Cancer Staging

~ Cervical Cancer ~

　

☆ International classification of cancer of the cervix:

　

Stage 0

Carcinoma in situ, intraepithelial carcinoma

Stage I

The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded

Stage Ia

Invasive cancer identified only microscopically; all gross lesions even the superficial invasion are stage Ib cancers.

Invasion is limited to measured stromal invasion with maximum depth of 5.0 mm and no wider than 7.0 mm

Stage Ia1

Measured invasion of stroma no greater than 3.0 mm in depth and no wider than 7.0 mm.

Stage Ia2

Measured invasion of stroma greater than 3 mm and no greater than 5 mm and no wider than 7 mm.

The depth of invasion should not be more than 5 mm taken from the base of the epithelium, surface or glandular, from which it originates. Vascular space involvement, venous or lymphatic, should not alter the staging.

Stage Ib

Clinical lesion confined to the cervix or preclinical lesion greater than stage Ia.

Stage Ib1

Clinical lesions no greaten than 4.0 cm in size

Stage Ib2

Clinical lesions greater than 4 cm in size

Stage II

Involvement of the vagina but not the lower third, or infiltration of the parametria but not out to the sidewall.

Stage IIa

Involvement of the vagina but no evidence of parametrial involvement

Stage IIb

Infiltration of the parametria but not out to the sidewall

Stage III

Involvement of the lower third of the vagina or extension to the pelvic sidewall; all cases with a hydronephrosis or nonfunctioning kidney should be included, unless they are know to be attributable to other cause

Stage IIIa

Involvement of the lower third of the vagina but not out to the pelvic sidewall if the parametria are involved

Stage IIIb

Extension onto the pelvic sidewall and/or hydronephrosis or nonfunctional kidney

Stage IV

Extension outside the reproductive tract

Stage IVa

Involvement of the mucosa of the bladder or rectum

Stage IVb

Distant metastasis or disease outside the true pelvis

☆ Incidence of pelvic and para-aortic nodal metastasis by stage:

　

Stage

% positive pelvic LN

% positive para-aortic LN

Ia1 (≦3mm)

0.5

0

Ia2 (>3-5mm)

4.8

<1

Ib

15.9

2.2

IIa

24.5

11

IIb

31.4

19

III

44.8

30

IVa

55

40

☆ Surgical management of Early invasive cancer of the cervix:

　

Stage Ia1

≦3mm invasion,

no Lymph-vascular space involvement

with Lymph-vascular space involvement

　

Conization, type I hysterectomy

Type I or II hysterectomy with (?) pelvic LN dissection

Stage Ia2

>3-5 mm invasion

Type II hysterectomy with pelvic lymphadenectomy

Stage Ib

> 5mm invasion

Type III hysterectomy with pelvic lymphadenectomy

~ Endometrial Cancer ~

　

☆ FIGO classification of endometrial carcinoma:

　

Stage Ia G123

Tumor limited to endometrium

Ib G123

Invasion of less than half of the myometrium

Ic G123

Invasion of more than half of the myometrium

IIa G123

Endocervical glandular involvement only

IIb G123

Cervical stromal invasion

IIIa G123

Tumor invades serosa and/or adnexae and/or positive peritoneal cytology

IIIb G123

Vaginal metastases

IIIc G123

Metastases to pelvic and/or para-aortic lymph nodes

IVa G123

Tumor invasion of bladder and/or bowel mucosa

IVb

Distant metastases, including intraabdominal and/or inguinal lymph node

　
Histopathology: Degree of differentiation

Cases of carcinoma of the corpus should be grouped according to the degree of differentiation of the adneocarcinoma as follows:

G1= 5% or less of a nonsquamous or nonmorular solid growth pattern

G2= 6% to 50% of a nonsquamous or nonmorular solid growth pattern

G3= more than 50% of a nonsquamous or nonmorular solid growth pattern

~ Ovarian Cancer ~

　

☆ Carcinoma of the ovary: staging classification using the FIGO nomenclature:

　

Stage

Description

I

Growth limited to the ovaries

Ia

Growth limited to one ovary; no ascites present containing malignant cells; no tumor on the external surfaces; capsule intact

Ib

Growth limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules intact

Ic

Tumor stage Ia or stage Ib but with tumor on the surface of one or both ovaries; or with capsule ruptured; or with ascites present containing malignant cells with positive peritoneal washings

