Cervical cancer staging

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Cervical cancer
Blausen 0221 CervicalDysplasia.png
Location of cervical cancer and an example of normal and abnormal cells
Pronunciation
Specialty Gynecologic oncology
Symptoms Early: none [2]
Later: vaginal bleeding, pelvic pain, pain during sexual intercourse [2]
Usual onsetOver 10 to 20 years [3]
Types Squamous cell carcinoma, adenocarcinoma, others [4]
Causes Human papillomavirus infection (HPV) [5] [6]
Risk factors Smoking, weak immune system, birth control pills, starting sex at a young age, many sexual partners or a partner with many sexual partners [2] [4] [7]
Diagnostic method Cervical screening followed by a biopsy [2]
PreventionRegular cervical screening, HPV vaccines, sexual intercourse with condoms, [8] [9] sexual abstinence
Treatment Surgery, chemotherapy, radiation therapy, immunotherapy [2]
Prognosis Five-year survival rate:
68% (US)
46% (India) [10]
Frequency604,127 new cases (2020) [11]
Deaths341,831 (2020) [11]

Cervical cancer staging is the assessment of cervical cancer to determine the extent of the spread of cancer beyond the cervix. [12] This is important for determining how serious the cancer is and to create the best treatment plan. [13]

Contents

Cervical cancer is a type of gynecological cancer that begins from cells lining the cervix, the lower part of the uterus. [14] Cervical cancer begins when the cells that line the cervix become abnormal and grow in a pattern that is atypical for non-cancerous cells. [14] Cervical cancer is typically first identified with an abnormal pap smear. [14] The final diagnosis of cervical cancer, including the stage of the cancer, is confirmed with additional testing. [12]

Cancer staging is determined by where the tumor is located, the size of the tumor, and how much the tumor has spread beyond where it originally began, such as to nearby lymph nodes or different parts of the body. [13]

Cancer staging is described on a spectrum from stage 0 to stage IV. Stage 0 describes pre-cancerous or non-invasive types of tumors. Stage IV is used to describe cancers that have spread throughout a significant part of the body. In general, the greater the stage of cancer, the more aggressive the disease and the worse the prognosis. [13]

Cervical cancer staging is described by the International Federation of Gynecology and Obstetrics (FIGO). [12] [15] In 2018, FIGO released the most recent guidelines for cervical cancer staging. [16] These guidelines recommend the use of various physical examinations, types of imaging, and biopsies to determine the stage of cervical cancer. [16]

Cervical cancer

Main article: cervical cancer

Cervical cancer is the abnormal growth of the cells that line the cervix, resulting in the cells growing out of control and potentially spreading to areas outside of the cervix. [14]

The cervix is the lower part of the uterus. It connects the upper part of the uterus with the vagina. The cervix is divided into two parts based on the types of cells. The outer portion of the cervix is called the ectocervix, while the inner portion of the cervix is the endocervix. These two portions of the cervix have different types of cells. The area where the endocervix and ectocervix meet is known as the transformation zone. Most cervical cancers arise from the cells in the transformation zone. [14]

Cervical cancer screening occurs with pap smears performed by an obstetrician-gynecologist. During a pap smear, doctors collect a sample of the cells from the cervix to look at under a microscope to examine for any abnormalities or signs of pre-cancerous changes. [17] While many abnormalities on pap smears are not indicative of cervical cancer, [14] the doctor may recommend additional testing to gain a better understanding of the cervical cells. [18] Additional testing that may be performed includes an endocervical curettage, colposcopy, or cervical conization. [18] Each of these procedures allows for the collection of a biopsy of the cells of the cervix. [18]

Pattern of progression

Abnormalities of cervical cells, or dysplasia, develop over time and along a continuum. There are several types of abnormalities of cervical cells known as pre-cancerous changes. These pre-cancerous changes are known as cervical intraepithelial neoplasm (CIN) and squamous intraepithelial lesion (SIL), based on whether the results are from a biopsy or a pap smear. CIN and SIL are graded from 1 to 3 based on the degree of change observed. CIN 1, 2, and 3 all represent pre-cancerous findings. [14]

