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Is it the size that maters more or the grade

Limelife50's picture
Limelife50
Posts: 411
Joined: Nov 2011

I see a lot or at least I think a lot of emphases being put on the stage of our disease or the size of our tumors.I admit while those two factors do have a direct impact on all of our long term survivals there is another aspect of our disease which can also have an affect on our long term survival and that would be what is refered to as the Fuhrman nuclear grade.The grading system goes from a grade 1 to a grade 4,with a grade. 4 type tumor being of the more aggressive.I am not trying to set off any alarms here ,I just thought I would mention this since I feel from all the things I have read on the Internet ,tumor grade is something to be concearned about as much as the size and stage of the disease.

garym's picture
garym
Posts: 1651
Joined: Nov 2009

Good point...

MikeK703's picture
MikeK703
Posts: 235
Joined: Sep 2010

You're right. The grading system does play a part in estimating the survival expectancy. A while ago I viewed an online algorithm predicting in years the survival of "cancer patients with metastatic clear cell carcinoma of the kidney." In the Fuhrman Grade section of the algorithm it assigned a score of "0" to patients with Fuhrman Grades 1, 2, or 3 and gave a score of "3" to patients with Fuhrman Grade 4. In the final scoring, after adding in the points for this AND the other factors, the higher the score, the fewer the expected years of survival. This is of course only educated guesswork on the part of the algorithm originator and cannot be viewed as being authoritative. I'm fortunate in that my Fuhrman Grade was 2 and, anyway, my life expectancy is in the hands of God.
Regards,
Mike

garym's picture
garym
Posts: 1651
Joined: Nov 2009

The Role of Staging and Grading

Staging of a cancer is the process of classifying how far a cancer has spread, while grading determines the characteristics and make up of the cancer’s cells. The two systems play different roles, but both staging and grading are important predictors of the course of the disease and treatment effectiveness (prognosis). They are useful tools in determining what therapy is appropriate and the chance of treatment success.
Staging

Certain imaging tests, including CT and MRI scans, can help determine staging. Blood tests will also be done to evaluate your overall health and to detect whether the cancer has spread to certain organs.

A staging system is a standardized way in which the cancer care team describes the extent of the cancer. The most commonly used staging system was developed by the American Joint Committee on Cancer (AJCC)
American Joint Committee on Cancer (AJCC) TNM Staging System

The AJCC staging system is based on the evaluation of the tumor size on the kidney (T), the number of lymph nodes (N) and the extent of metastisis (M). Evaluation of the T, N and M components is followed by a stage grouping.

The T component designates the size of the tumor. The numerical value increases with tumor size and extent of invasiveness. The letter T followed by a number from 0 to 3 describes the tumor's size and spread to nearby tissues. Some of these numbers are further subdivided with letters, such as T1a and T1b. Higher T numbers indicate a larger tumor and/or more extensive spread to tissues near the kidney.

The N component designates the presence or absence of tumor in the regional lymph nodes. In some sites there is an increasing numerical valued based on size, fixation, or capsular invasion. In other sites, numerical value is based on multiple node involvement or number of location and the regional lymph nodes. The letter N followed by a number from 0 to 2 indicates whether the cancer has spread to lymph nodes near the kidney and, if so, how many are affected. Lymph nodes are bean-sized collections of immune system cells that help fight infections and cancers.

The M component identifies the how distant the spread of the cancer has been, including lymph nodes that are not in the region of the original tumor. The letter M followed by a 0 or 1 indicates whether or not the cancer has spread (metastasized) to distant organs such as the lungs or bones, or to lymph nodes that are not near the kidneys.
Detailed Definitions of T, N, and M Categories
Primary tumor (T)

TX: Primary tumor cannot be assessed (information not available).
T0: No evidence of a primary tumor.
T1a: Tumor is 4 cm (about 11/2 inches) in diameter or smaller and is limited to the kidney.
T1b: Tumor is larger than 4 cm but smaller than 7 cm (about 2¾ inches) and is limited to the kidney.
T2: Tumor is larger than 7 cm but is still limited to the kidney.
T3a: Tumor has spread into the adrenal gland or into fatty tissue around the kidney, but not beyond a fibrous tissue called Gerota’s fascia, which surrounds the kidney and nearby fatty tissue.
T3b: Tumor has spread into the large vein leading out of the kidney (renal vein) and/or the part of the large vein leading into the heart (vena cava) that is within the abdomen.
T3c: Tumor has reached the part of the vena cava that is within the chest or invades the wall of the vena cava.
T4: Tumor has spread beyond Gerota’s fascia (fibrous tissue that surrounds the kidney and the fatty tissue next to the kidney).
Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed (information not available).
N0: No regional lymph node metastasis.
N1: Metastasis to one regional (nearby) lymph node.
N2: Metastasis to more than one regional (nearby) lymph node. Distant metastasis (M):
Extent of Metastasis (M)

MX: Presence of distant metastasis cannot be assessed (information not available).
M0: No distant metastasis.
M1: Distant metastasis present; includes metastasis to non-regional (not near the kidney) lymph nodes and/or to other organs (such as the lungs, bones, or brain).
Renal Cell Cancer Stage Grouping

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping to determine a patient’s overall disease stage. This is expressed in Roman numerals from stage I (the least serious or earliest stage) to stage IV (the most serious or advanced stage).

