15.5 Male Genital & Urinary Tract Staging (AJCC 8th Parts XIII–XIV): Prostate, Testis, Kidney, Bladder, Renal Pelvis & Ureter
Key Takeaways
Prostate clinical T is based on digital rectal exam (T1c is a nonpalpable tumor found by needle biopsy), pathological T has no pT2 subcategories, and stage groups combine T, N, M, PSA and Grade Group.
Testicular pT is assigned from radical orchiectomy, N is based on node size (2 cm or less, more than 2–5 cm, more than 5 cm), and the S category uses post-orchiectomy LDH, hCG and AFP levels.
Kidney T1a is 4 cm or less, T1b more than 4–7 cm, T2a more than 7–10 cm, T2b more than 10 cm; T3a is renal vein, pelvicalyceal system, or perirenal or sinus fat invasion; and T4 extends beyond Gerota's fascia, including contiguous adrenal invasion.
Bladder Ta is noninvasive papillary, Tis is flat carcinoma in situ, T1 invades the lamina propria, T2a and T2b invade the inner and outer half of the muscularis propria, and T3 invades perivesical tissue.
Bladder N1 is a single node in the true pelvis, N2 is multiple true-pelvis nodes, and N3 is common iliac nodes; nonregional nodes are M1a.
Prostate (AJCC 8th, Chapter 58)
T categories
| Clinical T (by DRE) | Definition |
|---|---|
| cT1a | Incidental finding in 5% or less of resected tissue (for example, TURP) |
| cT1b | Incidental finding in more than 5% of resected tissue |
| cT1c | Nonpalpable tumor identified by needle biopsy (for example, for an elevated PSA) |
| cT2a | Palpable, confined, half of one side or less |
| cT2b | More than half of one side, but not both sides |
| cT2c | Both sides |
| cT3a | Extraprostatic extension (one or both sides) |
| cT3b | Seminal vesicle invasion |
| cT4 | Fixed, or invades adjacent structures other than the seminal vesicles (external sphincter, rectum, bladder, levator muscles, pelvic wall) |
| Pathological T | Definition |
|---|---|
| pT2 | Organ confined. The 8th edition has no pT2 subcategories |
| pT3a | Extraprostatic extension, or microscopic invasion of the bladder neck |
| pT3b | Seminal vesicle invasion |
| pT4 | Fixed, or invades adjacent structures other than the seminal vesicles |
There is no pT1. A tumor found on biopsy that is not palpable is cT1c, even if imaging shows it. Clinical T uses the DRE findings.
N and M
- N1: regional nodes in the true pelvis (for example, obturator, internal and external iliac, sacral).
- M1a: nonregional lymph nodes. M1b: bone. M1c: other sites, with or without bone disease.
Stage groups
| Stage | T | N | M | PSA (ng/mL) | Grade Group |
|---|---|---|---|---|---|
| I | cT1a–c or cT2a, or pT2 | N0 | M0 | Less than 10 | 1 |
| IIA | cT1a–c or cT2a, or pT2 | N0 | M0 | 10 to less than 20 | 1 |
| IIA | cT2b–c | N0 | M0 | Less than 20 | 1 |
| IIB | T1–T2 | N0 | M0 | Less than 20 | 2 |
| IIC | T1–T2 | N0 | M0 | Less than 20 | 3 or 4 |
| IIIA | T1–T2 | N0 | M0 | 20 or more | 1–4 |
| IIIB | T3–T4 | N0 | M0 | Any | 1–4 |
| IIIC | Any T | N0 | M0 | Any | 5 |
| IVA | Any T | N1 | M0 | Any | Any |
| IVB | Any T | Any N | M1 | Any | Any |
Grade Group comes from the Gleason score (Section 13.4): GG1 is 6 or less, GG2 is 3+4, GG3 is 4+3, GG4 is 8, and GG5 is 9–10. PSA and the Gleason items are also recorded as SSDIs.
Testis (AJCC 8th, Chapter 59)
- Pathological T is assigned after radical orchiectomy. Clinical T uses cTX, cT0, cTis and cT4 only.
| pT | Definition |
|---|---|
| pTis | Germ cell neoplasia in situ |
| pT1 | Limited to the testis (including rete testis invasion) without lymphovascular invasion. For pure seminoma only: pT1a is less than 3 cm and pT1b is 3 cm or more |
| pT2 | Lymphovascular invasion, or invasion of hilar soft tissue, epididymis, or the visceral mesothelial layer covering the tunica albuginea |
| pT3 | Spermatic cord |
| pT4 | Scrotum |
- N (clinical): cN1 is a node mass 2 cm or less; cN2 is more than 2 cm to 5 cm; cN3 is more than 5 cm. Pathological N also counts the number of nodes and extranodal extension.
- M1a: non-retroperitoneal nodes or lung metastases. M1b: other visceral sites.
- S (serum tumor markers after orchiectomy):
| S | LDH | hCG (mIU/mL) | AFP (ng/mL) |
|---|---|---|---|
| S1 | Less than 1.5 × upper normal | Less than 5,000 | Less than 1,000 |
| S2 | 1.5–10 × upper normal | 5,000–50,000 | 1,000–10,000 |
| S3 | More than 10 × upper normal | More than 50,000 | More than 10,000 |
- Stage groups:
- IA: pT1 N0 M0 S0.
