What is the staging and treatment of cervical cancer based on the International Federation of Gynecology and Obstetrics (FIGO) staging system?

Cervical Cancer Staging and Treatment According to FIGO

The International Federation of Gynecology and Obstetrics (FIGO) staging system is the standard for cervical cancer classification, with the most recent update incorporating imaging findings and lymph node status to guide treatment decisions that optimize patient survival and quality of life. 1

FIGO Staging Classification

The FIGO staging system categorizes cervical cancer based on tumor extent:

• Stage I: Tumor confined to the cervix 1

  • Stage IA: Invasive carcinoma diagnosed only microscopically
    • IA1: Stromal invasion ≤3.0 mm in depth, ≤7.0 mm horizontal spread 1
    • IA2: Stromal invasion >3.0 mm but ≤5.0 mm, ≤7.0 mm horizontal spread 1
  • Stage IB: Clinically visible lesion or microscopic lesion >IA2
    • IB1: Clinically visible lesion ≤4.0 cm 1
    • IB2: Clinically visible lesion >4.0 cm 1

• Stage II: Tumor invades beyond uterus but not to pelvic wall or lower third of vagina 1

  • IIA: Without parametrial invasion
    • IIA1: Clinically visible lesion ≤4.0 cm 1
    • IIA2: Clinically visible lesion >4.0 cm 1
  • IIB: With parametrial invasion 1

• Stage III: Tumor extends to pelvic wall, involves lower third of vagina, or causes hydronephrosis/non-functioning kidney 1

  • IIIA: Involves lower third of vagina 1
  • IIIB: Extends to pelvic wall or causes hydronephrosis/non-functioning kidney 1

• Stage IV: Tumor invades bladder/rectum mucosa or extends beyond true pelvis 1

  • IVA: Invades bladder/rectum mucosa 1
  • IVB: Distant metastasis 1

Recent Updates to FIGO Staging

The 2018 FIGO staging system includes important modifications:

• Imaging findings are now incorporated into staging decisions 2
• Stage IB has been subdivided into three categories based on tumor size:
  • IB1: <2 cm
  • IB2: 2-4 cm
  • IB3: >4 cm 3
• Stage IIIC was added to recognize lymph node involvement:
  • IIIC1: Pelvic lymph node involvement
  • IIIC2: Para-aortic lymph node involvement 2, 3

Diagnostic Workup for Staging

• Clinical examination: Gynecological examination remains fundamental for initial staging 1
• MRI: Superior to CT for tumor extension assessment; preferred for pelvic and abdominal imaging 1
• CT scan: Optional for thoracic assessment to evaluate for metastasis 1
• PET: Under evaluation but useful for nodal assessment 1
• Laboratory tests: Blood counts, renal and liver function tests 1
• SCC antigen: May be useful for follow-up in squamous cell carcinomas if initially elevated 1

Stage-Specific Treatment Recommendations

Early-Stage Disease

• Stage IA1:

  • Conization with free margins or simple hysterectomy based on patient age 1
  • Pelvic lymphadenectomy if lymphovascular space invasion present 1
  • Complementary chemoradiation if pelvic nodes involved 1

• Stage IA2:

  • Surgery is standard - options include conization/trachelectomy (fertility preservation) or radical hysterectomy 1
  • Pelvic lymphadenectomy required 1
  • Complementary chemoradiation if nodes involved 1

• Stage IB1:

  • Multiple options: radical hysterectomy with pelvic lymphadenectomy, external radiation plus brachytherapy, or combined radio-surgery 1
  • Conservative surgery possible for tumors with excellent prognostic factors 1
  • Complementary chemoradiation if nodes involved 1

Advanced Disease

• Stages IB2-IVA:

  • Concurrent chemoradiation is standard treatment 1
  • External beam radiation to cover gross disease, parametria, and nodal volumes at risk 4
  • Brachytherapy is an essential component of definitive treatment 4

• Stage IVB:

  • Platinum-based combination chemotherapy 1

Follow-up Recommendations

• Clinical and gynecological examinations including PAP smear:
  • Every 3 months for first 2 years
  • Every 6 months for next 3 years
  • Yearly thereafter 1

Clinical Considerations and Pitfalls

• Stage migration: Nearly 59% of patients may be upstaged when using the 2018 FIGO system compared to previous versions 2
• Treatment planning: Multidisciplinary approach is mandatory for optimal outcomes 1
• Imaging limitations: While imaging is now incorporated into staging, availability and quality of imaging may vary across different healthcare settings 5
• Lymph node assessment: The prognostic significance of lymph node involvement is now formally recognized in staging, with stage IIIC patients showing better survival than stages IIIA/B in some studies 2
• Tumor size measurement: Careful assessment of tumor size is critical, especially for stage IB subdivisions, as it significantly impacts treatment decisions 5

Special Considerations

• Fertility preservation: For young patients with early-stage disease, fertility-sparing options like conization or trachelectomy should be considered when appropriate 1, 6
• HPV status: HPV 16/18 account for at least two-thirds of cervical carcinomas globally and may influence prognosis 1
• Histologic subtypes: Different histologic types may have varying prognoses and treatment responses 1