Clinicostatistical study of low potential malignancy ovarian cystadenoma (borderline cases)

Conservative surgery for borderline ovarian tumors: a review

OBJECTIVE

Borderline tumor of the ovary is an epithelial tumor with a low rate of growth and a low potential to invade or metastasize. This review will outline the most recent information regarding the molecular pathogenesis, pathology, fertility and tumor recurrence rate after conservative management of young women with early-stage borderline ovarian tumors.

METHODS

We performed a MEDLINE literature search of relevant clinical trials for the scope of this review that evaluated conservative treatment of borderline ovarian tumors for young women with low-stage disease who wish to preserve their fertility.

RESULTS

Recently, investigators have begun to identify subsets of patients with a worse prognosis, such as patients with aneuploid tumors. A number of oncogenes are under investigation to determine their role in the pathogenesis of borderline ovarian tumors. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Laparoscopic treatment of adnexal masses has proved to be a safe and effective diagnostic and therapeutic tool in the hands of experienced laparoscopists. For women who are treated conservatively, follow-up is important. Surgery remains the most effective therapy for later stage lesions. Adjuvant therapy for advanced stage of borderline ovarian tumors remains controversial.

CONCLUSION

Conservative management of borderline ovarian tumors is an appropriate therapeutic option for young women with early-stage lesions who wish to preserve their childbearing potential. Available data indicate that in these patients fertility, pregnancy outcome and survival remain excellent.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

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.

Clinicostatistical study of ovarian tumors of germ cell origin

Ovarian tumors of germ cell origin consisted of 440 dermoid cysts, 5 struma ovariis, 3 immature teratomas (G1, G2), 2 carcinoids, 8 dysgerminoma, 3 yolk sac tumors, one choriocarcinoma, 4 dermoid cysts with malignant transformation, and one immature teratoma (G3) of a total of 1,387 ovarian tumors. The patients' mean ages ranged between 17.3 years to 31.9 years, but the mean ages of those with carcinoid and dermoid cyst with malignant transformation were 46.0 and 53.0 years, respectively. In dermoid cyst bilaterality was 17.3% and occurrence during pregnancy or puerperium was 19.6%. In benign tumors, torsion of pedicle and association with pregnancy or puerperium were frequent unlike common epithelial carcinoma, but ascites was rare. Abdominal tumor, pain and metromenorrphagia were the main symptoms, but abdominal distension was scarce with dermoid cysts. The rate of malignant transformation of dermoid cysts was 0.9% overall but 4.3% in patients over 40 years. The prognosis for borderline germ cell tumors was good.