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Urinary Bladder (ICD‐O‐3 C67) Rules for Classification The classification applies 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 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 T0 Ta Tis
Primary tumour cannot be assessed No evidence of primary tumour Non‐invasive papillary carcinoma 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 (extravesical mass)
T4 Tumour invades any of the following: prostate stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall T4a Tumour invades prostate stroma, seminal vesicles, 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 in the true pelvis (hypogastric, obturator, external iliac, or presacral) N2 Metastasis in multiple regional lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or presacral) N3 Metastasis in a common iliac lymph node(s)
M – Distant Metastasis M0 No distant metastasis M1a Non‐regional lymph nodes M1b Other distant metastasis
pTNM Pathological Classification The pT and pN categories correspond to the T and N categories. For pM see page 8.
Stage Stage 0a Stage 0is Stage I Stage II Stage IIIA Stage IIIB Stage IVA Stage IVB
Ta Tis T1 T2a, T2b T3a, T3b, T4a T1,T2, T3, T4a T1, T2, T3, T4a T4b Any T Any T
N0 N0 N0 N0 N0 N1 N2, N3 N0 Any N Any N
M0 M0 M0 M0 M0 M0 M0 M0 M1a M1b
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Prognostic Factors Grid – Bladder Prognostic factors for progression to invasive disease in superficial bladder cancer (Ta, T1, Tis) Prognostic Tumour related factor
Host related
Environment related
Essential
Grade T stage Carcinoma in situ (Cis) Number of lesions Previous recurrences
Age Performance status Other co‐morbidities
Extent of transurethral resection (Intravesical chemotherapy reduces recurrence but limited evidence for reducing progression)
Additional
Tumour size Recurrence at 3‐month check
Gender Continued tobacco use
Novel/ promising
p53 NMP22 FGFR3 mutation status COX‐2 (especially upper tract) Claudin protein family members DNA methylation status Lymphovascular invasion Extent of invasion (T1microinvasive or T1extensive invasive)
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Prognostic Tumor related factors
Host related
Environment related
Essential
Age Performance status ALP Other co‐morbidities
Surgical margin status
Haemoglobin Response of primary to chemotherapy
Extent of lymph node resection Proportion (density) of involved lymph nodes
T category N category
Additional Grade Histological type Lymphovascular invasion Concomitant Cis Tumour size Hydronephrosis
Novel/ p53, p63, p21 (for Certain germline promising long‐term bladder singlenucleotide polymorphisms preservation) (SNPs) Rb protein Ki67 EGF receptor HER2 expression E‐cadherin Microvessel density Treatment resistance mechanisms (ERCC1, BRCA1 or MMR mutations) With established metastatic disease, visceral metastasis is associated with a poorer prognosis. Source: UICC Manual of Clinical Oncology, Ninth Edition. Edited by Brian O’Sullivan, James D. Brierley, Anil K. D’Cruz, Martin F. Fey, Raphael Pollock, Jan B. Vermorken and Shao Hui Huang. © 2015 UICC. Published 2015 by John Wiley & Sons, Ltd.
Urological
Prognostic factors for metastatic risk and survival in invasive, locally‐ advanced and/or node positive bladder cancer (T2–4 N0–1)