Federation Of Gynecology And Obstetrics Staging System Research Articles

Clinical application of FIGO 2023 staging system of endometrial cancer in a Chinese cohort

ObjectiveThe International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system for endometrial cancer (EC) was released with incorporating histology, lympho-vascular space invasion, and molecular classification together. Our objective is to further explore the clinical utility and prognostic significance of the 2023 FIGO staging system in China.MethodsA retrospective analysis was conducted for patients who received standard surgeries and underwent genetic testing using multigene next-generation sequencing (NGS) panels between December 2018 and December 2023 at Fudan University Shanghai Cancer Center, Shanghai, China. The genomic and clinical data of all patients were analyzed, and stages were determined by both the 2009 and 2023 FIGO staging systems. Kaplan–Meier estimators and Cox proportional hazards models were used for survival analysis.ResultsA total of 547 patients were enrolled in the study. After the restaged by the FIGO 2023 staging system, stage shifts occurred in 147/547 (26.9%) patients. In patients with early stages in FIGO 2009 (stage I-II), 63 cases were rearranged to IAmPOLEmut and 53 cases to IICmp53abn due to the molecular classification of POLEmut and p53abn. Altogether 345 cases were in stage I, 107 cases in stage II, 69 cases in stage III, and 26 cases in stage IV according to the FIGO 2023 staging criteria. For stage I diseases, the 3-year PFS rate was 92.7% and 95.3% in 2009 and 2023 FIGO staging systems, respectively. The 3-year PFS of stage II in 2023 FIGO was lower than that of FIGO 2009 (3-year PFS: 85.0% versus 90.9%), especially in substage IIC and IICmp53abn. Three cases (12%) of stage IIIA in FIGO 2009 were shifted to stage IA3 FIGO 2023, with 3-year PFS rates of 90.9% versus 100%, respectively. In NGS analysis, the most prevalent gene alterations were observed in PTEN and PIK3CA.ConclusionThe FIGO 2023 staging system was proved to be a good predictor of survival for EC patients with enhanced precision compared to FIGO 2009. Predominant stage shifts were observed in early-stage diseases. Distinct gene alterations of different subtypes may help to explore more accurate target therapies.

International Federation of Gynecology and Obstetrics Endometrial 2023 Is Better For Radiation Oncology Patients

The International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system for endometrial cancer has marked changes from the previous staging system instituted 14 years prior in 2009. The new staging system includes nonanatomic factors for the first time (lymphovascular space invasion and histology) and molecular classification, which impacts the stage in early-stage disease (IAmPOLEmut and IICmp53abn). The purpose of these changes was to provide (1) high accuracy in the predictive prognosis for patients and (2) identification of distinct treatment-relevant subgroups. Our understanding of the biology and natural history of endometrial cancer has undergone a radical transformation since the Cancer Genome Atlas results in 2013. The 2023 FIGO staging system harmonizes and integrates old and new knowledge on anatomic, histopathologic, and molecular features. Moreover, FIGO 2023 has distinct substages that improve adjuvant treatment decision making. Although the practicality of the new staging system has been debated, we postulate that FIGO 2023 is more useful for radiation oncologists aiming to provide personalized care recommendations. FIGO 2023 requires a change in our perception of a staging system, from a traditional anatomic borders-based system to a staging system integrating anatomy and tumor biology as pivotal prognostic factors for patients while providing important information for treatment decision making.

Impact of the 2023 FIGO Staging System for Endometrial Cancer on the Use of Imaging Services: An Indian Perspective

AbstractThe new 2023 update of the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer incorporates the advances made in the understanding of the pathology and molecular classifications into the staging system. While the new staging system aids in precision medicine and may lead to better documentation of prognostic risk categories of endometrial cancer, it is complex and calls for an integrated approach and better communication between multiple disciplines involved in the management of endometrial cancer. In this review article, we address how the referral patterns to imaging services might change considering the updated staging system for endometrial cancer. We also discuss the practical aspects and nuances involved in the radiology service delivery and reporting practices as we adopt the new FIGO staging system for managing endometrial cancer patients.

Significance of tumor size and number of positive nodes in patients with FIGO 2018 stage IIIC1 cervical cancer.

