TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

Tokunaga,, Hideki; Shimada,, Muneaki; Ishikawa,, Mitsuya; Yaegashi,, Nobuo

doi:10.1093/jjco/hyy206

TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

Tokunaga,, Hideki;Shimada,, Muneaki;Ishikawa,, Mitsuya;Yaegashi,, Nobuo 2019-04-01 00:00:00 Abstract The staging classification of gynaecological malignancies has been revised by the International Federation of Gynecology and Obstetrics (FIGO) and has been subsequently reviewed by the FIGO Committee on Gynecologic Oncology, the International Union for Cancer Control TNM Committee and the American Joint Committee on Cancer. The major change in the eighth edition of TNM classification of gynaecological malignant tumours is integrated staging for ovarian, fallopian tube and primary peritoneal carcinoma, whereas the seventh edition distinguished ‘ovary and primary peritoneal carcinoma’ and ‘Fallopian tube carcinoma’. Furthermore, the new edition describes a prognostic factor grid for vulvar, cervical, endometrial and ovarian, fallopian tube and primary peritoneal carcinoma. If these factors contribute strongly to the prognosis, they may be incorporated into future staging classifications. This paper reviews the staging system for gynaecological malignancies, how it was developed, and current problems to be resolved. TNM, FIGO, prognosis, female organs Introduction Cancer staging is fundamental for assessment of cancer status and development of treatment strategies. Over the last 30 years, all changes to the International Federation of Gynecology and Obstetrics (FIGO) classification and staging system have been extensively discussed by the FIGO Committee on Gynecologic Oncology and have been issued following approval by the International Union for Cancer Control (UICC) TNM Committee, the American Joint Committee on Cancer (AJCC), and the World Health Organization (WHO). The TNM classification of malignant tumours of UICC is defined by the UICC after discussing proposals for revisions from the AJCC. For gynaecological tumours, the definition in the FIGO is strongly reflected. International Classification of Diseases (ICD) is a classification published by WHO as an international statistical standard for the cause of death and disease. The code appended to each disease is defined by ICD. UICC defines TNM classification of anatomic disease stages based on WHO adoption of FIGO stages (1). In Japan, the Japan Society of Obstetrics and Gynecology (JSOG) and the Japanese Society of Pathology have formulated general rules for clinical and pathological management for each gynaecological malignant tumour, except for vulvar and vaginal tumours. Currently, the latest published Japanese general rules for management of gynaecological malignant tumours are as follows: The General Rules for Clinical and Pathological Management of Uterine Cervical Cancer (Pathological edition (fourth edition)). The General Rules for Clinical and Pathological Management of Uterine Corpus Cancer (Pathological edition (fourth edition)). The General Rules for Clinical and Pathological Management of Ovarian Tumour, Fallopian Tube Cancer and Primary Peritoneal Cancer (Clinical edition (first edition) and Pathological edition (first edition)). The General Rules for Clinical and Pathological Management of Trophoblastic Diseases (third edition). General rules and management for vulvar and vaginal tumours have not been published yet. Staging and treatment for those tumours are described in the guideline for vulvar and vaginal cancer published by the Japan Society of Gynecologic Oncology (JSGO) in 2015. The major change in the eighth edition is separate staging for ovarian, Fallopian (uterine) tube and primary peritoneal carcinoma; previously, the seventh edition only delineated ‘ovarian and primary peritoneal carcinoma’ and ‘Fallopian tube carcinoma’. Currently, tumour registration of the JSOG is based on the TNM classification (UICC eighth edition). In this article, staging of all gynaecological tumours are outlined. Vulvar carcinoma (ICD-O-3 C51) There is no change in TNM classification of vulvar carcinoma between the seventh and eighth editions. The classification reflects surgical staging adopted by FIGO in 2008 (Table 1a,b). FIGO adopted surgical staging classification instead of the conventional clinical staging classification in 1988. For vulvar cancer, surgical therapy was usually performed, thereby allowing pathological disease evaluation. It was speculated that pathologically evaluating regional lymph node metastasis, an important prognostic factor, enabling surgical staging classification to more accurately reflect prognosis. Additionally, even if the tumour was localized only to the vulva, a tumour with a maximum diameter exceeding 2 cm was considered to be Stage II. In 1994, Stage I was subdivided into Ia (T1a: depth of stromal invasion of 1 mm or less) and Ib (T1b: depth of stromal invasion exceeds 1 mm), but it was suggested that the prognosis was not yet accurately reflected. In 2008, tumours exceeding a maximum diameter of 2 cm without lymph node metastasis were included in Stage IB. The reason was based on data from the Surveillance, Epidemiology and End Results Program (SEER), which showed that prognosis was favourable in cases with negative lymph node metastasis, even with a bulky tumour (2). Vulvar cancer staging in the seventh edition of TNM staging classification was updated from the sixth edition in 2009 based on this FIGO 2008 staging, and it has not been changed in the eighth edition. Table 1a. TNM categoris of vulvar cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. bT3 is not used by FIGO. Table 1a. TNM categoris of vulvar cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. bT3 is not used by FIGO. Table 1b. Stages of vulvar cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 FIGO no longer includes Stage 0 (Tis). Table 1b. Stages of vulvar cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 FIGO no longer includes Stage 0 (Tis). The N classification is subdivided according to the size of lymph node metastatic lesion and the number of metastatic lymph nodes. For pN, histologic examination of regional lymphadenectomy specimens will ordinarily include six or more lymph nodes. For TNM staging, cases with fewer than six resected nodes should be classified using the TNM pathologic classification according to the status of those nodes (e.g. pN0; pN1) as per the general rules of TNM. In contrast, FIGO classifies cases with less than six nodes resected as pNX. Factors that reflect prognosis are shown in Table 1c; in addition to anatomical evaluation, biological characteristics may be reflected in future progressive stage classification. Table 1c. Prognostic risk factors for vulvar cancer Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Table 1c. Prognostic risk factors for vulvar cancer Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Vaginal cancer (ICD-O-3 C52) A tumour that spreads between the vagina and the uterine cervix is classified as cervical cancer. When a tumour spreads to the vulva, it is classified as vulvar cancer. Therefore, few cases are diagnosed as vaginal cancer. FIGO adopted clinical staging classification in 1971 and has not been revised thereafter. Seventy-five percent of vaginal cancer is diagnosed as Stage II–IV. However, pathological assessment is difficult, and surgical staging classification has not been adopted. Accordingly, radiotherapy is often chosen as the main treatment. The TNM classification follows the FIGO staging classification and has not been revised for a long time (Table 2a,b). The rule for pN of vaginal carcinoma follows that of cervical carcinoma. Table 2a. TNM categoris of vaginal cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe presence of bullous oedema is not sufficient evidence to classify a tumour as T4. Table 2a. TNM categoris of vaginal cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe presence of bullous oedema is not sufficient evidence to classify a tumour as T4. Table 2b. Stages of vaginal cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis FIGO no longer includes Stage 0 (Tis). aThe presence of bullous oedema is not sufficient evidence to classify a tumours as T4. Table 2b. Stages of vaginal cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis FIGO no longer includes Stage 0 (Tis). aThe presence of bullous oedema is not sufficient evidence to classify a tumours as T4. Cancer of the cervix uteri (ICD-O C53) Cervical cancer staging is the oldest staging in the literature. According to the FIGO staging system, cervical cancer is primarily a local disease in the pelvis. Finally, surgical staging cannot be employed worldwide, especially in low-resource countries where late stages are common and surgical facilities are scarce. In the eighth edition, the definitions of staging for cervical cancer have not been revised. The TNM category is shown in Table 3a, and correspondence between TNM and FIGO staging is listed in Table 3b. Table 3a. TNM categories of cervical cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa aExtension to corpus uteri should be disregarded. bThe depth of invasion should be taken from the base of the epithelium, either surface