Cervical cancer (staging)

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This pathway provides guidance on the staging of cervical cancer

Lead Researcher: Kieran Kusel

Experts & Contributors: Emmeline Lee, Ravinder Dhillon

Editorial Panel: Core Membership

Date reviewed: April 2019

Date Published: July 2019

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Staging of cervical cancer has traditionally been performed with clinical assessment and biopsy
Imaging has been found to better evaluate the extent of disease and often changes management. Imaging investigations are recommended when they are available
MRI is the best imaging modality to assess the primary tumour size, location, and invasion into the parametrium, pelvic sidewall and adjacent organs
PET/CT is the best modality to assess nodal and extrapelvic metastatic disease, and is recommended in patients at high risk of lymphatic involvement
Treatment for early stages of cervical cancer is generally surgical whereas chemoradiotherapy is usually indicated in advanced disease

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R. Cancer of the cervix uteri. Int J Gynaecol Obstet. 2018;143 Suppl 2:22-36 (Review article). View the reference
Cohen PA, Jhingran A, Oaknin A, Denny L. Cervical cancer. Lancet. 2019;393(10167):169-82 (Review article). View the reference
Narayan K, Lin MY. Staging for cervix cancer: Role of radiology, surgery and clinical assessment. Best Pract Res Clin Obstet Gynaecol. 2015;29(6):833-44 (Review article). View the reference
Siegel CL, Andreotti RF, Cardenes HR, Brown DL, Gaffney DK, Horowitz NS, et al. ACR Appropriateness Criteria(R) pretreatment planning of invasive cancer of the cervix. J Am Coll Radiol. 2012 (2015 update);9(6):395-402 (Clincial guidelines). View the reference
Devine C, Gardner C, Sagebiel T, Bhosale P. Magnetic Resonance Imaging in the Diagnosis, Staging, and Surveillance of Cervical Carcinoma. Semin Ultrasound CT MR. 2015;36(4):361-8 (Review article). View the reference
Koh WJ, Abu-Rustum NR, Bean S, Bradley K, Campos SM, Cho KR, et al. Cervical Cancer, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(1):64-84 (Clinical guidelines). View the reference
Kusmirek J, Robbins J, Allen H, Barroilhet L, Anderson B, Sadowski EA. PET/CT and MRI in the imaging assessment of cervical cancer. Abdom Imaging. 2015;40(7):2486-511 (Review article). View the reference
Fields EC, Weiss E. A practical review of magnetic resonance imaging for the evaluation and management of cervical cancer. Radiat Oncol. 2016;11:15 (Review article). View the reference
Oaknin A, Rubio MJ, Redondo A, De Juan A, Cueva Banuelos JF, Gil-Martin M, et al. SEOM guidelines for cervical cancer. Clin Transl Oncol. 2015;17(12):1036-42 (Review article). View the reference
Matsuo K, Machida H, Mandelbaum RS, Konishi I, Mikami M. Validation of the 2018 FIGO cervical cancer staging system. Gynecol Oncol. 2019;152(1):87-93 (Level III evidence). View the reference
Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A. AJCC cancer staging manual. 7th ed 2010. (Clinical guidelines).
Cibula D, Potter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018;28(4):641-55 (Clinical guidelines). View the reference
Balleyguier C, Sala E, Da Cunha T, Bergman A, Brkljacic B, Danza F, et al. Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology. Eur Radiol. 2011;21(5):1102-10 (Clinical guidelines). View the reference
Rizzo S, Calareso G, Maccagnoni S, Angileri SA, Landoni F, Raimondi S, et al. Pre-operative MR evaluation of features that indicate the need of adjuvant therapies in early stage cervical cancer patients. A single-centre experience. Eur J Radiol. 2014;83(5):858-64 (Level III evidence). View the reference
Sheu MH, Chang CY, Wang JH, Yen MS. Preoperative staging of cervical carcinoma with MR imaging: a reappraisal of diagnostic accuracy and pitfalls. Eur Radiol. 2001;11(9):1828-33 (Level II evidence). View the reference
Patel-Lippmann K, Robbins JB, Barroilhet L, Anderson B, Sadowski EA, Boyum J. MR Imaging of Cervical Cancer. Magn Reson Imaging Clin N Am. 2017;25(3):635-49 (Review article). View the reference
Testa AC, Di Legge A, De Blasis I, Moruzzi MC, Bonatti M, Collarino A, et al. Imaging techniques for the evaluation of cervical cancer. Best Pract Res Clin Obstet Gynaecol. 2014;28(5):741-68 (Review article). View the reference
Kim M, Suh DH, Kim K, Lee HJ, Kim YB, No JH. Magnetic Resonance Imaging as a Valuable Tool for Predicting Parametrial Invasion in Stage IB1 to IIA2 Cervical Cancer. Int J Gynecol Cancer. 2017;27(2):332-8 (Level III evidence). View the reference
Thomeer MG, Gerestein C, Spronk S, van Doorn HC, van der Ham E, Hunink MG. Clinical examination versus magnetic resonance imaging in the pretreatment staging of cervical carcinoma: systematic review and meta-analysis. Eur Radiol. 2013;23(7):2005-18 (Level I evidence). View the reference
