Stage Information for Ovarian Germ Cell Tumors

Note: The American Joint Committee on Cancer has recently published a new edition of the AJCC Cancer Staging Manual, which includes revisions to the staging for this disease. The PDQ Adult Treatment Editorial Board, which is responsible for maintaining this summary, is currently reviewing the new staging to determine the changes that need to be made in the summary. In addition to updating this Stage Information section, additional changes may need to be made to other parts of this summary to ensure that it is up-to-date. The changes will be made as soon as possible.

In the absence of obvious metastatic disease, accurate staging of germ cell tumors of the ovary requires laparotomy with careful examination of the entire diaphragm, both paracolic gutters, pelvic nodes on the side of the ovarian tumor, the para-aortic lymph nodes, and the omentum. The contralateral ovary should be carefully examined and biopsied if necessary. Ascitic fluid should be examined cytologically. If ascites is not present, it is important to obtain peritoneal washings before the tumor is manipulated. In patients with dysgerminoma, lymphangiography or computed tomography is indicated if the pelvic and para-aortic lymph nodes were not carefully examined at the time of surgery.

Although not required for formal staging, it is desirable to obtain serum levels of alpha fetoprotein (AFP) and human chorionic gonadotropin (HCG) as soon as the diagnosis is established since persistence of these markers in the serum after surgery indicates unresected tumor.

The Federation Internationale de Gynecologie et d’Obstetrique (FIGO) and the American Joint Committee on Cancer (AJCC) have designated staging for ovarian germ cell tumors.[1,2]

Stage I

Stage I ovarian germ cell cancer is growth limited to the ovaries.

• Stage IA: Tumor is limited to ovary; capsule is intact, and no tumor is present on the ovarian surface. No malignant cells are present in ascites or peritoneal washings.*
• Stage IB: Tumor is limited to both ovaries; capsules are intact, no tumor is present on the ovarian surface. No malignant cells are present in ascites or peritoneal washings.*
• Stage IC: Tumor is limited to one or both ovaries with any of the following:[1]
  • Capsule is ruptured.
  • Tumor is present on the ovarian surface.
  • Malignant cells are present in ascites or peritoneal washings.

* [Note: Malignant ascites is not classified. The presence of ascites does not affect staging unless malignant cells are present.]

Stage II

Stage II ovarian germ cell cancer is growth involving one or both ovaries with pelvic extension and/or implants.

• Stage IIA: Extension and/or implants are present on the uterus and/or fallopian tubes. No malignant cells are present in ascites or peritoneal washings.
• Stage IIB: Extension to and/or implants are present on other pelvic tissues. No malignant cells are present in ascites or peritoneal washings.
• Stage IIC: Pelvic extension and/or implants (stage IIA or stage IIB) with malignant cells are present in ascites or peritoneal washings.

Different criteria for designating cases to stages IC and IIC have an impact on the diagnoses. To evaluate the impact of the differing criteria, determine if rupture of the capsule was the result of any of the following possibilities:

• A spontaneous rupture.
• A rupture caused by the surgeon.

It is also important to determine if the source of the malignant cells detected was the result of either of the following:

• Peritoneal washings.
• Ascites.

Stage III

Stage III ovarian germ cell cancer is growth involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis but with histologically verified malignant extension to the small bowel or omentum.

• Stage IIIA: Microscopic peritoneal metastasis is present beyond the pelvis (no macroscopic tumor).
• Stage IIIB: Macroscopic peritoneal metastasis is present beyond the pelvis and is 2 cm or smaller in greatest dimension.
• Stage IIIC: Peritoneal metastasis is present beyond the pelvis and is larger than 2 cm in greatest dimension, and/or regional lymph node metastasis is present.

Stage IV

Stage IV ovarian germ cell cancer is growth involving one or both ovaries with distant metastasis. If pleural effusion is present, there must be positive cytologic test results to designate a case to stage IV. Parenchymal liver metastasis equals stage IV.

References

1. Shepherd JH: Revised FIGO staging for gynaecological cancer. Br J Obstet Gynaecol 96 (8): 889-92, 1989.  [PUBMED Abstract]
   
   
2. Ovary. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 275-284.