- The American Joint Commission on Cancer in combination with the International Union Cancer Consortium meets on a regular basis to determine the tumor, nodes, and metastases (TNM) staging classifications.
- Malignant tumors are now classified as low grade or high grade, regardless of invasion.
- Papillary tumors with orderly cellular arrangement, minimal architectural abnormalities, and minimal nuclear atypia are designated papillary urothelial neoplasm of low malignant potential (PUNLMP).
- The clinical significance of the WHO grading classification is shown
- Non–muscle-invasive bladder cancer (NMIBC) includes CIS, papillary urothelial neoplasia of low-malignant potential (PUNLMP).
- The grade distribution of NMIBC is 25% PUNLMP, 50% low grade, and 25% high grade (including CIS).
- CIS is characterized as nonpapillary, flat, high-grade tumors in which the surface epithelium contains cancer cells
- There is severe nuclear atypia, loss of cellular polarity, and a noncohesive cellular structure. The cells are large, pleomorphic, chromatin clumping, and abnormal mitotic figures are common. Loss of umbrella cells is a characteristic, separating CIS from dysplasia. All CIS is high grade by definition.
- The WHO 2004 grading scheme should be used routinely and replaces the 1973 and 1998 WHO classification system see tables below:
- The delineation of PUNLMP is important and describes bladder lesions that can recur but rarely invade.
- The elimination of the grade 1, grade 2, and grade 3 1973 WHO system is collapsed into low grade or high grade in the 2004 WHO classification.
- Low-grade papillary lesions are likely to recur in up to 60% of patients but invade in less than 10% of cases. High-grade lesions also recur; however, invasion and subsequent stage progression can occur in 50% of tumors.
- This is particularly true if CIS is associated with a high-grade papillary lesion.
- Stratification of T1 disease is desirable, but there is a lack of a reliable system to accurately identify the muscularis mucosa and therefore stratify tumors accurately.
- The genetic abnormalities associated with CIS include alterations to the RB, TP53, and PTEN genes
- Muscle-invasive bladder cancer leads to death in a significant proportion of patients despite aggressive therapy.
- The T1a and T1b stratifications suggest that the deeper the tumor invades in the lamina propria, the worse the survival.
- The most important risk factor for progression is grade, not stage.
Bladder Cancer TNM Staging System 2009
| Primary Tumor (T) | |
| TX | Primary tumor cannot be assessed |
| T0 | No evidence of primary tumor |
| Ta | Noninvasive papillary carcinoma |
| Tis | Carcinoma in situ (CIS) "flat tumor" |
| T1 | Tumor invades subepithelial connective tissue |
| T2 | Tumor invades muscularis propria |
| T2a | Tumor invades superficial muscularis propria (inner half) |
| T2b | Tumor invades deep muscularis propria (outer half) |
| T3 | Tumor invades perivesical tissue |
| T3a | Tumor invades perivesical tissue microscopically |
| T3b | Tumor invades perivesical tissue macroscopically |
| T4 | Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall |
| T4a | Tumor invades prostate, uterus, and vagina |
| T4b | Tumor invades pelvic wall, abdominal wall |
| Regional Lymph Nodes (N) | |
| NX | Regional lymph nodes cannot be assessed |
| NO | No regional lymph node metastasis |
| N1 | Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node) |
| N2 | Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis) |
| N3 | Lymph node metastasis to the common iliac lymph nodes |
| Distant Metastasis (M) | |
| MX | Distant metastasis cannot be assessed |
| M0 | No distant metastasis |
| M1 | Distant metastasis |
| Anatomic Stage - Grouping | |||
| Group | T | N | M |
| Stage 0a | Ta | N0 | M0 |
| Stage Ois | Tis | N0 | M0 |
| Stage I | T1 | N0 | M0 |
| Stage II | T2a | N0 | M0 |
| T2b | N0 | M0 | |
| Stage III | T3a | N0 | M0 |
| T3b | N0 | M0 | |
| T4a | N0 | M0 | |
| Stage IV | T4b | N0 | M0 |
| Any T | Any N | Any M | |
| Any T | Any N | M1 | |
| Prognostic Factors (Site-Specific Factors) | |||
| Required for staging | NONE | ||
| Clinically significant | Presence or absence of extranodal extension | ||
| Clinically significant | Size of the largest tumor deposit in the lymph nodes | ||
| Clinically significant | World Health Organization/International Society of Urologic Pathology (WHO/ISUP) grade | ||
References
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