Staging of Cervical Cancer: What has Changed?

Abstract

In India, cervical cancer is the second most common cause of cancer-related fatalities and the fourth most common malignancy worldwide affecting women. India accounts for 25% of all cervical cancer-related deaths worldwide each year. The main drawbacks of clinical staging were the imprecise estimation of tumor size and the challenge of determining the involvement of pelvic and para-aortic lymph nodes with the few studies that FIGO allowed to be done for staging of cancer cervix. The use of 2009 staging approach showed that when many cases were operated based only on clinical findings, they subsequently required adjuvant therapy; hence, treatment-related morbidity was negatively impacted by these errors. Changes have been made to the staging of cervical cancer according to the 2018 revised International Federation of Gynecology and Obstetrics (FIGO) guidelines. Correction to cancer of the cervix staging was published recently in 2024. The horizontal extent (lateral extent) of the disease is not taken into consideration for staging in cases of microinvasive disease. Three subgroups have been identified based on the stratification of tumor size: IB1 ≤ 2 cm, IB2 > 2– ≤ 4 cm, and IB3 > 4 cm. Pathology and imaging modalities are added to clinical diagnosis for staging of cancer cervix. The involvement of lymph nodes (LNs) is now classified based on pathology (p) or imaging (r) which specifies that lymph node involvement is diagnosed using pathology (p) or imaging (r). Stage IIIC has been added [IIIC1 (involvement of pelvic nodes) and IIIC2 (involvement of para-aortic nodes)] is assigned to the case in the event of lymph node positive status. Pathological assessment takes precedence over radiological and clinical findings. The involvement of vascular/lymphatic spaces should not change the staging. The lower staging should be assigned when there is doubt about stage. Overall, the revised FIGO staging of cancer cervix (2024) has a number of advantages, including the inclusion of imaging and pathology, tumor size and LN-based categorization. More studies on staging of cancer cervix in different populations using revised staging of cancer cervix will help to prognosticate use of this staging.

In India, cervical cancer is the second most common cause of cancer-related fatalities and the fourth most common malignancy worldwide affecting women. India accounts for 25% of all cervical cancer-related deaths worldwide each year. The incidence and mortality of cervical cancer are 123,907 cases and 77,438 fatalities, respectively, according to Globocon 2020.

FIGO assigned a clinical stage for cervical carcinoma in 1958. The first organ to be clinically staged was the cervix. TNM staging was a pathological staging method that was used to document nodal and metastatic disease in cervical cancer. Cervical cancer staging has undergone changes as mentioned in Tables 1 and 2. Table 1 mentions comparison of Cancer cervix staging using FIGO 2009 staging and FIGO staging of cancer cervix (revised in 2024). Table 2 mentions comparison of 2018 FIGO staging of Cancer cervix and FIGO staging of Cancer cervix (revised in 2024).

Table 1.

mentions comparison of Cancer cervix staging using FIGO 2009 staging and FIGO staging of cancer cervix (revised in 2024). [1–3]

2009 FIGO staging cancer cervix [1]	FIGO staging cancer cervix (revised in 2024) [3]
Stage I Confined to the cervix IA≤5 mm depth and ≤7 mm width IA1≤3 mm depth IA2>3 mm and not >5 mm depth	Stage I: The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded). IA Invasive carcinoma that can be diagnosed only by microscopy with maximum depth of invasion ≤5 mma  IA1 Measured stromal invasion ≤3 mm in depth IA2 Measured stromal invasion >3 mm and ≤5 mm in depth
IB>5 mm depth IB1≤4 cm maximum diameter IB2>4 cm maximum diameter	IB Invasive carcinoma with measured deepest invasion >5 mm (greater than stage IA); lesion limited to the cervix uteri with size measured by maximum tumor diameterb  IB1 Invasive carcinoma >5 mm depth of stromal invasion and ≤2 cm in greatest dimension  IB2 Invasive carcinoma >2 cm and ≤4 cm in greatest dimension  IB3 Invasive carcinoma >4 cm in greatest dimension
Stage II Beyond the uterus but not involving the lower one-third of the vagina or pelvic sidewall IIA Upper two-thirds of the vagina IIA1 Upper two-thirds of the vagina and ≤4 cm IIA2 Upper two-thirds of the vagina and >4 cm IIB Parametrial invasion	Stage II: The cervical carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall IIA Involvement limited to the upper two-thirds of the vagina without parametrial invasion IIA1 Invasive carcinoma ≤4 cm in greatest dimension IIA2 Invasive carcinoma >4 cm in greatest dimension IIB With parametrial invasion but not up to the pelvic wall
Stage III Involvement of lower vagina, pelvic sidewall, and ureters IIIA Lower one-third of the vagina IIIB Pelvic sidewall	Stage III: The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes  IIIA Carcinoma involves lower third of the vagina, with no extension to the pelvic wall  IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney (unless known to be due to another cause)  IIIC Involvement of pelvic and/or para-aortic lymph nodes (including micro-metastases)c, irrespective of tumor size and extent (with r and p notations).d o IIIC1 Pelvic lymph node metastasis only o IIIC2 Para-aortic lymph node metastasis
Stage IV Metastasis to adjacent and distant organs IVA Rectal or bladder involvement IVB Distant organs outside the pelvis	Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV  IVA Spread of the growth to adjacent organs  IVB Spread to distant organs
	aImaging and pathology can be used, when available, to supplement clinical findings with respect to tumor size and extent, in all stages. Pathological findings supercede imaging and clinical findings.  bThe involvement of vascular/lymphatic spaces should not change the staging. The lateral extent of the lesion is no longer considered.  cIsolated tumor cells do not change the stage but their presence should be recorded  dAdding notation of r (imaging) and p (pathology), to indicate the findings that are used to allocate the case to stage IIIC. The type of imaging modality or pathology technique used should always be documented. When in doubt, the lower staging should be assigned.

