The process for continuous improvement of the TNM classification

The relationship between nasopharyngeal carcinoma tumor volume and TNM T-classification: a quantitative analysis

Recent findings show that tumor volume is a significant prognostic factor for the treatment of nasopharyngeal carcinoma (NPC). The inclusion of tumor volume as an additional prognostic factor in the UICC TNM classification system was suggested; however, how tumor volume could possibly be incorporated is still unexplored. In this paper, we report a quantitative analysis on the relationship between NPC tumor volume and T-classification, using the data from 206 NPC patients. By T-classification and semi-automatic tumor volume measurement, the difference in tumor volumes among the various TNM T-classification groups was examined. In addition, a statistics-based analysis scheme, which used the T-classification as the "gold standard", was proposed to classify NPC tumors into volume-based groups to explore the possible links. The results show that NPC tumor volume has positive correlation with advancing T-classification groups and significant difference existed in the distribution of T-classification among various volume-based groups (P < 0.001). By the proposed statistical scheme, tumor volume could be included as an additional prognostic factor in the TNM framework, following validation studies.

Reevaluation of TNM staging of renal cortical tumors: Recurrence and survival for T1N0M0 and T3aN0M0 tumors are equivalent

OBJECTIVES

The current TNM staging system for renal cortical tumors (RCTs) differentiates between tumors confined to the kidney (T1, T2) and tumors that extend through the renal capsule and invade into the perinephric fat (T3a). We examined the relative survival rates of patients with T1 and T3a tumors to determine the accuracy of the current TNM staging classification.

METHODS

We analyzed the Columbia University Surgical Urological Oncology Database for all patients with clinically localized Stage T1, T2, and T3a RCTs treated surgically from 1988 to 2004. The primary outcomes included local and distant recurrence. Because the T3a classification is not limited by size, we compared T3a tumors with T1 tumors alone and tumors confined within the renal capsule (Stage T1 and T2 tumors combined).

RESULTS

A total of 819 patients underwent partial or radical nephrectomy for RCTs at Columbia University during the study period. After the exclusion criteria were applied, 131 patients with T1N0M0, 19 patients with T2N0M0, and 82 patients with T3aN0M0 conventional renal cell carcinoma were eligible for analysis. The median follow-up was 37 months. The median tumor diameter was 3.2, 3.8, and 5.0 cm for Stage T1, T1 and T2 combined, and T3a lesions, respectively. The estimated 5-year disease-free survival was 95.2% and 90.6% for T1 and T3a RCTs, respectively (P = 0.922).

CONCLUSIONS

Patients with Stage T3a tumors experienced similar outcomes as patients with tumors confined to the renal capsule. These data suggest that the T3a classification should be examined more closely to attempt to improve the prognostic validity of the TNM classification.

Outcomes Research: A Methodologic Review

OBJECTIVES

We explored the history and conceptual trends of outcomes research.

METHODS

We described different aspects of this field, after dividing it into conceptually distinct strata.

RESULTS

Outcomes research can be divided into macro, meso and micro levels. Each level is further subdivided. Macro-level research targets cost and health care utilization, as well as racial, ethnic and geopolitical population health determinants. Meso-level studies address effectiveness, variability, disease impact, clinical modeling and program evaluation studies. Finally, micro-level studies address all aspects of direct patient-clinician decision-making.

CONCLUSIONS

An explosion of outcomes research has occurred in the past decades. Wide access to information technology, data sharing and collaborative efforts between researchers represent some of the ingredients that did and will continue to fuel that growth.

Proposal for reclassification of the TNM staging system in patients with locally advanced (pT3-4) renal cell carcinoma according to the cancer-related outcome

OBJECTIVES

The optimal stratification of locally advanced renal cell carcinoma (RCC) is controversial, with the prognostic relevance of ipsilateral adrenal gland invasion and cranial extension of vena cava thrombosis being the most debatable issues. We evaluated the prognosis of patients with locally advanced RCC and identified a new model to stratify their outcome.

MATERIALS AND METHODS

We analyzed the data of 227 patients who had undergone partial or radical nephrectomy for pT3-4 RCC at two academic centers between 1986 and 2002. The log-rank test and Cox proportional hazards model were used for univariate and multivariate analysis, respectively.

