 Well, thanks for inviting me to talk today. So really it's about the small renal mass and I'm going to just start out by just defining what I mean by that because a lot of people talk about the small renal mass but what does that really mean and then talk a little bit about the management strategies that we can apply to it, mainly surveillance versus surgery and then talk a little bit about decision making as she said. So I figured we'd start with a case presentation to sort of put a patient to the sort of the whole decision making process. So this is a patient I had 60 year old male who presented to the ER and he had some lower back pain and this is actually a really common scenario we find. He came with another problem and then the ER obtained a CT scan. Even though his problem was actually lower back pain it was just some muscle strain. He was ultimately diagnosed also with this small renal mass which was discovered which is 1.6 centimeters and so this is often how these present. And so the question is what's his diagnosis and what are his options and I'm going to use this case to kind of circle back at the end to talk a little bit about putting this in perspective. So to start what is a small renal mass? Well it's defined as a renal tumor less than four centimeters and in the United States I think it's hard to understand what a centimeter is even myself and so I put a roller up here just to put it in perspective so forgive me if that's too simple but for me I just think of it as like a little over an inch and a half for a four centimeter tumor and then and sometimes it's defined as less than six centimeters depending on where you read but generally it's four centimeters. It's asymptomatic meaning there really are no symptoms that go along with it generally speaking. It's confined to the kidney so it hasn't spread and then in terms of imaging qualities we look at whether it's solid appearing and then we call enhancing with IV contrast. What that means is it's bright with IV contrast and so those are the things we're looking for and that was the characteristic of this gentleman's tumor. So a little background about small renal masses well over time the number of small renal tumors has increased and as you can see from 1997 to 2006 there's been this increase and that's due in part because we're imaging more in the ER we do CTs and MRIs on many people and I bet number if not almost all of us here has had some kind of imaging for something and so we call that an incidental finding whenever we find something that's not really related to why you got the imaging in the first place and you can see this actually separates out the graph based on stage and these small renal masses are by definition stage one and you can see that top line going up and this top line is on the incline and that really is responsible for that increase in renal masses and so what we know is that in the 1970s is really only 10% that were found on CT or MRI imaging and now it's almost half of patients with low stage are found this way and the issue is the greatest incident is actually in older folks in over 70 and in the autopsy series where they actually looked at patients after they died for other causes before widespread imaging was in play nearly three quarters of the renal cell masses were clinically in apparent meaning that the majority of them that wasn't the cause of death and so that supports the thought that maybe these renal cancers grow slowly and so that represents a dilemma for us because if we're having these small renal masses and there are older patients and perhaps these patients the risk for surgery or treatment is a little bit higher in these patients so can we safely observe some of these tumors and then if so what are the characteristics that define the tumors that can be observed and potentially undergo delayed intervention or no intervention at all and then finally what criteria what criteria might guide our decision between treatment and observation so this is just a schematic these are generally the three categories of management options for small renal masses so first is active surveillance and I'll talk a little bit about what that means it's also known as watchful waiting if you've heard of that term the second is ablative therapy I'm not going to really talk about that today but that's cryotherapy and radiofrequency ablation what that means is cryotherapy is freezing the tumor and then radiofrequency ablation is putting a probe in the tumor and basically heating it to destroy the tissue and these are newer therapies so the longer term outcomes are a little less known so I'm not going to talk about that so much today the third option is surgery and that's partial or radical nephrectomy and I'll talk a little bit about that as well I have a little X over radical nephrectomy not to say that that's not an appropriate therapy for some people with small real masses but generally speaking that's pretty aggressive so we try to steer away from that if we can and I'll talk a little bit more about that later as well so starting with active surveillance what is it well this is an approach that involves really no intervention at all other than the close follow-up of the patient mainly with clinic visits history and physical exam laboratory studies and imaging whether it be CT MRI and in some cases ultrasound for some patients and despite the earlier detection of these renal masses there's been there's not been a clear improvement in cancer specific survival so that suggests to us that maybe treatment of some of these tumors may not be necessary and we know that up to 20 to 30 percent of these very small renal masses actually will be benign so we