Strengthening the foundation of kidney cancer treatment and research: revising the AJCC staging system (original) (raw)
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Journal of Urological Surgery
What's known on the subject? and What does the study add? To the best of our knowledge, this is the first study that validates renal cell carcinoma 2010 tumor-node-metastasis for the Turkish population. Objective: The American Joint Committee on Cancer tumor-node-metastasis (TNM) classification has been updated by the 7 th edition in 2010. The objective of the study was to evaluate cancer-specific survival (CSS) in patients with renal cell carcinoma (RCC) and assess the concordance of 2002 and novel 2010 TNM primary tumor classifications. Materials and Methods: A retrospective analysis of RCC registries from 25 institutions of the Urooncology Association of Turkey Renal Cancer-Study Group was performed. Patients with RCC had a radical or partial nephrectomy. The database consisted of 1889 patients. Results: Median follow-up time was 25 months (interquartile range: 11.2-47.8). The 5-year CSS rate for pT1a, pT1b, pT2a, pT2b, pT3a and pT4 tumors were 97% [95% confidence interval (CI): 0.93-0.99], 94% (95% CI: 0.91-0.97), 88% (95% CI: 0.81-0.93), 77% (95% CI: 0.64-0.86) 74% (95% CI: 0.65-0.81) and 66% (95% CI: 0.51-0.77), respectively according to the 2010 TNM classification (p<0.001). CSS comparisons between pT1a-pT1b (p=0.022), pT1b-pT2a (p=0.030), pT3a-pT3b (p<0.001) and pT3b-pT4 (p=0.020) were statistically significant. Conversely, pT2a-pT2b (p=0.070) and pT2b-pT3a (p=0.314) were not statistically significant. Multivariable analyses revealed the pT stage in the 2010 TNM classification as an independent prognostic factor for CSS (p for trend=0.002). C-indexes for 2002 and 2010 TNM classifications were 0.8683 and 0.8706, respectively. Conclusion: Subdividing pT2 does not have a CSS advantage. Moving adrenal involvement to pT4 yielded a more accurate prognosis prediction. T stage and LNI are independent prognostic factors for CSS in RCC.
CURRENT TNM CLASSIFICATION OF RENAL CELL CARCINOMA EVALUATED: REVISING STAGE T3a
Journal of Urology, 2005
Purpose: Recent studies of rare cases of pT3a renal cell carcinoma extending directly into the adrenal gland showed worse survival than in other pT3a cases and recategorization as stage pT4 was suggested. We assessed the prognostic validity of a stage pT3a diagnosis based on perirenal fat infiltration.
2018
Staging criteria for renal cell carcinoma differ from many other cancers, in that renal tumors are often spherical with subtle, finger-like extensions into veins, renal sinus, or perinephric tissue. We sought to study interobserver agreement in pathologic stage categories for challenging cases. An online survey was circulated to urologic pathologists interested in kidney tumors, yielding 89% response (31/35). Most questions included 1 to 4 images, focusing on: vascular and renal sinus invasion (n=24), perinephric invasion (n=9), and gross pathology/specimen handling (n=17). Responses were collapsed for analysis into positive and negative/equivocal for upstaging. Consensus was regarded as an agreement of 67% (2/3) of participants, which was reached in 20/33 (61%) evaluable scenarios regarding renal sinus, perinephric, or vein invasion, of which 13/33 (39%) had 80% consensus. Lack of agreement was especially encountered regarding small tumor protrusions into a possible vascular lumen, close to the tumor leading edge. For gross photographs, most were interpreted as suspicious but requiring histologic confirmation. Most participants (61%) rarely used special stains to evaluate vascular invasion, usually endothelial markers (81%). Most agreed that a spherical mass bulging well beyond the kidney parenchyma into the renal sinus (71%) or perinephric fat (90%) did not necessarily indicate invasion. Interobserver agreement in pathologic staging of renal cancer is relatively good among urologic pathologists interested in kidney tumors, even when selecting cases that test the earliest and borderline thresholds for extrarenal extension. Disagreements remain, however, particularly for tumors with small, finger-like protrusions, closely juxtaposed to the main mass.
The American journal of surgical pathology, 2018
Staging criteria for renal cell carcinoma differ from many other cancers, in that renal tumors are often spherical with subtle, finger-like extensions into veins, renal sinus, or perinephric tissue. We sought to study interobserver agreement in pathologic stage categories for challenging cases. An online survey was circulated to urologic pathologists interested in kidney tumors, yielding 89% response (31/35). Most questions included 1 to 4 images, focusing on: vascular and renal sinus invasion (n=24), perinephric invasion (n=9), and gross pathology/specimen handling (n=17). Responses were collapsed for analysis into positive and negative/equivocal for upstaging. Consensus was regarded as an agreement of 67% (2/3) of participants, which was reached in 20/33 (61%) evaluable scenarios regarding renal sinus, perinephric, or vein invasion, of which 13/33 (39%) had ≥80% consensus. Lack of agreement was especially encountered regarding small tumor protrusions into a possible vascular lumen...
