Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The TNM classification calculator for renal cell carcinoma evaluates the stage of cancer based on user inputs regarding the primary tumor, regional lymph nodes, and distant metastasis. Each input correlates to specific stages in a detailed classification system, transforming these inputs into a comprehensive cancer staging result.

The classification splits inputs into three categories:

1. Tumor Classification (T):
   - Tx: Primary tumor cannot be assessed.
   - T0: No evidence of primary tumor.
   - T1a: Tumor limited to kidney, <= 4 cm.
   - T1b: Tumor limited to kidney, > 4 cm but <= 7 cm.
   - T2a: Tumor limited to kidney, > 7 cm but <= 10 cm.
   - T2b: Tumor limited to kidney, > 10 cm.
   - T3a: Tumor extends into the renal vein, or the pelvicalyceal system, or fat but not beyond Gerota fascia.
   - T3b: Tumor extends into vena cava below the diaphragm.
   - T3c: Tumor extends into vena cava above the diaphragm or invades the wall.
   - T4: Tumor invades beyond Gerota fascia.

2. Lymph Node Classification (N):
   - Nx: Regional lymph nodes cannot be assessed.
   - N0: No regional lymph node metastasis.
   - N1: Regional lymph node metastases.

3. Distant Metastasis (M):
   - M0: No distant metastasis.
   - M1: Distant metastasis present.

The result is computed by evaluating conditions combining each classification:

- Stage I: If T1a or T1b (tumor limited to kidney) and N0 with M0.
- Stage II: If T2a or T2b (larger tumors still confined to the kidney) and N0 with M0.
- Stage III: If either T1, T2 with N1 and M0, or any T3 combined with any N and no distant metastasis (M0).
- Stage IV: If T4 with any lymph node status (Nx, N0, N1) and M0, or if any T-status combined with any N-status and the presence of distant metastasis (M1).

If none of these conditions are met, the result is "Stage cannot be fully assessed." The system ensures that each input is assessed and classified correctly by matching them to conditions representing stages I through IV, or by indicating that the stage cannot be evaluated if inputs are incomplete or ambiguous. The output is a concise result of the cancer stage based on the given information.

The calculator in question is the TNM (Tumor, Node, Metastasis) Classification for Renal Cell Carcinoma. This is a staging system used by clinicians to determine the extent of cancer spread in patients diagnosed with renal cell carcinoma, a type of kidney cancer. 

The TNM system is universally used for the staging of various types of cancers. In the context of renal cell carcinoma, it helps to stratify patients based on the size and extent of the primary tumor (T), the involvement of nearby lymph nodes (N), and the presence of distant metastasis (M). 

The clinical utility of this calculator is to guide treatment decisions and to provide prognostic information. It helps clinicians to determine the most appropriate treatment options, ranging from surgery to systemic therapies, and to predict the patient's potential survival outcome. 

There are no specific exclusion criteria for the use of the TNM Classification for Renal Cell Carcinoma. However, it is important to note that this system is not used for other types of kidney cancers such as transitional cell carcinoma of the renal pelvis.

TNM classification for renal cell carcinoma

The IMDC risk model for metastatic renal cell carcinoma offers a method to evaluate patient risk, ultimately influencing treatment decisions and forecasting median survival times. This tool looks at six specific health indicators to compute a risk score. Here’s how it works:

- A patient’s score is based on the presence of the following conditions, each contributing 1 point if true:
  - Less than 1 year from the time of diagnosis to systemic therapy
  - Karnofsky Performance Status under 80%
  - Low hemoglobin levels, specifically below 120 g/L or 12 g/dL
  - Elevated corrected calcium, generally above 8.5-10.2 mg/dL
  - High neutrophil count, typically over 2.0-7.0×10⁹/L
  - Elevated platelet count, usually above 150,000-400,000 cells/mcL

The process involves evaluating each condition individually—assigning a point for each condition met—and summing these to yield a total score. This combined score provides a clear risk classification and suggests potential survival outcomes:

- A score of 0 signifies a "Favorable risk," corresponding to a median survival of 43.2 months.
- Scores of 1 or 2 reflect "Intermediate risk," with a median survival span of 22.5 months.
- Scores of 3 or higher designate a "Poor risk," indicating a median survival of just 7.8 months.

