Staging for low malignant potential ovarian tumors: a global perspective

Do survivors of borderline ovarian tumors have susceptibility to secondary primary malignancies? A SEER population-based study

OBJECTIVE

To describe the risk of women who have survived borderline ovarian tumors (BOT) developing second primary malignancies (SPM).

METHODS

This work employed the Surveillance, Epidemiology, and End Results (SEER) Program to conduct a retrospective study of patients diagnosed with BOT. The SEER stat software was used to calculate the standardized incidence ratio (SIR). Cases with pathologic diagnosis and for which information on prognostic factors were available were obtained and analyzed using the Fine and Gray model, with non-SPM death as a competing event.

RESULTS

The risk of developing SPM among BOT survivors was not elevated compared with that expected in the general population (SIR 0.88, 95% confidence interval [CI] 0.80-0.96) between 1975 and 2017. Of 3661 patients with BOT diagnosed between 1977 and 2000, 477 patients (13.03%) experienced the development of SPM during the median follow up of 19.43 years and the cumulative incidence of SPM over a span of 25 years was 15.52%. Patients with mucinous BOT (P = 0.028), age older than 50 years (P < 0.001), or no lymph node dissection (P = 0.042), had a higher cumulative incidence of SPM in univariate analysis. In the multivariable competing risk analysis, performing lymphadenectomy (subdistribution hazard ratios [sdHR] 0.79, 95% CI 0.64-0.98), age (sdHR 1.03, 95% CI 1.02-1.03) could strongly predict the risk of SPM.

CONCLUSION

In contrast to ovarian cancer, women with BOT were not more prone to develop SPM.

Anti-oncogenic PTEN induces ovarian cancer cell senescence by targeting P21

Deletion and mutation of phosphatase and tensin homolog deleted on chromosome10 (PTEN) are closely associated with the occurrence of tumors. Tumor suppressor gene PTEN mutation plays an important role in the pathogenesis of ovarian cancer. However, it has been unclear whether it can regulate the senescence of ovarian cancer cells. We speculated that PTEN might inhibit the occurrence and development of ovarian cancer by promoting the expression of P21. We found that the expression of TRIM39 in human ovarian cancer was significantly diminished. In SKOV3 cells treated with naringin, the expression of TRIM39, which binds P21 and inhibits P21 degradation, was significantly elevated. Real‐time polymerase chain reaction (PCR), Western blot, and immunofluorescence were used to detected the expression of PTEN, p21, and TRIM39, β‐galactosidase Staining was used to detect cell senescence, Ki67 staining was used to observe cell proliferation, Trim39 interference or overexpression assay was used to detect its function. We speculated that PTEN might promote SKOV3 cell senescence by increasing TRIM39 expression and decreasing P21 degradation. Furthermore, by interfering with TRIM39 in SKOV3 cells, we found that the expression of P21 was downregulated, and the number of senescent SKOV3 cells decreased. With overexpression of TRIM39 in SKOV3 cells, the expression of P21 was upregulated, and the number of senescent SKOV3 cells increased. When naringin, a PTEN agonist, was added to SKOV3 cells in which TRIM39 protein was interfered with, the expression of P21 was significantly lower than that in the control group, and the number of senescent ovarian cancer cells was significantly diminished. Our results indicated that PTEN maintained the stability of P21 and decreased the degradation of P21 by increasing TRIM39 expression, thus promoting the senescence of SKOV3 cells, and PTEN maintained the stability of p21 and promoted the aging of SKOV3 cells might be a novel therapeutic target for ovarian cancer.

Ovarian cancer health politics in Romania and Germany: A comparative study

Ovarian cancer is known to have a poor prognosis, being the 7th most common cancer type in women with regard to incidence and mortality worldwide. The present study underlines the importance of early diagnosis and prevention management of ovarian cancer. This study is a hospital-based case-control study that was conducted at the same time in two similar hospitals from different countries, Romania and Germany, over three years. The results showed that significant differences were identified for the two groups with regards to the age factor (P<0.001). A risk analysis was performed to determine whether the patients from Romania were exposed to a risk factor. The risk of developing deadly diseases was deemed much higher owing to insufficient protocols or informative programs in Romania. The medical information, early diagnosis and standardized therapy with optimum treatment based on health policy and health care systems, play a key role concerning the management and prognosis of ovarian cancer which are different from country to country.

