Ovarian Cancer Stages: FIGO 2014 Explained

Ovarian cancer staging in India follows the FIGO 2014 system, which sits one to one with the AJCC TNM eighth edition. This guide explains what each FIGO stage of ovarian cancer means, how stage is finalised in the operating theatre rather than on a scan, and what treatment looks like stage by stage at tertiary centres in Delhi, Gurgaon and Noida. It is written for patients and families who have just heard the words ovarian, fallopian tube or primary peritoneal cancer and want a clear picture before the next appointment [1][2].

Staging describes how far an ovarian, fallopian tube or primary peritoneal cancer has travelled from its starting point at the moment of diagnosis. Because the ovaries lie deep in the pelvis with no serosal barrier to the peritoneal cavity, ovarian cancer sheds cells onto peritoneal surfaces early, which is why imaging alone cannot finalise stage. The definitive FIGO stage is assigned after a laparotomy or laparoscopy in which the surgeon inspects the pelvis and abdomen, washes the peritoneal cavity for cytology, samples the omentum and biopsies suspicious peritoneal surfaces [1][9].

In epithelial ovarian cancer, FIGO stage is the single strongest driver of whether treatment is curative, debulking with adjuvant chemotherapy, or maintenance for life. A stage IA grade 1 endometrioid tumour in a young woman is treated very differently from stage IIIC high-grade serous disease with omental caking. The stage label is not just a number on a report; at Indian tumour boards it decides whether the patient walks into upfront surgery, neoadjuvant chemotherapy, a fertility-sparing pathway or a maintenance trial [2][9][12].

The 2014 FIGO system divides ovarian, fallopian tube and primary peritoneal cancer into four stages, each with substages that capture clinically meaningful detail. Stage I is confined to the ovaries or tubes. Stage II is pelvic extension. Stage III is peritoneal disease beyond the pelvis or retroperitoneal nodes. Stage IV is distant spread including pleural effusion with positive cytology, liver or splenic parenchymal involvement and inguinal nodes. FIGO 2014 corresponds one to one with AJCC TNM eighth edition, and is the system used by leading cancer centres [1][12].

The AJCC TNM eighth edition mirrors FIGO. T1 matches FIGO I, T2 matches FIGO II, T3 covers peritoneal disease beyond the pelvis or retroperitoneal nodes (FIGO III), and any M1 disease is FIGO IV. N1a denotes retroperitoneal nodes up to 10 mm and N1b nodes larger than 10 mm, which feed directly into the FIGO IIIA1 subdivisions. Indian pathology reports usually quote both labels side by side, so understanding the mapping helps a patient read their own histopathology report without a translator [1][12].

Ovarian cancer is not one disease. High-grade serous carcinoma is the commonest epithelial subtype, almost always TP53-mutated, frequently BRCA1 or BRCA2 altered, and accounts for most stage III and IV presentations. Low-grade serous carcinoma is slower, MAPK pathway driven and less platinum responsive. Endometrioid and clear cell carcinomas are more often caught at stage I and linked to endometriosis. Mucinous ovarian carcinoma at advanced stage is usually a metastasis from a gastrointestinal primary, which is why a colonoscopy is part of the workup. Germ cell and sex cord-stromal tumours follow their own behaviour and are usually curable even when advanced [1][2].

Stage I ovarian cancer is limited to one or both ovaries or fallopian tubes. Stage IA is one ovary with an intact capsule and negative washings. IB involves both ovaries with intact capsules. IC is subdivided by why the stage was upgraded: IC1 is surgical spill at the time of operation, IC2 is preoperative capsule rupture or tumour on the ovarian surface, and IC3 is malignant cells in ascites or peritoneal washings. The IC subdivisions matter because IC3 in particular carries a higher relapse risk and is generally treated with adjuvant carboplatin and paclitaxel chemotherapy [1][12].

Stage II disease has spread within the true pelvis but not beyond it. IIA involves the uterus or the fallopian tubes themselves. IIB extends to other pelvic peritoneal tissues such as the bladder serosa, the sigmoid serosa or the pelvic sidewall. Stage II is uncommon at first diagnosis in Indian cohorts because most ovarian cancers either present early when still confined to one ovary or have already crossed the pelvic brim onto the omentum by the time symptoms become unignorable. Stage II disease is treated with surgery followed by six cycles of carboplatin and paclitaxel [1][9].

