346.2 🩺 國考版

346.2.1 高頻考點

346.2.1.1 RCC Subtypes

  • Clear cell (75%, VHL): most common
  • Papillary (10-15%): type 1 (MET), type 2
  • Chromophobe (5%): better prognosis, BHD
  • Collecting duct / medullary: aggressive
  • MiT family: adolescent / young

346.2.1.2 RCC Risk Factors

  • Smoking
  • Obesity
  • HTN
  • CKD / dialysis
  • VHL syndrome
  • Other hereditary

346.2.1.3 RCC Paraneoplastic Syndromes

  • Erythrocytosis (EPO)
  • Hypercalcemia (PTHrP, osteolytic)
  • HTN (renin)
  • Cushing (ACTH)
  • Stauffer syndrome (hepatic dysfunction without metastases — IL-6)
  • Anemia chronic disease

346.2.1.4 RCC Classic Triad

  • Flank pain + hematuria + abdominal mass (only 10% — late stage)

346.2.1.5 RCC Treatment

  • Localized: partial nephrectomy preferred (vs radical)
  • Adjuvant: pembrolizumab (KEYNOTE-564, 2021) high-risk
  • Metastatic first-line: IO + TKI combinations:
    • Pembrolizumab + lenvatinib (CLEAR — longest PFS)
    • Cabozantinib + nivolumab (CheckMate 9ER)
    • Pembrolizumab + axitinib (KEYNOTE-426)
    • Nivolumab + ipilimumab (CheckMate 214)

346.2.1.6 Belzutifan

  • HIF-2α inhibitor
  • VHL-associated RCC (FDA 2021)
  • LITESPARK trials

346.2.1.7 Bladder Cancer

  • 90% urothelial
  • Smoking #1 risk factor
  • Schistosoma → squamous
  • Painless gross hematuria 80% classical
  • Cystoscopy + cytology + CT urography

346.2.1.8 NMIBC Treatment

  • TURBT first
  • Intravesical BCG for high-risk
  • Mitomycin for low-risk single
  • Pembrolizumab (KEYNOTE-057) for BCG-unresponsive

346.2.1.9 MIBC Treatment

  • Neoadjuvant cisplatin chemo
  • Radical cystectomy
  • Adjuvant nivolumab (CheckMate 274) post-resection
  • Bladder preservation alternative (TURBT + chemoradiation)

346.2.1.10 Metastatic Bladder Cancer

  • Cisplatin-based chemo (GC, MVAC)
  • Maintenance avelumab (JAVELIN Bladder 100)
  • EV-302 (2024): enfortumab vedotin + pembrolizumab first-line paradigm-shifting
  • Erdafitinib (FGFR3 alterations)
  • Sacituzumab govitecan

346.2.1.11 Bladder Cancer + Schistosomiasis

  • S. haematobium
  • Squamous cell carcinoma
  • Africa, Egypt
  • Praziquantel

346.2.1.12 Aristolochic Acid + Urothelial Cancer

  • Chinese herb nephropathy
  • Balkan endemic nephropathy
  • Upper tract urothelial carcinoma
  • Lynch syndrome

346.2.1.13 Key Trials

  • CLEAR (2021): pembrolizumab + lenvatinib RCC
  • CheckMate 9ER (2020): cabozantinib + nivolumab RCC
  • CheckMate 214: nivolumab + ipilimumab RCC
  • KEYNOTE-426 (2019): pembrolizumab + axitinib RCC
  • KEYNOTE-564 (2021): pembrolizumab adjuvant RCC
  • LITESPARK-005 (2023): belzutifan RCC
  • KEYNOTE-057: pembrolizumab BCG-unresponsive NMIBC
  • CheckMate 274 (2021): nivolumab adjuvant MIBC
  • JAVELIN Bladder 100 (2020): avelumab maintenance
  • EV-302 (2024): enfortumab vedotin + pembrolizumab first-line metastatic urothelial

346.2.2 易混淆比范

Cancer Pathology Risk Factors Presentation Key Treatment
Clear cell RCC VHL, clear cytoplasm Smoking, obesity, HTN Often incidental Partial nephrectomy + IO/TKI metastatic
Papillary RCC MET (type 1) Hereditary, sporadic Variable Type-specific
Urothelial bladder Transitional cell Smoking, occupational Painless gross hematuria TURBT + BCG / cystectomy + IO
Squamous bladder Squamous Schistosoma Variable Cystectomy
UTUC Urothelial Lynch, aristolochic Hematuria Nephroureterectomy

346.2.3 Special Topics

346.2.3.1 Hereditary RCC Syndromes

  • VHL: clear cell RCC + hemangioblastoma + pheo + retinal
  • HPRC: papillary type 1
  • HLRCC: papillary type 2 + uterine + skin leiomyomas
  • BHD (Birt-Hogg-Dubé): chromophobe + lung cysts + skin

346.2.3.2 IO + TKI Mechanism

  • Synergy: IO unleashes immune; TKI ↓ tumor vasculature + immune
  • Combination > each alone in many cases