Fuhrman Grade IS VERY IMPORTANT - even for small tumors

SushiSharon said:

Fuhrman Grade
Hi Minnesota Girl. I'm brand new to all of this, and am actually writing from the hospital, where I was admitted for pancreatitis/gastrtitis. Incidentally, an 8.4 cm mass was found on CT on my upper left kidney, touching my spleen. Can you tell me about this "Grade" and what I should expect? I will be seeing my urologist next week, followed laparoscopic nephrectomy in a few weeks.

MikeK703 said:

Fuhrman Grade
I've noticed that the folks who brought up Fuhrman Grading system remarked about not intending to scare or alarm anyone. They shouldn't worry about that. All of us need to be realistic and as knowledgeable as possible. I for one, welcome any information about kidney cancer and the battle I am facing in the near and long term. Knowledge is power, as they say.

I've quoted below from the UCLA kidney cancer site. Here is the web page:
http://kidneycancer.ucla.edu/body.cfm?id=37

Note that in addition to staging and grading, excellent and poor health are also factors in the system.

"There are two common staging systems for RCC, the TNM [tumor-node-metastasis] System and the New University of California Los Angeles Integrated Staging System (UISS). The Fuhrman Grading System is a system used to describe how kidney tumors appear under the microscope.

"The New UCLA Integrated Staging System (UISS) is a more complex but probably more accurate system that incorporates the TNM staging systems, a person's overall health and the Fuhrman grade of the tumor.

"In the UISS system: Patients without any tumor spread are divided into three groups: low risk, intermediate risk and high risk.

"The Low Risk group is considered Stage I; are in excellent health other than the cancer and have a low Fuhrman grade tumor.
The Intermediate Risk group is all others, without any spread.
The High Risk group is either Stage III (but without lymph node spread), in poor health and have a high Fuhrman grade score; or Stage IV (without any spread, T4, N0, M0).
The five-year cancer-specific survival (only deaths from cancer) for the low risk group is 91%, for the intermediate risk group is 80%, and for the high risk group is 55%."

Mike

MikeK703 said:

Fuhrman Grade
I've noticed that the folks who brought up Fuhrman Grading system remarked about not intending to scare or alarm anyone. They shouldn't worry about that. All of us need to be realistic and as knowledgeable as possible. I for one, welcome any information about kidney cancer and the battle I am facing in the near and long term. Knowledge is power, as they say.

I've quoted below from the UCLA kidney cancer site. Here is the web page:
http://kidneycancer.ucla.edu/body.cfm?id=37

Note that in addition to staging and grading, excellent and poor health are also factors in the system.

"There are two common staging systems for RCC, the TNM [tumor-node-metastasis] System and the New University of California Los Angeles Integrated Staging System (UISS). The Fuhrman Grading System is a system used to describe how kidney tumors appear under the microscope.

"The New UCLA Integrated Staging System (UISS) is a more complex but probably more accurate system that incorporates the TNM staging systems, a person's overall health and the Fuhrman grade of the tumor.

"In the UISS system: Patients without any tumor spread are divided into three groups: low risk, intermediate risk and high risk.

"The Low Risk group is considered Stage I; are in excellent health other than the cancer and have a low Fuhrman grade tumor.
The Intermediate Risk group is all others, without any spread.
The High Risk group is either Stage III (but without lymph node spread), in poor health and have a high Fuhrman grade score; or Stage IV (without any spread, T4, N0, M0).
The five-year cancer-specific survival (only deaths from cancer) for the low risk group is 91%, for the intermediate risk group is 80%, and for the high risk group is 55%."

Mike

MikeK703 said:

UISS and Fuhrman
Hi Michael,

This stuff about Fuhrman grade and UISS and other staging systems is mostly all Greek to me (no offense to my Greek friends out there). When my urologist explained the pathology report, he seemed to skim over the Fuhrman system. When I asked about the Fuhrman Grade 2 on my next visit, he made an attempt to explain it but it went right over my head. He ended up telling me not to worry about it. Most of the stuff online regarding Fuhrman and UISS is not written for the layman. But based on what I have read, I'm guessing (note the word "guessing") that the reason the doctor told you that UISS does not apply in your case is because yours is papillary RCC and not clear cell RCC and he may be of the school that thinks the Fuhrman grade (which is used by the UISS) is not necessarily valid for papillary RCC. Again that's just a guess. If it is bothering you, you should definitely ask him about it. I'm in a big HMO and all of my doctors respond to emails. (I'm not crazy about some of my HMO's policies but I have to admit they do a pretty good job of getting back to me.)

Here is a quote from a web page I found:

"Although use of the Fuhrman grading system as a prognostic tool has been validated for clear cell renal carcinoma, its use for the other histologic subtypes (especially papillary and chromophobe) is a topic of debate."

Here's the web page if you're interested:
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-6193-9..10040-5--s0040&isbn=978-1-4160-6193-9&type=bookPage&from=content&uniqId=315914895-2

And there's plenty more technical stuff on the web that is just as confusing as that page.

Regards,
Mike

keong72 said:

chromophobe
Hi BG,I am new member and my tumour also is chromophobe grade 2 size 6x5,can u give me some info about chromophobe tumour, I so worry about this tumour and very hard find info ,thank u,,,,,


Regards
keong72

Texas_wedge said:

Fuhrman Grade IS VERY IMPORTANT - even for small tumors
MNGirl is a valuable and well-informed contributor on this forum and I generally find myself in complete agreement with what she says. However, while appreciating that in starting this thread she had the best of intentions, I feel I must take issue with the statement in her subject line and the statistics she quotes. I think these are misleading and could be damaging to many readers. Let me explain why.

