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ABU Oral Boards > Renal Cancer > Flashcards

Renal Cancer Flashcards

1
Q

What percentage of surgically resected tumors < 4 cm are benign?

A

15-20%

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2
Q

What percentage of RCC cases are familial? What are syndromes?

A

4-6%

Von Hippel-Lindau (VHL)

Birt Hogg-Dube (BHD)

Hereditary leiomyomatosis RCC (HLRCC)

Succinate dehydrogenase deficiency

Tuberous sclerosis

BAP-1

PTEN hamartoma (Cowden Syndrome)

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3
Q

Major subtypes of RCC?

A

clear cell

papillary 1 or 2

chromophobe

collecting duct

unclassified

uncommon: acquired cystic, clear cell tubulo papillary, renal medullary (sickle cell)

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4
Q

Advanced PE findings?

A

Paraneoplastic syndromes (htn, polycythemia, hypercalcemia)

adenopathy

varicocele

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5
Q

Name benign renal tumors?

A

Papillary adenoma

Oncocytoma

AML

Metanephric adenoma

Adult cystic nephroma

Mixed epithelial stromal tumors

Juxtaglomerular cell tumor

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6
Q

What is T1 renal tumor? subtypes?

A

T1 → < 7 cm in greatest dimension, limited to kidney

T1a < 4 cm

T1b < 4 cm, but not > 7 cm

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7
Q

Describe renal tumor T2:

A

T2 → >7 cm in greatest dimension, limited to kidney

T2a → > 7 cm but < 10 cm

T2b → > 10 cm

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8
Q

Describe renal mass T3:

A

T3 → tumor extends into major veins or perinephric tissues, but not to adrenal or beyond Gerota’s

T3a → into renal vein or its segmental branches, or invades pelvicalyceal system, or invades perirenal and/or renal sinus fat but not beyond Gerota’s

T3b → Grossly extends into vena cava below diaphragm

T3c → extends into vena cava above diaphragm or invades wall of vena cava

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9
Q

Describe renal mass T4:

A

T4 → invades beyond Gerota’s (including contiguous adrenal extension)

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10
Q

Define renal cancer N and M stages:

A

Nx → LN not assessed

N0 → no region LN mets

N1 → mets to regional LN

M0 → no distant mets

M1 → distant mets

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11
Q

Describe renal mass stages:

A
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12
Q

Describe the treatment options for clinically localized renal cancer:

A

Active surveillance → cT1a < 4 cm → risk of mets <2%

Radical Nx → historically entire kidney, Gerota’s/ Zuckerkandel’s fascia, regional LN, and adrenal

Partial Nx → NSS

Thermal ablation → RFA and cryoablation

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13
Q

In a patient with renal mass, clinicians SHOULD obtain which imaging? How is mass characterized?

A

GUIDELINE STATEMENT 1

High-quality, multiphase, cross-sectional abdominal imaging (CT/MRI)

eGFR < 45 → hydration or MRI (especially characterizing small lesions < 2 cm)

NSF (CKD 4/5 → < 0.07%)

Characterize stage (size cranio-caudal, transverse, and A/P, morphology, involvement of vasculature, adenopathy)

Nephrometry score, PADUA score, C-index

Complexity (Bosniak 3 → irregular walls/septa + enhancement ~50% malignant; Bosniak 4 → complex cystic lesions, enhancing ~75-90% malginant)

Degree of contrast enhancement (> 15-20 HU on CT or 20% on MRI)

Presence or absence of fat

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14
Q

Nephrometry Score

A

RENAL

Radius, Exophytic/Endophyic, Nearness to CS, A/P, Location re: polar lines

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15
Q

In patients with suspected renal cancer, clinician SHOULD obtain which labs? Metastatic eval?

A

GUIDELINE STATEMENT 2

CMP, CBC, UA (proteinuria important prognostic factor)

UA 1+ protein → Protein: Cr or Alb:Cr

Elevated ALP → consider bone mets

Chest imaging → CXR or CT(evaluate for thoracic mets based on risk of dz)

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16
Q

What makes a renal mass higher risk?

