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
Follow-up:
After adjuvant therapy
(same as St 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
Follow-up:
After relapsed or Stage IV and surgically unresectable disease
H and P every 6-16 weeks (if receiving sys Tx), more frequent as indicated
Lab evaluation
CT or MRI baseline pretreatment or prior to observation
Ffup imaging every 6-16 weeks
MRI of the spine or bone scan as indicated
KID-B
Follow-up:
Long term (>5y)
H&P annually
Lab tests annually
Abdominal imaging may continue, with increasing intervals
Consider chest imaging for higher stage, with increasing intervals
KID-B
What does “MSKCC” stand for in the MSKCC Prognostic Model? 😅
Memorial Sloan Kettering Cancer Center
KID-D
MSKCC Prognostic Model: What are the factors and risk groups?
Interval from diagnosis to treatment < 1y Karnofsky score < 80% Serum LDH > 1.5x ULN Corrected serum Ca > ULN Serum Hgb < LLN
Low-risk: 0 RFs
Intermediate-risk: 1-2 RFs
Poor-risk: 3 or more RFs
KID-D
What “IMDC” stand for? 😅
International Metastatic Renal Cell Carcinoma Database Consortium
IMDC Criteria: What are the factors and risk groups?
Interval from diagnosis to treatment < 1y
Karnofsky score < 80%
Serum Hgb < LLN (N= 120 g/dL)
Corrected serum Ca > ULN (N= 8.5-10.2 mg/dL)
Neutrophil > ULN (N= 2.0-7.0)
Platelets > ULN
KID-D
Criteria for further genetic risk evaluation:
Diagnosed at 46 y
Bilateral or multifocal tumors
=> 1 first or second-degree relative with RCC
Criteria for further genetic risk evaluation: histologic characteristics
Multifocal papillary
Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) with fumarate hydratase (FH)
Birt-Hogg-Dube syndrome
Angiomyolipoma of the kidney
Succinate dehydrogenase (SDH)-deficient RCC histology
Major features of tuberous sclerosis (TSC)
Renal angiomyolipoma (AML)
Cardiac rhabdomyoma
Cortical dysplasias, including tubers and cerebral white matter migration lines
Angiofibromas (=>3) or fibrous cephalic plaque
Hypomelanotic macules (3 to >5mm in diameter)
Lymphangioleiomyomatosis (LAM)
Multiple retinal nodular hamartomas
Shagreen patch
Subependymal giant cell astrocytoma (SEGA)
Subependymal nodules (SENs)
Ungual fibromas (=>2)
Major features of VHL
Hemangioblastomas of the retina, spine, or brain
Clear cell RCC (ccRCC) diagnosed < 40 years of age or multiple/bilateral ccRCC diagnosed at any age
Adrenal or paraganglioma
Paraganglioma of abdomen, thorax, or neck
Retinal angiomas
T1 - T2
T1a =< 4 cm
T1b >4 and =< 7cm
T2a >7 and =< 10 cm
T2b > 10
T3a
Extends into the renal vein or its segmental branches, or invades the pelvicalyceal system, or invades perirenal and/or renal sinus fat but not beyond Gerota’s fascia
T3b
Extends into the vena cava below the diaphragm
T3c
Extends into the vena cava above the diaphragm or invades the wall of the vena cava
T4
Tumor invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral adrenal gland)
N1
Metastasis in regional lymph node (s)
M1
Distant metastasis
Stage I
T1 N0 M0
Stage II
T2 N0 M0
Stage III
T1-T2 N1 M0
T3 NX N0-M1 M0
Stage IV
T4 Any N M0
Any T Any N M1
Pazopanib: MOA
Oral angiogenesis inhibitor targeting VEGF receptors (VEGFR-1, -2, -3), platelet-derived growth factor receptors (PDGFR-alpha and beta) and stem cell factor receptor (c-KIT)
Sunitinib: MOA
Multikinase inhibitor targeting several receptor tyrosine kinases, including PDGFR-alpha and beta; VEGFR-1, -2, -3; c-KIT; FMS-like tyrosine kinase (FLT-3); colony-stimulating factor (CSF-1R); and neurotrophic factor receptor (RET).
Nivolumab: MOA
Antibody that selectively blocks the interaction between programmed death-1 (PD-1; expressed on activated T cells) and its ligands.
Ipilimumab: MOA
Antibody that selectively blocks the interaction between the negative regulator cytotoxic T-lymphocyte antigen 4 (CTLA-4 and its ligands CD80/CD86.
Cabozantinib: MOA
Small-molecule inhibitor of tyrosine kinases such as VEGFRs, MET, and AXL.
Axitinib: MOA
Selective, second-generation inhibitor of VEGFR-1, -2, and -3.
Bevacizumab: MOA
Recombinant humanized monoclonal antibody that binds and neutralizes circulating VEGF-A.
Temsirolimus: MOA
Inhibitor of the mTOR protein. mTOR regulates micronutrients, cell growth, apoptosis, and angiogenesis by its downstream effects on a variety of proteins.
Lenvatinib: MOA
Multi-targeted TKI.
Everolimus: MOA
Orally administered inhibitor of mTOR.