The main types of cervical cancer include squamous cell carcinomas and adenocarcinomas. Nearly 90% of cervical cancers are squamous cell carcinomas. Cervical cancers may also be a mix between squamous cell carcinomas and adenocarcinomas, known as adenosquamous carcinoma. [14]

Cervical cancer spreads directly from the cervix into surrounding organs and via the lymphatic system. [16] When spreading via the lymphatic system, cervical cancer will spread to nearby lymph nodes, including the obturator, external iliac, and internal iliac lymph nodes. [16] Nearby structures that cervical cancer may spread to directly include the peritoneum, vagina, uterus, bladder, and rectum. [16] If cervical cancer has spread to distant organs, such as the liver, lungs, or skeleton, this represents a late finding and significant disease. [16] The degree of spread of cancer to areas beyond the cervix is important in determining the stage of cervical cancer. [16]

Overview of staging

Staging is the process of determining the type of cervical cancer and the extent the cancer has spread beyond the cervix to local or distant parts of the body. [12] To determine the stage of the cancer, various modalities may be used including physical examination, biopsies, pathological examinations, and imaging, including MRI, ultrasound, CT, and PET scans. [16] The information gathered from all of these modalities is put together to determine the cancer stage. [16] FIGO guidelines recommend assigning a lower stage whenever possible. [16] The cervical cancer stage assigned at initial diagnosis cannot be altered later, regardless of recurrence or later disease spread. [19]

Staging modalities

Biopsy

A biopsy, or sample of the tissue, is the first step in determining the type and extent of cancer. This biopsy may be obtained through a punch biopsy, LEEP (loop electrosurgical excision procedure), or cone biopsy. These procedures allow the doctor to obtain a sample of the cancerous tissue to look at under a microscope. By examining the size of the cancer, the margins of the biopsy sample, and the type of abnormal cells, the type of cancer can be determined. [16]

Biopsy of nearby lymph nodes may also be necessary to determine if the cervical cancer has spread lymphatically. This may be done via fine-needle aspiration, minimally invasive surgery, or laparotomy (open incision of the abdomen). [16] Typically, these procedures are not done until after there is confirmation of cervical cancer and after imaging is performed, if possible.

Pathology

Following the collection of biopsies of the cervical cancer and areas where it may have spread, the cells of the cancer will be looked at under a microscope. This is vital in determining the stage of the cancer. There are several different ways that pathologists may classify the cancer. All cancers of the cervix must be confirmed under a microscope and are determined to be cervical in origin if the primary source of the cancer is the cervix. [16]

Histopathologic staging

The histopathologic stage describes the type of cells seen under the microscope. There are 10 histopathologic types of cervical cancers: [16]

Histopathologic grading

The grade of the cancer is another method to describe the appearance of the tumor cells under a microscope. This describes how different the cells look from typical cells of the cervix. [20] It may also indicate the speed at which the cancer cells grow. [20] The grades are described below, with grade 3 being the most aggressive. [16]

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly or undifferentiated

Imaging

Imaging modalities, including ultrasound, MRI, CT, and positron emission tomography (PET), may be beneficial in helping to determine the stage of the disease, where resources permit. These imaging modalities allow for the visualization of the tumor size, degree of spread of the cancer to lymph nodes and surrounding organs, and to evaluate for distant metastasis. [16]

For primary tumors over 10mm in size, MRI is the best imaging modality to evaluate the primary tumor. PET-CT scans are the imaging modality of choice to evaluate for lymph node metastasis. Ultrasound may also be a beneficial method of evaluating the extent of cancer spread when performed by an experienced sonographer. [16]

Overall, imaging has the benefit of providing greater information on cancer, including the size of the tumor and its spread beyond the cervix. This information is critical in determining the stage of the cancer and building the best treatment plan. [16]