The risk model simplifies complex clinical data into a straightforward score that offers critical insights into a patient’s prognosis, helping inform decisions about their treatment path and expected survival trajectory.

The calculator in question is the IMDC Risk Model, also known as the International Metastatic Renal Cell Carcinoma Database Consortium Model. This scoring system is specifically designed for patients with metastatic renal cell carcinoma (mRCC). 

The IMDC Risk Model is used to stratify patients into different risk groups (favorable, intermediate, and poor) based on six clinical and laboratory factors. These factors include time from diagnosis to treatment, Karnofsky performance status, hemoglobin, corrected calcium, neutrophils, and platelets. 

The clinical utility of this calculator is to predict overall survival and progression-free survival in patients with mRCC. It helps clinicians to make informed decisions about the most appropriate treatment strategy for individual patients, including the selection of first-line targeted therapy and the consideration for clinical trial enrollment.

There are no specific exclusion criteria for the use of the IMDC Risk Model. However, it should be noted that this model may not be applicable or accurate in patients with non-clear cell renal cell carcinoma or in those with brain metastases, as these patients were underrepresented in the original IMDC cohort.

IMDC risk model for metastatic renal cell carcinoma

The MSKCC score calculator for metastatic renal cell carcinoma uses five clinical criteria to estimate a patient's prognosis. This score helps to predict median survival outcomes based on certain health factors. Each criterion is evaluated as true or false, contributing to a total score that ranges from 0 to 5.

The criteria are:

- Elevated LDH: If lactate dehydrogenase levels are more than 1.5 times the upper limit of normal, the patient receives 1 point.
- Low Hemoglobin: If hemoglobin levels are less than 13.5 g/dL for males and less than 12 g/dL for females, the patient receives 1 point.
- High Corrected Calcium: If corrected calcium levels exceed 10 mg/dL (or 2.5 mmol/L), the patient receives 1 point.
- Reduced Karnofsky Performance Status: If the Karnofsky performance status is less than 80%, the patient receives 1 point.
- Prior Nephrectomy: The absence of prior nephrectomy results in 1 point (unlike the other criteria, this factor is positive when the answer is false).

The total score is determined by summing the points from these criteria. Based on this score, the calculator provides a prognosis interpretation:

- A score of 0 indicates a median survival of 20 months.
- Scores of 1 or 2 indicate a median survival of 10 months.
- Scores of 3 or higher indicate a median survival of 4 months. 

These interpretations help healthcare providers and patients understand potential outcomes and care strategies.

The MSKCC Score for Metastatic Renal Cell Carcinoma, also known as the Memorial Sloan Kettering Cancer Center Prognostic Score, is a clinical tool used to predict survival in patients with metastatic renal cell carcinoma (mRCC). This scoring system is based on five clinical and laboratory parameters: Karnofsky performance status, time from diagnosis to systemic treatment, lactate dehydrogenase (LDH) levels, hemoglobin levels, and corrected serum calcium levels. 

The MSKCC score stratifies patients into three risk groups (favorable, intermediate, and poor) based on the number of risk factors present. This helps clinicians to predict the prognosis of patients with mRCC and guide treatment decisions. 

The MSKCC score is specifically designed for patients with metastatic renal cell carcinoma and should not be used in patients with localized disease or other types of kidney cancer. It also may not be applicable in patients with significant comorbidities or those who have received prior systemic therapy for mRCC.

MSKCC score for metastatic renal cell carcinoma

The SSIGN score for renal cell carcinoma evaluates the severity of the disease based on six clinical and pathological criteria: T stage, N stage, M stage, tumor size, tumor nuclear grade, and tumor necrosis. Each criterion is assigned a numerical score according to specified response categories. The total score provides an estimate of the 5-year cancer-specific survival rate, with higher scores indicating poorer prognosis.

