CancerGuide: Guide to Staging and Grading of Renal Cell Cancer

Rather than repeat information which can be found elsewhere, this guide to kidney cancer grading and staging is intended to point you in the right direction for detailed definitions of stage and grade, and to give you some perspective on what it means. For a variety of reasons, including that you might not want to see it, I don't directly present statistical information. Towards the end of the article, I do point to a review of prognostic factors and statistical information elsewhere on the web.

Investigating Your Case

As an essential first step read my article on Understanding Cancer Types and Staging which explains the general workings of staging and grading systems for all cancers. Though it's not specific to kidney cancer, understanding this background is critical.
After you've reviewed the staging and grading systems for kidney cancer here, you'll be able to ask your doctor the right questions. If you haven't had surgery, you can still ask what stage they think it is.
If you've already had surgery, get a copy of your pathology and operative reports which will detail the findings (Your doctor's office should be able to provide copies).
There are several different varieties of renal cancer, and which you have sometimes makes a huge difference in both prognosis and treatment. See my article on Sub-Types of RCC. If you don't already have your pathology report, have a glance at my article now, and you'll know what to look for and what questions to ask your doctor when your report is available.

Staging

Staging for Renal Cell Cancer

There are two similar staging systems in use, by far the most common is the current AJCC TNM system. Occasionally the older Robson system is used. The newer system is better though still imperfect.

411Cancer has The best description of kidney cancer staging I've found on the web. (Will open in new window)

Stage III actually includes cases with a widely differing prognosis, specifically the prognosis with lymph node involvement is significantly worse than other cases in stage III. Only a small percentage of those with stage III have positive lymph nodes.

Significance of Staging in Kidney Cancer

The lower the stage, the better the prognosis.
Treatment for stages I-III consists of surgery to remove the kidney tumor (or rarely other methods to destroy it) while stage IV or recurrent renal cancer is treated with surgery, immunotherapy, and clinical trials of new treatments.
The surgical options change as you move from stage I through III, though the correspondence with stage isn't exact.
For patients with localized disease (stages I-III), post surgical follow-up is more intense with increasing stage. More intense means more frequent and with more detailed imaging studies, for example, a CT scan rather than chest X-Ray.
For patients with localized disease, clinical trials of treatment to prevent recurrence are more likely to be an option the higher your stage. See my article on Adjuvant Therapy for the details.
Where to go next here in CancerGuide depends on your stage:
- If you have stage I, II, or III RCC, see Localized Disease.
- If you have Stage IV or recurrent RCC, see Metastatic or Recurrent Disease.

Grading

The grade affects the prognosis, but doesn't currently affect treatment. The treatment is the same for a given stage regardless of the grade. Grade also correlates with stage in that larger tumors tend to be higher grade.

The most widely used and most predictive grading system for renal cell cancer is the "Fuhrman Nuclear Grade". Your pathology report should use the Fuhrman Grade. Fuhrman grade is on a scale of I-IV, where grade I carries the best prognosis and grade IV the worst.

Nuclear grade means that the system is based on just the appearance of the nuclei of the cancer cells, rather than the appearance or structure of the cells as a whole. Nuclear characteristics used in the Fuhrman Grade particularly indicate how actively the cells are making protein.

Nuclear Characteristics Used in the Fuhrman System

Size and shape of the nucleus as a whole.
Number and size of nucleoli (Nucleoli are organelles found in the cell nucleus which make ribosomes which in turn are protein making factories. More nucleoli implies more active protein synthesis).
Chromatin clumping (Chromatin is the substance of chromosomes and contains DNA and associated proteins. I'm not exactly sure why clumping indicates a more aggressive tumor).

Statistics: Stage, Grade and Other Prognostic Factors

Stage and grade aren't the only important factors. In reality, a great deal of why the prognosis varies so much is simply unknown and, although it's clear that the known prognostic factors matter quite a bit, there simply isn't any way to determine the prognosis with any great precision. A terse review of prognostic factors from Medical Algorithms (Opens in new window) gives survival statistics based on stage, grade, and several other recent models which incorporate various other prognostic factors.

NOTE: To access the articles on the prognostic factors for RCC, you must first go to www.medal.org and register (free). Then log in and choose "27: Oncology/Nonhematologic". That takes you to a new page and you have to scroll down until you find Renal Cell Carcinoma. The information is broken up into over 20 separate links. (Reviewed 7/07)

You'll also find precise definitions of the Fuhrman grade and several staging systems. The review is notably missing any detailed appreciation of the effect of the sub-type of RCC on prognosis. WARNING: Don't look at this unless you really want to see the statistics.

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