or glandular, from which it originates. The depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial papillae to the deepest point of invasion. Vascular space involvement, venous or lymphatic, does not affect classification. cAll macroscopically visible lesions even with superficial invasion are T1b/IB. dVascular space involvement, venous or lymphatic, does not affect classification. eBullous oedema is not sufficient to classify a tumour as T4. Table 3a. TNM categories of cervical cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa aExtension to corpus uteri should be disregarded. bThe depth of invasion should be taken from the base of the epithelium, either surface or glandular, from which it originates. The depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial papillae to the deepest point of invasion. Vascular space involvement, venous or lymphatic, does not affect classification. cAll macroscopically visible lesions even with superficial invasion are T1b/IB. dVascular space involvement, venous or lymphatic, does not affect classification. eBullous oedema is not sufficient to classify a tumour as T4. Table 3b. Stages of cervical cancer Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 3b. Stages of cervical cancer Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Stage IA cannot be assessed macroscopically. There are data indicating that subdividing by size (with a 4-cm cut-off for maximum diameter) is appropriate for Stage IIA, while there are no available data for Stage IIB in the literature supporting a subdivision regarding tumour size. The decision not to subdivide Stages IIB and IIIB according to uni- or bilateral parametrial extension is also because the treatment is identical in both situations and that subdivision would not affect management. Furthermore, lympho-vascular space invasion and lymph node metastasis affect prognosis and decision-making regarding treatment after hysterectomy. These factors have been taken into consideration when staging cervical cancer. Nevertheless, these important risk factors were not included in the staging nomenclature because of their subjective definition, as this influences the assessment of its extension and thus its significance. Despite improvements in imaging techniques, the FIGO Committee on Gynecologic Oncology has not performed lymph nodal assessment per se regarding its importance for staging. However, the FIGO Committee encourages the use of imaging techniques for the evaluation of the extension and size of the lesion(s). The TNM classification also recommends various imaging modalities such as magnetic resonance imaging and computed tomography, although they are not mandatory. Pelvic examination under anaesthesia, cystoscopy, sigmoid-colonoscopy and Drip Infusion Pyelography are optional rather than essential. The number of lymph nodes necessary to establish pN classification is six, which is the same as that for the vulva. FIGO classifies cases with less than six nodes resected as pNX. In April 2018, the FIGO Gynecologic Oncology Committee proposed modifications of the current Cervical Cancer Staging System. Although this is not a decision item, because of the poor disease prognosis associated with lymph node metastasis (3), the inclusion of lymph node metastasis is likely to be revised in the staging classification in the near future. Other risk factors for cervical cancer are shown in Table 3c. Table 3c. Prognostic risk factors for cervical cancer Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Table 3c. Prognostic risk factors for cervical cancer Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Endometrial cancer (ICD-O-3 C54.1, C55) In 1988, the FIGO Committee decided to divide the myometrium so that Stage IA was limited to the endometrium, Stage IB to the inner one-half, and Stage IC to the outer one-half of the myometrium. The current TNM categories and FIGO staging are shown in Table 4a and b . Prognostic factors not related to staging are listed in Table 4c. Table 4a. TNM categoris of endometrial cancer TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) aEndocervical glandular involvement only should be considered as Stage I. bPositive cytology has to be reported separately without changing the stage. cThe presence of bullous oedema is not sufficient evidence to classify as T4. Table 4a. TNM categoris of endometrial cancer TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) aEndocervical glandular involvement only should be considered as Stage I. bPositive cytology has to be reported separately without changing the stage. cThe presence of bullous oedema is not sufficient evidence to classify as T4. Table 4b. Stages of endometrial cancer Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 4b. Stages of endometrial cancer Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 4c. Prognostic risk factors for endometrial cancer Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Table 4c. Prognostic risk factors for endometrial cancer Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Staging has changed considerably, and data collection now allows identification and analysis of specific prognostic factors in surgical–pathological staging. In volume 26 of the FIGO Annual Report, surgical Stage IA G1, IB G1, IA G2 and IB G2 had 5-year survival rates of 93.4%, 91.6%, 91.3% and 93.4%, respectively, with no difference among the stages (4). This resulted in revisions to the staging system for endometrial cancer adopted in 2008. In addition, Stages IA and IB, adopted in 1988, have been combined so that now Stage IA involves the endometrium and/or myometrial invasion (MI) of less than one-half, and IB applies to tumours that extend to or beyond the outer one-half of the myometrium. In addition, Stage II no longer has a subsets A and B. Involvement of the endocervical glandular portion of the cervix is now considered Stage I. The other area of note is that pelvic and para-aortic node involvement have been separated rather than combining them in a single substage. This seems to be reasonable, since data suggest that the prognosis is worse if the para-aortic nodes are involved. As a result, Stage IIIC is now categorized as IIIC1 (indicating N1: positive pelvic nodes) and IIIC2 (indicating N2: positive para-aortic nodes with or without positive pelvic nodes) (5,6). Histologic grade is also an important prognostic factor: three grades (G1, G2 and G3) are defined according to the degree of differentiation of the adenocarcinoma. Special types such like serous, clear cell and mixed mesodermal tumours are high risk and considered G3 (4). Furthermore, positive cytological findings may adversely impact prognosis, but this remains controversial and requires further study. Regardless, although cytology results are no longer included in staging classification, they should be recorded. Uterine sarcomas (leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma) (ICD-O-3 53, 54) The staging described in this part is adopted to uterine sarcomas, except for carcinosarcoma (Table 4d–f). Sarcoma in the corpus uteri is distinguishable owing to its biological behaviour. Moreover, tumour size impacts prognosis of leiomyosarcoma (LMS) and endometrial stromal sarcoma (ESS), hence T1 is divided into two categories: T1a (tumour diameter 5 cm or less) and T1b (more than 5 cm) (7). In adenosarcoma, tumour size correlates with deep MI, which is an independent prognostic factor (8). T1 is divided into three categories: T1a (no MI), T1b (MI less than 1/2) and T1c (MI more than 1/2). In addition, incidence of lymph node metastasis is low. Moreover, many cases of uterine sarcoma that are thought to be benign are diagnosed after hysterectomy. The exact effect regarding the prognosis of lymph node metastasis were previously unknown. Table 4d. TNM categories of leiomyosarcoma and endometral stromal sarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Simultaneous tumours of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classified as independent primary tumours. Table 4d. TNM categories of leiomyosarcoma and endometral stromal sarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Simultaneous tumours of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classified as independent primary tumours. Table 4e. TNM categories of adenosarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Table 4e. TNM categories of adenosarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Table 4f. Stages of uterine sarcomas I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 aStage IC does not apply for leiomyosarcoma and endometrial stromal sarcoma. Table 4f. Stages of uterine sarcomas I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 aStage IC does not apply for leiomyosarcoma and endometrial stromal sarcoma. The prognosis of patients with uterine sarcomas has not changed in recent decades: the overall 5-year survival has been between 17.5% and 54.7% in various studies (9). In a recently reported series of 100 cases, the 2-, 5- and 10-year overall survival rates were 62%, 51% and 38%, respectively. Additionally, in multivariate analysis, stage, age, tumour size and parity have independently influenced overall survival (9–11). Recently, the impact of lymph node metastasis