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Self-Assessment Questions

Oncology

Renal Cell Carcinoma: Review Questions

Damian A. Laber, MD

Dr. Laber is an associate professor of medicine and director of the Hematology and Medical Oncology Fellowship Program, Division of Hematology and Medical Oncology, University of Louisville, and director of the Genitourinary Cancer Clinical Research Program, J.G. Brown Cancer Center, Louisville, KY.


Choose the single best answer for each question.

1. A 56-year-old woman with a past history of cholelithiasis presents to her primary care physician for a follow-up visit. One week prior, she had been hospitalized with right upper quadrant abdominal pain that responded to medical therapy, and she was discharged home within 2 days. A computed tomography (CT) scan revealed gallstones, minimally distended bile ducts, a normal gallbladder wall, and a 2-cm complex mass in the left kidney. On this visit, she has no complaints. Physical examination is normal. Complete blood count and metabolic testing are normal. Her estimated creatinine clearance is 90 mL/min, and urinalysis shows no hematuria. What is the next step in the management of this patient?
  1. Follow-up visit 3 months with a repeat CT scan
  2. Refer to urology for surgical resection of the left kidney mass
  3. CT-guided fine-needle aspiration (FNA) of the kidney mass
  4. Refer to general surgery for elective cholecystectomy
  5. Order an ultrasound of the abdomen to further characterize the gallstones and kidney mass
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2. Which of the following is correct regarding obesity, smoking, and risks for renal cell carcinoma?

  1. Smoking has been associated with an increased risk of developing renal cell carcinoma but obesity has not
  2. Obesity has been associated with an increased risk of developing renal cell carcinoma but smoking has not
  3. Both smoking and obesity have been associated with an increased risk of developing renal cell carcinoma
  4. Neither smoking nor obesity have been associated with an increased risk of developing renal cell carcinoma
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3. A 41-year-old man seeks advice regarding genetic testing for familial forms of renal cell carcinoma. He was diagnosed with metastatic renal cell carcinoma 1 year ago and currently is stable on therapy. He is married and has 2 adopted children. He is sterile due to childhood mumps, confirmed by objective sterility testing. He has 1 brother, aged 46 years, who is healthy. His father died at age 62 years from renal cell carcinoma. No other family member has had cancer. He is very close to his family, who support him in all decisions. How should this patient be advised regarding genetic testing for familial forms of renal cell carcinoma?

  1. The patient should be tested
  2. The patient should not be tested
  3. The patient’s brother should be tested
  4. The patient and his brother should be tested
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4. A 62-year-old woman presents for a consultation regarding nephrectomy as a potential treatment for her newly diagnosed renal cell carcinoma. Two months ago, she developed hematuria. A CT scan revealed a 9-cm complex mass in the right kidney and 3 bilateral lung nodules measuring 1 to 3 cm. Bone scan and magnetic resonance imaging (MRI) of the brain were normal. Fine-needle aspirates of the kidney mass and one of the lung nodules both revealed renal cell carcinoma. She has no comorbidities and has normal cardiac, pulmonary, and renal function. What is the recommendation regarding nephrectomy in this case?

  1. The patient should undergo nephrectomy
  2. There is no reason for nephrectomy because the patient has metastatic disease
  3. Initiate interferon therapy and consider nephrectomy at a later time
  4. Nephrectomy is a high-risk surgery and would worsen this patient’s quality of life
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5. A 68-year-old man presents to the oncologist regarding therapy for metastatic renal cell carcinoma. Three years ago, the patient developed right flank pain and was found to have a large kidney mass. He underwent a radical nephrectomy. Pathologic testing revealed an 8-cm tumor, clear cell type, Fuhrman grade III, extending into the fat but not through the Gerota’s fascia, and 1 of 9 lymph nodes revealed metastatic renal cell carcinoma. A follow-up CT scan 1 month ago revealed 3 liver lesions measuring 1 to 2 cm, mediastinal lymphadenopathy, and a few subcentimeter lung nodules that were not present on a CT scan 6 months ago. Evaluation of fine-needle aspirate of a liver lesion confirmed metastatic clear cell type renal cell carcinoma. He is fully active and asymptomatic. Past medical history includes a myocardial infarction followed by a triple-vessel coronary artery bypass graft surgery 5 years ago. His cardiac ejection fraction has been between 40% and 50% for years. Medications include aspirin, atenolol, and lisinopril. Physical examination is normal. Complete blood counts are normal and serum creatinine is 2.5 mg/dL and stable since the nephrectomy. Bone scan is normal. How should this patient be managed?
  1. Subcutaneous interferon alfa
  2. High-dose interleukin 2
  3. Sorafenib or sunitinib
  4. Metastasectomy or radiofrequency ablation of the 3 liver lesions
  5. Observation
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6. A 55-year-old man presents to his primary care physician with worsening fatigue for the last 3 months. Two weeks ago, he developed rib pain, and a chest radiograph revealed multiple lung and rib lesions. CT confirmed multiple lung, bone, and liver lesions and a 12-cm mass in the right kidney. Biopsy of a lesion in the rib was consistent with metastatic renal cell carcinoma, clear cell type. Prior to presentation 2 weeks ago, he had been healthy. He takes ibuprofen for pain. On questioning, he states that he has constipation, mild postural dizziness, and generalized weakness, and he has had occasional headaches all of his life without recent changes. On physical examination, he looks slightly lethargic but he is alert, oriented, and able to give an appropriate history. Temperature is normal, heart rate is 90 bpm, blood pressure is 105/62 mm Hg, and respiratory rate is 16 breaths/min. Neurologic examination demonstrated generalized weakness, no focal deficits, deep tendon reflexes 1+ and symmetrical, normal gait, and intact senses. The remainder of the physical examination is unremarkable. After ordering basic laboratory tests, what is the next best step in the management of this patient?

  1. Order immediate MRI of the brain
  2. Start sorafenib or sunitinib
  3. Administer opiates and refer to hospice
  4. Refer to urology for evaluation for nephrectomy
  5. Aggressive intravenous hydration
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