Oct 11, 2026 · 9 min · 7 segments
In this GODU episode, we discuss recent changes to the FIGO staging system for endometrial cancer, its implications and summarise the basics of staging. **For helpful resources, check out:**…
So FIGO, the Fédération Internationale de Gynécologie et d'Obstétrique, which is the International Federation of Gynecology and Obstetrics, have written the staging systems that we use for gynecological malignancies.
For endometrial cancer, the FIGO staging system is based on surgical staging, which means that the stage is usually only finalized after surgery has happened and histopathology results give us information about how far it has spread in and beyond the uterus.
Prior to surgery, staging can be approximated using imaging, usually CT of the chest, abdomen, and pelvis.
Some centers also use pelvic MRI to assess depth of invasion of the tumor, and if we are really worried about spread, then sometimes a PET scan can be helpful as well.
But ultimately, the final stage is confirmed on review of the surgical specimen.
To roughly summarize the stages, stage one is disease confined to the uterus.
Then stage two involves spread to the cervical stroma.
Stage three means spread beyond the uterus, but still in the pelvic or regional nodes, so that's including the adnexal structures, the vagina, and pelvic or para-aortic lymph nodes.
Stage four has spread further, including bladder or bowel invasion or distant metastases beyond the pelvis.
In addition to the physical location of the disease, the updated twenty-twenty three FIGO staging system includes the histological type, the molecular subtype, and grade.
So for example, an aggressive histology like serous carcinoma or P53 mutation can upstage a cancer even without deep myometrial invasion.
POLE mutation on the other hand, can result in downstaging.
These factors are not just for risk stratification, but also defining the stage and therefore the treatment recommendations.
This evolution in staging reflects our understanding of how important molecular classification is.
For example, a widespread cancer with POLE mutation may in fact have a better prognosis than local disease with P53 abnormalities.
But I suppose this is only helpful if treating sites have access to testing, right, Chloe?
Yes, and that is the challenge with this new staging.
While this twenty-twenty three staging system is published by FIGO, not every pathology service has access to or funding for the full molecular subtype testing, creating a significant issue with equity of management.
Discussion has also raised concerns about other aspects like objective assessment of extensive lymphovascular involvement or the long-term outcomes of deescalating adjuvant treatment based on molecular subtyping.
So we can expect to see more local validation studies in the coming years to review how this new system has affected our practice.
It's safe to say that in some centers, the twenty-twenty three staging system has not yet become established practice.
But let's go back a step.
Most of the time, diagnosis is made on hysteroscopic biopsy.
The biopsy can give us an idea of the histological type, grade, and molecular subtype, while imaging can give us an idea of the likely stage.
So then, Maddie, can you talk about what management actually looks like?
So FIGO, the Fédération Internationale de Gynécologie et d'Obstétrique, which is the International Federation of Gynecology and Obstetrics, have written the staging systems that we use for gynecological malignancies.
For endometrial cancer, the FIGO staging system is based on surgical staging, which means that the stage is usually only finalized after surgery has happened and histopathology results give us information about how far it has spread in and beyond the uterus.
Prior to surgery, staging can be approximated using imaging, usually CT of the chest, abdomen, and pelvis.
Some centers also use pelvic MRI to assess depth of invasion of the tumor, and if we are really worried about spread, then sometimes a PET scan can be helpful as well.
But ultimately, the final stage is confirmed on review of the surgical specimen.
To roughly summarize the stages, stage one is disease confined to the uterus.
Then stage two involves spread to the cervical stroma.
Stage three means spread beyond the uterus, but still in the pelvic or regional nodes, so that's including the adnexal structures, the vagina, and pelvic or para-aortic lymph nodes.
Stage four has spread further, including bladder or bowel invasion or distant metastases beyond the pelvis.
In addition to the physical location of the disease, the updated twenty-twenty three FIGO staging system includes the histological type, the molecular subtype, and grade.
So for example, an aggressive histology like serous carcinoma or P53 mutation can upstage a cancer even without deep myometrial invasion.
POLE mutation on the other hand, can result in downstaging.
These factors are not just for risk stratification, but also defining the stage and therefore the treatment recommendations.
This evolution in staging reflects our understanding of how important molecular classification is.
For example, a widespread cancer with POLE mutation may in fact have a better prognosis than local disease with P53 abnormalities.
But I suppose this is only helpful if treating sites have access to testing, right, Chloe?
Yes, and that is the challenge with this new staging.
While this twenty-twenty three staging system is published by FIGO, not every pathology service has access to or funding for the full molecular subtype testing, creating a significant issue with equity of management.
Discussion has also raised concerns about other aspects like objective assessment of extensive lymphovascular involvement or the long-term outcomes of deescalating adjuvant treatment based on molecular subtyping.
So we can expect to see more local validation studies in the coming years to review how this new system has affected our practice.
It's safe to say that in some centers, the twenty-twenty three staging system has not yet become established practice.
But let's go back a step.
Most of the time, diagnosis is made on hysteroscopic biopsy.
The biopsy can give us an idea of the histological type, grade, and molecular subtype, while imaging can give us an idea of the likely stage.
So then, Maddie, can you talk about what management actually looks like?
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