Stage Information for Ovarian Germ Cell Tumors
In the absence of obvious metastatic disease, accurate staging of germ cell tumors of the ovary requires laparotomy with careful examination of the following:
- Entire diaphragm.
- Both paracolic gutters.
- Pelvic nodes on the side of the ovarian tumor.
- The para-aortic lymph nodes.
- 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.Definitions: FIGO
The Féderation Internationale de Gynécologie et d’Obstétrique (FIGO) and the American Joint Committee on Cancer (AJCC) have designated staging to define ovarian germ cell tumors; the FIGO system is most commonly used.[1,2]Table 1. Carcinoma of the Ovarya
|I||Growth limited to the ovaries.|
|Ia||Growth limited to one ovary; no ascites present containing malignant cells. No tumor on the external surface; capsule intact.|
|Ib||Growth limited to both ovaries; no ascites present containing malignant cells. No tumor on the external surfaces; capsules intact.|
|Icb||Tumor either stage Ia or Ib, but with tumor on surface of one or both ovaries, or with capsule ruptured, or with ascites present containing malignant cells, or with positive peritoneal washings.|
|II||Growth involving one or both ovaries with pelvic extension.|
|IIa||Extension and/or metastases to the uterus and/or tubes.|
|IIb||Extension to other pelvic tissues.|
|IIcb||Tumor either stage IIa or IIb, but with tumor on surface of one or both ovaries, or with capsule(s) ruptured, or with ascites present containing malignant cells, or with positive peritoneal washings.|
|III||Tumor involving one or both ovaries with histologically confirmed peritoneal implants outside the pelvis and/or positive regional lymph nodes. Superficial liver metastases equals stage III. Tumor is limited to the true pelvis, but with histologically proven malignant extension to small bowel or omentum.|
|IIIa||Tumor grossly limited to the true pelvis, with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces, or histologic proven extension to small bowel or mesentery.|
|IIIb||Tumor of one or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negative.|
|IIIc||Peritoneal metastasis beyond the pelvis >2 cm in diameter and/or positive regional lymph nodes.|
|IV||Growth involving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive cytology to allot a case to stage IV. Parenchymal liver metastasis equals stage IV.|
|aAdapted from FIGO Committee on Gynecologic Oncology.|
|bIn order to evaluate the impact on prognosis of the different criteria for allotting cases to stage Ic or IIc, it would be of value to know if rupture of the capsule was spontaneous, or caused by the surgeon; and if the source of malignant cells detected was peritoneal washings, or ascites.|
- FIGO Committee on Gynecologic Oncology: Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet 105 (1): 3-4, 2009. [PUBMED Abstract]
- Ovary and primary peritoneal carcinoma. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 419-28.