| |
(1) Whether multifocal microinvasive cervical cancer be upstaged?
Reason: tumour volume is related to lymph nodes metastasis, addition of multifocal lesions each less than 3x7mm may add up to more than 3x7mm
Difficulties
• How to define multifocality
• How to measure different foci
• How to add the different foci
(2) Lymphovascular invasion should not be part of the staging but considered as an important risk factor
Reason: LVI is associated with lymph node metastasis and poor prognosis
Difficulties:
Subjective
Extent of LVI varies and significance may vary
(3) Microinvasive and invasive adenocarcinoma should be staged as squamous cell carcinoma of the cervix
Difficulties:
Definition of microinvasive adenocarcinoma is less well defined as microinvasive squamous cell carcinoma
(1) Merging of IA/B to 1A ie no or less than half myometrial invasion
IC become IB ie more than half myometrial invasion
(2) Merging of grade 1 and 2 to low grade and grade 3 as high grade
Stage IA NO CHANGE
Stage IB Tumor of any size confined to vulva.
Negative nodes
Reason:This is based on the SEER data which showed no difference in survival for lesions even greater than 8 cm if the nodes were negative.
Stage IIA Tumour of any size with spread to lower urethra/vagina/anus with negative nodes
Stage IIB Tumour of any size with:
(i) 1 nodal macrometastasis (> 5 mm) or
(ii) 2 nodal micrometastasis (= < 5mm)
Stage III Tumour of any size with
(i) 3 or more nodal micrometastases (=< 5 mm diameter)
(ii) 2 or more nodal macrometastasis (> 5mm)
(iii) positive nodes with extracapsular spread
Stage IVA Tumour invades the following:
(i) Upper urethra bladder mucosa, rectal mucosa, pelvic bone or
(ii) Fixed or ulcerated in-operable groin nodes.
Stage IVB Any distant metastasis including pelvic lymph nodes
Corpus
General:
Staging of MMMT same as ca corpus
Staging procedure
Omentum
An adequate sampling of infra-colic omentum is recommended in MMMT, uterine papillary serous carcinoma, clear cell carcinoma of endometrium and grade 3 endometrial cancer
Pelvic and para-aortic nodes
In low risk disease, only suspicious pelvic nodes should be removed
In high risk disease, systematic pelvic nodes and suspicious para-aortic nodes should be removed
Stage I :
Merging of IA/B to 1A ie no or less than half myometrial invasion
IC become IB ie more than half myometrial invasion
Merging of grade 1 and 2 to low grade and grade 3 as high grade
IC: Positive peritoneal cytology with disease confined to corpus
Stage II : Stage 2A/2B NO CHANGE
IIC: 2A/B with positive peritoneal cytology
Stage III :
In the presence of adnexal disease, positive cytology upstage stage 3A to 3C
Positive cytology in IIIB would not change the stage of the disease.
(Supporting papers on positive cytology in stage I disease has no prognostic significance: Tebeu et al 2004, Slomovitz etal 2005,Grimshaw 1990,Yazigi 1983, Kasamatsu 2003).
(Against, papers to support positive cytology even in stage I has prognostic significance: Haroung VR Obste Gynecol 73;394, 1988; Turner DA Obstet Gynecol 74;775, 1989; Sutton GP Oncology 4;21, 1990; Creasman WT Am j Obs-Gyn 141;921, 1981, Kennedy 1993, Obermair 2001)
Stage IV: NO CHANGE
Cervix:
General
Cervical cancer should remain as a clinically staged disease
Reason: 80% of cervical cancers are in developing countries and majority were in late stage where surgical staging has little benefit and not practical.
Pathological extent if available should be reported to the FIGO annual report or in publications
Reason: Lymph node status was considered as an important prognostic factor especially in early stage disease. Though pathological findings of parametrial or extrauterine spread and lymph node status should not change a clinical staging, analysis of their significance could be performed if data were continued to be provided to the FIGO annual report or reported in the literature.
Investigations
(1) Use of modern imaging especially MRI in the assessment of the size of tumour is encouraged though not mandatory
Reason: MRI has been reported to has better assessment on the size of a tumour in stage IB or IIA diseases than clinical examination. Hence, if resource permits,MRI can be used to assess the size of the cervical cancer and substage IB and IIA diseases.
(2) EUA is not mandatory and cystoscopy and sigmoidoscopy are indicated where bladder or rectal involvement is suspected.
Reason: Practically, many centres did not finda need to examine a patient under anesthesia unless there is difficulty on examination. Rarely would cystoscopy or sigmoidoscopy yielded positive findings in the absence of symptoms or advance disease involving anterior or posterior vagina.
Stage O:
Delete CIS and stage 0
Reason: CIS is not cancer and hence should not be included in a cancer staging system.
Stage 1 A1 and 1A2 – NO CHANGE
Stage 1B1 and IB2 - NO CHANGE
Stage II :
IIA substaged to 1 and 2 same as IB using size
IIA1 less than or equal to 4 cm involving last than 2/3 of upper vagina
IIA2 more than 4 cm involving last than 2/3 of upper vagina
Reason: Size has similar effect on prognosis similar to IB
(Hong JH etal 2005)
IIB substaged to 1 and 2 according to whether unilateral or bilateral parametrial involvement
IIB1 Unilateral parametrial invasion
IIB2 Bilateral parametrial invasion
Reason: Bilateral parametrial involvement has worse prognosis than unilateral (Kodaira T etal. 2003; Kovalic JJ et al Int J Rad Onco 1991 21:905-910)
Stage III:
IIIB substaged to 1, 2 according to whether unilateral or bilateral parametrial invasion
IIIB1 Unilateral parametrial invasion
IIIB2 Bilateral parametrial invasion
Reason: Bilateral parametrial involvement has worse prognosis than unilateral (Kodaira T etal. 2003; Kovalic JJ et al Int J Rad Onco 1991 21:905-910)
Stage IV: NO CHANGE
|
|
