FIGO Staging of Cervical Cancer
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Direct answer
FIGO staging of cervical cancer classifies disease extent from stage I, confined to the cervix, to stage IV, with spread beyond the pelvis. The 2018 revision allows imaging and pathology findings to be used and places pelvic or para-aortic node involvement in stage IIIC. Stage determines treatment, with early stages usually managed by surgery and advanced stages by chemoradiation.
What you must remember
- Stage I: Confined to the cervix, with IA microscopic invasion and IB clinically visible or larger lesions.
- IA subdivisions: IA1 invasion of 3 mm or less in depth, IA2 more than 3 mm up to 5 mm; the old horizontal spread limit was dropped in 2018.
- IB subdivisions: IB1 under 2 cm, IB2 2 cm to under 4 cm, and IB3 4 cm or more.
- Stage II: Beyond the uterus but not to the pelvic side wall or lower third of the vagina, with IIB meaning parametrial involvement.
- Stage III: Lower third of the vagina, pelvic side wall or hydronephrosis, and IIIC for pelvic or para-aortic nodes.
- Stage IV: IVA invasion of bladder or rectal mucosa, and IVB distant metastases.
- Investigations: MRI is preferred for local extent, while PET-CT or CT assesses nodes and distant spread.
Stage, not tumour type alone, sets the treatment
A 45-year-old woman has a 3.5 cm cervical tumour on MRI with no parametrial spread, which places her in the IB2 group. The table shows how each stage group is usually treated.
| Stage | Key feature | Usual treatment |
|---|---|---|
| IA1 without LVSI | Invasion up to 3 mm deep | Conization or simple hysterectomy |
| IA2 and IB1 | Small lesion, no nodal disease | Radical hysterectomy with pelvic nodal assessment |
| IB2 to IIA1 | 2 cm to under 4 cm, no parametrial spread | Radical surgery or chemoradiation |
| IB3, IIA2, IIB to IVA | 4 cm or more, or parametrial spread | Concurrent chemoradiation with brachytherapy |
| IVB | Distant metastases | Systemic chemotherapy with palliative radiotherapy |
Nodal status is now part of the stage, so an enlarged pelvic node moves a patient into IIIC even when the primary tumour is small. Treatment choices within a group also depend on fitness, local expertise and the patient's preference.
Staging examinations should be completed before any treatment begins, because a change in stage alters the plan.
Where the exam tries to catch you
The 2018 changes are the most frequently tested differences from the older system.
- Trap: Staging a node-positive cervical tumour as stage II Correct: Under the 2018 system, pelvic or para-aortic node involvement places the patient in IIIC regardless of primary size.
- Trap: Ignoring imaging in local staging Correct: Imaging and pathology can now be used in staging, with MRI preferred for parametrial and vaginal spread.
- Trap: Offering primary radical surgery to IB3 disease by default Correct: Tumours of 4 cm or more, and parametrial disease, are usually treated with chemoradiation rather than primary surgery.
Frequently asked questions
What are the FIGO 2018 subdivisions of stage IB cervical cancer?
Stage IB is divided into IB1 for tumours under 2 cm, IB2 for tumours of 2 cm to under 4 cm, and IB3 for tumours of 4 cm or more. These size groups help guide whether surgery or chemoradiation is preferred. Staging is clinical, supplemented by imaging and pathology.
Does FIGO 2018 staging allow the use of MRI?
Yes, FIGO 2018 allows imaging and pathological findings to be used in assigning the stage, so MRI, CT or PET-CT may define nodal and local spread. Clinical examination remains part of the staging process. This is a key change from earlier practice.
Where are lymph node metastases placed in FIGO 2018 staging?
Pelvic or para-aortic lymph node metastases place cervical cancer in stage IIIC, whatever the size of the primary tumour. Pelvic nodes are classified as IIIC1 and para-aortic nodes as IIIC2. Nodal involvement is therefore a major determinant of prognosis and treatment.
Which treatment is standard for stage IIB cervical cancer?
Stage IIB cervical cancer is usually treated with concurrent chemoradiation, meaning external beam radiotherapy with brachytherapy and weekly cisplatin. Radical surgery is less often the first choice at this stage. The final choice depends on local expertise and the patient's fitness.
What defines stage IA cervical cancer under FIGO 2018?
Stage IA is microscopic invasive cancer confined to the cervix. IA1 has invasion up to 3 mm in depth, and IA2 has invasion of more than 3 mm up to 5 mm; horizontal spread is no longer part of the definition. Treatment for stage IA depends on the presence or absence of lymphovascular invasion.