A

presence of thrombi, presumed adenopathy, larger tumor size, infiltrative appearance, extensive tumor necrosis, severe relevant sxs or PE findings

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17
Q

In patient with solid or Bosniak 3 or 4 mass, in addition to labs and metastatic workup, what other classifications SHOULD be done?

A

GUIDELINE STATEMENT 3

Assign CKD stage base on GFR and degree proteinuria

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18
Q

In regards to counseling for suspicious renal mass, who SHOULD be considered as players of the multidisciplinary team?

A

GUIDELINE STATEMENT 4

Urologist → lead counseling process

IR → RMB or ablation

Nephrologist → CKD, proteinuria, DMII, ongoing renal protection

Pathologist → GU dedicated, also evaluation of normal parenchyma

Medical Oncologist → poss neoadjuvant or adjuvant trials, recurrence

Genetic Counseling → 4-6% familial, multifocal or b/l

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19
Q

Clinicians SHOULD provide counseling that includes current perspectives about tumor biology and what patient-specific risk assessment:

A

GUIDELINE STATEMENT 5

Sex, tumor size/complexicty, histology, imaging characteristics

cT1a (low oncologic risk → indolent, <2% risk mets)

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20
Q

When counseling treatment options for renal mass, clinicians SHOULD review the most common urologic and non-urologic morbidities of each treatment pathway including:

A

GUIDELINE STATEMENT 6

the importance of age, comorbidities/frailty, and life expectancy

RN → greatest risk dec. GFR or de novo CKD, favorable peri-op outcomes and low risk of complication compared to PN

PN → excellent preservation of GFR, higher risk txf, urine leak or other complications needing additional tx (stent, drains, embolization of pseudo-aneurysm)

TA → inferior RFS, most favorable peri-operative outcome profile (best for small peripheral tumors)

AS → favorable oncologic and OS outcomes in well-selected patients; possible anxiety or poor outcomes

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21
Q

What SHOULD clinicians review in regards to renal function recovery related to renal mass management:

A

GUIDELINE STATEMENT 7

Progressive CKD

ST and LT need for RRT

LT OS considerations

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22
Q

Clinicians SHOULD refer to nephrology renal mass patients with:

A

GUIDELINE STATEMENT 8

High risk of CKD progression (eGFR < 45), confirmed proteinuria, DMII pre-existing CKD, or expected GFR < 30 after sx

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23
Q

In regards to renal cancer, when is genetic counseling RECOMMENDED:

A

GUIDELINE STATEMENT 9

< 46 yo

Multifocal or b/l masses

personal hx suggests familial renal neoplastic syndrome

1st or 2nd degree relative with hx of renal cancer or known clinical/genetic dx of familial neoplastic syndrome (even if kidney cancer not observed)

path demonstrates histologic features suggestive of syndrome

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24
Q

Syndrome: Von Hippel-Lindau (VHL)

A

Gene: VHL

Clear cell RCC, renal cysts, hemangioblastomas of CNS, retinal angiomas, pheochromocytoma

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25
Q

Syndrome: Hereditary Papillary Renal Carcinoma (HRPC)

A

Gene: MET

Type 1 papillary RCC

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26
Q

Syndrome: Birt Hogg-Dube (BHD)

A

Gene: FLCN

chromophobe RCC, oncocytoma, hybrid oncocytic/chromophobe tumors (HOCTs), cc RCC (less common), renal cysts, cutaneous fibrofolliculomas, lung cysts, spontaneous PTX

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27
Q

Syndrome: Hereditary Leiomyomatosis and RCC (FH)

A

Gene: FH

type 2 papillary or CD RCC, cutaneous leioyomyomas, uterine leiyomyomas

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28
Q

Syndrome: Succinate Dehydrogenase Kidney Cancer (SDH-RCC)

A

Gene: SDHB/C/D

ccRCC, choromophobe RCC, type 2 papillary RCC, oncocytoma, pheochromocytoma/paraganglioma

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29
Q

Syndrome: BAP-1 Tumor Predisposition Syndrome

A

Gene: BAP-1

ccRCC, uveal melanoma

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30
Q

Syndrome: Tuberous Sclerosis Complex

A

Gene: TSC 1 or 2

AML, ccRCC, oncocytoma, lymphangioleiyomyomastosis (LAM), seizures, developmental delay

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31
Q

Syndrome: Cowden/PTEN Syndrome associated RCC (CS-RCC)

A

Gene: PTEN

Thyroid, breast, and endometrial cancer, mucocutaneous lesions, RCC with papillary mc, other forms of RCC including cc

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32
Q

When considering RMB what SHOULD be counseled?