on survival of uterine sarcomas was reported by analyzing data from the SEER study. The incidence of lymph node metastasis in uterine sarcomas is low, especially in adenosarcoma compared with leiomyosarcoma and ESS; however lymph node metastasis is associated with a worse prognosis (8). Finally, ESS has two subtypes: high-grade and low-grade; lymph node metastasis is frequent in high-grade ESS compared with that of low-grade ESS and is a risk factor of cause-specific survival (12). Ovarian, fallopian tube and primary peritoneal carcinoma (ICD-O-3 C56; ICD-O-3 C57) TNM categories and FIGO stages are shown in Table 5a. Ovarian cancer is thought to arise from the surface epithelium of the ovary. However, the relationship between high-grade serous carcinoma (HGSC) in the tubal epithelium and the decreased incidence of ovarian cancer after prophylactic salpingectomy indicate that a significant number of HGSCs arise from the fallopian tube. Moreover, endometrioid carcinoma and clear cell carcinoma are strongly related to endometriosis on the ovary or peritoneum (13). Therefore, the committee decided to integrate the staging systems of the ‘ovary and peritoneum’ with that of the Fallopian tube in the eighth edition. Ovarian, fallopian tube and peritoneal cancers have a similar clinical presentation and are treated similarly, and current evidence supports staging all three cancers in a single system. The primary site (i.e. ovary, fallopian tube or peritoneum) should be designated where possible, and the histologic type should be recorded. Table 5a. The FIGO stages are based on surgical staging (TNM stages are based on clinical and/or pathological classification) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) aLiver capsule metastasis is T3/Stage III. bLiver parenchymal metastasis M1/Stage IV. Table 5a. The FIGO stages are based on surgical staging (TNM stages are based on clinical and/or pathological classification) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) aLiver capsule metastasis is T3/Stage III. bLiver parenchymal metastasis M1/Stage IV. In the seventh edition, T2a comprises tumours arising from the unilateral ovary (or tube) and extending to the tube(s) (or ovaries); in the eighth edition, T2a is defined as tumour involving one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer. When a tumour involves the bilateral ovaries (or tubes), it is difficult to determine whether the cancer is T1b or T2a. The presence of a transitional lesion of the malignant tumour from a benign tumour in each ovary (or tube) with an intact capsule may suggest T1b. Occasionally, a large-stage IB ovarian tumour is associated with a contralateral normal-size ovary exhibiting small and superficial foci of the tumour; this suggests that superficial foci are metastatic. Pathologically proofed Stage II cancer exhibits a worse prognosis than does surgical Stage II, demonstrating adherence between the tumour and pelvic organs without pathological tumour infiltration (14). Intraoperative rupture (‘surgical spill’) comprises T1c1, capsule rupture before surgery or a tumour on the ovarian or fallopian tube surface comprises T1c2, and positive peritoneal cytology with or without rupture comprises T1c3. However, it is controversial whether surgical spill affects prognosis. Nevertheless, preoperative capsule rapture and positive washings are independent predictors of worse disease-free survival (15). Stage II cancer comprises a small and heterogenous group. During revision, the committee described that there was a lack of biological evidence to support subdividing this small category into IIB1and IIB2. Moreover, for FIGO Stage II, the IIc Substage has been eliminated, as the cytology results do not influence outcome. The new staging includes a revision of Stage III patients; assignment to Stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination. In addition, N1 was divided into N1a and N1b according to size of the metastatic tumour nest in the lymph node. pN should be diagnosed pathologically by retrieving at least one node from both the pelvic and para-aortic lymph nodes or more than one node from each lesion. There is, however, a significant difference in overall survival between Stages IIIA/B and IIIC. Nonetheless, there are no data supporting quantification of the size of metastasis in IIIA1 (16,17). Stage IIIC (T3c-N0 or 1-M0) indicates spread to the surface of peritoneal cavity organs beyond the pelvis. In Stage III, the 2-cm cut-off between IIIB and IIIC remains a controversial issue, as it is unclear which is worse: a few metastatic sites over 2 cm or numerous sites under 2 cm. M1b indicates isolated parenchymal metastases and should be distinguished from T3 as a tumour on the surface without infiltration or metastases in the stroma of peritoneal cavity organs. Finally, positive cytology in pleural effusion is categorized as M1a and Stage IVA and does not necessarily suggest parenchymal metastasis of the lung (16,18). It has also been suggested that serous tubal intraepithelial carcinoma and BRCA gene status (somatic and germline) should be included in the staging system (19). The Committee will not be issuing a statement at this time, but will do so when the next cycle of revision takes place (20). Additional risk factors are shown in Table 5b. Table 5b. Prognostic risk factors for tumours of the ovary, fallopian tube and peritoneal carcinoma Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Table 5b. Prognostic risk factors for tumours of the ovary, fallopian tube and peritoneal carcinoma Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Gestational trophoblastic tumours (ICD-O-3 C58) The classification for gestational trophoblastic tumours is based on that of FIGO and were adopted in 1992 and updated in 2002. The definitions of T and M categories correspond to the FIGO stages (Table 6a). There is no regional designation in the staging of these tumours. Node metastases are classified as metastatic (M1) disease. A prognostic scoring index (Table 6b), based on factors other than the anatomic extent of the disease, is used to assign cases to high- and low-risk categories, and these categories are used in stage grouping. Table 6a. Stages of gestational trophoblastic tumours TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis aStages I–IV are subdivided into A and B according to the prognostic score. bGenital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. cAny involvement of non genital structures, whether by direct invasion or metastasis is described using the M classification. Table 6a. Stages of gestational trophoblastic tumours TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis aStages I–IV are subdivided into A and B according to the prognostic score. bGenital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. cAny involvement of non genital structures, whether by direct invasion or metastasis is described using the M classification. Table 6b. Prognostic scoring index for gestational trophoblastic tumours Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Risk categories. Total prognostic score 6 or less = low risk. Total score 7 or more = high risk. Table 6b. Prognostic scoring index for gestational trophoblastic tumours Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Risk categories. Total prognostic score 6 or less = low risk. Total score 7 or more = high risk. Anatomical spread of gestational trophoblastic disease does not always reflect prognosis. Lung is the first metastatic site in the earlier stage, so lung disease should be handled separately from that of other organs. In Japan, a diagnostic scoring index for clinical choriocarcinoma has been used, and the Japanese registration project for gestational trophoblastic disease has continued to be based on it. Moreover, although FIGO scoring system and the Japanese diagnostic scoring system have high commonality, the FIGO score does not indicate a pathological diagnosis. Conclusion The TNM classification is originally based on anatomic spread of malignant disease; this basic concept has been successfully adopted for almost all malignancies of various organs. With the development of new drugs, the development of medical technology and equipment, the staging classification has changed. Biological features are different among primary organs, histological types, and genetic backgrounds. New prognostic factors may be included into categories defining stages. A good staging system must be valid, reliable and practical. Special equipment and expensive inspections are not preferable for the staging system to be accepted globally. Stages of disease reflect prognosis of malignancies and are the most important guidelines to determine treatment strategy. Accordingly, clinicians must precisely record the stage of malignant tumours as well as the clinical information to assist in the development of better prognostic indicators. Funding None. Conflict of interest statement None declared. References 1 Odicino F , Pecorelli S , Zigliani L , Creasman WT . History of the FIGO cancer staging system . Int J Gynaecol Obstet 2008 ; 101 : 205 – 10 . Google Scholar Crossref Search ADS PubMed 2 Hacker NF . Revised FIGO staging for carcinoma of the vulva . Int J Gynaecol Obstet 2009 ; 105 : 105 – 6 . Google Scholar Crossref Search ADS PubMed 3 Kidd EA , Siegel BA , Dehdashti F , et al. Lymph node staging by positron emission tomography in cervical cancer: relationship to prognosis . J Clin Oncol 2010 ; 28 : 2108 – 13 . Google Scholar Crossref Search ADS PubMed 4 Creasman WT , Odicino F , Maisonneuve P , et al. Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer . Int J Gynaecol Obstet 2006 ; 95 : S105 – 43 . Google Scholar Crossref Search ADS 5 Creasman W . Revised FIGO staging for carcinoma of the endometrium . Int J Gynaecol Obstet 2009 ; 105 : 109 . Google Scholar Crossref Search ADS PubMed 6 Lewin SN , Wright JD . Comparative Performance of the 2009 International Federation of Gynecology and Obstetrics’ Staging System for Uterine Corpus Cancer . Obstet Gynecol 2011 ; 117 : 1226 . Google Scholar Crossref Search ADS PubMed 7 Giuntoli RL 2nd. , Lessard-Anderson CR , Gerardi MA , et al. Comparison of current staging systems and a novel staging system for uterine leiomyosarcoma. Int J Gynaecol . Cancer 2013 ; 23 : 869 – 76 . 8 Machida H , Nathenson MJ , Takiuchi T , Adams CL , Garcia-Sayre J , Matsuo K . Significance of lymph node metastasis on survival of women with uterine adenosarcoma . Gynecol Oncol 2017 ; 144 : 524 – 30 . Google Scholar Crossref Search ADS PubMed 9 Koivisto-Korander R , Butzow R , Koivisto AM , Leminen A . Clinical outcome and prognostic factors in 100 cases of uterine sarcoma: experience in Helsinki University Central Hospital 1990-2001 . Gynecol Oncol 2008 ; 111 : 74 – 81 . Google Scholar Crossref Search ADS PubMed 10 Giuntoli RL 2nd. , Metzinger DS , DiMarco CS , et al. Retrospective review of 208 patients with leiomyosarcoma of the uterus: prognostic indicators, surgical management, and adjuvant therapy . Gynecol Oncol 2003 ; 89 : 460 – 9 . Google Scholar Crossref Search ADS PubMed 11 Prat J . FIGO staging for uterine sarcomas . Int J Gynaecol Obstet 2009 ; 104 : 177 – 8 . 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Reply to staging classification for cancer of the ovary and fallopian tube should include in situ carcinoma . Cancer 2016 ; 122 : 652 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Japanese Journal of Clinical Oncology Oxford University Press http://www.deepdyve.com/lp/oxford-university-press/tnm-classification-of-gynaecological-malignant-tumours-eighth-edition-lHIlKIahuS

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ISSN: 0368-2811
eISSN: 1465-3621
DOI: 10.1093/jjco/hyy206
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Abstract

Abstract The staging classification of gynaecological malignancies has been revised by the International Federation of Gynecology and Obstetrics (FIGO) and has been subsequently reviewed by the FIGO Committee on Gynecologic Oncology, the International Union for Cancer Control TNM Committee and the American Joint Committee on Cancer. The major change in the eighth edition of TNM classification of gynaecological malignant tumours is integrated staging for ovarian, fallopian tube and primary peritoneal carcinoma, whereas the seventh edition distinguished ‘ovary and primary peritoneal carcinoma’ and ‘Fallopian tube carcinoma’. Furthermore, the new edition describes a prognostic factor grid for vulvar, cervical, endometrial and ovarian, fallopian tube and primary peritoneal carcinoma. If these factors contribute strongly to the prognosis, they may be incorporated into future staging classifications. This paper reviews the staging system for gynaecological malignancies, how it was developed, and current problems to be resolved. TNM, FIGO, prognosis, female organs Introduction Cancer staging is fundamental for assessment of cancer status and development of treatment strategies. Over the last 30 years, all changes to the International Federation of Gynecology and Obstetrics (FIGO) classification and staging system have been extensively discussed by the FIGO Committee on Gynecologic Oncology and have been issued following approval by the International Union for Cancer Control (UICC) TNM Committee, the American Joint Committee on Cancer (AJCC), and the World Health Organization (WHO). The TNM classification of malignant tumours of UICC is defined by the UICC after discussing proposals for revisions from the AJCC. For gynaecological tumours, the definition in the FIGO is strongly reflected. International Classification of Diseases (ICD) is a classification published by WHO as an international statistical standard for the cause of death and disease. The code appended to each disease is defined by ICD. UICC defines TNM classification of anatomic disease stages based on WHO adoption of FIGO stages (1). In Japan, the Japan Society of Obstetrics and Gynecology (JSOG) and the Japanese Society of Pathology have formulated general rules for clinical and pathological management for each gynaecological malignant tumour, except for vulvar and vaginal tumours. Currently, the latest published Japanese general rules for management of gynaecological malignant tumours are as follows: The General Rules for Clinical and Pathological Management of Uterine Cervical Cancer (Pathological edition (fourth edition)). The General Rules for Clinical and Pathological Management of Uterine Corpus Cancer (Pathological edition (fourth edition)). The General Rules for Clinical and Pathological Management of Ovarian Tumour, Fallopian Tube Cancer and Primary Peritoneal Cancer (Clinical edition (first edition) and Pathological edition (first edition)). The General Rules for Clinical and Pathological Management of Trophoblastic Diseases (third edition). General rules and management for vulvar and vaginal tumours have not been published yet. Staging and treatment for those tumours are described in the guideline for vulvar and vaginal cancer published by the Japan Society of Gynecologic Oncology (JSGO) in 2015. The major change in the eighth edition is separate staging for ovarian, Fallopian (uterine) tube and primary peritoneal carcinoma; previously, the seventh edition only delineated ‘ovarian and primary peritoneal carcinoma’ and ‘Fallopian tube carcinoma’. Currently, tumour registration of the JSOG is based on the TNM classification (UICC eighth edition). In this article, staging of all gynaecological tumours are outlined. Vulvar carcinoma (ICD-O-3 C51) There is no change in TNM classification of vulvar carcinoma between the seventh and eighth editions. The classification reflects surgical staging adopted by FIGO in 2008 (Table 1a,b). FIGO adopted surgical staging classification instead of the conventional clinical staging classification in 1988. For vulvar cancer, surgical therapy was usually performed, thereby allowing pathological disease evaluation. It was speculated that pathologically evaluating regional lymph node metastasis, an important prognostic factor, enabling surgical staging classification to more accurately reflect prognosis. Additionally, even if the tumour was localized only to the vulva, a tumour with a maximum diameter exceeding 2 cm was considered to be Stage II. In 1994, Stage I was subdivided into Ia (T1a: depth of stromal invasion of 1 mm or less) and Ib (T1b: depth of stromal invasion exceeds 1 mm), but it was suggested that the prognosis was not yet accurately reflected. In 2008, tumours exceeding a maximum diameter of 2 cm without lymph node metastasis were included in Stage IB. The reason was based on data from the Surveillance, Epidemiology and End Results Program (SEER), which showed that prognosis was favourable in cases with negative lymph node metastasis, even with a bulky tumour (2). Vulvar cancer staging in the seventh edition of TNM staging classification was updated from the sixth edition in 2009 based on this FIGO 2008 staging, and it has not been changed in the eighth edition. Table 1a. TNM categoris of vulvar cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. bT3 is not used by FIGO. Table 1a. TNM categoris of vulvar cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intrepidity neoplasia grade III (VIN III) T1 Tumour confined to vulva or vulva and perineum T1a Tumour 2 cm or less in greatest dimension and with stromal invasion no greater than 1.0 mma T1b Tumour greater than 2 cm and or with stromal invasion greater than 1 mma T2 Tumour invades any of the following structures: lower third urethra, lower third vagina, anus T3b Tumour invades any of the following perineal structures: upper 2/3 urethra, upper 2/3 vagina, bladder mucosa, rectal mucosa; or fixed to pelvic bone NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: N1a One or two lymph node metastasis each less than 5 mm N1b One lymph node metastases 5 mm or greater N2 Regional lymph node metastasis with the following features: N2a Three or more lymph node metastases each less than 5 mm N2b Two or more lymph node metastases 5 mm or greater N2c Lymph node metastasis with extracapsular spread N3 Fixed or ulcerated regional lymph node metastasis M-Distant Metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. bT3 is not used by FIGO. Table 1b. Stages of vulvar cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 FIGO no longer includes Stage 0 (Tis). Table 1b. Stages of vulvar cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 N0 