Stage I: T1a-T1b, N0, M0. The tumor is 7 cm or smaller and limited to the kidney. There is no spread to lymph nodes or distant organs.

Stage II: T2, N0, M0. The tumor is larger than 7 cm but is still limited to the kidney. There is no spread to lymph nodes or distant organs.

Stage III: T1a-T3b, N1, M0 or T3a-T3c, N0, M0. Several combinations of T and N categories are included in this stage. These include any tumor that has spread to only one nearby lymph node but not to other organs. Stage III also includes tumors that have not spread to lymph nodes or distant organs but have spread to the adrenal glands, to fatty tissue around the kidney, and/or have grown into the large vein (vena cava) leading from the kidney to the heart.

Stage IV: T4, N0-N1, M0 or Any T, N2, M0 or Any T, Any N, M1. Several combinations of T, N, and M categories are included in this stage, which includes any cancers that have spread directly through the fatty tissue and beyond Gerota’s fascia, the fibrous tissue that surrounds the kidney. Stage IV also includes any cancer that has spread to more than one lymph node near the kidney, or to any lymph node distant from the kidney, or to any distant organs such as the lungs, bone, or brain.
Grading

The system for determining the characteristics of a cancer’s cells is called Fuhrman grading. The Fuhrman grade is determined by a pathologist, who will review the cellular details of your tumor. The grade is based on an examination of how closely the cancer cell’s nucleus (part of a cell in which DNA is stored) resembles a normal kidney cell’s nucleus.

Kidney cancers are usually given a Fuhrman grade on a scale of 1 through 4. Grade 1 kidney cancers have cell nuclei that look very much like a normal kidney cell nucleus. These cancers are usually slow growing and are slow to spread to other parts of the body (metastasize). They tend to have a good outlook (prognosis). Grade 4 kidney cancer, on the upper end of the Fuhrman scale, looks quite different from normal kidney cells and has a worse prognosis. Generally, the higher the Fuhrman grade the worse the prognosis.

snydergirl
Posts: 15
Joined: Dec 2011

I am new here, my husband was diagnosed 11/23/11 with Stage 4/Grade 2 Clear Cell RCC. He had a 10.5 cm tumor in the lower base of his left kidney. He had an open radical nephrectomy on 12/29/12. After seeing the pathology of the tumor it was identified as a T3a, Nx, Mx. His lymph nodes in the abdomen were enlarged, but have not been biopsied. The surgical margins were clear, we met with an oncologist last wednesday and he had no plan going forward other than CT scans in 3 weeks. It seem we should be a little more proactive, or am I wrong? It seems to me that Stage IV should require a little more diligence. Fortunately the grade is 2, so slow growing , but still??
We found this tumor because David had a chest Xray which showed a mass in his chest,as well as enlarged lymph nodes, when they did the initial CT scan the tech spotted the tumor and we were off on this ride. Since the surgery the obviously enlarged lymph nodes has shrunken to the point of disappearing, they were obvious even to me. I am questioning the staging as well as why aren't they trying to find out what is going on in his lymph system. There is no evidence of mestasis in any other organ, lungs, brain or bone and no evidence in blood or urine. I am so confused and can't get a straight answer from any of the doctors we have seen. Did your doctors have experience specifically with RCC.We haven't found an oncologist that seems to know this cancer. I have I am now looking into going to MD Anderson. I welcome any thoughts..Jeanne

Limelife50's picture
Limelife50
Posts: 411
Joined: Nov 2011

Yes I am a strong believer in God even more now since my kidney diagnoses,I am not trying to be rude I just feel we all have some control on our lives,and educating ourselfs as much as we can and taking advantage of what God has provided for us can make a difference.I am sorry to say this but when I hear people say they are putting their lives in Gods hands I have a little bit of a hard time with that considering he has a universe to run,but I believe if we help ourselves then God will also help us.

MikeK703's picture
MikeK703
Posts: 235
Joined: Sep 2010

I absolutely agree with you except for the universe running part :)
I don't think God would be God if running the universe made it impossible or even difficult to become involved in our lives also.
Mike

myboys2's picture
myboys2
Posts: 50
Joined: Nov 2011

The reason I say that is I have seen people that are stage 1 no distant mets no local lymph etc in 3 months have fast growth in approx 3 months. And I have seen people that are stage 4 holding steady in comparison for years. I belong to 4 sites and read info on them daily to stay on top of new information and experiences.

