title: Critical analysis of a simplified Fuhrman grading scheme for prediction of cancer specific mortality in patients with clear cell renal cell carcinoma--Impact on prognosis.
abstract: OBJECTIVE
  The traditional 4-tiered Fuhrman grading system (FGS) is widely accepted as histopathological classification for clear cell renal cell carcinoma (ccRCC) and has shown prognostic value. As intra- and inter-observer agreement are sub-optimal, simplified 2- or 3-tiered FGSs have been proposed. We aimed to validate these simplified 2- or 3-tiered FGSs for prediction of cancer-specific mortality (CSM) in a large study population from 2 European tertiary care centers.
  
  
  METHODS
  We identified and followed-up 2415 patients with ccRCC who underwent radical or partial nephrectomy in 2 European tertiary care centers. Univariable and multivariable analyses and prognostic accuracy analyses were performed to evaluate the ability of several simplified FGSs (i.e. grades I + II vs., grades III + IV, grades I + II vs. grade III and grade IV) to predict CSM.
  
  
  RESULTS
  Independent predictor status in multivariate analyses was proved for the simplified 2-tiered FGS (high-grade vs. low-grade), for the simplified 3-tiered FGS (grades I + II vs. grade III and grade IV) as well as for the traditional 4-tiered FGS. The prognostic accuracy of multivariable models of 77% was identical for all tested models. Prognostic accuracy of the model without FG was 75%.
  
  
  CONCLUSIONS
  A simplified 2- or 3-tiered FGS could predict CSM as accurate as the traditional 4-tiered FGS in a large European study population. Application of new simplified 2- or 3-tiered FGS may reduce inter-observer-variability and facilitate clinical practice without compromising the ability to predict CSM in ccRCC patients after radical or partial nephrectomy.
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. Electronic address: a.becker@uke.de.
authors.forename: A
authors.initials: A
authors.lastname: Becker
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Hickmann
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Hansen
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Meyer
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Rink
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Schmid
authors.affiliation: Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Eichelberg
authors.affiliation: Department of Urology, Medical University of Graz, Auenbrugger Platz 1, 8036 Graz, Austria.
authors.forename: K
authors.initials: K
authors.lastname: Strini
authors.affiliation: Department of Urology, Medical University of Graz, Auenbrugger Platz 1, 8036 Graz, Austria.
authors.forename: T
authors.initials: T
authors.lastname: Chromecki
authors.affiliation: Department of Urology, Medical University of Graz, Auenbrugger Platz 1, 8036 Graz, Austria.
authors.forename: J
authors.initials: J
authors.lastname: Jesche
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center, Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Regier
authors.affiliation: Department of Urology, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
authors.forename: M
authors.initials: M
authors.lastname: Randazzo
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Tilki
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Ahyai
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Dahlem
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Fisch
authors.affiliation: Department of Urology, Medical University of Graz, Auenbrugger Platz 1, 8036 Graz, Austria.
authors.forename: R
authors.initials: R
authors.lastname: Zigeuner
authors.affiliation: Department of Urology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
authors.forename: F K H
authors.initials: FK
authors.lastname: Chun
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001707:Biopsy, Needle; D002292:Carcinoma, Renal Cell / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D005858:Germany; D006801:Humans; D007150:Immunohistochemistry; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D060787:Neoplasm Grading; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D015588:Observer Variation; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: Cancer specific mortality; Clear cell renal cell carcinoma; Fuhrman grading; Nephrectomy; Survival