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Renal Cancer viva questions

Created: 21/1/2008
Updated: 23/1/2008

Renal Cancer viva questions

1 What benign renal masses are you aware of?

What are the features of an AML?

Bright echo pattern on USS - with no acoustic shadow
Fat density on CT
This will often lead onto the association with tuberous sclerosis and its  features

How would you manage someone with an AML?

Remember it depends on the size-if it is more than 4cm in diameter it is more likely to cause symptoms and requires intervention
Patients with multiple lesions may require manegement in a specialist centre and conservative treatment should be considered

2 What are the risk factors for renal cell carcinoma?

3 What is a paraneoplastic syndrome?

Collection of signs and symptoms due to the presence of cancer in the body but not due to its local effects

What paraneoplastic syndromes associated with RCC are you aware of?

4 What is the Bosniak classification of renal cysts?

This is a popular question and will lead onto the chance of malignancy and the follow-up for each grade

see Warren et al BJUI 2005;93:939-42

5 What is the Fuhrman grade?

Examines nuclear size and shape, number and size of nucleoli and clumping of chromatin-essentially gives an idea of how actively cells are producing protein

6 How would you manage a patient referred with an ultrasound finding of a solid mass on ultrasound?

Symptoms from primary tumour
Symptoms of metatstatic disease
Symptoms of paraneoplastic syndrome

What investigations would you arrange?

Bloods FBC, calcium, U & E, LFT's
Pre-and post-contrast CT

Which phase post-contrast would you be interested in? What would you be looking for?

Diffuse nephrographic (80-120 seconds)
Looking for more than 20 HU enhancement

The aim is to:
-Verify the diagnosis of RCC
-Provide information regrading the contralateral kidney
-Determine the presence of local spread
-Determine the presence of metastatic disease

7 You are shown a CT of a 3.5cm localised renal cell carcinoma with an atrophic contralateral kidney. What are the treatment options?

This is a question from last year
It is a discussion regarding nephron-sparing surgery (NSS)

What are the indications for NSS?

Huang WC, Levey AS, Serio AM et al. Chronic Kidney Disease after Nephrectomy in Patients with Renal Cortical Tumours: A Retrospective Cohort Study. Lancet Oncology. 2006;7:735-40. Demonstrated that only 35% of patients treated with radical nephrectomy were free of new kidney disease

Remember the indications are: absolute, relative and elective

For solitary tumours less than 4cm, partial nephrectomy provides recurrence-free and long-term survival rates similar to radical surgery
see Uzzo and Novick 2001;J Urol;166:6-18

EAU Gudelines - open partial nephrectomy should be considered in all patients with tumours <4cm, with lap partial confined to experienced centres

How would you follow-up a patient who has a had a partial nehrectomy?

8 What are the treatment options for patients with metastatic RCC?

Immunotherapy-see EAU guidelines

Tumour nephrectomy +/- immunotherapy +/- tyrosine kinase inhibitors
see Flannigan RC 2004 et al J Urol; 171(3): 1071-6 Overall survival benefit 5.8 months with nephrectomy plus immunotherapy vs immunotherapy alone

Tyrosine kinase inhibitors are obviously very topical currently-EAU guidelines suggest they should be used as 1st or 2nd line treatment in patients with metastatic RCC

Useful papers:
Sorafenib-Target Trial Escudier et al 2007. N Engl J Med; 356(2): 125-134
Sunitinib-Motzer et al 2007.N Engl J Med; 356(2): 115-124
Temsirolimus-Hudes et al 2006. J Clin Oncol. 24(18S):LBA4

Remember NICE have yet to provide guidance of these drugs and many PCT's do not provide funding

How is performance status assessed?

Karnovsky (100 normal, 0 moribund) and ECOG (0 normal, 5 dead)

9 How would you consent a patient for a radical nephrectomy/lap nephrectomy?

Thay are less likely to ask about how to do a procedure but how to consent someone has become a favourite question

10 How would you follow-up a patient after nephrectomy?

There is no consensus regarding this, so be able to justify your local protocol

The aim of any follow-up is to
-Identify post-op complications
-Monitor renal function
-Identify local recurrence
-Identify metastatic disease

The Mayo scoring system for clear-cell carcinoma classifies patients into low, intermediate and high risk for metz and can be used to determine the frequency and type of investigations used

11 Why would you biopsy a renal mass?

Remember biopsy has a risk of complications and also a misleading result, possible indications for biopsy include

Distinguishing a primary from a secondary mass
Paediatric population with Wilm's tumour
Possibility of an inflammatory mass
Met RCC prior to chemo

12 How would you manage a patient referred with an incidental 1.2cm renal mass?

What minimally invasive techniques exist for the treatment of small renal cancers?

Do all lesions require treatment?

Reasons for surveillance
-Patient choice
-Need for post-op dialysis
-Bilateral disease, disease in a solitary kidney

Reasons for ending surveillance
-Patient choice
-Improvement in co-morbidities

Chawla's Metanalysis J Urol 2006-largest combined study of 234 lesions 1.7cm-4cm
Combined growth rate after 34 months of follow-up 0.28cm/year
80% showed no growth
Risk of progression is less than 1%
Unfortunately no identified predictors of progression

Any "active surveillance" protocol should only be undertaken with the full consent of the patient

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