Anatomy

• 1.
  

  Primary site: The cervix is the lower third of the uterus. It is roughly cylindrical in shape, projects through the upper anterior vaginal wall, and communicates with the vagina through an orifice called the external os. Cancer of the cervix may originate on the vaginal surface or in the canal.

  
  
• 2.
  

  Nodal stations : The cervix is drained by preureteral, postureteral, and uterosacral routes into the following first station nodes: parametrial, hypogastric (obturator), external iliac, presacral, and common iliac. Paraaortic nodes are second station and are considered metastases.

  
  
• 3.
  

  Metastatic sites: The most common sites of distant spread include the aortic and mediastinal nodes, the lungs, and the skeleton.

Rules for Classification

• 1.
  

  Clinical-diagnostic staging: Staging of cervical cancer is based on clinical evaluation; therefore, careful clinical examination should be performed in all cases by an experienced examiner, preferably with the patient under anesthesia. The clinical staging must not be changed because of subsequent findings. When there is doubt as to which stage a particular cancer should be allocated, the earlier stage is mandatory. The following examinations are permitted: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and radiographic examination of the lungs and skeleton. Suspected bladder or rectal involvement should be confirmed by biopsy and histologic evidence. Findings of optional examinations, such as lymphangiography, arteriography, venography, laparoscopy, computed tomography (CT) scan, and magnetic resonance imaging are valuable for planning therapy; however, because these are not generally available and the interpretation of results varies, the findings of such studies should not be the basis for changing the clinical staging.

  
  
• 2.
  

  Surgical-evaluative staging: Surgical evaluation is applicable only after laparotomy or laparoscopy and examination of tumor and nodes. Fine-needle aspiration (FNA) of scan-detected suspicious lymph nodes may be helpful when planning treatment. Conization or amputation of the cervix is regarded as a clinical examination. Invasive cancers thus identified should be included in the reports (see no. 4 below).

  
  
• 3.
  

  Postsurgical treatment — pathologic staging: In patients treated with surgical procedures, the pathologist’s findings in the removed tissues can be the basis for extremely accurate statements on the extent of disease. The findings should not be allowed to change the clinical staging but should be recorded in the manner described for the pathologic staging of disease. The TNM nomenclature is appropriate for this purpose. Infrequently, it happens that hysterectomy is carried out in the presence of unsuspected extensive invasive cervical carcinoma. Such cases cannot be clinically staged or included in therapeutic statistics, but it is desirable that they be reported separately. Only if the rules for clinical staging are strictly observed will it be possible to present comparable results between clinics and by differing modes of therapy.

  
  
• 4.
  

  Retreatment staging: Complete examination using the procedures cited in no. 2, including a search for distant metastases, is recommended in cases known or suspected to recur. Biopsy and histologic confirmation are particularly desirable when induration and fibrosis from previously treated disease are present.

  
  
• 5.
  

  Only if the rules for clinical staging are strictly observed will it be possible to compare results among clinics and by differing modes of therapy.

Staging Classification

Notes About the Staging

All macroscopically visible lesions, even with superficial invasion, are allotted to stage IB carcinomas. The diagnosis of stages IA ₁ and IA ₂ should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. 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 second dimension, the horizontal spread, must not exceed 7 mm. Vascular space involvement, either venous or lymphatic, should not alter the staging but should be specifically recorded because it may affect treatment decisions in the future. Larger lesions should be staged as IB. As a rule, it is impossible to estimate clinically if a cancer of the cervix has extended to the corpus. Extension to the corpus should therefore be disregarded.

A patient with a growth fixed to the pelvic wall by a short and indurated but not nodular parametrium should be allotted to stage IIB. It is impossible at clinical examination to decide whether a smooth and indurated parametrium is truly cancerous or only inflammatory. Therefore, the case should be placed in stage III only if the parametrium is nodular to the pelvic wall or if the growth itself extends to the pelvic wall.

The presence of hydronephrosis or nonfunctioning kidney resulting from stenosis of the ureter by cancer permits a case to be allotted to stage III even if according to the other findings the case should be allotted to stages I or II.

The presence of bullous edema, as such, should not permit a case to be allotted to stage IV. Ridges and furrows into the bladder wall should be interpreted as signs of submucous involvement of the bladder if they remain fixed to the growth at palposcopy (ie, examination from the vagina or the rectum during cystoscopy). Finding malignant cells in cytologic washings from the urinary bladder requires further examination and a biopsy from the wall of the bladder.

