Ep. 26 Management of Small Renal Masses with Dr. Phil Pierorazio

Enjoy the podcast, but want more? Download our new Backtable app. You'll get early access to episodes, case discussions, and courses in one place. Just search Backtable in the App Store or Google Play on your phone. This week on the Backtable podcast, to get back to your original point, partial versus radical, older, sicker, more complex patient, I think it really comes down to the kind of end-stage renal disease discussion and not to put it on the patients, but sometimes I put it on the patients. What is more scary to you? Is it dying of kidney cancer or is it dying while on dialysis? And often they will give you their perspectives on quality of life, on what their goals of care are, and that can help you guide them down the right pathway. There are patients who are rightfully so terrified of dialysis, and those are the patients you probably want to err on the side of an effron-sparing approach or a partial infrectomy, and there are patients who are terrified of cancer and less worried about their kidney health or kidney function. And so I think that's a very real conversation. [Music] Hello everyone, and welcome back to the Backtable podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at Backtable.com. This is Dithya Batgrode, Israel Host this week, and I'm very excited to introduce our guests today, Phil P. Arasio from the University of Pennsylvania Department of Erology. Welcome back Phil, how are you doing today? I'm doing great, it's just great to see you again. Absolutely, absolutely. I've been looking forward to this particular podcast, which we've been trying to get on the books now for some time. And in addition to talking about the management of small rental masses, it'll be nice to kind of get some of your insight as one of the panel members on the whole process. So let's just jump into it Phil. I'm assuming in your practice most patients are coming in with a diagnosis. You know, I had a CT scan from a car wreck or a lumbar spine MRI. And let's just talk about intake, you know, 101 when you're doing your history of present illness and so forth with patients. What are the aspects that you're kind of dialing in on? Yeah, so the mode of diagnosis is often one of the most important things you'll see. And as we know, most of the small rental masses are found incidentally. But when they're found for another reason, it's really important to note that reason. So if somebody's having another cancer worked up or if they had an injury or if they're undergoing a hematelier workup, which is really rare, but you will see. And that's often some of the intake is to what else is going on with their life, not necessarily what's going on with that mass. And then when you get the imaging, it's really is this solid, is this cystic? And as you alluded to, you know, we wrote guidelines with kind of the assumption or the direction that we're assuming most of these masses are cancer. But as you know, as an oncologist and many people know out there, most of the small rental masses we see are not cancers. Absolutely. And what about family history, social history, or your kind of high life that you touch on with any patient with a newly diagnosed small rental mass? Yeah, I think the three sentences I always jot in every note for these patients are no flank pain, no abdominal mass, no hematelier, and no family history of renal cell carcinoma or other renal malignancies. And those are the things you really want to think about kind of the obviously palpable flank mass, hematelier those lead to locally advanced cancers, those are the things you're thinking there. But family history certainly can play a role here. We know hereditary renal cell cancers are rare, but certainly when you see things running in families, it can give you a little more pause about exactly what's going on. Yeah, I kind of feel like maybe thinking about prostate a little bit that the explosion of genetics council, our patients that are in meat criteria for referrals to cancer genetics, for instance, is something that I kind of try to emphasize to the residents now when they're in clinic with me. And I actually thought it was quite nice with the most recent guidelines. If they have bilateral masses, if they're young to try to get them in to see the cancer genetics folks, it's likely going to be a low yield test, but just something to work into our standard workflow for the management and intake of patient with small renal masses. Yeah, I think it's a great point. You know, if you think about hereditary renal cancers in general, it's less than 2% of renal masses, but certain things will enhance that number. As you said, multiple bilateral renal masses, the younger the age is the guidelines emphasize 45 or 46 years old, based on, you know, the best available data. It's probably only gets as high as maybe a 20% risk of having a hereditary cancer, but certainly worth exploring with patients at higher risk. And, you know, of course, smoking many of these are smoking-related cancers. Do you actually do your own smoking cessation counseling? Are you typically trying to get them into seeing an expert? Yeah, as much as some people may say, I'm an expert in small renal masses, I'm definitely not an expert in smoking cessation, and I defer to the experts there. So I will have a conversation with them, and I will often tell them, you know, as we get further along in the conversation, we talk about management. Yeah, we could take out your mass, we could treat this, but the thing that will affect your longevity the most is you quitting smoking. And I'm not good at it. It's not my forte, but there's certainly people who are, so let me help you get to the people who can help you. And that's kind of verbatim, my extent of counseling is like the best thing I ever to do is for you is probably get to the quit smoking and maybe lose some weight if they're obese as well. You mentioned grossing materia, and are you getting a urinalysis on all your patients coming in with the small renal mass? I do. Everybody gets a urinalysis, everybody gets a BMP or basic metabolic panel. If they have advanced disease, you can consider a more comprehensive metabolic panel looking