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Uro Onc > Renal > Flashcards

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
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2
Q

RCC

Stage Ia Treatment

4

A
  • Partial Nx (p)
  • Radical Nx (select pts)
  • Ablative techniques
  • Active Surveillance
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3
Q

RCC

Stage Ib Treatment

4

A
  • Partial Nx
  • Radical Nx
  • Ablative techniques (select pts)
  • Active Surveillance (select pts)
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4
Q

RCC

Stage II Treatment

3

A
  • Partial Nx
  • Radical Nx
  • Adjuvant pembrolizumab (Grade 4 ccRCC +/- sarcomatoid)
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5
Q

RCC

Stage III Treatment

3

A
  • Radical Nx
  • Partial Nx (select pts)
  • Adjuvant pembrolizumab (ccRCC)
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6
Q

RCC

Stage IV (M0) Treatment

2

A
  • Resectable: Radical Nx and adjuvant pembrolizumab if ccRCC
  • Unresectable: First line systemic therapy
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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
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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
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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
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10
Q

RCC

Bosniak 1

7

A
  • Homogeneous
  • Smooth thin wall (less than 2mm)
  • No septa
  • No calcification
  • No enhancement
  • -9 - 20 HU
  • 1.7% malignant
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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
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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
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13
Q

RCC

Bosniak 3

3

A
  • Enhancing irregular walls or septa
  • One or more thick (>4mm) enhancing septa
  • 33% malignant
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14
Q

RCC

Bosniak 4

4

A
  • Thickened or irregular walls
  • Enhancing soft tissue components
  • Measurable contrast enhancement
  • 92.5% malignant
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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)
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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
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17
Q

RCC

von Hippel-Lindau

5

A
  • Clear cell
  • Autosomal dominant
  • Hemangioblastomas of retina, spine and brain (less common)
  • Pheochromocytoma
  • Treat with Belzutifan
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18
Q

RCC

Tuberous Sclerosis

6

A
  • Autosomal Dominant
  • LG Oncocytic tumor /Chromophobe RCC
  • Renal AMLs
  • Subependymal nodules
  • Shagreen patch
  • Treat with Everolimus
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19
Q

RCC

Birt-Hogg-Dube

5

A
  • Chromophobe/ Oncocytomas /Hybrid Oncocytic tumors
  • Clear cell RCC
  • Angiomyolipomas
  • Papillary RCC
  • Spontaneoous pneumothorax and pulmonary cysts
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20
Q

RCC

Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC)

4

A
  • Autosomal Dominant
  • FH-deficient RCC
  • Leiomyomas of skin and uterus
  • PET-positive adrenal adenomas
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21
Q

RCC

Hereditary papillary renal carcinoma (HPRC)

4

A
  • Papillary RCC
  • Autosomal Dominant
  • Multifocal bilateral renal cell tumors
  • Treat with Erlotinib + Bevacizumab
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22
Q

RCC

BAP1 tumor predisposition syndrome

4

A
  • Clear cell
  • Autosomal dominant
  • Melanoma (uveal and cutaneous)
  • Mesothelioma
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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)
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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
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25
Q

RCC

Risk Factors

8

A
  • Tobacco
  • Obesity
  • HTN
  • Male sex
  • NSAIDs
  • Dialysis
  • Genetics
  • RP radiation
26
Q

RCC

Oncocytoma

3

A
  • 25% of masses less than 3cm
  • Most common benign enhancing lesion
  • Associated with Birt-Hogg-Dube
27
Q

RCC

AML

4

A
  • 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
Q

RCC

First line nccRCC Systemic Therapy

8

A
  • Cabozantinib (p)
  • Cabozantinib + Nivolumab (p)
  • Lenvatinib + Pembrolizumab (p)
  • Erlotinib + Bevacizumab (select pts [pRCC or HLRCC]))
  • Everolimus + Lenvatinib
  • Nivolumab
  • Pembrolizumab
  • Sunitinib
29
Q

