TNM staging:
| Tx | Tumour can’t be assessed |
| T0 | No evidence primary tumour |
| T1a
T1b T2a T2b |
< 4 cm
4 – 7 cm 7 – 10 cm > 10 cm |
| T3a
|
Extends into renal vein or segmental branches
Invades pelvicalyceal system Invades perirenal or renal sinus fat |
| T3b | Extends into vena cava, below diaphragm |
| T3c | Extends into vena cava, above diaphragm
Or extends into vena cava wall |
| T4 | Invades beyond Gerota fascia, including into adrenal |
| Nx | Nodes can’t be assessed |
| N0 | No regional lymph node mets |
| N1 | Regional lymph node mets |
| Mx | Distant mets can’t be assessed |
| M0 | No distant mets |
| M1 | Distant metastatic disease |
Stage grouping:
| Stage I | T1 |
| Stage 2 | T2 |
| Stage 3 | T3, or T1-2 and N1 |
| Stage 4 | T4, or M1 |
Clinical staging:
CT provides the best modality for staging of the primary mass, contra-lateral kidney, regional nodes and distant metastatic disease (including chest/lungs).
MRI is useful for further assessment of tumour thrombus, and in patients who can’t have CT. It is also useful for locally invasive disease i.e. T4 and surgical planning.
Bone mets are usually symptomatic at diagnosis – routine bone scan is not indicated.
Bone scan or CT brain can be used in the presence of concerning symptoms.
PET is not recommended for initial staging (although emerging role for PSMA in ccRCC).
Consider biopsy of sites of potential metastatic disease.
What factors affect prognosis in renal cell carcinoma?
(Above table from Campbell’s)
- Pathological stage has proven to be the single most important prognostic factor
- pT4, and lymph node involvement particularly
- Clinical features – poor performance status and cachexia
- Direct invasion of the vein wall is more important in portending poor prognosis, cf. level and extent of thrombus