title: Proposal for revision of the TNM classification system for renal cell carcinoma.
abstract: BACKGROUND
  The current study defined an optimal tumor size breakpoint to stratify localized renal cell carcinoma (RCC) into groups with significantly different cancer-related outcomes and proposed a revision of the TNM classification system.
  
  
  METHODS
  The authors analyzed the data from 1138 patients who had undergone partial or radical nephrectomy for localized RCC at 7 European urologic centers. The optimal pathologic size breakpoint was calculated using the martingale residuals from a Cox proportional hazards regression model.
  
  
  RESULTS
  The mean follow-up time was 87 months. The scatterplot of tumor size versus expected risk of death per patient suggested that an interval of 5-6 cm was appropriate. A total of 720 (63.3%) and 418 (36.7%) patients had tumors measuring < or = 5.5-cm and tumors measuring > 5.5-cm, respectively. Significant cancer-specific survival differences between the two groups of patients were reported in the series by all the centers participating in the study. On univariate analysis, the other variables found to be associated with cancer-specific survival were the patient's age, symptomatic tumor presentation, and the Fuhrman nuclear grade. On multivariate analysis, the pathologic stage of the primary tumor defined according to the 5.5-cm breakpoint was found to be an independent predictor of cancer-specific survival, as well as age, mode of presentation, and nuclear grade. According to the multivariate analysis, the authors clustered patients into 3 groups with statistically significant outcome differences: 1) patients with < or = 5.5-cm incidentally detected RCC; 2) patients with < or = 5.5-cm symptomatic RCC; and 3) patients with > 5.5-cm RCC. This cancer-related outcome stratification was valid regardless of the patient's age.
  
  
  CONCLUSIONS
  The 5.5-cm breakpoint was found to be the optimal tumor size breakpoint with which to stratify patients with organ-confined RCC. The study supported the upgrade of the TNM classification system according to this breakpoint.
authors.affiliation: Department of Urology, University of Verona, Verona, Italy. vincenzo.ficarra@univr.it
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ficarra
authors.forename: François
authors.initials: F
authors.lastname: Guillè
authors.forename: Luigi
authors.initials: L
authors.lastname: Schips
authors.forename: Alexander
authors.initials: A
authors.lastname: de la Taille
authors.forename: Tommaso
authors.initials: T
authors.lastname: Prayer Galetti
authors.forename: Jacques
authors.initials: J
authors.lastname: Tostain
authors.forename: Luca
authors.initials: L
authors.lastname: Cindolo
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.forename: Richard
authors.initials: R
authors.lastname: Zigeuner
authors.forename: Emiliano
authors.initials: E
authors.lastname: Bratti
authors.forename: Guorong
authors.initials: G
authors.lastname: Li
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Altieri
authors.forename: Claude C
authors.initials: CC
authors.lastname: Abbou
authors.forename: Luisa
authors.initials: L
authors.lastname: Zanolla
authors.forename: Walter
authors.initials: W
authors.lastname: Artibani
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Patard
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000145:classification* / Q000401:mortality / Q000473:pathology*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000145:classification* / Q000401:mortality / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016019:Survival Analysis