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

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.