for liver dysfunction. But really, the basic metabolic panel and the UA is not really for hematerias for renal function. And the vast majority of patients I'm looking at a creatinine, an estimated GFR, and you're looking for the presence of protein in their urine. Very rarely are you going to find hemateria that's actually attributable to a small renal mass. Right, right. I do think it's worth mentioning that especially if they've got a history of smoking, it's probably worth just kind of checking that box and doing their system completing the hemateria work up. I'm sure you've seen it and had patients I certainly had where along with their maybe more advanced tumor with the thrombus etc. You scope them and they sure enough have a concomitant bladder cancer. Absolutely. So you kind of touched on this that patients are getting a whole host of different things. Spinal MRIs, ultrasounds for a perquaderant pain, non-contress, CT scans, look for stones. What is your kind of preferred imaging modality when you want to have a multi-phase contrast at scant? Yeah, I think the easiest one to use a CT scan, it's easily reproducible. It's easily interpreted by the vast majority of people out there. I think it's the easiest one to work with. So quick, easy, yes there's radiation, but you'll get the highest quality, most reproducible images, I think at a more consistent basis. That being said, MRIs a wonderful modality. I have a very hard time if somebody shows up with a good quality MRI asking them to get a CT scan in addition to it, even though I feel more comfortable with the patient. I feel more comfortable sometimes reading a CT scan than an MRI because an MRI is suitable and you get better, the more you read them, the better you get it. And if you find a good radiologist, you can work with who can kind of show you when you're confused. MRI is a very reasonable modality as well. Yeah, I think it's nice that you mentioned being more comfortable with CT scans. I think a lot of people on the urology side are not, you know, for starters, you have your non-contress, your contrasts, it phases and it's kind of digestible. Sometimes be a little bit tricky. I've been very lucky to work with radiologists that have a tremendous experience with MRIs and not only, you know, of course your standard size, character, features, etc. But they can really give you the next level of, you know, cancer, yes, no, and if cancer, high grade, low grade, with accuracies that actually approach biopsies. Yeah, Dr. Pedro is a pretty amazing guy at UT Southwestern and his imaging is pretty excellent as is ours at the University of Pennsylvania and as it was at Hopkins, you know, before I came to this institution. But it is highly experienced and reader dependent and you will see tremendous variability in the reading and interpretation of MRIs around the country. So I think you've got to kind of know yourself. You've got to know your colleagues. You've got to know your institution. Use the imaging modalities that's going to give you the best, most reproducible answer. Fair, fair. So, and are you getting a chest x-ray or anything to kind of check that box? Yeah. So really depends on the mass. I think as a good oncologist, we need to stage someone's chest. You know, as we know, pulmonary metastasis are one of the more common locations of metastasis for renal cell cancer. The chance of pulmonary metastasis with a small renal mass is about 2% or less. So I don't think it's worth the bang for the buck of getting a chest CT scan to look for small isolated pulmonary nodules. In a population we already know is elderly, maybe smokers may have other comorbidities. I think you end up buying them a lot of benign workup for no reason to be honest with you. But I think a chest x-ray is really important to be to check the oncologic box. Make sure you've looked at the chest. You're not missing anything big because there are, you'll see a handful a year in our practice at least. Patients who show up with diffuse metastatic disease in a small renal mass, which is very different from a patient with a small renal mass and a risk of developing metastatic disease later. All right. Fantastic. So I think we've talked about intake 101 patient specific questions imaging. Now, when we get to the guidelines, in a course, broad strokes, there's obtained more information with imaging plus or minus biopsy or move on to treatment via different approaches. And it's nuanced, right? It's hard to have this conversation or like, what are your reflex things? But maybe start out with who are the patients, both patient wise and tumor wise that kind of have you on high alert, so to speak, with the small renal mass? Yeah. You know, the big controversy in small renal mass management is active surveillance. balance a durable option. And I'm sure we're going to talk more about that. So the things you want to think about are, or the way I think about this are, you want to think about those patient and tumor characteristics that are going to help you determine if this is a durable, reliable option. So the first thing is patient age, right? Thrill comorbidities out for a second. If you have a 40 year old patient, are you going to be able to watch a small rental mass for 40 or 50 years, unlikely, no, even if we know most of these things are slow growing and indolent in nature? To that extent, life expectancy, right? So then you can start calculating in comorbidities. And in this population, the group from Fox Chase, when we were at Hopkins, we looked at similar data. Cardiovascular comorbidities are going to be your number one competitor for other cause mortality. So if someone has a number of cardiovascular comorbidities, they are much more likely to die of other disease than they are of a small rental mass. Those things register really highly on my radar. And then when you're looking at the tumor, bigger tumors are less likely to be watched for an extended period of time. There's been controversial data about bigger tumors growing faster than smaller tumors. I don't think you see that until you get into larger tumors, T1, B and T2 tumors. So for most T1A tumors, they're going to grow slowly. So there's really no difference in growth rate between