Epithelial borderline ovarian tumor: Diagnosis and treatment strategy

A giant 25 litre volume ovarian cystic mucinous borderline ovarian tumour with intraepithelial carcinoma in a 24-year-old nulliparous woman: Case report

INTRODUCTION AND IMPORTANCE

Giant ovarian cysts are rare and usually pose significant diagnostic challenges especially in adolescents and young adults. There is limited report of such cases reported in existing literature with hardly any cases published from the Sub-Sharan African region.

CASE PRESENTATION

We present the case of a 24-year-old young woman who reported to our gynaecology clinic on the 23rd of January 2023 with a year's history of a progressively increasing abdominopelvic mass. She was successfully managed surgically and made smooth recovery.

CLINICAL DISCUSSION

Based on the history and examination findings, confirmed the diagnosis clinically with abdomino-pelvic ultrasound scan, removed the tumour surgically and undertook histopathological studies to confirm a benign disease. To the best of our knowledge, our successful management of this patient is the first case of such a huge borderline ovarian tumour reported in Ghana and the Sub-Saharan African region to inform clinicians on safe surgical management in our context.

CONCLUSION

Our successful management of this giant mucinous BOT reiterates the fact that in the absence of precise prognostic marker of malignancy, clinicians should always balance the oncologic safety of the patient against less radical treatment modality.

An algorithm for the pre-operative differentiation of benign ovarian tumours based on magnetic resonance imaging interpretation in a regional core hospital: A retrospective study

Objective

For selecting minimally invasive surgery (i.e. laparoscopic ovarian cystectomy) for treating ovarian tumours (OTs) in premenopausal patients, the pre-operative differentiation of benign ovarian tumours (Be-OTs) based on magnetic resonance imaging (MRI) interpretation is important. This paper describes the authors' 8-year experience of approximately 1000 OT cases, and provides information about a diagnostic algorithm to help other hospitals.

Study design

The medical records of 901 patients aged < 50 years with OTs from 1 January 2015-31 March 31 2023 were reviewed. First, the accuracy of pre-operative differentiation between Be-OTs and borderline/malignant ovarian tumours (Bo/Ma-OTs) was compared in each type of OT. Second, to identify the factors influencing differentiation between Be-OTs and Bo/Ma-OTs in 164 serous/mucinous ovarian tumours (SM-OTs), a multi-variate logistic regression analysis was performed to assess the effect of 13 factors, including MRI findings, OT size and tumour markers.

Results

In the comparison of diagnostic accuracy of pre-operative MRI for each OT type, accuracy was found to be notably high for ovarian endometrial cyst (OEC) (n = 409), ovarian mature cystic teratoma (OMCT) (n = 308), ovarian endometrioid adenocarcinoma (OEA) (n = 6) and ovarian clear cell adenocarcinoma (OCCA) (n = 14). On the other hand, discrepancies between MRI and pathological findings often occurred in SM-OTs, including ovarian serous cystadenoma (n = 86), ovarian mucinous adenocarcinoma (n = 61), ovarian serous adenocarcinoma (n = 12) and ovarian mucinous adenocarcinoma (n = 5). In the multi-variate logistic regression analysis of the latter 164 patients, in addition to MRI findings, OT size and carbohydrate antigen 125 also had an effect to some extent. The combination of MRI interpretation and OT size may enhance differentiation of Be-OTs and Bo/Ma-OTs.

Conclusions

Among four types of OTs (OEC, OMCT, OEA and OCCA), MRI interpretation was able to differentiate between Be-OTs and Bo/Ma-OTs almost perfectly. Additionally, to mitigate the difficulty in differentiating SM-OTs, OT size may be useful in combination with MRI findings, although further accumulation and analysis of OT cases is needed.

