INTRODUCTION — Epithelial, germ cell, and stromal cancers of the ovary, fallopian tube, and peritoneum are staged surgically. In this topic, we will focus on epithelial carcinomas and generally refer to carcinoma at these sites as epithelial ovarian carcinoma (EOC), but distinctions between sites, where present, will be addressed.
The majority of patients with EOC are diagnosed at an advanced stage: distant metastases (48 percent), spread to regional lymph nodes (23 percent), localized at diagnosis (21 percent), and unstaged (8 percent) . Complete surgical staging of EOC is important for treatment planning and prognostic counseling. For example, approximately 30 percent of patients undergoing comprehensive surgical staging for clinical findings of stage I EOC are found to have more advanced disease, usually positive cytology, and are upstaged and treated accordingly .
Surgical staging of patients with EOC will be reviewed here. The preoperative evaluation of these patients, cytoreductive surgery, and chemotherapy are discussed separately.
STAGING SYSTEM — EOC is surgically staged according to the 2017 8th Edition American Joint Committee on Cancer (AJCC) and the International Federation of Gynecology and Obstetrics (FIGO) Tumor, Node, Metastasis (TNM) classification system (table 1) . A single system is now used for ovarian, fallopian tube, and peritoneal carcinomas, although this has not always been the case.
Some nuances of staging are discussed below:
●It is not possible to have stage I peritoneal carcinoma.
●Surface involvement of the ovary or fallopian tube is defined as neoplastic cells directly exposed to the peritoneal cavity . This usually takes the form of an exophytic papillary tumor on the surface of the ovary or fallopian tube or on the outer surface of a cystic neoplasm replacing these organs. Rarely, surface involvement may be an exposed layer of neoplastic epithelium on a smooth ovarian tumor surface. Assessment for surface involvement requires careful gross examination as its presence may influence therapeutic decision making.
Stage IB (tumor limited to both ovaries [capsules intact] or fallopian tubes; no tumor on ovarian or fallopian tube surface; no malignant cells in ascites or peritoneal washings) is relatively uncommon (1 to 5 percent of stage I cases) [5,6]. One-third of carcinomas with bilateral involvement will have an enlarged ovary on one side and a normal size ovary on the other side; any tumor identified on the ovarian or fallopian tube surface is upstaged to IC2 .
●Capsule rupture – Rupture of the ovarian tumor capsule may occur preoperatively or during surgical removal and may disseminate malignant cells via the peritoneal circulation [8,9]. This is reflected in the staging system: for stage I disease, surgical spill is IC1, and rupture prior to surgery is IC2. Patients with disease confined to one or both ovaries who have intraoperative capsule rupture are upgraded from IA or IB to IC1, which is clinically significant because stage IC is typically the threshold for treating with chemotherapy for certain histologies.
Preoperative rupture appears to be associated with a worse prognosis. In a meta-analysis of 17 observational studies including over 18,000 patients with early-stage ovarian cancer undergoing surgical management, those with intraoperative capsule rupture (63 percent) compared with no capsule rupture had worse progression-free survival (hazard ratio [HR] 1.92, 95% CI 1.34-2.76) and worse overall survival (HR 1.48, 95% CI 1.15-1.91) . However, data regarding the prognosis of intraoperative rupture are inconsistent [11-14] and it remains unclear whether the worse prognosis with intraoperative rupture is due to rupture or to a missed diagnosis of advanced disease in patients who are incompletely staged.
●Dense adhesions with histologically proven neoplastic cells justify upgrading to stage II. Because data are inconsistent regarding whether sharp dissection of dense adhesions in patients with an apparent stage I carcinoma results in outcomes equivalent to stage II [15,16], the recommendation for upstaging is limited to dense adhesions with malignant cells. Sampling the adhesions after removal of the mass may assist with appropriate staging.
●Evaluation of the peritoneum above and below the pelvic brim – The presence or absence of disease above or below the pelvic brim should be described in the operative report, especially if there is no evidence of gross disease outside of the pelvis. Stage II EOC includes direct extension to the peritoneum below the pelvic brim. Stage III EOC includes extrapelvic (above the pelvic brim) peritoneal involvement. Thus, the pelvic brim is a landmark for appropriate surgical staging.
