What is the standard approach for staging and treating ovarian tumors in a patient with a suspected ovarian tumor?

Staging of Ovarian Tumors

Ovarian tumor staging requires comprehensive surgical staging via midline laparotomy with systematic evaluation of the entire abdomen, and the FIGO staging system guides all subsequent treatment decisions. 1

Pre-Operative Evaluation

Before surgery, obtain the following mandatory workup 1:

• Abdomino-pelvic CT scan to assess disease extent 1
• Chest X-ray to evaluate for pleural involvement 1
• Serum CA-125 as a baseline tumor marker 1
• Complete blood count with differential 1
• Renal and hepatic function tests 1

Surgical Staging Requirements

Standard Staging Procedure

All suspected ovarian malignancies require comprehensive surgical staging through a midline (para-median) incision, not laparoscopy, unless performed by highly experienced endoscopic surgeons. 1, 2

The complete staging procedure must include 1, 2:

• Peritoneal washings or ascitic fluid collection for cytological examination 1
• Thorough exploration and palpation of the entire abdominal cavity 1
• Infracolic omentectomy (complete removal of the omentum below the transverse colon) 1
• Appendectomy (mandatory component of staging) 1, 2
• Multiple peritoneal biopsies from diaphragm, paracolic gutters, and pelvic peritoneum 1
• Biopsies of all visible lesions 1
• Assessment of pelvic and para-aortic lymph nodes 1

Lymphadenectomy Considerations

The approach to lymphadenectomy depends critically on histologic subtype 2:

• For high-grade serous and infiltrative-type mucinous carcinoma: Perform systematic pelvic and para-aortic lymphadenectomy 2
• For expansile-type mucinous carcinoma with radiologically and clinically negative nodes: Lymphadenectomy can be omitted (lymph node metastasis rate <1%) 2
• For sex cord-stromal tumors: Retroperitoneal evaluation is not mandatory due to very low incidence of nodal metastases in early stage 1
• For granulosa cell tumors: Endometrial curettage must be performed to rule out concomitant uterine cancer 1

Critical caveat: If trochar tracks were used during diagnostic laparoscopy, these must be resected during the staging laparotomy 1

FIGO Staging Classification

The FIGO staging system is used universally 1:

Stage I - Limited to ovaries 1:

• Ia: One ovary only 1
• Ib: Both ovaries 1
• Ic: Ruptured capsule, surface tumor, or positive washings 1

Stage II - Pelvic extension 1:

• IIa: Extension to uterus or fallopian tube(s) 1
• IIb: Extension to other pelvic tissues 1
• IIc: Positive washings or ascites 1

Stage III - Abdominal extension and/or regional lymph nodes 1:

• IIIa: Microscopic peritoneal metastases 1
• IIIb: Macroscopic peritoneal metastases <2 cm 1
• IIIc: Macroscopic peritoneal metastases >2 cm and/or regional lymph nodes 1

Stage IV - Distant metastases outside peritoneal cavity 1

Importance of Complete Staging

Incomplete staging leads to significant undertreatment: 31-60% of patients with apparent early ovarian cancer are upstaged after complete surgical staging, and 77% of upstaged patients actually have stage III disease. 2 This upstaging directly determines whether adjuvant chemotherapy is needed and significantly impacts survival outcomes 2.

Surgical Approach by Stage

Early Stage Disease (FIGO I and IIa)

For post-menopausal women or those not desiring fertility 1:

• Total abdominal hysterectomy 1
• Bilateral salpingo-oophorectomy 1
• Omentectomy 1
• Complete staging biopsies as described above 1
• At least pelvic/para-aortic lymph node sampling 1

For young patients desiring fertility preservation with stage I, unilateral, favorable histology tumors 1:

• Unilateral salpingo-oophorectomy may be performed 1
• Wedge biopsy of contralateral ovary if not normal on inspection 1
• Complete staging procedure still mandatory 1
• Hysteroscopy and endometrial curettage required 1

Important upstaging rule: FIGO stage I tumors with dense adhesions to pelvic structures should be upstaged and treated as FIGO II tumors due to similar relapse rates 1

Advanced Disease (FIGO IIb-IV)

The surgical goal shifts from staging to maximal cytoreductive surgery with the objective of achieving no residual disease (R0 resection). 1, 2 Patients without residual disease or minimal residue have significantly better survival than those with suboptimal cytoreduction 1.

Standard surgery includes 1:

• Total abdominal hysterectomy 1
• Bilateral salpingo-oophorectomy with complete excision of lumbar-ovarian vessels 1
• Complete infragastric omentectomy 1
• Appendectomy 1
• Resection of all visible disease, which may require bowel resection, peritoneal stripping, or other ultra-radical procedures 1

For stage IV disease: Maximal surgical cytoreduction at initial laparotomy provides survival advantage even in metastatic disease 1. Young patients with good performance status, pleural effusion as only extra-abdominal site, small volume metastases, and no major organ dysfunction should be considered for aggressive cytoreductive surgery 1.

Post-Operative Treatment by Stage

Early Stage (Ia/Ib, well-differentiated, non-clear cell)

Surgery alone is adequate—no adjuvant chemotherapy needed. 1

Early Stage Requiring Chemotherapy

For stage Ia/Ib poorly differentiated, densely adherent, clear cell histology, and all grades of stage Ic and IIa: Adjuvant chemotherapy with carboplatin AUC 5-7 is recommended 1, 3

Advanced Disease (IIb-IIIc)

Standard chemotherapy is carboplatin AUC 5-7.5 plus paclitaxel 175 mg/m² over 3 hours every 3 weeks for 6 cycles. 1, 3

If initial maximal cytoreduction was not achieved: Interval debulking surgery (IDS) should be considered after 3 cycles of chemotherapy in patients responding or with stable disease, followed by 3 additional cycles 1

Common Pitfalls to Avoid

• Never perform inadequate staging surgery: This is the most critical error, leading to undertreatment in up to 60% of cases 2
• Do not perform "second-look" surgery after completion of chemotherapy in patients in complete remission outside of clinical trials—there is no survival benefit 1
• Avoid laparoscopy for staging unless performed by highly experienced surgeons; midline laparotomy is standard 1, 2
• Do not omit appendectomy, especially for mucinous tumors where appendiceal primaries must be excluded 1, 2
• Never use aluminum-containing needles or IV sets when administering carboplatin, as aluminum causes precipitate formation and loss of potency 3

Prognostic Factors

Beyond surgical stage, established prognostic factors include 1:

• Small tumor volume before and after surgery 1
• Younger age 1
• Good performance status 1
• Cell type other than mucinous or clear cell 1
• Well-differentiated tumor 1
• Absence of ascites 1