This study aimed to investigate the prognostic significance of tumor size and number of positive pelvic lymph nodes (PLN) in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIIC1 cervical cancer patients. Clinical data from 626 women with cervical cancer treated at Osaka International Cancer Center in 2010-2020 were retrospectively reviewed. Using the cutoff value obtained on the receiver operating characteristic analysis, the prognostic significance of tumor size and number of positive PLN in stage IIIC1 patients was first evaluated via uni- and multivariate analyses. Then, the impact of incorporating tumor size and number of positive PLN into the FIGO staging system was investigated using the Kaplan-Meier method. Among 196 women with Stage IIIC1 disease, larger tumors (>4cm) and multiple PLN metastases (≥4) were independent predictors of progression-free survival (PFS) in patients with stage IIIC1 cervical cancer. The PFS of patients with stage IIIC1 disease was inversely associated with the number of risk factors. Although patients with stage IIIC1 disease had significantly increased survival rates compared to those with stage IIIA or IIIB disease in the original FIGO 2018 staging system, this reversal phenomenon was resolved by incorporating larger tumors (>4cm) and multiple PLN metastases (≥4) into the revised staging system. Incorporating tumor size and number of metastatic lymph nodes into the FIGO staging system allows additional risk stratification for women with stage IIIC1 cervical cancer and improves survival prediction performance.

Verification of the prognostic precision of the new 2023 FIGO staging system in endometrial cancer patients – An international pooled analysis of three ESGO accredited centres

BackgroundRecently, the new 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer (EC) critically integrating new pathological and molecular features was published. The present study evaluated the clinical impact of the new 2023 FIGO staging system by comparing it to the previous 2009 system. MethodsThis is an international, pooled retrospective study of 519 EC patients who underwent primary treatment (and molecular characterisation) at three European Society of Gynaecological Oncology (ESGO) accredited centres in Austria/Italy. Patients were categorised according to the 2009 and the 2023 FIGO staging systems. Stage shifts were analysed and (sub)stage specific 5-year progression-free (PFS) and overall survival (OS) rates were calculated and compared. Different statistical tests were applied to evaluate the prognostic precision of the two FIGO staging systems and to compare them to each other. Results(Sub)stage shifts occurred in 143/519 (27.6%) patients: 123 upshifts (23.7%) and 20 (3.9%) downshifts. 2023 FIGO staging system identified a stage I cohort with a notably higher 5-year PFS rate compared to 2009 (93.0% versus 87.4%, respectively). For stage II disease, the 5-year PFS rate was similar in the 2023 and the 2009 FIGO staging systems (70.2% versus 71.2%, respectively). The two new molecularly defined 2023 FIGO substages IAmPOLEmut and IICmp53abn displayed distinct, particularly favourable and adverse oncologic outcomes within early stage disease, respectively. A remarkably lower 5-year PFS rate for stage III patients was revealed in the 2023 FIGO staging system compared to 2009 (44.4% versus 54.1%, respectively). All applied statistical tests confirmed a more accurate prediction of PFS and OS by the 2023 FIGO staging system compared to 2009. ConclusionThe new 2023 FIGO stating system led to a substantial stage shift in about one quarter of patients leading to a higher prognostic precision. In early stage disease, the new substages added further prognostic granularity and identified treatment relevant subgroups.

Establishment of a risk stratification model based on the combination of post-treatment serum squamous cell carcinoma antigen levels and FIGO stage of cervical cancer for treatment and surveillance decision-making

ObjectiveTo develop a risk stratification model based on the International Federation of Gynecology and Obstetrics (FIGO) staging combined with squamous cell carcinoma antigen (SCC-Ag) for the classification of patients with cervical squamous cell carcinoma (CSCC) into different risk groups.MethodsWe retrospectively reviewed the data of 664 women with stage IIA–IVB CSCC according to the 2018 FIGO staging system who received definitive radiotherapy from March 2013 to December 2017 at the department of radiation oncology of Sun Yat-sen University Cancer Center. Cutoff values for continuous variables were estimated using receiver operating characteristic curve analysis. Using recursive partitioning analysis (RPA) modeling, overall survival was predicted based on the prognostic factors determined via Cox regression analysis. The predictive performance of the RPA model was assessed using the consistency index (C-index). Intergroup survival differences were determined and compared using Kaplan–Meier analysis and the log-rank test.ResultsMultivariate Cox regression analysis identified post-treatment SCC-Ag (< 1.35 ng/mL and > 1.35 ng/mL; hazard ratio (HR), 4.000; 95% confidence interval (CI), 2.911–5.496; P < 0.0001) and FIGO stage (II, III, and IV; HR, 2.582, 95% CI, 1.947–3.426; P < 0.0001) as the independent outcome predictors for overall survival. The RPA model based on the above prognostic factors divided the patients into high-, intermediate-, and low-risk groups. Significant differences in overall survival were observed among the three groups (5-year overall survival: low vs. intermediate vs. high, 91.3% vs. 76.7% vs. 29.5%, P < 0.0001). The predictive performance of the RPA model (C-index, 0.732; 95% CI, 0.701–0.763) was prominently superior to that of post-treatment SCC-Ag (C-index, 0.668; 95% CI, 0.635–0.702; P < 0.0001) and FIGO stage (C-index, 0.663; 95% CI, 0.631–0.695; P < 0.0001).ConclusionsThe RPA model based on FIGO staging and post-treatment SCC-Ag can predict the overall survival of patients with CSCC, thereby providing a guide for the formulation of risk-adaptive treatment and individualized follow-up strategies.

