A. The International Federation of Gynecologists and Obstetricians (FIGO) staging system is based upon clinical evaluation. This examination should be performed under anesthesia whenever necessary.
B. Based upon FIGO guidelines, the following examinations are appropriate to establish the stage of disease: palpation and inspection of the primary tumor, palpation of groin and supraclavicular lymph nodes, colposcopy, endocervical curettage, conization, hysteroscopy, cystoscopy, proctoscopy, intravenous pyelogram (IVP), and radiographic examination of the lungs and skeleton.
C. Chest X-rays are indicated in all patients with cervical cancer, and imaging of the urinary tract (IVP, magnetic resonance or computed tomography urogram) should be carried out in all patients with more than microscopic cervical cancer. Suspected rectal or bladder involvement requires confirmation by biopsy.
IV. Optional evaluation procedures. Although they are not used to assign disease stage in the FIGO classification, optional staging examinations, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), lymphangiography, ultrasonography, or laparoscopy, may be of value for planning treatment, particularly the extent of the radiation therapy (RT) field or scope of surgery.
A. MRI is the preferred modality to provide information about tumor size, degree of stromal penetration, nodal metastasis, and local tissue extension. Positive findings should be histologically confirmed by fine needle aspiration under CT guidance.
V. Surgical evaluation. Although cervical cancer is staged clinically, the results of surgical staging can be used for treatment planning. The staging procedure can be performed through a laparotomy (transperitoneal or extraperitoneal) or laparoscopically. Surgical staging allows for a complete pelvic and paraaortic lymphadenectomy. Nodal tissue obtained at the time of surgery can detect microscopic disease. Staging offers an opportunity to resect bulky metastatic lymph nodes and allows for individualization of the radiation field. In premenopausal women, oophoropexy can be done at the same time to protect the ovaries from radiation damage.
VI. Treatment of microinvasive cervical cancer. According to the FIGO criteria, patients with stage Ia 1 carcinoma could be treated with simple hysterectomy without nodal dissection or conization in selected cases. Those patients with invasion greater than 3 mm and no greater than 5 mm (stage Ia2) should undergo radical hysterectomy and pelvic lymphadenectomy. Although lymphatic-vascular invasion should not alter the FIGO stage, it is an important factor in treatment decisions. The risk of recurrence with lymphatic-vascular involvement is 3.1% if the extent of invasion is 3 mm or less and 15.7% if it is greater than 3 mm and no greater than 5 mm. Therefore, the presence of lymphatic-vascular invasion would suggest the need for more radical treatment.
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