|
* The depth of
incvasion should not be more than 5 mm taken from the base of
the epithelium, either surface or glandular, from which it
originate. Vascular space involveme,ent, either venous or
lymphatic, should not alter the staging
Stages of Cervical Cancer
Staging
System
|
I |
Strictly confined to cervix |
|
IA. |
Preclinical carcinomas of
cervix diagnosed only by microscopy. All gross lesions
even with superficial invasion are stage IB
cancers. Invasion is limited to measured stromal
invasion with maximum depth of 5.0 mm and no wider than
7.0mm*. |
|
IA1 |
Stromal invasion no greater
than 3.0 mm and no wider than 7.0 mm |
|
IA2 |
Maximum depth of invasion of
stroma greater than 3 mm and no greater than 5 mm taken
from base of epithelium, either surface or glandular,
from which it originates; horizontal invasion not more
than 7 mm |
|
IB |
Clinical lesions confined to
the cervix or preclinical lesions greater than stage IA. |
|
IB1 |
Clinical lesion no longer
than 4.0 cm in size |
|
IB2 |
Clinical lesion greater than
4.0 cm in size |
|
II |
Extension beyond
cervix but not to pelvic wall. Involves vagina, but not
the lower third. |
|
IIA |
Involves vagina, but not
lower third. No obvioius extension to parametria. |
|
IIB |
Involves vagina, but not
lower third. Obvious parametrial involvement. |
|
III |
Extension to
pelvic wall. On rectal exam, no cancer-free space
between tumor and pelvic wall. Involves lower third of
vagina. |
|
IIIA |
No extension to pelvic side
wall. |
|
IIIB |
Extension to pelvic side
wall. |
|
IV |
Extension beyond
true pelvis or involvement of bladder or rectal mucosa.
Bullous edema does not permit a case to be assigned to
Stage IV. |
Notes
Diagnosis of both
Stages IA1 and IA2 is based on microscopic examination of
removed tissue, preferably a cone, which must include the entire
lesion. The lower limit of Stage IA2 should be measurable
macroscopically (even if dots need to be placed on the slide
prior to measurement). The upper limit of IA2 is determined by
measurement of the two largest dimensions in any given section.
Revised staging -
adopted in 1988 - varies from the previous staging primarily in
the stage I category. These changes have occasioned a good deal
of controversy and a substantial body of opposition from some
gynecologic oncologists. The defined limits of the 1a2 often
appear impractical in clinical practice. Multiple foci of
invasion may be present, the cone biopsy may not include the
entire lesion, and prior colposcopic biopsies which encroach on
the lesion may alter the volumetric dimensions. A major concern
is that clinicians will interpret the stage Ia2 lesion as one
that can be approached in a more conservative manner such as
simple hysterectomy. Taken as a group, a retrospective study
done here suggested that such lesions carry a risk of nodal
metastases in excess of 4% and a recurrence rate of 6% even when
treated by radical hysterectomy. The G.O.G. previously had
described "microinvasion" as a lesion with less than 3 mm of
invasion, no vascular space involvement and no areas of
confluence. as possibly suitable for conservative treatment. It
has been suggested that this guideline be substituted in
treatment planning.
Cervical cancer
remains the one remaining major gynecologic cancer that is
subjected to "clinical" staging as opposed to surgical staging.
This decision, of course, reflects an appreciation that a large
number of cases - perhaps a majority - are treated with
radiation therapy without surgical intervention. It is generally
agreed that the most experienced clinician involved in the case
should stage the lesion and if there is a doubt as to which
stage applies, the earlier stage is mandatory.
Examination for
clinical staging permits palpation, inspection, colposcopy,
hysteroscopy, curettage, cystoscopy, proctoscopy and roentgen
examinations to include X-rays of the lungs and skeleton and
intravenous urography. Other procedures such as laparoscopy or
lymphography may not be employed. A conization of the cervix is
regarded as a clinical examination. An IVP revealing
hydronephrosis or a nonfunctioning kidney attributable to
stenosis of the ureter by cancer permits the allotment of a case
to Stage III regardless of other factors.
