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Recent Modifications to the Staging System for Cervical and Vulvar Cancers
' ' ' ' '
G U EST
The Society of Obstetricians and Gynaecologists of Canada COUNCIL MEMBERS 1995-1996 PRESIDENT Dr. Garry Krepart- Winnipeg PAST PRESIDENT: Dr. Rodolphe Maheux- Quebec
EDITORIAL
' ' ' ' '
Recent Modifications to the Staging System for Cervical and Vulvar Cancers
PRESIDENT ELECT: Dr. Nan Schuurmans- Edmonton EXECUTIVE VICE-PRESIDENT: Dr. Andre B. Lalonde- Ottawa ASSOCIATE EXECUTIVE VICE-PRESIDENT: Dr. Robert Kinch- Ottawa TREASURER: Dr. Anton in Rochette- Loretteville VICE PRESIDENTS: Dr. Robert Reid - Kingston Dr. Thomas Baskett- Halifax REGIONAL CHAIRS & DEPUTY CHAIRS WESTERN REGION Dr. Don Davis- Medicine Hat Dr. Jan Christi law- White Rock CENTRAL REGION Dr. Chui Kin Yuen- Winnipeg Dr. Thirza Smith- Saskatoon ONTARIO REGION Dr. Donna Fedorkow- Hamilton Dr. Catherine Claire Kane- Ottawa QUEBEC REGION Dr. Cajetan Gauthier- Levis Dr. Vyta Senikas- Montreal ATLANTIC REGION Dr. David A. Knickle- Charlottetown Dr. Garth Christie- Fredericton PUBLIC REPRESENTATIVE Ms. Janet MacMillan - Halifax JUNIOR FELLOW REPRESENTATIVE Dr. Georges Sylvestre- Montreal ASSOCIATE MD REPRESENTATIVE Dr. T. Riley- Oakville ASSOCIATE NURSING REPRESENTATIVE Ms. Marie-Josee Trepanier- Ottawa NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Dr. Andre B. Lalonde DIRECTOR OF COMMUNICATIONS Martine Joly
774 Echo Drive Ottawa, Ontario K1S 5N8 tel: (613) 730-4192 or 1-800-561-2416 fax: (613) 730-4314
The basic rules for the classification and staging of malignant neoplasms of the female genital tract originated in the late 1920s when the Cancer Commission of the League of Nations initiated work that led to an international classification. In 193 7, the Health Organization of the League of Nations began the publication of annual reports on the results of radiotherapeutic treatment of cancer of the cervix. These reports were based on a clinical classification of tumour extent and formed the J.L. Benedet, MD, FRCSC, basis for the existing staging system. In 1958, the Chairman, and Professor International Federation of Gynecology and Department of Obstetrics and Gynaecology, University of British Obstetrics (FIGO) assumed sponsorship of these Columb1a, Vancouver Hospital and Health Sciences Centre reports and, through its Oncology Committee, the responsibility for the classification and staging of gynaecological cancers. Currently, these reports are issued at three-yearly intervals to coincide with the FIGO World Congresses. Historically, staging systems were developed to permit the comparison of various treatment techniques that were developed by different centres. These stage groupings enabled the treating physicians in the various centres to have a reliable, reproducible system so that treatment results would be between comparable groups of patients. In 1954, the International Union Against Cancer (UICC) appointed a committee with the task of establishing rules for the classification and clinical staging of malignant tumours of all sites and for the presentation of therapeutic results. This led to the tumour-node-metastasis (TNM) classification and, in 1966, a TNM system was proposed for carcinoma of the cervix which took into consideration the FIGO rules for staging and its existing stage groupings. In 1959, the American Joint Committee for Cancer Staging and End-Results (AJCC) was organized to develop a system of clinical staging for all cancers which would be acceptable to the American medical profession. Currently, FIGO continues to provide leadership in close collaboration between the TNM Committee of the UICC and the AJCC. At present, there is complete concordance between these
JOURNAL SOGC
11 79
DECEMBER 1995
