What is the recommended approach to describe cervical lesions?

Recommended Approach to Describe Cervical Lesions

The most effective approach to describe cervical lesions is to use the FIGO (International Federation of Gynecology and Obstetrics) staging system, which is the standard classification for documenting cervical lesions based on their extent and invasion. 1

Classification Systems

FIGO Staging System

• FIGO staging is the most widely used classification system for cervical lesions and should always be used either alone or combined with another classification system 1
• This system distinguishes between limited forms (IA, IIA, IIB) and advanced forms (III, IV) of disease 1
• Within stage IIB, lesions with invasion proximal to the parametrium are considered limited disease, while others are considered advanced disease 1

TNM Classification

• Can be used alongside FIGO staging to provide additional information about tumor size, nodal involvement, and metastasis 1
• Provides complementary information that aligns with the FIGO stages (e.g., T1a1 corresponds to FIGO IA1) 1

Key Elements for Describing Cervical Lesions

1. Histologic Tumor Type

• Specify whether the lesion is:
  • Squamous intraepithelial lesion (SIL) - low grade or high grade 1
  • Squamous cell carcinoma - keratinizing, non-keratinizing, verrucous, warty, etc. 1
  • Adenocarcinoma - endocervical, mucinous, clear-cell, etc. 1
  • Neuroendocrine tumors - carcinoids, atypical carcinoids, neuroendocrine carcinomas 1

2. Lesion Size and Extent

• Document the maximum dimension of the lesion in centimeters 1
• For microinvasive lesions, measure:
  • Maximum depth of invasion in millimeters from the base of the epithelium 1
  • Horizontal spread in millimeters 1
  • For FIGO stage IA1: invasion ≤3.0 mm in depth and ≤7.0 mm in horizontal spread 1
  • For FIGO stage IA2: invasion >3.0 mm and ≤5.0 mm with horizontal spread ≤7.0 mm 1

3. Tumor Grade

For adenocarcinomas, specify the grade 1:

• Grade 1 - well-differentiated (≤10% solid growth)
• Grade 2 - moderately differentiated (11-50% solid growth)
• Grade 3 - poorly differentiated (>50% solid growth)

4. Additional Critical Features

• Presence or absence of lymphovascular space invasion (LVSI) 1
• Parametrial involvement 1
• Vaginal involvement and extent 1
• Status of surgical margins 1
• Lymph node status if assessed 1
• HPV status (particularly HPV 16/18) 1

Visual Inspection Findings

When describing visual inspection findings with acetic acid (VIA) 2:

• Raised dull white changes (positive VIA) - highly correlated with higher grade CIN (CIN 2/3)
• Flat white changes (negative VIA) - mostly correlated with CIN 1/koilocytosis

Common Pitfalls to Avoid

• Inadequate sampling: For microinvasive carcinoma, the entire abnormal lesion must be included in the specimen for accurate diagnosis 1
• Imprecise measurements: Depth of invasion should be measured from the base of the epithelium to the deepest point of invasion 1
• Missing the junctional zone: If the superior limit of the lesion cannot be seen during colposcopy, endocervical curettage should be added to confirm the diagnosis 1
• Overlooking HPV status: HPV 16/18 account for at least two-thirds of cervical carcinomas, and HPV 18 is associated with poorer prognosis in squamous cell carcinomas 1
• Inconsistent terminology: Use standardized terminology for squamous intraepithelial lesions (low-grade SIL/high-grade SIL) 1

Documentation Algorithm

1. Identify and document the histologic type of lesion
2. Measure and record the size and extent of invasion
3. Assess and document lymphovascular space involvement
4. Determine the FIGO stage based on measurements and extent
5. Document additional features (margins, lymph nodes, HPV status)
6. Provide a final classification using FIGO staging and TNM classification

This standardized approach ensures consistent and comprehensive description of cervical lesions, facilitating appropriate treatment planning and outcome assessment.