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FIGO-staging of cervical cancer: Can’t it be communicated in a better way?

  • Kathmandu University/ Nobel Medical College/ Biratnagar /Nepal

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Aim : To correlate existing format of FIGO-staging of cervical cancer in clinical practice. Method : Review of clinical practice guidelines and journal publications. Result of clinical practice guidelines. Conclusion : A modified form of cervical cancer staging is proposed to make it practical for clinical evaluation, provisional management plan and prognosis based on tumor size and parametrial invasion. DOI: Nepal Journal of Obstetrics and Gynaecology Vol.3(2) 2008; 62-65
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All recommended treatment modalities for carcinoma
cervix, so far depend on tumor size and status of
parametrial spread for primary treatment plan, and
surgical margin and lymph node status for further
management. Globally accepted staging for cervical
cancer is FIGO clinical staging.1 It has helped the
medical community to compare and communicate data
in a uniform format. But it is not devoid of inconvenience
during clinical practice at times. It has its intrinsic
drawbacks like inaccuracies and mis-staging when
compared to surgical staging. Inaccuracies2 between
clinical staging and surgical staging were found 22.9%
in stage 2b and 64.4 % in stage 3b. Another gray area
of labeling a particular stage is at the surgeons’
aggressiveness towards radical surgery especially at
around FIGO stage 1b2. It is subjective and will be
guided by learning curve on radical surgery. Staging is
a method of communicating clinical stage of cancer
and a means of evaluating the management plans used.
But it should not prevent us trying to communicate the
disease status and evaluate the treatment on better
FIGO-staging of cervical cancer:
Can’t it be communicated in a better way ?
Gehanath Baral
Paropakar Maternity and Womens’ Hospital, Thapathali
Gehanath Baral, MD
Senior Consultant Gynecologist and Obstetrician: Paropakar Maternity and Women’s Hospital,
Thapathali, Kathmandu, Nepal.
E-mail:; GPO-8975, EPC-1554 Kathmandu, Nepal.
: To correlate existing format of FIGO-staging of cervical cancer in clinical practice.
: Review of clinical practice guidelines and journal publications.
Result of clinical practice guidelines.
: A modified form of cervical cancer staging is proposed to make it practical for clinical
evaluation, provisional management plan and prognosis based on tumor size and parametrial invasion.
Key words:Key words:
Key words:Key words:
Key words: Modification, parametrial invasion, survival, tumor size.
way. One option would be to modify existing staging
system to a simpler and a better form based on
prognostic factors like tumor size and invasion.
Table 1. Linear projection relating tumor size and volume
Tumor size (in cm) Tumor volume (in cm3)
1 0.5
2 4.2
3 14.1
4 33.5
5 65.5
6 113.1
NB: Volume= ð/6 × width × length × height, or
Volume = ð/6 x Diameter3 using three diameters of the
tissue sample. For regular tumor obtained from LEEP.
For irregular shaped tumor continuous planimetric
calculation software used in MRI system.
NJOG 2008 Nov-Dec; 3 (2): 62 - 65
Significance of tumor size, parametrial invasion and
lymph node involvement has been described by various
treatment guidelines and publications3 from
practitioners. Some of them have been discussed in
National Comprehensive Cancer Network guideline4
fully recommends radical hysterectomy and lymph node
dissection as an effective treatment for stage 1b1 and
2a < 4cm tumor. Post radical hysterectomy adjuvant
therapy as well as adjuvant hysterectomy have to be
decided by the size of tumor whether < 4cm or > 4cm.
For patients who desire fertility preservation, radical
trachelectomy and pelvic lymph node dissection with
or without para-aortic lymph node sampling for stage
1a2 and 1b1 < 2cm tumor.
Histopathological evaluation of 556 patients5 who
underwent radical abdominal hysterectomy with pelvic
lymphadenectomy for carcinoma of the uterine cervix
was done. The rate of parametrial involvement
increased significantly with FIGO stage (18% in stage
IB, 28.5% in stage IIA and 34% in stage IIB; p <0.001)
and pelvic lymph node involvement in 27.8%, 28.6%
and 46% of patients, respectively (p <0.0004). The rate
of pelvic node involvement amongst patients with
stage IB-IIB disease, it was 25% in those without
parametrial spread and 70% in patients with parametrial
spread (p <0.0001). Survival was better in patient
without parametrial invasion. This shows the
parametrial invasion as an independent prognostic
LVSI (lymphovascular space invasion)6 is a frequent
occurrence in patients with early stage cervical cancer.
