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Tumour thrombus consistency: a new tool to stage patients with pT3 renal cell carcinoma (RCC) with venous tumour thrombus?

Despite the further refinements included in the newly released seventh edition, the pT3 substages identified by the 2010 American Joint Committee on Cancer–Union Internationale Contre le Cancer TNM classification present overlapping prognoses and include patients with heterogeneous outcomes. Novara et al. [1] showed that 5-year cancer-specific survival (CSS) for the pT3a subcategory was 75% in patients with renal vein invasion only and 32.4% in patients with concomitant renal vein and perirenal fat invasion. Similarly, CSS probability for the pT3b subcategory was 65.9% in patients with infra-diaphragmatic vena caval thrombus only and 36.5% in patients with concomitant invasion of the perirenal fat. In addition, the Mayo Clinic validation of the 2010 TNM classification showed that pT3b and pT3c disease behaved similarly to each other [2] and patients with pT3a disease and concomitant perirenal fat invasion and renal vein thrombus had a markedly lower 10-year CSS than those with level 0 renal vein thrombus alone. These results confirm that staging tumour disease according to cephalic extension of venous tumour thrombus (VTT) is controversial, as previously shown by several studies [3,4].