don't want to over treat when we don't need to be so what's the issue here well the problem is that not all renal tumors behave the same and it's really difficult to tell which one is going to have malignant potential and which one or which ones are benign we do have biopsies to aid our to aid our diet our decision-making process but a negative biopsy doesn't necessarily mean that it's not a renal cell carcinoma also CT MRI and imaging can actually understage renal cell carcinoma so who is active surveillance for well it's reserved mainly for patients who have a limited life expectancy due to other competing medical conditions in patients where surgery is not an option and intervention where the intervention has a significant chance of decreasing quality of life now that's not to say that's that's all it's for I mean there are younger patients that are very appropriate for this and and really what I what I really stress to my patient this is a shared decision that's not just the surgeon who's making this decision it's very important the patient weighs in as well so it's really a shared decision-making process so this is just a general scheme but certainly there are many other patients who this would be appropriate for as well so how do we decide when to treat or if to treat well we don't have a lot we have biopsy and that can be helpful but there's also the growth rate and I think that's really the mainstay of how we decide what we do so there is a study that looked at over 200 patients who had an average follow-up of two and a half years and they took a look at the growth rate the average growth rate overall was about 0.28 centimeters per year which is small and that was smaller than the average growth rate for RCC proven masses which is 0.4 centimeters per year and so we we generally like to think that if there is a increased growth rate that's going to sort of push us toward an actual intervention the other thing that was helpful to know in the study is that only three of those 234 patients had metastatic disease and of on all three ended up having some kind of growth so there were no reports of metastatic disease without some renal mass growth and that's actually comforting to know since we use that as part of our our decision-making process but there's no growth mean no cancer and the answer is unfortunately no this is a smaller study looking at two groups one group had no growth one had growth and you can see that the renal cell carcinoma on pathology in that last row is not that different so it's really don't have a perfect method but we do use growth rate to sort of guide what we do know in biopsy as well so what's the follow-up schedule if you're placed on active surveillance so the first thing I'll say is that compliance is mandatory so you again you want to have a patient who's going to come back because it's important to keep monitoring this so if I have a patient who I don't don't think or it's gonna be very difficult for them to come back to see me I may not recommend active surveillance for that patient again percutaneous biopsy can be considered in in the American neurological association guidelines they mentioned the role of biopsy in that in that way and they also recommend that there is a CT or MRI of or imaging of some sort at six months and then annually thereafter and that's pretty conservative we we actually do a little bit more of an aggressive surveillance regimen at UNC so in the first year we'll image every three to four months and the reason we do that is because you really want to have a growth trajectory you want to have two points on that line so you can see you're here or you're here and that kind of gives you an idea of where we're going with the surveillance and then if there's stable size in that first year we'll move that out to every six months and then and then beyond that to annually and then if there was a biopsy proven renal cell and so we know that we're following renal cell carcinoma versus just a small renal mass then it's recommended to get an annual chest x-ray just to look if there's any spread of disease and then I have this last question what's the trigger to treat and I it's intentionally there's no answer there because there really is no gold standard and exactly when to treat but I think that it's again a shared decision between the patient and the in a surgeon and I also think that it really comes down to growth rate and then a lot of a lot about what the patient what the risks are for the patient for treatment how sick they are and and so forth so that moves into surgery so when we do treat and I just I know many of you know this if not all but I'm gonna just say this one more time and kind of kind of go through what a radical nephrectomy is and what a partial nephrectomy is for those who who are not aware so radical nephrectomy is removing the entire kidney and a partial nephrectomy is just removing the kidney mass leaving the rest of the kidney the normal kidney behind so this is just a schematic but it's it's pretty simple there are three main steps the first step is to find the renal artery in vain and then we use either a stapler or or some kind of clips or just suture to divide the blood vessels and then the second step is to divide the ureter the basically the tube that runs from the kidney down to the bladder and then finally removing the remaining attachments of the kidney and the entire kidneys removed for a partial nephrectomy like I said it was just it's just removing the actual kidney tumor and so it's similar steps but obviously a little bit different here because instead of dividing the renal vessels here we we identify and then we put clips on them or our bulldogs