Bhatla et al. Int J Gynaecol Obstet 2019; Indian J Med Res 2021
Lymph Node (IIIC) Notation Requirement
Any lymph node metastasis automatically assigns stage IIIC. Use “r” if based on imaging (e.g., IIIC1r, IIIC2r) and “p” if based on pathological examination (e.g., IIIC1p, IIIC2p). Pathological findings supersede imaging when both are available. Micrometastases (0.2–2 mm) qualify as IIIC; isolated tumor cells (≤0.2 mm) do not change stage but must be recorded.
Sources: Medscape (2026); Bhatla N, et al. Int J Gynaecol Obstet. 2019;145:129-135; Bhatla N, et al. Indian J Med Res. 2021;154(2):273-283.
Imaging (MRI/CT/PET) and pathology findings are permitted to modify stage assignment per 2018 FIGO revision.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
Primary Clinical Uses
Universal staging system for carcinoma of the cervix uteri to guide treatment and predict prognosis
Determines eligibility for fertility‑sparing surgery, radical hysterectomy, primary chemoradiation, or systemic therapy
Mandatory for clinical trial enrollment and international research comparisons
2018 Paradigm Shift (Bhatla et al., 2021)
Prior to 2018, staging was strictly clinical (palpation, basic imaging). The revision integrates cross‑sectional imaging (MRI, CT, PET) and surgical pathology findings, recognizing that clinical examination understages tumor size and lymph node involvement in 20‑30% of cases.
Section 2
Formula & Logic
Stage I – Confined to Cervix
Substage
Definition
IA1
Microscopic stromal invasion ≤3 mm depth (horizontal spread no longer considered)
IA2
Microscopic stromal invasion >3 mm and ≤5 mm depth
IB1
Invasive carcinoma >5 mm depth AND ≤2 cm in greatest dimension
IB2
>2 cm and ≤4 cm in greatest dimension
IB3
>4 cm in greatest dimension
Stage II – Beyond Uterus, Not to Pelvic Wall/Lower 1/3 Vagina
Substage
Definition
IIA1
Upper 2/3 vaginal involvement, no parametrial invasion, ≤4 cm tumor
IIA2
Upper 2/3 vaginal involvement, no parametrial invasion, >4 cm tumor
IIB
Parametrial invasion (not reaching pelvic wall)
Stage III – Lower Vagina, Pelvic Wall, or Lymph Nodes
Substage
Definition
IIIA
Tumor involves lower 1/3 of vagina, no extension to pelvic wall
IIIB
Tumor extends to pelvic wall and/or causes hydronephrosis/non‑functioning kidney
IIIC1
Pelvic lymph node metastasis (any primary tumor size/extent) – use notation r (imaging) or p (pathology)
IIIC2
Para‑aortic lymph node metastasis – use notation r or p
Stage IV – Adjacent Organs or Distant Metastasis
Substage
Definition
IVA
Tumor invades bladder or rectal mucosa (biopsy‑proven); bullous edema alone does not qualify
Retrospective analyses show that the 2018 staging better discriminates survival than the 2009 system. For example, 5‑year overall survival for stage IB1, IB2, and IB3 is 97%, 92%, and 83% respectively. Stage IIIC1 has intermediate prognosis between IIIB and IVA, emphasizing the need to record tumor size even in node‑positive cases (currently not captured).
Section 5
Evidence Appraisal
Primary Sources
Revised FIGO staging for carcinoma of the cervix uteri.
Bhatla N et al. • Int J Gynaecol Obstet.. 2019;The official 2018 revision document that introduced stage IIIC, removed horizontal spread from IA, and permitted imaging/pathology for staging.
Implications of the revised cervical cancer FIGO staging system.
Bhatla N et al. • Indian J Med Res.. 2021;Comprehensive review of the 2018 changes from the perspectives of gynecologic oncologists, radiologists, and pathologists.
The International Federation of Gynecology and Obstetrics (FIGO) Committee on Gynecologic Oncology first published a staging system for cervical cancer in 1961. The 2018 revision (effective 2019) is the most substantial update in decades, aligning staging with modern diagnostic tools while maintaining relevance for low‑resource settings.
