G 3.3 Epithelial Carcinoma of the Ovary, Fallopian Tube, And Peritoneum_ Surgical Staging - UpToDate

15/6/23, 11:29 Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Surgical staging - UpToDate
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Epithelial carcinoma of the ovary, fallopian tube, and

peritoneum: Surgical staging
AUTHORS: Ritu Salani, MD, MBA, Casey M Cosgrove, MD
SECTION EDITORS: Barbara Goff, MD, Rochelle L Garcia, MD
DEPUTY EDITOR: Alana Chakrabarti, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2023.

This topic last updated: Jan 30, 2023.
INTRODUCTION
Epithelial, germ cell, and stromal cancers of the ovary, fallopian tube, and peritoneum are
staged surgically. In this topic, we will focus on epithelial carcinomas and generally refer to
carcinoma at these sites as epithelial ovarian carcinoma (EOC), but distinctions between sites,
where present, will be addressed.
The majority of patients with EOC are diagnosed at an advanced stage: distant metastases (48
percent), spread to regional lymph nodes (23 percent), localized at diagnosis (21 percent), and
unstaged (8 percent) [1]. Complete surgical staging of EOC is important for treatment planning
and prognostic counseling. For example, approximately 30 percent of patients undergoing
comprehensive surgical staging for clinical findings of stage I EOC are found to have more
advanced disease, usually positive cytology, and are upstaged and treated accordingly [2].
Surgical staging of patients with EOC will be reviewed here. The preoperative evaluation of these
patients, cytoreductive surgery, and chemotherapy are discussed separately.
● (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction".)
● (See "Patient selection and approach to neoadjuvant chemotherapy for newly diagnosed
advanced ovarian cancer".)
● (See "Adjuvant therapy of early-stage (stage I and II) epithelial ovarian, fallopian tube, or
peritoneal cancer".)
https://www.uptodate.com/contents/epithelial-carcinoma-of-the-ovary-fallopian-tube-and-peritoneum-surgical-staging/print?search=EPITHELIALCAR… 1/24
● (See "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian
tube, and peritoneal cancer".)
STAGING SYSTEM
EOC is surgically staged according to the 2017 8th Edition American Joint Committee on Cancer
(AJCC) and the International Federation of Gynecology and Obstetrics (FIGO) Tumor, Node,
Metastasis (TNM) classification system ( table 1) [3]. A single system is now used for ovarian,
fallopian tube, and peritoneal carcinomas, although this has not always been the case.
Some nuances of staging are discussed below:
● It is not possible to have stage I peritoneal carcinoma.
● Surface involvement of the ovary or fallopian tube is defined as neoplastic cells directly
exposed to the peritoneal cavity [4]. This usually takes the form of an exophytic papillary
tumor on the surface of the ovary or fallopian tube or on the outer surface of a cystic
neoplasm replacing these organs. Rarely, surface involvement may be an exposed layer of
neoplastic epithelium on a smooth ovarian tumor surface. Assessment for surface
involvement requires careful gross examination as its presence may influence therapeutic
decision making.
Stage IB (tumor limited to both ovaries [capsules intact] or fallopian tubes; no tumor on
ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings) is
relatively uncommon (1 to 5 percent of stage I cases) [5,6]. One-third of carcinomas with
bilateral involvement will have an enlarged ovary on one side and a normal size ovary on
the other side; any tumor identified on the ovarian or fallopian tube surface is upstaged to
IC2 [7].
● Capsule rupture – Rupture of the ovarian tumor capsule may occur preoperatively or
during surgical removal and may disseminate malignant cells via the peritoneal circulation
[8,9]. This is reflected in the staging system: for stage I disease, surgical spill is IC1, and
rupture prior to surgery is IC2. Patients with disease confined to one or both ovaries who
have intraoperative capsule rupture are upgraded from IA or IB to IC1, which is clinically
significant because stage IC is typically the threshold for treating with chemotherapy for
certain histologies.
Preoperative rupture appears to be associated with a worse prognosis. In a meta-analysis of 17