A

GUIDELINE STATEMENT 10

generally safe & complications low risk: hematoma, pain, hematuria, PTX, hemorrhage (txf)

Sensitivity 9.67%, Specificity 94.4%, PPV 98.8% (core), NPV 60-80%

non-diagnostic rate 14%, concern for missed histologic heterogeneity

Discussion:

RMB is safe and low risk (no reported tumor seeding)

Dx of RCC is highly reliable

LImits:

Benign bx must be distinguished from non-dx

Benign is not always correct

Grade concordance from bx to sx is not perfect

Oncocytic neoplasm are diagnostic dilemma

Bx or aspiration of cystic mass not advised (spillage)

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33
Q

When concerned about hematologic, metastatic, inflammatory, or infectious mass, clinicians SHOULD consider? What type of cancers are common?

A

GUIDELINE STATMENT 11

RMB

Lymphoma, lung, melanoma, colon, thyroid

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34
Q

RMB SHOULD be obtained on utility-based approach when it may influence mgmt. It is NOT required when:

A

GUIDELINE STATMENT 12

Young or healthy patients who are unwilling to accept uncertainties

older or frail patients who will be managed conservatively no matter results

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35
Q

How SHOULD RMB be done?

A

GUIDELINE STATEMENT 13

Multiple core biopsies and preferred over FNA

36
Q

Why is NSS (PNx) important? When is it appropriate to consider?

A

GUIDELINE STATEMENT 14

for mgmt of cT1a mass

**reduces risk of CKD or CKD progression and is associated with favorable outcomes

GUIDELINE STATEMENT 15

solid or Bosniak 3 or 4 complex cystic masses in anatomically or functional solitary kidney, bilateral tumors, known familial RCC, pre-existing CKD, or proteinuria

GUIDELINE STATEMENT 16

solid or Bosniak 3 or 4 complex cystic masses who are young, multifocal masses, or comorbidities likely to impact GFR in future (htn, DM, stones, obesity)

37
Q

Intraoperatively, how SHOULD clinicians prioritize nephron sparing and balance with what other goals?

A

GUIDELINE STATEMENT 17

optimize nephron mass preservation

avoid prolonged warm ischemia (<25-30 mins)

GUIDELINE STATEMENT 18

Prioritize negative sx margins

Enucleation should be considered in pts with familial RCC, multifocal dz, severe CKD

*depends on tumor characteristics, growth pattern, interface with normal tissue

38
Q

When SHOULD a clinician consider RNx?

A

GUIDELINE STATEMENT 19

Solid or Bosniak 3 or 4 complex cystic renal mass with:

increased oncologic potential (size, RMB, imaging features)

ALL of following:

high tumor complexity (PN challenging in experienced hands)

no pre-existing CKD or proteinuria

normal contralateral kidney (new baseline GFR would be >45)

39
Q

Patients undergoing renal sx, SHOULD have LND when?

A

GUIDELINE STATEMENT 20

clnically concerning regional LAN, perform LND including all clinically positive nodes for staging (no real survival benefit)

(concerning features: > 10 cm mass, clinical stage T¾, high grade tumors (3 or 4), sarcomatoid features, histologic tumor necrosis)

40
Q

For patients with renal mass, when SHOULD adrenalectomy be performed?

A

GUIDELINE STATEMENT 21

imaging and/or intraoperative findings suggest mets or direct invasion of adrenal gland

pT4 (contiguous)

M+ if hematogenous

41
Q

How SHOULD renal mass surgery be performed?

A

GUIDELINE STATEMENT 22

Minimally invasive (when it would not compromise outcomes)

*benefits in ST complications, fewer longer term

42
Q

After PNx of RNx, adjacent renal parenchyma SHOULD be evaluated:

A

GUIDELINE STATEMENT 23

evaluate for intrinsic renal dz and particularly for CKD or risk factors for CKD

43
Q

When SHOULD clinicians refer to medical oncology for renal masses?

