And we're actually gonna start off with doctor Lee, um who is an assistant professor department of urology. And he is gonna talk about management of cystic renal masses, the wolf in sheep's clothing. Perfect. As Randall gets up here, I'll just give him a plug. Randall. Come on up. This is the newest member of the Philadelphia uh Fox Chase Temple Logic Institute and uh Randall joins us. He did a residency at Temple Super Talent in every domain of urology. And he went to what he said was, uh you know, West Coast, best coast and did a uh urological oncology Robotics fellowship with uh with Indy Gill. And we said, come on back to East Coast Beast Coast and he came back and, uh you know, just today in the R I mean, Randall is about six months in uh one of the or nurses came to me and said, where the hell did you find him? The guy, you know, guys doing 23 robots a day finishing at the same time as the senior guys. Um Just fantastic. It's busy, busy practice already. Uh We're very lucky to have him. Thank you, everyone and Alex for that warm welcome. And it's such an honor for me to, to, to be the first to kick off, you know, the, the first lecture in tonight's event. And, uh, you know, I'm really gonna be talking about um, uh a clinical dilemma to the practicing urologist and that's the management of cystic renal masses. And you'll see why I call these, the, the wolf in sheep's clothing. These are my disclosures and I really wanted to start first by talking about defining a cystic renal mass and and how we characterize these lesions. So, radiographically, these are any renal mass in which there's a a solid enhancing component that comprises of less than 25% of the total lesion. And how we characterize these lesions is by what's the Bosniak classification system which has really been around since the 19 eighties. And it's how we classify the complexity of the, of these, of these lesions. Now, uh scores one and two possess negligible risk risk for malignancy. So the focus in the literature is really paid to the Bosniak two f to the Bosniak four lesions. And as the lesions increase in complexity, whether that be the number of septations, the calcifications in them, how thick the septations are or if there's an enhancing solid component, there is an increased risk of malignancy, as you can see here with increasing score. So with the risk of malignancy, how do we manage these lesions? Well, we know that the early literature on these lesions and on long term reported follow up that these lesions do excellent. However, the reported le uh the reports on these lesions were based on pathologically confirmed cystic RCC. For example, this is a paper published in the early two thousands by Doctor Lebovich and his group looking at the surgical outcomes uh on long term follow up of these pathologically confirmed cystic RCC renal masses and they saw on cancers uh five year cancer specific survival of the cystic variant that these really approach 100% survival and they do very well. And this really kicked off and spurred all these other literature uh promote uh describing, you know, the excellent outcomes of these pathologically confirmed cystic renal masses. And it's even led to the who redefining what how we call cystic RCC. And they redefined that and called them. Now, uh this multilocular cystic renal neoplasm of low malignant potential. So these reports have really led to the consideration of the de escalation of care for these lesions and for the treatment of the cystic renal masses, swinging the pendulum in our opinion too far in one direction. And the problem is like we had mentioned is how these reports have been, you know, described and how they collected their patients. So let's for, let's for uh the role of a cystic renal mass. Let's look at a, a start and finish line. They start representing how the patient presents to us. And that's a radiographic image that they find incidentally usually of a cystic renal mass and the finish line representing this cystic RCC or this multilocular neoplasm of low malignant potential. So, what these reports were doing is that they were identifying these lesions at the finish line, looking at the outcomes and applying all those outcomes and and how they do to all the lesions that we see at the starting line. However, when you look at these lesions from the starting line and follow the natural history of these lesions, you really find that the pathology is, is more than what we, what we think there is. So what did we see when we, when we looked at this in this light at at Fox Chase? Well, we looked at our database of kidney cancer, which is one of the largest in the world of 4300 patients that have uh been treated over 20 years. And of that, we found 387 cystic radiographically confirmed cystic renal masses. And this is the largest report to uh to be published to date. And of these 387 247 underwent some sort of intervention while 100 and 84 underwent uh some sort of active surveillance uh protocol. So how did these lesions do at our institution undergoing surgical intervention? Well, like I said, 247 underwent some sort of intervention and about 20% had some time on active surveillance and were monitored. 