Renal Flashcards
1
Q
RCC
Localized Workup
10
A
- H&P
- Labs (CBC/ CMP/ LDH)
- UA
- CT A/P or MRI
- CT chest or CXR
- FH (genetic evaluation if indicated)
- Bone scan if indicated
- Brain MRI if indicated
- Ureteroscopy if indicated
- RMB if indicated
2
Q
RCC
Stage Ia Treatment
4
A
- Partial Nx (p)
- Radical Nx (select pts)
- Ablative techniques
- Active Surveillance
3
Q
RCC
Stage Ib Treatment
4
A
- Partial Nx
- Radical Nx
- Ablative techniques (select pts)
- Active Surveillance (select pts)
4
Q
RCC
Stage II Treatment
3
A
- Partial Nx
- Radical Nx
- Adjuvant pembrolizumab (Grade 4 ccRCC +/- sarcomatoid)
5
Q
RCC
Stage III Treatment
3
A
- Radical Nx
- Partial Nx (select pts)
- Adjuvant pembrolizumab (ccRCC)
6
Q
RCC
Stage IV (M0) Treatment
2
A
- Resectable: Radical Nx and adjuvant pembrolizumab if ccRCC
- Unresectable: First line systemic therapy
7
Q
RCC
Stage IV (M1) Treatment
2
A
- Resectable: Cytoreductive nephrectomy (select pts) or First line systemic therapy (consoder tissue sampling
- Tissue sampling and First-line systemic therapy
8
Q
RCC
First line Favorable ccRCC Systemic Therapy
8
A
- Axitinib + Pembrolizumab (p)
- Cabozantinib + Nivolumab (p)
- Lenvatinib + Pembrolizumab (p)
- Ipilimumab + Nivolumab (p)
- Axitinib + Avelumab
- Cabozantinib
- Pazopanib
- Sunitinib
9
Q
RCC
First line Int/ Poor ccRCC Systemic Therapy
8
A
- Axitinib + Pembrolizumab (p)
- Cabozantinib + Nivolumab (p)
- Ipilimumab + Nivolumab (p)
- Lenvatinib + Pembrolizumab (p)
- Cabozantinib (p)
- Axitinib + Avelumab
- Pazopanib
- Sunitinib
10
Q
RCC
Bosniak 1
6
A
- Homogeneous
- Smooth thin wall (less than 2mm)
- No septa
- No calcification
- No enhancement
- 1.7% malignant
11
Q
RCC
Bosniak 2
8
A
- Homogeneous hyperdense and less than 3cm
- Smooth thin wall (less 2mm)
- Few enhancing septa (1-3)
- Small calcifications
- Non contrast - 9 to 20HU or over 70HU
- Contrast nonenhancing masses over 20 HU
- Contrast enhancing less than 30
- Homogeneous low attenuation masses that are too small too characterize
12
Q
RCC
Bosniak 2F
7
A
- Homogeneous
- Smooth 3mm enhancing wall
- Smooth 3mm enhancing septa
- More than 4 smooth thin (<2mm) enhancing septa
- Few calcifications
- Hyperdense cyst greater than 3cm
- 18.5% malignant
13
Q
RCC
Bosniak 3
3
A
- Enhancing irregular walls or septa
- One or more thick (>4mm) enhancing septa
- 33% malignant
14
Q
RCC
Bosniak 4
4
A
- Thickened or irregular walls
- Enhancing soft tissue components
- Measurable contrast enhancement
- 92.5% malignant
15
Q
RCC
Hereditary RCC Syndromes
7
A
- Von Hipple-Lindau
- Hereditary Papillary Renal Carcinoma
- Birt-Hogg-Dube Syndrome
- Tuberous Sclerosis Complex
- Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC)
- BAP1 tumor predisposition syndrome
- Hereditary paraganglioma/ Pheochromocytoma syndrome (PGL/PCC)
16
Q
RCC
Common RCC Pathology
7
A
- Clear cell RCC
- Papillary RCC type 1 and 2
- Chromophobe
- Collecting Duct (Bellini) carcinoma
- Medullary Renal carcinoma
- Hereditary leiomyomatosis associated RCC (FH-deficient RCC)
- Succinate dehydrogenase-deficient RCC
17
Q
RCC
von Hippel-Lindau
5
A
- Clear cell
- Autosomal dominant
- Hemangioblastomas of retina, spine and brain (less common)
- Pheochromocytoma
- Treat with Belzutifan
18
Q
RCC
Tuberous Sclerosis
6
A
- Autosomal Dominant
