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OVARIAN,

FALLOPIAN TUBE
and PERITONEAL
CARCINOMA

RONALD LANZ R. LATAP, MD, DPOGS,


DSGOP, DPSCPC
Current Staging Classification of Ovarian,
Fallopian Tube and Peritoneal Cancer
INTRODUCTION
Ovarian Cancer

- group of diseases with different morphology


and biological behavior.

- different types based on histopathology,


immunohistochemistry and molecular genetic
analysis.

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INTRODUCTION
• Seventh most common cancer worldwide.
• 6.3 per 100,000 women
• Fifth most common cancer in higher resource
regions.
• 9.3 per 100,000 women

Most Common Malignancy in the Philippines (2010)


1. Breast 12,262 6. Leukemia 3,153
2. Lungs 11,458 7. Stomach 3,129
3. Liver 7,331 8. Prostate 2,752
4. Colon 5,787 9. Brain 2,236
5. Cervix 4,812 10. Ovary 2,165

Philippine Cancer Society 2010 Philippine Cancer Facts and Estimates


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INTRODUCTION
Fallopian Tube Cancer
- rare
- 1% of gynecologic malignancy

Primary Peritoneal Cancer


- True incidence remains unknown
- Estimated relative frequency to ovarian cancer is
1:10

Ovarian, Fallopian Tube and Peritoneal


Cancer are managed similarly
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INTRODUCTION
• Objectives of Staging Systems:

• To provide standard terminology that allows


comparison of patients between centers.

• To assign patients and their tumors to prognostic


groups requiring specific treatments.

• To improve utility and reproducibility.

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INTRODUCTION

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INTRODUCTION

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INTRODUCTION
Epithelial Ovarian Tumors

• Diagnosed by light microscopy


• Inherently different diseases
• epidemiologic and genetic risk factors
• precursor lesions
• pattern of spread
• molecular events during oncogenesis
• response to chemotherapy
• prognosis

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Prevalence of Histologic Types of EOC and
associated Molecular Genetic Changes

Kurman and Shih. Molecular pathogenesis and extraovarian origin of


epithelial ovarian cancer—Shifting the paradigm Human Pathology (2011) 42, 918–931
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RISK FACTORS
 Family history
 Unopposed estrogen or estrogen plus
progestin
 Endometriosis
 PID
 Obesity
 Smoking
 High meat and fat intake

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High grade Low grade Mucinous Endometrioid Clear Cell
Serous Serous

Risk Factors BRCA 1/2 HNPCC


Precursor Tubal Serous Cystadenoma/ Atypical Atypical
Lesions Intraepithelial borderline borderline endometriosis endometriosi
carcinoma tumor tumor s
Analogous to
type II
endometrial
carcinoma

Pattern of Very early transcoelo Usually Usually Usually


spread transcoelo mic spread confined to confined to confined to
mic spread ovary pelvis pelvis
Chemo High Intermediate Low High Low
sensitivity
Prognosis Poor Intermediate Favorable Favorable intermediate

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Prat J .Annals of Oncology 23 (Supplement 10): 111–117, 2012
• Patients who underwent risk reducing salpingo-
oophorectomy were found to have high grade serous
tubal intraepithelial neoplasia in the fallopian tube.

• High grade STIC is present in patients with advance


stage sporadic HGSC of the ovary and peritoneal
tumors.

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INTRODUCTION

• Gynecology Cancer Intergroup


• International Gynecologic Cancer Society
• The European Organization for Research and Treatment of
Cancer
• The American Society of Gynecologic Oncology
• The National Cancer Research Network
• The Australian Society of Gynaecological Oncology
• The Korean Society of Gynecologic Oncology
• The Japanese Society of Obstetrics and Gynecology
Approved by:
 FIGO Executive Board
 American Joint Commission on Cancer
 International Union Against Cancer
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STAGING
Stage I: Tumor confined to the ovaries or fallopian tube
(T1-N0-M0)

T1a-N0-M0

IA: Tumor limited to 1 ovary (capsule intact) or fallopian tube;


no tumor on ovarian or fallopian tube surface; no malignant
cells in the ascites or peritoneal washings

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STAGING

Stage I: Tumor confined to the ovaries or fallopian tube

T1b-N0-M0

IB: Tumor limited to both ovaries (capsule intact) of


fallopian tubes; no tumor on ovarian or fallopian tube
surface; no malignant cells in the ascites or peritoneal
washings

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Controversial Issue for Stage IB Disease
• Bilateral involvement (stage IB). Independent
contralateral primary tumor versus implants
or metastases

• Stage 1B is relatively uncommon (1-5%)


• 1/3 of cases presents with a large stage 1B ovarian
tumor associated with a contralateral normal-size
ovary exhibiting a small and superficial foci of
tumor suggesting a metastasis.

