Ovarian Cancer Staging and Management

Introduction to Ovarian Cancer Staging

The International Federation of Gynecology and Obstetrics (FIGO) system is used for ovarian cancer staging, which was updated in 2014 to include ovarian, fallopian tube, and primary peritoneal cancers into a unified classification system, as recommended by the National Comprehensive Cancer Network 1.

The FIGO staging system divides ovarian cancer into four main stages based on the anatomic extent of disease, with stage I being disease limited to the ovaries, stage II indicating pelvic extension, stage III signifying peritoneal implants outside the pelvis and/or retroperitoneal lymph nodes, and stage IV representing distant metastases, according to the Journal of the National Comprehensive Cancer Network 3, 4, 5.

All patients with suspected ovarian cancer must undergo comprehensive surgical staging via midline or para-median laparotomy performed by a trained gynecologic oncologist, as recommended by the National Comprehensive Cancer Network with a category 1 recommendation based on data showing improved survival when surgery is performed by experienced gynecologic oncologists 3, 4, 6, 7.
Mandatory staging procedures include peritoneal washings, thorough visual and palpable examination of the entire abdominal cavity, intact removal of the ovarian tumor with frozen section analysis, bilateral salpingo-oophorectomy, total abdominal hysterectomy, infracolic omentectomy, systematic peritoneal biopsies, and bilateral pelvic and para-aortic lymph node dissection or sampling, as outlined by the Journal of the National Comprehensive Cancer Network and Praxis Medical Insights 2, 3, 4, 6.

For early-stage disease (Stage I-IIA), surgery alone is adequate for Stage IA/IB, well-differentiated (grade 1), non-clear cell histology, while adjuvant chemotherapy is required for Stage IA/IB poorly differentiated (grade 2-3), densely adherent, clear cell histology, and all grades Stage IC and IIA, with the recommended adjuvant chemotherapy regimen being carboplatin AUC 5-7 mg/mL/min + paclitaxel 175 mg/m² IV every 3 weeks for 3-6 cycles, as recommended by the Annals of Oncology and Praxis Medical Insights 6, 8, 9.
For advanced-stage disease (Stage IIB-IV), maximal upfront surgical cytoreduction with the goal of no residual disease (R0 resection) is the standard approach, with surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and removal of all visible disease, and standard chemotherapy being carboplatin AUC 5-7.5 mg/mL/min + paclitaxel 175 mg/m² IV over 3 hours every 3 weeks for 6 cycles, as recommended by the Annals of Oncology and Praxis Medical Insights 6, 8, 9.

Established prognostic factors beyond surgical stage include small tumor volume, younger age, good performance status, histologic subtype (non-mucinous and non-clear cell types having better prognosis), well-differentiated tumor (grade 1), absence of ascites, and complete surgical resection (no residual disease), as reported by the Annals of Oncology 5, 8, 9.

Before surgery and/or chemotherapy, patients should have an abdominal/pelvic CT or MRI scan, chest imaging, serum CA-125, complete blood count and differential, renal and hepatic function tests, and consideration of CEA and CA 19-9 if mucinous tumor or gastrointestinal origin is suspected, as recommended by the Annals of Oncology and the Journal of the National Comprehensive Cancer Network 1, 2, 5, 7, 8, 9.