What is the current recommendation for uterine cancer staging as of 2023?

Current Recommendations for Uterine Cancer Staging (2023)

The 2023 FIGO staging system is the current recommendation for uterine cancer staging, which now incorporates not only anatomical factors but also histological types, tumor patterns, and molecular classification to guide treatment decisions. 1

Evolution of Uterine Cancer Staging

The staging of uterine cancer has evolved significantly over time:

• The original 1970 FIGO staging system used only presurgical evaluation (physical examination and diagnostic D&C)
• The 1988 FIGO system emphasized surgical/pathologic assessment
• The 2009 FIGO system streamlined stages I and II of endometrial carcinoma 2
• The 2023 FIGO system represents a major revision that integrates anatomical borders and tumor biology 3

Key Components of the 2023 FIGO Staging System

Anatomical Factors

• Stage IA: Tumors with <50% myometrial invasion
• Stage IB: Tumors with ≥50% myometrial invasion
• Stage II: Tumors that invade the cervical stroma 2
• Stage III: Local and regional spread (with multiple substages)
• Stage IV: Distant metastasis

Non-Anatomical Factors (New in 2023)

• Histological type and grade
• Lymphovascular space invasion (LVSI)
• Molecular classification 4, 3

Notable Changes in the 2023 System

1. Stage I disease decreased by 27.1% while stage II disease increased by 390.5% compared to the 2009 system 5
2. Introduction of stage IA3 for low-risk synchronous endometrial and ovarian tumors with clonal relationship 5
3. Differentiation between micrometastasis (IIIC1-i, IIIC2-i) and macrometastasis (IIIC1-ii, IIIC2-ii) in lymph nodes 6
4. Division of stage IV into more specific substages with prognostic differences 6

Surgical Staging Principles

Surgical staging remains the cornerstone of uterine cancer management:

• Total hysterectomy and bilateral salpingo-oophorectomy
• Peritoneal fluid collection for cytology
• Thorough exploration of the abdominal cavity and nodal areas 1
• Pathologic nodal assessment for apparent uterine-confined endometrial cancer 2

Sentinel Lymph Node (SLN) Approach

• The NCCN sentinel lymph node algorithm is recommended if sentinel node mapping is used 2
• SLNs should undergo ultrastaging for detection of low-volume metastases 2
• This approach is increasingly used as an alternative to complete lymphadenectomy 1

Pathological Assessment

A comprehensive pathologic evaluation should include:

• Hysterectomy type and specimen integrity
• Tumor site and size
• Histologic type and grade
• Myometrial invasion (depth of invasion in mm/myometrial thickness in mm)
• Cervical stromal involvement
• Lymphovascular space invasion (LVSI) 2
• Estrogen receptor testing (recommended for stage III, IV, or recurrent endometrioid carcinoma)
• HER2 testing for advanced-stage or recurrent serous endometrial carcinoma or carcinosarcoma 2

Clinical Implications

The 2023 FIGO staging system offers:

• More precise prognostication with widened survival rate differences between stages 6
• Better alignment with treatment recommendations 3
• Identification of distinct treatment-relevant subgroups 3

Cautions and Controversies

• The 2023 system represents a significant departure from traditional staging systems 4
• Some experts suggest the new system should have been appraised at a multi-institutional and global level before implementation 4
• The complexity of the new system may present challenges in implementation, particularly in resource-limited settings

The 2023 FIGO staging system reflects our evolving understanding of endometrial cancer biology and aims to provide more personalized and relevant prognostication and management guidance for patients with uterine cancer.