your answer and you haven't... Because I don't think he can do a partial nephrectomy on that right side. She would render the patient an effort. So let's say in six to eight weeks the lung nodules have not increased. They're the same. Then I take a look at the right kidney. If the right kidney hasn't changed, then I'd say, well, let's wait another couple of months. I mean, I think the only reason to operate on that right kidney is to cure. And if you can't cure her, then you have not done her any favors. Isn't your suspicion high that what this lady has is, I forgot if it's a female. Female. She has metastasis to the kidney, to the right kidney with three lesions. They could be suspicious lesions in the lung. So this could be metastatic disease. It could be metastatic disease. I mean, I don't think we can make that determination. I'm not sure it's to be candid. I don't think it's relevant whether those are met or primary tumors. The fact is that they're there. And the real issue is, does she have metastatic disease elsewhere? If she has metastatic disease elsewhere, then operating on that kidney is not gonna be helpful. And in fact, it might likely be harmful by rendering her dialysis dependent. No, what I'm thinking, my alternative is how I may provide an alternative view is that what she has is metastatic disease. So, you know, if you obviously have to decide are you gonna ever treat the patient before she develops symptoms or obviously disease is really progressive or are you gonna initiate therapy earlier? So, you know, I mean, you can make the case that she should not have surgery even if those things in the lungs are staying the same because she has three leashes in the right kidney. These are metastases and therefore, she is not gonna be... So, would you treat her with the information we have? I would treat her. I mean, that's an alternative. Michael, would you? I probably wouldn't treat her. I'd probably watch for a little while since we don't know what's going on. Would you do a biopsy to improve recurrence? Suppose she came back and the nodules in the lungs stayed the same, but the tumors in the kidney increased. What would you do? Dr. Delacroix? Why did she believe he could get it first? That'd be very difficult to add. I think I'd try to treat her with systemic, or refer to my colleagues for systemic treatment because I still think, I mean, looking at the CT scan of the chest, even if those pulmonary meds or pulmonary lesions don't show any growth in six weeks and the primary tumor or the tumor in the right kidney shows a small increase, I would still either watch her or send her down to medical oncology because I think I'm almost pretty sure that those are gonna be metastasis in the lung. I would get a biopsy because she has a history of melanoma. So we have to make sure, before we start systemic therapy, to know what we're dealing with. Biopsy of... The right, one of those three lesions in the right kidney because the lungs and nodules are too small to biopsy to give you a yield. And again, if she didn't have melanoma, I would say, well, there is overwhelming evidence that or probability that this is going to be renal cell. But with the history of melanoma, you wanna make sure you're treating the right tumor. So I would get a biopsy. If it's melanoma, then she will be obviously sent to the melanoma people to treat her. And if it is RCC, I would treat her with systemic therapy. So I know a little bit more. Brian had actually asked me to look at her kidney and see if we can appellate all those three lesions in the kidney. And I think it's doable, but I was worried about the extent of the, one of the larger tumors, one of the larger of the tree extended behind one of the cysts. So that's why we went for the biopsy. And the biopsy was actually RCC, great for, nuclear great for. The question is, should we do an appellation? And I, technically feasible, challenging in a solitary kidney, but we haven't reached an agreement yet. Yeah, I think he's going, I think though he's going to watch her because with the nodules in the lung, those nodules in the lung would really suspicious to me. All right. One more.