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Prostate and Bladder Cancer Staging and Grading - A review for students

Written by Thomas Lemon · Sunday 22nd September 2013

Amended from Wikipedia and other sources
T.I Lemon

Stage means spread
Grade means histology

Prostate cancer staging – spread of the cancer
There are two schemes commonly used to stage prostate cancer. TMN and Whitmore Jewett

Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as benign prostatic hypertrophy, and the cells closely resemble normal cells and the gland feels normal to the examining finger
Stage II more of the prostate is involved and a lump can be felt within the gland.
Stage III, the tumour has spread through the prostatic capsule and the lump can be felt on the surface of the gland.
In Stage IV disease, the tumour has invaded nearby structures, or has spread to lymph nodes or other organs.

Grading - Gleason Grading System is based on cellular content and tissue architecture from biopsies, which provides an estimate of the destructive potential and ultimate prognosis of the disease.
TX: cannot evaluate the primary tumor
T0: no evidence of tumor
T1: tumor present, but not detectable clinically or with imaging
• T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
• T1b: tumor was incidentally found in greater than 5% of prostate tissue resected
• T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
• T2a: the tumor is in half or less than half of one of the prostate gland's two lobes
• T2b: the tumor is in more than half of one lobe, but not both
• T2c: the tumor is in both lobes but within the prostatic capsule
• T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
• T3a: the tumor has spread through the capsule on one or both sides
• T3b: the tumor has invaded one or both seminal vesicles
• T4: the tumor has invaded other nearby structures
It should be stressed that the designation "T2c" implies a tumor which is palpable in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c.
Evaluation of the regional lymph nodes ('N')
NX: cannot evaluate the regional lymph nodes
• N0: there has been no spread to the regional lymph nodes
• N1: there has been spread to the regional lymph nodes
Evaluation of distant metastasis ('M')
• MX: cannot evaluate distant metastasis
• M0: there is no distant metastasis
• M1: there is distant metastasis
• M1a: the cancer has spread to lymph nodes beyond the regional ones
• M1b: the cancer has spread to bone
• M1c: the cancer has spread to other sites (regardless of bone involvement)

Evaluation of the histologic grade ('G')
Usually, the grade of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages.
• GX: cannot assess grade
• G1: the tumor closely resembles normal tissue (Gleason 2–4)
• G2: the tumor somewhat resembles normal tissue (Gleason 5–6)
• G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10)
Of note, this system of describing tumors as "well-", "moderately-", and "poorly-" differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is:
• Gleason 3+3: tumor is low grade (favorable prognosis)
• Gleason 3+4 / 3+5: tumor is mostly low grade with some high grade
• Gleason 4+3 / 5+3: tumor is mostly high grade with some low grade
• Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade
Note that under current guidelines, if any Pattern 5 is present it is included in final score, regardless of the percentage of the tissue having this pattern, as the presence of any pattern 5 is considered to be a poor prognostic marker.

Overall staging
The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity.
Stage Tumor Nodes Metastasis Grade
Stage I T1a N0 M0 G1
Stage II T1a N0 M0 G2–4
T1b N0 M0 Any G
T1c N0 M0 Any G
T1 N0 M0 Any G
T2 N0 M0 Any G
Stage III T3 N0 M0 Any G
Stage IV T4 N0 M0 Any G
Any T N1 M0 Any G
Any T Any N M1 Any G

T (Primary tumour)
• TX Primary tumour cannot be assessed
• T0 No evidence of primary tumour
• Ta Non-invasive papillary carcinoma
• Tis Carcinoma in situ (‘flat tumour’)
• T1 Tumour invades subepithelial connective tissue
• 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)
• T4a Tumour invades prostate, uterus or vagina
• T4b Tumour invades pelvic wall or abdominal wall
N (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.


Urothelial papilloma – non cancerous (benign) tumour
•Papillary urothelial neoplasm of low malignant potential (PUNLMP) – very slow growing and unlikely to spread
•Low grade papillary urothelial carcinoma – slow growing and unlikely to spread
•High grade papillary urothelial carcinoma – more quickly growing and more likely to spread