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Gynecologic Oncology 115 (2009) 325328

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Gynecologic Oncology
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y g y n o

Meeting Report

The new FIGO staging system for cancers of the vulva, cervix, endometrium and sarcomas
The International Federation of Gynecology and Obstetrics (FIGO) proposed the rst rules for classi cation and staging of gynecologic cancers in 1958. This staging system was adopted from work initiated by the Radiological Sub-Commission of the Cancer Commission of the Health Organization of the League of Nations. Since this time physicians caring for women with genital cancer have re ned cancer assessment in order to standardize communication and improve treatment. The primary purpose of staging systems is two-fold: (1) to allow comparison of patients between centers and (2) to divide patients and their tumors into prognostic groups. Cancer staging is in continual evolution as diagnostic tools change and more prognostic information becomes available. In keeping with this, gynecologic cancer staging has evolved as well. FIGO was the rst organization to develop its own staging system and the International Union Against Cancer (UICC) who established its own staging system in 1966 followed this effort. In 1976 the American Joint Commission on Cancer (AJCC) followed suit. Since that time these three organizations have tried to coordinate their efforts to adopt a single staging system. This year represents the rst time in over a decade that the FIGO staging systems have been revised. This process began 3 years ago in October of 2006 at the International Gynecologic Cancer Society (IGCS) and continued through the summer of 2009. After initial discussions, proposed changes were solicited, these were further discussed at the Annual meeting of the TNM Prognostic Factors Core Group in May of 2007. The changes were again circulated to the FIGO Committee. Professor Sergio Pecorelli then invited other international societies and agencies specializing in research and treatment of gynecologic malignancies to contribute to this process. This expanded committee consisted of representatives of the IGCS, the Gynecologic Intergroup (GCIG), Society of Gynecologic Oncologists (SGO), the International Society of Gynecologic Pathologists (ISGyP) and the AJCC. This enlarged committee met in Tampa, Florida at the annual SGO meeting and amended the staging system for the following cancers: vulva, cervix, endometrium and developed a new staging system for uterine sarcomas. The following is the consensus agreement that has resulted from these efforts and represents new criteria for staging of these gynecologic cancers now approved by FIGO and the enlarged committee. prognostic factors include the size of the lesion and number and size of nodal metastases. Controversies in the staging of vulvar cancers are the following Depth of invasion of less than 1 mm, this is now classi ed as a Stage 1A Size of vulvar lesion in the absence of positive nodes: the lesion size does not matter with regard to survival if the lymph nodes are negative Number and size of nodal metastasis seem to be prognostic and these have been separated in the new staging system. Stage I: tumor con ned to the vulva with negative nodes IA: lesions less than or equal to 2 cm in size, con ned to the vulva or perineum and with stromal invasion of less than or equal to 1.0 mm. IB: lesions greater than 2 cm in size or with stromal invasion of greater than 1.0 mm, con ned to the vulva or perineum. Stage II: tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina and/or extension to the anus) with negative nodes. Stage III: tumor of any size with or without extension to the adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes. IIIA: (i) 1 lymph node metastasis greater than or equal to 5 mm (ii) 12 lymph node metastasis(es) of less than 5 mm IIIB: (i) 2 or more lymph node metastases greater than or equal to 5 mm (ii) 3 or more lymph node metastases less than 5 mm IIIC: Positive node(s) with extracapsular spread Stage IV: tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or other distant structures. IVA: cancer invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or xation to boney pelvic structures. (ii) xed or ulcerated inguino-femoral lymph nodes IVB: any distant metastasis including pelvic lymph nodes Carcinoma of the vulva Stage I: tumor con ned to the vulva IA Lesions 2 cm in size, con ned to the vulva or perineum and with stromal invasion 1.0 mm , no nodal metastasis

Vulva Prior to 1988 the staging system for vulvar cancers was clinical. There was a signi cant error rate in predicting positive nodes and in 1988 the surgical staging system we use today was adopted. The current system does not re ect prognosis in some groups and these areas have been changed to re ect that lack of predictive value. These
doi:10.1016/j.ygyno.2009.10.050

