Borderline malignancy of the ovary and controlled hyperstimulation, a report of 2 cases

Does controlled ovarian hyperstimulation in women with a history of borderline tumor influence recurrence rate?

PURPOSE

To determine the recurrence rate in the women with controlled ovarian hyperstimulation after a history of borderline ovarian tumors (BOT).

METHODS

This was a retrospective analysis of 275 patients with BOT undergoing surgery for fertility preservation in our hospital between 2001 and 2017. Cases were divided into an assisted reproductive technology (ART) treatment group (n = 15) and a non-ART treatment group (n = 260). We compared the recurrence rate, survival rate and pregnancy outcomes between these two groups.

RESULTS

The ART group had a higher recurrence rate (33.33% vs. 10.80%, P = 0.023). Survival analysis indicated that the recurrence time in patients undergoing ART was significantly shorter (P = 0.026). A low pregnancy rate before diagnosis, and high intraoperative blood loss, were associated with postoperative ART treatment (P < 0.05). Multivariate analysis showed that ART treatment and bilateral lesions both significantly increased the risk of recurrence (P < 0.05). The pathological type of recurrent tumors was often the same as the initial tumor.

CONCLUSION

The postoperative use of ART in patients with BOT significantly increased the recurrence rate, but does not significantly affect the overall survival rate of patients. Therefore, ART in such patients should be individualized, and close follow-up is necessary after ART.

Fertility-Sparing Surgery for Ovarian Cancer

(1) Background: although most patients with epithelial ovarian cancer (EOC) undergo radical surgery, patients with early-stage disease, borderline ovarian tumor (BOT) or a non-epithelial tumor could be offered fertility-sparing surgery (FSS) depending on histologic subtypes and prognostic factors. (2) Methods: we conducted a systematic review to assess the safety and fertility outcomes of FSS in the treatment of ovarian cancer. We queried the MEDLINE, PubMed, Cochrane Library, and Cochrane (“Cochrane Reviews”) databases for articles published in English or French between 1985 and 15 January 2021. (3) Results: for patients with BOT, FSS should be offered to young women with a desire to conceive, even if peritoneal implants are discovered at the time of initial surgery. Women with mucinous BOT should undergo initial unilateral salpingo-oophorectomy, whereas cystectomy is an acceptable option for women with serous BOT. Assisted reproductive technology (ART) can be initiated in patients with stage I BOT if infertility persists after surgery. For patients with EOC, FSS should only be considered after staging for women with stage IA grade 1 (and probably 2, or low-grade in the current classification) serous, mucinous or endometrioid tumors. FSS could also be offered to patients with stage IC grade 1 (or low-grade) disease. For women with serous, mucinous or endometrioid high-grade stage IA or low-grade stage IC1 or IC2 EOC, bilateral salpingo-oophorectomy and uterine conservation could be offered to allow pregnancy by egg donation. Finally, FSS has a large role to play in patients with non- epithelial ovarian cancer, and particularly women with malignant ovarian germ cell tumors.

Fertility and borderline ovarian tumor: a systematic review of conservative management, risk of recurrence and alternative options

BACKGROUND

The aim of this systematic review was to evaluate the fertility outcome after borderline ovarian tumor (BOT) management and the results of conservative management, risk of recurrence and alternative options.

METHODS

The search strategy was based on relevant terms concerning BOT using Medline and the Central Cochrane Library. Both early and advanced stages of serous and mucinous BOT were included, but not rare entities such as endometrioid, Brenner or clear-cell BOT because of their low incidence. We considered all articles-case reports, original studies, meta-analyses and reviews-in English and French.

RESULTS

Overall, 230 articles were screened of which 120 were retained for review. Most pregnancies were spontaneous but some data were obtained from studies analyzing the contribution of assisted reproductive technology (ART). However, not all studies differentiated spontaneous pregnancy from those obtained after fertility treatment including ovulation induction, intrauterine insemination and IVF. Conservative management of early stage BOT resulted in a pooled estimate for spontaneous pregnancy rate of 54% with a low risk of lethal recurrence (pooled estimate: 0.5%). In patients with advanced stage BOT, the spontaneous pregnancy rates was lower (34% in the single series reporting pregnancy rate in this context) and the risk of lethal recurrence increased (pooled estimate: 2%).

CONCLUSIONS

This systematic review underlines that fertility subsequent to treatment of BOT depends mainly on histology and initial staging to distinguish early from advanced stages. In patients with advanced stage BOT, several alternative options to conservative management are available to allow patients to conceive without compromising their prognosis.

