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79 Cards in this Set
- Front
- Back
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What is the classic triad of renal tumors? |
Flank mass, hematuria, and pain, but the triad is rare now because so many masses are picked up incidentally. When the triad is present, |
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What is the work-up for Renal mass? |
H and P Blood pressure either Renal US, Abd ct w/wo, MRI with contrast |
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What do you do if the imaging for renal mass shows a urotheliel lesion? |
urine tumor markers, pyelography, w/wo ureteroscopy |
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What is the bosniak scoring system? |
It grades renal cysts. |
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What would a cyst look like if it was bosniak I and how do you manage it? |
A bosniak 1 is a simple cyst and it needs no further work up. |
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What is a sign of paraneoplastic syndrome from RCC? |
HTN |
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What are 5 skin lesions associated with RCC? |
ash-leaf spots adenoma sebaceum shagreen patches periungal fibromas fibrofolliculomas |
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Once a renal mass is suspected to be a renal malignancy, what further tests need to be done? |
CT/MRI, chest xray, BUN, creatinine, alk phos, lfts, Ca++, cbc, urinalysis |
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If the creatinine is elevated in a patient with a suspected renal malignancy, what test should be performed? |
Renal scan |
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If the patient has a suspected renal malignancy and has bone pain, bone fracture, elevated Ca++, or elevated alk phos, what further testing should be performed? |
Bone scan, but it could also be caused by a paraneoplastic syndrome |
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What are some benign primary renal masses? |
Simple renal cyst oncocytoma Angiomyolipoma papillary adenoma pseudotumors juxtoglomerular tumors multilocular cystic nephorma mesoblastic nephroma
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What are some examples of primary malignant renal masses |
RCC Wilm tumor Clear cell sarcoma rhabdoid tumor |
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What is the most common malignant primary renal mass in adults? |
Renal cell carcinoma |
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What is the most common malignant primary renal mass in children? |
Wilms tumor |
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What are the most common malignant secondary renal masses from most common to least? |
Lymphoma/leukemia Lung Breast stomach/colon/cervix/melanoma |
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How can you tell the difference between a pseudotumor and a tumor if they both appear to be a solid renal mass? |
Renal scan with DMSA can tell the difference. The pseudotumor will take up the isotope and eliminate it. The RCC will not take up the isotope as well. |
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What is a dromedary hump? |
This is a hump in the kidney that mimics a renal mass (aka pseudotumor) and is caused by splenic or liver pressure on the mid lateral kidney during development. It is named after the arabian camel which only has one hump. |
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What percentage of solid renal masses <4cm are malignant? What percentages of solid renal masses >4cm are malignant? |
<4cm 80% are malignant >4cm 92% are malignant |
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What is the most common solid renal mass? |
RCC |
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What percentage of solid renal masses are Clear cell RCC? |
65% |
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What percentage of Solid renal masses are papillary RCC? |
10-15% |
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What are the 6 hereditary syndromes associated with renal tumors? |
Hereditary clear cell RCC Hereditary papillary rcc Familial oncocytoma Von hippel lindau (clear cell rcc) Birt-Hogg Dube syndrome Tuberous sclerosis (RCC and angiomyolipoma) |
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What is Birt-Hogg Dube? (BHD) |
BHD is a autosomal dominant condition with skin, pulmonary, and renal characteristics. flesh colored papules on upper trunk and head. |
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What is tuberous sclerosis? classic triad and % with kidneys affected? |
TS is a classic triad of mental retardations, seizures and adenoma sebaceum. 60% of people with TS develop AML |
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From what types of cells do RCC arise from? |
Proximal tubule |
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What is an oncocytoma? What is the cell features commonly seen? What is the hallmark on radiology? |
It is a benihn renal tumor composted of oncocytes. The cell commonly seen on path is a cell with eosinophilic granular cytoplasm. The radiology hallmark is the spoke-wheel or spiculated appearance, but it can appear with RCC too. |
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What does oncocytoma look like grossly and microscopically? |
gross: mahongany or tan mass with a fibrous capsule and central scar. Rare necrosis or hemorrhage micro: eosinophilic granular cytoplasm with polygonal cells in nests. |
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What percentage of oncocytomas have RCC in them? |
