The "Great Physicians' Benevolence · The 5th Greater Bay Area China-Foreign Ovarian Cancer Academic Conference" lasted for three days, bringing together top experts and scholars in the fields of gynecologic oncology and ovarian cancer from domestic and international institutions. Focusing on core difficulties and international frontier advances in the full-cycle diagnosis and treatment of ovarian cancer, the conference conducted comprehensive, multi-dimensional, and in-depth academic sharing and discussions through live surgery broadcasts, academic lectures, and hot topic debates. This resulted in a deep collision of technology and concepts, presenting an intellectual feast that combines clinical value with forward-looking vision.

During the conference, Obgy had the honor of inviting Prof. Anita Y.N. Cheung from the University of Hong Kong Li Ka Shing Faculty of Medicine, Queen Mary Hospital, to share her expert insights regarding the evolution of the FIGO staging guidelines for ovarian cancer.

OBGY: From its early versions to the present day, what do you consider to be the core factors driving the continuous revision and refinement of the ovarian cancer FIGO staging guidelines? Among these evolutions, which landmark changes in staging criteria have had the most profound impact on clinical practice?

Prof. Anita Y.N. Cheung: The core value of ovarian cancer FIGO staging lies in its direct determination of patient prognosis assessment and treatment strategy formulation. This requires us to clearly understand the dissemination pathways of ovarian cancer and their corresponding survival outcomes to implement proper individualized treatment.

Looking back at its evolution, the 1973 staging primarily established the basic framework for ovarian cancer spread: Stage I was confined to the primary tissue (e.g., ovary), Stage II spread to the pelvis, Stage III involved the peritoneum and upper abdomen, and Stage IV indicated distant metastasis; at that time, Stage III already included retroperitoneal lymph node metastasis. With the accumulation of clinical evidence, the 1988 staging system saw its first major refinement. It introduced A, B, and C subgroups for Stage I. Initially, Stage IC was defined only by the presence of ascites, but it was subsequently discovered that tumor rupture was also a key factor for poor prognosis and was thus included in Stage IC. Furthermore, it was strictly required that cancer cells be identified in the ascitic fluid for diagnosis. Meanwhile, perceptions regarding Stage IV thoracic metastasis changed; previously, both pleural effusion and lung parenchymal metastasis were classified as Stage IV. However, given that patients with positive pleural cytology alone have a significantly better prognosis than those with lung parenchymal metastasis, this distinction prompted a reclassification. The 1988 revision further subdivided Stage IC into intraoperative rupture (IC1, relatively best prognosis) versus preoperative rupture or malignant ascites (IC2).

In 2014, the FIGO staging underwent a more profound transformation, mainly reflected in four aspects:

2. Refinement of IC: Stage IC was further stratified, confirming that intraoperative rupture (IC1) has a better prognosis than IC2 and IC3.

3. Simplification of Stage II: The classification of Stage II was simplified by removing the original IIC stage (ascites was no longer used as an independent staging criterion), as studies showed that in cases with pelvic organ involvement (2A, 2B), the presence of ascites did not significantly affect prognostic stratification.

4.Major Structural Adjustment in Stage III: Recognizing that the prognosis of retroperitoneal lymph node metastasis is actually better than that of peritoneal metastasis, the system was adjusted. Lymph node metastasis was downgraded from the original IIIC to IIIA (now termed IIIA1), subdivided based on lesion size into ≤10mm (IIIA1(i)) and >10mm (IIIA1(ii)). Meanwhile, the original IIIA and IIIB micro- or macro-peritoneal metastases were reclassified sequentially as IIIA2, IIIB, and IIIC. Additionally, the 2014 staging clarified that inguinal lymph node metastasis should be classified as Stage IV as it lies outside the peritoneal cavity.

Behind these dynamic adjustments lies the ever-increasing body of evidence-based medicine that continuously refines our understanding of prognostic factors—factors once considered extremely poor (like isolated lymph node metastasis) were found to have relatively favorable survival outcomes. Therefore, precise staging is not only a basis for predicting survival but also the cornerstone of guiding clinical decisions. This also highlights the importance of comprehensive surgical staging: if one merely satisfies oneself with removing visible ovarian masses without systematic exploration of the peritoneum, omentum, and lymph nodes, a case appearing to be IA could jump to Stage III upon discovery of missed lymph nodes or microscopic peritoneal metastases postoperatively, changing the treatment plan from surgery alone to surgery combined with adjuvant chemotherapy. This vividly illustrates how the staging system directly impacts treatment.

OBGY: Combined with FIGO staging, what are the core differences in surgical options for ovarian cancer across different stages? For instance, regarding comprehensive staging surgery in early-stage patients versus debulking surgery in advanced patients, how can surgical strategies be optimized in conjunction with staging?

Prof. Anita Y.N. Cheung: FIGO staging for ovarian cancer has a decisive influence on surgical decision-making. Since ovarian cancer staging is essentially based on surgical pathology rather than relying solely on imaging or clinical assessment, this must be fully considered when formulating surgical plans. Even if imaging shows only an ovarian mass appearing early-stage, communication with the patient must clearly state that the surgical scope is by no means limited to total hysterectomy and bilateral salpingo-oophorectomy; it must include a complete set of staging procedures—systematic resection of pelvic and para-aortic lymph nodes, the omentum, and random biopsies of pelvic and abdominal peritoneum. This is because the typical dissemination pathway of ovarian cancer involves the flow of ascites within the abdomen, spreading from the pelvis to the abdomen, subdiaphragm, and back; therefore, thorough exploration and resection of the pelvis, omentum, and lymph nodes along the lymphatic routes are necessary to definitively determine whether the tumor is confined to Stage I or has progressed to Stage II or III.

