Gynecologic Oncology 133 (2014) 401404

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Gynecologic Oncology
journal homepage: www.elsevier.com/locate/ygyno

Clinical Commentary

2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer

Cancer staging is a core principle in understanding the severity of patients' clinical condition, predicting the outcome, and planning adequate treatment. Staging is necessary for explaining epidemiologic
changes, dening the disease at presentation, and evaluating the overall
impact of new therapies. In essence, it assigns patients to prognostic
groups that require specic treatments. The steps of staging typically
begin by establishing the histopathologic diagnosis, according to the
tumor cell type, and assessing prognosis based on extent of disease
and other known prognostic parameters. Recently, the presence of various molecular genetic alterations has been used in the establishment of
prognosis and even staging classication in some tumors but gynecologic cancers have continued to rely on physical, radiographic and surgical ndings.
This editorial is written to make the readership aware of the recent
changes that have been made by the International Federation of Gynecology and Obstetrics (FIGO) in the staging classication of ovarian cancer and the reasoning behind those changes [1]. Even if the FIGO
Committee on Gynecologic Oncology utilized the best evidence currently available, this is always a somewhat subjective process. Furthermore,
one needs to be aware that FIGO is an international organization that
must take into account the needs of women with gynecologic cancers
throughout the world, and not just those from countries that are resource rich. The rst FIGO ovarian cancer staging was published in
1973 in Volume 15 of the FIGO Annual Report. Since that time there
have been two other changes including this one in 1988 and 2013.
Ovarian cancer is not one disease. Several distinct tumors with
unique clinical and pathological features may arise in the ovary. Approximately 90% of ovarian cancers are carcinomas (malignant epithelial tumors) and, based on histopathology, immunohistochemistry, and
molecular genetic analysis, at least 5 main types are currently distinguished: high-grade serous carcinoma (HGSC [70%]); endometrioid carcinoma (EC [10%]); clear-cell carcinoma (CCC [10%]); mucinous
carcinoma (MC [3%]); and low-grade serous carcinoma (LGSC [less
than 5%] [2]). These tumor types (which account for 98% of ovarian carcinomas) can be reproducibly diagnosed by light microscopy and are essentially different diseases, as indicated by differences in epidemiologic
and genetic risk factors; precursor lesions; ways of spread; and molecular changes during oncogenesis, response to chemotherapy, and outcome [3] Much less frequent are malignant germ cell tumors
(dysgerminomas, yolk sac tumors, and immature teratomas [3% of ovarian cancers]) and potentially malignant sex cord-stromal tumors (1%
2%, mainly granulosa cell tumors). The biomarker expression prole
within a given histotype is consistent across stages. In short, ovarian
cancers differ primarily based on histotype.
Primary fallopian tube cancer and primary peritoneal cancer are rare
malignancies but share many clinical and morphologic similarities with

