t3, n0, m0 tumor extends to major veins or perinephric tissue but not into ipsilateral adrenal gland nor beyond gerota's fascia t3a, n0, m0 tumor grossly extends into renal vein or its segmental branches, or tumor invades the pelvicalyceal system, or tumor invades perirenal and/or renal sinus fat but not beyond gerota's fascia t3b, n0, m0 tumor grossly extends into vena cava below the diaphragm t3c, n0, m0 tumor grossly extends into vena cava above the diaphragm or invades the wall of the vena cava t1-t3, n1, m0 the main tumor can be any size and may be outside the kidney, but it has not spread beyond gerota’s fascia. the cancer has spread to regional lymph nodes (n1) but has not spread to distant lymph nodes or other organs (m0). iv t4, any n, m0 tumor invades beyond gerota's fascia any t, any n, m1 tumor has spread to distant lymph nodes and/or other organs. the lungs are the most common site for metastasis, with other common sites including bone, brain, liver, adrenal gland and distant lymph nodes. stage 1 kidney cancer stage 2 kidney cancer stage 3 kidney cancer stage 4 kidney cancer treatment treatment for kidney cancer depends on the type and stage of the disease. surgery is the most common treatment as kidney cancer does not often respond to chemotherapy and radiotherapy. surgical complexity can be estimated by the renal nephrometry scoring system. if the cancer has not spread it will usually be removed by surgery. in some cases this involves removing the whole kidney however most tumors are amenable to partial removal to eradicate the tumor and preserve the remaining normal portion of the kidney. surgery is not always possible – for example, the patient may have other medical conditions that prevent it, or the cancer may have spread around the body and doctors may not be able to remove it. there is currently no evidence that body-wide medical therapy after surgery where there is no known residual disease, that is, adjuvant therapy, helps to improve survival in kidney cancer. if the cancer cannot be treated with surgery other techniques such as freezing the tumour or treating it with high temperatures may be used. however, these are not yet used as standard treatments for kidney cancer. other treatment options include biological therapies such as everolimus, torisel, nexavar, sutent, and axitinib, the use of immunotherapy including interferon and interleukin-2. immunotherapy is successful in 10 to 15% of people. sunitinib is the current standard of care in the adjuvant setting along with pazopanib; these treatments are often followed by everolimus, axitinib, and sorafenib. immune checkpoint inhibitors are also in trials for kidney cancer, and some have gained approval for medical use. in the second line setting, nivolumab demonstrated an overall survival advantage in advanced clear renal cell carcinoma over everolimus in 2015 and was approved by the fda. cabozantinib also demonstrated an overall survival benefit over everolimus and was approved by the fda as a second-line treatment in 2016. lenvatinib in combination with everolimus was approved in 2016 for patients who have had exactly one prior line of angiogenic therapy. in wilms' tumor, chemotherapy, radiotherapy and surgery are the accepted treatments, depending on the stage of the disease when it is diagnosed. children the majority of kidney cancers reported in children are wilms' tumors. these tumors can begin to grow when a fetus is still developing in the uterus, and may not cause problems until the child is a few years old. wilms' tumor is most common in children under the age of 5, but can rarely be diagnosed in older children or in adults. it is still not clear what causes most wilms' tumors. the most common symptoms are swelling of the abdomen and blood in the urine. epidemiology around 208,500 new cases of kidney cancer are diagnosed in the world each year, accounting for just under 2% of all cancers. the highest rates are recorded in north america and the lowest rates in asia and africa. lifestyle risk factors certain lifestyle factors have been associated with the development of renal cancer, although not all of them can be considered definitive causes. these include smoking, chemical carcinogens, radiation, viruses, diet and obesity, hypertension, diuretics, and alcohol consumption. only a small percentage of kidney cancer cases have been linked to genetic factors. with obesity listed as one of the risk factors, daily physical activity and engaging in a healthy diet is proven to lower the rates of developing kidney cancer in the future. age the incidence rate of renal cancer increases with the age of an individual, with 75 being the approximate age of the peak incidence rate, as of 2018. however, nearly one half of all cases are diagnosed before the age of 65. in both male and female children, renal tumors represent 2% to 6% of kidney cancer, with wilms' tumor being the most common. sex the incidence of kidney cancer is two times greater in men than in women, and this is thought to be due to biological differences. mortality rates typically decrease more rapidly in women compared to men. international variations incidence rates of kidney cancer can vary throughout the world. as of 2018, czech republic and lithuania have the highest incidence rate of kidney cancer worldwide, with an age-standardized rate of 21.9/100,000 in males (czech republic) and 18.7/100,000 in males (lithuania.) china, thailand, and african countries (low-risk countries) have an incidence rate that is less than 2/100,000. since the early 2000s, austria and poland have been the only countries to report a decrease in kidney cancer rates. diagnosis access bias plays a large role in the epidemiology of kidney cancer. differences in kidney cancer diagnosis across regions are likely due to differences in healthcare access, rather than a population's biological factors. discrepancies in kidney cancer diagnosis has most likely led to the underrepresentation of mortality and incidence in low income countries. race race and ethnicity may be a factor in the distribution of kidney cancer around the united states. there are higher incidence rates in black men and hispanics, an average rate for american indians, and low rates in asians in the united states. black people with kidney cancer have lower mortality rates than caucasians in the united states. screening accessibility for cancer screening is not very common due to high expenses. improving cancer registries can improve care to those who have kidney cancer as well as decreasing the incidence and death rates. safe and dependable treatment is key with the screening and treatment, which is not always the case in many developing nations. united states the united states' nih estimates for 2013 around 64,770 new cases of kidney cancer and 13,570 deaths from the disease. the incidence of kidney cancer is also increasing in the united states. this is thought to be a real increase, not only due to changes in the way the disease is diagnosed. europe the most recent estimates of incidence of kidney cancer suggest that there are 63,300 new cases annually in the eu25. in europe, kidney cancer accounts for nearly 3% of all cancer cases. kidney cancer is the eighth most common cancer in the uk (around 10,100 people were diagnosed with the disease in 2011), and it is the fourteenth most common cause of cancer death (around 4,300 people died in 2012).