A 58-year-old postmenopausal woman from Delhi presents with progressive abdominal distension and early satiety for 3 months. On examination, she has a firm, fixed pelvic mass and ascites. CA-125 is elevated at 480 U/mL. Imaging shows a complex ovarian mass with peritoneal deposits. She is referred for staging laparotomy. Intraoperatively, the surgeon finds a 12 cm left ovarian mass with rupture, omental caking, and peritoneal nodules. Liver surface is smooth. What is the most likely FIGO stage?

Explanation

## FIGO Staging of Epithelial Ovarian Cancer **Key Point:** FIGO 2014 staging is based on the extent of tumour spread and presence of peritoneal/distant metastases. Capsular rupture (spontaneous or intraoperative) does NOT upstage but indicates aggressive biology. ### Stage Assignment Logic This patient has: - Large left ovarian mass (12 cm) with **rupture** → Stage IB (tumour limited to ovaries with capsular rupture) - **Omental caking** (peritoneal metastases) → upgrades to Stage III - **Peritoneal nodules** (microscopic or macroscopic peritoneal involvement) → Stage IIIC (metastases beyond pelvis) - Smooth liver surface (no parenchymal metastases) → excludes Stage IVB ### FIGO 2014 Ovarian Cancer Staging Summary | Stage | Extent | |-------|--------| | IA | Tumour limited to one ovary; intact capsule; no ascites | | IB | Tumour limited to both ovaries; intact capsule; no ascites | | IC | Stage I tumour with capsular rupture OR positive peritoneal fluid/washings | | IIA | Extension to uterus/fallopian tubes; no peritoneal metastases | | IIB | Extension to other pelvic organs; no peritoneal metastases | | IIC | Stage II with positive peritoneal fluid/washings | | IIIA | Microscopic peritoneal metastases beyond pelvis | | IIIB | Macroscopic peritoneal metastases ≤2 cm | | IIIC | Macroscopic peritoneal metastases >2 cm OR positive retroperitoneal lymph nodes | | IVA | Pleural effusion with positive cytology | | IVB | Parenchymal liver/splenic metastases or distant metastases | **Clinical Pearl:** Omental caking (>2 cm peritoneal deposits) = **Stage IIIC**. The presence of ascites alone does not change staging; peritoneal involvement does. **High-Yield:** Capsular rupture (even intraoperative) does NOT upstage beyond Stage IC if disease is confined to ovaries. However, this patient has **omental and peritoneal involvement**, which mandates Stage III. **Tip:** Always distinguish between: - Rupture without peritoneal spread → Stage IC - Rupture WITH peritoneal spread → Stage IIIC (if >2 cm deposits or omental involvement) [cite:FIGO 2014 Ovarian Cancer Staging]