' ' ' three committees, and modifications to existing staging definitions for gynaecological cancers are only made after joint consultation and agreement. During the past fifty years, various changes have been made to the staging system of gynaecological cancers based on our evolving knowledge of the biology and natural history of these disorders, and also in response to suggestions from practising clinicians. In essence, a simple clinical classification system which can be easily applied and accurately reflects the known extent of disease is the basis of staging systems. For most cancer sites, the staging classifications are concerned with the anatomic extent of disease and those consistent features that define its life history. As the size of the primary tumour (T) increases, regional lymph node (N) involvement occurs, followed by distant metastasis (M). These three features and their presence or absence as determined by clinical examination before therapy are used to indicate the extent of disease, i.e. its stage. Staging for cervical cancer remains clinical, whereas staging for most of the other gynaecological cancers is surgical where information obtained at the time of surgery regarding nodal disease is used in the staging system. In some instances, tumour grades are also factors that have been shown to have prognostic significance and have, thus, been incorporated into the staging system. At the most recent FIGO World Congress in Montreal in September 1994, the Oncology Committee reviewed the staging of cervical and vulvar cancers. After considerable discussion and comprehensive review of the literature, modifications were made to the staging systems for these cancers. These modifications, in essence, focused on the depth of invasion in early stage cervical and vulvar cancers and were in response to current usage by clinicians internationally and their recommendations for amendment. Modifications that were produced were as follows:
Stage IA1
Stage IAz
* 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. Vascular space involvement, either venous or lymphatic, should not alter the staging. Stage IB Stage IB1 Stage lBz
Stage IA
The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded). Invasive cancer identified only microscopically. All gross lesions, even with superficial invasion, are Stage IB cancers. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm. *
JOURNAL SOGC
Clinical lesions confined to the cervix or preclinical lesions greater than IA. Clinical lesions no greater than 4 em in size. Clinical lesions greater than 4 em in size.
The more advanced stages remain as previously defined: Stage II The carcinoma extends beyond the cervix, but has not extended on to the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third. Stage IIA No obvious parametrial involvement. Stage liB Obvious parametrial involvement. Stage III The carcinoma has extended on to the pelvic wall. On rectal examination, there is no cancer-free space between the tumour and the pelvic wall. The tumour involves the lower third of the vagina. All cases with a hydronephrosis or non-functioning kidney should be included, unless they are known to be due to other causes. Stage IliA No extension on to the pelvic wall, but involvement of the lower third of the vagina. Stage IIIB Extension on to the pelvic wall or hydronephrosis or non-functioning kidney. Stage IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Stage IVA Spread of the growth to adjacent organs. Stage IVB Spread to distant organs.
CERVICAL CANCER STAGING
Stage I
Measured invasion of stroma no greater than 3 mm in depth and no wider than 7mm. Measured invasion of stroma greater than 3 mm and no greater than 5 mm in depth and no wider than 7 mm.
VULVAR CANCER
Stage I
1180
Lesions 2 em or less in size confined to the vulva or perineum. No nodal metastases.
DECEMBER 1995
T
Stage lA
Stage lB
T
Lesions 2 em or less in size confined to the vulva or perineum and with stromal invasion no greater than 1.0 mm. * No nodal metastasis. Lesions 2 em or less in size confined to the vulva or peri- neum and with stromal invasion greater than 1.0 mm. No nodal metastasis.*
T
Stage II
Tumour confined to the vulva and/or perineum or more than 2 em in the greatest dimension, with no nodal metastasis. Stage III Tumour of any size with: i. Adjacent spread to the lower urethra and/or the vagina or anus, and/or ii. unilateral regional lymph node metastasis(Nl)· Stage IVA Tumour invades any of the following: upper urethra, bladder mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis (Nz). Stage IVB Any distant metastasis including pelvic lymph nodes.
