Published August 2002
Classification Criteria
T - Primary Tumour
- TX: Primary tumour cannot be assessed
- T0: No evidence of primary tumour
- Ta: Non-invasive papillary carcinoma
- Tis: Carcinoma in situ
- T1: Tumour invades subepithelial connective tissue
- T2: Tumour invades muscularis
- T3: (Renal pelvis) Tumour invades beyond muscularis into peripelvic fat or renal parenchyma
(Ureter) Tumour invades beyond muscularis into periureteric fat - T4: Tumour invades adjacent organs or through the kidney into the perinephric fat
N - Regional Lymph Nodes
The regional lymph nodes are the hilar, abdominal para-aortic, paracaval and, for ureter, intrapelvic irrespective of laterality. Laterality does not affect the N classification.
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Metastasis in a single node 2 cm or less in greatest dimension
- N2: Metastasis in a single node greater 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: Presence of distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
Staging Diagram
Investigations for Staging
- History and physical examination
- Intravenous pyelogram
- Chest X-ray
- Urinalysis and culture
- Urine cytology
- Cystoscopy and retrograde pyelograms
- In special cases where diagnosis is still in doubt, brush biopsy and/or basket biopsy
- CT scan
- Ureteroscopy
T1-3 N0 M0
Nephroureterectomy with cuff of bladder ± regional lymph node dissection for staging. T1N0M0 tumours, specifically low grade lesions, ureteroscopic treatment would seem appropriate for selected circumstances.
Distal ureteral lesions may be considered for ureterectomy and reimplantation. Cystoscopy and biopsy of suspicious bladder lesions should be performed before extirpative surgery of the upper ureteral lesion.
Treatment: nephroureterectomy with cuff of bladder ± regional lymph node dissection for staging.
T4 N0 M0
- Palliative nephrectomy or
- Palliative radiotherapy
T1-3 N1-3 M0-1
Selected patients with more advanced disease by virtue of more extensive nodal involvement or dissemination may be considered for palliative chemotherapy and/or radiation
In cases with carcinoma of the renal pelvis or ureter in a solitary kidney or in patients who have had multiple recurrences after conservative therapy, special treatment modalities may be indicated, depending on patient preference and Agency consultation.
Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.
- For patients who have received radiotherapy, one month post-treatment appointment at the Agency.
- Regular cystoscopy and examination by urologist six-monthly for two years, thereafter annually as indicated.
Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.
Notification is requested in the event of any of the following:
- Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
- Metastasis at regional or distant sites
- Complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic
- Death with primary cause and whether cancer or treatment contributed
The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.
