A 42-year-old woman from rural Maharashtra presents with postcoital bleeding and vaginal discharge for 3 months. She is a known tobacco chewer and had her first child at age 16. On speculum examination, a friable, bleeding mass is seen on the cervix. Pap smear shows atypical squamous cells of undetermined significance (ASCUS). Cervical biopsy confirms squamous cell carcinoma. MRI pelvis shows a 4 cm lesion confined to the cervix with no parametrial involvement, negative pelvic lymph nodes, and normal upper abdomen. What is the FIGO 2009 stage of this cervical cancer?

Explanation

## FIGO 2009 Cervical Cancer Staging **Key Point:** FIGO 2009 staging is based on clinical examination and imaging findings. Tumour size is the primary determinant within Stage IB. ### Stage Classification for This Case The patient has: - Tumour confined to the cervix (no parametrial or vaginal involvement) - Tumour size: **4 cm** (as measured on MRI) - Negative pelvic lymph nodes - No distant metastases This corresponds to **Stage IB** (tumour confined to cervix), and specifically **Stage IB2**. **High-Yield:** FIGO 2009 subdivides Stage IB by size: - **IB1**: Clinically visible lesion **≤4 cm** (i.e., less than or equal to 4 cm) — *some sources phrase this as <4 cm* - **IB2**: Clinically visible lesion **>4 cm** in greatest dimension Per the standard FIGO 2009 definition (as stated in FIGO Guidelines and Shaw's Textbook of Gynaecology): - IB1 = lesion **<4 cm** (strictly less than) - IB2 = lesion **≥4 cm** (4 cm or greater) Since the lesion is **exactly 4 cm**, it falls into **Stage IB2**. ### FIGO 2009 Staging Summary | Stage | Criteria | |-------|----------| | IA | Invasive cancer diagnosed only by microscopy | | IB1 | Clinically visible lesion <4 cm, confined to cervix | | IB2 | Clinically visible lesion ≥4 cm, confined to cervix | | IIA | Tumour extends beyond cervix but not to pelvic sidewall/lower vagina; no parametrial involvement | | IIB | Tumour with parametrial involvement | | IIIA | Tumour extends to lower third of vagina | | IIIB | Pelvic sidewall involvement or hydronephrosis | | IVA | Bladder/rectal mucosa involvement | | IVB | Distant metastases | **Why not the other options?** - **Stage IB1 (A):** Requires lesion <4 cm; this lesion is exactly 4 cm, placing it in IB2. - **Stage IIB (B):** Requires parametrial involvement, which is explicitly absent on MRI. - **Stage IIA (D):** Requires extension beyond the cervix (upper vaginal involvement without parametrial spread); the lesion here is confined to the cervix. **Clinical Pearl:** The 4 cm cutoff in FIGO 2009 is critical for treatment planning. Stage IB2 lesions (≥4 cm) are typically managed with concurrent chemoradiation (cisplatin-based) rather than primary surgery, due to higher recurrence risk. This is in contrast to IB1 lesions, which may be treated with radical hysterectomy (Wertheim's) + pelvic lymph node dissection. **Reference:** Shaw's Textbook of Gynaecology (16th ed.), FIGO 2009 staging guidelines — IB1 defined as <4 cm; IB2 defined as ≥4 cm confined to cervix.