Download Revised FIGO Staging System for Endometrial Cancer

CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 54, Number 2, 215–218
r 2011, Lippincott Williams & Wilkins
Revised FIGO
Staging System for
Endometrial Cancer
SHARYN N. LEWIN, MD
Division of Gynecologic Oncology, Department of Obstetrics and
Gynecology, Columbia University College of Physicians and
Surgeons, New York, New York
Abstract: In 1988 the International Federation of
Gynecologists and Obstetricians (FIGO) developed
a surgical staging system for endometrial cancer. The
FIGO staging system was recently revised in 2009 to
reflect our growing understanding of the natural
history of endometrial cancer. In this review, we
describe the revised 2009 FIGO staging system for
tumors of the uterine corpus and examine the effect of
the new changes in the staging criteria.
Key words: endometrial cancer, staging, lymphadenectomy, FIGO
between uterine factors such as grade
and depth of invasion and the risk of
lymph node metastasis in women with
apparent early-stage tumors.2–4 The importance of nodal disease as a prognostic
factor was recognized in 1988 when the
International Federation of Gynecologists and Obstetricians (FIGO) determined
that tumors of the corpus uteri should be
staged surgically. Surgical staging uncovered more accurate information with regard
to the extent of disease further tailoring appropriate adjuvant therapy.1 The 1988
FIGO system incorporated 3 substages
for women with uterine confined cancer,
whereas those with nodal disease were
classified as stage IIIC.1
In 2009, FIGO proposed a revised staging classification system for endometrial
cancer (Table 1). After analyzing survival
data for more than 42,000 women who
underwent surgical staging for endometrial carcinoma, the FIGO Committee
could further evaluate substages and
prognosis.1 The revised staging systems
contained a number of changes as the FIGO
Committee felt some substages could be
combined. First, women with stage IA
Before the 1970s, endometrial cancer was
staged clinically.1 Historically, at that
time, the surgical-pathologic pattern of
endometrial cancer spread had not been
elucidated.1 In 1971, a new classification
system was introduced, adding tumor grade
as part in parcel of the clinical staging
system as most endometrial cancers were
felt to be uterine confined. A number of
surgical-pathologic studies carried out by
the Gynecologic Oncology Group then
ensued, which revealed the association
Correspondence: Sharyn N. Lewin, MD, Division of
Gynecologic Oncology, Department of Obstetrics and
Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 8th
Floor, New York, NY. E-mail: [email protected]
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TABLE 1.
Revised FIGO 2009 Staging
System
Stage I
IA
Tumor confined to the corpus uteri
No or less than half myometrial
invasion
Invasion to or more than half of
the myometrium
Tumor invades cervical stroma, but
does not extend beyond the uterus
Local and/or regional spread of the
tumor
Tumor invades the serosa and/or
adnexae
Vaginal and/or parametrial
involvement
Metastases to the pelvic and/or
para-aortic lymph nodes
Positive pelvic nodes
Positive para-aortic lymph nodes
with or without positive pelvic
lymph nodes
Tumor invades bladder and/or
bowel mucosa, and/or distant
metastases
Tumor invasion of bladder and/or
bowel mucosa
Distant metastases, including intraabdominal metastases and/or
inguinal lymph nodes
IB
Stage II
Stage III
IIIA
IIIB
IIIC
IIIC1
IIIC2
Stage IV
IVA
IVB
FIGO indicates Federation of Gynecologists and Obstetricians.
and IB tumors were combined into a
single stage, stage IA. Second, cervical
glandular involvement was eliminated
from the staging criteria; only women
with cervical stromal invasion were classified as stage II. Third, peritoneal cytology
was removed as a staging criterion. Finally,
patients with nodal metastasis have been
stratified into those with pelvic node disease (stage IIIC1) and those with paraaortic nodal disease (stage IIIC2).1 The
histologic grades still apply.
As the revised FIGO staging system
was introduced in 2009, 2 groups have
analyzed the prognostic significance of
the new (FIGO 1988) versus old (FIGO
2009) staging systems for endometrioid
adenocarcinomas of the uterine corpus.