RESULTS

At a median follow-up of 29 mo, we censored 108 (47.6%) cancer-related deaths. On univariate analysis, the 2002 T stage was not statistically significant. According to cancer-related outcome, we identified three subgroups of patients with different prognoses: pT3a(n): tumors with perirenal fat invasion or renal vein thrombosis or thrombosis within the vena cava below the diaphragm; pT3b(n): tumors with renal vein thrombosis or thrombosis within the vena cava below the diaphragm and concomitant perirenal fat invasion; pT4(n): adrenal gland or Gerota fascia invasion or thrombosis within the vena cava above the diaphragm. The three subgroups had significantly different prognoses. The new reclassification was an independent predictive variable on multivariate analysis, as well as the pathologic lymph node stage.

CONCLUSIONS

The 2002 version of TNM of locally advanced RCC did not stratify patient outcome. The present study suggests the possibility of reclassifying pT3-4 RCC into three categories capable of predicting cancer-specific survival, regardless of all other prognostic factors.

Staging of nasopharyngeal carcinoma investigated by magnetic resonance imaging

BACKGROUND AND PURPOSE

To investigate the American Joint Commission on Cancer (AJCC) sixth edition staging system of nasopharyngeal carcinoma (NPC) by Magnetic Resonance Imaging (MRI).

PATIENTS AND METHODS

One hundred and fifty-nine non-disseminated biopsy-proven NPC patients were studied with MRI before treatment. Retrieval of MRI information enabled us to restage all patients accurately according to the sixth edition of the AJCC staging system. Splitting the respective T and N stages by the significant defining factors identified, the cancer death hazard ratios were modeled by the Cox model in SPSS 10.0 for windows (SPSS Inc, Chicago, IL).

RESULTS

Single site of skull base abnormality (HR = 3.91, 95% CI: 0.74-20.56) has a superior result to others involved in T3 (HR = 5.83, 95% CI: 1.24-27.29). Involvement of either anterior or posterior cranial nerves solely (HR = 6.02, 95% CI: 1.55-35.60) was not found to be as a poor prognostic indicator as others involved in T4 (HR = 7.81, 95% CI: 1.81-33.63). Less than or equal to 3 cm of N1 (HR = 4.01, 95% CI: 0.48-33.83) and N2 (HR = 4.72, 95% CI: 0.62-35.78) have a better result than >3 cm of N1 (HR = 8.09, 95% CI: 0.95-68.97) and N2 (HR = 10.58, 95% CI: 1.32-84.62), respectively.

CONCLUSIONS

Perhaps, it is better to down-stage single site of skull base abnormality from T3 to T2, and involvement of either anterior or posterior cranial nerves solely from T4 to T3, meanwhile, < or =3 cm of N2 down-stage to N1, >3 cm of N1 up-stage to N2.

Staging of colon and rectal cancer: from endoscopy to molecular markers

The primary management of colorectal cancer begins with preoperative diagnosis and the ability to stage the extent of the tumor burden clinically. Endoscopic approaches have been pivotal in this management strategy, and have given rise to endoscopic techniques allowing for primary resection and treatment of metastases. This advance has allowed for the continued development of pathologic staging as used in the tumor node metastasis (TNM) system. The next major milestone in the staging of large bowel cancer will be to blend current anatomic staging strategies with specific molecular markers that will refine subsets appropriate for targeted therapy.

Comparison of tumor- and comorbidity-related predictors of mortality after radical prostatectomy

OBJECTIVES

To identify and compare tumor- and non-tumor-related predictors of survival after radical prostatectomy and to incorporate the latter into the tumor node metastasis classification of prostate cancer.

MATERIAL AND METHODS

A total of 402 patients who underwent radical prostatectomy (mean follow-up period 6.9 years) were stratified according to postoperative tumor stage, Gleason score, prostate-specific antigen level, age and five comorbidity classifications. Cox proportional hazard models were used to identify independent prognostic factors predicting overall survival.

RESULTS

Comorbidity (American Society of Anesthesiologists Physical Status classification), Gleason score and age, but not tumor stage, were independent predictors of overall survival. Based on tumor stage and the identified independent prognostic factors, an easily applicable prognostic score was developed to predict overall mortality.