http://dx.doi.org/10.1016/j.ygyno.2014.04.013
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HGSC; i.e., the most common type of ovarian cancer (in the past, referred to as papillary serous carcinoma) and the prototype tumor occurring in women with BRCA1 or BRCA2 germline mutations. In these
patients, compelling evidence for a tubal derivation of their tumors,
mainly those encountered at early stage, has accumulated over the
past decade [46]. Evidence of a tubal origin is weaker in the far more
common sporadic HGSCs, and a multicentric origin of these tumors
(i.e. arising from ovarian surface mesothelial invaginations or cortical
inclusion cysts, implantation of tubal-type epithelium into the ovary
[endosalpingiosis], or the pelvic peritoneum [the so-called secondary
mllerian system]) cannot be ruled out. Recently, it has been hypothesized that cytokeratin7-positive embryonic/stem cells would be capable
of mullerian differentiation in cortical inclusion cysts resulting from
ovarian surface epithelium (mesothelium) invaginations. Thus, embryonic progenitors would give rise to immunophenotypically distinct neoplastic progeny [7] which would support the old concept of mullerian
neometaplasia. On the other hand, it has been demonstrated that the
vast majority of ECs and CCCs arise in the ovary from endometriosis.
Based on the putative tubal or peritoneal origin of a number of
BRCA + HGSCs, and the fact that they are managed clinically in a similar
manner regardless their ovarian, tubal, or peritoneal derivation, most
FIGO Committee members felt that FIGO staging of ovarian, peritoneal,
and fallopian tube cancers should be considered collectively [8]. The primary site (i.e. ovary, fallopian tube, or peritoneum) should be designated where possible. In some cases, it might not be possible to delineate
the primary site clearly; such cases should be listed as undesignated.
The process of updating the staging classication of ovarian,
fallopian tube, and primary peritoneal cancer started 4 years ago with
a proposal that was sent to all relevant gynecology oncology organizations and societies throughout the world and input was collated, evaluated, and formulated into the staging that is presented below. All
suggestions are based on the best available evidence. The committee acknowledged that there are areas that are not supported by strong evidence and has been careful to ensure that changes are not made
without quality evidence when available. The new staging below was
reached by consensus of all participating in the FIGO meeting held in
Rome, Italy, on October 7th, 2012, some of whom were representatives
of their organizations. The new staging was presented to the FIGO Executive Board on October 12, 2012, and approved two weeks later.
Ovarian cancer remains largely a surgically staged disease. The prognosis is based on histologic type, radiographic, and operative extent of
the disease. The proposed staging system is noted below (Table 1).
(See Tables 2 and 3).
Precise histopathologic diagnosis is mandatory for successful categorization and treatment of ovarian cancers, as different histologic types
respond differently to treatment. To be practical, the FIGO committee

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Clinical Commentary

Table 1
2014 FIGO ovarian, fallopian tube, and peritoneal cancer staging system and corresponding TNM.
I

Tumor conned to ovaries or fallopian tube(s)

IA

Tumor limited to one ovary (capsule intact) or fallopian tube, No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal T1a
washings
T1b
Tumor limited to both ovaries (capsules intact) or fallopian tubes
No tumor on ovarian or fallopian tube surface
No malignant cells in the ascites or peritoneal washings
Tumor limited to one or both ovaries or fallopian tubes, with any of the following:
T1c
IC1 Surgical spill intraoperatively
IC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface
IC3 Malignant cells present in the ascites or peritoneal washings

IB

IC

II
IIA
IIB

T1

Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer (Tp)
Extension and/or implants on the uterus and/or fallopian tubes/and/or ovaries
Extension to other pelvic intraperitoneal tissues

Tumor involves one or both ovaries, or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically conrmed spread to the
peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes
IIIA
Metastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal involvement beyond the pelvis
IIIA1
Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
IIIA1(i) Metastasis 10 mm in greatest dimension (note this is tumor dimension and not lymph node dimension)
IIIA1(ii) Metastasis N 10 mm in greatest dimension
IIIA 2
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes
IIIB
Macroscopic peritoneal metastases beyond the pelvic brim 2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes
III C
Macroscopic peritoneal metastases beyond the pelvic brim N 2 cm in greatest dimension, with or without metastases to the retroperitoneal nodes (Note 1)

T2
T2a
T2b

III

IV

Distant metastasis excluding peritoneal metastases

Stage IV A: Pleural effusion with positive cytology
Stage IV B: Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of abdominal cavity) (Note 2)
(Note 1: includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ)
(Note 2: Parenchymal metastases are Stage IV B)

T3
T1,T2,T3aN1
T3a/T3aN1
T3a/T3aN1
T3b/T3bN1
T3c/T3cN1

Any T, Any N,
M1
T3c/T3cN1)

Notes:
1. Includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ.
2. Parenchymal metastases are Stage IV B.

chose a staging classication system that takes into account the most
relevant prognostic parameters shared by all tumor types. However, it
was agreed on by all that histologic type should be designated at the
time of diagnosis and staging. The ve agreed upon epithelial histologic
types, as well as much less common malignant germ cell and potentially
malignant sex cord-stromal tumors, are listed below.