Oncofertility outcomes after fertility-sparing treatment of bilateral serous borderline ovarian tumors: results of a large retrospective study

STUDY QUESTION

What are the oncofertility outcomes of young women (≤40 years old) with bilateral serous borderline ovarian tumors (SBOTs) after fertility-sparing surgery?

SUMMARY ANSWER

Fertility preservation with the bilateral ovarian cystectomy procedure is feasible for bilateral SBOTs, with an acceptable oncological outcome and worthwhile pregnancy rates.

WHAT IS KNOWN ALREADY

Fertility-sparing approaches are becoming the standard management of young patients with unilateral SBOTs and other borderline histological subtypes. However, there is a paucity of evidence to dictate the best management in bilateral SBOTs.

STUDY DESIGN, SIZE, DURATION

This was a retrospective observational study performed at the Peking Union Medical College Hospital in Beijing, China, between January 1999 and January 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ninety-four women (≤40 years old) with pathologically confirmed bilateral SBOTs were included. Following preoperative counseling, patients self-selected into one of three treatment modalities: bilateral ovarian cystectomy (n = 48), unilateral adnexectomy plus contralateral cystectomy (UAC; n = 31), and radical surgery (n = 15). Univariate and multivariate analyses were used to determine the clinical and pathological features associated with disease-free survival and reproductive outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

During the median follow-up of 64 months (range, 4-243 months), 61 patients (65%) developed relapse, including 3 (20%) in the radical group, 26 (84%) in the UAC group and 32 (67%) in the bilateral cystectomy group. In the multivariate analyses, preoperative CA-125>300 U/mL, fertility preservation and micropapillary pattern were independently associated with adverse disease-free survival (P = 0.001, 0.03 and 0.026, respectively). Fourteen patients (15%) experienced invasive recurrence, and three (3%) died of progressive disease. The micropapillary pattern was significantly associated with invasive evolution risk (P = 0.006). Of the 49 patients who attempted to conceive, 23 (47%) achieved 27 pregnancies (24 spontaneous and three after IVF-ET), resulting in 19 live births. There was no significant difference in disease-free survival (P = 0.13) or pregnancy rate (41 vs. 50%, P = 0.56) between the UAC and bilateral procedures.

LIMITATIONS, REASONS FOR CAUTION

As a retrospective study conducted in a referral center, inherent biases exist. The nonrandom allocation to treatment groups and relatively small number of patients attempt to conceive might limit the statistical power of our findings. Only 41 patients (43.6%) received complete staging during their initial surgeries, so an underestimation bias in terms of the FIGO stage and extraovarian implants might have occurred.

WIDER IMPLICATIONS OF THE FINDINGS

The ultraconservative bilateral ovarian cystectomy procedure should be proposed in bilateral SBOTs when technically feasible. Invasive evolution occurs frequently in these women, and intense follow-up and oncofertility counseling are warranted, especially for those with micropapillary patterns.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Predicting Lymph Node Involvement in Borderline Ovarian Tumors with a Quantitative Model and Nomogram: A Retrospective Cohort Study

Purpose

This study aimed to establish a predictive model for lymph node involvement (LNI) in patients with borderline ovarian tumor (BOT) using clinicopathological factors.

Patients and Methods

We collected clinical data from consecutive patients who underwent lymphadenectomy for BOT between 2001 and 2018 and analyzed their clinicopathological features. Multivariate logistic regression was used to identify all independent risk factors associated with LNI; these were then incorporated into the prediction model.

Results

In total, we included 248 patients with BOT who were undergoing lymphadenectomy. These were divided into a training cohort (n=174) and a validation cohort (n=74). When considering histopathological data, 16 and 5 patients were identified to have LNI in the training and validation cohorts, respectively. Overall, 13.5% (21/156) patients with serous BOT had LNI while 0% (0/92) patients with non-serous BOT had LNI. We identified several predictors of LNI: the largest tumor being ≥ 12.2cm in diameter, the presence of lesions on the ovarian surface, and the presence of pelvic or abdominal lesions. We created a prediction model and nomogram that incorporated these three risk factors for serous BOT. The model achieved good discriminatory abilities of 0.951 and 0.848 when predicting LNI in the training and validation cohorts, respectively. The LNI-predicting nomogram had an area under curve (AUC) of 0.951 and generated well-fitted calibration curves.