The scoring system assigns values as follows:
- T Stage: pT1 = 0, pT2 = 1, pT3a-c = 2, pT4 = 3
- N Stage: pNx = 0, pN0 = 0, pN1 = 2, pN2 = 2
- M Stage: M0 = 0, M1 = 4
- Tumor Size: < 5 cm = 0, >= 5 cm = 2
- Tumor Nuclear Grade: 1-2 = 0, 3 = 1, 4 = 3
- Tumor Necrosis: Absent = 0, Present = 2

To compute the total score, each of the inputs is mapped to its corresponding score value. These values are summed to yield a total score between 0 and 16. The interpretation of the total score is based on survival likelihood estimates:

- Scores 0 to 1: Estimated 5-year cancer-specific survival is 99.4%
- Score 2: Estimated 5-year cancer-specific survival is 94.8%
- Score 3: Estimated 5-year cancer-specific survival is 87.8%
- Score 4: Estimated 5-year cancer-specific survival is 79.1%
- Score 5: Estimated 5-year cancer-specific survival is 65.4%
- Score 6: Estimated 5-year cancer-specific survival is 54%
- Score 7: Estimated 5-year cancer-specific survival is 41%
- Score 8: Estimated 5-year cancer-specific survival is 23.6%
- Score 9: Estimated 5-year cancer-specific survival is 19.6%
- Scores 10 or higher: Estimated 5-year cancer-specific survival is 7.4%

The SSIGN Score, or the Stage, Size, Grade, and Necrosis Score, is a prognostic calculator specifically designed for patients with renal cell carcinoma (RCC). This scoring system is used to predict the survival rate of patients with RCC after undergoing nephrectomy. It takes into account the tumor stage, tumor size, Fuhrman grade, and the presence of tumor necrosis. The SSIGN score helps clinicians to stratify patients into different risk groups and guide treatment decisions. It is not applicable to patients with non-renal cell carcinoma or those who have not undergone nephrectomy.

SSIGN score for renal cell carcinoma

The Eastern Cooperative Oncology Group (ECOG) performance status calculator is designed to evaluate a patient's functional ability and categorize it into a specific score from 0 to 5. This quantitative measure helps clinicians make informed decisions about treatment based on the patient's capacity for daily activities and self-care. Here's how it operates:

The user provides input by selecting the description that best matches the patient's current condition from a list of predefined options. These options encapsulate various levels of activity and ability:

- A patient who is "Fully active, able to carry on all pre-disease performance without restriction" is assigned a score of ECOG PS 0. This indicates that the patient is not limited in any capacity by their disease.
- If a patient is "Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, such as light housework, office work," they receive an ECOG PS 1. This means the patient can perform some self-care and work activities but faces restrictions with strenuous tasks.
- "Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours" corresponds to an ECOG PS 2. This reflects moderate impairment, where the patient is active for the majority of the day but not capable of work activities.
- A patient who is "Capable of only limited self-care, confined to bed or chair more than 50% of waking hours" gets an ECOG PS 3. This score denotes significant limitation, as the patient is mobile for less than 50% of the time and requires assistance for most activities.
- With "Completely disabled, cannot carry on any self-care, totally confined to bed or chair," the patient is categorized as ECOG PS 4, indicating severe impairment and complete dependency.
- Finally, if the patient is "Dead," they are assigned an ECOG PS 5.

These score assignments help standardize assessments, providing an objective measure of a patient's status which can be pivotal in guiding medical decisions and evaluating treatment options.

The Eastern Cooperative Oncology Group (ECOG) performance status, also known as the ECOG score, is a widely used tool in oncology to assess a patient's level of functioning in terms of their ability to care for themselves, daily activity, and physical ability (walking, working, etc.). It is applicable to patients with cancer of any type and at any stage.

The ECOG score ranges from 0 to 5, with 0 indicating fully active and able to carry on all pre-disease activities without restriction, and 5 indicating death. The score is used to determine a patient's prognosis, assess how a disease is progressing, and to determine appropriate treatment strategies. It is also often used in clinical trials to assess eligibility and to monitor patient progress.

There are no specific exclusion criteria for the use of the ECOG score, but it is important to note that it is a subjective measure and may not fully capture a patient's functional status. It is also less useful in patients with fluctuating or rapidly changing conditions.

Eastern Cooperative Oncology Group performance status (ECOG score)

The Karnofsky Performance Scale (KPS) provides a practical method to evaluate a patient's functional ability and the extent of care required based on their health status. The scale ranges from 0% to 100%, where higher percentages signify better functional capacity and health.

