Radiation Oncology/Cervix/Staging

Cervical Cancer Staging Current staging AJCC 7th Edition (2009) Is based on revised FIGO staging (2009) FIGO 2009 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 TNM FIGO Description Tis 0 Carcinoma in situ T1 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 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) 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 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.