Cervix
General
Staging

Editorial Board Member: Gulisa Turashvili, M.D., Ph.D.
Deputy Editor-in-Chief: Jennifer A. Bennett, M.D.
Carlos Parra-Herran, M.D.

Topic Completed: 27 January 2021

Minor changes: 27 January 2021

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

Carlos Parra-Herran, M.D.
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Cite this page: Parra-Herran C. Staging. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/cervixstaging.html. Accessed March 3rd, 2021.
Definition / general
Essential features
  • According to the FIGO 2019 update (Int J Gynaecol Obstet 2019;145:129, Int J Gynaecol Obstet 2019;147:279):
    • Imaging and pathology can be used, when available, to supplement clinical findings of tumor size and extent
    • Pathological findings supercede imaging and clinical findings
      • In other words, pathology findings can now modify the clinical stage (former versions of FIGO staging dictated otherwise)
Terminology
  • Tumor size:
    • Maximum tumor dimension; can be provided in centimeters (if tumor is grossly visible) or in millimeters (for microscopic tumors)
    • Macroscopic tumor size should be measured in terms of length (dimension parallel to the endocervical canal length), width (dimension perpendicular to the length) and thickness (dimension from mucosal surface to deepest aspect of the tumor, including any exophytic portion)
  • Depth of invasion:
    • Extent of invasive disease measured from the nearest epithelial-stromal interface to the deepest point of invasion into the stroma
    • If continuity between in situ and invasive population, measure depth from base of epithelium from which carcinoma arises (surface or crypt)
    • If invasive focus is not in continuity with in situ disease, locate the nearest dysplastic crypt or surface and measure from there
    • If no obvious epithelial origin, measure from base of nearest surface epithelium
  • Horizontal extent:
    • Dimension of the tumor in the plane parallel to the mucosal surface
    • In a grossly visible tumor, this measurement corresponds to the tumor length obtained grossly
    • In a microscopic tumor, this measurement is obtained by measuring the tumor extent from the most proximal (towards the uterine cavity) to the most distal (towards the ectocervix / vagina) aspect of the tumor (Gynecol Oncol 2020;158:266)
  • Multifocality:
FIGO 2019 staging system for cervical cancer
  • Stage I: carcinoma is strictly confined to the cervix (extension to the corpus is allowed)
    • IA: invasive carcinoma that can be diagnosed only by microscopy with maximum depth of invasion ≤ 5 mm a
      • IA1: measured stromal invasion ≤ 3 mm in depth
      • IA2: measured stromal invasion > 3 mm and ≤ 5 mm in depth
    • IB: invasive carcinoma with measured deepest invasion > 5 mm; lesion limited to the cervix uteri with size measured by maximum tumor diameter b
      • IB1: invasive carcinoma > 5 mm depth of stromal invasion and ≤ 2 cm in greatest dimension c
      • IB2: invasive carcinoma > 2 cm and ≤ 4 cm in greatest dimension
      • IB3: invasive carcinoma > 4 cm in greatest dimension
  • Stage II: cervical 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 invasion
      • IIA1: invasive carcinoma ≤ 4 cm in greatest dimension
      • IIA2: invasive carcinoma > 4 cm in greatest dimension
    • IIB: with parametrial invasion but not up to the pelvic wall
  • Stage III: carcinoma involves the lower third of the vagina or extends to the pelvic wall or causes hydronephrosis or nonfunctioning kidney or involves pelvic or paraaortic lymph nodes
    • IIIA: carcinoma involves lower third of the vagina, with no extension to the pelvic wall
    • IIIB: extension to the pelvic wall or hydronephrosis or nonfunctioning kidney (unless known to be due to another cause)
    • IIIC: involvement of pelvic or paraaortic lymph nodes (including micrometastases) d, irrespective of tumor size and extent (with r and p notations) e
      • IIIC1: pelvic lymph node metastasis only
      • IIIC2: paraaortic lymph node metastasis
  • Stage IV: carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum; a bullous edema, as such, does not permit a case to be allotted to stage IV
    • IVA: spread of the growth to adjacent organs
    • IVB: spread to distant organs
  • Reference: Int J Gynaecol Obstet 2019;147:279