This tool involves selecting a descriptive statement that best reflects a patient's current condition from a predefined list. Each statement is connected to a specific KPS percentage that indicates the patient’s ability to perform daily activities and their dependency levels. Here’s how the assessment works:

- When a patient is described as "Normal, no complaints, no evidence of disease," this is assessed as KPS 100%. At this level, the individual can engage in all regular activities, including work, without needing special care.

- If a patient can "carry on normal activity" but exhibits "minor signs or symptoms of disease," they are scored at KPS 90%, indicating the capability to maintain routine activities without requiring special care.

- A description of "Normal activity with effort, some signs or symptoms of disease" aligns with KPS 80%. This suggests the patient can still carry out normal activities but might require some extra effort.

- When the condition reflects "Cares for self, unable to carry on normal activity or to do active work," it corresponds to KPS 70%. The patient can handle most personal needs independently but may need occasional assistance.

- "Requires occasional assistance but is able to care for most personal needs" is rated as KPS 60%, implying increased dependency on assistance though the patient remains mostly self-sufficient.

- At KPS 50%, for conditions described as "Requires considerable assistance and frequent medical care," the patient can live at home but needs considerable help with personal care.

- As the need for care intensifies, with descriptions like "Disabled, requires special care and assistance," the KPS drops to 40%. This marks a significant deterioration in self-care ability.

- "Severely disabled, hospital admission is indicated, death not imminent" corresponds to KPS 30%, highlighting a need for hospitalization without immediate life-threatening conditions.

- For those "Very sick," necessitating hospital admission and "active supportive treatment," the KPS is 20%, indicating critical care requirements.

- At KPS 10%, "Moribund" denotes an inability to care for oneself, with urgent need for hospital-level care and a poor prognosis.

- Lastly, "Dead" is considered as KPS 0%.

This scale is instrumental in providing a quick overview of a patient's ability to function independently and their need for medical support, thereby facilitating better care planning and resource allocation.

The Karnofsky Performance Status Scale (KPSS) is a clinical calculator used primarily in patients with cancer. It is a simple, numerical scale that measures a patient's functional status, ability to perform daily activities, and overall quality of life. The KPSS ranges from 0 (indicating death) to 100 (indicating perfect health). 

The clinical utility of the KPSS is to assess a patient's prognosis, determine appropriate treatment strategies, and monitor changes in a patient's condition over time. It is particularly useful in oncology for determining eligibility for certain treatments, such as chemotherapy or surgery, and for predicting survival outcomes. 

There are no specific exclusion criteria for the use of the KPSS. However, it is less useful in patients with non-cancer illnesses or in those with cognitive impairment who may not be able to accurately self-report their functional status.

Karnofsky Performance Scale

The Modified Glasgow Prognostic Score (mGPS) is a key tool in predicting cancer outcomes, relying on the assessment of two biochemical markers: C-reactive protein (CRP) and albumin. This score helps to categorize the prognosis into three levels: good, intermediate, and poor.

To compute the mGPS:

- C-reactive protein is evaluated first. Two options are considered:  
  - If the CRP is less than or equal to 10 mg/L, it indicates lower systemic inflammation.
  - If the CRP is greater than 10 mg/L, it signifies higher inflammation levels.

- Albumin is the second marker, with two possibilities:  
  - An albumin level of less than 3.5 g/dL [35 g/L] suggests malnutrition or potential inflammatory conditions.
  - An albumin level equal to or greater than 3.5 g/dL [35 g/L] signifies a normal nutritional status and protein reserves.

The mGPS score is derived based on the following systematic interpretation:

- If CRP is <= 10 mg/L, regardless of the albumin level, the score is mGPS 0, corresponding to a good prognosis. This combination indicates a low level of inflammation, which is a favorable signal in cancer outcomes.
 
- If CRP is > 10 mg/L and albumin is >= 3.5 g/dL [35 g/L], the score is mGPS 1, associated with an intermediate prognosis. This combination suggests elevated inflammation yet with sufficient nutritional status, resulting in a moderate outlook.

- If CRP is > 10 mg/L and albumin is < 3.5 g/dL [35 g/L], the result is mGPS 2, indicating a poor prognosis. This reflects high inflammation levels coupled with low albumin, suggesting a more severe condition.