Additional modalities

If there is evidence that the cervical cancer has spread to local or distant organs, such as the bladder, rectum, or lungs, additional imaging or procedures may be necessary to determine the extent of cancer spread. This may include a chest X-ray to evaluate for lung metastasis, a cystoscopy (camera in the bladder) to look for bladder metastasis, a renal ultrasound to evaluate for the tumor blocking the ureter (tubes connecting the kidney to the bladder), and a sigmoidoscopy (camera in the rectum) to evaluate for cancer that has spread to the colon. The performance of these procedures and imaging modalities is highly individualized based on the symptoms the patient has and the evidence of disease progression. [16]

Stages

Following the collection and interpretation of all imaging and pathology reports, the stage of cervical cancer is determined. [16] Stages of cervical cancer range from stage I to stage IV, with stage 1 indicating local cancerous cells at the cervix, to stage IV indicating advanced disease and the spread of cancer cells to distant parts of the body. [12] Stage 0 represents the presence of precancerous cells, but does not represent a cervical cancer diagnosis. [13] [20] Controversially, the presence of the spread of cervical cancer to nearby lymph nodes does not change the stage of the diagnosis but is important to note as it may alter the treatment plan. Additionally, the involvement of the body of the uterus does not factor into the stage of cervical cancer. [16] [21]

Stage 0

The precancerous cells are confined to the surface layer (cells lining) of the cervix. [16] This is also known as carcinoma in situ (CIS). [20]

Stage I

Cervical cancer is confined only to the cervix. The size of the cancer may include the corpus or fundus (upper portion of the uterus), but there is no cancer growth beyond the cervix or the uterus. Stage I is subdivided based on the depth of the cancer as follows: [16] [19] [22]

Diagram showing stage 1A cervical cancer CRUK 200.svg
Stage IA cervical cancer
Diagram-showing-stage-1B1-cervical-cancer.png
Stage IB1 cervical cancer
Diagram-showing-stage-1B2-cervical-cancer.png
Stage IB2 cervical cancer
Diagram-showing-stage-1B3-cervical-cancer.png
Stage IB3 cervical cancer

Stage II

Cervical cancer invades beyond the uterus, but does not extend to the pelvic wall or the lower third of the vagina. [16] [19] [22]

Diagram showing stage 2A cervical cancer CRUK 212.svg
Stage IIA cervical cancer
Diagram showing stage 2B cervical cancer CRUK 216.svg
Stage IIB cervical cancer

Stage III

Cervical cancer has spread to involve any or all of the following: lower third of the vagina, pelvic wall, pelvic or para-aortic lymph nodes (more distant lymph nodes), is causing hydronephrosis (blockage of the kidney), and/or is causing a non-functioning kidney. [16] [19] [22]

Stage IV

The cancer has spread beyond the true pelvis (the internal reproductive organs, bladder, and colon) or has involved the mucosa of the bladder or rectum. Spread to the bladder or rectum must be biopsy-proven. [16] [19] [22]

Diagram showing stage 4A cervical cancer CRUK 236.svg
Stage IVA cervical cancer
Diagram showing stage 4B cervical cancer CRUK 239.svg
Stage IVB cervical cancer

History of cervical cancer staging

The drive to develop a staging for gynecological malignancies, including cancer of the cervix, was the need to have a uniform method to describe the extent of the disease. Comparing outcomes from different treatments could only be possible if the comparison were made for groups of patients with a similar degree of disease burden. [23]

Major Historical Timepoints

Source: [23]

1929 - League of Nations Classification for Cervical Cancer

1937 - First annual report of statistics on radiotherapy outcomes in cervical cancer patients

1938 - Atlas of Cervical Cancer Staging (Heyman and Strandquist)

1950 - The International Classification of the Stages of Carcinoma of the Uterine Cervix

1954 - Founding of FIGO

1958 - FIGO becomes the official publisher of the Annual Report

1973 - Commencement of triennial publication of the Annual Report on the Results of Treatment in Gynecological Cancer

