Radiation Oncology/Cervix/Staging

Cervical Cancer Staging

Current staging

AJCC 7th Edition (2009)

Is based on revised FIGO staging (2009)

FIGO 2009 PMID 19342051 -- "Revised FIGO staging for carcinoma of the cervix."

see also: Revised FIGO Staging (2009)(PDF)

• Clinical stage should be determined prior to start of definitive therapy; it must not be changed once therapy started
• Results of CT, MRI, PET, lymphangiography, arteriography, and venography may not be used to determined clinical staging, but they may be used to develop a clinical plan
• Pathologic staging does not change clinical staging, but should be recorded
• Hysterectomy performed in case of unsuspected invasive cervical carcinoma cannot be clinically staged, and should be reported separately

Primary Tumor: (FIGO stage in parentheses)

• Tis - Carcinoma in situ
• T1 (FIGO I) - Confined to uterus (extension to corpus should be disregarded)
  • T1a (IA) - Invasive carcinoma visible only by microscopy
    • T1a1 (IA1) - Stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
    • T1a2 (IA2) - Stromal invasion >3.0-5.0 mm in depth and 7.0 mm or less in horizontal spread
  • T1b (IB) - Clinically visible lesion, or microscopic lesion > IA2

    Note: all macroscopically visible lesions, even with superficial invasion, are T1b

    • T1b1 (IB1) - Clinically visible lesion 4.0 cm or less
    • T1b2 (IB2) - Clinically visible lesion more than 4.0 cm
• T2 (II) - Invades beyond uterus but not to pelvic wall or lower 1/3 of vagina
  • T2a (IIA) - Without parametrial invasion (i.e. involves upper 2/3 of vagina)
    • T2a1 (IIA1) - Clinically visible lesion 4.0 cm or less
    • T2a2 (IIA2) - Clinically visible lesion more than 4.0 cm
  • T2b (IIB) - With parametrial invasion
• T3 (III) - Extends to pelvic wall, lower 1/3 of vagina, or causes hydronephrosis
  • T3a (IIIA) - Involves lower 1/3 of vagina, no extension to pelvic wall
  • T3b (IIIB) - Extends to pelvic wall or causes hydronephrosis or non-functioning kidney
• T4 (IVA) - Invades mucosa of bladder or rectum or extends beyond true pelvis (bullous edema not sufficient)

Regional Lymph Nodes: - parametrial, paracervical, obturator, internal iliac, external iliac, common iliac, sacral, presacral. (Paraaortic lymph nodes are M1 disease.)

• N0 - No regional LN metastasis
• N1 - Regional LN metastasis (lymph node involvement not listed in FIGO update 2009)

Distant metastasis: - including peritoneal spread, involvement of supraclavicular, mediastinal, or paraaortic LN, lung, liver, or bone

• M0 - No distant metastasis
• M1 (FIGO IVB) - Distant metastasis

Stage Grouping:

• Corresponds with FIGO Stage (noted above in parentheses)

Changes from 6th Edition:

• Subdivided T2a into T2a1 and T2a2 based on size (similar to IB1 and IB2)

Allowed procedures in FIGO staging:

The FIGO stage is a clinical stage. The below procedures may be used in determining the clinical stage.

Allowed procedures: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, X-rays of lungs and skeleton. Suspected involvement of bladder or rectal mucosa must be confirmed by biopsy. FNA of palpable nodes or masses is allowed; however, laparoscopic or radiologically-guided biopsy is not allowed for clinical staging.

Not allowed for staging: CT, MRI, PET, lymphangiogram, arteriogram, venogram.

Older staging systems

AJCC 6th Edition (2002)

Is based on FIGO stage

TNM	FIGO	Description
Tis	0	Carcinoma in situ
T1	I	Confined to uterus (extension to corpus should be disregarded)
T1a	IA	Invasive carcinoma visible only by microscopy
T1a1	IA1	Stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
T1a2	IA2	Stromal invasion 3.0-5.0 mm in depth and 7.0 mm or less in horizontal spread
T1b	IB	Clinically visible lesion, or microscopic lesion > IA2
T1b1	IB1	Clinically visible lesion 4.0 cm or less
T1b2	IB2	Clinically visible lesion more than 4.0 cm
T2	II	Invades beyond uterus but not to pelvic wall or lower 1/3 of vagina
T2a	IIA	Without parametrial invasion (i.e. involves upper 2/3 of vagina)
T2b	IIB	With parametrial invasion
T3	III	Extends to pelvic wall, lower 1/3 of vagina, or causes hydronephrosis
T3a	IIIA	Involves lower 1/3 of vagina, no extension to pelvic wall
T3b	IIIB	Extends to pelvic wall or causes hydronephrosis or non-functioning kidney
T4	IVA	Invades mucosa of bladder or rectum or extends beyond true pelvis (bullous edema not sufficient)

Regional nodes: parametrial, paracervical, obturator, internal iliac, external iliac, common iliac, sacral, presacral
Paraaortic lymph nodes are M1 disease

• N0 - No regional LN metastasis
• N1 - Regional LN metastasis (Stage IIIB)

Distant metastasis:

• M0 - No distant metastasis
• M1 - Distant metastasis (Stage IVB)

Changes in FIGO stage:

• 1985
  • IA (<= 5mm stromal invasion, <= 7mm horizontal). IA1 (minimal microscopic invasion but exact specifications not given). IA2 was all other.
• 1995
  • Added precise definitions of IA1 and IA2. Divided IB into IB1 and IB2.