observational studies including over 18,000 patients with early-stage ovarian cancer undergoing
surgical management, those with intraoperative capsule rupture (63 percent) compared with no
capsule rupture had worse progression-free survival (hazard ratio [HR] 1.92, 95% CI 1.34-2.76)
and worse overall survival (HR 1.48, 95% CI 1.15-1.91) [10]. However, data regarding the
prognosis of intraoperative rupture are inconsistent [11-14] and it remains unclear whether the
worse prognosis with intraoperative rupture is due to rupture or to a missed diagnosis of
advanced disease in patients who are incompletely staged.
● Dense adhesions with histologically proven neoplastic cells justify upgrading to stage II.
Because data are inconsistent regarding whether sharp dissection of dense adhesions in
patients with an apparent stage I carcinoma results in outcomes equivalent to stage II
[15,16], the recommendation for upstaging is limited to dense adhesions with malignant
cells. Sampling the adhesions after removal of the mass may assist with appropriate
staging.
● Evaluation of the peritoneum above and below the pelvic brim – The presence or
absence of disease above or below the pelvic brim should be described in the operative
report, especially if there is no evidence of gross disease outside of the pelvis. Stage II EOC
includes direct extension to the peritoneum below the pelvic brim. Stage III EOC includes
extrapelvic (above the pelvic brim) peritoneal involvement. Thus, the pelvic brim is a
landmark for appropriate surgical staging.
● Distinguishing between stage III and IV – The majority of EOC will present at an
advanced stage (III/IV). Some considerations for intraoperative distinction between stage
III and IV disease are bowel infiltration (transmural with mucosal involvement), umbilical
deposit, inguinal lymph node metastasis, and parenchymal (not surface) metastases in liver
or spleen, all of which are considered stage IVB.
STAGING PROCEDURE
Overview — In the setting of clinically early stage EOC, the standard staging procedure consists
of all of the following:
● Peritoneal cytology (washings or ascites).
● Visual assessment of the upper abdomen, peritoneal surfaces, and large and small bowel
mesentery and other abdominal organs, with biopsies of abnormal findings.
● Hysterectomy with bilateral salpingo-oophorectomy.
● Pelvic and paraaortic lymph node dissection.

● Infracolic or infragastric omentectomy.
However, fertility preservation is an acceptable option in young patients with ovarian tumors of
low malignant potential or nonepithelial ovarian cancers, and patients with stage IA EOC who
prefer this approach. (See 'Staging in patients who desire fertility preservation' below.)
Role of the gynecologic oncologist — Staging and initial surgical management should be
performed by a gynecologic oncologist whenever possible. Outcomes of these procedures,
when performed by a gynecologic oncologist, have been shown to be better than when the
procedure is performed by other surgeons. These data are reviewed separately. (See "Approach
to the patient with an adnexal mass", section on 'When to refer to a gynecologic oncologist'.)
Mode of surgery
Open laparotomy versus minimally invasive surgery — Open laparotomy is the standard
surgical approach for treatment of these cancers. Minimally invasive surgery (MIS) with
traditional and robotic-assisted laparoscopy has mainly been investigated in patients with
presumed stage I or II ovarian cancer in whom cytoreduction is not necessary [17-19]. While
technically possible, the MIS approach is controversial and requires further investigation before
use becomes widespread.
Technical concerns regarding use of MIS include the following:
● Intact removal of the ovarian mass is often not possible, and rupture of the mass may
worsen prognosis [13]. In an observational study of 8850 patients with stage I epithelial
ovarian cancer, capsule rupture occurred more frequently in patients undergoing MIS (ie,
either traditional or robotic-assisted laparoscopy) compared with laparotomy (adjusted
relative risk 1.17, 95% CI 1.06-1.29) and was associated with an increase in all-cause
mortality in both groups [20]. This is discussed in more detail elsewhere. (See 'Staging
system' above.)
● Thorough inspection of the entire pelvis and abdomen, especially inspection of all bowel
surfaces and mesentery, is challenging.
● Tumor seeding of the laparoscopic access sites (port site metastasis) may occur. This
usually happens in the setting of peritoneal carcinomatosis or positive peritoneal cytology
and often resolves with adjuvant therapy [21]. (See "Complications of laparoscopic
surgery".)
Advantages of MIS compared with laparotomy include less blood loss, shorter hospital stay, and
lower rates of postoperative complications [17,22-24].
Carbon dioxide pneumoperitoneum does not appear to adversely affect survival in patients with
intraabdominal metastases [25].
Robotic-assisted versus traditional laparoscopy — Although open laparotomy is preferred

