Wednesday, December 24, 2014

Gynecological Tumours Cervix Uteri

1. Rules for Classification

The classification applies only to carcinomas. There should be histological confirmation of the disease.

The following are the procedures for assessing T, N, and M categories:

T categories. Physical examination, cystoscopy,* and imaging including urography
N categories. Physical examination and imaging including urography
M categories. Physical examination and imaging

The FIGO stages are based on clinical staging. This includes histological examination of a cone or amputation of the cervix. (TNM stages are based on clinical and/or pathological classification.)

The definitions of the T and M categories correspond to the FIGO stages. Both systems are included for comparison.

2. Anatomical Subsites

1. Endocervix (C53.0)
2. Exocervix (C53.1)

3. Regional Lymph Nodes

The regional lymph nodes are the paracervical, parametrial, hypogastric (internal iliac, obturator), common and external iliac, presacral, and lateral sacral nodes.

4. TNM Clinical Classification

4.1.T - Primary Tumour

TNM Categories FIGO Stages
Primary tumour cannot be assessed
No evidence of primary tumour
Tis 0 Carcinoma in situ (preinvasive carcinoma)
T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded)
T1a IA Invasive carcinoma diagnosed only by microscopy. All macroscopically visible lesions-even with superficial invasion-are T1b/Stage IB
T1a1 IA1 Stromal invasion no greater than 3.0 mm in depth and 7.0 mm or less in horizontal spread
T1a2 IA2 Stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread 7.0 mm or less
Note: The depth of invasion should not be more than 5 mm 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 superficial epithelial papilla to the deepest point of invasion.
Vascular space involvement, venous or lymphatic, does not affect classification.
T1b IB Clinically visible lesion confined to cervix or microscopic lesion greater than T1a2/IA2
T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension
T1b2 IB2 Clinically visible lesion more than 4 cm in greatest dimension
T2 II Tumour invades beyond uterus but not to pelvic wall or to lower third of vagina
T2a IIA Without parametrial invasion
T2b IIB With parametrial invasion
T3 III Tumour extends to pelvic wall, involves lower third of vagina, or causes hydronephrosis or non-functioning kidney
T3a IIIA Tumour involves lower third of vagina, no extension to pelvic wall
T3b IIIB Tumour extends to pelvic wall or causes hydronephrosis or non-functioning kidney
T4 IVA Tumour invades mucosa of bladder or rectum or extends beyond true pelvis
Note: The presence of bullous oedema is not sufficient to classify a tumour as T4. The lesion should be confirmed by biopsy.
M1 IVB Distant metastasis

4.2. N - Regional Lymph Nodes

NX. Regional lymph nodes cannot be assessed
N0. No regional lymph node metastasis
N1. Regional lymph node metastasis

4.3. M - Distant Metastasis

MX. Distant metastasis cannot be assessed
M0. No distant metastasis
M1. Distant metastasis 

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5. pTNM Pathological Classification

The pT, pN, and pM categories correspond to the T, N, and M categories.

pN0. Histological examination of a pelvic lymphadenectomy specimen will ordinarily include 10 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0.

6. G Histopathological Grading

GX. Grade of differentiation cannot be assessed
G1. Well differentiated
G2. Moderately differentiated
G3. Poorly differentiated
G4. Undifferentiated

7. Stage Grouping

Stage 0 Tis N0 M0
Stage IA T1a N0 M0
Stage IA1 T1a1 N0 M0
Stage IA2 T1a2 N0 M0
Stage IB T1b N0 M0
Stage IB1 T1b1 N0 M0
Stage IB2 T1b2 N0 M0
Stage IIA T2a N0 M0
Stage IIB T2b N0 M0
Stage IIIA T3a N0 M0
Stage IIIB T1, T2, T3a N1 M0
T3b Any N M0
Stage IVA T4 Any N M0
Stage IVB Any T Any N M1

8. Summary

TNM Cervix Uteri FIGO
Tis In situ 0
T1 Confined to uterus I
T1a Diagnosed only by microscopy IA
T1a1 Depth ≤3 mm, horizontal spread ≤7 mm IA1
T1a2 Depth >3-5 mm, horizontal spread ≤7 mm IA2
T1b Clinically visible or microscopic lesion, greater than T1a2 IB
T1b1 ≤4 cm IB1
T1b2 >4 cm IB2
T2 Beyond uterus but not pelvic wall or lower third vagina II
T2a No parametrium IIA
T2b Parametrium IIB
T3 Lower third vagina/pelvic wall/hydronephrosis III
T3a Lower third vagina IIIA
T3b Pelvic wall/hydronephrosis IIIB
T4 Mucosa of bladder/rectum; beyond true pelvis IVA
N1 Regional -
M1 Distant metastasis IVB