Pregnancy after fertility-sparing surgery for borderline ovarian tumors

Serous Borderline Ovarian Tumor Diagnosis, Management and Fertility Preservation in Young Women

Borderline ovarian tumors (BOT) represent about 10 to 20 percent of all epithelial tumors of the ovary. They constitute intermediate lesions between benign ovarian cysts and invasive carcinomas. They often occur in young women of reproductive age, and, albeit with a favorable prognosis, it may recur on the ipsilateral or contralateral ovary. Controversies surround the diagnostic criteria used for their assessment, and the optimal management to minimize their risk of recurrence and/or transformation into malignant carcinoma. Fertility preservation (FP) is considered a priority in the management of these patients, and studies aim at finding the safest and most effective way to help women with BOT history conceive with minimal risk. We present the experience of a single institution in managing three cases of serous BOT in young nulliparous women, followed by a thorough review of the existing literature, highlighting controversies and exploring the possible FP techniques for these women.

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature

OBJECTIVE

To compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.

DATA SOURCES

PubMed was searched from January 1, 1995, to May 29, 2020.

METHODS OF STUDY SELECTION

Studies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.

CONCLUSION

Fertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.

Fertility and prognosis of borderline ovarian tumor after conservative management: Results of the multicentric OPTIBOT study by the GINECO & TMRG group

OBJECTIVES

Description of fertility and prognosis of patients with borderline ovarian tumor (BOT) treated by fertility-sparing surgery through a longitudinal study from the French national cancer network.

METHODS

All consecutive patients diagnosed with BOT from the French National Network dedicated to Ovarian Malignant Rare Tumors from 2010 and 2017 were selected. In 2018, an update was made by sending a questionnaire regarding recurrence and fertility to patients aged under 43 years at diagnosis and treated conservatively. We compared the characteristics of the patients with/without recurrence and with/without live birth.

RESULTS

Fifty-two patients aged 18 to 42 years presented a desire of pregnancy. Thirty patients (58%) presented a FIGO IA tumor, and 20 patients were treated by bilateral cystectomies (38%). We observed at least one live birth for 33 patients (63%) and local recurrences in 20 patients (38%). Both recurrence and live birth in 17 patients (33%) were reported, with recurrence occurring before pregnancy, after a second fertility-sparing treatment, in half of the cases. No factors associated with recurrence or live birth in this study were identified. Moreover, in this population, both recurrence and live birth were independent of age, with a linear risk along time. Disease-free survival was worse for patients treated with bilateral cystectomy (n = 20, 38%), with no difference in terms of fertility.

CONCLUSION

Two third of the patients experienced life birth after conservation surgery. We did not highlight an age/time from surgery for which the risk of recurrence outweighs the chance of pregnancy and to radicalize surgery. Moreover, almost a quarter of the live birth occurred after recurrence, with no more further event to date in these patients. The results encourage to consider a second fertility-sparing surgery after local borderline recurrence in the case of pregnancy desire. All these decisions must be discussed in specialized multidisciplinary boards.

Reproductive and obstetrical outcomes with the overall survival of fertile-age women treated with fertility-sparing surgery for borderline ovarian tumors in Sweden: a prospective nationwide population-based study

OBJECTIVE

To assess the efficacy of fertility-sparing surgery (FSS) in terms of reproductive outcomes by following FSS for borderline ovarian tumors (BOTs) and comparing the safety of FSS versus radical surgery (RS).

DESIGN

Nationwide cohort study based on prospectively recorded data.

SETTING

Sweden.

PATIENT (S)

All women of reproductive age (18-40 years) treated in Sweden for stage I BOT with the use of FSS or RS from 2008 to 2015, identified in the Swedish Quality Registry for Gynecologic Cancer (SQRGC).

INTERVENTIONS (S)

FSS or RS.