The changes made in staging of cancer cervix in FIGO 2009 staging, FIGO 2018 staging and revision in FIGO staging made in 2024 have been mentioned in bold

Table 2.

mentions comparison of 2018 FIGO staging of Cancer cervix and FIGO staging of Cancer cervix (revised in 2024)

FIGO staging of cancer of the cervix uteri (2018). [4]	FIGO staging cancer cervix (revised in 2024) [2]
Stage I The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be disregarded)	Stage I: The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded)
IA Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of invasion < 5 mma IA1 Measured stromal invasion < 3 mm in depth IA2 Measured stromal invasion ≥ 3 mm and < 5 mm in depth	IA Invasive carcinoma that can be diagnosed only by microscopy with maximum depth of invasion ≤ 5 mma IA1 Measured stromal invasion ≤ 3 mm in depth IA2 Measured stromal invasion > 3 mm and ≤ 5 mm in depth
IB Invasive carcinoma with measured deepest invasion ≥ 5 mm (greater than Stage IA), lesion limited to the cervix uterib IB1 Invasive carcinoma ≥ 5 mm depth of stromal invasion, and < 2 cm in greatest dimension IB2 Invasive carcinoma ≥ 2 cm and < 4 cm in greatest dimension IB3 Invasive carcinoma ≥ 4 cm in greatest dimension	IB Invasive carcinoma with measured deepest invasion > 5 mm (greater than stage IA); lesion limited to the cervix uteri with size measured by maximum tumor diameterb o  IB1 Invasive carcinoma > 5 mm depth of stromal invasion and ≤ 2 cm in greatest dimension o  IB2 Invasive carcinoma > 2 cm and ≤ 4 cm in greatest dimension o  IB3 Invasive carcinoma > 4 cm in greatest dimension
Stage II The carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall IIA Involvement limited to the upper two-thirds of the vagina without parametrial involvement IIA1 Invasive carcinoma < 4 cm in greatest dimension IIA2 Invasive carcinoma ≥ 4 cm in greatest dimension IIB With parametrial involvement but not up to the pelvic wall	Stage II: The cervical carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall IIA Involvement limited to the upper two-thirds of the vagina without parametrial invasion IIA1 Invasive carcinoma ≤ 4 cm in greatest dimension IIA2 Invasive carcinoma > 4 cm in greatest dimension IIB With parametrial invasion but not up to the pelvic wall
Stage III The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodesc IIIA The carcinoma involves the lower third of the vagina, with no extension to the pelvic wall IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney (unless known to be due to another cause) IIIC Involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumor size and extent (with r and p notations)c IIIC1 Pelvic lymph node metastasis only IIIC2 Para-aortic lymph node metastasis	Stage III: The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes IIIA Carcinoma involves lower third of the vagina, with no extension to the pelvic wall IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney (unless known to be due to another cause) IIIC Involvement of pelvic and/or para-aortic lymph nodes (including micro-metastases)c, irrespective of tumor size and extent (with r and p notations).d o  IIIC1 Pelvic lymph node metastasis only o  IIIC2 Para-aortic lymph node metastasis
Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. (A bullous edema, as such, does not permit a case to be allotted to Stage IV) IVA Spread to adjacent pelvic organs IVB Spread to distant organs	Stage IV: The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV  IVA Spread of the growth to adjacent organs  IVB Spread to distant organs
When in doubt, the lower staging should be assigned aImaging and pathology can be used, where available, to supplement clinical findings with respect to tumor size and extent, in all stages b.The involvement of vascular/lymphatic spaces does not change the staging. The lateral extent of the lesion is no longer considered cAdding notation of r (imaging) and p (pathology) to indicate the findings that are used to allocate the case to Stage IIIC. Example: If imaging indicates pelvic lymph node metastasis, the stage allocation would be Stage IIIC1r, and if confirmed by pathologic findings, it would be Stage IIIC1p The type of imaging modality or pathology technique used should always be documented	aImaging and pathology can be used, when available, to supplement clinical findings with respect to tumor size and extent, in all stages. Pathological findings supercede imaging and clinical findings  bThe involvement of vascular/lymphatic spaces should not change the staging. The lateral extent of the lesion is no longer considered  cIsolated tumor cells do not change the stage but their presence should be recorded  dAdding notation of r (imaging) and p (pathology), to indicate the findings that are used to allocate the case to stage IIIC. The type of imaging modality or pathology technique used should always be documented. When in doubt, the lower staging should be assigned

