319
Int J Gynecol Obslet, 1992, 38: 319-323 International Federation of Gynecology and Obstetrics
Classification
and staging of gynecologic malignancies
ACOG Technical Bulletin Number 155 (Replaces No. 47, June 1977)
In 1988, the General Assembly of the International Federation of Gynaecology and Obstetrics (FIGO) approved recommendations of the Cancer Committee of FIG0 for a revised classification and staging system. As of 1988, important changes in the staging system now include the surgical-pathologic staging of endometrial and vulvar cancer and a revised definition of stage I cervical cancer (1, 2). While the use of the revised FIG0 classification (as reflected here exactly according to FIGO) is recommended for uniform staging, the treatment of patients may be individualized. Comments relative to management considerations are reflected accordingly. Management considerations are covered in more detail elsewhere and should be developed in consultation with a gynecologic oncologist.
Conrnrentson Cefvkal Cancer Staging The staging of cervical cancer remains under a clinical staging system based on the findings of physical examination and limited radiographic investigation (chest Xray and intravenous pyelogram). In addition, c ystoscopy and proctoscopy ate allowed in the staging system. Because other radiographic tests are not available in certain parts of the world, they have not been included. In the United States, however, attempts at further delineation of metastases, especially lymph node metastases, is often undertaken. Computed tomography, magnetic resonance imaging, and lymphangiography may be used to further evaluate the lymph nodes in the pelvic and aortic chain. In some institutions, especially those participating in organized treatment protocols, retroperitoneal staging and lymphadenectomy is considered in selected patients. Although the findings of these radiographic or surgical procedures are not included in the final staging of patients with cervical
May 1991
cancer, they may be helpful in individualizing treatment. In the revised FIG0 staging, significant changes were made in the staging of clinical stage IA carcinoma. Attempts were made to further delineate between “microinvasive carcinoma” and frankly invasive carcinoma, which has a significantly higher risk of lymph node metastasis. While most gynecologic oncologists would consider stage IA 1disease as early microinvasive carcinoma and requiring less than radical therapy, stage IA2 is problematic. This revised stage attempts to represent tumor volume in a clinically useful way by measuring the volume of tumor by both the depth of invasion and the extent of superficial spread. This diagnosis, therefore, requires pathologic evaluation of a cervical conization specimen. Most gynecologic oncologists in the United States have not been satisfied with this revised stage, as it contains both patients who have microinvasion and those who have frank invasion. In general, gynecologists in the United States consider 3 mm of invasion or less as microinvasion and more than 3 mm of invasion as frankly invasive carcinoma requiring radical therapy. Because stage IA2 disease encompasses microinvasive as well as invasive carcinoma, there may be different treatment options for different patients with this clinical stage of disease. Therefore, the actual depth of invasion and notation of capillary or lymphatic space involvement must be noted, and the treatment for a stage IA2 disease should be decided after review of all this information.
Comments on Endometrial Cancer Staging The revised staging system for endometrial carcinoma is based on the findings at surgical exploration. This revised system is felt to contain critical prognostic factors that were not previously considered in the cliniInt J Gynecol Obstet
38
ACOG Technical Bullelin
320
FIB0 #tO#ill# for #OrCinOIliO Of the COrh Uteri Stage 0
Carcinoma in situ, intraepithelial carcinoma
Stage IVA Stage IVB
Stage
I
The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded)
Stage IA
Preclinical carcinomas of the cervix, that is, those diagnosed only by microscopy
Stage IA1
Minimal microscopically evident stromal invasion
Stage IA.2
Lesions detected microscopically that can be measured. The upper limit of the measurement should not show a depth of invasion of more than 5 mm taken from the base of the epithelium. either surface or glandular, from which it originates, and a second dimension, the horizontal spread, must not exceed 7 mm. Larger lesions should be classified as stage IB
Stage IB
Lesions of greater dimensions than stage IA2, whether seen clinically or not. Preformed space involvement should not alter the staging but should be specifically recorded so as to determine whether it should affect treatment decisions in the future
II
Stage IIA
The carcinoma extends beyond the cervix but has not extended to the pelvic wall. The carcinoma involves the vagina but not as far as the lower third No obvious parametrial involvement
Stage IIB
Obvious parametrial involvement
Stage
The carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involyes the lower third of the vagina.
