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04. RCC (937) > HYU Onc - Kidney > Flashcards

HYU Onc - Kidney Flashcards

1
Q

Renal Mass Staging: T1a, T1b

A

T1a: < or = 4 cm
T1b: < or = 7 cm

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2
Q

Renal Mass Staging: T2a, T2b

A

T2a: < or = 10 cm
T2b: >10 cm

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3
Q

Renal Mass Staging: T3a

A

T3a: renal vein, pelvicalyceal, perirenal/renal sinus fat within Gerota

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4
Q

Renal Mass Staging: T3b

A

IVC below diaphragm

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5
Q

Renal Mass Staging: T3c

A

VC above diaphragm

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6
Q

Renal Mass Staging: T4

A

Outside of Gerota or involving adrenal

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7
Q

Stage I

A

T1N0M0

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8
Q

Stage II

A

T2N0M0

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9
Q

Stage III

A

T3N0-1M0
T1-2N1M0

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10
Q

Stage IV

A

M1

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11
Q

Postoperative Risk Stratification

A

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

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12
Q

Evaluation of renal mass:
- Imaging?
- Labs?
- CKD?

A

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)

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13
Q

When to consult nephrology?

A

Consider for eGFR <45, expected postop GFR <30, proteinuria, DM with CKD

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14
Q

When to consult Med Onc?

A

Concerned for potential clinical mets
Incomplete resection

Consider adjuvant treatment for High Risk (T3 and G) or locally advanced, fully resected cancers

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15
Q

When to consult genetics?

A

Recommend for age 46 or less, multifocal/bilateral renal masses, whenever the personal/family history suggests a familial renal neoplastic syndrome

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16
Q

When to perform Renal Mass Biopsy (RMB)?

A

Consider if suspicious for hematologic/metastatic/inflammatory/infectious mass

For solid mass, multiple cores&raquo_space; FNA

PPV ~100%, NPV ~60%, Nondiagnostic ~15%

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17
Q

Partial Nephrectomy:
- When do you prioritize this?
- When do you consider it?
- Surgical considerations?

A

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

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18
Q

When is radical nephrectomy preferred over partial nephrectomy?

A

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

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19
Q

When is Thermal Ablation appropriate? How to follow up?

A

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

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20
Q

When to consider active surveillance? Triggers for intervention?

A

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

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21
Q

Follow-up labs post-op?

A

Cr, UA, eGFR –> refer to nephrology PRN

Consider other labs as needed and if advanced disease expected (CBC, LDH, LFTs, Alk Phos, Ca++)

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22
Q

Abdominal imaging after nephrectomy and partial nephrectomy?

Chest imaging?

A

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

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23
Q

What to do when renal artery vasospasm during hilar dissection?

A

Reduced perfusion
Pale kidney

  1. Reduce insufflation pressure
  2. Apply topical papaverine (opium alkaloid antispasmodic vasodilator) to renal hilar vessels
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24
Q

When to consider when using argon gas laparoscopically?

A

Argon beam will increase abdominal pressure due to addition of argon gas
- Important to vent abdomen via a port to relieve pressure

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25
Q

Interaortocaval nodes only drain the right kidney

A

They drain the left kidney with advanced disease

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26
Q

Incidence of local recurrence after nephrectomy?
What does this mean for 5 year survival?

A

Incidence 2.9%
Poor prognosis: 5 year survival 30%

Synchronous mets at the time of recurrence are an independent predictor of poor prognosis

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27
Q

Hand-assisted lap compared to straight lap?

What does this mean for donor nephrectomies?

A

Hand-assisted lap has higher rates of wound complications (infections and hernias)

In setting of donor nephrectomy, warm ischemia time of donor kidney is reduced because specimen can be quickly removed via hand-port. Other outcomes are similar to straight lap.