over MIS, the benefits of robotic-assisted compared with traditional laparoscopy are less clear. In
a study comparing outcomes of robotic-assisted laparoscopy with traditional laparoscopy for
clinical stage I ovarian cancer (n = 1901 patients in the National Cancer Database), robotic-
assisted laparoscopy was less likely to result in conversion-to-open surgery (conversion rate 7.2
versus 17.9 percent), and survival was similar for the two approaches [26]. Compared with
traditional laparoscopy, robotic-assisted laparoscopy one-, three-, and five-year mortality hazard
ratios were 0.97 (95% CI 0.43-2.18), 0.68 (95% CI 0.43-1.08), and 0.78 (95% CI 0.53-1.16),
respectively.
Incision — A vertical midline incision is the best approach for laparotomy for staging and
cytoreductive surgery as it provides full exposure of the pelvis and abdomen. Due to limitations
of exposure or access, Pfannenstiel incision should be avoided; however, Pfannenstiel incision
can be converted to a modified Maylard or Cherney incision if it was initially chosen because of
erroneous expectations of benign findings. (See "Incisions for open abdominal surgery".)
Peritoneal cytology — As soon as the peritoneal cavity is entered, any ascites/peritoneal fluid
should be collected and a representative sample sent for cytologic evaluation. If only a minimal
or negligible volume of fluid is present, peritoneal washings are obtained by instilling 50 to 200
mL of saline into the peritoneal cavity and then removing the fluid by suction. Positive washings
have prognostic significance and may be an indicator of peritoneal/omental metastases [27].
Pelvic and abdominal exploration and biopsies — Pelvic and abdominal exploration is
conducted in a systematic manner, assessing the status of the pelvic organs, small and large
intestines, bowel mesentery, appendix, stomach, liver, gallbladder, spleen, omentum, both sides
of the diaphragms, and the entire peritoneal surface. Retroperitoneal structures, such as the
kidneys and pancreas, are palpated through the peritoneum and adipose tissue. The umbilicus is
carefully palpated, as metastasis to the peritoneal side can occur, and may require excision.
In the absence of metastatic disease, multiple random biopsies should be taken from peritoneal
surfaces, including the posterior cul-de-sac (pouch of Douglas), bladder peritoneum, paracolic
gutters, pelvic side wall, and both sides of the diaphragm, for the evaluation of occult disease. In
an observational study of patients enrolled in the European Organisation for Research and
Treatment of Cancer (EORTC) ACTION trial, patients who had blind biopsies (and thus more
accurate information on stage of disease) had improved five-year disease-free and overall
survival compared with those who did not [28]. Additionally, any adhesions or peritoneal surface
irregularities should also be biopsied, as tumor involving these tissues impacts stage. In some
cases, an inflammatory or desmoplastic reaction is a manifestation of an otherwise occult tumor.
The role of pafolacianine (Cytalux) as an intraoperative adjunct to visual inspection and palpation
is discussed in detail separately. (See "Cancer of the ovary, fallopian tube, and peritoneum:
Surgical cytoreduction", section on 'Role of pafolacianine'.)
Identifying primary site of tumor origin — The primary site of origin (ovary, fallopian tube, or
peritoneum) should be determined when possible, although this does not affect staging or
therapeutic strategy [4,29]. If this is not possible, the primary site should be noted as
"undesignated" [30]. Determining the primary site can be accomplished easily when only one
site is involved (eg, tumor confined to the ovary) but is challenging when multiple sites are
involved. To improve consistency among pathologic review, the Gynecologic Oncology Group
(GOG) and the College of American Pathologists (CAP) have established criteria for assigning
primary site for these carcinomas [30,31]:
● Fallopian tube primary, if serous tubal intraepithelial carcinoma (STIC) is present OR

