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Adnexal mass in pregnancy

Aut hors: Carolyn D Runowicz, MD, Molly Brewer, DVM, MD, MS
Sect ion Editor: Barbara Goff, MD
Deput y Editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Lit erat ure review current t hrough: Dec 2020. | T his topic last updat ed: Jun 16, 2020.

INTRODUCTION

The liberal use of prenat al ult rasound for evaluat ion of t he fet us has also result ed in increased
det ect ion of asympt omat ic adnexal masses during pregnancy. Alt hough t he vast majorit y of t hese
masses are benign, t he possibilit y of cancer must be considered.

This t opic will discuss management of t he adnexal mass in pregnancy, wit h an emphasis on pat ient s
wit h suspect ed malignancy. Det ailed reviews on t he evaluat ion and management of t he nonpregnant
pat ient wit h an adnexal mass can be found separat ely:

● (See "Approach t o t he pat ient wit h an adnexal mass".)

● (See "Management of an adnexal mass".)
● (See "Different ial diagnosis of t he adnexal mass".)

PREVALENCE

The incidence of adnexal masses complicat ing pregnancy varies from 0.05 t o 2.4 percent , and
approximat ely 1 t o 6 percent of t hese masses are malignant [1-4]. A review of publicat ions on ovarian
cancer during pregnancy from 1958 t o 2007 included 41 cases [5]. The mean age at present at ion was
32.6 years (range 23 t o 46 years); st age at diagnosis was recorded in 39 cases: Int ernat ional
Federat ion of Gynecology and Obst et rics (FIGO) I (59 percent ), FIGO II (5 percent ), FIGO III (26
percent ), and FIGO IV (10 percent ). It is import ant t o remember t hat t he use of obst et ric ult rasound
and cesarean delivery were much less common in t he init ial decades of t his int erval, t hus t here was
less opport unit y for incident al det ect ion of asympt omat ic adnexal masses.
In a populat ion-based hospit al regist ry series of malignancies ident ified during pregnancy using birt h
records linked t o hospit al discharge dat a (1992 t o 1997), ovarian cancer was t he fift h most common
cancer diagnosed during pregnancy aft er breast , t hyroid, cervical cancer, and Hodgkin lymphoma [2,6].
There was also a high proport ion of t umors of low malignant pot ent ial (n = 115) report ed separat ely,
wit h t he majorit y in early st age and associat ed wit h favorable mat ernal and neonat al out comes. A
ret rospect ive review report ed t hat ovarian cancer was t he sixt h most common cancer in an Asian
populat ion [6].

PATIENT PRESENTATION

Prior t o t he widespread use of ult rasound, most adnexal masses in pregnant pat ient s remained
unrecognized unt il cesarean delivery or unt il t hey became sympt omat ic, usually in t he post part um
period. Now many asympt omat ic masses are recognized in t he first half of pregnancy when t hey are
ident ified incident ally during an ant enat al ult rasound performed for obst et ric indicat ions [1,5,7,8].
Adnexal masses t hat have not been diagnosed ant epart um may be ident ified at cesarean delivery. In a
ret rospect ive st udy of over 46,500 t erm cesarean deliveries performed for obst et ric indicat ions, 151
pat ient s (0.3 percent ) underwent concurrent surgery of an adnexal mass, which was an incident al
finding at surgery in just over half of t he pat ient s (83 of 151; 55 percent ) [9].

Ot her clinical present at ions include:

● Nonspecific symptoms – Sympt oms and signs t hat precede t he diagnosis of ovarian cancer
include abdominal or back pain, const ipat ion, abdominal swelling, and urinary sympt oms [10,11].
Since t hese sympt oms are almost universally present in normal pregnancies, t heir presence is
unlikely t o t rigger a diagnost ic evaluat ion.

● Palpable mass – In some pat ient s, a suspicious finding, such as a palpable adnexal mass or
post erior cul-de-sac mass or nodularit y, may be ident ified during a rout ine ant enat al physical
examinat ion and subsequent ly evaluat ed by ult rasound.

● Acute abdominal pain – In a few pat ient s, acut e abdominal pain due t o t orsion of t he adnexa
prompt s t he diagnost ic evaluat ion. Adnexal t orsion occurs in approximat ely 5 percent of pregnant
pat ient s wit h an adnexal mass (benign or malignant ) [1]. In one review, adnexal masses bet ween 6
and 8 cm in diamet er had a significant ly higher rat e of t orsion (22 percent ) t han eit her smaller or
larger masses [12]. Sixt y percent of t he t orsions occurred bet ween t he 10t h and 17t h week of
gest at ion; only 6 percent occurred aft er 20 weeks. (See "Ovarian and fallopian t ube t orsion".)

● Elevated maternal analytes – Many germ cell and sex cord-st romal t umors of t he ovary
produce hormonal t umor markers, some of which are measured in prenat al screening programs for
 fet al abnormalit ies (eg, alpha-fet oprot ein [AFP], inhibin A) ( t able 1) [13]. An unexplained
elevat ion in t hese mat ernal serum analyt es, obt ained while screening for neural t ube defect s or
Down syndrome, may be t he first sign of one of t hese t umors [13]. (See 'Tumor markers in ovarian
malignancy' below.)

TYPES OF ADNEXAL MASSES IN PREGNANT PATIENTS

In a review of seven st udies, t here were 563 adnexal masses in 557 pat ient s. Of t hese, 48 percent
were classified as simple and 53 percent as complex. Among t he simple masses, 1 percent were
malignant whereas in t he complex masses, 9 percent were malignant [3]. In anot her ret rospect ive
st udy of 151 pat ient s who underwent surgery of an adnexal mass at cesarean delivery, t he adnexal
mass was benign in 148 cases. Hist opat hologies account ing for over 4 percent of cases in t he series
included dermoid (24 percent ), parat ubal/paraovarian (19 percent ), simple serous (15 percent ),
mucinous cyst adenoma (11 percent ), serous cyst adenoma (7 percent ), corpus lut eum (5 percent ),
endomet rioma (5 percent ), and fibroma (5 percent ) [9]. The t hree malignancies in t he series consist ed
of t wo granulosa cell t umors and one mucinous carcinoma.

Benign neoplasms — Most adnexal masses ident ified in pregnant pat ient s are benign simple cyst s
less t han 5 cm in diamet er. Most of t hese are funct ional ovarian cyst s, eit her follicular or corpus
lut eum cyst s, t hat occur as part of t he normal physiological funct ion of t he ovary. Approximat ely 70
percent of all adnexal cyst ic masses det ect ed in t he first t rimest er spont aneously resolve by t he
early part of t he second t rimest er, which is consist ent wit h t he nat ural hist ory of funct ional cyst s [7].
The majorit y of persist ent adnexal masses 5 cm or great er in diamet er are mat ure t erat omas [1].