II

Growth involving one or both ovaries with pelvic extension

IIa

Extension and/or metastases to the uterus and/or tubes

IIb

Extension to other pelvic tissues

IIc

tumor stage IIa or stage IIb but with tumor on the surface of one of both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washing

III

Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III; tumor is limited to the true pelvis but with histologically verified malignant extension to small bowel or omentum

IIIa

Tumor grossly limited to the true pelvis with negative nodes with histologically confirmed microscopic seeding of abdominal peritoneal surfaces

IIIb

Tumor of one or both ovaries; histologically confirmed implants of abdominal peritoneal surfaces; none exceeding 2 cm in diameter; nodes negative

IIIc

Abdominal implants 2 cm in diameter and/or positive retroperitoneal or inguinal nodes

IV

Growth involving one or both ovaries with distant metastasis; if pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV; parenchymal liver metastasis equals stage IV

In order to evaluate the impact on prognosis of the different criteria for allotting cases to stage Ic or IIc, it would be of value to know if rupture of the capsule was (1) spontaneous or (2) caused by the surgeon and if the source of the malignant cells detected was (1) peritoneal washing or (2) ascites.

　

~ Trophoblastic Tumors ~

　

☆ FIGO staging for trophoblastic tumors:

　

Stage I

Disease confined to the uterus

Stage Ia

Disease confined tot he uterus with no risk factors

Stage Ib

Disease confined to the uterus with one risk factor

Stage Ic

Disease confined to the uterus with two risk factors

Stage II

GTT extends outside the uterus but is limited to the genital structures (adnexa, vagina, broad ligament)

Stage IIa

GTT involving genital structures without risk factors

Stage IIb

GTT extends outside of the uterus but limited to genital structures with one risk factor

Stage IIc

GTT extends outside of the uterus but limited tot he genital structures with two risk factors

Stage III

GTT extends to the lungs with or without known genital tract involvement

Stage IIIa

GTT extends to the lungs with or without genital tract involvement and with no risk factors

Stage IIIb

GTT extends to the lungs with or without genital tract involvement and with one risk factor

Stage IIIc

GTT extends to the lungs with or without genital tract involvement and has two risk factors

Stage IV

All other metastatic sites

Stage IVa

All other metastatic sites without risk factors

Stage IVb

All other metastatic sites with one risk factor

Stage IVc

All other metastatic sites with two risk factors

　
Risk factors affecting staging include the following:

1. hCG>100,000 mIU/ml;

2. duration of disease > 6 months from termination of the antecedent pregnancy

The following factors should be considered and noted in reporting:

1. prior chemotherapy for known GTT;

2. placental site tumors should be reported separately;

3 histological verification of disease is not required.

　

☆ Protocol for treatment of GTT:

　

Stage I

Initial

Resistant

　

Single –agent C/T or hysterectomy with adjunctive C/T

Combination C/T

Hysterectomy with adjunctive C/T

Local resection

Pelvic infusion

Stage II and III

Low risk

Initial

Resistant

High risk

Initial

Resistant

　

　

Single agent C/T

Combination C/T

　

Combination C/T

Second-line combination C/T

Stage IV

Initial

Brain

　

Liver

Resistant

　

Combination C/T

Whole-heat irradiation (3000cGy)

Craniotomy to manage complications

Resection to manage complications

Second-line combination C/T

Hepatic arterial infusion

　

☆ Scoring system based on prognostic factors:

　

　
score

　
0

1

2

4

Age (yrs)

≦39

>39
　　

Antecedent pregnancy

Hydatidiform mole

Abortion

Term
　

Interval of antecedent pregnancy

and start of C/T (months)

<4

4-6

7-12

>12

HCG (IU/liter)

<1000

1000-10000

10000-100000

>100000

ABO groups
　
O or A

B or AB
　

Largest tumor, including uterine (cm)

<3

3-5

>5
　

Site of metastasis
　
Spleen, kidney

GI tract, liver

Brain

Number of metastasis
　
1-3

4-8

>8

Prior C/T
　　
1 drug

≧2 drugs

The total score for a patient is obtained by adding the individual scores for each prognostic factor.

