Educated Patient® Kidney Cancer Summit Staging Presentation: April 9, 2022

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Standard staging classification of kidney cancer utilizes the acronym TNM, which stands for tumors, nodes and metastasis, allowing a clinician to create a treatment plan based on one’s individual cancer.

Dr. Vitaly Margulis, professor of urologic oncology at UT Southwestern Medical Center in Dallas, explained why it is important for patients to understand their diagnosis better, at CURE®’s Educated Patient® Kidney Cancer Summit.

He explained further that the “T” tells clinicians how extensive a patient’s tumor is within the kidney. The “N” shows if the cancer has spread to the regional lymph nodes. And “M,” which he said is probably the most important part, shows if the cancer has metastasized or spread to other parts of the body.

“The combination of these factors determines … how to treat each individual patient. They help us to understand after treatment how to properly monitor. It also helps us understand among other things, (if) there (are) any preventative options or any treatments that can be given in an adjuvant fashion after surgery to prevent recurrences. In addition, this system is generally used for prognosis, based on the specifics of the TNM stage, one can speculate about the probability of the cancer coming back,” he explained in an interview with CURE®.

When staging for tumors, there are four categories in which a patient can fall into:

• T0 – there is no evidence of a primary tumor
• T1 – a tumor is less than 7 centimeters in dimension
  • T1a – tumor is less than 4 centimeters
  • T1b – tumor is greater than 4 centimeters
• T2 – tumor is greater than 7 centimeters in dimension
  • T2a – tumor is less than at least 10 centimeters
  • T2b – tumor is greater than 10 centimeters
• T3 – the tumor extends into major veins or perinephric tissue (tissue around the kidney, proximal uterus, adrenal glands)
  • T3a – the tumor invades the renal vein or segmental branches, pelvicalyceal system, or perirenal or renal sinus fat
  • T3b – extends into vena cava below the diaphragm
  • T3c – same as T3b or invades the vena cell wall
• T4 – tumor extends beyond Gerota’s fascia (connective tissue that encapsulates the kidneys and adrenal glands)

When staging for the nodes and metastasis, it is only two or three categories. For nodes it is either Nx (regional nodes cannot be assessed), N0 (it has not metastasized to the nodes) or N1 (it has metastasized to the nodes). And then either M0 (no distant metastasis) or M1 (distant metastasis).

Generally, most patients who have T1 with N0 and M0 are stage 1, T2 with N0 and M0 is stage 2. And then those with T1-2 with N1 and M0 are stage 3, as well as those with T3 any N and M0. And finally, T4 with any N and M0 or any T with any N and M1 are stage 4, Margulis explained.

“For each individual patient, the TNM stage will guide the patient and the clinicians in terms of how to manage the cancer,” he said.

For example, he added, stage 4 kidney cancer with metastases are treated with systemic therapies, while those without metastases are treated with surgery upfront — which is where the T stage is important, Margulis explained. Patients staged with T1 and T2 categories can generally undergo surgery that only takes part of the kidney, called a partial nephrectomy, and those with T3 or T4 categories usually undergo a radical nephrectomy to remove the whole kidney.

“You can see how understanding the exact details of TNM staging guides therapy after the treatment,” Margulis said. “I think it’s important that, based on TNM staging, a rational surveillance strategy is determined. Discussions can be held about availability and need for additional treatment options to minimize the probability of cancer coming back.”

Because of the details about the disease TNM staging can provide patients, Margulis said it is important for them to understand it and be educated on this. Additionally, being educated on different treatment options available for their specific stage can create a more open and dynamic relationship with their clinician and even allow them to think of alternate treatment options than the ones given to them, he said.

“The more patients know (and) understand about their disease process, the more dynamic a patient-doctor relationship becomes. Being aware and understanding the extent of one’s cancer helps understand why their physicians choose certain therapies. … I think it’s important to be informed, it’s important to question or ask specific questions about your diagnosis and staging, because I think it ultimately leads to better outcomes,” he concluded.

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