a two and a three or a three and a half centimeter tumor. But if you start closer to a four centimeter cutoff, where the majority of people are going to offer intervention at that point, the closer you start to that cut point, the more likely you are to get there. - Absolutely. Yeah, I think that's fair. Of course, there's ends of the spectrum where things, I guess, are a little bit more straightforward. Younger patients in good health, opposite endermy, sicker, highly comorbid patients, maybe towards into their life. Now maybe a couple of niche scenarios in younger patients. If you see that they've got uterine fibroids, African American ancestry, I'm talking young patients, 20s and 30s. So of course, we still have to see genetic counselors. Are there other things that you're doing at the time of managing those masses? - Yeah, and you're getting towards the genetics again. And they are, it's important to remember that these are rare circumstances, but they can be profoundly impactful on patients and their outcomes. You'll see, for most patients with genetic syndromes, you can treat them in kind of the VHL pathway where you know they have two tumors, you know they're likely to need intervention throughout their lifetime. You know the vast majority of these things are going to grow slowly, and we kind of employ that three centimeter rule, right? When they get to about three centimeters is when you're gonna offer treatment. But the hereditary cancers with the really aggressive cancers are rare but really important. And where you will see them to your point, it's not only young women with fibroid history, but often with a early hysterectomy. So if you see hysterectomy on that intake form, or it's a good question to ask young women, when you see them, if they've had a hysterectomy for fibroids in their 20s or 30s, that can be a real indication of something more aggressive going on. Often these renal tumors will not be completely solid, they will actually have a cystic component. So in those patients, sometimes they'll come to you with a cyst or suspicion of a cyst. I will always confirm that with multiple modalities. So if they show up with a CT scan, get an MRI or an ultrasound, you really wanna rule out that this is not a solid mass masquerading as a cyst. Often these tumors, and we're talking about basically the fumarate hydroteus, tumors are often papillary in nature. So at a CT scan where you have kind of modeling, or you can have some artifact that will make them appear cystic when they truly are a solid mass underlying. - Right, right, and you kind of hit the nail on the head. I think it's this clinical scenario, maybe not your VHL, but your other more aggressive phenotypes where, the things that I'm thinking in my mind is I'm doing a lymphatic dissection, whether I do a partial or reticone effect to me. And if I'm gonna do a partial, I'm not gonna nucleate it, it'll be a formal partial and effect to me. They're kind of fringe scenarios, but I think we've all had a handful of these folks that you do see lymph node metastases, and sometimes these tumors can't have a prolonged local regional phase, and maybe you can help 'em. - Agreed completely. - So question, when you see a Bosnian ecclesion, three, four, does that get you excited, or does that kind of, you're like, all right, this is one that's not really that dangerous? - Yeah, the cysts are a great conversation, and I think we've learned over the years that most cysts are benign, and even cystic renal cell carcinomas tend to be really indolent. So I don't get worked up over Bosnianic threes or fours, and the way I explain it to patients are, we don't get so much worried about the size, like we do with a solid mass. We get more worried about the complexity, and obviously the more complex of masses, the higher it goes up on that Bosnianic scale. And what we're really worried about are solid masses masquerading assists, rather than even cystic masses with a small solid component. We know that most cystic renal cell cancers are not dangerous. People are highly unlikely to die from them. They're really low grade tumors, in general, and they behave that way, but there are these memakers that you kind of brought up before, like a hereditary Lyon mitomas, renal cell carcinoma, that can be really aggressive and look like a cyst. And so one thing I do when I have a three or four, radiologists will argue with me, but I'll change modality. If the initial scan was a CT, I'll get an MRI next one, or if it was an MRI, I'll get a CT or an ultrasound. Mixing modalities gives you extra confirmation that you're truly dealing with a cyst or a cystic mass versus a solid mass, and then you can go back to your more consistent imaging. - I feel the exact same way. I mean, Bosnianic threes and fours usually are at the, and one end of the spectrum of the ones that I get pretty excited about. And I was a little bit surprised, you know, in the guidelines that Bosnianic three fours and solid renal masses were kind of lumped together in management. I think it's whether it's a cyst associated RCC in a patient with perfectly good renal function or even cystic associate RCCs and patients with severe chronic kidney disease on dialysis. Those are not tumors that I get particularly excited about. You know, of course we follow them, treat them when necessary, et cetera, but it seems like I'm hearing something similar. - Yeah, and I think part of that, we get to realize that the guidelines, when written, have to reflect the best available literature, especially AUA guidelines. And while most of us who treat renal cancers and renal cysts and renal tumors on a regular basis, don't get too excited about Bosnianic threes or fours, the literature, it's really difficult to parse out those cystic masses from solid renal masses in a lot of the literature. And so the best available science and evidence, you kind of have to lump them in together 'cause that's what most studies do. Now there are really good data from the University of Toronto and other kind of emerging groups that are really pulling out the cysts and looking at threes and fours and showing that they're indolent, but it does not meet the level of evidence that supports the studies