Recently FIGO has updated staging for cervical cancer, one of the commonest cancer worldwide. I have tried to summarize the changes in respect to earlier 2009 staging. It might benefit everyone and I thought to share it here.

1. New FIGO (2018) staging for Carcinoma Cervix
Dr Dodul Mondal
MD, DNB, MNAMS, UICC Fellow (USA)
Consultant Radiation Oncologist
Dharamshila Narayana Superspeciality Hospital, Delhi, India
Previously Fellow, Precision Radiation Oncology
Cancer Institute of New Jersey, Robert Wood Johnson University Hospital
NJ, USA
dodulmondal@gmail.com

2. ➢Staging for carcinoma cervix is the oldest staging system in oncology practice
➢First FIGO consensus staging came into 1950
➢Initial staging systems largely considered it as a local pelvic disease
➢Initially surgically staged
➢Recent staging systems were vastly clinical with ancillary diagnostic tools
➢Previous modification was in 2009 highlighting importance of clinical and imaging finding
➢Latest modification in 2018
➢Incorporates imaging and pathological findings
➢Presence of LVSI does not change staging
Introduction
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3. ➢Significant change in early stage and locally advanced stage tumor
➢Microscopic disease (IA) now considers only deep stromal invasion disregarding
horizontal spread
➢Early clinically visible tumor (IB) now incorporates microscopical finding and
imaging as well depending on availability
➢IB is further subdivided into IB1, IB2, IB3 depending on size of tumor
➢Addition of IB3 is new in this staging system
Introduction
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4. Stage II largely remained unchanged
Introduction
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5. ➢Stage III now has additional IIIC compared to earlier staging
➢Stage IIIA and IIIB remains unchanged
➢Stage IIIC includes imaging or pathologic information as well to
diagnose pelvic and/or para-aortic LN involvement
Introduction
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6. Introduction
Stage IV remains unchanged (IVA as well as IVB)
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7. Stage Description 2018 Description 2009
I
Confined to cervix only, disregarding uterine corpus
involvement
Confined to cervix only, disregarding uterine
corpus involvement
IA
Invasive carcinoma, diagnosed only by
microscopy, with maximum depth of invasion <5
mm
Invasive carcinoma, diagnosed only by
microscopy. Maximum depth of stromal
invasion 5mm, maximum horizontal spread
7mm
IA1
Stromal invasion <3 mm in depth Stromal invasion ≤3 mm in depth, horizontal
spread ≤7mm
IA2
Stromal invasion ≥3 mm and <5 mm in depth Stromal invasion >3 ≤5 mm in depth,
horizontal spread ≤7mm
IB
Stromal invasion ≥5 mm (greater than Stage IA)
but limited to the cervix uteri
Clinically visible lesion confined to cervix or
lesion > IA2 including superficial lesions
IB1
Stromal invasion ≥5 mm and tumor <2 cm in
greatest dimension
Clinically visible lesion, ≤ 4cm in greatest
dimension
IB2
Invasive carcinoma ≥2 cm and <4 cm in greatest
dimension
Clinically visible lesion, > 4cm in greatest
dimension
IB3 Invasive carcinoma ≥4 cm in greatest dimension NONE
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8. Stage Description 2018 Description 2009
II Carcinoma invades beyond the uterus but not
extending onto the lower third of the vagina
or to the pelvic wall
Carcinoma invades beyond the uterus but
not extending onto the lower third of the
vagina or to the pelvic wall
IIA Tumor extending beyond uterus but not
involving lower third of vagina and without
parametrial invasion
Tumor extending beyond uterus but not
involving lower third of vagina and without
parametrial invasion
IIA1 Invasive carcinoma <4 cm in greatest
dimension
Clinically visible, ≤ 4cm in greatest
dimension
IIA2 Invasive carcinoma ≥4 cm in greatest
dimension
Clinically visible tumor, >4cm in greatest
dimension
IIB With parametrial involvement but not up to
the pelvic wall
With parametrial involvement but not up to
the pelvic wall
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9. Stage Description 2018 Description 2009
III Carcinoma involves lower third of vagina and/or
extends to pelvic wall and/or causes hydronephrosis
or nonfunctoning kidney and/or involves pelvic
and/or para-aortc lymph nodes
Carcinoma extending to lateral pelvic wall and/or
involving the lower third of vagina and/or causing
hydronephrosis or nonfunctioning kidney
IIIA The carcinoma involves the lower third of the
vagina, with no extension to the pelvic wall
The carcinoma involves the lower third of the
vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or
hydronephrosis or nonfunctoning kidney (unless
known to be due to another cause)
Extension to the pelvic wall and/or
hydronephrosis or nonfunctoning kidney
(unless known to be due to another cause)
IIIC Pelvic and or para-aortic lymphadenopathy
irrespective of tumor size and extent. r or p used
to denote radiological or pathological involvement
NONE
IIIC1 Pelvic LN only
IIIC2 Para aortic (± Pelvic LN)
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10. Stage Description 2018 Description 2009
IV
The carcinoma has extended beyond the true
pelvis or has involved (biopsy proven) the
mucosa of the bladder or rectum. (A bullous
edema, as such, does not permit a case to be
alloted to Stage IV) or spread to distant organs
The carcinoma has extended beyond the
true pelvis or has involved (biopsy proven)
the mucosa of the bladder or rectum. (A
bullous
edema, as such, does not permit a case to be
alloted to Stage IV) or spread to distant
organs
IVA
Spread to adjacent pelvic organs
Invading bladder or rectal mucosa (biopsy
proven). Bullous edema alone disregarded
IVB
Spread to distant organs Distant organ metastasis
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11. Conclusion
➢ Very recently, FIGO staging for cervical cancer has been revised in 2018
➢Incorporates importance of modern imaging finding
➢Incorporates microscopic finding in early cervix limited disease as well
➢Abolishes importance of horizonal spread in microscopic disease
➢Specific stage group has been assigned to lymph node positive patients
➢Treatment protocols need to be redefined
Source of information: Bhatla N et al.
Int J Gynaecol Obstet. Oct 2018
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12. Thank you
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