- LG Oncocytic tumor /Chromophobe RCC
- Renal AMLs
- Subependymal nodules
- Shagreen patch
- Treat with Everolimus
19
Q
RCC
Birt-Hogg-Dube
5
A
- Chromophobe/ Oncocytomas /Hybrid Oncocytic tumors
- Clear cell RCC
- Angiomyolipomas
- Papillary RCC
- Spontaneoous pneumothorax and pulmonary cysts
20
Q
RCC
Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC)
4
A
- Autosomal Dominant
- FH-deficient RCC (type II)
- Leiomyomas of skin and uterus
- PET-positive adrenal adenomas
21
Q
RCC
Hereditary papillary renal carcinoma (HPRC)
4
A
- Papillary RCC
- Autosomal Dominant
- Multifocal bilateral renal cell tumors
- Treat with Erlotinib + Bevacizumab
22
Q
RCC
BAP1 tumor predisposition syndrome
4
A
- Clear cell
- Autosomal dominant
- Melanoma (uveal and cutaneous)
- Mesothelioma
23
Q
RCC
Hereditary paraganglioma/ pheochromocytoma syndrome (PGL/PCC)
5
A
- SDH-deficient RCC
- Autosomal dominant
- Head and neck PGL
- Adrenal and extra-adrenal PCCs
- Gastrointstinal stromal tumors (GIST)
24
Q
RCC
Malignancy based on size
3
A
- 46% of masses less than 1cm are benign
- 40% of masses less than 2cm are benign
- 20-30% of masses less than 4cm are benign
25
# RCC
Risk Factors
| 8
* Tobacco
* Obesity
* HTN
* Male sex
* NSAIDs
* Dialysis
* Genetics
* RP radiation
26
# RCC
Oncocytoma
| 3
* 25% of masses less than 3cm
* Most common benign enhancing lesion
* Associated with Birt-Hogg-Dube
27
# RCC
AML
| 4
* Associated with TSC
* Macroscopic fat is diagnostic (-15 to -20HU)
* Treat if greater than 4cm or aneurysm greater than 5mm
* Can treat with mTOR inhibitor for pre-op shrinkage in TSC patients
28
# RCC
First line nccRCC Systemic Therapy
| 8
* Cabozantinib (p)
* Cabozantinib + Nivolumab (p)
* Lenvatinib + Pembrolizumab (p)
* Erlotinib + Bevacizumab (select pts [pRCC or HLRCC]))
* Everolimus + Lenvatinib
* Nivolumab
* Pembrolizumab
* Sunitinib
29
# RCC
Second line ccRCC Systemic Therapy IO Naive
| 7
* Axitinib + Pembrolizumab
* Cabozantinib
* Cabozantinib + Nivolumab
* Everolimus + Lenvatinib
* Ipilimumab + Nivolumab
* Lenvatinib + Pembrolizumab
* Nivolumab
30
# RCC
Second line ccRCC Systemic Therapy Prior IO
| 5
* Axitinib
* Belzutifan
* Cabozantinib
* Everolimus + Lenvatinib
* Tivozanib
31
# RCC
T1 staging
| 2
T1a -> Less than 4cm
T1b -> 4cm -7cm
32
# RCC
T2 staging
| 2
T2a -> 7cm -10cm
T2b -> Greater than 10cm
33
# RCC
T3 staging
| 3
T3a -> Extends into renal vein or segmental branches, invades the pelvicalyceal system or invades perirenal fat but not beyond Gerota's
T3b -> Extends into IVC below the diaphragm
T3c -> Extends into IVC above the diaphragm
34
# RCC
T4 staging
| 1
T4 -> Extends beyond Gerota's (including contiguous extension into ipsilateral adrenal)
35
# RCC
N staging
| 1
N1 -> regional LN metastasis
36
# RCC
M staging
| 1
M1 -> Distant metastasis (including non-contguous lesion in ipsilateral adrenal gland)
37
# RCC
Stage I
| 1
T1 N0 M0
38
# RCC
Stage II
| 1
T2 N0 M0
39
# RCC
Stage III
| 1
T1-3 N0-1 M0
40
# RCC
Stage IV
| 1
T1-4 N0-1 M0-1
41
Tumor thrombus staging
| 5
Level 0: limited to the renal vein
Level 1: Extending less than 2cm above the renal vein
Level 2: Extending more than 2cm above the renal vein but below the hepatic confluence
Level 3: At or above the hepatic confluence but below the diaphragm
Level 4: Above the diaphragm
42
