NCCN Kidney 1.2021 Flashcards Preview

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Flashcards in NCCN Kidney 1.2021 Deck (53)
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1

Initial workup for a suspicious renal mass

H and PE
CBC + comprehensive metabolic panel LDH
UA
Abdominal _+ pelvic CT or MRI
CXR
If clinically indicated: bone scan, brain MRI, chest CT, needle biopsy
If considering urothelial CA (central mass): urine cytology, URS or percutaneous biopsy
Genetic evaluation (multiple renal masses OR < 46 yo)


KID-1

2

When should you consider doing a needle biopsy for renal masses?

Small lesions
If considering urothelial CA (central mass): percutaneous biopsy

Purpose: to obtain/confirm diagnosis, guide surveillance or ablative techniques, cryosurgery, radiofrequency ablation strategies


KID-1

3

PRIMARY TREATMENT:
Stage I T1a

Partial nephrectomy (PREFERRED)
Active surveillance
Ablative techniques
Radical nephrectomy (if nephron-sparing NOT indicated or feasible)


KID-1

4

PRIMARY TREATMENT:
Stage I T1b

Partial nephrectomy (PREFERRED)
Active surveillance
Radical nephrectomy (if nephron-sparing NOT indicated or feasible)

*note: ablative techniques NOT recommended for T1b above
KID-1

5

PRIMARY TREATMENT:
Stage II

Partial nephrectomy
Radical nephrectomy


KID-1

6

PRIMARY TREATMENT:
Stage III

Partial nephrectomy, if clinically indicated
Radical nephrectomy


KID-1

7

TREATMENT:
Stage IV, potentially surgically resectable

Consider tissue sampling, then:

Cytoreductive nephrectomy in select patients
OR
Systemic therapy (PREFERRED in clear cell histology with poor-risk features)


KID-2

8

TREATMENT:
Stage IV, tissue sampling: clear cell histology, favorable risk

Clinical trial
OR
First-Line Systemic Therapy: axitinib + pembrolizumab OR pazopanib OR sunitinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)


KID-3, KID-C

9

Treatment options for:
Stage IV, tissue sampling: NON-clear cell histology

Clinical trial
OR
Systemic Therapy: (preferred) clinical trial OR sunitinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)


KID-3, KID-C

10

Treatment options for:
Stage IV, tissue sampling: clear cell histology, poor/intermediate risk

Clinical trial
OR
Systemic Therapy (preferred): ipilimumab + nivolumab (CAT 1) OR axitinib + pembrolizumab (CAT 1) OR cabozantinib
OR
Metastasectomy or SBRT or ablative techniques for oligometastatic disease
AND
Best supportive care (palliative RT, bisphosphonates, or RANK ligand inhibitors for bony metastases)


KID-3, KID-C

11

Nephron-sparing surgery (partial nephrectomy) is appropriate in which patients?

Unilateral stage I-III tumors, where technically feasible
Uninephric state
Renal insufficiency
Bilateral renal masses
Familial renal cell CA
Patients at risk for developing progressive CKD due to young age or medical risk factors


KID-A

12

Regional lymph node dissection is OPTIONAL but RECOMMENDED in which patients?

Adenopathy on preop imaging
OR
Palpable/visible adenopathy at the time of surgery


KID-A

13

During renal surgery, adrenalectomy may be omitted if ____

If the adrenal gland is not involved.


KID-A

14

Thermal ablation is an option for clinical stage ____ lesions.

Compared to conventional surgery, it is associated with ____ rates of ____.

T1. Higher rates of local recurrence compared to conventional surgery.

It is an option for masses < 3cm.

Also an option for masses >3cm, but with higher rates of local recurrence/persistence and complications.


KID-A

15

What is active surveillance?

Active surveillance entails:
Serial abdominal imaging with timely intervention should the mass demonstrate changes (eg, increasing tumor size, growth rate, infiltrative pattern) indicative of increasing metastatic potential.

