European Association of Urology
Guidelines
Education & Events
Join our events Join our events
On-demand education Learn at your own pace
Scholarships Enrich your capabilities
Exchange Programmes Urology beyond Europe
Education Educational Platforms Talent Incubator Programme Accreditation
Science & Publications
Publications Our publications
Research & Science Passionate about research?
About
Who we are Our mission and history
Our Board and Offices How we work
Join the EAU Find out about membership
Vacancies Contact
Guidelines

Renal Cell Carcinoma

Want to read the guideline in your own time? Download the PDF

Download full guideline

Looking for a quick overview? Check the pocket guidelines.

Download pocket guidelines
Full text guidelineSummary of ChangesPublications & AppendicesPanelRelated content
No results found
  1. Introduction
  2. Methods
  3. Epidemiology Aetiology And Pathology
  4. Staging And Classification Systems
  5. Diagnostic Evaluation
  6. Prognostic Factors
  7. Disease Management
  8. Hereditary And Syndrome Specific Rcc
  9. Follow Up
  10. References
  11. Conflict Of Interest
  12. Citation Information
  13. Copyright And Terms Of Use
4. Staging And Classification Systems
  • 1. Introduction
  • 2. Methods
  • 3. Epidemiology Aetiology And Pathology
  • 4. Staging And Classification Systems
  • 5. Diagnostic Evaluation
  • 6. Prognostic Factors
  • 7. Disease Management
  • 8. Hereditary And Syndrome Specific Rcc
  • 9. Follow Up
  • 10. References
  • 11. Conflict Of Interest
  • 12. Citation Information
  • 13. Copyright And Terms Of Use
  • No elements found. Consider changing the search query.
  • List is empty.

4. STAGING AND CLASSIFICATION SYSTEMS

4.1. Staging

The Tumour Node Metastasis (TNM) classification system is recommended for clinical and scientific use [81]. A supplement was published in 2012, and the latter’s prognostic value was confirmed in single- and multi-institution studies [82,83]. Tumour size, venous invasion, renal capsular invasion, adrenal involvement, LN and distant metastasis are included in the TNM classification system (Table 4.1). However, some uncertainties remain:

  • The sub-classification of T1 tumours using a cut-off of 4 cm might not be optimal in NSS for localised cancer [84];
  • The value of size stratification of T2 tumours has been questioned [85];
  • Renal sinus fat invasion might carry a worse prognosis than perinephric fat invasion but is nevertheless included in the same pT3a stage group [86-89] (LE: 3);
  • Sub T-stages (pT2b, pT3a, pT3c and pT4) may overlap [83];
  • For adequate M staging, accurate pre-operative imaging (chest and abdominal CT) should be performed [90,91] (LE: 4).

A proposed imaging analysis of Tumour Contour Irregularity might be a valuable tool to enhance the preoperative staging between T1 and T3a RCCs for treatment decisions [92].

The TNM classification should not be considered the only criterion for clinical decision-making, but patient’s condition, comorbidities and wishes are of fundamental importance to select the most optimal treatment. A clinically-guided RCC staging classification was proposed in 2022 by the EAU panel, based on changes observed in the management of small renal masses (SRM), locally advanced and metastatic disease [84].

Table 4.1: 2017 TNM classification system [93]

2017 TNM classification system
T - Primary tumour
TXPrimary tumour cannot be assessed
T0No evidence of primary tumour
T1Tumour ≤ 7 cm or less in greatest dimension, limited to the kidney
 T1aTumour ≤ 4 cm or less
 T1bTumour > 4 cm but ≤ 7 cm
T2Tumour > 7 cm in greatest dimension, limited to the kidney
 T2aTumour > 7 cm but ≤ 10 cm
 T2bTumours > 10 cm, limited to the kidney
T3Tumour extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond Gerota fascia
 T3aTumour extends into the renal vein or its segmental branches, or invades the pelvicalyceal system or invades perirenal and/or renal sinus fat*, but not beyond Gerota fascia*
 T3bTumour grossly extends into the vena cava below diaphragm
 T3cTumour grossly extends into vena cava above the diaphragm or invades the wall of the vena cava
T4Tumour invades beyond Gerota fascia (including contiguous extension into the ipsilateral adrenal gland)
N - Regional Lymph Nodes
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Metastasis in regional lymph node(s)
M - Distant metastasis
M0No distant metastasis
M1Distant metastasis
pTNM stage grouping
Stage IT1N0M0
Stage IIT2N0M0
Stage IIIT3N0M0
  T1, T2, T3N1M0
Stage IVT4Any NM0
  Any TAny NM1

A help desk for specific questions about TNM classification is available at http://www.uicc.org/tnm. *Adapted based on the American Joint Committee on Cancer (AJCC), 8th Edn. 2017 [94]

4.2. Anatomic classification systems

Objective anatomic classification systems, such as the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification system, the R.E.N.A.L. nephrometry score, the C-index, an Arterial Based Complexity (ABC) Scoring System and Zonal NePhRO scoring system, have been proposed to standardise the description of renal tumours [95-97]. These systems include assessment of tumour size, exophytic/endophytic properties, proximity to the collecting system and renal sinus, and anterior/posterior or lower/upper pole location. Increasing tumour shape irregularity on imaging is associated with an increased risk of pT3a upgrading and grade 3-4 disease, but the positive marign rate was similar [98].

The use of such a system is helpful as it allows objective prediction of potential morbidity of NSS and tumour ablation techniques. These tools provide information for treatment planning, patient counselling, and comparison of PN and tumour ablation series. However, when selecting the most optimal treatment option, anatomic scores must be considered together with patient features and surgeon experience.

About EAU
  • Who we are
  • How we work
  • Become a member
Services
  • MyEAU
  • Congress registrations
  • Abstract submission
Media
  • EAU News
  • EAU Newsletter
  • EAU Press Releases
Contact
  • EAU Central Office
    PO Box 30016
    NL-6803 AA ARNHEM
    The Netherlands

  • Contact us
About EAU
Who we areHow we workBecome a member
Services
MyEAUCongress registrationsAbstract submission
Media
EAU NewsEAU NewsletterEAU Press Releases
Contact

EAU Central Office
PO Box 30016
NL-6803 AA ARNHEM
The Netherlands

Contact us
European Association of Urology
Privacy PolicyDisclaimer