Cervix
Miscellaneous
Staging of cervical carcinoma

Author: Sucheta Srivastava, M.D.

Revised: 13 February 2018, last major update January 2018

Copyright: (c) 2002-2018, PathologyOutlines.com, Inc.

PubMed search: Staging[TI] cervical carcinoma[TI]

Cite this page: Srivastava, S. Staging of cervical carcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/cervixstaging.html. Accessed February 20th, 2018.

Pathologic TNM staging of cervical carcinoma, AJCC 8th edition
Definition / general
  • Clinical stage: determined prior to the start of definitive therapy and is not altered because of subsequent findings once treatment has started
  • Pathologic stage: for cases treated by surgical procedures, pathologic evaluation provides a fairly accurate estimate of the extent of disease
    • These findings are not used to change the clinical stage but are reported separately as pathologic stage
Updates
  • Pathologic staging classification (pTNM) is updated per Amin: AJCC Cancer Staging Manual, 8th Edition, 2017
  • Modifications from prior edition:
    • For stromal invasion, the horizontal extent or circumferential / width needs to be documented in millimeters for tumors that cannot be measured grossly
      • This step is not necessary in larger tumors that can be measured grossly
    • Margins: in addition to the distance from closest margins (endocervical, ectocervical and circumferential), the location (of closest margin) needs to be specified for both invasive carcinoma and high grade squamous intraepithelial lesion (HSIL)
    • Lymph nodes: presence of isolated tumor cells and size of micrometastasis need to be specified (isolated tumor cells: i+ or i-)
      • Size criteria for isolated tumor cells (ITCs), micrometastasis and macrometastasis are adopted from the experience in breast carcinoma
      • ITCs: single cells or small clusters of cells not more than 0.2 mm in greatest dimension
      • Micrometastasis: metastasis greater than 0.2 mm but less than 2 mm
      • ITCs found by either histologic examination (e.g. immunohistochemical evaluation for cytokeratin) or nonmorphological techniques (e.g. flow cytometry, DNA analysis, polymerase chain reaction [PCR] amplification of a specific tumor marker) should be identified
      • There is currently no guidance in the literature as to how these patients should be coded; until more data are available, they should be coded as "N0(i+)" with a comment noting how the cells were identified
      • There is little data to assign risk for nonsentinel lymph node metastasis based on the size of the metastasis in the sentinel lymph node
  • Multifocal disease:
    • Lower Anogenital Squamous Terminology (LAST) consensus recommends superficially invasive squamous cell carcinoma (SISCCA) to include multifocal disease and that reporting include presence, number and size of independent multifocal carcinoma; however, no LAST recommendation was made on the methodology to define multifocal disease
    • Recent publication by Day et al. states that multifocal tumors should be defined as invasive foci separated by a tissue block within which there is no evidence of invasion or as invasive foci in the same tissue block that are more than 2 mm apart or as invasive foci on different cervical lips (Int J Gynecol Pathol 2016;35:467)
    • They recommend that multifocal tumors should be staged based on the largest focus
pTNM, AJCC 8th edition
Primary tumor and FIGO stage:
  • TX: Primary tumor cannot be assessed
  • T0: No evidence of primary tumor
  • T1 (FIGO I): Cervical carcinoma confined to uterus (extension to corpus should be disregarded)
    • T1a (FIGO IA): Invasive carcinoma diagnosed by microscopy only; stromal invasion with a maximum depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less; vascular space involvement, venous or lymphatic, does not affect classification
      • T1a1 (FIGO IA1): Measured stromal invasion of 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
      • T1a2 (FIGO IA2): Measured stromal invasion of more than 3.0 mm and not more than 5.0 mm, with a horizontal spread of 7.0 mm or less
    • T1b (FIGO IB): Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a2 / IA2; includes all macroscopically visible lesions, even those with superficial invasion
      • T1b1 (FIGO IB1): Clinically visible lesion 4.0 cm or less in greatest dimension
      • T1b2 (FIGO IB2): Clinically visible lesion more than 4.0 cm in greatest dimension
  • T2 (FIGO II): Cervical carcinoma invading beyond the uterus but not to the pelvic wall or to the lower third of the vagina
    • T2a (FIGO IIA): Tumor without parametrial invasion
      • T2a1 (FIGO IIA1): Clinically visible lesion 4.0 cm or less in greatest dimension
      • T2a2 (FIGO IIA2): Clinically visible lesion more than 4.0 cm in greatest dimension
    • T2b (FIGO IIB): Tumor with parametrial invasion
  • T3 (FIGO III): Tumor extending to the pelvic sidewall or involving the lower third of the vagina or causing hydronephrosis or nonfunctioning kidney
    • T3a (FIGO IIIA): Tumor involving the lower third of the vagina but not extending to the pelvic wall
    • T3b (FIGO IIIB): Tumor extending to the pelvic wall or causing hydronephrosis or nonfunctioning kidney
  • T4 (FIGO IVA): Tumor invading the mucosa of the bladder or rectum or extending beyond the true pelvis (bullous edema is not sufficient to classify a tumor as T4)

Notes:
  • All macroscopically visible lesions - even with only superficial invasion - are at least pT1b (FIGO IB)
  • Lower Anogenital Squamous Terminology (LAST) definition of superficial invasive squamous cell carcinoma (SISCCA) conforms to T1a1 (FIGO IA1)
  • For FIGO IA cancers, 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; vascular space invasion should not alter the staging
  • Pelvic sidewall is defined as the muscle, fascia, neurovascular structures and skeletal portions of the bony pelvis; on rectal examination, there is no cancer free space between the tumor and pelvic sidewall
Regional lymph nodes (N)
  • NX: Regional lymph nodes cannot be assessed
  • N0: No regional lymph node metastasis
  • pN0(i+): Isolated tumor cells in regional lymph node(s) no greater than 0.2 mm
  • N1 (FIGO IIIB): Regional lymph node metastasis

Modifier for regional lymph nodes:
+ (sn)
+ (sn)(i-)
+ (sn)(i+)
Distant metastasis (M)
  • M0: No distant metastasis
  • M1 (FIGO IVB): Distant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal or paraaortic lymph nodes, lung, liver or bone)
FIGO stage (2015 FIGO Cancer Report)
Stage I T1 N0 M0
Stage IA T1a N0 M0
Stage IA1 T1a1 N0 M0
Stage IA2 T1a2 N0 M0
Stage IB T1b N0 M0
Stage IB1 T1b1 N0 M0
Stage IB2 T1b2 N0 M0
Stage II T2 N0 M0
Stage IIA T2a N0 M0
Stage IIA1 T2a1 N0 M0
Stage IIA2 T2a2 N0 M0
Stage IIB T2b N0 M0
Stage III T3 N0 M0
Stage IIIA T3a N0 M0
Stage IIIB T3b Any NM0
T1 - 3 N1 M0
Stage IVA T4 Any N M0
Stage IVB Any T Any N M1

  • Note: FIGO no longer includes stage 0 (Tis)
Board review question #1
Which of the following is NOT included in the recent update of staging of cervical carcinoma?

  1. Distance from closest margin
  2. Horizontal extent of grossly invisible tumors
  3. Isolated tumor cells
  4. Location of closest margin
  5. All are included
Board review answer #1
E. All are included