Fertility drugs and the risk of breast and gynecologic cancers

The evaluation of cancer risk among patients treated for infertility is complex, given the need to consider indications for use, treatment details, and the effects of other factors (including parity status) that independently affect cancer risk. Many studies have had methodologic limitations. Recent studies that have overcome some of these limitations have not confirmed a link between drug use and invasive ovarian cancers, although there is still a lingering question as to whether borderline tumors might be increased. It is unclear whether this merely reflects increased surveillance. Investigations regarding breast cancer risk have produced inconsistent results. In contrast, an increasing number of studies suggest that fertility drugs may have a special predisposition for the development of uterine cancers, of interest given that these tumors are recognized as particularly hormonally responsive. Additional studies are needed to clarify the effects on cancer risk of fertility drugs, especially those used in conjunction with in vitro fertilization. Because many women who have received such treatments are still relatively young, further monitoring should be pursued in large well-designed studies that enable assessment of effects within a variety of subgroups defined by both patient and disease characteristics.

Is There a Relationship between Ovarian Epithelial Dysplasia and Infertility?

Aim. Ovarian epithelial dysplasia was initially described in material from prophylactic oophorectomies performed in patients at genetic risk of ovarian cancer. Similar histopathological abnormalities have been revealed after ovulation stimulation. Since infertility is also a risk factor for ovarian neoplasia, the aim of this study was to study the relationship between infertility and ovarian dysplasia. Methods. We blindly reviewed 127 histopathological slides of adnexectomies or ovarian cystectomies according to three groups-an exposed group to ovulation induction (n = 30), an infertile group without stimulation (n = 35), and a spontaneously fertile control group (n = 62)-in order to design an eleven histopathological criteria scoring system. Results. The ovarian dysplasia score was significantly higher in exposed group whereas dysplasia score was low in infertile and control groups (resp., 8.21 in exposed group, 3.69 for infertile patients, and 3.62 for the controls). In the subgroup with refractory infertility there was a trend towards a more severe dysplasia score (8.53 in ovulation induction group and 5.1 in infertile group). Conclusion. These results raise questions as to the responsibility of drugs used to induce ovulation and/or infertility itself in the genesis of ovarian epithelial dysplasia.

Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort

BACKGROUND

Long-term effects of ovarian stimulation for IVF on the risk of ovarian malignancies are unknown.

METHODS

We identified a nationwide historic cohort of 19,146 women who received IVF treatment in the Netherlands between 1983 and 1995, and a comparison group of 6006 subfertile women not treated with IVF. In 1997-1999, data on reproductive risk factors were obtained from 65% of women and data on subfertility (treatment) were obtained from the medical records. The incidence of ovarian malignancies (including borderline ovarian tumours) through 2007 was assessed through linkage with disease registries. The risk of ovarian malignancies in the IVF group was compared with risks in the general population and the subfertile comparison group.

RESULTS

After a median follow-up of 14.7 years, the risk of borderline ovarian tumours was increased in the IVF group compared with the general population [standardized incidence ratio (SIR) = 1.76; 95% confidence interval (CI) = 1.16-2.56]. The overall SIR for invasive ovarian cancer was not significantly elevated, but increased with longer follow-up after first IVF (P = 0.02); the SIR was 3.54 (95% CI = 1.62-6.72) after 15 years. The risks of borderline ovarian tumours and of all ovarian malignancies combined in the IVF group were significantly increased compared with risks in the subfertile comparison group (hazard ratios = 4.23; 95% CI = 1.25-14.33 and 2.14; 95% CI = 1.07-4.25, respectively, adjusted for age, parity and subfertility cause).

CONCLUSIONS

Ovarian stimulation for IVF may increase the risk of ovarian malignancies, especially borderline ovarian tumours. More large cohort studies are needed to confirm these findings and to examine the effect of IVF treatment characteristics.

Ovarian stimulation: is there a long-term risk for ovarian, breast and endometrial cancer?

Adverse effects have been related to infertility treatments. Infertility in general, and female infertility in particular, is a well established risk factor for cancer development, especially ovarian, breast and endometrial cancer. This article addresses the possible association between infertility and cancer development, with an emphasis on the influence of infertility treatments, through a meticulous search of the literature published thus far. While results regarding the possible association of infertility, ovulation induction medications and invasive ovarian cancer show no increased risk and are reassuring, results for increased risk for breast cancer and endometrial cancer following exposure to ovarian stimulation medications are inconclusive. Larger population studies with longer periods of follow-up and better adjustment for confounding factors are needed.

Pregnancy outcomes after conservative surgical management of ovarian neoplasms treated at a single institution

HYPOTHESIS

Conservative surgical management of ovarian neoplasms can result in favorable oncologic and obstetric outcomes.

METHODS

All reproductive-age women (18-45 years old) with stage IA to stage IIC ovarian neoplasms (N = 161) were retrospectively identified from a single institution's tumor registry between 1990 and 2007. Operative, pathological, outpatient, and delivery records were reviewed to confirm histological findings, stage, extent of surgical resection, adjuvant treatment, oncologic outcomes, and pregnancy outcomes.