After cervical cancer has been
diagnosed, tests are done to find out if cancer cells have
spread within the cervix or to other parts of the body.
The process used to find out
if cancer has spread within the cervix or to other parts of the
body is called staging. The information gathered from the
staging process determines the stage of the disease. It is
important to know the stage in order to plan the best treatment.
The following tests and procedures may be used in the staging
process:
Chest x-ray: Brief exposure of
the chest to radiation to produce an image of the chest and its
internal structures.
CT scan (CAT scan): A CT scan
creates a series of detailed pictures of areas inside the body,
taken from different angles. The pictures are created by a
computer linked to an x-ray machine. This test is also called
computed tomography, computerized tomography, or computerized
axial tomography.
Lymphangiography: An x-ray is
made of the lymph system. A dye is injected into a lymph vessel
and travels through the lymph system. The dye outlines the lymph
vessels and organs on the x-ray. This test helps determine
whether cancer has spread to the lymph nodes.
Pretreatment surgical
staging: Surgery (an operation) is done to find out if the
cancer has spread within the cervix or to other parts of the
body. In some cases, the cervical cancer can be removed at the
same time. Pretreatment surgical staging is usually done only as
part of a clinical trial.
Ultrasound: A test
that uses sound waves to create images of body tissues.
MRI (magnetic
resonance imaging): A procedure in which a magnet linked to a
computer is used to create detailed pictures of areas inside the
body. This test is also called nuclear magnetic resonance
imaging (NMRI).
The results of these
tests are viewed together with the results of the original tumor
biopsy to determine the cervical cancer stage.
How
cancer of the cervix is treated
There are treatments
for all patients with cancer of the cervix. Three kinds of
treatment are used:
-
surgery
(removing the cancer in an operation)
-
radiation therapy
(using high-dose x-rays or other high-energy rays to kill
cancer cells)
-
chemotherapy
(using drugs to kill cancer cells)
A doctor may use one
of several types of surgery for carcinoma in situ to destroy the
cancerous tissue:
-
Cryosurgery kills
the cancer by freezing it.
Laser surgery is
the use of a narrow beam of intense light to kill
cancerous cells.
A doctor may remove
the cancer using one of these operations:
-
Conization is the
removal of a cone-shaped piece of tissue
where the abnormality is found. Conization may be used to
take out a piece of tissue for biopsy, but it can also be
used to treat early cancers of the cervix.
Alternatively, a
doctor may perform a loop electrosurgical excision
procedure (LEEP) to remove the abnormal tissue. LEEP uses an
electrical current passed through a thin wire loop to act as
a knife.
A laser beam can
also be used as a knife to remove the tissue.
A hysterectomy is
an operation in which the uterus and cervix are taken out
along with the cancer. If the uterus is taken out through
the vagina, the operation is called a vaginal hysterectomy.
If the uterus is taken out through a cut (incision) in the
abdomen, the operation is called a total abdominal
hysterectomy. Sometimes the ovaries and fallopian tubes are
also removed, which is called a bilateral
salpingo-oophorectomy.
A radical
hysterectomy is an operation in which the cervix, uterus,
and part of the vagina are removed. Lymph nodes in the area
are also removed. This is called lymph node dissection.
(Lymph nodes are small bean-shaped structures that are found
throughout the body. They produce and store cells that fight
infection).
If the cancer has
spread outside the cervix or the female organs, a
doctor may take out the lower colon, rectum, or bladder
(depending on where the cancer has spread) along with the
cervix, uterus, and vagina. This is called an exenteration
and is rarely needed. Plastic surgery may be needed to make
an artificial vagina after this operation.
Radiation therapy is
the use of x-rays or other high-energy rays to kill cancer cells
and shrink tumors. Radiation may come from a machine outside the
body (external radiation) or from putting materials that produce
radiation (radioisotopes) through thin plastic tubes into the
area where the cancer cells are found (internal radiation).
Radiation may be used alone or in addition to surgery.
