U J All Final for WEB.pdf 774 | Urological Oncology Department of Urology, School of Medicine, Uni- versity of Ankara, Ankara, Turkey Evren Süer, Sümer Baltaci, Berk Burgu, Özgü Aydoğdu, Çağatay Göğüş Significance of Tumor Size in Renal Cell Cancer with Perinephric Fat Infiltration Is TNM Staging System Adequate for Predicting Prognosis? Corresponding Author: Evren Süer, MD Department of Urology, School of Medicine, Ankara University 06700, İbni Sina Hospital, Samanpazarı, Ankara, Turkey Tel: +90 312 508 22 58 Fax: +90 312 311 21 67 E-mail: drevrensuer@ gmail.com Received November 2011 Accepted April 2012 Purpose: Materials and Methods: - performed in order to evaluate the prognostic factors. Results: Conclusion: into consideration for better prognostic analysis. Keywords: renal cell carcinoma, prognosis, fatal outcome, humans UROLOGICAL ONCOLOGY 775Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L Predicting Prognosis of RCC | Süer et al INTRODUCTION Pathologic staging according to TNM staging system has been accepted as the most important prognos- (RCC). (3) - tions have been generated to increase the prognostic accu- racy of this staging system. This tumor size system. value.(6) Distinctly, these revisions did not include pT3a tu- - nostic factor is still unclear.(7) Recent studies demonstrated different results and achieved contrary conclusions. - - MATERIALS AND METHODS - - - nal computed tomography, abdominal ultrasonography, and - ined for tumor size, Fuhrman grade, and histological cell sub- staging. Fuhrman grading system and Heidelberg histologic - st nd year, and annually thereafter. t compare the means of continuous and categorical variables, mortality due to RCC progression and estimated using the Kaplan Meier method. A Receiver Operating Characteristic - P - RESULTS P patients (P analysis determined the optimal tumor size cutoff value as 7 Table 1. Multivariate analysis for disease-specific survival in patients with pT1-3aN0M0 renal cell carcinoma. Variable Hazard Ratio 95% Confidence Interval P Age 1.578 0.776 to 3.208 .208 Perinephric fat invasion 3.521 1.700 to 7.294 .001 Grade (Grades 1 to 2 vs Grades 3 to 4) 5.239 2.418 to 11.353 < .001 Tumor size (≤7 cm vs >7 cm) 1.624 0.806 to 3.272 .175 776 | - (P P invasion (P only tumor grade and perinephric fat invasion as prognostic as an independent prognostic factor in multivariate analysis - - perinephric fat invasion using the 7 cm cutoff value (Table P - P To evaluate the prognostic effects of perinephric fat invasion - tect perinephric fat invasion as a prognostic factor. Unlikely, and multivariate analyses demonstrated perinephric fat inva- Table 2. Clinicopathological parameters compared according to the 7 cm cutoff value, which was defined by the ROC curve analysis.* Tumor size >7 cmTumor size ≤7 cm PPFI (+)PFI (-)PPFI (+)PFI (-) 693220631No .18 40 (58%) 29 (42%) 23 (71.9%) 9 (28.1%) .062 131 (63.6%) 75 (36.4%) 25 (80.6%) 6 (19.4%) Gender Male Female .30256.7 (± 10.11)59 (± 10.9).03155.6 (± 11.7)60.5 (± 10.5)Mean age (± SD) .121 50 (73.5%) 13 (19.1%) 5 (7.4%) 30 (93.7%) 2 (6.3%) 0 (0%) .346154 (77.7%) 31 (15.6%) 13 (7.4%) 22 (75.8%) 6 (20%) 1 (4.2%) No cell type (%)£ Clear cell Papillary Chromophobe .001 48 (69.6%) 21 (30.4%) 9 (28.1%) 23 (71.9%).126 159 (77.2%) 47 (22.8%) 20 (64.5%) 11 (35.5%) No grade (%) 1 to 2 3 to 4 .4710.71(± 2.86)10.01(± 1.79).5434.34 (± 1.49)4.48 (± 1.42)Mean tumor size (± SD), cm .0017 (10.1%)12 (37.5%).04311 (5.4%)5 (16.1%)Death by RCC *ROC indicates receiver operating characteristic; PFI, perinephric fat invasion; SD, standard deviation; and RCC, renal cell carcinoma. £Histologic subtypes besides clear cell. Papillary and chromophobe subtypes were omitted for statistical accuracy and 327 patients were included for the analysis. Urological Oncology 777Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L DISCUSSION and involvement of the adjacent tissues. Tumor size and per- inephric fat invasion are basic features to classify the RCC according to the TNM staging system. Although evolution included many variables in the TNM staging system of RCC, - - tients. Unlike tumor size, perinephric fat invasion remained as a sta- ble staging parameter regardless of tumor size. Perinephric as pT3a tumor regardless of tumor size in all recent TNM invasion compared to tumor size is unclear. pT3a according to their clinicopathological features. The than perinephric fat invasion. Siemer and associates, simi- the cutoff value for tumor size, according to the DSS. They have assigned 7 cm as a cutoff value. They have compared the staging of patients by merging all patients according to 7 a prognostic predictor, and proposed not to use perinephric fat invasion to assign T category.(7) Predicting Prognosis of RCC | Süer et al Table 3. Significance of perinephric fat invasion at multivariate analysis. Risk Ratio (95% Confidence Interval) P Tumors ≤4 cm No perinephric fat invasion Perinephric fat invasion 1.0 1.65 (0.22 to 12.04) .618 Tumors 4 to 7 cm No perinephric fat invasion Perinephric fat invasion 1.0 8.3 (1.49 to 19.09) .016 Tumors >7 cm No perinephric fat invasion Perinephric fat invasion 1.0 5.01 (1.85 to 13.52) .001 Disease-specific survival for renal cell carcinoma >7 cm and ≤7 cm. 778 | value of perinephric fat invasion. The univariate and multi- - favorable prognostic factor in all of the tumor size groups. They have concluded that utilizing tumor size for grouping pT3a is unnecessary. and pT3a patients in their recent study. They found out that large tumor burden. Their suggestion is to include tumor size Aforementioned studies revealed that utilization of per- inephric fat invasion in TNM staging system and classifying are unclear. To evaluate the prognostic role of perinephric - The 7 - outcomes of Siemer,(7) Yoo, and Murphy studies. Gofrit and associates emphasized the heterogeneity of pT3a tumors and represented perinephric fat invasion as an insig- applies only tumor size and venous involvement. This in- ference is contrary to our results since perinephric fat inva- shared opinion of these authors is the prominent role of the tumor size on prognosis. In our study, the 7 cm cutoff value provided prognostic They suggested the consideration - these groups. The univariate and multivariate analyses did not demonstrate any negative impact of perinephric fat invasion on DSS in - - - tive feature of this study and the relatively small number of - CONCLUSION Although perinephric fat invasion is an accepted prognostic - cacy in TNM staging system and help to differentiate patient - studies are needed for higher level of evidence. CONFLICT OF INTEREST None declared. REFERENCES 1. Belldegrun A, Tsui KH, deKernion JB, Smith RB. Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system. J Clin Oncol. 1999;17:2868-75. 2. Gettman MT, Blute ML. Update on pathologic staging of renal cell carcinoma. Urology. 2002;60:209-17. Urological Oncology 779Vol. 10 | No. 1 | Winter 2013 |U R O LO G Y J O U R N A L 3. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours. 3 ed. Geneva; 1978. 4. Hermanek P, Sobin LH. TNM classification of malignant tumours. 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