RESULTS

Women who underwent conservative surgical management for ovarian neoplasms (n = 61 [37.9%]) were identified, including those with low malignant potential (LMP, n = 36), epithelial (n = 12), germ cell (n = 6), and sex cord (n = 7) tumors. Thirteen women conceived 23 pregnancies, producing a pregnancy rate of 25.0% overall and of 68.4% for those attempting conception. Women with LMP tumors conceived most pregnancies and had the highest number of antenatal complications. Of those receiving adjuvant chemotherapy (n = 8), 12.5% were able to conceive after their treatment and with no reported congenital anomalies. Pregnancy after a diagnosis of ovarian neoplasm did not impact disease recurrence (0% vs 7.7%, P = 0.56) or survival (100% vs 100%, P = 1.0).

CONCLUSIONS

Conservative surgery may be an acceptable option for reproductive-age women with early-stage ovarian neoplasms. We report pregnancy and oncologic outcomes for a cohort of women managed conservatively for LMP, epithelial, germ cell, and sex cord ovarian neoplasms.

[Ovarian low malignant potential tumor: how to preserve fertility?]

Ovarian low malignant potential tumor account for 10 to 20 percent of ovarian epithelial tumors. They differ from typical ovarian cancers in that they do not grow into the ovarian stroma. Likewise, if they spread outside the ovary, for example, into the abdominal cavity, they do not usually grow into the lining of the abdomen. These cancers tend to affect women at a younger age than the typical ovarian cancers and are less life-threatening than most ovarian cancers. Guidelines for surgical treatment of borderline ovarian tumors are similar to those for ovarian cancer and include hysterectomy with bilateral salpingo-oophorectomy. However, patients with borderline ovarian tumors tend to be younger than women with invasive ovarian cancer. For many of these patients, fertility is an important issue. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Despite infrequent data, this observation has been expanded to include women with advanced-stage disease. Recurrence is noted more often after this type of treatment, but does not seem to have a negative effect on survival. Management of conservative treatment (complete staging, cystectomy or oophorectomy, oophorectomy or adnexectomy) are still under debate since none avoids the malignant transformation risk. Thus, close follow-up is mandatory and the optimal moment for final oophorectomy remains unclear. When ovarian preservation is impossible, oocyte/ovarian cryopreservation or emergency ovarian induction before the surgical procedure to obtain embryos are promising but still under evaluated options.

Outcomes after conservative treatment of advanced-stage serous borderline tumors of the ovary

BACKGROUND

The aim of this study was to assess the outcomes of the largest series of patients treated conservatively for a stage II or III serous borderline ovarian tumor.

MATERIALS AND METHODS

From 1969 to 2006, 41 patients were treated conservatively for an advanced-stage serous borderline ovarian tumor. Patient outcomes were reviewed.

RESULTS

Twenty patients had undergone a unilateral salpingo-oophorectomy, 18 a unilateral cystectomy and two bilateral cystectomy (unknown for one patient). Three patients had invasive implants. The median duration of follow-up was 57 months (range 4-235). The recurrence rate was high (56%), but overall survival remained excellent (100% at 5 years, 92% at 10 years). One death had occurred due to an invasive ovarian recurrence. Eighteen pregnancies (nine spontaneous) were observed in 14 patients.

CONCLUSIONS

This study demonstrates that spontaneous pregnancies can be achieved after conservative treatment of advanced-stage borderline ovarian tumors (with noninvasive implants) but the recurrence rate is high. Nevertheless, this high rate has no impact on survival. Conservative surgery can be proposed to patients with a borderline tumor of the ovary and noninvasive peritoneal implants. Should infertility persist following treatment of the borderline tumor, an in vitro fertilization procedure can be cautiously proposed.

Fertility drugs and risk of ovarian cancer: dispelling the myth

PURPOSE OF REVIEW

Worldwide 50-80 million people suffer from infertility. Assisted reproductive technology has provided a way of overcoming infertility and childlessness. The current article will focus on data linking infertility and its treatment to ovarian cancer.

RECENT FINDINGS

Ovarian cancer risks associated with fertility drug treatment are encouraging, but not decisive. In view of the limited ability to evaluate drug effects on borderline tumors, given their rare occurrence, studies involving patient reports of prior drug exposures have noted an elevated risk of borderline tumors associated with fertility drugs. Nevertheless, the risk of invasive ovarian cancer appears to be restricted to those women who remain childless despite the infertility treatment.

SUMMARY

As long as doubt persists, it might be advisable to reflect on a few clinical recommendations: identify high-risk infertile patients for ovarian cancer, investigate preexisting cancer before fertility treatment, inform patients regarding potential risks, obtain an informed consent, avoid exposure to long periods of ovulation induction cycles that are given before patients are referred for in-vitro fertilization and embryo transfer for women at greater risk and monitor women who have been treated with these drugs, especially those who failed to conceive, regularly and thoroughly.