Stage III
All cases with a hydronephrosis or nonfunctioning kidney are included unless they are known to be due to other causes. Stage IIIA Stage IIIB
Stage IV
International FIGO. 1999
No extension to the pelvic wall Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. A bullous edema as such does not permit a case to be allotted to stage IV
Federation
of Gynecology
Int J Gynecol Obstet 38
and Obstetrics.
Annual
Spread of the growth to adjacent organs Spread to distant organs
Notes sbout ths stsging: Stage IA carcinoma should include minimal microscopically evident stromal invasion as well as small cancerous tumors of measurable size. Stage IA should be divided into those lesions with minute foci of invasion visible only microscopically as stage IA1 and macroscopically measurable microcarcinomas as stage IA2. in order to gain further knowledge of the clinical behavior of these lesions. The term ‘IB occult” should be omitted. The diagnosis of both stage IA1 and IA2 cases should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. The lower limit of stage IA2 should be measurable macroscopically (even if dots need to be placed on the slide prior to measurement), and the upper limit of stage IA2 is given by measurement of the two largest dimensions in any given section. The depth of invasion should not be more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originates. The second dimension, the horizontal spread, must not exceed 7 mm. Vascular space involvement, either venous or lymphatic, should not alter the staging but should be specifically recorded, as it may affect treatment decisions in the future. Lesions of greater size should be classified as stage IB. As a rule, it is impossible to estimate clinically whether a cancer of the cervix has extended to the corpus or not. Extension to the corpus should therefore be disregarded. A patient with a growth fixed to the pelvic wall by a short and indurated but not nodular parametrium should be allotted to stage flB. It is impossible, at clinical examination, to decide whether a smooth and indurated parametrium is truly cancerous or only inflammatory. Therefore, the case should be placed in stage Ill only if the parametrium is nodular on the pelvic wall or if the growth itself extends to the pelvic wall. The presence of hydronephrosis or nonfunctioning kidney due to stenosis of the ureter by cancer permits a case to be allotted to stage Ill even if, according to the other findings, the case should be allotted to stage I or stage II. The presence of bullous edema, as such, should not permit a case to be allotted to stage IV. Ridges and furrows in the bladder wall should be interpreted as signs of submucous involvement of the bladder if they remain fixed to the growth during palpation (ie, examination from the vagina or the rectum during cystoscopy). A finding of malignant cells in cytologic washings from the urinary bladder requires further examination and a biopsy from the wall of the bladder.
report on the results of tmatt7Wnt
in gynecological
cancer.
Vol 20.
Stockholm:
ACOG Technical
321
FlllO StagingforCerchtomeol the Corpus Uteri Stage IA G123
Tumor limited to endometrium
Stage IB G123
Invasion to less than one-half the myometrium
Stage IC G123
Invasion to more than one-half the myometrium
Stage IIA G123
Endocervical glandular involvement only
Stage IIB G123
Cervical stromal invasion
Stage IIIA G123
Tumor invades serosa and/or adnexa. and/or positive peritoneal WologY Vaginal metastases
Stage IIIB G123 Stage IIIC G123
Metastases to pelvic and/or paraaortic lymph nodes
Stage IVA G123 Tumor invasion of bladder and/or bowel mucosa Stage IVB Distant metastases including intraabdominal and/or inguinal lymph nodes Histopathobgy-degree
of Mferentiatlon:
Cases of carcinoma of the corpus should be classified (or graded) according to the degree of histologic differentiation, as follows: Gl = 5% or less of a nonsquamous or nonmorular solid growth pattern lnlernational Federatm of Gynecology Obstet 1989;28:199-190
and Obstetrrs.
G2 = 640% of a nonsquamous or nonmorular solid growth pattern G3 = more than 50% of a nonsquamous or nonmorular solid growth pattern Notes on pathological grading: 1) Notable nuclear atypia, inappropriate for the architectural grade, raises the grade of a grade 1 or grade 2 tumor by 1. 2) In serous adenocarcinomas, clear-cell adenocarcinomas, and squamous cell carcinomas, nuclear grading takes precedence. 3) Adenocarcinomas with squamous differentiation are graded according to the nuclear grade of the glandular component. l&f/es dated fo sfaging: 1) Because corpus cancer is now staged surgically, procedures previously used for determination of stages are no longer applicable, such as the findings from fractional D&C to differentiate between stage I and stage Il. 2) It is appreciated that there may be a small number of patients with corpus cancer who will be treated primarily with radiation therapy. If that is the case, the clinical staging adopted by FIG0 in 1971 would still apply, but designation of that staging system would be noted. 3) Ideally, width of the myometrium should be measured along with the width of tumor invasion.