The different ial diagnosis of t he adnexal mass is reviewed in det ail separat ely (see "Different ial
diagnosis of t he adnexal mass"). Briefly, benign adnexal masses are charact erized by t heir
ult rasonographic appearance and, in some cases, associat ed clinical findings (see "Ult rasound
different iat ion of benign versus malignant adnexal masses"):

● Benign masses wit hout complex feat ures on ult rasound are generally physiologic/funct ional
cyst s (eg, follicular cyst s), but may be unilocular serous or mucinous cyst adenoma or
hydrosalpinx.

● Benign masses wit h complex feat ures on ult rasound include corpus lut eum, mat ure t erat omas,
hydrosalpinx wit h sept at ion, t heca lut ein cyst s, endomet riomas, mult ilocular cyst adenomas, as
well as ext raut erine pregnancies [14]. The corpus lut eum persist s longer during pregnancy and
t hus is likely t o reach a larger size and may become hemorrhagic, rupt ure, or undergo t orsion.
 Theca lut ein cyst s (also called lut ein cyst s, hyperreact io lut einalis) are lut einized follicle cyst s
t hat form as a result of overst imulat ion from high human chorionic gonadot ropin (hCG) levels or
hypersensit ivit y t o hCG. Bilat eral mult isept at ed cyst ic adnexal masses in a pat ient wit h
gest at ional t rophoblast ic disease, mult iple gest at ion, ovulat ion induct ion, or a pregnancy
complicat ed by fet al hydrops are likely t o represent t heca lut ein cyst s.

● A lut eoma is an uncommon solid benign lesion specific t o pregnancy. It is a non-neoplast ic ovarian
change associat ed wit h pregnancy t hat can simulat e a neoplasm on clinical, gross, or microscopic
examinat ion. The diagnosis should be suspect ed when a solid adnexal mass is associat ed wit h
mat ernal hirsut ism or virilizat ion.

● Uncomplicat ed pedunculat ed leiomyomas are usually hypoechoic compared wit h normal

myomet rium, but may have a complex appearance when t here is necrosis or degenerat ion.

The presence of pain should suggest t he possibilit y of het erot opic pregnancy, t orsion or rupt ure of an
ovarian neoplasm, or degenerat ion of a leiomyoma. (See "Abdominal pregnancy, cesarean scar
pregnancy, and het erot opic pregnancy", sect ion on 'Het erot opic pregnancy' and "Ovarian and fallopian
t ube t orsion" and "Evaluat ion and management of rupt ured ovarian cyst " and "Ut erine fibroids
(leiomyomas): Epidemiology, clinical feat ures, diagnosis, and nat ural hist ory", sect ion on 'Fibroid
degenerat ion or t orsion'.)

Malignant neoplasms — Epit helial ovarian t umors comprise approximat ely one-half of all ovarian
malignancies in pregnant pat ient s, germ cell ovarian malignancies make up approximat ely one-t hird,
and st romal t umors and a variet y of ot her t umor t ypes (eg, sarcomas, met ast at ic t umors) account for
t he remainder ( figure 1).

Epithelial ovarian tumors — Approximat ely 50 percent of epit helial ovarian t umors det ect ed in
pregnancy are of low malignant pot ent ial (formerly called "borderline"), and t he ot her 50 percent are
invasive. Epit helial ovarian t umors of low malignant pot ent ial diagnosed in pregnancy may exhibit
at ypical charact erist ics suggest ive of invasive cancer such as nuclear enlargement , anisocyt osis, and
mult ifocal microinvasion. (See "Borderline ovarian t umors" and "Epit helial carcinoma of t he ovary,
fallopian t ube, and perit oneum: Clinical feat ures and diagnosis".)

Germ cell tumors — Approximat ely t hree-fourt hs of malignant ovarian germ cell t umors in
pregnancy are dysgerminomas; endodermal sinus t umors, immat ure t erat omas, and mixed germ cell
t umors comprise t he remainder [15]. Most germ cell t umors are grossly limit ed t o one adnexa, but
lymphat ic spread t o pelvic or para-aort ic nodes occurs, most commonly in dysgerminoma [16].
Dysgerminomas are bilat eral in 10 t o 15 percent of cases; ot her germ cell t umors are almost always
unilat eral. (See "Ovarian germ cell t umors: Pat hology, epidemiology, clinical manifest at ions, and
diagnosis".)
 Sex cord-stromal tumors — Approximat ely half of all pregnancy-associat ed st romal t umors are
granulosa cell t umors, one-t hird are Sert oli-Leydig cell t umors, and t he remainder are unclassified
st romal t umors [17]. Most of t hese t umors are limit ed t o one ovary at t he t ime of diagnosis. Prior t o
t he rout ine use of prenat al ult rasound, approximat ely 20 percent of t hese lesions present ed wit h
int raperit oneal hemorrhage and/or hemorrhagic shock, but t his has become less common wit h earlier
diagnosis.

Bet ween 10 and 15 percent of st romal t umors secret e androgens and produce virilizat ion. Alt hough
est rogen secret ion also occurs, sympt oms of a hyperest rogenic st at e are masked by t he already high
est rogen concent rat ion associat ed wit h pregnancy.

Pregnancy-relat ed hist ologic changes in t hese t umors include a disorderly arrangement of cells,
increased edema, and unusually large numbers of lut ein or Leydig cells [17]. (See "Sex cord-st romal
t umors of t he ovary: Epidemiology, clinical feat ures, and diagnosis in adult s".)

DIAGNOSIS

Definit ive diagnosis can only be made by resect ing t he ovarian neoplasm for pat hologic examinat ion.
However, some benign ovarian masses, including follicular or corpus lut eal cyst s, endomet riomas, and
mat ure t erat omas (dermoid), have charact erist ic sonographic feat ures, and t he diagnosis is reasonably
cert ain wit hout surgical explorat ion.

It is import ant t hat ovarian t issue is examined by a pat hologist skilled in int erpret at ion of hist ologic
findings in t he cont ext of an ongoing pregnancy and t hat t he pat hologist is informed of t he
coexist ent pregnancy. Pregnancy-relat ed changes in t he hist ologic appearance of t umors of low
malignant pot ent ial can result in at ypical charact erist ics suggest ive of invasive cancer. In one series, 8
of 10 serous neoplasms diagnosed in pregnancy had microscopic and clinical feat ures suggest ing
aggressive behavior; however, all of t hese feat ures regressed post part um in t his small series,
confirming t hat t he neoplasms were of low malignant pot ent ial [18].