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Recommendations for Surgeons for Stage IB

– For patients whose contralateral ovary appears


grossly enlarged, bisection and frozen section
should be done.

– Wedge biopsy of a grossly normal-looking ovary is


not recommended.

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STAGING
Stage I: Tumor confined to the ovaries or fallopian tube
IC: Tumor limited to 1 or both ovaries or fallopian tubes, with any of the
following:
IC1: (T1c1-N0-M0) Surgical spill
IC2: (T1c2-N0-M0) Capsule ruptured before surgery or tumor on
ovarian or fallopian tube surface
IC3: (T1c3-N0-M0) Malignant cells in the ascites or peritoneal washings

OLD Ovarian Cancer Staging(1988) Stage IC


IC: Tumor Stage IA or IB but with tumor on surface of one or both ovaries; or
with capsule ruptured; or with ascites present contaning malignant cells or with
positive peritoneal washings

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Controversial Issues for Stage IC1 and IC3
Disease
• Does rupture during surgery worsen
prognosis in the absence of excresences,
ascites, or positive washings?
• Controversial
• Intraoperative capsule rupture portends a higher
risk of recurrence for Stage 1 Epithelial Ovarian
Cancer.
• Survival is shortest in patients with capsule rupture
with excresences and positive washings.

Obstetric and Gynecology 2009 Jan;113(1):11-7. doi: 10.1097/AOG.0b013e3181917a0c.


Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer.
Bakkum-Gamez JN1, Richardson DL, Seamon LG, Aletti GD, Powless CA, Keeney GL, O'Malley DM, Cliby WA
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Recommendations for Surgeons for Stage IC

 If rupture is noted, peritoneal washings and


cytology study are indicated.

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Controversial Issues for Stage IC3 Disease
• What constitutes ovarian surface
involvement? Excresences? Microscopic
involvement?

Excresences exposed to the peritoneal cavity


• Characterized by exophytic papillary
tumor on the surface of the ovary or
fallopian tube.

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http://www.ivstock.com/scripts/ivstock/imag
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e.aspx?site=ivstock&img=192/192-016.jpg
Controversial Issues for Stage I Disease
Does histologic grade influence prognosis of
stage I tumors?

– Degree of differentiation is the most


powerful prognostic indicator of disease-
free survival.
– Grade 2-3 tumors are associated with
poorer prognosis (HGSC, CCC)

Obstetrics and Gynecology 1990 Feb;75(2):263-73.


Prognostic factors in patients with stage I epithelial ovarian cancer.
Dembo AJ1, Davy M, Stenwig AE, Berle EJ, Bush RS, Kjorstad K
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Summary for Stage I Ovarian Cancer
GENERAL RULE:
• Stage I ovarian or fallopian tube cancer is
confined to the ovaries or the fallopian
tubes and peritoneal fluid/washings.

• No stage I peritoneal cancer.

• Tumor rupture or surface involvement by


tumor cells warrants a stage of IC.

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Recommendations for Stage I Ovarian Cancer

• Histologic type including tumor grade should be


recorded.

• All individual subsets of stage IC disease should be


recorded.

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Controversial Issues for between Stage I and II Disease

Dense adhesions often cause rupture during surgery.


Should these cases be considered stage II?

• Upstaging based on dense adhesion should be


supported by histology.

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STAGING
Stage II: Tumor involves 1 or both ovaries or fallopian
tubes with pelvic extension (below the pelvic brim) or
primary peritoneal carcinoma (T2-N0-M0)

T2a-N0-M0
IIA: Extension and/or implants on the uterus and/or fallopian
tubes and/ or ovaries

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STAGING
Stage II: Tumor involves 1 or both ovaries or fallopian
tubes with pelvic extension (below the pelvic brim) or
primary peritoneal carcinoma (T2-N0-M0)

T2b-N0-M0
IIB: Extension to other pelvic intraperitoneal tissues

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Old Ovarian Cancer Staging (1988)

Stage IIC: Tumor Stage IIA or IIB but with tumor on surface of one or both ovaries;
with capsule ruptured; or with ascites present containing malignanct cells or with
positive peritoneal washings

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Controversial Issues for Stage II Disease
Is it biologically justified to separate the pelvic
from the extrapelvic peritoneum? Is disease
outside the ovary but below the pelvic brim so
much better that it warrants a separate stage?

