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Comparison between 1973 and 2004/2016 WHO grading systems in patients with Ta urothelial carcinoma of urinary bladder
  1. Claudia Collà Ruvolo1,2,
  2. Christoph Wuernschimmel1,3,
  3. Mike Wenzel1,4,
  4. Luigi Nocera1,5,
  5. Gianluigi Califano2,
  6. Zhe Tian1,
  7. Shahrokh F Shariat6,7,8,9,10,11,
  8. Fred Saad1,
  9. Felix C H Chun4,
  10. Alberto Briganti5,
  11. Paolo Verze12,
  12. Ciro Imbimbo2,
  13. Vincenzo Mirone2,
  14. Pierre I Karakiewicz1
  1. 1Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, CRCHUM, Montreal, Quebec, Canada
  2. 2Urology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Campania, Italy
  3. 3Martini-Klinik Prostate Cancer Center, University of Hamburg Faculty of Medicine, Hamburg, Germany
  4. 4Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Faculty 16 Medicine, Frankfurt am Main, Hessen, Germany
  5. 5Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IBCAS San Raffaele Scientific Institute, Milan, Lombardia, Italy
  6. 6Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
  7. 7Departments of Urology, Weill Cornell Medical College, New York, New York, USA
  8. 8Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
  9. 9Department of Urology, Second Faculty of Medicine, Charles University, Prag, Czech Republic
  10. 10Institute for Urology and Reproductive Health, I.M, Sechenov First Moscow State Medical University, Moscow, Russia
  11. 11Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
  12. 12Department of Medicine and Surgery “Scuola Medica Salernitana”, University of Salerno, Fisciano, Campania, Italy
  1. Correspondence to Dr Claudia Collà Ruvolo, Urology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy; c.collaruvolo{at}


Aims To compare the 1973 WHO and the 2004/2016 WHO grading systems in patients with urothelial carcinoma of urinary bladder (UCUB), since no consensus has been made which classification should supersede the other and since both are recommended in clinical practice.

Methods Newly diagnosed patients with Ta UCUB treated with transurethral resection of bladder tumour were abstracted from the Surveillance, Epidemiology and End Results database (2010–2016). Kaplan-Meier plots and multivariable Cox regression models (CRMs) tested cancer-specific mortality (CSM), according to 1973 WHO (G1 vs G2 vs G3) and to 2004/2016 WHO (low-grade vs high-grade) grading systems.

Results Of 35 986 patients, according to 1973 WHO grading system, 8165 (22.7%) were G1, 17 136 (47.6%) were G2 and 10 685 (29.7%) were G3. According to 2004/2016 WHO grading system, 24 961 (69.4%) were low-grade versus 11 025 (30.6%) high-grade. In multivariable CRMs, G3 (HR: 2.05, p<0.001), relative to G1, and high-grade(HR: 2.13, p<0.001), relative to low-grade, predicted higher CSM. Conversely, G2 (p=0.8) was not an independent predictor. The multivariable models without consideration of either grading system were 74% accurate in predicting 5-year CSM. After addition of 1973 WHO or 2004/2016 WHO grade, the accuracy increased to 76% and 77%, respectively.

Conclusions From a statistical standpoint, it appears that the 2004/2016 WHO grading system holds a small, although measurable advantage over the 1973 WHO grading system. Other considerations, such as intraobserver and interobserver variability may represent an additional matric to consider in deciding which grading system is better.

  • urinary bladder
  • urologic diseases
  • urologic neoplasms

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  • Handling editor Runjan Chetty.

  • Contributors CCR: protocol/project development, data analysis, manuscript writing. CW: protocol/project development, data analysis. MW: protocol/project development, manuscript writing. LN: protocol/project development, data analysis. GC: manuscript editing. ZT: data collection or management. SFS: manuscript editing. FS: data collection or management. FCHC: manuscript editing. AB: data management. PV: data management. CI: manuscript editing. VM: supervisor. PIK: protocol/project development, manuscript editing, supervisor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Due to the anonymously coded design of the Survelliance Epidemiology and End Results (SEER) database, study-specific institutional review board ethics approval was not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The data were extracted from the Surveillance Epidemiology and End Results database. The statistical code used can be share upon reasonable request.