New FIGO staging of CA cervix (October, 2018)

In the latest issue of International Journal of Gynecology & Obstetrics, FIGO has come up with a new staging system of CA cervix. It was first published on 11^th October, 2018.

It is extremely important this year from the exam point of view. We will discuss all important points in the new staging system as simplified as possible to remember.

Stages

1. Strictly confined to the cervix
2. Invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall
3. Involves the lower third of the vagina / extends to the pelvic wall / causes hydronephrosis or nonfunctioning kidney / involves pelvic and/or para-aortic lymph nodes
4. Extended beyond the true pelvis or has involved the mucosa of the bladder or rectum.

 

Substages

Substages of stage I:

• 1A: Microscopic invasion
  • 1A1: Depth of stromal invasion <3 mm
  • 1A2: Depth of stromal invasion ≥3 mm and <5 mm
• 1B: Deepest invasion ≥5 mm
  • 1B1: Greatest dimension <2 cm
  • 1B2: Greatest dimension ≥2 cm and <4 cm
  • 1B3: Greatest dimension ≥4 cm.

 

Substages of stage II:

• 2A: Limited to the upper two-thirds of the vagina without parametrial involvement
  • 2A1: <4 cm in greatest dimension
  • 2A2: ≥4 cm in greatest dimension
• 2B: Parametrial involvement ⨁.

 

Substages of stage III:

• 3A: Involves the lower third of the vagina
• 3B: Extension to the pelvic wall / hydronephrosis or nonfunctioning kidney
• 3C: Involvement of pelvic / para-aortic lymph nodes
  • 3C1: Pelvic LN metastasis
  • 3C2: Para-aortic LN metastasis.

 

Substages of stage IV:

• 4A: Spread to adjacent pelvic organs
• 4B: Spread to distant organs.

 

Stage wise management

Stage 1A1:

Situation	Management
Management of choice	Cervical conization
Fertility is desired	Cervical conization
Completed childbearing or elderly women	Type 1 hysterectomy
Lymphovascular space invasion (LVSI)	Type 2 hysterectomy + Pelvic lymphadenectomy

 

Stage 1A2:

Situation	Management
Management of choice	Type 2 hysterectomy + Pelvic lymphadenectomy
Fertility is desired	1.    Cervical conization or 2.    Radical trachelectomy Add pelvic lymphadenectomy to either.

 

Stage IB1, IB2, IIA1:

Situation	Management
Management of choice	Type 3 hysterectomy + Pelvic lymphadenectomy

Stage IB3 and IIA2:

Situation	Management
Management of choice	Concurrent platinum-based chemoradiation

 

Stage IIB–IVA:

Situation	Management
Management of choice	Concurrent chemoradiation

 

Commonly used chemoradiation regimen:

1. Once-weekly infusion of cisplatin for 5–6 cycles during external beam radiotherapy (MC)
2. Alternative agent: 5-Fluoro-Uracil (5FU).

 

Delivery of external beam radiotherapy (EBRT):

1. Through Cobalt-60 teletherapy machine
2. Through linear accelerators (preferred).

Intracavitary radiotherapy (ICRT)/ Brachytherapy:

• Although EBRT plays an important role in the treatment of cervical cancer, ICRT is also an extremely important component of curative treatment of cervical cancer since it delivers a high central dose to the primary tumor and reduced doses to adjacent normal organs
• The combination of EBRT and ICRT maximizes the likelihood of locoregional control.

Stage IVB:

Situation	Management
Management of choice	Concurrent chemoradiation
Para-aortic LN involvement	Extended field radiotherapy (EFRT) + Concurrent chemotherapy

Reference: FIGO Cancer Report 2018

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