30 Ovary
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SUMMARY OF CHANGES
• The definitions of TNM and the Stage Grouping for this chapter have not changed from the Fifth Edition.
C56.9 Ovary
ANATOMY
Primary Site. The ovaries are a pair of solid, flattened ovoids, 2 to 4 cm in diameter that are connected by a peritoneal fold to the broad ligament and by the infundibulopelvic ligament to the lateral wall of the pelvis. They are attached medially to the uterus by the utero-ovarian ligament. (See Figure 28.1.)
In some cases, an adenocarcinoma is primary in the peritoneum. The ovaries are not involved or are only involved with minimal surface implants. The clinical presentation, surgical therapy, chemotherapy, and prognosis of these peritoneal tumors mirror those of papillary serous carcinoma of the ovary.
Patients who undergo prophylactic oophorectomy for a familial history of ovarian cancer appear to retain a 1 to 2% chance of developing peritoneal ade- nocarcinoma, which is histopathologically and clinically similar to primary ovarian cancer.
Regional Lymph Nodes. The lymphatic drainage occurs by the utero-ovarian and round ligament trunks and an external iliac accessory route into the fol- lowing regional nodes:
External iliac
Internal iliac (hypogastric) Obturator
Sacral Common iliac Para-aortic Inguinal Pelvic, NOS Retroperitoneal, NOS
For pN0, histologic examination should include both pelvic and para-aortic lymph nodes. Figure 30.1 illustrates the regional lymph nodes.
Metastatic Sites. The peritoneum, including the omentum and the pelvic and abdominal visceral and parietal peritoneum, comprises common sites for seeding. Diaphragmatic and liver surface involvement are also common.
However, to be consistent with FIGO staging, these implants within the abdominal cavity (T3) are not considered distant metastases. Primary peritoneal adenocarcinoma is always metastatic at diagnosis (M1). Extraperitoneal sites,
including parenchymal liver, lung, skeletal metastases, and supraclavicular and axillary nodes, are M1.
DEFINITIONS Primary Tumor (T)
TNM FIGO
Categories Stages Definitions
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 I Tumor limited to ovaries (one or both)
T1a IA Tumor limited to one ovary; capsule intact, no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings(1)(Figure 30.2)
T1b IB Tumor limited to both ovaries; capsule intact, no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings(1)(Figure 30.3)
T1c IC Tumor limited to one or both ovaries with any of the fol- lowing: capsule ruptured, tumor on ovarian surface, malig- nant cells in ascites or peritoneal washings (Figure 30.4) T2 II Tumor involves one or both ovaries with pelvic extension T2a IIA Extension and/or implants on uterus and/or tube(s); no
malignant cells in ascites or peritoneal washings (Figure 30.5)
T2b IIB Extension to and/or implants on other pelvic tissues; no malignant cells in ascites or peritoneal washings (Figure 30.6)
5
1
6 7 2
4
3 7
6
C77.2
C77.5
C77.4
FIGURE 30.1. Regional lymph nodes: (1) hypogastric; (2) common iliac; (3) external iliac; (4) lateral sacral; (5) para-aortic; (6) inguinal; (7) obturator.
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T1a TNM:
FIGO: IA
FIGURE 30.2. T1a is tumor limited to one ovary; capsule intact, no tumor on ovarian surface, and no malignant cells in ascites or peritoneal washings.(1)
T1b TNM:
FIGO: IB
FIGURE 30.3. T1b is tumor limited to both ovaries; capsule intact, no tumor on ovarian surface. No malignant cells in ascites or peritoneal washings.(1)
T1c TNM:
FIGO: IC
T1c TNM:
FIGO: IC
Ascites, peritoneal washing
FIGURE 30.4. Two views of T1c, defined as tumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface (left side of dotted line), malignant cells in ascites or peritoneal washings (right side of dotted line).
TNM:T2a FIGO: IIA
FIGURE 30.5. T2 is tumor involving one or both ovaries with pelvic extension.
T2a involves extension and/or implants on uterus (shown) and/or tube(s) without any malignant cells in ascites or peritoneal washings.
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T2b TNM:
FIGO: IIB
FIGURE 30.6. T2b is defined as tumor extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings.
TNM:T2c FIGO: IIC
Ascites, peritoneal washing
FIGURE 30.7. T2c is defined as tumor with pelvic extension and/or implants (T2a or T2b) and with malignant cells in ascites or peritoneal washings.
T2c IIC Pelvic extension and/or implants (T2a or T2b) with malig- nant cells in ascites or peritoneal washings (Figure 30.7) T3 III Tumor involves one or both ovaries with microscopically
confirmed peritoneal metastasis outside the pelvis(2)(Figures 30.8, 30.9)
T3a IIIA Microscopic peritoneal metastasis beyond pelvis (no macro- scopic tumor)(2)(Figure 30.8)
T3b IIIB Macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension(2)(Figure 30.8)
TNM:T3 FIGO: III
3c/IIIC:
Peritoneal metastasis
>2 cm 3b/IIIB:
Macroscopic peritoneal metastasis
£2 cm
3a/IIIA:
Microscopic peritoneal metastasis only TNM:T3
FIGO: III
FIGURE 30.8. Three views of T3: T3a (top right) is defined as microscopic peritoneal metastasis beyond pelvis (no macroscopic tumor)(2); T3b (bottom right) is defined as macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension(2); T3c (left side) is defined as peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis.
M1 TNM:T3
FIGO: III
TNM:
FIGO: IV
Parenchymal
Liver capsule
FIGURE 30.9. Liver capsule metastasis classified as T3/Stage III. Liver parenchymal metastasis classified as M1/Stage IV.
T3c IIIC Peritoneal metastasis beyond pelvis more than 2 cm in great- est dimension and/or regional lymph node metastasis(2) (Figure 30.8)
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis
N1 IIIC Regional lymph node metastasis (Figure 30.10) Distant Metastasis (M)
MX Distant metastasis cannot be assessed M0 No distant metastasis
M1 IV Distant metastasis (excludes peritoneal metastasis)(2)(Figure 30.9)
STAGE GROUPING (AJCC/UICC/FIGO)
I T1 N0 M0
IA T1a N0 M0
IB T1b N0 M0
IC T1c N0 M0
II T2 N0 M0
IIA T2a N0 M0
IIB T2b N0 M0
IIC T2c N0 M0
III T3 N0 M0
IIIA T3a N0 M0
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N1 FIGO: IIIC
FIGURE 30.10. N1: regional lymph node metastasis.
IIIB T3b N0 M0
IIIC T3c N0 M0
Any T N1 M0
IV Any T Any N M1
NOTES
1. The presence of nonmalignant ascites is not classified. The presence of ascites does not affect staging unless malignant cells are present.
2. Liver capsule metastasis T3/III, liver parenchymal metastasis M1/Stage IV. Pleural effusion must have positive cytology for M1/Stage IV.