# RCC
Internation Metastatic RCC Database Consortium (IMDC) Risk Factors
| 9
* Dx to treatment less than 1 year
* Karnofsky performance status less than 80%
* Elevated Ca level
* Decreased Hgb
* Elevated neutrophil count
* Elevated platelet count
Favorable: 0
Intermediate: 1-2
Poor: 3 or more
43
# RCC
Tyrosine Kinase Inhibitors
| 5
* Sunitinib
* Sorafenib
* Pazopanib
* Cabozantinib
* Axitinib
44
# RCC
Anti-VEGF antibodies
| 1
* Bevacizumab
45
# RCC
VEGF pathway
| 3
* Result of inactivation of the VHL tumor suppressor gene
* Leads to activation of HIF and overproduction of HIF-related proteins (including VEGF)
* VEGF drives angiogenesis
46
# RCC
mTOR pathway
| 3
* mTOR is an important mediator of tumor growth and proliferation
* Also an upstream activator of HIF
* Activated mTOR results in production of VEGF and HIF-1
47
# RCC
mTOR kinase inhibitors
| 2
* Everolimus
* Temsirolimus
48
# RCC
Immune Checkpoint Inhibitors
| 4
* Nivolumab (PD-1)
* Pembrolizumab (PD-1)
* Avelumab (PD-L1)
* Ipilimumab (CTLA-4)
49
# RCC
RENAL nephrometry score
| 8
* Radius [diameter] (<4, 4-7cm, >7cm)
* Exo/Endophytic (>50% exo, <50% exo, endophytic)
* Nearness to collecting system (>7mm, 4-7mm, <4mm)
* Ant/ Posterior
* Location of polar lines (entirely above/below, crosses polar line, >50% over polar line/ crosses axial midline/ entirely between polar lines)
Low: 4-6, 6.4% major complication
Int: 7-9, 11.1% major complication
High: 10-12, 21.9% major complication
50
# RCC
CKD Stage
| 5
1. 90+
2. 60+
3. 30+
4. 15+
5. Less than 15 or dialysis
51
# RCC
Renal Mass Biopsy
| 2
* PPV ~100%, NPV 60%, Non-dx rate 15%
* Used to establish dx in equivical imaging, rule out UCC, guide AS or before ablative techniques
52
# RCC
Ipi/Nivo Response
| 2
20% do not respond
Consider IO/TKI
53
# RCC
Genetic Testing Risk Evaluation
| 7
* Close relative with pathologic variant
* RCC and <46 yo or bilateral or multifocal or first/ second degree relative with RCC
* Multifocal papillary tumor, HLRCC-associated RCC, RCC with fumarate hydratase deficiency
* Multiple chromophobe, oncocytoma or oncocytic hybrid
* AML with one additional TSC feature
* Succinate dehydrogenase-deficient RCC
* 2 first/ second degree relatives with RCC
54
# RCC
Steriotactic body radiation therapy
| 6
* May be considered for non-optimal surgical candidates with stage I, II or III tumors
* May be considered for T1 tumors (T1a and T1b)
* Tumors abutting bowel should not be considered amenable to SBRT
* Should be considered for oligometastasis unless metastasectomy is planned
* May be considered for palliative treatment (including palliative whole brain RT)
* Sterotactic Radiosurgery can be considered for brain metastasis
55
# RCC
Stage I AS: Follow up
| 3
* H&P: annual
* A/P Img: q6 x1y, annual
* CXR: annual
56
# RCC
Stage I Ablation: Follow up
| 3
* H&P: annual
* A/P Img: q3 x1y, annual
* CXR: annual
57
# RCC
Stage I Surgery: Follow up
| 3
* H&P: annual
* A/P Img: q2 x1y, annual
* CXR: annual
58
# RCC
Stage II Surgery: Follow up
| 3
* H&P: annual
* A/P Img: q2 x2y, annual
* CXR: annual
59
# RCC
Stage II s/p adjuvant therapy and Stage III: Follow up
| 3
* H&P: q3-6 x3y, annual
* A/P Img: q3-6 x3y, annual
* CT Chest: q3-6 x3y, annual
60
# RCC
Stage IV: Follow up
| 3
* H&P: q2-4 x3y, q6
* A/P Img: q2-4 x3y, q6
* CT Chest: q2-4 x3y, q6