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28
Q

Acute bleed following ligation/division of left renal hilum

A

Think about disruption of a lumbar vein, because this inserted into the renal vein posteriorly

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29
Q

Workflow for urine leak after partial nephrectomy

A

Start with perc drain placement if drain not already present
If leak persists, make sure drain isn’t directly on leak site, and take off of suction
Place urethral catheter and do RPG + ureteral stent
If unable to place stent, place PCN

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30
Q

Severe, persistent back pain resistant to pain meds after renal surgery

A

Consider rhabdomyolysis (if pain contralateral to side of surgery, check CK)
Pancreatic injury (if pain is on left following left-sided renal surgery, check amylase and lipase)

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31
Q

Proposed criteria for cytoreductive nephrectomy

A

Ability to resect >75% of the tumor
No brain mets (need to be treated with radiation or surgery prior to cNx)
Adequate pulmonary and cardiac reserve
ECOG performance status of 0-1

(0=Fully active, able to carry on all pre-disease performance without restriction
1=Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work)

Predominantly clear-cell histology
Disease has not progressed through systemic therapy (sunitinib)

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32
Q

Vaccinations s/p splenectomy

A

Indicated due to risk of severe infection with encapsulated bacteria

SHiN - Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis

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33
Q

New lesion with early enhancement and prompt washout at prior tumor site after partial nephrectomy

A

Get US with doppler to determine pseudoaneurysm vs. recurrence

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34
Q

RCC tumor thrombus levels

A

0 = renal vein
1 = <2cm into IVC
2 = >2cm into IVC but still below hepatic veins
3 = above hepatic veins but below diaphragm
4 = above diaphragm

3 and 4 may need bypass during sugrery

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35
Q

“Persistent central enhancement”

A

Tumor recurrence after cryoablation

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36
Q

Ways to optimize (lap) renal cryoablation

A

Real-time intraop US to monitor progression of cryo lesion
Cryoprobe tip at deepest margin of tumor
Target temperature below -40C
Extend the cryo lesion ~1cm beyond the margin of the tumor
Active double freeze-thaw cycle

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37
Q

Small renal mass(es) are identified in conjunction with widespread LAD outside of typical LN drainage zones

A

Suspect renal involvement of lymphoma

Perc LN biopsy to determine Tx plan

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38
Q

Renal tumor with high signal on T1 on MRI

A

Fat in lesion
Think AML
Think a/w tuberous sclerosis

AML = benign tumor of perivascular epithelioid cell origin

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39
Q

MRI sequence most likely to confirm AML

A

T2 with fat suppression

On CT, suspect AML if negative HU (fat) are mentioned

Angioembolization often effective, particularly in setting of acute bleed
If massive, will need nephrectomy

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40
Q

Drug that can be used to shrink AMLs

A

Everolimus (Afinitor)
Tumor growth typically resumes when treatment is discontinued

Can watch AMLs when small, can cause problems if >4 cm

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41
Q

Benign tumor in 20yo with elevated peripheral renin

A

Juxtaglomerular tumor
Tumor secretes renin
patients typically <20yo
Cured with surgery

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42
Q

Rare, extremely aggressive tumor associated with sickle cell trait

A

Renal medullary carcinoma

  • Arises from collecting duct
    <100 cases ever
    Mean survival <6 months
    75% on right side
    Central/infiltrative, not amenable to partial
    Does not typically respond to chemo/immunotherapies
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43
Q

Treatment for metastatic renal medullary carcinoma

A

Carboplatin + paclitaxel is first line (not upfront surgical resection)

Gemcitabine + adriamycin is 2nd line

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44
Q

Collecting duct RCC

A

More aggressive –> younger age of presentation

Resistant to standard chemos for RCC, but sometimes responsive to gemcitabine and cisplatin chemos (behave more like UCC)

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45
Q

Renal pseudotumor

A

Column of Bertin
Focal cortical hyperplasia

Best established with DMSA scan

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46
Q

How to follow patients with oncocytoma or indeterminate histology on renal mass biopsy

A

Follow with same imaging protocols used for untreated low risk renal cancers due to risk of substantial growth and risk of inaccurate biopsy results

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47
Q

How to distinguish between oncocytoma and RCC?