DIAGNOSTIC EVALUATION

Patient selection for surgery — The general consensus regarding management of adnexal masses in
pregnancy is t o surgically resect asympt omat ic masses t hat are present aft er t he first t rimest er and
(1) are >10 cm in diamet er or (2) are solid or cont ain solid and cyst ic areas or have papillary areas or
sept ae [1,4,12,19-22]. The rat ionale for t his approach is t hat t hese findings increase t he likelihood of
malignancy, and it is desirable t o diagnose malignancy, if present , at an early st age. In addit ion,
resect ion of large adnexal masses (benign or malignant ) reduces t he risk of complicat ions such as
adnexal t orsion, rupt ure, or obst ruct ion of labor. Emergency surgery during pregnancy for management
of a t orsed or rupt ured adnexal mass is uncommon (<5 percent of cases [1,23]) and can lead t o
pret erm delivery [19,20,24].

Adnexal masses t hat do not have concerning feat ures (eg, persist ence int o t he second t rimest er,
large size, or solid component s) are likely t o be physiologic cyst s and can be managed expect ant ly
[1,25-31], and oft en resolve during pregnancy. Expect ant management is also appropriat e for cyst s
wit h t hese feat ures if t he sonographer is reasonably cert ain t hat t he neoplasm is a follicular or corpus
lut eal cyst , endomet rioma, or mat ure t erat oma. Surgical t reat ment of endomet riomas depends upon
whet her t he pat ient is sympt omat ic. Most mat ure t erat omas are benign, but surgery may be indicat ed
post part um t o prevent t orsion (see "Ovarian germ cell t umors: Pat hology, epidemiology, clinical
manifest at ions, and diagnosis", sect ion on 'Mat ure t erat oma (dermoid)'). For any ovarian mass, if t he
diagnosis is uncert ain, furt her evaluat ion is required. Up t o 10 percent of adnexal masses t hat persist
during pregnancy are malignant [4,26,32]. A subst ant ial port ion of t hese are epit helial low malignant
pot ent ial t umors or germ cell t umors, bot h t umors wit h a t ypically favorable prognosis. (See
"Management of an adnexal mass", sect ion on 'Suspect ed malignancy or uncert ain et iology'.)

Timing — The opt imal t ime for semi-elect ive surgery during pregnancy is aft er t he first t rimest er for
a number of reasons:

● Almost all funct ional cyst s will have resolved by t his t ime.

● Organogenesis is most ly complet e, t hus minimizing t he risk of drug-induced t erat ogenesis.

● The hormonal funct ion of t he corpus lut eum has been replaced by t he placent a, so reduct ion in
progest erone secret ion from oophorect omy or cyst ect omy does not result in loss of t he
pregnancy if not replaced.

● Spont aneous pregnancy losses due t o int rinsic fet al abnormalit ies are likely t o have already
occurred and will not be erroneously at t ribut ed t o t he surgery.

Preoperative assessment — In most cases, t he preoperat ive workup for a pregnant pat ient wit h a
pelvic mass can be limit ed t o ult rasound imaging. If t he ult rasound findings cannot dist inguish
bet ween a possible pedunculat ed or degenerat ing leiomyoma and an ovarian neoplasm, we suggest
obt aining magnet ic resonance imaging (MRI). The more precise diagnosis afforded by MRI may be
useful in opt ing for expect ant management unt il delivery [33]. (See "Ult rasound different iat ion of
benign versus malignant adnexal masses".)

A rout ine preoperat ive chest radiograph is unnecessary; however, if t he hist ory and physical
examinat ion suggest pulmonary disease, t hen a chest radiograph should be obt ained wit h shielding of
t he abdomen/pelvis.
 Secondary imaging — In most cases, ult rasound examinat ion provides sufficient informat ion t o
guide a decision for explorat ory surgery versus conservat ive, expect ant management , but
occasionally, furt her radiologic evaluat ion is required. MRI has excellent resolut ion for soft t issue
pat hology and does not expose t he pat ient (or fet us) t o ionizing radiat ion. Therefore, MRI is
part icularly useful in charact erizing a pedunculat ed leiomyoma, red degenerat ion of leiomyomas,
endomet riomas, decidualized endomet riomas, and massive ovarian edema and dist inguishing t hese
lesions from ovarian cancer [33,34]. Gadolinium-based cont rast mat erial should generally be avoided in
pregnancy because fet al safet y has not been est ablished. (See "Diagnost ic imaging in pregnant and
nursing pat ient s", sect ion on 'Fet al and infant risks from iodinat ed cont rast mat erials'.)

Comput ed t omography (CT) is avoided in pregnant pat ient s if ot her imaging met hods can provide t he
needed informat ion. The fet al ionizing radiat ion dose for a single CT t hrough t he pelvis is 0.035 Gy.
Alt hough fet al radiat ion exposure of less t han 0.05 Gy has not been associat ed wit h an increased risk
of abort ion, congenit al anomalies, growt h rest rict ion, or perinat al mort alit y, t here remain concerns
regarding a possible increase in t he risk of developing childhood cancer [35,36]. In addit ion, t he use of
iodinat ed cont rast agent s wit h CT carries a risk of t ransient suppression of t he fet al t hyroid. (See
"Diagnost ic imaging in pregnant and nursing pat ient s".)

Tumor markers in ovarian malignancy — Alt hough serum t umor markers are rout inely drawn
preoperat ively when planning a laparot omy for management of a pelvic mass in nonpregnant pat ient s,
we do not suggest t his approach during pregnancy. Pregnancy-associat ed pelvic masses are
infrequent ly malignant , and t he int erpret at ion of t hese t umor markers varies wit h gest at ional age and
comorbid condit ions. If a malignancy is proven, t hen appropriat e t umor markers may be drawn in t he
immediat e post operat ive period.

Several of t he t umor markers used t o follow epit helial and nonepit helial ovarian cancers in
nonpregnant pat ient s ( t able 1) are difficult t o int erpret in pregnancy because oncofet al ant igens
(eg, alpha-fet oprot ein [AFP], human chorionic gonadot ropin [hCG], carcinoembryonic ant igen [CEA],
cancer ant igen 125 [CA 125]) are involved in biological funct ions associat ed wit h fet al development ,
different iat ion, and mat urat ion. The levels are normally elevat ed during gest at ion and fluct uat e wit h
gest at ional age, or t hey may be abnormally elevat ed due t o abnormal placent at ion or fet al
abnormalit ies (eg, preeclampsia, Down syndrome, open neural t ube defect ) [13].