It represents an unfavorable prognostic factor. With a
small tumor (< 2cm) amongst 89 patients, the overall
survival was significantly correlated with the presence
of LVSI. Study7 of clinical records and pathological
slides of 93 patients at stage 1a2, 1b and 2a
demonstrated that the presence of LVSI in the parametria
was an independent predictor of metastasis in pelvic
and para-aortic lymphatic chains. Large tumor size
(greater than 4cm), parametrial perineural invasion,
cervical lymphovascular space invasion, and tumor
depth (greater than two thirds) were found to be
simultaneous predictors of recurrence as well. So LSVI
appears as a beneficial parameter for staging in early
stage (< 2cm) tumor provided that the reproducibility
of reporting LVSI is acceptably high.
Surgically treated 566 patients8 in stage 1b were studied.
Though the cut off for bulky tumor was not agreed, the
tumor size was an independently significant risk factor
for the prognosis of clinical stage Ib cervical cancer.
A study9 of 107 patients in stage 1b and 2a, who
underwent type 3 radical hysterectomies, found pelvic
lymph nodes as good predictors of parametrial status,
especially in node-negative patients, and could be used
to decrease the paratrectomy in radical surgery.
For the tumor size < 2cm the nodal metastasis is only
6% which increases up to 36% for tumors > 4cm with
Proposed Staging Description FIGO Staging
0 (CIS) Pre-invasive or Carcinoma in situ 0
1 (Early) Tumor less than 2 cm confined to cervix
a Less than 3 mm invasion 1a1
b 3- 5 mm invasion 1a2
c More than 5 mm invasion, more than 7 mm lateral spread 1b1
2 (Intermediate) Tumor more than 2 cm without parametrial invasion
a Less than 4 cm without vaginal invasion 1b1
b Less than 4 cm with upper vaginal invasion 2a
c More than 4 cm with or without upper vaginal invasion 1b2/2a
3 (Late) Tumor with parametrial invasion
a Medial parametrial invasion 2b
b Lower vaginal invasion 3a
c Lateral parametrial or ureteric invasion 3b
4 (Advanced) Extension outside reproductive tract
a Bladder, rectum or extrapelvic invasion 4a
b Distant metastasis 4b
Table 2. Modified FIGO staging of Cervical Cancer (proposed):
FIGO-staging of Cervical Cancer: Can’t it be communicated in a better way ?
Gehanath Baral
likelihood of using adjuvant chemoradiation. Lymph
node involvement in stage 1a2 (3-6%) and 6% in stage
1b1 < 2 cm appear close to each other in terms of tumor
spread.10 There is no recommendation of surgery in
stage 1b2 and 2a>4cm in either WHO11 or UK
(Scotland)10 national guideline. Lymph node metastasis
was well correlated with tumor size12 and the survival
was correlated with size and lymph node status in early
studies.10, 11, 13
In another study lymph node metastasis was found in
35.2% of 1b2 (> 4cm) tumor and up to 60% for the size
6 cm or more. But it was 21.1% for tumor less than
4cm.10 Even if the clinical stage is early one; there is
already tumor spread outside the uterus which can’t
be clearly detected clinically.
Stage 1b2 and 2a > 4cm behave similarly in terms of
survival and resectability. Treatment plan is also
recommended by many authorities in the same way.
Thus practically stage 1b2 and 2a > 4cm are considered
a same stage all over. Likewise tumor size over 2cm is
not recommended for trachelectomy. Thus parametrial
invasion and tumor size are the two main parameters
taken into consideration to plan treatment for cervical
cancer by many.
A comparative study14 on laparoscopy and laparotomy
method of radical hysterectomy reported a similar
progression-free survival for tumors less than 2cm
(4.2cm3), whereas the recurrence was found
significantly higher in laparoscopic arm for tumors more
than 4.2cm3. There is exponential increase in tumor
volume15, 16 by each centimeter increase in tumor size.
