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Wo m e n s I m a g i n g R ev i ew

Javadi et al.
Imaging of Ovarian Cancer and the Revised
FIGO Staging System

Womens Imaging
Review
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Ovarian Cancer, the Revised


FIGOStaging System, and the
Roleof Imaging
Sanaz Javadi1 OBJECTIVE. It is now recognized that ovarian cancer includes a heterogeneous group
Dhakshina M. Ganeshan2 of malignant epithelial tumors originating from the ovaries, fallopian tubes, or peritoneum.
Aliya Qayyum 2 This development has prompted the International Federation of Gynecology and Obstetrics
Revathy B. Iyer 2 (FIGO) to issue a revised staging system that can provide prognostic information and guid-
ance on personalized management of ovarian cancer.
Priya Bhosale2
CONCLUSION. We review the epidemiology of ovarian cancer, the new FIGO staging
Javadi S, Ganeshan DM, Qayyum A, Iyer RB, system, and the role of imaging in the assessment, staging, and follow-up of ovarian cancer.
Bhosale P
varian cancer has the highest disease. The lifetime risk of developing ovarian

O mortality rate of all gynecologic


malignancies. The goal of imag-
ing is to help diagnose and differ-
cancer increases from one in 70 to one in 30 if
a first-degree relative has ovarian cancer [4, 5].
The other three groups who are at higher risk
entiate malignant tumors from benign lesions for ovarian cancer are individuals with BRCA1
and to stage ovarian malignancy. Cancer stag- and BRCA2 tumor suppressor genes and those
ing is a fundamental principle and one of the with hereditary nonpolyposis colorectal can-
first and most important steps used to predict cer (HNPCC) (Lynch II syndrome). Women
patient outcome as well as to plan the most ap- with BRCA1 and BRCA2 genes have a predis-
propriate treatment. The International Federa- position to develop ovarian and breast cancer
tion of Gynecology and Obstetrics (FIGO) with autosomal dominant transmission. Mean
ovarian cancer staging system was first pub- lifetime risk for ovarian cancer is approxi-
lished in 1973 and was revised in 1988 and mately 30% in BRCA1 and 27% in BRCA2
2014 [1, 2]. Recent progress in understanding mutation carriers, but the risk of ovarian can-
of the origin, pathogenesis, and prognosis of cer has been reported to be as high as 4460%
different ovarian cancer subtypes prompted in high-penetrance families (individuals car-
the 2014 revision (Fig. 1). rying a mutation who have higher susceptibil-
Keywords: International Federation of Gynecology and
We review the epidemiology and histolog- ity to manifest the disease) [68]. Ovarian car-
Obstetrics (FIGO), ovarian cancer, staging
ic types of ovarian cancer and the differences cinoma occurs in almost 10% of patients with
DOI:10.2214/AJR.15.15199 between the new and old FIGO staging sys- HNPCC [9]. Less significant risk factors for
tems as well as the role of imaging in the new ovarian cancer include infertility, nulliparity,
Received June 22, 2015; accepted after revision FIGO staging system. late menopause, and early menarche [4]. Late
November 23, 2015.
menarche, early menopause, and use of hor-
1
Department of Radiology, Duke University Medical Epidemiology monal contraceptives (fewer ovulation cycles)
Center, Durham, NC 27710. Of all gynecologic malignancies, ovarian are protective factors [10].
cancer is the most frequently fatal and is the
fifth most frequent cause of cancer mortality in
2
Department of Diagnostic Radiology, University of Background
Texas, M. D. Anderson Cancer Center, 1400 Pressler St,
Unit 1473, Houston, TX 77030. Address correspondence
women in the United States. In 2014, approx- Ovarian tumors are divided into three
to P. Bhosale (Priya.Bhosale@mdanderson.org). imately 22,000 new cases and 14,180 deaths major categories according to the anatomic
were expected. The frequency and mortality structures from which they arise: epithelial-
This article is available for credit. rate of ovarian cancer has been decreasing [3]. stromal tumors, sex cordstromal tumors,
Approximately 90% of ovarian cancers are and germ cell tumors [11].
AJR 2016; 206:13511360
sporadic and 10% are seen in patients with in- Epithelial-stromal tumors are the most
0361803X/16/20661351 herited familial syndromes. Ovarian cancer common type and account for approximately
has various causes; the most important risk fac- 60% of all ovarian tumors and 90% of ma-
American Roentgen Ray Society tor for ovarian cancer is a family history of the lignant ovarian tumors. Epithelial tumors can

