title: The European Network for the Study of Adrenal Tumors staging system is prognostically superior to the international union against cancer-staging system: a North American validation.
abstract: BACKGROUND
  A reclassification of the International Union Against Cancer (UICC) staging system for adrenocortical carcinoma (ACC) patients has recently been proposed by the European Network for the Study of Adrenal Tumors (ENSAT) to better discriminate between cancer-specific mortality (CSM) risk strata. We formally tested the validity of the modified staging system in a large North American population-based cohort.
  
  
  METHODS
  Kaplan-Meier survival curves depicted CSM rates in the overall population and after stratification according to the 2004 UICC or the 2008 ENSAT-staging system. Cox regression models addressing CSM tested the prognostic value of respectively the UICC or the ENSAT-staging system. Harrell's concordance index quantified the accuracy of the standard versus the modified staging system.
  
  
  RESULTS
  In the overall population (n=573), the CSM-free survival rates at 1, 3, and 5 years were, respectively, 62.9%, 47.0%, and 38.1%. No statistically significant differences in survival were recorded between 2004 UICC stages II and III patients (p=0.1). Conversely, a statistically significant difference was observed between 2008 ENSAT stage II and stage III patients (p<0.001). The 2008 ENSAT-staging system showed higher accuracy (83.0%) in predicting 3-year CSM rates, relative to the 2004 UICC-staging system (79.5%) (p<0.001).
  
  
  CONCLUSIONS
  Our study corroborates the superior accuracy of the ENSAT-staging system for ACC relative to the 2004 UICC-staging system. In consequence, the 2008 ENSAT-staging system may warrant consideration in the next update of staging manuals.
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Lughezzani
authors.forename: Maxine
authors.initials: M
authors.lastname: Sun
authors.forename: Paul
authors.initials: P
authors.lastname: Perrotte
authors.forename: Claudio
authors.initials: C
authors.lastname: Jeldres
authors.forename: Ahmed
authors.initials: A
authors.lastname: Alasker
authors.forename: Hendrik
authors.initials: H
authors.lastname: Isbarn
authors.forename: Lars
authors.initials: L
authors.lastname: Budäus
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.forename: Giorgio
authors.initials: G
authors.lastname: Guazzoni
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
mesh_terms: D000293:Adolescent; D000310:Adrenal Gland Neoplasms / Q000401:mortality / Q000473:pathology*; D018268:Adrenocortical Carcinoma / Q000401:mortality / Q000473:pathology* / Q000556:secondary; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000592:standards*; D011379:Prognosis; D014481:United States / Q000453:epidemiology; D055815:Young Adult