Tumor volume of 4.2 cm3 at 2cm tumor size will be 8
times at 4cm (33.5cm3) ( Table 1).
Thus for the tumors bigger than 4cm radicality of
surgery may not be promising. Patients of cancers
0.42cm3 or less usually do not develop pelvic node
metastases. Tumors with a volume less than 2cm3, have
a five-year survival rate of about 90%, in contrast to
those with volumes of more than 30cm3, with less than
65% survival.17 As the tumor size increases its volume
will not be entirely on the site of origin but at the
metastatic site also. Estimating tumor volume by linear
measurement is only clinical means not enough for late
stage tumor. Other means of measurement such as
imaging16,18, surgery, and histopathology19 will
supplement to estimate the tumor load.20 Tumor volume
can now be measured with great accuracy using
magnetic resonance imaging.
On univariate analysis21 of different prognostic factors
amongst 1115 cervical cancer patients with radical
hysterectomy, recurrence rate was found in 42% in
tumor size > 4cm and 29% in < 4cm; 33% in +ve
parametrium and 15% in -ve parametrium; 39% with
LVSI and 22% without LVSI; 46% in +ve lymph node
and 18% in -ve lymph node. Multivariate analysis of
both recurrence and survival time in the patients with
squamous cell carcinoma shared a consensus that
pelvic lymph node metastasis and deep stromal invasion
were significant risk factors.
Staging based on clinically correlated anatomy will
communicate better than the anatomical basis only.
Tumor size of 2cm and 4cm appear to be the cut-offs
for management plan used all over. Other two factors
are parametrial invasion and lymph node involvement.
Stages of tumor, like 1b1/2a < 4cm, 1b2/2a > 4cm, each
having similar treatment plan and prognosis seem to
be more convenient to keep in a single stage. Same
applies to the cut-off for trachelectomy for stage
1b1 < 2cm. So that stage skip will also be corrected
while formulating management guideline and looks
sequential as well. Thus modification is felt to make
the existing FIGO staging system handier with
sequential tumor invasiveness based on clinical
evaluation by tumor size and parametrial invasion,
provisional management plan and prognosis (Table 2).
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classifications and clinical practice guidelines in
the management of gynecologic cancers. FIGO
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2. DiSaia P.and Creasman W. Clinical Gynecologic
Oncology. 7th edition. Mosby Elsevier. 2007.
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multivariate analysis. Annals of Oncology.
14(10):1511-1517, October 2003.
7. Memarzadeh S, Natarajan S, Dandade D et al.
Lymphovascular and Perineural Invasion in the
Parametria: A Prognostic Factor for Early-Stage
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11. World Health Organization. Comprehensive
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12. Baltzer J and Koepcke W.Tumor size and lymph
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FIGO-staging of Cervical Cancer: Can’t it be communicated in a better way ?
ResearchGate has not been able to resolve any citations for this publication.
The aim of this study was to determine whether the pelvic lymph nodes would predict the parametrial status in patients with cervical cancer stages IB1–IIA submitted to radical surgery and pelvic lymphadenectomy. To this end, we evaluated the relationship between positive and negative pelvic lymph nodes and their parametria. Our final purpose was to use this information to recommend the tailoring of the parametrial resection according to the status of pelvic lymph nodes to decrease the morbidity related with radical paratrectomy. From January 1996 to December 2001, 107 consecutive patients with cervical cancer stages IB1 and IIA were primarily treated by radical hysterectomy type III with systematic pelvic lymphadenectomy in a prospective study. Parametria were studied in two sections: the first included the tissue adjacent to the cervix, and the second the distal 2/3. Lymph nodes were routinary processed. Twenty-two patients (20.6%) had positive pelvic nodes and 16 patients (14.9%) had parametrial involvement, mostly by direct extension. Eight patients with positive pelvic nodes (36.4%) had parametrial involvement, whereas among 85 patients with negative pelvic nodes only eight patients (9.4%) had parametrial involvement ( P < 0.001), most in internal parametria (62.5%). The sensitivity of pelvic lymph nodes for parametrial involvement was 50% and the positive predictive value was 36.4%, whereas the specificity was 84.6%; and the negative predictive value 90.6%. In the group of negative pelvic lymph nodes, only two patients (2.3%) had parametrial involvement beyond internal parametria. The univariated and multivariated analysis of prognostic factors was always significant but without a significant independent factor for positive parametria. Pelvic lymph nodes appear as good predictors of parametrial status, especially in node-negative patients, and could be used to decrease the paratrectomy in radical surgery.
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We evaluated the prognostic significance of histologic parametrial involvement in a series of 556 patients who underwent radical abdominal hysterectomy with pelvic lymphadenectomy for carcinoma of the uterine cervix. The histologic specimens were processed as step-serial giant sections. The rate of parametrial involvement increased significantly with FIGO stage (18 in stage IB, 28.5 in stage IIA and 34% in stage IIB; p < 0.001). We observed pelvic lymph node involvement in 27.8, 28.6 and 46% of patients, respectively (p < 0.0004). The rate of pelvic node involvement in patients with stage IB-IIB disease was 25% in those without parametrial spread and 70% in patients with parametrial spread (p < 0.0001). Among patients with negative pelvic lymph nodes, parametrial involvement did not affect survival rates. The size of the parametrial lymph node metastasis (< 2, 2-5, > 5 mm) was significantly associated with survival (74, 39 and 33%, respectively). There were no significant differences between patients with squamous cell carcinomas and those with adenocarcinomas in the rate of parametrial involvement (26 and 29%, p = 0.5), pelvic lymph node involvement (37 and 38%, p = 0.9) or 5-year survival.
In this review, prognostic factors in microinvasive cervical carcinoma are discussed in seven parts: 1. clinical characteristics, cytology, colposcopy and staging, 2. the major prognostic factors, 3. stereological method for estimation of tumour volume, 4. additional prognostic factors, 5. prognostic factors at cellular level and immunohistochemical markers, 6. prognostic factors pertinent to treatment modalities, and 7. the Ljubljana experience on management of stage IA cervical cancer. In the majority of cases, microinvasive cervical carcinoma is clinically asymptomatic, cytologically and colposcopically un-certain to predict. Therefore, a suspected microinvasive carci-noma can be definitely confirmed or excluded only at com-plete excision of the whole lesion by conisation or by hysterec-tomy. As the major prognostic factor, the depth of invasion is one of the most widely used parameters of microinvasive car-cinoma categorisation that showed an evident statistically sig-nificant relationship with the presence of lymph node metas-tasis, recurrence and death from cancer in many studies. All the other prognostic factors, such as horizontal spread, involvement of lymphatic and vascular space, type of invasion and cell type are considered as non-independent prognostic factors. In our series of 331 cases of microinvasive cervical carcinoma, univariate and multivariate statistical analysis of quantitative and qualitative variables have demonstrated sig-nificant correlation of these prognostic predictors with the depth of invasion and the tumour volume as well, indicating the importance of the morphological parameters of disease outcome. Stereology is an objective method for estimation of tumour volume that has been extensively used in our material to determine morphological characteristics of microinvasive carcinoma as well. The results of this analysis demonstrated a highly significant correlation between stereological variables and morphological parameters, such as the lymphatic space involvement and different patterns of invasion. Based on morphometric evaluation of the tumour size and histological parameters, the classification of cases is more objective and the results of individual treatment are more comparable. Important additional prognostic factors are misdiagnosis of microinvasion and imprecise estimation of surgical margins. The reason for incorrect identification of microinvasion is inadequate experience of the pathologist, often associated with the deficiencies and variations in pathological sampling technique. The latter is the most frequent cause of inaccurate assessment of surgical margins and residual neoplasia after conisation. To investigate the behaviour of tumours classified as microinvasive carcinoma that recurred and progressed to frankly invasive carcinomas, the detection of HPV DNA, ex-pression of cell adhesion molecules and other markers on a cellular level could also be used in the diagnostic procedure. As demonstrated in 25 series, 20 of them reported in the past 10 years, microinvasive cervical carcinoma has evidently bet-ter prognosis compared to the frankly invasive cervical carci-noma. Even when stage IA1 and stage IA2 carcinomas were treated with conservative surgical approach, very low risk of recurrence (1.7%), lymph node disease (0.7%), or death caused by cancer (0.5%) was indicated in these reports. The Ljubljana experience on management of stage IA cervical cancer consists of accumulated experience during several observation periods. In the first period (1960-1972), radical hysterectomy with lymphadenectomy was performed in the majority of microinvasive carcinoma. A conservative surgical approach for microinvasive cervical carcinoma was adopted when a scoring system was implemented in 1979, based on the evaluation of morphological criteria and the exact estimation of the tumour size. Consequently, in the most recent observa-tion period (1993-1997), conisation was performed in 65% of the cases, simple hysterectomy in 27.5%, hysterectomy with pelvic lymph node dissection in 7.5% and no cases with indi-cations for radical hysterectomy. Based on our experience, conservative management of stage IA cervical cancer is indi-cated and safe when exact evaluation of tumour extension and surgical margins of the cone are assured.
Tumor size was accurately measured in 684 patients who had surgical treatment of cervical carcinoma after a small biopsy and received no preoperative radiotherapy. Frequency of lymph node metastases increased as five different tumor size parameters went up, depth of tumor invasion being of particular importance. When micrometastases, macrometastases, and tumor cell emboli were considered, a correlation was statistically verifiable for micrometastases and macrometastases. Such correlations could not be determined for tumor cell emboli. They are to be regarded as a random event.
There were 289 radical hysterectomies performed at Roswell Park Memorial Institute for Stage IB, IIA, and recurrent cervical cancer from 1957 to 1967. The prognostic significance of cervical lesion size, pelvic node metastases, and type of radical hysterectomy have been evaluated. Excellent 5-year survival rates for women with Stage IB cervical carcinoma were associated with cervical lesions measuring less than 3 cm and resected pelvic lymph nodes which did not contain metastatic cancer. In addition, 31% of women with recurrent cervical cancer treated by radical hysterectomy survived 5 years without recurrence.
To evaluate the prognostic significance of three-dimensional determination of tumor size in stage I cervical adenocarcinoma. Tumor volume was measured using hematoxylin and eosin-stained sections of cone biopsy and hysterectomy specimens from 36 patients with stage I adenocarcinoma of the cervix. The volume was then correlated with pelvic lymphatic spread and clinical outcome. The subjects were followed for a mean (+/- SEM) of 63 +/- 8 months. No recurrence or lymphatic seeding was encountered in the 22 tumors measuring no more than 500 mm3. Two of 25 tumors (8%) having up to 5 mm depth of stromal invasion had lymph node metastasis, one of which was 1.5 mm, compared with four of 11 (36%) in the group with deeper than 5 mm invasion (P < .02). The depth of stromal invasion predicted recurrence less significantly. Among the 25 tumors with up to 5 mm stromal invasion, two recurred, compared with three of 11 with more than 5 mm invasion (P < .1). Two women who had tumor volumes below 500 mm3 and depths of stromal invasion up to 8.5 mm were disease-free at 52 and 96 months of follow-up. On the other hand, tumors with 2.6 and 3.8 mm stromal invasion, but with volumes exceeding 500 mm3, recurred. Tumor volume is a better predictor of pelvic lymph node metastasis and recurrence than is the depth of stromal invasion in stage I cervical adenocarcinoma.
Many clinicopathological factors of cervical cancer are still controversial in their prognostic significance. The case records of 1,115 patients who received radical hysterectomy at the Veterans General Hospital, Taipei, from 1980 to 1989 were collected to evaluate prognosis-related factors by univariate and multivariate analyses. The pathology was reviewed retrospectively by one pathologist. Ten parameters known to be prognostic in the literature were included for analysis. Univariate analysis showed that patients with all these factors had higher recurrence rates. However, when the effects of parametrial invasion, progressive stage and stromal invasion were weighed against the presence of lymph node metastasis, their influence on recurrence became unimportant. Nevertheless, these factors still influenced prognosis when there was no lymph node metastasis. Multivariate analysis of both recurrence and survival time in the patients with squamous cell carcinoma shared a consensus that pelvic lymph node metastasis and deep stromal invasion were significant risk factors. We conclude that these simplified and consistent results obtained by multivariate analysis provide a basis for subclassification of patients to predict prognosis and change therapy.