1. Changes in FIGO 2014 Staging of Ovarian Cancer
SUJOY DASGUPTA
MBBS (Gold Medalist)
MS (OBGY-Gold Medalist)
DNB (OBGY)
Senior Resident,
Deptt of Gynaecological Oncology,
Chittaranjan National Cancer Institute (CNCI)

3. Prof J Heyman, Stockholm

5. Characteristics of Staging
Valid
Practical
Reliable
Characteristics of Staging

6. Objectives of Staging To plan treatment To explain prognosis
To evaluate the results of treatment
To facilitate the exchange of information between treatment centers

7. Ovarian Cancer Staging
FIGO, 1973
FIGO, 1988

9. October 7-12, 2012; Rome, Italy
Gynecology Cancer Intergroup
International Gynecologic Cancer Society
European Organization for Research and Treatment of Cancer
American Society of Gynecologic Oncology; the European Society of Gynecologic Oncology
National Cancer Research Network, UK
Australian Society of Gynaecological Oncology
Korean Society of Gynecologic Oncology
Japanese Society of Obstetrics and Gynecology
Professor Lynette Denny, The Chair of FIGO Committee on Gynecologic Oncology

10. May, 2013
FIGO Executive Board
AJCC
UICC

11. January 1, 2014

12. FIGO, 2014 Staging Histologic type and grading must be mentioned
Primary site- Ovarian, Fallopian tube and Peritoneal Cancer

13. New Staging

14. Stage I (FIGO, 1988) Stage I Growth limited to ovaries IA
Growth limited to one ovary; no tumour on the external surface, capsule intact, no ascites IB
Growth limited to both ovaries; no tumour on the external surface, capsule intact, no ascites IC
Tumour with IA or IB but with tumour on the external surface, capsule ruptured; ascites containing malignant cells or positive peritoneal washing*
* It is important to know (i) If the capsule was ruptured intraoperatively or before surgery (ii) Whether malignant cells were present in the ascitic fluid or in peritoneal washing

15. Controversies

16. Surgical Spill Can affect prognosis???

17. Studies showing conflicting results1-4
Capsule rupture and positive cytologic washings are independent predictors of worse disease-free survival 1
Clear Cell Ca is more likely to rupture 5
Bakkum-Gamez, J.N., Richardson, D.L., Seamon, L.G., Aletti, G.D., Powless, C.A., Keeney, G.L. et al. Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer. Obstet Gynecol. 2009; 113: 11–17
Seidman, J.D., Yemelyanova, A.V., Khedmati, F., Bidus, M.A., Dainty, L., Boice, C.R. et al. Prognostic factors for stage I ovarian carcinoma. Int J Gynecol Pathol. 2010; 29: 1–7
Chan, J.K., Tian, C., Monk, B.J., Herzog, T., Kapp, D.S., Bell, J. et al. Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. Cancer. 2008; 112: 2202–2210
Obermair, A., Fuller, A., Lopez-Varela, E., van Gorp, T., Vergote, I., Eaton, L. et al. A new prognostic model for FIGO stage 1 epithelial ovarian cancer. Gynecol Oncol. 2007; 104: 607–611
Seidman, J.D., Cosin, J.A., Wang, B.G., Alsop, S., Yemelyanova, A., Fields, A. et al. Upstaging pathologic stage I ovarian carcinoma based on dense adhesions is not warranted: a clinicopathologic study of 84 patients originally classified as FIGO stage II. Gynecol Oncol. 2010; 119: 250–254in early ovarian cancer: same prognosis in a large randomized trial. Int J Gynecol Cancer. 2009; 19: 88–93 HR
95% CI
P value
Capsule rupture
4.2
=0.001
+ve cytology
6.4
<0.001

18. Meta-analysis of 9 studies included 2382 patients
Prat J, FIGO Committee on Gynecologic Oncology (2014). Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 124:1‐5.
Meta-analysis of 9 studies included 2382 patients
Progression free survival (PFS)
Pre-op rupture << Intra-op rupture << No rupture
“Intra-op rupture” vs “No rupture”-
in patients who underwent a complete surgical staging with or without adjuvant platinum‐based chemotherapy

