What is the 2023 National Comprehensive Cancer Network (NCCN) staging system for uterine cancer?

2023 NCCN Uterine Cancer Staging System

The 2023 National Comprehensive Cancer Network (NCCN) guidelines for uterine cancer continue to use the 2009 FIGO staging system, which classifies stage IA as tumors with <50% myometrial invasion, stage IB as tumors with ≥50% myometrial invasion, and stage II as tumors that invade the cervical stroma. 1

Key Components of the NCCN-Endorsed Staging System

Surgical-Pathologic Staging

• The NCCN emphasizes that staging should be performed by a team with expertise in imaging, pathologic evaluation, and surgery
• The 2009 FIGO staging system (endorsed by NCCN in 2023) includes:
  • Stage I: Tumor confined to the corpus uteri
    • Stage IA: Tumor limited to endometrium or invades <50% of myometrium
    • Stage IB: Tumor invades ≥50% of myometrium
  • Stage II: Tumor invades cervical stroma (not just endocervical glandular involvement)
  • Stage III: Local and/or regional spread
    • Stage IIIC1: Pelvic node involvement
    • Stage IIIC2: Para-aortic lymph node involvement (with or without pelvic node involvement)
  • Stage IV: Distant metastasis or advanced local disease 1

Important Pathologic Assessment Elements

• 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) 1

Surgical Staging Principles

Recommended Procedures

• Total hysterectomy/bilateral salpingo-oophorectomy (TH/BSO) with surgical staging
• Peritoneal washings (recommended by FIGO/AJCC but no longer affects stage)
• Lymph node assessment using either:
  • Complete lymphadenectomy, or
  • Sentinel lymph node (SLN) mapping following the NCCN SLN algorithm 1

Minimally Invasive Approach

• Minimally invasive surgery is preferred when technically feasible
• Considered a quality measure by the Society of Gynecologic Oncology (SGO) and American College of Surgeons 1

Special Considerations

Incomplete Surgical Staging

• For patients with incomplete surgical staging and high-risk intrauterine features:
  • Imaging is recommended, especially with higher-grade histologies
  • Surgical restaging, including lymph node dissection, can be performed 1

Fertility-Sparing Options

• May be considered for highly selected patients with:
  • Grade 1, stage IA (noninvasive) endometrioid adenocarcinoma
  • Desire to preserve fertility
  • Meeting all criteria outlined in the NCCN algorithm
• Not recommended for high-risk histologies (serous, clear cell, carcinosarcoma, etc.) 1

Important Notes on Recent Changes

• While a 2023 FIGO staging system revision has been published that incorporates histology, lymphovascular space invasion, and molecular classification 2, 3, 4, 5, 6, the 2023 NCCN guidelines still utilize the 2009 FIGO staging system
• The 2009 FIGO system streamlined stages I and II compared to the previous 1988 system 1
• Peritoneal cytology results are still recommended to be collected and recorded, but no longer affect staging 1

Common Pitfalls to Avoid

• Misclassifying endocervical glandular involvement (mucosal involvement) as stage II disease - this is no longer considered stage II unless there is cervical stromal invasion 1
• Failing to perform adequate pathologic assessment, which is critical for accurate staging and treatment planning
• Intraperitoneal morcellation should be avoided to optimize outcomes 1
• Overlooking the importance of expert pathologic review to determine specific histotype, which can be challenging especially in high-grade cancers 1

The NCCN guidelines emphasize that proper staging by experienced teams is essential for determining appropriate treatment and predicting outcomes in patients with uterine cancer.