●Distinguishing between stage III and IV – The majority of EOC will present at an advanced stage (III/IV). Some considerations for intraoperative distinction between stage III and IV disease are bowel infiltration (transmural with mucosal involvement), umbilical deposit, inguinal lymph node metastasis, and parenchymal (not surface) metastases in liver or spleen, all of which are considered stage IVB.
Overview — In the setting of clinically early stage EOC, the standard staging procedure consists of all of the following:
●Peritoneal cytology (washings or ascites).
●Visual assessment of the upper abdomen, peritoneal surfaces, and large and small bowel mesentery and other abdominal organs, with biopsies of abnormal findings.
●Hysterectomy with bilateral salpingo-oophorectomy.
●Pelvic and paraaortic lymph node dissection.
●Infracolic or infragastric omentectomy.
However, fertility preservation is an acceptable option in young patients with ovarian tumors of low malignant potential or nonepithelial ovarian cancers, and patients with stage IA EOC who prefer this approach. (See 'Staging in patients who desire fertility preservation' below.)
Role of the gynecologic oncologist — Staging and initial surgical management should be performed by a gynecologic oncologist whenever possible. Outcomes of these procedures, when performed by a gynecologic oncologist, have been shown to be better than when the procedure is performed by other surgeons. These data are reviewed separately. (See "Approach to the patient with an adnexal mass", section on 'When to refer to a gynecologic oncologist'.)
Mode of surgery
Open laparotomy versus minimally invasive surgery — Open laparotomy is the standard surgical approach for treatment of these cancers. Minimally invasive surgery (MIS) with traditional and robotic-assisted laparoscopy has mainly been investigated in patients with presumed stage I or II ovarian cancer in whom cytoreduction is not necessary [17-19]. While technically possible, the MIS approach is controversial and requires further investigation before use becomes widespread.
Technical concerns regarding use of MIS include the following:
●Intact removal of the ovarian mass is often not possible, and rupture of the mass may worsen prognosis . In an observational study of 8850 patients with stage I epithelial ovarian cancer, capsule rupture occurred more frequently in patients undergoing MIS (ie, either traditional or robotic-assisted laparoscopy) compared with laparotomy (adjusted relative risk 1.17, 95% CI 1.06-1.29) and was associated with an increase in all-cause mortality in both groups . This is discussed in more detail elsewhere. (See 'Staging system' above.)
●Thorough inspection of the entire pelvis and abdomen, especially inspection of all bowel surfaces and mesentery, is challenging.
●Tumor seeding of the laparoscopic access sites (port site metastasis) may occur. This usually happens in the setting of peritoneal carcinomatosis or positive peritoneal cytology and often resolves with adjuvant therapy . (See "Complications of laparoscopic surgery", section on 'Trocar site metastasis'.)
Advantages of MIS compared with laparotomy include less blood loss, shorter hospital stay, and lower rates of postoperative complications [17,22-24].
Carbon dioxide pneumoperitoneum does not appear to adversely affect survival in patients with intraabdominal metastases .
Robotic-assisted versus traditional laparoscopy — Although open laparotomy is preferred over MIS, the benefits of robotic-assisted compared with traditional laparoscopy are less clear. In a study comparing outcomes of robotic-assisted laparoscopy with traditional laparoscopy for clinical stage I ovarian cancer (n = 1901 patients in the National Cancer Database), robotic-assisted laparoscopy was less likely to result in conversion-to-open surgery (conversion rate 7.2 versus 17.9 percent), and survival was similar for the two approaches . Compared with traditional laparoscopy, robotic-assisted laparoscopy one-, three-, and five-year mortality hazard ratios were 0.97 (95% CI 0.43-2.18), 0.68 (95% CI 0.43-1.08), and 0.78 (95% CI 0.53-1.16), respectively.
Incision — A vertical midline incision is the best approach for laparotomy for staging and cytoreductive surgery as it provides full exposure of the pelvis and abdomen. Due to limitations of exposure or access, Pfannenstiel incision should be avoided; however, Pfannenstiel incision can be converted to a modified Maylard or Cherney incision if it was initially chosen because of erroneous expectations of benign findings. (See "Incisions for open abdominal surgery".)