Annual report on the resuks of
cal staging system. Important surgical-pathologic prognostic factors include the depth of myometrial invasion, the extent of cervical involvement, adnexal and peritoneal metastases, peritoneal cytology, and pelvic or paraaortic lymph node metastasis. The FIG0 staging does not specify the surgical procedure required to stage endometrial cancer; however, without the surgical-pathologic data, the accuracy of the staging is uncertain. The presence of metastases in the pelvic and paraaortic lymph nodes is clearly a prognostic feature of importance and may guide subsequent therapy. Because the propensity of lymph node metastases varies considerably in different clinical stage subgroups, the need for lymph node dissection may be individualized. The decision to perform a pelvic and paraaortic lymphadenectomy must be evaluated in the context of benefits and risks of obtaining this additional surgicalpathologic staging information. In some subgroups of
treatmentI”gynecological cancer.IntJ
Gynecol
patients (eg, those with good prognostic factors), the risks of pelvic and paraaortic lymph node metastasis is less than 3%, and therefore lymphadenectomy may not be warranted. Consultation with a gynecologic oncologist is advised todetermine which patients might benefit from lymph node dissection. Imaging techniques that might also be employed to augment staging include computed tomography, magnetic iesonance imaging, or lymphangiography. While these are not included as part of the FIG0 staging, they may be helpful in evaluating selected patients. Magnetic resonance imaging, in particular, has been found to be useful in determining the depth of myometrial invasion. If hysterectomy is already planned, however, preoperative magnetic resonance imaging will add nothing to the understanding of the depth of invasion, which will be provided by the pathologist.
Int J Gynecol Obster 38
FISO Stagingfor Carcinoma of the Ovary Stage Ill
Staging of ovarian carcinoma is based on findings at clinical examination and by surgical exploration. The histologic findings are to be considered in the staging, as are the cytologic findings as far as effusions are concerned. It is desirable that a biopsy be taken from suspicious areas outside of the pelvis. Stage
I
Stage IA
Stage I6
Stage IC
Stage II
Growth limited to the ovaries Growth limited to one ovary; no ascites present containing malignant cells. No tumor on the external surface; capsule intact Growth limited to both ovaries; no ascites present containing malignant cells. No tumor on the external surfaces; capsules intact Tumor classified as either stage IA or IB but with tumor on the surface of one or both ovaries: or with ruptured capsule(s): or with ascites containing malignant cells present or with positive peritoneal washings Growth involving one or both ovaries, with pelvic extension
Stage IIA
Extension and/or metastases to the uterus and/or tubes
Stage 118
Extension to other pelvic tissues Tumor either stage IIA or IIB but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites containing malignant cells present or with positive peritoneal washings
Stage IIC’
International Federation Obstet 1999;29:199-190
of Gynecology
and Obstetrics.
Annual
Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
Stage IIIB
Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces none exceeding 2 cm in diameter; nodes are negative
Stage IIIC
Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes Stage IV Growth involving one or both ovaries, with distant metastases. If pleural effusion is present, there must be positive cytologic findings to allot a case to stage IV. Parenchymal liver metastasis equals stage IV. ‘Notes about the steglng: To evaluate the impact on prognosis of the different criteria for allotting cases to stage IC or IIC, it would be of value to know whether the rupture of the capsule was spontaneous or caused by the surgeon and if the source of malignant cells detected was peritoneal washings or ascites.
FIG0 Staging for Carcinoma of the Vagina Stage 0
Carcinoma in situ, intraepithelial carcinoma
Stage I
The carcinoma is limited to the vaginal wall
Stage II
The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall
Stage Ill
The carcinoma has extended to the pelvic wall
Stage IV
The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Bullous edema as such does not permit a case to be allotted to stage IV Spread of the growth to adjacent organs and/or direct extension beyond the true pelvis
Stage IVB
Spread to distant organs
International Federation of Gynecology and Obstetrics. Annual report on the results of treatment in gynecological cancer. Vol 20. Stockholm: FIGO, 1988
Inr J Gynecol Obstet 38
Stage IIIA
report on the resultt
Stage IVA
Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum
of treatment
in gynecological
cancer.
