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Anatomy & Surgery (Tumor Thrombus)
Metastatic RCC (systemic therapy)
Metastatic RCC (local therapy/cytoreductive nephrectomy)
Wild Card
Clinical Trials
100

Describe T staging for patients with renal mass + tumor thrombus

  • T3a tumor grossly extends into the renal vein or its segmental (muscle containing) branches
  • T3b tumor grossly extends into the vena cava below the diaphragm
  • T3c tumor grossly extends into the vena cava above the diaphragm
100

Which tool is used to guide first line therapy selection in mRCC?

International mRCC Database Consortium (IMDC) prognostic model

100

How is oligometastatic RCC defined?

Five or fewer metastatic lesions

100

What is the difference between tumor thrombus and bland thrombus?

Tumor thrombus is enhancing, vascular, connected to tumor and expands the IVC.
Bland thrombus is avascular, non-enhancing, and treated like a clot (anticoagulation if appropriate).

100

Demonstrated that first-line Nivolumab + Ipilimumab significantly improved overall survival and response rate compared with Sunitinib in intermediate/poor-risk metastatic RCC.

Checkmate-214

200

Describe the more technical (Neves Zincke) classification for tumor thrombus

  • Level 0: Tumor thrombus limited to renal vein
  • Level 1: Extending ≤2 cm above the renal vein
  • Level 2: Extending >2 cm above the renal vein but below the confluence of the hepatic veins
  • Level 3: At or above the hepatic vein confluence, but below the diaphragm
  • Level 4: Extending above the diaphragm
200

Name the 5 predictors of overall survival included in the MSKCC prognostic Criteria.


Bonus Q not worth making it's own question: What changes make it the IMDC model?

1. KPS <80%

2. Dx of RCC to treatment interval < 1 year

3. Anemia

4. Elevated LDH

5. Hypercalcemia

Bonus q:

Remove elevated LDH, add neutrophilia and thrombocytosis.

200

Which local therapy is utilized to treat painful bone metastases?

Radiation therapy is preferred for painful bone metastases and lesions threatening spinal stability.

200

What percentage of renal cell carcinomas present with venous tumor thrombus?

~10%

200

Showed Pembrolizumab + Axitinib improved PFS, OS, and ORR across all IMDC risk groups versus Sunitinib.

Keynote-426

300

What do you need to clamp before opening the IVC for thrombectomy, and in what order?

1. Ipsilateral renal artery

2. Infrarenal IVC (below thrombus)

3. Lumbar veins between the clamps

4. Contralateral renal vein

5. Hepatic inflow occlusion — if thrombus above hepatic veins (Level III/IV)

6. Suprarenal / suprahepatic IVC (above thrombus)

300

What is the most commonly used first-line approach for metastatic RCC today?

Immunotherapy + VEGF-TKI combination therapy

300

What makes a good candidate for cytoreductive nephrectomy?

Good performance status, clear cell histology without sarcomatoid differentiation, absence of brain/liver/extensive bone mets, ability to debulk most of the tumor with surgery

300

Which laterality is more often associated with IVC tumor thrombus requiring complex thrombectomy?

Right-sided tumors.


Shorter venous course → easier IVC access → more extension.

300

Demonstrated Nivolumab + Cabozantinib improved OS, PFS, and quality of life compared with Sunitinib.

Checkmate-9ER

400

How do you occlude the hepatic inflow for a level III/IV thrombus? What is the technique called?

Pringle maneuver - Clamp portal triad via tourniquet/clamp on hepatoduodenal ligament

400

Which first-line IO + VEGF-TKI improves OS across all IMDC risk groups?

pembrolizumab + axitinib "axi-pembro"


Supported by the KEYNOTE‑426 trial. 

400

What was the outcome of the 2001 era cytoreductive nephrectomy (CN) trials?

Showed interferon-alpha + CN improved OS by ~6 months vs interferon alone.

400

What specific anatomy allows you to ligate the IVC in right-sided disease without reconstruction?

Left renal vein appreciable collateral drainage via gonadal, adrenal, lumbar veins.

400

Showed Nivolumab monotherapy improved overall survival over Everolimus in patients previously treated with VEGF-TKI therapy.

Checkmate-025

500

You notice that the IVC is completely occluded by tumor thrombus on imaging with extensive collaterals. How do you approach this surgically, if possible?

Remove the involved segment of IVC en bloc with the kidney and thrombus, then reconstruct or ligate the IVC.

500

What IO/IO regimen showed higher response rates, PFS, and OS vs sunitinib and is recommended for intermediate/poor risk patients. 

Nivolumab + ipilimumab


CheckMate‑214 trial (phase III, untreated advanced RCC vs sunitinib). 

500

Describe the CARMENA trial?

Demonstrated sunitinib alone was not inferior to CN → sunitinib in intermediate/poor-risk clear-cell RCC.

500

What is utilized intra-op to evaluate tumor fragility, clamp placement, and detect real-time embolization. 

TEE

500

Demonstrated Lenvatinib + Pembrolizumab produced significantly higher response rates and PFS compared with Sunitinib in untreated advanced RCC.

CLEAR