Okay, so, okay, got it. So I have to start again. So good morning, everybody, and sorry for mixing the time last time. So what I'm going to talk about is something very basic. It's staging. The reason why I chose this topic is because of the revision recently on the vehicle staging. So go back to history. So if a cancer is clinically staged, there were debates over years whether we should go for surgical staging. And the main argument is that if there's lymph node mass, they have poorer prognosis, but the clinical staging cannot do that. Another argument is that with clinical staging, it's difficult to assess the size or the parametrial invasion. But in 2009, we have a sort of hot debate at the IGCS and FECAL. And after a lot of debate, we think that because 80% of cervical cancer is in developing world, and majority are ready in late stage. So we think that probably we should stay with clinical staging, because if you look at the FECAL report in the past, they do give quite discriminatory prognostic curves. So at that time, we think that maybe it's not practical for surgical staging or feasible or beneficial in majority of cervical cancer, especially managed in low resources setting. Well, of course, we've advances in the management and the imaging. So the committee in 2016 and 18, we addressed this problem and determined that we need to revise the staging process to maintain unanimity worldwide, incorporate new technology where feasible and improve the utility and applicability. So that's why in the revision, they recommend that we can use the imaging as well as pathology assessment of the pulses and evaluation of the lymph nodes. And that can be incorporated into the staging. And of course, then it led to changes in the staging in 2018, which was published in 2019. So basically, it affected staging in stage one and stage three disease. So this is just a summary of the changes. Number one, they allow the use of imaging and pathology in locating the stage. And for stage one, the measurements is mainly in the microscope definition and for 1A and for 1B is the change in the size. And for stage two, actually there's no change in the staging. It also allowed the use of imaging or pathology to assess the size and extent of the disease. And for stage one through three, it allow you to do imaging to assess the status and you can change or upgrade if there's evidence that you suspect there's lymph node staging. There's no recommendation for routine investigations as before. So it's actually depends on your clinical findings and your standard of care or your resources. So the good thing about this revised staging system is that it allows you to use whatever clinical resources you have. That's why there's no specific request for what imaging technique you have to use. And also they didn't actually ask you, you must do say surgical staging in order to assess the lymph node status or whatever. So in no resolve condition, if you don't have anything, you can still use clinical staging as a method of staging. You can assess the size of the disease clinically by imaging or pathology, and you can assess the lymph node metastasis by imaging again, whether you would like to have a finalized way to confirm or not is also allowed. So that's why it's more flexible. But of course, when we change this, keep in mind that it's not that simple that say imaging, you put a R to designate, that means that already that you have a clear answer. The problem that we are going to anticipate is that depending on the different imaging technique in future, you may have a different outcome. So we just have to keep in mind, and I think it's worthwhile to report the method of imaging, although it's not requested by fecal. And the other is the pathology technique use, whether you are doing on a surgical specimen or just a biopsy or fine needle aspirate may also have implication in future. So as to the imaging, it's that the main purpose, as said, is mainly for, you can now accurately measure the tumor size. And then also test whether there's paramedic invasion or any metastasis to the lymph nodes or other organs in the pelvis or the abdomen. So, but we recognize that in low resources setting, they may not have a lot of imaging technique. So it allows you to do whatever choice you have. So just go back to the revision for the stage one. The main revision is that they take away the width of the invasion, 70 millimeter, because there's always this debate, how to measure whether one focus or you can add multi-focus. So that's why now it's just depends the depth of the stromal invasion to define whether it's 1A1 or 1A2. And for 1B, then this previously is just more than four centimeter or less. But now they add in one more category, it's the two centimeter. So 1B2 is two to four and 1B3 is more than four. Now, why this was introduced is because more and more, we find that less than two centimeter tumor, they tend to have better prognosis. So you can do reticulococcalectomy safely. And even nowadays, there's some data showing that you may be able to do a simple hysterectomy for a tumor less than two centimeter. So actually, there's data already shown the recurrence significantly lower for stage one, if it's less than two centimeter. However, the presence of vascular lymphatic space invasion still were not taken into the staging, although they have prognostic significance because of the difficulties in defining the extent. And the extension to the