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Review: Updates in Staging and Reporting of Genitourinary Malignancies

Key findings

  • The eighth edition of the Cancer Staging Manual of the American Joint Committee on Cancer went into effect on January 1, 2018
  • Some pathologists may not be aware of the changes made in the recommended tumor, node, metastasis staging system for genitourinary cancers and not consistently implemented
  • This review summarizes the major changes in the staging of prostate, penile, testicular, bladder, urethral, renal pelvis/ureter and kidney cancers
  • Standardized reporting by pathologists will help clinicians with prognostication, management and clinical registry research

The eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual went into effect on January 1, 2018. Kristine Cornejo, MD, genitourinary pathologist and assistant pathologist at Massachusetts General Hospital and the Mass General Cancer CenterChin-Lee Wu, MD, PhD, director of Genitourinary Pathology Services at Mass General and the Mass General Cancer Center, and colleagues highlight changes in the recommended tumor, node, metastasis classification system for genitourinary cancers which may not be consistently implemented. 

In Archives of Pathology and Laboratory Medicine, the authors summarize the major revisions and give examples of how standardized reporting by pathologists will help clinicians with prognostication, management and clinical registry research.

Prostate Cancer

The three subdivisions of pT2 have been merged into a single category because they have no separate effects on prognosis.

Grade groups are more accurate than Gleason score (GS) in predicting disease progression, so they should be reported along with GS:

  • 1 (GS 6)
  • 2 (GS 3+4=7)
  • 3 (GS 4+3=7)
  • (GS 8)
  • 5 (GS 9–10)

Both tumor grade and prostate-specific antigen (PSA) level influence prognosis and treatment, so AJCC prognostic stage group III may include organ-confined disease:

  • IIIA—T1 or T2, grade group 1–4 and PSA ≥20 ng/mL
  • IIIB—T3 or T4, grade group 1–4 and any PSA level
  • IIIC—Any T, grade group 5 and any PSA level

Penile Cancer

The category of nonurethral penile skin-derived cancers has been expanded to include noninvasive localized squamous cell carcinoma (Ta).

T1 invasive tumors should be defined according to the location (glans, foreskin, shaft) and the anatomic layers invaded. T1 has been subcategorized according to the absence (T1a) or presence (T1b) of perineural invasion.

Involvement of the corpus spongiosum or corpora cavernosa was formerly considered T2 disease; invasion of these sites is now T2 or T3, respectively. Urethral involvement, formerly T3, can now be either T2 or T3.

A grade should follow the World Health Organization system:

  • 1—Well differentiated
  • 2—Moderately differentiated
  • 3—Poorly differentiated, including sarcomatoid/spindled morphologies and any proportion of anaplastic cells

Testicular Cancer

In pure seminoma, T1 is now subclassified as T1a or T1b at a cutoff of 3 cm. Both hilar soft tissue and epididymal invasion have been upstaged to T2.

Discontinuous involvement of the spermatic cord soft tissue by lymphovascular invasion is now considered metastasis (M1).

Intratubular germ cell neoplasia should now be called germ cell neoplasia in situ—the aim is to distinguish intratubular germ cell neoplasia, which is a precursor lesion, from the intratubular spread of germ cell tumors.

Bladder Cancer

Perivesical lymph nodes were added as a primary drainage site (classified as N1). AJCC prognostic stage groups III and VI are both subdivided into A and B according to the amount of regional lymph node metastases and M1 disease, respectively. M1 metastatic disease should be substaged as M1a (non-regional lymph node only) or M1b (non–lymph node distant metastases).

Urethral Cancer

Urothelial carcinoma in situ involving prostatic urethra (Tis pu) or the prostatic ducts and acini (Tis pd) has been collapsed into a single-stage designation, Tis.

The definition of the N category is now based on the number of lymph nodes, not the extent of metastasis, and perivesical lymph nodes have been added to the nodes considered:

  • N1—single regional lymph node metastasis in the inguinal region or true pelvis (perivesical, obturator, internal [hypogastric] and external iliac), or presacral lymph node
  • N2—As above, except multiple nodes

The review also addresses minor changes in staging of malignancies of the renal pelvis/ureter and kidney.

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