Fernando, thank you for joining us on UroToday.
Fernando Pablo Secin: No, thank you for the invitation. It's a pleasure. And thank you for coming to South America.
Zachary Klaassen: It's been absolutely fantastic. One of the highest populations of UroToday interactions is in South America, so we're delighted to be here.
Just at a high level, give our listeners an idea of just how many small renal masses, not just you and I as urologic oncologists, but urologists across the US, South America. It's a big population, isn't it?
Fernando Pablo Secin: Yes. I would say today with the advent of new imaging modalities, the incidental finding of kidney cancer increased dramatically. And I would say 80 to 90% of the patients we see in the office today are incidental small renal masses.
Zachary Klaassen: Right. Absolutely.
Fernando Pablo Secin:
And that generates a lot of sometimes the risks of overtreatment.
Zachary Klaassen: Sure.
Fernando Pablo Secin: So that's why over the last few years there has been a lot of interest in new modalities and new therapies for small kidney masses.
Zachary Klaassen: Yeah, absolutely.
In general, and maybe at your institution, what's sort of the imaging modalities we have available today and how often are you utilizing renal mass biopsy in your practice?
Fernando Pablo Secin: Well, normally the incidental finding is either coming from an ultrasound or a CAT scan that is done for any other reason.
Zachary Klaassen: Stones.
Fernando Pablo Secin: Abdominal pain, back pain, kidney stones. And then sometimes we need to either do it with contrast, or sometimes when these lesions may have a cystic component, we can get an MRIs with and without any contrast. And then eventually we stage the disease with a CT of the chest. So that's basically, ultrasound, CAT scan, MRI.
Zachary Klaassen: And what about renal mass biopsy? Are you using that to get tissue diagnosis on everybody? Some patients? Which patients are you biopsying?
Fernando Pablo Secin: I would say over the last 20 years there has been a rise in interest in kidney tumor biopsies. I only take biopsies when this is going to change decision-making. Otherwise, it's something we discuss with patients. We put all the cards on the table, decide together because for kidney biopsies we need expertise, may potentially have complications, of course, lower in the hands of expert people. But still, there's always this phantom and we debate all the time the possibility of implants, of seeding, which the evidence is not there. But there are occasional case reports. So biopsy is only when we are going to change decisions, otherwise I personally avoid it.
Zachary Klaassen: Yeah, absolutely.
In terms of treatment options, let's say three centimeter renal mass, we've got lots of options. Maybe walk our listeners through what options we have and what your workflow looks like at the Cleveland Clinic.
Fernando Pablo Secin: Yes. The discussion we normally have or I normally like to have with patients is that I explain the patient this is a career against life expectancy.
Zachary Klaassen: Yes.
Fernando Pablo Secin: So the first thing we look at is not so much on the tumor characteristics, but the characteristics of the patients, comorbidities. And these days, I would say at least in the US Cleveland Clinic, we see people with triple, quadruple heart bypass, valve replacement, diabetes, cholesterol, tobacco exposure, sometimes drug addictions. And these guys today survive. Some people with more than one malignancy. And this is the discussion we have upfront. I would say today, I would dare to say 90% of the patients I see with small renal masses are under active surveillance. And many people understand, many people accept the situation. Of course, active surveillance doesn't mean telling the patients you don't need to come back.
Zachary Klaassen: That's right.
Fernando Pablo Secin: I mean, you need to have a compliant patient. The reality in Cleveland Clinic sometimes may be different from the reality we have in South America, Colombia, Argentina, when perhaps especially in the public setting, these patients may not ever come back.
Zachary Klaassen: That's right.
Fernando Pablo Secin: So that is also you have to add into the equation at the time of making decisions. But roughly speaking, I would say 90% of the patients are under active surveillance. Of course, surgery is an option. Ablative technologies are an option. But I would say active surveillance is the first recommended.
Zachary Klaassen: And I think the data from Cleveland, from Fox Chase, from Toronto and other places definitely shows that a period of active surveillance with a compliant patient and a compliant physician is certainly reasonable, so.
Fernando Pablo Secin: Definitely yes, because if life is not put ... I mean if the life expectancy is reasonably good, then we think about the life expectancy of the kidney function.
Zachary Klaassen: That's right.
Fernando Pablo Secin: So today we favor, we know that kidney dysfunction, chronic kidney failure may lead to other, I mean, number one, increased mortality and have many other complications. So that's the other component that we look into and we explain to patients. And I think I would say patients are good at understanding and ...
Zachary Klaassen: No, absolutely. And it's counseling the patient. That's what this is all about. Which kind of leads me to my next question, and you alluded to it earlier about new technologies and counseling and more information. We saw ZIRCON data presented a couple of years ago now published in Lancet Oncology, looking at girentuximab PET/CT scan for kidney masses. Maybe just take our listeners through what that trial showed and what this maybe means for our practice pending FDA approval.
Fernando Pablo Secin: Yes, this is an interesting trial because I mean, they randomized patients with, it was around 300 patients with kidney tumors less than seven centimeters. So these patients were already pre-planned to do a nephrectomy or partial nephrectomy. So all these patients were done this girentuximab PET scan. And what it was found is actually the sensitivity and the specificity was very, very good, was like 85 and 87% roughly for sensitivity and specificity. So that clearly outperforms all the historical data on the results of CAT scans and MRI.
Zachary Klaassen: Yeah.
Fernando Pablo Secin: So I think this is very promising. I understand there is still pending FDA approval, but I think that once it's out there, I think will be used to establish if there is clear cell renal cancer. The question is will this replace biopsy? Most likely not, but we will avoid certainly quite few numbers of biopsy in the future.
Zachary Klaassen: Yeah, absolutely.
Put you on the spot a little bit. What patients do you think you'd be using in active surveillance, surgical pre-op planning, staging? How do you see yourself using it in the practice?
Fernando Pablo Secin: Yes. I would dare to say that perhaps there are three subset of patients. Number one is the small renal mass that you would say, "I want to know if we have clear cell histology." I think that would be a nice niche. And that is actually the trial.
Perhaps there's another niche with perhaps a large mass that you would say, "Listen, you have many comorbidities. If I do a nephrectomy, I may put your life at risk." And those are patients that we make historically biopsies because ... So I think that may be another subset of patients that may be of help.
And then perhaps another option is to, I wouldn't be surprised if in the near future this may also be used for staging either before or after treatment. So this initial trial is only for identification of clear cell tumors. But I think when people start to use it, I would say that the indications will expand.
Zachary Klaassen: Yeah, no, great answer. And I think it may even lead to the theranostic aspect as well, which could be really exciting for metastatic disease too.
Fernando Pablo Secin: Absolutely. Yes, absolutely.
Zachary Klaassen: Great discussion. Anything we haven't hit on that you want to talk about? Maybe a couple concluding statements for our listeners?
Fernando Pablo Secin: Yes. I would say regarding small renal masses, I think the biggest change we saw over the last 15, 10, 20 years is we abandoned that situation of diagnose and treat. And now I think we diagnose, discuss with patients and consider just treatment in certain patients. I think I would say as a take on message, that is the biggest thing. We dissociate the diagnosis from treatment, which in the past used to be the opposite, we found and we treat.
Zachary Klaassen: And I think this is just perfect for shared decision-making, which you nicely summarized.
Fernando, great to have you on UroToday. Thank you for taking time out of the busy congress to join us.
Fernando Pablo Secin: No, pleasure. Thank you for having me. And I hope it doesn't take too long before we can see each other again.
Zachary Klaassen: Absolutely. Thank you very much.
Fernando Pablo Secin: No, thank you. Thanks a lot.