Oncological and Reproductive Outcomes after Fertility-Sparing Surgery in Patients with Advanced-Stage Serous Borderline Ovarian Tumor: A Single-Center Retrospective Study

Our study aimed to analyze the prognosis and reproductive outcomes of patients with advanced-stage serous borderline ovarian tumors (SBOTs) who underwent fertility-sparing surgery (FSS). This study included patients aged ≤ 45 years diagnosed with advanced-stage (International Federation of Gynecology and Obstetrics II and III) SBOTs who were treated with FSS. Conservative surgeries were performed in 65 patients with advanced-stage SBOT with a median age of 28 years (range, 16-44 years). Nine patients had invasive implants. The median follow-up was 81.7 months. Forty-six patients (70.8%) had a relapse (median time to first recurrence, 22.8 months). Thirteen patients subsequently developed recurrence as an invasive disease, and two died due to disease progression. After multivariate analysis, age < 30 years and incomplete cytoreduction were independent risk factors for recurrence. Invasive implants and postoperative residual tumors were significantly associated with shorter disease-free survival. Of 35 patients attempting to conceive, 12 underwent assisted reproductive technology. Additionally, 19 pregnancies, including 15 full-term births, were documented. FSS provides a good chance of reproductive success in women with advanced-stage SBOT who desire fertility preservation, but it has a high recurrence rate and risk of malignancy transformation. Patients with invasive implants should be strictly selected for FSS.

Rapid recurrence of a ruptured mucinous borderline ovarian tumor harboring K-RAS mutation followed by progression into anaplastic carcinoma with TP53 mutation

We describe the case of a young patient with a borderline mucinous ovarian tumor that progressed into ipsilateral ovarian anaplastic carcinoma in only 3 months with metastasis to the contralateral ovary and extensive spread in the pelvic and abdominal regions. The mucinous tumor harbored micro-foci of intraepithelial carcinoma, but no mural nodules, microinvasion, or invasive adenocarcinoma were detected. Notably, a rupture on the ovarian mass and low-grade pseudomyxoma peritonei were present. Next-generation sequencing identified an identical KRAS mutation in the mucinous tumor and anaplastic carcinoma, while the latter had KRAS gene amplification and CDKN2A, MPL and TP53 mutations. These findings indicate the anaplastic carcinoma might have arisen via recurrence, malignant transformation and dedifferentiation of the former low-grade mucinous tumor. We consider that the mass rupture and pseudomyxoma peritonei were high-risk factors for recurrence, while genetic mutations were key drivers of progression. Accordingly, such cases may benefit from active surgical treatment and early chemotherapy.

Clinical Analysis of 17 Cases of Borderline Ovarian Tumors During Pregnancy

Objective

The study retrospectively analyzed the clinical characteristics and prognosis of 17 cases of pregnancy complicated by borderline ovarian tumors to provide help for clinical workers.

Materials and Methods

The clinicopathological data of 17 patients with ovarian borderline tumors during pregnancy at the Shengjing Hospital of China Medical University from January 2015 to June 2021 were collected and analyzed retrospectively. The average age of the patients was 31.82 years (25–45 years), the average number of pregnancies was 2.06 times (1–6 times), and the average number of births was 0.41 times (0–1 time).

Results

Among the 17 patients, 4 were diagnosed in the first trimester, 2 in the second trimester, and 11 in the third trimester. Most of the first symptoms were cysts, cyst enlargement, or cyst rupture. Among them, 3 cases (1 in the first trimester and 2 in the second trimester) continued pregnancy after a conservative operation, 9 cases underwent cesarean section and a conservative operation simultaneously, and the mother and child had a good outcome. Two cases underwent conservative operations and induced abortion, and 1 case underwent an ectopic pregnancy operation at the same time. The prognosis of the patients was good without recurrence.

Conclusion

Preoperative diagnosis of borderline ovarian tumors in pregnancy is delayed, and imaging and tumor markers are not specific. The coincidence rate between intraoperative frozen pathology and postoperative paraffin pathology was not high. Borderline tumors are mainly treated by surgery, and the prognosis for mothers and infants is good.

A New Insight on Exophytic Serous Borderline Adnexal Tumors: Specific Sonographic Features

OBJECTIVES

To characterize and compare the sonographic features of exophytic serous borderline ovarian tumors (ESBOT) with those of high-grade serous carcinoma of the ovary (HGSC).

METHODS

Seven patients with histological diagnosis of ESBOT diagnosed between 2011 and 2019 and 10 consecutive cases of HGSC detected during 2019, both depicting an exophytic growth pattern, were identified retrospectively. The sonographic imaging of the masses was reassessed and characterized according to the International Ovarian Tumor Analysis terms.