Stage III is the commonest stage at presentation in India. IIIA1 is positive retroperitoneal nodes only, with IIIA1(i) up to 10 mm and IIIA1(ii) larger than 10 mm. IIIA2 is microscopic extrapelvic peritoneal involvement with or without positive nodes. IIIB is macroscopic peritoneal disease 2 cm or smaller beyond the pelvis. IIIC is macroscopic peritoneal disease larger than 2 cm beyond the pelvis, including extension to the capsule of the liver or spleen without parenchymal invasion. Most Indian patients fall into IIIC at first presentation, often with omental caking visible on the staging CT [1][5].

Stage IV is distant spread. IVA is a malignant pleural effusion with positive cytology, not just the presence of an effusion on the chest film. IVB is parenchymal liver or splenic metastasis, or spread to extra-abdominal organs including inguinal lymph nodes and any nodes outside the abdominal cavity. A stage IV patient may first reach a pulmonologist with breathlessness or a gastroenterologist with subacute bowel obstruction, and the ovarian primary is identified only on cross-sectional imaging. Capsule rupture during surgery upgrades a stage I tumour to IC1 and is not stage II, which is a common point of confusion when patients read their reports [1][12].

Early ovarian cancer is famously quiet. Stage I disease is often picked up incidentally on a pelvic scan ordered for fibroids or infertility, or during surgery for what was thought to be a benign cyst. When stage I and II symptoms do appear they are vague: dull pelvic ache, fullness after small meals, mild bloating that does not settle with diet, urinary frequency without infection. By stage III, ascites is common, the waistband no longer fits and weight loss appears in the face of a distended belly. A stage IV pleural effusion presents as breathlessness on exertion that worsens over weeks [4][5].

Germline BRCA1 and BRCA2 mutations raise lifetime ovarian cancer risk to roughly 40 percent and 15 percent respectively. Patients from known BRCA families who enter surveillance or risk-reducing salpingo-oophorectomy programmes present earlier, often at stage I, compared with sporadic cases. Lynch syndrome, caused by mismatch repair gene mutations, is a smaller but real contributor and is associated with endometrioid and clear cell histologies. Nulliparity, early menarche, late menopause and long uninterrupted ovulatory cycles raise risk modestly. Five years or more of combined oral contraceptive use lowers it. Endometriosis raises the risk of clear cell and endometrioid subtypes [4][5][8].

Roughly seven in ten Indian patients are first diagnosed at FIGO stage III or IV, a pattern that has held steady across ICMR hospital-based cancer registries for the last decade. The dominant reason is the absence of an effective population screening tool. Transvaginal ultrasound and CA-125 together failed to reduce ovarian cancer mortality in the long-term UKCTOCS analysis, which is why no major guideline body, including ICMR, recommends general population screening. Only women with a germline predisposition or a strong family history are offered surveillance, and most Indian women with BRCA mutations still do not know they carry one [4][5].

A patient with bloating, ascites, a pelvic mass or unexplained weight loss is taken through a defined sequence. The first investigation is a transvaginal and transabdominal ultrasound, which characterises the mass as solid, cystic or mixed and looks for ascites, papillary projections and bilateral involvement. A serum CA-125 is drawn at the same visit, with HE4 added where available to calculate the ROMA score. CEA and CA 19-9 are added when imaging suggests a possible gastrointestinal primary, and AFP, beta-a leading cancer centre and LDH are added for women under 40 to screen for germ cell histology [1][9].

CA-125 is the workhorse marker in epithelial ovarian cancer but it is neither sensitive nor specific enough on its own to confirm or exclude malignancy. HE4 is a complementary glycoprotein elevated in epithelial ovarian cancers, particularly serous and endometrioid subtypes, and is less affected by benign gynaecological conditions than CA-125. The Risk of Ovarian Malignancy Algorithm combines CA-125, HE4 and menopausal status to estimate the probability that a pelvic mass is malignant, which helps decide whether a patient should be operated by a gynaecological oncologist at a tertiary centre rather than at a general gynaecology unit [1][9].