* The depth of invasion is defined as the measurement of the tumour from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. The more advanced stages are as previously defined:
J SOGC
1995;17:1179-81
,
Edition 1996 du Programme de FMC Quebec/Atlantique 1996 Quebec/Atlantic CME Programme du 8 au 10 fevrier I February 8 to 10 Seances plenieres et discussions en petits groupes Plenary Sessions iJ"ndSm~ll Group Discussions
. Nforritoragefoeta! 1Fetal~tt'tv~inance (fmtraceptijsbraux et tabaz.isme {O~alCorztraceptives andSJr1oking Declenchenient du travail}Indultion of Labour , Menopause: sante urogtnitale I JYU:naparm: U.rogenitaiHealth Viol~ncefait~ auxfem~es I Violiince !J:gainSt Women .Hemorrl1gie Posf;parttim 1Postpartum Haemqh;hage .r)ire~tives sur l'hy~terecf~mie I B~terectomy Guidelines Batterios~ vaginale I B~derial Wgino$Ys Efplusencore I and much more ... Membres SOGC Members Membres de I'AOGQ. de I'AOPQ et de Ia Atlantic Society of Ob/Gyn Members of the AOGQ. AOPQ and the Atlantic Society of Ob/Gyn Non-Membres I Non·Members
5150 5150 5225
Pour de plus am pies renseignements au sujet de ce programme de FMC, veuillez communiquer avec le secteur de !'education de Ia SOGC. I For more information on this CME Programme, please contact the SOGC Education Division. Tel: (613) 730-4192; Telec./Fax.: (613) 730-4314
Commanditaires I Sponsors: Berlex Canada Inc., Duchesnay, CIBA-Geigy, Ferring, Organon Canada, Janssen-Ortho, Parke-Davis, Pharmacia, Pfizer Canada Inc., Roberts Pharmaceuticals, Roche Diagnostic Systems, Schering, Searle, The Upjohn Company of Canada, Wyeth·Ayerst Canada Inc., Zeneca Pharma
JOURNAL SOGC
1181
DECEMBER 1995
G U EST
The Society of Obstetricians and Gynaecologists of Canada COUNCIL MEMBERS 1995-1996 PRESIDENT Dr. Garry Krepart- Winnipeg PAST PRESIDENT: Dr. Rodolphe Maheux- Quebec
EDITORIAL
' ' ' ' '
Recent Modifications to the Staging System for Cervical and Vulvar Cancers
PRESIDENT ELECT: Dr. Nan Schuurmans- Edmonton EXECUTIVE VICE-PRESIDENT: Dr. Andre B. Lalonde- Ottawa ASSOCIATE EXECUTIVE VICE-PRESIDENT: Dr. Robert Kinch- Ottawa TREASURER: Dr. Anton in Rochette- Loretteville VICE PRESIDENTS: Dr. Robert Reid - Kingston Dr. Thomas Baskett- Halifax REGIONAL CHAIRS & DEPUTY CHAIRS WESTERN REGION Dr. Don Davis- Medicine Hat Dr. Jan Christi law- White Rock CENTRAL REGION Dr. Chui Kin Yuen- Winnipeg Dr. Thirza Smith- Saskatoon ONTARIO REGION Dr. Donna Fedorkow- Hamilton Dr. Catherine Claire Kane- Ottawa QUEBEC REGION Dr. Cajetan Gauthier- Levis Dr. Vyta Senikas- Montreal ATLANTIC REGION Dr. David A. Knickle- Charlottetown Dr. Garth Christie- Fredericton PUBLIC REPRESENTATIVE Ms. Janet MacMillan - Halifax JUNIOR FELLOW REPRESENTATIVE Dr. Georges Sylvestre- Montreal ASSOCIATE MD REPRESENTATIVE Dr. T. Riley- Oakville ASSOCIATE NURSING REPRESENTATIVE Ms. Marie-Josee Trepanier- Ottawa NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Dr. Andre B. Lalonde DIRECTOR OF COMMUNICATIONS Martine Joly
774 Echo Drive Ottawa, Ontario K1S 5N8 tel: (613) 730-4192 or 1-800-561-2416 fax: (613) 730-4314
The basic rules for the classification and staging of malignant neoplasms of the female genital tract originated in the late 1920s when the Cancer Commission of the League of Nations initiated work that led to an international classification. In 193 7, the Health Organization of the League of Nations began the publication of annual reports on the results of radiotherapeutic treatment of cancer of the cervix. These reports were based on a clinical classification of tumour extent and formed the J.L. Benedet, MD, FRCSC, basis for the existing staging system. In 1958, the Chairman, and Professor International Federation of Gynecology and Department of Obstetrics and Gynaecology, University of British Obstetrics (FIGO) assumed sponsorship of these Columb1a, Vancouver Hospital and Health Sciences Centre reports and, through its Oncology Committee, the responsibility for the classification