Here's a concise summary table for reference:

| C-reactive Protein | Albumin               | mGPS Score | Interpretation          |
|---------------------|-----------------------|-------------|-----------------------|
| <= 10 mg/L          | < 3.5 or >= 3.5 g/dL  | 0           | Good prognosis         |
| > 10 mg/L           | >= 3.5 g/dL           | 1           | Intermediate prognosis |
| > 10 mg/L           | < 3.5 g/dL            | 2           | Poor prognosis         |

This systematic approach enables healthcare providers to improve risk stratification in cancer patients, allowing for more tailored treatment planning.

The Modified Glasgow Prognostic Score (mGPS) is a clinical calculator used in the field of oncology to predict the prognosis of patients with cancer. It is applicable to a wide range of cancer types and stages, making it a versatile tool for clinicians. The mGPS is based on two simple, routinely measured inflammatory markers: C-reactive protein (CRP) and albumin levels. 

The clinical utility of the mGPS lies in its ability to stratify patients into different risk groups based on their inflammatory response to cancer. This can guide clinicians in making decisions about treatment strategies and follow-up plans. It can also provide valuable prognostic information to patients and their families.

There are no specific exclusion criteria for the use of the mGPS. However, it should be noted that the score may not be as accurate in patients with concurrent inflammatory or infectious conditions, as these can also affect CRP and albumin levels. Additionally, the mGPS may not be applicable to patients with rare types of cancer or those with very early or very advanced disease, as it has not been extensively validated in these groups.

Modified Glasgow Prognostic Score for cancer outcomes (mGPS)

Renal cell carcinoma

Management of advanced/metastatic disease

Management of advanced/metastatic disease, papillary cell RCC

Management of local/locoregional disease

Management of local/locoregional disease (definitive therapy)

Management of advanced/metastatic disease, clear cell RCC, second-line therapy

Imaging for staging

Management of local/locoregional disease, ablation

Surveillance for recurrence

Surveillance for recurrence (low-risk, pT1 tumors)

Management of advanced/metastatic disease, other non-clear cell RCC

Management of advanced/metastatic disease (metastasis-directed therapy, tumor thrombus)

Patients with renal oncocytoma

Classification

Management of advanced/metastatic disease, metastasis-directed therapy, brain metastases

Indications for referral

Genetic testing

Management of local/locoregional disease, adjuvant therapy

Patients with Bosniak III-IV cysts

Patients with Bosniak III-IV cysts (risk assessment)

Surveillance for recurrence, general principles

Management of advanced/metastatic disease, sarcomatoid features

Management of advanced/metastatic disease, cytoreductive nephrectomy

Management of local/locoregional disease, lymphadenectomy

Patients with small renal masses

Patients with small renal masses, watchful waiting

Patients with Bosniak III-IV cysts, management

Patients with Bosniak III-IV cysts, counseling

Management of local/locoregional disease, tumor resection

Management of advanced/metastatic disease, clear cell RCC, first-line therapy

Patients with small renal masses (definition)

Management of local/locoregional disease, adrenalectomy

Management of advanced/metastatic disease, metastasis-directed therapy, bone metastases

Patients with small renal masses, ablation

Diagnosis

Management of advanced/metastatic disease, watchful waiting

Patients with Bosniak III-IV cysts, watchful waiting

History and physical examination

Management of local/locoregional disease, watchful waiting

General principles

Management of local/locoregional disease, neoadjuvant therapy

Surveillance for recurrence (high-risk, pT3/pT4 and N+ tumors)

Management of advanced/metastatic disease, metastasis-directed therapy, general principles

Renal biopsy

Laboratory tests

Patients with small renal masses (indications for referral)

Patients with small renal masses (surgical resection)

General counseling

Indications for screening

Prognostic models

Management of advanced/metastatic disease (general principles)

Surveillance for recurrence (intermediate-risk, pT2 tumors)

Patients with Bosniak III-IV cysts (biopsy)

Patients with small renal masses (biopsy)

Psychosocial support

Updated 2024 ESMO and 2024 EAU guidelines for the diagnosis and management of renal cell carcinoma


Renal cell carcinoma

Guidelines

Key sources