Staging description
1, Stage 0 refers to atypical proliferative cells involving the entire epithelium but without mesenchymal infiltration.
2, Stages IA1 and IA2 are diagnosed based on microscopic examination of the excised tissue, preferably a cervical cone biopsy, and the excised tissue must contain the entire lesion. Whether the primary lesion is surface epithelium or glandular epithelium, the depth of infiltration must not exceed 5 mm below the epithelial basement membrane, with no more than 7 mm of horizontal spread. Involvement of vascular areas such as veins and lymphatic vessels cannot change the stage, but must be specifically documented, as this can affect treatment decisions. Larger lesions are classified as IB. It is often impossible to estimate clinically whether cervical cancer extends to the body of the uterus; therefore, the spread of the body will be ignored. Zhang Yan, Department of Nuclear Medicine, The First Affiliated Hospital of the Chinese People’s Liberation Army General Hospital
Short, hard, but non-nodular parametrial tissue developing fixed to the pelvic wall is classified as stage IIB. Because it is difficult to determine whether the smooth, hard parametrial tissue is cancer infiltration or inflammation by clinical examination, it is classified as stage III only when the parametrial tissue is nodular and fixed to the pelvic wall, or the mass itself extends to the pelvic wall.
3. Cases classified as stage I or II according to other examinations should be classified as stage III if there is hydronephrosis or non-functional kidney due to ureteral stenosis caused by the infiltration of cancer.
Those with vesicular edema should not be classified as stage IV. A protrusion or depression in the bladder wall found through rectovaginal examination and a fixed mass is a sign of submucosal involvement of the bladder. If malignant cells are found in the bladder irrigation fluid, further histological examination is required to confirm the diagnosis before consideration of stage IVA.
Primary tumor cannot be evaluated TX
No evidence of primary tumor TO
Stage 0 Carcinoma in situ (preinvasive carcinoma) Tis
Stage I Cervical cancer confined to the uterus (extension to the uterine body will be ignored) T1
I A Microscopic invasive carcinoma. All lesions visible to the naked eye, T1a
including superficial infiltration, are ⅠB
ⅠA1 Depth of interstitial infiltration <3 mm, horizontal spread ≤7 mm T1a1
ⅠA2 Mesenchymal infiltration depth 3~5 mm, horizontal spread ≤7 mma T1a2
ⅠB Visible cancer foci confined to the cervix, or microscopic lesions >ⅠA2 T1b
ⅠB1 The maximum diameter of cancer foci visible to the naked eye ≤ 4 cm T1b1
ⅠB2 The maximum diameter of visible cancer foci >4 cm T1b2
Stage II Tumor beyond the uterus, but not reaching the pelvic wall or the lower 1/3 of the vagina T2
ⅡA Without parametrial infiltration T2a
ⅡB with parametrial infiltration T2b
Stage III Tumor extends into the pelvic wall and/or involves the lower third of the vagina and/or T3
Causing hydronephrosis or renal non-function
IIIA Tumor involves the lower 1/3 of the vagina and does not extend to the pelvic wall T3a
IIIB Tumor extends into the pelvic wall and/or causes hydronephrosis or renal nonfunction T3b
ⅣA Tumor invades bladder mucosa or rectal mucosa and/or extends beyond the true pelvisb T4
ⅣB Distant metastasis M1
Note a: For lesions of either glandular or superficial epithelial origin, the depth of infiltration from the basement membrane of the epithelium should not exceed 5 mm. The depth of tumor infiltration should be measured from the most superficial papillae at the epithelial-mesenchymal junction to the deepest point of infiltration. Infiltration in the vascular region, whether venous or lymphatic, does not affect the staging.
Note b: Vesicular edema cannot be classified as T4 stage.
Treatment of cervical cancer
1.Minor infiltrating carcinoma
The diagnosis of cervical cancer stage IA1 or IA2 can only be made after cervical cone biopsy with negative margins, or cervical excision or total hysterectomy. In case of cervical epithelioma-like lesion (CIN) grade III with positive cervical cone margins or invasive carcinoma, another cervical cone is needed or treated as stage IB1.
Colposcopy should be done to rule out associated vaginal intraepithelial neoplasia (VAIN) before definitive treatment.
Stage IA1 Total transabdominal or transvaginal hysterectomy is recommended. If vaginal intraepithelial neoplasia is also present, the appropriate vaginal segment should be removed.
If the patient has a fertility requirement, cervical conization is feasible, and cervical cytology smears are followed up at 4 and 10 months after surgery. If both cervical cytology smears are negative, subsequent pap smears will be performed annually. level B evidence
Stage IA2 Stage IA2 cervical cancer has clear potential for lymph node metastasis and treatment options should include pelvic lymph node dissection.
The recommended treatment is a modified extensive hysterectomy (type II hysterectomy) plus pelvic lymph node dissection. In the absence of lymphovascular regional infiltration, extrafascial hysterectomy and pelvic lymph node dissection may be considered. grade C evidence
Those who require preservation of reproductive function may opt for: (i) extensive cervical cone biopsy plus extraperitoneal or laparoscopic lymph node dissection; (ii) extensive hysterectomy plus extraperitoneal or laparoscopic lymph node dissection.