Int J Gynecd
Comments on Ovarian Cancer Staging Ovarian cancer is a surgically staged disease. More recent changes in the staging of ovarian cancer have emphasized the need to document malignant cells in peritoneal cytology or ascites in order to assign disease to stage IC or IIC. Further, the volume of intraperitoneal metastases has been incorporated into the substages of surgical stage III disease. In order to assign disease to stage IIIA, random biopsies of the abdominal peritoneum or omentum, including cytologic evaluation of the right hemidiaphragm, must be obtained and a search made for microscopic metastases in these settings. Stage IIIB and stage IIIC disease requires careful documentation by the surgeon as to the extent and volume of metastases in the upper abdomen. Pelvic and paraaortic lymph node sampling is particularly helpful to accurately stage disease that is less than IIIC. Other imaging techniques, such as computed tomography, are often performed in the assessment of patients with undiagnosed abdominal-pelvic mass. The value of such imaging techniques in assigning stage of patients is limited because the actual surgical findings are more accurate.
ACOG Technical Bulletin
323
Fl60 StagingforCmcinomooftko Vuivo Stage 0 Tis Stage I Tl NO MO
Stage II T2 NO MO
Ruler3 for Cllnlcal Sfaging Carcinoma in situ; intraepithelial carcinoma
The rules for staging are similar to those for carcinoma of the cervix.
Tumor confined to the vulva and/or perineum-2 cm or less in greatest dimension, nodes are not palpable
TNM Classlflcaflon of Carcinoma of ths Vulvs (PUW T Primary tumor Tis Preinvasive carcinoma (carcinoma in situ)
Tumor confined to the vulva and/or perineum- more than 2 cm in greatest dimension, nodes are not palpable
Stage Ill T3 NO MO
Tumor of any size with...
T3 Nl MO
1) Adjacent spread to the lower urethra and/or the vagina, or the anus, and/or...
Tl Nl MO
Tl
Tumor confined to the vulva and/or perineum+Z2 cm in greatest dimension
T2
Tumor confined to the vulva and/or perineum-->2 cm in greatest dimension.
T3
Tumor of any size with adjacent spread to the urethra and/or vagina and/or to the anus
T4
Tumor of any size infiltrating the bladder mucosa and/or the rectal mucosa, including the upper part of the urethral mucosa and/or fixed to the bone
NO Nl
No lymph node metastasis
N2
Bilateral regional lymph node metastasis
MO
No clinical metastasis
Ml
Distant metastasis (including pelvic lymph node metastasis)
2) Unilateral regional lymph node metastasis
T2 Nl MO N
Stage IVA Tl N2 MO
Tumor invades any of the following:
T2 N2 MO
Upper urethra, bladder mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis
T4 any N MO Stage IVB
International Federation obstet 1989;29:199-190
Unilateral regional lymph node metastasis
Distant metastasis
M
T3 N2 MO
Any T Any N, Ml
Regional lymph nodes
Any distant metastasis including pelvic lymph nodes of Gynecology
and Obstetrics.
Annual
report on the results of treatment
The revised FlGO staging of vulvar cancer has changed from a clinical to a surgical staging system. The need for this change is based on the fact that the clinical assessment of inguinal-femoral lymph nodes is often in error. Because lymph node metastases are the most critical prognostic factor for vulvar cancer, surgical removal and pathologic assessment of inguinal-femoral lymph nodes is now required before assigning specific stage. The extent of involvement by the primary lesion as well as its maximum dimensions should also be carefully recorded.
in 9ynecological
cancer.
Int J Gynecol
I.
Creasman WT. New gynecologic cancer staging. Obstet Gynecol 1990;75:287-288
2.