Serum CA 125 — Serum levels of CA 125 are elevat ed in most cases of epit helial ovarian
cancer (EOC). CA 125 is also produced by normal t issues, including endomet rium, and may be elevat ed
during early gest at ion and immediat ely following delivery ( t able 2) [13]. However, CA 125 may be
helpful as a t umor marker of EOC bet ween 15 weeks of gest at ion and delivery, as serum values at t his
t ime are unlikely t o be markedly elevat ed solely as a consequence of pregnancy. A CA 125 in t he
range of 1000 t o 10,000 is likely (but not invariably) relat ed t o cancer, but values in t he range of 75 t o
150 could be eit her pregnancy-relat ed or due t o an ovarian cancer t hat does not demonst rat e high
expression of CA 125.

Alpha-fetoprotein — Mat ernal serum levels of AFP (MSAFP) normally rise during pregnancy;
serum levels are rout inely assayed as part of t he screen for fet al neural t ube defect s and Down
syndrome. High MSAFP levels are seen in some t ypes of ovarian germ cell t umors (eg, endodermal
sinus t umor, embryonal carcinoma, and mixed t umors). These levels are oft en >1000 ng/mL, especially
wit h pure endodermal sinus (yolk sac) t umors, which can be associat ed wit h levels >10,000 ng/mL
[37,38]. By comparison, MSAFP levels are t ypically <500 ng/mL in pregnancies complicat ed by neural
t ube defect s. (See "Ovarian germ cell t umors: Pat hology, epidemiology, clinical manifest at ions, and
diagnosis".)

During pregnancy, AFP result s are t ypically expressed as mult iples of t he median (MoM) for each
gest at ional week because t hese values are easy t o derive, more st able, and allow for int er-laborat ory
variat ion. MSAFP levels t hat are above 2.0 t o 2.5 MoMs are considered abnormal. The AFP levels
associat ed wit h ovarian cancer t ypically t ranslat e int o much higher MoM values t han seen wit h neural
t ube defect s. In one case report , a MSAFP of 26,300 ng/mL t ranslat ed int o a MoM value of 24 [39]; in
anot her, a level of 477.8 int . unit /mL (370 ng/mL) t ranslat ed int o a MoM of 12.5 [40]. Some aut hors
suggest t hat a MSAFP level above 9 MoM should prompt concern for germ cell t umors of eit her
gonadal or nongonadal origin in t he absence of fet al abdominal wall defect s or anencephaly [39]. (See
"Open neural t ube defect s: Risk fact ors, prenat al screening and diagnosis, and pregnancy
management " and "Laborat ory issues relat ed t o mat ernal serum screening for Down syndrome".)

Lactate dehydrogenase — Serum lact at e dehydrogenase (LDH) is elevat ed in t he serum of

pat ient s wit h ovarian dysgerminomas and is a reliable marker for diagnosis and follow-up of t hese
t umors in pregnant pat ient s [41]. LDH is not elevat ed in normal pregnancy, alt hough elevat ions can
occur in some pregnancy-relat ed disorders such as preeclampsia and HELLP syndrome (Hemolysis,
Elevat ed Liver funct ion t est s, Low Plat elet s) [42]. (See "Ovarian germ cell t umors: Pat hology,
epidemiology, clinical manifest at ions, and diagnosis", sect ion on 'Dysgerminoma' and "Preeclampsia:
Clinical feat ures and diagnosis" and "HELLP syndrome (hemolysis, elevat ed liver enzymes, and low
plat elet s)".)

Inhibin A — Alt hough serum inhibin A is a useful t umor marker for following t he course of
t reat ment for ovarian granulosa cell t umors in nonpregnant pat ient s, inhibin A is made in t he developing
placent a, and serum levels are elevat ed in early gest at ion [43,44]. This limit s t he value of inhibin A as a
t umor marker during pregnancy. Like AFP, inhibin A levels may be measured as a component of
screening for Down syndrome. Inhibin A concent rat ions are, on average, t wofold higher in pregnancies
complicat ed by Down syndrome t han in unaffect ed pregnancies. (See "Sex cord-st romal t umors of
t he ovary: Epidemiology, clinical feat ures, and diagnosis in adult s" and "Laborat ory issues relat ed t o
mat ernal serum screening for Down syndrome".)

Human chorionic gonadotropin — The bet a subunit of hCG is a useful marker for some germ
cell neoplasms (part icularly choriocarcinoma, ( t able 1)). However, it cannot be used as a t umor
marker during pregnancy due t o t he large physiologic increase in t his hormone. (See "Human chorionic
gonadot ropin: Biochemist ry and measurement in pregnancy and disease".)

Human epididymis protein 4 (HE4) — Human epididymis prot ein 4 (HE4) is t he product of t he

WFDC 2 (HE4) gene t hat is overexpressed in ovarian cancer. Assessment of t he HE4 level is approved
for monit oring pat ient s wit h ovarian cancer for disease recurrence or progression, but not for
screening. In a st udy of serum samples from 67 pregnant pat ient s wit hout ovarian cancer, median HE4
values were significant ly lower in pregnant pat ient s t han in healt hy, nonpregnant , premenopausal
pat ient s (30.5 versus 46.6 pmol/L) [45]. The 95t h percent iles for HE4 in pregnant pat ient s in t he first ,
second, and t hird t rimest ers were 49.6, 35.1, and 50.2 pmol/L, respect ively. Levels were measured
using an enzyme immunomet ric assay (EIA) assay kit from Fujirebio Diagnost ics Inc. In anot her series,
higher concent rat ions of HE4 were det ect ed in pregnant versus nonpregnant serum, but were not
st at ist ically significant . The aut hors concluded t hat HE4 serum biomarkers are unaffect ed by
pregnancy [46], and t herefore may be helpful in t he evaluat ion of pelvic masses in pregnancy.

SURGERY

Issues relat ed t o preparat ion of t he pregnant pat ient for nonobst et ric surgery and management of
anest hesia in pregnant pat ient s are reviewed separat ely. (See "Anest hesia for nonobst et ric surgery
during pregnancy".)

