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Ovarian Epithelial Cancer Treatment (Professional) (cont.)

Stage Information for Ovarian Epithelial Cancer

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.[2,3,4] 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

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted 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.
b Liver capsule metastasis T3/stage III; liver parenchymal metastasis M1/stage IV. Pleural effusion must have positive cytology for M1/stage IV.
TNM CategoriesFIGO Stages
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
T1Tumor limited to ovaries (one or both).
T1aIATumor limited to one ovary; capsule intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings.
T1bIBTumor limited to both ovaries; capsules intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings.
T1cICTumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings.
T2IITumor involves one or both ovaries with pelvic extension.
T2aIIAExtension to and/or implants on uterus and/or tube(s). No malignant cells in ascites or peritoneal washings.
T2bIIBExtension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings.
T2cIICPelvic extension and/or implants (T2a or T2b) with malignant cells in ascites or peritoneal washings.
T3IIITumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis.
T3aIIIAMicroscopic peritoneal metastasis beyond pelvis (no macroscopic tumor).
T3bIIIBMacroscopic peritoneal metastasis beyond pelvis =2 cm in greatest dimension.
T3cIIICPeritoneal metastasis beyond pelvis >2 cm in greatest dimension and/or regional lymph node metastasis.

Table 2. Regional Lymph Nodes (N)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted 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.
TNM CategoriesFIGO Stages
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1IIICRegional lymph node metastasis.

Table 3. Distant Metastasis (M)a

FIGO = Féderation Internationale de Gynécologie et d'Obstétrique.
a Reprinted 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.
TNM CategoriesFIGO Stages
M0No distant metastasis.
M1IVDistant metastasis (excludes peritoneal metastasis).

Table 4. Anatomic Stage/Prognostic Groupsa

a Reprinted 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.
StageTNM
IT1N0M0
IAT1aN0M0
IBT1bN0M0
ICT1cN0M0
IIT2N0M 0
IIAT2aN0M0
IIBT2bN0M0
IICT2cN0M0
IIIT3N0M0
IIIAT3aN0M0
IIIBT3bN0M0
IIICT3cN0M0
Any TN1M0
IVAny TAny NM1

Table 5. Carcinoma of the Ovarya

a Adapted from FIGO Committee on Gynecologic Oncology.[9]
b In 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.
Stage
IGrowth limited to the ovaries.
IaGrowth limited to one ovary; no ascites present containing malignant cells. No tumor on the external surface; capsule intact.
IbGrowth limited to both ovaries; no ascites present containing malignant cells. No tumor on the external surfaces; capsules intact.
IcbTumor 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.
IIGrowth involving one or both ovaries with pelvic extension.
IIaExtension and/or metastases to the uterus and/or tubes.
IIbExtension to other pelvic tissues.
IIcbTumor 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.
IIITumor 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.
IIIaTumor 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.
IIIbTumor of one or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negative.
IIIcPeritoneal metastasis beyond the pelvis >2 cm in diameter and/or positive regional lymph nodes.
IVGrowth 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.

References:

  1. Hoskins WJ: Surgical staging and cytoreductive surgery of epithelial ovarian cancer. Cancer 71 (4 Suppl): 1534-40, 1993.
  2. Mogensen O: Prognostic value of CA 125 in advanced ovarian cancer. Gynecol Oncol 44 (3): 207-12, 1992.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
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