A

GUIDELINE STATEMENT 24

whenever there is concern for potential clinical mets or incompletely resected dz (macroscopic positive margin or gross residual dz)

patients with high-risk or locally advanced, fully resected renal cancers should be counseled of risk, benefits of adjuvant tx and encourage to participate in trials

44
Q

What types of TA can be considered for renal mass? Who SHOULD be considered?

A

GUIDELINE STATEMENT 26

radiofrequency ablation (RFA) and cryoablation

GUIDELINE STATEMENT 25

consider as alternative mgmt of cT1a solid masses < 3 cm (percutaneous preferred over sx approach)

45
Q

Describe RFA and cyroablation:

A

RFA → high frequency alternative current (460-500 kHz) to induce frictional agitation and heating in adjacent tissues

Cryo → temp -20 to -40 C, resulting in coagulative necrosis

46
Q

When treating with TA, what SHOULD be performed prior to or at time of tx? What should counseling include?

A

GUIDELINE STATEMENT 27

RMB to provide pathologic dx and guide surveillance

GUIDELINE STATEMENT 28

info regarding increased likelihood of persistence or local recurrence vs. sx which may be addressed with repeat ablation or further intervention

47
Q

Patient related factors for AS vs. Expectant Mgmt vs. Intervention

A
48
Q

When SHOULD AS be utilized?

A

GUIDELINE STATEMENT 29

For solid renal mass < 2 cm, or complex but cystic

*Repeat imaging in 3-6 mo to assess growth/change, then periodic imaging based on growth rate

GUIDELINE STATEMENT 30

For solid or Bosniak 3 or 4 cystic complex mass, WHEN anticipated risk of intervention or competing risk of death outweigh oncologic benefits (asx pts periodic imaging)

GUIDELINE STATEMENT 31

For patients with solid or Bosniak 3 or 4 WHEN risk/benefit is equivocal and who prefer AS, consider RMB

49
Q

When is intervention RECOMMENDED over AS? When is AS possible in this case?

A

GUIDELINE STATEMENT 32

solid or Bosniak 3 or 4 mass with oncologic benefits of intervention > risks of tx and risk of death

**Median growth rates > 5 mm/year are indicative of oncologically active tumors

AS with potential for delayed intervention → only if patient understands and willing to accept associated oncologic risk

Encourage RMB for additional stratification

continues to prefer AS → close clinical and cross sectional imaging continued

50
Q

Follow up after intervention of renal mass: benign vs. malignant?

A

GUIDELINE STATEMENT 33

Discuss implications of stage, grade, and histology including risk of recurrence and sequelae of tx

Benign → occasional clinical eval and labs (no imaging)

GUIDELINE STATEMENT 34

Periodic H&P, labs, imaging for mets and local recurrence based on stage

51
Q

What follow up labs for malignant renal mass s/p tx?

A

GUIDELINE STATEMENT 35

Cr, eGFR, UA

CBC, LDH, LFT, ALP, Ca → discretion of MD or if advanced dz

52
Q

When following patient s/p tx for renal mass, when do you refer to nephrology?

A

GUIDELINE STATEMENT 36

with progressive renal insufficiency or proteinuria

53
Q

When do you perform bone scan for renal mass f/up post tx? When head or spine CT/MRI?

A

GUIDELINE STATEMENT 37

clinical sxs bone pain, elevated ALP, or imaging suggestive of bony mets

GUIDELINE STATEMENT 38

Acute neuro sxs

GUIDELINE STATEMENT 39

site specific imaging warranted by sxs

PET should not be routinely used (selectively)

54
Q

Patients renal mass with suggestive sxs/signs of mets next steps?

A

GUIDELINE STATEMENT 40

evaluate to define extent of dz

refer to med onc

sx or ablation considered with isolated or oligo-mets

55
Q

In pts with new renal primary or local recurrence, what is next steps?