• There was a clear division of stage II and III


disease in terms of survival.

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Recommendations for Stage II Disease

• To separate direct extension from metastasis.

• To compare outcome of stage II and early


stage III cases.

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Stage III Disease
• 84% of High Grade Serous Carcinoma present in stage III.
• Characteristically spread along peritoneal surfaces involving
both pelvic and abdominal peritoneum, omentum, surface of
small and large intestines, mesentery, paracolic gutters,
diaphragm, peritoneal surface of the liver and spleen.
• 2/3 has ascites.
• Majority who underwent node sampling or dissection has lymph
node metastasis:
• Stage I: 9%
• Stage II: 26%
• Stage III: 55%
• Stage IV: 88%

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STAGING
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 nodes

T1/T2-N1-M0
IIIA1: Positive retroperitoneal lymph nodes only (cytologically or
histologically proven)
IIIA1 (i): Metastasis up to 10 mm in greatest dimension.
IIIA1 (ii): Metastasis more than 10 mm in greatest dimension.

Old Ovarian Cancer Staging (1988)


Stage IIIC: Abdominal implants greater than 2 cm in diameter and/or positive
retroperitoneal or inguinal nodes
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• Less than 10% extend beyond the pelvis exclusively as
retroperitoneal lymph node.
• Better prognosis compared with abdominal peritoneal
involvement.

• Involvement of retroperitoneal lymph nodes must be proven


cytologically or histologically.

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Controversial Issues for Stage IIIA1 Disease
Could some carcinomas that have extended beyond the
pelvis with exclusively retroperitoneal lymph node
involvement (stage IIIA1) represent independent
LGSC arising in retroperitoneal lymph nodes from
endosalpingiosis?

• Serous borderline tumors and LGSCs may develop


in retroperitoneal and cervical lymph nodes from
endosalpingiosis, often in association with serous
borderline tumors of the ovary with favorable
prognosis.

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Controversial Issues for Stage IIIA1
Disease
Should the new stage IIIA1 be limited to the involvement
of the retroperitoneal lymph nodes below the
diaphragm?

• It was suggested that upward nodal involvement


should be included but not accepted for now.

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Recommendations for Stage IIIA1 Disease

• To classify IIIA1 cases histologically


• To compare outcome of stage IIIA1 (i) and IIIA1 (ii)
cases
• To compare outcome of stage IIIA1 and IIIA2 cases

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STAGING
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 nodes

T3a2-N0/N1-M0
IIIA2: Microscopic extrapelvic (above the pelvic brim)
peritoneal involvement with or without positive retroperitoneal
involvement
Old Ovarian Cancer Staging (1988)
Stage IIIA: Tumors grossly limited to the true pelvis with negative nodes but with
histologically confirmed microscopic seeding of abdominal peritoneal surface
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STAGING
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 nodes

T3b-N0/N1-M0
IIIB: Macroscopic peritoneal metastasis beyond the pelvis up
to 2 cm in greatest dimension, with or without metastasis to
the retroperitoneal lymph nodes

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STAGING
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 nodes

T3c-N0/N1-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)

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Controvertial Issues for Stage IIIB and IIIC Disease
• Is the 2-cm cut off between IIIB and IIIC justified?

Survival Rate (4 years)


Microscopic Disease 60%
<2 cm 35%
>2 cm 20%

Annual Report on the Results of Treatment of Gynecological Cancer, Volume 23. Stockholm, International
Federation of Gynecology and Obstetrics, 1998.

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Recommendations for Surgeons (Stage IIIB & IIIC)

• Location and size of macroscopic metastasis


should be recorded.

