Gynecological Tumours

Cervix uteri and corpus uteri were among the first sites to be classified by the TNM system. The "League of Nations" stages for carcinoma of the cervix have been used with minor modifications for over 50 years, and, because these are accepted by the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO), the TNM categories have been defined to correspond to the FIGO stages. Some amendments have been made in collaboration with FIGO, and the classifications now published have the approval of the FIGO, UICC, and the national TNM committees including the AJCC.
Each site is described under the following headings:

• Rules for classification with the procedures for assessing T, N, and M categories; additional methods may be used when they enhance the accuracy of appraisal before treatment
• Anatomical subsites where appropriate
• Definition of the regional lymph nodes
• TNM Clinical classification
• pTNM Pathological classification
• Stage grouping
• Summary

2. Distant Metastasis

The categories M1 and pM1 may be further specified according to the following notation:

Pulmonary PUL Bone marrow MAR Osseous OSS Pleura PLE Hepatic HEP Peritoneum PER Brain BRA Adrenals ADR Lymph nodes LYM Skin SKI Others OTH

3. Histopathological Grading

The definitions of the G categories apply to all classified tumours except gestational trophoblastic tumours. These are:

GX. Grade of differentiation cannot be assessed
G1. Well differentiated
G2. Moderately differentiated
G3. Poorly differentiated or undifferentiated

4. R Classification

The absence or presence of residual tumour after treatment is described by the symbol R. The definitions of the R classification are:
RX. Presence of residual tumour cannot be assessed
R0. No residual tumour
R1. Microscopic residual tumour
R2. Macroscopic residual tumour

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Gestational Trophoblastic Tumours

1. Rules for Classification

The following classification for gestational trophoblastic tumours is based on that of FIGO adopted in 1992 and updated in 2001 (Gestational trophoblastic tumours. Ngan HYS, Odicino F, Maisonneuve P, Beller U, Benedet JL, Heintz APM, Pecorelli S, Sideri M, Creasman WT. J Epidemiol Biostatist 2001;6:175-184). The definitions of T and M categories correspond to the FIGO stages. Both systems are included for comparison. In contrast to other sites, an N (regional lymph node) classification does not apply to these tumours. A prognostic scoring index, which is based on factors other than the anatomic extent of the disease, is used to assign cases to high risk and low risk categories, and these categories are used in stage grouping.

The classification applies to choriocarcinoma (9100/3), invasive hydatidiform mole (9100/1), and placental site trophoblastic tumour (9104/1). Placental site tumours should be reported separately. Histological confirmation is not required if the human chorionic gonadotropin (hCG) level is abnormally elevated. History of prior chemotherapy for this disease should be noted.

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

T categories. Physical examination, imaging including urography and cystoscopy
M categories. Physical examination and imaging
Risk categories. Age, type of antecedent pregnancy, interval from index pregnancy, pretreatment hCG, diameter of largest tumour, site of metastasis, number of metastases, and antecedent treatment are integrated to provide a prognostic score that divides cases into low and high risk categories.

2.1. Primary Tumour

TM Categories FIGO Stages * TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour confined to uterus T2 II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension M1a III Metastasis to lung(s) M1b IV Other distant metastasis

^*Note: Stages I to IV are subdivided into A and B according to the prognostic score.

2.2. M - Distant Metastasis

MX. Metastasis cannot be assessed
M0. No distant metastasis
M1. Distant metastasis
  M1a. Metastasis to lung(s)
  M1b. Other distant metastasis
Note: Genital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. Any involvement of non-genital structures, whether by direct invasion or metastasis is described using the M classification.

3. pTM Pathological Classification

The pT and pM categories correspond to the T and M categories.

4. Prognostic Score

Prognostic Factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy H. mole Abortion Term pregnancy Months from index pregnancy <4 4-<7 7-12 >12 Pretreatment serum hCG (IU/ml) <103 103-<104 104-<105 ≥105 Largest tumour size including uterus <3 cm 3-<5 cm ≥5 cm Sites of metastasis Lung Spleen, kidney Gastrointes-tinal tract Liver, brain Number of metastasis 1-4 5-8 >8 Previous failed chemotherapy Single drug Two or more drugs

5. Stage Grouping

Stage T M Risk Category I T1 M0 Unknown IA T1 M0 Low IB T1 M0 High II T2 M0 Unknown IIA T2 M0 Low IIB T2 M0 High III Any T M1a Unknown IIIA Any T M1a Low IIIB Any T M1a High IV Any T M1b Unknown IVA Any T M1b Low IVB Any T M1b High

6. Summary

TM and risk Gestational Trophoblastic Tumours Stage T1 Confined to uterus I T2 Other genital structures II M1a Metastasis to lung(s) III M1b Other distant metastasis IV Low risk Prognostic score 7 or less IA-IVA High risk Prognostic score 8 or more IB-IVB

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Gynecological Tumours Fallopian Tube

Introduction

The following classification for carcinoma of the fallopian tube is based on that of FIGO adopted in 1992. The definitions of the T, N, and M categories correspond to the FIGO stages. Both systems are included for comparison.

1. Rules for Classification

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

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

T categories. 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 staging.)

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 Tis 0 Carcinoma in situ (preinvasive carcinoma) T1 I Tumour confined to fallopian tube(s) T1a IA Tumour limited to one tube, without penetrating the serosal surface T1b IB Tumour limited to both tubes, without penetrating the serosal surface T1c IC Tumour limited to one or both tube(s) with extension onto or through the tubal serosa, or with malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both fallopian tube(s) with pelvic extension T2a IIA Extension and/or metastasis to uterus and/or ovaries T2b IIB Extension to other pelvic structures 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 fallopian tube(s) with peritoneal implants outside the pelvis and/or positive regional lymph nodes T3a IIIA Microscopic peritoneal metastasis outside the pelvis T3b IIIB Macroscopic peritoneal metastasis outside the pelvis 2 cm or less in greatest dimension T3c and/or N1 IIIC Peritoneal metastasis more than 2 cm in greatest dimension and/or positive regional lymph nodes 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 examined lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0.

5. G Histopathological Grading

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

6. 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 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 Fallopian Tube FIGO T1 Limited to tube(s) I T1a One tube; serosa intact IA T1b Both tubes; serosa intact IB T1c Serosa involved; malignant cells in ascites or peritoneal washings IC T2 Pelvic extension II T2a Uterus and/or ovaries IIA T2b Other pelvic structures IIB T2c Malignant cells in ascites or peritoneal washings IIC T3 and/or N1 Peritoneal metastasis outside the pelvis and/or regional lymph node metastasis III T3a Microscopic peritoneal metastasis IIIA T3b Macroscopic peritoneal metastasis ≤2 cm IIIB T3c 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 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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