- IB: pT2–pT4 N0 M0 S0.
- IS: any pT, N0 M0, S1–S3 (persistently raised markers).
- IIA, IIB, IIC: N1, N2, N3, with M0 and S0–S1.
- IIIA: M1a with S0–S1.
- IIIB: N1–N3 (M0) or M1a, with S2.
- IIIC: N1–N3 (M0) or M1a, with S3; or any M1b.
Kidney (AJCC 8th, Chapter 60)
| T | Definition |
|---|---|
| T1a | 4 cm or less, limited to the kidney |
| T1b | More than 4 cm to 7 cm, limited to the kidney |
| T2a | More than 7 cm to 10 cm, limited to the kidney |
| T2b | More than 10 cm, limited to the kidney |
| T3a | Extends into the renal vein or its segmental branches, invades the pelvicalyceal system, or invades perirenal or renal sinus fat but not beyond Gerota's fascia |
| T3b | Extends into the vena cava below the diaphragm |
| T3c | Extends into the vena cava above the diaphragm, or invades the wall of the vena cava |
| T4 | Invades beyond Gerota's fascia, including contiguous extension into the ipsilateral adrenal gland |
- N1: regional node metastasis (there is no N2). M1: distant metastasis. A non-contiguous adrenal metastasis is M1, not T4.
- Stage groups: I is T1 N0; II is T2 N0; III is T3 N0, or T1–T3 N1; IV is T4 any N, or any M1.
- Grade uses the WHO/ISUP nucleolar grade for clear cell and papillary renal cell carcinoma.
Urinary bladder (AJCC 8th, Chapter 62)
| T | Definition |
|---|---|
| Ta | Noninvasive papillary carcinoma |
| Tis | Urothelial carcinoma in situ, the flat tumor |
| T1 | Invades the lamina propria (subepithelial connective tissue) |
| T2a | Invades the inner half of the muscularis propria |
| T2b | Invades the outer half of the muscularis propria |
| T3a | Perivesical tissue, microscopically |
| T3b | Perivesical tissue, macroscopically (extravesical mass) |
| T4a | Prostatic stroma, seminal vesicles, uterus or vagina |
| T4b | Pelvic wall or abdominal wall |
| N | Definition |
|---|---|
| N1 | Single node in the true pelvis (perivesical, obturator, internal and external iliac, or sacral) |
| N2 | Multiple nodes in the true pelvis |
| N3 | Common iliac node(s) |
- M1a: nonregional lymph nodes beyond the common iliac nodes. M1b: other distant sites.
- Stage groups:
- 0a: Ta N0. 0is: Tis N0.
- I: T1 N0. II: T2a–T2b N0.
- IIIA: T3a–T4a N0, or T1–T4a N1.
- IIIB: T1–T4a N2–N3.
- IVA: T4b, or M1a. IVB: M1b.
- Registry tips:
- A TURBT gives clinical staging information; pathological T needs a cystectomy.
- A TURBT specimen without muscularis propria cannot show whether the tumor invades muscle.
- "Muscularis mucosae" invasion is not muscle-invasive disease. That is lamina propria, T1.
Renal pelvis and ureter (AJCC 8th, Chapter 61)
| T | Definition |
|---|---|
| Ta / Tis | Noninvasive papillary / carcinoma in situ |
| T1 | Subepithelial connective tissue |
| T2 | Muscularis |
| T3 | Renal pelvis: beyond the muscularis into peripelvic fat or renal parenchyma. Ureter: beyond the muscularis into periureteric fat |
| T4 | Adjacent organs, or through the kidney into perinephric fat |
- N1: a single node 2 cm or less. N2: a single node larger than 2 cm, or multiple nodes.
- Stage groups: 0a, 0is, I (T1), II (T2), III (T3), and IV (T4, any N1–N2, or M1).
Worked cases
- Needle biopsy for PSA 6.2, no palpable nodule, Gleason 3+4 on biopsy, no imaging evidence of spread: cT1c N0 M0, PSA less than 10, GG2, stage IIB.
- Radical prostatectomy with extraprostatic extension, PSA 8, Gleason 4+3: pT3a N0 M0, GG3, stage IIIB.
- Orchiectomy shows seminoma, 2.5 cm, no lymphovascular invasion, normal markers after surgery, negative CT: pT1a N0 M0 S0, stage IA.
- Nephrectomy shows a 5.5 cm clear cell RCC with renal sinus fat invasion: pT3a. With N0 M0, stage III.
- TURBT shows high-grade papillary urothelial carcinoma invading the lamina propria, with muscularis propria present and uninvolved: cT1, stage I.
A man has a PSA of 14 ng/mL and a normal digital rectal exam. Needle biopsy shows Gleason 3+3=6 adenocarcinoma in 4 of 12 cores, and imaging shows no spread. What is the AJCC 8th edition clinical stage group?
I
IIA
IIB
IIIA
After radical orchiectomy for a nonseminomatous germ cell tumor, the patient has no nodal or distant disease on imaging, but AFP remains elevated at 1,500 ng/mL. Which stage group applies?
IA
IB
IIIA
IS
A cystectomy shows urothelial carcinoma invading the outer half of the muscularis propria, with metastases in two obturator lymph nodes and no distant metastasis. What is the stage group?
II
IIIA
IIIB
IVA
Sections you finish are checked off in the contents.