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;103-104)- 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 I
IA
IB

Tumour limited to uterus

<5 cm
>5 cm

Stage II
IIA
IIB

Tumour extends to the pelvis

Adnexal involvement
Tumour extends to extrauterine pelvic tissue

Stage III
IIIA
IIIB
IIIC

Tumour invades abdominal tissues (not just protruding into the abdomen)
One site
> one site
Metastasis to pelvic and/or para-aortic lymph nodes

Stage IV
IVA
IVB

Tumour invades bladder and/or rectum

Distant metastasis

Endometrial stromal sarcomas (ESS) and adenosarcomas- FIGO 2009

Stage I
IA
IB
IC

Tumour limited to uterus

Tumour limited to endometrium/endocervix with no myometrial invasion
Less than or equal to half myometrial invasion
More than half myometrial invasion

Stage II
IIA
IIB

Tumour extends to the pelvis

Adnexal involvement
Tumour extends to extrauterine pelvic tissue

Stage III
IIIA
IIIB
IIIC

Tumour invades abdominal tissues (not just protruding into the abdomen)
One site
> one site
Metastasis to pelvic and/or para-aortic lymph nodes

Stage IV
IVA
IVB

Tumour invades bladder and/or rectum

Distant metastasis

ENDOMETRIAL CARCINOMA

Carcinoma of the endometrium- FIGO 2009

Stage I
IA
IB

Tumour confined to the corpus uteri

No or less than half myometrial invasion
Invasion equal to or more than half of the myometrium

Stage II

Tumour invades cervical stroma, but does not extend beyond the uterus

Stage III
IIIA
IIIB
IIIC
IIIC1
IIIC2

Local and/or regional spread of the tumour

Tumour invades the serosa of the corpus uteri and/or adnexae
Vaginal and/or parametrial involvement
Metastases to pelvic and/or para-aortic lymph nodes
Positive pelvic nodes
Positive para-aortic lymph nodes with or without positive pelvic lymph nodes

Stage IV
IVA
IVB

Tumour invades bladder and/or bowel mucosa, and/or distant metastases

Tumour invasion of bladder and/or bowel mucosa
Distant 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 I
IA
IA1
IA2
IB
IB1
IB2
Stage II
IIA
IIA1
IIA2
IIB

The carcinoma is strictly confined to the cervix (extension to the corpus would
be disregarded)
Invasive carcinoma which can be diagnosed only by microscopy, with deepest
invasion <5 mm and the largest extension >7 mm
Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm
Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of
not >7.0 mm
Clinically visible lesions limited to the cervix uteri or pre-clinical cancers
greater than stage IA
Clinically visible lesion <4.0 cm in greatest dimension
Clinically visible lesion >4.0 cm in greatest dimension
Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower
third of the vagina
Without parametrial invasion
Clinically visible lesion <4.0 cm in greatest dimension
Clinically visible lesion >4.0 cm in greatest dimension
With obvious parametrial invasion

Stage III
IIIA
IIIB
Stage IV
IVA
IVB

The tumour extends to the pelvic wall and/or involves lower third of the vagina and/or
causes hydronephrosis or non-functioning kidney
Tumour involves lower third of the vagina, with no extension to the pelvic wall
Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
The 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
Spread of the growth to adjacent organs
Spread 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; IIA2- >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 I
IA
IB
Stage II
Stage III
IIIA
IIIB
IIIC
Stage IV
IVA

IVB

Tumour confined to the vulva

Lesions <2 cm in size, confined to the vulva or perineum and with stromal
invasions <1.0 mm*, no nodal metastasis
Lesions >2 cm in size or with stromal invasion >1.0 mm* confined to the
vulva or perineum, with negative nodes
Tumour of any size with extension to adjacent perineal structures (1/3 lower
urethra, 1/3 lower vagina, anus) with negative nodes
Tumour 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.
(i) With 1 lymph node metastasis (>5 mm), or
(ii) 1-2 lymph node metastasis(es) (<5 mm)
(i) With 2 or more lymph node metastases (>5 mm), or
(ii) 3 or more lymph node metastases (<5 mm)
With positive nodes with extracapsular spread
Tumour invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures.
Tumour 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
Any 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 7th 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