The changes made in staging of cancer cervix in FIGO 2009 staging, FIGO 2018 staging and revision in FIGO staging made in 2024 have been mentioned in bold

The main drawbacks of clinical staging were the imprecise estimation of tumor size and the challenge of determining the involvement of pelvic and para-aortic lymph nodes with the few studies that FIGO allowed to be done for staging of cancer cervix. The use of 2009 staging approach showed that when many cases were operated based only on clinical findings, they subsequently required adjuvant therapy; hence, treatment-related morbidity was negatively impacted by these errors. Only simple imaging methods were permitted to alter the staging in earlier FIGO staging schemes, which were dependent majorly on clinical evaluation [1]. In order to get over these restrictions, diagnostic imaging has been added to the updated FIGO staging to evaluate the disease's loco-regional spread and identify distant metastases.

The FIGO Gynaecologic Oncology Committee collaborated with all main societies for nearly three years before presenting the 2018 staging of cervical cancer at the XXII FIGO World Congress in Rio de Janeiro, Brazil [4]. Correction to cancer of the cervix uteri staging was published recently in 2024 [2].

Changes have been made to the staging of cervical cancer according to the 2024 revised International Federation of Gynecology and Obstetrics (FIGO) guidelines [2, 5].

1. The horizontal extent (lateral extent) of the disease is not taken into consideration for staging in cases of microinvasive disease. Since there is no evidence that the horizontal dimension affects survival, it is no longer taken into account in the 2018 revision.

2. In order to improve patient treatment, particularly when fertility-sparing surgery is necessary, stage 1b has been divided into three subcategories. Three subgroups have been identified based on the stratification of tumor size: IB1 ≤ 2 cm, IB2 > 2– ≤ 4 cm, and IB3 > 4 cm. (Fertility-sparing surgeries are usually done when tumor size is less than 2 cm.)

3. Pathology and imaging modalities are added to clinical diagnosis for staging of cancer cervix. Any imaging approach can be used to determine the stage in the FIGO 2018 staging. FIGO does not, however, require any specific imaging modality; instead, the selection of an imaging modality is contingent upon availability and competence, taking into account regional variations in resource availability. Although this suggestion is useful, it is unclear if it could result in the same patient being assigned a different stage if a different kind of modality is employed—drawback of this classification. Therefore, in order to enable future appropriate interpretation of the data, it is advised to specify imaging techniques employed for patient staging. Cross-sectional imaging can show both distant metastases and the loco-regional extent of the disease.

4. The involvement of lymph nodes (LNs) is now classified based on pathology (p) or imaging (r) which specifies that lymph node involvement is diagnosed using pathology (p) or imaging (r). Stage IIIC has been added [IIIC1 (involvement of pelvic nodes) and IIIC2 (involvement of para-aortic nodes)] is assigned to the case in the event of lymph node positive, which is associated with worse oncologic outcomes. The case is assigned to stage IIIC due to the existence of micro-metastases. This change has been done as lymph node involvement has consistently played a significant role in treatment planning. Regardless of the size or other features of the tumor, patients with positive nodes were not deemed fit for surgery and are instead referred directly to chemotherapy and radiation.

5. Pathological assessment takes precedence over radiological and clinical findings. This staging allows the user to select clinical, radiological, or pathological evidence as the foundation for stage assignment, based on resource availability; this flexibility takes into consideration the challenges encountered in low- and middle-income countries. Once all pathology and imaging findings are obtained, the stage is assigned. It is not to be changed afterward, as during a recurrence.

6. The involvement of vascular/lymphatic spaces should not change the staging. Though the presence of isolated tumor cells does not change the stage of cancer, it should be recorded.

7. The lower staging should be assigned when there is doubt about stage.

Several centers retrospectively analyzed their data after the 2018 revised staging was published, and they found a significant shift in stage and influence on prognosis across all stages. In 23 and 32 percent of cases, respectively, the primary factors causing this stage transition were tumor size and localized node involvement [5, 6].

Overall, the revised FIGO 2024 staging method has a number of advantages, including the inclusion of imaging and pathology, tumor size and LN-based categorization. Therefore, the updated staging approach necessitates thorough and consistent reporting from pathologists, radiologists, and physicians alike. In comparison with the former staging method, which had worse outcomes as the stage progressed, it offers a clearer demarcation between stages and more accurately represents survival outcome [7].

More studies on staging of cancer cervix in different populations using revised staging of cancer cervix will help to prognosticate use of this staging.

Declarations

Conflict of interests

I, the author of this article, hereby declare that I have no conflict of interest or financial interests for the article.

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