Outcomes of controlled ovarian hyperstimulation/in vitro fertilization for infertile patients with borderline ovarian tumor after conservative treatment

To evaluate the outcomes of controlled ovarian hyperstimulation (COH)-in vitro fertilization (IVF) such as clinical pregnancy rate (CPR), implantation rate (IR) and live birth rate (LBR) for infertile patients with borderline ovarian tumor (BOT) after conservative treatment, 10 IVF cycles in five patients from January 1999 to July 2005 were analyzed. At the time of diagnosis with BOT, the mean age of patients was 30.0 yr (range, 22-40). For 8 cycles out of 10 attempted IVF cycles, except for 2 cancellation cycles, the mean number of oocytes retrieved was 5.6 (range, 2-16) with a mean fertilization rate of 74.4%. The CPR, IR, and LBR were 50.0% (4/8 cycles), 31.6% (6/19) and 50.0% (4/8 cycles) respectively. The mean follow-up period after COH-IVF initiation was 29.6 (range, 14-61) months. A gynecological oncologist followed all patients every 3 months during the first year and every 6 months thereafter. There was no recurrence during the follow-up period. Our results suggest that COH-IVF may be acceptable for infertile patients with BOT, especially in patients with early-stage BOT after conservative treatment.

Long-term effects of ovulation-stimulating drugs on cancer risk

Although nulliparity has been extensively related to the risk of ovarian, breast and endometrial cancers, with many studies showing the relationship largely attributable to infertility, treatment effects on cancer risk are poorly understood. Two early studies raised substantial concern when ovulation-stimulating drugs were linked with large increases in ovarian cancer, supporting the notion of an important aetiological role of incessant ovulation. Subsequent studies have been mainly reassuring, although some have suggested possible risk increases among nulligravid women, those with extensive follow-up, and those developing borderline tumours. Results regarding effects of fertility drugs on breast cancer risk are conflicting, with some showing no associations and others demonstrating possible risk increases, although for varying subgroups. In contrast, endometrial cancer results are more consistent, with two recent studies showing increased risks related to clomiphene usage. This is of interest given that clomiphene is structurally similar to tamoxifen, a drug extensively linked with this cancer. Given the recent marketing of fertility drugs and the fact that exposed women are only beginning to reach the cancer age range, further follow-up is necessary. This will also be important to fully resolve effects of exposures such as gonadotrophins, used more recently in conjunction with IVF.

Impact of infertility drugs after treatment of borderline ovarian tumors: results of a retrospective multicenter study

OBJECTIVE

To evaluate safety and fertility outcome after the use of infertility drugs in patients who were treated conservatively for a borderline ovarian tumor (BOT).

DESIGN

A retrospective multicenter study.

SETTING

Centers participating in the French National Register on In Vitro Fertilization registry.

PATIENT(S)

Thirty patients who were treated for BOT who underwent ovarian induction (OI).

INTERVENTION(S)

Ovarian induction was performed in 25 patients for infertility after conservative surgery and before surgery for recurrent disease in 5 patients with a single ovary (emergency cases).

MAIN OUTCOMES MEASURE(S)

Fertility and recurrences rates.

RESULT(S)

The mean number of cycles of OI per patient was 2.6 (range, 1-10 cycles). The median follow-up time after treatment of the BOT was 93 months (range, 26-276 months). After a median follow-up time of 42 months after OI, 4 recurrences were observed (initial management was simple cystectomy in 3 of them). All recurrences were borderline tumors on a remaining ovary that had been treated by surgery alone. All patients are currently disease-free. Thirteen pregnancies were observed (10 pregnancies (40%) in the group of 25 patients who were treated for infertility).

CONCLUSION(S)

These results suggest that infertility drugs could be used safely in patients who experience infertility after conservative management of an early-stage BOT.

Impact of gonadotrophins and steroid hormones on tumour cells derived from borderline ovarian tumours

BACKGROUND

Conservative surgery is currently proposed for young patients with borderline ovarian tumours (BOT). For those experiencing infertility, the question of medically assisted procreation is raised. We have evaluated in vitro the proliferation of cultured BOT cells in response to FSH or estradiol (E(2)).

METHODS

Primary cell cultures were prepared from BOT. The presence of FSH and E(2) receptors was evaluated by immunochemistry. Cultures in vitro were stimulated with FSH (40 and 200 mUI/ml) or E(2) (300 and 2000 pg/ml) for 96 h and proliferation was evaluated with the WST-1 test.

RESULTS

Four primary cultures were obtained that expressed FSH and E(2) receptors to different extents. Growth was generally similar to controls when treated with either FSH or E(2) although 300 pg/ml E(2) caused a significant inhibitory effect on cell proliferation (P = 0.035).

CONCLUSION

No stimulatory effect of FSH or E(2) on cultured BOT cells was found, despite the presence of receptors. Although preliminary, these results suggest that gonadotrophins and E(2) could be used in patients experiencing infertility after conservative surgery.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Induction of ovulation and ovarian cancer: a critical review of the literature

OBJECTIVE

To critically examine the possible association between ovulation-inducing drugs and ovarian cancer.