Histopathology

Cases should be classified as carcinomas of the cervix if the primary growth is in the cervix. All histologic types must be included. Grading by any of several methods is encouraged but is not a basis for modifying the stage groupings. When surgery is the primary treatment, the histologic findings permit the case to have pathologic staging as described in Rules for Classification, no. 2. All tumors are to be microscopically verified.

Histopathologic Types

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  Squamous cell carcinoma in situ

  
  
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  Squamous cell carcinoma

  
  
  
  
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    Keratinizing

    
    
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    Nonkeratinizing

  
  
  
  
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  Verrucous

  
  
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  Adenocarcinoma in situ

  
  
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  Adenocarcinoma in situ, endocervical type

  
  
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  Endometrioid adenocarcinoma

  
  
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  Clear cell adenocarcinoma

  
  
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  Adenosquamous carcinoma

  
  
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  Adenoid cystic carcinoma

  
  
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  Small cell carcinoma

  
  
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  Undifferentiated carcinoma

Histopathologic Grade

Stage Grouping for the Cervix

Anatomy

1.1 Primary site: The upper two-thirds of the uterus above the level of the internal cervical os is called the corpus. The fallopian tubes enter at the upper lateral corners of a pear-shaped body. The portion of the muscular organ that is above a line joining the tubouterine orifices is often referred to as the fundus.

1.2 Nodal stations: The major lymphatic trunks are the utero-ovarian (infundibulopelvic), parametrial, and presacral, which drain into the hypogastric, external iliac, common iliac, presacral, and paraaortic nodes.

1.3 Metastatic sites: The vagina and lung are the common metastatic sites.

Rules for Classification

The FIGO committee on gynecologic oncology agreed on the system for surgical staging for carcinoma of the corpus uteri at the meeting in Rio de Janeiro in October 1988 with modification made in 2009.

Surgical Staging Classification

Notes: Tumor grade, cell type, and presence or absence of malignant cytology in pelvic washings should be reported along with stage.

Abdominal and pelvic peritoneal metastases are stage IVB.

Notes About the Staging

Notes on Pathologic Grading

• 1.
  

  Notable nuclear atypia, inappropriate for the architectural grade, raises the grade of a grade 1 or 2 tumor by 1.

  
  
• 2.
  

  In serous and clear cell adenocarcinomas, nuclear grading takes precedence.

  
  
• 3.
  

  Adenocarcinomas with squamous differentiation are graded according to the nuclear grade of the glandular component.

Rules Related to Staging

• 1.
  

  Because corpus cancer is now surgically staged, procedures previously used for determination of stages are no longer applicable, such as the finding of fractional dilatation and curettage (D&C) to differentiate between stages I and II.

  
  
• 2.
  

  It is understood that there may be a few patients with corpus cancer who will be treated primarily with radiation therapy. If that is the case, the clinical staging adopted by FIGO in 1971 would still apply, but designation of that staging system would be noted.

  
  
• 3.
  

  Ideally, the width of the myometrium should be measured along with the width of tumor invasion.

Histopathology

The histopathologic types are:

• •
  

  Endometrioid carcinoma

  
  
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  Adenocarcinoma

  
  
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  Adenocanthoma (adenocarcinoma with squamous metaplasia)

  
  
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  Adenosquamous carcinoma (mixed adenocarcinoma and squamous cell carcinoma)

  
  
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  Mucinous adenocarcinoma

  
  
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  Serous adenocarcinoma

  
  
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  Clear cell adenocarcinoma

  
  
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  Squamous cell adenocarcinoma

  
  
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  Undifferentiated adenocarcinoma

Anatomy

1.1 Primary site: Ovaries are a pair of solid bodies, flattened ovoids that are 2 to 4 cm in diameter; they are connected by a peritoneal fold to the broad ligament and by the infundibulopelvic ligament to the lateral wall of the pelvis.

1.2 Nodal stations: The lymphatic drainage occurs by the utero-ovarian and round ligament trunks and an external iliac accessory route into the following regional nodes: external iliac; common iliac; hypogastric; lateral sacral; and paraaortic nodes; and, rarely, inguinal nodes.

