Purpose of review: Accurate pathologic staging systems provide valuable prognostic information. As our understanding of the biology of renal cell carcinoma improves, so does the staging system has undergo periodic modification. The modification of the tumor-node-metastasis staging system in 2002 has been applied to various populations, and several changes have been proposed.
Recent findings: The tumor diameter chosen as a break point in the staging system for noninvasive tumors is debated. Although 4 cm, the break point between T1a and T1b tumors, was chosen, in part, to select tumors amenable to partial nephrectomy, newer data show that this may no longer be appropriate. Size appears to have continual prognostic significance, especially in the range of 4-6 cm. T3a tumors with adrenal involvement appear to have a poor prognosis similar to T4 tumors. In addition, while renal sinus invasion may have a worse prognosis, perinephric fat invasion appears to have less impact on survival than overall tumor size.
Summary: Refinements of the current staging system on the basis of current understanding of tumor characteristics will improve prognostic accuracy. The addition of molecular markers and other features should be considered while not allowing increased complexity to disrupt clinical utility.