CONCLUSION

A prognostic classification of radical prostatectomy patients based on Gleason score, comorbidity and age and supplementary to a coarsened variant of the tumor node metastasis classification may be of clinical value.

Tumor size improves the accuracy of TNM predictions in patients with renal cancer

OBJECTIVES

Current staging for renal cancer (RC) does not directly rely on tumor size. We examined the increment in accuracy related to inclusion of pathologically determined tumor size in prediction of nodal metastases (N+), distant metastases (M+), and cancer-specific survival (CSS).

METHODS

Partial or radical nephrectomy was performed in 2245 patients with clear cell histology. Pathologic stages were T1a in 566, T1b in 490, T2 in 303, T3 in 831, and T4 in 55 patients. Tumor size was 0.5-25 cm (mean, 6.8). Multivariate models relied on 1997 and 2002 TNM variables and addressed N+, M+ disease, and CCS. Their accuracy was compared according to either the presence or absence of tumor size.

RESULTS

In all univariate and multivariate models, tumor size was a statistically significant predictor of all outcomes (p< or =0.001). In all multivariate models, tumor size added between 3.7% and 0.8% to predictive accuracy of either 1997 or 2002 TNM categories.

CONCLUSIONS

Tumor size represents a highly significant, multivariate, and informative predictor of RC outcomes and may warrant inclusion in future TNM revisions.

Proposal for revision of the TNM classification system for renal cell carcinoma

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.

Correlation between MR imaging–derived nasopharyngeal carcinoma tumor volume and TNM system

PURPOSE

To measure nasopharyngeal carcinoma tumor volume based on magnetic resonance images using a validated semiautomated measurement methodology and correlate tumor volume with TNM T classification.

METHODS AND MATERIALS

The study population consisted of 206 consecutive nasopharyngeal carcinoma patients who had magnetic resonance imaging staging scans. Tumor volume was measured using a semisupervised knowledge-based fuzzy clustering algorithm. Patients were divided into 4 groups according to TNM T classification. The difference in tumor volumes among the various TNM T-classification groups was examined.

RESULTS

The mean tumor volume in each T-classification group is as follows: T1, 8.6 mL +/- 5.0 (standard deviation [SD]); T2, 18.1 mL +/- 8.1 (SD); T3, 25.8 mL +/- 14.1 (SD); and T4, 36.2 mL +/- 18.9 (SD). The mean tumor volume increased significantly with advancing T classification (p < 0.0001). Tumor volume in a more advanced T group was significantly larger than that in an adjacent early T group (p < 0.01).

CONCLUSION

Validated magnetic resonance imaging-based tumor volume shows positive correlation between tumor volume and advancing T-classification groups. It may be possible to incorporate tumor volume as an additional prognostic factor into the existing TNM system.

WHO classification of alveolar echinococcosis: principles and application

Alveolar echinococcosis is caused by the larval stage of the fox tapeworm (Echinococcus multilocularis) and is frequently diagnosed as a space occupying lesion in the liver. The growth pattern resembles that of a malignant tumor with infiltration throughout the liver, spreading into neighbouring organs and metastases formation in distant organs. Thus, one of the prevailing differential diagnoses is liver cancer. Guided by the Tumor-Node-Metastasis (TNM) system of liver cancer, the European Network for Concerted Surveillance of Alveolar Echinococcosis and the WHO Informal Working Group on Echinococcosis proposed a clinical classification for alveolar echinococcosis. It was designated as PNM system (P = parasitic mass in the liver, N = involvement of neighbouring organs, and M = metastasis). As for TNM in oncology, single PNM categories were combined into four stages, I to IV. The system was developed by a retrospective analysis of 97 patients' records from two treatment centers (Besançon/France and Ulm/Germany). Recently, this WHO classification was applied to 222 patients in 4 clinical centers around the world (Besançon/France, n = 26; Urumqi/China, n = 46; Sapporo/Japan, n = 58; and Ulm/Germany, n = 92). All patients could be classified who had been diagnosed in the period from January 1998 to June 2005. The stage grouping indicated center differences, but appeared to segregate patients according to various treatment regimens. The WHO classification not only serves as a tool for the international standardization of disease manifestation but also aids to evaluate the outcome of a chosen diagnostic and treatment procedure in different treatment centers in Europe and Asia.

Is renal sinus fat invasion the same as perinephric fat invasion for pT3a renal cell carcinoma?

