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Staging and grades

Cancer of the ovary spreads in two main ways. The most common is along the surface of the lining of the abdomen (the peritoneum) and bowel. Eventually the cancer spreads to involve the layer of fat inside the abdomen (the omentum) and the outside of the liver.  The other frequent direction of spread is within the circulation of lymph fluid in the body which is important for immunity (the lymph system). The lymph from the ovaries goes initially to lymph nodes (glands) on the wall of the pelvis (pelvic lymph nodes) and then to lymph nodes around the aorta (para-aortic lymph nodes).

Cancer of the ovary can also spread in the blood to the liver, lungs or brain but this is quite uncommon.

There are four stages of ovarian cancer:

Stage I

Stage I is the earliest stage and indicates that the cancer affects only one or both of the ovaries.  At this stage the cancer causes few symptoms and most women are not aware that anything is wrong. Sometimes stage I cancers do cause symptoms such as discomfort, passing urine more frequently or constipation. These symptoms are usually due to the tumour pressing on the bladder or bowel.

Because stage I ovarian cancer has so few symptoms only a small number of women have the cancer detected at this early stage (approximately 15%). In order to be certain that a cancer is stage I, careful exploration and sampling of the common sites of spread is important. Even if a cancer appears at surgery to only affect the ovary it is possible that spread has occurred. This sort of spread may only be seen under the microscope. Samples must therefore be taken from the pelvic lymph nodes, paraaortic lymph nodes and omentum for closer examination.

If a cancer is confirmed to be a stage I the outlook is good. This is particularly the case if the cancer is confined to the inside of one ovary
(stage Ia) or both ovaries (stage Ib), in which case surgery alone may be sufficient treatment. If the cancer involves the surface of the ovary or is found in fluid in the abdomen (stage Ic) further treatment with chemotherapy may be considered.

Stage II

In stage II ovarian cancer the cancer has spread outside the ovary to the lining of the pelvis and can involve the uterus, fallopian tubes, bladder
and rectum.  Stage II is fairly uncommon (approximately 10% of women with ovarian cancer). This is because the lining of the pelvis and abdomen are not separated and consequently the cancer usually spreads to the abdomen at the same time as it spreads to the pelvis.

Most women with cancer diagnosed at stage II will be advised to have treatment with chemotherapy as well as surgery.

Stage III

This is the most common stage and is found in approximately 65% of women with ovarian cancer.  At this stage the cancer may have spread to involve the lining of the abdomen, the bowel surface, the omentum and the lymph glands in the pelvis or around the aorta. Often the tumour
on the lining of the abdomen releases fluid which collects inside the abdomen and is called ascites.

The symptoms of ovarian cancer at this stage are indigestion, constipation, poor appetite, distention of the abdomen and discomfort. These symptoms are usually due to disturbance to the bowel or to the pressure of the fluid and tumour.  These sort of symptoms are, of course, extremely common in women who have nothing at all wrong with them. In fact the vast majority of women with these sort of symptoms do not have cancer of the ovary and this makes it very difficult to diagnose the condition.

When a stage III cancer is discovered the aim of the initial surgery is to remove as much of the tumour as possible. Further treatment usually
involves chemotherapy. Sometimes a second operation during the chemotherapy may also be suggested.

Stage IV

Approximately 10% of women with ovarian cancer will be found to have stage IV disease.  Stage IV involves spread outside as well as inside the abdomen. This sort of spread most commonly involves the lungs.

Women with stage IV cancer may experience the same symptoms as women with stage III cancer and have the lung spread detected by a chest x-ray.

Sometimes the lung spread may be the first symptom of the cancer if it causes shortness of breath or a cough.  Stage IV ovarian cancer may be treated by surgery followed by chemotherapy or by chemotherapy alone.

Grades

This is divided into three categories - I (low), II (intermediate) and III (high) - and is a prognostic factor. In other words, patients with low-grade tumours have a better outlook (and some may coexist with their disease for many years) than those with high grade tumour of the same stage. However, this is only one of a number of prognostic factors and cannot be taken in isolation. For example, a grade III Stage IA tumour will usually have a better outlook than a Stage IIIC grade I tumour.