M0 IA T1a N0 M0 IA T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T1, T2 N1a, N1b M0 IIIA(i) T1, T2 N1a M0 IIIA(ii) T1, T2 N1b M0 IIIB T1, T2 N2a, N2b M0 IIIB(i) T1, T2 N2a M0 IIIB(ii) T1, T2 N2b M0 IIIC T1, T2 N2c M0 IIIC T1, T2 N2c M0 IVA T1, T2 N3 M0 IVA T1, T2 N3 M0 T3 Any N M0 T3 Any N M0 IVB Any T Any N M1 IVB Any T Any N M1 FIGO no longer includes Stage 0 (Tis). The N classification is subdivided according to the size of lymph node metastatic lesion and the number of metastatic lymph nodes. For pN, histologic examination of regional lymphadenectomy specimens will ordinarily include six or more lymph nodes. For TNM staging, cases with fewer than six resected nodes should be classified using the TNM pathologic classification according to the status of those nodes (e.g. pN0; pN1) as per the general rules of TNM. In contrast, FIGO classifies cases with less than six nodes resected as pNX. Factors that reflect prognosis are shown in Table 1c; in addition to anatomical evaluation, biological characteristics may be reflected in future progressive stage classification. Table 1c. Prognostic risk factors for vulvar cancer Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Table 1c. Prognostic risk factors for vulvar cancer Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Prognostic factors Tumour related Host related Environment related Essential Lymph node metastases: Number Size Extracapsular tumour growth Experience of treating centre/concentration of care for vulvar cancer patients in tertiary referral centres Additional FIGO stage Depth of invasion Diameter of primary tumour Histological type Age Smoking Adjacent dermatosis (LS, VIN) Immune Status Surgical margins New and promising EGFR status p53 over expression P16INK4a level Microvessel density HPV status Pre-treatment haemoglobin level Vaginal cancer (ICD-O-3 C52) A tumour that spreads between the vagina and the uterine cervix is classified as cervical cancer. When a tumour spreads to the vulva, it is classified as vulvar cancer. Therefore, few cases are diagnosed as vaginal cancer. FIGO adopted clinical staging classification in 1971 and has not been revised thereafter. Seventy-five percent of vaginal cancer is diagnosed as Stage II–IV. However, pathological assessment is difficult, and surgical staging classification has not been adopted. Accordingly, radiotherapy is often chosen as the main treatment. The TNM classification follows the FIGO staging classification and has not been revised for a long time (Table 2a,b). The rule for pN of vaginal carcinoma follows that of cervical carcinoma. Table 2a. TNM categoris of vaginal cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe presence of bullous oedema is not sufficient evidence to classify a tumour as T4. Table 2a. TNM categoris of vaginal cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma) T1 Tumour confined to vagina T2 Tumour invades paravaginal tissues (paracolpium) T3 Tumour extends to pelvic wall T4 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa N-Regional Lymph Nodes Regional Lymph Nodes Upper two-thirds of vagina: the pelvic nodes including obturator, internal iliac (hypogastric), external iliac and pelvic nodes, NOS. Lower third of vagina: the inguinal and femoral nodes. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M0 No distant metastasis M1 Distant metastasis (including pelvic lymph node metastasis) aThe presence of bullous oedema is not sufficient evidence to classify a tumour as T4. Table 2b. Stages of vaginal cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis FIGO no longer includes Stage 0 (Tis). aThe presence of bullous oedema is not sufficient evidence to classify a tumours as T4. Table 2b. Stages of vaginal cancer Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis Anatomic stage/TNM categories FIGO stages T N M 0 Tis N0 M0 I T1 N0 M0 I T1 Tumour confined to vagina II T2 N0 M0 II T2 Tumour invades paravaginal tissues (paracolpium) III T3 N0 M0 III T3 Tumour extends to pelvic wall T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 Tumour invades mucosa of bladder or rectum, or extends beyond the true pelvisa IVB Any T Any N M1 IVB M1 Distant metastasis FIGO no longer includes Stage 0 (Tis). aThe presence of bullous oedema is not sufficient evidence to classify a tumours as T4. Cancer of the cervix uteri (ICD-O C53) Cervical cancer staging is the oldest staging in the literature. According to the FIGO staging system, cervical cancer is primarily a local disease in the pelvis. Finally, surgical staging cannot be employed worldwide, especially in low-resource countries where late stages are common and surgical facilities are scarce. In the eighth edition, the definitions of staging for cervical cancer have not been revised. The TNM category is shown in Table 3a, and correspondence between TNM and FIGO staging is listed in Table 3b. Table 3a. TNM categories of cervical cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa aExtension to corpus uteri should be disregarded. bThe depth of invasion should be taken from the base of the epithelium, either surface or glandular, from which it originates. The depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial papillae to the deepest point of invasion. Vascular space involvement, venous or lymphatic, does not affect classification. cAll macroscopically visible lesions even with superficial invasion are T1b/IB. dVascular space involvement, venous or lymphatic, does not affect classification. eBullous oedema is not sufficient to classify a tumour as T4. Table 3a. TNM categories of cervical cancer TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ (pre-invasive carcinoma), intra-epithelial neoplasia grade III (VIN III) T1 Tumour confined to the cervixa T1ab,c Invasive carcinoma diagnosed only by microscopy. Stromal invasio with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or lessd T1a1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread T1a2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread of 7.0 mm or less T1b Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 T1b1 Clinically visible lesion 4.0 cm or less in greatest dimension T1b2 Clinically visible lesion more than 4.0 cm in greatest dimension T2 Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina T2a Tumour without parametrial invasion T2a1 Clinically visible lesion 4.0 cm or less in greatest dimension T2a2 Clinically visible lesion more than 4.0 cm in greatest dimension T2b Tumour with parametrial invasion T3 Tumour, involves lower third of vagina, or extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T3a Tumour involves lower third of vagina T3b Tumour extends to pelvic wall, or causes hydronephrosis or non-functioning kidney T4 Tumour invades mucosa of the bladder or rectum, or extends beyond true pelvise NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis with the following features: Regional lymph nodes The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral and lateral sacral nodes. Para-aortic nodes are not regional. M0 No distant metastasis M1 Distant metastasis (includes inguinal lymph nodes and intraperitoneal disease). It excludes metastasis to vagina, pelvic serosa and adnexa aExtension to corpus uteri should be disregarded. bThe depth of invasion should be taken from the base of the epithelium, either surface or glandular, from which it originates. The depth of invasion is defined as the measurement of the tumour from the epithelial–stromal junction of the adjacent most measurement of the tumour from the epithelial–stromal junction of the adjacent most superficial papillae to the deepest point of invasion. Vascular space involvement, venous or lymphatic, does not affect classification. cAll macroscopically visible lesions even with superficial invasion are T1b/IB. dVascular space involvement, venous or lymphatic, does not affect classification. eBullous oedema is not sufficient to classify a tumour as T4. Table 3b. Stages of cervical cancer Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 3b. Stages of cervical cancer Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 I T1 M0 IA T1a N0 M0 IA T1a M0 IA1 T1a1 N0 M0 IA1 T1a1 M0 IA2 T1a2 N0 M0 IA2 T1a2 M0 IB T1b N0 M0 IB T1b M0 IB1 T1b1 N0 M0 IB1 T1b1 M0 IB2 T1b2 N0 M0 IB2 T1b2 M0 II T2 N0 M0 II T2 M0 IIA T2a N0 M0 IIA T2a M0 IIA1 T2a1 N0 M0 IIA1 T2a1 M0 IIA2 T2a2 N0 M0 IIA2 T2a2 M0 IIB T2b N0 M0 IIB T2b M0 III T3 N0 M0 III T3 M0 IIIA T3a N0 M0 IIIA T3a M0 IIIB T3b Any N M0 IIIB T3b M0 T1, T2, T3 N1 M0 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Stage IA cannot be assessed macroscopically. There are data indicating that subdividing by size (with a 4-cm cut-off for maximum diameter) is appropriate for Stage IIA, while there are no available data for Stage IIB in the literature supporting a subdivision regarding tumour size. The decision not to subdivide Stages IIB and IIIB according to uni- or bilateral parametrial extension is also because the treatment is identical in both situations and that subdivision would not affect management. Furthermore, lympho-vascular space invasion and lymph node metastasis affect prognosis and decision-making regarding treatment after hysterectomy. These factors have been taken into consideration when staging