A

GUIDELINE STATEMENT 41

met evaluation including chest and abdomen

if isolated to ipsilateral kidney and/or retroperitoneum, sx resection or ablation can be considered

56
Q

Describe risk categories of patients s/p PNx or RNx:

A

GUIDELINE STATEMENT 42

See table, sx margins positive → increase risk category by one level

57
Q

Recurrence rates by risk level for renal mass post sx:

A

pT1 → 9.2% (Grade 1: 6.4%, Grade 2: 15.4%)

pT2 → 32% (organ confined RCC, Grade 3 or 4: 20-30%)

pT4 (most present mets) → 64.7% (N1 → CSS 2.8 y, 64.3% mortality after recurrence)

58
Q

Follow up after TA:

A

GUIDELINE STATEMENT 45

bx confirmed malignancy or non-dx

CTU/MRU w/in 6 mo (then follow same as intermediate risk category)

59
Q

f/up schedule after surgery for renal cancer:

A

GUIDELINE STATEMENT 43 and 44

Low risk → pT1, G1 or 2 → CT/MRI and CXR/CT q 12 mo

*after 2 years abd US alternating with CT/MRI can be considered

*after 5 y joint decision making

Intermediate risk → pT1 grade 3 or 4, pT2 any grade → CT/MRI and CXR/CT at 6 mo, then q 12 mo for 5 years (can consider abd US after 2 years alternating)

High risk → pT3 any grade → CT/MRI and CXR/CT q 6 mo for 3 y, then q 12 mo for 5 years

Very high risk → pT4 or N1 or sarcomatoid, rhabdoid, macro pos margin → CT/MRI q 3 mo x 1year, then q 6 mo years 2-3, then annually

60
Q

f/up algorithm table for renal mass

A
61
Q

Describe an extraperitoneal flank approach for Nx:

A
  1. Anesthesia, Foley, SCDs, abx
  2. Position lateral decubitus (side down opposite tumor), flexion to increase space btw ribs, pressure points padded, secured to table, right arm supported in anatomic position to protect brachial plexus
  3. Incise btw 11-12 ribs, dissect through flank layers, care to avoid perforating nerves
  4. Enter retroperitoneum, divide lumbodorsal fascia, avoid entry to pleura posteriorly and peritoneum anteriorly
  5. Mobilize kidney w/in Gerota’s posteriorly, laterally, superiorly, and anteriorly
  6. ID ureter
  7. Place kidney on anterior and medial traction to isolate hilum
  8. Dissect artery posteriorly
  9. Defat kidney near renal mass, maintain fat pedicle to possibly use for reconstruction
  10. Use US if needed to define boundaries and depth
  11. Mannitol??? /IVF (out of favor…)
  12. Clamp RA, surround kidney in slush
  13. Incise capsule 1 cm from tumor edge, excise tumor with neg margin
  14. Sample areas from bed if concern of incomplete excision
  15. Assess and repair CS
  16. Achieve hemostasis with focal suture ligatures, electrocautery, and hemostatic agents
  17. Reconstruct and reinforce defect (bolsters)
  18. Remove clamp ASAP
  19. Assess for arterial pulse/perfusion kidney
  20. Assess for hemostasis
  21. Re-approximate perinephric fat pedicle
  22. Place drain in proximity of kidney
  23. Inspect retroperitoneum, peritoneal boundary and pleura
  24. Inspect vasculature
  25. Remove flexion, reapproximate ribs
  26. Close muscle and facial layers
  27. Close skin
62
Q

How do you manage an acute post operative urine leak?

A
  1. vast majority close with conservative mgmt
  2. small leaks → adjust drain to make sure not contributing, suction on renorrhaphy vs. obs
  3. larger or persistent leaks → urinary diversion, stent, IR drain/PCN; with stent need Foley to prevent VUR
  4. Secondary closure, fistula repair, nx (challenging cases or nephrocutaneous fistula)
  5. Algorithm:

leak from drain → take off suction → adjust away from anastomosis

Insert stent → placed PCN → IR drain urinoma → antegrade stent

63
Q

Most important prognostic determinant of RCC?

A

local tumor extent/size/stage

histologic subtype

surgical margins

regional nodal status

evidence of distant met status

performance status

64
Q

What about margins?

A

<1 cm margins not associated with higher rates of local recurrence

positive margin slightly higher risk of local recurrence (but with adequate surveillance, no statistically higher mortality)

65
Q

What are risk factors and pathogenesis of ccRCC? what about VHL association?

