REVISED FIGO STAGING SYSTEMS FOR GYNAECOLOGICAL CANCERS (2009) Glenn McCluggage, Belfast Trust

BACKGROUND Groups set up several years ago March 2009-staging system for uterine sarcomas published (IJGO 2009;104;179)- PATHOLOGICAL INPUT May 2009-staging systems for endometrial, cervical and vulval tumours published (IJGO 2009;105; )- NO PATHOLOGICAL INPUT

OTHER TUMOURS groups set up to look at staging of ovarian, fallopian tube and trophoblastic neoplasms

NEW FIGO STAGING FOR UTERINE SARCOMAS never had staging system previously carcinosarcomas staged as per uterine carcinomas staging system for leiomyosarcomas different system for ESS and adenosarcoma

Leiomyosarcomas- FIGO 2009 Stage ITumour limited to uterus IA<5 cm IB>5 cm Stage IITumour extends to the pelvis IIAAdnexal involvement IIBTumour extends to extrauterine pelvic tissue Stage IIITumour invades abdominal tissues (not just protruding into the abdomen) IIIAOne site IIIB> one site IIICMetastasis to pelvic and/or para-aortic lymph nodes Stage IV IVATumour invades bladder and/or rectum IVBDistant metastasis

Endometrial stromal sarcomas (ESS) and adenosarcomas- FIGO 2009 Stage ITumour limited to uterus IATumour limited to endometrium/endocervix with no myometrial invasion IBLess than or equal to half myometrial invasion ICMore than half myometrial invasion Stage IITumour extends to the pelvis IIAAdnexal involvement IIBTumour extends to extrauterine pelvic tissue Stage IIITumour invades abdominal tissues (not just protruding into the abdomen) IIIAOne site IIIB> one site IIICMetastasis to pelvic and/or para-aortic lymph nodes Stage IV IVATumour invades bladder and/or rectum IVBDistant metastasis

ENDOMETRIAL CARCINOMA

Carcinoma of the endometrium- FIGO 2009 Stage ITumour confined to the corpus uteri IANo or less than half myometrial invasion IBInvasion equal to or more than half of the myometrium Stage IITumour invades cervical stroma, but does not extend beyond the uterus Stage IIILocal and/or regional spread of the tumour IIIATumour invades the serosa of the corpus uteri and/or adnexae IIIBVaginal and/or parametrial involvement IIICMetastases to pelvic and/or para-aortic lymph nodes IIIC1Positive pelvic nodes IIIC2Positive para-aortic lymph nodes with or without positive pelvic lymph nodes Stage IVTumour invades bladder and/or bowel mucosa, and/or distant metastases IVATumour invasion of bladder and/or bowel mucosa IVBDistant metastases, including intra-abdominal metastases and/or inguinal lymph nodes

CHANGES TO STAGE I old IA and IB is now IA (FIGO figures show no difference in outcome; pathological difficulties) old IC is now IB endocervical glandular involvement alone will still be stage I

CHANGES TO STAGE II single category of stage II (cervical stromal involvement)

CHANGES TO STAGE III IIIA- uterine serosal or adnexal involvement IIIB- vaginal and/or parametrial involvement IIIC- pelvic and/or para-aortic nodes (IIIC1- pelvic nodes; IIIC2- para-aortic nodes)

CHANGES TO STAGE IV none

PERITONEAL WASHINGS to be performed and reported separately ie not part of staging system significance to be discussed at MDTM

PATHOLOGY PROFORMAS ? still include confined to endometrium or inner half of endometrium ? still include cervical glandular involvement (? will be treated with radiotherapy)

CERVICAL CARCINOMA

Carcinoma of the cervix uteri- FIGO 2009 Stage IThe carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded) IAInvasive carcinoma which can be diagnosed only by microscopy, with deepest invasion 7 mm IA1Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm IA2Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm IBClinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA IB1Clinically visible lesion <4.0 cm in greatest dimension IB2Clinically visible lesion >4.0 cm in greatest dimension Stage IICervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina IIAWithout parametrial invasion IIA1Clinically visible lesion <4.0 cm in greatest dimension IIA2Clinically visible lesion >4.0 cm in greatest dimension IIBWith obvious parametrial invasion

Stage IIIThe tumour extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney IIIATumour involves lower third of the vagina, with no extension to the pelvic wall IIIBExtension to the pelvic wall and/or hydronephrosis or non-functioning kidney Stage IVThe carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous oedema, as such, does not permit a case to be allotted to Stage IV IVASpread of the growth to adjacent organs IVBSpread to distant organs

CERVICAL CARCINOMA no stage 0

CHANGES TO STAGE I none

CHANGES TO STAGE II IIA- without parametrial invasion ie vaginal involvement (IIA1- 4cm)

CHANGES TO STAGE III none

CHANGES TO STAGE IV none

VULVAL CARCINOMA MUCH MORE COMPLICATED significant changes

Carcinoma of the vulva- FIGO 2009 Stage ITumour confined to the vulva IALesions <2 cm in size, confined to the vulva or perineum and with stromal invasions <1.0 mm*, no nodal metastasis IBLesions >2 cm in size or with stromal invasion >1.0 mm* confined to the vulva or perineum, with negative nodes Stage IITumour of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes Stage IIITumour of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes. IIIA(i) With 1 lymph node metastasis (>5 mm), or (ii) 1-2 lymph node metastasis(es) (<5 mm) IIIB(i) With 2 or more lymph node metastases (>5 mm), or (ii) 3 or more lymph node metastases (<5 mm) IIICWith positive nodes with extracapsular spread Stage IVTumour invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures. IVATumour invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or (ii) fixed or ulcerated inguino-femoral lymph nodes IVBAny distant metastasis including pelvic lymph nodes * The depth of invasion is defined as the measurement of the tumour from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

CHANGES TO STAGE I IA- < 2cm, stromal invasion <1mm, confined to vulval or perineum, no nodal metastasis IB- previous IB and II combined- >2cm size or with stromal invasion >1mm, confined to vulval or perineum, no nodal metastasis

CHANGES TO STAGE II any size with extension to lower third of urethra, lower third of vagina or anus and negative nodes

CHANGES TO STAGE III any size, with or without extension to lower third of urethra, lower third of vagina or anus and positive inguino-femoral nodes IIIA- 1 nodal metastasis > 5mm or up to 2 nodes <5mm IIIB- 2 or more nodes >5mm or 3 or more nodes <5mm IIIC- extracapsular spread

CHANGES TO STAGE IV upper two thirds of urethra or vagina or distant structures various substages bilateral nodal involvement now not taken into account

IMPLICATIONS/DIFFICULTIES dissemination of information to surgical oncologists, gynaecologists, non-surgical oncologists, pathologists, radiologists ? set start date endocervical glandular involvement in endometrial cancer (marked interobserver variation) pathologists difficulty in distinguishing cervical glandular from stromal involvement TNM will differ for a while- will be updated in 7 th TNM edition (? drop TNM from pathology proformas)

WIDER QUESTIONS rest of UK (role of British Gynaecological Cancer Society, British Association of Gynaecological Pathologists) if piecemeal introduction, will create difficulties