invasive mucosal carcinoma in the fallopian tube with or without STIC OR the fallopian tube
is partially or entirely incorporated into a tubo-ovarian mass.
● Ovarian primary, if no STIC or invasive mucosal carcinoma in the fallopian tube. In these
circumstances, the fallopian tubes should be fully examined by sectioning and extensively
examining the fimbriated end (SEE-FIM) protocol.
● Peritoneal primary, if both fallopian tubes and both ovaries are grossly and microscopically
normal and examined in their entirety in the presence of peritoneal carcinoma.
Classification may be "tubo-ovarian" in some circumstances, such as biopsy or
postchemotherapy with no residual disease.
STIC lesions are precursor lesions for high-grade serous carcinoma but have the potential for
metastatic spread. There is no clear evidence that surgical staging and/or adjuvant therapy is
beneficial in patients with STIC lesions alone. Referral to a genetic counselor is recommended
because these patients may have a 10 percent chance of carrying a BRCA1 or BRCA2 mutation
[32].
Frozen section — If the diagnosis has been made definitively prior to surgery (eg, via
paracentesis or omental biopsy), frozen section is not necessary (see "Epithelial carcinoma of the
ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Fluid cytology
or omental/pleural biopsy'). Otherwise, the diagnosis of EOC is usually made at the time of
surgery based on frozen section of the specimen (eg, affected ovary, other primary site, biopsies
of metastases). In the absence of grossly visible ovarian or fallopian tube disease, a biopsy of a
peritoneal or omental lesion should be sent for evaluation ( picture 1 and picture 2).
Omentectomy — The omentum is resected rather than biopsied. Resection of the omentum,
especially when replaced by extensive metastatic disease (so-called omental cake), may be
performed even when optimal cytoreduction is not possible in order to decrease tumor bulk and
formation of postoperative ascites ( picture 3).
The peritoneal reflection is separated from the transverse colon, after which the lesser sac is
entered. This allows for further assessment of the retroperitoneum (pancreas, high aortic lymph
nodes) as well as the posterior aspect of the gastrum. During this portion of the procedure, the
mesentery of the transverse colon is identified and preserved.
An infracolic or a complete omentectomy is then performed by isolating and clamping the

gastroepiploic vessels. This may be done with suture ligation, a surgical stapler, or a bipolar
energy ligating device. If necessary, hepatic and splenic flexures can be mobilized to allow for
removal of all of the omentum. Care must be taken not to put undue tension on the spleen while
mobilizing the omentum, as this may result in bleeding.
Hysterectomy and salpingo-oophorectomy — Hysterectomy and bilateral salpingo-

oophorectomy are performed in almost all patients (see "Hysterectomy: Abdominal (open)
route" and "Oophorectomy and ovarian cystectomy"). Fertility preservation is rarely an effective
option because of advanced disease; however, if the patient meets criteria and desires fertility
preservation, unilateral salpingo-oophorectomy may be performed along with staging. (See
'Staging in patients who desire fertility preservation' below.)
The rationale for hysterectomy and bilateral salpingo-oophorectomy is to remove (if present)
occult metastases in the contralateral ovary, adnexa, or uterus. Occasionally, a synchronous
primary endometrial cancer will be present, or the uterus will be the site of origin of the
suspected EOC.
Avoidance of intraoperative tumor rupture — Avoidance of intraoperative rupture is the

basis of the practice of removing the entire ovary and fallopian tube rather than performing a
cystectomy when ovarian cancer is suspected. Intraperitoneal spillage of cells can be minimized
in laparoscopic cases with salpingo-oophorectomy and use of a laparoscopic bag. The surgeon
should note in both the operative report and the pathology requisition whether rupture
occurred prior to surgery, in a controlled fashion within a bag (eg, to facilitate removal), or if
there was gross spillage. If rupture occurs, copious irrigation should be performed.
Role of radical oophorectomy — In patients with locally advanced disease with extensive
involvement of the reproductive organs and/or obliteration of the posterior cul-de-sac, "radical
oophorectomy" has been described [33]. However, few patients are appropriate candidates for
such an approach, and data on outcomes after the postoperative period are sparse.
In a radical oophorectomy procedure, the round ligaments are divided as laterally as possible,
the lateral broad ligament peritoneum overlying the psoas muscle is incised, and the pararectal
and paravesical spaces are developed. The ureters are exposed and mobilized. Infundibulopelvic
ligaments are identified, clamped, cut, and ligated as high as possible out of the pelvis. The
uterine artery can be divided laterally or at its origin. The anterior cul-de-sac peritoneum is
incised at the reflection, and the bladder is mobilized off of the lower uterine segment. If there
are implants on the anterior cul-de-sac peritoneum, the space of Retzius can be developed, the
bladder elevated, and tumor sharply dissected off. The remainder of the hysterectomy can then
be carried out in a routine fashion.
If the posterior cul-de-sac is obliterated by cancer, disease-free bowel can usually be identified
below the peritoneal reflection since ovarian cancer implants are generally on the peritoneal
surface or bowel serosa, leaving the retroperitoneal structures intact. Disease in the cul-de-sac
can then be approached laterally. In extreme cases, the peritoneum overlying the paracolic
gutters may be incised, the retroperitoneum entered, the ureters and vessels identified, and the
pelvis entered from above.
Role of supracervical hysterectomy — Supracervical hysterectomy is rarely performed in