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Javadi et al.

be further subdivided into five types by order BRCA mutation undergoing prophylactic sal- as in screening of high-risk patients [23, 24].
of frequency: high-grade serous carcinoma pingo-oophorectomy have been found to have Ultrasound relies on morphologic features to
(HGSC), 70%; endometrioid carcinoma, 10%; high-grade serous tubal intraepithelial carci- distinguish between benign and malignant
clear cell carcinoma, 10%; mucinous carcino- noma (STIC) in the fallopian tube and fimbria lesions; features such as thick irregular walls,
ma, 3%; and low-grade serous carcinoma, < but not in the ovary [18, 20]. In another study, papillary projections, and solid echogenic
5%. Transitional cell carcinoma, which was STIC was found to coexist with all forms of locules are considered signs of malignancy
initially reported as a subtype of Brenner tu- pelvic serous carcinomas, thus prompting the [2528]. A morphologic scoring system us-
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mor, lacked benign features of Brenner tu- possibility of the peritoneal origin of these tu- ing endovaginal ultrasound was suggested
mors but included urothelial features. These mors [21]. The proportion of HGSCs of ovar- to distinguish benign from malignant ovar-
tumors are now considered a morpholog- ian and tubal origin is unknown because tumor ian lesions. This system showed sensitivity of
ic variant of HGSC, and Brenner tumors are growth in advanced stages of cancer obscures 100% and specificity of 83% [25].
considered low-grade carcinomas [2, 1113]. the primary site. When possible, the primary The risk of malignancy index (RMI) com-
Sex cordstromal tumors originate from site of cancer should be designated; when it is bines the results of ultrasound examination,
one of four cell types (theca cells, stro- not possible to find the primary site, the case menopausal status, and serum levels of can-
mal cells, granulosa cells, or Sertoli-Leydig should be listed as undesignated [1]. Singh et cer antigen 125 (CA-125) to provide a quan-
cells) and account for approximately 7% of al. [22] proposed a new protocol for assigning titative assessment of the risk of malignan-
all malignant ovarian tumors. They are of- the primary site of HGSCs that involves sec- cy [29]. For this index, each of the following
ten associated with hormonal abnormalities tioning and extensively examining the fimbri- ultrasound features scores 1 point: multiloc-
[11]. Germ cell tumors arise from primordi- ated end of the fallopian tube. Determining the ular cyst, solid component, metastases, as-
al germ cells and account for approximately primary site of the other types of ovarian carci- cites, and bilateral ovarian lesions. An ultra-
25% of all ovarian tumors and 37% of ma- noma is not difficult because these tumors are sound score of 0 is assigned in patients with
lignant ovarian tumors [14, 15]. Mixed epi- often confined to the ovary and tubal involve- none of these features; a score of 1 is given
thelial tumors are made of various subtypes ment is uncommon. The correct determination in patients with one feature; and a score of 3
of surface epithelial tumors. These tumors of tumor subtype is important, particularly in is assigned if two or more features are pres-
are named after the predominant component. the evolving era of personalized medicine and ent. A premenopausal female patient is given
The predominant tissue needs to constitute targeted treatment. a menopausal status of 1; a postmenopausal
more than 10% of the entire tumor [16]. woman, 3. The RMI score is then calculat-
Compelling evidence has emerged that can- Role of Imaging Modalities ed by multiplying the ultrasound value by the
cer of the ovaries, fallopian tubes, and perito- Ultrasound score for menopausal status by the patients
neum share similar molecular, morpholog- Ultrasound plays an important role in the serum CA-125 level. An RMI score greater
ic, and clinical features [1719]. Patients with initial evaluation of an adnexal mass as well than 200 is highly specific for malignancy.
Patients without ultrasound features of ma-
lignancy would have an RMI score of 0 re-
gardless of their menopausal status or serum
CA-125 level [29, 30]. When 3D power Dop-
pler ultrasound is added to RMI, the sensitiv-

