Kidney Cancer FRCR CO2A Flashcards
Radical Nephrectomy
Removal of kidney, perinephric fat, adrenal gland along with Gerota fascia
what should be removed with radical nephrectomy
the tumor or tumor thrombus from the infra and supradiaphragmatic venacava and rarely right atrium
open operation vs laparoscopic surgery
equivalent survival and equal local recurrence rate
when is partial nephrectomy preferred
tumor < 4 cm
whats the role of radiotherapy pre and post nephrectomy
No beneficial role, not used routinely
Chemotherapy in adjuvant setting
no evidence of its use
Immunotherapy in RCC
No e/o adjuant IFN or IL 2, post radical nephrectomy
Role of IO In adjuvant setting
Adjuvant pembrolizumab is stage II
Adjuvant pembrolizumab in Stage III (clear cell)
Survellance in non clear cell
Treatment of T4N0
Nephrectomy and Adjuvant pembrolizumab for clear cell, survellance for non clear cell
M1 treatment
Cytoreductive nephrectomy or systemic therapy
stage IV or Relapsed for clear cell
Metastasectomy or stereotactic body
radiation therapy (SBRT)h or ablative
techniques for oligometastatic disease
or
Metastasectomy with complete
resection of disease, followed by
adjuvant pembrolizumab within 1 year of
nephrectomy
and
Best supportive care
Non Clear cell M1 disease treament
Systemic Therapy
or
Metastasectomy or SBRTh or ablative
techniques for oligometastatic disease
and
Best supportive care
what are systemic therapy options for IO naive clear cell patients in Metastatic setting?
Axitinib + pembrolizumabb
* Cabozantinib
* Cabozantinib + nivolumabb
* Everolimus + lenvatinib
* Ipilimumab + nivolumabb
* Lenvatinib + pembrolizumab
* Nivolumab
what are systemic therapy options for prior IO treated clear cell patients in Metastatic setting?
- Axitinib
- Belzutifane
- Cabozantinib
- Everolimus + lenvatinib
- Tivozanibf
what are SYSTEMIC THERAPY FOR NON-CLEAR CELL HISTOLOGY ?
Erlotinib + bevacizumabg + for selected
patients with advanced papillary RCC including
hereditary leiomyomatosis and renal cell cancer
(HLRCC)-associated RCC (HERED-RCC-D)
* Everolimus + lenvatinib
* Nivolumabb
* Pembrolizumabb
* Sunitinib
what is the role of RT in palliative setting
to control bleeding and pain relief, though results are often disappointing
How is RT for palliation given and Dose?
Parallel oposed antr and postr fields, 6-10 MV photons, large tumors CT planning can be done
20 Gy in 5 fractions or 6-10 Gy single fraction
what are the good prognositic factors in M1 disease
Good PS
absence of weight loss,
presence of only pulmonary metastasis, removal of primary tumor and
a long disese free interval between nephrectomy and appearance of metastases
What is Heng Criteria
its a prognostic model based on 6 risk factors:
KPS < 80
Hb < LLN
Time from Dx to Rx < 1 year
Corrected Ca > ULN
Platelets > ULN
Neutrophils > ULN
Number of RFs 0, favorable group, 2 yr survival 75%
Number of RFs 1-2, Intermediate, 2 yr survival 53%
Number of RFs 3-6, Poor, 2 year survival 7%
What are types of kidney cancer
RCC 95 %and transitional cell carcinoma of renal pelvis 5%
what are the RFs for Kidney Cancer
Smoking (dose response effect)
Radiation,
Trichloroethylene,
obesity,
use of phenacetin analgesic
Arsenic and Cadmium
Acquired cystic kidney disease
what are the occupational RFS for Kidney Cancer
leather tanners
shoe workers
printing process workers
asbestos workers
What is the classical triad of Kidney cancer and in what % of pts it is present
pain, mass and hematuria, 19%
what are the Genetic RFs for Kidney Cancer
VHL on Chromosome 3
Tuberous Sclerosis
PCKD
what are Paraneoplastic syndromes a/w Kidney cancer
Hypercalcemia (PTH r peptide)
Polycythemia (EPO like molecule)
Hypertension (renin) and Hepatic dysfunction (IL 06)
what does classical trial present?
poor prognosis
What are staging investigations?
Renal USG
CECT Chest Abdomen and Pelvis to look at perirenal extension, renal vein involvment, LN enlargement and pulmonary mets
MRI useful in imaging venacava
Bone Scan
FBC and
Ca LDH and ALP
DMSA or MAG3 if there is impaired renal function
