BACKGROUND• Groups set up several years ago• March 2009-staging system for uterine sarcomas published (IJGO 2009;104;179)- PATHOLOGICAL INPUT• May 2009-staging systems for endometrial, cervical and vulval tumours published (IJGO 2009;105;103-104)- NO PATHOLOGICAL INPUT
OTHER TUMOURS• groups set up to look at staging of ovarian, fallopian tube and trophoblastic neoplasms
NEW FIGO STAGING FOR UTERINE SARCOMAS• never had staging system previously• carcinosarcomas staged as per uterine carcinomas• staging system for leiomyosarcomas• different system for ESS and adenosarcoma
Leiomyosarcomas- FIGO 2009Stage I Tumour limited to uterusIA <5 cmIB >5 cmStage II Tumour extends to the pelvisIIA Adnexal involvementIIB Tumour extends to extrauterine pelvic tissueStage III Tumour invades abdominal tissues (not just protruding into the abdomen)IIIA One siteIIIB > one siteIIIC Metastasis to pelvic and/or para-aortic lymph nodesStage IVIVA Tumour invades bladder and/or rectumIVB Distant metastasis
Endometrial stromal sarcomas (ESS) and adenosarcomas- FIGO 2009Stage I Tumour limited to uterusIA Tumour limited to endometrium/endocervix with no myometrial invasionIB Less than or equal to half myometrial invasionIC More than half myometrial invasionStage II Tumour extends to the pelvisIIA Adnexal involvementIIB Tumour extends to extrauterine pelvic tissueStage III Tumour invades abdominal tissues (not just protruding into the abdomen)IIIA One siteIIIB > one siteIIIC Metastasis to pelvic and/or para-aortic lymph nodesStage IVIVA Tumour invades bladder and/or rectumIVB Distant metastasis
Carcinoma of the endometrium- FIGO 2009Stage I Tumour confined to the corpus uteriIA No or less than half myometrial invasionIB Invasion equal to or more than half of the myometriumStage II Tumour invades cervical stroma, but does not extend beyond the uterusStage III Local and/or regional spread of the tumourIIIA Tumour invades the serosa of the corpus uteri and/or adnexaeIIIB Vaginal and/or parametrial involvementIIIC Metastases to pelvic and/or para-aortic lymph nodesIIIC1 Positive pelvic nodesIIIC2 Positive para-aortic lymph nodes with or without positive pelvic lymph nodesStage IV Tumour invades bladder and/or bowel mucosa, and/or distant metastasesIVA Tumour invasion of bladder and/or bowel mucosaIVB Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes
CHANGES TO STAGE I• old IA and IB is now IA (FIGO figures show no difference in outcome; pathological difficulties)• old IC is now IB• endocervical glandular involvement alone will still be stage I
CHANGES TO STAGE II• single category of stage II (cervical stromal involvement)
Carcinoma of the cervix uteri- FIGO 2009Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion <5 mm and the largest extension >7 mmIA1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mmIA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mmIB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IAIB1 Clinically visible lesion <4.0 cm in greatest dimensionIB2 Clinically visible lesion >4.0 cm in greatest dimensionStage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vaginaIIA Without parametrial invasionIIA1 Clinically visible lesion <4.0 cm in greatest dimensionIIA2 Clinically visible lesion >4.0 cm in greatest dimensionIIB With obvious parametrial invasion
Stage III The tumour extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidneyIIIA Tumour involves lower third of the vagina, with no extension to the pelvic wallIIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidneyStage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous oedema, as such, does not permit a case to be allotted to Stage IVIVA Spread of the growth to adjacent organsIVB Spread to distant organs
VULVAL CARCINOMA• MUCH MORE COMPLICATED• significant changes
Carcinoma of the vulva- FIGO 2009Stage I Tumour confined to the vulvaIA Lesions <2 cm in size, confined to the vulva or perineum and with stromal invasions <1.0 mm*, no nodal metastasisIB Lesions >2 cm in size or with stromal invasion >1.0 mm* confined to the vulva or perineum, with negative nodesStage II Tumour of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodesStage III Tumour of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes.IIIA (i) With 1 lymph node metastasis (>5 mm), or (ii) 1-2 lymph node metastasis(es) (<5 mm)IIIB (i) With 2 or more lymph node metastases (>5 mm), or (ii) 3 or more lymph node metastases (<5 mm)IIIC With positive nodes with extracapsular spreadStage IV Tumour invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures.IVA Tumour invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or (ii) fixed or ulcerated inguino-femoral lymph nodesIVB Any distant metastasis including pelvic lymph nodes* The depth of invasion is defined as the measurement of the tumour from the epithelial-stromaljunction of the adjacent most superficial dermal papilla to the deepest point of invasion.
CHANGES TO STAGE I• IA- < 2cm, stromal invasion <1mm, confined to vulval or perineum, no nodal metastasis• IB- previous IB and II combined- >2cm size or with stromal invasion >1mm, confined to vulval or perineum, no nodal metastasis
CHANGES TO STAGE II• any size with extension to lower third of urethra, lower third of vagina or anus and negative nodes
CHANGES TO STAGE III• any size, with or without extension to lower third of urethra, lower third of vagina or anus and positive inguino-femoral nodes• IIIA- 1 nodal metastasis > 5mm or up to 2 nodes <5mm• IIIB- 2 or more nodes >5mm or 3 or more nodes <5mm• IIIC- extracapsular spread
CHANGES TO STAGE IV• upper two thirds of urethra or vagina or distant structures• various substages• bilateral nodal involvement now not taken into account
IMPLICATIONS/DIFFICULTIES• dissemination of information to surgical oncologists, gynaecologists, non-surgical oncologists, pathologists, radiologists• ? set start date• endocervical glandular involvement in endometrial cancer (marked interobserver variation)• pathologists difficulty in distinguishing cervical glandular from stromal involvement• TNM will differ for a while- will be updated in 7th TNM edition (? drop TNM from pathology proformas)
WIDER QUESTIONS• rest of UK (role of British Gynaecological Cancer Society, British Association of Gynaecological Pathologists)• if piecemeal introduction, will create difficulties
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