cervical cancer. Nevertheless, these important risk factors were not included in the staging nomenclature because of their subjective definition, as this influences the assessment of its extension and thus its significance. Despite improvements in imaging techniques, the FIGO Committee on Gynecologic Oncology has not performed lymph nodal assessment per se regarding its importance for staging. However, the FIGO Committee encourages the use of imaging techniques for the evaluation of the extension and size of the lesion(s). The TNM classification also recommends various imaging modalities such as magnetic resonance imaging and computed tomography, although they are not mandatory. Pelvic examination under anaesthesia, cystoscopy, sigmoid-colonoscopy and Drip Infusion Pyelography are optional rather than essential. The number of lymph nodes necessary to establish pN classification is six, which is the same as that for the vulva. FIGO classifies cases with less than six nodes resected as pNX. In April 2018, the FIGO Gynecologic Oncology Committee proposed modifications of the current Cervical Cancer Staging System. Although this is not a decision item, because of the poor disease prognosis associated with lymph node metastasis (3), the inclusion of lymph node metastasis is likely to be revised in the staging classification in the near future. Other risk factors for cervical cancer are shown in Table 3c. Table 3c. Prognostic risk factors for cervical cancer Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Table 3c. Prognostic risk factors for cervical cancer Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Prognostic factors Tumour related Host related Environment related Essential Unilateral vs. bilateral disease Parametrial invasion Invasion to side wall Size of tumour Lymph node invasion Positive surgical margins Immunosuppression (i.e., HIV infection) Performance status Morbid obesity Quality of and availability of anticancer therapies Expertise of healthcare personnel Multidisciplinary teams Additional Lympho-vascular space invasion Histological type Anaemia during treatment Ability to manage co morbid conditions New and promising Tumour hypoxia VEGF, mEGFR, HIF 1α, COX2 PAI1 expression SCC Ag and hsCRP for early detection of recurrence Serum MyoDI hypermethylation Persistence of HPV infection following treatment Adequate laboratory facilities to measure tumour markers Endometrial cancer (ICD-O-3 C54.1, C55) In 1988, the FIGO Committee decided to divide the myometrium so that Stage IA was limited to the endometrium, Stage IB to the inner one-half, and Stage IC to the outer one-half of the myometrium. The current TNM categories and FIGO staging are shown in Table 4a and b . Prognostic factors not related to staging are listed in Table 4c. Table 4a. TNM categoris of endometrial cancer TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) aEndocervical glandular involvement only should be considered as Stage I. bPositive cytology has to be reported separately without changing the stage. cThe presence of bullous oedema is not sufficient evidence to classify as T4. Table 4a. TNM categoris of endometrial cancer TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) TNM categories FIGO stage TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 Tumour confined to the corpus uteria Ia T1a Tumour limited to endometrium or invading less than half of myometrium IAa T1b Tumour invades one-half or more of myometrium IB T2 Tumour invades cervical stroma, but does not extend beyond the uterus II T3 Local and/or regional spread as specified here: III T3a Tumour invades the serosa of the corpus uteri or adnexae (direct extension or metastasis) IIIA T3b Vaginal or parametrial involvement (direct extension or metastasis) IIIB N1, N2 Metastasis to pelvic or para-aortic lymph nodesb IIIC N1 Metastasis to pelvic lymph nodes IIIC1 N2 Metastastis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes IIIC2 T4c Tumour invades bladder/bowel mucosa IV NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis to pelvic lymph nodes N2 Regional lymph node metastasis to para-aortic lymph nodes with or without metastasis to pelvic lymph nodes M0 No distant metastasis M1 Distant metastasis (excluding metastasis to vagina, pelvic serosa or adnexa, including metastasis to inguinal lymph nodes, intra-abdominal lymph nodes other than para-aortic or pelvic nodes) aEndocervical glandular involvement only should be considered as Stage I. bPositive cytology has to be reported separately without changing the stage. cThe presence of bullous oedema is not sufficient evidence to classify as T4. Table 4b. Stages of endometrial cancer Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 4b. Stages of endometrial cancer Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Anatomic Stage/TNM categories FIGO Stages T M O Tis N0 M0 I T1 N0 M0 Ia T1 N0 M0 IA T1a N0 M0 IAa T1a N0 M0 IB T1b N0 M0 IB T1b N0 M0 II T2 N0 M0 II T2 N0 M0 IIIA T3a N0 M0 IIIA T3a N0 M0 IIIB T3b Any N M0 IIIB T3b N0 M0 III T1, T2, T3 N1, N2 M0 IIIC N1, N2 IIIC1 T1, T2, T3 N1 M0 IIIC1 N1 IIIC2 T1, T2, T3 N2 M0 IIIC2 N2 IVA T4 Any N M0 IVA T4 M0 IVB Any T Any N M1 IVB M1 Table 4c. Prognostic risk factors for endometrial cancer Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Table 4c. Prognostic risk factors for endometrial cancer Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Prognostic factors Tumour related Host related Environment related Essential Depth of myometrial invasion Grade of differentiation Tumour cell type Lympho-vascular space invasion Post-surgical treatment Additional Metastasis to lymph nodes Site of distant metastasis Age Performance status Race Comorbidities Extent of resection Post-surgical treatment New and promising Molecular profile Staging has changed considerably, and data collection now allows identification and analysis of specific prognostic factors in surgical–pathological staging. In volume 26 of the FIGO Annual Report, surgical Stage IA G1, IB G1, IA G2 and IB G2 had 5-year survival rates of 93.4%, 91.6%, 91.3% and 93.4%, respectively, with no difference among the stages (4). This resulted in revisions to the staging system for endometrial cancer adopted in 2008. In addition, Stages IA and IB, adopted in 1988, have been combined so that now Stage IA involves the endometrium and/or myometrial invasion (MI) of less than one-half, and IB applies to tumours that extend to or beyond the outer one-half of the myometrium. In addition, Stage II no longer has a subsets A and B. Involvement of the endocervical glandular portion of the cervix is now considered Stage I. The other area of note is that pelvic and para-aortic node involvement have been separated rather than combining them in a single substage. This seems to be reasonable, since data suggest that the prognosis is worse if the para-aortic nodes are involved. As a result, Stage IIIC is now categorized as IIIC1 (indicating N1: positive pelvic nodes) and IIIC2 (indicating N2: positive para-aortic nodes with or without positive pelvic nodes) (5,6). Histologic grade is also an important prognostic factor: three grades (G1, G2 and G3) are defined according to the degree of differentiation of the adenocarcinoma. Special types such like serous, clear cell and mixed mesodermal tumours are high risk and considered G3 (4). Furthermore, positive cytological findings may adversely impact prognosis, but this remains controversial and requires further study. Regardless, although cytology results are no longer included in staging classification, they should be recorded. Uterine sarcomas (leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma) (ICD-O-3 53, 54) The staging described in this part is adopted to uterine sarcomas, except for carcinosarcoma (Table 4d–f). Sarcoma in the corpus uteri is distinguishable owing to its biological behaviour. Moreover, tumour size impacts prognosis of leiomyosarcoma (LMS) and endometrial stromal sarcoma (ESS), hence T1 is divided into two categories: T1a (tumour diameter 5 cm or less) and T1b (more than 5 cm) (7). In adenosarcoma, tumour size correlates with deep MI, which is an independent prognostic factor (8). T1 is divided into three categories: T1a (no MI), T1b (MI less than 1/2) and T1c (MI more than 1/2). In addition, incidence of lymph node metastasis is low. Moreover, many cases of uterine sarcoma that are thought to be benign are diagnosed after hysterectomy. The exact effect regarding the prognosis of lymph node metastasis were previously unknown. Table 4d. TNM categories of leiomyosarcoma and endometral stromal sarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Simultaneous tumours of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classified as independent primary tumours. Table 4d. TNM categories of leiomyosarcoma and endometral stromal sarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour 5 cm or less in greatest dimension T1b IB Tumour more than 5 cm T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Simultaneous tumours of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classified as independent primary tumours. Table 4e. TNM categories of adenosarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Table 4e. TNM categories of adenosarcoma TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis TNM categories FIGO stages Definition T1 I Tumour limited to the uterus T1a IA Tumour limited to the endometrium/endocervix T1b IB Tumour invades to less than half of the myometrium T1c IC Tumour invades more than half of the myometrium T2 II Tumour extends beyond the uterus, within the pelvis T2a IIA Tumour involves adnexa T2b IIB Tumour involves other pelvic tissues T3 III Tumour infiltrates abdominal tissues T3a IIIA One site T3b IIIB More than one site N1 IIIC Metastasis to regional lymph nodes T4 IVA Tumour invades bladder or rectum M1 IVB Distant metastasis Table 4f. Stages of uterine sarcomas I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 aStage IC does not apply for leiomyosarcoma and endometrial stromal sarcoma. Table 4f. Stages of uterine sarcomas I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 I T1 N0 M0 IA T1a N0 M0 IB T1b N0 M0 ICa T1c N0 M0 II T2 N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T1, T2, T3 N1 M0 IVA T4 Any N M0 IVB Any T Any N M1 aStage IC does not apply for leiomyosarcoma and endometrial stromal sarcoma. The prognosis of patients with uterine sarcomas has not changed in recent decades: the overall 5-year survival has been between 17.5% and 54.7% in various studies (9). In a recently reported series of 100 cases, the 2-, 5- and 10-year overall survival rates were 62%, 51% and 38%, respectively. Additionally, in multivariate analysis, stage, age, tumour size and parity have independently influenced overall survival (9–11). Recently, the impact of lymph node metastasis on survival of uterine sarcomas was reported by analyzing data from the SEER study. The incidence of lymph node metastasis in uterine sarcomas is low, especially in adenosarcoma compared with leiomyosarcoma and ESS; however lymph node metastasis is associated with a worse prognosis (8). Finally, ESS has two subtypes: high-grade and low-grade; lymph node metastasis is frequent in high-grade ESS compared with that of low-grade ESS and is a risk factor of cause-specific survival (12). Ovarian, fallopian tube and primary peritoneal carcinoma (ICD-O-3 C56; ICD-O-3 C57) TNM categories and FIGO stages are shown in Table 5a. Ovarian cancer is thought to arise from the surface epithelium of the ovary. However, the relationship between high-grade serous carcinoma (HGSC) in the tubal epithelium and the decreased incidence of ovarian cancer after prophylactic salpingectomy indicate that a significant number of HGSCs arise from the fallopian tube. Moreover, endometrioid carcinoma and clear cell carcinoma are strongly related to endometriosis on the ovary or peritoneum (13). Therefore, the committee decided to integrate the staging systems of the ‘ovary and peritoneum’ with that of the Fallopian tube in the eighth edition. Ovarian, fallopian tube and peritoneal cancers have a similar clinical presentation and are treated similarly, and current evidence supports staging all three cancers in a single system. The primary site (i.e. ovary, fallopian tube or peritoneum) should be designated where possible, and the histologic type should be recorded. Table 5a. The FIGO stages are based on surgical staging (TNM stages are based on clinical and/or pathological classification) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) aLiver capsule metastasis is T3/Stage III. bLiver parenchymal metastasis M1/Stage IV. Table 5a. The FIGO stages are based on surgical staging (TNM stages are based on clinical and/or pathological classification) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) TNM categories FIGO stages Definition TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries (one or both) or fallopian tube(s) T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1b IB Tumour limited to both ovaries or fallopian tubes; capsule intact, no tumour on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings T1c IC Tumour limited to one or both ovaries or fallopian tubes with any of the following: T1c1 Surgical spill T1c2 Capsule ruptured before surgery or tumour on ovarian or fallopian tube surface T1c3 Malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer T2a IIA Extension and/or implants on uterus and/or fallopian tube(s) and or ovary(ies) T2b IIB Extension to other pelvic tissues, including bowel within the pelvis T3 and/or N1 IIIa Tumour involves one or both ovaries or fallopian tubes or primary peritoneal carcinoma with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes N1 Retroperitoneal lymph node metastasis only N1a IIIA1i Lymph node metastasis not more than 10 mm in greatest dimension N1b IIIA1ii Lymph node metastasis more than 10 mm in greatest dimension T3a any N IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without retroperitoneal lymph node, including bowel involvement T3b any N IIIB Macroscopic peritoneal metastasis beyond pelvic brim 2 cm, or less in greatest dimension, including bowel involvement outside the pelvis with or without retroperitoneal nodes T3c any N IIIC Peritoneal metastasis beyond pelvic brim more than 2 cm in greatest dimension and/or retroperitoneal lymph node metastasis (includes extension of tumour to capsule of liver and spleen without parenchymal involvement of either organ) M1 IV Distant metastasis (excludes peritoneal metastasis) M1a IVA Pleural effusion with positive cytology M1bb IVB Parenchymal metastasis and metastasis to extra abdominal organs (including inguinal lymph nodes and lymph nodes outside the abdominal cavity) aLiver capsule metastasis is T3/Stage III. bLiver parenchymal metastasis M1/Stage IV. In the seventh edition, T2a comprises tumours arising from the unilateral ovary (or tube) and extending to the tube(s) (or ovaries); in the eighth edition, T2a is defined as tumour involving one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer. When a tumour involves the bilateral ovaries (or tubes), it is difficult to determine whether the cancer is T1b or T2a. The presence of a transitional lesion of the malignant tumour from a benign tumour in each ovary (or tube) with an intact capsule may suggest T1b. Occasionally, a large-stage IB ovarian tumour is associated with a contralateral normal-size ovary exhibiting small and superficial foci of the tumour; this suggests that superficial foci are metastatic. Pathologically proofed Stage II cancer exhibits a worse prognosis than does surgical Stage II, demonstrating adherence between the tumour and pelvic organs without pathological tumour infiltration (14). Intraoperative rupture (‘surgical spill’) comprises T1c1, capsule rupture before surgery or a tumour on the ovarian or fallopian tube surface comprises T1c2, and positive peritoneal cytology with or without rupture comprises T1c3. However, it is controversial whether surgical spill affects prognosis. Nevertheless, preoperative capsule rapture and positive washings are independent predictors of worse disease-free survival (15). Stage II cancer comprises a small and heterogenous group. During revision, the committee described that there was a lack of biological evidence to support subdividing this small category into IIB1and IIB2. Moreover, for FIGO Stage II, the IIc Substage has been eliminated, as the cytology results do not influence outcome. The new staging includes a revision of Stage III patients; assignment to Stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination. In addition, N1 was divided into N1a and N1b according to size of the metastatic tumour nest in the lymph node. pN should be diagnosed pathologically by retrieving at least one node from both the pelvic and para-aortic lymph nodes or more than one node from each lesion. There is, however, a significant difference in overall survival between Stages IIIA/B and IIIC. Nonetheless, there are no data supporting quantification of the size of metastasis in IIIA1 (16,17). Stage IIIC (T3c-N0 or 1-M0) indicates spread to the surface of peritoneal cavity organs beyond the pelvis. In Stage III, the 2-cm cut-off between IIIB and IIIC remains a controversial issue, as it is unclear which is worse: a few metastatic sites over 2 cm or numerous sites under 2 cm. M1b indicates isolated parenchymal metastases and should be distinguished from T3 as a tumour on the surface without infiltration or metastases in the stroma of peritoneal cavity organs. Finally, positive cytology in pleural effusion is categorized as M1a and Stage IVA and does not necessarily suggest parenchymal metastasis of the lung (16,18). It has also been suggested that serous tubal intraepithelial carcinoma and BRCA gene status (somatic and germline) should be included in the staging system (19). The Committee will not be issuing a statement at this time, but will do so when the next cycle of revision takes place (20). Additional risk factors are shown in Table 5b. Table 5b. Prognostic risk factors for tumours of the ovary, fallopian tube and peritoneal carcinoma Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Table 5b. Prognostic risk factors for tumours of the ovary, fallopian tube and peritoneal carcinoma Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Prognostic factors Tumour related Host related Environment related Essential Histological type Grade Surgical stage Residual disease