Stage Information for Ovarian Epithelial Cancer
Definitions of TNM and FIGO
In the absence of extra-abdominal metastatic disease, definitive staging of ovarian cancer requires laparotomy. The role of surgery in patients with stage IV disease and extra-abdominal disease is yet to be established. If disease appears to be limited to the ovaries or pelvis, it is essential at laparotomy to examine and biopsy or to obtain cytologic brushings of the diaphragm, both paracolic gutters, the pelvic peritoneum, para-aortic and pelvic nodes, and infracolic omentum, and to obtain peritoneal washings.[1]
The serum CA 125 level is valuable in the follow-up and restaging of patients who have elevated CA 125 levels at the time of diagnosis.[2-4] While an elevated CA 125 level indicates a high probability of epithelial ovarian cancer, a negative CA 125 level cannot be used to exclude the presence of residual disease.[5] CA 125 levels can also be elevated in other malignancies and benign gynecologic problems such as endometriosis, and CA 125 levels should be used with a histologic diagnosis of epithelial ovarian cancer.[6,7]
Definitions of TNM and FIGO The American Joint Committee on Cancer (AJCC) and the Féderation Internationale de Gynécologie et d’Obstétrique (FIGO) have designated staging to define ovarian epithelial cancer.[8,9] The definitions of the AJCC's T, N, and M categories correspond to the stages accepted by FIGO. Both systems are included for comparison.
Table 1. Primary Tumor (T)a,b| TNM Categories | FIGO Stages | |
| TX | | Primary tumor cannot be assessed. |
| T0 | | No evidence of primary tumor. |
| T1 | | Tumor limited to ovaries (one or both). |
| T1a | IA | Tumor limited to one ovary; capsule intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings. |
| T1b | IB | Tumor limited to both ovaries; capsules intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings. |
| T1c | IC | Tumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings. |
| T2 | II | Tumor involves one or both ovaries with pelvic extension. |
| T2a | IIA | Extension to and/or implants on uterus and/or tube(s). No malignant cells in ascites or peritoneal washings. |
| T2b | IIB | Extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings. |
| T2c | IIC | Pelvic extension and/or implants (T2a or T2b) with malignant cells in ascites or peritoneal washings. |
| T3 | III | Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis. |
| T3a | IIIA | Microscopic peritoneal metastasis beyond pelvis (no macroscopic tumor). |
| T3b | IIIB | Macroscopic peritoneal metastasis beyond pelvis ≤2 cm in greatest dimension. |
| T3c | IIIC | Peritoneal metastasis beyond pelvis >2 cm in greatest dimension and/or regional lymph node metastasis. |
| FIGO = Féderation Internationale de Gynécologie et d’Obstétrique. |
| aReprinted with permission from AJCC: 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. |
| bLiver capsule metastasis T3/stage III; liver parenchymal metastasis M1/stage IV. Pleural effusion must have positive cytology for M1/stage IV. |
Table 2. Regional Lymph Nodes (N)a| TNM Categories | FIGO Stages | |
| NX | | Regional lymph nodes cannot be assessed. |
| N0 | | No regional lymph node metastasis. |
| N1 | IIIC | Regional lymph node metastasis. |
| FIGO = Féderation Internationale de Gynécologie et d’Obstétrique. |
| aReprinted with permission from AJCC: 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. |
Table 3. Distant Metastasis (M)a| TNM Categories | FIGO Stages | |
| M0 | | No distant metastasis. |
| M1 | IV | Distant metastasis (excludes peritoneal metastasis). |
| FIGO = Féderation Internationale de Gynécologie et d’Obstétrique. |
| aReprinted with permission from AJCC: 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. |
Table 4. Anatomic Stage/Prognostic Groupsa| Stage | T | N | M |
| aReprinted with permission from AJCC: 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. |
| I | T1 | N0 | M0 |
| IA | T1a | N0 | M0 |
| IB | T1b | N0 | M0 |
| IC | T1c | N0 | M0 |
| II | T2 | N0 | M 0 |
| IIA | T2a | N0 | M0 |
| IIB | T2b | N0 | M0 |
| IIC | T2c | N0 | M0 |
| III | T3 | N0 | M0 |
| IIIA | T3a | N0 | M0 |
| IIIB | T3b | N0 | M0 |
| IIIC | T3c | N0 | M0 |
| Any T | N1 | M0 |
| IV | Any T | Any N | M1 |
Table 5. Carcinoma of the Ovarya| Stage | |
| 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.[9] |
| 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. |
References
- Hoskins WJ: Surgical staging and cytoreductive surgery of epithelial ovarian cancer. Cancer 71 (4 Suppl): 1534-40, 1993. [PUBMED Abstract]
- Mogensen O: Prognostic value of CA 125 in advanced ovarian cancer. Gynecol Oncol 44 (3): 207-12, 1992. [PUBMED Abstract]
- Högberg T, Kågedal B: Long-term follow-up of ovarian cancer with monthly determinations of serum CA 125. Gynecol Oncol 46 (2): 191-8, 1992. [PUBMED Abstract]
- Rustin GJ, Nelstrop AE, Tuxen MK, et al.: Defining progression of ovarian carcinoma during follow-up according to CA 125: a North Thames Ovary Group Study. Ann Oncol 7 (4): 361-4, 1996. [PUBMED Abstract]
- Makar AP, Kristensen GB, Børmer OP, et al.: CA 125 measured before second-look laparotomy is an independent prognostic factor for survival in patients with epithelial ovarian cancer. Gynecol Oncol 45 (3): 323-8, 1992. [PUBMED Abstract]
- Berek JS, Knapp RC, Malkasian GD, et al.: CA 125 serum levels correlated with second-look operations among ovarian cancer patients. Obstet Gynecol 67 (5): 685-9, 1986. [PUBMED Abstract]
- Atack DB, Nisker JA, Allen HH, et al.: CA 125 surveillance and second-look laparotomy in ovarian carcinoma. Am J Obstet Gynecol 154 (2): 287-9, 1986. [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.
- 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]
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