A positive attitude is crucial for all of us here and MNGirl is a staunch supporter of that view and has done much to promote it. A major, probably THE major, obstacle to maintaining that attitude is undue attention to the "statistics" , many of which are, for our purposes as individual patients, virtually meaningless (for reasons some of which I shall detail below) and an oncologist who flourishes 'survival charts' is an oncologist who doesn't know what he/she is doing.

For the vast majority of RCC patients, the principal prognostic factors are tumour size and, particularly, stage. Fuhrman grade is not of as much relevance. Even for the few that MNGirl has in mind, with small tumours and early stage but high grade, (and there are surely few stage 1 but grade 4 tumours?) it is questionable whether it often makes a practical difference to the actions of the patient or the treatment indicated. It does, however, give the patient yet another thing to worry about. This has just been illustrated by a newbie, Cool Breeze, who is a RN and yet still says "I'm freaked about the prognosis of grade 3." and "Now after reading all the posts on the furhman scale I have to say I'm frightened."

It's fine to exercise sensible caution and not be complacent about one's prognosis but for many patients that can easily tip over into a paranoid preoccupation with the statistics and consequent counter-productive anxiety and over-attention to every little ache and pain that might be 'important'. These threads attest to the emotional lability and vulnerability most of us have felt.

Mike made the sound comment that "Knowledge is power", a view I've also always taken. However, one must also remember the equally valid observation by Alexander Pope "A little learning is a dangerous thing; drink deep, or taste not the Pierian spring". The problem is that it's difficult to drink deep when there's not much there to drink - the knowledge landscape of RCC is still a fairly barren wasteland.

Advances in the medical world, for a combination of both good and bad reasons, take a long while to filter though to general acceptance. Luckily for us progress in cancer research is going on at a good pace. Nonetheless, particularly with the less common cancers we have only just scratched the surface so far.

The statistics and survival calculators based on them are essential for making scientific progress in epidemiology and R & D in developing new treatments. They are not of much value for us, as patients, though - for many reasons.

The first is that any familiarity with probability theory will tell you that you can't extrapolate from population statistics to individual cases in any way that is genuinely helpful for us. [If I believed otherwise, contemplating Bosniak grade 4, Fuhrman grade 4, T4, unknown lymph node involvement, unknown met. status, residual chromophobe now predominantly sarcomatoid (and it gets worse from there) I might just as well not bother to get out of bed tomorrow morning. BUT, in fact, I'll start my day with 18 holes of golf on frozen ground and be busy all day, reading, writing and researching.]

An analogy may help to illustrate the point. When the Belgian polymath Quetelet came up with the Quetelet Index in 1832 (now, due to Ancel Key, known to us as the Body Mass Index or BMI) it was of enormous value for population studies. However, It should never have been applied to individuals where, in various cases, it gives completely spurious results. Until there is widespread use of a better indicator though, it continues to be used with the imprimatur of the World Health Organisation as a measure of obesity for individuals (which it isn't).

Another point is that in this complex field no-one has a monopoly of expertise. We patients need not only 'plumbers' and 'electricians' (urologists, radiologists, oncologists etc) but researchers who are knowledgable about experimental design and sophisticated in statistical theory. No-one can cover all the bases. The result can be calculators devised by people who lack depth of medical knowledge, numbers emanating from medical sources unversed in the necromancy of the statisticians, and so on.

Even the best of survival calculator designers can't make a silk purse from a sow's ear. So much remains to be discovered. The TNM system has seen many refinements over recent years and more can be expected. With the rarer forms of RCC the data are too exiguous to permit of any reliable conclusions. 'The statistics' can't take proper account of an individual's condition (who can even guess what parameters are important - muscular strength, VO2 max. endurance, immune system robustness?). The putative improvement of prediction by the UISS classification is still, inevitably very crude. What are the relative weightings of different aspects of one's 'general health"? How does one know which co-morbidities may be of particular relevance? Very little is known for certain at the present time about the significance of different histological profiles, especially with the rarer forms. So much is still wide open.

Finally, it must be recognised that the 'survival' stats (which are expressed in terms of medians, not 'averages') are all based on data which are hopelessly out-of-date, typically involving cases dating back to years before all the new modalities of detection and treatment. Even the stats in the superb website of the late Steve Dunn (a treasure trove of information and still probably the best starting point for anyone concerned with kidney cancer) all pre-date the major recent advances in adjuvant therapy and the numerous clinical trials now under way.

Speaking personally, looking at "the statistics" I have less to be cheerful about than almost anyone else here but they don't weigh too heavily with me. I'm certainly not going to curl up in a corner and invite the inevitable. If RCC is due to get me it's going to have to go some if it's going to take me out before a wayward golf ball does the job!

Minnesota Girl said:

With all due respect
I have to say, the key message I wanted to emphasize was "to encourage those of us that had small, high-grade tumors to be especially vigilant in our follow-up care." The response I get from "the minority who post links to real information on relevant topics" is that my oncologist is a bad doctor - because he gave me information that I asked for??

Dozens of times on this site, others have stated "the survival rate for small tumors is 99%." That is NOT universally true and I've never seen it challenged. I would not want someone to become complacent because THAT statistic is misunderstood.