PURPOSE

Perinephric and renal sinus fat invasion are classified as pT3a renal cell carcinoma (RCC) according to the 2002 American Joint Committee on Cancer. We investigated the prognostic significance of each of these pathological features using a cohort of pT3a patients.

MATERIALS AND METHODS

Between 1970 and 2002, 205 patients without direct adrenal invasion underwent nephrectomy for pT3a clear cell RCC. The associations of fat invasion with death from RCC were evaluated using Cox proportional hazards regression models.

RESULTS

Of the 162 patients with perinephric fat invasion and 43 patients with renal sinus fat invasion 95 (59%) and 31 (72%), respectively, died of RCC. Patients with renal sinus fat invasion were 63% more likely to die of RCC compared with those with perinephric fat invasion (RR 1.63, 95% CI 1.09-2.46, p=0.018). In addition, the risk of death persisted in multivariate analysis after adjusting for regional lymph nodes and distant metastases (RR 1.91, 95% CI 1.26-2.89, p=0.002) and after adjusting for the Mayo Clinic SSIGN (stage, size, grade and necrosis) score (RR 1.90, 95% CI 1.25-2.88, p=0.003).

CONCLUSIONS

Our results indicate that clear cell tumors invading the renal sinus fat are more aggressive than tumors with perinephric fat involvement. We believe both of these features should be individually assessed during routine pathological examination. External validation is needed before suggesting a change to the TNM staging system.

Pathologisch-anatomische Aufarbeitung und Befundung von Lymphknoten bei gynäkologischen Malignomen

The nodal status is one of the strongest prognostic factors in gynecologic malignancies. Metastatic involvement of regional and distant lymph nodes represents the selection basis for adjuvant therapy in a large number of solid neoplasms. The number of resected lymph nodes is one of the most important parameters in the quality control of the surgical procedure, in particular with respect to radicality. The present paper provides recommendations for gross dissection, laboratory procedures and reporting for lymph node biopsies, lymph node dissections and sentinel lymph node biopsies (SLN) for cancers of the vulva, vagina, uterine cervix, endometrium, Fallopian tubes and the ovaries, submitted for the evaluation of metastatic disease. The pathologic oncology report should include information about the number and size of resected lymph nodes, the number of involved lymph nodes with the maximum size of metastases and the presence of paranodal infiltration. In addition, the detection of isolated tumor cells should be reported, particularly with respect to the detection method (immunostains or molecular methods). In cases of metastatic disease and carcinoma of unknown primary (CUP-syndrome), information should be given regarding the primary tumor.

A Review of Prognostic Pathologic Features and Algorithms for Patients Treated Surgically for Renal Cell Carcinoma

Accurate subtyping of RCC is critically important and should be considered in algorithms that are developed as prognostic tools for the patient and clinician. The TNM classification, already a powerful prognostic factor, will continue to evolve. The authors recommend that each component of the classification be assessed and reported during pathologic examination. This article also highlighted the importance of assigning a nuclear grade that is based on standardized and reproducible criteria that reflect the heterogeneity of nuclear and nucleolar features within RCC. Lastly, it is increasingly evident that coagulative tumor necrosis and sarcomatoid differentiation are compelling prognostic factors, on par with nuclear grade, and should be assessed routinely. To conclude, the complete list of pathologic features that are evaluated as part of the Mayo Clinic Nephrectomy Registry is presented. The features that are reported routinely in clinical practice also are indicated; this can serve as a guide for the reporting of results from the pathologic examination of RCC.

The altered DNA methylation pattern and its implications in liver cancer

DNA methylation is the most intensively studied epigenetic phenomenon, disturbances of which result in changes in gene transcription, thus exerting drastic imparts onto biological behaviors of cancer. Both the global demethylation and the local hypermethylation have been widely reported in all types of tumors, providing both challenges and opportunities for a better understanding and eventually controlling of the malignance. However, we are still in the very early stage of information accumulation concerning the tumor associated changes in DNA methylation pattern. A number of excellent recent reviews have covered this issue in depth. Therefore, this review will summarize our recent data on DNA methylation profiling in cancers. Perspectives for the future direction in this dynamic and exciting field will also be given.

