Renal Flashcards
RCC
Localized Workup
10
- 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
RCC
Stage Ia Treatment
4
- Partial Nx (p)
- Radical Nx (select pts)
- Ablative techniques
- Active Surveillance
RCC
Stage Ib Treatment
4
- Partial Nx
- Radical Nx
- Ablative techniques (select pts)
- Active Surveillance (select pts)
RCC
Stage II Treatment
3
- Partial Nx
- Radical Nx
- Adjuvant pembrolizumab (Grade 4 ccRCC +/- sarcomatoid)
RCC
Stage III Treatment
3
- Radical Nx
- Partial Nx (select pts)
- Adjuvant pembrolizumab (ccRCC)
RCC
Stage IV (M0) Treatment
2
- Resectable: Radical Nx and adjuvant pembrolizumab if ccRCC
- Unresectable: First line systemic therapy
RCC
Stage IV (M1) Treatment
2
- Resectable: Cytoreductive nephrectomy (select pts)
- First line systemic therapy
RCC
First line Favorable ccRCC Systemic Therapy
8
- Axitinib + Pembrolizumab (p)
- Cabozantinib + Nivolumab (p)
- Lenvatinib + Pembrolizumab (p)
- Ipilimumab + Nivolumab (p)
- Axitinib + Avelumab
- Cabozantinib
- Pazopanib
- Sunitinib
RCC
First line Int/ Poor ccRCC Systemic Therapy
8
- Axitinib + Pembrolizumab (p)
- Cabozantinib + Nivolumab (p)
- Ipilimumab + Nivolumab (p)
- Lenvatinib + Pembrolizumab (p)
- Cabozantinib (p)
- Axitinib + Avelumab
- Pazopanib
- Sunitinib
RCC
Bosniak 1
7
- Homogeneous
- Smooth thin wall (less than 2mm)
- No septa
- No calcification
- No enhancement
- -9 - 20 HU
- 1.7% malignant
RCC
Bosniak 2
8
- 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
RCC
Bosniak 2F
7
- 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
RCC
Bosniak 3
3
- Enhancing irregular walls or septa
- One or more thick (>4mm) enhancing septa
- 33% malignant
RCC
Bosniak 4
4
- Thickened or irregular walls
- Enhancing soft tissue components
- Measurable contrast enhancement
- 92.5% malignant
RCC
Hereditary RCC Syndromes
7
- 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)
RCC
Common RCC Pathology
7
- 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
RCC
von Hippel-Lindau
5
- Clear cell
- Autosomal dominant
- Hemangioblastomas of retina, spine and brain (less common)
- Pheochromocytoma
- Treat with Belzutifan
RCC
Tuberous Sclerosis
6
- Autosomal Dominant
- LG Oncocytic tumor /Chromophobe RCC
- Renal AMLs
- Subependymal nodules
- Shagreen patch
- Treat with Everolimus
RCC
Birt-Hogg-Dube
5
- Chromophobe/ Oncocytomas /Hybrid Oncocytic tumors
- Clear cell RCC
- Angiomyolipomas
- Papillary RCC
- Spontaneoous pneumothorax and pulmonary cysts
RCC
Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC)
4
- Autosomal Dominant
- FH-deficient RCC
- Leiomyomas of skin and uterus
- PET-positive adrenal adenomas
RCC
Hereditary papillary renal carcinoma (HPRC)
4
- Papillary RCC
- Autosomal Dominant
- Multifocal bilateral renal cell tumors
- Treat with Erlotinib + Bevacizumab
RCC
BAP1 tumor predisposition syndrome
4
- Clear cell
- Autosomal dominant
- Melanoma (uveal and cutaneous)
- Mesothelioma
RCC
Hereditary paraganglioma/ pheochromocytoma syndrome (PGL/PCC)
5
- SDH-deficient RCC
- Autosomal dominant
- Head and neck PGL
- Adrenal and extra-adrenal PCCs
- Gastrointstinal stromal tumors (GIST)
RCC
Malignancy based on size
3
- 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
RCC
Risk Factors
8
- Tobacco
- Obesity
- HTN
- Male sex
- NSAIDs
- Dialysis
- Genetics
- RP radiation
RCC
Oncocytoma
3
- 25% of masses less than 3cm
- Most common benign enhancing lesion
- Associated with Birt-Hogg-Dube
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
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
RCC
Second line ccRCC Systemic Therapy IO Naive
7
- Axitinib + Pembrolizumab
- Cabozantinib
- Cabozantinib + Nivolumab
- Everolimus + Lenvatinib
- Ipilimumab + Nivolumab
- Lenvatinib + Pembrolizumab
- Nivolumab
RCC
Second line ccRCC Systemic Therapy Prior IO
5
- Axitinib
- Belzutifan
- Cabozantinib
- Everolimus + Lenvatinib
- Tivozanib
RCC
T1 staging
2
T1a -> Less than 4cm
T1b -> 4cm -7cm
RCC
T2 staging
2
T2a -> 7cm -10cm
T2b -> Greater than 10cm
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
RCC
T4 staging
1
T4 -> Extends beyond Gerota’s (including contiguous extension into ipsilateral adrenal)
RCC
N staging
1
N1 -> regional LN metastasis
RCC
M staging
1
M1 -> Distant metastasis (including non-contguous lesion in ipsilateral adrenal gland)
RCC
Stage I
1
T1 N0 M0
RCC
Stage II
1
T2 N0 M0
RCC
Stage III
1
T1-3 N0-1 M0
RCC
Stage IV
1
T1-4 N0-1 M0-1
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
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
RCC
Tyrosine Kinase Inhibitors
5
- Sunitinib
- Sorafenib
- Pazopanib
- Cabozantinib
- Axitinib
RCC
Anti-VEGF antibodies
1
- Bevacizumab
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
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
RCC
mTOR kinase inhibitors
2
- Everolimus
- Temsirolimus
RCC
Immune Checkpoint Inhibitors
4
- Nivolumab (PD-1)
- Pembrolizumab (PD-1)
- Avelumab (PD-L1)
- Ipilimumab (CTLA-4)
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
RCC
CKD Stage
5
- 90+
- 60+
- 30+
- 15+
- Less than 15 or dialysis
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
RCC
Ipi/Nivo Response
2
20% do not respond
Consider IO/TKI
RCC
Regional LND
1
- Optional but should be considered for patients with resectable adenopathy
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
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
RCC
Stage I AS: Follow up
3
- H&P: annual
- A/P Img: q6 x1y, annual
- CXR: annual
RCC
Stage I Ablation: Follow up
3
- H&P: annual
- A/P Img: q3 x1y, annual
- CXR: annual
RCC
Stage I Surgery: Follow up
3
- H&P: annual
- A/P Img: q2 x1y, annual
- CXR: annual
RCC
Stage II Surgery: Follow up
3
- H&P: annual
- A/P Img: q2 x2y, annual
- CXR: annual
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
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