and staging of gynaecological cancers. Currently, these reports are issued at three-yearly intervals to coincide with the FIGO World Congresses. Historically, staging systems were developed to permit the comparison of various treatment techniques that were developed by different centres. These stage groupings enabled the treating physicians in the various centres to have a reliable, reproducible system so that treatment results would be between comparable groups of patients. In 1954, the International Union Against Cancer (UICC) appointed a committee with the task of establishing rules for the classification and clinical staging of malignant tumours of all sites and for the presentation of therapeutic results. This led to the tumour-node-metastasis (TNM) classification and, in 1966, a TNM system was proposed for carcinoma of the cervix which took into consideration the FIGO rules for staging and its existing stage groupings. In 1959, the American Joint Committee for Cancer Staging and End-Results (AJCC) was organized to develop a system of clinical staging for all cancers which would be acceptable to the American medical profession. Currently, FIGO continues to provide leadership in close collaboration between the TNM Committee of the UICC and the AJCC. At present, there is complete concordance between these
JOURNAL SOGC
11 79
DECEMBER 1995
' ' ' three committees, and modifications to existing staging definitions for gynaecological cancers are only made after joint consultation and agreement. During the past fifty years, various changes have been made to the staging system of gynaecological cancers based on our evolving knowledge of the biology and natural history of these disorders, and also in response to suggestions from practising clinicians. In essence, a simple clinical classification system which can be easily applied and accurately reflects the known extent of disease is the basis of staging systems. For most cancer sites, the staging classifications are concerned with the anatomic extent of disease and those consistent features that define its life history. As the size of the primary tumour (T) increases, regional lymph node (N) involvement occurs, followed by distant metastasis (M). These three features and their presence or absence as determined by clinical examination before therapy are used to indicate the extent of disease, i.e. its stage. Staging for cervical cancer remains clinical, whereas staging for most of the other gynaecological cancers is surgical where information obtained at the time of surgery regarding nodal disease is used in the staging system. In some instances, tumour grades are also factors that have been shown to have prognostic significance and have, thus, been incorporated into the staging system. At the most recent FIGO World Congress in Montreal in September 1994, the Oncology Committee reviewed the staging of cervical and vulvar cancers. After considerable discussion and comprehensive review of the literature, modifications were made to the staging systems for these cancers. These modifications, in essence, focused on the depth of invasion in early stage cervical and vulvar cancers and were in response to current usage by clinicians internationally and their recommendations for amendment. Modifications that were produced were as follows:
Stage IA1
Stage IAz
* 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. Vascular space involvement, either venous or lymphatic, should not alter the staging. Stage IB Stage IB1 Stage lBz
Stage IA
The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded). Invasive cancer identified only microscopically. All gross lesions, even with superficial invasion, are Stage IB cancers. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm. *
JOURNAL SOGC
Clinical lesions confined to the cervix or preclinical lesions greater than IA. Clinical lesions no greater than 4 em in size. Clinical lesions greater than 4 em in size.