RESULTS

A unilateral irregular solid adnexal mass was demonstrated in all patients with ESBOT. The mass typically wrapped an apparently normal ovary, with a clear demarcation line depicted between them and it contained tiny cystic inclusions and calcifications. On color Doppler study of all the ESBOT cases, a unique vascular pattern could be demonstrated: an intratumoral vascular bundle originating from the ovarian vessels and supplying a rich radial blood flow to the tumor periphery. These characteristic morphological and color Doppler features could not be observed in any of the HGSC cases (P < .001). In 42.8% of the patients with ESBOT, additional unilocular-solid components (ipsilateral or contralateral) could be detected, whereas all the HGSC patients presented with a multilocular-solid tumor morphology (P < .001). The interface of the external mass border with the adjacent pelvic walls was regular in all the cases with ESBOT, whereas in 80% of HGSC patients, it was irregular, suggesting invasiveness (P = .002).

CONCLUSIONS

ESBOT can mimic HGSC. Our results suggest that ESBOT has specific B-mode and color Doppler features, enabling differentiation from HGSC and planning appropriate intervention.

A Novel Case of Recurrent Mucinous Borderline Ovarian Tumor: Early Relapse and Fatal Outcome

Unlike ovarian carcinomas, borderline ovarian tumors (BOTs) are associated with a favorable prognosis: their recurrence rate is around 5–7%, and the survival rate is more than 97% when diagnosed early. There are only a few reports of recurrence and fatal outcomes. Herein, we report a novel case of recurrent mucinous BOT, with a literature review. A 63-year-old woman presented to a local doctor with abdominal fullness. She was diagnosed as having a polycystic tumor. The lesion was suspected to be a mucinous BOT (M-BOT) on magnetic resonance imaging. Upper and lower gastrointestinal endoscopy revealed no digestive cancerous lesions, and surgery was performed. Intra-operative diagnosis confirmed the diagnosis, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The final pathological diagnosis was non-invasive M-BOT (stage I c1 (T1c1N0M0)). The result of immunohistochemical staining supported the diagnosis of primary ovarian mucinous tumor.Four months after surgery, relapse occurred. Blood tests revealed an elevated carbohydrate antigen 19-9 level, and computed tomography revealed multiple liver metastases, peritoneal dissemination, left ureter infiltration, and carcinomatous peritonitis. Although the patient underwent chemotherapy, she died. This case of a very short progression-free and overall survival in stage I M-BOT indicates that some M-BOTs could result in fatal clinical outcomes despite diagnosis at an early stage. Frequent follow-up appointments after surgery could help detect relapse and increase survival in such cases.

High-grade ovarian cancer associated H/ACA snoRNAs promote cancer cell proliferation and survival

Small nucleolar RNAs (snoRNAs) are an omnipresent class of non-coding RNAs involved in the modification and processing of ribosomal RNA (rRNA). As snoRNAs are required for ribosome production, the increase of which is a hallmark of cancer development, their expression would be expected to increase in proliferating cancer cells. However, assessing the nature and extent of snoRNAs' contribution to cancer biology has been largely limited by difficulties in detecting highly structured RNA. In this study, we used a dedicated midsize non-coding RNA (mncRNA) sensitive sequencing technique to accurately survey the snoRNA abundance in independently verified high-grade serous ovarian carcinoma (HGSC) and serous borderline tumour (SBT) tissues. The results identified SNORA81, SNORA19 and SNORA56 as an H/ACA snoRNA signature capable of discriminating between independent sets of HGSC, SBT and normal tissues. The expression of the signature SNORA81 correlates with the level of ribosomal RNA (rRNA) modification and its knockdown inhibits 28S rRNA pseudouridylation and accumulation leading to reduced cell proliferation and migration. Together our data indicate that specific subsets of H/ACA snoRNAs may promote tumour aggressiveness by inducing rRNA modification and synthesis.