that are actually going to be removed at the end of the case so we clip it to to make sure the blood supply is not such that we're going to have a lot of bleeding when we cut the tumor out and that's the second step is is removing that tumor just kind of cutting out that area and then finally sewing that defect together and then removing the clips at the end so I just want to talk a little bit about the rationale for partial nephrectomy you remember at the beginning I had that like X around radical nephrectomy again radical nephrectomy can be appropriate in many scenarios but partial nephrectomy the rationale for for doing partial nephrectomy over a radical stems from a couple different things so this the first the first study that I want to talk about is just the fact that they looked at chronic kidney disease so renal function that's diminished and that was an independent risk factor for death cardiovascular events like heart attack stroke and then hospitalization as well and so they did another study that looked at patients survival for those who had small renal masses in both radical and partial nephrectomy and the top line here is partial nephrectomy and they had better survival than those with radical nephrectomy and the basis for that may result from a greater decrease in the renal function after radical nephrectomy and all this is up for debate but this is the the at least what we think about why we push partial nephrectomy over radical nephrectomy there's also been shown to be an improved quality of life after partial there's been shown to be equivalent cancer-free survival in patients who had partial versus radical for these small renal masses and then I just want to remind you up to 30% of these renal masses under four centimeters or benign so again we may be taking out a whole kidney for a benign lesion so despite all of these factors that I mentioned it's still fairly underutilized for renal masses that are small and you can see this this chart so the black line the black bars here are radical nephrectomy and these lightly shaded bars are partial you can see that that's been increasing from the late 1980s up to the early 2000 it continues to increase currently but the potential reasons for that under utilization is that there's a belief that maybe patients aren't really at risk for chronic kidney disease if they already have a normal normal kidney function or if they have a normal kidney on the other side and there's also a question of lack of comfort of the surgeon and performing the partial nephrectomy because there was previously there was a lot of people who were very comfortable with the radical nephrectomy using I'm sorry using small incisions for that and doing it with doing that for a partial nephrectomy was more technically challenging but now there's more use of the robot and I'll talk about that just in a moment and that has allowed a lot of surgeons who perhaps couldn't do that with pure laparoscopy to do it with a different type of technology and still have good outcomes and still have small incisions for the patient and so as I mentioned the robotic partial wasn't really described until 2004 and now we're seeing much more utilization of that since 2008 and I think that's going to just continue to increase so just a little word about what the robot is and I say this because this is a really common question I get from patients in the clinic because they think that there were an actual robot is doing the surgery and that's not the case so it's actually the surgeon who is who is really at this console that's away from the patient that's making the robot move so it really isn't automated in any way there's a surgeon involved in fact there are two surgeons involved the surgeon who's at the console and then an assistant surgeon who's next to the patient sort of in this background over here and this person actually puts the instruments in all these arms and also assists the the console surgeon and it's important to remember that the surgeon's hands are placed in these special devices so their actual fingers are are actually making all the movements themselves and and performing the procedure and this is what it looks like on the patient's belly so just a few small incisions whereas it used to be for an open procedure if it was it would be a very large incision and they would they would have a longer stay in the hospital be a longer recovery time so this is made a big impact for a lot of the patients with small renal masses who require treatment so these are just a couple pictures from the OR just to kind of give you an idea of what it looks like so this is just normal kidney is going to be flat but these small renal masses will show up as just sort of little mound and you can usually tell and if you can't we can actually put an ultrasound in to identify the tumor so we identify it and like I said we we have already identified our renal vessels are artery and vein and we're going to put a clamp on it so that we reduce flow just temporarily so we don't get a lot of blood loss and then we take scissors and we cut around the tumor it almost looks like an acorn once you remove it because it's almost like a little cone that you're cutting out right here so this is the base of the tumor and they're cutting down and he's going to cut all the way around this tumor and then remove it once you're done you get this divot right here in the kidney so this is all healthy kidney and and once you have that you're going to take really just a fancy needle and thread to sew it back together and that room that's the final part of the procedure so at UNC you can even see this takeoff of partial nephrectomy this is for tumors that were