The significance of this precise staging is directly reflected in treatment strategies: if confirmed as very early-stage IA, the patient may not require postoperative chemotherapy; however, once Stage III (e.g., IIIA1 lymph node metastasis) is confirmed, postoperative adjuvant chemotherapy or combined targeted therapy must be arranged immediately. For patients where imaging or clinical findings clearly suggest advanced disease preoperatively, the surgical goal shifts to "cytoreductive surgery," with the core principle being the removal of all visible lesions to achieve the best prognosis and chemotherapeutic response. Thus, preoperative assessment of the feasibility of achieving optimal debulking is crucial. If extensive distant metastasis (e.g., late-stage lung metastasis) or poor physical condition is found, forcing surgery may yield no benefit. In such cases, a neoadjuvant chemotherapy strategy should be chosen—administering 2-3 cycles of chemotherapy first to shrink the tumor before performing interval debulking surgery, followed by completion of chemotherapy and targeted therapy.

Although this "chemotherapy-first, then surgery" strategy offers the greatest survival advantage, it poses challenges for staging accuracy and subsequent molecular testing. On one hand, tumors often undergo necrosis after chemotherapy, making it difficult to obtain sufficient tissue samples for precise pathological subtype review postoperatively. On the other hand, essential BRCA and HRD genetic testing in current clinical practice may be limited by insufficient preoperative biopsy sample volume. While cytology or histology must confirm the diagnosis of ovarian, fallopian tube, or peritoneal cancer before initiating chemotherapy, the limited sample size indeed constitutes a practical difficulty in the precise treatment of advanced ovarian cancer.

OBGY: For gynecologists in primary healthcare institutions, what misconceptions do you think are most likely to occur when mastering and applying the FIGO staging guidelines? What specific guidance or suggestions can help them improve the accuracy of staging diagnosis?

Prof. Anita Y.N. Cheung: In primary hospitals with relatively limited medical resources lacking advanced imaging, pathology, or specialist support, clinicians should be particularly vigilant and cautious in their assessments. When encountering an ovarian mass with ultrasound suggesting solid components, accompanied by elevated tumor markers like CA-125, or assessed as high-risk malignancy via ROMA index, the possibility of ovarian cancer must be highly suspected. At this point, it is strongly recommended to refer the patient to a medical center equipped with specialized gynecologic oncology services or experienced surgeons, as handling such diseases requires highly specialized training and surgical skills. Performing surgery without appropriate qualifications, merely removing the tumor while omitting critical staging steps (such as lymphadenectomy, peritoneal biopsy, etc.), causes irreversible harm to the patient.

For doctors who have received basic training but are still inexperienced, they must objectively recognize their own competency boundaries. According to current guidelines, comprehensive surgical staging is mandatory for early ovarian cancer; if one lacks the technical ability for lymph node dissection, one should not force the procedure to avoid inaccurate staging affecting subsequent treatment plans.

As for advanced ovarian cancer, where the surgical goal shifts to cytoreductive surgery, the technical threshold is even higher. It is suggested to stratify surgical difficulty: if the tumor is confined to the pelvis, a basic gynecologic oncologist might manage it; however, if the tumor invades the diaphragm, liver surface, or upper abdomen, support from experts or teams with advanced surgical skills must be sought.

Therefore, in general hospitals lacking an independent gynecologic oncology department, establishing a Multidisciplinary Team (MDT) approach is an effective solution. Through joint discussions involving gastrointestinal surgery, urology, and hepatobiliary surgery to assess surgical feasibility preoperatively and collaborate on complex resections intraoperatively ensures surgical quality. Ultimately, doctors must be clearly aware of their own limitations. When anticipating that satisfactory tumor debulking cannot be achieved, initiating multidisciplinary consultation promptly or referring the patient to a higher-level center is the best choice for ensuring patient prognosis.

Every iteration of ovarian cancer staging standards represents a deeper interpretation of the code of life. Taking the MDT model as the cornerstone and aiming for R0 resection to perform precise cytoreductive surgery, only precision and collaboration can maximize survival benefits for patients in the battle against ovarian cancer.

Expert Profile

• Professor and Chair of Obstetrics and Gynaecology, The University of Hong Kong; President of the Family Planning Association of Hong Kong
• IGCS Global Curriculum Trainer, The University of Hong Kong-Shenzhen Hospital
• Chief of Service, Department of Obstetrics and Gynaecology, HKU-SZH (from its establishment in 2012 to 9/2024)
• Former Head, Department of Obstetrics and Gynaecology, Queen Mary Hospital (2009-2015)
• Former Chairman, Department of Obstetrics and Gynaecology, The University of Hong Kong (2009-2021)
• Chief of Service, Department of Obstetrics and Gynaecology, Gleneagles Hong Kong Hospital (2015-2021)
• President, International Society for the Study of Trophoblastic Diseases (ISSTD) (2022-2024)
• President, Hong Kong College of Obstetricians and Gynaecologists (HKCOG) (2010-2012)
• President, Asia Oceania Research Organisation in Genital Infection and Neoplasia (AOGIN) (2010-2012)

• Appointed President of the FIGO Committee on Gynecologic Oncology (2000-2006)

  
  

Editor: Ma Ye