Near Infrared Fluorescence Imaging of Intraperitoneal Ovarian Tumors in Mice Using Erythrocyte-Derived Optical Nanoparticles and Spatially-Modulated Illumination

Simple Summary

Ovarian cancer has a greater mortality rate than all gynecological malignancies combined. While cytoreductive surgery remains the primary therapeutic approach, its success is limited by the inability to visualize all tumor nodules for resection. We developed light activated nano-sized particles derived from red blood cells as potential imaging probes for near infrared fluorescence imaging of tumors during cytoreductive surgery. We present the first demonstration of the use of these nanoparticles in conjunction a spatially-modulated illumination (SMI) modality to image ovarian intraperitoneal tumors in mice. Our findings indicate that, at 24 h post-administration, these nanoparticles accumulated at higher levels in tumors as compared to organs, and that use of SMI enhances the image contrast.

Abstract

Ovarian cancer is the deadliest gynecological cancer. Cytoreductive surgery to remove primary and intraperitoneal tumor deposits remains as the standard therapeutic approach. However, lack of an intraoperative image-guided approach to enable the visualization of all tumors can result in incomplete cytoreduction and recurrence. We engineered nano-sized particles derived from erythrocytes that encapsulate the near infrared (NIR) fluorochrome, indocyanine green, as potential imaging probes for tumor visualization during cytoreductive surgery. Herein, we present the first demonstration of the use of these nanoparticles in conjunction with spatially-modulated illumination (SMI), at spatial frequencies in the range of 0–0.5 mm⁻¹, to fluorescently image intraperitoneal ovarian tumors in mice. Results of our animal studies suggest that the nanoparticles accumulated at higher levels within tumors 24 h post-intraperitoneal injection as compared to various other organs. We demonstrate that, under the imaging specifications reported here, use of these nanoparticles in conjunction with SMI enhances the fluorescence image contrast between intraperitoneal tumors and liver, and between intraperitoneal tumors and spleen by nearly 2.1, and 3.0 times, respectively, at the spatial frequency of 0.2 mm⁻¹ as compared to the contrast values at spatially-uniform (non-modulated) illumination. These results suggest that the combination of erythrocyte-derived NIR nanoparticles and structured illumination provides a promising approach for intraoperative fluorescence imaging of ovarian tumor nodules at enhanced contrast.

The Diagnosis, Treatment, Prognosis and Molecular Pathology of Borderline Ovarian Tumors: Current Status and Perspectives

Borderline ovarian tumors (BOTs) are a type of low malignant potential tumor that is typically associated with better outcomes than ovarian cancer. Indeed, its 10-year survival rate is as high as 95%. However, there is a small subset of patients who experience relapse and eventually die. It has been shown that the prognosis of BOTs was based on pathological diagnosis, the age at diagnosis, pre-operative carbohydrate antigen 125 level, invasive implants, and micropapillary patterns. Now the molecular-targeted therapy and molecular-genetic diagnosis have developed into a form of precision medicine. Recent studies on extensive molecular characterizations and molecular pathological mechanisms of BOTs have helped us understand the genomic landscapes of BOTs, and therefore BOTs could be reclassified into biologically and clinically more accurate and effective subtypes. The purpose of this review is to summarize current status for the diagnosis and treatment of BOTs and to describe the research progress on molecular pathologies, with a goal of providing a theoretical perspective for the diagnosis and treatment of BOTs.

Scoring systems for the evaluation of adnexal masses nature: current knowledge and clinical applications

Adnexal masses are a common finding in women, with 20% of them developing at least one pelvic mass during their lifetime. There are more than 30 different subtypes of adnexal tumours, with multiple different subcategories, and the correct characterisation of the pelvic masses is of paramount importance to guide the correct management. On that basis, different algorithms and scoring systems have been developed to guide the clinical assessment. The first scoring system implemented into the clinical practice was the Risk of Malignancy Index, which combines ultrasound evaluation, menopausal status, and serum CA-125 levels. Today, current guidelines regarding female patients with adnexal masses include the application of International Ovarian Tumours Analysis simple rules, logistic regression model 1 (LR1) and LR2, OVERA, cancer ovarii non-invasive assessment of treating strategy, and assessment of Different Neoplasias in the adnexa. In this scenario, the choice of the scoring system for the discrimination between benign and malignant ovarian tumours can be complex when approaching patients with adnexal masses. This review aims to summarise the available evidence regarding the different scoring systems to provide a complete overview of the topic.