Zhang W, Zhang J, Yang J, Xue H, Cao D, Huang H, et al. The role of magnetic resonance imaging in pretreatment evaluation of early-stage cervical cancer. Int J Gynecol Cancer. 2014;24(7):1292-8 (Level III evidence). View the reference
Shen G, Zhou H, Jia Z, Deng H. Diagnostic performance of diffusion-weighted MRI for detection of pelvic metastatic lymph nodes in patients with cervical cancer: a systematic review and meta-analysis. Br J Radiol. 2015;88(1052):20150063 (Level I evidence). View the reference
Vural GU, Akkas BE, Demirel BB. Standardized uptake value and metabolic tumor volume measured by (1)(8)F FDG PET/CT are sensitive biomarkers for the presence of lymph node metastasis in patients with cervical carcinoma. Rev Esp Med Nucl Imagen Mol. 2014;33(5):268-73 (Level III evidence). View the reference
Hricak H, Gatsonis C, Chi DS, Amendola MA, Brandt K, Schwartz LH, et al. Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network 6651-Gynecologic Oncology Group 183. J Clin Oncol. 2005;23(36):9329-37 (Level II evidence). View the reference
Scheidler J, Hricak H, Yu KK, Subak L, Segal MR. Radiological evaluation of lymph node metastases in patients with cervical cancer. A meta-analysis. JAMA. 1997;278(13):1096-101 (Level I evidence). View the reference
Fleming S, Cooper RA, Swift SE, Thygesen HH, Chowdhury FU, Scarsbrook AF, et al. Clinical impact of FDG PET-CT on the management of patients with locally advanced cervical carcinoma. Clin Radiol. 2014;69(12):1235-43 (Level III evidence). View the reference
Loft A, Berthelsen AK, Roed H, Ottosen C, Lundvall L, Knudsen J, et al. The diagnostic value of PET/CT scanning in patients with cervical cancer: a prospective study. Gynecol Oncol. 2007;106(1):29-34 (Level II evidence). View the reference
Hansen HV, Loft A, Berthelsen AK, Christensen IJ, Hogdall C, Engelholm SA. Survival outcomes in patients with cervical cancer after inclusion of PET/CT in staging procedures. Eur J Nucl Med Mol Imaging. 2015;42(12):1833-9 (Level III evidence). View the reference
Rose PG, Adler LP, Rodriguez M, Faulhaber PF, Abdul-Karim FW, Miraldi F. Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study. J Clin Oncol. 1999;17(1):41-5 (Level III evidence). View the reference
Chen MY, Chou HH, Liu FY, Chen CY, Lin G, Yang LY, et al. (18)F-FDG PET in small-cell cervical cancer: a prospective study with long-term follow-up. Eur J Nucl Med Mol Imaging. 2016;43(4):663-74 (Level III evidence). View the reference
Choi HJ, Roh JW, Seo SS, Lee S, Kim JY, Kim SK, et al. Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymph node metastases in patients with uterine cervical carcinoma: a prospective study. Cancer. 2006;106(4):914-22 (Level II evidence). View the reference
Dong Y, Wang X, Wang Y, Liu Y, Zhang J, Qian W, et al. Validity of 18F-fluorodeoxyglucose positron emission tomography/computed tomography for pretreatment evaluation of patients with cervical carcinoma: a retrospective pathology-matched study. Int J Gynecol Cancer. 2014;24(9):1642-7 (Level III evidence). View the reference
Lv K, Guo HM, Lu YJ, Wu ZX, Zhang K, Han JK. Role of 18F-FDG PET/CT in detecting pelvic lymph-node metastases in patients with early-stage uterine cervical cancer: comparison with MRI findings. Nucl Med Commun. 2014;35(12):1204-11 (Level III evidence). View the reference
Naga Ch P, Gurram L, Chopra S, Mahantshetty U. The management of locally advanced cervical cancer. Curr Opin Oncol. 2018;30(5):323-9 (Review article). View the reference
Palaniswamy SS, Borde CR, Subramanyam P. 18F-FDG PET/CT in the evaluation of cancer cervix: Where do we stand today? Nucl Med Commun. 2018;39(7):583-92 (Review article). View the reference
Vandeperre A, Van Limbergen E, Leunen K, Moerman P, Amant F, Vergote I. Para-aortic lymph node metastases in locally advanced cervical cancer: Comparison between surgical staging and imaging. Gynecol Oncol. 2015;138(2):299-303 (Level III evidence). View the reference
Yen TC, Ng KK, Ma SY, Chou HH, Tsai CS, Hsueh S, et al. Value of dual-phase 2-fluoro-2-deoxy-d-glucose positron emission tomography in cervical cancer. J Clin Oncol. 2003;21(19):3651-8 (Level II evidence). View the reference
Morkel M, Ellmann A, Warwick J, Simonds H. Evaluating the Role of F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scanning in the Staging of Patients With Stage IIIB Cervical Carcinoma and the Impact on Treatment Decisions. Int J Gynecol Cancer. 2018;28(2):379-84 (Level III evidence). View the reference
Gemer O, Eitan R, Gdalevich M, Mamanov A, Piura B, Rabinovich A, et al. Integration of PET/CT into the preoperative evaluation of patients with early cervical cancer does not decrease the proportion of patients with positive lymph nodes found after surgery. Int J Gynecol Cancer. 2014;24(8):1461-5 (Level III evidence). View the reference