A

Technetium-sestamibi nuclear scanning
- oncocytoma will have high radiotracer uptake
- RCC will have low radiotracer uptake

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48
Q

Preferred regimens for relapse or stage IV metastatic CCRCC (favorable and poor/intermediate risk)

A

Pembrolizumab + axitinib - Keynote-426
Nivolumab + cabozantinib - CheckMate-9ER
Pembrolizumab + lenvatinib - CLEAR

Cabozantinib monotherapy (CABOSUN) is a preferred option for poor/intermediate risk

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49
Q

Metastatic RCC sites with worst to best prognosis

A

Brain, liver, bone, LNs, lung, adrenal

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50
Q

What labs do you need to monitor Sunitinib with/for?

A

Associated with hypothyroidism - get thyroid labs

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51
Q

Renovascular fistulae treatment
- If asymptomatic due to biopsy?
- If asymptomatic due to RCC?
- What symptoms do they cause when symptomatic?
- Cirsoid AV fistula?

A
  • If asymptomatic due to biopsy? 70% will close spontaneously, observe
  • If asymptomatic due to RCC? Nephrectomy
  • What symptoms do they cause when symptomatic? HTN, hematuria, high output heart failure. Treat with embo, ligation, partial or complete nephrectomy
  • Cirsoid AV fistula? Cirsoid means to resemble a varix. These are too complex for angioembolization. Treatment of choice is nephrectomy.
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52
Q

Von Hippel Lindau
- Inheritance pattern?
- Manifestations?
- Gene associated?
- Gene location?
- Leading cause of death in VHL?

A
  • Inheritance pattern? AD
  • Manifestations? Hemangioblastomas of retina, cerebellum, medulla (~70%, get brain/spine MRI when diagnosed), cavernous hemangiomas in skin, mucosa and organs, pancreatic masses. About half will develop multiple bilateral RCCs and other tumors associated with deletion of the tumor suppressor gene VHL on 3p
  • Gene associated? (VHL (tumor suppressor gene))
  • Gene location? Short arm of 3p25
  • Leading cause of death in VHL? Kidney cancer

Ipsilateral cysts should be removed at time of partial nephrectomy (when a solid mass is >3 cm) because they can harbor carcinoma

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53
Q

Medication that is FDA approved for treatment of VHL-associated RCC? Mechanism?

A

Belzutifan (HIF-2a inhibitor)

Common side effects include anemia (from reduced epo), and fatugue

When VHL (a TSG) is deleted, causes constitutive expression of HIF (a transcription factor), which activated angiogenic growth factors (like VEGF, EPO)

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54
Q

Hereditary syndrome with type 1 papillary RCC?
- Gene?
- Location of gene?

A

Hereditary papillary renal cell carcinoma

RAre
cMet codes for RTK protein –> papillary RCCs only, no extra-renal findings

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55
Q

Hereditary syndrome with type 2 papillary RCC?
Gene?
Location of gene?

A

Hereditary leiomyomatosis RCC (HLRCC)
FH gene codes for fumarate hydratase (TSG) –> painful leiomyomas (cutaneous, uterine) + papillary RCC –> bad disease, patients may die young –> start annual screening with contrasted MRI at age 8

Surveillance of tumors not recommended, take them out

1q42

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56
Q

Birt-Hogg-Dube
- Gene?
- Gene location?
- Tumor type?
- Manifestations?

A

Gene - BHD1
On 17p11

Mutated gene codes for folliculin –> painless fibrofolliculomas (benign)
Bilateral RCCs (chromophobe RCC or oncocytomas)

Lung cysts, risk of pneumothorax

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57
Q

Tuberous Sclerosis
- Inheritance pattern?
- Manifestations?

A
  • AD
    Facial lesions (adenoma sebaceum)
    Hypopigmented “ash leaf spots” on skin
    Cortical and retinal hamartomas
    Seizures/epilepsy
    Mental retardation
    Renal cysts
    Renal AMLs
    Cardiac rhabdomyomas
    Increased incidence of astrocytomas
    Incomplete penetrance, variable presentation
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58
Q

Lynch syndrome
- Where are mutations?
- What organs most likely to get cancer?