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Meeting Report

IB Lesions >2 cm in size or with stromal invasion N1.0 mm , con ned to the vulva or perineum, with negative nodes Stage II: tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes Stage III: tumor of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguinofemoral lymph nodes Stage III IIIA (i) with 1 lymph node metastasis (5 mm), or (ii) 12 lymph node metastasis(es) (b5 mm). IIIB (i) with 2 or more lymph node metastases (5 mm), or (ii) 3 or more lymph node metastases (b5 mm). IIIC: with positive nodes with extracapsular spread Stage IV: tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures. IVA: tumor invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or xed to pelvic bone, or (ii) xed or ulcerated inguino-femoral lymph nodes. IVB: any distant metastasis including pelvic lymph nodes. The depth of invasion is de ned as the measurement of the tumor from the epithelial stroma junction of the adjacent most super cial dermal papilla to the deepest point of invasion. Cervix The original staging for cervical carcinoma was introduced in 1928. This was a staging system based on clinical exam and it largely remains so today. There have been 7 revisions since 1950 and the most recent changes occurred in 1994. Controversies with regard to cervical cancer staging are the following Surgical versus clinical staging: Surgical staging may be more quantitative and therefore clinical staging somewhat less accurate however, 80% of cancers are diagnosed within the developing world. A clinical staging system is more applicable to these countries. Hence, the current system will remain a clinical staging system. Microinvasive adenocarcinoma of the uterine cervix will be staged using the same criteria as microinvasive squamous cell carcinoma uterine cervix. Examination under anesthesia, cystocopy, sigmoidoscopy and IVP are optional and no longer mandatory. Lymphvascular space involvement (LVSI) is not included in the staging but should be reported along with all other surgical pathologic ndings even if they are not part of the staging system. MRI/CT scanning with tumor size and parametrial involvement should be recorded and sent to FIGO in the request for the Annual Report for data entry. Stage 0deleted Early stromal invasion: epithelial buds emanating from the base of CIN 3 lesions have no difference in outcome from CIN 3 lesions hence both can be treated similarly with conservative surgery. There was no consensus as how to de ne multifocality or how to measure it. Therefore it cannot be a prognostic feature and is not a staging criteria.

Stage 1A Invasive carcinoma, which can be diagnosed only by microscopy. All macroscopically visible lesionseven with super cial invasionare allotted to Stage IB. Invasion is limited to a measured stromal invasion with a maximal depth of invasion 5.0 mm and a horizontal extension of 7 mm. Depth of invasion should be taken from the base of the epithelium of the original tissuesuper cial or glandular. The involvement of vascular spacesvenous or lymphaticdoes not change the stage. These rules now apply to adenoma carcinomas. IA1: disease invading less than 3 mm into the cervical stroma and less than 7 mm in greatest diameter in greatest lateral dimension. IA2: disease invading the cervical stroma 3 mm or more but less than 5 mm and less than 7 mm in greatest lateral dimension. IB: clinically visible lesions limited to the cervix uteri or preclinical cancers greater than Stage IA. IB1: clinically visible lesions not greater than 4 cm IB2: clinically visible lesion greater than 4 cm II: tumor involving the upper 2/3 of the vagina or parametrium but not to the pelvic side wall. IIA: involvement of the upper 2/3 vagina with no obvious parametrial involvement IIA1: tumor size of less than 4 cm with involvement of less than the upper two thirds of the vagina. IIA2: tumor size of greater than 4 cm with involvement of less than the upper two thirds of the vagina. IIB: parametrial involvement bilateral or unilateral without extension to the pelvic sidewall. Stage III (unchanged) The carcinoma involves the lower one third of the vagina. The carcinoma has extended to the pelvic sidewall. On rectal exam there is no cancer-free space between the tumor and the pelvic side wall. All cases with hydronephrosis or a non-functioning kidney should be included, unless they are known to be due to other causes. IIIA: tumor involves the lower-third of the vagina, with no extension to the pelvic wall IIIB: extension to the pelvic sidewall and/or hydronephrosis or non-functioning kidney Stage IV: (unchanged) IVA: spread of the cancer to adjacent organs (bowel or bladder) IVB: spread to distant organs Carcinoma of the cervix uteri Stage I: the carcinoma is strictly con ned to the cervix (extension to the corpus would be disregarded). IA: invasive carcinoma that can be diagnosed only by microscopy, with deepest invasion 5 mm and largest extension 7 mm. IA1: measured stromal invasion of 3.0 mm in depth and extension of 7.0 mm. IA2: measured stromal invasion of >3.0 mm and b5.0 mm with an extension of not more than 7.0 mm. IB: clinically visible lesions limited to the cervix uteri or preclinical cancers greater than stage IA. IB1: clinically visible lesion 4.0 cm in greatest dimension. IB2: clinically visible lesion >4.0 cm in greatest dimension.