ovarian cancer surgery. Reasons to perform a supracervical hysterectomy would be if additional
extensive dissection is required to remove the cervix, in the setting of high-volume ascites, or if
intraperitoneal chemotherapy is planned. In patients with ascites or planned intraperitoneal
chemotherapy, there is a risk of vaginal leakage if the vaginal cuff is not fully healed after total
hysterectomy, but there is little to no risk of vaginal leakage if the cervix is conserved.
Data comparing oncologic outcomes after supracervical versus total hysterectomy are limited
[34]. Disadvantages of the procedure include the potential for bleeding from the retained stump
and interference in detecting recurrent disease.
Lymph node evaluation — In patients with gross metastatic disease, only enlarged/suspicious
nodes are removed if optimal cytoreduction is feasible. No statistically significant overall survival
advantage has been demonstrated with systematic lymphadenectomy in patients with advanced
ovarian cancer. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical
cytoreduction", section on 'Lymphadenectomy'.)
In most patients with apparent early ovarian cancer, pelvic and paraaortic lymph node sampling
is performed to detect occult stage III disease, which can occur in up to one-third of patients
with apparent stage I disease ( figure 1) [35]. Though lymph node sampling is associated with
an increased duration of surgery and a 13 percent risk of lymphocyst formation, failure to detect
nodal disease can have major prognostic implications. In the EORTC ACTION trial, pelvic and
paraaortic lymph node sampling was associated with improved survival outcomes compared
with no lymph node dissection [28].
The pelvic and paraaortic nodal beds are sampled bilaterally, even when the disease appears to
be confined to one ovary. In a series of 96 patients with disease visibly confined to one ovary, 54
patients had bilateral sampling, of whom 10 had lymph node metastases; 2 of these 10 patients
had bilateral lymph node metastases, and 3 of the 10 had metastases confined to a contralateral
lymph node [36]. Sentinel node biopsy is investigational [37].
An exception to routine lymph node sampling is patients with apparent early disease with
mucinous tumors that appear confined to the ovary. In a systematic review and meta-analysis,
the rate of lymph node metastases was 0.7 percent, and no survival difference was noted in
those with and without lymph node sampling [38]. Thus, in patients with mucinous ovarian
tumors (3 percent of EOC), staging is performed without lymph node sampling.
Paraaortic lymph nodes above the inferior mesenteric artery are more likely to be involved than
other lymph nodes, and efforts should be made to sample nodes above this vessel [35,39,40].
The procedure for lymphadenectomy is described separately. (See "Pelvic and paraaortic
lymphadenectomy in gynecologic cancers".)
Appendectomy — If the appendix is involved with tumor, then an appendectomy should be

performed; additionally, some experts perform routine appendectomy if mucinous histology is a
concern [41,42]. A meta-analysis of studies of patients with mucinous ovarian tumors found that
metastatic disease to the appendix or a primary appendiceal cancer was relatively common (1.4
percent) when the appendix appeared normal and increased to 59 percent for a macroscopically
abnormal appendix [43]. Although the authors concluded that appendectomy is only warranted
when the appendix appears abnormal, others have concluded that appendectomy should be
performed in all mucinous ovarian cancer cases since complications are rare and a normal-
looking appendix does not exclude metastatic disease [42].
When an appendectomy is performed, the mesentery with the appendiceal artery is clamped,
cut, and ligated, and the appendix is clamped close to the cecum. The appendix is then removed,
and the stump is ligated. The use of absorbable sutures is acceptable if the selected material has
delayed absorption to prevent leakage from the stump. Complex procedures involving
manipulation of the stump are unnecessary. Stapling devices may be used but increase the costs
of the procedure without any proven benefit.
Other radical procedures — Other radical procedures may include diaphragm peritonectomy
or resection, multiple resections of the bowel, liver resection, partial gastrectomy,
cholecystectomy, and splenectomy (with or without distal pancreatectomy). Posterior
exenteration is rarely performed. These procedures are usually performed as part of surgical
cytoreduction and are discussed in detail separately. (See "Cancer of the ovary, fallopian tube,
and peritoneum: Surgical cytoreduction", section on 'Cytoreduction procedures'.)
STAGING IN PATIENTS WHO DESIRE FERTILITY PRESERVATION
Fertility preservation is an acceptable option in young patients with ovarian tumors of low
malignant potential or nonepithelial ovarian cancers and patients with stage IA EOC who prefer
this approach.
If unilateral salpingo-oophorectomy is being considered, we recommend documenting localized