Conclusion

Non-serous BOT may not require lymphadenectomy as part of surgical staging. The individual risk of LNI in patients with serous BOT can be accurately estimated using our prediction model and nomogram. The use of LNI criteria provides a practical way to support the clinician in making an optimal decision relating to surgical scope for patients with BOT.

Staging procedures fail to benefit women with borderline ovarian tumours who want to preserve fertility: a retrospective analysis of 448 cases

Background

To evaluate the effect of clinicopathologic factors on the prognosis and fertility outcomes of BOT patients.

Methods

We performed a retrospective analysis of BOT patients who underwent surgical procedures in West China Second University Hospital from 2008 to 2015. The DFS outcomes, potential prognostic factors and fertility outcomes were evaluated.

Results

Four hundred forty-eight patients were included; 52 recurrences were observed. Ninety-two patients undergoing FSS achieved pregnancy. No significant differences in fertility outcomes were found between the staging and unstaged surgery groups. Staging surgery was not an independent prognostic factor for DFS. Laparoscopy resulted in better prognosis than laparotomy in patients with stage I tumours and a desire for fertility preservation.

Conclusion

Patients with BOT fail to benefit from surgical staging. Laparoscopy is recommended for patients with stage I disease who desire to preserve fertility. Physicians should pay more attention to risk of recurrence in patients who want to preserve fertility.

Significance of lymph node ratio on survival of women with borderline ovarian tumors

PURPOSE

To assess the qualitative and quantitative measures of the effect of pelvic lymph node involvement on survival of women with borderline ovarian tumors (BOTs).

METHODS

This is a retrospective study examining the Surveillance, Epidemiology, and End Results Program between 1988 and 2003. Women with stage T1-3 BOTs who had results of pelvic lymph node status at surgery were included. The effect of lymph node involvement on cause-specific survival (CSS) was evaluated using multivariable analysis with the following approaches: (1) any involvement, (2) involvement of multiple nodes (≥ 2 nodes), and (3) lymph node ratio (LNR), defined as the ratio of the number of tumor-containing lymph nodes to the total number of harvested lymph nodes.

RESULTS

A total of 1524 women were examined for analysis. Median count of sampled nodes was 8 (interquartile range 3-15), and there were 81 (5.3%, 95% confidence interval [CI] 4.2-6.4) women who had lymph node involvement. Median follow-up was 15.8 (interquartile range 13.8-18.9) years, and 83 (5.4%) women died of BOTs. After controlling for age, histology, stage, and tumor size, only LNR remained an independent prognostic factor for decreased CSS (adjusted hazard ratio [HR] per percentage unit 1.015, 95% CI 1.003-1.026, P = 0.014), whereas any involvement (adjusted HR 1.700, 95% CI 0.843-3.430, P = 0.138) and involvement of multiple nodes (adjusted HR 1.644, 95% CI 0.707-3.823, P = 0.249) did not. On cutoff analysis, LNR ≥ 13% had the largest magnitude of significance on multivariable analysis of CSS (adjusted HR 2.399, 95% CI 1.163-4.947, P = 0.018).

CONCLUSION

Our study suggests that high pelvic LNR may be a prognostic factor associated with decreased CSS in women with BOTs.

Utero-ovarian preservation and overall survival of young women with early-stage borderline ovarian tumors

PURPOSE

To examine survival of women who had uterine and ovarian preservation during surgical treatment for early-stage borderline ovarian tumors (BOTs).

METHODS

The Surveillance, Epidemiology, and End Results Program was used to identify women aged < 50 years with stage I BOTs who underwent ovarian conservation at surgical treatment between 1988 and 2003. Survival outcomes were examined based on the use of concurrent hysterectomy at surgery.

RESULTS

Among 6379 cases of BOT, there were 1065 women who had utero-ovarian preservation at surgery, and there were 52 women who had hysterectomy with ovarian preservation alone. Women who had uterine preservation were more likely to be single and diagnosed in recent years (both, P < 0.05). On univariable analysis, women who had utero-ovarian preservation had cause-specific survival similar to those who had ovarian preservation alone without uterine preservation (10-year rates: 99.2% versus 98.1%, P = 0.42); however, overall survival was higher in the utero-ovarian preservation group compared to the hysterectomy group (95.8% versus 87.6%, P < 0.001). On multivariable analysis, utero-ovarian preservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.35, 95% confidence interval 0.15-0.79, P = 0.012). Cardiovascular disease mortality was lower in the utero-ovarian preservation group compared to the hysterectomy group, but it did not reach statistical significance (20-year cumulative rate, 0.8% versus 3.0%, P = 0.29).