A B

C D E
Fig. 1Illustration of new International Federation of Gynecology and Obstetrics staging system for ovarian cancer.
A, In stage IA cancer, tumor is limited to one ovary or fallopian tube (yellow). In stage IB cancer, tumor is limited to both ovaries or fallopian tubes (blue).
B, Stage IC1 cancer results from intraoperative spill.
C, In stage IC3 cancer, malignant cells are found in ascites or peritoneal washings.
D, In stage IIA, tumor extends to or is implanted on (or both) uterus or fallopian tubes (or both).
E, Stage IIIA1 cancer shows positive retroperitoneal lymph nodes.
(Fig. 1 continues on next page)

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Imaging of Ovarian Cancer and the Revised FIGO Staging System
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F G H
Fig. 1 (continued)Illustration of new International Federation of Gynecology and Obstetrics staging system for ovarian cancer.
F, In stage IIIA2 cancer, microscopic, extrapelvic (above pelvic brim) peritoneal involvement is seen with or without positive retroperitoneal lymph nodes.
G, In stage IIIB or stage IIIC cancer, macroscopic, extrapelvic (above pelvic brim) peritoneal involvement is seen with or without positive retroperitoneal lymph nodes
(2cm for stage IIIB and> 2 cm for stage IIIC).
H, Stage IVA cancer indicates pleural effusion with positive cytology. In stage IVB cancer, hepatic or splenic parenchymal metastasis is seen (or both), as well as
metastasis to extraabdominal organs.

ity of RMI for prediction of malignancy in- predict resectability. The overall accuracy of water as a contrast agent because calcified
creases from 88% to 99% [31]. MDCT for diagnosis of malignant adnexal metastases may be obscured by high-density
Although ultrasound can be used for diag- masses was reported to be as high as 89%. contrast material [39].
nosis, it is not the imaging modality used to MDCT findings predictive of malignancy CT is particularly useful in patients with
stage ovarian cancer. The sensitivity of Dop- are presence of papillary projections in a large amounts of ascites, which is encoun-
pler ultrasound in the detection of peritoneal cystic lesion, necrosis in a solid mass, and tered in most women with ovarian cancer [40].
metastases is low at 69%, compared with 95% peritoneal metastases [36]. Also, CT is used Additionally, CT has been used to predict the
for MRI and 92% for CT in patients with ad- frequently to detect persistent or recurrent outcome of primary cytoreductive surgery of
vanced cancer (stages III and IV) [32]. More- ovarian carcinoma and to monitor tumor re- advanced ovarian cancer. It is crucial to deter-
over, ultrasound is limited by operator de- sponse to therapy [37]. However, CT is lim- mine which patients will benefit from surgery,
pendence and obscuration of findings due to ited in detecting small peritoneal metastases. minimizing the number of patients undergo-
bowel gas [33, 34]. CT can depict tumor implants larger than 1 ing unnecessary surgery. In one study, perito-
cm with sensitivity of 8593% and specific- neal thickening, peritoneal implants ( 2 cm),
CT ity of 9196%, but the sensitivity decreases bowel mesentery involvement ( 2 cm), supra-
CT is the recommended imaging modality to 2550% in detecting implants that are 1 renal paraaortic lymph nodes ( 1 cm), omen-
for staging ovarian cancer [35]. MDCT pro- cm or smaller [32, 38]. Opacification of the tal extension (spleen, stomach, or lesser sac),
vides clinically relevant information includ- gastrointestinal tract with oral contrast mate- pelvic sidewall involvement, and hydroureter
ing size of the primary tumor, size and loca- rial helps to distinguish peritoneal implants were most strongly associated with poor sur-
tion of any peritoneal implants, and lymph from bowel and is useful for detecting bowel gical outcome. On the basis of statistical prob-
nodes. This information can then be used to invasion. Some authors have advocated using ability of each factor predicting cytoreductive

Fig. 354-year-old
Fig. 266-year-old woman with stage
woman with stage IIA high-grade serous
IA mucinous ovarian ovarian carcinoma.
cancer. Axial CT image Axial CT image shows
shows left ovarian bilateral ovarian cystic
cystic mass with thin and solid masses
enhancing septations (arrows). On histology
(arrows). Tumor was evaluation, tumors were
confined to left ovary. involving fallopian tubes.

