Renal Cancer

Question 1

Imaging guidelines for renal mass

Answer 1

High quality multiphase cross sectional imaging
-Review complexity, degree of enhancement, and fat

Question 2

Lab workup

Answer 2

CBC, CMP, UA
chest imaging
Assign CKD stage via GFR and degree of proteinuria

Question 3

Genetic counseling indications

Answer 3

Patients <46
Multifocal or bilateral masses
Personal or FMHx suggests familial renal neoplastic syndrome
1st or 2nd degree relative with renal malignancy
Path suggests syndrome

Question 4

When should RMB be performed?

Answer 4

hematologic, metastatic, inflammatory, or infectious etiology
NOT for young health patients, NOT for old frail patients
Use multiple cores instead of FNA

Question 5

Bosniak classification

Answer 5

I - hairline-thin wall with water attenuation, no calcifications, nonenhancing
II
-few thin septa with or without enhancement, fine calcification OR
-high attenuating <3cm masses that are sharply marginated but do not enhance
IIF
-Minimally thickened or more than a few thin septa that may have thick nodular calcification OR
>3cm intrarenal nonenhancing hyperattenuating mass
III - thickened or irrefular walls/septa with enhancement
IV - soft tissue components with measurable enhancement

Question 6

T staging for renal masses

Answer 6

T1 <7cm, limited to kidney
-T1a <4cm
-T1b 4-7cm
T2 >7cm, limited to kidney
-T2a 7-10cm
-T2b 10+cm
T3 extends into major veins or perinephric tissue but NOT ipsilateral adrenal and NOT outside Gerota’s
-T3a invades renal vein or renal sinus fat
-T3b extends into cava below diaphragm
-T3c extends into cava above diaphragm or into caval wall
T4 beyond gerota’s or into ipsilateral adrenal

Question 7

Renal cancer N staging

Answer 7

N1 regional LN mets

Question 8

Renal cancer M staging

Answer 8

M1 distant mets

Question 9

What should prompt nephron sparing surgery?

Answer 9

cT1a masses
B3/B4 cysts
Functional or anatomic solitary kidney
Bilateral tumors
Familial RCC
CKD
Proteinuria
Young patients with HTN/DM2, recurrent stones, morbid obesity

Question 10

When should radical nephrectomy be prioritized?

Answer 10

high tumor complexity
no CKD
Normal contralateral kidney with good postop GFR

Question 11

When can thermal ablation be offered?

Answer 11

<3cm masses - either RF or cryo
RMB first!!!

Question 12

When can AS be offered?

Answer 12

masses <2cm
Repeat imaging in 3-6 months

Question 13

Indication for bone scan

Answer 13

bone pain
Elevated AP
radiographic findings of bony neoplasm

Question 14

Risk categories for renal mass

Answer 14

Low = pT1 and grade 1/2
Intermediate = pT1 and grade 3/4 or pT2 any grade
High = pT3 any grade
Very high = pT3, pN1, sarcomatoid/rhabdoid, R1

Question 15

Follow up testing

Answer 15

Contrasted abdominal imaging, then US after 2 years
CXR or CT chest
“periodic” labs

Question 16

Indication for LND

Answer 16

Clinically concerning nodes