International Federation of Gynecology and Obstetrics (FIGO). Changes in gynecologic cancer staging by the International Federation of Gynecology and Obstetrics. Am J Obstet Gynecol 1990;162:610
Int J Gynecol Obstet 38
Int J Gynecol Obslet, 1992, 38: 319-323 International Federation of Gynecology and Obstetrics
Classification
and staging of gynecologic malignancies
ACOG Technical Bulletin Number 155 (Replaces No. 47, June 1977)
In 1988, the General Assembly of the International Federation of Gynaecology and Obstetrics (FIGO) approved recommendations of the Cancer Committee of FIG0 for a revised classification and staging system. As of 1988, important changes in the staging system now include the surgical-pathologic staging of endometrial and vulvar cancer and a revised definition of stage I cervical cancer (1, 2). While the use of the revised FIG0 classification (as reflected here exactly according to FIGO) is recommended for uniform staging, the treatment of patients may be individualized. Comments relative to management considerations are reflected accordingly. Management considerations are covered in more detail elsewhere and should be developed in consultation with a gynecologic oncologist.
Conrnrentson Cefvkal Cancer Staging The staging of cervical cancer remains under a clinical staging system based on the findings of physical examination and limited radiographic investigation (chest Xray and intravenous pyelogram). In addition, c ystoscopy and proctoscopy ate allowed in the staging system. Because other radiographic tests are not available in certain parts of the world, they have not been included. In the United States, however, attempts at further delineation of metastases, especially lymph node metastases, is often undertaken. Computed tomography, magnetic resonance imaging, and lymphangiography may be used to further evaluate the lymph nodes in the pelvic and aortic chain. In some institutions, especially those participating in organized treatment protocols, retroperitoneal staging and lymphadenectomy is considered in selected patients. Although the findings of these radiographic or surgical procedures are not included in the final staging of patients with cervical
May 1991
cancer, they may be helpful in individualizing treatment. In the revised FIG0 staging, significant changes were made in the staging of clinical stage IA carcinoma. Attempts were made to further delineate between “microinvasive carcinoma” and frankly invasive carcinoma, which has a significantly higher risk of lymph node metastasis. While most gynecologic oncologists would consider stage IA 1disease as early microinvasive carcinoma and requiring less than radical therapy, stage IA2 is problematic. This revised stage attempts to represent tumor volume in a clinically useful way by measuring the volume of tumor by both the depth of invasion and the extent of superficial spread. This diagnosis, therefore, requires pathologic evaluation of a cervical conization specimen. Most gynecologic oncologists in the United States have not been satisfied with this revised stage, as it contains both patients who have microinvasion and those who have frank invasion. In general, gynecologists in the United States consider 3 mm of invasion or less as microinvasion and more than 3 mm of invasion as frankly invasive carcinoma requiring radical therapy. Because stage IA2 disease encompasses microinvasive as well as invasive carcinoma, there may be different treatment options for different patients with this clinical stage of disease. Therefore, the actual depth of invasion and notation of capillary or lymphatic space involvement must be noted, and the treatment for a stage IA2 disease should be decided after review of all this information.
Comments on Endometrial Cancer Staging The revised staging system for endometrial carcinoma is based on the findings at surgical exploration. This revised system is felt to contain critical prognostic factors that were not previously considered in the cliniInt J Gynecol Obstet
38
ACOG Technical Bullelin
320
FIB0 #tO#ill# for #OrCinOIliO Of the COrh Uteri Stage 0
Carcinoma in situ, intraepithelial carcinoma
Stage IVA Stage IVB
Stage
I
The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded)
Stage IA
Preclinical carcinomas of the cervix, that is, those diagnosed only by microscopy
Stage IA1
Minimal microscopically evident stromal invasion
Stage IA.2
Lesions detected microscopically that can be measured. The upper limit of the measurement should not show a depth of invasion of more than 5 mm taken from the base of the epithelium. either surface or glandular, from which it originates, and a second dimension, the horizontal spread, must not exceed 7 mm. Larger lesions should be classified as stage IB
Stage IB
Lesions of greater dimensions than stage IA2, whether seen clinically or not. Preformed space involvement should not alter the staging but should be specifically recorded so as to determine whether it should affect treatment decisions in the future
II
Stage IIA
The carcinoma extends beyond the cervix but has not extended to the pelvic wall. The carcinoma involves the vagina but not as far as the lower third No obvious parametrial involvement
Stage IIB
Obvious parametrial involvement
Stage
The carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involyes the lower third of the vagina.
Stage III
All cases with a hydronephrosis or nonfunctioning kidney are included unless they are known to be due to other causes. Stage IIIA Stage IIIB
Stage IV
International FIGO. 1999
No extension to the pelvic wall Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. A bullous edema as such does not permit a case to be allotted to stage IV
Federation
of Gynecology
Int J Gynecol Obstet 38
and Obstetrics.
Annual
Spread of the growth to adjacent organs Spread to distant organs
Notes sbout ths stsging: Stage IA carcinoma should include minimal microscopically evident stromal invasion as well as small cancerous tumors of measurable size. Stage IA should be divided into those lesions with minute foci of invasion visible only microscopically as stage IA1 and macroscopically measurable microcarcinomas as stage IA2. in order to gain further knowledge of the clinical behavior of these lesions. The term ‘IB occult” should be omitted. The diagnosis of both stage IA1 and IA2 cases should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. The lower limit of stage IA2 should be measurable macroscopically (even if dots need to be placed on the slide prior to measurement), and the upper limit of stage IA2 is given by measurement of the two largest dimensions in any given section. The depth of invasion should not be more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originates. The second dimension, the horizontal spread, must not exceed 7 mm. Vascular space involvement, either venous or lymphatic, should not alter the staging but should be specifically recorded, as it may affect treatment decisions in the future. Lesions of greater size should be classified as stage IB. As a rule, it is impossible to estimate clinically whether a cancer of the cervix has extended to the corpus or not. Extension to the corpus should therefore be disregarded. A patient with a growth fixed to the pelvic wall by a short and indurated but not nodular parametrium should be allotted to stage flB. It is impossible, at clinical examination, to decide whether a smooth and indurated parametrium is truly cancerous or only inflammatory. Therefore, the case should be placed in stage Ill only if the parametrium is nodular on the pelvic wall or if the growth itself extends to the pelvic wall. The presence of hydronephrosis or nonfunctioning kidney due to stenosis of the ureter by cancer permits a case to be allotted to stage Ill even if, according to the other findings, the case should be allotted to stage I or stage II. The presence of bullous edema, as such, should not permit a case to be allotted to stage IV. Ridges and furrows in the bladder wall should be interpreted as signs of submucous involvement of the bladder if they remain fixed to the growth during palpation (ie, examination from the vagina or the rectum during cystoscopy). A finding of malignant cells in cytologic washings from the urinary bladder requires further examination and a biopsy from the wall of the bladder.
report on the results of tmatt7Wnt
in gynecological
cancer.
Vol 20.
Stockholm:
ACOG Technical
321
FlllO StagingforCerchtomeol the Corpus Uteri Stage IA G123
Tumor limited to endometrium
Stage IB G123
Invasion to less than one-half the myometrium
Stage IC G123
Invasion to more than one-half the myometrium
Stage IIA G123
Endocervical glandular involvement only
Stage IIB G123
Cervical stromal invasion
Stage IIIA G123
Tumor invades serosa and/or adnexa. and/or positive peritoneal WologY Vaginal metastases
Stage IIIB G123 Stage IIIC G123
Metastases to pelvic and/or paraaortic lymph nodes
Stage IVA G123 Tumor invasion of bladder and/or bowel mucosa Stage IVB Distant metastases including intraabdominal and/or inguinal lymph nodes Histopathobgy-degree
of Mferentiatlon:
Cases of carcinoma of the corpus should be classified (or graded) according to the degree of histologic differentiation, as follows: Gl = 5% or less of a nonsquamous or nonmorular solid growth pattern lnlernational Federatm of Gynecology Obstet 1989;28:199-190
and Obstetrrs.
G2 = 640% of a nonsquamous or nonmorular solid growth pattern G3 = more than 50% of a nonsquamous or nonmorular solid growth pattern Notes on pathological grading: 1) Notable nuclear atypia, inappropriate for the architectural grade, raises the grade of a grade 1 or grade 2 tumor by 1. 2) In serous adenocarcinomas, clear-cell adenocarcinomas, and squamous cell carcinomas, nuclear grading takes precedence. 3) Adenocarcinomas with squamous differentiation are graded according to the nuclear grade of the glandular component. l&f/es dated fo sfaging: 1) Because corpus cancer is now staged surgically, procedures previously used for determination of stages are no longer applicable, such as the findings from fractional D&C to differentiate between stage I and stage Il. 2) It is appreciated that there may be a small number of patients with corpus cancer who will be treated primarily with radiation therapy. If that is the case, the clinical staging adopted by FIG0 in 1971 would still apply, but designation of that staging system would be noted. 3) Ideally, width of the myometrium should be measured along with the width of tumor invasion.