Small cell neuroendocrine carcinoma of the cervix: Analysis of prognostic factors and patterns of metastasis

ObjectivesTo describe characteristics and outcomes of patients with small cell neuroendocrine carcinoma of the cervix (SCNCC) and determine the staging system most predictive of outcome—the two-tier (limited-stage [LS] vs. extensive-stage [ES]) or International Federation of Gynecology and Obstetrics (FIGO) staging system. MethodsPatients with SCNCC evaluated at our institution from 1/1/1990–6/30/2021 were included. Medical records were reviewed for variables of interest. Appropriate statistical tests were performed to determine associations. Survival curves were created using the Kaplan-Meier method. Concordance probability estimates (CPEs) were calculated to evaluate the prediction probability of the staging systems. ResultsOf 63 patients, 41 had LS and 22 ES SCNCC. Patients with ES disease were significantly older than those with LS disease (median, 54 and 37 years, respectively; p < 0.001). Smoking status, race, and history of HPV were not associated with stage or outcomes. Forty-eight patients had metastatic disease (24 [50%] at initial diagnosis). The most common first sites of metastasis were lung (n = 20/48, 42%), lymph nodes (n = 19/48, 40%), and liver (n = 13/48, 27%). Nine patients had brain metastasis (8 symptomatic at recurrence; 1 asymptomatic at initial diagnosis). Both staging systems were associated with progression-free and overall survival. Adjusted CPE found the FIGO staging system was more predictive of outcomes than the two-tier staging system. ConclusionsProviders should have a low threshold to obtain brain imaging for patients with SCNCC, especially in the presence of visceral metastases. FIGO staging should be used to classify SCNCC. Further research is necessary to understand prognostic factors of this rare disease.