looking at solid renal masses. And as you know, for decades, we treated threes, fours and solid renal masses the same. - Okay. So let's talk about biopsies. Who are you getting biopsies in? - Yeah, so I am a judicious utilizer of biopsy. I like biopsies in kind of three distinct areas. I like them when you're unsure what the correct management option is. And that can be either you're not sure if this is a cancer or you're not sure if it's an aggressive cancer. You want some help from tumor biology or it's a tumor in a tough location. You're not sure partial versus radical. Think we're much more comfortable removing a kidney for a cancer, even if it's a low grade indolent cancer than we are for benign tumor. The second circumstance is for small renal mass patients on surveillance. There are a growing number of groups that biopsy everybody up front. And I don't think there's necessarily anything wrong with that, but it's just not the way we do it or I believe it. But I think the vast majority of patients can be watched first. And so we put our patients on surveillance. If their tumors grow across a size threshold, I think that's a great time to biopsy a patient. That way you can often distinguish uncle cytomas, which are fast growing, but benign masses from some of the more aggressive clear cell histologies. For instance. And then the last circumstance, because biopsy has gotten so much easier, so much safer, low risk of complications, low risk of tumor seeding can be done in an office under sedation. Any patient who wants more information, I will never refuse them a biopsy. I think we can certainly provide more information if somebody wants it. It doesn't often change our management in the vast majority of patients. So that's why we don't routinely offer it. But I would never turn a patient away from a biopsy who wanted one. Totally. I think that first kind of three, six month interval scans to get a little bit of information. Maybe as you mentioned, you go from a CT scan to an MRI or vice versa, you're picking up some additional information. And using it as a bit of a stratifier filter, instead of reflexively biopsy kind of is pretty reasonable. And for sure, if it's kind of a oddball mass, very central high probability of a radical, I think a biopsy is kind of nice just to make sure you're not going to lump out somebody's kidney for something benign ultimately. And what are your size thresholds for either treatment or biopsy in a patient on surveillance? Yeah, so I know I'm a little heretical with this statement, but I really believe that two centimeters and less nobody needs an operation immediately. And it doesn't mean you shouldn't operate on some people with tumors less than two centimeters, but nobody needs an operation immediately. I think the literature is really clear here that the risk of metastatic progression and metastatic disease in a tumor less than two centimeters is much less than 1% and really approaches 0%. Depending on age, comorbidities, life expectancy, et cetera, I basically draw a cutoff at two centimeters, three centimeters and four centimeters. And basically your metastatic risk increases slightly at each cutoff. So if you look at the plethora of data from a number of institutions around the country, around the world, less than 1% at 2 centimeters, about 1 to 2 percent for a 3 centimeter tumor. And then as soon as you cross over the threshold for 4 centimeters, the risk of metastatic disease increases to 5 or 10 percent as tumors get larger. And those are the numbers I use to counsel patients. So for a young healthy patient, once that tumor hits 3 centimeters, say, well, listen, your risk of developing metastatic disease is still incredibly low. But why would we wait until 4 centimeters when we're going to potentially double your risk of developing or dying of metastatic disease? Let's not wait. Let's treat it now where we know we can still cure you. For somebody who's a little bit older and sicker, we may say, listen, 1 to 2 percent versus 5 percent, where you have a 10 to 15 percent risk of dying of something else in the next 5 to 10 years is not a terribly bad calculation. And so that may change the size threshold for that patient. So in general, most surgical patients were using a 3 centimeter cutoff for somewhere in that range. We may extend that criteria for patients who are older or who have comorbidities putting them at risk of dying of something else. Agreed. And agreed. I mean, 3 centimeters just evoke so many emotions when it comes to talking about small renal masses. Yeah, absolutely. You know, older sicker patients, oxygenarians, multiple comorbidities. I think we've all kind of pushed it into 5, 6 centimeters. And I feel like I've heard Babu's a gift in pretty cool talks on how the whole paradigm of active surveillance is actually pushed by a patient when they started doing things at Fox Chase. So I hear you, it's not going to be a one size shoe fits all. So, you know, I think so much of our 3 centimeter data experience comes from the VHL population, which again is going to be, you know, a small minority of patients. But broad strokes, I'd like to hear your approach to VHL patients. Yeah, I think, as you said, you know, we have a variety of data sources for that 3 centimeter rule, but the best data by far is from the VHL population and the VHL literature is now supported, not only by clinical data, but by genetic data by, you know, obviously, Marc Bahl, the crew at the NCI who's been studying this extensively now for decades. And I really adhere to the 3 centimeter rule. And we know for VHL related tumors, they're going to be clear cell, renal cell carcinoma, the vast majority of the time. They're going to grow incredibly slowly. So, if I know someone's VHL, where a sporadic tumor we may watch every six months or so for the first year or two, VHL patients right away, you can start following them once a year. You know that they are highly unlikely to have any dramatic growth rates within that period. We also want to minimize their testing, their imaging, radiation exposure, all of that stuff, because they're going to require it for the rest of their life. The other part of this is recognizing there are definitely different