Context: Grading is the mainstay for treatment decisions for patients with non-muscle-invasive bladder cancer (NMIBC).
Objective: To determine the requirements for an optimal grading system for NMIBC via expert opinion.
Evidence acquisition: A multidisciplinary working group established by the International Society of Urological Pathology reviewed available clinical, histopathological, and molecular evidence for an optimal grading system for bladder cancer.
Evidence synthesis: Bladder cancer grading is a continuum and five different grading systems based on historical grounds could be envisaged. Splitting of the World Health Organization (WHO) 2004 low-grade class for NMIBC lacks diagnostic reproducibility and molecular-genetic support, while showing little difference in progression rate. Subdividing the clinically heterogeneous WHO 2004 high-grade class for NMIBC into intermediate and high risk categories using the WHO 1973 grading is supported by both clinical and molecular-genetic findings. Grading criteria for the WHO 1973 scheme were detailed on the basis of literature findings and expert opinion.
Conclusions: Splitting of the WHO 2004 high-grade category into WHO 1973 grade 2 and 3 subsets is recommended. Provision of more detailed histological criteria for the WHO 1973 grading might facilitate the general acceptance of a hybrid four-tiered grading system or-as a preferred option-a more reproducible three-tiered system distinguishing low-, intermediate (high)-, and high-grade NMIBC.
Patient summary: Improvement of the current systems for grading bladder cancer may result in better informed treatment decisions for patients with bladder cancer.
Keywords: Bladder cancer; Expert opinion; Grading system; Non-muscle invasive bladder cancer; Pathology; WHO 1973; WHO 2004.
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