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Bladder Cancer Treatment (PDQ®)

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Last Modified: 02/21/2014

Stage Information for Bladder Cancer

AJCC Stage Groupings and TNM Definitions

The clinical staging of carcinoma of the bladder is determined by the depth of invasion of the bladder wall by the tumor. This determination requires a cystoscopic examination that includes a biopsy and examination under anesthesia to assess the following:

  • Size and mobility of palpable masses.
  • Degree of induration of the bladder wall.
  • Presence of extravesical extension or invasion of adjacent organs.

Clinical staging, even when computed tomographic (CT) and/or magnetic resonance imaging (MRI) scans and other imaging modalities are used, often underestimates the extent of tumor, particularly in cancers that are less differentiated and more deeply invasive. CT imaging is the standard staging modality. A clinical benefit from obtaining MRI or positron emission tomography scans rather than CT imaging has not been demonstrated.[1,2]

AJCC Stage Groupings and TNM Definitions

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification to define bladder cancer.[3]

Table 1. Definitions of TNM Stages 0 and 0is
Stage  TNM Description Illustration 
0aTa, N0, M0Ta = Noninvasive papillary carcinoma.
N0 = No lymph node metastasis.
M0 = No distant metastasis.
0isTis, N0, M0Tis = Carcinoma in situ: "flat tumor."
N0 = No lymph node metastasis.
M0 = No distant metastasis.

T = primary tumor; N = regional lymph nodes; M = distant metastasis.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497–505.

Table 2. Definition of TNM Stage I
Stage  TNM Description Illustration 
IT1, N0, M0T1 = Tumor invades subepithelial connective tissue.
N0 = No lymph node metastasis.
M0 = No distant metastasis.

T = primary tumor; N = regional lymph nodes; M = distant metastasis.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497–505.

Table 3. Definition of TNM Stage II
Stage  TNM Description Illustration 
IIT2a, N0, M0T2a = Tumor invades superficial muscularis propria (inner half).
N0 = No lymph node metastasis.
M0 = No distant metastasis.
T2b, N0, M0T2b = Tumor invades deep muscularis propria (outer half).
N0 = No lymph node metastasis.
M0 = No distant metastasis.

T = primary tumor; N = regional lymph nodes; M = distant metastasis.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497–505.

Table 4. Definition of TNM Stage III
Stage  TNM Description Illustration 
IIIT3a, N0, M0T3a = Tumor invades perivesical tissue microscopically.
N0 = No lymph node metastasis.
M0 = No distant metastasis.
T3b, N0, M0T3b = Tumor invades perivesical tissue macroscopically (extravesical mass).
N0 = No lymph node metastasis.
M0 = No distant metastasis.
T4a, N0, M0T4a = Tumor invades prostatic stroma, uterus, vagina.
N0 = No lymph node metastasis.
M0 = No distant metastasis.

T = primary tumor; N = regional lymph nodes; M = distant metastasis.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497–505.

Table 5. Definition of TNM Stage IV
Stage  TNM Description Illustration 
IVT4b, N0, M0T4b = Tumor invades pelvic wall, abdominal wall.
N0 = No lymph node metastasis.
M0 = No distant metastasis.
Any T, N1–N3, M0TX = Primary tumor cannot be assessed.
T0 = No evidence of primary tumor.
Ta = Noninvasive papillary carcinoma.
Tis = Carcinoma in situ: “flat tumor.”
T1 = Tumor invades subepithelial connective tissue.
T2 = Tumor invades muscularis propria.
pT2a = Tumor invades superficial muscularis propria (inner half).
pT2b = Tumor invades deep muscularis propria (outer half).
T3 = Tumor invades perivesical tissue.
pT3a = Tumor invades perivesical tissue microscopically.
pT3b = Tumor invades perivesical tissue macroscopically (extravesical mass).
T4 = Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall.
T4a = Tumor invades prostatic stroma, uterus, vagina.
T4b = Tumor invades pelvic wall, abdominal wall.
N1 = Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node).
N2 = Multiple regional lymph node metastases in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node).
N3 = Lymph node metastases to the common iliac lymph nodes.
M0 = No distant metastasis.
Any T, any N, M1TX = Primary tumor cannot be assessed.
T0 = No evidence of primary tumor.
Ta = Noninvasive papillary carcinoma.
Tis = Carcinoma in situ: "flat tumor."
T1 = Tumor invades subepithelial connective tissue.
T2 = Tumor invades muscularis propria.
pT2a = Tumor invades superficial muscularis propria (inner half).
pT2b = Tumor invades deep muscularis propria (outer half).
T3 = Tumor invades perivesical tissue.
pT3a = Tumor invades perivesical tissue microscopically.
pT3b = Tumor invades perivesical tissue macroscopically (extravesical mass).
T4 = Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall.
T4a = Tumor invades prostatic stroma, uterus, vagina.
T4b = Tumor invades pelvic wall, abdominal wall.
NX = Lymph nodes cannot be assessed.
N0 = No 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 metastases in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node).
N3 = Lymph node metastases to the common iliac lymph nodes.
M1 = Distant metastasis.

T = primary tumor; N = regional lymph nodes; M = distant metastasis.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497–505.

Table 6. WHO/ISUP Recommended Grading System
GXGrade cannot be assessed.
G1Well differentiated.
G2Moderately differentiated.
G3Poorly differentiated.
G4Undifferentiated.

WHO = World Health Organization; ISUP = International Society of Urologic Pathology.
Reprinted with permission from AJCC: Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, p 497.

References
  1. Cowan NC, Crew JP: Imaging bladder cancer. Curr Opin Urol 20 (5): 409-13, 2010.  [PUBMED Abstract]

  2. Green DA, Durand M, Gumpeni N, et al.: Role of magnetic resonance imaging in bladder cancer: current status and emerging techniques. BJU Int 110 (10): 1463-70, 2012.  [PUBMED Abstract]

  3. Urinary bladder. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 497-505.