-isolated vs diffuse

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Controvertial Issues for Stage IIIC and IVB
Disease
Isolated liver and splenic parenchymal metastases

• According to some investigators, these should be


considered as stage IIIC because of its
susceptibility to cytoreductive surgery

• Not adopted by the committee

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Controvertial Issues for Stage IIIC and IVB
Disease
Umbilical deposit (currently IVB)

• Some consider it as IIIC because it represents


peritoneal extension into the urachal remnant

• Not adopted by the committee

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STAGING
Stage IV: Distant metastasis excluding peritoneal
metastasis

Any T, any N, M1
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)
Old Ovarian Cancer Staging (1988)

Stage IIIC: Abdominal implants greater than 2 cm in diameter and/or positive


retroperitoneal or inguinal nodes
Stage IV: Growth involving one or both ovaries with distant metastasis. Pleural
effusion with positive cytology and Liver Parenchymal metastasis

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Recommendations for Surgeons

• Extension of tumor from the omentum to spleen


and liver should be differentiated from isolated
parenchymal disease

• Location and size of macroscopic metastasis


should be recorded.

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Controversial Issues to be Resolved in the Future

• Should macroscopic and positive lymph nodes above


the renal vessels be considered stage III or IV?

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SUMMARY

• The primary site should be designated. If not possible


to delineate, it should be listed as “undesignated”.
• The histologic type should be recorded.
• Include revision of stage IC, III and IV patients.
• Involvement of adhesions and retroperitoneal lymph
nodes must be proven cytologically or histologically.
• Extension of tumor from omentum to spleen or liver
should be differentiated from isolated parenchymal
metastases.

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Recommendation for Future Consideration

• Splenectomy seems to take care of isolated


metastases in a better way than partial hepatectomy.
In future, isolated splenic metastasis may be
considered stage IIIC rather than stage IV, whereas
parenchymal liver metastasis would remain stage IVB.

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Treatment
(Epithelial Tumors)

Society of Gynecologic Oncologists of the Philippines (Foundation), Inc. Clinical


Practice Guidelines. 6th Edition. November 2012.
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Treatment
(Germ Cell Tumors)

Society of Gynecologic Oncologists of the Philippines (Foundation), Inc. Clinical


Practice Guidelines. 6th Edition. November 2012.
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Treatment
(Sex Cord Stromal Tumors)

Society of Gynecologic Oncologists of the Philippines (Foundation), Inc. Clinical


Practice Guidelines. 6th Edition. November 2012.
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Interactive Session
Case 1
A 23 year old, G0, underwent exploratory laparotomy and
surgical staging. Intraoperatively the right ovary was
converted to a 20 x 20 cm multiloculated multiseptated mass
with a 1 cm point of rupture and surface excresence. The rest
of the abdominopelvic organs were grossly normal. Histopath
showed mucinous cystadenocarcinoma of the ovary with
malignant cells on the peritoneal fluid. All lymph nodes were
negative for tumor and there was no lymphovascular space
invasion. What is the stage of the patient?

a. IA
b. IB
c. IC1
d. IC2
e. IC3

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Interactive Session
Case 2
A 50 year old woman came in for a 1 year history of an
enlarging abdominal mass and sudden difficulty of breathing. On
thoracentesis, there were malignant cells on the pleural fluid.
After optimizing patient's condition, what is the appropriate
surgical plan for this patient?

A. EL, PFC, THBSO, BLND, PALS, RPB IO


B. EL, THBSO, BLND, PALS, RPB, IO
C. EL, THBSO, selective lymphadenectomy
D. EL, THBSO, tumor debulking
E. EL, BSO

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Interactive Session
Case 2
On final histopath, all specimens (uterus, ovaries,
omentum) were positive for tumor. what is the stage
of the patient?

• A. stage IIIA
• B. stage IIIB
• C. stage IIIC
• D. stage IVA
• E. stage IVB

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Interactive Session
Case 3
A 45 year old underwent EL , PFC , adhesiolysis , THBSO
, BLND, PALS, IO and RPB. Final histopath revealed clear cell
adenocarcinoma, left ovary with positive for tumor in the
peritoneal fluid, left obturator nodes (9 mm on greatest
dimension), left external iliac nodes (11 mm on greatest
dimenssion, adhesions in the cul de sac and left pelvic side
wall and paracolic peritoneal biopsy. What is the stage of the
patient?

A. IIB
B. IIIA1 (i)
C. IIIA1 (ii)
D. IIIA2

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Interactive Session
Case 4
A 65 year old G0 underwent exploratory laparotomy.
Histopath revealed high grade serous carcinoma, right ovary
with positive tumor on the left ovarian surface, uterine serosa
and peritoneal fluid. What is the stage?

A. 1B
B. 1C3
C. IIA
D. IIB

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