Presentation at Chittaranjan Seva Sadan, Kolkata where Dr Dasgupta was invited as faculty in the CME organized by Medical Education and research Committee, Bengal Obstetrics and Gynaecological Society

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

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
Professor Lynette Denny,
The Chair of FIGO
Committee on
Gynecologic Oncology
• 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

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
1. 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
2. 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
3. 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
4. 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
5. 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 1.8-10.9 =0.001
+ve cytology 6.4 2.5-16.0 <0.001

18. 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
1. 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
2. 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
3. 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
1. 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
2. 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
3. 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
1.Potentially curable tumors- direct extension to
adjacent organs but have not yet metastasized
2.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)
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

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
1. 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
2. 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
3. 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
4. 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., 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. 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%)
•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%)
Malignant germ cell tumors
(3%)
• Dysgerminomas
• Yolk sac tumors
• Immature teratomas
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 (1849-1919)