Bladder Cancer: Stages and Grades

Approved by the Lineagotica Editorial Board, 10/2017

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as the way the tumor cells look when viewed under a microscope. This is called the stage and grade. Use the menu to see other pages.

Staging is a way of describing where the cancer is located, if or where it has invaded or spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

For bladder cancer, the stage is determined based on examining the sample removed during a TURBT (see Diagnosis) and finding out whether the cancer has spread to other parts of the body.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?

  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Staging can be clinical or pathological. Clinical staging is based on the results of physical examinations, imaging scans, and biopsies. Pathological staging is based on what is found during surgery plus the results of physical examinations, imaging scans, and biopsies. Pathological staging gives the health care team the most amount of information to make a prognosis. Here are more details on each part of the TNM system for bladder cancer.

Tumor (T)

Using the TNM system, the "T" plus a letter and/or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. If there is more than 1 tumor, the lowercase letter "m" (multiple) is added to the "T" stage category. If the “T” stage starts with a lowercase “c,” it means that the tumor was staged clinically. If it starts with a lowercase “p,” it means that the tumor was staged pathologically. If a patient’s tumor is removed, specific tumor stage information is listed below.

Bladder cancer

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a primary tumor in the bladder.

Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT.

Tis: This stage is carcinoma in situ (CIS) or a "flat tumor." This means that the cancer is only found on or near the surface of the bladder. The doctor may also call it non-muscle-invasive bladder cancer, superficial bladder cancer, or noninvasive flat carcinoma. This type of bladder cancer often comes back after treatment, usually as another noninvasive cancer in the bladder.

T1: The tumor has spread to the connective tissue (called the lamina propria) that separates the lining of the bladder from the muscles beneath, but it does not involve the bladder wall muscle.

T2: The tumor has spread to the muscle of the bladder wall.

  • T2a: The tumor has spread to the inner half of the muscle of the bladder wall, which may be called the superficial muscle.

  • T2b: The tumor has spread to the deep muscle of the bladder (the outer half of the muscle).

T3: The tumor has grown into the perivesical tissue (the fatty tissue that surrounds the bladder).

  • T3a: The tumor has grown into the perivesical tissue, as seen through a microscope.

  • T3b: The tumor has grown into the perivesical tissue macroscopically. This means that the tumor(s) is large enough to be seen during imaging tests or to be seen or felt by the doctor.

T4: The tumor has spread to any of the following: the abdominal wall, the pelvic wall, a man’s prostate or seminal vesicle (the tubes that carry semen), or a woman’s uterus or vagina.

  • T4a: The tumor has spread to the prostate, seminal vesicles, uterus, or vagina.

  • T4b: The tumor has spread to the pelvic wall or the abdominal wall.

Renal pelvis and ureter

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a primary tumor in the bladder.

Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT.

Tis: This stage is carcinoma in situ (CIS) or a "flat tumor."

T1: The tumor has spread to the connective tissue beneath the lining of the renal pelvis or ureter.

T2: The tumor has spread to the muscle.

T3: The tumor has grown into the peripelvic fat (layers of fat around the kidney), into the renal parenchyma (the part of the kidney that filters blood and makes urine), or into the fat around the ureter.

T4: The tumor has spread to nearby organs or into the outer layer of fat on the kidney.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph nodes near where the cancer started, within the true pelvis (called hypogastric, obturator, iliac, perivesical, pelvic, sacral, and presacral lymph nodes), are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

Bladder cancer

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to a single regional lymph node in the pelvis.

N2: The cancer has spread to 2 or more regional lymph nodes in the pelvis.

N3: The cancer has spread to the common iliac lymph nodes, which are located behind the major arteries in the pelvis, above the bladder.

Renal pelvis and ureter

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread to the regional lymph nodes.

N1: The cancer is 2 centimeters (cm) or smaller in a single lymph node.

N2: The cancer is larger than 2 cm in a single lymph node, or it has spread to more than 1 lymph node.

Metastasis (M)

The "M" in the TNM system indicates whether the cancer has spread to other parts of the body, called distant metastasis.

Bladder cancer

M0 (M plus zero): The disease has not metastasized.

M1: There is distant metastasis.

  • M1a: The cancer has spread only to lymph nodes outside of the pelvis.

  • M1b: The cancer has spread other parts of the body.

Renal pelvis and ureter

M0 (M plus zero): The disease has not metastasized.

M1: There is distant metastasis.