Notes:
a  Imaging and pathology can be used, when available, to supplement clinical findings with respect to tumor size and extent, in all stages
  • Pathological findings supercede imaging and clinical findings
b  Involvement of vascular / lymphatic spaces should not change the staging
  • Lateral extent of the lesion is no longer considered
c  Stage IB1 is defined as grossly visible tumor < 2 cm or tumor with depth > 5 mm, < 50% cervical wall invasion, no suspicious nodes clinically
  • Therefore, it is recommended to report the wall thickness at the deepest point of invasion or at least the percentage of cervical wall involved by tumor
d  Isolated tumor cells do not change the stage but their presence should be recorded
e  Adding notation of r (imaging) and p (pathology), to indicate the findings that are used to allocate the case to stage IIIC
  • For example, if imaging indicates pelvic lymph node metastasis, the stage allocation would be stage IIIC1r; if confirmed by pathological findings, it would be stage IIIC1p
  • Type of imaging modality or pathology technique used should always be documented
  • When in doubt, the lower staging should be assigned

AJCC staging system (8th edition, 2017)
Primary tumor (pT) and FIGO stage
  • pTX: primary tumor cannot be assessed
  • pT0: no evidence of primary tumor
  • pT1: cervical carcinoma confined to uterus (extension to corpus should be disregarded)
    • pT1a: 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
      • pT1a1: measured stromal invasion of 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
      • pT1a2: 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
    • pT1b: clinically visible lesion confined to the cervix or microscopic lesion greater than pT1a2 / IA2; includes all macroscopically visible lesions, even those with superficial invasion
      • pT1b1: clinically visible lesion 4.0 cm or less in greatest dimension
      • pT1b2: clinically visible lesion more than 4.0 cm in greatest dimension
  • pT2: cervical carcinoma invading beyond the uterus but not to the pelvic wall or to the lower third of the vagina
    • pT2a: tumor without parametrial invasion
      • pT2a1: clinically visible lesion 4.0 cm or less in greatest dimension
      • pT2a2: clinically visible lesion more than 4.0 cm in greatest dimension
    • pT2b: tumor with parametrial invasion
  • pT3: tumor extending to the pelvic sidewall or involving the lower third of the vagina or causing hydronephrosis or nonfunctioning kidney
    • pT3a: tumor involving the lower third of the vagina but not extending to the pelvic wall
    • pT3b: tumor extending to the pelvic wall or causing hydronephrosis or nonfunctioning kidney
  • pT4: 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 pT4)
  • Reference: Amin: AJCC Cancer Staging Manual, 8th Edition, 2017

Notes:
  • Stromal invasion 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
  • All macroscopically visible lesions - even with only superficial invasion - are at least FIGO IB
  • 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 (pN)
  • pNX: regional lymph nodes cannot be assessed
  • pN0: no regional lymph node metastasis
  • pN0(i+): isolated tumor cells in regional lymph node(s) no greater than 0.2 mm
  • pN1: any metastasis greater than 0.2 mm (per the 8th edition)

Notes:
  • Modifier for regional lymph nodes:
    • + (sn)
    • + (sn)(i-)
    • + (sn)(i+)
  • Size criteria for nodal metastatic diseases is adopted from breast carcinoma staging
    • Isolated tumor cells (ITCs): single cells or small clusters of cells not more than 0.2 mm in greatest dimension
Distant metastasis (pM)
  • pM0: no distant metastasis
  • pM1: distant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal or paraaortic lymph nodes, lung, liver or bone)
Prefixes
  • m: multiple primary tumors
  • r: recurrent
  • y: posttreatment
Board review style question #1
According to the latest FIGO staging system, which of the following prognostic variables affects the staging of patients with cervical cancer?

  1. Horizontal tumor extent
  2. Lymphovascular space invasion
  3. Multifocal disease
  4. Depth of invasion
  5. Margin status
Board review style answer #1
D. Depth of invasion. All other variables are important for reporting purposes but are not part of the FIGO staging criteria.

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Reference: Cervix - Staging
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