19. Rupture should be avoided during primary surgery of malignant ovarian tumors confined to the ovaries

20. Bilateral tumours Independent contralateral primary tumor vs implants or metastases ???
Primary bilateral tumour- Relatively uncommon, occurring in only 1%–5% of stage I cases 1, 2
Implants/ metastasis- seen in 30% of stage I tumours 3
Heintz, A.P., Odicino, F., Maisonneuve, P., Quinn, M.A., Benedet, J.L., Creasman, W.T. et al. Carcinoma of the ovary. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynecol Obstet. 2006; : S161–S192
Yemelyanova, A.V., Cosin, J.A., Bidus, M.A., Boice, C.R., and Seidman, J.D. Pathology of stage I versus stage III ovarian carcinoma with implications for pathogenesis and screening. Int J Gynecol Cancer. 2008; 18: 465–469
Seidman, J.D., Yemelyanova, A.V., Khedmati, F., Bidus, M.A., Dainty, L., Boice, C.R. et al. Prognostic factors for stage I ovarian carcinoma. Int J Gynecol Pathol. 2010; 29: 1–7

21. Surface involvement Gross Excrescences vs Microscopic Involvement ???
Exophytic papillary tumor on the surface of the ovary or fallopian tube
Smooth surfaced tumours rarely have exposed cancer cells on the surface
Assessment of surface involvement requires careful GROSS examination

22. Dense Adhesions Should be considered stage II ???
Adhesions of an apparent stage I tumor requiring sharp dissection (or when dissection results in tumor rupture)
Dense adhesions may result in outcomes equivalent to tumors in stage II 1,2
Upstaging to stage II based on dense adhesion- ????? 3
Dembo, A.J., Davy, M., Stenwig, A.E., Berle, E.J., Bush, R.S., and Kjorstad, K. Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol. 1990; 75: 263–273
Ozols, R.F., Rubin, S.C., and Thomas, G.M. Epithelial Ovarian Cancer. in: W.J. Hoskins, R.C. Young, M. Markman, C.A. Perez, R. Barakat, M. Randall (Eds.) Principles and Practice of Gynecologic Oncology. 4th ed. Lippincott, New York; 2005: 895–987
Seidman, J.D., Cosin, J.A., Wang, B.G., Alsop, S., Yemelyanova, A., Fields, A. et al. Upstaging pathologic stage I ovarian carcinoma based on dense adhesions is not warranted: a clinicopathologic study of 84 patients originally classified as FIGO stage II. Gynecol Oncol. 2010; 119: 250–254

23. Stage I (FIGO 2014) Stage I Growth limited to ovaries IA
T1a N0 M0
Growth limited to one ovary; no tumour on the external surface, capsule intact, no ascites IB
T1b N0 M0
Growth limited to both ovaries; no tumour on the external surface, capsule intact, no ascites IC
T1c N0 M0
Tumor limited to one or both ovaries
IC1
Surgical spill
IC2
Capsule rupture before surgery
or tumor on ovarian surface
IC3
Malignant cells in the ascites
or peritoneal washings

24. Recommendations
Histologic type, which in most cases includes grade, should be recorded.
All individual subsets of stage IC disease should be recorded.
Dense adhesions with histologically proven tumor cells justify upgrading to stage II.
Primary Peritoneal Ca can never be stage I

25. Stage II (FIGO, 1988) Stage II
Growth involving one or both ovaries with pelvic extension
IIA
Extension and/or metastasis to tubes and/or uterus
IIB
Extension to other pelvic tissues
IIC
Tumour with IIA or IIB but with tumour on the external surface, capsule ruptured; ascites containing malignant cells or positive peritoneal washing

26. Controversies

27. What is exactly Stage II ???
Difficult to define
<10% of ovarian cancers
A heterogeneous group
Potentially curable tumors- direct extension to adjacent organs but have not yet metastasized
Tumour seeded the pelvic peritoneum by metastasis (Poor Prognosis)

28. Pelvic Tissue???
Sigmoid colon
Bladder
Transmural involvement ???

29. Pelvic peritoneum Is separate from abdominal peritoneum?
Peritoneum is a continuous anatomic unit
Pelvic involvement and extrapelvic involvement are prognostically similar (as for stage IIIA endometrial carcinoma)
Anatomically stage II disease