VHL phenotypes. So, you see families who develop a lot of renal tumors, you'll see families who develop pancreatic tumors, and you just need to be aware of kind of what that family trajectory is to, because it'll tell you how closely you need to watch their kidneys or their adrenals or their pancreas or whatever else is related. But in terms of surgical management, I adhere pretty strictly to the 3 centimeter rule. Once the biggest tumor hits 3 centimeters and one of the kidneys basically go in and clear out everything visible in that kidney. For the vast majority of patients prefer to do that robotically, even in reduced surgeries. That wasn't always my practice when I first started, and I was a little more worried about losing kidneys. I would make more incisions and really cool kidneys down and worry about prolonged warmest chemion, things like that, in damage and kidneys. As I've become more proficient with kidney surgery and kidney tumors, I do the vast majority of these robotically. I'm not a huge fan of a nucleation. I don't know if you want to go there today, but this is the one patient group where I think a nucleation makes a ton of sense. We know these tumors are typically well encapsulated. We know they're very often low grade at 3 centimeters or less. And so I think a nucleation makes a ton of sense. It makes the operation technically more feasible. You're less likely to lose blood. You can do a lot of the tumors off clamp to save them on a schemia time. And I think it's the goal for these patients is really prolonging their renal function more than it is worried about cancer outcomes. Our new back table app is live. Get early access to episodes, case discussions, courses, and a better learning experience. All free to download and use. Search back table in the app store and join us there. Yeah. And you know, 3 centimeters of course also has implications on ablation. And you know, one of my mentors and teachers who I really respect, Jeff Kadeh who's been a pioneer in ablation, you know, recognizing of course limitations with heat sink, etc. I mean, maybe use IRE for those scenarios. But you know, on the one hand, we kind of heard exactly what you describe once one hit 3 centimeters, you go in and do a clean out. Then as things start kind of bubbling back up, you ablate before they get to 3 centimeters right where you start having a drop off an efficacy. And then once you're done kind of ablating, then you kind of pull the trigger and the kidneys in the bucket. And you know, now you're starting that whole process. And Jeff, I haven't really asked him if this is evolved or changed, but he was then ablate ablate ablate until he can't ablate anymore. Then partial and refractumized. And when you can't do that anymore, then the kidney comes out. You know, of course it's patient-specific anatomy specific. But I always thought it was a, you know, at least moderately compelling way to think about these patients. Yeah, I think it's a very reasonable approach too. And it kind of is analogous to the MRI conversation we were having before. Jeff Kadeh, U.T. Southwestern, amazing teams at ablation, ton of experience, really good at what they do. As was the crew at Hopkins, as is the crew here at Penn. But I think it's also center-specific and provider-specific. And you want to work with someone who has a lot of experience ablating these tumors. And to your point, the literature is very clear. 3 centimeters or less. Ablation is a wonderful technique for ablating the vast majority of renal masses. But not all renal masses are amenable to ablation. There are some tumors that are more ideal to ablation. I guess we could say peripheral away from higher structures and make them definitely more amenable to ablation. I have tended to go the opposite way of Jeff. And it's not to say that he's wrong or I'm right. I may be wrong and Jeff's often right. But I've tended to do partial refractomy once the redo partial refractomy has gotten too challenging. Or it's too many tumors then move to ablation. And then kind of when surgery is no longer an option. And the kidney ends up in the bucket. I agree with you. Yeah. And just kind of think of back to your comments about management of masses, up to about 3 centimeters. You're okay watching them. And I always kind of struggle as they start hitting 26, 27, 28 millimeters. Where I'm like, well, goodness. I could just pull the trigger on an ablation. Of course, you could do a partial. But say it's an older patient, maybe on an anticoagulation or whatever, not the ideal surgical cannon, not a catastrophe. But I mean, who knows? It's 3.1 versus 2.9. Does that really matter? But if they pop up to 3.4 centimeters over the course of the last six months or a year, then perhaps you've missed that window or now you're looking at repeat ablations. Yeah. No, it's a great point. And I think, you know, once again, to get to guidelines, this is where guidelines struggle because this is really nuanced management. And I will tell you that I agree with you completely. And there are certainly when you're counseling a patient and you're thinking that their number one option for management is going to be ablation. I may not wait for 3 centimeters just as you allude to. Right. If you know somebody who's older or sicker or not even older sicker, but say they're on anticoagulation for whatever reason, it's much safer and easier to do an ablation at 2 or 2.5 centimeters, then it is to wait till they get to 3.5 or 4 centimeters and doing a partial refractomy where you know ablation has less efficacy or a higher risk of complications. So yeah, I agree with you. These are nuance conversations. You got to think about each patient and each tumor individually. There's no way to lump everyone into the same guideline-based bus bucket. But exactly as I say, their guidelines, they help kind of point you in the right direction. What about younger patients in ablation? I don't love ablation in younger patients. It's the same kind of thing. If they're 2 centimeters, 3 centimeters or less, the data is very clear. The oncologic efficacy is equivalent. It may take multiple ablations to get them to the same treatment. It may take two ablations rather than one partial