approx 10% |
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What is the treatment for oncocytoma? |
surgical excision becuase even biopsy can miss malignant elements, RCC can be in it, and imaging cannot distinguish it from RCC |
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What is a JGA tumor? |
This is a tumor of juxtoglomerular cells. It is rare and secretes renin. It presents in houing people with htn headaches, elevated renin and hyperaldosteronism with hypokalemia. |
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How do you treat JGA tumor? |
nephron sparing excision |
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What is an AML? |
AML = angiomyolipoma - it consists of vessels, muslce, and fat |
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a renal mass has calcium and fat in it. What is the most likely dx? |
This is most likely RCC. Most AML's do not have calcifications |
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How does AML look on CT with contrast and US? |
because it is vascular, it will enhance on imaging. the hounsfield units are usually -20 to -80 on NCCT because of the fat content. it will also be: homogenous not calcified not cystic. On US it will be hyperechoic which is the same as RCC |
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A primary renal tumor stains positive for HMB-45. What is it? |
AML |
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What is the concerning result of AML? |
Hemorrhage |
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How does AML present? |
Generally it is asymptomatic, but if they have symptoms it will be flank pain, hematuria and hemorrhage with hypotension. |
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How is AML hemmorhage with a stable patient treated? |
embolization, if stable, |
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What do you do if asymptomatic patient has aml <4cm? >4cm? |
<4cm - q6-12 month renal US |
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What are the 6 risk factors for RCC? |
Smoking obesity acquired cystic renal disease from renal failure (1-3% develop rcc) hypertension horseshoe kidney hereditary disorders fam hx VHL TS APKD |
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What are the 2 preventable risk factors for RCC? |
Obesity and smoking |
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What is the most common type of RCC? |
Clear cell |
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What does clear cell carcinoma look like - micro? |
clear cells with low N/C ratio, filled with glycogen and lipids |
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What does chromophobe look like? |
abundant cytoplasm and distinct cell borders, granular eosinophilic cytoplasm with perinuclear halos. microvesicles |
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What type of benign cells look very similar to chromophobe cells? |
oncocytoma looks very similar Hales colloidal iron stains only the cell border blue in oncocytoma and the whole cell in chromophobe |
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What are the What are the different types of RCC? |
Clear cell Chromophobe Chromophil (papillary) unclassified collecting duct carcinoma renal medullary carcinoma |
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What does chromophil look like? |
Papillary architecture. |
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What kind of medical history would make chromophil more likely? |
CKD |
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What do you need to kno about collecting duct carc? (bellini duct carc) |
highly malignant, 40% have mets hobnail cells on micro low 5 year survival |
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What do you need to know about renal medullary carcinoma? |
primarily in African american's with sickle cell rarely confined to kidney rarely respond to chemo or radiation mean survival of 15 weeks |
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What is unclassified renal cell carc? |
The histology does not match anything else. It is usually high grade and poor prognosis. |
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What are paraneoplastic syndromes associated with RCC? what percentage of pts have it? What if the patient has it, tumor is resected and still has it? |
high esr, weight loss, fever, anemia, htn, high Ca++, hepatic dysfunction, high alk phos, poly cythemia (high epo) 20-30% have it if the tumor is resection and the patient still has paraneoplastic syndrome then there is probably mets |
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What percentage of pts have mets of rcc? |
25% |
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What is the location of mets? |
only 1% is single location most to least common: lung, bone(spine), lymph nodes, liver, adrenal, other kidney, brain |
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What is the route of RCC mets? |
lymphatic or hematogenous 50/50 |
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What is the utility of lymph node dissection? |
Very little, the lymph node path is random for kidneys |
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most mets after nephrectomy develop within what time period? |
one year |
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what is the risk of mets with a RCC tumor: |
<3cm =4% >10cm = 43% |
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How do you grade each type of RCC? |