disease by performing the following:
● Full surgical staging, including washings, omentectomy, pelvic and paraaortic

lymphadenectomy, and peritoneal biopsies.
● Thorough abdominal exploration and biopsy of any abnormal areas.
● Endometrial biopsy to exclude synchronous endometrial cancer.
Most surgeons do not routinely biopsy the contralateral ovary if it appears normal. The
contralateral ovary, uterus, and fallopian tube infrequently contain occult disease in staged
patients. In the Danish and Dutch database of 1234 patients with apparent stage I EOC, 393
were upstaged, and upstaging was based on microscopic spread to both ovaries in only 0.8
percent [2].
Patients who desire fertility preservation should clearly understand that data regarding outcome
are limited; in particular, there is little information on the frequency and outcome of recurrent
disease or the safety of ovulation induction or hormonal contraception [44-46]. Young patients
with a well-differentiated lesion of one ovary who have had a full staging operation, but limited
organ extirpation to preserve childbearing, are advised to undergo hysterectomy and removal of
the remaining ovary upon completion of childbearing or by age 35. Advanced fertility
preservation technologies continue to improve in efficacy, including egg and embryo freezing.
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In a review of studies of 282 patients with EOC who received conservative treatment, 33 relapses
and 16 disease-related deaths occurred; there were also 113 deliveries [44]. In subsequent
studies, patients with stage I EOC who underwent fertility-sparing surgery compared with
conventional surgery were not at increased risk of death (hazard ratio [HR] 0.8, 95% CI 0.49-1.29)
[47], and do not appear to be at increased risk for adverse pregnancy outcomes (eg, preterm
birth, small for gestational age neonates, severe maternal or neonatal morbidity) [48].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Ovarian, fallopian tube,
and peritoneal cancer".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Treatment of ovarian cancer (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
● General principles – Epithelial cancers of the ovary, fallopian tube, and peritoneum are
termed epithelial ovarian carcinoma (EOC). While the staging of cancer at these three
anatomic sites is the same, the different histologic types of EOC are a heterogeneous set of
diseases that vary in pathogenesis, clinical behavior, and response to treatment. (See
'Introduction' above.)
● Staging system – EOC is surgically staged according to the International Federation of

Gynecology and Obstetrics (FIGO) Tumor, Node, Metastasis (TNM) classification system
( table 1). Surgery is usually also required to confirm the diagnosis and for cytoreduction.
(See 'Staging system' above.)
● Patients who have completed childbearing – Open laparotomy is the standard approach
for staging, but laparoscopic or robot-assisted approaches are used by experienced
gynecologic oncologists for selected patients. In patients not desiring fertility preservation,
the procedure consists of all of the following (see 'Overview' above and 'Role of the
gynecologic oncologist' above and 'Open laparotomy versus minimally invasive surgery'
above):
• Peritoneal cytology (washings or ascites). (See 'Peritoneal cytology' above.)
• Visual assessment of the upper abdomen, peritoneal surfaces, and large and small
bowel mesentery and other abdominal organs, with biopsies of abnormal findings
(frozen section if EOC has not been previously confirmed). (See 'Pelvic and abdominal
exploration and biopsies' above and 'Identifying primary site of tumor origin' above and
'Frozen section' above.)
• Infracolic or infragastric omentectomy. (See 'Omentectomy' above.)
• Hysterectomy with bilateral salpingo-oophorectomy, avoiding tumor rupture. Radical

oophorectomy/posterior exenteration may be useful for patients with confluent pelvic
disease. (See 'Hysterectomy and salpingo-oophorectomy' above.)
• In patients with apparent early disease (stage I or II), pelvic and paraaortic lymph node
sampling to exclude occult stage III disease. In patients with gross metastatic disease,
only enlarged/suspicious nodes are removed if cytoreduction is feasible; no overall
survival advantage has been demonstrated with systematic lymphadenectomy in these
patients. (See 'Lymph node evaluation' above.)
● Role of appendectomy – An appendectomy is performed if the appendix is involved with

tumor; some experts perform routine appendectomy if mucinous histology is known or
suspected. (See 'Appendectomy' above.)
● Patients desiring fertility preservation – Fertility preservation is an acceptable option in

