Friday, June 11, 2010

The New FIGO Staging for Carcinoma of the Vulva, Cervix, Endometrium, and Sarcomas

The International Federation of Gynecology and Obstetrics (FIGO) staging systems for vulva, cervix, endometrium, and sarcomas have been revised for the first time in over a decade. The purpose of the staging system is to provide uniform terminology for better communication among health professionals and to provide appropriate prognosis to the patients which results in treatment improvement. This is a constantly evolving process as new therapeutic modalities are developed, new imaging and surgical approaches are applied, and more prognostic information becomes available. The previous system did not reflect the prognosis in some patient subsets where medical research and practice have shown explosive growth of new knowledge in recent years. The 41st Annual Meeting of the Society of Gynecologic Oncologists was held in March 2010. Several abstracts reported retrospective studies that evaluated the prognostic significance of new 2009 FIGO staging guidelines compared to the old 1988 FIGO system. In endometrial cancer, the reduction in the substages within stage I, and the separation of pelvic and para-aortic nodal involvement further clarified important prognostic factors that yielded clear delineation of survival. The new 2009 FIGO vulvar cancer staging system was validated by clearly demonstrating distinct groups with differing survivals. The following revisions on carcinoma of vulva, cervix, and endometrium staging will replace prior tables 41-6, 41-8, and 41-9, respectively.

Carcinoma of the Vulva

IA Tumor confined to the vulva or perineum, = 2cm in size with stromal invasion = 1mm, negative nodes

IB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodes

II Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodes

IIIA Tumor of any size with positive inguino-femoral lymph nodes

(i) 1 lymph node metastasis greater than or equal to 5 mm

(ii) 1-2 lymph node metastasis(es) of less than 5 mm

(i) 2 or more lymph nodes metastases greater than or equal to 5 mm

(ii) 3 or more lymph nodes metastases less than 5 mm

IIIC Positive node(s) with extracapsular spread

(i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone

(ii) Fixed or ulcerated inguino-femoral lymph nodes
IVB Any distant metastasis including pelvic lymph nodes

Carcinoma of the Cervix

IA1 Confined to the cervix, diagnosed only by microscopy with invasion of <>
IA2 Confined to the cervix, diagnosed with microscopy with invasion of > 3 mm and <>
IB1 Clinically visible lesion or greater than A2, <>
IB2 Clinically visible lesion, > 4 cm in greatest dimension
IIA1 Involvement of the upper two-thirds of the vagina, without parametrial invasion, <>
IIA2 > 4 cm in greatest dimension

IIB With parametrial involvement

IIIA/B Unchanged

IVA/B Unchanged

Carcinoma of the Endometrium

IA Tumor confined to the uterus, no or < ½ myometrial invasion
IB Tumor confined to the uterus, > ½ myometrial invasion

II Cervical stromal invasion, but not beyond uterus

IIIA Tumor invades serosa or adnexa

IIIB Vaginal and/or parametrial involvement

IIIC1 Pelvic node involvement

IIIC2 Para-aortic involvement

IVA Tumor invasion bladder and/or bowel mucosa

IVB Distant metastases including abdominal metastases and/or inguinal lymph nodes

Uterine sarcomas were staged previously as endometrial cancers, which did not reflect clinical behavior. Therefore, a new corpus sarcoma staging system was developed based on the criteria used in other soft tissue sarcomas. This is described as a best guess staging system, so data will need to be collected and evaluated for further revision.

Uterine Sarcomas (Leiomyosarcoma, Endometrial Stromal Sarcoma, and Adenosarcoma)

IA Tumor limited to uterus <>
IB Tumor limited to uterus > 5 cm

IIA Tumor extends to the pelvis, adnexal involvement

IIB Tumor extends to extra-uterine pelvic tissue

IIIA Tumor invades abdominal tissues, one site

IIIB More than one site

IIIC Metastasis to pelvic and/or para-aortic lymph nodes

IVA Tumor invades bladder and/or rectum

IVB Distant metastasis

Adenosarcoma Stage I Differs from Other Uterine Sarcomas

IA Tumor limited to endometrium/endocervix

IB Invasion to < ½ myometrium
IB Invasion to > ½ myometrium