Post-Test Questions

Article One (3–8)

1. Which statement regarding the incidence and mortality of RCC is correct?

   • Kidney cancer incidence in the United States increased in the early 21st century but has decreased in recent years

   • Incidence in Europe is increasing

   • Incidence rates are highest in India

   • Mortality in Asia is higher than in the United States

2. Which of the following is not a known risk factor for the development of renal carcinoma?

   • Obesity

   • Cigarette smoking

   • Antihypertensive medication

   • Male gender

3. Which of the following conditions is not associated with RCC?

   • Cystic fibrosis

   • Von Hippel–Lindau syndrome

   • Birt–Hogg–Dubé syndrome

   • Hereditary leiomyomatosis

4. Which statement regarding RCC histologic subtypes is true?

   • Chromophobe RCC is the most common type of RCC, comprising 90% of cases

   • Papillary RCC is further divided into two different subtypes, type 1 and type 2, in order of worsening prognosis

   • Clear cell carcinoma is the rarest histologic subtype, comprising 5% of cases

   Article Two (9–19)

5. 3.5-cm cystic renal mass that is homogenously hyperattenuating without enhancement would be placed in which category according to the Bosniak classification?

   • Category II

   • Category IIF

   • Category III

   • Category IV

6. What is the most likely diagnosis when a small noncalcified solid renal mass with areas of fat attenuation is encountered?

   • Oncocytoma

   • Renal cell carcinoma, papillary subtype

   • Angiomyolipoma

   • Metanephric adenoma

7. Which of the following diagnoses is most likely when presented with a small renal mass that is hypointense on T2-weighted MR imaging?

   • Renal cell carcinoma, papillary subtype

   • Cystic nephroma

   • Renal cell carcinoma, clear cell subtype

   • Bosniak Category 1 cyst

   Article Three (20–26)

8. A 42-year-old woman with history of hypertension presents with right flank pain. An unenhanced CT of the abdomen and pelvis is performed demonstrating a 3-cm homogeneous mass arising from the right kidney that measures 42 Hounsfield units. What is the next best step?

   • Percutaneous biopsy

   • Partial nephrectomy

   • Radical nephrectomy

   • Further imaging

9. A 70-year-old man with history of recurrent urinary tract infections, diabetes mellitus type 2, and benign prostatic hypertrophy presents with a 2-cm ill-defined cortically based solid mass in his right kidney. The mass was not present 2 months ago. Repeat imaging 2 months later after a 1-week course of antibiotics demonstrates persistence of the mass. What is the next best step?

   • Percutaneous biopsy

   • Partial nephrectomy

   • Radical nephrectomy

   • Further imaging

10. A 52-year-old man with hypertension undergoes a renal mass protocol CT that demonstrates a 1.5-cm solid left renal mass. The mass is homogeneous, 60 Hounsfield units precontrast, and 150 Hounsfield units in the nephrographic phase. No macroscopic fat is evident on unenhanced or postcontrast imaging. A percutaneous biopsy of this mass is performed under ultrasound guidance and the final histology reveals “angiomyolipoma.” Which of the following is the next best step?

    • Discordant histology given absent macroscopic fat, recommend repeat biopsy

    • Discordant histology given absent macroscopic fat, recommend partial nephrectomy

    • Discordant histology, recommend antibiotics and follow-up imaging

    • Concordant histology, recommend observation

    Article Four (27–32)

11. Which statement is TRUE regarding radical nephrectomy for RCC?

    • The adrenal gland should always be removed, even if it appears normal with cross-sectional imaging

    • The risk of lymph node involvement is not very predictable by cross-sectional imaging, and might be as high as 50% even if not suspected by cross-sectional imaging.

    • Laparoscopic nephrectomy is recommended for all patients regardless of tumor stage.

    • Nephrectomy causes new onset chronic kidney disease in a large number of patients

12. Partial nephrectomy has been widely adopted for small renal masses. Which statement is FALSE regarding partial nephrectomy?