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Javadi et al.

Fig. 471-year-old
woman with stage
IIIC ovarian cancer.
A, Axial CT image
shows metastatic
ovarian cancer in
pelvis and malignant
ascites (arrows).
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B, Axial CT image
shows enlarged
retroperitoneal lymph
node (arrowhead)
and malignant ascites
(arrow).

A B

outcome, each radiologic parameter as well undergo complete primary cytoreductive sur- larly in the setting of negative imaging findings
as performance status of the patients was as- gery. In one study, MRI more accurately pre- but increasing tumor markers [5259]. Perito-
signed a numeric value, and total predictive dicted peritoneal cancer index (PCI) preoper- neal tumor deposits are often less than 1 cm,
index score was calculated for each patient. A atively in patients undergoing evaluation for a size at which PET has limited spatial resolu-
predictive index score of 4 or more showed ac- cytoreductive surgery than CT. PCI measures tion. Also, false-positive findings may be seen
curacy of 93%, sensitivity of 100%, specificity the size and extent of peritoneal tumor at lapa- in inflammatory processes such as corpus lu-
of 85%, positive predictive value of 87%, and rotomy [47]. For predicting resectability, MRI teum cysts or physiologic gastrointestinal ac-
negative predictive value of 100% in predict- had sensitivity of 95%, specificity of 70%, and tivity [44]. In one study, the concordance be-
ing suboptimal surgical outcome in patients accuracy of 88% compared with 55%, 86%, tween PET/CT staging and surgical staging
with advanced ovarian cancer [41, 42]. and 63%, respectively, for CT [47]. for ovarian cancer was reportedly 69% [60]. In
MRI can also detect recurrent ovarian can- other studies that used contrast-enhanced CT
MRI cer with sensitivity of 90%, specificity of 88%, as the CT component of PET/CT, the concor-
MRI provides excellent tissue differentia- and accuracy of 89% [48]. In patients with in- dance between PET/CT findings and patholog-
tion and can be used as a problem-solving creasing serum CA-125 levels and negative ic findings was reported to be as high as 78%
tool for characterization of indeterminate findings on abdominopelvic CT, MRI had [61, 62]. PET/CT can help in selection of pa-
lesions seen on CT or ultrasound. Lesions sensitivity and accuracy of 84% and specific- tients for site-specific treatment, including ra-
containing fat or blood products can be eas- ity of 100% [49, 50]. However, some studies diation treatment planning and selection of op-
ily differentiated using MRI. MRI features suggest that there is no statistically significant timal surgical candidates [63, 64].
of malignancy are similar to those seen on difference between CT and MRI for the de-
CT and ultrasound, such as cyst wall irregu- piction of recurrent ovarian cancer [51]. FIGO Staging of Ovarian Cancer 2014
larity, intramural nodules, papillary projec- Stage I
tions, septations, complex masses contain- PET/CT Stage I ovarian cancer is relatively rare be-
ing solid and cystic components, large size, PET/CT is limited in characterizing ovarian cause most patients are diagnosed in higher
and early enhancement on dynamic con- masses, but it is helpful in staging ovarian can- stages (stages III and IV), but it is associated
trast-enhanced MR images. MRI has overall cer and for detecting recurrent disease, particu- with excellent survival rates [65].
accuracy of distinguishing benign from ma-
lignant ovarian masses of 8391% [43, 44].
MRI has staging accuracy similar to con-
ventional [45] and helical [46] CT. Because
of its superior soft-tissue contrast resolution,
MRI can accurately identify invasion of pel- Fig. 549-year-old
woman with stage
vic organs [45]. Preoperative imaging of the IIIC ovarian cancer.
abdomen and pelvis plays an important role Axial T2-weighted
in determining the extent of peritoneal dis- fat-saturated
MR image shows
ease in patients who are being considered for hyperintense
cytoreductive surgery. peritoneal mass
Delayed gadolinium-enhanced imaging (arrow) in left
combined with diffusion-weighted MRI has upper quadrant
of abdomen
been shown to be a superior imaging modal- consistent with
ity to predict which patients will be able to peritoneal implant.