A

= Hereditary Non-polyposis Colorectal Cancer
- Genes MLH1, MSH2/6, PMS2

  • Colorectal, endometrial, digestive, ovarian, upper tract cancers
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59
Q

Cowden Syndrome

A

PTEN hamartoma syndrome

PTEN = phosphatase and tensin homolog mutations

–> hamartomas
Endometrial and kidney cancers

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60
Q

Li-Fraumeni Syndrome

A

Tumor suppressor p53 mutation

Breast cancer, osteosarcoma, soft tissue sarcoma, leukemia, lymphoma

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61
Q

Neurofibromatosis

A

Caused by oncogene mutation in MF1 (csome 17) or NF2 (csome 22)
Classically manifests with cafe au lait spots

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62
Q

MEN 2A

A

Gain of function in RET proto-oncogene

Medullary thyroid cancer, parathyroid hyperplasia, pheochromocytoma

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63
Q

MEN 2B

A

Gain of function in RET proto-oncogene

Medullary thyroid cancer, pheochromocytoma, marfanoid body habitus, mucosal neuroma

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64
Q

RCC Screening?

A

Renal US for ESRD patients after 3 years of dialysis
HLRCC patients at age 8
VHL patients at age 16

65
Q

Favorable molecular markers for survival in RCC

A

Absent vimentin, absent p53, High CAIX

66
Q

Bosniak 1 Classification

A

Simple cyst, imperceptible wall, no work-up indicated

0% chance of malignancy

67
Q

Bosniak 2

A

Minimally complex
A few thin, <1 mm septations or thin calcifications
Non-enhancing high-attenuation (due to proteinaceous or hemorrhagic contents)

Risk of malignancy ~0%

68
Q

Bosniak 2F

A

Minimally complex
Increased number of septa
Minimally thickened with nodular or thick calcifications
May be perceived but not measurable enhancement of a hairline smooth thin septa

Hyperdense cyst >3cm in diameter, mostly intrarenal
No enhancement
Requiring follow-up - US or CT around 6 months

Cancer risk 5-10%

69
Q

Bosniak 3

A

Indeterminate, thick, nodular, multiple septa or wall with measurable enhancement, hyperdense on CT

Tx: partial nephrectomy or ablation in poor surgical candidates

~50% risk of cancer

70
Q

Bosniak 4

A

Clearly malignant
Solid mass with large cystic or necrotic component

Treatment: partial or radical nephrectomy

~100% risk of cancer

71
Q

Lit: localized RCC in VHL

A

Belzutifan for localized RCC in VHL
HIF-2a inhibition can shrink small RCCs in VHL

72
Q

Lit: Radical Nx with or without LND

A

EORTC
Completely LND NOT needed during radical nephrectomy for N0M0 RCC
- OS, PFS, time to progression and complications rates didn’t differ

73
Q

Lit: EORTC partial vs radical nephrectomy and renal function

A

Partial nephrectomy is better than radical nephrectomy for preserving renal function… duh

Similar for OS, median follow-up 9.3 years

74
Q

Lit: Cytoreductive nephrectomy and interferon

SWOG 8949 2001

A

cytoreductive nephrectomy and interferon improved median OS by 3 months (11 vs. 8) over interferon alone

75
Q

Lit: EORTC cytoreductive nephrectomy trial 2001

A

Cytoreductive nephrectomy + interferon improves median OS by 10 months (17 vs. 7) over interferon alone

A combined analysis for SWOG and WORTC studies similarly revealed a survival benefit with cNx (13.6 vs. 7.8 months)

76
Q

Lit: CARMENA 2018 (cNx)

A

cNx + sunitinib has WORSE median OS than sunitinib alone (!)

