Scoring and Staging of Renal Cell Cancers: The Role of CT and MR
G Ballester MD, F Moron MD, J Szklaruk , MD, PhD
The University of Texas MD Anderson Cancer Center
R.E.N.A.L. Scoring RCC
Purpose
P.A.D.U.A. Scoring RCC
• To present the tumor-node-metastasis (TNM) staging system and
compare the various scoring systems for renal cell cancer (RCC).
• Preoperative Aspects and Dimensions Used for Anatomic
scoring systems for renal neoplasms
• Used for nephron-sparing surgery.
• PADUA system score 10 had a 30-37-fold higher risk of
complications.
Staging (TNM) – Renal Cell Cancer
Polar
Location
Primary Tumor (T)
T0
No evidence of primary tumor
T1
Tumor ≤7cm in greatest dimension, limited (ltd) to the kidney
(a)
T1a
Tumor ≤4 cm, ltd to the kidney.
T3 - Staging. (a) Diagram showing vascular tumor extension into the inferior
vena cava (IVC) below the diaphragm (T3b). (b) Coronal post-Gd T1 MR
image of the abdomen shows large mass (arrow head) in the right kidney
with tumor extension into the IVC below the diaphragm (yellow arrow) (T3b).
(c) Diagram shows vascular extension of tumor into the IVC above the
diaphragm (T3c). IVC and atrial tumor thrombus is an independent
predictor of survival.
T1b
Tumor >4 cm but not >7 cm, ltd to the kidney
T2
Tumor >7 cm, ltd to the kidney.
T2a
Tumor >7 cm but ≤10 cm, ltd to the kidney.
T2b
Tumor >10 cm, ltd to the kidney.
T3
Tumor extends into major veins or perinephric tissues but not into
the ipsilateral adrenal gland and not beyond Gerota’s fascia.
T3a
Tumor grossly extends into the renal vein or its segmental
branches, or tumor invades perirenal and/or renal sinus fat but
not beyond Gerota’s fascia.
T3b
Tumor extends into the vena cava below the diaphragm
T3c
Tumor extends into the IVC above the diaphragm or invades the
wall of the IVC.
T4
Tumor invades beyond Gerota’s fascia (including contiguous
extension into the ipsilateral adrenal gland)
Regional Lymph Nodes (N)
and Distant Metastasis (M)
N0
N1
Metastases in regional lymph
node(s)
MO
No distant metastasis
M1
Distant metastases
TNM Staging RCC – Lymph Nodes (N)
Stage I
T1
N0
M0
Stage II
T2
N0
M0
T1 or T2 N1
Stage III
Stage IV
M0
T3
N0 or N1
T4
Any N
M0
Any T
Any N
M1
Urinary
Collecting
System
• Superior/Inferior
• Middle
• 1 point
• 2 points
• >50% exophytic
• <50% exophytic
• endophytic
• 1 point
• 2 points
• 3 points
Exophytic
• Involved (+)
• Not Involved (-)
• 2 points
• 1 point
Nearness to
collecting system
• Involved (+)
• Not Involved (-)
• 2 points
• 1 point
(a)
(a)
N1 - Staging. (a) Diagram showing lymph nodes infiltrated by tumor in the
precaval nodal station. (b) Axial post-contrast CT image of the kidneys
shows a large necrotic node in the interaortocaval nodal station (orange
arrow), and a smaller necrotic node in the left paraaortic nodal station
(yellow arrow), in keeping with N1 staging classification.
Anterior or
Posterior
Location
(a)
(a) Diagram demonstrating the scoring for the P.A.D.U.A. Scoring System
for renal cancer: (I) Polar Location – the dashed lines define the lower and
upper margins of the midpole location. This is an example of a renal mass
in the inferior pole of the kidney (1 point). (II) Exophytic Component – the
mass is more than 50% exophytic (1 point). (III) Sinus Involvement – the
mass extends to the renal sinus (2 points). (IV) Urinary Collecting
System Involvement – the mass extends to the renal pelvis (2 points). (b)
Coronal single shot fast spin echo image of the right kidney. The mass is in
the inferior pole, with more than 50% exophytic component, and no renal
pelvis or renal sinus involvement. The mass is located in posterior face of
the kidney. (Calculated P.A.D.U.A. SCORE = 2b)
• Centrality Index (C-Index) = C/r (C= distance of tumor from
kidney center; r= tumor radius)
• Use as an indicator for both short-term and long-term renal
functional outcome after partial nephrectomy.
• Only central tumor growth had a significant predictive value for
postoperative complications.
