# Radiation Oncology/Cervix/Staging

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Cervical Cancer Staging

## Current staging

AJCC 7th Edition (2009)
    Is based on revised FIGO staging (2009)
    FIGO 2009 PMID 19342051 -- "Revised FIGO staging for carcinoma of the cervix."
    see also: Revised FIGO Staging (2009)(PDF)
* Clinical stage should be determined prior to start of definitive therapy; it must not be changed once therapy started
* Results of CT, MRI, PET, lymphangiography, arteriography, and venography may not be used to determined clinical staging, but they may be used to develop a clinical plan
* Pathologic staging does not change clinical staging, but should be recorded
* Hysterectomy performed in case of unsuspected invasive cervical carcinoma cannot be clinically staged, and should be reported separately
Primary Tumor: (FIGO stage in parentheses)
* Tis - Carcinoma in situ
* T1 (FIGO I) - Confined to uterus (extension to corpus should be disregarded)
** T1a (IA) - Invasive carcinoma visible only by microscopy
*** T1a1 (IA1) - Stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
*** T1a2 (IA2) - Stromal invasion >3.0-5.0 mm in depth and 7.0 mm or less in horizontal spread
** T1b (IB) - Clinically visible lesion, or microscopic lesion > IA2
    Note: all macroscopically visible lesions, even with superficial invasion, are T1b
*** T1b1 (IB1) - Clinically visible lesion 4.0 cm or less
*** T1b2 (IB2) - Clinically visible lesion more than 4.0 cm
* T2 (II) - Invades beyond uterus but not to pelvic wall or lower 1/3 of vagina
** T2a (IIA) - Without parametrial invasion (i.e. involves upper 2/3 of vagina)
*** T2a1 (IIA1) - Clinically visible lesion 4.0 cm or less
*** T2a2 (IIA2) - Clinically visible lesion more than 4.0 cm
** T2b (IIB) - With parametrial invasion
* T3 (III) - Extends to pelvic wall, lower 1/3 of vagina, or causes hydronephrosis
** T3a (IIIA) - Involves lower 1/3 of vagina, no extension to pelvic wall
** T3b (IIIB) - Extends to pelvic wall or causes hydronephrosis or non-functioning kidney
* T4 (IVA) - Invades mucosa of bladder or rectum or extends beyond true pelvis (bullous edema not sufficient)
Regional Lymph Nodes: - parametrial, paracervical, obturator, internal iliac, external iliac, common iliac, sacral, presacral. (Paraaortic lymph nodes are M1 disease.)
* N0 - No regional LN metastasis
* N1 - Regional LN metastasis (lymph node involvement not listed in FIGO update 2009)
Distant metastasis: - including peritoneal spread, involvement of supraclavicular, mediastinal, or paraaortic LN, lung, liver, or bone
* M0 - No distant metastasis
* M1 (FIGO IVB) - Distant metastasis
Stage Grouping:
* Corresponds with FIGO Stage (noted above in parentheses)
Changes from 6th Edition:
* Subdivided T2a into T2a1 and T2a2 based on size (similar to IB1 and IB2)
Allowed procedures in FIGO staging:
The FIGO stage is a clinical stage. The below procedures may be used in determining the clinical stage.
Allowed procedures: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, X-rays of lungs and skeleton. Suspected involvement of bladder or rectal mucosa must be confirmed by biopsy. FNA of palpable nodes or masses is allowed; however, laparoscopic or radiologically-guided biopsy is not allowed for clinical staging.
Not allowed for staging: CT, MRI, PET, lymphangiogram, arteriogram, venogram.

### Older staging systems

AJCC 6th Edition (2002)
    Is based on FIGO stage
| TNM | FIGO | Description |
| Tis | 0 | Carcinoma in situ |
| T1 | I | Confined to uterus (extension to corpus should be disregarded) |
| T1a | IA | Invasive carcinoma visible only by microscopy |
| T1a1 | IA1 | Stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread |
| T1a2 | IA2 | Stromal invasion 3.0-5.0 mm in depth and 7.0 mm or less in horizontal spread |
| T1b | IB | Clinically visible lesion, or microscopic lesion > IA2 |
| T1b1 | IB1 | Clinically visible lesion 4.0 cm or less |
| T1b2 | IB2 | Clinically visible lesion more than 4.0 cm |
| T2 | II | Invades beyond uterus but not to pelvic wall or lower 1/3 of vagina |
| T2a | IIA | Without parametrial invasion (i.e. involves upper 2/3 of vagina) |
| T2b | IIB | With parametrial invasion |
| T3 | III | Extends to pelvic wall, lower 1/3 of vagina, or causes hydronephrosis |
| T3a | IIIA | Involves lower 1/3 of vagina, no extension to pelvic wall |
| T3b | IIIB | Extends to pelvic wall or causes hydronephrosis or non-functioning kidney |
| T4 | IVA | Invades mucosa of bladder or rectum or extends beyond true pelvis (bullous edema not sufficient) |
Regional nodes: parametrial, paracervical, obturator, internal iliac, external iliac, common iliac, sacral, presacral Paraaortic lymph nodes are M1 disease
* N0 - No regional LN metastasis
* N1 - Regional LN metastasis (Stage IIIB)
Distant metastasis:
* M0 - No distant metastasis
* M1 - Distant metastasis (Stage IVB)
Changes in FIGO stage:
* 1985
** IA (<= 5mm stromal invasion, <= 7mm horizontal). IA1 (minimal microscopic invasion but exact specifications not given). IA2 was all other.
* 1995
** Added precise definitions of IA1 and IA2. Divided IB into IB1 and IB2.