Also includes: mets survey: blood work, chest imaging


KID-A

16

Active surveillance is an option for _____

Clinical stage T1 lesions: small renal masses < 2 cm, given the high rates of benign tumors and low mets potential.
AND
T1a (=<4cm) tumors with predominantly cystic component

KID-A

17

Candidates for cytoreductive nephrectomy prior to systemic therapy:

Excellent performance status (ECOG PS < 2)
No brain metastasis


KID-A

18

Follow-up for:

Stage I (T1a)
During active surveillance

H and PE + lab tests ANNUALLY, as indicated
Abdominal CT or MRI with contrast if contraindication, within 6 months; then CT, MRI, or US at least annually
CXR or Chest CT baseline, then annually
Renal mass biopsy at initiation of AS, or as indicated
Individualized ffup schedule


KID-B

19

Follow-up for:

Stage I (T1a)
After ablative techniques

H and PE
Lab tests annually, as indicated
Abdominal CT or MRI with contrast if no contraindication, at 3-6 months; then CT, MRI, or US at least annually for 5 years or longer, as indicated
CXR or Chest CT annually for 5 years for biopsy-proven low-risk RCC
Renal mass biopsy at initiation of AS, or as indicated
Individualized ffup schedule


KID-B

20

Follow-up for:

Stage I (T1a)
After partial or radical nephrectomy

H and PE
Lab tests annually, as indicated
Abdominal CT or MRI (preferred), or US within 3-12 months of surgery, then annually for 3 years or longer, as indicated
If positive margins or adverse features (sarcomatoid, high-grade [grade 3/4], positive margins). then: MORE RIGOROUS imaging schedule or technique modality


KID-B

21

Follow-up for:

Stage II or III

H and PE every 3-6 mo for 3y; then annually for up to 5 y
Comprehensive metabolic panel every 6 mo for 2y then annually up to 5y, then as indicated
Baseline CT or MRI within 3-6 mo, then CT or MRI (preferred) or US every 3-6 mo for at least 3y then annually for 5 y
Chest CT within 3-6 mo with continued imaging every 3-6 mo for at least 3y then annually up to 5y
Additional imaging PRN: bone scan, brain imaging


KID-B

22

Follow-up:

After adjuvant therapy

(same as St II or III)

H and PE every 3-6 mo for 3y; then annually for up to 5 y
Comprehensive metabolic panel every 6 mo for 2y then annually up to 5y, then as indicated
Baseline CT or MRI within 3-6 mo, then CT or MRI (preferred) or US every 3-6 mo for at least 3y then annually for 5 y
Chest CT within 3-6 mo with continued imaging every 3-6 mo for at least 3y then annually up to 5y
Additional imaging PRN: bone scan, brain imaging


KID-B

23

Follow-up:

After relapsed or Stage IV and surgically unresectable disease

H and P every 6-16 weeks (if receiving sys Tx), more frequent as indicated
Lab evaluation
CT or MRI baseline pretreatment or prior to observation
Ffup imaging every 6-16 weeks
MRI of the spine or bone scan as indicated


KID-B

24

Follow-up:

Long term (>5y)

H&P annually
Lab tests annually
Abdominal imaging may continue, with increasing intervals
Consider chest imaging for higher stage, with increasing intervals


KID-B

25

What does "MSKCC" stand for in the MSKCC Prognostic Model? 😅

Memorial Sloan Kettering Cancer Center


KID-D

26

MSKCC Prognostic Model: What are the factors and risk groups?

Interval from diagnosis to treatment < 1y
Karnofsky score < 80%
Serum LDH > 1.5x ULN
Corrected serum Ca > ULN
Serum Hgb < LLN

Low-risk: 0 RFs
Intermediate-risk: 1-2 RFs
Poor-risk: 3 or more RFs


KID-D

27

What "IMDC" stand for? 😅

International Metastatic Renal Cell Carcinoma Database Consortium

28

IMDC Criteria: What are the factors and risk groups?

Interval from diagnosis to treatment < 1y
Karnofsky score < 80%
Serum Hgb < LLN (N= 120 g/dL)
Corrected serum Ca > ULN (N= 8.5-10.2 mg/dL)
Neutrophil > ULN (N= 2.0-7.0)
Platelets > ULN


KID-D

29

Criteria for further genetic risk evaluation:

Diagnosed at 46 y
Bilateral or multifocal tumors
=> 1 first or second-degree relative with RCC

30

Criteria for further genetic risk evaluation: histologic characteristics

Multifocal papillary
Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) with fumarate hydratase (FH)
Birt-Hogg-Dube syndrome
Angiomyolipoma of the kidney
Succinate dehydrogenase (SDH)-deficient RCC histology