young patients with ovarian tumors of low malignant potential or nonepithelial ovarian
cancers and in patients with stage IA disease who prefer this approach. (See 'Staging in
patients who desire fertility preservation' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges William Mann, Jr, MD; Eva Chalas, MD, FACOG, FACS;
Fidel Valea, MD; and Heidi Gray, MD, who contributed to earlier versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
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Topic 3193 Version 52.0
GRAPHICS
Ovary, fallopian tube, and primary peritoneal carcinoma TNM staging AJCC
UICC 8th edition
Primary tumor (T)
T category FIGO stage T criteria
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 I Tumor limited to ovaries (one or both) or fallopian

tube(s)
T1a IA Tumor limited to one ovary (capsule intact) or

fallopian tube, no tumor on ovarian or fallopian
tube surface; no malignant cells in ascites or
peritoneal washings
T1b IB Tumor limited to both ovaries (capsules intact) or

fallopian tubes; no tumor on ovarian or fallopian
tube surface; no malignant cells in ascites or
peritoneal washings
T1c IC Tumor limited to one or both ovaries or fallopian

tubes, with any of the following:
T1c1 IC1 Surgical spill
T1c2 IC2 Capsule ruptured before surgery or tumor

on ovarian or fallopian tube surface
T1c3 IC3 Malignant cells in ascites or peritoneal

washings
T2 II Tumor involves one or both ovaries or fallopian

tubes with pelvic extension below pelvic brim or
primary peritoneal cancer
T2a IIA Extension and/or implants on the uterus and/or

fallopian tube(s) and/or ovaries
T2b IIB Extension to and/or implants on other pelvic

tissues
T3 III Tumor involves one or both ovaries or fallopian

tubes, or primary peritoneal cancer, with
microscopically confirmed peritoneal metastasis
outside the pelvis and/or metastasis to the
retroperitoneal (pelvic and/or para-aortic) lymph

nodes
T3a IIIA2 Microscopic extrapelvic (above the pelvic brim)

peritoneal involvement with or without positive
retroperitoneal lymph nodes
T3b IIIB Macroscopic peritoneal metastasis beyond pelvis

2 cm or less in greatest dimension with or without
metastasis to the retroperitoneal lymph nodes
T3c 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)
Regional lymph nodes (N)
N category FIGO stage N criteria
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N0(i+) Isolated tumor cells in regional lymph node(s) no

greater than 0.2 mm
N1 IIIA1 Positive retroperitoneal lymph nodes only

(histologically confirmed)
N1a IIIA1i Metastasis up to and including 10 mm in greatest

dimension
N1b IIIA1ii Metastasis more than 10 mm in greatest

dimension
Distant metastasis (M)
M category FIGO stage M criteria
M0 No distant metastasis
M1 IV Distant metastasis, including pleural effusion with

positive cytology; liver or splenic parenchymal
metastasis; metastasis to extra-abdominal organs
(including inguinal lymph nodes and lymph nodes
outside the abdominal cavity); and transmural
involvement of intestine
M1a IVA Pleural effusion with positive cytology
M1b IVB Liver or splenic parenchymal metastases;

metastases to extra-abdominal organs (including
inguinal lymph nodes and lymph nodes outside

the abdominal cavity); transmural involvement of
intestine
Prognostic stage groups
When T is... And N is... And M is... Then the stage group
is...
T1 N0 M0 I
T1a N0 M0 IA
T1b N0 M0 IB
T1c N0 M0 IC
T2 N0 M0 II
T2a N0 M0 IIA
T2b N0 M0 IIB
T1/T2 N1 M0 IIIA1
T3a NX, N0, N1 M0 IIIA2
T3b NX, N0, N1 M0 IIIB
T3c NX, N0, N1 M0 IIIC
Any T Any N M1 IV
Any T Any N M1a IVA
Any T Any N M1b IVB
TNM: Tumor, Node, Metastasis; AJCC: American Joint Committee on Cancer; UICC: Union for
International Cancer Control.
Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the
AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing. Corrected at 4th printing,
2018.
Graphic 113545 Version 8.0
Uterus with bilateral ovarian malignancies
Photo courtesy of William Mann, MD.
Fallopian tube carcinoma
Surgical specimen of a left fallopian tube carcinoma.
Courtesy of Mitchel Hoffman MD.
Ovarian cancer metastatic to the omentum
Large omental cake (C) overlying small bowel.
Courtesy of William Mann, MD.
Female pelvic and paraaortic lymph nodes
The pelvic and paraaortic lymph nodes and their relationship to the
female pelvic organs and the major retroperitoneal blood vessels.
IVC: inferior vena cava.
Reproduced with permission from: Berek JS, Hacker NF. Practical Gynecologic Oncology,
Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2005. Copyright © 2005
Lippincott Williams & Wilkins.
Contributor Disclosures
Ritu Salani, MD, MBA Consultant/Advisory Boards: Arcus biologics [Cervical cancer]; AstraZeneca [Ovarian
cancer]; Clovis [Ovarian cancer]; Genentech [Cervix]; GlaxoSmithKline [Ovarian and endometrial cancers];
Immunogen [Ovarian cancer]; Instil Bio [Cervix]; Merck [Endometrial and cervical cancer]; Regeneron
[Cervix]; Seagen [Cervical cancer]. All of the relevant financial relationships listed have been
mitigated. Casey M Cosgrove, MD No relevant financial relationship(s) with ineligible companies to
disclose. Barbara Goff, MD No relevant financial relationship(s) with ineligible companies to
disclose. Rochelle L Garcia, MD No relevant financial relationship(s) with ineligible companies to
disclose. Alana Chakrabarti, MD No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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15/6/23, 11:29 Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Surgical staging - UpToDate

