Cervical cancer is the fourth commonest cancer in the world. It, is, however, the second commonest amongst women in low and middle-income countries. 85% of the estimated 567,847 new cases identified in 2018, occurred in the developing world.
Staging of any cancer enables clinicians to define the extent of disease anatomically, as well as improving the ability to differentiate survival. Cervical cancer staging, just like any other malignancies, has been evolving with the advancement in technology. The widespread use of pathological diagnosis, in addition to advances in radiological investigations, has made it paramount to incorporate it to differentiate how the experts reach the staging of cancer. Also, the availability of minimal access surgery in low- and middle-income countries, has increased the ability not only to access the abdomen, pelvis, and retroperitoneal space through imaging, but also an enhancement in the accurate sampling of para-aortic lymph nodes.
Following these observations, there was a need to have unanimity in the cervical cancer staging, reporting through incorporating both imaging on top of the surgicopathological documentation, such that clinicians can apply the revised staging protocol in all clinical settings.
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Following a series of research, consultative meetings, and thorough discussions, the FIGO Gynecologic Oncology Committee revised the staging of cervical cancer (cancer of the cervix uteri) and made the following amendments in 2018.
- The committee allows the use of any imaging modality +/- pathological findings for allocating the stage.
- In stage I, clinicians can use imaging +/-pathological findings to assess the size of cancer, and so, changes to the microscopic pathological findings. The clinicians made size designations.
- Imaging +/- pathological assessment of the tumour size and extent is now allowed in stage II.
- Assessment of the retroperitoneal lymph nodes by imaging and/ pathology is allowed from, stages I to III, and if there’s any evidence of metastatic disease, the case is designated IIIC. It is important to annotate the method used for stage allocation.
- The committee did not recommend any routine investigations. These will depend on the clinical findings and standard of care.
That said. Here is the revised FIGO staging of the cancer of the cervix (2018).
Cancer strictly confines to the cervix uteri (disregard extension to the corpus)
- IA – invasive carcinoma that can be diagnosed only by microscopy, with a maximum depth of invasion <5 mm*.
- IA1 – measured stromal invasion in depth
- IA2 – measured stromal invasion ≥3 mm and <5 mm in depth
- IB – invasive carcinoma with a measured depth of invasion ≥5 mm ( greater than in stage IA), lesion limited to the cervix uteri**
- IB1 – Invasive carcinoma ≥5 mm depth of stromal invasion and <2 cm in greatest dimension
- IB2 – Invasive carcinoma ≥2 cm and <4 cm in greatest dimension
- IB3 – Invasive carcinoma ≥4 cm in greatest dimension
The carcinoma invades beyond the uterus but has not extended onto the lower third of the vagina or to the pelvic wall
- IIA – involvement limited to the upper two-thirds of the vagina without parametrial involvement
- IIA1 – invasive carcinoma <4 cm in dimension
- IIA2 – invasive carcinoma ≥4 cm in greatest dimension
- IIB – with parametrial involvement, but not up to the pelvic wall
The carcinoma involves the lower third of the vagina +/- extends to the pelvic wall +/- causes hydronephrosis or non-functioning kidney +/- paraaortic lymph nodes***.
- IIIA – carcinoma involves the lower third of the vagina, with no extension to the pelvic wall
- IIIB – extension to the pelvic wall +/- hydronephrosis or non-functioning kidney (unless known to be due to another cause)
- IIIC – involvement of pelvic +/- paraaortic lymph nodes, irrespective of tumour size and extent (with r and p notations)
- IIIC1 – pelvic lymph node metastasis only
- IIIC2 – paraaortic lymph node metastasis
The carcinoma has extended beyond the literal pelvis or has involved (biopsy-proven) the mucosa of the bladder or rectum. Bullous oedema, as such, does not permit a case to be allocated to Stage IV
- IVA – the spread of the growth to adjacent organs
- IVB – spread to distant organs
You can use imaging and pathology, when available, to supplement clinical findings concerning tumour size and extent, in all stages.
**The involvement of vascular/lymphatic spaces does not change the staging. We no longer consider the lateral extent of the lesion.
***Adding notation of r (imaging) and p (pathology) to indicate the findings that the clinicians have used to allocate the case to stage IIIC. For example, if imaging indicates pelvic lymph node metastasis, the stage allocation would be stage IIIC1r and, if confirmed by pathological findings, it would become stage IIIC1p. Always document the type of imaging modality or pathology technique used. When in doubt, assign the lower staging.
We adopted this classification from a report by the FIGO Committee. This revised cervical cancer staging applies to all resource levels.