Radiation Oncology/Endometrium/Staging

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Current staging edit

Endometrial Carcinomas

FIGO Staging (2023)

PMID 37593813 -- "FIGO staging of endometrial cancer: 2023"

  • Stage I - Confined to the uterine corpus and ovary
    • IA - Disease limited to the endometrium OR non-aggressive histological type, i.e., low-grade endometroid, with invasion of less than half of myometrium with no or focal LVSI OR good prognosis disease
      • IA1 : Non-aggressive histological type limited to an endometrial polyp OR confined to the endometrium
      • IA2 : Non-aggressive histological types involving less than half of the myometrium with no or focal LVSI
      • IA3 : Low-grade endometrioid carcinomas limited to the uterus and ovary
    • IB - Non-aggressive histological types with invasion of half or more of the myometrium, and with no or focal LVSI
    • IC - Aggressive histological types limited to a polyp or confined to the endometrium
  • Stage II - Invasion of cervical stroma without extrauterine extension OR with substantial LVSI OR aggressive histological types with myometrial invasion
    • IIA - Invasion of the cervical stroma of non-aggressive histological types
    • IIB - Substantial LVSI of non-aggressive histological types
    • IIC - Aggressive histological types with any myometrial involvement
  • Stage III - Local and/or regional spread of the tumor of any histological subtype
    • IIIA - Invasion of uterine serosa, adnexa, or both by direct extension or metastasis
      • IIIA1 : Spread to ovary or fallopian tube (except when meeting stage IA3 criteria)
      • IIIA2 : Involvement of uterine subserosa or spread through the uterine serosa
    • IIIB - Metastasis or direct spread to the vagina and/or to the parametria or pelvic peritoneum
      • IIIB1 : Metastasis or direct spread to the vagina and/or the parametria
      • IIIB2 : Metastasis to the pelvic peritoneum
    • IIIC - Metastasis to the pelvic or para-aortic lymph nodes or both
      • IIIC1 : Metastasis to the pelvic lymph nodes {IIIC1i: micrometastasis; IIIC1ii: macrometastasis}
      • IIIC2 : Metastasis to para-aortic lymph nodes up to the renal vessels, with or without metastasis to the pelvic lymph nodes {IIIC2i: micrometastasis; IIIC2ii: macrometastasis}
  • Stage IV - Spread to the bladder mucosa and/or intestinal mucosa and/or distant metastasis
    • IVA - Invasion of the bladder mucosa and/or the intestinal/bowel mucosa
    • IVB - Abdominal peritoneal metastasis beyond the pelvis
    • IVC - Distant metastasis, including metastasis to any extra-or intra-abdominal lymph nodes above the renal vessels, lungs, liver, brain, or bone

Staging footnotes:

  • Disease limited to low-grade endometrioid carcinomas involving the endometrium and ovaries (Stage IA3) must be distinguished from extensive spread of the endometrial carcinoma to the ovary (Stage IIIA1), by the following criteria: 1) no more than superficial myometrial invasion is present (<50%); 2) absence of extensive/substantial LVSI; 3) absence of additional metastases; and 4) the ovarian tumor is unilateral, limited to the ovary, without capsule invasion/rupture (equivalent to pT1a).
  • LVSI: LVSI as defined in WHO 2021: extensive/substantial, ≥5 vessels involved.
  • Aggressive histological types:
    • non-aggressive: G1-2 EEC.
    • aggressive: G3 EEC, serous, clear cell, undifferentiated, mixed, mesonephric-like, gastrointestinal mucinous type carcinomas, and carcinosarcomas

AJCC 7th Edition (2009)

Corresponds to updated FIGO staging (2009)
FIGO 2009 PMID 19345353 -- "Revised FIGO staging for carcinoma of the endometrium."
This staging now applies only to endometrial carcinomas and there is now a separate staging for uterine sarcomas.
Carcinosarcomas (MMMT) should be staged as high grade carcinoma.

Primary Tumor: (FIGO Stage in parentheses)

Note: FIGO uses pathologic staging
  • Tis - in situ
    Note: FIGO no longer includes Stage 0
  • T1 (I) - confined to corpus
    • T1a (IA) - limited to endometrium or invades less than 1/2 of myometrium
    • T1b (IB) - invades ≥ 1/2 of myometrium
  • T2 (II) - invades stromal tissue of the cervix but does not extend beyond uterus
    Note: endocervical glandular involvement only should be considered as Stage I not Stage II
  • T3
    • T3a (IIIA) - involves serosa and/or adnexa (direct extension or metastasis)
    • T3b (IIIB) - vaginal involvement (direct extension or metastasis) or parametrial involvement
  • T4 (IVA) - invades bladder mucosa and/or bowel mucosa

Regional Lymph Nodes:

  • N0 - none
  • N1 (IIIC1) - metastasis to pelvic lymph nodes
  • N2 (IIIC2) - metastasis to para-aortic lymph nodes
    Note: Regional nodes include obturator, internal iliac, external iliac, common iliac, para-aortic, presacral, and parametrial
    Note: For pathologic staging, FIGO classifies cases with <6 resected LNs as pNX

Distant Metastases:

  • M0 - none
  • M1 (IVB) - distant metastasis - includes inguinal LN, intraperitoneal disease (including omentum), lung, liver, or bone.

Stage Grouping:

  • Corresponds to FIGO stage given above (in parentheses)

Changes from 6th Edition:

  • No longer includes uterine sarcoma (now staged with a new staging system)
  • Positive peritoneal cytology is no longer considered (previously was T3a/IIIA)
  • Involvement of the endocervical glands is no longer considered (previously was Stage IIA)
  • Stages IA+IB combined (now: IA). IC moved to IB.
  • Stage IIIC subdivided into IIIC1 and IIIC2.

Older staging systems edit

FIGO moved to surgical staging in 1988 (AJCC 6th edition same). There is also a clinical staging system developed by FIGO in 1971.

Note: until the update of the FIGO / AJCC in 2009, uterine sarcomas and carcinomas were staged using the same system

AJCC 6th Edition (2002)

  • IA - Limited to endometrium
  • IB - < 1/2 of myometrium
  • IC - 1/2 or more of myometrium
  • II - invades cervix
    • IIA - glandular epithelium of endocervix
    • IIB - stroma of cervix
  • III - extra-uterine
    • IIIA - involves serosa and/or adnexa (direct extension or mets) and/or ascites or positive peritoneal washings
    • IIIB - vaginal involvement (direct extension or mets)
    • IIIC - LN+ (pelvic and/or paraaortic)
  • IV - other organs
    • IVA - bladder or bowel
    • IVB - distant mets

Clinical staging edit

Staging is now surgical (see above), but clinical staging may be utilized for non-operative pts.

FIGO 1971

  • I - Confined to corpus
    • IA - Length of uterine cavity 8 cm or less
    • IB - Length of uterine cavity > 8 cm
  • II - Involves corpus and cervix, but no extension beyond the uterus
  • III - Extends outside uterus but not outside true pelvis
  • IV - Outside the true pelvis or involves bladder or rectum
    • IVA - Involves bladder, rectum, sigmoid, or small bowel
    • IVB - Distant mets

Stage distribution edit

Stage Distribution
Stage US SEER (PMID 16977653) FIGO (PMID 17161155)
Stage I 73% 67%
Stage II 10% 11%
Stage III 10% 13%
Stage IV 7% 3%