DESIGN

Medline literature review and cross-reference of published data.

RESULTS(S)

The studies that have adjusted for the effects of confounding factors such as duration of oral contraceptive use and number of pregnancies have noted an increased risk of ovarian cancer among infertile women who remain childless despite long periods of unprotected intercourse. Whether such women are at risk due to the primary basis for their infertility or factors such as ovulation-inducing drugs, has been the subject of several studies. Overall, the findings on ovarian cancer (especially invasive epithelial and non-epithelial) risk associated with fertility drug treatment are reassuring. However, a stronger association between fertility drug use and borderline tumors of the ovary has been observed.

CONCLUSION(S)

Despite the overall reassuring findings of the available studies, there is a need for well-designed clinical trials to understand the possible carcinogenic effects of the ovulation-inducing drugs.

Borderline tumours of the ovary and fertility

Standard management of borderline ovarian tumours (BOT) is historically radical and based on hysterectomy, bilateral salpingo-oophorectomy and peritoneal staging. But, as 1/3 of BOTs are diagnosed in patients aged less than 40 years, treatments preserving fertility-potential (with preservation of the uterus and at least part of one ovary) has seen great developments in the last decade. Such treatments increase the rate of recurrences (between 15% and 35% depending on the type of conservative surgery), but without any impact on patient survival as most recurrent diseases are of the borderline type, easily curable and with excellent prognosis. The spontaneous pregnancy rate is nearly 50%. In case of persistent infertility, it seems that the use of ovarian induction or in vitro fertilization procedures could be proposed in selected cases. Follow-up is essential and based on clinical examination and routine ultrasonography. The interest of completion surgery (removal of the retained ovary) in patients who obtained pregnancy remains debated. In conclusion, conservative management of at least part of one ovary and uterus could be safely proposed at least to patients with early stage BOT, in order to preserve fertility-potential. The rate of recurrence is increased but without any impact on survival.

Management of borderline ovarian tumors: results of an Italian multicenter study

OBJECTIVE

A rising number of patients affected by ovarian masses suspected of borderline ovarian tumor are operated on primary laparoscopic procedure.

METHODS

From January 1992 to June 2004, 113 patients affected by low malignant ovarian tumor were followed at the Gynecologic Departments of five Italian Institutions. Fifty-two (46.0%) patients were operated on laparoscopic surgery, whereas traditional laparotomic approach was preferred in 61 cases (54%). In 53 patients (46.9%), a fertility-sparing surgical treatment was chosen.

RESULTS

The diameter of the ovarian cysts ranged between 20 and 300 mm; in 20 out 113 patients (17.7%), the borderline tumor was bilateral. In 22/113 (19.5%) cases, we observed tumor rupture or spilling during surgery, and this incidence was greater in the group of patients treated by laparoscopy compared to laparotomy, and this difference is statistically significative. In 13/113 (11.5%) patients, we observed a relapse; the incidence of relapse, however, is not dependent on the type of surgical approach. The progression-free survival is higher for stages IA-IC if compared to stages more than Ist and the difference is statistically significant. Type of surgical approach, laparoscopic versus laparotomic, does not seem to influence the PFS; when cystectomy is performed, the PFS is significantly lower if compared with demolitive surgery or monolateral annessectomy. Eight pregnancies were obtained: in one case, miscarriage was observed, whereas 7 healthy babies were born all but two by vaginal delivery.

CONCLUSIONS

Conservative laparoscopic surgery may be the treatment of choice; an attractive option is that this surgery should be performed by an oncologist surgeon to obtain correct surgical staging and better results in terms of both relapse-free survival and pregnancies.

Fertility after conservative treatment for borderline ovarian tumors: A French multicenter study

OBJECTIVE

To examine fertility outcomes and determinants of fertility after conservative surgery for women with borderline ovarian tumors.

DESIGN

Retrospective multicenter study.

SETTING

Thirteen specialized gynecologic units and one cancer center.

PATIENT(S)

In a study of women with borderline ovarian tumors, 162 of 360 women underwent conservative surgery; from these 162, we compared epidemiologic, surgical, and histological parameters between 21 women who conceived and 44 women who failed to conceive.

INTERVENTION(S)

Conservative surgery for borderline ovarian tumors.

MAIN OUTCOME MEASURE(S)

Fertility results and outcome.

RESULT(S)

Women undergoing conservative treatment were significantly younger and more likely to be nulliparous. Tumor size was significantly smaller in the conservative treatment group. Thirty pregnancies occurred in 21 (32.3%) of the 65 women who wished to conceive after conservative treatment. Twenty-seven pregnancies were spontaneous, whereas three occurred after ovarian stimulation and IUI (one case) or IVF (2 cases). Women who conceived did not differ from women who did not conceive in terms of the tumor recurrence rate or the mean time to recurrence (39.6 +/- 28.2 and 22.9 +/- 14.9 months, respectively). Age at initial treatment was the only determinant of fertility.