Laparoscopy is an accept able alt ernat ive t o laparot omy for management of benign adnexal masses in
pregnancy [47]. In a met a-analysis of four st udies (one was a randomized t rial) wit h a t ot al of 240
pat ient s evaluat ing laparoscopic versus open surgery for management of adnexal masses in t he
second t rimest er, laparoscopy was associat ed wit h bet t er surgical out comes but longer operat ive
t imes. Of not e, t he laparoscopic group had smaller ovarian cyst s.

If a malignancy is suspect ed, a laparot omy should be performed. A Pfannenst iel incision should be
avoided, as it would not provide sufficient exposure. The vert ical midline incision should be adequat e
t o minimize t he need t o manipulat e t he gravid ut erus while obt aining exposure t o t he adnexal mass.

Immediat ely aft er ent ry int o t he perit oneal cavit y, perit oneal washings should be obt ained for st aging
purposes in case t he mass is malignant . The opposit e adnexa should be carefully inspect ed and
palpat ed for a cont ralat eral adnexal mass. Cont ralat eral ovarian biopsy is recommended if t he ovary
appears t o be involved, but rout ine biopsy or wedge resect ion of a normal-appearing cont ralat eral
ovary is unwarrant ed.

The most common findings at surgery are persist ent corpus lut eal funct ional cyst s, benign dermoid
cyst s, and serous or mucinous cyst adenomas. If t he preoperat ive imaging and int raoperat ive gross
findings are bot h consist ent wit h a benign diagnosis, it is reasonable t o at t empt a cyst ect omy rat her
t han perform a salpingo-oophorect omy. If t he mass is larger t han 10 cm, it may not be t echnically
feasible t o perform an ovarian cyst ect omy. If t he mass is solid, has surface excrescences, is
associat ed wit h ascit es, or has ot her feat ures suggest ing malignancy, t hen ipsilat eral salpingo-
oophorect omy is appropriat e. The mass should be sent for frozen sect ion and t he pat hologist
informed of t he concurrent pregnancy. Resect ion of t he cont ralat eral ovary should not be performed
unless bilat eral disease is ident ified; t his decision must await t he frozen sect ion analysis. All
suspicious lesions should be biopsied.

If t he pat hologist confirms a malignant t umor at frozen sect ion, t he surgeon should be prepared t o
complet e an adequat e surgical st aging procedure, and a gynecologic oncologist should be consult ed.
The general principles of t he st aging procedure for a malignant ovarian t umor are described in t he
t able ( t able 3) and in det ail separat ely. Obviously, hyst erect omy is not performed if preservat ion of
t he pregnancy is desired, and t he surgeon must individualize each case, weighing t he pros and cons of
st aging versus pot ent ial risk t o t he mot her and fet us. In cert ain malignant germ cell t umors of t he
ovary (eg, endodermal sinus t umors), lymph node dissect ion may be omit t ed, as t he pat ient will require
chemot herapy based on t he hist opat hology alone. (See "Epit helial carcinoma of t he ovary, fallopian
t ube, and perit oneum: Surgical st aging".)

Adequat e surgical st aging is of part icular import ance for st age I cancers (ie, t hose t hat are limit ed t o
t he ovary ( t able 4)), as many, but not all, of t hese neoplasms are adequat ely t reat ed wit h surgery
alone. In such cases, t he need for post operat ive adjuvant chemot herapy is det ermined by t he
hist ologic t umor t ype. Surgical st aging (eg, sampling of lymph nodes) is less crit ical in t he set t ing of
obvious advanced disease (eg, st age IIIB/C disease), as t hese t umors (wit h t he except ion of t umors
of low malignant pot ent ial) will require chemot herapy. (See "Chemot herapy of ovarian cancer in
pregnancy" and "Treat ment of malignant germ cell t umors of t he ovary" and "Sex cord-st romal t umors
of t he ovary: Epidemiology, clinical feat ures, and diagnosis in adult s".)

If a met ast at ic ovarian cancer is ident ified, cyt oreduct ion should be at t empt ed. The ext ent of
surgical cyt oreduct ion involves individual judgment , balancing t he ext ent of surgery wit h t he expect ed
benefit . It is rare t hat removal of t he gravid ut erus is required for maximal cyt oreduct ive surgery at t he
init ial surgery because it is possible, if necessary, t o ret urn for secondary cyt oreduct ion following
chemot herapy and successful complet ion of t he pregnancy. This management st rat egy is not
t hought t o adversely impact survival, alt hough as a general rule, survival is poor for pat ient s who have
lat e-st age disease.

Despit e t he import ance of early surgical debulking t o out comes in ovarian cancer, t he surgeon should
keep in mind t he sensit ivit y of t hese t umors t o plat inum-based chemot herapy when aggressive
resect ion of met ast at ic disease is considered. Wit h modern plat inum-based adjuvant chemot herapy,
approximat ely 70 percent of pat ient s who present wit h advanced disease will respond t o
chemot herapy, even if t hey have residual disease remaining aft er cyt oreduct ive surgery.

The hazard of overly aggressive surgery and delay in st art ing chemot herapy can be illust rat ed by a
case report of a pat ient wit h a yolk sac t umor t hat was resect ed at 19 weeks of gest at ion [48].
Chemot herapy was delayed because of t he pregnancy and at 32 weeks of gest at ion, t umor
recurrence necessit at ed a cesarean-hyst erect omy and bowel resect ion wit h colost omy. Three weeks
lat er, t he colost omy was t aken down and anot her suprahepat ic t umor mass was resect ed. The
pat ient was t hen given bleomycin, et oposide, and cisplat in (BEP) for four cycles, but t he course was
complicat ed by a fecal fist ula t hat developed at t he colost omy sit e. (See "Chemot herapy of ovarian
cancer in pregnancy".)

For pat ient s wit h advanced-st age ovarian cancer diagnosed before delivery, hyst erect omy and
secondary cyt oreduct ive surgery are reasonable post part um t o remove persist ent disease. This
surgery can be performed following vaginal delivery or in conjunct ion wit h cesarean delivery. This
approach has been t aken by a few invest igat ors who report ed managing advanced epit helial ovarian
cancer (EOC) cases during pregnancy [49-52]. In four case report s, t wo pat ient s had persist ent
disease involving t he adnexa [49,50], t wo cases involved t he bowel [50,51], and one case also involved
t he pelvic perit oneum, oment um, and appendix [50].