Age Comorbidities Performance status Maximum diameter of residual disease after optimal debulking Additional Nodal involvement Site of metastasis DNA ploidy CA125 BRCA1 Genetic predisposition Type of chemotherapy CA125 fall Ultra radical surgery New and promising Molecular profile Cellular proliferative activity Tumour angiogenesis markers p53 expression Expression of human kallikrein (hK) genes, particularly hKs6-10-11 Interval debulking surgery (IDS) Neoadjuvant chemotherapy Gestational trophoblastic tumours (ICD-O-3 C58) The classification for gestational trophoblastic tumours is based on that of FIGO and were adopted in 1992 and updated in 2002. The definitions of T and M categories correspond to the FIGO stages (Table 6a). There is no regional designation in the staging of these tumours. Node metastases are classified as metastatic (M1) disease. A prognostic scoring index (Table 6b), based on factors other than the anatomic extent of the disease, is used to assign cases to high- and low-risk categories, and these categories are used in stage grouping. Table 6a. Stages of gestational trophoblastic tumours TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis aStages I–IV are subdivided into A and B according to the prognostic score. bGenital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. cAny involvement of non genital structures, whether by direct invasion or metastasis is described using the M classification. Table 6a. Stages of gestational trophoblastic tumours TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis TNM categories FIGO stagesa Definition TX Primary tumour cannot be assessed Stage T0 No evidence of primary tumour I T1 M0 T1 I Tumour confined to uterus II T2 M0 T2b II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension III Any T M1a M1a III Metastasis to lung(s) IV Any T M1b M1bc IV Other distant metastasis aStages I–IV are subdivided into A and B according to the prognostic score. bGenital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. cAny involvement of non genital structures, whether by direct invasion or metastasis is described using the M classification. Table 6b. Prognostic scoring index for gestational trophoblastic tumours Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Risk categories. Total prognostic score 6 or less = low risk. Total score 7 or more = high risk. Table 6b. Prognostic scoring index for gestational trophoblastic tumours Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Prognostic factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy Months from index pregnancy (months) <4 4–6 7–12 >12 Pre-treatment serum hCG (IU/ml) <103 103–104 104–105 >105 Largest tumour size including uterus Lung Spleen, kidney Gastrointestinal tract Liver, brain Sites of metastasis 1–4 5–8 >8 Previous failed chemotherapy Single drug Two or more drugs Risk categories. Total prognostic score 6 or less = low risk. Total score 7 or more = high risk. Anatomical spread of gestational trophoblastic disease does not always reflect prognosis. Lung is the first metastatic site in the earlier stage, so lung disease should be handled separately from that of other organs. In Japan, a diagnostic scoring index for clinical choriocarcinoma has been used, and the Japanese registration project for gestational trophoblastic disease has continued to be based on it. Moreover, although FIGO scoring system and the Japanese diagnostic scoring system have high commonality, the FIGO score does not indicate a pathological diagnosis. Conclusion The TNM classification is originally based on anatomic spread of malignant disease; this basic concept has been successfully adopted for almost all malignancies of various organs. With the development of new drugs, the development of medical technology and equipment, the staging classification has changed. Biological features are different among primary organs, histological types, and genetic backgrounds. New prognostic factors may be included into categories defining stages. A good staging system must be valid, reliable and practical. Special equipment and expensive inspections are not preferable for the staging system to be accepted globally. Stages of disease reflect prognosis of malignancies and are the most important guidelines to determine treatment strategy. Accordingly, clinicians must precisely record the stage of malignant tumours as well as the clinical information to assist in the development of better prognostic indicators. Funding None. Conflict of interest statement None declared. References 1 Odicino F , Pecorelli S , Zigliani L , Creasman WT . History of the FIGO cancer staging system . Int J Gynaecol Obstet 2008 ; 101 : 205 – 10 . Google Scholar Crossref Search ADS PubMed 2 Hacker NF . Revised FIGO staging for carcinoma of the vulva . Int J Gynaecol Obstet 2009 ; 105 : 105 – 6 . Google Scholar Crossref Search ADS PubMed 3 Kidd EA , Siegel BA , Dehdashti F , et al. Lymph node staging by positron emission tomography in cervical cancer: relationship to prognosis . J Clin Oncol 2010 ; 28 : 2108 – 13 . Google Scholar Crossref Search ADS PubMed 4 Creasman WT , Odicino F , Maisonneuve P , et al. Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer . Int J Gynaecol Obstet 2006 ; 95 : S105 – 43 . Google Scholar Crossref Search ADS 5 Creasman W . Revised FIGO staging for carcinoma of the endometrium . Int J Gynaecol Obstet 2009 ; 105 : 109 . Google Scholar Crossref Search ADS PubMed 6 Lewin SN , Wright JD . Comparative Performance of the 2009 International Federation of Gynecology and Obstetrics’ Staging System for Uterine Corpus Cancer . Obstet Gynecol 2011 ; 117 : 1226 . Google Scholar Crossref Search ADS PubMed 7 Giuntoli RL 2nd. , Lessard-Anderson CR , Gerardi MA , et al. Comparison of current staging systems and a novel staging system for uterine leiomyosarcoma. Int J Gynaecol . Cancer 2013 ; 23 : 869 – 76 . 8 Machida H , Nathenson MJ , Takiuchi T , Adams CL , Garcia-Sayre J , Matsuo K . Significance of lymph node metastasis on survival of women with uterine adenosarcoma . Gynecol Oncol 2017 ; 144 : 524 – 30 . Google Scholar Crossref Search ADS PubMed 9 Koivisto-Korander R , Butzow R , Koivisto AM , Leminen A . Clinical outcome and prognostic factors in 100 cases of uterine sarcoma: experience in Helsinki University Central Hospital 1990-2001 . Gynecol Oncol 2008 ; 111 : 74 – 81 . Google Scholar Crossref Search ADS PubMed 10 Giuntoli RL 2nd. , Metzinger DS , DiMarco CS , et al. Retrospective review of 208 patients with leiomyosarcoma of the uterus: prognostic indicators, surgical management, and adjuvant therapy . Gynecol Oncol 2003 ; 89 : 460 – 9 . Google Scholar Crossref Search ADS PubMed 11 Prat J . FIGO staging for uterine sarcomas . Int J Gynaecol Obstet 2009 ; 104 : 177 – 8 . Google Scholar Crossref Search ADS PubMed 12 Seagle BL , Shilpi A , Buchanan S , Goodman C , Shahabi S . Low-grade and high-grade endometrial stromal sarcoma: a National Cancer Database study . Gynecol Oncol 2017 ; 146 : 254 – 62 . Google Scholar Crossref Search ADS PubMed 13 Kurman RJ , Shih IeM . The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory . Am J Surg Pathol 2010 ; 34 : 433 – 43 . Google Scholar Crossref Search ADS PubMed 14 Seidman JD , Cosin JA , Wang BG , et al. Upstaging pathologic stage I ovarian carcinoma based on dense adhesions is not warranted: a clinicopathologic study of 84 patients originally classified as FIGO stage II . Gynecol Oncol 2010 ; 119 : 250 – 4 . Google Scholar Crossref Search ADS PubMed 15 Bakkum-Gamez JN , Richardson DL , Seamon LG , et al. Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer . Obstet Gynecol 2009 ; 113 : 11 – 7 . Google Scholar Crossref Search ADS PubMed 16 Prat J . Oncology FCoG. Staging classification for cancer of the ovary, fallopian tube, and peritoneum . Int J Gynaecol Obstet 2014 ; 124 : 1 – 5 . Google Scholar Crossref Search ADS PubMed 17 Pereira A , Perez-Medina T , Magrina JF , et al. International Federation of gynecology and obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum: estimation of survival in patients with node-positive epithelial ovarian cancer . Int J Gynecol Cancer 2015 ; 25 : 49 – 54 . Google Scholar Crossref Search ADS PubMed 18 Prat J . Abridged republication of FIGO’s staging classification for cancer of the ovary, fallopian tube, and peritoneum . Cancer 2015 ; 121 : 3452 – 4 . Google Scholar Crossref Search ADS PubMed 19 Tjalma WA . Staging classification for cancer of the ovary and fallopian tube should include in situ carcinoma . Cancer 2016 ; 122 : 651 . Google Scholar Crossref Search ADS PubMed 20 Denny L . Reply to staging classification for cancer of the ovary and fallopian tube should include in situ carcinoma . Cancer 2016 ; 122 : 652 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Japanese Journal of Clinical Oncology – Oxford University Press

Published: Apr 1, 2019

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TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

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TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

TNM classification of gynaecological malignant tumours, eighth edition: changes between the seventh and eighth editions

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