Partnership of Interventional Radiology and Urology in the Treatment of RCC

In today’s video discussion, Dr. Maxine Tran and Dr. David Breen discuss the partnership of interventional radiology and urology in the treatment of RCC. Some of the topics of specific interest are the collaboration between urologists and interventional radiologists, weighing the treatment options, and advancing the data for streamlined and optimized kidney cancer treatment.

 

Partnership of Interventional Radiology and Urology in the Treatment of RCC from HMP on Vimeo.

Welcome to IO Learning, a digital publication providing information on the latest advancements in interventional oncology treatments. In today’s video discussion, Dr. Maxine Tran and Dr. David Breen discuss the partnership of interventional radiology and urology in the treatment of RCC. Some of the topics of specific interest are the collaboration between urologists and interventional radiologists, weighing the treatment options, and advancing the data for streamlined and optimized kidney cancer treatment. 

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Dr. Breen: 

Well, thank you very much for that introduction. My name is David Breen. I'm an interventional radiologist with a particular interest in interventional oncology down here in the University Hospital of Southampton, in the South UK. As is traditional for radiologists, I'm talking to you from a dingy dark office. But, I'm pleased to be talking today with Professor Dr. Maxine Tran from the Royal Free and University College in London. 

Hello, Maxine. Tell us what you do at UCH briefly before we kick off. 

Dr. Tran: 

So, the Royal Free Hospital is home to the specialists for kidney cancer, and that's where I do my clinical work as an honorary consultant urologist. And this was established in around 2015 and has now become the biggest kidney cancer treatment center in the whole of the UK, probably most of Europe. So, we see over 1,800 referrals with suspected kidney cancers. And I think you'd agree that the incidence of kidney cancer is just rising and rising. So, it's keeping us busy.

Dr. Breen: 

Yeah, brilliant. Well, look, similarly, we're a very active ablation unit amongst interventional oncology. I don't wanna say how long I've been doing it—forever, since it started. So RF, microwave, cryo, etc. So we're here, you and me, we're gonna have a discussion today on small volume kidney cancer and its management, and in particular, probably honing in on T1a sub 4cm disease. Tell me, Maxine, what do you think's the problem—what I think, it represents quite a bulk of the disease coming to our renal cancer MDTs—what are the problems?

Dr. Tran: 

Yeah, I mean, I completely agree. I think it's increasingly started around a year ago 30% or a third of the cases would be these small renal masses, but that's creeping up. I think, with more people having investigations for other conditions and symptoms, we’re getting these incidental owners being diagnosed and referred to us. And I think, you know, the big clinical need is just improving on how we deal with this diagnosis and optimizing patient care. Basically, kidney cancer treatment has moved so far in the last 20 years. And we know now from research and large natural history studies that not all kidney cancers are very dangerous. And, you know, not all kidney cancers are going to spread and cause harm. And so, the traditional approach of performing surgery, removing every kidney cancer that we see, is not the right approach anymore.

And I think that the clinical need is there for us to work together with the interventional radiologists and and also with the basic scientists, etc. to understand disease a bit more so that we can know how to counsel our patients and choose the right treatment for the right patient, I think.

Dr. Breen:

Absolutely. Put bluntly, the cure mustn't be worse than the disease. [Chuckles] We're talking sub 4cm disease here. Let me flip this around for a moment and look at it from a patient point of view. What do you think the patient experience is like? They're told often, incidentally on a scan for often an entirely other reason, that they had a 3cm tumor picked up. What is it you say to them in-clinic when you see them? Often, as I said, this comes as an entire surprise when they're being investigated for other symptoms. How do you pick up that conversation with them?

Dr. Tran: 

Oh, well, the first thing I tell most patients who do present that way is not to worry, you know. At first, I explain to them that small renal masses are not always cancers. You know, a significant portion, up to 30%, can be benign in nature. And then, I tell them that even if it is a type of kidney cancer, we know that they tend to grow very slowly. You know, as low as minimally to a year. So, I basically tell them not to panic and that there are many, many options, all of which have got really good results. So, it’s all just to slow down the pace of anxiety, I guess, as you would have as a patient when you first hear the words ‘tumor’ or ‘cancer.’ I think most patients understand, but we get very anxious and get very worried. And the first thing to tell them is that this is a small renal tumor, and it can be benign, even if it is cancer. It's slow-growing. It has got a very, very, very small chance of spreading. And we've plenty of time to discuss all the treatment and management options.

Dr. Breen: 

Yeah, absolutely. I mean you and I know, we don't worry too much. There’s the elderly, very frail patient with sub 25mm disease with renal impairment, and what have you—But let's you and me hone in here a bit on who, I think, is an under-acknowledged group. You know, the moderately fit 73-year-old male patient, reasonable fitness, reasonable longevity, and outlook. And he's being told he's got a 28mm tumor in his kidney. What are the options you give him? And then I'll tell you how I couch it.

