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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] CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 54 / NUMBER 2 / JUNE 2011 www.clinicalobgyn.com | 215 Lewin 216 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. References 1. Creasman W. Revised FIGO staging for carcinoma of the endometrium. Int J Gynaecol Obstet. 2009;105:109. www.clinicalobgyn.com 218 Lewin 2. Morrow CP, Bundy BN, Kurman RJ, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol. 1991;40:55–65. 3. Boronow RC, Morrow CP, Creasman WT, et al. Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study. Obstet Gynecol. 1984; 63:825–832. 4. Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer: a Gynecologic Oncology Group Study. Cancer. 1987; 60:2035–2041. 5. Lewin SN, Herzog TH, Medel NI, et al. Comparative performance of the 2009 Internationl Federation of gynecology and obstetrics’ staging system for uterine corpus cancer. Obstet Gyn. 2010;116:1141–1149. 6. Chan JK, Wu H, Cheung MK, et al. The outcomes of 27,063 women with unstaged endometrioid uterine cancer. Gynecol Oncol. 2007;106:282–288. 7. Straughn JM Jr, Huh WK, Kelly FJ, et al. Conservative management of stage I endometrial carcinoma after surgical staging. Gynecol Oncol. 2002;84:194–200. 8. Reisinger SA, Staros EB, Mohiuddin M. Survival and failure analysis in stage II endometrial cancer using the revised 1988 FIGO staging system. Int J Radiat Oncol Biol Phys. 1991;21:1027–1032. 9. Sartori E, Gadducci A, Landoni F, et al. Clinical behavior of 203 stage II endometrial cancer cases: the impact of primary surgical approach and of adjuvant radiation therapy. Int J Gynecol Cancer. 2001;11:430–437. 10. DiSaia PJ, Creasman WT, Boronow RC, et al. Risk factors and recurrent patterns in Stage I endometrial cancer. Am J Obstet Gynecol. 1985;151:1009–1015. 11. Greven KM, Lanciano RM, Corn B, et al. Pathologic stage III endometrial carcinoma: www.clinicalobgyn.com 12. 13. 14. 15. 16. 17. 18. 19. 20. prognostic factors and patterns of recurrence. Cancer. 1993;71:3697–3702. Geller MA, Ivy J, Dusenbery KE, et al. A single institution experience using sequential multi-modality adjuvant chemotherapy and radiation in the ‘‘sandwich’’ method for high risk endometrial carcinoma. Gynecol Oncol. 2010;118:19–23. Secord AA, Havrilesky LJ, O’Malley DM, et al. A multicenter evaluation of sequential multimodality therapy and clinical outcome for the treatment of advanced endometrial cancer. Gynecol Oncol. 2009;114:442–447. Bansal S, Buck AM, Herzog TJ, et al. Stage IIIA endometrial carcinoma: outcome and predictors of survival. Obstet Gynecol. 2009;114:100–105. Havrilesky LJ, Cragun JM, Calingaert B, et al. The prognostic significance of positive peritoneal cytology and adnexal/serosal metastasis in stage IIIA endometrial cancer. Gynecol Oncol. 2007;104: 401–405. Mariani A, Webb MJ, Keeney GL, et al. Assessment of prognostic factors in stage IIIA endometrial cancer. Gynecol Oncol. 2002;86:38–44. Mariani A, Dowdy SC, Podratz KC. New surgical staging of endometrial cancer: 20 years later. Int J Gynaecol Obstet. 2009; 105:110–111. Seamon LG, Fowler JM, Cohn DE. Lymphadenectomy for endometrial cancer: the controversy. Gynecol Oncol. 2010;117:6–8. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy versus no lymphadenectomy in earlystage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100:1707–1716. Kitchener H, Swart AM, Qian Q, et al. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009;373:125–136.