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Understanding Your Report · Reviewed by CION Oncologists · NABH Accredited
FIGO Staging — What the Numbers Actually Describe
Stage answers one question and one question only: how far has the cancer travelled? Not how aggressive it looks — that is grade, and it is a separate matter. The FIGO system runs from I, confined to the body of the uterus, to IV, which has reached the bladder or bowel lining or distant organs. One thing surprises almost everyone: the stage is decided by the surgery, not by the scan. Imaging gives a working estimate to plan the operation; the pathologist examining what was removed produces the definitive answer — which is why stages shift afterwards, in both directions.
- Stage is about extent — how far it has gone, not how abnormal the cells look
- It is decided surgically — the removed specimen settles it, not the MRI
- Four stages, with subdivisions — and the letters matter as much as the numbers
- The system changed in 2023 — so two reports can look different and both be correct
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The Four Stages
Broadly, each stage is defined by one boundary the tumour has crossed.
| Stage | Where the cancer is | What it means in practice |
|---|---|---|
| Stage I | Confined to the body of the uterus — within the lining and the muscle wall. | The commonest stage at diagnosis. Treated surgically, and for a large group nothing follows the operation. See stage 1. |
| Stage II | Has grown into the supporting tissue of the cervix, but not outside the uterus. | Still inside the uterus and still treated to cure. Radiation after surgery becomes considerably more likely. See stage 2. |
| Stage III | Beyond the uterus but within the pelvis and abdomen — the ovaries, the uterine surface, the vagina, or the lymph nodes. | A wide range within one number, from a microscopic node deposit to bulky abdominal nodes. Still treated with the aim of cure. See stage 3. |
| Stage IV | Into the lining of the bladder or bowel (IVA), or to distant sites such as lungs, liver or bone (IVB). | Two quite different situations. IVA is local and sometimes treated to cure; IVB usually aims at control. See stage 4. |
The letters matter. “Stage 4” without the letter is genuinely ambiguous — IVA and IVB carry different treatment intent. Within stage III, a single microscopic deposit in one sentinel node and involved para-aortic nodes are both stage III and are not comparable. If you have been given a number without a letter, that is a short question with a clear answer.
Did You Know? FIGO revised this staging system in 2023, and the change was more fundamental than a renumbering. For the first time, stage incorporates the biology of the tumour alongside its anatomy — histological type, whether substantial lymphovascular invasion is present, and which of four molecular groups the cancer falls into. The reasoning is that a POLE-mutated tumour and a p53-abnormal tumour at the same anatomical extent behave so differently that giving them the same stage misdescribes both. The practical consequence for patients: a report issued under the 2009 system and one issued under the 2023 system can look quite different for the same disease, and neither is wrong. Sources: FIGO staging system for cancer of the endometrium, 2023 revision, and the preceding 2009 revision; ESGO–ESTRO–ESP guidelines for the management of patients with endometrial carcinoma; NCCN Clinical Practice Guidelines in Oncology — Uterine Neoplasms.
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What the Pathologist Is Measuring
Five findings from the operative specimen determine the stage. All of them come from tissue, and none can be established with certainty beforehand.
- Depth of invasion into the muscle wall. The key measurement within stage I. Less than half the myometrial thickness, or half or more — the distinction predicts the chance of nodal involvement and sits directly in the staging system.
- Cervical stromal invasion. Whether the tumour has grown into the substance of the cervix. Note that involvement of the surface lining of the cervical canal alone does not upstage under current rules — a change from the older system that causes real confusion.
- Adnexal, serosal, vaginal or parametrial involvement. Any of these takes the case to stage III, and the specific site determines the subdivision.
- Lymph node status. Pelvic nodes and para-aortic nodes are distinguished, the latter representing a more advanced position within stage III. See lymph node involvement.
- And under the 2023 system, the biology. Histological type, substantial lymphovascular space invasion, and molecular group now feed into stage rather than sitting alongside it. See MMR and MSI testing.
Given a Stage and Not Sure What It Implies?
Stage on its own decides very little. Read alongside grade, invasion depth and markers, it decides most things.
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The Scan Plans the Operation. The Operation Settles the Stage.
Which is why a stage can change afterwards, in either direction — and why that is the system working rather than failing.
Why Your Stage Might Change After Surgery
It is unsettling to be told one stage before an operation and another afterwards, and it happens often enough to be worth explaining in advance. It is almost never an error.
- Imaging cannot see microscopic disease. A lymph node of entirely normal size can contain tumour cells. This is the commonest reason a woman goes into surgery expecting stage I and is told afterwards that a sentinel node was involved. See MRI for endometrial cancer staging.
- Depth of invasion is an estimate on a scan and a measurement on a slide. Fibroids, adenomyosis or a polypoid tumour all make the imaging assessment harder, and the specimen resolves it definitively.
- It moves in both directions. Stages are revised down as well as up. A tumour that looked as though it had reached the cervix may prove only to have involved the surface lining, which does not upstage.
- The grade and even the type can be revised too. A biopsy samples a fragment; the whole uterus can show a different predominant grade, or occasionally a serous or clear cell component the biopsy never reached. See endometrial cancer grades.
This is precisely why decisions about treatment after surgery are made once the final pathology is available rather than beforehand, and why a provisional plan discussed before the operation is genuinely provisional. See the adjuvant decision.
Four Things People Get Wrong About Stage
Each of these comes up repeatedly, and each is easy to correct once seen.
Confusing stage with grade
They answer different questions. Stage is how far the cancer has travelled; grade is how abnormal the cells look under a microscope. A Grade 3 tumour confined to the lining and a Grade 1 tumour that has reached the lymph nodes are very different situations, and neither number means much without the other. Ask for both, along with depth of invasion, lymphovascular invasion and molecular group.
