Stage | Description |
Stage I | Confined to the uterine corpus and ovaryΔ |
IA | Disease limited to the endometrium or non-aggressive histological type (ie, low-grade endometroid) with invasion of less than half of myometrium with no or focal LVSI or good prognosis disease IA1 Non-aggressive histological type limited to an endometrial polyp or confined to the endometrium IA2 Non-aggressive histological types involving less than half of the myometrium with no or focal LVSI IA3 Low-grade endometrioid carcinomas limited to the uterus and ovaryΔ |
IB | Non-aggressive histological types with invasion of half or more of the myometrium, and with no or focal LVSI◊ |
IC | Aggressive histological types§ limited to a polyp or confined to the endometrium |
Stage II | Invasion of cervical stroma without extrauterine extension or with substantial LVSI or aggressive histological types with myometrial invasion |
IIA | Invasion of the cervical stroma of non-aggressive histological types |
IIB | Substantial LVSI◊ of non-aggressive histological types |
IIC | Aggressive histological types§ with any myometrial involvement |
Stage III | Local and/or regional spread of the tumor of any histological subtype |
IIIA | Invasion of uterine serosa, adnexa, or both by direct extension or metastasis IIIA1 Spread to ovary or fallopian tube (except when meeting stage IA3 criteria)Δ IIIA2 Involvement of uterine subserosa or spread through the uterine serosa |
IIIB | Metastasis or direct spread to the vagina and/or to the parametria or pelvic peritoneum IIIB1 Metastasis or direct spread to the vagina and/or the parametria IIIB2 Metastasis to the pelvic peritoneum |
IIIC | Metastasis to the pelvic or para-aortic lymph nodes or both¥ IIIC1 Metastasis to the pelvic lymph nodes IIIC1i Micrometastasis IIIC1ii Macrometastasis IIIC2 Metastasis to para-aortic lymph nodes up to the renal vessels, with or without metastasis to the pelvic lymph nodes IIIC2i Micrometastasis IIIC2ii Macrometastasis |
Stage IV | Spread to the bladder mucosa and/or intestinal mucosa and/or distance metastasis |
IVA | Invasion of the bladder mucosa and/or the intestinal/bowel mucosa |
IVB | Abdominal peritoneal metastasis beyond the pelvis |
IVC | Distant metastasis, including metastasis to any extra- or intra-abdominal lymph nodes above the renal vessels, lungs, liver, brain, or bone |
FIGO: International Federation of Gynecology and Obstetrics; ITCs: isolated tumor cells; EEC: endometrioid carcinoma; LVSI: lymphovascular space involvement; SLN: sentinel lymph node; ESGO: European Society of Gynaecological Oncology; ESTRO: European SocieTy for Radiotherapy and Oncology; ESP: European Society of Pathology.
* Endometrial cancer is surgically staged and pathologically examined. In all stages, the grade of the lesion, the histological type and LVSI must be recorded. If available and feasible, molecular classification testing (POLEmut, MMRd, NSMP, p53abn) is encouraged in all patients with endometrial cancer for prognostic risk-group stratification and as factors that might influence adjuvant and systemic treatment decisions.
¶ In early endometrial cancer, the standard surgery is a total hysterectomy with bilateral salpingo-oophorectomy via a minimally invasive laparoscopic approach. Staging procedures include infracolic omentectomy in specific histological subtypes, such as serous and undifferentiated endometrial carcinoma, as well as carcinosarcoma, due to the high risk of microscopic omental metastases. Lymph node staging should be performed in patients with intermediate-high/high-risk patients. SLN biopsy is an adequate alternative to systematic lymphadenectomy for staging proposes. SLN biopsy can also be considered in low-/low-intermediate-risk patients to rule out occult lymph node metastases and to identify disease truly confined to the uterus. Thus, the ESGO-ESTRO-ESP guidelines allow an approach of SLN in all patients with endometrial carcinoma, which is endorsed by FIGO. In assumed early endometrial cancer, an SLN biopsy is an adequate alternative to systematic lymphadenectomy in high-intermediate and high-risk cases for the purpose of lymph node staging and can also be considered in low-/intermediate-risk disease to rule out occult lymph node metastases. An SLN biopsy should be done in association with thorough (ultrastaging) staging as it will increase the detection of low-volume disease in lymph nodes.
Δ Low-grade EECs involving both the endometrium and the ovary are considered to have a good prognosis, and no adjuvant treatment is recommended if all the below criteria are met. Disease limited to low-grade endometrioid carcinomas involving the endometrium and ovaries (Stage IA3) must be distinguished from extensive spread of the endometrial carcinoma to the ovary (Stage IIIA1), by the following criteria: (1) no more than superficial myometrial invasion is present (<50%); (2) absence of extensive/substantial LVSI; (3) absence of additional metastases; and (4) the ovarian tumor is unilateral, limited to the ovary, without capsule invasion/rupture (equivalent to pT1a).
◊ LVSI as defined in WHO 2021: extensive/substantial, ≥5 vessels involved.
§ Grade and histological type:¥ Micrometastases are considered to be metastatic involvement (pN1 [mi]). The prognostic significance of ITCs is unclear. The presence of ITCs should be documented and is regarded as pN0(i+). According to TNM8, macrometastases are >2 mm in size, micrometastases are >0.2 to 2 mm and/or >200 cells, and isolated tumor cells are ≤0.2 mm and ≤200 cells. Based on staging established by FIGO and the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 8th ed (Springer 2017).
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