Editors: Rouzan Karabakhtsian, MD, PhD, professor of pathology and director of the Women’s Health Pathology Fellowship, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY; Shaomin Hu, MD, PhD, staff pathologist, Cleveland Clinic; S. Emily Bachert, MD, breast pathology fellow, Brigham and Women’s Hospital, Boston; and Amarpreet Bhalla, MD, assistant professor of pathology, Albert Einstein College of Medicine, Montefiore Medical Center.
Revised FIGO staging of endometrial cancer
September 2023—Understanding of the pathologic and molecular features of endometrial cancer has advanced measurably since the FIGO (International Federation of Gynecology and Obstetrics) staging system was updated in 2009. New treatments, results of clinical trials, and prognostic survival data that correlate with pathologic and surgical findings have been reported. Therefore, the FIGO Committee on Women’s Cancer determined that changes to the FIGO system were necessary. The goals of the revised staging system are to further clarify the diverse biologic nature of endometrial carcinomas with differing prognostic outcomes, better define the prognostic groups, and create substages that yield more appropriate surgical, radiation, and systemic therapies. The cancer committee developed a subcommittee on endometrial cancer staging in October 2021, of which the authors are members. Since then, committee members have met frequently and reviewed new and established evidence about the treatment, prognosis, and survival of endometrial cancer patients. They identified opportunities for improvement in the categorization and stratification of these factors in each of the four stages of endometrial carcinoma. Data and analyses from the molecular and histological classifications published in the recently developed ESGO/ESTRO/ESP (European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology) guidelines were used as a template for adding the new subclassifications to the proposed 2023 molecular and histological staging system. The first substage is broken down into IA1, a nonaggressive histological type of endometrial carcinoma limited to a polyp or confined to the endometrium; IA2, nonaggressive histological types of tumors involving less than 50 percent of the myometrium with no lymphovascular space invasion (LVSI) or focal LVSI, as defined by WHO criteria; IA3, low-grade endometrioid carcinomas limited to the uterus with simultaneous low-grade endometrioid ovarian involvement; IB, nonaggressive histological types involving 50 percent or more of the myometrium with no LVSI or focal LVSI; and IC, aggressive histological types, including serous, high-grade endometrioid, clear cell, carcinosarcomas, undifferentiated, mixed, and other unusual types without myometrial invasion. The second substage composes IIA, nonaggressive histological types of endometrial carcinoma that infiltrate the cervical stroma; IIB, nonaggressive histological types that have substantial LVSI; and IIC, aggressive histological types with myometrial invasion. The third substage is made up of IIIA, differentiation between adnexal and uterine serosa infiltration; IIIB, infiltration of the vagina/parametria and pelvic peritoneal metastasis; and IIIC, refinements for lymph node metastasis to pelvic and para-aortic lymph nodes, including micrometastasis and macrometastasis. The fourth substage includes IVA, locally advanced disease infiltrating the bladder or rectal mucosa; IVB, extrapelvic peritoneal metastasis; and IVC, distant metastasis. Complete molecular classification (POLEmut, MMRd, NSMP, p53abn) is encouraged for all endometrial cancers. Known molecular subtypes are recorded in the FIGO stage with the addition of “m” for molecular classification and a subscript indicating the specific molecular subtype. Molecular classification that reveals p53abn or POLEmut status in substages I and II leads to upstaging or downstaging of the disease (IICmp53abn or IAmPOLEmutb). In summary, 2023 FIGO staging of endometrial cancer includes the various histological types and tumor patterns and molecular classification to better reflect improved understanding of the complex nature of the types of endometrial carcinoma and their underlying biologic behavior. The revised system should provide a more evidence-based context for making treatment recommendations and collecting outcome and survival data.
Berek JS, Matias-Guiu X, Creutzberg C, et al. FIGO staging of endometrial cancer: 2023. Int J Gynecol Obstet. 2023. doi:10.1002/ijgo.142923
Correspondence: Dr. Jonathan S. Berek at [email protected]
An integrated pathologic score to stratify select patients with pancreatic ductal adenocarcinoma
Neoadjuvant therapy is increasingly used to treat patients with pancreatic ductal adenocarcinoma. Pathologic parameters of treated PDAC, including tumor (ypT) and lymph node (ypN) stage and tumor-response grading (TRG), are important prognostic factors in this patient group. To the authors’ knowledge, a multifactorial prognostic score combining pathologic features, including ypT, ypN, and TRG, in treated PDAC patients has not been reported. Therefore, the authors performed a retrospective analysis on a cohort of 398 PDAC patients who received neoadjuvant therapy and underwent pancreaticoduodenectomy at their institution. All pancreaticoduodenectomy specimens were evaluated grossly and microscopically using a standard protocol. The integrated pathologic score (IPS) was calculated as the sum of the scores for ypT, ypN, and TRG according to the MD Anderson grading system (IPSMDA) or College of American Pathologists grading system (IPSCAP). The IPSMDA and IPSCAP were correlated with clinicopathologic parameters and patient survival. Using the IPSMDA or IPSCAP, PDAC patients were stratified into three distinct prognostic groups for disease-free (P<.001) and overall (P<.001) survival. The IPSMDA and IPSCAP correlated with tumor differentiation, margin status, American Joint Committee on Cancer (AJCC) stage, and tumor recurrence (P<.05). In multivariate analysis, IPSMDA, IPSCAP, margin status, and tumor differentiation were independent prognostic factors for disease-free (P<.05) and overall (P<.05) survival. However, patients with AJCC stage IB, IIA, or IIB disease had no significant difference in disease-free or overall survival (P>.05). The authors concluded that the IPS appears to provide better prognostic information than AJCC staging for patients with PDAC treated preoperatively.
Sohn AJ, Taherian M, Katz MHG, et al. Integrated pathologic score effectively stratifies patients with pancreatic ductal adenocarcinoma who received neoadjuvant therapy and pancreaticoduodenectomy. Am J Surg Pathol. 2023;47:421–430.
Correspondence: Dr. Huamin Wang at [email protected]