less than seven centimeters so these are small renal tumors some but some of them are larger and you can see that over the years these partials are really overtaking radical nephrectomy which is in the light blue and then it's even more dramatic when you look at these true small renal masses that are less than four centimeters and you can see this kind of dramatic up tick in partial nephrectomy so how does the follow-up schedule differ from active surveillance and that's something to think about in terms of how often you want to be seen and the AUA guidelines again they recommend even though this is again there's not a lot of evidence that's behind all of this is sort of just expert guidelines they recommend a baseline imaging within three to 12 months after surgery and that's just to take a look at how things look sort of the baseline so you have something to compare in the future if anything is worrisome if you underwent a radical nephrectomy additional imaging is actually optional in these small renal masses and so you could potentially be done with imaging at least from the kidney standpoint at that point if you had a partial nephrectomy the additional imaging is recommended annually every year for about three years and it in you know in some cases you may want to extend that and then for all patients a yearly chest x-ray for three years to evaluate for any spread of disease based on the AUA guidelines and again this comes from the AUA as well this is a their decision-making algorithm I kind of it's a little more complicated than this but I think this is really the gist of what they're getting at and they they categorize patients into four categories so we have healthy patients here and here and we have sick patients and we all have very small masses which are the masses less than four centimeters and then small masses which are the this four to six centimeter category and you can see that really the gold standard yes is surgery and and when I say surgery partial nephrectomy is truly gold standard but radical nephrectomy in some cases especially if the tumors in a location where a partial nephrectomy is not is not able to be to be performed but you can see that it's also recommended when patients are sick so you can see it here either surveillance surgery because this is a large slightly larger mass surveillance or ablation which I didn't talk about today but cryo or radio frequency ablation for the very small mass in a sick patient so but it's still an option and that's what I was mentioning it's still an option for anybody with these very small or small renal masses and that's something to consider and again it's about the decision-making process between the patient and the surgeon so I want to circle back to that first case presentation and sort of put in a perspective because this patient sort of did both and so it's a 60 year old male again with the 1.6 centimeter renal mass and he opted for active surveillance which I think was appropriate he actually had some comorbidities he had had a stroke and he had some other medical issues so I think active surveillance was very appropriate for him and so we decided to do imaging every three months just to start to kind of get that trajectory and to understand the growth rate of the kidney tumor and so what we found was that it was a stable size at the three month but at six month we found a jump in the size and you can see there's that first image and then here it looks what it looks like it's six months and the whole point is to capture this before it becomes something bigger but yet not over treat those who really didn't require treatment to begin with so we made the decision together to go ahead and pursue robotic partial nephrectomy and so that was performed in the path confirmed renal cell carcinoma it still was staged one T1A because it was very small and we pour the guidelines obtained a follow-up scan about three months later and you can actually see a little bit where the defect was no tumor anymore but that's generally the appearance that we find after for the baseline follow-up scan so what we're going to do with him is annual imaging for three years because we did a partial nephrectomy and that'll include not just a CT but also a chest x-ray and so far he's been doing very well so just my summary slide I want to just these are the key points here I think small renal masses are being detected with increasing frequency we're going to see more and more of these as time goes on and as we do more and more imaging in the ER there's no reliable way yet to know which tumors are going to behave aggressively and so active surveillance and some ablative therapies like cryo and radio frequency ablation are options for the carefully selected patient or the high-risk surgical patient but partial nephrectomy still is the gold standard and we have to remember that when we're counseling the patients now with this the advent of the robotic partial nephrectomy it's become easier on the patient to have this surgery and that's an important point not saying that it's an easy procedure to go through but it certainly it can be easier than the open partial and that that's saying something right there but I think that our hope is that improvements in both biopsy techniques and imaging techniques and even just molecularly characterizing the tumor itself will help us to better characterize not just just in general these tumors but really individualize it for each patient and that's really the hope once we have that it'll be even easier to figure out who would be best served with active surveillance so with that I'd like to thank you for your time and if there are any questions be happy I answer them