Cancer stage grouping

Doctors assign the stage of the bladder cancer by combining the T, N, and M classifications.

Bladder cancer

Stage 0a: This is an early cancer that is only found on the surface of the inner lining of the bladder. Cancer cells are grouped together and can often be easily removed. The cancer has not invaded the muscle or connective tissue of the bladder wall. This type of bladder cancer is also called noninvasive papillary urothelial carcinoma (Ta, N0, M0).

Stage 0is: This stage of cancer, also known as a flat tumor or carcinoma in situ (CIS), is found only on the inner lining of the bladder. It has not grown in toward the hollow part of the bladder, and it has not spread to the thick layer of muscle or connective tissue of the bladder (Tis, N0, M0). This is always a high-grade cancer (see “Grades,” below) and is considered an aggressive disease because it can often lead to muscle-invasive disease.

Stage I: The cancer has grown through the inner lining of the bladder and into the lamina propria. It has not spread to the thick layer of muscle in the bladder wall or to lymph nodes or other organs (T1, N0, M0).

Stage II: The cancer has spread into the thick muscle wall of the bladder. It is also called invasive cancer or muscle-invasive cancer. The tumor has not reached the fatty tissue surrounding the bladder and has not spread to the lymph nodes or other organs (T2, N0, M0).

Stage III: The cancer has spread throughout the muscle wall to the fatty layer of tissue surrounding the bladder (perivesical tissue) or to the prostate in a man or the uterus and vagina in a woman. Or, the cancer has spread to the regional lymph nodes.

  • Stage IIIA: The tumor has grown into the perivesical tissue or has spread to the prostate, uterus, or vagina, but has not spread to the lymph nodes or other organs (T3a, T3b, or T4a; N0; M0), or the cancer has spread to a single regional lymph node (T1 to T4a, N1, M0).

  • Stage IIIB: The cancer has spread to 2 or more regional lymph nodes or to the common iliac lymph nodes (T1 to T4a, N2 or N3, M0).

Stage IV: The tumor has spread into the pelvic wall or abdominal wall, or the cancer has spread to lymph nodes outside of the pelvis or to other parts of the body.

  • Stage IVA: The tumor has spread to the pelvic wall or the abdominal wall but not to other parts of the body (T4b, any N, M0), or the cancer has spread to lymph nodes located outside of the pelvis (any T, any N, M1a).

  • Stage IVB: The cancer has spread other parts of the body (any T, any N, M1b).

Renal pelvis and ureter

Stage 0a: This is an early cancer that is only found on the surface of the inner lining of the renal pelvis or ureter. Cancer cells are grouped together and can often be easily removed. This type of cancer is also called noninvasive papillary carcinoma (Ta, N0, M0).

Stage 0is: This stage of cancer, also known as a flat tumor or carcinoma in situ (CIS), is found only on the inner lining of the renal pelvis or ureter (Tis, N0, M0).

Stage I: The cancer has grown into the inner lining of the renal pelvis or ureter. The cancer has not spread to the lymph nodes or other parts of the body (T1, N0, M0).

Stage II: The cancer has grown into the muscle behind the inner lining of the renal pelvis or ureter. The cancer has not spread to the lymph nodes or other parts of the body (T2, N0, M0).

Stage III: The cancer has grown past the muscle and into the fat surrounding the kidney or ureter or into the renal parenchyma. The cancer has not spread to the lymph nodes or other parts of the body (T3, N0, M0).

Stage IV: The tumor has invaded nearby organs or to the outer layer of fat of the kidney (T4, NX or N0, M0), or the cancer involves the lymph nodes (any T, N1 or N2, M0), or there is distant metastasis (any T, any N, M1).

Recurrent cancer

Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Grade (G)

Doctors also describe this type of cancer by its grade (G), which describes how much cancer cells look like healthy cells when viewed under a microscope.

The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks similar to healthy tissue and contains different cell groupings, it is called differentiated or a low-grade tumor. If the cancerous tissue looks very different from healthy tissue, it is called poorly differentiated or a high-grade tumor.

Many urologic surgeons classify a tumor’s grade based on the chance that the cancer will recur or grow and spread, called progression. They often plan treatment based on the grade, using the following categories:

  • Low grade. This type of cancer may recur.

  • High grade. This type of cancer is more likely to recur and grow.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Doctors have different ways to treat bladder cancer. The next section in this guide is Treatment Options. You may use the menu to choose a different section to read in this guide.