Management of corpus luteum — Removal of t he corpus lut eum should be avoided prior t o eight
weeks of gest at ion because t he corpus lut eum is primarily responsible for progest erone product ion
and maint enance of t he pregnancy at t his t ime [53]. If t he corpus lut eum is removed prior t o eight
weeks, progest erone supplement at ion should be given as a 50 t o 100 mg vaginal supposit ory every 8
t o 12 hours or as a daily int ramuscular inject ion of 1 mL (50 mg) progest erone in oil. Aft er eight weeks,
t he ovary gradually shift s progest erone product ion t o t he placent a (called t he lut eal-placent al shift )
[54]. As of 10 weeks of gest at ion, t he placent a is t he primary provider of progest erone, so
progest erone supplement at ion is no longer indicat ed. (See "Anest hesia for nonobst et ric surgery during
pregnancy".)

Adnexal mass at cesarean delivery — At cesarean delivery, any adnexal mass t hat appears
suspicious for malignancy should be removed and sent for frozen sect ion. Complet e surgical removal
is preferred t o aspirat ion and cyt ologic evaluat ion of cyst ic fluid, since malignancy could be missed
wit h t he lat t er. If t he mass is an incident al finding at cesarean delivery, t he pat ient t ypically will not
have an appropriat e incision for surgical st aging. In t hese cases, if frozen sect ion indicat es malignancy,
salpingo-oophorect omy is performed and post part um, t he pat ient is referred t o a gynecologic
oncologist for counseling, st aging, and possible hyst erect omy wit hin t he next one t o t wo weeks.

If an adnexal mass suspicious for malignancy is det ect ed ant epart um, t he pat ient should be
counseled and consent ed appropriat ely. Cesarean delivery should be performed t hrough a midline
incision, and a gynecologic oncologist should be available, if required. Aft er delivery of t he infant and
placent a and cont rol of bleeding, t he adnexal mass is resect ed and sent for frozen sect ion. If posit ive
for malignancy, full surgical st aging can be performed. (See "Epit helial carcinoma of t he ovary,
fallopian t ube, and perit oneum: Surgical st aging".)

CHEMOTHERAPY

(See "Chemot herapy of ovarian cancer in pregnancy".)

PROGNOSIS

There is no evidence t hat pregnancy worsens t he prognosis of ovarian t umors compared wit h
nonpregnant pat ient s mat ched for t umor hist ology, st age, and grade [55]. Approximat ely 75 percent
of invasive ovarian malignancies in pregnant pat ient s are early-st age disease. Due t o t he favorable mix
of st age, grade, and hist ology, t he five-year survival rat e for ovarian t umors associat ed wit h pregnancy
is bet ween 72 and 90 percent . The presence of ascit es at diagnosis implies advanced disease and
poor prognosis [56]. Alt hough one cohort st udy found t hat post part um lact at ing pat ient s diagnosed
wit h ovarian cancer had a poorer prognosis t han pat ient s diagnosed before or during pregnancy, t he
number of cases was small [57]. This finding needs t o be confirmed in larger st udies.

The decision t o cont inue or t erminat e a pregnancy when ovarian cancer is diagnosed in t he first
t rimest er should be individualized and made by a fully informed pat ient in collaborat ion wit h t he
clinician. Early t erminat ion of pregnancy does not improve t he out come of ovarian cancer. In addit ion
t o t he usual reasons for pregnancy t erminat ion, some fact ors t hat should be considered in pat ient s
wit h ovarian cancer include:

● Whet her t he pat ient is willing t o assume a possible risk of fet al t oxicit y or complicat ions from
ovarian cancer t reat ment during pregnancy.

● The pat ient 's prognosis and abilit y t o care for t he offspring.

● The effect of ovarian cancer t reat ment on fut ure fert ilit y.
SOCIETY GUIDELINE LINKS

Links t o societ y and government -sponsored guidelines from select ed count ries and regions around
t he world are provided separat ely. (See "Societ y guideline links: Ovarian and fallopian t ube disease".)

SUMMARY AND RECOMMENDATIONS

● Approximat ely 0.05 t o 2.4 percent of pregnancies are complicat ed by an adnexal mass, and
approximat ely 1 t o 6 percent of t hese masses are malignant . (See 'Prevalence' above.)

● The vast majorit y of adnexal masses in pregnant pat ient s are benign and asympt omat ic and are
discovered incident ally eit her on obst et ric ult rasound examinat ion or at cesarean delivery.
Sympt oms and signs of ovarian cancer include abdominal or back pain, const ipat ion, abdominal
swelling, and urinary sympt oms, which are also almost universally present during normal
pregnancies. (See 'Pat ient present at ion' above.)

● An unexplained elevat ion in some mat ernal serum analyt es (alpha-fet oprot ein [AFP], inhibin A),
obt ained during screening for neural t ube defect s or Down syndrome, can be a sign of an ovarian
germ cell t umor. (See 'Pat ient present at ion' above and 'Tumor markers in ovarian malignancy'
above.)

● Most adnexal masses ident ified in pregnant pat ient s are benign simple cyst s less t han 5 cm in
diamet er. Most of t hese are funct ional ovarian cyst s, eit her follicular or corpus lut eum cyst s, t hat
occur as part of t he normal physiological funct ion of t he ovary. Approximat ely 70 percent of all
adnexal cyst ic masses det ect ed in t he first t rimest er spont aneously resolve by t he early part of
t he second t rimest er, which is consist ent wit h t he nat ural hist ory of funct ional cyst s. The
majorit y of persist ent adnexal masses 5 cm or great er in diamet er are dermoids. Up t o 10 percent
of adnexal masses t hat persist during pregnancy are malignant . (See 'Types of adnexal masses in
pregnant pat ient s' above.)

● Epit helial ovarian t umors comprise approximat ely one-half of all ovarian malignancies in pregnant
pat ient s; germ cell ovarian malignancies make up approximat ely one-t hird. (See 'Malignant
neoplasms' above.)

● Definit ive diagnosis can only be made by resect ing t he ovarian neoplasm for pat hologic
examinat ion. However, some benign ovarian masses, including follicular or corpus lut eal cyst s,
endomet riomas, and mat ure t erat omas (dermoid), have charact erist ic sonographic feat ures and
t he diagnosis is reasonably cert ain wit hout surgical explorat ion. (See 'Diagnosis' above.)
● Pregnancy-associat ed ovarian t umors should be evaluat ed by a pat hologist skilled in reading t he
pat hologic findings in t he cont ext of t he ongoing pregnancy, and t he pat hologist should be
informed of t he coexist ent pregnancy. (See 'Diagnosis' above.)