Peritoneal cytology — As soon as the peritoneal cavity is entered, any ascites/peritoneal fluid should be collected and a representative sample sent for cytologic evaluation. If only a minimal or negligible volume of fluid is present, peritoneal washings are obtained by instilling 50 to 200 mL of saline into the peritoneal cavity and then removing the fluid by suction. Positive washings have prognostic significance and may be an indicator of peritoneal/omental metastases .
Pelvic and abdominal exploration and biopsies — Pelvic and abdominal exploration is conducted in a systematic manner, assessing the status of the pelvic organs, small and large intestines, bowel mesentery, appendix, stomach, liver, gallbladder, spleen, omentum, both sides of the diaphragms, and the entire peritoneal surface. Retroperitoneal structures, such as the kidneys and pancreas, are palpated through the peritoneum and adipose tissue. The umbilicus is carefully palpated, as metastasis to the peritoneal side can occur, and may require excision.
In the absence of metastatic disease, multiple random biopsies should be taken from peritoneal surfaces, including the posterior cul-de-sac (pouch of Douglas), bladder peritoneum, paracolic gutters, pelvic side wall, and both sides of the diaphragm, for the evaluation of occult disease. In an observational study of patients enrolled in the European Organisation for Research and Treatment of Cancer (EORTC) ACTION trial, patients who had blind biopsies (and thus more accurate information on stage of disease) had improved five-year disease-free and overall survival compared with those who did not . Additionally, any adhesions or peritoneal surface irregularities should also be biopsied, as tumor involving these tissues impacts stage. In some cases, an inflammatory or desmoplastic reaction is a manifestation of an otherwise occult tumor.
The role of pafolacianine (Cytalux) as an intraoperative adjunct to visual inspection and palpation is discussed in detail separately. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction", section on 'Role of pafolacianine'.)
Identifying primary site of tumor origin — The primary site of origin (ovary, fallopian tube, or peritoneum) should be determined when possible, although this does not affect staging or therapeutic strategy [4,29]. If this is not possible, the primary site should be noted as "undesignated" . Determining the primary site can be accomplished easily when only one site is involved (eg, tumor confined to the ovary) but is challenging when multiple sites are involved. To improve consistency among pathologic review, the Gynecologic Oncology Group (GOG) and the College of American Pathologists (CAP) have established criteria for assigning primary site for these carcinomas [30,31]:
●Fallopian tube primary, if serous tubal intraepithelial carcinoma (STIC) is present OR invasive mucosal carcinoma in the fallopian tube with or without STIC OR the fallopian tube is partially or entirely incorporated into a tubo-ovarian mass.
●Ovarian primary, if no STIC or invasive mucosal carcinoma in the fallopian tube. In these circumstances, the fallopian tubes should be fully examined by sectioning and extensively examining the fimbriated end (SEE-FIM) protocol.
●Peritoneal primary, if both fallopian tubes and both ovaries are grossly and microscopically normal and examined in their entirety in the presence of peritoneal carcinoma. Classification may be "tubo-ovarian" in some circumstances, such as biopsy or postchemotherapy with no residual disease.
STIC lesions are precursor lesions for high-grade serous carcinoma but have the potential for metastatic spread. There is no clear evidence that surgical staging and/or adjuvant therapy is beneficial in patients with STIC lesions alone. Referral to a genetic counselor is recommended because these patients may have a 10 percent chance of carrying a BRCA1 or BRCA2 mutation .
Frozen section — If the diagnosis has been made definitively prior to surgery (eg, via paracentesis or omental biopsy), frozen section is not necessary (see "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Fluid cytology or omental/pleural biopsy'). Otherwise, the diagnosis of EOC is usually made at the time of surgery based on frozen section of the specimen (eg, affected ovary, other primary site, biopsies of metastases). In the absence of grossly visible ovarian or fallopian tube disease, a biopsy of a peritoneal or omental lesion should be sent for evaluation (picture 1 and picture 2).