Correlation between clinical and pathological staging in a series of radical cystectomies for bladder carcinoma

OBJECTIVE

To analyse the rate of concordance between the clinical and pathological Tumour-Nodes-Metastasis staging systems in a homogeneous series of patients who had undergone radical cystectomy for locally advanced or recurrent multifocal superficial bladder carcinoma.

PATIENTS AND METHODS

The clinical data of 156 patients who had undergone radical cystectomy and bilateral iliaco-obturator lymphadenectomy for bladder cancer in our department were analysed retrospectively. RESULTS The clinical stage of the primary tumour was carcinoma in situ in three patients (1.9%), cT1 in 67 (42.9%), cT2 in 70 (44.9%), cT3 in five (3.2%) and cT4 in nine (5.8%). Clinical lymph node involvement was detected in 19 patients (12.2%). The differences between clinical and pathological stages were statistically significant (P < 0.001), the concordance was moderate (kappa = 0.27, P < 0.001). Of the 70 patients with < or = cT1, 40 (57%) were reconfirmed as having pathological stage < or = T1; of the 70 with cT2, 16 (23%) had pT2 carcinoma. Of the 140 patients with clinically organ-confined (< or =T2) neoplasms, 70 (50%) had been understaged after radical cystectomy. The clinical and pathological systems were statistically overlapping for locally advanced cases only. Pathological lymph node involvement was diagnosed in 45 patients (28.8%); this was foreseen with pelvic computed tomography in 19 (12%) only (P < 0.001). All patients designated cN+ were also pN+.

CONCLUSION

These data confirm the high risk of clinical understaging of both local extension of the primary tumour and lymph node involvement.

CANCER SPECIFIC SURVIVAL FOR PATIENTS WITH pT3 RENAL CELL CARCINOMA—CAN THE 2002 PRIMARY TUMOR CLASSIFICATION BE IMPROVED?

PURPOSE

The 2002 primary tumor classification for renal cell carcinoma (RCC) does not distinguish between patients with tumor thrombus involving the renal vein only and those with inferior vena cava tumor thrombus below the diaphragm. We evaluated the association of tumor thrombus level and fat invasion with outcome to determine if further subclassification would improve the prognostic accuracy of the current classification.

MATERIALS AND METHODS

We studied 675 patients treated with radical nephrectomy or nephron sparing surgery for pT3a (206, 30.5%), pT3b (422, 62.5%), pT3c (19, 2.8%) or pT4 (28, 4.2%) RCC at the Mayo Clinic between 1970 and 2000. Associations with outcome were evaluated using Cox proportional hazards regression.

RESULTS

There were 531 deaths from RCC at a median of 1.5 years following nephrectomy. Patients with pT3b RCC and level I, II or III tumor thrombus were significantly more likely to die of RCC compared to patients with pT3b RCC and level 0 tumor thrombus (risk ratio 1.62, p <0.001). Patients with peripheral perinephric or renal sinus fat invasion were also more likely to die of RCC compared to patients without fat invasion (risk ratio 1.87, p <0.001). Therefore, patients with pT3 RCC were reclassified into 4 groups as thrombus level 0 without fat invasion, fat invasion only, thrombus level 0 with fat invasion or thrombus level I, II or III without fat invasion, and thrombus level I, II or III with fat invasion or thrombus level IV. This reclassification significantly improved prediction of death from RCC compared with the current classification (c indexes of 0.61 versus 0.55, respectively).

CONCLUSIONS

Further subclassification of the primary tumor classification for patients with pT3 RCC improved prognostic accuracy.

Hierarchical clustering analysis of tissue microarray immunostaining data identifies prognostically significant groups of breast carcinoma