Announcing the winner of the John J. Sciarra IJGO Prize Paper Award for 2021

The editors of the International Journal of Gynecology & Obstetrics (IJGO) are pleased to announce the winner of the prize paper award for the best clinical research paper from a low- or middle-income country published in IJGO during 2021. The winning paper is: Tang X, Guo C, Liu S, Guo J, Hua K and Qiu J. A novel prognostic nomogram utilizing the 2018 FIGO staging system for cervical cancer: A large multicenter study. Int J Gynecol Obstet 2021;155:86–94. https://doi.org/10.1002/ijgo.13644. It was published in the October 2021 issue of IJGO. This award brings with it a stipend of £800, a certificate of recognition, and complimentary access to IJGO for a period of 1 year from the date the prize is awarded. All clinical research articles submitted to the IJGO from low- and middle-income countries that were published in 2021 were considered for this prize. The paper was chosen from 95 qualifying articles. Selection and review were undertaken by the editors, and the Editorial Board of IJGO endorsed the decision. The winning paper by Tang et al. evaluated the prognostic performance of the revised 2018 FIGO staging system for cervical cancer in a multicentre study across four sites. In 3238 patients with cervical cancer, 1841 (almost 60%) were re-staged. Almost one third of these were re-staged due to tumor size, approximately 30% due to lymph node metastasis, and one third due to the inconsistency between the pre-operative and post-operative assessments. They concluded that the 2018 FIGO staging system was a better reflection of the survival of cervical cancer patients. This very important work also allowed the group to establish a nomogram that allowed them to predict the prognosis of cervical cancer more accurately. Additional papers that are worthy of special recognition are awarded an honorable mention. While the honorable mention recognition does not include a financial award, each author receives a certificate of recognition and a letter of commendation from the editors of IJGO. The IJGO Prize Paper Award was established in 1998 for the purpose of encouraging investigators, especially young scientists, from low- and middle-income countries to submit their best clinical research articles for publication in the journal. IJGO is the official publication of FIGO (International Federation of Gynecology and Obstetrics), the primary international organization for the specialty of obstetrics and gynecology. FIGO is dedicated to enhancing the health care of women worldwide. HONORABLE MENTIONS 2021 The following 11 papers receive an honorable mention: China Li Y, Wang H, Zhang Y, et al. Correlation between multi-type human papillomavirus infections and viral loads and the cervical pathological grade. Int J Gynecol Obstet. 2020;152:96–102. https://doi.org/10.1002/ijgo.13406 Wang X, Zhang C, Li X, Qi H, Liu Q, Lei J. Safety and efficacy of titrated oral misoprostol solution versus vaginal dinoprostone for induction of labor: a single-center randomized control trial. Int J Gynecol Obstet. 2021;154:436–443. https://doi.org/10.1002/ijgo.13546 Brazil Laporte M, Becerra A, Castro L, Veiga N Jr, Espejo-Arce X, Bahamondes L. Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional. Int J Gynecol Obstet. 2021;152:196–201. https://doi.org/10.1002/ijgo.13396 Barbieri MM, Herculano TB, Dantas Silva A, Bahamondes L, Juliato CRT, Surita FG. Acceptability of ENG-releasing subdermal implants among postpartum Brazilian young women during the COVID-19 pandemic. Int J Gynecol Obstet. 2021;154:106–112. https://doi.org/10.1002/ijgo.13663 Turkey Karakas LA, Atilgan AO, Akilli H, Kuscu UE, Haberal A, Ayhan A. Nulliparity and postmenopausal status are independent factors of malignancy potential of endometrial intraepithelial neoplasia in polyps. Int J Gynecol Obstet. 2021;152:433–438. https://doi.org/10.1002/ijgo.13448 Iran Ghotbizadeh Vhdani F, Nasiri Khormoji N, Eftekhar N, et al. A double-blind randomized trial on subendometrial injection of vasopressin to control bleeding in postpartum hysterectomy due to abnormally invasive placenta. Int J Gynecol Obstet. 2021;153:228–233. https://doi.org/10.1002/ijgo.13440 South Africa Budhram S, Vannevel V, Botha T, et al. Maternal characteristics and pregnancy outcomes of hospitalized pregnant women with SARS-CoV-2 infection in South Africa: An International Network of Obstetric Survey Systems-based cohort study. Int J Gynecol Obstet. 2021;155:455–465. https://doi.org/10.1002/ijgo.13917 Goldman B, Naidoo T. Formal training in cardiotocograph interpretation of healthcare practitioners improves interpretation: a prospective descriptive analytical study in a resource constrained setting. Int J Gynecol Obstet. 2021;153:527–532. https://doi.org/10.1002/ijgo.13513 Kenya Gwako GN, Obimbo MM, Gichangi PB, Kinuthia J, Gachuno OW, Were F. Association between obstetric and medical risk factors and stillbirths in a low-income urban setting. Int J Gynecol Obstet. 2021;154:331–336. https://doi.org/10.1002/ijgo.13528 Egypt Abdallah A, Khairy M, Tawfik M, et al. Role of first-trimester three-dimensional (3D) power Doppler of placental blood flow and 3D placental volume in early prediction of pre-eclampsia. Int J Gynecol Obstet. 2021;154:466–473. https://doi.org/10.1002/ijgo.13572 Malaysia Goh YP, Tan PC, Hong JGS, Sulaiman S, Omar, SZ. Combined massage and warm compress to the perineum during active second stage of labor in nulliparas: a randomized trial. Int J Gynecol Obstet. 2021;155:532–538. https://doi.org/10.1002/ijgo.13613

Nomograms Predicting Survival of Cervical Cancer Patients Treated With Concurrent Chemoradiotherapy Based on the 2018 FIGO Staging System.

BackgroundIn 2018, a revised staging system was released for cervical cancer, which defined pelvic and paraaortic lymph node metastasis as stages IIIC1 and IIIC2, respectively. In this study, we constructed and validated nomograms to predict the 3- and 5-year survival of patients with cervical cancer based on the revised International Federation of Gynecology and Obstetrics (FIGO) staging system.MethodsWe retrospectively examined patients with 2009 FIGO stage IB–IVA cervical cancer who were treated at our institute between 2011 and 2015. Patients were randomized into the model development and validation cohorts (2:1). Univariate and multivariate analyses were conducted for the model development cohort to identify prognostic factors. In the multivariate analysis, nomograms were built to predict overall survival (OS) and disease-free survival (DFS) using significant variables. The nomograms were assessed based on the discrimination and calibration in both cohorts. Discrimination was assessed using the concordance index. Calibration was performed by comparing the mean nomogram estimated survival and the mean observed survival.ResultsWe included 1,192 patients, with 795 and 397 patients in the model development and validation cohorts, respectively. In the model development cohort, the median follow-up period was 49.2 months. After multivariate analysis, age, histology, 2018 FIGO stage, and pelvic lymph node number were independent factors for OS. Histology, 2018 FIGO stage, squamous cell carcinoma antigen, and pelvic lymph node number were significant predictors of DFS. The nomograms constructed to predict OS and DFS were based on these factors. In both model cohorts, the concordance index for the nomogram-predicted OS and DFS was 0.78 and 0.75 and 0.74 and 0.67, respectively. The calibration curve revealed good agreement between the nomogram predictions and actual values.ConclusionWe constructed robust nomograms to predict the OS and DFS of patients with cervical cancer undergoing treatment with concurrent chemoradiotherapy based on the 2018 FIGO staging system.