Omentectomy — The omentum is resected rather than biopsied. Resection of the omentum, especially when replaced by extensive metastatic disease (so-called omental cake), may be performed even when optimal cytoreduction is not possible in order to decrease tumor bulk and formation of postoperative ascites (picture 3).
The peritoneal reflection is separated from the transverse colon, after which the lesser sac is entered. This allows for further assessment of the retroperitoneum (pancreas, high aortic lymph nodes) as well as the posterior aspect of the gastrum. During this portion of the procedure, the mesentery of the transverse colon is identified and preserved.
An infracolic or a complete omentectomy is then performed by isolating and clamping the gastroepiploic vessels. This may be done with suture ligation, a surgical stapler, or a bipolar energy ligating device. If necessary, hepatic and splenic flexures can be mobilized to allow for removal of all of the omentum. Care must be taken not to put undue tension on the spleen while mobilizing the omentum, as this may result in bleeding.
Hysterectomy and salpingo-oophorectomy — Hysterectomy and bilateral salpingo-oophorectomy are performed in almost all patients (see "Hysterectomy: Abdominal (open) route" and "Oophorectomy and ovarian cystectomy"). Fertility preservation is rarely an effective option because of advanced disease; however, if the patient meets criteria and desires fertility preservation, unilateral salpingo-oophorectomy may be performed along with staging. (See 'Staging in patients who desire fertility preservation' below.)
The rationale for hysterectomy and bilateral salpingo-oophorectomy is to remove (if present) occult metastases in the contralateral ovary, adnexa, or uterus. Occasionally, a synchronous primary endometrial cancer will be present, or the uterus will be the site of origin of the suspected EOC.
Avoidance of intraoperative tumor rupture — Avoidance of intraoperative rupture is the basis of the practice of removing the entire ovary and fallopian tube rather than performing a cystectomy when ovarian cancer is suspected. Intraperitoneal spillage of cells can be minimized in laparoscopic cases with salpingo-oophorectomy and use of a laparoscopic bag. The surgeon should note in both the operative report and the pathology requisition whether rupture occurred prior to surgery, in a controlled fashion within a bag (eg, to facilitate removal), or if there was gross spillage. If rupture occurs, copious irrigation should be performed.
Role of radical oophorectomy — In patients with locally advanced disease with extensive involvement of the reproductive organs and/or obliteration of the posterior cul-de-sac, "radical oophorectomy" has been described . However, few patients are appropriate candidates for such an approach, and data on outcomes after the postoperative period are sparse.
In a radical oophorectomy procedure, the round ligaments are divided as laterally as possible, the lateral broad ligament peritoneum overlying the psoas muscle is incised, and the pararectal and paravesical spaces are developed. The ureters are exposed and mobilized. Infundibulopelvic ligaments are identified, clamped, cut, and ligated as high as possible out of the pelvis. The uterine artery can be divided laterally or at its origin. The anterior cul-de-sac peritoneum is incised at the reflection, and the bladder is mobilized off of the lower uterine segment. If there are implants on the anterior cul-de-sac peritoneum, the space of Retzius can be developed, the bladder elevated, and tumor sharply dissected off. The remainder of the hysterectomy can then be carried out in a routine fashion.
If the posterior cul-de-sac is obliterated by cancer, disease-free bowel can usually be identified below the peritoneal reflection since ovarian cancer implants are generally on the peritoneal surface or bowel serosa, leaving the retroperitoneal structures intact. Disease in the cul-de-sac can then be approached laterally. In extreme cases, the peritoneum overlying the paracolic gutters may be incised, the retroperitoneum entered, the ureters and vessels identified, and the pelvis entered from above.
Role of supracervical hysterectomy — Supracervical hysterectomy is rarely performed in ovarian cancer surgery. Reasons to perform a supracervical hysterectomy would be if additional extensive dissection is required to remove the cervix, in the setting of high-volume ascites, or if intraperitoneal chemotherapy is planned. In patients with ascites or planned intraperitoneal chemotherapy, there is a risk of vaginal leakage if the vaginal cuff is not fully healed after total hysterectomy, but there is little to no risk of vaginal leakage if the cervix is conserved.