● We suggest surgical resect ion rat her t han expect ant management of asympt omat ic masses
present aft er t he first t rimest er t hat are (1) >10 cm in diamet er (Grade 2C) or (2) solid or
cont aining solid and cyst ic areas or papillary areas or sept ae (Grade 2B). These findings increase
t he likelihood of malignancy, and it is desirable t o diagnose malignancy, if present , at an early
st age. In addit ion, resect ion of large adnexal masses reduces t he risk of complicat ions such as
adnexal t orsion, rupt ure, or obst ruct ion of labor. However, we suggest expect ant management of
asympt omat ic corpus lut eal cyst s, endomet riomas, and mat ure t erat omas (dermoid) during
pregnancy if t he diagnosis is reasonably cert ain based on t he sonographic charact erist ics (Grade
2C). (See 'Pat ient select ion for surgery' above.)

● In most cases, t he preoperat ive st aging workup for a pregnant pat ient wit h a pelvic mass can be
limit ed t o ult rasound imaging. (See 'Preoperat ive assessment ' above.)

● If t he preoperat ive imaging and int raoperat ive gross findings are bot h consist ent wit h a benign
diagnosis, we suggest cyst ect omy rat her t han salpingo-oophorect omy (Grade 2C). If t he mass is
larger t han 10 cm, it may not be t echnically feasible t o perform an ovarian cyst ect omy. If t he
mass is solid, has surface excrescences, is associat ed wit h ascit es, or has ot her feat ures
suggest ing malignancy, t hen ipsilat eral salpingo-oophorect omy is appropriat e. The mass should
be sent for frozen sect ion. Resect ion of t he cont ralat eral ovary should not be performed unless
bilat eral disease is ident ified. All suspicious lesions should be biopsied. (See 'Surgery' above.)

● Adequat e surgical st aging is import ant for st age I cancers, as many of t hese neoplasms are
adequat ely t reat ed wit h surgery alone. The need for post operat ive adjuvant chemot herapy is
det ermined by t he hist ologic t umor t ype. Surgical st aging (eg, sampling of lymph nodes) is less
crit ical in advanced disease (eg, st age IIIB/C disease), as t hese t umors (wit h t he except ion of
t umors of low malignant pot ent ial) will require chemot herapy. If a met ast at ic ovarian cancer is
ident ified, t he ext ent of surgical cyt oreduct ion involves individual judgment , balancing t he ext ent
of surgery wit h t he expect ed benefit . Before delivery, we leave as much of t he reproduct ive
t ract in sit u as possible, as pat ient s wit h advanced-st age epit helial ovarian cancer can undergo
complet ion of debulking of t he reproduct ive organs following delivery. (See 'Surgery' above.)

● Removal of t he corpus lut eum prior t o eight weeks of gest at ion requires post operat ive
progest erone supplement at ion. (See 'Management of corpus lut eum' above.)

Use of UpToDat e is subject t o t he Subscript ion and License Agreement .

Topic 3201 Version 22.0
GRAPHICS
Markers that may be secreted by germ cell and sex cord-stromal tumors of the ovary

  AFP hCG LDH E2 Inhibin* T A4 DHEA AMH

Ge rm c e ll t umors

Dysgerm inom a –¶ ±Δ + ± – – – – –

Em bryona l ± + ± ± – – – – –

Im m a ture ± – ± ± – – – ± –
tera tom a

Chorioca rcinom a – + ± – – – – – –

Yolk sa c tum or + – + – – – – – –
(endoderm a l sinus
tum or)

Gona dobla stom a ◊ – – – ± ± ± ± ± –

Polyem bryona ± + – – – – – – –

Mixed germ cell ± ± ± ± – – – – –

Se x c ord-st roma l t umors

Thecom a -fibrom a – – – – – – – – –

Thecom a – – – ± ± – – – –

Gra nulosa cell – – – ± + ± – – +

Sex cord tum or with – – – + – – – – –

a nnula r tubules

Sertoli-Leydig ± – – ± ± ± ± ± –

Sertoli – – – – ± ± – – –

AFP: a lpha -fetoprotein; hCG: hum a n chorionic gona dotropin; LDH: la cta te dehydrogena se; E2: estra diol; T: testosterone; A4: a ndrostenedione;
DHEA: dehydroepia ndrostenedione; AMH: a nti-m ülleria n horm one.
* Both inhibin A a nd inhibin B levels should be determ ined (tum ors m ight over-secrete A or B).
¶ Borderline eleva tions in ca se reports (<16 ng/m L).
Δ Low levels seen in dysgerm inom a s with either nondysgerm inom a tous elem ents or syncytiotrophobla stic cells.
◊ Type of germ cell sex cord-strom a l tum or consisting of neopla stic germ cells a nd sex cord-strom a l deriva tives.

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Proportion of histologic types of ovarian cancers among all patients
compared with proportions in pregnant women

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Conditions associated with an elevated serum CA 125 concentration

Gynecologic malignancies Nongynecologic condit ions

Endom etria l ca ncer Ascites

Epithelia l ova ria n, fa llopia n tube, a nd prim a ry peritonea l Appendicula r a bscess

ca ncers
Cirrhosis a nd other liver disea se
Benign gynecologic condit ions Colitis
Adenom yosis Cystic fibrosis
Benign ova ria n neopla sm s Diverticulitis
Endom etriosis Hea rt fa ilure
Functiona l ova ria n cysts Myoca rdia l infa rction
Meig syndrom e Myoca rdiopa thy
Menstrua tion Pa ncrea titis
Ova ria n hyperstim ula tion Perica rdia l disea se
Pelvic infla m m a tory disea se Pleura l effusion
Pregna ncy Pneum onia
Uterine leiom yom a s Pulm ona ry em bolism

Recent surgery

Rena l insufficiency

Sa rcoidosis

System ic lupus erythem a tosus

Tuberculosis peritonitis

Urina ry tra ct infection 

Nongynecologic cancers
Brea st

Colon

Ga llbla dder

Hem a tologic m a ligna ncies

Liver

Lung

Pa ncrea s

CA: ca ncer a ntigen.

Data from:
1. Buamah P. Benign conditions associated with raised serum CA-125 concentration. J Surg Oncol 2000; 75:264.
2. Miralles C, Orea M, Espana P, et. al. Cancer antigen 125 associated with multiple benign and malignant pathologies. Ann Surg Oncol
2003; 10:150.
3. Moss EL, Hollingworth J, Reynolds TM. The role of CA125 in clinical practice. J Clin Pathol 2005; 58:308.