CONCLUSION(S)

Despite a high recurrence rate, our results confirm that conservative surgery for women with borderline ovarian tumors is an acceptable option and that fertility is preserved in nearly one third of cases.

Safety and efficacy of infertility treatment after conservative management of borderline ovarian tumors: A preliminary report

OBJECTIVE

To evaluate the safety and efficacy of infertility treatment in a group of patients after conservative management of borderline ovarian tumors.

DESIGN

Retrospective study.

SETTING

University IVF unit.

PATIENT(S)

Five patients with previous conservative treatment of borderline ovarian tumor.

INTERVENTION(S)

Seventeen IVF cycles.

MAIN OUTCOME MEASURE(S)

Recurrence, IVF outcome.

RESULT(S)

At the time of diagnosis, the mean age of the patients was 32.2 +/- 6.9 years. The mean time elapsed between the initial diagnosis of a borderline tumor and the performance of IVF was 42.2 months. After IVF, the mean number of oocytes retrieved was 7.9 +/- 4.0 with a mean fertilization rate of 57.1% and a mean number of 3.1 +/- 1.4 day 3 embryos transferred. Six pregnancies were achieved in three of the five patients with a pregnancy rate per retrieval of 37.5% and per transfer of 42.9%. The mean follow-up time that elapsed since the first IVF cycle was 39.2 months (range 9-78 months). One patient had three recurrences 13, 27, and 43 months after her first IVF cycle, all of which remained histologically serous borderline tumor. All patients were without evidence of disease at the time of last follow-up.

CONCLUSION(S)

At a mean follow-up time of 39.2 months, our results suggest that IVF may be considered for patients with conservatively treated borderline tumors. Furthermore, overall IVF success rates were very satisfactory, suggesting no perceptible negative impact of prior borderline ovarian neoplasia on pregnancy rates after IVF.

The possible association between in vitro fertilization treatments and cancer development

The objective of this paper is to assess whether ovarian hyperstimulation and in vitro fertilization (IVF) are associated with increased risk of cancer development, using an historical cohort analysis of infertile women who attended the IVF unit, Lis Maternity Hospital Tel Aviv Medical Center, Tel Aviv, Israel. One thousand and 82 women participated in the IVF treatment program between 1984 and 1992. Cancer incidence rates were determined through the National Cancer Registry and were compared to the expected rates with respect to appropriate age and continent of birth. Twenty-one cases of cancer were observed as compared to 11 that were expected (SIR 1.91; 95% CI 1.18-2.91). When cancer cases that were diagnosed within one year of the IVF treatment were excluded from the analysis (SIR = 1.46; 95% CI 0.83-2.36), no significant excess risk of cancer was noted. We conclude that in this cohort of infertile women, the higher than expected cancer rate could not be attributed to IVF treatments. Special attention should be made to women who may be diagnosed with cancer during or shortly after IVF treatment.

[Prognosis and fertility after conservative treatment for ovarian tumors of limited malignity: review of 68 cases]

The aim of this retrospective study was to evaluate the rate of recurrence and the reproductive outcome after surgical conservative treatment of low malignant ovarian tumors (LMOT).

MATERIAL AND METHODS

Sixty-eight patients with 50 Stage I LMOT and 18 LMOT with peritoneal implants treated conservatively at institut Gustave-Roussy, between January 1969 and December 2000. Fifty-nine patients had an unilateral adnexectomy (associated twelve times with a contralateral cystectomy), Seven had a bilateral cystectomy and two an unilateral cystectomy. Five patients received adjuvant therapy.

RESULTS

With a median follow-up of 71.5 months, 16 patients recurred and one had evolutive peritoneal disease. The histologic pattern of ovarian recurrences was always of borderline type. The histologic patterns of peritoneal recurrence was similar to those initially diagnosed except in one case. Peritoneal implants, exophytic tumor and serous type tumor were significatively associated with a higher 5-year recurrence rate. Recurrence was more frequent after cystectomy than unilateral adnexectomy (p = 0.13). None of patients treated conservatively recurred under the form of ovarian carcinoma. None patient died of tumor. Nineteen patients experienced 26 pregnancies: 24 were spontaneous in a median delay of 19 months. Seven infertile patients underwent ovarian stimulation. None recurred after infertility treatments. The 2-year and 5-year cumulative pregnancy rate were respectively 41.9% and 59.8%. Four patients experienced a pregnancy after a conservative treatment of their recurrence.

CONCLUSION

Despite a high recurrence rate, especially in stage II and III serous LMOT, conservative treatment of LMOT does not affect survival and should be considered in young patients. Such treatment is not advised in case of invasive peritoneal implants. Spontaneous pregnancy rate is good but the frequent infertility associated with these tumors can afterwards require ovarian stimulation. Limited number of stimulation cycles is acceptable in such patients.

