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	Any N	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 (PDF)

4.3 Investigations for Staging

History and physical examination
Routine blood work including CBC, creatinine, electrolytes, liver enzymes, alkaline phosphatase, and CEA ideally should be included for muscle-invasive disease.
Urinalysis, urine cytology
Assessment of upper tracts with IVP, CT or retrograde pyelograms.
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
Metastatic work up: chest X-ray, CT scan of the abdomen and pelvis, and bone scan in symptomatic patients.
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 diagram.