refractomy. But the way I often kind of think about it is get the right operation rather than the easier one. And if somebody's a surgical candidate, I think a partial refractomy, I mean, we all have our biases, but I think it's the preferred management strategy for the majority of these small renal masses. At least one caveat to that are patients who have sub 2 centimeter endophytic tumors. I actually think we can have a really challenging time doing them robotically, even with a good ultrasound machine in the operating room, sometimes finding that tumor and really doing nephron sparing right, you end up sometimes cutting out a lot more kitty than you would want to, where good interventional radiologists with a contrast enhanced imaging, whether they're going to use CT MRI or even contrast enhanced ultrasound, can often nail that endophytic mass and do a much more reliable job sometimes than we can robotically. Yeah, I remember over the course of at least a decade of M&Ms for these very small endophytic tumors, sometimes it's worthwhile even getting a preoperative ultrasound just to make sure you can find that little fellow in the operating room and not have a stressful experience. And I totally agree, you know, you're kind of alluded to a high quality intervention radiologist. One of the things that always admired, I kind of share your biases in terms of partial and effect to me. I think in the right patient, which is oftentimes determined by me, I'll bring up a blacin if I think it's a good option. But one of the things I've always admired is when urologists and interventional radiologists that you do the procedures together. Because it's inconvenience. You're working around another team's schedule. You're not doing your cases and even though it's completely secondary tertiary, the billing isn't ultra favorable, it is still your patient. And not to say that the intervention of a doctor is just doing a procedure to move on to the next one, but I think just having that extra set of eyes, that QC to make sure that the ablation goes perfectly, I mean, A requires expertise and time, but that's the way it's been done historically in this institutions that I've been at and I think it's reflected in the outcomes. Yeah, I think you're right. I think practically that poses a lot of challenges for a number of practices, but yeah, in the ideal world, that's a great way to do it. Now, you'd mention enucleation versus resection and now there's enucleover sections and part of me is like, this is, I don't know, just kind of fun, urologic oncology academia. My kind of take on it is, it's going to be duck tissue handling because you don't rush over the tumor, assessing, you know, if it's got a thick capsule, four millimeters thick and it's just kind of shelling out and you quadrize it base, it's fine. You know, oftentimes I think it's actually your chromophobes that'll pop up that don't have an enucleation plane and that can be a longer day at the office. So my take on it without like coming through the data, which is going to lead to margin rates and so forth. And of course, you should have, I think, a pain negative surgical margins is assess what's going on real time, handle the tumor carefully and, you know, try to minimize the scheme yet, but I know it's kind of broad, but anything you add on that, Phil. Yeah. You know, nobody intentionally cuts into a tumor leaves a positive margin, but those rates certainly are higher with enucleation. It's not because people are bad people are bad surgeons. It just because that's the nature of the tumor and it's really hard to predict what you're going to get. So when I teach this operation with our residents and fellows, I teach, there's partial refractive me and there's nephron spare surgery, even though really it's a little bit of semantics. Partial refractive me is the patient with two healthy kidneys and a normal GFR who's got a small renal mass that we just that we're not going to take out their entire kidney. We're going to treat just the tumor. And in those patients, there's lots of arguments that taking out one, two, or even five millimeters of normal perancuma is not going to make a long term difference in their renal function. The EORTC study, the Van Poppel study, partial versus radical, there were no difference in the long term renal functional outcomes in healthy patients who had two healthy kidneys going into the operating room, half of which had an entire kidney removed versus those who had a partial refractive me. That being said, that identifies the important caveats. So patients who don't have two normal kidneys, patients who have pre-existing chronic kidney disease, patients who have multiple bilateral tumors, patients who have familial syndromes, these are patients who are at higher risk of developing chronic kidney disease and times where we should consider nephron spare surgery, which is kind of the way I teach the semantics. So that as I said, residents and fellows, really think about maximally sparing perancuma rather than your oncologic outcomes. And so those are the patients I will consider a nucleation and I don't do it in all patients, but I certainly will consider it in those patients. They've got to have good capsule. You've got to be able to adjust your margin status kind of in real time in the operating room because it's not a big deal to explain a difference in GFR of one, two, five, or even ten points, but it's really hard and challenging not only to explain to a patient, but to manage a patient postoperatively who's got a high grade positive margin. And it's very rare that we know that going into the operating room or even coming out of the operating room. So I, first and foremost, if we're in the operating room, we're there for cancer, this is cancer operation, make sure you clear your margins, and then everything else is a secondary consideration in my opinion. Totally, right. It's an ecological operation first. And you mentioned ERTC, which, you know, of course is I think also fun to talk about at multiple different levels, but older, sicker patients, complex, partial or a in and out radical. What's your general kind of philosophy? Oh, this is a tough one. We just had this debate last week in our indications