30. Committee felt that……….
Older IIC is redundant
Prognostic difference exists between stage IIA and IIB
(5 year OS 78% and 73% respectively)

31. Stage II (FIGO 2014) IIC Stage II
Tumor involves 1 or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer
IIA
T2A N0 M0
Extension and/or implant on uterus and/or Fallopian tubes
IIB
T2B N0 M0
Extension to other pelvic intraperitoneal tissues
IIC

32. Stage III (FIGO, 1988) Stage III
Growth involving one/ both ovaries with peritoneal implants outside the pelvis and/ or retroperitoneal and/or inguinal lymph nodes.
Superficial liver metastasis equals stage III.
Tumour limited to true pelvis but histologically proven malignant extension to small bowel and omentum.
IIIA
Tumour grossly limited to true pelvis with negative nodes
But histologically confirmed microscopic seeding of abdominal peritoneal surface
IIIB
Tumour of one or bothe ovaries
With histologically confirmed implants on abdominal peritoneal surface, none more than 2 cm in diameter, node negative
IIIC
Abdominal implants more than 2 cm diameter
And/or retroperitoneal or inguinal lymph nodes or both

33. Controversies

34. Lymph nodes- in IIIC ??? 1. Diffuse omental and peritoneal disease
2. Only lymph node involvement without any other evidence of intra-abdominal disease (<10% of apparent stage I tumours)
The 2nd group has better prognosis in terms of DFS and OS1-4
Onda, T., Yoshikawa, H., Yasugi, T., Mishima, M., Nakagawa, S., Yamada, M. et al. Patients with ovarian carcinoma upstaged to stage III after systematic lymphadenctomy have similar survival to Stage I/II patients and superior survival to other Stage III patients. Cancer. 1998; 83: 1555–1560
Kanazawa, K., Suzuki, T., and Tokashiki, M. The validity and significance of substage IIIC by node involvement in epithelial ovarian cancer: impact of nodal metastasis on patient survival. Gynecol Oncol. 1999; 73: 237–241
Cliby, W.A., Aletti, G.D., Wilson, T.O., and Podratz, K.C. Is it justified to classify patients to Stage IIIC epithelial ovarian cancer based on nodal involvement only?. Gynecol Oncol. 2006; 103: 797–801
Ferrandina, G., Scambia, G., Legge, F., Petrillo, M., and Salutari, V. Ovarian cancer patients with "node-positive-only" Stage IIIC disease have a more favorable outcome than Stage IIIA/B. Gynecol Oncol. 2007; 107: 154–156

35. Baek, S. J. , Park, J. Y. , Kim, D. Y. , Kim, J. H. , Kim, Y. M
Baek, S.J., Park, J.Y., Kim, D.Y., Kim, J.H., Kim, Y.M., Kim, Y.T. et al. Stage IIIC epithelial ovarian cancer classified solely by lymph node metastasis has a more favorable prognosis than other types of stage IIIC epithelial ovarian cancer. J Gynecol Oncol. 2008; 19: 223–228
Conclusion- Patients with stage IIIC epithelial ovarian cancer due to positive nodes only had a more favorable prognosis compared to other stage IIIC patients. Therefore, reevaluation of the current FIGO staging system for stage IIIC epithelial ovarian cancer is required.

36. The Committee felt that…………
RPLN involvement only- in IIIA1,
rather than IIIC
Stage IIIA1 is further subdivided into
Involvement of retroperitoneal lymph nodes must be proven cytologically or histologically
IIIA1 (i)
Mets ≤10 mm in greatest dimension
IIIA1 (ii)
Mets >10 mm in greatest dimension

37. Stage III (FIGO, 2014)

38. Positive retroperitoneal lymph nodes
Stage III
Tumor involves 1 or both ovaries or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes
IIIB
T3B N0/1 M0
Macroscopic peritoneal metastasis beyond the pelvis up to 2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes
IIIC
T3C N0/1 M0
IIIC: Macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes (includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ)
IIIA
Positive retroperitoneal lymph nodes
and/or microscopic metastasis beyond the pelvis
IIIA1
T1/2 N1 M0
Positive retroperitoneal lymph nodes only (cytologically or histologically proven):
IIIA1 (i)
IIIA1 (ii)
Metastasis up to 10 mm in greatest dimension
Metastasis more than 10 mm in greatest dimension
IIIA2
T3A N0/1 M0
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes

39. Stage IV (FIGO, 1988) Stage IV
Growth involving one/ both ovaries with distant metastasis
If pleural effusion is present, there must be a cytologic result
Parenchymal liver metastasis equals to stage IV

40. Stage IV (FIGO, 2014) Stage IV
T any N any M1
Distant metastasis excluding peritoneal metastases
IVA
Pleural effusion with positive cytology
IVB
Parenchymal metastases and metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

41. Controversies left behind

42. Abdominal Involvement
Umbilicus
Represents peritoneal extension into the urachal remnant- IIIC or IVB ???
Isolated parenchymal liver/ spleen metastasis
IIIC or IVB ???
Splenectomy
Till date, the committee considers them stage IVB

43. Other Changes

44. Primary site Should be designated where possible Ovary Fallopian tube
Peritoneum
“Undesignated”- when not possible to delineate the primary site clearly

45. Histologic types Epithelial Cancers (>90%)
Malignant germ cell tumors (3%)
Dysgerminomas
Yolk sac tumors
Immature teratomas
Epithelial Cancers (>90%)
High-grade serous carcinoma (HGSC-70%)
Endometrioid carcinoma (EC 10%)
Clear-cell carcinoma (CCC 10%)
Mucinous carcinoma (MC 3%)
Low-grade serous carcinoma (LGSC <5%)
Undifferentiated (1%)
Potentially malignant sex cord-stromal tumors (1%–2%)
Granulosa cell tumors)

46. To summarize Comprehensive surgical staging
Histological type should be included
Primary site should be mentioned wherever possible

47. FIGO 1988 FIGO 2014 Stage I Growth limited to ovaries IA
Growth limited to one ovary; no tumour on the external surface, capsule intact, no ascites IB
Growth limited to both ovaries; no tumour on the external surface, capsule intact, no ascites IC
Tumour with IA or IB but with tumour on the external surface, capsule ruptured; ascites containing malignant cells or positive peritoneal washing
Tumor limited to one or both ovaries
IC1
Surgical spill
IC2
Capsule rupture before surgery or tumor on ovarian surface
IC3
Malignant cells in the ascites
or peritoneal washings

48. FIGO 1988
FIGO 2014
Stage II
Growth involving one or both ovaries with pelvic extension
IIA
Extension and/or metastasis to tubes and/or uterus
IIB
Extension to other pelvic tissues
IIC
Tumour with IIA or IIB but with tumour on the external surface, capsule ruptured; ascites containing malignant cells or positive peritoneal washing
No IIC

49. FIGO 1988
FIGO 2014
Stage III
Tumor involves 1 or both ovaries with cytologically or histologically
confirmed spread to the peritoneum outside the pelvis and/or metastasis to the
retroperitoneal lymph nodes
IIIA
Tumour grossly limited to true pelvis with negative nodes
But histologically confirmed microscopic seeding of abdominal peritoneal surface
Positive retroperitoneal lymph nodes and
/or microscopic metastasis beyond the pelvis
IIIA1
Positive retroperitoneal lymph nodes only (cytologically or histologically proven):
IIIA1 (i)
IIIA1(ii)
Metastasis up to 10 mm in greatest dimension
Metastasis more than 10 mm in greatest dimension
IIIA2
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes
IIIB
Abdominal implants ≤2 cm diameter, nodes negative
Abdominal implants ≤2 cm diameter, nodes positive/ negative
IIIC
Abdominal implants more than 2 cm diameter
And/or retroperitoneal or inguinal lymph nodes or both
Abdominal implants more than 2 cm diameter, nodes positive/ negative

50. FIGO 1988
FIGO 2014
Stage IV
Distant metastasis excluding peritoneal metastasis
IVA
Pleural effusion with positive cytology
IVB
Parenchymal metastases and metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

51. “To study medicine without books is to sail an uncharted sea, while to study medicine only from books is not to go to sea at all.”
- Sir William Osler ( )