NCCN Kidney 1.2021 Flashcards
To become an NCCN master.
Initial workup for a suspicious renal mass
H and PE
CBC + comprehensive metabolic panel LDH
UA
Abdominal _+ pelvic CT or MRI
CXR
If clinically indicated: bone scan, brain MRI, chest CT, needle biopsy
If considering urothelial CA (central mass): urine cytology, URS or percutaneous biopsy
Genetic evaluation (multiple renal masses OR < 46 yo)
KID-1
When should you consider doing a needle biopsy for renal masses?
Small lesions
If considering urothelial CA (central mass): percutaneous biopsy
Purpose: to obtain/confirm diagnosis, guide surveillance or ablative techniques, cryosurgery, radiofrequency ablation strategies
KID-1
PRIMARY TREATMENT:
Stage I T1a
Partial nephrectomy (PREFERRED)
Active surveillance
Ablative techniques
Radical nephrectomy (if nephron-sparing NOT indicated or feasible)
KID-1
PRIMARY TREATMENT:
Stage I T1b
Partial nephrectomy (PREFERRED) Active surveillance Radical nephrectomy (if nephron-sparing NOT indicated or feasible)
*note: ablative techniques NOT recommended for T1b above
KID-1
PRIMARY TREATMENT:
Stage II
Partial nephrectomy
Radical nephrectomy
KID-1
PRIMARY TREATMENT:
Stage III
Partial nephrectomy, if clinically indicated
Radical nephrectomy
KID-1
TREATMENT:
Stage IV, potentially surgically resectable
Consider tissue sampling, then:
Cytoreductive nephrectomy in select patients OR Systemic therapy (PREFERRED in clear cell histology with poor-risk features)
KID-2
TREATMENT:
Stage IV, tissue sampling: clear cell histology, favorable risk
Clinical trial
OR
First-Line Systemic Therapy: axitinib + pembrolizumab OR pazopanib OR sunitinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)
KID-3, KID-C
Treatment options for:
Stage IV, tissue sampling: NON-clear cell histology
Clinical trial
OR
Systemic Therapy: (preferred) clinical trial OR sunitinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)
KID-3, KID-C
Treatment options for:
Stage IV, tissue sampling: clear cell histology, poor/intermediate risk
Clinical trial
OR
Systemic Therapy (preferred): ipilimumab + nivolumab (CAT 1) OR axitinib + pembrolizumab (CAT 1) OR cabozantinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)
KID-3, KID-C
Nephron-sparing surgery (partial nephrectomy) is appropriate in which patients?
Unilateral stage I-III tumors, where technically feasible
Uninephric state
Renal insufficiency
Bilateral renal masses
Familial renal cell CA
Patients at risk for developing progressive CKD due to young age or medical risk factors
KID-A
Regional lymph node dissection is OPTIONAL but RECOMMENDED in which patients?
Adenopathy on preop imaging
OR
Palpable/visible adenopathy at the time of surgery
KID-A
During renal surgery, adrenalectomy may be omitted if ____
If the adrenal gland is not involved.
KID-A
Thermal ablation is an option for clinical stage ____ lesions.
Compared to conventional surgery, it is associated with ____ rates of ____.
T1. Higher rates of local recurrence compared to conventional surgery.
It is an option for masses < 3cm.
Also an option for masses >3cm, but with higher rates of local recurrence/persistence and complications.
KID-A
What is active surveillance?
Active surveillance entails:
Serial abdominal imaging with timely intervention should the mass demonstrate changes (eg, increasing tumor size, growth rate, infiltrative pattern) indicative of increasing metastatic potential.
Also includes: mets survey: blood work, chest imaging
KID-A
Active surveillance is an option for _____
Clinical stage T1 lesions: small renal masses < 2 cm, given the high rates of benign tumors and low mets potential.
AND
T1a (=<4cm) tumors with predominantly cystic component
KID-A
Candidates for cytoreductive nephrectomy prior to systemic therapy:
Excellent performance status (ECOG PS < 2)
No brain metastasis
KID-A
Follow-up for:
Stage I (T1a) During active surveillance
H and PE + lab tests ANNUALLY, as indicated
Abdominal CT or MRI with contrast if contraindication, within 6 months; then CT, MRI, or US at least annually
CXR or Chest CT baseline, then annually
Renal mass biopsy at initiation of AS, or as indicated
Individualized ffup schedule
KID-B
Follow-up for:
Stage I (T1a) After ablative techniques
H and PE
Lab tests annually, as indicated
Abdominal CT or MRI with contrast if no contraindication, at 3-6 months; then CT, MRI, or US at least annually for 5 years or longer, as indicated
CXR or Chest CT annually for 5 years for biopsy-proven low-risk RCC
Renal mass biopsy at initiation of AS, or as indicated
Individualized ffup schedule
KID-B
Follow-up for:
Stage I (T1a) After partial or radical nephrectomy
H and PE
Lab tests annually, as indicated
Abdominal CT or MRI (preferred), or US within 3-12 months of surgery, then annually for 3 years or longer, as indicated
If positive margins or adverse features (sarcomatoid, high-grade [grade 3/4], positive margins). then: MORE RIGOROUS imaging schedule or technique modality
KID-B
Follow-up for:
Stage II or III
H and PE every 3-6 mo for 3y; then annually for up to 5 y
Comprehensive metabolic panel every 6 mo for 2y then annually up to 5y, then as indicated
Baseline CT or MRI within 3-6 mo, then CT or MRI (preferred) or US every 3-6 mo for at least 3y then annually for 5 y
Chest CT within 3-6 mo with continued imaging every 3-6 mo for at least 3y then annually up to 5y
Additional imaging PRN: bone scan, brain imaging
KID-B