clear cell - fuhrman grade chromophil/papillary - fuhrman grade and type chromophobe, renal medullary, unclassified, and collecting duct - should be high or low grade |
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What is fuhrman grade based upon? |
Size, contour, and nucleoli and presence of spindle cells |
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What are the stages of kidney cancer? |
tx- cannot be assessed to- no evidence of tumor t1- tumor 7cm or less in greatest dimension - limited to the kidney t1a - tumor 4cm or less in greatest dimension, limited to the kidney t1b - tumor >4-7cm in greatest dimension, limited to the kidney t2 - tumor more than 7cm in greatest dimension, limited to the kidney t2a - tumor >7, but less than 10cm in greatest dimension and limited to the kidney t2b - tumor >10cm at the greatest dimension, and limited to the kidney t3 - tumor extends into major veins or perinephric tissues, but not the adrenal gland and not beyond gerotas fascia t3a - tumor extends into renal vein or its segmental branches or tumor invades perirenal and or renal sinus fat, but not beyond gerotas fascia t3b tumor grossly extends into the vena cava below the diaphragm t3c - tumor grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava t4 - tumor invades beyond gerotas fascia/adrenal gland |
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What is the only therapy for RCC that has been proven to cure with long term follow up? |
Surgical excision |
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In a patient with a very short life expectancy and a renal mass <3cm. What should treatment be? |
treatment with surveillence and periodic monitoring may be reasonable in this patient. |
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Laparoscopic is better than open radical nephrectomy, Why? |
better perioperative and postoperative morbidity, but equal long term cure rates |
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What are the 6 reasons renal sparing surgery would be considered? |
1. solitary kidney 2. Bilateral renal tumors 3. poor renal function 4. Contralateral kidney is threatened by familial disease (TS, VHL, HTN, DM) 5. definitive dx of a likely benign tumor 6. Renal mass (stage 1) <7cm in the absence of above indications. |
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What margin of tissue is desired for partial nephrectomy. How does this effect the patient? |
most say 1cm of healthy tissue, but a close margin has the same outcome as a wide margin |
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What are the three types of renal sparing surgery? |
1. enucleation (less desirable because there is no margin of negative tissue 2. partial nephrectomy 3. ablation - also less desireable, but may be useful for patient who cannot have surgery |
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How can you minimize warm ischemic renal damage during partial nephrectomy? |
mannitol - it scavenges free radicals by reducing oxidative cellular damage |
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if renal ischemia time is more than 30 minutes what should you do? |
cool the kidney for 15 min with ice bath and recool every 30 minutes. This can be done for 3 hours without permanent damage |
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What complications are more common in partial nephrectomy as opposed to radical nephrectomy? |
partial - urine leak/fistula, hemorrhage, reoperation |
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What is the advantage of partial nephrectomy over radical nephrectomy? |
better creatinine. less risk of ckd, longer survival for t1, should be utilized in bilat rcc. |
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a patient has bilateral rcc. one side will need radical neph and the other will need partial. What is the appriate timeline?
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partial first then radical to keep the patient from having to have dialysis. |
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What is the benefit of regional lymph node dissection for RCC? |
There is not a benefit. no difference in outcomes for patients with regional lymph node disseciton. |
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What should be the treatment for patients with RCC and mets? |
Radical neph and interferon which improves overall survival. |
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What other treatments are there for RCC? |
IL2- clear cell only mtor - rcc (clear and non clear) Tyrosine kinase inhibitors - clear cell bevacizumab - rcc
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What is glomerular hyperfiltration? |
This is when the remaining renal tissue filters more blood to maintain the same parameters. This can cause damage to the remaining tissue and focal segmental glomerulosclerosis. It may take more than 10 years to develop and proteinuria is the harbinger. |
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how to avoid hyperfiltration injury? |
ace inhibitors proper DM management weight loss low protein/low sodium diets htn control avoid steroids hld control avoid nsaids and nephrotoxins |
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What should be assessed to monitor for recurrence after RCC? |
h and p bp renal function UA for proteinuria any paraneoplastic parameters that were present alk phos ca++ ct/mri and chest imaging at 4-6 months and yearly thereafter bone scan/brain MRI when indicated. |
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What precautions should be taken with solitary kidney? |
contact sports can cause injury and death. |