conference. We're all biased by what we do and what we do on a regular basis. I think if you have a patient and there's not a hard cutoff, but in general, patients who are over 75 years old with a GFR above 45 are unlikely to progress to end stage renal disease and dialysis in the remainder of their lifetime. That gives a little bit of guidance. And I think you really just have to look at the patient and say, what is their chance? What are their underlying risk factors that's giving them CKD? How likely are they going to progress through a medical CKD route to end stage renal disease and dialysis versus, you know, what is the risk of this cancer and this operation? And realistically, you can make the argument if someone shouldn't be in the operating room, then watch them. Even at 45, six, seven centimeters, we briefly touched on active surveillance on the larger tumors later, but even at six centimeters, the chance of having a high greater locally advanced tumors, only 10%. That sounds really high to you or I who are healthy and have kids and, you know, it is high and that's a risk we're not willing to take. But if you're 75 years old and you've got serious comorbidities and you're worried about anesthetic risks, then you could consider surveillance in that patient. So to get back to your original point, partial versus radical older sick or more complex patient, I think it really comes down to the kind of end stage renal disease discussion and not to put it on the patients, but sometimes I put it on the patients. And often they will give you their perspectives on quality of life. On what their goals of care are and that can help you guide them down the right pathway. There are patients who are rightfully so terrified of dialysis and those are the patients you probably want to err on the side of an effron sparing approach or a partial refractomy and there are patients who are terrified of cancer and less worried about their kidney health or kidney function. Totally. And I mean, I think the way I think about it, of course, there's a patient specific factors, the renal function outcomes and then the tumor. If it's something exophidic and amenable and they've got a reasonable life expectancy, I don't think ERT season out to do a radical on everybody and just kind of convince yourself that you're doing the right thing. But in the same breath, I think ultra complex, partial with risks of leaky pseudoaneurysms, you know, all the kind of things that make for a long course for the patient can really take a toll, especially as reserve goes down. So maybe it's not always the right thing to do a heroic partial for a central high nephronometry score tumor. Yeah, I think, you know, it's kind of, it's a little bit tongue-in-cheek, but very few patients die of partial refractomy, but they will die of the complications of a partial refractomy. Yeah, yeah, no, it's fair. It's fair. You know, one thing I meant to ask you earlier, when you mentioned we don't like to do kidney surgery on benign masses and of course I agree. And I was just kind of reflecting, I don't have my exact data in front of me. Like, I can't think of many patients that have done surgeries on for benign masses. And I think it's this combination of imaging multidisciplinary teams, taking a little bit of a deep breath, following things for a bit of time before jumping in. Have you had any opinions on that, Phil? Yeah, I think, you know, this is where we see some of the discrepancies between institutional data and large population-based data. I think most centers of excellence and providers who treat a lot of kidney tumors and kidney masses really are more adapted, avoiding surgery for cysts, avoiding tumors for benign masses like angiomile, ipomas, and an oncocyte-tomas. It doesn't mean that rate should be 0%. But if you look at the population-based data, it's still in the range of 20 to 30% of people getting kidney surgery are getting it for benign masses. And there's really nothing, not nothing wrong, but listen, a well-done partial refractomy, it doesn't have a complication that removes a benign mass. You could argue there's a high-quality biopsy, right? But when you lose a kidney or you have complications, it becomes almost a never-event. And I think one of the things we'll see in the next five to ten years in kidney cancer, quality care, is going to be measuring the number of benign tumors that are removed and the number of radical nephrectomy is performed for benign masses. And once again, it shouldn't be 0%, it's never going to be 0%, but it shouldn't be high either and we'll figure out what the correct benchmarks are and how to measure these things moving forward. So I think we've seen major progress in both of those. You could say maybe inappropriate use of radical nephrectomy or inappropriate surgical management. Interproperty is a bit of a loaded term here. And you've done some work on like Sesame B scans, are those a part of your algorithm now? They are. I think they're a huge part. They're a really nice non-invasive way to look at people you have high suspicion of an anchocytomas for. So these can be tumors that just radiographically appear like they have a large central scar. Sesame B is completely appropriate there. Sometimes in a patient, we talked about indications for biopsy before or times when I would use biopsy. Sometimes in those patients, you want to offer them a non-invasive process. We could do a biopsy or we could try this nuclear medicine test first. It's pretty cheap. It's very easy test in most centers. Once again, the biggest barrier or boundary to widespread use of sesame bee is experience. They're not the easiest scans to read and you have to look at a lot of them and you have to know which tumors were benign and which tumors were cancerous kind of on the back end. So it's kind of a continuous quality project to make sure that you're reading them well and reading them well with the radiologists. But I think the data is now clear that a hot sesame bee scan is one that lights up brightly. It's highly indicative of an anchocytoma or a benign anchocytic tumor. And remember this test is not designed to pick out cancer. It's designed to pick out a benign tumor. And so all of the