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Renal tumors > RCC Treatments > Flashcards

RCC Treatments Flashcards

1
Q

What is the R.E.N.A.L. Nephrometry Score?

A

a nomogram to assess the complexity of a renal tumor, and is predictive of surgical outcomes.

acronym for Radius, Exophytic, Nearness to collecting system, Anterior/posterior, and Location

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2
Q

What are the RENAL nephrometry scoring stratifications?

A

Low complexity: 4-6
Moderate complexity: 7-9
High complexity: 10-12 or has “h” suffix

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3
Q

RENAL Nephrometry Score: Radius points?

A

1: <4 cm
2: 4-7 cm
3: > 7cm

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4
Q

RENAL Nephrometry Score: Exophytic points?

A

1: >50% exophytic
2: < 50% exophytic
3: completely endophytic

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5
Q

RENAL Nephrometry Score: Nearness to collecting system points?

A

1: > 7mm
2: 4-7mm
3: < 4mm

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6
Q

RENAL Nephrometry Score: Anterior/posterior points?

A

No score given. Simply assign the tumor anterior, posterior, neither, or hilar

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7
Q

RENAL Nephrometry Score: Location points?

A

1: above/below polar lines
2: crosses polar lines

3:
a) > 50% of mass crosses polar line
b) or mass crosses axial renal midline
c) or mass completely between polar lines

*suffix “h” if mass is touching a main renal artery or vein (for herniation)

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8
Q

When is thermal ablation usually reserved for?

A

Masses < 4cm (T1a tumors)

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9
Q

Indications for partial nephrectomy:

A

Bilateral tumors
Tumors in solitary kidney
Small renal masses <4cm (T1a; lots of discrepancy here)
Decreased renal function or comorbidities that lead to poor renal function

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10
Q

What are some of the important key steps in a partial nephrectomy?

A

Early and complete vascular control
Diuresis (mannitol)
Ischemia time (<30 minutes of warm ischemia)
Adequate renal reconstruction to avoid urine leak and/or post-operative bleeding

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11
Q

When and why is mannitol used in partial nephrectomy?

A

Used prior to hilar clamping to reduce oxidative damage and free radicals and to induce diuresis

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12
Q

Treatment of stage 4 RCC with solitary metastasis?

A

Nephrectomy + metastasectomy

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13
Q

Treatment of stage 4 RCC and multiple mets?

A

Attempt cytoreductive nephrectomy and medical therapy

- if not medically cleared, surgically unresectable, or brain mets, then medical therapy only

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14
Q

When is regional lymph node dissection recommended?

A

If gross adenopathy seen, otherwise optional

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15
Q

Should adrenal gland be removed during radical nephrectomy?

A

Only if direct tumor extension (T4)

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16
Q

Post-surgery, recurrence is most likely within how long after surgery?

A

within 2 years

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17
Q

MC sites of recurrence?

A

Lung > bone > liver

18
Q

Recommended AUA Guidelines for post-op CT scan and further follow up imaging for a pT1, N0, Nx tumor?

A

Post-op CT scan 3-12 months, then annual abdominal CT and CXR x 3 years

19
Q

Recommended AUA Guidelines for post-op CT scan and further follow up imaging for a pT2-4, N-any tumor?

A

Post-op CT scan 3-6 months, semiannual abdominal CT and CXR x 3 years, then annual CT and CXR x 2 years

20
Q

Recommended AUA Guidelines for post-op CT scan and further follow up imaging after renal ablation?

A

Post-op CT scan 3-6 months, then annual abdominal CT and CXR x 5 years

21
Q

Recommended AUA Guidelines for post-biopsy or post-diagnosis CT scan and further follow up imaging for renal tumor Active Surveillance?

A

CT scan 6 months from diagnosis or biopspy, then annual CT and CXR indefinitely

22
Q

What is hyperfiltration injury?

How much loss of functional renal tissue is generally concerning for this?

A

When reduction of one renal unit leads to increased perfusion, thus hyperfiltration of the remaining renal unit(s).

> 75% loss of functional renal tissue is concerning for hyperfiltration injury

23
Q

What is the first indicator of hyperfiltration injury?

What specific nephropathy occurs with hyperfiltration injury?

A

Proteinuria is first indicator, which may then lead to hypertension.

Focal segemental sclerosis that progresses to renal failure

24
Q

How is a urine leak after partial nephrectomy managed?

A

maintain or establish drainage (e.g. Jackson-Pratt drain, Double-J ureteral stent)

25
Q

What are the targets of the three specific pathways, involved with the RCC tumorigenesis pathway of HIF-1, that are inhibited for the medical treatment of RCC?

A
  1. Tyrosine kinase inhibitors
  2. mTOR inhibitors
  3. VEGF inhibitors
26
Q

What are the tyrosine kinase inhibitors for treating RCC?

A

Sunitinib (1st line therapy)

Sorafenib

Pazopanib

Axitinib

** TKI’s always end in -nib

27
Q

Classic side effects of the tyrosine kinase inhibitors?

A
  1. Hand-foot syndrome (desquamation)
  2. Hepatotoxicity
  3. LV dysfunction, heart failure
    - also diarrhea, fatigue
28
Q

What is the mTOR inhibitor?

Drug schedule?

A

Temsirolimus

25mg IV weekly

29
Q

What is the indicaiton/who gets temsirolimus?

A

indicated for poor risk patients with advanced RCC

30
Q

What are the criteria that make a patient poor risk?

A
  1. LDH > 1.5x normal (bulky disease)
  2. Anemia
  3. Hypercalcemia
  4. Interval < 1 year from original diagnosis to the start of systemic therapy
  5. Karnofsky performance status < 70
  6. > 1 sites of metastasis
31
Q

Classic SE of temisirolimus?

A

Mucositis, rashes, fatigue

32
Q

What are the 2 cytokine therapies?

A

Interleukin-2

Interferon-alpha

33
Q

Which cytokine therapy has 5% durable complete remissions, but has harsh side effects and is recommended in patients with excellent performance status (i.e. only pulmonary mets)

A

Interleukin-2

34
Q

Interferon-alpha is always used in conjunction with what other drug?

A

Bevacizumab

35
Q

What is the VEGF inhibitor?

A

Bevacizumab (Avastin)

36
Q

What are the worrisome SE’s of bevacizumab?

A

hemorrhage
**wound healing complications
fatigue, proteinuria, HTN

37
Q

How often is bevacizumb + IFN-a given?

A

10mg/kg IV infusion every 2 weeks until disease progression

38
Q

What is the half-life of bevacizumab? Why must this be considered?

A

T 1/2 ~ 20 days

Drug MUST be stopped or helt at least 28 days (1 month) prior and after surgery.

  • consider 80-100 days (3 months) to allow for 4-5 half-lives
  • *must discontinue in patient with Fournier’s gangrene
39
Q

Second line RCC medical therapies?

A 
Everolimus (mTOR)
Axitinib
Sorafenib
Pazopanib
Temsirolimus (mTOR)
Bevacizumab + IFNa
IL-2
40
Q

Drug schedule for Sunitinib?

A

50mg oral daily; 4 weeks on, 2 weeks off

May reduce dosing for side effects

Renal tumors (6 decks)

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