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Imaging of Ovarian Cancer and the Revised FIGO Staging System

TABLE 1: International Federation of Gynecology and Obstetrics (FIGO) Stage Ia Definitions


Definition of Tumor Stage
FIGO Staging System IA IB IC
1988 Tumor confined to one ovary, intact Tumor involves both ovaries, Tumor involves one or both ovaries
capsule, no tumor on surface, no otherwise like stage IA with any of the following: capsule
tumor cells in ascites or washings rupture, tumor on surface of the
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ovary, positive peritoneal washings,


or ascites
2014 Tumor confined to one ovary or Tumor involves both ovaries or fallopian IC1: Intraoperative spill
fallopian tube, intact capsule, no tubes, otherwise like stage IA IC2: Capsule rupture before surgery or
tumor on surface, no tumor cells in tumor on ovarian or fallopian tube
ascites or washings surface
IC3: Positive peritoneal washings or
ascites
aIn stage I cancer, tumor is confined to the ovaries or fallopian tubes.

TABLE 2: International Federation of Gynecology and Obstetrics (FIGO) Stage IIa Definitions
Definition of Tumor Stage
FIGO Staging System IIA IIB IIC
1988 Extension to or implant on uterus or Extension to other pelvic IIA or IIB with positive peritoneal
fallopian tubes, or some combination intraperitoneal tissues washings or ascites
thereof
2014 Extension to or implant on uterus or Extension to other pelvic Eliminated
fallopian tubes, or some combination intraperitoneal tissues
thereof
aIn stage II cancer, tumor involves one or both ovaries or fallopian tubes with pelvic extension or primary peritoneal cancer.

The most significant update in the FIGO washings (IC3) [1]. When evaluating patients disease-free survival [69, 71, 76]. Histologic
staging system for stage I ovarian cancer is with stage I ovarian cancer, radiologists must grade is given with the histotype except for
that the system now considers the fallopian remember that bilateral tumors with a unilat- endometrioid carcinoma and mucinous can-
tube and peritoneal origins of ovarian tumors eral dominant mass and contralateral multiple cers. High-grade serous, clear cell carcino-
collectively (Table 1, Fig. 2). Also, with regard or small masses may actually represent meta- mas, and high-grade endometrial carcinomas
to time and cause of capsule rupture, stage IC static disease in up to 30% of patients [66, 67]. are essentially high grade. Grade 3 endome-
has been subdivided to specify intraoperative Careful gross examination is required to trioid carcinomas are considered the same as
rupture (IC1) or preoperative rupture (IC2) assess surface involvement of the ovary. If HGSCs. Most mucinous cancers are consid-
with malignant ascites or positive peritoneal exophytic papillary tumor on the surface of ered metastatic lesions from the gastrointes-
the ovary or fallopian tube is exposed to the tinal tract and low grade [1, 77].
peritoneal cavity, then surface involvement For stage I ovarian cancer, the FIGO com-
is considered present. Tumors with a smooth mittee recommends recording histologic
surface usually do not display an exposed type, grading the tumor, and documenting
layer of neoplastic cells. stage IC cases. Tumors with dense adhesions
Capsular rupture remains a controversial containing histologically proven tumor cells
topic with regard to prognosis and the need should be upgraded to stage II. Once capsu-
for upstaging. Some studies suggest that in- lar rupture is noted, peritoneal washing and
traoperative rupture, which is often due to cytology studies should be performed [1].
dense adhesions, indicates a worse prog-
nosis and may require upstaging to stage II Stage II
[68, 69]. Other studies advocate the opposite Stage II ovarian cancer remains contro-
[7073]. In one study, both capsule rupture versial and difficult to define. At this stage,
and positive cytology were independent pre- tumor involves one or both ovaries or fallo-
dictors of decreased duration of disease-free pian tubes with direct extension, implants on
survival [74]. Some studies concluded that the surface of the uterus, implants on the fal-
Fig. 670-year-old woman with stage IIIC ovarian stage I clear cell carcinomas are often higher lopian tubes, or some combination of those
cancer. Axial CT image shows subcapsular hepatic stage (stage IC) than other cell types because features (IIA) or it extends to other pelvic in-
lesion (arrow) and nodular soft-tissue density in of increased risk of rupture [70, 75]. traperitoneal tissues (below the pelvic brim)
gastrosplenic ligament (arrowhead) consistent with
metastatic disease. Parenchymal hepatic lesion In stage I ovarian cancer, histologic grad- (IIB) (Table 2). This group makes up less
would be considered stage IV. ing is the most important factor influencing than 10% of tumors and is considered cur-