77
Q

Lit: SURTIME 2018 (cNx)

A

Sunitinib + delayed cNx (when indicated) has better OS than upfront cNx

78
Q

Lit: (not) ASSURE(d) 2016

Adjuvant systemic therapy after rNx

A

Adjuvant targeted therapy (sunitinib or sorafenib) does not improve disease free survival (DFS) over placebo

Stopped early due to side effects with no evidence of improved DFS with either therapy

Non-metastatic patients

79
Q

Lit: S-TRAC 2016

Adjuvant systemic therapy after rNx

A

Adjuvant sunitinib improves median DFS by one year over placebo (no OS benefit)

RCT
Locoregional high risk RCC patients

80
Q

Lit: KEYNOTE-564 2021

Adjuvant systemic therapy after rNx

A

Adjuvant pembro improves DFS s/p rNx for high-risk RCC

RCT
OS data immature, but seems to favor pembro group at 24 months

81
Q

Lit: Global ARCC - Temsirolimus, Interferon-a or both?
2007

Advanced RCC

A

Temsirolimus identified as best choice for poor-prognosis RCC

RCT
Temsirolimus - mTOR inhibitor
IFN - activates inflammatory and immune responses

82
Q

Lit: Sunitinib vs. IFN-a for mRCC?
2007

Advanced RCC

A

Sunitinib > IFN-a for mRCC
PFS and objective response rate better

RCT
Sunitinib - TKI –> VEGF and PDGFR
IFN - activates inflammatory and immune responses

83
Q

Lit: TARGET 2007

Advanced RCC

A

Sorafenib > placebo for mRCC s/p 1 prior systemic therapy

RCT
Sorafenib - TKI –> VEGF, PDGFR and RAF kinase
- Significant SE profile includes rare cardiac ischemia

84
Q

Lit: RECORD-1 2008

Advanced RCC

A

mccRCC patients who fail sunitinib should get Everolimus

RCT
everolimus –> mTOR inhibitor

PFS was improved in the everolimus group compared to placebo

85
Q

Lit: COMPARZ 2013

Advanced RCC

A

Pazopanib is non-inferior to sunitinib for m-ccRCC and has superior safety profile

Pazopanib –> TKI - VEGF, PDGFR, fibroblast growth factor receptor (FGFR), and c-kit

RCT
Median PFS and OS were similar and non-inferior to sunitinib

86
Q

Lit: METEOR 2015

Advanced RCC

A

Cabozantinib has better PFS than everolimus for RCC with progression through a VEGFR-targeted treatment

Median PFS and rate or progression or death favored cabozantinib

87
Q

Lit: CheckMate 025 2015

Advanced RCC

A

Nivolumab has better OS than everolimus for advanced RCC s/p 1-2 anti-angiogenic Txs (sunitinib)

RCT

88
Q

Lit: CABOSUN 2017

Advanced RCC

A

Cabozantinib extends PFS vs. sunitinib in poor/intermediate risk met ccRCC

RCT
Previously untreated patients

89
Q

Lit: CheckMate 214 2018

Advanced RCC

A

Nivolumab + ipilimumab has better 18 month OS than sunitinib for poor and intermediate risk patients with untreated advanced RCC (with clear cell component)

RCT
Previously untreated

Ipilimumab = monoclonal Ab to CTLA-4 –> inhibits T-cell suppression

90
Q

Lit: IMmotion151 2019

Advanced RCC

A

Atezolizumab + bevacizumab > sunitinib for PD-L1+ mRCC patients

RCT
Patients with mRCC (cc or sarcomatoid)

Atezolizumab = igG4l mAb to PD-L1
Bevacizumab = mAb that inhibits VEGF-A to block angiogenesis

91
Q

Lit: KEYNOTE 426 2019

Advanced RCC

A

Pembro + axitinib has increased 1-yr OS over sunitinib REGARDLESS of PD-L1 status

Pembrolizumab = IgG4k mAb to PD-1
Axitinib = TKI –> VEGFR, c-kit, PDGFR

92
Q

Lit: TIVO-3 2020

Advanced RCC

A

Tivozanib has better PFS than sorafenib in mRCC s/p multiple prior systemic Tx

RCT

Tivozanib = potent and selective TKI –> VEGF
Sorafenib = TKI –> VEGF, RAF kinase, PDGFR

93
Q

Lit: CheckMate 9ER 2021

Advanced RCC

A

Cabozantinib + nivolumab has better OS than sunitinib for previously untreated advanced or mRCC