MAIN OUTCOME MEASURE (S)

Reproductive outcomes: natural conception, use of assisted reproductive technology (ART), live birth and obstetrical outcomes. Safety outcome: overall survival (OS) rates, comparing women undergoing FSS versus RS. The FSS cohort was linked to the Swedish Medical Birth Register to identify all women who had given birth after FSS and to obtain detailed obstetrical data. For information on ART treatment, the National Quality Registry for Assisted Reproduction was consulted. OS rate comparisons were conducted by means of Kaplan-Meier estimates.

RESULT (S)

Of the 277 women with BOTs, 213 (77%) underwent FSS, 183 (86%) unilateral salpingo-oophorectomy, and 30 (14%) cystectomy. Following FSS, 50 women gave birth to 62 healthy children, 8% of which were preterm. Only 20 (9%) of the women underwent ART treatment. OS was similar in women treated with FSS and RS.

CONCLUSION (S)

Natural fertility was maintained after FSS; only 9% required ART treatment. FSS was also deemed to be equivalent to RS regarding survival outcome.

The safety of fertility and ipsilateral ovary procedures for borderline ovarian tumors

Objective

To explore the optimal treatment options for women with borderline ovarian tumors (BOTs).

Materials and Methods

The medical records of consecutive patients with BOTs in two academic institutions were retrospectively collected. The pertinent data, including clinicopathological characteristics and, treatment and prognostic information were evaluated.

Results

A total of 281 cases of BOTs were included in this analysis. For the entire series, the 5- year disease-free survival (DFS) and overall survival (OS) rates were 91.8% and 98.5%, respectively. In the multivariate analysis, reservation of the ipsilateral ovary (HR: 0.104 [95% CI, 0.036–0.304], p = 0.000) and FIGO stage II–III (HR: 6.811 [95% CI, 2.700–17.181], p = 0.000) were the independent risk factors for recurrence. Ovarian surface involvement (HR: 64.996 [95% CI, 4.054–1041.941], p = 0.003) was the only independent prognostic factor for OS. Lymphadenectomy and adjunct chemotherapy had no significant impact on patients’ recurrence and survival (recurrence: p = 0.332 and 0.290, respectively, survival: p = 0.896 and 0.216, respectively).

Conclusions

Fertility-sparing surgery with healthy ovarian preservation seems safe and feasible for young women who prefer fertility-sparing treatment. Ovarian cystectomy to conserve the affected ovary/ovaries without ovarian surface involvement may be cautiously performed under fully informed consent for young women with bilateral BOTs who strongly prefer fertility-sparing treatment and have no evidence of infertility. However, long-term follow-up is necessary due to the relapse susceptibility of the ovary.

Preservation of Fertility or Ovarian Function in Patients with Breast Cancer or Gynecologic and Internal Malignancies

Because of the efficacy of systemic therapies, neoplasias which occur in pediatric and adolescent patients and in young adults have high cure rates. This means that fulfilling their wish to have children has become a more pressing concern, particularly among young women with malignant tumors. Premature ovarian failure is also a not insignificant problem as it has a lasting detrimental effect on quality of life. Every oncology patient who may potentially wish to have children should be informed about their options for preserving fertility prior to starting treatment. The rates of patient who received detailed briefing on this point remain low. This review presents the effects of different chemotherapeutic drugs on gonadal function together with an overview of currently valid recommendations on fertility preservation. Risk groups are defined and the specific approaches for malignancies of various organ systems are described. Cryopreservation of oocytes, fertilized embryos and ovarian tissue are fertility-preserving options for girls/young women. The data on the benefits of administering GnRH analogs for ovarian protection prior to starting chemotherapy are not clear. In postpubertal boys or male cancer patients, the standard approach is to cryopreserve sperm before starting therapy. The cryopreservation of testicular tissue is possible for prepubertal boys, however in-vitro sperm maturation is still in its experimental stages. This review also presents existing drug options for the preservation of ovarian function in oncology patients prior to chemotherapy, particularly for patients with (hormone-sensitive) breast cancer, and looks at the special issues of fertility-preserving surgery and radiation therapy in patients with gynecologic malignancies.