Annual report on the resuks of
cal staging system. Important surgical-pathologic prognostic factors include the depth of myometrial invasion, the extent of cervical involvement, adnexal and peritoneal metastases, peritoneal cytology, and pelvic or paraaortic lymph node metastasis. The FIG0 staging does not specify the surgical procedure required to stage endometrial cancer; however, without the surgical-pathologic data, the accuracy of the staging is uncertain. The presence of metastases in the pelvic and paraaortic lymph nodes is clearly a prognostic feature of importance and may guide subsequent therapy. Because the propensity of lymph node metastases varies considerably in different clinical stage subgroups, the need for lymph node dissection may be individualized. The decision to perform a pelvic and paraaortic lymphadenectomy must be evaluated in the context of benefits and risks of obtaining this additional surgicalpathologic staging information. In some subgroups of
treatmentI”gynecological cancer.IntJ
Gynecol
patients (eg, those with good prognostic factors), the risks of pelvic and paraaortic lymph node metastasis is less than 3%, and therefore lymphadenectomy may not be warranted. Consultation with a gynecologic oncologist is advised todetermine which patients might benefit from lymph node dissection. Imaging techniques that might also be employed to augment staging include computed tomography, magnetic iesonance imaging, or lymphangiography. While these are not included as part of the FIG0 staging, they may be helpful in evaluating selected patients. Magnetic resonance imaging, in particular, has been found to be useful in determining the depth of myometrial invasion. If hysterectomy is already planned, however, preoperative magnetic resonance imaging will add nothing to the understanding of the depth of invasion, which will be provided by the pathologist.
Int J Gynecol Obster 38
FISO Stagingfor Carcinoma of the Ovary Stage Ill
Staging of ovarian carcinoma is based on findings at clinical examination and by surgical exploration. The histologic findings are to be considered in the staging, as are the cytologic findings as far as effusions are concerned. It is desirable that a biopsy be taken from suspicious areas outside of the pelvis. Stage
I
Stage IA
Stage I6
Stage IC
Stage II
Growth limited to the ovaries Growth limited to one ovary; no ascites present containing malignant cells. No tumor on the external surface; capsule intact Growth limited to both ovaries; no ascites present containing malignant cells. No tumor on the external surfaces; capsules intact Tumor classified as either stage IA or IB but with tumor on the surface of one or both ovaries: or with ruptured capsule(s): or with ascites containing malignant cells present or with positive peritoneal washings Growth involving one or both ovaries, with pelvic extension
Stage IIA
Extension and/or metastases to the uterus and/or tubes
Stage 118
Extension to other pelvic tissues Tumor either stage IIA or IIB but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites containing malignant cells present or with positive peritoneal washings
Stage IIC’
International Federation Obstet 1999;29:199-190
of Gynecology
and Obstetrics.
Annual
Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
Stage IIIB
Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces none exceeding 2 cm in diameter; nodes are negative
Stage IIIC
Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes Stage IV Growth involving one or both ovaries, with distant metastases. If pleural effusion is present, there must be positive cytologic findings to allot a case to stage IV. Parenchymal liver metastasis equals stage IV. ‘Notes about the steglng: To evaluate the impact on prognosis of the different criteria for allotting cases to stage IC or IIC, it would be of value to know whether the rupture of the capsule was spontaneous or caused by the surgeon and if the source of malignant cells detected was peritoneal washings or ascites.
FIG0 Staging for Carcinoma of the Vagina Stage 0
Carcinoma in situ, intraepithelial carcinoma
Stage I
The carcinoma is limited to the vaginal wall
Stage II
The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall
Stage Ill
The carcinoma has extended to the pelvic wall
Stage IV
The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Bullous edema as such does not permit a case to be allotted to stage IV Spread of the growth to adjacent organs and/or direct extension beyond the true pelvis
Stage IVB
Spread to distant organs
International Federation of Gynecology and Obstetrics. Annual report on the results of treatment in gynecological cancer. Vol 20. Stockholm: FIGO, 1988
Inr J Gynecol Obstet 38
Stage IIIA
report on the resultt
Stage IVA
Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum
of treatment
in gynecological
cancer.