Comparing your report with a relative's
FIGO revised the system in 2023, and some units still report using the 2009 version. A report saying "IA" and one saying "IA1" or "IC" may describe the same disease under different editions. Worse, the rules themselves changed — cervical surface involvement used to upstage to II and no longer does. Two reports that look inconsistent can both be correct.
Reading stage as a prognosis
Stage is one input among several. Histological type, grade, lymphovascular invasion and molecular group all shape the outlook alongside anatomical extent — which is exactly why the 2023 revision folded some of them into the staging system. A survival figure quoted for a bare stage number averages across genuinely different diseases.
Assuming a lower stage means no treatment
Many women with stage I need nothing after surgery, but not all. Substantial lymphovascular invasion, deep muscle invasion, high grade, an aggressive histological type or a p53-abnormal molecular group can all prompt treatment in a tumour that never left the uterus. The stage sets the frame; the other findings decide within it.
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Stage, grade, invasion depth, lymphovascular invasion and molecular group — that combination is what the tumour board discusses. The opinion is free.
What Changed in 2023, and Why
Worth understanding if you are comparing sources, because a good deal of material online predates the revision.
The older system described anatomy alone: where the tumour had reached. The difficulty was that tumours at identical anatomical extent were behaving very differently, and the reason turned out to be biological rather than positional.
- Molecular classification entered the system. Four groups — POLE-mutated, mismatch repair deficient, p53-abnormal, and no specific molecular profile. POLE-mutated tumours behave very favourably even at high grade; p53-abnormal tumours behave badly even when apparently early.
- Histological type was incorporated. Serous, clear cell and carcinosarcoma are recognised within the staging rather than only alongside it, reflecting their more aggressive behaviour. See Type 2 endometrial cancer.
- Substantial lymphovascular space invasion was given weight. A finding that independently predicts recurrence and previously sat outside the stage entirely.
- Stage I was subdivided more finely. Which is why a modern report may carry a subdivision that older material does not describe.
The practical upshot for a patient is simple: ask your team which edition they are using, and read your own report rather than trying to map it onto something found online. And if a figure or a rule you have read does not match what you have been told, the edition difference is the likeliest explanation.
Why Staging Is a Team Judgement, Not a Number
Anatomy, pathology and molecular biology have to be read together. That is what a tumour board is for.
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Common questions
FIGO Staging — Frequently Asked Questions
What does FIGO staging mean?
FIGO is the International Federation of Gynecology and Obstetrics, and its staging system describes how far a gynaecological cancer has spread. For endometrial cancer it runs from stage I, confined to the body of the uterus, through stage II, which has grown into the supporting tissue of the cervix, to stage III, which has extended beyond the uterus within the pelvis and abdomen including the lymph nodes, and stage IV, which has reached the lining of the bladder or bowel or distant organs. Each stage has letter subdivisions that matter as much as the number. Stage describes extent only — how aggressive the cells look is a separate question answered by grade.
Is the stage decided by the scan or the surgery?
By the surgery, which surprises most people. Endometrial cancer is surgically staged: the definitive stage comes from the pathologist examining the removed uterus, cervix, tubes, ovaries and any sampled lymph nodes. Imaging — usually MRI — provides a provisional assessment used to plan the operation, estimating how deeply the tumour has invaded the muscle wall and whether nodes are enlarged. But imaging cannot detect microscopic deposits in normal-sized nodes and cannot measure invasion with complete accuracy. This is why stages are revised after surgery in both directions, and why decisions about further treatment are made on the final pathology.
Why does my report look different from what I read online?
Most likely because FIGO revised the staging system in 2023 and some units still report using the 2009 version. The revision was substantial: stage I was subdivided more finely, and for the first time the system incorporates tumour biology — histological type, substantial lymphovascular space invasion, and molecular classification into POLE-mutated, mismatch repair deficient, p53-abnormal and no specific molecular profile groups. Some rules also changed, notably that involvement of the surface lining of the cervical canal no longer upstages a case to stage II. Two reports can therefore look inconsistent for the same disease and both be correct. Ask which edition your team uses.
Does a higher stage mean the cancer is more aggressive?
Not necessarily, and conflating the two is the commonest misunderstanding on this subject. Stage describes distance travelled; grade and molecular group describe behaviour. A Grade 3 tumour still confined to the lining is aggressive in character but early in extent, while a Grade 1 tumour that has reached the lymph nodes is the reverse. This mismatch is exactly why the 2023 revision folded some biological features into the staging system — tumours at identical anatomical extent were behaving very differently, and the explanation turned out to be biological. A stage on its own does not tell you your outlook.
Can my stage change after the operation?
Yes, and it is common enough to expect rather than to be alarmed by. Before surgery the stage is provisional, based mainly on MRI. Afterwards it is established from tissue. Stages are revised upward when a normal-sized lymph node turns out to contain tumour cells, or when invasion proves deeper than the scan suggested. They are revised downward just as genuinely — a tumour that appeared to involve the cervix may prove only to have involved its surface lining, which does not upstage under current rules. The grade and occasionally the histological type can also be revised once the whole specimen is examined.
Medical disclaimer: This page explains the FIGO staging system for endometrial cancer and is reviewed by a CION oncologist, following the FIGO 2023 revision and current NCCN and ESGO–ESTRO–ESP guidance. Some units continue to report using the 2009 revision, so reports may differ in format without either being incorrect. It is general information about how staging works rather than an interpretation of your own report, and it does not predict an outcome for any individual.