Prognostically relevant cluster groups, based on gene expression profiles, have been recently identified for breast cancers, lung cancers, and lymphoma. Our aim was to determine whether hierarchical clustering analysis of multiple immunomarkers (protein expression profiles) improves prognostication in patients with invasive breast cancer. A cohort of 438 sequential cases of invasive breast cancer with median follow-up of 15.4 years was selected for tissue microarray construction. A total of 31 biomarkers were tested by immunohistochemistry on these tissue arrays. The prognostic significance of individual markers was assessed by using Kaplan-Meier survival estimates and log-rank tests. Seventeen of 31 markers showed prognostic significance in univariate analysis (P < or = 0.05) and 4 markers showed a trend toward significance (P < or = 0.2). Unsupervised hierarchical clustering analysis was done by using these 21 immunomarkers, and this resulted in identification of three cluster groups with significant differences in clinical outcome. chi2 analysis showed that expression of 11 markers significantly correlated with membership in one of the three cluster groups. Unsupervised hierarchical clustering analysis with this set of 11 markers reproduced the same three prognostically significant cluster groups identified by using the larger set of markers. These cluster groups were of prognostic significance independent of lymph node metastasis, tumor size, and tumor grade in multivariate analysis (P=0.0001). The cluster groups were as powerful a prognostic indicator as lymph node status. This work demonstrates that hierarchical clustering of immunostaining data by using multiple markers can group breast cancers into classes with clinical relevance and is superior to the use of individual prognostic markers.

Prognostic value of the 2002 TNM classification for breast carcinoma with regard to the number of metastatic axillary lymph nodes

BACKGROUND

The American Joint Committee on Cancer (AJCC) TNM classification for breast carcinoma had not been changed for 15 years, since the publication of the third edition in 1987. However, in the sixth edition, published in 2002, significant modifications were made with regard to the number of metastatic axillary lymph nodes. The authors investigated whether the sixth edition of the TNM classification provided more reliable prognostic information compared with the third edition.

METHODS

The records of 1230 patients who underwent surgery for invasive breast carcinoma between 1993 and 1999 were reviewed. Each patient was assigned to axillary lymph node and disease stage groups according to the 1987 and 2002 AJCC TNM classifications. Disease-free survival (DFS) curves were calculated and plotted using the Kaplan-Meier method and the two-sided log-rank test was used to compare the survival curves of the patient groups.

RESULTS

Of the 1067 patients who were classified as having Stages II and III disease according to the 1987 classification, 411 (38.5%) were shifted to higher disease stages using the 2002 classification. Among the 1987 Stage IIA, Stage IIB, and Stage IIIA patients, the DFS rates of the patients who were shifted to higher stages of disease were significantly worse than those of the patients for whom the stage of disease was not changed. Among those patients classified as having T4anyNM0 (Stage IIIB) disease according to the 1987 classification, there was no survival difference noted between those patients with T4N0,1,2M0 disease (who formed the Stage IIIB group) and those with T4N3M0 disease (who formed the Stage IIIC group) according to the new staging system. Of the 221 patients who formed the new Stage IIIC group, 12.2% were classified as having Stage IIA disease, 42.1% as having Stage IIB disease, 38.9% as having Stage IIIA disease, and 6.8% as having Stage IIIB disease according to the 1987 classification. The survival rates of these Stage IIA, Stage IIB, and Stage IIIA patients were not found to be significantly different; however, the survival of patients in the Stage IIIB group was found to be significantly worse than the survival of the patients in the other disease stage groupings, and the patients in the Stage IIIC group were not a prognostically homogeneous group. On the basis of these results, the authors placed patients with T4anyNM0 disease in the same group (Stage IIIB). When the 2002 classification was rearranged in this manner, patients with Stage IIIC disease formed a homogeneous group; the 5-year DFS rate of patients with Stage IIIB disease was found to be significantly worse than that for patients with Stage IIIC disease (P = 0.0011).

CONCLUSIONS

In the 2002 TNM classification for breast carcinoma, patients with T4anyNM0 disease should form a distinct stage grouping and this stage grouping (Stage IIIC) should be placed before Stage IV, and Stage IIIB disease groupings should include patients with T1,2,3N3M0 disease. In this way, the authors hope that the 2002 AJCC TNM classification, which provides more reliable prognostic information than the 1987 classification, will become more refined.

Improving the reproducibility of diagnosing micrometastases and isolated tumor cells

BACKGROUND

The latest edition of the tumor-lymph node-metastasis (TNM) classification of malignant tumors distinguishes between isolated tumor cells (pN0) and micrometastases (pN1mi). The reproducibility of these categories has not been assessed previously.

METHODS

Digital images from 50 cases with low-volume lymph node involvement from axillary sentinel lymph nodes were circulated twice for evaluation (Evaluation Rounds 1 and 2) among the members of the European Working Group for Breast Screening Pathology, and the members were asked to categorize lesions as micrometastasis, isolated tumor cells, or something else and to classify each case into a pathologic lymph node (pN) category of the pathologic TNM system. Methods for improving the low reproducibility of the categorizations were discussed between the two evaluation rounds. kappa Statistics were used for the assessment of interobserver variability.

