**3. Staging and risk stratification in renal cell carcinoma**

Staging for RCC is based on the TNM 8 classification and staging groups [8]. The staging takes into account the size and loco-regional extent of the tumour in addition to lymph node and distant metastatic spread [9]. **Table 1** illustrates this is in further detail.

In metastatic renal cell carcinoma, the decision to treat and, more importantly the choice of initial treatment, is based on risk stratification of the patients into three groups. The choice of initial systemic therapy in metastatic RCC may be informed by risk stratification using the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic model [10–12].

The six adverse risk factors in the IMDC model are as follows [11]:


Patients with none of these risk factors are considered to be in the favourable-risk group, those with one or two are considered to be in the intermediate-risk group, and those with three or more risk factors are considered to be in the poor-risk group. These groups correlate with median overall survival: 43.2 months in the favourable-risk group, 22.5 months in the intermediate-risk group, and 7.8 months in the poor-risk group [11]. Oncologists use this, or similar risk stratification, to decide upon the most appropriate treatment from the systemic options available. The advantage of the IMDC-model-based risk stratification is that it has been validated in both clear cell and non-clear cell histopathological groups and after first line

Primary tumour cannot be assessed No evidence of primary tumour

adrenal gland and not beyond Gerota's fascia

Regional lymph nodes cannot be assessed No regional lymph nodes metastasis Metastasis in regional lymph node(s)

Tumour extends into the vena cava below the diaphragm

fascia

cava

T stage N stage M stage Stage group

T1 N0 M0 I T1 N1 M0 III T2 N0 M0 II T2 N1 M0 III T3 Nx, N0 M0 III T3 N1 M0 III T4 Any N M0 IV Any T Any N M1 IV

ipsilateral adrenal gland)

No distant metastasis Distant metastasis

Tumour ≤7 cm in greatest dimension, limited to the kidneys Tumour ≤4 cm in greatest dimension, limited to the kidneys Tumour >4 and ≤7 cm in greatest dimension, limited to the kidneys Tumour >7 cm in greatest dimension, limited to the kidneys

Tumour >7 and ≤10 cm in greatest dimension, limited to the kidneys Tumour >10 cm in greatest dimension, limited to the kidneys

Tumour extends into major veins or perinephric tissues, but not into the ipsilateral

pelvicalyceal system, or invades perirenal and/or renal sinus fat but not beyond Gerota's

Medical Management of Renal Cell Cancer http://dx.doi.org/10.5772/intechopen.85931 157

Tumour extends into the vena cava above the diaphragm or invades the wall of the vena

Tumour invades beyond Gerota's fascia (including contiguous extension into the

Tumour extends into the renal veins or its segmental branches, or invades the

and subsequent lines of treatment [11–14].

**Table 1.** TNM staging of renal cell carcinoma [8].

TX T0 T1 T1a T1b T2 T2a T2b T3 T3a T3b T3c T4

NX N0 N1

M0 M1

Prognostic groups


**Table 1.** TNM staging of renal cell carcinoma [8].

**2. Histological subtypes**

156 Evolving Trends in Kidney Cancer

model [10–12].

• Karnofsky performance score < 80;

• haemoglobin < lower limit of normal;

• serum calcium > upper limit of normal.

• neutrophil > upper limit of normal; • platelet > upper limit of normal; and

and revolutionised the metastatic treatment landscape.

**3. Staging and risk stratification in renal cell carcinoma**

distant metastatic spread [9]. **Table 1** illustrates this is in further detail.

The six adverse risk factors in the IMDC model are as follows [11]:

• time from original diagnosis to initiation of targeted therapy <1 year;

Renal cell carcinoma is divided into several histological subtypes, of which the most common is clear cell renal cell carcinoma (ccRCC), accounting for approximately three-quarters of all kidney cancers [7]. Clear cell RCC originates from the epithelium of the proximal convoluted tubules. Most are sporadic, but there is a strong familial connection with those with a first-degree relative more likely to be effected and around 5% are associated with hereditary conditions such as Von Hippel–Lindau disease, tuberous sclerosis, and adult polycystic disease. The next most prevalent histological subtypes are papillary (10%) and chromophobe (5%) [7]. These three histological subtypes make up 90% of renal cell carcinomas and are also most common in patients over the age of 50 years. Other rarer subtypes, such as medullary and Xp11 translocation, are typically seen in younger people. A better understanding of the genetic drivers for renal cell carcinoma has led to the development of targeted systemic agents

Staging for RCC is based on the TNM 8 classification and staging groups [8]. The staging takes into account the size and loco-regional extent of the tumour in addition to lymph node and

In metastatic renal cell carcinoma, the decision to treat and, more importantly the choice of initial treatment, is based on risk stratification of the patients into three groups. The choice of initial systemic therapy in metastatic RCC may be informed by risk stratification using the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic

Patients with none of these risk factors are considered to be in the favourable-risk group, those with one or two are considered to be in the intermediate-risk group, and those with three or more risk factors are considered to be in the poor-risk group. These groups correlate with median overall survival: 43.2 months in the favourable-risk group, 22.5 months in the intermediate-risk group, and 7.8 months in the poor-risk group [11]. Oncologists use this, or similar risk stratification, to decide upon the most appropriate treatment from the systemic options available. The advantage of the IMDC-model-based risk stratification is that it has been validated in both clear cell and non-clear cell histopathological groups and after first line and subsequent lines of treatment [11–14].