1976 - The American Joint Committee on Cancer accepts the FIGO stage grouping for gynecological cancers

2018 - Latest triennial FIGO Cancer Report [22]

The most recent updates to cervical cancer staging included in the 2018 edition marked a departure from a system based mainly on clinical evaluation to one that allows imaging and pathological methods to help determine tumor size and extent of disease to assign the stage. A major topic of debate was the impact that newer diagnostic modalities would have on low- and middle-income countries, which bear most of the disease burden. [21] The final recommendations make findings from imaging and pathology optional for staging rather than a requirement.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in the any layer of the wall of the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Cytopathology</span> A branch of pathology that studies and diagnoses diseases on the cellular level

Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Cytopathology is frequently, less precisely, called "cytology", which means "the study of cells".

<span class="mw-page-title-main">Carcinoma</span> Malignancy that develops from epithelial cells

Carcinoma is a malignancy that develops from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesodermal or ectodermal germ layer during embryogenesis.

<span class="mw-page-title-main">Endometrial cancer</span> Uterine cancer that is located in tissues lining the uterus

Endometrial cancer is a cancer that arises from the endometrium. It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. Endometrial cancer occurs most commonly after menopause.

<span class="mw-page-title-main">Anal cancer</span> Medical condition

Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A change in bowel movements may also occur.

Cancer staging is the process of determining the extent to which a cancer has grown and spread. A number from I to IV is assigned, with I being an isolated cancer and IV being a cancer that has metastasized and spread from its origin. The stage generally takes into account the size of a tumor, whether it has invaded adjacent organs, how many regional (nearby) lymph nodes it has spread to, and whether it has appeared in more distant locations (metastasized).

Carcinoma <i>in situ</i> Pre-cancerous abnormal growth of tissue

Carcinoma in situ (CIS) is a group of abnormal cells. While they are a form of neoplasm, there is disagreement over whether CIS should be classified as cancer. This controversy also depends on the exact CIS in question. Some authors do not classify them as cancer, however, recognizing that they can potentially become cancer. Others classify certain types as a non-invasive form of cancer. The term "pre-cancer" has also been used.

<span class="mw-page-title-main">Ovarian clear-cell carcinoma</span> One of the subtypes of ovarian carcinoma

Ovarian clear-cell carcinoma, or clear-cell carcinoma of the ovary, also called ovarian clear-cell adenocarcinoma, is one of several subtypes of ovarian carcinoma – a subtype of epithelial ovarian cancer, in contrast to non-epithelial cancers. According to research, most ovarian cancers start at the epithelial layer which is the lining of the ovary. Within this epithelial group ovarian clear-cell carcinoma makes up 5–10%.

<span class="mw-page-title-main">Pelvic exenteration</span> Surgical removal of all pelvic organs

Pelvic exenteration is a radical surgical treatment that removes all organs from a person's pelvic cavity. It is used to treat certain advanced or recurrent cancers. The urinary bladder, urethra, rectum, and anus are removed. In women, the vagina, cervix, uterus, Fallopian tubes, ovaries and, in some cases, the vulva are removed. In men, the prostate is removed. The procedure leaves the person with a permanent colostomy and urinary diversion.

The uterine sarcomas form a group of malignant tumors that arises from the smooth muscle or connective tissue of the uterus.

<span class="mw-page-title-main">Vulvar cancer</span> Cancer involving the vulva

Vulvar cancer is a cancer of the vulva, the outer portion of the female genitals. It most commonly affects the labia majora. Less often, the labia minora, clitoris, or Bartholin's glands are affected. Symptoms include a lump, itchiness, changes in the skin, or bleeding from the vulva.

Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma, and melanoma have also been reported – while secondary vaginal cancer involves the metastasis of a cancer that originated in a different part of the body. Secondary vaginal cancer is more common. Signs of vaginal cancer may include abnormal vaginal bleeding, dysuria, tenesmus, or pelvic pain, though as many as 20% of women diagnosed with vaginal cancer are asymptomatic at the time of diagnosis. Vaginal cancer occurs more frequently in women over age 50, and the mean age of diagnosis of vaginal cancer is 60 years. It often can be cured if found and treated in early stages. Surgery alone or surgery combined with pelvic radiation is typically used to treat vaginal cancer.

