The organs of the true pelvis are the bladder, ureters, urethra, uterus, fallopian tubes, ovaries, vagina and rectum.
The adnexa include the ovaries, fallopian tubes, supporting ligaments of internal genitalia (round, broad).
Both ovaries are commonly found to be involved simultaneously. The pathology report will state whether these are concurrent primaries or if tumor in one ovary has metastasized to the other. If this information is not apparent from the pathology report, it needs to be clarified, because it does affect staging.
Bilateral involvement of ovaries with the same histology is considered a single primary site.
The operative report and the pathology report should be reviewed carefully for indications of whether the ovarian capsule was ruptured. Note whether the rupture was spontaneous or caused by the surgeon.
If the operative report states that the adnexa were palpated but gives no mention of nodes, assume that the lymph nodes are negative.
If exploratory or definitive surgery is performed and lymph nodes are not mentioned in the operative report, assume that the lymph nodes are negative.
If a resection of one ovary is done for diagnosis and a more complete procedure, such as resection of the other ovary, is done as cancer directed surgery, code the more complete surgical procedure. If a left oophorectomy was done in the past for a previous primary or other problem and a right oophorectomy is now being performed for a new primary, code the current procedure as bilateral oophorectomy. The surgical code should indicate the status of the primary organ at the completion of the procedure.
Seeding, implants, and tumor nodules in the omentum, peritoneum or on the diaphragm are considered distant disease.
Size of tumor is not applicable to ovarian cancer; record 999 in the field "Size of Tumor."
For TNM staging purposes, it is important to determine whether liver metastases are surface or parenchymal (in the central tissue of the organ). Surface or capsule liver metastases are coded to T3; internal liver metastases are hematogenous in nature and are coded M1 (Stage IV).
Both pleural effusion and ascites must be cytologically proven to have an effect on TNM staging.
If tumor is identified in an ovarian cyst (a low stage tumor), the size of the tumor should be recorded, not the size of the cyst.
Endometrioid carcinoma may be primary in the ovary. It should not be coded as metastatic from the endometrium, nor should the endometrium be coded as a metastatic site unless histologically proven.
FIGO is the acronym for the French term that means International Federation for Gynecology and Obstetrics. The American Joint Committee on Cancer has developed the tumor (T) component of the TNM staging system to correspond to FIGO staging.
Residual disease after debulking refers to the size of the largest tumor mass left in the pelvis and abdomen. In other words, a 1 cm residual means that the largest of any remaining tumor nodules is 1 cm. Residual tumor may be described as minimal (1 cm or less) or macroscopic (over 1 cm).
Fallopian tube carcinoma may be determined to be primary only if tumor is confined to the tube and any ovarian involvement is on the surface.
Stage II confined to pelvis
Structures in the pelvis
- Bladder, bladder serosa
- Sigmoid colon; sigmoid mesentery
- Uterus; uterine serosa
- Fallopian tubes
- Pelvic wall
- Cul de sac
- Broad ligament (mesovarium)
- Pelvic peritoneum
- Adnexae, NOS
Stage III spread to the abdomen
Structures in the abdomen
- Liver (peritoneal surface)
- Small intestine
- Large intestine except rectum and sigmoid colon
- Kidneys; ureters
- Peritoneum, NOS
- Abdominal mesentery
- Retroperitoneal lymph nodes
- Infracolic omentum
- Pericolic gutter