The more advanced stages remain as previously defined: Stage II The carcinoma extends beyond the cervix, but has not extended on to the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third. Stage IIA No obvious parametrial involvement. Stage liB Obvious parametrial involvement. Stage III The carcinoma has extended on to the pelvic wall. On rectal examination, there is no cancer-free space between the tumour and the pelvic wall. The tumour involves the lower third of the vagina. All cases with a hydronephrosis or non-functioning kidney should be included, unless they are known to be due to other causes. Stage IliA No extension on to the pelvic wall, but involvement of the lower third of the vagina. Stage IIIB Extension on to the pelvic wall or hydronephrosis or non-functioning kidney. Stage IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Stage IVA Spread of the growth to adjacent organs. Stage IVB Spread to distant organs.
CERVICAL CANCER STAGING
Stage I
Measured invasion of stroma no greater than 3 mm in depth and no wider than 7mm. Measured invasion of stroma greater than 3 mm and no greater than 5 mm in depth and no wider than 7 mm.
VULVAR CANCER
Stage I
1180
Lesions 2 em or less in size confined to the vulva or perineum. No nodal metastases.
DECEMBER 1995
T
Stage lA
Stage lB
T
Lesions 2 em or less in size confined to the vulva or perineum and with stromal invasion no greater than 1.0 mm. * No nodal metastasis. Lesions 2 em or less in size confined to the vulva or peri- neum and with stromal invasion greater than 1.0 mm. No nodal metastasis.*
T
Stage II
Tumour confined to the vulva and/or perineum or more than 2 em in the greatest dimension, with no nodal metastasis. Stage III Tumour of any size with: i. Adjacent spread to the lower urethra and/or the vagina or anus, and/or ii. unilateral regional lymph node metastasis(Nl)· Stage IVA Tumour invades any of the following: upper urethra, bladder mucosa, rectal mucosa, pelvic bone, and/or bilateral regional node metastasis (Nz). Stage IVB Any distant metastasis including pelvic lymph nodes.
* The depth of invasion is defined as the measurement of the tumour from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. The more advanced stages are as previously defined:
J SOGC
1995;17:1179-81
,
Edition 1996 du Programme de FMC Quebec/Atlantique 1996 Quebec/Atlantic CME Programme du 8 au 10 fevrier I February 8 to 10 Seances plenieres et discussions en petits groupes Plenary Sessions iJ"ndSm~ll Group Discussions
. Nforritoragefoeta! 1Fetal~tt'tv~inance (fmtraceptijsbraux et tabaz.isme {O~alCorztraceptives andSJr1oking Declenchenient du travail}Indultion of Labour , Menopause: sante urogtnitale I JYU:naparm: U.rogenitaiHealth Viol~ncefait~ auxfem~es I Violiince !J:gainSt Women .Hemorrl1gie Posf;parttim 1Postpartum Haemqh;hage .r)ire~tives sur l'hy~terecf~mie I B~terectomy Guidelines Batterios~ vaginale I B~derial Wgino$Ys Efplusencore I and much more ... Membres SOGC Members Membres de I'AOGQ. de I'AOPQ et de Ia Atlantic Society of Ob/Gyn Members of the AOGQ. AOPQ and the Atlantic Society of Ob/Gyn Non-Membres I Non·Members
5150 5150 5225
Pour de plus am pies renseignements au sujet de ce programme de FMC, veuillez communiquer avec le secteur de !'education de Ia SOGC. I For more information on this CME Programme, please contact the SOGC Education Division. Tel: (613) 730-4192; Telec./Fax.: (613) 730-4314
Commanditaires I Sponsors: Berlex Canada Inc., Duchesnay, CIBA-Geigy, Ferring, Organon Canada, Janssen-Ortho, Parke-Davis, Pharmacia, Pfizer Canada Inc., Roberts Pharmaceuticals, Roche Diagnostic Systems, Schering, Searle, The Upjohn Company of Canada, Wyeth·Ayerst Canada Inc., Zeneca Pharma
JOURNAL SOGC
1181
DECEMBER 1995