Meeting Report

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Stage II: cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina. IIA: without parametrial invasion. IIA1: clinically visible lesion 4.0 cm in greatest dimension. IIA2: clinically visible lesion >4 cm in greatest dimension. IIB: with obvious parametrial invasion. Stage III: the tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney. IIIA: tumor involves lower third of the vagina, with no extension to the pelvic wall. IIIB: extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney. Stage IV: the 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. All macroscopically visible lesionseven with super cial invasion are allotted to stage IB carcinomas. A IA Lesion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal extension of not more than 7.00 mm. Depth of invasion should not be more than 5.00 mm taken from the base of the epithelium of the original tissuesuper cial or glandular. The depth of invasion should always be reported in mm, even in those cases with early (minimal) stromal invasion (1 mm). The involvement of vascular/lymphatic spaces should not change the stage allotment. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to another cause. Endometrial carcinoma The current surgical staging system was adopted in 1989. This staging system represented a signi cant change in philosophy from the previous clinical system. Much has been learned over the past 20 years about the prognostic variables involved that has been in place 20 years since this system and there are only a few changes from the FIGO committee. Controversies with regard to endometrial cancer staging are the following In the face of negative nodes there was little survival difference between no myometrial invasion and less than 50% invasion. Therefore these are combined. There was no stage for parametrial involvementthis is now a IIIB. Cytology is highly variable based on sampling of washings, procedures prior to de nitive surgery and widely disparate survival results within the FIGO database depending on other prognostic features. Hence it has been eliminated as a staging criteria though it must be reported. Survival difference depending on whether pelvic or paraaortic nodes are involved. These have now been separated to better evaluate prognosis. Stage I: cancer con ned to the uterus. IA: no invasion and anything less than 50% of the myometrium. 1B: myometrial invasion that is equal to or greater than 50% of the myometrium.

Stage II: cancer that involves the cervical stroma. Note that in situ involvement of the endocervix that does not invade the stoma is not a Stage II lesion. Stage III: disease outside the uterus con ned to the pelvis or retroperitoneum. IIIA: cancer that invades to the serosa. Cancer that involves the adnexa. IIIB: Endometrial cancer involves the vagina. Endometrial cancer involves the parametrium. Endometrial cancer involves the pelvic peritoneum. IIIC: retroperitoneal node involvement. IIIC1: pelvic node involvement. IIIC2: paraaortic involvement. IV: disease outside the uterus. IVA: invasion to surrounding organs, i.e., invasion of the bowel or bladder. IVB: distant metastasis. Carcinoma of the endometrium Stage I : tumor con ned to the corpus uteri. IA : no or less than half myometrial invasion. IB : invasion equal to or more than half of the myometrium. Stage II : tumor invades cervical stroma, but does not extend beyond the uterus . Stage III : local and/or regional spread of the tumor. IIIA : tumor invades the serosa of the corpus uteri and/or adnexae#. IIIB : vaginal and/or parametrial involvement#. IIIC : metastases to pelvic and/or para-aortic lymph nodes#. IIIC1 : positive pelvic nodes. IIIC2 : positive paraaortic lymph nodes with or without positive pelvic lymph nodes. Stage IV : tumor invades bladder and/or bowel mucosa, and/or distant metastases. IVA : tumor invasion of bladder and/or bowel mucosa. IVB : distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes. Either G1, G2, or G3. Endocervical glandular involvement only should be considered as Stage I and no longer as Stage II. #Positive cytology has to be reported separately without changing the stage. Ovarian cancer (no change) Uterine sarcomas Prior to this time uterine sarcomas were staged as endometrial cancers. This was not re ective of survival. The committee has established a sarcoma staging system based on the criteria used in other soft tissue sarcomas. This is, in a sense, a best guess staging system. Data will need to be collected until the system can be revised. Staging of uterine sarcomas (leiomyosarcomas, endometrial stromal sarcomas, and adenosarcomas). Stage I : tumor limited to uterus. IA: less than 5 cm. IB: greater than or equal to 5 cm [12].