CONCLUSION

Our study suggests that utero-ovarian preservation for young women with early-stage BOTs may be associated with improved overall survival compared to ovarian preservation alone without affecting BOT-related survival outcome.

Accuracy of Intraoperative Frozen Section Diagnosis of Borderline Ovarian Tumors by Hospital Type

STUDY OBJECTIVE

To compare the accuracy of frozen section diagnosis of borderline ovarian tumors among 3 distinct types of hospital-academic hospital with gynecologic pathologists, academic hospital with nongynecologic pathologists, and community hospital with nongynecologic pathologists-and to determine if surgical staging alters patient care or outcomes for women with a frozen section diagnosis of borderline ovarian tumor.

DESIGN

Retrospective study (Canadian Task Force classification II-1).

SETTING

Tertiary care, academic, and community hospitals.

PATIENTS

Women with an intraoperative frozen section diagnosis of borderline ovarian tumor at 1 of 3 types of hospital from April 1998 through June 2016.

INTERVENTIONS

Comparison of final pathology with intraoperative frozen section diagnosis.

MEASUREMENTS AND MAIN RESULTS

Two hundred twelve women met the inclusion criteria. The frozen section diagnosis of borderline ovarian tumor correlated with the final pathologic diagnosis in 192 of 212 cases (90.6%), and the rate of correlation did not differ among the 3 hospital types (p = .82). Seven tumors (3.3%) were downgraded to benign on final pathologic analysis and 13 (6.1%) upgraded to invasive carcinoma. The 3 hospital types did not differ with respect to the proportion of tumors upgraded to invasive carcinoma (p = .62). Mucinous (odds ratio, 7.1; 95% confidence interval, 2.1-23.7; p = .002) and endometrioid borderline ovarian tumors (odds ratio, 32.4; 95% confidence interval, 1.8-595.5; p = .02) were more likely than serous ovarian tumors to be upgraded to carcinoma. Only 88 patients (41.5%) underwent lymphadenectomy, and only 1 (1.1%) had invasive carcinoma in a lymph node.

CONCLUSIONS

A frozen section diagnosis of borderline ovarian tumor correlates with the final pathologic diagnosis in a variety of hospital types.

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

OBJECTIVE

To examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery.

METHODS

This is a retrospective study examining The Surveillance, Epidemiology, and End Results Program to identify surgically-treated stage T1 BOTs between 1988 and 2003 (n=4943). Association of surgery patterns and cause-specific survival (CSS) was examined in multivariable analysis.

RESULTS

Mean age was 48.7. The majority had stage T1a disease (75.3%). Median follow-up was 15.6years and 159 (3.2%) women died of BOTs. Hysterectomy and lymphadenectomy were performed in 1909 (38.6%) and 1295 (26.2%) cases, respectively. Most commonly, neither procedure was performed (46.5%), followed by hysterectomy alone (27.3%), lymphadenectomy alone (14.9%), and both procedures (11.3%). Surgery patterns for hysterectomy and lymphadenectomy significantly differed across age, ethnicity, marital status, registry area, year at diagnosis, histology type, sub-stage, and tumor size (all, P<0.001). On multivariable analysis, surgery patterns for hysterectomy and lymphadenectomy were not associated with CSS: 20-year rates for neither hysterectomy and lymphadenectomy 96.7%, hysterectomy alone 94.5%, lymphadenectomy alone 95.7%, and both procedures 95.2% (adjusted-P>0.05). Age≥50, T1b-c stages, and mucinous histology remained independent prognostic factors for decreased CSS (all, P<0.05). Among 3723 women with stage T1a disease, hysterectomy and lymphadenectomy patterns were not associated with CSS in 2115 women aged <50 (P=0.14) and 1608 women aged ≥50 (P=0.48).

CONCLUSION

Our study suggests that both hysterectomy and lymphadenectomy may be omitted in the surgical management of women with stage T1 BOTs, especially for those with T1a disease regardless of age.