Revised FIGO staging for carcinoma of the cervix

Cervical cancer staging is the oldest staging in the literature, dating back to 1928 when, for the first time, physicians grouped cancer of the cervix uteri into different stages according to the extent of tumor growth. At this time the scientific gynecologic community also believed that a uniform staging instrument and common nomenclature were needed. In 1950, the Annual Report Editorial Committee met in New York during the International Gynecological Congress and the 4th American Congress of Obstetrics and Gynecology. On that occasion it was felt that several modifications to the classification and staging should be adopted, and it was recommended that this new classification be termed “The International Classification of the Stages of Carcinoma of the Uterine Cervix.” Since then the staging for cervical cancer has undergone 7 revisions, the most recent in 1994. Almost all of these changes were relevant to Stage I 1 and its division into substages, including the Society of Gynecologic Oncologists' criteria of 3 mm to define microinvasion 2. The main controversies surrounding cervical cancer staging that have contributed to the present revision are described here. This has been an important issue for many years. Firstly, clinical staging is less accurate than surgical staging despite the significant advances in imaging techniques and better assessment of tumor size 3-6. Secondly, according to the FIGO staging system, cervical cancer staging is primarily a local disease in the pelvis. Finally, surgical staging cannot be employed worldwide, especially in low-resource countries where late stages are common and surgical facilities are scarce. Nevertheless, we know that when staging is performed surgically the stage is often more advanced 7. Correlation between the FIGO (clinical) stage and the pT (TNM) in patients treated with up-front surgery shows inaccuracy in the clinical staging, especially in Stages IB2 and II (IIA and IIB) 8-10. Surgical staging of local disease (i.e., tumor size assessment, vaginal and parametrial involvement) is good in early stage disease amenable to surgical treatment. On the contrary, the assessment of size and parametria are difficult in locally advanced and late stage disease, i.e. in those patients who are not candidates for up-front surgery. These patients are the vast majority of cervical cancer patients in low-resource settings. The FIGO Committee on Gynecologic Oncology agrees on the possible important benefits of a pre-treatment surgical staging, but cost-effectiveness and some scientific issues are still a matter of investigation and debate in a disease that can be cured with the same efficacy by other non-surgical treatment modalities. According to some pathological assessments, early (minimal) stromal invasion should be considered as Stage IA1 and not deleted. If we take 50–100 sections of a conization specimen with cervical intraepithelial neoplasia (CIN) 3, microscopic epithelial buds that emanate from the base of the CIN might be found. Lesions may not be seen if only 10–15 sections are obtained. These patients are equally treated with conization and the outcome is the same in either case. These meaningless lesions—pathologically identifiable as early stromal invasion (ESI)—represent approximately 80% of Stage IA1 and tend to dilute its prognostic value 11. The decision not to revise the definition of Stage IA, in particular Stage IA1, arises from the difficulty in reaching a worldwide common interpretation of the pathological data. Other important difficulties arise from the definition of multifocality, how to measure it, and how to combine data observed in the different foci. There are data indicating that size subdivision (with a 4 cm cut-off in maximum diameter) is appropriate for Stage IIA 12-15, 10; while for Stage IIB there are no available data in the literature supporting a subdivision regarding tumor size. The decision not to subdivide Stage IIB and IIIB according to uni- or bilateral parametrial extension is also based on the fact that the treatment is identical in both situations and this subdivision would not affect management. Lymphovascular space invasion (LVSI) has been taken into consideration when staging cervical cancer. Nevertheless, this important risk factor was not included in the staging nomenclature because of its subjective definition influencing the assessment of its extension, and thus its significance. However, LVSI should be reported. Cervical cancer has a poor prognosis in the presence of lymph nodal metastasis, and this is particularly evident in early stage disease 16-20. Despite improvements in imaging techniques and pilot studies dealing with minimally invasive surgical-pathological assessment of lymph nodal status, the FIGO Committee on Gynecologic Oncology decided not to perform lymph nodal assessment per se regarding the staging 21-25. However, the FIGO Committee encourages the use of imaging techniques for the evaluation of the extension and size of the lesion(s). Microinvasive and invasive adenocarcinoma should be staged as squamous cell carcinoma of the cervix. Deletion of Stage 0: FIGO has decided to delete Stage 0 from the staging of all tumors, since it is a pre-invasive lesion. Stage IIA: Several reports in the literature and data analyses from the FIGO Annual Report database consistently demonstrate that, in Stage IIA patients, size, defined as the maximum tumor diameter, has an effect on prognosis similar to that observed in Stage IB 26. Therefore, definitions of Stage IIA substages have been included: Stage IIA1: tumor size of less than or equal to 4 cm with involvement of less than the upper two-thirds of the vagina. Stage IIA2: tumor size of more than 4 cm with involvement of less than the upper two-thirds of the vagina. The new staging is effective from January 2009. Cervical cancer remains a clinically staged disease; nevertheless, research in the field of surgical staging is encouraged. When available, all surgical-pathological findings (such as LVSI) should be reported to the FIGO Annual Report Editorial Office or in other scientific publications, although not included in the staging system. The use of diagnostic imaging techniques to assess the size of the primary tumor is encouraged but is not mandatory. For those institutions with access to MRI/CT scanning, radiological tumor volume and parametrial invasion should be recorded and sent to the FIGO Annual Report Editorial Office for data entry and inclusion in the Annual Report. Other investigations (i.e., examination under anesthesia, cystoscopy, sigmoidoscopy, intravenous pielography) are optional and no longer mandatory. Vaginal carcinoma may occur within 5 years after treatment, and sustained complete response in cervical carcinoma is regarded as primary vaginal cancer. The aim of reaching a useful, as well as a unified, cancer staging system depends on its ability to cope with new epidemiological and clinical evidence, i.e. the increase in population screening for cancer, the discovery of new treatments, and the use of new molecular biomarkers. There is an increasing demand that more biological prognostic factors (histological grades, LVSI, serum biomarkers, etc) be included in the staging system, with the aim to better identify patients at high and low risk of dying of their disease 1. For this reason, scientists should improve their understanding of tumor biology as well as their ability to tailor treatment.