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Meeting Report

Stage II: tumor extends to the pelvis. IIA: adnexal involvement. IIB: tumor extends to extrauterine pelvic tissue. Stage III: tumor invades abdominal tissues (not just protruding into the abdomen). IIIA: one site. IIIB: more than one site. IIIC: metastasis to pelvic and/or para-aortic lymph nodes. Stage IV: tumor invades bladder and/or rectum and/or distant metastasis. IVA: tumor invades bladder and/or rectum. IVB: distant metastasis. Two different substagings for LMS/ESS and adenosarcomas. Endometrial stromal sarcomas (ESS) [3] Simultaneous tumors of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classi ed as independent primary tumors. Adenosarcomas ( ) Stage I: tumor limited to uterus. IA: tumor limited to endometrium/endocervix (without myometrial invasion). IB: tumor invades up to less than half of myometrium. IC: tumor invades to more than one half of myometrium [4]. Stage II: tumor extends to the pelvis. IIA: adnexal involvement. IIB: tumor extends to extrauterine pelvic tissue. Stage III: tumor invades abdominal tissues (not just protruding into the abdomen). IIIA: one site. IIIB: more than one site. IIIC: metastasis to pelvic and/or para-aortic lymph nodes. Stage IV: tumor invades bladder and/or rectum and/or distant metastasis. IVA: tumor invades bladder and/or rectum.

IVB: distant metastasis. Two different substagings for LMS/ESS and adenosarcomas. Carcinosarcomas [5] Carcinosarcomas should be staged as carcinomas of the corpus uteri. Acknowledgments FIGO Committee on Gynecologic Oncology: Sergio Pecorelli, Italy, Chairperson Lynette Denny, South Africa, Co-Chairperson Hextan Ngan, People's Republic of China, Past Chairperson Neville Hacker, Australia, member Adriana Bermudez, Argentina, member David Mutch, United States, member Scott McMeekin, United States, American Joint Commission on Cancer (AJCC) Edgar Petru, Austria, Gynecologic Cancer Intergroup (GCIG) Jaime Prat, Spain, International Society of Gynecological Pathologists (ISGyP) Adriana Bermudez, Argentina, International Gynecologic Cancer Society (IGCS) David Mutch, United States, Society of Gynecologic Oncologists (SGO) References
[1] Giuntoli RL, Metzinger DS, DiMarco CS, et al. Gynecol Oncol 2003;89:4609. [2] Nordal RR, Kristensen GB, Kaern J, et al. Acta Oncol 1995; 34:797-802; Evans HL, et al. Cancer 1988;62:223947. [3] Young RH, Prat J, Scully RE. Endometrial stromal sarcomas of the ovary. A clinicopathologic analysis of 23 cases. Cancer 1984; 53: 1143-1155. Chang KL, Crabtree GS, Lim-Tan SK, et al. Primary extrauterine endometrial stromal neoplasms: a clinicopathologic study of 20 cases and review of the literature. Int J Gynecol Pathol 1993;12:28296. [4] Clement PB, Scully RE. Mullerian adenosarcoma of the uterus: a clinicopathologic analysis of 100 cases with a review of the literature. Hum Pathol 1990;21:36381. [5] Bitterman P, et al. Am J Surg Pathol 1990; 14:317-328. Sreenan JJ, Hart WR. Am J Surg Pathol 1995;19:66674.

David G. Mutch Judith and Ira Gall Professor, Director Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA

12 October 2009