Data comparing oncologic outcomes after supracervical versus total hysterectomy are limited . Disadvantages of the procedure include the potential for bleeding from the retained stump and interference in detecting recurrent disease.
Lymph node evaluation — In patients with gross metastatic disease, only enlarged/suspicious nodes are removed if optimal cytoreduction is feasible. No statistically significant overall survival advantage has been demonstrated with systematic lymphadenectomy in patients with advanced ovarian cancer. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction", section on 'Lymphadenectomy'.)
In most patients with apparent early ovarian cancer, pelvic and paraaortic lymph node sampling is performed to detect occult stage III disease, which can occur in up to one-third of patients with apparent stage I disease (figure 1) . Though lymph node sampling is associated with an increased duration of surgery and a 13 percent risk of lymphocyst formation, failure to detect nodal disease can have major prognostic implications. In the EORTC ACTION trial, pelvic and paraaortic lymph node sampling was associated with improved survival outcomes compared with no lymph node dissection .
The pelvic and paraaortic nodal beds are sampled bilaterally, even when the disease appears to be confined to one ovary. In a series of 96 patients with disease visibly confined to one ovary, 54 patients had bilateral sampling, of whom 10 had lymph node metastases; 2 of these 10 patients had bilateral lymph node metastases, and 3 of the 10 had metastases confined to a contralateral lymph node . Sentinel node biopsy is investigational .
An exception to routine lymph node sampling is patients with apparent early disease with mucinous tumors that appear confined to the ovary. In a systematic review and meta-analysis, the rate of lymph node metastases was 0.7 percent, and no survival difference was noted in those with and without lymph node sampling . Thus, in patients with mucinous ovarian tumors (3 percent of EOC), staging is performed without lymph node sampling.
Paraaortic lymph nodes above the inferior mesenteric artery are more likely to be involved than other lymph nodes, and efforts should be made to sample nodes above this vessel [35,39,40]. The procedure for lymphadenectomy is described separately. (See "Pelvic and paraaortic lymphadenectomy in gynecologic cancers".)
Appendectomy — If the appendix is involved with tumor, then an appendectomy should be performed; additionally, some experts perform routine appendectomy if mucinous histology is a concern [41,42]. A meta-analysis of studies of patients with mucinous ovarian tumors found that metastatic disease to the appendix or a primary appendiceal cancer was relatively common (1.4 percent) when the appendix appeared normal and increased to 59 percent for a macroscopically abnormal appendix . Although the authors concluded that appendectomy is only warranted when the appendix appears abnormal, others have concluded that appendectomy should be performed in all mucinous ovarian cancer cases since complications are rare and a normal-looking appendix does not exclude metastatic disease .
When an appendectomy is performed, the mesentery with the appendiceal artery is clamped, cut, and ligated, and the appendix is clamped close to the cecum. The appendix is then removed, and the stump is ligated. The use of absorbable sutures is acceptable if the selected material has delayed absorption to prevent leakage from the stump. Complex procedures involving manipulation of the stump are unnecessary. Stapling devices may be used but increase the costs of the procedure without any proven benefit.
Other radical procedures — Other radical procedures may include diaphragm peritonectomy or resection, multiple resections of the bowel, liver resection, partial gastrectomy, cholecystectomy, and splenectomy (with or without distal pancreatectomy). Posterior exenteration is rarely performed. These procedures are usually performed as part of surgical cytoreduction and are discussed in detail separately. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction", section on 'Cytoreduction procedures'.)
STAGING IN PATIENTS WHO DESIRE FERTILITY PRESERVATION — Fertility preservation is an acceptable option in young patients with ovarian tumors of low malignant potential or nonepithelial ovarian cancers and patients with stage IA EOC who prefer this approach.
If unilateral salpingo-oophorectomy is being considered, we recommend documenting localized disease by performing the following:
●Full surgical staging, including washings, omentectomy, pelvic and paraaortic lymphadenectomy, and peritoneal biopsies.
●Thorough abdominal exploration and biopsy of any abnormal areas.
●Endometrial biopsy to exclude synchronous endometrial cancer.