Fertility results after conservative treatment of advanced stage serous borderline tumour of the ovary

OBJECTIVE

To assess the fertility of patients treated conservatively for a Stage II or III borderline ovarian tumour.

DESIGN

A retrospective study.

SETTING

Gynaecological oncology department in a French anti-cancer centre.

POPULATION

Seventeen patients treated with conservative management for a Stage II (n = 6) or III (n = 11) borderline ovarian tumour were followed up. Fifteen patients underwent a unilateral salpingo-oophorectomy (with contralateral cystectomy in six patients), one had unilateral cystectomy and one a bilateral cystectomy. Fourteen patients had non-invasive implants and three had invasive implants.

MAIN OUTCOME MEASURES

Pregnancy rates and outcome.

RESULTS

Eight pregnancies were observed in seven patients in a median delay of eight months following the surgical procedure. Six pregnancies were observed spontaneously, one occurred after an ovarian stimulation and one after an IVF procedure. None of these patients recurred under the form of invasive ovarian carcinoma on the spared ovary. Two patients (one with a non-invasive disease and one with an invasive one) had recurrence in the form of evolutive invasive implants, but neither woman died.

CONCLUSION

Spontaneous pregnancy can occur after conservative treatment of advanced stage borderline tumour of the ovary (with non-invasive implants). Such management, performed in a close follow up of the patients, does not affect the overall survival. Conservative surgery could be proposed in patients with borderline tumour of the ovary and non-invasive peritoneal implants.

Cancer incidence in a cohort of infertile women who underwent in vitro fertilization

OBJECTIVE

To assess whether ovarian hyperstimulation and IVF increase the risk for cancer.

DESIGN

Historical cohort analysis. SETTING; IVF units of two medical centers in Israel.

PATIENT(S)

Five thousand twenty-six women who underwent IVF between 1981 and 1992. INTERVENTION(S); Cancer incidence rates were determined through linkage to the National Cancer Registry and were compared with expected rates with respect to age, sex, and place of birth.

MAIN OUTCOME MEASURE(S)

Development of cancer.

RESULT(S)

Twenty-seven cases of cancer were observed, and 35.6 were expected (standardized incidence ratio, 0.76 [95% CI, 0.50-1.10]). Eleven cases of breast cancer were observed, whereas 15.86 were expected (standardized incidence ratio, 0.69 [95% CI, 0.46-1.66]). One case of ovarian cancer and 1 case of cervical cancer were observed, compared with 1.74 and 1.73 cases expected, respectively. The type of infertility, number of IVF cycles, and treatment outcome did not significantly affect risk for cancer.

CONCLUSION(S)

In a cohort of women treated with IVF, no excess risk for cancer was noted.

Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors

OBJECTIVE

To assess clinical outcome and fertility in patients treated conservatively for a low malignant potential (LMP) ovarian tumor.

DESIGN

Retrospective study.

SETTING

Gynecologic oncology department of a cancer care center in France.

PATIENT(S)

Forty-four patients treated with conservative management for a stage I (n = 32) or stage II or III (n = 12) LMP tumor.

INTERVENTION(S)

Thirty-three patients had unilateral adnexectomy and 11 had cystectomy. Cystectomy was bilateral in 1 patient and was done in conjunction with contralateral adnexectomy in 5 patients.

MAIN OUTCOME MEASURE(S)

Tumor recurrence and pregnancy rates.

RESULT(S)

Tumor recurrence rates after radical surgery (hysterectomy with bilateral salpingo-oophorectomy), adnexectomy, and cystectomy were 5.7%, 15.1%, and 36.3%, respectively (P<.01). Among patients who initially received conservative treatment, tumors did not recur in the form of invasive carcinoma. Five patients who had recurrence underwent repeated conservative management; these patients are alive and free of disease. Seventeen pregnancies (of which 15 were spontaneous) occurred in 14 patients; 13 pregnancies occurred in patients with stage I disease and 4 occurred in patients with stage III disease.

CONCLUSION(S)

Conservative management of LMP tumor significantly increases the risk of recurrence but does not affect overall survival. Such management offers even patients with advanced disease the chance to have spontaneous pregnancy. Conservative management might be proposed in young patients who wish to preserve their fertility, but careful follow-up will be required to detect tumor recurrence.

The management of borderline epithelial tumors of the ovary

The histopathological diagnosis and treatment of borderline epithelial tumors of the ovary (BTO) still pose problems to both pathologists and gynecologists. BTO is a disease of younger, fertile females and generally has an excellent prognosis. A minority of patients, however, succumb to this disease. A review of the literature is given addressing aspects of epidemiology, histology, treatment and prognosis, resulting in a proposal for the management of serous and mucinous borderline tumors of the ovary.

