Ovarian Cancer

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Ovarian Cancer Staging (TNM System)

When ovarian cancer is suspected, patients usually undergo an exploratory laparotomy to determine the stage of the disease (i.e., how far it has spread). During exploratory laparotomy, the physician (usually a gynecologic oncologist) makes an incision through the abdomen to the ovaries.

If cancer is detected, the physician removes as much of the tumor as possible. The extent of surgery depends on the type of cancer and how far it has spread. In some cases, one ovary is removed in a procedure called unilateral oophorectomy. Usually, the physician removes both ovaries, the uterus, the fallopian tubes, and the omentum (fatty tissue that covers the bowels).

A biopsy (sample of tissue for microscopic evaluation) of pelvic and abdominal lymph nodes (small glands that filter out infectious organisms) may be performed. Finally, the abdominal cavity is "washed" with fluid that is then collected and examined under a microscope for cancer cells (called peritoneal lavage).

To stage the cancer, the physician reviews the histopathology report from the samples obtained during laparotomy, as well as results from needle biopsy, blood tests, imaging studies, or other tests. Staging provides an estimate of disease-free survival, overall survival, and the risk for recurrence or relapse. Staging also helps the physician and patient to choose appropriate treatment(s).

Staging System

Stage I:	Ovarian cancer that is confined to one or both ovaries.
Stage II:	Ovarian cancer that has spread to pelvic organs (e.g., uterus, fallopian tubes), but has not spread to abdominal organs.
Stage III:	Ovarian cancer that has spread to abdominal organs (e.g., abdominal lymph nodes, liver, bowel).
Stage IV:	Ovarian cancer that has spread outside to distant sites (e.g., lung, brain, lymph nodes in the neck).
Recurrent:	Ovarian cancer that has recurred (come back) even though the patient has completed treatment.

Once ovarian cancer is assigned a stage, the classification does not change, even if the cancer recurs or metastasizes to other sites within the body.

Ovarian cancer staging usually is described in terms of the FIGO system (staging scheme developed by the International Federation of Gynecology and Obstetrics) and the TNM system (classification system developed by the American Joint Committee on Cancer [AJCC]). According to the TNM system:

T = Tumor Size
N = Node Involvement
M = Metastasis Status

Ovarian cancer treatment ultimately depends upon such staging. In general, the lower the stage, the more favorable is the prognosis.

Tumors
The primary tumor (T) is classified according to the following categories:

T1:	Tumor is limited to one or both ovaries.
T1a:	Tumor is limited to one ovary. The capsule, or outer wall of the tumor, is intact, there is no tumor on the ovarian surface, and there are no cancer cells in ascites (abdominal fluid build-up) or peritoneal lavage ("washings" from the abdominal cavity).
T1b:	Tumor is limited to both ovaries. The capsule is intact, there is no tumor on the ovarian surface, and there are no cancer cells in ascites or peritoneal lavage.
T1c:	Tumor is limited to one or both ovaries with any of the following: ruptured capsule (burst outer wall of the tumor), tumor on ovarian surface, or cancer cells in the ascites or peritoneal lavage.
T2:	Tumor involves one or both ovaries with spread into the pelvis.
T2a:	Tumor has spread and/or attaches to the uterus and/or fallopian tubes. There are no cancer cells in ascites or peritoneal lavage.
T2b:	Tumor has spread to other pelvic tissues. There are no cancer cells in ascites or peritoneal lavage.
T2c:	Tumor has spread to pelvic tissues, with cancer cells in ascites or peritoneal lavage.
T3:	Tumor involves one or both ovaries, with microscopically confirmed peritoneal metastasis outside the pelvis and/or metastasis to regional (nearby) lymph node(s).
T3a:	Microscopic peritoneal metastasis beyond the pelvis.
T3b:	Macroscopic (visible to the naked eye) peritoneal metastasis beyond the pelvis, 2 cm or less in greatest dimension.
T3c:	Peritoneal metastasis beyond the pelvis, more than 2 cm in greatest dimension.

Nodes
The regional lymph nodes (N) are clinically divided into the following categories:

N0: Regional lymph nodes contain no metastases.
N1: Evidence of lymph node metastasis.

The state of metastasis (M) is defined as follows:

M0: No distant metastases are found (this excludes peritoneal metastasis).
M1: Distant metastases are present.

Stage Grouping
The TNM system places ovarian cancer growth at a particular stage. There are four basic stage groupings within the TNM system:

Stage Ia: T1a, N0, M0
Stage Ib: T1b, N0, M0
Stage Ic: T1c, N0, M0

Stage IIa: T2a, N0, M0
Stage IIb: T2b, N0, M0
Stage IIc: T2c, N0, M0

Stage IIIa: T3a, N0, M0
Stage IIIb: T3b, N0, M0
Stage IIIc: T3c, N0, M0, or T(any), N1, M0

Stage IV: T(any), N(any), M1

Tumor Grade
Tumor grade generally refers to the degree of differentiation - or maturity - of the cells that make up the tumor within the ovary. Yet, worldwide, there are many different systems for the grading of ovarian cancers, without a common standard. Most investigators use criteria such as the architectural "pattern" of the cells and their nuclear content (e.g., DNA "ploidy," or how many pairs of chromosomes are present), although additional factors may be considered, such as the tumor's margin, invasion of the blood vessels, and penetration of the ovarian capsule (surface).

Most epithelial cancers are categorized by three grades of cells:

Overall, low-grade (e.g., Grade 1) tumors grow more slowly and have a better prognosis than high-grade tumors.

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