Gail mother of Cody 21
diagnosis 8/10/11 unclassified RCC T1B N0 M1
8/16 checked into NYU as emergency surgeon concerned head skull tumor was closing ventricle to brain
8/17 embolization via femoral artery to bone lesion on skull 7 hours
8/18 repeat
8/19 10.5 hour surgery to remove skull mass (about 45% right skull)
8/20 began a vegan(from an animal product standpoint) gluten free low glycemic diet; no casein but we do eat ocean caught fish and org chicken; org green drink every day
9/4 titanium skull inserted
9/29 begin sutent 25mg 2 weeks on one week off; then 37.5 2 weeks on 1 week off; then 50mg for 3 weeks then off 5 days (preop tests show 3 tiny liver lesions shrinking) Also Xgeva injection. No lymph,lung or brain involvement
11/16 full neph of lft kidney 5.5 tumor (started at 6cm but sutent was working!!) Still unclassified 
12/1 begin sutent again at 37.5 to work into it
12/8 sutent to 50mg for a week then off a week and continue cycle of 50 2 weeks on 1 week off until next scans (due in late Feb)
12/12 began radiation of remaining skull mets Monday and Thursday for 3 weeks high dose (already noted necrosis of tumor after one dose)
12/31 completed high dose radiation of skull mets
1/10 rescans stability and continued remission
1/13 Dr. Dutcher confirmed what we thought to be true on 1/10; remaining on Sutent 50 mg 2/1 week cycle

1/14 We have stable disease with less conspicuous liver tumors (2). Don’t know why they just don’t say they are shrinking and necrosis is setting in but Dr. Dutcher does not. We are almost to NED and Sutent seems to be working marvelously. Hopefully we will get a long run from it. Cody will be returning to college Monday 1/16 and back to his life.
When he returns in May we have to consider HDIL2 or not, wait for PD1 which has far less side affects and rave response rate, or just remain stable w remission on Sutent.

Limelife50's picture
Limelife50
Posts: 411
Joined: Nov 2011

I was trying to look at the full picture and I am sorry but I think we can always find exceptions.I have always felt statistics do not lie,but then again there are always exceptions,let me give you an example.My uncle who is 85 years old smokes a pack of cigarettes a day and he is in good health considering his age,so now does that mean I should ignore the facts or statistics when it comes to the risks of smoking,I'm sorry but I do not think so.

snydergirl
Posts: 15
Joined: Dec 2011

I am new here, my husband was diagnosed 11/23/11 with Stage 4/Grade 2 Clear Cell RCC. He had a 10.5 cm tumor in the lower base of his left kidney. He had an open radical nephrectomy on 12/29/12. After seeing the pathology of the tumor it was identified as a T3a, Nx, Mx. His lymph nodes in the abdomen were enlarged, but have not been biopsied. The surgical margins were clear, we met with an oncologist last wednesday and he had no plan going forward other than CT scans in 3 weeks. It seem we should be a little more proactive, or am I wrong? It seems to me that Stage IV should require a little more diligence. Fortunately the grade is 2, so slow growing , but still??
We found this tumor because David had a chest Xray which showed a mass in his chest,as well as enlarged lymph nodes, when they did the initial CT scan the tech spotted the tumor and we were off on this ride. Since the surgery the obviously enlarged lymph nodes has shrunken to the point of disappearing, they were obvious even to me. I am questioning the staging as well as why aren't they trying to find out what is going on in his lymph system. There is no evidence of mestasis in any other organ, lungs, brain or bone and no evidence in blood or urine. I am so confused and can't get a straight answer from any of the doctors we have seen. Did your doctors have experience specifically with RCC.We haven't found an oncologist that seems to know this cancer. I have I am now looking into going to MD Anderson. I welcome any thoughts..Jeanne

MikeK703's picture
MikeK703
Posts: 235
Joined: Sep 2010

Hi Jeanne,
I'm afraid I can't help much with your questions; hopefully somebody here with more knowledge will respond. But I do know the importance of finding an oncologist who specializes in kidney cancer. If you're not happy with your doctors, find somebody you can trust. I don't know anything about MD Anderson, but if they have oncologists who specialize in kidney cancer, you're on the right track. Your husband is fortunate to have a caregiver who will stubbornly refuse to tolerate haphazard medical care. Best wishes.
Mike

snydergirl
Posts: 15
Joined: Dec 2011

Thanks Mike,

I appreciate your thoughts. I asked one oncologist if he specialized in RCC and he told me that there was no such specialist. That was all I had to hear, especially after reading these boards.

Jeanne

MikeK703's picture
MikeK703
Posts: 235
Joined: Sep 2010

Jeanne,
Perhaps they are correct in the terminology "specialist" but there are oncologists who have a lot more experience with kidney cancer than other oncologists. Those are the ones you need to seek out.
Mike

MikeK703's picture
MikeK703
Posts: 235
Joined: Sep 2010

Jeanne,

I hope the terminology I used didn't confuse you. I would think your urologist should know whether or not an oncologist he is working with is experienced in kidney cancer. You may have to do your own legwork to find the right doctor.

But for after you do find one here are some good questions to ask:

http://www.cancermonthly.com/questions_oncologist.asp

foxhd's picture
foxhd
Posts: 1951
Joined: Oct 2011

Jeanne and Mike. I believe my oncologist is a "specialist" in kidney cancer and melanoma. You may have to go to a larger cancer hospital to find specialists.

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