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Steps in staging ovarian cancer

1. Obta in a ny free fluid for cytologic eva lua tion.

2. If no free fluid is present, obta in wa shings by instilling sa line a nd recovering the fluid. The fluid should irriga te the cul-de-sa c,
pa ra colic gutters, a nd a rea benea th ea ch dia phra gm .

3. System a tica lly explore a ll intra a bdom ina l orga ns a nd surfa ces: Bowel, liver, ga llbla dder, dia phra gm s, m esentery, om entum , a nd
the entire peritoneum should be visua lized a nd pa lpa ted, a s indica ted.

4. Suspicious a rea s or a dhesions should be biopsied. If there a re no suspicious a rea s, m ultiple biopsies should be obta ined from the
peritoneum of the cul-de-sa c, pa ra colic gutters, bla dder, a nd intestina l m esentery when the disea se a ppea rs confined to the ova ry.
These biopsies a re not needed if the pa tient ha s a dva nced disea se.

5. The dia phra gm should be biopsied or scra ped for cytology. A la pa roscope a nd biopsy instrum ent m ay be used.

6. The om entum should be resected from the tra nsverse colon.

7. The retroperitoneum should be explored to eva lua te pelvic nodes. Suspicious nodes should be rem oved a nd sent for frozen section
exa m ina tion.

8. The pa ra a ortic nodes should be exposed a nd enla rged nodes rem oved. Nodes superior to the inferior m esenteric a rtery should a lso be
resected.

9. In the a bsence of suspicious nodes, pelvic a nd pa ra a ortic nodes should still be sa m pled to exclude the possibility of m icroscopic
sta ge III disea se.

10. A tota l a bdom ina l hysterectom y a nd bila tera l sa lpingo-oophorectom y is perform ed. (Fertility-conserving surgery m ay be a n option
for som e wom en.)

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Ovary, fallopian tube, and primary peritoneal carcinoma TNM staging AJCC UICC 8th edition

Primar y t umor (T)

T c a t e gor y FIGO st a ge T c rit e ria

TX   Prim a ry tum or ca nnot be a ssessed

T0   No evidence of prim a ry tum or

T1 I Tum or lim ited to ova ries (one or both) or fa llopia n tube(s)

T1a IA Tum or lim ited to one ova ry (ca psule inta ct) or fa llopia n tube, no
tum or on ova ria n or fa llopia n tube surfa ce; no m a ligna nt cells
in a scites or peritonea l wa shings

T1b IB Tum or lim ited to both ova ries (ca psules inta ct) or fa llopia n tubes;
no tum or on ova ria n or fa llopia n tube surfa ce; no m a ligna nt
cells in a scites or peritonea l wa shings

T1c IC Tum or lim ited to one or both ova ries or fa llopia n tubes, with a ny
of the following:

T1c1 IC1 Surgica l spill

T1c2 IC2 Ca psule ruptured before surgery or tum or on ova ria n or

fa llopia n tube surfa ce

T1c3 IC3 Ma ligna nt cells in a scites or peritonea l wa shings

T2 II Tum or involves one or both ova ries or fa llopia n tubes with pelvic
extension below pelvic brim or prim a ry peritonea l ca ncer

T2a IIA Extension a nd/or im pla nts on the uterus a nd/or fa llopia n tube(s)
a nd/or ova ries

T2b IIB Extension to a nd/or im pla nts on other pelvic tissues

T3 III Tum or involves one or both ova ries or fa llopia n tubes, or prim a ry
peritonea l ca ncer, with m icroscopica lly confirm ed peritonea l
m eta sta sis outside the pelvis a nd/or m eta sta sis to the
retroperitonea l (pelvic a nd/or pa ra -a ortic) lym ph nodes

T3a IIIA2 Microscopic extra pelvic (a bove the pelvic brim ) peritonea l
involvem ent with or without positive retroperitonea l lym ph nodes

T3b IIIB Ma croscopic peritonea l m eta sta sis beyond pelvis 2 cm or less in
grea test dim ension with or without m eta sta sis to the
retroperitonea l lym ph nodes

T3c IIIC Ma croscopic peritonea l m eta sta sis beyond the pelvis m ore tha n 2
cm in grea test dim ension with or without m eta sta sis to the
retroperitonea l lym ph nodes (includes extension of tum or to
ca psule of liver a nd spleen without pa renchym a l involvem ent of
either orga n)

Regional lymph nodes (N)

N c a t e gor y FIGO st a ge N c rit e ria

NX   Regiona l lym ph nodes ca nnot be a ssessed

N0   No regiona l lym ph node m eta sta sis

N0(i+)   Isola ted tum or cells in regiona l lym ph node(s) no grea ter tha n 0.2
mm

N1 IIIA1 Positive retroperitonea l lym ph nodes only (histologica lly

confirm ed)

N1a IIIA1i Meta sta sis up to a nd including 10 m m in grea test dim ension
 N1b IIIA1ii Meta sta sis m ore tha n 10 m m in grea test dim ension

Dist ant met ast asis (M)

M c a t e gor y FIGO st a ge M c rit e ria

M0   No dista nt m eta sta sis

M1 IV Dista nt m eta sta sis, including pleura l effusion with positive

cytology; liver or splenic pa renchym a l m eta sta sis; m eta sta sis to
extra -a bdom ina l orga ns (including inguina l lym ph nodes a nd
lym ph nodes outside the a bdom ina l cavity); a nd tra nsm ura l
involvem ent of intestine

M1a IVA Pleura l effusion with positive cytology

M1b IVB Liver or splenic pa renchym a l m eta sta ses; m eta sta ses to extra -
a bdom ina l orga ns (including inguina l lym ph nodes a nd lym ph
nodes outside the a bdom ina l cavity); tra nsm ura l involvem ent of
intestine

Prognost ic st age groups

Whe n T is... And N is... And M is... T he n t he st a ge group is...

T1 N0 M0 I

T1a N0 M0 IA

T1b N0 M0 IB

T1c N0 M0 IC

T2 N0 M0 II

T2a N0 M0 IIA

T2b N0 M0 IIB

T1/T2 N1 M0 IIIA1

T3a NX, N0, N1 M0 IIIA2

T3b NX, N0, N1 M0 IIIB

T3c NX, N0, N1 M0 IIIC

Any T Any N M1 IV

Any T Any N M1a IVA

Any T Any N M1b IVB

TNM: Tum or, Node, Meta sta sis; AJCC: Am erica n Joint Com m ittee on Ca ncer; UICC: Union for Interna tiona l Ca ncer Control.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer
Staging Manual, Eighth Edition (2017) published by Springer International Publishing. Corrected at 4th printing, 2018.

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