Primary fallopian tube cancer (PFTC), often just tubal cancer, is a malignant neoplasm that originates from the fallopian tube.

<span class="mw-page-title-main">Uterine serous carcinoma</span> Type of cancer of the uterus

Uterine serous carcinoma is a malignant form of serous tumor that originates in the uterus. It is an uncommon form of endometrial cancer that typically arises in postmenopausal women. It is typically diagnosed on endometrial biopsy, prompted by post-menopausal bleeding.

Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers.

Neuroendocrine carcinoma of the cervix is best defined separately:Neuroendocrine: Of, relating to, or involving the interaction between the nervous system and the hormones of the endocrine glands.Carcinoma: An invasive malignant tumor derived from epithelial tissue that tends to metastasize to other areas of the body.

<span class="mw-page-title-main">Adenosarcoma</span> Type of tumor

Adenosarcoma is a rare malignant tumor that occurs in women of all age groups, but most commonly post-menopause. Adenosarcoma arises from mesenchymal tissue and has a mixture of the tumoral components of an adenoma, a tumor of epithelial origin, and a sarcoma, a tumor originating from connective tissue. The adenoma, or epithelial component of the tumor, is benign, while the sarcomatous stroma is malignant. The most common site of adenosarcoma formation is the uterus, but it can also occur in the cervix and ovaries. It more rarely arises in the vagina and fallopian tubes as well as primary pelvic or peritoneal sites, such as the omentum, especially in those with a history of endometriosis. The rare cases of adenosarcoma outside the female genital tract usually occur in the liver, bladder, kidney, as well as the intestine and are typically associated with endometriosis.

Carcinoma of the tonsil is a type of squamous cell carcinoma. The tonsil is the most common site of squamous cell carcinoma in the oropharynx. It comprises 23.1% of all malignancies of the oropharynx. The tumors frequently present at advanced stages, and around 70% of patients present with metastasis to the cervical lymph nodes. . The most reported complaints include sore throat, otalgia or dysphagia. Some patients may complain of feeling the presence of a lump in the throat. Approximately 20% patients present with a node in the neck as the only symptom.

<span class="mw-page-title-main">Squamous cell carcinoma of the vagina</span> Medical condition

Squamous cell carcinoma of the vagina is a potentially invasive type of cancer that forms in the tissues of the vagina. Though uncommonly diagnosed, squamous cell cancer of the vagina (SCCV) is the most common type of vaginal cancer, accounting for 80-90% of cases. SCCV forms in squamous cells, which are the thin, flat cells lining the vagina. SCCV initially spreads superficially within the vaginal wall and can slowly spread to invade other vaginal tissues. This carcinoma can metastasize to the lungs, and less frequently in the liver, bone, or other sites. SCCV has many risk factors in common with cervical cancer and is similarly strongly associated with infection with oncogenic strains of human papillomavirus (HPV).

<span class="mw-page-title-main">Ovarian squamous cell carcinoma</span> Medical condition

Ovarian squamous cell carcinoma (oSCC) or squamous ovarian carcinoma (SOC) is a rare tumor that accounts for 1% of ovarian cancers. Included in the World Health Organization's classification of ovarian cancer, it mainly affects women above 45 years of age. Survival depends on how advanced the disease is and how different or similar the individual cancer cells are.

References

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  2. 1 2 3 4 5 "Cervical Cancer Treatment (PDQ®)". NCI. 14 March 2014. Archived from the original on 5 July 2014. Retrieved 24 June 2014.
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  12. 1 2 3 4 5 "Cervical Cancer Stages". www.cancer.org. Archived from the original on 2017-01-21. Retrieved 2021-01-02.
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