title: Evaluation of the prognostic significance of perirenal fat invasion and tumor size in patients with pT1-pT3a localized renal cell carcinoma in a comprehensive multicenter study of the CORONA project. Can we improve prognostic discrimination for patients with stage pT3a tumors?
abstract: BACKGROUND
  The current TNM system for renal cell carcinoma (RCC) merges perirenal fat invasion (PFI) and renal vein invasion (RVI) as stage pT3a despite limited evidence concerning their prognostic equivalence. In addition, the prognostic value of PFI compared to pT1-pT2 tumors remains controversial.
  
  
  OBJECTIVE
  To analyze the prognostic significance of PFI, RVI, and tumor size in pT1-pT3a RCC.
  
  
  METHODS
  Data for 7384 pT1a-pT3a RCC patients were pooled from 12 centers. Patients were grouped according to stages and PFI/RVI presence as follows: pT1-2N0M0 (n=6137; 83.1%), pT3aN0M0 + PFI (n=1036; 14%), and pT3aN0M0 (RVI ± PFI; n=211; 2.9%).
  
  
  METHODS
  Radical nephrectomy or nephron-sparing surgery (NSS) (1992-2010).
  
  
  METHODS
  Cancer-specific survival was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional-hazards regression models, as well as sensitivity and discrimination analyses, were used to evaluate the impact of clinicopathologic parameters on cancer-specific mortality (CSM).
  
  
  CONCLUSIONS
  Compared to stage pT1-2, patients with stage pT3a RCC were significantly more often male (59.4% vs 53.1%) and older (64.9 vs 62.1 yr), more often had clear cell RCC (85.2% vs 77.7%), Fuhrman grade 3-4 (29.4% vs 13.4%), and tumor size >7 cm (39.1% vs 13%), and underwent NSS less often (7.5% vs 36.6%; all p<0.001). According to multivariate analysis, CSM was significantly higher for the PFI and RVI ± PFI groups compared to pT1-2 patients (hazard ratio [HR] 1.94 and 2.12, respectively; p<0.001), whereas patients with PFI only and RVI ± PFI did not differ (HR 1.17; p=0.316). Tumor size instead enhanced CSM by 7% per cm in stage pT3a (HR 1.07; p<0.001) with a 7 cm cutoff yielding the highest prediction accuracy.
  
  
  CONCLUSIONS
  Since the prognostic impact of PFI and RVI on CSM seems to be comparable, merging both as stage pT3a RCC might be justified. Enhanced prognostic discrimination of stage pT3a RCC appears to be possible by applying a tumor size cutoff of 7 cm within an alternative staging system.
  
  
  RESULTS
  Prognosis prediction for patients with localized renal cell carcinoma up to stage pT3a can be enhanced by including tumor size with a cutoff of 7 cm as an additional parameter in the TNM classification system.
authors: Department of Urology, Ludwig Maximilians University, Munich, Germany; Janssen Pharma Research and Development, Beerse, Belgium. Electronic address: sabine.brookman-may@email.de.
authors: Sabine D
authors: SD
authors: Brookman-May
authors: Department of Urology, St. Elisabeth Hospital Straubing, Straubing, Germany.
authors: Matthias
authors: M
authors: May
authors: Department of Urology, Carl Thiem Klinikum, Cottbus, Germany.
authors: Ingmar
authors: I
authors: Wolff
authors: Department of Urology, Medical University of Graz, Graz, Austria.
authors: Richard
authors: R
authors: Zigeuner
authors: Department of Urology, Medical University of Graz, Graz, Austria.
authors: Georg C
authors: GC
authors: Hutterer
authors: Department of Urology, Pio Da Pietrelcina Hospital, Vasto, Italy.
authors: Luca
authors: L
authors: Cindolo
authors: Department of Urology, Pio Da Pietrelcina Hospital, Vasto, Italy.
authors: Luigi
authors: L
authors: Schips
authors: Division of Urology, European Institute of Oncology, Milan, Italy.
authors: Ottavio
authors: O
authors: De Cobelli
authors: Department of Urology, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
authors: Bernardo
authors: B
authors: Rocco
authors: Department of Urology, Faculty of Health Sciences, University La Sapienza, Rome, Italy.
authors: Cosimo
authors: C
authors: De Nunzio
authors: Department of Urology, Faculty of Health Sciences, University La Sapienza, Rome, Italy.
authors: Andrea
authors: A
authors: Tubaro
authors: Department of Urology, Clinical Municipal Hospital, Cluj-Napoca, Romania.
authors: Ioman
authors: I
authors: Coman
authors: Department of Urology, Klinikum Dortmund, Dortmund, Germany.
authors: Michael
authors: M
authors: Truss
authors: Department of Urology, Carl Thiem Klinikum, Cottbus, Germany; Department of Urology, Klinikum Dortmund, Dortmund, Germany.
authors: Orietta
authors: O
authors: Dalpiaz
authors: Department of Urology, Emergency Hospital Satu Mare, Satu Mare, Romania.
authors: Bogdan
authors: B
authors: Feciche
authors: Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors: Robert S
authors: RS
authors: Figenshau
authors: Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors: Kerry
authors: K
authors: Madison
authors: Department of Urology, Hospital Universitario Principe de Asturias, Madrid, Spain.
authors: Manuel
authors: M
authors: Sánchez-Chapado
authors: Department of Urology, Hospital Universitario Principe de Asturias, Madrid, Spain.
authors: Maria del Carmen
authors: Mdel C
authors: Santiago Martin
authors: Department of Urology, G. Rummo Hospital, Benevento, Italy.
authors: Luigi
authors: L
authors: Salzano
authors: Department of Urology, G. Rummo Hospital, Benevento, Italy.
authors: Giuseppe
authors: G
authors: Lotrecchiano
authors: Department of Urology, Carl Gustav Carus University, Dresden, Germany.
authors: Stefan
authors: S
authors: Zastrow
authors: Department of Urology, Carl Gustav Carus University, Dresden, Germany.
authors: Manfred
authors: M
authors: Wirth
authors: Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors: Petros
authors: P
authors: Sountoulides
authors: Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.
authors: Shahrokh
authors: S
authors: Shariat
authors: Department of Urology, Ludwig Maximilians University, Munich, Germany; Janssen Pharma Research and Development, Beerse, Belgium.
authors: Raphaela
authors: R
authors: Waidelich
authors: Department of Urology, Ludwig Maximilians University, Munich, Germany; Janssen Pharma Research and Development, Beerse, Belgium.
authors: Christian
authors: C
authors: Stief
authors: Department of Pathology, Johanniter Hospital Stendal, Stendal, Germany.
authors: Sven
authors: S
authors: Gunia
mesh_terms: D000273:Adipose Tissue / Q000473:pathology*; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D007668:Kidney / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging / Q000401:mortality / Q000592:standards*; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D016016:Proportional Hazards Models; D012082:Renal Veins / Q000473:pathology*
keywords: Cancer-specific survival; Perirenal fat invasion; Renal cell carcinoma; Renal vein invasion; Tumor size