HYU Onc - Kidney Flashcards
Renal Mass Staging: T1a, T1b
T1a: < or = 4 cm
T1b: < or = 7 cm
Renal Mass Staging: T2a, T2b
T2a: < or = 10 cm
T2b: >10 cm
Renal Mass Staging: T3a
T3a: renal vein, pelvicalyceal, perirenal/renal sinus fat within Gerota
Renal Mass Staging: T3b
IVC below diaphragm
Renal Mass Staging: T3c
VC above diaphragm
Renal Mass Staging: T4
Outside of Gerota or involving adrenal
Stage I
T1N0M0
Stage II
T2N0M0
Stage III
T3N0-1M0
T1-2N1M0
Stage IV
M1
Postoperative Risk Stratification
Low Risk: pT1 and Grade 1-2
Intermediate Risk: pT1 and Grade 3-4, or pT2 and any G
High Risk: pT3 and any G
Very High Risk: pT4 or pN1, sarcomatoid, rhabdoid, macroscopic R1
*Note, positive final margin should increase risk category by one level and increase clinical vigilance
Evaluation of renal mass:
- Imaging?
- Labs?
- CKD?
Get multi-phase cross sectional imaging (enhancing = greater that 20 HU)
Consider MRI if suspicion for IVC thrombus
Get CT chest for advanced tumors
If malignancy suspected –> CBC, UA, CMP, chest imaging
Solid or Bosniak 3/4 mass: Use GFR to assign CKD stage I-V
- (90+, 60+, 30+, 15+, <15 or Dialysis)
When to consult nephrology?
Consider for eGFR <45, expected postop GFR <30, proteinuria, DM with CKD
When to consult Med Onc?
Concerned for potential clinical mets
Incomplete resection
Consider adjuvant treatment for High Risk (T3 and G) or locally advanced, fully resected cancers
When to consult genetics?
Recommend for age 46 or less, multifocal/bilateral renal masses, whenever the personal/family history suggests a familial renal neoplastic syndrome
When to perform Renal Mass Biopsy (RMB)?
Consider if suspicious for hematologic/metastatic/inflammatory/infectious mass
For solid mass, multiple cores»_space; FNA
PPV ~100%, NPV ~60%, Nondiagnostic ~15%
Partial Nephrectomy:
- When do you prioritize this?
- When do you consider it?
- Surgical considerations?
Prioritize PNx: cT1a (when Tx is indicated), cases with solitary kidney, bilateral tumors, familial RCC, multifocal, severe CKD
Consider PNx: young patients, multifocal masses, increased risk for future CKD (HTN, DM, urolithiasis, morbid obesity)
Surgical considerations: minimize warm ischemia time, prioritize negative margins, consider enucleation if familial RCC, multifocal or severe CKD
When is radical nephrectomy preferred over partial nephrectomy?
Radical only preferred over partial if:
1. High tumor complexity and pNx would be difficult even in experienced hands
2. No preexisting CKD or proteinuria
3. Normal contralateral kidney and new baseline GFR likely to be >45
Consider radical when oncologic potential is suggested by tumor size, RMB, and/or imaging characteristics
When is Thermal Ablation appropriate? How to follow up?
Consider for cT1a <3cm AFTER renal mass biopsy
Radio and cryo are options
Counsel slightly worse outcomes (i.e. local recurrence rates)
Can repeat ablation as needed
Obtain pre and post contrast abdominal imaging within 6 months of ablation, then follow IR postop protocol
When to consider active surveillance? Triggers for intervention?
Consider especially for <2cm, repeat imaging in 3-6 months
Consider RMB for mass with solid component
Individualize surveillance based on growth rate and shared decision making (SDM)
Potential triggers for intervention in healthier patients?
- Growth to >3cm
- >5mm/year of growth
Follow-up labs post-op?
Cr, UA, eGFR –> refer to nephrology PRN
Consider other labs as needed and if advanced disease expected (CBC, LDH, LFTs, Alk Phos, Ca++)
Abdominal imaging after nephrectomy and partial nephrectomy?
Chest imaging?
CT w/ and w/o contrast or MRI for 5 years
Consider switching LR and IR patients to alternating cross sectional imaging and abdominal US
SDM for further imaging after 5 years
LR: yearly for 5 years
IR + TA: 6, 12, 24, 36, 48, 60 (q6m for a year)
HR: 6, 12, 18, 24, 30, 36, 48, 60 (q6m for 3 years)
VHR: 3, 6, 9, 12, 18, 24, 30, 36, 48, 60 (every 3 months for a year, then every 6 months to 3 years, then yearly)
Chest imaging: CXR for LR+IR, CT for HR and VHR
SDM after 5 years
What to do when renal artery vasospasm during hilar dissection?
Reduced perfusion
Pale kidney
- Reduce insufflation pressure
- Apply topical papaverine (opium alkaloid antispasmodic vasodilator) to renal hilar vessels
When to consider when using argon gas laparoscopically?
Argon beam will increase abdominal pressure due to addition of argon gas
- Important to vent abdomen via a port to relieve pressure