Int J Gynecd
Comments on Ovarian Cancer Staging Ovarian cancer is a surgically staged disease. More recent changes in the staging of ovarian cancer have emphasized the need to document malignant cells in peritoneal cytology or ascites in order to assign disease to stage IC or IIC. Further, the volume of intraperitoneal metastases has been incorporated into the substages of surgical stage III disease. In order to assign disease to stage IIIA, random biopsies of the abdominal peritoneum or omentum, including cytologic evaluation of the right hemidiaphragm, must be obtained and a search made for microscopic metastases in these settings. Stage IIIB and stage IIIC disease requires careful documentation by the surgeon as to the extent and volume of metastases in the upper abdomen. Pelvic and paraaortic lymph node sampling is particularly helpful to accurately stage disease that is less than IIIC. Other imaging techniques, such as computed tomography, are often performed in the assessment of patients with undiagnosed abdominal-pelvic mass. The value of such imaging techniques in assigning stage of patients is limited because the actual surgical findings are more accurate.
ACOG Technical Bulletin
323
Fl60 StagingforCmcinomooftko Vuivo Stage 0 Tis Stage I Tl NO MO
Stage II T2 NO MO
Ruler3 for Cllnlcal Sfaging Carcinoma in situ; intraepithelial carcinoma
The rules for staging are similar to those for carcinoma of the cervix.
Tumor confined to the vulva and/or perineum-2 cm or less in greatest dimension, nodes are not palpable
TNM Classlflcaflon of Carcinoma of ths Vulvs (PUW T Primary tumor Tis Preinvasive carcinoma (carcinoma in situ)
Tumor confined to the vulva and/or perineum- more than 2 cm in greatest dimension, nodes are not palpable
Stage Ill T3 NO MO
Tumor of any size with...
T3 Nl MO
1) Adjacent spread to the lower urethra and/or the vagina, or the anus, and/or...
Tl Nl MO
Tl
Tumor confined to the vulva and/or perineum+Z2 cm in greatest dimension
T2
Tumor confined to the vulva and/or perineum-->2 cm in greatest dimension.
T3
Tumor of any size with adjacent spread to the urethra and/or vagina and/or to the anus
T4
Tumor of any size infiltrating the bladder mucosa and/or the rectal mucosa, including the upper part of the urethral mucosa and/or fixed to the bone
NO Nl
No lymph node metastasis
N2
Bilateral regional lymph node metastasis
MO
No clinical metastasis
Ml
Distant metastasis (including pelvic lymph node metastasis)
2) Unilateral regional lymph node metastasis
T2 Nl MO N
Stage IVA Tl N2 MO
Tumor invades any of the following:
T2 N2 MO
Upper urethra, bladder mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis
T4 any N MO Stage IVB
International Federation obstet 1989;29:199-190
Unilateral regional lymph node metastasis
Distant metastasis
M
T3 N2 MO
Any T Any N, Ml
Regional lymph nodes
Any distant metastasis including pelvic lymph nodes of Gynecology
and Obstetrics.
Annual
report on the results of treatment
The revised FlGO staging of vulvar cancer has changed from a clinical to a surgical staging system. The need for this change is based on the fact that the clinical assessment of inguinal-femoral lymph nodes is often in error. Because lymph node metastases are the most critical prognostic factor for vulvar cancer, surgical removal and pathologic assessment of inguinal-femoral lymph nodes is now required before assigning specific stage. The extent of involvement by the primary lesion as well as its maximum dimensions should also be carefully recorded.
in 9ynecological
cancer.
Int J Gynecol
I.
Creasman WT. New gynecologic cancer staging. Obstet Gynecol 1990;75:287-288
2.
International Federation of Gynecology and Obstetrics (FIGO). Changes in gynecologic cancer staging by the International Federation of Gynecology and Obstetrics. Am J Obstet Gynecol 1990;162:610
Int J Gynecol Obstet 38