Total score: <4 = low-risk; 5-7 = middle risk; ≧8 high risk

　

~ Vulvar Cancer ~

　

☆ FIGO staging of invasive cancer of the vulva:

　

Stage 0 (Tis)

Carcinoma in situ, intraepithelial carcinoma

Stage I
　

T1N0M0

Tumor confined to the vulva and/or perineum--2cm or less in greatest dimension (no nodal metastasis)

Stage Ia: lesion 2 cm or less in size confined to the vulva or perineum and with stromal invasion no greater than 1.0 mm(The depth of invasion is defined as the measurement of the tumor from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion)(no nodal metastasis)

Stage Ib: lesion 2 cm or less in size confined to the vulva or perineum and with stromal invasion greater than 10 mm (no nodal metastasis)

Stage II
　

T2N0M0

Tumor confined to the vulva and/or perineum--more than 2 cm in greatest dimension (no nodal metastasis)

Stage III
　

T3N0M0

T3N1M0

T1N1M0

T2N1M0

Tumor any size with

1. adjacent spread to the lower urethra and/or the vagina, or the anus, and/or

2. unilateral regional lymph node metastasis

Stage IVa
　

T1N2M0

T2N2M0

T3N2M0

T4 any M0

Tumor invades any of the following: upper urethra, bladder, mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis

Stage IVb
　

any T

any N M1

Any distant metastasis including pelvic lymph nodes

Stage 0	Carcinoma in situ, intraepithelial carcinoma
Stage I	The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded
Stage Ia	Invasive cancer identified only microscopically; all gross lesions even the superficial invasion are stage Ib cancers. Invasion is limited to measured stromal invasion with maximum depth of 5.0 mm and no wider than 7.0 mm
Stage Ia1	Measured invasion of stroma no greater than 3.0 mm in depth and no wider than 7.0 mm.
Stage Ia2	Measured invasion of stroma greater than 3 mm and no greater than 5 mm and no wider than 7 mm. The depth of invasion should not be more than 5 mm taken from the base of the epithelium, surface or glandular, from which it originates. Vascular space involvement, venous or lymphatic, should not alter the staging.
Stage Ib	Clinical lesion confined to the cervix or preclinical lesion greater than stage Ia.
Stage Ib1	Clinical lesions no greaten than 4.0 cm in size
Stage Ib2	Clinical lesions greater than 4 cm in size
Stage II	Involvement of the vagina but not the lower third, or infiltration of the parametria but not out to the sidewall.
Stage IIa	Involvement of the vagina but no evidence of parametrial involvement
Stage IIb	Infiltration of the parametria but not out to the sidewall
Stage III	Involvement of the lower third of the vagina or extension to the pelvic sidewall; all cases with a hydronephrosis or nonfunctioning kidney should be included, unless they are know to be attributable to other cause
Stage IIIa	Involvement of the lower third of the vagina but not out to the pelvic sidewall if the parametria are involved
Stage IIIb	Extension onto the pelvic sidewall and/or hydronephrosis or nonfunctional kidney
Stage IV	Extension outside the reproductive tract
Stage IVa	Involvement of the mucosa of the bladder or rectum
Stage IVb	Distant metastasis or disease outside the true pelvis

Stage	% positive pelvic LN	% positive para-aortic LN
Ia1 (≦3mm)	0.5	0
Ia2 (>3-5mm)	4.8	<1
Ib	15.9	2.2
IIa	24.5	11
IIb	31.4	19
III	44.8	30
IVa	55	40

Stage Ia G123	Tumor limited to endometrium
Ib G123	Invasion of less than half of the myometrium
Ic G123	Invasion of more than half of the myometrium
IIa G123	Endocervical glandular involvement only
IIb G123	Cervical stromal invasion
IIIa G123	Tumor invades serosa and/or adnexae and/or positive peritoneal cytology
IIIb G123	Vaginal metastases
IIIc G123	Metastases to pelvic and/or para-aortic lymph nodes
IVa G123	Tumor invasion of bladder and/or bowel mucosa
IVb	Distant metastases, including intraabdominal and/or inguinal lymph node
	Histopathology: Degree of differentiation Cases of carcinoma of the corpus should be grouped according to the degree of differentiation of the adneocarcinoma as follows: G1= 5% or less of a nonsquamous or nonmorular solid growth pattern G2= 6% to 50% of a nonsquamous or nonmorular solid growth pattern G3= more than 50% of a nonsquamous or nonmorular solid growth pattern