corpus also not included, although there's some data showing that there's some prognostic significance. Okay, so for the method of the imaging, oh, you're allowed to use whatever you think is best, say, ultrasound CT, MRI, PET, PET CT or MRI, based on your local resources. But actually, data show that MRI seems to give you the best sensitivity and specificity in assessing the size of the lesion. But there are some data coming out that if you're very experienced in doing ultrasound, ultrasound also give you very good assessment on size and also parametrial invasion. For stage two, as mentioned, there's no change in the definition, but you're allowed to use the imaging to assess the parametrial invasion, which is sometimes a bit difficult on clinical, whether it's invasion or just some inflammatory changes. So the utility of imaging can be used to assess the parametrium, as well as whether there's some upper vaginal invasion. Again, MRIs actually do better than CT scan with less negative or false positive results. And for some center, if they want, they can use the corpuscope to help them to assess the extent of vaginal involvement. Although if you want, you can still use EUA examination, then it's easier for better assessment of whether it's parametrial or vaginal invasion. For the involvement of the ovary, it's reported in less than 1% for SEC and less than five. So that's why it's not incorporated staging. I think it's probably too rare. Now for stage three, the major change is that we have introduced a new staging category called 3C. And when there is pelvic or parotid node involvement, irrespective of size or extent, if it's the pelvic node, it's a 3C1 and parotid node is 3C2. And you can actually determine that by imaging. Then you put a small R after your 1C1 or 1C2. And if it's done by histology, then you do a P, which is pathology, to designate what method you use to do the staging. So the imaging techniques, again, includes everything that you can use. And some may use that to guide for a fine needle or to selective biopsy. And the sensitivity of these modalities for detecting nodal mass varies from 60 to 88%. And the specificity is 97%. And it seems that PET-CT is the best performer in detecting metastasis in lymph node or else. So again, the limitation of imaging is that in many places where they have a high cell cancer burden, they also have a high burden of other infections like TB or HIV. So in this endemic area, the enlarged node may not be due to metastasis, may be due to the infection. But unfortunately, we don't have a very clear sort of radiological differentiation between the two. And the other issue being discussed is that nowadays we can do Sentinel-Node, especially for early stage. It's proven to be very effective for valve endometrium. So maybe in future, we have to also accept the role of Sentinel-Node in the staging. So I think currently, especially not for stage one, early stage, then we probably will put this as a research protocol. But remember that if you want to do Sentinel-Node, you have to do a ultra staging and you need good pathological support and also immunostaging. So the controversy arising from this sort of approach is that, of course, people will still challenge that the gold standard should be pathology. But I think it's a good move. With now such good imaging technology, we should start taking this into consideration. And again, I want to emphasize that the choice of the imaging has not been fixed by vehicle. You can use whatever is available. So in other words, don't take the long availability of the imaging mortality as a reason of delaying any treatment. So just treat the patient on whatever facilities you have. And also, as mentioned, they cannot actually define the differentiation between cancer or inflammation. So again, it's left to the clinician to make a decision and maybe how you would like to further confirm it. So the final conclusion is that we should use the best available technology for assessment. And if you are not certain, then the lowest appropriate stage should be assigned. So that's, well, if in doubt, then you assign the lowest stage. So stage four, again, there's no change in staging, but again, you can use imaging to help you. But if imaging find there may be bladder or rectal invasion, then we need to confirm with a cystoscopy or somatoscopy to confirm indeed it is a stage four. So there's also some suggestion that if there's a bulky endosarcoma tumor that you are not certain, maybe you can still perform a cystoscopy and EUA to find whether there's actually any invasion. So for stage four, remember, you need histology confirmation, not just based on imaging. So at the present time, there's lack of facilities universally is recognized. And so we remember that we must accept clinical assessment should be accepted as well. And what we need to do is just record how we do the staging. So this actually, I will commend, this is the original articles about the revision of the staging. So lastly, I just want to say that one shoe does not fit all. So the neophageal staging is good because it allow us to collect more data from different methods of the staging. I think only time will tell whether this revision is going to help us to better assess the outcome and so to offer a better management to our patients. So thank you. Thank you, Professor An.

revised staging system

cervical cancer

imaging

pathology assessment

Sentinel-Node assessment