**4. Staging**

The cervix was the first organ for which The International Federation of Gynecology and Obstetrics (FIGO) established a system for only clinical staging in 1958. Thereafter, to document the presence or absence of nodes and distant metastases, a pathological TNM staging system was developed and implemented. The FIGO Committee of Gynecological Oncology updated the staging system in 2018 so that clinical, radiological, or pathological evidence may be used to designate the stage (**Table 3**).

Clinical examination and physical evaluation initiate staging. FIGO 2018 staging allows ultrasonography, CT, MRI, and PET to offer further information about tumor size, nodal status, and local or systemic metastasis [18]. MRI is helpful for primary


*a Imaging and pathology can be used, where available, to supplement clinical findings with respect to tumor size and extent, in all stages. Pathological findings supersede imaging and clinical findings.b The involvement of vascular/ lymphatic spaces should not change the staging. The lateral extent of the lesion is no longer considered.<sup>c</sup> Isolated tumor cells do not change the stage but their presence should be recorded.<sup>d</sup> Adding notation of r (imaging) and p (pathology) to indicate the findings that are used to allocate the case to Stage IIIC. For example, if imaging indicates pelvic lymph node metastasis, the stage allocation would be Stage IIIC1r; if confirmed by pathological findings, it would be Stage IIIC1p. The type of imaging modality or pathology technique used should always be documented. When in doubt, the lower staging should be assigned.*

#### **Table 3.**

*FIGO staging of cancer of the cervix uteri (2018).*

cancers beyond 10 mm. In experienced hands, ultrasonography provides high diagnostic preciseness. For future evaluation, note the staging modality. Imaging can provide new prognostic indicators to assist in choosing the best therapy. PET-CT is

more accurate than CT and MRI (4–15% false-negative results) at detecting nodal metastases above 10 mm.
