REVISED FIGO STAGING SYSTEMS FOR

GYNAECOLOGICAL CANCERS (2009)

Glenn McCluggage, Belfast Trust

BACKGROUND

• Groups set up several years ago• March 2009-staging system for uterine

sarcomas published (IJGO 2009;104;179)- PATHOLOGICAL INPUT

• May 2009-staging systems for endometrial, cervical and vulval tumours published (IJGO 2009;105;103-104)- NO PATHOLOGICAL INPUT

OTHER TUMOURS

• groups set up to look at staging of ovarian, fallopian tube and trophoblastic neoplasms

NEW FIGO STAGING FOR UTERINE SARCOMAS

• never had staging system previously• carcinosarcomas staged as per uterine

carcinomas• staging system for leiomyosarcomas• different system for ESS and

adenosarcoma

Leiomyosarcomas- FIGO 2009

Stage I Tumour limited to uterusIA <5 cmIB >5 cm

Stage II Tumour extends to the pelvisIIA Adnexal involvementIIB Tumour extends to extrauterine pelvic tissue

Stage III Tumour invades abdominal tissues (not just protruding into the abdomen)IIIA One siteIIIB > one siteIIIC Metastasis to pelvic and/or para-aortic lymph nodes

Stage IVIVA Tumour invades bladder and/or rectumIVB Distant metastasis

Endometrial stromal sarcomas (ESS) and adenosarcomas- FIGO 2009

Stage I Tumour limited to uterusIA Tumour limited to endometrium/endocervix with no myometrial invasionIB Less than or equal to half myometrial invasionIC More than half myometrial invasion

Stage II Tumour extends to the pelvisIIA Adnexal involvementIIB Tumour extends to extrauterine pelvic tissue

Stage III Tumour invades abdominal tissues (not just protruding into the abdomen)IIIA One siteIIIB > one siteIIIC Metastasis to pelvic and/or para-aortic lymph nodes

Stage IVIVA Tumour invades bladder and/or rectumIVB Distant metastasis

ENDOMETRIAL CARCINOMA

Carcinoma of the endometrium- FIGO 2009

Stage I Tumour confined to the corpus uteriIA No or less than half myometrial invasionIB Invasion equal to or more than half of the myometrium

Stage II Tumour invades cervical stroma, but does not extend beyond the uterus

Stage III Local and/or regional spread of the tumourIIIA Tumour invades the serosa of the corpus uteri and/or adnexaeIIIB Vaginal and/or parametrial involvementIIIC Metastases to pelvic and/or para-aortic lymph nodesIIIC1 Positive pelvic nodesIIIC2 Positive para-aortic lymph nodes with or without positive pelvic lymph nodes

Stage IV Tumour invades bladder and/or bowel mucosa, and/or distant metastasesIVA Tumour invasion of bladder and/or bowel mucosaIVB Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes

CHANGES TO STAGE I

• old IA and IB is now IA (FIGO figures show no difference in outcome; pathological difficulties)

• old IC is now IB• endocervical glandular involvement alone

will still be stage I

CHANGES TO STAGE II

• single category of stage II (cervical stromal involvement)

CHANGES TO STAGE III

• IIIA- uterine serosal or adnexal involvement

• IIIB- vaginal and/or parametrial involvement

• IIIC- pelvic and/or para-aortic nodes (IIIC1-pelvic nodes; IIIC2- para-aortic nodes)

CHANGES TO STAGE IV

• none

PERITONEAL WASHINGS

• to be performed and reported separately ie not part of staging system

• significance to be discussed at MDTM

PATHOLOGY PROFORMAS

• ? still include confined to endometrium or inner half of endometrium

• ? still include cervical glandular involvement (? will be treated with radiotherapy)

CERVICAL CARCINOMA

Carcinoma of the cervix uteri- FIGO 2009

Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)

IA Invasive carcinoma which can be diagnosed only by microscopy, with deepestinvasion <5 mm and the largest extension >7 mm