Driscoll DO, Halpenny D, Johnston C, Sheehy N, Keogan M. 18F-FDG-PET/CT is of limited value in primary staging of early stage cervical cancer. Abdom Imaging. 2015;40(1):127-33 (Level III evidence). View the reference
Selman TJ, Mann C, Zamora J, Appleyard TL, Khan K. Diagnostic accuracy of tests for lymph node status in primary cervical cancer: a systematic review and meta-analysis. Cmaj. 2008;178(7):855-62 (Level I evidence). View the reference
Gee MS, Atri M, Bandos AI, Mannel RS, Gold MA, Lee SI. Identification of Distant Metastatic Disease in Uterine Cervical and Endometrial Cancers with FDG PET/CT: Analysis from the ACRIN 6671/GOG 0233 Multicenter Trial. Radiology. 2018;287(1):176-84 (Level II evidence). View the reference
Yilmaz B, Dag S, Ergul N, Cermik TF. The efficacy of pretreatment and after treatment 18F-FDG PET/CT metabolic parameters in patients with locally advanced squamous cell cervical cancer. Nucl Med Commun. 2019;40(3):219-27 (Level III evidence). View the reference
Zhang L, Sun H, Du S, Xu W, Xin J, Guo Q. Evaluation of 18F-FDG PET/CT parameters for reflection of aggressiveness and prediction of prognosis in early-stage cervical cancer. Nucl Med Commun. 2018;39(11):1045-52 (Level III evidence). View the reference
Takagi H, Sakamoto J, Osaka Y, Shibata T, Fujita S, Sasagawa T. Usefulness of the maximum standardized uptake value for the diagnosis and staging of patients with cervical cancer undergoing positron emission tomography/computed tomography. Medicine (Baltimore). 2018;97(7):e9856 (Level III evidence). View the reference
Lee JW, Jeon S, Mun ST, Lee SM. Prognostic Value of Fluorine-18 Fluorodeoxyglucose Uptake of Bone Marrow on Positron Emission Tomography/Computed Tomography for Prediction of Disease Progression in Cervical Cancer. Int J Gynecol Cancer. 2017;27(4):776-83 (Level III evidence). View the reference
Gubbi A, Kacheria S, Ahmad S, Stavitzski NM, Kendrick JE. Prognostic Significance of the Standardized Uptake Value of Pretherapeutic 18F-Labeled 2-Fluoro-2-Deoxyglucose Positron Emission Tomography/Computed Tomography in Patients With Locally Advanced Cervical Cancer. Int J Gynecol Cancer. 2017;27(3):530-6 (Level III evidence). View the reference
Stecco A, Buemi F, Cassara A, Matheoud R, Sacchetti GM, Arnulfo A, et al. Comparison of retrospective PET and MRI-DWI (PET/MRI-DWI) image fusion with PET/CT and MRI-DWI in detection of cervical and endometrial cancer lymph node metastases. Radiol Med. 2016;121(7):537-45 (Level III evidence). View the reference
Grueneisen J, Schaarschmidt BM, Heubner M, Aktas B, Kinner S, Forsting M, et al. Integrated PET/MRI for whole-body staging of patients with primary cervical cancer: preliminary results. Eur J Nucl Med Mol Imaging. 2015;42(12):1814-24 (Level II evidence). View the reference
Sarabhai T, Schaarschmidt BM, Wetter A, Kirchner J, Aktas B, Forsting M, et al. Comparison of (18)F-FDG PET/MRI and MRI for pre-therapeutic tumor staging of patients with primary cancer of the uterine cervix. Eur J Nucl Med Mol Imaging. 2018;45(1):67-76 (Level II evidence). View the reference
Kitajima K, Suenaga Y, Ueno Y, Kanda T, Maeda T, Deguchi M, et al. Fusion of PET and MRI for staging of uterine cervical cancer: comparison with contrast-enhanced (18)F-FDG PET/CT and pelvic MRI. Clin Imaging. 2014;38(4):464-9 (Level III evidence). View the reference
Moloney F, Ryan D, Twomey M, Hewitt M, Barry J. Comparison of MRI and high-resolution transvaginal sonography for the local staging of cervical cancer. J Clin Ultrasound. 2016;44(2):78-84 (Level II evidence). View the reference
Arribas S, Alcazar JL, Arraiza M, Benito A, Minguez JA, Jurado M. Three-Dimensional Transvaginal Sonography and Magnetic Resonance Imaging for Local Staging of Cervical Cancer: An Agreement Study. J Ultrasound Med. 2016;35(5):867-73 (Level II evidence). View the reference
Han XS, Ning CP, Sun LT, Li XY, Peng YQ, Dang MZ. Three-dimensional transvaginal tomographic ultrasound imaging for cervical cancer staging. Ultrasound Med Biol. 2015;41(9):2303-9 (Level III evidence). View the reference
Bermudez A, Bhatla N, Leung E. Cancer of the cervix uteri. Int J Gynaecol Obstet. 2015;131 Suppl 2:S88-95. View the reference
ACOG practice bulletin. Diagnosis and treatment of cervical carcinomas. Number 35, May 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;78(1):79-91 (Review article). View the reference
Hoogendam JP, Zweemer RP, Verkooijen HM, de Jong PA, van den Bosch MA, Verheijen RH, et al. No Value for Routine Chest Radiography in the Work-Up of Early Stage Cervical Cancer Patients PLoS One. 2015;10(7):e0131899 (Level III evidence). View the reference
Prasad TV, Thulkar S, Hari S, Sharma DN, Kumar S. Role of computed tomography (CT) scan in staging of cervical carcinoma. Indian J Med Res. 2014;139(5):714-9 (Level II evidence). View the reference

