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Cervical Cancer Treatment (Professional) (cont.)

Cellular Classification of Cervical Cancer

Squamous cell (epidermoid) carcinoma comprises approximately 90%, and adenocarcinoma comprises approximately 10% of cervical cancers. Adenosquamous and small cell carcinomas are relatively rare. Primary sarcomas of the cervix have been described occasionally, and malignant lymphomas of the cervix, primary and secondary, have also been reported.

Stage Information for Cervical Cancer

Note: This Stage Information section has been updated to include information from the seventh edition (2010) of the American Joint Committee on Cancer's AJCC Cancer Staging Manual. The PDQ Adult Treatment Editorial Board, which is responsible for maintaining this summary, is currently reviewing the new staging categories to determine whether additional changes need to be made to other parts of the summary. Any necessary changes will be made as soon as possible.

Cervical carcinoma has its origins at the squamous-columnar junction whether in the endocervical canal or on the portion of the cervix. The precursor lesion is dysplasia or carcinoma in situ (cervical intraepithelial neoplasia [CIN]), which can subsequently become invasive cancer. This process can be quite slow. Longitudinal studies have shown that in untreated patients with in situ cervical cancer, 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. However, in about 10% of patients, lesions can progress from in situ to invasive in a period of less than 1 year. As it becomes invasive, the tumor breaks through the basement membrane and invades the cervical stroma. Extension of the tumor in the cervix may ultimately manifest as ulceration, exophytic tumor, or extensive infiltration of underlying tissue including bladder or rectum.

In addition to local invasion, carcinoma of the cervix can spread via the regional lymphatics or bloodstream. Tumor dissemination is generally a function of the extent and invasiveness of the local lesion. While cancer of the cervix generally progresses in an orderly manner, occasionally a small tumor with distant metastasis is seen. For this reason, patients must be carefully evaluated for metastatic disease.

Pretreatment surgical staging is the most accurate method to determine the extent of disease.[1] Because there is little evidence to demonstrate overall improved survival with routine surgical staging, the staging usually should be performed only as part of a clinical trial. Pretreatment surgical staging in bulky but locally curable disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. If abnormal nodes are detected by computed tomography scan or lymphangiography, fine-needle aspiration should be negative before a surgical staging procedure is performed.

Definitions of TNM and FIGO

The American Joint Committee on Cancer (AJCC) and the Féderation Internationale de Gynécologie et d'Obstétrique (FIGO) have designated staging to define cervical cancer.[2,3] The definitions of the AJCC's T, N, and M categories correspond to the stages accepted by FIGO. Both systems are included for comparison.

Table 1. Primary Tumor (T)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted with permission from AJCC: Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 395-402.
b FIGO no longer includes stage 0 (Tis).
c All macroscopically visible lesions–even with superficial invasion–are T1b/IB.
TNM CategoriesFIGO Stages
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
TisbCarcinoma in situ (preinvasive carcinoma).
T1ICervical carcinoma confined to uterus (extension to corpus should be disregarded).
T1acIAInvasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of =7.0 mm. Vascular space involvement, venous or lymphatic, does not affect classification.
T1a1IA1Measured stromal invasion =3.0 mm in depth and =7.0 mm in horizontal spread.
T1a2IA2Measured stromal invasion >3.0 mm and =5.0 mm with a horizontal spread of =7.0 mm.
T1bIBClinically visible lesion confined to the cervix or microscopic lesion >T1a/IA2.
T1b1IB1Clinically visible lesion =4.0 cm in greatest dimension.
T1b2IB2Clinically visible lesion >4.0 cm in greatest dimension.
T2IICervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina.
T2aIIATumor without parametrial invasion.
T2a1IIA1Clinically visible lesion =4.0 cm in greatest dimension.
T2a2IIA2Clinically visible lesion >4.0 cm in greatest dimension.
T2bIIBTumor with parametrial invasion.
T3IIITumor extends to pelvic wall and/or involves lower third of vagina, and/or causes hydronephrosis or nonfunctioning kidney.
T3aIIIATumor involves lower third of vagina, no extension to pelvic wall.
T3bIIIBTumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney.
T4IVATumor invades mucosa of bladder or rectum, and/or extends beyond true pelvis (bullous edema is not sufficient to classify a tumor as T4).

Table 2. Regional Lymph Nodes (N)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted with permission from AJCC: Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 395-402.
TNM CategoriesFIGO Stages
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1IIIBRegional lymph node metastasis.

Table 3. Distant Metastasis (M)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted with permission from AJCC: Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 395-402.
TNM CategoriesFIGO Stages
M0No distant metastasis.
M1IVBDistant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal, or para-aortic lymph nodes, lung, liver, or bone).

Table 4. Anatomic Stage/Prognostic Groups (FIGO 2008)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted with permission from AJCC: Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 395-402.
b FIGO no longer includes stage 0 (Tis).
StageTNM
0bTisN0M0
IT1N0M0
IAT1aN0M0
IA1T1a1N0M0
IA2T1a2N0M0
IBT1bN0M0
IB1T1b1N0M0
IB2T1b2N0M0
IIT2N0M0
IIAT2aN0M0
IIA1T2a1N0M0
IIA2T2a2N0M0
IIBT2bN0M0
IIIT3N0M0
IIIAT3aN0M0
IIIBT3bAny NM0
T1–3N1M0
IVAT4Any NM0
IVBAny TAny NM1

Table 5. Carcinoma of the Cervix Uteria

a Adapted from FIGO Committee on Gynecologic Oncology.[3]
b All macroscopically visible lesions—even with superficial invasion—are allotted to stage IB carcinomas. Invasion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal extension of not >7.00 mm. Depth of invasion should not be >5.00 mm taken from the base of the epithelium of the original tissue—superficial or glandular. The depth of invasion should always be reported in mm, even in those cases with "early (minimal) stromal invasion" (~1 mm).
The involvement of vascular/lymphatic spaces should not change the stage allotment.
c On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or nonfunctioning kidney are included, unless they are known to be the result of another cause.
Stage
IThe carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded).
IAInvasive carcinoma, which can be diagnosed only by microscopy with deepest invasion =5 mm and largest extension =7 mm.
IA1Measured stromal invasion of =3.0 mm in depth and extension of =7.0 mm.
IA2Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm.
IBClinically visible lesions limited to the cervix uteri or preclinical cancers greater than stage IA.b
IB1Clinically visible lesion =4.0 cm in greatest dimension.
IB2Clinically visible lesion >4.0 cm in greatest dimension.
IICervical carcinoma invades beyond the uterus but not to the pelvic wall or to the lower third of the vagina.
IIAWithout parametrial invasion.
IIA1Clinically visible lesion =4.0 cm in greatest dimension.
IIA2Clinically visible lesion >4.0 cm in greatest dimension.
IIBWith obvious parametrial invasion.
IIIThe tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney.c
IIIATumor involves lower third of the vagina with no extension to the pelvic wall.
IIIBExtension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney.
IVThe carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV.
IVASpread of the growth to adjacent organs.
IVBSpread to distant organs.

References:

  1. Gold MA, Tian C, Whitney CW, et al.: Surgical versus radiographic determination of para-aortic lymph node metastases before chemoradiation for locally advanced cervical carcinoma: a Gynecologic Oncology Group Study. Cancer 112 (9): 1954-63, 2008.
  2. Cervix uteri. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 395-402.
  3. Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 105 (2): 103-4, 2009.
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