RESULTS

The kappa value for the consistency of categorizing low-volume lymph node load into micrometastasis, isolated tumor cells, or neither of those changed from 0.39 to 0.49 between Evaluation Rounds 1 and 2, but it was slightly lower for the pN categories (0.35 and 0.44, respectively). Interpretation of the definitions of isolated tumor cells (especially with respect to their localization within the lymph node), lack of guidance on how to measure them if they were multiple, and lack of any definitions for multiple simultaneous foci of lymph node involvement were listed among the causes of discordant diagnoses.

CONCLUSIONS

The results of the current study indicated that the definitions available have minor contradictions and do not permit a reproducible distinction between micrometastases and isolated tumor cells. Refinement of these definitions, therefore, is required. One refinement that may improve reproducibility is suggested in this report.

Reclassification of patients with pT3 and pT4 renal cell carcinoma improves prognostic accuracy

BACKGROUND

The significance of adrenal invasion and tumor thrombus in renal cell carcinoma (RCC) has been debated recently. The authors evaluated the associations of direct adrenal invasion, perinephric fat invasion, and tumor thrombus level with outcome to determine whether reclassification would improve the prognostic accuracy of the current primary tumor classification.

METHODS

The authors studied 697 patients treated with nephrectomy for pT3 and pT4 RCC between 1970 and 2000. Associations with outcome were evaluated using Cox proportional hazards regression and prognostic accuracy was measured using the c index.

RESULTS

Among patients with pT3 RCC, direct adrenal invasion was significantly associated with death from RCC (risk ratio, 2.11; P = 0.004). No significant difference in survival was found between patients with pT4 RCC and pT3 tumors with direct adrenal invasion (P = 0.490). Among patients with pT3b RCC, those with level I-III tumor thrombus were significantly more likely to die of RCC compared with patients harboring level 0 tumor thrombus (risk ratio, 1.62; P < 0.001). In addition, patients with fat invasion were more likely to die of RCC compared with pT3 patients without fat invasion (risk ratio, 1.87; P < 0.001). Therefore, patients with pT3 RCC were reclassified into 4 prognostic groups, and this reclassification significantly improved prediction of death from RCC compared with the current classification (c indices of 0.61 vs. 0.55, respectively).

CONCLUSIONS

Direct adrenal invasion from RCC should be reclassified as pT4. In addition, the proposed reclassification for patients with pT3 RCC improved prognostic accuracy.

The Renal Sinus Is the Principal Invasive Pathway

A total of 100 renal cell carcinomas were prospectively examined for renal sinus invasion, 74 clear cell renal cell carcinomas (CC), 3 renal cell carcinomas, unclassified (RUC), 16 papillary renal cell carcinomas (PapC), and 7 chromophobe renal cell carcinomas (ChC). Using the 2002 TNM staging formulation, 49 tumors were T1, 5 were T2, and 46 were T3 or T4. Renal sinus invasion occurred more often than renal capsule invasion. No tumor invaded the capsule that did not also invade the sinus. Renal sinus invasion correlated with Fuhrman grade; 17% of grades 1/2 tumors invaded the sinus, while 71% of grade 3/4 tumor invaded the sinus (P < 0.001). Sinus invasion correlated with tumor type; 2 of 23 PapC and ChC invaded the sinus compared with 44 of 77 CC and RUC. Sinus invasion occurred in approximately 16% of tumors 1 to 4 cm in size, then abruptly increased for larger tumors (P < 0.001). When tumors are staged by the 1997 and 2002 TNM formulation, renal sinus invasion upstaged 28% of cases stage T1 or T2 by the 1997 formulation, to T3 using the 2002 criteria. In conclusion, renal sinus invasion is the most common site of extrarenal extension of renal carcinoma and correlates with tumor type, grade and size. Appropriate evaluation for sinus invasion reduces the incidence of T1b and T2 CC tumors, limiting prognostic utility and suggesting reassessment of the T1 and T2 stage designations.

Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging

BACKGROUND

The recently revised American Joint Committee on Cancer (AJCC) sixth edition cancer staging system increased the stratification within colon cancer stages II and III defined by the AJCC fifth edition system. Using nationally representative Surveillance, Epidemiology, and End Results (SEER) data, we compared survival rates associated with colon cancer stages defined according to both AJCC systems.

METHODS

Using SEER data (from January 1, 1991, through December 31, 2000), we identified 119,363 patients with colon adenocarcinoma and included all patients in two analyses by stages defined by AJCC fifth and sixth edition systems. Tumors were stratified by SEER's "extent of disease" and "number of positive [lymph] nodes" coding schemes. Kaplan-Meier analyses were used to compare overall and stage-specific 5-year survival. All statistical tests were two-sided.

RESULTS

Overall 5-year survival was 65.2%. According to stages defined by the AJCC fifth edition system, 5-year stage-specific survivals were 93.2% for stage I, 82.5% for stage II, 59.5% for stage III, and 8.1% for stage IV. According to stages defined by the AJCC sixth edition system, 5-year stage-specific survivals were 93.2% for stage I, 84.7% for stage IIa, 72.2% for stage IIb, 83.4% for stage IIIa, 64.1% for stage IIIb, 44.3% for stage IIIc, and 8.1% for stage IV. Under the sixth edition system, 5-year survival was statistically significantly better for patients with stage IIIa colon cancer (83.4%) than for patients with stage IIb disease (72.2%) (P<.001).

CONCLUSIONS

The AJCC sixth edition system for colon cancer stratifies survival more distinctly than the fifth edition system by providing more substages. The association of stage IIIa colon cancer with statistically significantly better survival than stage IIb in the new system may reflect current clinical practice, in which stage III patients receive chemotherapy but stage II patients generally do not.

Neoplasm Staging and Organ-Confined Renal Cell Carcinoma: A Systematic Review

OBJECTIVES

Several TNM staging system editions were published over the years for renal cell carcinoma (RCC). Using a search strategy similar to the one used by the TNM process Subcommittee for "literature watch", we searched MEDLINE with the intent to critically analyze literature concerning the different TNM editions and the data regarding the optimal breakpoints to substratify localized RCC.

MATERIAL AND METHODS

The electronic search was conducted as follows: "Neoplasm staging" [MeSH] AND "Carcinoma, Renal Cell" [MeSH]. At the end of a process of abstract analysis performed separately by three of the authors, 34 papers were included in the systematic review.

RESULTS

All the 34 selected papers were retrospective studies. According to the 1987 version of TNM classification, no paper showed statistically significant cancer-specific survival probability differences between stage I and stage II RCC. According to the 1997 TNM version, the results were controversial. While a few papers found significantly different cancer-specific survival rates between stage I and stage II RCC, several others failed to do so. With the aim to stratify patients with localized RCC, most of the papers proposed an ideal breakpoint ranging from 4.5 to 5.5 cm.

CONCLUSION

This literature review highlighted that a correct definition of the staging of organ-confined RCC was far from being achieved and provided an appropriate synopsis of the available data for further update of the TNM staging system.

Correlation between symptom graduation, tumor characteristics and survival in renal cell carcinoma

OBJECTIVES

To compare renal tumors with respect to initial clinical presentation and assess the prognostic value of a symptom based classification.

MATERIAL AND METHODS

Based on symptoms at diagnosis, 388 renal tumors were stratified into three groups: (1) asymptomatic tumors; (2) tumors with local symptoms (3) tumors with systemic symptoms. The three groups were compared for usual clinical and pathological variables using chi(2)-tests and Anova regression, for qualitative and quantitative variables, respectively. Survival assessment was made with univariate and multivariate analysis using the Kaplan-Meier method and Cox regression analysis.

RESULTS

The three defined groups were significantly different for all analysed variables except for age, sex ratio and pathological subtype. In univariate analysis: ECOG performance status, symptom classification, tumour size, TNM stage and grade, adrenal, perinephric fat or vein invasion were significant prognostic factors (p<0.001). In multivariate analysis, symptom classification, TNM stage, Fuhrman grade and perinephric fat invasion remained independent prognostic factors (p<0.001).

CONCLUSION

The proposed classification merits further validation through multi-institutional studies before integrating it in further prognosis algorithms.