Reviewing FIGO 2018 cervical cancer staging

We have read the article titled “Rationality of FIGO 2018 IIIC restaging of cervical cancer according to local tumor size: a cohort study” with great interest.1 The study highlights that relying solely on lymph node status is insufficient in determining a homogeneous patient group. Although the study's strength lies in the extensive number of patients evaluated, information about para-aortic lymph node metastasis was not available, potentially suggesting that tumors may not have prognostic significance in such cases. In 2022, we further emphasized that certain conditions in the FIGO 2018 staging system require adjustments to effectively differentiate each stage.2 An ideal staging system should fulfill several essential functions: it must assign cases to prognostic categories, define the anatomical extent of the disease, guide the appropriate treatments for patients, and facilitate the comparison of patients and their outcomes across different centers.2 When grouping cases, the underlying assumption is that they share similar prognoses and can be managed with a similar approach. The accurate prediction of long-term survival in cancer patients through the staging system is of paramount importance as it guides treatment and monitoring decisions. The introduction of the FIGO 2018 staging system represented a substantial advancement in this area. Notably, it became the first system to consider lymph node status, and as a result, classifying individuals with cervical cancer who have lymph node metastasis as having advanced disease, even if their tumors have not locally progressed.3 In fact, we believe that not only stage IIIC should be further subdivided based on other characteristics of cancer. For instance, in previous studies, stage IIIB presents an example where the concurrent involvement of the parametrium and the lower third part of the vagina has been shown to indicate a worse prognosis compared to cases involving only the parametrium.4, 5 Consequently, we have proposed a subdivision of this stage. Furthermore, it is essential to consider the histological type when determining the appropriate approach. For patients with cervical adenocarcinoma, radiotherapy may not be the most effective treatment, as it has been identified as a significant prognostic factor for local failure.2 Moreover, Duan et al. proposed an integration of stages IIIC-T1, T2a, and T2b into a single-stage IIC as a potential solution to address the different prognoses within the IIIC. However, considering the significance of lymph node involvement, an alternative approach could involve subdividing stage IIIC into IIIC1, with IIIC1a encompassing cases up to T2B with pelvic lymph node involvement, and IIIC1b for cases beyond these stages. This approach would serve as a crucial indicator for lymph node involvement while maintaining the overall stage as stage IIIC. We advocate for a comprehensive revision of the FIGO 2018 staging system, encouraging extensive discussions to improve the grouping of cases and determine more effective treatments while achieving better prognostic similarity within the same stage.