    • Quality of life seems to be better in patients after partial nephrectomy than in patients after radical nephrectomy

    • For small renal masses up to 4 cm, 5-year cancerspecific survival is similar after partial nephrectomy when compared to radical nephrectomy

    • A positive margin on the final specimen indicates a high chance of recurrence

    • The detection of small renal masses has increased four- to sixfold with widespread use of cross-sectional imaging

13. Which statement is TRUE?

    • Cross-sectional imaging is highly sensitive in detecting venous thrombi and can adequately predict its extent

    • Radical nephrectomy with a renal thrombus is entirely different than a radical nephrectomy without thrombus

    • Cytoreductive nephrectomy clearly provides long-term benefit in the era of targeted agents

    • Metastasectomy has no value in metastatic renal cell carcinoma

    Article Five (33–41)

14. Which of the following patients would currently be the most appropriate candidate for percutaneous thermal ablation?

    • Patient with a T1a tumor in a peripheral location with severe obstructive lung disease and ischemic cardiomyopathy

    • Patient with a T1a tumor in a peripheral location with no past medical history

    • Patient with a T3a tumor extending into the renal vein with no past medical history

    • Patient with a T3a tumor extending into the renal vein with severe obstructive lung disease and ischemic cardiomyopathy

15. Which of the following is a benefit to preablation renal biopsy?

    • Avoidance of unnecessary therapy in patients with lipid-poor angiomyolipomas

    • Provide the patient with a definitive diagnosis

    • Improved accuracy to clinical research

    • Biopsy results can help guide follow-up after ablation

    • All of the above

16. Which of the following adjunctive procedures is used to protect the renal collecting system during percutaneous ablation?

    • External manual displacement

    • Hydrodissection with normal saline

    • Hydrodissection with iodinated contrast

    • Pyeloperfusion

    • Iatrogenic pneumothorax

    Article Six (42–49)

17. One technique to minimize the risk of ureteral injury from renal tumor RFA is:

    • Preablation tumor embolization

    • Arterial line placement

    • Artificial pneumothorax

    • Retrograde pyeloperfusion

18. Which of the following is true regarding hemorrhagic complications from renal mass ablation?

    • Hemorrhage occurs more commonly following ablation of large or central renal tumors

    • Preablation embolization should be performed before ablation of small renal masses

    • Cold-induced hypercoagulability and smaller applicator caliber are likely responsible for the decreased incidence of bleeding following renal cryoablation compared to RFA

    • Prompt blood transfusion is indicated if retroperitoneal hemorrhage is evident on CT immediately following renal ablation

19. Which of the following is true concerning iatrogenic nerve injury from renal tumor ablation?

    • Central renal tumors have increased risk of nerve injury due to vulnerable nerves at the renal hilum

    • Nerves at risk of injury during renal tumor ablation include intercostal nerves and those in the lumbar plexus located along the psoas muscles

    • Motor nerve injury does not occur following renal tumor ablation

    • Displacement techniques are not used to minimize risk of nerve injury

    Article Seven (50–63)

20. What is the most typical appearance of a successfully treated renal tumor on MR imaging after percutaneous radiofrequency ablation?

    • T1-dark and T2-bright with no significant enhancement

    • T1-bright and T2-bright with no significant enhancement

    • T1-bright and T2-dark with no significant enhancement

    • None of the above

21. Which of the following is FALSE regarding the “halo sign” within the treatment zone after renal tumor ablation?

    • It may be seen on both CT and MRI

    • It usually becomes evident by 6 months after treatment and resolves by 1 year as the treated tumor involutes

    • It is most commonly seen in association with treated lesions in an exophytic location

    • It is most commonly seen in association with tumors treated using a percutaneous approach as opposed to an open or laparoscopic surgical approach

    • It may be seen in association with tumors treated by RFA or cryoablation, but is more commonly seen after RFA.

22. Which of the following statements is FALSE regarding “benign periablational enhancement” at the treatment zone on follow-up imaging?

    • It appears as a thin, concentric, symmetric, and uniform process with smooth margins

    • It typically resolves by 3 months after treatment

    • It is more commonly seen after cryoablation than after RFA

    • It may be associated with the development of focal areas of nodular enhancement if persistent beyond 1 month after treatment, and this should not be considered suspicious for residual tumor.

    Article Eight (64–69)

23. The current gold standard for the management of stage T1a renal masses is

    • Radical nephrectomy

    • Partial nephrectomy

    • Laparoscopic cryoablation

    • Percutaneous microwave ablation

24. Which of the following therapies best preserves renal function?

    • Radical nephrectomy

    • Partial nephrectomy

    • Renal embolization

    • Laparoscopic cryoablation

25. Which of the following therapies has demonstrated the best oncologic efficacy in the treatment of small renal masses?