A

family hx, smoking, hereditary, obesity, HD

arises from PCT, associated with defects in VHL (60% sporadic)

VHL → works as tumor suppressor to inhibit ubiquitination of HIF → when mutated HIF builds up overproducing VEGF, GLUT-1 TGF-a, PDGF → angiogenesis, proliferation

66
Q

Describe trans peritoneal lap Nx:

A
  1. anesthesia, foley, NGT
  2. lateral decubitus (tumor side up), 45 degree angle, pad pressure points (peroneal nerve, brachial plexus stretch injury)
  3. trochar placement to triangulate kidney
  4. Veress → incision at umbilical camera site → Kelly clamp to spread fat, ID fascia → grasp fascia using Kocher, upward traction, pass veress (2 pops) → 10 cc syringe, inject 5 cc saline without force to confirm intraperitoneal → advance needle 1 cm, no resistance → confirm low starting pressure → remove Veress, place trochar, attach gas, pass camera to inspect
  5. Hasson → consider with prev. abd sx → ID fascia, incised, peritoneum incised → 2 heavy sutures placed on either size of incision (incorporate fascia/peritoneum) → Hasson trochar in place and insufflation started
  6. Place working trochars under direct vision
  7. take down colon (white line of Toldt), care not to enter Gerota’s (left splenic flexure mobilized → drop from field, care to avoid tail of pancreas
  8. ID ureter on psoas
  9. gonadal ID and traced to hilum
  10. RV skeletonized (care not to avulse adrenal vein or lumbar (entering posterior RV)
  11. ID RA posterior and superior (make sure 1)
  12. Secure RA with Weck Clips (2-3, 1 on kidney side) or Stapler, Take vein with stapler
  13. Take gonadal and ureter, dissect free posterior, lateral, and superior aspect of kidney, place in bag
  14. Extract in lap bag to facilitate removal and reduce incision site implants
  15. Port sites > 10 mm closed
67
Q

Common locations of positioning injuries for renal sx:

A

Brachial plexus

Lateral popliteal nerve

Femoral nerve

Sciatic Nerve

*usually resolve 4-6 weeks, can last up to 2y

68
Q

What are insufflation/access related complications and treatment:

A

gas embolus → Millwheel murmur, CV collapse, head/neck cyanosis, dysrhythmia, hypoxia, decreased end tidal CO2 → terminate insufflation, release pneumo, left lateral decubitus, cardiopulmonary resuscitation, aspiration of gas via central line, 100% O2

Veress needle/trochar placement → major vascular injury → leave needle in place, use second Veress and try to repair injury → if trochar injury, open conversion, explore and repair → do not remove until conversion made and ID location and severity

Extraperitonal insufflation → high intra-abd pressure after small volume insufflated, subq emphysema, pneumoscrotum, PTX, pneumomediastinum → reposition insufflation needle

69
Q

Name vascular complications and tx of lap surgery:

A

mgmt. based on severity of injury: clip vessel, increase pressure, apply pressure (gauze or instrument), biosealants (slow ooze), oversew, convert to open/hand assist (leave instrument on bleed), lower pressure to 5 mHg at end to ensure no active bleeding (watch trochar removal)

post operative bleeding → prolonged pain, distention, tachy, fall in hct → CT AP, obs. vs. exploration

Hollow viscus → electrocautery, access (needle/trochar), blind passage of instruments

Recognize in OR → repair, abx irrigation, broad spectrum

Post op → trochar site pain, fever, leukopenia with left shift, low threshold for CT w/oral contrast and delayed views to visualize colon

Solid Viscus → veress, trochar, retraction (do gently)

Minor injury → biosealants, argon beam, cellulose gauze, open if fail

Kidney trochar injury → if Gerota’s intact, stable RP hematoma, patient stable _> conservative obs

Explore if expanding hematoma, vascular instability, or unknown extent of injury

70
Q

Complications of PNx:

A

Intraoperative hemorrhage

Delayed bleeding

Persistent leak from CS

Perirenal abscess

Urinoma

Reno-cutaneous fistula

Acute tubular necrosis

Conversion to RN

71
Q

what control is needed with IVC thrombectomy?