82% of the patients had did identify some malignancy with a breakdown of the pathology showed here. And interestingly, what we found is that about 23 to 25% of these lesions demonstrated high grade malignancy. So, you know, while yes, many of the lesions do harbor low grade pathology, um there are these, you know, they're not all indolent sheep and there are definitely these aggressive wolves that are in there lurking. And it's our job to kind of identify these lesions. So, what is the risk of taking out these lesions? Well, one of the dreaded risk is the risk of rupturing this thing in these are uh these are fluid filled cysts that uh have the a risk of rupturing. And you know, the the implications of a cyst rupture is, has been debated and I'll, I'll show you why this was a p paper published out of the Netherlands. And they look at 50 of these lesions that ruptured intraoperatively and they reported no recurrences or metastasis. But however, you know, when we've, that's the theme of this talk, I guess is looking closer at the data that 50% of this was this multilocular cystic renal neoplasm, low malignant potential, which we know has shown some indolent biology. Follow up studies by Chen and, and Xu at all, looked at their uh uh cohort of cystic ruptured and compared to the previous study, they showed that the clear cell component, the the clear cell RCC was the majority of the pathology c not the uh indolent biology that we had mentioned. And when they looked at their long term outcomes, they saw significant differences in their recurrences on cyst rupture. Now, does this mean, excuse me, does this mean that all these lesions should be undergoing an operative or uh intervention approach? No, because we still had 100 and 84 lesions that were under active surveillance. And when we compare those lesions to those that underwent surgery, that we saw no significant difference in in in long term survival and cancer specific survival. So really where does this pendulum shift? And it probably shifts right in the middle and it's our job to look at these lesions specifically on radiographic imaging to determine which lesions should undergo intervention or not. So, how do we do that? Well, one of the things that we looked at on patients on active surveillance was the role of linear growth rate. Do these things grow over time? And one of the we are one of the first studies that published that, you know, the the lesions based on Bosnia classification score, uh the blue representing the lesions that ultimately underwent surgical intervention or some sort of intervention versus the ones that are in red that stayed on surveillance. And we noticed that the Bosniak four classification group had the highest rate of uh linear growth. But however, when we looked at is this a predictor of aggressive pathology, we didn't really find any associations with that. So, one of the things that we talked about was these wolves that are dressed in sheep's clothing. Well, one of the things that we worry about is the classic misclassifying the cyst. And one of the things that can dress up as a, as a common cyst is the uh uh uh aggressive renal mass with necrotic tumor inside of it. So, this is uh an MRI image of um a cystic or of a renal mass uh that appears to be cystic. However, on final pathology appeared to be a clear cell with a necrotic component to it. And how do we determine, how do we determine what a necrotic mass is? Well, the necrotic masses tend to have more centrally located fluid filled structures and the periphery are, are usually thick walled, uh thick walled cysts. Here, here's a nice picture of a uh you know, uh necrotic renal mass with the central fluid component. And you can appreciate the thick walled outer lining of, of the renal mass. So, what's the impact of necrosis when you find these in renal mass? Why does this matter that these can be dressed up? Well, uh you know, one of the uh papers that were published out of Fox Chase by Doctor Crea and Doctor Rob Uzo was a uh uh a cancer nomogram predicting the the risk of recurrence, the risk of overall survival and early progression. And when they looked at all the variables, they identified five variables that were shown to be significant predictors of recurrence. And one of those was uh coag the presence of coagulate necrosis. So, in conclusion, you know, the incidence of high grade malignancy in these cystic renal masses are probably higher than we pre previously reported. Um You know, we are very good at identifying which of these cystic renal masses have malignancy, but identifying which of those cystic renal masses would benefit from surgical intervention. That's still a clinical challenge. You know, these lesions require thorough evaluation, not just by the urologist by by us as well. You know, to look for these necrotic components to to identify those characteristics. And you know, while we did not see any association with linear growth rate, you know, one of the things that we are thinking is is the biologic component uh represented by the solid component in the cystic renal masses. And we've demonstrated based on our long term follow up on active surveillance that these lesions that are surveillance and those are the ones that have shown uh different imaging characteristics and maybe should undergo intervention that is a safe and effective management strategy for these renal masses. Thank you.
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