Official reprint from UpToDate®

Epithelial carcinoma of the ovary, fallopian tube, and

Literature review current through: May 2023.

Some nuances of staging are discussed below:

● It is not possible to have stage I peritoneal carcinoma.

Preoperative rupture appears to be associated with a worse prognosis. In a meta-analysis of 17

● Peritoneal cytology (washings or ascites).

● Hysterectomy with bilateral salpingo-oophorectomy.

● Pelvic and paraaortic lymph node dissection.

● Infracolic or infragastric omentectomy.

Technical concerns regarding use of MIS include the following:

Robotic-assisted versus traditional laparoscopy — Although open laparotomy is preferred

● Fallopian tube primary, if serous tubal intraepithelial carcinoma (STIC) is present OR

An infracolic or a complete omentectomy is then performed by isolating and clamping the

Hysterectomy and salpingo-oophorectomy — Hysterectomy and bilateral salpingo-

Avoidance of intraoperative tumor rupture — Avoidance of intraoperative rupture is the

Role of supracervical hysterectomy — Supracervical hysterectomy is rarely performed in

Appendectomy — If the appendix is involved with tumor, then an appendectomy should be

STAGING IN PATIENTS WHO DESIRE FERTILITY PRESERVATION

If unilateral salpingo-oophorectomy is being considered, we recommend documenting localized

● Full surgical staging, including washings, omentectomy, pelvic and paraaortic

● Thorough abdominal exploration and biopsy of any abnormal areas.

● Endometrial biopsy to exclude synchronous endometrial cancer.

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Staging system – EOC is surgically staged according to the International Federation of

• Peritoneal cytology (washings or ascites). (See 'Peritoneal cytology' above.)

• Infracolic or infragastric omentectomy. (See 'Omentectomy' above.)

• Hysterectomy with bilateral salpingo-oophorectomy, avoiding tumor rupture. Radical

● Role of appendectomy – An appendectomy is performed if the appendix is involved with

● Patients desiring fertility preservation – Fertility preservation is an acceptable option in

Use of UpToDate is subject to the Terms of Use.

8. Canis M, Rabischong B, Botchorishvili R, et al. Risk of spread of ovarian cancer after

Gynecol 2020; 222:474.e1.

Primary tumor (T)

T category FIGO stage T criteria

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

T1 I Tumor limited to ovaries (one or both) or fallopian

T1a IA Tumor limited to one ovary (capsule intact) or

T1b IB Tumor limited to both ovaries (capsules intact) or

T1c IC Tumor limited to one or both ovaries or fallopian

T1c1 IC1 Surgical spill

T1c2 IC2 Capsule ruptured before surgery or tumor

T1c3 IC3 Malignant cells in ascites or peritoneal

T2 II Tumor involves one or both ovaries or fallopian

T2a IIA Extension and/or implants on the uterus and/or

T2b IIB Extension to and/or implants on other pelvic

T3 III Tumor involves one or both ovaries or fallopian

retroperitoneal (pelvic and/or para-aortic) lymph

T3a IIIA2 Microscopic extrapelvic (above the pelvic brim)

T3b IIIB Macroscopic peritoneal metastasis beyond pelvis

T3c IIIC Macroscopic peritoneal metastasis beyond the

Regional lymph nodes (N)

N category FIGO stage N criteria

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis