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

Authors:
  • Kathmandu University/ Nobel Medical College/ Biratnagar /Nepal

Abstract and Figures

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: http://dx.doi.org/10.3126/njog.v3i2.10837 Nepal Journal of Obstetrics and Gynaecology Vol.3(2) 2008; 62-65
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62
Introduction:
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
BRIEF COMMUNICATON
FIGO-staging of cervical cancer:
Can’t it be communicated in a better way ?
Gehanath Baral
Paropakar Maternity and Womens’ Hospital, Thapathali
Correspondence
Gehanath Baral, MD
Senior Consultant Gynecologist and Obstetrician: Paropakar Maternity and Women’s Hospital,
Thapathali, Kathmandu, Nepal.
E-mail: gehanath@yahoo.com; GPO-8975, EPC-1554 Kathmandu, Nepal.
Abstract
AimAim
AimAim
Aim::
::
: To correlate existing format of FIGO-staging of cervical cancer in clinical practice.
MethodMethod
MethodMethod
Method::
::
: Review of clinical practice guidelines and journal publications.
Result of clinical practice guidelines.
ConclusionConclusion
ConclusionConclusion
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.
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.
Result
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
63
Discussion
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
brief.
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
factor.
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 ?
64
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.
Conclusion
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).
References
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FIGO-staging of Cervical Cancer: Can’t it be communicated in a better way ?
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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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