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Staging

Updated March 2008

4.1 Classification Criteria

The classification applies only to carcinomas. Papilloma is excluded. There should be histological or cytological confirmation of the disease.

The following are the procedures for assessing T. N. and M categories:

  • T categories: Physical examination, imaging, and endoscopy
  • N categories: Physical examination and imaging
  • M categories: Physical examination and imaging

Regional Lymph Nodes

The regional lymph nodes are the nodes of the true pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries. Laterality does not affect the N classification.

TNM Clinical Classification 1997 (unchanged in 2002 update)

T- Primary Tumour

The suffix (m) should be added to the appropriate T category to indicate multiple tumours. The suffix (is) may be added to any T to indicate presence of associated carcinoma in situ.

 TX 

 Primary tumour cannot be assessed

 T0 

 No evidence of primary tumour

 Ta

 Noninvasive papillary carcinoma

 Tis 

 Carcinoma in situ: "flat tumour"

 T1

 Tumour invades subepithelial connective tissue

 T2

 Tumour invades muscle 

 

 T2a Tumour invades superficial muscle (inner half)

 

 T2b Tumour invades deep muscle (outer half)

 T3

 Tumour invades perivesical tissue:

 

 T3a microscopically

 

 T3b macroscopically (2-dimensional palpable mass)

 T4

 Tumour invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall

 

 T4a Tumour invades prostate or uterus or vagina

 

 T4b Tumour invades pelvic wall or abdominal wall

 

N - Regional Lymph Nodes

 NX 

 Regional lymph nodes cannot be assessed

 N0

 No regional lymph node metastasis

 N1

 Metastasis in a single lymph node 2 cm or less in greatest dimension

 N2

 Metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimension

 N3

 Metastasis in a lymph node more than 5 cm in greatest dimension


M - Distant Metastasis 

 MX 

 Distant metastasis cannot be assessed

 M0

 No distant metastasis

 M1

 Distant metastasis

pTNM Pathological Classification

The pT, pN, and pM categories correspond to the T, N, and M categories.

G Histopathological Grading

 GX 

 Grade of differentiation cannot be assessed

 G1

 Low grade

 G2

 Intermediate grade

 G3

 High grade

Stage Grouping

 0a

 Ta

 N0

 M0

 0is

 Tis

 N0

 M0

 I

 T1

 N0

 M0

 II

 T2a

 N0

 M0

 

 T2b

 N0

 M0

 III

 T3a

 N0

 M0

 

 T3b

 N0

 M0

 

 T4a

 N0

 M0

 IV

 T4b

 N0

 M0

 

 Any T

 N1,2,3

 M0

 

 Any T

 AnyN

 M1

 

Pathologic Classification of Bladder Neoplasms

  • Non-invasive papillary urothelial carcinoma (low grade, high grade) 80%
  • Invasive urothelial carcinoma(Transitional cell carcinoma grade 1-3) 20%
  • Several subtypes with prognostic importance including micropapillary, sarcomatoid (spindle cell) and undifferentiated.
  • Urothelial carcinoma in-situ (Transitional cell carcinoma in-situ) 3%
  • Squamous cell carcinoma - 3 - 8% in Western world, 30% in Egypt.
    Needs to be pure squamous cell carcinoma. If there is a component of urothelial carcinoma, invasive or in-situ, the tumour is classified as urothelial carcinoma with squamous differentiation.
  • Adenocarcinoma – 1% (Note: it is common to find glandular differentiation in TCC which does not constitute "bladder adenocarcinoma". All bladder adenocarcinomas are a diagnosis of exclusion of other primaries, especially colon, even if apparent adenocarcinoma in situ in bladder).
  • Small cell (neuroendocrine) carcinoma - 0.5-1% (56% pure, 46% combined with various other types)
  • Sarcoma – rare, careful exclusion of benign mimics is very important
  • The most recent WHO Classification of Tumours of the urinary system is an adaptation of the ISUP classification and is currently recommended. (5)

4.2 Staging Diagram

4.3 Investigations for Staging

  1. History and physical examination
  2. Routine blood work including CBC, creatinine, electrolytes, liver enzymes, alkaline phosphatase, and CEA ideally should be included for muscle-invasive disease.
  3. Urinalysis, urine cytology
  4. Assessment of upper tracts with IVP, CT or retrograde pyelograms.
  5. Cystoscopy and examination under anesthesia
    1. Complete description of the lesion (number, size, location, surface characteristics)
    2. Bimanual examination prior to resection
    3. Resection or at least deep cold cut biopsies of the lesion to include muscle
    4. Bimanual examination after resection (essential for staging)
    5. Description of bladder mucosa remote from the lesion and random biopsies
    6. Measurement of bladder capacity
    7. Biopsy of prostatic urethra if CIS, multi-centric bladder tumours or disease at the bladder neck
    8. Examination of the prostate and biopsy of any abnormality
  6. Metastatic work up: chest X-ray, CT scan of the abdomen and pelvis, and bone scan in symptomatic patients.
  7. Clinico-pathologic staging: with the results of the above, the stage of bladder cancer can be assigned and appropriate management can be made. See staging diag​ram.

SOURCE: Staging ( )
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