Radiation Oncology/Endometrium/Staging

Current staging Endometrial Carcinomas FIGO Staging (2023) 37593813 -- "FIGO staging of endometrial cancer: 2023" Stage I - Confined to the uterine corpus and ovary IA - Disease limited to the endometrium OR non-aggressive histological type, i.e., low-grade endometroid, with invasion of less than half of myometrium with no or focal LVSI OR good prognosis disease IA1 : Non-aggressive histological type limited to an endometrial polyp OR confined to the endometrium IA2 : Non-aggressive histological types involving less than half of the myometrium with no or focal LVSI IA3 : Low-grade endometrioid carcinomas limited to the uterus and ovary IB - Non-aggressive histological types with invasion of half or more of the myometrium, and with no or focal LVSI IC - Aggressive histological types limited to a polyp or confined to the endometrium Stage II - Invasion of cervical stroma without extrauterine extension OR with substantial LVSI OR aggressive histological types with myometrial invasion IIA - Invasion of the cervical stroma of non-aggressive histological types IIB - Substantial LVSI of non-aggressive histological types IIC - Aggressive histological types with any myometrial involvement Stage III - Local and/or regional spread of the tumor of any histological subtype IIIA - Invasion of uterine serosa, adnexa, or both by direct extension or metastasis IIIA1 : Spread to ovary or fallopian tube (except when meeting stage IA3 criteria) IIIA2 : Involvement of uterine subserosa or spread through the uterine serosa IIIB - Metastasis or direct spread to the vagina and/or to the parametria or pelvic peritoneum IIIB1 : Metastasis or direct spread to the vagina and/or the parametria IIIB2 : Metastasis to the pelvic peritoneum IIIC - Metastasis to the pelvic or para-aortic lymph nodes or both IIIC1 : Metastasis to the pelvic lymph nodes {IIIC1i: micrometastasis; IIIC1ii: macrometastasis} IIIC2 : Metastasis to para-aortic lymph nodes up to the renal vessels, with or without metastasis to the pelvic lymph nodes {IIIC2i: micrometastasis; IIIC2ii: macrometastasis} Stage IV - Spread to the bladder mucosa and/or intestinal mucosa and/or distant metastasis IVA - Invasion of the bladder mucosa and/or the intestinal/bowel mucosa IVB - Abdominal peritoneal metastasis beyond the pelvis IVC - Distant metastasis, including metastasis to any extra-or intra-abdominal lymph nodes above the renal vessels, lungs, liver, brain, or bone Staging footnotes: Disease limited to low-grade endometrioid carcinomas involving the endometrium and ovaries (Stage IA3) must be distinguished from extensive spread of the endometrial carcinoma to the ovary (Stage IIIA1), by the following criteria: 1) no more than superficial myometrial invasion is present (<50%); 2) absence of extensive/substantial LVSI; 3) absence of additional metastases; and 4) the ovarian tumor is unilateral, limited to the ovary, without capsule invasion/rupture (equivalent to pT1a). LVSI: LVSI as defined in WHO 2021: extensive/substantial, ≥5 vessels involved. Aggressive histological types: non-aggressive: G1-2 EEC. aggressive: G3 EEC, serous, clear cell, undifferentiated, mixed, mesonephric-like, gastrointestinal mucinous type carcinomas, and carcinosarcomas AJCC 7th Edition (2009) Corresponds to updated FIGO staging (2009) FIGO 2009 19345353 -- "Revised FIGO staging for carcinoma of the endometrium." This staging now applies only to endometrial carcinomas and there is now a separate staging for uterine sarcomas. Carcinosarcomas (MMMT) should be staged as high grade carcinoma. Primary Tumor: (FIGO Stage in parentheses) Note: FIGO uses pathologic staging Tis - in situ Note: FIGO no longer includes Stage 0 T1 (I) - confined to corpus T1a (IA) - limited to endometrium or invades less than 1/2 of myometrium T1b (IB) - invades ≥ 1/2 of myometrium T2 (II) - invades stromal tissue of the cervix but does not extend beyond uterus Note: endocervical glandular involvement only should be considered as Stage I not Stage II T3 T3a (IIIA) - involves serosa and/or adnexa (direct extension or metastasis) T3b (IIIB) - vaginal involvement (direct extension or metastasis) or parametrial involvement T4 (IVA) - invades bladder mucosa and/or bowel mucosa Regional Lymph Nodes: N0 - none N1 (IIIC1) - metastasis to pelvic lymph nodes N2 (IIIC2) - metastasis to para-aortic lymph nodes Note: Regional nodes include obturator, internal iliac, external iliac, common iliac, para-aortic, presacral, and parametrial Note: For pathologic staging, FIGO classifies cases with <6 resected LNs as pNX Distant Metastases: M0 - none M1 (IVB) - distant metastasis - includes inguinal LN, intraperitoneal disease (including omentum), lung, liver, or bone. Stage Grouping: Corresponds to FIGO stage given above (in parentheses) Changes from 6th Edition: No longer includes uterine sarcoma (now staged with a new staging system) Positive peritoneal cytology is no longer considered (previously was T3a/IIIA) Involvement of the endocervical glands is no longer considered (previously was Stage IIA) Stages IA+IB combined (now: IA). IC moved to IB. Stage IIIC subdivided into IIIC1 and IIIC2. Older staging systems FIGO moved to surgical staging in 1988 (AJCC 6th edition same). There is also a clinical staging system developed by FIGO in 1971. Note: until the update of the FIGO / AJCC in 2009, uterine sarcomas and carcinomas were staged using the same system AJCC 6th Edition (2002) IA - Limited to endometrium IB - < 1/2 of myometrium IC - 1/2 or more of myometrium II - invades cervix IIA - glandular epithelium of endocervix IIB - stroma of cervix III - extra-uterine IIIA - involves serosa and/or adnexa (direct extension or mets) and/or ascites or positive peritoneal washings IIIB - vaginal involvement (direct extension or mets) IIIC - LN+ (pelvic and/or paraaortic) IV - other organs IVA - bladder or bowel IVB - distant mets Clinical staging Staging is now surgical (see above), but clinical staging may be utilized for non-operative pts. FIGO 1971 I - Confined to corpus IA - Length of uterine cavity 8 cm or less IB - Length of uterine cavity > 8 cm II - Involves corpus and cervix, but no extension beyond the uterus III - Extends outside uterus but not outside true pelvis IV - Outside the true pelvis or involves bladder or rectum IVA - Involves bladder, rectum, sigmoid, or small bowel IVB - Distant mets Stage distribution + Stage Distribution Stage US SEER (16977653) FIGO (17161155) Stage I 73% 67% Stage II 10% 11% Stage III 10% 13% Stage IV 7% 3%