RCT
Cabozantinib = TKI –> VEGF, MET, TAm
Nivolumab = IgG4 mAb to PD-1 –> inhibits T cell suppression

Cabo/nivo patients have increase QoL

94
Q

Lit: CLEAR 2021

Advanced RCC

A

(Lenvatinib + pembrolizumab) > (lenvatinib + temsirolimus) > sunitinib for PFS in previously untreated, advanced RCC

Pembrolizumab = IgG4k mAb to PD-1
Lenvatinib = TKI–> VEGF, FGFR, PDGFR

95
Q

Sunitinib mechanism

A

TKI –> VEGF + PDGFR
Decreases tumor angiogenesis and growth

96
Q

Sunitinib side effects

A

Myelosuppression, nephrotoxicity, hepatotoxicity, diarrhea, fatigue, nausea, stomatitis, vomiting, HTN, HTN, Hand-Foot Sx, rash

97
Q

Sorafenib mechanism

A

TKI –> VEGF + PDGFR + RAF kinase
Decreases tumor angiogenesis and growth

98
Q

Sorafenib side effects

A

Cardiac ischemia or infarction (3%), lymphopenia, hepatotoxicity, diarrhea, fatigue, nausea, anorexia, vomiting, HTN, rash

99
Q

Tivozanib mechanism

A

TKI –> VEGF
Decreases tumor angiogenesis and growth

100
Q

Tivozanib side effects

A

HTN, fatigue, diarrhea, rash, hoarse voice

101
Q

Cabozantinib mechanism

A

TKI –> VEGF + MET + TAM
Decreases tumor angiogenesis and growth

102
Q

Cabozantinib side effects

A

GI perforation and fistula
HTN
Fatigue
Diarrhea
Rash
Seizures
Jaw osteonecrosis
Anorexia
HA
Dizziness

103
Q

Nivolumab mechanism

A

IgG4 mAb to PD-1
Decreases T-cell suppression
Increases T-cells killing cancer cells

104
Q

Nivolumab side effects

A

Immune-mediated inflammation, hypothyroidism or hyperthyroidism, pancreatitis with Type I DM, colitis, rash, peripheral edema, neuropathy

105
Q

Ipilimumab mechanism

A

IgG1-mAb to CTLA-4
Decreases T-cell suppression
Increases T-cells killing cancer cells

106
Q

Ipilimumab side effects

A

Colitis
Diarrhea
Fever
Stomach pain
Bloating
Difficulty breathing

107
Q

Atezolizumab mechanism

A

IgG4-mAb to PD-L1
Decreases T-cell suppression
Increases T-cells killing cancer cells

108
Q

Atezolizumab side effects

A

Fatigue
Anorexia
Nausea
UTI

109
Q

Bevacizumab mechanism

A

IgG1-mAb to VEGF
Decreased tumor angiogenesis
Increased apoptosis

110
Q

Bevacizumab side effects

A

HTN
Rash
Nose bleeds
Infection

111
Q

Lenvatinib mechanism

A

TKI –> VEGF + FGFR + PDGFR
Decreased tumor angiogenesis
Increased apoptosis

112
Q

Lenvatinib side effects

A

HTN
Diarrhea
Fatigue
Anorexia
Hypotension
Thrombocytopenia

113
Q

Pembrolizumab mechanism

A

IgG4-mAb to PD-1
Decreased T-cell suppression
Increased T-cells killing cancer cells

(Same mechanism as nivolumab?)

114
Q

Pembrolizumab side effects

A

Immune-mediated inflammation
Hypo- or hyperthyroidism
Pancreatitis with Type 1 DM
Colitis
Rash
Fatigue
Diarrhea
Nausea

115
Q

Axitinib mechanism

A

TKI –> VEGF, PDGFR, c-kit
Decreases tumor angiogenesis and growth

116
Q

Axitinib side effects

A

Diarrhea
HTN
Fatigue
Anorexia
Nausea
Dysphonia
Hand-foot sxs
Weight loss
Vomiting
Constipation