IA1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mmIA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of

not >7.0 mmIB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers

greater than stage IAIB1 Clinically visible lesion <4.0 cm in greatest dimensionIB2 Clinically visible lesion >4.0 cm in greatest dimension

Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lowerthird of the vagina

IIA Without parametrial invasionIIA1 Clinically visible lesion <4.0 cm in greatest dimensionIIA2 Clinically visible lesion >4.0 cm in greatest dimensionIIB With obvious parametrial invasion

Stage III The tumour extends to the pelvic wall and/or involves lower third of the vagina and/orcauses hydronephrosis or non-functioning kidney

IIIA Tumour involves lower third of the vagina, with no extension to the pelvic wallIIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney

Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) themucosa of the bladder or rectum. A bullous oedema, as such, does not permit a case tobe allotted to Stage IV

IVA Spread of the growth to adjacent organsIVB Spread to distant organs

CERVICAL CARCINOMA

• no stage 0

CHANGES TO STAGE I

• none

CHANGES TO STAGE II

• IIA- without parametrial invasion ie vaginal involvement (IIA1- < 4cm; IIA2- >4cm)

CHANGES TO STAGE III

• none

CHANGES TO STAGE IV

• none

VULVAL CARCINOMA

• MUCH MORE COMPLICATED• significant changes

Carcinoma of the vulva- FIGO 2009

Stage I Tumour confined to the vulvaIA Lesions <2 cm in size, confined to the vulva or perineum and with stromal

invasions <1.0 mm*, no nodal metastasisIB Lesions >2 cm in size or with stromal invasion >1.0 mm* confined to the

vulva or perineum, with negative nodesStage II Tumour of any size with extension to adjacent perineal structures (1/3 lower

urethra, 1/3 lower vagina, anus) with negative nodesStage III Tumour of any size with or without extension to adjacent perineal structures

(1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes.IIIA (i) With 1 lymph node metastasis (>5 mm), or

(ii) 1-2 lymph node metastasis(es) (<5 mm)IIIB (i) With 2 or more lymph node metastases (>5 mm), or

(ii) 3 or more lymph node metastases (<5 mm)IIIC With positive nodes with extracapsular spreadStage IV Tumour invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures.IVA Tumour invades any of the following:

(i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or(ii) fixed or ulcerated inguino-femoral lymph nodes

IVB Any distant metastasis including pelvic lymph nodes

* The depth of invasion is defined as the measurement of the tumour from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

CHANGES TO STAGE I

• IA- < 2cm, stromal invasion <1mm, confined to vulval or perineum, no nodal metastasis

• IB- previous IB and II combined- >2cm size or with stromal invasion >1mm, confined to vulval or perineum, no nodal metastasis

CHANGES TO STAGE II

• any size with extension to lower third of urethra, lower third of vagina or anus and negative nodes

CHANGES TO STAGE III

• any size, with or without extension to lower third of urethra, lower third of vagina or anus and positive inguino-femoral nodes

• IIIA- 1 nodal metastasis > 5mm or up to 2 nodes <5mm

• IIIB- 2 or more nodes >5mm or 3 or more nodes <5mm

• IIIC- extracapsular spread

CHANGES TO STAGE IV

• upper two thirds of urethra or vagina or distant structures

• various substages• bilateral nodal involvement now not taken

into account

IMPLICATIONS/DIFFICULTIES• dissemination of information to surgical oncologists,

gynaecologists, non-surgical oncologists, pathologists, radiologists

• ? set start date• endocervical glandular involvement in endometrial

cancer (marked interobserver variation)• pathologists difficulty in distinguishing cervical glandular

from stromal involvement• TNM will differ for a while- will be updated in 7th TNM

edition (? drop TNM from pathology proformas)

WIDER QUESTIONS

• rest of UK (role of British Gynaecological Cancer Society, British Association of Gynaecological Pathologists)

• if piecemeal introduction, will create difficulties