A contrast-enhanced CT of the chest, abdomen and pelvis is the standard staging scan. It maps the disease, looks for omental caking, peritoneal nodules, retroperitoneal nodal involvement, liver surface deposits and pleural effusion, and helps the surgeon judge whether complete cytoreduction is achievable upfront. MRI of the pelvis is reserved for cases where the CT is equivocal about the origin of the mass. PET-CT is not part of routine first staging but is used selectively when extra-abdominal disease is suspected, when the CA-125 is rising in follow-up without a clear CT correlate, or when planning interval surgery after neoadjuvant chemotherapy [1][9].

Definitive staging in ovarian cancer is surgical. The operation, whether by laparotomy or laparoscopy, includes inspection of the pelvis and the entire abdomen, peritoneal washings for cytology, total hysterectomy and bilateral salpingo-oophorectomy, infracolic or total omentectomy, biopsies of any suspicious peritoneal surfaces, and pelvic and para-aortic lymph node sampling where indicated. In a patient with bulky stage IIIC or IV disease where upfront cytoreduction would be unsafe, an image-guided core biopsy of an omental or peritoneal nodule is preferred to ascitic fluid cytology because a core sample preserves architecture and allows immunohistochemistry and BRCA testing on tissue [1][6].

Stage IA and IB grade 1 endometrioid or low-grade serous tumours in a woman who has completed her family are treated with total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal washings and staging biopsies, with no adjuvant chemotherapy. Stage IC, stage II and any high-grade stage I tumour are taken to surgery and then to adjuvant carboplatin AUC 5 to 6 with paclitaxel 175 mg per square metre every three weeks for six cycles. The GOG-157 trial established that six cycles are not clearly better than three for early stage disease, but six cycles remain standard for high-grade serous histology [1][9].

A young woman with stage IA grade 1 epithelial ovarian cancer who wants to preserve fertility can be offered unilateral salpingo-oophorectomy with comprehensive staging, leaving the uterus and the contralateral ovary in place, followed by close surveillance and completion surgery after childbearing. Germ cell tumours, which most often present in adolescents and young women, are routinely managed with fertility-sparing surgery and BEP chemotherapy with cure rates above 90 percent even when advanced. Decisions about fertility preservation are best made in a tertiary centre with a gynaecological oncologist and a reproductive medicine specialist working together [1][9].

Primary debulking surgery aims to remove all visible disease. The volume of residual disease left behind at the end of the operation is the strongest modifiable prognostic factor in stage III and IV epithelial ovarian cancer. A complete cytoreduction to no visible residual is the goal, accepted as the standard at leading cancer centres in the region and other Indian gynaecological oncology units. The operation may include bowel resection, diaphragm stripping, splenectomy and partial peritonectomy, which is why it is reserved for fit patients with disease judged resectable on the staging CT and at examination under anaesthesia [1][6][9].

Neoadjuvant chemotherapy with three cycles of carboplatin and paclitaxel followed by interval debulking surgery and three more cycles is an accepted alternative to upfront surgery for bulky stage IIIC and IV disease, supported by the EORTC 55971 and CHORUS trials. Both trials showed equivalent overall survival with lower perioperative morbidity in patients who could not be safely cytoreduced at presentation. The decision between primary debulking and neoadjuvant chemotherapy rests on a joint review by a gynaecological oncology surgeon and a medical oncologist, taking into account the CT findings, performance status, comorbidities and nutritional state [6][7].

Six cycles of intravenous carboplatin AUC 5 to 6 with paclitaxel 175 mg per square metre every three weeks is the backbone of first-line treatment across all stages from IC onwards. Dose-dense weekly paclitaxel was studied in the Japanese JGOG 3016 trial with promising results that were not replicated in the larger ICON8 and GOG-262 trials, so three-weekly dosing remains the default in Indian practice. Carboplatin is preferred over cisplatin for tolerability. Premedication with steroids and antihistamines, growth factor support where indicated, and routine bloodwork between cycles are part of every Indian day-care unit protocol [1][9].