Vulvar Cancer: 2021 Revised FIGO Staging System and the Role of Imaging.

Simple SummaryPrimary vulvar malignancy is a rare gynecological neoplasm constituting 5–8% of cases. Considering the prognostic capability of staging, FIGO has introduced the revised 2021 staging for vulvar cancer. We review the etiopathogenesis revised 2021 International Federation of Gynecology and Obstetrics (FIGO) classification and emphasize imaging in the staging of vulvar cancer.Vulvar cancer is a rare gynecological malignancy. It constitutes 5–8% of all gynecologic neoplasms, and squamous cell carcinoma is the most common variant. This article aims to review the etiopathogenesis revised 2021 International Federation of Gynecology and Obstetrics (FIGO) classification and emphasize imaging in the staging of vulvar cancer. The staging has been regulated by FIGO since 1969 and is subjected to multiple revisions. Previous 2009 FIGO classification is limited by the prognostic capability, which prompted the 2021 revisions and issue of a new FIGO classification. Although vulvar cancer can be visualized clinically, imaging plays a crucial role in the staging of the tumor, assessing the tumor extent, and planning the management. In addition, sentinel lymph node biopsy facilitates the histopathological staging of the draining lymph node, thus enabling early detection of tumor metastases and better survival rates.

Interobserver agreement and prognostic impact for MRI–based 2018 FIGO staging parameters in uterine cervical cancer

ObjectivesTo evaluate the interobserver agreement for MRI–based 2018 International Federation of Gynecology and Obstetrics (FIGO) staging parameters in patients with cervical cancer and assess the prognostic value of these MRI parameters in relation to other clinicopathological markers.MethodsThis retrospective study included 416 women with histologically confirmed cervical cancer who underwent pretreatment pelvic MRI from May 2002 to December 2017. Three radiologists independently recorded MRI–derived staging parameters incorporated in the 2018 FIGO staging system. Kappa coefficients (κ) for interobserver agreement were calculated. The predictive and prognostic values of the MRI parameters were explored using ROC analyses and Kaplan–Meier with log-rank tests, and analyzed in relation to clinicopathological patient characteristics.ResultsOverall agreement was substantial for the staging parameters: tumor size > 2 cm (κ = 0.80), tumor size > 4 cm (κ = 0.76), tumor size categories (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) (κ = 0.78), parametrial invasion (κ = 0.63), vaginal invasion (κ = 0.61), and enlarged lymph nodes (κ = 0.63). Higher MRI–derived tumor size category (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) was associated with a stepwise reduction in survival (p ≤ 0.001 for all). Tumor size > 4 cm and parametrial invasion at MRI were associated with aggressive clinicopathological features, and the incorporation of these MRI–based staging parameters improved risk stratification when compared to corresponding clinical assessments alone.ConclusionThe interobserver agreement for central MRI–derived 2018 FIGO staging parameters was substantial. MRI improved the identification of patients with aggressive clinicopathological features and poor survival, demonstrating the potential impact of MRI enabling better prognostication and treatment tailoring in cervical cancer.Key Points• The overall interobserver agreement was substantial (κ values 0.61–0.80) for central MRI staging parameters in the 2018 FIGO system.• Higher MRI–derived tumor size category was linked to a stepwise reduction in survival (p ≤ 0.001 for all).• MRI–derived tumor size > 4 cm and parametrial invasion were associated with aggressive clinicopathological features, and the incorporation of these MRI–derived staging parameters improved risk stratification when compared to clinical assessments alone.

Added-value of texture analysis of ADC in predicting the survival of patients with 2018 FIGO stage IIICr cervical cancer treated by concurrent chemoradiotherapy