statistics are based around predicting of benign disease. So if you have a hot meaby or a bright sesameby scan, you're very likely to have an aquasytoma or benign mass. It doesn't necessarily mean if you're cold that you're 100% guaranteed to have cancer. Remember, it doesn't work. You know, it's not dichotomous like that. But I think it's a very powerful test. And even now, I think the more robust data is if you combine sesameby with a biopsy, you are extremely likely with almost 95% certainty or better to know what the histology is before you go into the operating room. - I think it's great. And I think it's going to be, you know, of course, aquasytomas make up a small fraction of the small renal mass this period. But much of, I think the future is going to be trying to sort out these relatively lower probability events. Like who's the patient with a small renal mass? That's actually got some very aggressive biology. And, you know, maybe as we approach 45 minutes, you know, what are you most excited about over the next five or 10 years as it pertains to small renal masses? Whether it's the science or population health and implementation of quality metrics, what kind of gets you excited? - Yeah, there are two things that get me excited. And the first is improved diagnostics. And I think sesameby scan is a great segue into that. Sesameby was a great test. I don't think it's necessarily the long term answer here. I think there will be additional molecular imaging that will likely really help us in the diagnosis and management of renal tumors. There's already ongoing trials, CA9, which is kind of the clear cell renal cell carcinoma molecular kind of byproduct. There's lots of agents out there now that are being investigated to study that. There's potentially the ability to use dual tracers. So something like a CA9 molecule and a sesameby in the same setting for a patient can help you in the same scan, differentiate, benign from malignant. So I think molecular imaging and other diagnostics and what I say by other diagnostics, I think the Holy Grail is a urine test. We're working on ways to either detect directly or indirectly in the urine, whether someone has benign, indolent or aggressive renal cell cancer. I hope that that's the future. Wouldn't it be nice to just do a simple urine test? Not only somebody shows up with a mask to tell them what they have, but then potentially at a population-based level screen patients with a urine test. That's one way we actually really could impact mortality in kidney cancer. And then the second thing I'm more personally interested in is quality metrics and quality outcomes in kidney cancer. For years, we've talked about things like blood loss and ischemia time and length of stay, which are important metrics for probably have little long-term impact on patient care and management of the disease. And so I think myself, others around the country are really trying to work on, define and decide what are the important quality metrics. Like you said, is it radical nephrectomy for benign tumors? Yeah, that probably is an important quality metric. We just need to find out what the right numbers are and how do we work through these things. Yeah, I totally share your sentiments. I think it's pretty exciting with machine learning, artificial intelligence, you've got MRI that's got six million bits of information and put that together with histopathology, put that together with some molecular diagnostics, I mean, non-invasive blood-based markers as well. Without getting too futurist, we talked a little bit about sapiens and homeodias, which I think you're reading. Imagine a nanobot that's kind of screening for 3P associative VHL type of mutation as soon as one pops up, your iPhone, Pings, and it's time to go see your local X, Y, and Z. And it's a crazy thing to think about, but it's also probably not outside of the realm of possibilities. And then also I think biopsies, I'm kind of with you on judicious use. And even as a research tool, I think to get biopsies along with longitudinal, good, high-quality, clinical, and radiographic data, maybe we start picking up who's got that nasty underlying low, ill-eal frequency mutation that could potentially act up down the way. But this is great. I think there's just a wealth of information. I think absolutely. And the last thing I'll just kind of mention when you talked about ischemia times, preservation of normal princoma, cold versus hot. In my relatively short career, various iterations of nephromatry scores, I mean, I think these have all been massively important in just to kind of elevate the field, bring partial in effect with the forefront, of course, is still a relatively newer operation. I think the first ones were in the early '90s, but so much of it does seem almost very, very incremental and trivial. And it was necessary, but now we really can spend our brain space on what are the most critical, broad strokes things that are gonna affect patients. Yeah, I agree with you completely. I think you look at the evolution of the management of kidney cancer care over the last 30 years, right? We saw an explosion in small, renal masses. We saw the emergence of partial and refractomy. Now we're seeing, I wouldn't even say widespread acceptance yet, but at least the acceptance of active surveillance and recognizing that most of these tumors are not dangerous. I think the future's really exciting in this disease. If you look down the metastatic pathways, we're seeing all kinds of drug development and therapeutic agents for a disease that had no active agents 10, 15 years ago. So I think this is an incredibly exciting field. I think we're seeing some tremendous changes in the management of kidney tumors and kidney cancers in the next 10, 15 years. Well, fantastic Phil, always a pleasure to have you and hope the transition to Philly has been smooth and until next time. Bye, guys. (upbeat music) (upbeat music) - Backtable now offers personalized specialty feeds inside the app. Whether you practice IR, cardiology, ENT, urology or oncology, you can follow curated playlists and explore case discussions. Download Backtable and tailor your learning experience on your phone via the App Store or Google Play.