This information supports clinicians to manage cervical cancer using the latest evidence-based information to inform diagnosis, treatment and follow-up care.
Histological features
Cervical cancer is most often caused by high oncogenic risk human papillomavirus (HPV). Clinicians classify these as HPV-associated cervical cancers. However, several HPV-independent types also occur, including gastric, clear cell and mesonephric subtypes. These can be missed by HPV-based cervical screening programs which HPV vaccination does not prevent.
Small cell carcinoma of the cervix is rare but highly aggressive and requires distinction from other subtypes due to its poor prognosis.
Key histological and staging features include:
- histological cell type
- tumour size (microscopic and, if visible, macroscopic)
- depth of cervical stromal invasion
- lymphovascular space invasion (LVSI)
- lymph node metastases (if surgically staged).
Staging
Cervical cancer staging is primarily based on clinical examination and biopsy.1
Clinicians can consider these staging investigations:
- Rectal and pelvic examination – assess tumour size and parametrial extension
- Colposcopy
- Cystoscopy, proctoscopy or sigmoidoscopy – used when bladder or rectal involvement is suspected; confirm with histology
- Intravenous pyelogram (IVP) – optional for stage IB2 lesions or higher
- Chest X-ray (and skeletal X-ray if symptomatic)
- Cervical biopsy (or diagnostic cone biopsy if a simple biopsy is non-diagnostic)
- Examination-under-anaesthesia (EUA) – preferably performed jointly by 2 expert clinicians, usually a gynaecological oncologist and radiation oncologist. Document a consensus clinical stage; if clinicians disagree, assign the lower stage.
International Federation of Gynecology and Obstetrics (FIGO) staging of carcinoma of the cervix uteri:1
Stage I
The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded).
| Stage IA | Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of invasion <5 mm. |
| Stage IA1 | Tumour invades the stroma to a measured depth of ≤3 mm. |
| Stage IA2 | The tumour invades the stroma to a measured depth of >3 mm and ≤5 mm. |
| Stage IB | This carcinoma invades the stroma to a measured deepest depth of >5 mm (greater than Stage IA). The lesion remains limited to the cervix uteri, with size measured by maximum tumour diameter. |
| Stage IB1 | This carcinoma invades the stroma to a depth of >5 mm and measures ≤2 cm in greatest dimension. |
| Stage IB2 | This invasive carcinoma measures >2 cm and ≤4 cm in greatest dimension. |
| Stage IB3 | This invasive carcinoma measures >4 cm in greatest dimension. |
Stage II
The carcinoma invades beyond the uterus but has not extended onto the lower third of the vagina or to the pelvic wall.
| Stage IIA | The lesion involves the upper two-thirds of the vagina without involving the parametrium. |
| Stage IIA1 | This invasive carcinoma measures ≤4 cm in greatest dimension. |
| Stage IIA2 | This invasive carcinoma measures >4 cm in greatest dimension. |
| Stage IIB | The carcinoma involves the parametrium but does not extend to the pelvic wall. |
Stage III
The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or a non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes.
| Stage IIIA | The carcinoma involves the lower third of the vagina without extending to the pelvic wall. |
| Stage IIIB | The carcinoma extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney, unless this is known to be due to another cause. |
Stage IIIC | The carcinoma involves pelvic and/or para-aortic lymph nodes, including micrometastases, irrespective of tumour size and extent, with “r” and “p” notations indicating radiology and pathology respectively (see below for additional considerations for staging). |
| Stage IIIC1 | Pelvic lymph node metastasis only. |
| Stage IIIC2 | The carcinoma involves para-aortic lymph node metastasis. |
Stage IV
The carcinoma extends beyond the true pelvis or involves the mucosa of the bladder or rectum, as confirmed by biopsy.
Bullous oedema alone does not permit classification as Stage IV.
| Stage IVA | The carcinoma spreads to adjacent organs. |
| Stage IVB | The carcinoma spreads to distant organs. |
Additional considerations for staging
- When the extent of disease is uncertain, clinicians should assign the lower stage to avoid overstaging and maintain consistency.
- Clinicians report lymphovascular space invasion (LVSI) as present or absent only, and it does not affect staging. They do not consider lateral tumour extent. Unlike endometrial cancer, where the 2023 International Federation of Gynecology and Obstetrics (FIGO) system incorporates semi-quantitative LVSI categories (nil, focal, substantial), cervical cancer staging does not yet include this refinement.
- Standardising synoptic reporting across gynaecological cancers supports data collection and outcomes research. Although adjuvant pelvic radiation often reduces the prognostic impact of LVSI, its extent distribution (focal vs substantial; intratumoural vs advancing edge vs distant) may remain clinically relevant, particularly in fertility-sparing surgery where radiation is not used. This distinction is important for patients seeking to preserve fertility, and consistent data capture will support evolving epidemiology in vaccinated populations.
- In stage IIIC disease, clinicians specify “r” (imaging) or “p” (pathology) to indicate how they identify lymph node involvement. For example, they record pelvic lymph node metastasis on imaging as Stage IIIC1r, and, when confirmed by pathology, as Stage IIIC1p. They document the method used in all cases. Isolated tumour cells do not change the stage but must be reported.
Imaging
- Clinicians use imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI) or positron emission tomography (PET) scans in staging and treatment planning.
- Imaging identifies nodal disease, including microscopic or macroscopic involvement, that may not be apparent on clinical examination.
- MRI provides optimal assessment of the primary tumour and local soft tissue extension.
- Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is recommended to assess nodal involvement and detect distant metastases.
Surgical staging
Clinicians should consider that:
- non-randomised studies show no survival benefit of surgical staging compared with clinical staging
- surgical staging may increase morbidity and mortality, particularly with transperitoneal para-aortic lymph node dissection
- some studies report a benefit from laparoscopic surgical staging in selected patients with stage IB2–III disease, but clinicians prefer PET imaging.2-4
References
- Bhatla N, Aoki D, Sharma DN, et al. Cancer of the cervix uteri. Int J Gynecol Cancer. 2018;143(Suppl 2):22–36
- Dargent D, Martin X, Sacchetoni A, et al. Laparoscopic vaginal radical trachelectomy: a treatment to preserve the fertility of cervical carcinoma patients. Cancer. 2000;88(8):1877–1882
- Querleu D, Dargent D, Ansquer Y, et al. Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas. Cancer. 2000;88(8):1883–1891
- Vergote I, Amant F, Berteloot P, et al. Laparoscopic lower para-aortic staging lymphadenectomy in stage IB2, II, and III cervical cancer. Int J Gynecol Cancer. 2002;12(1):22–26