PurposeTo investigate the value of texture analysis of ADC in predicting the survival of patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IIICr cervical squamous cell cancer (CSCC) treated with concurrent chemoradiotherapy (CCRT). MethodsA total of 91 patients with stage IIICr CSCC treated by CCRT between January 2014 and December 2018 were retrospectivelyenrolled in this study. Clinical variables and 21 first-order texture features extracted from ADC maps were collected. Univariate and multivariate Cox hazard regression analyses were performed to evaluate these parameters in predicting progression-free survival (PFS) and overall survival (OS). The independent variables were combined to build a prediction model and compared with the 2018 FIGO staging system. Survival curves were generated using the Kaplan-Meier method, and the log-rank test was used for comparison. ResultsMean Absolute Deviation (MAD), T stage, and the number of lymph node metastasis (LNM) were independently associated with PFS, while MAD, energy, T stage, number of LNM, and tumor grade were independently associated with OS. The C-index values of the combined models for PFS and OS, which were respectively 0.750 and 0.832, were significantly higher compared to 2018 FIGO staging system values of 0.629 and 0.630, respectively (P < 0.05). ConclusionsThe texture analysis of the ADC maps could be used along with clinical prognostic biomarkers to predict PFS and OS in patients with stage IIICr CSCC treated by CCRT.

Prognostic Analysis and Comparison of the 2014 and 2018 International Federation of Gynecology and Obstetrics Staging System on Overall Survival in Patients with Stage IIB-IVA Cervix Carcinoma.

PurposeThis study aimed to assess the prognostic factors of overall survival (OS) in patients with stage IIB–IVA cervix carcinoma (CC) who underwent external beam radiation therapy (EBRT) and brachytherapy (BRT) and to compare the prognostic accuracy of the 2014 and 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system using the Surveillance, Epidemiology, and End Results (SEER) database.MethodsPatients with a histopathological diagnosis of CC between 2004 and 2016 were included. The primary endpoint was OS. The prognostic significance for OS was analyzed by the Cox regression model. Prognostic accuracy in evaluating 3- and 5-year OS in different staging systems was evaluated using time-dependent receiver operating characteristic (tdROC) curves.ResultsA total of 2585 patients with stage IIB–IVA CC, staged according to the 2014 FIGO staging system, were included in the study. The 3- and 5-year OS rates were 63.9% and 56.6%, respectively, with a median OS of 98 months. Independent variables, such as older age at diagnosis, histological grades apart from well or moderately differentiated, large tumor size, advanced tumor stages classified according to the 2014 and 2018 FIGO staging systems and treatment without chemotherapy or unknown were associated with a worse OS. A tdROC analysis conducted using DeLong’s tests revealed no significant difference in the prediction of 3- and 5-year OS between the 2014 and 2018 FIGO staging systems (P = 0.912 and 0.863, respectively).ConclusionBoth 2014 and 2018 FIGO staging systems were strong prognostic factors for OS. No significant risk classification was observed for stage IIIC1 disease in the revised 2018 FIGO staging system for patients who underwent EBRT and BRT.

Clinical advantage and outcomes of computed tomography-based transvaginal hybrid brachytherapy performed only by sedation without general or saddle block anesthesia.

Three-dimensional image-guided brachytherapy is the standard of care in cervical cancer radiotherapy. In addition, the usefulness of the so-called "hybrid brachytherapy (HBT)" has been reported, which involves the addition of needle applicators to conventional intracavitary brachytherapy for interstitial irradiation. To evaluate the clinical outcomes of CT-based HBT consisting of transvaginal insertion of needle applicators (CT-based transvaginal HBT) and only intravenous sedation without general or saddle block anesthesia. This is a retrospective chart review of patients who received definitive radiotherapy, including CT-based transvaginal HBT, between February 2012 and July 2019. The inclusion criteria were as follows: (i) histologically diagnosed disease, (ii) untreated cervical cancer, (iii) International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IVA disease in the 2008 FIGO staging system, and (iv) patients who underwent CT-based transvaginal HBT at least once in a series of intracavitary brachytherapy. Overall, 54 patients fulfilled the eligibility criteria in the present study. The median follow-up period was 32 (IQR, 19-44) months. No patient complained of symptoms such as persistent bleeding or abdominal pain after the treatment. The 3-year local control (LC), disease-free survival, and overall survival rates for all 54 patients were 86.6%, 60.3%, and 90.7% (95% CI [81.3%-100.0%]), respectively. The 3-year LC rate was 87.7% in patients with FIGO III-IVA and 90.4% in tumor size >6.0cm. The incidence rate of late adverse events, grade ≥3, in the rectum and bladder was 0% and 1.8%, respectively. In the dose-volume histogram analyses, transvaginal HBT increased the dose of HR-CTVD90 by ~7.5% without significantly increasing the dose of organs at risk. Considering the favorable clinical outcomes, CT-based transvaginal HBT may be a good option for treating cervical cancer.

Stage Migration in Cervical Cancer Using the FIGO 2018 Staging System: A Retrospective Survival Analysis Using a Single-Institution Patient Cohort.