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Javadi et al.
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A B
Fig. 758-year-old woman with stage IIIC ovarian cancer.
A, Axial T2-weighted fat-saturated MR image shows hyperintense mass (arrow) at splenic hilum.
B, Axial T1-weighted contrast-enhanced MR image shows mildly enhancing mass (arrow) at splenic hilum consistent with splenic hilar implant.

able [1]. All stage II tumors are treated with static lymph nodes does not have prognostic had lower rates of overall survival when com-
chemotherapy (Fig. 3). significance in terms of overall or disease- pared with patients with a similar burden of
The controversy surrounding this stage is free survival [80]. The important factor is the peritoneal disease but without lymph node in-
separating the pelvic and extrapelvic perito- presence of lymphatic metastasis rather than volvement. This study concluded that regional
neum. Some investigators suggest peritoneal the extent of abdominal or pelvic lymph node lymph node metastasis in patients with ovar-
involvement warrants upstaging to stage III, involvement [81]. ian serous carcinoma may be a poor prognos-
arguing that the peritoneum should be con- Patients with HGSC of the ovary with me- tic indicator only if it occurs with extrapelvic
sidered a separate unit. This division is based tastasis limited to the regional lymph nodes peritoneal metastasis [82].
on anatomic location of the pelvic peritone- without extrapelvic peritoneal metastasis had Several studies have found that patients
um only. Because the sigmoid colon is within a significantly better overall survival rate with exclusively retroperitoneal lymph
the pelvis, involvement of only the sigmoid compared with patients with extrapelvic peri- node involvement have a better progno-
colon is considered stage II [1]. toneal metastasis with or without regional sis than patients with abdominal peritone-
The major change in this group was elimi- lymph node metastasis or patients with peri- al involvement, which the new staging sys-
nating stage IIC (IIA or IIB with positive find- toneal metastasis. However, these types of tem includes as stage IIIA [8388] (Table
ings from pelvic wash or ascites) (Table 2). cancer were upstaged to IIIC in the old FIGO 3). The new category is further subdivid-
Because of the clear distinction between stage staging system on the basis of lymph node in- ed into stage IIIA1(i), in which metastasis
II and III disease in terms of survival, the sub- volvement despite their significantly better is 10 mm or smaller in greatest dimension,
division of IIA and IIB remains the same. overall survival rate. Also, one study showed and stage IIIA1(ii), in which metastasis is
that patients with extrapelvic peritoneal dis- larger than 10 mm in greatest dimension.
Stage III ease and additional lymph node metastasis However, this subdivision does not appear
Stage III tumor involves one or both ova-
ries with cytologically or histologically con-
firmed spread to the peritoneum outside the
pelvis, metastasis to retroperitoneal lymph
nodes, or both. The majority of ovarian can-
cers present as stage III (84% are stage IIIC)
and are HGSCs [78].
The lymphatic drainage of the ovaries oc-
curs through the uteroovarian and round lig-
ament trunks as well as by an external iliac Fig. 849-year-old
accessory route into the following regional woman with recurrent
ovarian cancer. Axial
nodes: external iliac, common iliac, hypo- T2-weighted, with fat
gastric, lateral sacral, and paraaortic nodes, suppression MR image
with occasional spread to inguinal nodes [78] shows hyperintense
(Fig. 4). Lymph node metastases are found mass (arrow) in
gastrohepatic ligament
in up to 78% of patients with an advanced consistent with
stage of cancer [79]. The number of meta- metastatic implant.

