Radiation Oncology/Ovary/Staging

Ovarian Cancer Staging

FIGO (2014)

2014 FIGO staging

• Ovarian cancer staging is by FIGO staging system and uses information obtained after surgery, which should include a total abdominal hysterectomy, removal of (usually) both ovaries, pelvic (peritoneal) washings for cytology, and biopsies (omentum, mesentery, diaphragm, peritoneal surfaces, pelvic and para-aortic nodes)
• Also includes primary peritoneal carcinoma

Primary Tumor: (FIGO stage in parentheses)

• I - limited to one or both ovaries
  • IA - involves one ovary; capsule intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings
  • IB - involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings
  • IC - tumor limited to ovaries with any of the following: surgical spill (IC1), capsule ruptured or tumor on ovarian surface (IC2), positive washings (IC3)
• II - pelvic extension or primary peritoneal cancer
  • IIA - extension or implants onto uterus or fallopian tube
  • IIB - extension or implants onto other pelvic structures
• III - microscopic peritoneal implants outside of the pelvis or positive LN
  • IIIA
    • IIIA1 - retroperitoneal lymph nodes; IIIA1(i) - ≤ 10 mm; IIIA1(ii) - > 10 mm
    • IIIA2 - microscopic peritoneal metastases beyond pelvis (w/ or w/o positive LN)
  • IIIB - macroscopic peritoneal metastases beyond pelvis ≤ 2cm (w/ or w/o positive LN). Includes extension to capsule of liver or spleen.
  • IIIC - peritoneal metastases beyond pelvis > 2 cm (w/ or w/o positive LN). Includes extension to capsule of liver or spleen.
• IV - distant metastases
  • IVA - pleural effusion with positive cytology
  • IVB - hepatic or splenic parenchymal metastases, extra-abdominal metastases, or distant LNs (inguinal LN, or LNs outside of abdominal cavity)

Changes from AJCC 7th Edition:

Substaging of IC into IC1-3. Removed stage IIC. Positive lymph nodes are IIIA (previously IIIC). IIIA subdivided into IIIA1(i-ii) and IIIA2. IV subdivided into IVA and B. Inguinal lymph nodes are Stage IV (all LNs previously IIIC).

AJCC 7th Edition (2009)

• Ovarian cancer staging is by FIGO staging system and uses information obtained after surgery, which should include a total abdominal hysterectomy, removal of (usually) both ovaries, pelvic (peritoneal) washings for cytology, and biopsies (omentum, mesentery, diaphragm, peritoneal surfaces, pelvic and para-aortic nodes)
• The AJCC stage is the same as the FIGO stage
• Also includes primary peritoneal carcinoma

Primary Tumor: (FIGO stage in parentheses)

• T1 (I) - limited to one or both ovaries
  • T1a (IA) - involves one ovary; capsule intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings
  • T1b (IB) - involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings
  • T1c (IC) - tumor limited to ovaries with any of the following: capsule ruptured, tumor on ovarian surface, positive washings
• T2 (II) - pelvic extension or implants
  • T2a (IIA) - extension or implants onto uterus or fallopian tube; negative washings
  • T2b (IIB) - extension or implants onto other pelvic structures; negative washings
  • T2c (IIC) - pelvic extension or implants (T2a or T2b) with positive peritoneal washings
• T3 (III) - microscopic peritoneal implants outside of the pelvis
  • T3a (IIIA) - microscopic peritoneal metastases beyond pelvis
  • T3b (IIIB) - macroscopic peritoneal metastases beyond pelvis less than 2cm in size
  • T3c (IIIC) - peritoneal metastases beyond pelvis > 2 cm. (lymph node metastasis is also IIIC for FIGO)

Regional Lymph Nodes: includes pelvic, para-aortic, inguinal, retroperitoneal

• N0 - no
• N1 (IIIC) - yes

Distant Metastases:

• M0 - no
• M1 (IV) - yes

Stage Grouping:

Follows FIGO staging above (in parentheses). T3c and N1 are both IIIC.

Note: primary peritoneal tumors are usually either Stage III or IV

Note: seeding of the liver capsule is Stage III but liver parenchymal mets are Stage IV.

Older staging systems

AJCC 6th Edition (2002)

Same as 7th Edition, except primary peritoneal carcinoma is always metastatic (M1) at diagnosis