TNM staging system for renal-cell carcinoma: current status and future perspectives
The Lancet Oncology, 2007
The Tumour, Nodes, and Metastasis (TNM) staging system is a method of stratifying patients with cancer and is based on data obtained from large multicentre studies that involved large numbers of patients, and have a good level of evidence. However, despite continual revisions to the methodology to incorporate evidence from new clinical studies, the optimum stratifi cation of patients with renal-cell carcinoma (RCC) using the TNM staging system remains controversial and further revisions, in our opinion, are needed. Revision of the TNM staging system for renal-cell cancer could also result in the simultaneous update of the integrated prognostic systems that are currently used along side this traditional method of staging. These integrated systems could become key instruments for guiding patient counselling, for appropriate follow up strategies, for patient selection for clinical trials, and for appropriate assessment of results if the perception that they are complex is overcome. This perception is driven by the presence of more than one system, the heterogeneity of clinical and pathological variables included in the methodology, and the need for robust comparative studies between the various systems. Therefore, in everyday clinical practice, the TNM system is regarded as a more reliable method of staging. In this Essay, we aim to highlight the problems associated with the current version of the TNM staging system and highlight areas in which this grading instrument can be improved in future to become a more refi ned and standardised method of communication between all clinicians involved in clinical management of RCC.
Journal of the National Comprehensive Cancer Network, 2015
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. The NCCN Guidelines ® Insights highlight important changes in the NCCN Guidelines ® recommendations from previous versions. Colored markings in the algorithm show changes and the discussion aims to further understanding of these changes by summarizing salient portions of the panel's discussion, including the literature reviewed. The NCCN Guidelines Insights do not represent the full NCCN Guidelines; further, the National Comprehensive Cancer Network ® (NCCN ®) makes no representation or warranties of any kind regarding the content, use, or application of the NCCN Guidelines and NCCN Guidelines Insights and disclaims any responsibility for their applications or use in any way. The full and most current version of these NCCN Guidelines are available at NCCN.org.
The Journal of Urology, 2011
In 2010 the American Joint Committee on Cancer updated the renal cell carcinoma TNM classification. Without independent validation of the new classification its predictive ability for cancer specific survival and generalizability remains unknown. In this setting we determined the predictive ability of the 2010 TNM classification compared to that of the 2002 classification. Materials and Methods: Using the nephrectomy registry at our institution we retrospectively reviewed the records of 3,996 patients with unilateral or bilateral synchronous renal cell carcinoma treated with radical nephrectomy or nephron sparing surgery between 1970 and 2006. Cancer specific survival was estimated using the Kaplan-Meier method and predictive ability was evaluated using the concordance index. Results: There were 1,165 deaths (29.1%) from renal cell carcinoma a median of 1.9 years after surgery compared to a median followup of 7.4 years for survivors. The estimated 10-year cancer specific survival rate was 96%, 80%, 66%, 55%, 36%, 26%, 25% and 12% for patients with 2010 primary tumor classifications of pT1a, pT1b, pT2a, pT2b, pT3a, pT3b, pT3c and pT4, respectively (p Ͻ0.001). The multivariate concordance index for the 2002 and 2010 TNM classifications was 0.848 and 0.850, respectively. Conclusions: The new 2010 classification remains a robust predictor of cancer specific survival compared to the 2002 classification by dividing pT2 lesions into pT2a and pT2b, reclassifying ipsilateral adrenal involvement as pT4, reclassifying renal vein involvement as pT3a and simplifying nodal involvement as pN0 vs pN1. However, the 2010 TNM classification showed only modest improvement in predictive ability compared to the 2002 classification.
Journal of Urological Surgery, 2018
Cancer staging has an important role in combating cancer. The American Joint Committee on Cancer (AJCC) has recently published the 8 th edition of the AJCC Cancer Staging Manual (8E AJCC) (1). Contributions from genitourinary pathology are evident in the AJCC classification from many of the International Society of Urological Pathology (ISUP) consensus conferences on prostate, renal, testicular, and penile neoplasms that addressed staging issues and the 4 th edition of the World Health Organization (WHO) classification of urinary and male genital organ tumors, which was published in early 2016 and was incorporated as the histologic classification system in the 8E AJCC, but the revised form of staging was not encompassed by the WHO classification totally (2). Actual grading systems were adopted for renal, prostate and penile cancers. In fact, major changes are fixed in testicular, penile, and prostate cancer. This review summarizes the changes for renal, bladder, urinary tract, prostatic, testicular and penile cancers in the 8 th tumornode-metastasis (TNM) staging systems. Changes in the 8 th Tumor-Node-Metastasis Staging of Renal Cancers Resection of the primary tumor along with the overlying Gerota's fascia and perinephric fat is recommended to interpret pathological staging of renal cancers (3,4). Changes in kidney cancer staging were minimal compared with other sites of the male genital and urinary tract. T3a criteria in the 7 th edition are based on the pathologist's gross inspection of the hilar vessels. Sometimes tumor involvement of the renal vein and, its branches are unrecognized at the time of gross examination of the specimen. This problem is more common in partial nephrectomy specimens. Microscopic evaluation is much reliable to determine renal vein invasion. Therefore, clarifications were made in T3 category especially in T3a disease classification involving renal vein and its branches (Table 1). The wall of the renal vein and its branches may be thin with minimal muscular wall, and it may be so difficult to identify these structures (5). Tumor nodules and cords within the renal sinus mostly reveals intravascular tumor (5). Thus, the word "grossly" has been excluded in the current pathological T3a (pT3a) staging, and also invasion of the pelvicalyceal system is added in T3a category (Figure 1). Perinephric/sinus fat invasion should be confirmed microscopically. Invasion into fat by tumor cells with or without desmoplastic reaction, and vascular invasion in perinephric soft tissue are all evidence of perinephric invasion. Modifications in T3a may have impact on clinical trials for adjuvant chemotherapy when defining locally-invasive disease. Especially for clear cell and papillary renal cell carcinoma subtypes, the new four-tiered WHO/ISUP nucleolar grading is adopted instead of the traditional Fuhrman nuclear grading (2,4,6). Changes in the 8 th Tumor-Node-Metastasis Staging of Urinary Bladder Cancers The AJCC provides a staging system for bladder cancer and the 8 th edition was updated in 2017 (1).