Kidney Cancer 2 - General Overview

Front 1

How does mTOR work?

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http://vimeo.com/8320394

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another mtor resource

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http://www.targetmtor.com/health-care-professional/mtor/index.jsp

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Front 6

When was the first planned nephrectomy in the United States?

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*1870 by a guy named Gilbert in Mobile, AL for atrophic pyelonephritis and chronic recurrent UTIs.

Front 7

What are some tumors of the renal capsule?

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*You can have a fibroma, leiomyoma, a lipoma, or some mixed variety of these.

Front 8

Are IVPs good studies for the detection of renal masses, why or why not?

What features on IVP will be suggestive of a renal mass?

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*IVPs used to be the test of choice for renal masses, obviously this was before CT or MRI became available. IVPS will miss lesions that are small and anterior or posterior and thus don't distort the collecting system anatomy or the anatomy of the renal contour.

*As far as if a mass is seen on IVP then it is worrisome for malignancy if it has calcifications, increased tissue density, irregularity of the margin, and distortion of the collecting system.

Front 9

What are strict sonographic criteria for simple renal cysts?

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*The cyst has a smooth wall, there are no internal echos, a round or oval shape, and strong through-transmission with strong acoustic shadows posteriorly.

Smooth wall
no Internal echos
Major through transmission
Posterior acoustic shadowing
Lovely circle shape
Empty - no internal echos again.

Front 10

What is the Ddx for a complex cyst seen on a kidney radiographically?

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* Cystic nephroma, Cystic RCC, Hemorrhagic cyst, Infected cyst, Renal abscess, Septated cyst, Hydrocalyx, Cystic Wilms' Tumor, Renal artery aneurysm, AV malformation, Tuberculosis.

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What is the Ddx for a renal mass that has fat in it radiographically?

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*Angiomyolipoma, Lipoma, Liposarcoma

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What enhancement criteria for a renal mass with a CT scan is concerning for malignancy?

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*If there is a difference in enhancement of the mass between the non-contrasted and the contrasted phase of 15 HU or more then this should be considered RCC until proven otherwise.

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What is almost diagnostic of AML on a CT scan?

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*Areas of the renal mass with HU less than 20 are diagnostic of AMLs, per Campbell's however there have been shown to be RCC with these areas, that are from Necrosis, these will tend to have areas of calcifications within them radiographically.

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What is a renal pseudotumor? How does one distinguish this from a real tumor?

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*There are certain circumstances in which the CT scan may be inconclusive. There is an area of an enhancing renal segment that is isodense with the remainder of the kidney, suggesting a renal pseudotumor. This may be a hypertrophied column of Bertin, renal dysmorphism, or simply an unusual shape.

A DMSA scan will help differentiate this from a renal tumor in that in a DMSA scan there will be increased uptake there and in a renal tumor there will be decreased uptake there. This makes sense to me in that a renal tumor won't be functional and thus will not take up and excrete the radioisotope.

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What are the primary indications for renal biopsy?

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*They are the concern for metastatic disease, renal abscess, or renal lymphoma.

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What are the most common of the Bosniak type cysts?

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*These are Bosniak type 1 cysts, and do not need to be followed.

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What are Bosniak class II cysts?

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*These lesions have some radiologic findings that may be a cause for concern.

These lesions include septated cysts with minimal calcification in the walls or the septum, infected cysts, hyperdense cysts (which are benign lesions that contain old, degenerated blood, therefore the CT attenuation is high like >20HU, they are classically small <3cm)

Campbell's doesn't break them down into II and IIF, but says they should be periodically imaged as a whole and the risk of malignancy is 0-5%.

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What is a Bosniak class III lesion?

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*This is more worrisome than a II obviously. There are irregular margins, thickened septa, thick irregular calcifications.

*These lesions are about 50% of the time malignant and thus need to be removed.

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What is a Bosniak class IV lesion?

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*These have large cystic components, irregular, shaggy margins; and most important some solid enhancing portions that provide a definitive diagnosis of malignancy. These gotta go!

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Is it possible to get Wilm's tumor in an adult patient?

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Adults can also be affected by WT, but this happens rarely, and there are less than 300 cases reported in the literature

Karlson, 2011. High-resolution genomic profiling of an adult Wilms’ tumor: evidence for a pathogenesis distinct from corresponding pediatric tumors

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What are the most common chromosome abnormalities in Wilm's Tumor in children?

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In children with WT, the most
common large-scale chromosomal abnormalities include loss of heterozygosity (LOH) for 1p, gain of 1q, LOH for 7p, and LOH or hemizygous deletion of 16q [4–7]. Gain of 1q and LOH 16q are both associated with poor outcome in WT patients diagnosed with favorable histology [4, 5]. In addition, gain of genetic material on chromosomes 6, 7, 8, 12, 13, and 18 are also frequently detected [8].

Karlson, 2011. High-resolution genomic profiling of an adult Wilms’ tumor:
evidence for a pathogenesis distinct from corresponding
pediatric tumors.

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What is Vandetinib?

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It is a VEGF inhibitor and an EGFR inhibitor it is also known as ZD6474

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What is everolimus?

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This is a Rapa analogue or a rapalogue...Afinitor is a rapa analog and blocks TOR1 only

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What is one of the best predicters of survival in patients with locally advanced disease?

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The
presence of lymph node metastasis in patients with
locally advanced RCC is one of the strongest prognostic
factors influencing survival.

Wood. Role of LN dissection

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What is the incidence of LN mets if there is enlargement of a LN greater than 1cm on cross-sectional imaging in the short axis?

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Depending on the extent of local disease and presence or
absence of distant metastatic disease, lymphadenopathy
(short-axis size
1 cm) detected in the retroperitoneum
on cross-sectional imaging harbors metastatic disease in 30% to 70% of patients.

Wood C. Role of LN Dissection.

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So Woods here addresses the incidence of LN mets as isolated regional node + disease in paitents that don't have distant metastatic disease and are staged as clinically node negative with moder cross sectional imaging...what is that rate? what are the limitations of these rates?

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In the absence of distant metastatic disease, the incidence of isolated regional lymphatic metastases
(pN1M0) in patients staged as clinically nodenegative
(cN0) withmodern cross-sectional imaging is rare and estimated to occur in only 1% to 5% of patients. However, these pathologic rates
(pN1) vary considerably based on multiple clinical and pathologic features,whether the patient actually undergoes an LND, and the extent of LND performed.

Woods. Role of LN Dissection

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Is a renal hilar LND a good practice of attempting to do a limited LN sampling for a nephrectomy patient?

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Most
importantly, the renal hilar lymph nodes are not
the initial landing sites in most patients with
regional lymphatic metastasis, and therefore isolated
sampling of the hilar lymph nodes is inadequate
when an LND is being performed.

Wood C. Role of LN Dissection

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Wood's group decides on whether or not to do a lymph node dissection at time of OR with patients that are high risk, what is that criteria?

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Patients were defined as high-risk if they had two adverse
primary tumor features. This high-risk protocol uses intraoperative pathologic assessment of the
primary tumor for nuclear grade 3 or 4, presence
of sarcomatoid dedifferentiation, size of 10 cm or greater, stage T3 or higher, and the presence of
histologic tumor necrosis.

Wood C. Role of LN Dissection.