Messenger ribonucleic acid expression of LH/hCG receptor gene in human ovarian carcinomas

The mRNA expression of luteinizing hormone (LH)/human chorionic gonadotropin (hCG) receptors was analysed by the RT-nested PCR method in five normal ovarian tissues, 62 ovarian tumours (5 benign, 7 borderline and 43 malignant epithelial tumours, 3 sex cord-stromal tumours and 4 germ cell tumours) and in 2 ovarian cancer cell lines. In normal ovaries, two cDNA fragments of different sizes were detected using primers designed to amplify a region including exon 9. Sequencing revealed that the larger fragment was derived from a full-length receptor, while the smaller fragment was a splice variant lacking exon 9. In ovarian tumours, the larger fragment of LH/hCG receptors was detected in 40% of the epithelial ovarian carcinomas, none of the germ cell tumours, all of the sex cord-stromal tumours and one of the 2 ovarian cancer cell lines. Immunohistochemistry confirmed the localisation of LH/hCG receptor protein in the tumour cells which correlated with mRNA expression. Patients with full-length LH/hCG receptors in carcinomas showed a better prognosis compared with those without the receptors.

Ovulation induction, infertility, and ovarian cancer risk

OBJECTIVE

To review critically the published data regarding the proposed association of ovulation induction, infertility, and an increased risk of ovarian cancer.

DESIGN

A medline search was conducted to identify all case reports, epidemiologic studies, and clinical investigations containing data relevant to infertility, treatment of infertility, and the associated risk of ovarian cancer. Additional sources were obtained from reference lists of original research and review articles. Particular emphasis was placed on the most recently published reports examining these associations.

RESULTS

Four case-control studies and three retrospective cohort studies, as well as a large meta-analysis of three additional case-control studies were identified as presenting the most pertinent clinical data.

CONCLUSION

Currently available data in the literature suggest that an association between ovulation induction and ovarian cancer does not indicate necessarily a causal effect. Infertility alone is an independent risk factor for the development of ovarian cancer. Nulliparous women with refractory infertility may harbor a particularly high risk of ovarian cancer, irrespective of their use of fertility drugs. Furthermore, the apparent association between fertility drug use and ovarian cancer may arise because these women are the most likely to have used ovulation-stimulating agents as part of their infertility treatment. Close clinical surveillance of patients before, during, and after treatment of infertility is warranted.

Borderline ovarian tumors

Borderline tumor of the ovary (BOT) is an epithelial tumor with a low rate of growth and a low potential to invade or metastasize. This tumor often is associated with a significantly better prognosis than epithelial ovarian cancer. Most tumors are either serous or mucinous in histology and present as early stage lesions. However, stage III lesions with peritoneal implants are not uncommon. Patients with early stage lesions have an excellent prognosis. Patients with higher stage lesions have a worse prognosis. Long-term follow-up of patients with BOT is required since the tumor can recur up to 20 years after the initial diagnosis. Recently, investigators have begun to identify subsets of patients with a worse prognosis, such as patients with aneuploid tumors. Treatment for early stage lesions is surgical and conservative surgery can be accomplished successfully in younger patients who desire to maintain fertility. Treatment for later stage lesions has been approached in a variety of ways. All approaches initially begin with maximal cytoreductive surgery. Studies suggest that early stage disease should be managed with surgery alone. Conflicting results on the usefulness of adjuvant therapy for patients with later stage disease have been obtained. At this time, the usefulness of adjuvant therapy for advanced disease remains undetermined. Further understanding of the basis of the disease and analysis of specific higher risk subsets might identify patients in whom adjuvant therapy could be tested in the setting of controlled clinical trials.

Epidemiology, etiology, and fertility drugs in ovarian epithelial carcinoma: where are we today?

OBJECTIVE

To review studies that have examined the epidemiology and etiology of the development of epithelial carcinoma of the ovary.

DATA IDENTIFICATION

Important published studies related to the topic were identified through a computerized bibliography search.

CONCLUSION

A review of the literature reveals that the etiology of epithelial ovarian cancer is probably multifactorial and that genetic, environmental, hormonal, and viral factors appear to be directly or indirectly related to the development of the disease. An attempt to implicate specific agents has not produced conclusive results. However, based on large epidemiologic studies, it seems that there is a clear trend of decreasing risk with increasing number of pregnancies, deliveries, use of oral contraceptives, and the duration of breast feeding. An increased risk was found to be associated with ovarian dysfunction leading to infertility and exposure to asbestos and talc. The recent observation that infertile women who used fertility drugs might experience an increased risk for the development of epithelial ovarian cancer should be examined very carefully because of the small number of patients in the study, lack of appropriate information about the type of infertility, drugs used, dosage, and duration of treatment. Because there are no screening tests that are consistently accurate enough to detect ovarian cancer at an early stage, translating the current information into disease prevention requires careful clinical evaluation with a routine follow-up of patients at risk.