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Cervical Cancer (Staging)

The FIGO staging system is most commonly used and is based on clinical examination and biopsy. Imaging can further evaluate the extent of disease and alter management

Globally, cervical cancer remains the fourth most common cancer in women
It is now recognised that cervical cancer is a rare long-term outcome of persistent infection of the lower genital tract by one of the high-risk Human Papilloma Virus (HPV) types
Since the introduction of formal screening programs (Pap smear and now liquid-based cytology and HPV testing) and more recently prevention programs with HPV vaccination, cervical cancer incidence and mortality have halved in high-income countries
The majority of cases now occur in low-income and middle-income countries
Cervical cancer spreads by direct extension into the parametrium, vagina, uterus and adjacent organs. It also spreads via lymphatics to regional lymph nodes. Distant metastasis to the lungs, liver and bones is a late phenomenon
Accurate staging is crucial to determine the most appropriate treatment
The International Federation of Gynaecology and Obstetrics (FIGO) system is the most widely used in cervical cancer staging
FIGO staging is mainly based on clinical examination, in part because it is accessible in low and middle-income countries. However, evidence suggests that parametrial, pelvic sidewall, bladder and rectal invasion, and metastatic disease are often poorly evaluated on clinical assessment alone
When available, imaging investigations (ultrasound, CT, MRI and PET/CT) can provide further details about tumour size, nodal status and systemic spread, and can improve staging accuracy, help plan treatment (e.g. radiation therapy fields) and estimate prognosis. Chest radiographs are also helpful in some cases
The 2018 revision of the FIGO staging system now allows imaging and pathological findings, when accessible, to help assign the stage
Treatment for early disease where the cancer is confined to the cervix/upper vagina is usually with surgery (up to stage IIA) whereas advanced disease where the cancer extends beyond the cervix/upper vagina to involve the parametrium or lower vagina is generally treated with radiation therapy (stage IIB and above). Chemotherapy is a valuable adjunct treatment. Stage IB2 and IIA are also treated with chemoradiation at some centres