1.3 Metastatic sites: The peritoneum, including the omentum and pelvic and abdominal viscera, is a common site for seeding. Diaphragmatic involvement and liver metastases are common. Pulmonary and pleural involvement is often seen.

Rules for Classification

Ovarian cancer is surgically staged. Operative findings before tumor debulking determine the stage, which may be modified by histopathologic as well as clinical or radiologic evaluation. Laparotomy and resection of the ovarian mass, as well as hysterectomy, form the basis for staging. Biopsies of all suspicious sites, such as the omentum, mesentery, liver, diaphragm, pelvic, and paraaortic nodes, are required. The final histologic findings after surgery (and cytologic ones when available) should be considered in the staging. Clinical studies, if carcinoma of the ovary is diagnosed, include routine radiology of the chest. CT scanning may be helpful in initial staging and follow-up of tumors.

• 1.
  

  Clinical-diagnostic staging: Although clinical studies similar to those for other sites may be used, the establishment of a diagnosis most often requires a laparotomy, which is most widely accepted in surgical-pathologic staging. Clinical studies, if carcinoma of the ovary is diagnosed, include routine radiography of the chest and abdomen, liver studies, and hemograms.

  
  
• 2.
  

  Surgical-evaluative staging: Laparotomy and biopsy of all suspected sites of involvement provide the basis for this type of staging; this staging is often identical to postsurgical staging. Histologic and cytologic data are required.

  
  
• 3.
  

  Postsurgical treatment—pathologic staging: This treatment should include laparotomy and resection of ovarian masses as well as a hysterectomy. Biopsies of all suspicious sites, such as the omentum, mesentery, liver, diaphragm, and pelvic and paraaortic nodes, are required. Pleural effusions should be documented by cytology.

  
  
• 4.
  

  Retreatment staging: Second-look laparotomies and laparoscopy are being evaluated because of the limitation of routine pelvic and abdominal examinations in detecting early recurrence. Other optional and investigative procedures include ultrasonography and CT scanning. All suspected recurrences need biopsy confirmation.

Staging Classification

Staging is based mainly on findings seen at surgical exploration. Clinical evaluation and imaging studies should be done when appropriate. These findings may affect final staging. The histology is to be considered in the staging, as is cytology as far as effusions are concerned. It is desirable that a biopsy be taken from suspicious areas outside of the pelvis.

Histopathology

The task force of the AJCC endorses the histologic typing of ovarian tumors, as presented in the World Health Organization publication no. 9, 1973, and recommends that all ovarian epithelial tumors be subdivided according to a simplified version. The types recommended are as follows: serous tumors, mucinous tumors, endometrioid tumors, clear cell (mesonephroid) tumors, undifferentiated tumors, and unclassified tumors.

• •
  

  Serous tumors

  
  
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  Benign serous cystadenomas

  
  
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  Of borderline malignancy: serous cystadenomas with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (carcinomas of low potential malignancy)

  
  
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  Serous cystadenocarcinomas

  
  
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  Mucinous tumors

  
  
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  Benign mucinous cystadenomas of borderline malignancy: mucinous cystadenomas with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (carcinomas of low potential malignancy)

  
  
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  Mucinous cystadenocarcinomas

  
  
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  Endometrioid tumors

  
  
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  Benign endometrioid cystadenomas

  
  
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  Endometrioid tumors with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (carcinomas of low potential malignancy)

  
  
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  Endometrioid adenocarcinomas

  
  
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  Clear cell tumors

  
  
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  Benign clear cell tumors

  
  
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  Clear cell tumors with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (low potential malignancy)

  
  
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  Clear cell cystadenocarcinomas

  
  
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  Brenner

  
  
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  Benign Brenner

  
  
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  Borderline malignancy

  
  
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  Malignant

  
  
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  Transitional cell

  
  
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  Undifferentiated carcinomas

  
  
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  A malignant tumor of epithelial structure that is too poorly differentiated to be placed in any other group

  
  
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  Mixed epithelial tumors

These tumors consist of two or more of the five major cell types of common epithelial tumors (types should be specified).

Cases with intraperitoneal carcinoma in which the ovaries appear to be incidentally involved and not the primary origin should be labeled as extraovarian peritoneal carcinoma.

Stage Grouping for Ovary

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