TABLE 53.1 Risk Factors for Ovarian Cancer | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLE 53.2 Serum Markers in Ovarian Cancer | ||||||||||||||||||
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TABLE 53.3 Lymph Nodal Metastases in Patients with Clinically Apparent Stage I Epithelial Ovarian Cancer | ||||||||||||||||||||||||||||||||
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TABLE 53.4 World Health Organization Histological Classification of Ovarian Tumors | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The volume of ascitic fluid should be recorded, and a minimum of 25 mL should be sent for cytologic evaluation.
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In the absence of ascites, separate saline washings should be obtained from the (a) pelvic cul-de-sac, (b) right paracolic space, (c) left paracolic space, and (d) undersurface of each hemidiaphragm. Approximately 100 mL of saline should be instilled in each of these areas, recovered, and sent for cytologic evaluation.TABLE 53.5 FIGO Ovarian Cancer Staging (January 01, 2014)
STAGE I: Tumor confined to ovaries
OLD
NEW
IA
Tumor limited to 1 ovary, capsule intact, no tumor on surface, negative washings/ascites
IA
Tumor limited to 1 ovary, capsule intact, no tumor on surface, negative washings
IB
Tumor involves both ovaries
IB
Tumor involves both ovaries otherwise like IA
IC
Tumor involves 1 or both ovaries with any of the following: capsule rupture, tumor on surface, positive washings/ascites
IC Tumor limited to 1 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
STAGE II: Tumor involves 1 or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer
OLD
NEW
IIA
Extension and/or implant on uterus and/or fallopian tubes
IIA
Extension and/or implant on uterus and/or fallopian tubes
IIB
Extension to other pelvic intraperitoneal tissues
IIB
Extension to other pelvic intraperitoneal tissues
IICa
IIA or IIB with positive washings/ascites
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
OLD
NEW
IIIA
Microscopic metastasis beyond the pelvis
IIIA (Positive retroperitoneal lymph nodes and /or microscopic metastasis beyond the pelvis)
IIIA1
Positive retroperitoneal lymph nodes only
IIIA1(i) Metastasis ≤ 10 mm
IIIA1(ii) Metastasis > 10 mm
IIIA2
Microscopic, extrapelvic (above the brim) peritoneal involvement ± positive retroperitoneal lymph nodes
IIIB
Macroscopic, extrapelvic, peritoneal metastasis ≤2 cm in greatest dimension
IIIB
Macroscopic, extrapelvic, peritoneal metastasis ≤2 cm ± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
IIIC
Macroscopic, extrapelvic, peritoneal metastasis >2 cm in greatest dimension and/or regional lymph node metastasis
IIIC
Macroscopic, extrapelvic, peritoneal metastasis >2 cm ± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
STAGE IV: Distant metastasis excluding peritoneal metastasis
OLD
NEW
IV
Distant metastasis excluding peritoneal metastasis. Includes hepatic parenchymal metastasis.
IVA
Pleural effusion with positive cytology
IVB
Hepatic and/or splenic parenchymal metastasis, metastasis to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)
a Old stage IIC has been eliminated.
Other major recommendations are as follows:
• Histologic type including grading should be designated at staging.
• Primary site (ovary, fallopian tube, or peritoneum) should be designated where possible.
• Tumors that may otherwise qualify for stage I but involved with dense adhesions justify upgrading to stage II if tumor cells are histologically proven to be present in the adhesions.
Reprinted from Prat J, for the FIGO Committee on Gynecologic Oncology. Staging classification for cancer of the ovary, fallopian tube and peritoneum. Intl J Gynecol Obstet 2014;124:1-5. Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Reprinted with permission from Elsevier.
TABLE 53.6 Surgical Staging of Apparent Early-Stage Ovarian CancerVertical midline incision
Evacuation of ascites or multiple cytologic washings
Complete abdominal inspection and palpation
Resection of ovaries, fallopian tubes, and uterusa
Omentectomy
Random peritoneal biopsies
Retroperitoneal lymph node sampling
a Exceptions may be made in selected patients who wish to preserve fertility.
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The ovarian tumor should be inspected, with particular attention to the presence of papillary excrescences on the surface or rupture of the capsule. The contralateral ovary and uterus should be examined for the presence of metastatic tumor. The pathways of ovarian tumor should be removed and sent for frozen section examination. Removal of the opposite ovary and/or uterus is dependent on several factors and is discussed on the following pages.
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Careful inspection and palpation of the peritoneal surfaces and intra-abdominal viscera should be performed. This evaluation should be approached in a systematic fashion, beginning with the peritoneum of the cul-de-sac and small bowel mesentery. Inspection should continue with the ascending colon, liver, omentum, undersurface of the right and left hemidiaphragms, and stomach. Finally, the transverse colon, spleen, descending colon, and bladder peritoneum should be evaluated.
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All areas suspicious for malignancy should be biopsied. In the absence of visible disease, biopsies should be taken of the cul-de-sac peritoneum, bladder peritoneum, both lateral pelvic walls, paracolic peritoneum bilaterally, and undersurface of the right hemidiaphragm. An infracolic omentectomy should be performed in patients with epithelial ovarian cancer and an omental wedge biopsy taken in patients with germ-cell or stromal tumors. Appendectomy should be performed in all patients with mucinous epithelial cancers involving the ovary. Primary appendiceal cancers, although rare, commonly spread to the ovaries and usually require right hemicolectomy as part of initial surgical staging.
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As has been mentioned, ovarian cancer commonly spreads to both pelvic and paraaortic lymph nodes. Some patients with early-stage ovarian cancer have paraaortic lymph node metastases in the absence of pelvic lymph node spread. Therefore, these lymph node groups should be sampled separately in all patients. It is important that sampling include lymph nodes on the opposite side of the primary ovarian tumor, because isolated contralateral spread has been reported. In the setting of advanced-stage disease, prospective randomized trials reviewed by Panici et al. have shown that routine lymphadenectomy is not associated with a higher survival rate; however, it is associated with an improvement in the disease-free interval.
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Finally, it should be emphasized that operative findings present at the time of staging must be carefully documented. Prognosis is related to the site and volume of metastatic tumor, as well as the amount of residual disease remaining after surgical debulking. Important data concerning the location and size of tumor metastases are often lost if the details concerning operative staging are not recorded.
TABLE 53.7 Criteria for Potential Fertility-Sparing Surgery in Ovarian Cancer Patients | ||||||||||||||||
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