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Renal Flashcards

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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

6

A
  • Homogeneous
  • Smooth thin wall (less than 2mm)
  • No septa
  • No calcification
  • No enhancement
  • 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 (type II)
  • 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
# 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
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