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

Cervical Cancer Staging and Treatment

FIGO Staging System Overview

The FIGO (International Federation of Gynecology and Obstetrics) staging system is the standard classification for cervical cancer, with the 2018 revision incorporating imaging findings and lymph node status to guide treatment decisions that directly impact survival and quality of life. 1, 2

The staging system is fundamentally based on clinical gynecological examination, allowing worldwide standardization even in resource-limited settings, though modern imaging now plays a critical role in treatment planning. 3, 2

Diagnostic Workup for Staging

Clinical Examination

• Perform gynecological examination to assess tumor size, vaginal extension, parametrial involvement, and potential bladder or rectal extension. 2
• Clinical examination remains the fundamental basis for FIGO staging despite the availability of advanced imaging. 3, 2

Essential Laboratory Tests

• Obtain complete blood count including platelets. 2
• Check renal function tests, as hydronephrosis defines stage IIIB. 2
• Measure liver function tests. 2
• Consider squamous cell carcinoma (SCC) antigen for follow-up if initially elevated in squamous histology. 3, 2

Imaging Strategy

MRI is superior to CT for tumor extension assessment and should be the preferred imaging modality for pelvic and abdominal evaluation. 3, 1, 2

• MRI is essential for accurately measuring tumor size, which is critical for distinguishing IB1 vs IB2 and IIA1 vs IIA2. 2, 4
• MRI can detect disease high in the endocervix that may be missed on clinical examination. 2
• Imaging is mandatory for any clinically visible tumor or microscopic tumor with >5 mm invasion (stage IB or greater). 2

PET/CT shows high sensitivity and specificity for nodal disease and is increasingly important with the 2018 FIGO staging incorporating lymph node status. 2, 4

• CT pelvis is equal to MRI for nodal assessment but inferior for local tumor extension. 2
• Obtain chest imaging (chest radiograph or thoracic CT) for metastasis assessment. 3, 2

FIGO Staging Classification

Stage IA: Microscopic Disease

• Stage IA1: ≤3 mm stromal invasion, ≤7 mm horizontal spread. 2
• Stage IA2: >3 mm but ≤5 mm stromal invasion, ≤7 mm horizontal spread. 2

Stage IB: Clinically Visible Lesions Confined to Cervix

• Stage IB1: Clinically visible lesion ≤2 cm (updated in 2018 revision). 5
• Stage IB2: Clinically visible lesion >2 cm but ≤4 cm. 5
• Stage IB3: Clinically visible lesion >4 cm (added in 2018 revision). 5, 2

Stage II: Extension Beyond Cervix

• Stage IIA1: Vaginal involvement (upper 2/3) without parametrial extension, ≤4 cm. 3, 2
• Stage IIA2: Vaginal involvement >4 cm. 3, 2
• Stage IIB: Parametrial extension. 2

Stage III: Extension to Pelvic Wall or Lower Vagina

• Stage IIIA: Lower 1/3 vaginal involvement. 2
• Stage IIIB: Pelvic wall extension or hydronephrosis. 2
• Stage IIIC1: Positive pelvic lymph nodes (added in 2018 revision). 2, 5
• Stage IIIC2: Positive para-aortic lymph nodes (added in 2018 revision). 2, 5

Stage IV: Extension Beyond True Pelvis

• Stage IVA: Bladder or rectal mucosa invasion. 2
• Stage IVB: Distant metastasis. 2

Treatment by Stage

Stage IA1 Without LVSI

Perform conization with negative margins or simple hysterectomy based on patient age. 3, 1, 6

Stage IA1 With LVSI

• Add pelvic lymphadenectomy to the surgical approach. 3, 1, 6
• Some experts recommend treating stage IA1 with extensive LVSI using stage IB1 treatment protocols. 3, 2
• If pelvic nodes are involved, administer complementary concurrent chemoradiation. 3, 1

Stage IA2

Perform radical hysterectomy with mandatory pelvic lymphadenectomy. 3, 1, 6

• Fertility-sparing options include conization or trachelectomy in young patients desiring fertility. 3, 1, 6
• If pelvic nodes are involved, administer complementary concurrent chemoradiation. 3, 1

Stage IB1 and IIA1 (≤4 cm)

Multiple treatment options are available with equivalent outcomes: radical hysterectomy with pelvic lymphadenectomy, external beam radiation plus brachytherapy, or combined radio-surgery. 3, 1, 6

• Conservative surgery can be considered for tumors with excellent prognostic factors. 3, 1
• Fertility-sparing options include cone biopsy with negative margins or trachelectomy for young women. 6
• If pelvic nodes are involved after surgery, administer complementary concurrent chemoradiation. 3, 1

Stage IB2, IB3, and IIA2 (>4 cm)

Administer concurrent chemoradiation as the preferred treatment for tumors >4 cm. 1, 6

• Use weekly cisplatin 40 mg/m² during external beam radiation therapy. 6
• Include brachytherapy as an essential component of definitive treatment. 1

Stage IIB-IVA (Locally Advanced Disease)

Administer concurrent chemoradiation with weekly cisplatin 40 mg/m² as standard treatment. 1, 6

• This regimen provides an absolute 5-year survival benefit of 8% for overall survival. 6
• External beam radiation should cover gross disease, parametria, and nodal volumes at risk. 1
• Brachytherapy is an essential component of definitive treatment. 1

Stage IVB (Metastatic Disease)

Administer platinum-based combination chemotherapy with bevacizumab. 3, 1, 6

Locoregional and Metastatic Recurrence

• Palliative chemotherapy is the standard option for most patients. 3
• Pelvic surgery (exenteration in most cases) and radiotherapy are options in selected cases. 3

Special Considerations

Lymphovascular Space Invasion (LVSI)

• LVSI does not alter FIGO stage because pathologists lack consistent agreement on its presence. 3, 2
• However, LVSI is an important risk factor for recurrence and should guide adjuvant treatment decisions. 3

Fertility Preservation

• Consider ovarian preservation for premenopausal women with squamous cell carcinoma undergoing hysterectomy. 6
• Recommend ovarian transposition before pelvic radiation in women <45 years. 6

Sedlis Criteria for Adjuvant Treatment

The following intermediate risk factors guide adjuvant treatment decisions after surgery: 3

• Greater than one-third stromal invasion
• Capillary lymphatic space involvement
• Cervical tumor diameter >4 cm

Additional risk factors include adenocarcinoma histology and close or positive surgical margins. 3

Follow-Up Protocol

Perform clinical and gynecological examination with PAP smear every 3 months for the first 2 years, every 6 months for years 3-5, and yearly thereafter. 3, 6

• Include annual cervical/vaginal cytology and imaging as indicated. 6
• Note that PAP smear interpretation may be altered in irradiated patients. 3