 Okay, why don't we go ahead and get started? Good morning. Welcome to Houston. I'm Chris Wood. I'm a member of the Department of Urology here at MD Anderson. Just a few housekeeping issues. If you do have any housekeeping issues, please see the conference staff members at the registration desk and they'll be happy to assist you. Just to let you know, our conference today will be producing a live stream YouTube broadcast as well as a videotape for webcast to be posted for the kidney cancer association website at a later date. As we are streaming live today during our question and discussion sessions, I'd like to ask you to not identify yourselves or any patients you may reference during a question presented to our panel members. There will be no facial recognition caught by our cameras of the audience, only audio. And please be certain you fill out the authorization for the use and disclosure of protected health information form in return to my Secretary Carol at the registration desk. Please silence all electronic devices during the duration of the day. If you need to place any phone calls, please step outside the room to avoid taping interruptions. We have scheduled two breaks, one at 10.30, one at 2.10. And lunch will also be provided at 12 noon. Seating for lunch is available in rooms one, two, and three on the opposite side of these conference rooms. And for those of you who want to attend, we have scheduled a luncheon meeting with the Department of Social Work. These are two separate closed session meetings. One for patients and one for caregivers. The caregiver meeting is in the telemedicine room and the patient meeting is in room four. Staff members from the Department of Social Work will meet with both groups to facilitate an open discussion session. And then finally we'd like to thank our conference supporters, both Pfizer and Genentech. So welcome again to Houston. We're going to try a very different format this year. We've done this, I don't know, maybe the last five years I think here in Houston. Sometimes I look out at the audience and I see sort of this glazed look in your eye and not sure whether you're taking it all in, whether it's valuable to you. So we're going to try a totally different format and we do need your feedback. If you like this format, then let us know. If you hate this format, then also let us know that and we can switch back or maybe have a mixture of the two. But this is what we in the health profession call a tumor board. And basically this is how we practice medicine. We take difficult cases that present to us and present them to our colleagues and get their opinions about how best to manage it. And we pick these cases so that hopefully we can cover what we would normally cover during the didactic sessions. We have a very esteemed expert panel. We have Jose Caram, who's on the faculty at MD Anderson with us. Roberto Pili is visiting us. He's a medical oncologist. We have Scott Delacroix, a urologist. Michael Harrison, another medical oncologist. Brian Chapin, urologist here at MD Anderson. Cameron Arar, who's an interventional radiologist, who is an expert in ablation. Serena Matine, another urologist. Nazar Taneer, and myself. So if I could first have the panel come up for the localized and locally advanced disease, that's Jose, Nazar, Michael, Serena, Brian, Scott, and Cameron. And hopefully we have enough chairs. So during the course of the case presentations, if you have questions, please don't hesitate to get up, step to the mic. And I'll acknowledge you and you can ask your question. If you have a question about what somebody says or things are not clear, please let us know. In all fairness and against my wishes, these guys have already seen the cases. So they've already probably prepared some of their answers, but I'll do my best to try and confuse them with the best I can. All right, so let's start with our first case. This is a 52 year old white female who presented with a history of metastatic carcinoid. And during the course of her evaluation for her carcinoid was noted to have an incidental renal mass. She also has a history of Hodgkin's lymphoma, cervical CIS, thyroid cancer, diabetes, and hypertension. She's had numerous surgeries in the past. She's had a splenectomy, a partial liver resection, partial stomach resection. Her gallbladder's been removed, her uterus has been removed, as well as her thyroid. She has an excellent performance status, meaning she has no side effects from her disease. Her labs are all within normal limits and her CT scan of the chest is negative, meaning no evidence of any metastases to the chest. Here's her scan, and you can see here in her left kidney, medially, she has a solid mass present that enhances with the administration of contrast. There's two views here. And I guess I'm gonna throw this out to first Dr. Matine. How would you approach this patient? What would you offer this patient and why? So I think the first thing that everybody thinks of is whether this is the carcinoid that's spread to the kidney, right? I mean, she's got already a cancer. And what we've learned over the years is that, first of all, carcinoid doesn't go to the kidney very often. And secondly, metastatic lesions to the kidney tend to have a somewhat distinct appearance in that they're not actually very well vascularized for whatever reason. So anyway, my first instinct looking at this is that it's probably not this carcinoid, depending on what the status of that was, that if it's sort of widely metastatic, then I would reconsider. But if it looks like it's one of these smoldering, for those of you that don't know, carcinoid has a very long history. Patients can live with it for a very long time. It's still not a great disease. But anyway, my point with this is I think, depending on what the status of her carcinoid was and how active it was at the time, continuing to observe it would be reasonable given its size. And I can go into that more if you wanted to. All right, so you're recommending just observation. You wouldn't recommend any intervention. Yeah, and I think I just need to hear a little bit more about what's going on with her carcinoid, what kind of interventions she's had and things like that. You saw the surgery that she's had. Those were interventions. Currently, she has no other disease aside from the serenal mass. Yeah, so in that setting, I think continued observation is reasonable and the alternative is for her to have this treated and resected and a part of it, the patient has to be involved with the choice. She says, whatever you think, Dr. Matin. Yeah. No, listen, I think because carcinoid has such a long history, I think treatment would be what I would probably recommend. And what would that treatment be? Options would be a partial nephrectomy, either open or robotic or doing ablative therapy. It's a little bit tricky for that