Table 2
Carcinoma of the ovaryfallopian tubeperitoneum stage grouping.
FIGO

UICC

(Designate primary: Tov, Tft, Tp or Tx)

Stage
T
N
IA
T1a
N0
IB
T1b
N0
IC
T1c
N0
IIA
T2a
N0
IIB
T2b
N0
IIIA
T3a
N0
T3a
N1
IIIB
T3b
N0
T3b
N1
IIIC
T3c
N01
T3c
N1
IV
Any T
Any N
Regional nodes (N)
Nx
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
Distant metastasis (M)
Mx
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis (excluding peritoneal metastasis)

M
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1

Notes:
1. The primary site i.e. ovary, fallopian tube or peritoneum should be designated where
possible. In some cases, it may not be possible to clearly delineate the primary site, and
these should be listed as undesignated.
2. The histologic type of should be recorded.
3. The staging includes a revision of the stage III patients and allotment to stage IIIA1 is
based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination, because an analysis of these patients indicates that their survival is signicantly better than those who have intraperitoneal dissemination.
4. Involvement of retroperitoneal lymph nodes must be proven cytologically or
histologically.
5. Extension of tumor from omentum to spleen or liver (Stage III C) should be differentiated from isolated parenchymal splenic or liver metastases (Stage IVB).

Histologic types:
Carcinomas (by order of frequency)
High-grade serous carcinoma (HGSC)
Endometrioid carcinoma (EC)
Clear-cell carcinoma (CCC)
Mucinous carcinoma (MC)
Low-grade serous carcinoma (LGSC).
Note: Transitional cell carcinoma is currently interpreted as a morphologic variant of HGSC; malignant Brenner tumor is considered a
low-grade carcinoma which is extremely rare.
Malignant germ cell tumors (dysgerminomas, yolk sac tumors, and
immature teratomas) Potentially malignant sex cord-stromal tumors
(mainly rare cases of granulosa cell tumors and SertoliLeydig cell tumors with heterologous sarcomatous elements).
The issues discussed and concluded by the FIGO committee will be
taken one stage at a time, controversial issues raised, and the available
data cited as appropriate.
Staging should be considered uid. As more prognostic features become available these should be used to further predict outcomes and
determine treatment. The world is getting smaller in the sense that
staging systems must be applicable universally and including resource
rich as well as resource poor regions. Toward this end, three members
of FIGO will now be on the AJCC staging committee and there is representation of the UICC on the AJCC. The International Gynecologic Cancer
Society and the Society of Gynecologic Oncology now have nonvoting
representation on the FIGO committee as well. We need to continue to
gain consensus internationally by having cross representation on our

Clinical Commentary

403

Table 3
Explantation of the Staging Changes
Stage I
Disease conned to the ovary after comprehensive staging
Stages IA and IB are unchanged from the 1988 staging.
IA remains tumor limited to one ovary (capsule intact) or fallopian tube. There can be no disease on the ovary or fallopian tube surface. There are no malignant cells in
the ascites or peritoneal washings. Primary peritoneal has no Stage IA.
1B is unchanged and remains tumor limited to both ovaries with capsule intact or fallopian tubes; and there can be no malignant cells on ovarian or fallopian tube
surfaces. There are no malignant cells in the ascites or peritoneal washings.
IC represents a change for the 1988 staging system. It still designates positive cytology but, if possible, must designate the reason for malignant cells being present;
hence, this substage is divided into three groups.
1C1 represents disease conned to one or both ovaries with capsule rupture during surgery
1C2 represents rupture before surgery or tumor excrescences on the surface of the tube or ovary.
1C3 represents malignant cells in the peritoneal cavity regardless of cause.
Comments
Specic issues surrounding stage I tumors need to be considered when evaluating Stage I patients surgically and pathologically. Bilateral tumors that are large on one
side and multiple or small on the other could represent metastases up to one third of the time [9,10]. The signicance of positive cytology is poorly understood and
is one of the reasons that the committee elected to divide it into three categories. Some studies have found that intraoperative rupture portends a worse prognosis
than if the capsule is unruptured. In one multivariate analysis, both capsule rupture and positive cytology were independent predictors of worse disease free
survival [11]. Surface involvement of the ovary or fallopian tube should be considered present only when excrescences have cancer cells in direct contact with the
peritoneal cavity, breaking through the surface of the ovarian capsule. Tumors with a smooth surface usually don't show an exposed layer of neoplastic cells.
Histologic grade inuences survival and is given with the histotype except for endometrioid carcinoma and mucinous cancers which should be graded. Practically
all clear cell carcinomas are high grade.