Stage	Description
I	Growth limited to the ovaries
Ia	Growth limited to one ovary; no ascites present containing malignant cells; no tumor on the external surfaces; capsule intact
Ib	Growth limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules intact
Ic	Tumor stage Ia or stage Ib but with tumor on the surface of one or both ovaries; or with capsule ruptured; or with ascites present containing malignant cells with positive peritoneal washings
II	Growth involving one or both ovaries with pelvic extension
IIa	Extension and/or metastases to the uterus and/or tubes
IIb	Extension to other pelvic tissues
IIc	tumor stage IIa or stage IIb but with tumor on the surface of one of both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washing
III	Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III; tumor is limited to the true pelvis but with histologically verified malignant extension to small bowel or omentum
IIIa	Tumor grossly limited to the true pelvis with negative nodes with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
IIIb	Tumor of one or both ovaries; histologically confirmed implants of abdominal peritoneal surfaces; none exceeding 2 cm in diameter; nodes negative
IIIc	Abdominal implants 2 cm in diameter and/or positive retroperitoneal or inguinal nodes
IV	Growth involving one or both ovaries with distant metastasis; if pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV; parenchymal liver metastasis equals stage IV

Stage I	Disease confined to the uterus
Stage Ia	Disease confined tot he uterus with no risk factors
Stage Ib	Disease confined to the uterus with one risk factor
Stage Ic	Disease confined to the uterus with two risk factors
Stage II	GTT extends outside the uterus but is limited to the genital structures (adnexa, vagina, broad ligament)
Stage IIa	GTT involving genital structures without risk factors
Stage IIb	GTT extends outside of the uterus but limited to genital structures with one risk factor
Stage IIc	GTT extends outside of the uterus but limited tot he genital structures with two risk factors
Stage III	GTT extends to the lungs with or without known genital tract involvement
Stage IIIa	GTT extends to the lungs with or without genital tract involvement and with no risk factors
Stage IIIb	GTT extends to the lungs with or without genital tract involvement and with one risk factor
Stage IIIc	GTT extends to the lungs with or without genital tract involvement and has two risk factors
Stage IV	All other metastatic sites
Stage IVa	All other metastatic sites without risk factors
Stage IVb	All other metastatic sites with one risk factor
Stage IVc	All other metastatic sites with two risk factors
	Risk factors affecting staging include the following: 1. hCG>100,000 mIU/ml; 2. duration of disease > 6 months from termination of the antecedent pregnancy The following factors should be considered and noted in reporting: 1. prior chemotherapy for known GTT; 2. placental site tumors should be reported separately; 3 histological verification of disease is not required.

Stage I Initial Resistant	Single –agent C/T or hysterectomy with adjunctive C/T Combination C/T Hysterectomy with adjunctive C/T Local resection Pelvic infusion
Stage II and III Low risk Initial Resistant High risk Initial Resistant	Single agent C/T Combination C/T 　 Combination C/T Second-line combination C/T
Stage IV Initial Brain 　 Liver Resistant	Combination C/T Whole-heat irradiation (3000cGy) Craniotomy to manage complications Resection to manage complications Second-line combination C/T Hepatic arterial infusion

	score
	0	1	2	4
Age (yrs)	≦39	>39
Antecedent pregnancy	Hydatidiform mole	Abortion	Term
Interval of antecedent pregnancy and start of C/T (months)	<4	4-6	7-12	>12
HCG (IU/liter)	<1000	1000-10000	10000-100000	>100000
ABO groups		O or A	B or AB
Largest tumor, including uterine (cm)	<3	3-5	>5
Site of metastasis		Spleen, kidney	GI tract, liver	Brain
Number of metastasis		1-3	4-8	>8
Prior C/T			1 drug	≧2 drugs

Stage 0 (Tis)	Carcinoma in situ, intraepithelial carcinoma
Stage I
T1N0M0	Tumor confined to the vulva and/or perineum--2cm or less in greatest dimension (no nodal metastasis) Stage Ia: lesion 2 cm or less in size confined to the vulva or perineum and with stromal invasion no greater than 1.0 mm(The depth of invasion is defined as the measurement of the tumor from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion)(no nodal metastasis) Stage Ib: lesion 2 cm or less in size confined to the vulva or perineum and with stromal invasion greater than 10 mm (no nodal metastasis)
Stage II
T2N0M0	Tumor confined to the vulva and/or perineum--more than 2 cm in greatest dimension (no nodal metastasis)
Stage III
T3N0M0 T3N1M0 T1N1M0 T2N1M0	Tumor any size with 1. adjacent spread to the lower urethra and/or the vagina, or the anus, and/or 2. unilateral regional lymph node metastasis
Stage IVa
T1N2M0 T2N2M0 T3N2M0 T4 any M0	Tumor invades any of the following: upper urethra, bladder, mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis
Stage IVb
any T any N M1	Any distant metastasis including pelvic lymph nodes