and maybe Cameron wants to comment on that. What would you recommend, though? What would I recommend? Sir, I would do a robotic partial. You'd do a robotic partial. Dr. Delacroix, what would you recommend for this patient and why? I would do an open partial nephrectomy, especially given her history of multiple abdominal surgeries. I'd wanna go through a flank incision and do an open robotic partial. Yeah, I would think it would be very challenging to do anything lapyscopically after having stomach, liver, spleen, everything else for a second. I mean, if you had to point, pin me down, I'd say open partial, but active surveillance would also be reasonable. Open partial. Okay, Cameron, what about ablation? Do you think this is something that could be ablated? Yeah, so for those of you who don't know, thermal ablation can be done either in the operating room or in a radiology suite using an MRI or a CT scan. We look at a tumor. Two things that are most important to consider. One is the size of the tumor. The other one is the location of the tumor. In this case, this tumor being less than four centimeters is a good candidate. The location, like Dr. Matin said, is a little tricky, is a little close to the hyalum of the kidney where the connection to the ureter is and excessive heat or excessive cooling of the tumor can damage the drainage of the kidney. So in this case, I think I would suggest that we can ablate this. We would take some measures to protect the kidney, the inside of the kidney, the ureter, the UPJ from excessive heating. Yeah, we can ablate this. Would anyone consider a biopsy of this lesion? I noticed no one said biopsy. Would anyone do a biopsy? Sorry. You go first. So, yes, we actually, so the concept of biopsy is a tricky one to discuss. As you know, before the days of ablation and this dates back before 2000, really, the appellation has gained acceptance since 2000, 2001. But before the days of appellation where all of these tumors were taken out surgically, nobody did biopsies. Still, even now, when a surgery is planned, we don't biopsy these tumors. 85, 90% of them are thought to be renal cell carcinoma and they go to surgery. Some of them do turn out to be benign. In this particular case with prior history, I think it's reasonable to do a biopsy. The question becomes whether you do the biopsy a week before so that you know exactly what you're treating or you go in with the intent to treat the tumor, but you take a biopsy at the time of the treatment for follow-up purposes to know what it was that was treated. So, yes, I would definitely incorporate it into the treatment, whether you do it ahead of time or at the time of the procedure. That varies. And Cameron, I'd like you to comment on one thing. Many patients bring up the concept of, you know, when you biopsy a tumor that it could potentially pull cells out of the tumor and potentially seed the cancer. And also, could you speak to maybe the MD Anderson experience with regards to the accuracy of biopsy? How often do you actually get a result that's meaningful? So, yes. The risk of track seeding, as Dr. Wood mentions, putting a needle inside the tumor and taking some of the tumor out, does it increase the risk of seeding the track? Traditionally, when I went to medical school, people said, my professor taught me never touch a kidney cancer. They all go to surgery. Don't put a needle in it. But that has changed drastically over the years. We have now learned that we don't see this. The entire concept of track seeding for kidney biopsy is based on six individual case reports that were reported in probably 70s. And since then, a lot of the research has been done on biopsies before surgery or before appellation or for medical therapy have shown that biopsy is very safe. The risk of track seeding or seeding the area that the biopsy is less than 1%. And that's true for majority of tumors. Now, there are some questions about some sarcoma, some transitional cell carcinoma, and other tumors other than kidney cancer. But generally accepted in this day and age, the risk of track seeding is less than 1%. Our experience has been very positive. Being a cancer center, biopsy is one of our most common procedure in interventional radiology. We're pretty good at it. We can get small tumors. We can get large tumors. We can get tumors that are partially or nearly completely dead, but they have a nodule, very small part of it that's alive and we go after that and we get that. And our results are pretty much 90% diagnostic, 90%, 95% diagnostic. Very rarely you will have false positive, almost never heard of. Occasionally you will have false negative, that is there is cancer but we didn't find it. That happens probably about 5% of the times. Anyone else have any other comments? So this patient actually underwent ablation. Cameron, you probably did this ablation. I did, yes. Do you wanna just sort of take us through the thinking behind us? I guess questions I have are, when do you decide to do cryoablation versus radiofrequency ablation? And how did you decide on this approach versus some other approach? Sure, so a couple of things I need to explain first. There are two ways you can treat the tumors by means of thermal energy. You can either heat it to excessive temperatures, almost nearly boiling water temperature pretty much and heat up an area where we call appellation zone, which engulfs not only the tumor but a little bit of a normal kidney around it. So you get enough margin around the tumor that you're happy about, you didn't leave any tumor behind. That's one, it's called radiofrequency appellation. The other end of the spectrum is actually cooling the tumor to temperatures minus 180, 160 degree centigrade which creates a very cold ice ball which essentially kills all the cells that are engulfed in that ice ball. Both technologies are available pre-cutaneously and both are effective. Now every time you look at a tumor you decide which technology would be more appropriate or which one you would feel more comfortable. There are some minor technical details that I don't wanna bore you with but in this particular case we decided to do radiofrequency appellation and in fact we had our urology colleagues come to our suite and place a catheter up the ureter into the kidney where they could actually infuse where we could infuse cold water inside the kidney where we are heating the tumor right next to it so that inside the kidney would be protected from the excessive heat. We normally place one, two or three of these needle-like electrodes. Chris if you wanna highlight it with the mouse they can see it. We placed one, two or three of those needle-like electrodes between the tumor and we created an appellation zone that covers the entire tumor. This technology has been available since 2000. Nowadays we think it's about 95%, 90, 95% effective. Okay very good.