T1N0M0
T1aN0M0

T1bN0M0
T1cN0M0

Stage II
Stage II ovarian cancer includes disease conned to the pelvis (below the pelvic brim). It involves one or both ovaries or fallopian tubes with pelvic extension or
T2N0M0
primary peritoneal cancer.
IIA Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries
T2aN0M0
IIB Extension to other pelvic intraperitoneal tissues/organs
T2bN0M0
Comments:
Stage II ovarian cancer remains controversial and ill dened. It comprises a small group of ovarian cancer patients that have direct extension of their tumors to other
pelvic organs without evidence of metastatic disease. However, it also includes a group of patients that has metastases to the pelvic peritoneum. In this second
group of patients, disease is similar to that of stage III patients. Disease invading through the bowel wall and into the mucosa increases the stage to IVB.
Stage III
Stage III Cancer involves 1 or both ovaries, fallopian tubes, or is primarily from the peritoneum with histologically conrmed spread outside of the pelvis and/or
metastases to the retroperitoneal nodes.
IIIA1 Positive retroperitoneal nodes only. This can be conrmed histologically or cytologically.
lllA(i) Metastases up to and including 10 mm in greatest dimension
IIIA(ii) Metastases more than 10 mm in greatest dimension
Stage IIIA2: Microscopic extrapelvic (above the boney pelvic brim) peritoneal involvement with or without metastases to the retroperitoneal lymph nodes

T1/T2N1MO

T3a2N0/N1
M0
IIIB: Macroscopic peritoneal metastases beyond the pelvis up to and including 2 cm in greatest dimension, with or without metastases to the retroperitoneal lymph T3bN0/N1
nodes.
M0
IIIC: Macroscopic peritoneal disease beyond the pelvis more than 2 cm in greatest diameter, with or without metastases to the retroperitoneal lymph nodes (includes
tumor extension to the capsule of the liver and spleen but no parenchymal metastases).
Comments
Approximately, 85% of ovarian cancers present as stage III tumors and the vast majority are high-grade serous carcinomas [12]. A little less than 10% of patients with
ovarian cancer that appear to have stage I disease will have isolated lymph node metastases. The likelihood of having nodal metastasis in other stages are: III, 55%
and IV, 88% [13]. There is some evidence that exclusive retroperitoneal disease portends a better prognosis and for this reason the new staging system addresses
this issue in the IIIA category [1419]. It should be noted that the size separating the IIIA tumors applies to the tumor size and not the lymph node size.
Stage IV: Distant metastases excluding peritoneal or retroperitoneal nodal disease below the diaphragm.
IVA: Pleural effusion with positive cytology
IVB: Metastases to extra abdominal sites including inguinal lymph nodes and parenchymal involvement of visceral organs including liver and spleen. Transmural
involvement of a visceral structure also represents stage IVB disease.

entire representative staging committees. This will help us standardize

care and staging systems throughout the world. In the future it is
hoped that organizations such as UICC, AJCC, and FIGO will continue to
work together to achieve this goal.
Conict of interest statement
The authors declare that there are no conicts of interest.

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Clinical Commentary

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David G. Mutch
Department of Obstetrics and Gynecology, Washington University School of
Medicine, 4911 Barnes Hospital Plaza, St. Louis, MO 63110, United States
Jaime Prat
Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous
University of Barcelona, Sant Quinti, 87-89, 08041 Barcelona, Spain