117
Q

Pazopanib mechanism

A

TKI –> VEGF, PDGFR, FGFR, c-kit
Decreased tumor angiogenesis and growth

118
Q

Pazopanib side effects

A

Nausea
Vomiting
Diarrhea
HTN
Anorexia
Rash
Hair Loss
Fatigue

119
Q

Temsirolimus mechanism

A

mTOR inhibitor
Decreased protein synthesis
Decreased tumor survival and growth

120
Q

Temsirolimus side effects

A

Fatigue
Rash
Mucositis
Myelosuppression
Hyperglycemia

121
Q

Everolimus mechanism

A

mTOR inhibitor
Decreased protein synthesis
Decreased tumor survival and growth

122
Q

Everolimus side effects

A

Fatigue
Rash
Diarrhea
Stomatitis
Infections
Myelosuppression
Hyperglycemia

123
Q

Von Hippel Lindau - RCC type

A

Clear cell

124
Q

Birt Hogg Dube - RCC type

A

Chromophobe

125
Q

Hereditary Leiomyomatosis - RCC type

A

Papillary

126
Q

Tumor syndrome with bilateral, multifocal RCC, pancreatic, brain, eye, and ear tumors

A

VHL

127
Q

In patients with bilateral tumors, you should delay surgery until largest tumor is at least ___ cm

A

3

128
Q

Renal tumors, skin growths, lung cysts

A

Birt Hogg Dube

129
Q

Uterine fibroids, cutaneous leiomyomas, RCC

A

HLRCC (hereditary leiomyomatosis RCC)

130
Q

Further work-up after incidental discovery of small renal mass

A

CMP, CBC, UA

CXR / CT chest for staging

131
Q

Renal biopsy is limited by ___ non-diagnostic & false negative rates & concern for seeding of ____

A

high… biopsy tract

132
Q

Renal masses with hyper-enhancement on CT

A

Clear cell & oncocytoma

133
Q

Renal mass with hypo-enhancement on CT

A

Papilary

134
Q

Renal mass with variable enhancement on CT

A

Chromophobe

135
Q

___ of renal mass correlates with risk of metastasis

A

Size

136
Q

Active surveillance should be prioritized when risk of ____ outweigh potential benefits

A

surgery

AS best for elderly with low life expectancy & multiple co-morbidities

137
Q

After ablation, patient has increased risk of ___ persistence & local ____ compared to surgery

A

tumor persistence

local recurrence

138
Q

TX

A

Primary tumour cannot be assessed

139
Q

T0

A

No evidence of primary tumour

140
Q

T1

A

Tumour ≤ 7cm or less in greatest dimension, limited to the kidney

141
Q

T1a

A

Tumour ≤ 4 cm or less

142
Q

T1b

A

Tumour > 4cm ≤ 7 cm

143
Q

T2

A

Tumour >7 cm in greatest dimension, limited to the kidney

144
Q

T2a

A

Tumour >7 cm but ≤10 cm

145
Q

T2b

A

Tumour >10 cm limited to the kidney

146
Q

T3

A

Tumour extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond Gerotas fascia

147
Q

T3a

A

Tumour grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumour invades perirenal and/or renal sinus fat (peripelvic fat), but not beyond Gerotas fascia

148
Q

T3b

A

Tumour grossly extends into the vena cava below the diaphragm

149
Q

T3c

A

Tumour grossly extends into vena cava above the diaphragm or invades the wall of the vena cava

150
Q

T4

A

Tumour invades beyond Gerotas fascia (including contiguous extension into the ipsilateral adrenal gland)

151
Q

NX

A

Regional lymph nodes can not be assessed

152
Q

N0

A

No regional lymph node metastasis

153
Q

N1

A

Metastasis in regional lymph node(s)

154
Q

M0

A

No distant metastasis

155
Q

M1

A

Distant metastasis

156
Q

Stage I

A

T1N0M0

157
Q

Stage II

A

T2N0M0

158
Q

Stage III

A

T3N0M0

T1,T2,T3 N1N0

159
Q

Stage IV

A

T4 AnyNM0

Any T Any N M1

04. RCC (937) (10 decks)

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