RCC

Second line ccRCC Systemic Therapy IO Naive

7

A
  • Axitinib + Pembrolizumab
  • Cabozantinib
  • Cabozantinib + Nivolumab
  • Everolimus + Lenvatinib
  • Ipilimumab + Nivolumab
  • Lenvatinib + Pembrolizumab
  • Nivolumab
30
Q

RCC

Second line ccRCC Systemic Therapy Prior IO

5

A
  • Axitinib
  • Belzutifan
  • Cabozantinib
  • Everolimus + Lenvatinib
  • Tivozanib
31
Q

RCC

T1 staging

2

A

T1a -> Less than 4cm
T1b -> 4cm -7cm

32
Q

RCC

T2 staging

2

A

T2a -> 7cm -10cm
T2b -> Greater than 10cm

33
Q

RCC

T3 staging

3

A

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
Q

RCC

T4 staging

1

A

T4 -> Extends beyond Gerota’s (including contiguous extension into ipsilateral adrenal)

35
Q

RCC

N staging

1

A

N1 -> regional LN metastasis

36
Q

RCC

M staging

1

A

M1 -> Distant metastasis (including non-contguous lesion in ipsilateral adrenal gland)

37
Q

RCC

Stage I

1

A

T1 N0 M0

38
Q

RCC

Stage II

1

A

T2 N0 M0

39
Q

RCC

Stage III

1

A

T1-3 N0-1 M0

40
Q

RCC

Stage IV

1

A

T1-4 N0-1 M0-1

41
Q

Tumor thrombus staging

5

A

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
Q

RCC

Internation Metastatic RCC Database Consortium (IMDC) Risk Factors

9

A
  • 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
Q

RCC

Tyrosine Kinase Inhibitors

5

A
  • Sunitinib
  • Sorafenib
  • Pazopanib
  • Cabozantinib
  • Axitinib
44
Q

RCC

Anti-VEGF antibodies

1

A
  • Bevacizumab
45
Q

RCC

VEGF pathway

3

A
  • 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
Q

RCC

mTOR pathway

3

A
  • 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
Q

RCC

mTOR kinase inhibitors

2

A
  • Everolimus
  • Temsirolimus
48
Q

RCC

Immune Checkpoint Inhibitors

4

A
  • Nivolumab (PD-1)
  • Pembrolizumab (PD-1)
  • Avelumab (PD-L1)
  • Ipilimumab (CTLA-4)
49
Q

RCC

RENAL nephrometry score

8

A
  • 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
Q

RCC

CKD Stage

5

A
  1. 90+
  2. 60+
  3. 30+
  4. 15+
  5. Less than 15 or dialysis
51
Q

RCC

Renal Mass Biopsy

2

A
  • 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
Q

RCC

Ipi/Nivo Response

2

A

20% do not respond
Consider IO/TKI

53
Q

RCC

Regional LND

1

A
  • Optional but should be considered for patients with resectable adenopathy
54
Q

RCC

Genetic Testing Risk Evaluation

7

A
  • 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
55
Q

RCC

Steriotactic body radiation therapy

6

A
  • 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
56
Q

RCC

Stage I AS: Follow up

3

A
  • H&P: annual
  • A/P Img: q6 x1y, annual
  • CXR: annual
57
Q

RCC

Stage I Ablation: Follow up

3

A
  • H&P: annual
  • A/P Img: q3 x1y, annual
  • CXR: annual
58
Q

RCC

Stage I Surgery: Follow up

3

A
  • H&P: annual
  • A/P Img: q2 x1y, annual
  • CXR: annual
59
Q

RCC

Stage II Surgery: Follow up

3

A
  • H&P: annual
  • A/P Img: q2 x2y, annual
  • CXR: annual
60
Q

RCC

Stage II s/p adjuvant therapy and Stage III: Follow up

3

A
  • H&P: q3-6 x3y, annual
  • A/P Img: q3-6 x3y, annual
  • CT Chest: q3-6 x3y, annual
61
Q

RCC

Stage IV: Follow up

3

A
  • H&P: q2-4 x3y, q6
  • A/P Img: q2-4 x3y, q6
  • CT Chest: q2-4 x3y, q6

Uro Onc (23 decks)

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