Gynecological Tumours Ovary

1. Rules for Classification

The classification applies to malignant surface epithelial-stromal tumours including those of borderline malignancy or of low malignant potential (WHO histological classification, 2nd edition, Scully 1999) corresponding to "common epithelial tumours" of the earlier terminology. Non-epithelial ovarian cancers may also be classified using this scheme. There should be histological confirmation of the disease and division of cases by histological type. The following are the procedures for assessing T, N, and M categories:
T categories. Physical examination, imaging, laparoscopy, and/or surgical exploration N categories. Physical examination, imaging, laparoscopy, and/or surgical exploration M categories. Physical examination, imaging, laparoscopy, and/or surgical exploration The FIGO stages are based on surgical staging. (TNM stages are based on clinical and/or pathological classification.)
The definitions of the T, N, and M categories correspond to the FIGO stages. Both systems are included for comparison.

2. Regional Lymph Nodes

The regional lymph nodes are the hypogastric (obturator), common iliac, external iliac, lateral sacral, para-aortic, and inguinal nodes.

3. TNM Clinical Classification

3.1. T - Primary Tumour

TNM Categories FIGO Stages TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour limited to the ovaries T1a IA Tumour limited to one ovary; capsule intact, no tumour on ovarian surface; no malignant cells in ascites or perito-neal washings T1b IB Tumour limited to both ovaries; capsule intact, no tumour on ovarian surface; no malignant cells in ascites or perito-neal washings T1c IC Tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both ovaries with pelvic extension T2a IIA Extension and/or implants on uterus and/or tube(s); no malignant cells in ascites or peritoneal washings T2b IIB Extension to other pelvic tissues; no malignant cells in ascites or peritoneal washings T2c IIC Pelvic extension (2a or 2b) with malignant cells in ascites or peritoneal washings T3 and/or N1 III Tumour involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasis T3a IIIA Microscopic peritoneal metastasis beyond pelvis T3b IIIB Macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension T3 and/or N1 IIIC Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis M1 IV Distant metastasis (excludes peritoneal metastasis)

Note: Liver capsule metastasis is T3/stage III, liver parenchymal metastasis M1/stage IV. Pleural effusion must have positive cytology for M1/stage IV. 3.2. N - Regional Lymph Nodes
NX. Regional lymph nodes cannot be assessed N0. No regional lymph node metastasis N1. Regional lymph node metastasis
3.3. M - Distant Metastasis
MX. Distant metastasis cannot be assessed M0. No distant metastasis M1. Distant metastasis

4. 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.

5. G Histopathological Grading

See definitions on .

6. Stage Grouping

Stage IA T1a N0 M0 Stage IB T1b N0 M0 Stage IC T1c N0 M0 Stage IIA T2a N0 M0 Stage IIB T2b N0 M0 Stage IIC T2c N0 M0 Stage IIIA T3a N0 M0 Stage IIIB T3b N0 M0 Stage IIIC T3c N0 M0 Any T N1 M0 Stage IV Any T Any N M1

7. Summary

TNM Ovary FIGO T1 Limited to the ovaries I T1a One ovary, capsule intact IA T1b Both ovaries, capsule intact IB T1c Capsule ruptured, tumour on surface, malignant cells in ascites or peritoneal washings IC T2 Pelvic extension II T2a Uterus, tube(s) IIA T2b Other pelvic tissues IIB T2c Malignant cells in ascites or peritoneal washings IIC T3 and/or N1 Peritoneal metastasis beyond pelvis and/or regional lymph node metastasis III T3a Microscopic peritoneal metastasis IIIA T3b Macroscopic peritoneal metastasis ≤2 cm IIIB T3 and/or N1 Peritoneal metastasis >2 cm and/or regional lymph node metastasis IIIC M1 Distant metastasis (excludes peritoneal metastasis) IV

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Gynecological Tumours Corpus Uteri

1. Rules for Classification

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

The classification applies to carcinomas and malignant mixed mesodermal tumours. There should be histological verification with subdivision by histological type and grading of the carcinomas. The diagnosis should be based on examination of specimens taken by endometrial biopsy.

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

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

The FIGO stages are based on surgical staging. (TNM stages are based on clinical and/or pathological classification.)

2. Anatomical Subsites

1. Isthmus uteri (C54.0)
2. Fundus uteri (C54.3)

3. Regional Lymph Nodes

The regional lymph nodes are the pelvic (hypogastric [obturator, internal iliac], common and external iliac, parametrial, and sacral) and the para-aortic nodes.

4. TNM Clinical Classification

4.1. T - Primary Tumour

TNM Categories FIGO Stages TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis 0 Carcinoma in situ (preinvasive carcinoma) T1 I Tumour confined to corpus uteri T1a IA Tumour limited to endometrium T1b IB Tumour invades less than one half of myometrium T1c IC Tumour invades one half or more of myometrium T2 II Tumour invades cervix but does not extend beyond uterus T2a IIA Endocervical glandular involvement only T2b IIB Cervical stromal invasion T3 and/or N1 III Local and/or regional spread as specified in T3a, b, N1, and FIGO IIIA, B, C below T3a IIIA Tumour involves serosa and/or adnexa (direct extension or metastasis) and/or cancer cells in ascites or peritoneal washings T3b IIIB Vaginal involvement (direct extension or metastasis) N1 IIIC Metastasis to pelvic and/or para-aortic lymph nodes T4 IVA Tumour invades bladder mucosa and/or bowel mucosa Note: The presence of bullous edema is not sufficient evidence to classify a tumour as T4. The lesion should be confirmed by biopsy. M1 IVB Distant metastasis (excluding metastasis to vagina, pelvic serosa, or adnexa) Note: FIGO (2001) recommends that Stage I patients given primary radiation therapy can be clinically classified as follows: Stage I: Tumour confined to corpus uteri Stage IA: Length of uterine cavity 8 cm or less Stage IB: Length of uterine cavity more than 8 cm

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

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

For histopathological grading see: Creasman WT, Odicino F, Maisoneuve P, Beller U, Benedet JL, Heintz APM, Ngan HYS, Sideri M, Pecorelli S. FIGO Annual Report on the results of treatment in gynaecological cancer. Vol. 24. Carcinoma of the corpus uteri. J Epidemiol Biostat 2001;6:45-86.

7. Stage Grouping

Stage 0 Tis N0 M0 Stage IA T1a N0 M0 Stage IB T1b N0 M0 Stage IC T1c N0 M0 Stage IIA T2a N0 M0 Stage IIB T2b N0 M0 Stage IIIA T3a N0 M0 Stage IIIB T3b N0 M0 Stage IIIC T1, T2, T3 N1 M0 Stage IVA T4 Any N M0 Stage IVB Any T Any N M1

8. Summary

TNM Corpus Uteri FIGO Tis In situ 0 T1 Confined to corpus I T1a Tumour limited to endometrium IA T1b Less than half of myometrium IB T1c One half or more of myometrium IC T2 Invades cervix II T2a Endocervical glandular only IIA T2b Cervical stroma IIB T3 and/or N1 Local or regional as specified below III T3a Serosa/adnexa/positive peritoneal cytology IIIA T3b Vaginal involvement IIIB N1 Regional lymph node metastasis IIIC T4 Mucosa of bladder/bowel IVA M1 Distant metastasis IVB

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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 TX Primary tumour cannot be assessed T0 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

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