Presentation of Cases /Audience Voting/Panel/Discussion

Transcription

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2 Presentation of Cases /Audience Voting/Panel/Discussion JJ Patard Tim O Brien Ninth European International Kidney Cancer Symposium Dublin April 2014

3 Clinical case 1 63 years old women Medical past history: TVT for stress urinary incontinence Incidental discovery of synchronous bilateral renal tumors Right upper pole T: 13mm Left upper pole T: 37mm Baseline Creatinine: 0.8 mg/dl Baseline MDRD GFR: 93 ml/mins

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5 Voting questions for the audience 1. No biopsy, Partial nephrectomy on both sides? 2. Bilateral Biopsies, Partial nephrectomy on both sides? 3. No biopsy, Right partial nephrectomy and left radical nephrectomy? 4. Bilateral Biopsies, Right partial nephrectomy and left radical nephrectomy? 5. No biopsies, RFA or CA on both sides? 6. Bilateral biopsies, RFA or CA on both sides?

6 Questions for the panel 1. CT or US guided biopsies? (R?, L?, both?) 2. Upfront partial nephrectomy (R first?, L first?, both in a unique procedure?) 3. Would you consider a radical NX on the left side? 4. What approach for PN: open/lap/robot? 5. In case of ablation TT what would be your first choice: RFA or Cryo (R, L)?

7 Decision: right PN first (without Bx) Robotic PN WIT: 16 min Estimated blood loss <50cc Uneventful post operative course LHS: 3 D Post op creatinine 0.7 mg/dl Post op GFR 83 ml/min Histology: Angiomyolipoma

8 Left Side: Questions for the panel 1. CT or US guided biopsies? 2. Left partial nephrectomy without BX? 3. Left Radical Nx? 4. What approach for PN: open/lap/robot? 5. In case of ablation TT what would be your first choice: RFA or Cryo?

9 Decision: left PN(without Bx) Based on different radiologic features for the left T we decided Robotic left PN (2 months after right side) WIT: 20 min Blood loss <50cc Uneventful post operative course LHS: 3 D Post op creatinine 0.78 mg/dl Post op GFR 74 ml/min Histology: clear cell carcinoma, Fuhrman grade 2, T1a, NxM0, R0.

10 Clinical case 2 62 years old women Right partial nephrectomy in 2000 (CCRCC) Right radical nephrectomy in 2011 for local recurrence (CCRCC) May 2013, tumor 23mm on the left side Baseline Creatinine: 0.97 mg/dl Baseline MDRD GFR: 58 ml/min

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12 Voting questions for the audience 1. Biopsy and Partial nephrectomy 2. No Biopsy and Partial nephrectomy 3. Biopsy and RFA or CA 4. No Biopsy and RFA or CA 5. Upfront radical Nx and dialysis

13 Questions for the panel 1. CT or US guided biopsies before any kind of TT? 2. Partial nephrectomy 1. OPN, LPN, RPN? 2. trans vs RP approach? 3. Main artery clamping vs hyperselective art. clamp? 3. RFA or CA? 4. What would you do for a new unique recurrence 1 year later? 1. PN again? 2. RFA or cryo? 3. Radical nephrectomy?

14 Decision: left RPN without Bx Retropéritoneal approch Main Renal artery clamping time: 8 min Uneventful post operative course LHS: 3 d 3 months post op creatinine 1.1 mg/dl Post op GFR 50 ml/min Histology: clear cell carcinoma, Fuhrman grade 1, T1a, NxM0, R0.

15 Clinical case 3 45 yrs old man No medical past history Incidental diagnosis of bilateral adrenal masses and right renal tumor No distant metastases ECOG 0

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17 Voting questions for the audience 1. Clinical trial (Bx, neoadjuvant TT followed by surgery) 2. Systemic treatment with no upfront surgery (Bx, treat and see what happens) 3. No bx, Right radical nephrectomy and adrenalectomy (open) and left adrenalectomy 1 month later (lap) 4. No Bx, Right radical nephrectomy and bilateral adrenalectomy (open)

18 Questions for the panel 1. Clinical trial (Bx, neoadjuvant TT followed by surgery) 2. Systemic treatment with no upfront surgery (Bx, treat and see what happens) 3. Right radical nephrectomy and adrenalectomy (open) and left adrenalectomy 1 month later (lap) 4. Right radical nephrectomy and bilateral adrenalectomy (open)

19 The patient was included in the Neorad trial (everolimus 2 months followed by surgery) No effect on tumor masses Complete resection of abdominal tumors Bx and final pathology: pt4, type II pap carc, R0 Local recurrence and distant mets 3 months later Progressed (CNS, liver, lung), refractory to TKI Died 5 months following surgery

20 Clinical case 4 52 yrs old Male patient No medical past history Left flank pain Left renal mass with major nodal invasion No distant metastases

21 Voting questions for the audience 1. Bx, Systemic treatment without nephrectomy? 2. No Bx, Left nephrectomy without LND followed by systemic treatment? 3. No Bx, Left nephrectomy and extensive LND 4. Bx, Neoadjuvant treatment before Left nephrectomy and extensive LND

22 Questions for the panel 1. CT or US guided biopsies before any kind of TT? 2. Systemic treatment without nephrectomy? 3. Left nephrectomy without LND followed by systemic treatment? 4. Left nephrectomy and extensive LND 5. Neoadjuvant treatment before Left nephrectomy and extensive LND

23 Combining surgery and targeted therapy The patient recurred locally 18 months later Remained stable or slowly progressive during 2 yrs with sunitinib He died 4 years later from multi visceral metastases

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