Bevacizumab at 7.5 to 15 mg per kilogram every three weeks added to first-line chemotherapy and continued as maintenance prolongs progression-free survival in stage IIIC and IV disease, established by the GOG-218 and ICON7 trials. The benefit is largest in the highest-risk subgroup with bulky residual disease or stage IV disease. Indian-manufactured biosimilar bevacizumab has cut the cost of fifteen months of maintenance by roughly half over the last three years, which has made the regimen reachable for more patients in private and PMJAY-funded settings across the National Capital Region [11][15].

Maintenance after first-line chemotherapy is now defined by BRCA and HRD status. Patients with a germline or somatic BRCA1 or BRCA2 mutation are offered olaparib maintenance for two years on the basis of SOLO-1, which showed a hazard ratio for progression of 0.30. Patients without a BRCA mutation but with homologous recombination deficiency are offered olaparib plus bevacizumab on the basis of PAOLA-1, or niraparib monotherapy on the basis of PRIMA. Patients who are HRD-negative still derive a smaller benefit from niraparib maintenance, although the magnitude is debated. Generic olaparib and patient assistance programmes have made these options accessible in India [8][16][17].

Hyperthermic intraperitoneal chemotherapy at the time of interval debulking is an option supported by the OVHIPEC trial, which randomised stage III patients undergoing interval surgery and showed an overall survival benefit with the addition of HIPEC to standard cytoreduction. Uptake in India is uneven and limited to a handful of centres in Delhi, Mumbai, Bangalore and Chennai that have invested in the perfusion equipment and trained nursing teams. HIPEC is not appropriate for every patient; the decision rests on disease distribution, patient fitness, surgeon experience and the resources of the centre offering it [10].

Platinum-sensitive recurrence is defined as relapse more than six months after the last platinum dose and is treated with platinum doublet rechallenge, commonly carboplatin with pegylated liposomal doxorubicin per the CALYPSO regimen, or carboplatin with gemcitabine, with bevacizumab added per OCEANS and PARP inhibitor maintenance after response per Study 19, SOLO-2 and NOVA. Platinum-resistant recurrence is treated with single agent weekly paclitaxel, pegylated liposomal doxorubicin or topotecan, with bevacizumab where not previously used, supported by the AURELIA trial. Mirvetuximab soravtansine, an antibody-drug conjugate, is becoming available in select Indian centres for FRalpha-high platinum-resistant disease [8][9][12].

Staging laparotomy with hysterectomy, bilateral salpingo-oophorectomy and omentectomy runs roughly Rs 1.2 to 2.5 lakh at a tertiary cancer centre and other government tertiary units, Rs 2.5 to 5 lakh at mid-tier private hospitals, and Rs 5 to 9 lakh at corporate centres. Primary or interval debulking for advanced disease runs Rs 2 to 4 lakh in government settings and Rs 6 to 14 lakh in private corporate hospitals. Six cycles of carboplatin and paclitaxel run Rs 60,000 to 1.2 lakh at government hospitals and Rs 2.5 to 5 lakh at private hospitals. Bevacizumab maintenance adds Rs 8 to 18 lakh; PARP inhibitor maintenance ranges from Rs 8 lakh on a generic with assistance to Rs 40 lakh at originator MRP. PMJAY covers the surgical and chemotherapy components within scheme rates [3][11].

Is ovarian cancer curable if caught early? Stage IA and IB grade 1 disease has a five-year survival above 90 percent with surgery alone. Fewer than one in five Indian patients present at this stage because early symptoms are vague [4][13]. Why was I told I need chemotherapy before surgery? Neoadjuvant chemotherapy is offered when imaging suggests upfront removal of all visible disease is unlikely or when a patient is not fit for a long operation, supported by EORTC 55971 and CHORUS [6][7]. What does BRCA testing change for me? A BRCA1 or BRCA2 mutation makes a patient eligible for olaparib maintenance after first-line chemotherapy, which roughly halves the risk of progression at three years per SOLO-1 [8]. Does Ayushman Bharat cover ovarian cancer treatment? PMJAY covers surgery and chemotherapy within scheme rates at empanelled hospitals across Delhi, Gurgaon and Noida; PARP inhibitor maintenance is generally not within the package and is funded through patient assistance programmes [3][11]. Can I have HIPEC at my hospital? HIPEC is offered at a small number of NCR centres and is supported by the OVHIPEC trial in the interval debulking setting [10].

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