Dr. Tran: 

So these these patients all get discussed once they are referred at our multi-disciplinary team meeting or tumor board. And, we discuss patient history, clinical history, and then look at the scans and decide the most appropriate management. Obviously, if this is a theoretical patient, we would presume if he was fit and well for active treatment, then we say he’s open or suitable for all types of treatment for a small renal mass. And this is where the consultation comes in, because this is the chance that we have, the opportunity that we have, to find out from the patient their current state of health, and then their expectations, and how they want this lesion to be treated. As a 73-year-old, with a 28mm mass, if we’re seeing that it's in a favorable location, meaning it's not in the deep depths of the kidney, or it's not close to vital structures, then it's amenable to a diagnostic tumor biopsy or a period of even active surveillance for a patient that may be going through quite a lot of other medical or other competing life events at the time. And monitoring these patients, placing them on active surveillance for at least an initial 6 months, is not going to do any harm whatsoever, and gives us a bit of an idea of the biology and natural growth rate of their tumor. And if the patient is very keen for active treatment, we discuss with them surgery, if the tumor is amenable to a partial nephrectomy, then that's the treatment of choice, or radical nephrectomy if partial nephrectomy is not feasible. 

Dr. Breen: 

I’m gonna jump in here, Maxine. Is that how you present options to them? You say, “the treatment of choice is partial nephrectomy or radical nephrectomy?

Dr. Tran: 

No, no. [Chuckles] So, the treatment of choice, if they wanted active treatment, would be—the surgical treatment of choice would be a partial nephrectomy or radical nephrectomy. If they wanted ablation, then you need to have a biopsy first and then, if the biopsy showed that it was  cancer, then they would need to see the interventional radiologist to discuss cryoablation. So all of those treatments—we call them T1a options or small renal mass lesion options—would be active surveillance. A renal tumor biopsy followed by cryoablation or surgery all goes straight to surgery. 

Dr. Breen: 

So, when you see them in-clinic, and forgive me, I'm already getting into the provoked stuff, you serve up to them ablation as an option in equipoise?

Dr. Tran:

Yeah, it’s already been discussed at our MDT that the tumor is suitable for ablation, so then yes. 

Dr. Breen: 

Yeah, that's good. And that's something I emphasize to our audiences is—and I think something we do really well in the UK—which is, every tumor is mandated to be discussed in front of a multi-disciplinary panel. Because one of the things you and I, we're gonna talk about, is collaboration. And I think that getting that right out, front and center, so a discussion is had in open forum with an interventional radiologist in attendance, and a broad direction of travel for that patient is determined in the MDT and not independently in the clinic. Is that fair? 

Dr. Tran: 

Yeah, I agree, I think that’s been a major step-change in the way we manage cancer in the UK. And I think that it brings a patient benefit in terms of standardization of care and reducing variability, and the fact that you have several clinicians there of different disciplines giving their opinion, reviewing the patient, I think there's a strength behind that decision-making, and I'm really pleased that we've adopted that practice.

Dr. Breen: 

Yeah. And just to deal with that biopsy issue, all of them, or what proportion of T1as go into active surveillance? I'm just curious. I'm trying to get a feel for your practice.

Dr. Tran: 

The strongest evidence that I can give you is from my small renal mass study, the NEST study where we ask patients to come who were diagnosed with small renal masses to consent to be part of our cohort of patients which we would follow-up with on a long-term basis. And of all patients who were diagnosed with a small renal mass who consented to the cohort, about half of them went on to an initial period of active surveillance. I just gotta caveat that with the fact that this study was performed in the time of Covid as well, so that may have influenced the management decision slightly, because patients themselves didn't really want to have to come to hospital for treatment or biopsies or anything. And clinicians were also limited in terms of Covid prioritization, triaging, etcetera. But I think that's probably a realistic figure, around 50% go on initial active surveillance, because of the patient demographics that we have. A lot of them do tend to be elderly.

A lot of them do have competing medical problems that are much more clinically significant that need to be dealt with. And so, the small renal mass, because we know it grows slowly, because we know it's not really dangerous in the medium term, the short and medium term, we can put them on the period of active surveillance in a safe manner.

Dr. Breen: 

We've likewise got a very big urological practice down here on the Central South coast, and credit to my urological colleagues I work with, when they're in equipoise, they absolutely put that to the patients and often, a sensible patient will see active surveillance, partial nephrectomy, and a middle way which is cryoablation in our practice, and will often opt for that central option. Do you then bounce them across to the IRs to see them in clinic? Or, how does that referral work? 

Dr. Tran: 

Yes, so we're really lucky in the way that our service is set up. We have our MDT in the morning where we, like you, have our interventional radiologists, our oncologists, our surgeons, and our standard radiologists there. And then, in the afternoon, we do a multi-disciplinary clinic where we're all there as well. So, there's a clinic that must have at least 7 or 8 clinic rooms. And, you know, the surgeons are there, the interventional radiology consultant’s there, and the oncology consultants are there. And, if a patient says to me in the clinic that they are interested in cryotherapy, then I ask my interventional radiologist if he's got time to speak to the patient, and they tend to get seen on the same day. So, they have 2 consultations on the same day. I understand that we are fortunate because it is especially sensitive to kidney cancer. And we've set the service up to be able to provide that service which may not be available elsewhere.