A
  • Prior to IVC thrombectomy vascular occlusion should include:
    • Renal artery supplying the affect kidney with tumor thrombus
    • Infrarenal IVC below thrombus
    • Lumbar veins feeding in to the IVC
    • Contralateral renal vein
    • Hepatic blood supply for thrombus that extends about the hepatic veins. A Pringle maneuver is performed to decreased hepatic blood flow by placing a clamp across the hepatic artery and portal vein within the hepatoduodenal ligament. This is mainly done for level 3 or higher tumor thrombus.
    • Suprarenal IVC above the thrombus
72
Q

IVC thrombus classification:

A
  • In the eighth edition AJCC staging manual, venous invasion is classified by the T stage according to the extent of invasion as described below:
    • T3a tumor grossly extends into the renal vein or its segmental (muscle containing) branches
    • T3b tumor grossly extends into the vena cava below the diaphragm
    • T3c tumor grossly extends into the vena cava above the diaphragm
  • However, the Neves Zincke classification is more useful from a technical surgical approach:113
    • Level 0: Tumor thrombus limited to renal vein
    • Level 1: Extending ≤2 cm above the renal vein
    • Level 2: Extending >2 cm above the renal vein but below the hepatic veins
    • Level 3: At or above the hepatic veins but below the diaphragm
    • Level 4: Extending above the diaphragm
73
Q

Where does RCC metastasize?

A

Lung → 50%

Liver → 33%

Bone 32 → 32

Brain → 25%

74
Q

5 year survival for RN by stage?

A

Stage 1 → 95%

Stage II → 85%

Stage III → 60%

Stage IV → 20%

75
Q

What are s/s important to ask at renal mass f/up after Nx or PNx? PE components?

A

History:

abdominal/flank/bladder pain or tenderness

fatigue

gross hematuria

weight loss

lower extremity edema

neuro complaints

MSK pain

SOB

PE:

LN, lower extremities, neuro exam, VS (weight and BP), abdominal exam

76
Q

Labs to consider for f/up of post sx renal mass??

A

CBC, LDH, LFTs, UA, BUN/Cr (eGFR), ALP (sxs)

77
Q

What is ddx of post sx bone pain (ribs) and elevated ALP on f/up?

A

Hyperthyroidism

Pregnancy

Hepatitis

Biliary Obstruction

Non malignant bone conditions (Pagets)

Bone mets

78
Q

What is ddx of solid enhancing renal mass?

A

RCC

vascular malformation

infarct

urothelial carcinoma

oncocytoma

AML

metanephric adenoma

Met dz

renal abscess

XGP

79
Q

What are risk factors for AKI with IV contrast?

A

htn

pre-existing CKD

hemodynamic instability

volume depletion

Age > 75 yo

CHF

High volume contrast media

80
Q

What tactics can be utilized to prevents kidneys with IV contrast load?

A

adequate oral hydration

IV NaCl or NaCO3 solution

discontinue nephrotoxic meds

stop metformin and restart in 48 h

use lowest dose

iso- or low osmolar IV contrast agent

NAC

81
Q

What do you look at for post-ablation CT?

A

additional, new renal nodules

satellite or port site soft tissue nodules

size change of mass (increase or decrease)

enhancement

82
Q

what are tx options for post ablation failure?

A

salvage RNx

salvage PNx

repeat bx

repeat ablation

83
Q

MC IVC injuries during PNx or Nx

A

avulsion of right adrenal vein from IVC or right gonadal from IVC

84
Q

Define Bosniak classification of renal cystic tumors:

A

Bosniak 1: simple cyst, 0% malignancy

Bosniak 2: minimally complex cyst, 0% malignancy

Bosniak 2F: more minimally complex cyst, 5% malignancy

Bosniak 3: indeterminate, 55% malignancy

Bosniak 4: clearly malignant, 100% malignancy

85
Q

Early Post-Op complication of PNx?

A
  1. Delayed bleeding
    1. work up pseudo-aneurysm with CT w/IV contrast → call IR for embolization
  2. Urinoma
    1. Place ureteral stent anf oley
    2. If persists, IR drain
  3. Perinephric abscess
    1. evaluate for urinoma source
    2. IR rain
    3. if persists, consider open drainage
86
Q

Late Post-op complications of PNx?

A
  1. UJPO: scarring around hilum and UPJ
  2. HTN, with renal trauma also 5% (page kidney)
  3. AVM

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