28 Cervix Uteri 28

28 Cervix Uteri

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SUMMARY OF CHANGES

• The definitions of TNM and the Stage Grouping for this chapter have not changed from the Fifth Edition.

C53.0 Endocervix C53.1 Exocervix

C53.8 Overlapping lesion of cervix uteri

C53.9 Cervix uteri

ANATOMY

Primary Site. The cervix is in the lower third of the uterus. It is roughly cylin- drical in shape and projects into the upper vagina. Through the cervix runs the endocervical canal, which is the passageway connecting the vagina with the uterine cavity. The endocervical canal is lined by glandular or columnar epithe- lium. The vaginal portion of the cervix, known as the exocervix, is covered by squamous epithelium. The squamocolumnar junction is usually located at the external cervical os, where the endocervical canal begins. Cancer of the cervix may originate from the squamous epithelium of the exocervix or the glandular epithelium of the canal (Figure 28.1).

Regional Lymph Nodes. The cervix is drained by parametrial, cardinal, and uterosacral ligament routes into the following regional lymph nodes (Figure 28.2):

Parametrial Paracervical Obturator

Internal iliac (hypogastric) External iliac

Common iliac Sacral Presacral

Metastatic Sites. The most common sites of distant spread include the aortic and mediastinal nodes, lungs, and skeleton. Para-aortic node involvement is considered distant metastasis and is coded M1.

DEFINITIONS

The definitions of the T categories correspond to the stages accepted by the

Federation Internationale de Gynecologie et d’Obstetrique (FIGO). Both

systems are included for comparison.

Primary Tumor (T)

TNM FIGO Definitions

Categories Stages

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis 0 Carcinoma in situ

C52.9 C53.1 C53.0 C54.0

C56.9 C57.2

C54.1

C57.0 C54.3

C54

C53

C54.2

FIGURE 28.1. Anatomic sites and subsites of the cervix uteri.

5

4

2

1

3 3

C77.5 6

FIGURE 28.2. Regional lymph nodes of the cervix: (1) paracervical; (2) parametrial; (3) hypogastric (internal iliac) including obturator; (4) external iliac;

(5) common iliac; (6) presacral.

T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded)

T1a IA Invasive carcinoma diagnosed only by microscopy.

All macroscopically visible lesions—even with superficial inva- sion— are T1b/IB. Stromal invasion with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less. Vascular space involve- ment, venous or lymphatic, does not affect classification.

(Figure 28.3)

T1a1 IA1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread (Figure 28.4)

T1a2 IA2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm with a horizontal spread 7.0 mm or less (Figure 28.5)

T1b IB Clinically visible lesion confined to the cervix or micro- scopic lesion greater than Tla2/IA2 (Figure 28.6)

T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension (Figure 28.7)

T1b2 IB2 Clinically visible lesion more than 4.0 cm in greatest dimen- sion (Figure 28.8)

T2 II Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina (Figure 28.9)

T2a IIA Tumor without parametrial invasion (Figure 28.9) T2b IIB Tumor with parametrial invasion (Figure 28.9)

T3 III Tumor extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or nonfunctioning kidney (Figure 28.10)

T3a IIIA Tumor involves lower third of vagina, no extension to pelvic wall (Figure 28.10)

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Invasive carcinoma diagnosed only by microscopy

A

B C

TNM: T1a FIGO: IA

FIGURE 28.3. T1a is defined as invasive carcinoma diagnosed only by

microscopy

with stromal invasion to a maximal depth of 5.0 mm measured from

the base of the epithelium and a horizontal spread of 7.0 mm or less.

£3 mm

£7 mm

Invasive carcinoma diagnosed only by microscopy

A

B T1a1 TNM:

FIGO: IA1

>3-5 mm

£7 mm

A

B

Invasive carcinoma diagnosed only by microscopy T1a2

TNM:

FIGO: IA2

FIGURE 28.5. T1a2 is defined as invasive carcinoma diagnosed only by microscopy with measured stromal invasion more than 3.0 mm and not more than 5.0 mm with horizontal spread 7.0 mm or less B.

FIGURE 28.4. T1a1 is defined as invasive

carcinoma diagnosed only by microscopy

with measured stromal invasion 3.0 mm

or less in depth and 7.0 mm or less in

horizontal spread B.

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£5 mm

>7 mm

>5 mm

A

C B

£7 mm

Microscopic lesion >T1a/IA2 TNM: T1b

FIGO: IB

FIGURE 28.6. T1b is defined as a microscopic lesion greater than Tla2/IA2, i.e., stromal invasion greater than 5.0 mm and/or horizontal spread greater than 7.0 mm B and C or a clinically visible lesion confined to the cervix.

TNM: T1b1 FIGO: IB1

£4 cm

FIGURE 28.7. T1b1 is defined as a clinically visible lesion 4.0 cm or less in greatest

dimension.

TNM: T1b2 FIGO: IB2

>4 cm

FIGURE 28.8. T1b2 is defined as a clinically visible lesion more than 4.0 cm in greatest dimension.

TNM: T2a FIGO: IIA

TNM: T2b FIGO: IIB

2/3

1/3

FIGURE 28.9. T2 is defined as a cervical carcinoma that invades beyond uterus but

not to pelvic wall or to lower third of vagina. T2a (left of the vertical dotted line) is

T2 tumor without parametrial invasion. T2b (right of the vertical dotted line) is T2

tumor with parametrial invasion.

T3b IIIB Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney (Figure 28.10)

T4 IVA Tumor invades mucosa of bladder or rectum and/or extends beyond true pelvis (bullous edema is not sufficient evidence to classify a tumor as T4) (Figure 28.11)

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis

N1 Regional lymph mode metastasis (Figure 28.12)

Distant Metastasis (M)

MX Distant metastasis cannot be assessed M0 No distant metastasis

M1 IVB Distant metastasis

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TNM: T3a FIGO: IIIA

TNM: T3b FIGO: IIIB

2/3

1/3

FIGURE 28.10. T3 tumor extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or nonfunctioning kidney. T3a (left of vertical dotted line) involves lower third of vagina with no extension to pelvic wall.

T3b (right of vertical dotted line) extends to pelvic wall and/or causes

hydronephrosis or nonfunctioning kidney.

TNM: T4 FIGO: IVA

T4 TNM:

FIGO: IVA

FIGURE 28.11. Two views of T4. Bottom of illustration (below dotted line), tumor invades mucosa of bladder or rectum. Top of illustration (above dotted line), tumor extends beyond true pelvis.

N1

FIGURE 28.12. N1 is defined as regional lymph node metastasis.

STAGE GROUPING (AJCC/UICC/FIGO)

0 Tis N0 M0

I T1 N0 M0

IA T1a N0 M0

IA1 T1a1 N0 M0

IA2 T1a2 N0 M0

IB T1b N0 M0

IB1 T1b1 N0 M0

IB2 T1b2 N0 M0

II T2 N0 M0

IIA T2a N0 M0

IIB T2b N0 M0

III T3 N0 M0

IIIA T3a N0 M0

IIIB T1 N1 M0

T2 N1 M0

T3a N1 M0

T3b Any N M0

IVA T4 Any N M0

IVB Any T Any N M1

NOTE

1. The depth of invasion is defined as the measurement of the tumor from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

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