Keep it simple, stupid.

Top Line: Recent sweeping changes to staging algorithms brought a huge transition to the gyn cancer world in 2018 when, for the first time, imaging findings were incorporated into FIGO staging.

The Study: This means a huge proportion of women were reclassified as stage IIIC1 (radiographically apparent pelvic nodes) or IIIC2 (radiographically apparent paraaortic nodes). While it certainly makes sense to actually recognize, rather than ignore, imaging findings, does anyone really know if involved pelvic nodes should supersede a locally-advanced primary tumor? In other words, does a woman with a PET-avid obturator node (IIIC) really do worse than one with a cervical tumor extending all the way down to the distal vagina(IIIA)? That’s the inspiration for this retrospective review of outcomes for 632 women treated with definitive chemoradiation for cervical cancer at Tata Memorial Hospital between 2015-2017. All women were assigned four stages based on different schema: 2009 FIGO, 2018 FIGO, TNM, and a newly-proposed slightly modified (and simplified) TNM. Over one-third were reclassified to 2018 FIGO stage IIIC1 (29%) or IIIC2 (8%), and, indeed, disease-free survival (DFS) at 3 years was worse for stage IIIA (53%) than for IIIC1 (74%) or even IIIC2 (61%). Instead, DFS was much better distinguished among IIIC1 patients according to primary tumor stage: 84% for T1, 74% for T2, and 70% for T3. Finally, both the current, and especially the newly-proposed, TNM systems delineated DFS outcomes much better than either FIGO system (see the summary table in Figure 3). This may all be because the new TMN sticks with 4 categories whereas 2018 FIGO relies on 14.

TBL: Stage IIIC1-2 cervical cancer  per 2018 FIGO is now a big catch-all, with outcomes that can be strikingly delineated based on primary tumor stage, meaning standard TNM staging with or without minor modifications is likely the better way to go. | Raut, Int J Radiat Oncol Biol Phys 2020