IntroductionThe International Federation of Gynecology and Obstetrics (FIGO) changed the staging system for cervical cancer in 2018 and formally allowed cross-sectional imaging for staging purposes. Stage IB is now divided into three substages based on tumor size (IB1 < 2 cm, IB2 2-4 cm and IB3 > 4 cm). The presence of lymph nodes in the pelvis or para-aortic region will upstage the patient to stage IIIC. The purpose of this study was to evaluate the extent of stage migration using the FIGO 2018 staging system for cervical cancer and validate the new staging system by assessing the survival outcomes.MethodsAn Institutional Review Board-approved and Health Insurance Portability and Accountability Act-compliant retrospective analysis was performed on 158 patients from the cervical cancer database at the University of Mississippi Medical Center, USA. Patients had been treated between January 2010 and December 2018, and they were all staged according to the FIGO 2009 staging system previously. We collected data regarding tumor size, lymph node presence, and extent of metastatic disease in the pretreatment CT, positron emission tomography (PET), or MRI scans and restaged the patients using the FIGO 2018 system. The extent of stage migration was evaluated using the new staging system. We analyzed the three-year overall survival (OS) using both FIGO 2009 and 2018 staging systems for validation purposes. Kaplan-Meier analyses were performed using SPSS version 24.ResultsFifty-nine percent of the patients were upstaged when they were restaged using the FIGO 2018 staging system. In the current 2018 staging system, Stage IB3 accounted for 4%, and Stage IIIC accounted for 48% of the patient cohort, while other stages accounted for the rest. The median overall survival of the entire cohort was 20.5 months. There was a change in the survival curves using FIGO 2018 stages compared to those of FIGO 2009. There was a numerical improvement in three-year OS in stages IB and III among the two staging systems; however, it was not statistically significant. Interestingly, the three-year overall survival of Stage IIIC patients was better when compared to Stages III A& B combined (61% vs. 25%, p=0.017).ConclusionThe increased availability of cross-sectional imaging across the world has led to recent changes in the FIGO staging system for cervical cancer, which allowed imaging in staging. We identified a significant stage migration in our patient cohort with the FIGO 2018 staging system, but no difference in the three-year overall survival was observed. Local tumor extent may be a worse prognostic indicator than nodal metastasis among stage III patients.

Re-classification of uterine cervical cancer cases treated with radical hysterectomy based on the 2018 FIGO staging system

ObjectiveWe re-classified patients with stage IB–II disease (based on the 2008 system) and compared the outcomes with those obtained after using the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system. Materials and methodsWe reviewed the data of 154 patients with cervical cancer who underwent radical hysterectomy at our hospital during 2006–2016. Pathological, histological, and radiographic data were used to re-classify the cases based on the 2018 FIGO system. We compared these outcomes to those obtained after using the 2008 FIGO assignments. Overall survival (OS) was calculated from primary therapy initiation until death or the last follow-up examination. ResultsThe histological types were squamous cell carcinoma (108 cases) and others (46 cases). The 2008 FIGO system assignments were stage IB1, IB2, IIA1, IIA2, and IIB (87, 27, seven, five, and 28 patients, respectively). The new 2018 FIGO system assignments were stage IB1, IB2, IB3, IIA1, IIA2, IIB, and IIIC1 (52, 26, 16, six, three, 21, and 30 patients, respectively). Re-classification to stage IIIC1 disease was observed for previously assigned stage IB1, IB2, IIA1, IIA2, and IIB cases (10, seven, two, two, and nine cases, respectively). The median OS durations based on the 2018 FIGO system were 71.7, 61.1, and 62.3 months for patients with stage IB1, IB2, and IB3 (p = 0.04) disease, respectively. The new stage IB3/IIA2/IIB cases had longer OS than the old stage IB2/IIA2/IIB cases. A positive computed tomography (CT) finding of nodal involvement was observed in 37% of cases with pathological confirmation of pelvic lymph node (LN) involvement. Using CT to identify pelvic LN metastasis had a sensitivity of 37% and specificity of 93%. ConclusionThe 2018 FIGO staging system for cervical cancer after radical hysterectomy showed a better ability to differentiate survival outcomes. However, the image evaluation method should be reconsidered.

Prognostic significance of tumor laterality in advanced ovarian cancer.