Staging of cervical cancer based on the International Federation of Gynaecology and Obstetrics (FIGO) and the American Joint Committee on Cancer TNM staging systems

FIGO Stage		TNM
I	Cervical carcinoma confined to the cervix	T1
IA	Invasive carcinoma diagnosed only by microscopy with a maximum depth of invasion < 5mm	T1a
IA1	Measured stromal invasion < 3mm	T1a1
IA2	Measured stromal invasion ≥ 3mm but < 5mm in depth	T1a2

IB	Invasive carcinoma with measured deepest invasion ≥ 5mm, lesion limited to cervix uteri	T1b
IB1	Invasive carcinoma ≥ 5mm depth of stromal invasion, and < 2cm in greatest dimension	T1b1
IB2	Invasive carcinoma ≥ 2cm and < 4cm in greatest dimension	T1b2
IB3	Invasive carcinoma ≥ 4cm in greatest dimension

II	Cervical carcinoma invades beyond the uterus but not the pelvic wall or lower third of vagina	T2
IIA	Tumour without parametrial invasion	T2a
IIA1	Invasive carcinoma < 4cm in greatest dimension	T2a1
IIA2	Invasive carcinoma ≥ 4cm in greatest dimension	T2a2
IIB	With parametrial invasion but not up to the pelvic wall	T2b

III	Carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes	T3
IIIA	Tumour involves lower third of vagina without extending to the pelvic wall	T3a
IIIB	Tumour extends to pelvic wall, causes hydronephrosis or non-functioning kidney, or both	T3b
IIIC	Involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumour size and extent
IIIC1	Pelvic lymph node metastasis only
IIIC2	Para-aortic lymph node metastasis

IV	Tumour invades mucosa of bladder or rectum, extends beyond the true pelvis, or both	T4
IVA	Spread to adjacent pelvic organs	T4a
IVB	Spread to distant organs

Magnetic Resonance Imaging (MRI)

The most accurate imaging modality to determine the extent of pelvic disease

A number of international guidelines (e.g. the European Society for Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology, the European Society for Urogenital Radiology, and the American College of Radiology) recommend pelvic MRI for assessment of pelvic tumour extent. It is recommended for staging of all tumours IB and above, or smaller if fertility sparing surgery is being considered
MRI is the best imaging modality to assess the primary tumour and is accurate in determining tumour size, location, depth of stromal invasion, parametrial and local extension. This can have significant implications in deciding between surgery or primary chemoradiotherapy and, when surgery is indicated, whether fertility-sparing surgery can be considered
For women with advanced disease, MRI provides clear visualisation of the cervical tumour in multiple planes allowing for a reliable volumetric definition of the target tissue for external beam radiation and brachytherapy treatment planning
Overall staging accuracy ranges from 75-96% and tumour measurements are within 5mm of surgical size in 70-94% of cases
Sensitivity for evaluating parametrial invasion ranges from 40-84% and specificity 77-91%. Accuracy is reported to lie between 74-96%.
A systematic review by Thomeer et al. comparing clinical examination with MRI found a pooled sensitivity of 40% for the evaluation of parametrial invasion with clinical examination compared with 84% with MRI. For the evaluation of advanced disease, sensitivity of clinical examination was 53% compared with 79% for MRI
When evaluating lymph node involvement with MRI, a wide range of sensitivities and specificities have been reported between different studies. A systematic review of 15 studies involving 1021 patients found a pooled sensitivity and specificity for diffusion weighted imaging (DWI)-MRI in detecting pelvic lymph node metastases of 86% and 84% respectively. MRI performs less well in detecting small-volume metastatic involvement of normal sized lymph nodes
Hricak et al. found a similar sensitivity and specificity between MRI and CT for detecting lymph node involvement. A meta-analysis by Scheidler et al. also found CT and MRI to perform similarly in detecting lymph node metastasis
Reported sensitivity of MRI in the evaluation of bladder and rectal invasion is 71-100% with a specificity of 88-91%. This has resulted in the reduced use of cystoscopic and endoscopic staging

Cervical cancer (staging)

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Cervical Cancer

Clinical presentation, examination and biopsy

Magnetic Resonance Imaging (MRI)

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