Most surgeons do not routinely biopsy the contralateral ovary if it appears normal. The contralateral ovary, uterus, and fallopian tube infrequently contain occult disease in staged patients. In the Danish and Dutch database of 1234 patients with apparent stage I EOC, 393 were upstaged, and upstaging was based on microscopic spread to both ovaries in only 0.8 percent .
Patients who desire fertility preservation should clearly understand that data regarding outcome are limited; in particular, there is little information on the frequency and outcome of recurrent disease or the safety of ovulation induction or hormonal contraception [44-46]. Young patients with a well-differentiated lesion of one ovary who have had a full staging operation, but limited organ extirpation to preserve childbearing, are advised to undergo hysterectomy and removal of the remaining ovary upon completion of childbearing or by age 35. Advanced fertility preservation technologies continue to improve in efficacy, including egg and embryo freezing.
In a review of studies of 282 patients with EOC who received conservative treatment, 33 relapses and 16 disease-related deaths occurred; there were also 113 deliveries . In subsequent studies, patients with stage I EOC who underwent fertility-sparing surgery compared with conventional surgery were not at increased risk of death (hazard ratio [HR] 0.8, 95% CI 0.49-1.29) , and do not appear to be at increased risk for adverse pregnancy outcomes (eg, preterm birth, small for gestational age neonates, severe maternal or neonatal morbidity) .
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ovarian, fallopian tube, and peritoneal cancer".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Treatment of ovarian cancer (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●General principles – Epithelial cancers of the ovary, fallopian tube, and peritoneum are termed epithelial ovarian carcinoma (EOC). While the staging of cancer at these three anatomic sites is the same, the different histologic types of EOC are a heterogeneous set of diseases that vary in pathogenesis, clinical behavior, and response to treatment. (See 'Introduction' above.)
●Staging system – EOC is surgically staged according to the International Federation of Gynecology and Obstetrics (FIGO) Tumor, Node, Metastasis (TNM) classification system (table 1). Surgery is usually also required to confirm the diagnosis and for cytoreduction. (See 'Staging system' above.)
●Patients who have completed childbearing – Open laparotomy is the standard approach for staging, but laparoscopic or robot-assisted approaches are used by experienced gynecologic oncologists for selected patients. In patients not desiring fertility preservation, the procedure consists of all of the following (see 'Overview' above and 'Role of the gynecologic oncologist' above and 'Open laparotomy versus minimally invasive surgery' above):
•Peritoneal cytology (washings or ascites). (See 'Peritoneal cytology' above.)
•Visual assessment of the upper abdomen, peritoneal surfaces, and large and small bowel mesentery and other abdominal organs, with biopsies of abnormal findings (frozen section if EOC has not been previously confirmed). (See 'Pelvic and abdominal exploration and biopsies' above and 'Identifying primary site of tumor origin' above and 'Frozen section' above.)
•Infracolic or infragastric omentectomy. (See 'Omentectomy' above.)
•Hysterectomy with bilateral salpingo-oophorectomy, avoiding tumor rupture. Radical oophorectomy/posterior exenteration may be useful for patients with confluent pelvic disease. (See 'Hysterectomy and salpingo-oophorectomy' above.)
•In patients with apparent early disease (stage I or II), pelvic and paraaortic lymph node sampling to exclude occult stage III disease. In patients with gross metastatic disease, only enlarged/suspicious nodes are removed if cytoreduction is feasible; no overall survival advantage has been demonstrated with systematic lymphadenectomy in these patients. (See 'Lymph node evaluation' above.)
●Role of appendectomy – An appendectomy is performed if the appendix is involved with tumor; some experts perform routine appendectomy if mucinous histology is known or suspected. (See 'Appendectomy' above.)
●Patients desiring fertility preservation – Fertility preservation is an acceptable option in young patients with ovarian tumors of low malignant potential or nonepithelial ovarian cancers and in patients with stage IA disease who prefer this approach. (See 'Staging in patients who desire fertility preservation' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges William Mann, Jr, MD; Eva Chalas, MD, FACOG, FACS; Fidel Valea, MD; and Heidi Gray, MD, who contributed to earlier versions of this topic review.
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