ObjectiveThis study aimed to investigate the effect of incorporating tumor laterality into the International Federation of Gynecology and Obstetrics (FIGO) staging system for advanced ovarian cancer.MethodsThe clinical data of 131 patients with advanced ovarian cancer treated between 2008 and 2018 were retrospectively reviewed. To investigate the prognostic significance of tumor laterality, we divided the patients into unilateral and bilateral groups. The prognostic significance of tumor laterality (bilateral vs. unilateral) was evaluated using univariate and multivariate analyses. The effect of incorporating tumor laterality into the FIGO staging system to predict survival outcomes was evaluated using the Kaplan-Meier method.ResultsBoth overall survival (OS) and progression-free survival (PFS) were longer in the unilateral group than in the bilateral group. Multivariate analysis demonstrated that tumor laterality was an independent predictor of OS (hazard ratio, 1.75; confidence interval, 1.05-2.92; P=0.032). In patients with stage III disease, the bilateral group had a shorter OS than the unilateral group, but it was comparable to the OS in stage IV patients (P=0.354). The incorporation of tumor laterality into the FIGO staging system improved the stratification of survival probabilities.ConclusionTumor laterality can be an independent prognostic factor in patients with advanced ovarian cancer. The incorporation of tumor laterality may improve the predictive performance of the FIGO staging system in patients with advanced ovarian cancer.

Development and Validation of Prognostic Nomogram for Primary Peritoneal Serous Carcinoma Compared With FIGO Staging System: A Population-Based Study.

BackgroundPrimary peritoneal serous carcinoma (PPSC) is a rare tumor that lacks a prognostic prediction model. Our study aims to develop a nomogram to predict overall survival (OS) of PPSC patients.MethodsPatients confirmed to have PPSC between 2004 and 2012 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. LASSO and multivariate Cox regression analyses were used to screen for meaningful independent prognostic factors to construct a nomogram model for 3-, 5-, and 10-year OS among patients with PPSC. The nomogram compared the discrimination, calibration, and net benefits with the International Federation of Gynecology and Obstetrics (FIGO) staging system of PPSC patients.ResultsEight variables were selected to establish the nomogram for PPSC. The established nomogram performed significantly better than the FIGO staging system (p < 0.05). The 3-, 5-, and 10-year OS of PPSC was 0.498, 0.306, and 0.152, respectively. Patients of old age, widowed marital status, grade high, FIGO IIIB, IIIC, or IV, lymph node metastasis, no lymphadenectomy, no surgery, and no chemotherapy got higher score which corresponds with higher risk and lower OS. In the multivariate Cox regression analysis, age, histological grade, FIGO staging, lymph node metastasis, and lymphadenectomy (four or more) were identified as independent prognostic factors for PPSC.ConclusionsPPSC patients have distinct characteristics with respect to their presentation and survival outcomes. A prognostic nomogram constructed by various clinical indicators can provide better and more accurate predictions for patients with PPSC.

Imaging in Carcinoma Cervix and Revised 2018 FIGO Staging System: Implications in Radiology Reporting.

The International Federation of Gynecology and Obstetrics (FIGO) staging system of carcinoma cervix saw a radical change in 2018 with the inclusion of cross-sectional imaging tools for the assessment of disease extent and staging. One of the major revisions is the inclusion of lymph node status, detected either on imaging or pathological evaluation, in the staging system. The changes were based on long-term patient follow-up and survival rates reported in literature. Thus, it becomes imperative for a radiologist to be well versed with the recent staging system, its limitations, and implications on the patient management.

Prognostic impact of the subclassification of Müllerian cancer stage IV in the FIGO 2014 staging system with a focus of extra-abdominal lymph node metastases.

The International Federation of Gynecology and Obstetrics (FIGO) staging system for Müllerian cancer was changed in 2014. Our objective was to evaluate the prognostic impact of stage IV subclassification in this new staging system, especially focusing on extra-abdominal lymph node metastasis. Eighty-two patients with stage IV Müllerian cancer treated between 2005 and 2016 at our hospital were retrospectively analyzed. Data for the following clinicopathological variables were analyzed: (1) FIGO stage; (2) tumor stage; (3) lymph node status; (4) histologic type; (5) neoadjuvant chemotherapy; (6) optimal surgery; and (7) bevacizumab use. Survival analysis was performed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models. In accordance with the new classification, 28 and 54 patients were classified as FIGO IVA and IVB, respectively. In the Cox proportional hazards model, early-stage tumors (T1b-3b) and optimal surgery were statistically significant favorable prognostic factors. However, the new FIGO system did not discriminate prognostically between stage IVA and IVB. Median overall survival of stage IVB patients diagnosed with extra-abdominal lymph node metastasis only was better than that of stage IVA and stage IVB patients diagnosed with solid organ metastasis. In this analysis of the revised FIGO system of patients reclassified as FIGO stage IVA or IVB, no new prognostic information was obtained. There is a possibility that stage IVB patients diagnosed with extra-abdominal lymph node metastasis only can be classified as an earlier stage. Further modification of the FIGO staging system may be needed to improve the prediction of patient prognosis.