    • Laparoscopic cryoablation

    • Sorafenib

    • Partial nephrectomy

    • Active surveillance

    Article Nine (70–81)

26. The presence of metastatic disease decreases the 5-year survival rate of renal cell carcinoma from 90% for localized disease to:

    • 50%

    • 30%

    • 20%

    • 10%

    • Nearly zero

27. True or false? Preoperative embolization of renal cell carcinoma has been shown to definitively decrease the amount of blood requirement during operation?

28. The most optimal time between embolization and definitive surgical resection is most likely

    • Within 1 hour

    • < 48 hours

    • < 1 week

    • The time interval is irrelevant.

    Article Ten (82–85)

29. What size renal mass has thermal ablation shown to be effective for local tumor control?

    • 2 cm

    • 4 cm

    • 6 cm

    • 8 cm

30. Combined embolization and ablation has proven effective for tumors up to 7 cm in what organ?

    • Kidney

    • Spleen

    • Liver

    • Lung

31. Which lesions are most amenable to combined embolization and ablation?

    • Exophytic

    • Central

    • Mixed

    • A and B

    • B and C

    • A and C

    Article Eleven (86–90)

32. For resected renal cell carcinoma, radiation therapy:

    • Is strongly indicated in high-risk patients

    • Has an unproven role

    • Has a phase III trial that has shown survival benefit

    • Is absolutely contraindicated

33. Regarding preoperative radiation therapy in renal cell carcinomas:

    • RT dose is 70 Gy

    • RT dose is 20 Gy

    • May be beneficial in select patients

    • Has shown significant benefit in R0 resections in phase III RCT

34. Regarding stereotactic radiation in RCC

    • Has been tried in the lab only, not on patients

    • Uses low-dose fractions to a total high dose

    • Uses high dose per fraction

    • Has proven to be better than conventional radiation

    Article Twelve (91–97)

35. A 77-year-old man presented with left flank pain and hematuria, and was found to have a left renal mass on CT scan. He underwent a left radical nephrectomy for a 9.5-cm clear cell renal cell carcinoma. Eighteen months later he presented with hemoptysis. A CT scan showed greater than 10 pulmonary nodules ranging from 0.5 to 2 cm in diameter, and multiple bone metastases. Histopathological exam of tissue obtained from a CTguided biopsy of a pulmonary nodule was consistent with clear cell renal cell carcinoma. Other comorbidities include diabetes mellitus and cardiac stent placement for coronary artery disease 5 years ago with good cardiac function currently.

    • Which of the following is true regarding first-line therapy for this patient?

    • missing

    • Sunitinib or pazopanib as first-line treatment would be a standard treatment option for this patient

    • This patient would be a proper candidate for interleukin-2 therapy

    • Chemotherapy with doxorubicin and gemcitabine is a reasonable treatment option

    • None of the above are correct.

36. A 68-year-old woman presents with a left supraclavicular 3-cm lymph node. Biopsy of the lymph node reveals adenocarcinoma compatible with metastatic RCC. Further workup shows a 6-cm right renal mass, multiple sub-cm liver metastases, and enlarged mediastinal lymph nodes. The patient is started on Pazopanib 800 mg a day and follow-up examination 2 weeks later shows he has a mild facial rash and normal laboratory tests. He is again seen 2 weeks later for follow-up. The rash has resolved and the patient feels well. Routine laboratory tests show her liver function tests as follows: aspartate transaminase (AST) 360 IU/L (normal range 15–41 IU/L), alanine transaminase (ALT) 595 IU/L (normal range 17–63 IU/L), and total bilirubin 0.9 mg/dL (normal range 0.3–1.2). Which of the following represents the next best step in management?

    • Schedule a return appointment in 1 month

    • Repeat the CT scan of the abdomen to assess for disease progression in the liver

    • Discontinue the pazopanib and recheck liver function tests in 1 week

    • Change therapy to everolimus

37. A 63-year-old former smoker with a history of hypertension presents with a 3-month history of painless hematuria, lower back pain, and nonproductive cough. A CT scan of his chest, abdomen, and pelvis shows a 10.2 × 8.3 cm rightsided renal mass, numerous pleural-based pulmonary nodules in both lungs, and a lytic bony lesion in L2 without epidural extension. Fine needle aspiration of a lung nodule showed metastatic papillary renal cell carcinoma. On laboratory evaluation, his hemoglobin is 11.7 g/dL, LDH is 420 U/L, and his serum calcium is 11.2 g/dL. Which of the following is the most appropriate initial systemic therapy?

    • Interleukin-2

    • Temsirolimus combined with interferon alpha

    • Temsirolimus

    • Bevacizumab combined with interferon alpha