TNM Definitions
AJCC Stage Groupings

Though comparable in many respects to staging systems described for bladder cancer, unique structural aspects of the renal pelvis and ureter have led to several differences in the classification schema of tumors that involve the upper tracts. Clinical staging is based on a combination of radiographic procedures (e.g., intravenous pyelogram and computed tomographic scans) and, more recently, ureteroscopy and biopsy.

The advent of rigid and flexible ureteroscopic techniques has permitted endoscopic access to the ureter and renal pelvis. This may permit greater accuracy in preoperative definition of the stage and grade of an upper tract neoplasm. In addition, fulguration and endourological access permit resection or laser coagulation of highly selected low-stage, low-grade lesions of the ureters.[1] However, this approach is still under clinical evaluation since there is the possibility of inaccurate assessment of the stage and extent of disease, and the adequacy and risks of such treatment have not yet been defined.[2-5]

Because of the inaccessibility of ureteral and pelvic anatomy, accurate staging requires pathologic analysis of the surgically excised specimen.

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification to define carcinoma of the renal pelvis and ureter.[6]

Primary tumor (T)

• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
  • Ta: Papillary noninvasive carcinoma
• Tis: Carcinoma in situ
• T1: Tumor invades subepithelial connective tissue
• T2: Tumor invades the muscularis
• T3: (For renal pelvis only) Tumor invades beyond muscularis into peripelvic fat or the renal parenchyma
• T3: (For ureter only) Tumor invades beyond muscularis into periureteric fat
• T4: Tumor invades adjacent organs or through the kidney into perinephric fat

Regional lymph nodes (N)*

• 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

*  [Note: Laterality does not affect the N classification.]

Distant metastasis (M)

• MX: Distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Stage 0a

• Ta, N0, M0

Stage 0is

• Tis, N0, M0

Stage I

• T1, N0, M0

Stage II

• T2, N0, M0

Stage III

• T3, N0, M0

Stage IV

• T4, N0, M0
• Any T, N1, M0
• Any T, N2, M0
• Any T, N3, M0
• Any T, any N, M1

Patients may also be designated as having localized, regional, or metastatic disease, as follows:

Localized

Patients with localized disease may be classified into three groups:

• Group 1: Low-grade tumor confined to the urothelium without lamina propria invasion (“Papilloma” Grade I transitional cell cancer).



• Group 2: Grade I–III carcinomas without demonstrable subepithelial invasion or focal microscopic invasion or papillary carcinomas with carcinoma in situ and/or carcinoma in situ elsewhere in the urothelium.



• Group 3: High-grade tumors that have infiltrated the renal pelvic wall or renal parenchyma or both but are still confined to the kidney. Infiltration of muscle in the upper tract may not be associated with as much potential for distant dissemination as appears to be the case for bladder cancer.

Regional

• Group 4: Extension of tumors beyond the renal pelvis or parenchyma and invasion of peripelvic and perirenal fat, lymph nodes, hilar vessels, and adjacent tissues.

Metastatic

• Spread of the tumor to distant tissues.

Each of these classifications has been subclassified into categories of unicentricity or multicentricity. The latter category indicates a more pervasive tumor diathesis and generally a less favorable prognosis.

Although the classifications listed above have prognostic significance, they can only be determined at the time of nephroureterectomy, which is the treatment of choice for patients with this disease. Because of the high incidence of tumor recurrence within the intramural ureter among patients who have had incomplete excision of this area, nephroureterectomy should include the entire ureter and a margin of periureteral orifice mucosa (i.e., bladder cuff).

A TNM system for staging has been established and has demonstrated accurate predictions of survival. The TNM staging system may be a better predictor of prognosis than tumor grade, though both are strongly predictive of survival. Median survival for patients with tumors confined to the subepithelial connective tissue was 91.1 months compared to 12.9 months for patients with tumors invading the muscularis and beyond in one report. Flow cytometry analysis identifies low-stage, low-grade tumors at high risk of recurrence by virtue of their aneuploid histograms.[7,8]

References

1. Grossman HB, Schwartz SL, Konnak JW: Ureteroscopic treatment of urothelial carcinoma of the ureter and renal pelvis. J Urol 148 (2 Pt 1): 275-7, 1992.  [PUBMED Abstract]
   
   
2. Batata M, Grabstald H: Upper urinary tract urothelial tumors. Urol Clin North Am 3 (1): 79-86, 1976.  [PUBMED Abstract]
   
   
3. Cummings KB, Correa RJ Jr, Gibbons RP, et al.: Renal pelvic tumors. J Urol 113 (2): 158-62, 1975.  [PUBMED Abstract]
   
   
4. Nocks BN, Heney NM, Daly JJ, et al.: Transitional cell carcinoma of renal pelvis. Urology 19 (5): 472-7, 1982.  [PUBMED Abstract]
   
   
5. Heney NM, Nocks BN, Daly JJ, et al.: Prognostic factors in carcinoma of the ureter. J Urol 125 (5): 632-6, 1981.  [PUBMED Abstract]
   
   
6. Renal pelvis and ureter. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 329-334. 
   
   
7. Huben RP, Mounzer AM, Murphy GP: Tumor grade and stage as prognostic variables in upper tract urothelial tumors. Cancer 62 (9): 2016-20, 1988.  [PUBMED Abstract]
   
   
8. Blute ML, Tsushima K, Farrow GM, et al.: Transitional cell carcinoma of the renal pelvis: nuclear deoxyribonucleic acid ploidy studied by flow cytometry. J Urol 140 (5): 944-9, 1988.  [PUBMED Abstract]
   
   

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