In the largest study, data from the
National Cancer Institute’s Surveillance,
Epidemiology, and End Results database
was obtained.5 A total of 81,902 patients
www.clinicalobgyn.com
with endometrioid histology treated between 1998 and 2006 were analyzed. Patients were classified based on the old
FIGO 1988 versus new FIGO 2009 staging
systems. Five-year survival was calculated
based on stage and further stratified based
on tumor grade and whether or not lymphadenectomy had been performed. Overall, findings suggested that the new 2009
FIGO staging system for uterine corpus
cancer is highly prognostic for women
with endometrioid adenocarcinomas. Removal of women with cervical glandular
involvement from stage II and stratification of patients with stage IIIC disease
improved the correlation of stage with
survival. As survival is very similar for
patients with tumors confined to the endometrium and women with superficial
myometrial invasion, combining FIGO
1988 stages IA and IB provided a reduction
in the number of stage I substages without
reducing prognostic discrimination.
The prognosis for most women with
uterine-confined endometrial cancer is excellent.6–7 In an institutional review of more
than 600 women with stage I neoplasms
5-year survival was 99% for women with
tumors confined to the endometrium and
97% for patients with tumors invading
<50% into the uterine wall.7 Findings
from this recent study were in accord with
this data, for patients with tumors limited
to the endometrium 5-year survival was
91% compared with 89% for those with
early myometrial invasion. Even among
women with high-grade tumors survival was very similar between FIGO 1988
stage IA grade 3 and stage IB grade 3
tumors (80% vs. 81%, respectively). Given the similar prognosis of these subgroups it seems reasonable to combine
FIGO 1988 stages IA and IB into a single
substage (FIGO 2009 stage IA).
The prognostic significance of cervical
glandular involvement (FIGO 1988 stage
IIA) for endometrial cancer has been
questioned.8,9 Although there is a clear difference in survival for women with cervical
Revised FIGO Staging for Endometrial Cancer
glandular and cervical stromal invasion,
it seems that tumor grade and depth of
myometrial invasion are more significant
prognostic factors than cervical glandular
involvement.8,9 In an earlier study, the
median 5-year survival for FIGO 1988 stage
IIA disease was similar to that of FIGO
1988 stage IC tumors. When stratified by
grade, survival for stage IIA grade 1 tumors
approached that of stage IA disease. These
findings strongly support the decision to
eliminate cervical glandular involvement
from the 2009 staging system. With inclusion of only women with cervical stromal
invasion as stage II in the FIGO 2009
scheme the survival for stage II disease is
inferior to that of all stage I substages.
Metastasis to the regional lymph nodes
is one of the most important prognostic
factors for women with endometrial cancer.2,4,10,11 In the Gynecologic Oncology
Group surgical-pathology study of women with clinical stage I and II endometrial cancer, there was a clear differential
in survival between women with pelvic
and para-aortic nodal metastases.4 Authors noted similar trends when analyzing
Surveillance, Epidemiology, and End Results data, 5-year survival was 58% for
women with only pelvic nodal metastases
(stage IIIC1) compared with 51% for
those with para-aortic nodal disease
(stage IIIC2). In addition to important
prognostic information, the stratification
of stage IIIC tumors has important implications for treatment planning as multimodality therapy with both radiation
and chemotherapy is now frequently used
for women with nodal metastases.12,13
In addition to the changes described
above, the revised FIGO staging system
has eliminated peritoneal cytology from the
staging criteria. Whether positive peritoneal
cytology is an independent risk factor for
endometrial cancer is actively debated.
Although some groups have found that
positive pelvic washings are an independent
predictor of decreased survival, other investigators have suggested that cytologic disease
217
just potentiates the effects of other poor
prognostic factors.14–16 Although peritoneal
washings are not a part of the new staging
guidelines, it is recommended that peritoneal
cytology can be reported separately.
Although data suggests that the revised FIGO staging system is highly prognostic, a number of controversies remain.
Perhaps most importantly is the lack of
consensus with regard to the extent of
staging that is required for women with
endometrial cancer. Currently, there is no
consensus on which patients require lymphadenectomy and what defines an adequate lymph node dissection in those
women who undergo the procedure.17,18
Recently, 2 large, randomized European
trials have both reported that lymphadenectomy had no effect on survival for
women with apparent early-stage endometrial cancer.19,20 Although significant
methodologic issues have been raised with
regard to both trials, the fact remains that
a large number of women with endometrial cancer do not undergo staging lymphadenectomy.18 In the aforementioned
study, 46% of patients underwent some
form of nodal evaluation. Although survival clearly differed by stage when the nodal
status was known, the general performance
characteristics of the revised FIGO system
remained were similar regardless of whether the nodal status was known.
Overall, findings suggest that the revised FIGO 2009 staging system for uterine corpus cancer is highly prognostic in
women with endometrioid tumors. The
reduction in stage I substages, the elimination of cervical glandular involvement,
and the stratification of women with nodal disease all improves the performance
of the staging system.
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