# Radiation Oncology/Endometrium/Staging

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## Current staging

Endometrial Carcinomas
FIGO Staging (2023)
PMID 37593813 -- "FIGO staging of endometrial cancer: 2023"
* Stage I - Confined to the uterine corpus and ovary
** IA - Disease limited to the endometrium OR non-aggressive histological type, i.e., low-grade endometroid, with invasion of less than half of myometrium with no or focal LVSI OR good prognosis disease
*** IA1 : Non-aggressive histological type limited to an endometrial polyp OR confined to the endometrium
*** IA2 : Non-aggressive histological types involving less than half of the myometrium with no or focal LVSI
*** IA3 : Low-grade endometrioid carcinomas limited to the uterus and ovary
** IB - Non-aggressive histological types with invasion of half or more of the myometrium, and with no or focal LVSI
** IC - Aggressive histological types limited to a polyp or confined to the endometrium
* Stage II - Invasion of cervical stroma without extrauterine extension OR with substantial LVSI OR aggressive histological types with myometrial invasion
** IIA - Invasion of the cervical stroma of non-aggressive histological types
** IIB - Substantial LVSI of non-aggressive histological types
** IIC - Aggressive histological types with any myometrial involvement
* Stage III - Local and/or regional spread of the tumor of any histological subtype
** IIIA - Invasion of uterine serosa, adnexa, or both by direct extension or metastasis
*** IIIA1 : Spread to ovary or fallopian tube (except when meeting stage IA3 criteria)
*** IIIA2 : Involvement of uterine subserosa or spread through the uterine serosa
** IIIB - Metastasis or direct spread to the vagina and/or to the parametria or pelvic peritoneum
*** IIIB1 : Metastasis or direct spread to the vagina and/or the parametria
*** IIIB2 : Metastasis to the pelvic peritoneum
** IIIC - Metastasis to the pelvic or para-aortic lymph nodes or both
*** IIIC1 : Metastasis to the pelvic lymph nodes {IIIC1i: micrometastasis; IIIC1ii: macrometastasis}
*** IIIC2 : Metastasis to para-aortic lymph nodes up to the renal vessels, with or without metastasis to the pelvic lymph nodes {IIIC2i: micrometastasis; IIIC2ii: macrometastasis}
* Stage IV - Spread to the bladder mucosa and/or intestinal mucosa and/or distant metastasis
** IVA - Invasion of the bladder mucosa and/or the intestinal/bowel mucosa
** IVB - Abdominal peritoneal metastasis beyond the pelvis
** IVC - Distant metastasis, including metastasis to any extra-or intra-abdominal lymph nodes above the renal vessels, lungs, liver, brain, or bone
Staging footnotes:
* Disease limited to low-grade endometrioid carcinomas involving the endometrium and ovaries (Stage IA3) must be distinguished from extensive spread of the endometrial carcinoma to the ovary (Stage IIIA1), by the following criteria: 1) no more than superficial myometrial invasion is present (<50%); 2) absence of extensive/substantial LVSI; 3) absence of additional metastases; and 4) the ovarian tumor is unilateral, limited to the ovary, without capsule invasion/rupture (equivalent to pT1a).
* LVSI: LVSI as defined in WHO 2021: extensive/substantial, ≥5 vessels involved.
* Aggressive histological types:
** non-aggressive: G1-2 EEC.
** aggressive: G3 EEC, serous, clear cell, undifferentiated, mixed, mesonephric-like, gastrointestinal mucinous type carcinomas, and carcinosarcomas
AJCC 7th Edition (2009)
    Corresponds to updated FIGO staging (2009)
    FIGO 2009 PMID 19345353 -- "Revised FIGO staging for carcinoma of the endometrium."
    This staging now applies only to endometrial carcinomas and there is now a separate staging for uterine sarcomas.
       Carcinosarcomas (MMMT) should be staged as high grade carcinoma.
Primary Tumor: (FIGO Stage in parentheses)
    Note: FIGO uses pathologic staging
* Tis - in situ
    Note: FIGO no longer includes Stage 0
* T1 (I) - confined to corpus
** T1a (IA) - limited to endometrium or invades less than 1/2 of myometrium
** T1b (IB) - invades ≥ 1/2 of myometrium
* T2 (II) - invades stromal tissue of the cervix but does not extend beyond uterus
    Note: endocervical glandular involvement only should be considered as Stage I not Stage II
* T3
** T3a (IIIA) - involves serosa and/or adnexa (direct extension or metastasis)
** T3b (IIIB) - vaginal involvement (direct extension or metastasis) or parametrial involvement
* T4 (IVA) - invades bladder mucosa and/or bowel mucosa
Regional Lymph Nodes:
* N0 - none
* N1 (IIIC1) - metastasis to pelvic lymph nodes
* N2 (IIIC2) - metastasis to para-aortic lymph nodes
    Note: Regional nodes include obturator, internal iliac, external iliac, common iliac, para-aortic, presacral, and parametrial
    Note: For pathologic staging, FIGO classifies cases with <6 resected LNs as pNX
Distant Metastases:
* M0 - none
* M1 (IVB) - distant metastasis - includes inguinal LN, intraperitoneal disease (including omentum), lung, liver, or bone.
Stage Grouping:
* Corresponds to FIGO stage given above (in parentheses)
Changes from 6th Edition:
* No longer includes uterine sarcoma (now staged with a new staging system)
* Positive peritoneal cytology is no longer considered (previously was T3a/IIIA)
* Involvement of the endocervical glands is no longer considered (previously was Stage IIA)
* Stages IA+IB combined (now: IA). IC moved to IB.
* Stage IIIC subdivided into IIIC1 and IIIC2.

### Older staging systems

FIGO moved to surgical staging in 1988 (AJCC 6th edition same). There is also a clinical staging system developed by FIGO in 1971.
Note: until the update of the FIGO / AJCC in 2009, uterine sarcomas and carcinomas were staged using the same system
AJCC 6th Edition (2002)
* IA - Limited to endometrium
* IB - < 1/2 of myometrium
* IC - 1/2 or more of myometrium
* II - invades cervix
** IIA - glandular epithelium of endocervix
** IIB - stroma of cervix
* III - extra-uterine
** IIIA - involves serosa and/or adnexa (direct extension or mets) and/or ascites or positive peritoneal washings
** IIIB - vaginal involvement (direct extension or mets)
** IIIC - LN+ (pelvic and/or paraaortic)
* IV - other organs
** IVA - bladder or bowel
** IVB - distant mets

### Clinical staging

Staging is now surgical (see above), but clinical staging may be utilized for non-operative pts.
FIGO 1971
* I - Confined to corpus
** IA - Length of uterine cavity 8 cm or less
** IB - Length of uterine cavity > 8 cm
* II - Involves corpus and cervix, but no extension beyond the uterus
* III - Extends outside uterus but not outside true pelvis
* IV - Outside the true pelvis or involves bladder or rectum
** IVA - Involves bladder, rectum, sigmoid, or small bowel
** IVB - Distant mets

## Stage distribution

Stage Distribution :
| Stage | US SEER (PMID 16977653) | FIGO (PMID 17161155) |
| Stage I | 73% | 67% |
| Stage II | 10% | 11% |
| Stage III | 10% | 13% |
| Stage IV | 7% | 3% |