Chemotherapy is the
use of drugs to kill cancer cells. Chemotherapy may be taken by
pill, or it may be put into the body by a needle inserted into a
vein. Chemotherapy is called a systemic treatment because the
drugs enter the bloodstream, travel through the body, and can
kill cancer cells outside the cervix.
Treatment by stage
Treatments for cancer
of the cervix depend on the stage of the disease, the size of
the tumor, and the patient's age, overall condition, and desire
to have children.
Treatment of cervical
cancer during pregnancy may be delayed depending on the stage of
the cancer and how many months a patient has been pregnant.
STAGE 0
CERVICAL CANCER
Stage 0 cervical
cancer is sometimes called carcinoma in situ.
Treatment may be one
of the following:
-
1. Conization.
2. Laser surgery.
3. Loop
electrosurgical excision procedure (LEEP).
4. Cryosurgery.
5. Surgery to
remove the cancerous area, cervix, and uterus (total
abdominal or vaginal hysterectomy) for those women who
cannot or no longer want to have children.
Hysterectomy for
women who cannot or no longer want to have children.
Internal radiation therapy for women who cannot have
surgery.
STAGE I
CERVICAL CANCER
Treatment may be one
of the following depending on how deep the tumor cells have
invaded into the normal tissue:
-
For stage IA
cancer:
-
1. Surgery to
remove the cancer, uterus, and cervix (total abdominal
hysterectomy). The ovaries may also be taken out
(bilateral salpingo- oophorectomy), but are usually not
removed in younger women.
2. Conization.
3. For tumors
with deeper invasion (3-5 millimeters): Surgery to
remove the cancer, the uterus and cervix, and part of
the vagina (radical hysterectomy) along with the lymph
nodes in the pelvic area (lymph node dissection).
4. Internal
radiation therapy.
For stage IB
cancer:
-
1. Internal
and external radiation therapy.
2. Radical
hysterectomy and lymph node dissection.
3. Radical
hysterectomy and lymph node dissection followed by
radiation therapy plus chemotherapy.
4. Radiation
therapy plus chemotherapy.
Treatment of
stage IB cervical cancer may include the following:
A combination
of internal radiation therapy and external radiation
therapy.
Radical
hysterectomy and removal of lymph nodes.
Radical
hysterectomy and removal of lymph nodes followed by
radiation therapy plus chemotherapy.
Radiation
therapy plus chemotherapy.
A clinical
trial of high-dose internal radiation therapy combined
with external radiation therapy.
This summary
section refers to specific treatments under study in
clinical trials, but it may not mention every new
treatment being studied. Information about ongoing
clinical trials is available from the NCI Cancer.gov Web
site.
STAGE II
CERVICAL CANCER
Treatment may be one
of the following:
-
For stage IIA
cancer:
-
1. Internal
and external radiation therapy.
2. Radical
hysterectomy and lymph node dissection.
3. Radical
hysterectomy and lymph node dissection followed by
radiation therapy plus chemotherapy.
4. Radiation
therapy plus chemotherapy.
Treatment of
stage IIA cervical cancer may include the following:
A combination of
internal radiation therapy and external radiation therapy.
Radical
hysterectomy and removal of lymph nodes.
Radical
hysterectomy and removal of lymph nodes followed by
radiation therapy plus chemotherapy.
Radiation therapy
plus chemotherapy.
A clinical trial
of high-dose internal radiation therapy combined with
external radiation therapy.
This summary
section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment
being studied. Information about ongoing clinical trials is
available from the NCI Cancer.gov Web site.
For stage IIB
cancer:
-
1. Internal
and external radiation therapy plus chemotherapy.
STAGE
III CERVICAL CANCER
Treatment may be one
of the following:
-
1. Internal and
external radiation therapy plus chemotherapy.
STAGE IV
CERVICAL CANCER
Treatment may be one
of the following:
-
For stage IVA
cancer:
-
1. Internal
and external radiation therapy plus chemotherapy.
For stage IVB
cancer:
-
1. Radiation
therapy to relieve symptoms caused by the cancer.
2.
Chemotherapy.
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