Dr. Breen: 

That's fabulous. I must confess I have an ablation clinic, and they get referred across that, but it's not a synchronous same-day thing. Let's just deal with that thorny one a moment, whereby, let's get it right out. Some urologists feel threatened by ablation as a treatment option. That is certainly not the case in my institution. My urologists have got plenty of, how can I put this, very grown-up operating to do on disease, you know what I mean? And, you and I have got to minimize the morbidity of what we do. I'm just telling you now rather than me asking you another question. I'm just telling you about our institution. So, we get on very well. I'm aware of some institutions where there's a lot of anxiety about referring to interventional radiology. Certainly, our experience has been that it's allowed my urological colleagues to even build their referral base. You know, it doesn't actually detract, funnily enough, it actually makes you a better all-service provision. I don't know, how have you managed to overcome that sort of anxiety?

Dr. Tran:

I agree. I agree with everything you said. We we are very fortunate to work in the environment where there is this collaboration between interventional radiologists and urologists, and we work very well together. In the clinics, it goes both ways. Sometimes, a patient who’s being seen for cryotherapy wants to just have a quick discussion with the surgeons to see whether surgery could be an option as well. So, it does work both ways, and I also agree that that's not the same throughout the whole country. And some of our colleagues will not refer within, you know, between disciplines as easily as we do, and I think the way to address that or the way to improve that, is to provide more evidence. The fact is, there are no head to head data to show that cryoablation is as effective for kidney cancer as surgery is, there are no real guidelines to actually guide us on what lesions would be equally suitable for cryotherapy or partial, you know, which patients would be better serve with cryoablation or nephrectomy, etc., etc. 

So, there is so much that we can do to help our colleagues understand and give them more information to use and to enable them to make that recommendation, to make that referral to their colleagues. But I agree with you, I think we should work together and just say it's another option that we can provide our patients. Not all patients want surgery, not all patients want ablation. And equally, not all patients are suitable for both, and it's not one size fits all. We need to deal with each patient on an individual basis. And that's the way forward, really.

Dr. Breen: 

Absolutely. And on that, that brings me neatly into guidelines which are just that, and I get very excited about them and all of us do. They are just that, they are guidance. I'm interested that the AUA guidelines, I think, are almost more inclusive of ablation than the current European guidelines. My reading of the AUA guidelines at the moment, they've even said that ablation should be an option for sub 3cm disease. I think they're harking back to the era of RF ablation outcome, which is now mature, you know, it's 10 or 15 years old, and so they've left that in. The EAU, The European Association of Urologists, are a little bit more negative on this, to be blunt, and just say there's just not strong enough data to recommend ablation either way. Any thoughts on that?

Dr. Tran: 

No, I mean, I have just joined the EAU panel so I think they're limited with the evidence that's available and there is no level one evidence available. So, they have to be limited in what they can and cannot recommend, and I think that’s what it boils down to, evidence. Meanwhile, AUA develops their guidelines and their process. So, yeah.

Dr. Breen: 

Brilliant. Well, that boils into this issue of improving that evidence so we can improve the status of ablation. Okay, what's been happening, I've been around for a few years, I've seen a couple of study trials collapse, you know, interventional oncology where it's IR, Interventional Radiology, can I say it bluntly, versus surgery has caused the collapse of a lot of interventional oncology trials, including one in the UK called Conserve a few years ago. Where are we? And, I know that you've been putting a lot of work into the NEST trial. Where are we and where should we be going, Maxine? 

Dr. Tran: 

Yes, so I'm really delighted to say that we've completed a feasibility NEST trial from everything that we just discussed in this conversation, you know the clinical need, the the lack of evidence, the wanting of the professionals, just wanting clear cut evidence to be able to guide our treatment decisions, to improve patient outcomes in small renal masses. I mean, I'm really pleased that the feasibility part of NEST, which is a clinical trial directly comparing cryoablation versus partial nephrectomy, robot-assisted partial nephrectomy, in this population, has been successfully completed. This shows us that this trial can be done, you know, we can show level one evidence that this treatment can or should be considered as an alternative for selective patients, because another part of this trial, I think, that would be really important is which patients and which tumors would be suitable for ablation and surgery. So, the feasibility has been successfully completed. It will be shortly published in European Urology. And, I think it's really exciting that it will guide us on, you know, what the future trial will look like. And so, I'm feeling very positive that we should get some high-level evidence to help us and our colleagues shortly.

Dr. Breen: 

Brilliant. Well, look absolutely, all power to your hand and we, on behalf of the interventional radiology community, are very keen to help move that forward. So, thank you very much, Maxine. I've enjoyed this conversation. Pleasure. Catch up with you soon.

Dr. Tran: 

Yes, you, too. Thank you.

That wraps up another insightful discussion for IO Learning.