Follow-up The main application of cytological smear (Pap smear) follow-up, after two normal smears at 4 and 10 months postoperatively, annual smear examination.
2.Infiltrating carcinoma
Initial evaluation Lesions visible to the naked eye should be biopsied to confirm the diagnosis. The initial evaluation includes clinical examination (under anesthesia if necessary), colposcopy to rule out VAIN. understanding the associated clinical symptoms, and cystoscopy or colonoscopy to evaluate the bladder or rectum if symptoms related to the bladder and rectum are present. x-ray chest examination and renal evaluation (which may include renal ultrasound, intravenous pyelogram, CT or MRI) are mandatory. CT and/or MRI and/or PET exams can provide insight into lymph nodes and systemic spread.
Stage IB1 and IIA
(tumor diameter <4 cm)
Early stage cervical cancer (IB1, IIA <4 cm) has a good prognosis with either surgery or radiotherapy. grade A evidence
Complications will increase with the combined application of surgery and radiotherapy. To reduce the occurrence of complications, the combination of extensive surgery and radiotherapy should be avoided during the initial treatment regimen. level A evidence
Surgical treatment
The standard surgical treatment for stage IB1 and IIA (tumor diameter <4 cm) cervical cancer is modified extensive hysterectomy or extensive hysterectomy and pelvic lymph node dissection.
The ovaries can be preserved in young patients, and if postoperative radiotherapy is required, they should be suspended outside the pelvic cavity.
In exceptional cases, extensive transvaginal hysterectomy and laparoscopic pelvic lymph node dissection can be performed. level C evidence
Radiation therapy
The standard radiotherapy regimen for stage IB1 and IIA (tumor diameter <4 cm) cervical cancer is external pelvic irradiation plus intracavitary brachytherapy. The recommended doses [including external pelvic irradiation and low-dose ratio (LDR) intracavitary brachytherapy] are 80-85 Gy at site A and 50-55 Gy at site B. The total amount of external pelvic irradiation should be 45-55 Gy at 180-200 cGy each time. application of High dose ratio (HDR) intracavitary brachytherapy, the dose should be set according to the equivalent biological dose.
Postoperative adjuvant therapy
The risk of recurrence is increased in those with the following conditions after radical surgery: positive lymph nodes, positive parametrium, positive surgical margins. These patients have improved survival with concurrent postoperative radiotherapy (5-FU + cisplatin or cisplatin alone) compared to those treated with radiotherapy alone. grade A evidence
An increased risk of recurrence is also seen in those without lymph node involvement but with a giant tumor, capillary-like space (CLS) involvement and extension into the outer 1/3 of the cervical mesenchyme.Adjuvant total pelvic irradiation after surgery reduces the rate of local recurrence and improves tumor-free survival (PFS) compared to those treated with surgery alone, especially in adenocarcinoma or adenosquamous carcinoma.Grade A evidence
Stage IB2 and IIA
(tumor diameter >4 cm)
Initial treatment includes: (1) radiotherapy; (2) extensive hysterectomy and bilateral pelvic lymph node dissection, usually followed by adjuvant radiotherapy; and (3) neoadjuvant chemotherapy (3 courses of platinum-based rapid infusion chemotherapy) followed by extensive hysterectomy and pelvic lymph node dissection with or without postoperative adjuvant radiotherapy or radiotherapy.
Concurrent radiotherapy
The most common treatment is external pelvic irradiation plus intracavitary brachytherapy and chemotherapy with platinum-based agents once a week. The recommended dose of radiotherapy is 85-90 Gy at site A and 55-60 Gy at site B. Cisplatin 40 mg/m2 chemotherapy is applied weekly during external pelvic irradiation. Expanded radiotherapy should be considered for those with positive common iliac or para-aortic lymph nodes. There is little information on the toxicity of concurrent chemotherapy and expanded radiotherapy. level A evidence
Surgery plus adjuvant radiotherapy
Because of the large tumor, adjuvant radiotherapy is more likely to be required. Extensive choroidal regional involvement and cancer infiltration into the outer 1/3 of the cervical mesenchyme are high risk factors for local recurrence. Patients at high risk with negative lymph nodes can be treated with total pelvic radiotherapy or small-scale pelvic radiotherapy. Patients with positive common iliac and para-aortic lymph nodes can be treated with expanded radiotherapy with or without chemotherapy. grade C evidence
Extensive hysterectomy with pelvic lymph node dissection after neoadjuvant chemotherapy
Data from randomized trials suggest that the use of platinum-based neoadjuvant chemotherapy prior to surgery is more effective than initial radiotherapy. No data are available comparing the difference in efficacy between concurrent radiotherapy and pre-surgical neoadjuvant chemotherapy. level B evidence
3.Advanced cervical cancer (including stage IIB, III and IVA)
Initial treatment
The standard initial treatment is radiotherapy, including external pelvic irradiation and intracavitary brachytherapy combined with concurrent chemotherapy. level A evidence
The initial treatment for stage IVA patients whose cancer has not infiltrated the pelvic wall, especially in combination with vesicovaginal fistula or rectovaginal fistula, may be pelvic organ removal. level C evidence