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Imaging of Ovarian Cancer and the Revised FIGO Staging System

TABLE 3: International Federation of Gynecology and Obstetrics (FIGO) Stage IIIa Definitions
Definition of Tumor Stage
FIGO Staging System IIIA IIIB IIIC
1988 Microscopic metastasis beyond the Macroscopic, extrapelvic, peritoneal Macroscopic, extrapelvic, peritoneal
pelvis metastasis 2 cm in greatest metastasis > 2 cm with or without
dimension regional lymph node metastasis
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2014 IIIA1(i): Metastasis of 10 mm to the Macroscopic, extrapelvic, peritoneal Macroscopic, extrapelvic, peritoneal
retroperitoneal lymph nodes metastasis 2 cm with or without metastasis > 2 cm with or without
IIIA1(ii): Metastasis of > 10 mm to the involvement of retroperitoneal lymph involvement of retroperitoneal lymph
retroperitoneal lymph nodes nodes (includes extension to capsule nodes (includes extension to capsule
IIIA2: Microscopic, extrapelvic of liver or spleen) of liver or spleen)
peritoneal involvement (above the
brim) with or without involvement of
retroperitoneal lymph nodes
aIn stage III cancer, tumor involves one or both ovaries or fallopian tubes with involvement of the peritoneum outside the pelvis, metastasis to the retroperitoneal lymph

nodes, or both.

TABLE 4: International Federation of Gynecology and Obstetrics (FIGO) Stage IV Definitions


Definition of Tumor Stage
FIGO Staging System IV IVA IVB
1988 Distant metastasis excluding NA NA
peritoneal metastasis but including
hepatic or splenic parenchymal
metastasis
2014 NA Pleural effusion with positive cytology Distant metastasis including
parenchymal metastasis to liver,
spleen, or extraabdominal organs
NoteNA = not applicable.

to be supported by published data [1]. The giosis, which have more favorable prognoses considered stage IIIC disease. However, the
size criterion used to divide the IIIA tu- [89, 90] and may not behave in the same way 2-cm size cutoff of peritoneal metastases be-
mors represents the size of the metastasis as higher-grade tumors [91]. tween stage IIIB and IIIC is subjective and
within the lymph node and not the overall The extent of peritoneal involvement in not evidence-based [77] (Fig. 5).
lymph node size [2]. It is important to re- patients with ovarian carcinoma is a strong Extension of peritoneal disease to the cap-
member that involvement of retroperitoneal prognostic indicator [92, 93]. Regarding the sule of the liver or spleen is considered stage
lymph nodes must be proven cytologically amount of peritoneal involvement, the pres- IIIC and should be differentiated from isolat-
or histologically. ence of microscopic (stage IIIA2) versus ed parenchymal metastases to these organs
One of the controversies in patients with macroscopic (stage IIIB) disease should be (stage IVB) (Figs. 68). Because isolated pa-
exclusive involvement of retroperitoneal distinguished. Also, the size of peritoneal renchymal metastasis to the liver or spleen
nodes is that these nodes may actually repre- metastases is important; peritoneal metasta- is amenable to cryoreductive surgery, some
sent serous borderline tumor and low-grade ses of 2 cm or smaller indicates stage IIIB, investigators suggest these cases should be
serous carcinoma arising from endosalpin- and peritoneal metastases larger than 2 cm is considered stage IIIC as well.

Fig. 968-year-old woman with recurrent ovarian


cancer.
A, Axial T2-weighted MR image shows
heterogeneous implant (arrowhead) involving right
vaginal apex. Internal hyperintense component
(arrow) represents area of necrosis.
B, Sagittal T2-weighted MR image shows lobulated
heterogeneous mass (arrow) involving vaginal apex
with areas of necrosis.
A B

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Javadi et al.

Fig. 1067-year-old Cramer D. Rates and risks of ovarian cancer in


woman with stage subgroups of white women in the United States.
IVB high-grade serous
Obstet Gynecol 1994; 84:760764
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Axial CT image shows 6. Ford D, Easton D, Bishop D, Narod S, Goldgar D.
left malignant pleural Risk of cancer in BRCA-1 mutation carriers.
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