Current Updates on Gynecologic Cancer Staging
Overview of Major Staging Revisions
The most significant recent updates to gynecologic cancer staging include the 2018 FIGO revision for cervical cancer (incorporating radiologic and pathologic data), the 2014 FIGO revision for ovarian cancer (recognizing similarities between ovarian, fallopian tube, and primary peritoneal carcinomas), and the 2009 FIGO system for endometrial cancer (which remains the current standard with a 2023 update pending broader validation). 1, 2
Cervical Cancer Staging Updates
Key 2018 FIGO Revisions
The 2018 FIGO staging system for cervical cancer now incorporates radiologic and pathologic findings into stage designation, representing a fundamental shift from purely clinical staging 1
Advanced imaging (MRI, CT, PET/CT) findings are now formally integrated into staging decisions, reflecting recognition that cross-sectional imaging provides actionable information not obtainable by physical examination alone 1
Accurate determination of tumor size, local extension, nodal status, and distant metastases is critical as these factors determine treatment strategy (surgery versus chemoradiation) and strongly influence prognosis 1
Imaging Role in Cervical Cancer
Imaging is recommended for any clinically visible tumor or microscopic tumor with >5 mm invasion on biopsy (stage IB or greater) 1
Nodal status is particularly important prognostically, with outcomes strongly linked to the presence of lymph node metastases 1
Ovarian Cancer Staging Updates
2014 FIGO Revisions
- The International Federation of Gynecologists and Obstetricians revised ovarian cancer staging criteria in 2014, recognizing the morphologic and molecular similarities between fallopian tube, primary peritoneal carcinomas, and ovarian malignancy 1
Current Staging Classification
Stage I: Tumor limited to one or both ovaries or fallopian tubes 1
Stage II: Spread to the surface of other pelvic organs 1
Stage III: Spread to retroperitoneal lymph nodes (IIIA1) or abdominal peritoneal surfaces (IIIA2 if microscopic disease, IIIB or IIIC with macroscopic nodules) 1
Stage IV: Advanced disease with distant metastases to solid organs or malignant pleural effusion 1
Imaging Modalities
CT, FDG-PET/CT, and MRI are used to assess tumor resectability, candidacy for effective cytoreductive surgery, need for postoperative chemotherapy, and need for referral to a gynecologic oncologist 1
Referral to a gynecologic oncologist for optimal staging and debulking is the second most important determinant for survival after tumor stage 1
Endometrial Cancer Staging Updates
Current 2009 FIGO System
The 2009 FIGO surgical/pathologic staging system remains the standard in clinical practice for uterine adenocarcinoma, with a 2023 update pending broader validation before adoption 1, 2
This system replaced the outdated 1970 clinical staging system, which was inaccurate in 15-20% of patients 1, 2
Key Staging Criteria
Stage II: Cervical stromal invasion only; patients with endocervical glandular involvement without cervical stromal invasion are no longer considered stage II 1, 2
Stage IIIC: Now subdivided into IIIC1 (pelvic lymph node involvement) and IIIC2 (para-aortic lymph node involvement), because survival is worse with positive para-aortic nodes 1, 2
Critical Changes from Previous Systems
Positive peritoneal cytology no longer affects FIGO staging, as it is not viewed as an independent risk factor, though FIGO and AJCC continue to recommend that peritoneal washings be obtained and results recorded 1, 2
The 2009 system streamlined stages I and II because survival rates for some previous sub-stages were similar 1
Separate staging systems for malignant epithelial tumors and uterine sarcomas are now available 1
Vaginal Cancer Staging
Current Status
The 2009 FIGO staging system for vaginal cancer indicates that findings on advanced imaging (CT, MRI, PET/CT) should not modify stage designation 1
However, such imaging findings are routinely employed in clinical practice to prognosticate and guide management decisions 1
Recent updates to cervical cancer staging (incorporating advanced imaging) reflect wide recognition that cross-sectional imaging provides actionable staging information not readily obtained by physical examination 1
Rationale for Imaging Integration
Accurate initial staging is fundamental to prognostication and permits selection of the most appropriate treatment based on extent of disease 1
Pretreatment knowledge of suspicious nodes may impact the decision to pursue surgery versus radiation 1
Detection of extraregional nodal or solid organ lesions can obviate unnecessarily morbid radical pelvic surgery and direct care toward palliative regimens 1
Common Pitfalls to Avoid
Endometrial Cancer
Do not upstage patients based solely on positive peritoneal cytology, as this is no longer part of the staging criteria 2
Do not classify endocervical glandular involvement without stromal invasion as Stage II; these patients remain Stage I 2
Ensure proper distinction between Stage IIIC1 (pelvic nodes only) and IIIC2 (para-aortic involvement), as survival differs significantly 2
Recognize that clinical staging is inaccurate in 15-20% of cases, making surgical/pathologic staging essential for accurate prognostication 2
General Principles
Staging should be performed by a multidisciplinary team with expertise in imaging, pathology, and surgery 1, 2
The extent of surgical staging depends on preoperative and intraoperative assessment by experienced surgeons 1
Expert pathologic review determines specific histotype and is essential for accurate staging 2