C
r
(b)
(c)
T1 - Staging. (a) Diagram of the primary tumor (T1) staging. Lesions T1a are
less than 4cm. Lesions T1b are less than 7 and larger than 4cm limited to the
kidney. (b) Axial post-contrast T1 MR image of the left kidney shows a 2.5cm
mass (arrow) in keeping with a T1a staging classification. (c) Axial postcontrast CT image of the right kidney shows a 6cm mass (arrow) in keeping
with a T1b staging classification.
(a)
(b)
M - Staging. (a) Diagram showing the primary tumor in the left kidney with
a metastatic lesion in the right liver lobe, (M1) staging. (b) Axial postcontrast CT image of the abdomen shows a heterogeneous enhancing
mass in the left kidney (yellow arrow) and multiple peripheral-enhancing
lesions in the right liver lobe, in keeping with M1 staging classification.
Tumor size, N+, and M+ are stronger independent predictors for survival in
patients with RCC.
• >50% exophytic
• <50% exophytic
• endophytic
• 1 point
• 2 points
• 3 points
• > 7mm
• > 4mm but < 7mm
• < 4mm
• 1 point
• 2 points
• 3 points
• Anterior (a)
• Posterior (b)
• Above Upper Pole or Lower Polar
Line
• Crosses polar line
• > 50% of mass is across polar line
• Mass crosses axial renal midline
• Mass 100% between poles
•
•
•
•
•
1 point
2 points
3 points
3 points
3 points
(b)
(a) Diagram demonstrating the scoring for the R.E.N.A.L Scoring System for renal
cancer: (I) Radius – This is an example of a renal mass less than 4cm in size (1 pt).
(II) Exophytic Component – the mass is more than 50% exophytic (1 pt). (III)
Nearness to Collecting System – the mass extends to less than 4mm from the
renal pelvis (3 pts). (IV) Location – the mass is 100 % between the poles (3 pts).
(b) Coronal single shot fast spin echo image of the right kidney. There is a 4.5cm
mass in the lower pole, with more than 50% exophytic component, and no renal
pelvis or renal sinus involvement. The mass is located in posterior face of the
kidney. (Calculated R.E.N.A.L. SCORE = 4b)
Key Concepts for the Radiology Report
• Size and Location: <4cm vs. 4 to 7cm vs 7cm to 10cm, and 10cm;
Upper vs. lower pole vs. interpolar region, distance from center of
kidney – C-index
• Extension: Vascular (renal vein vs. IVC ); Collecting System; Renal
Sinus; Gerota’s fascia; Ipsilateral adrenal gland.
• Nodal metastases and Distal metastases.
Major Teaching Points
References
•
(a)
• 1 point
• 2 points
• 3 points
• TNM staging and scoring systems for patients with renal cancer are
important in the prognosis and the critical decision on the selection of
treatment options for patients with renal cancer.
• CT and MR play a central role in the diagnosis, staging and scoring of
patient with renal cancer.
• The radiology report should be complete and include critical information to
properly stage and score patients with renal cell cancer.
TNM Staging RCC – Metastases (M)
(a)
• < 4cm
• > 4 but < 7cm
• > 7 cm
(b)
(a)
(b)
(b)
Radius
• “a”
• “b”
• Anterior (+)
• Posterior (+)
C – Index Scoring RCC
Diagram of the primary
tumor (T) component of the
TNM classification for RCC.
TNM Staging RCC – Primary Tumor (T)
Renal Sinus
Face
T4 - Staging. (a) Diagram showing tumor extension into the ipsilateral
adrenal gland and tumor through Gerota’s fascia. (b) Axial T1 Out-of-Phase
non contrast MR image of the right kidney shows large mass in the right
kidney with tumor extension beyond Gerota’s fascia (arrow) (T4 lesion).
No regional lymph node
metastasis
Exophytic
Rate
(c)
(b)
• Radius Exophytic/endophytic Nearness Anterior/posterior Location
scoring systems for renal neoplasms
• R.E.N.A.L. score is associated with tumor aggressiveness and greater
proportion of major complications.
• R.E.N.A.L. score 9 = high-risk factor for perioperative complications.
(b)
•
•
•
(a) Diagram demonstrating the scoring for the C-Index Scoring System for
renal cancer. There are three masses with different sizes and distances to
the center of the kidney. (b) Coronal single shot fast spin echo image of the
right kidney. There is a 4.5cm mass in the lower pole; its radius (r) =
2.25cm. The mass is located at 6cm from the center of the kidney.
(Calculated C-Index = 6/22.5 = 2.7)
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