Mucinous borderline ovarian tumors with and without Intraepithelial Carcinoma: Differences in clinicopathologic features and fertility results

AIM

To investigate the clinicopathologic characteristic and fertility results of patients with mucinous borderline ovarian tumors (MBOTs), and the effects of intraepithelial carcinoma (IECA) on them.

METHODS

Fifty-two patients treated for MBOTs with or without IECA were retrospectively analyzed.

RESULTS

Patients with IECA were more frequently observed at stage Ic (3/12 vs 1/40, P = 0.034) and accompanied by microinvasive carcinoma (3/12 vs 1/40, P = 0.034). The detected rate of IECA by intraoperative frozen section (5/12, 41.7%) was much lower than that of MBOTs (82.5%, P = 0.010). About 61.5% patients in our study underwent fertility-sparing surgery. Follow-up information was retained completely in 41 patients. And all four tumor recurrences were observed (9.8%) in conservative surgery group in 66 months, though there was no statistical association (P = 0.280). There were three patients who recurred more than once, even one occurred tumor-related death. Only one recurrent patient was in IECA group (P > 0.05). However, patients with IECA were more likely to receive adjuvant chemotherapy (3 of 12 vs 0 of 40, P = 0.010) and surgical staging (75% vs 52.5%, P = 0.200). As for fertility results, nine patients wished to be pregnant and seven of them (77.8%) were successful.

CONCLUSION

For young patients with MBOTs, fertility results are satisfactory after conservative surgery. But patients should be fully informed about the relative high recurrent rate. And IECA has no statistical negative effects on MBOTs till now, but a long-term follow-up is required.

Recurrence rate and associated factors of borderline ovarian tumors in the south of Vietnam

AIM

This study aimed to determine the recurrence rate and related risk factors of borderline ovarian tumors (BOT).

METHODS

We conducted a retrospective cohort study with 433 patients who were surgically treated for primary BOT at Tu Du Hospital from 11/2008 to 09/2015. We used the life table method to estimate the cumulative recurrence rate. We used the log-rank test and Cox proportional hazard model to determine recurrence-associated factors.

RESULTS

Median follow-up time was 43 months (range: 3-105 months). Eighteen patients developed recurrence. The cumulative BOT recurrence rates at year 1, 2, 3 and 4 were 1.2% (95% confidence interval [CI] = 0.5-2.8), 3.0% (95% CI = 1.7-5.2), 4.6% (95% CI = 2.9-7.4), and 5.1% (95% CI = 3.2-8.0), respectively. In the final multivariate model, a higher recurrence rate was significantly associated with primary tumor stages (stage I vs stages II and III, hazards ratio [HR] = 4.44, 95% CI = 1.60-12.38), pre-operative tumor's capsule rupture (HR = 4.14, 95% CI = 1.78-9.64), and cystectomy (HR = 5.33, 95% CI = 1.43-19.91).

CONCLUSION

The overall BOT recurrence rate in women in southern Vietnam was moderate. Primary tumor stage, capsule rupture, and cystectomy were main factors associated with BOT recurrence. Appropriate follow-up strategies for patients with high-risk factors are needed for early detection and management of recurrence.

Pelvic Inflammatory Disease: Possible Catches and Correct Management in Young Women

The incidence of adnexal masses increases exponentially with age and the most frequent causes in young women are physiologic cysts and pelvic abscesses with pelvic inflammatory disease (PID). Clinical examination can direct physicians to an appropriate management of adnexal mass, but the role of transvaginal ultrasound is crucial for diagnosis and treatment decision, even if it sometimes can be misleading, especially in young women. Ca 125, blood count, and CRP are useful to clarify suspected etiology of a pelvic mass, but specificity and positive predictive value are low because elevation of laboratory tests may occur in several benign conditions. In our work we present four cases of suspected pelvic masses. Despite guidelines for management of PID, the right timing to switch to surgical therapy is not clear. Therefore, the treatment decision should be based on a careful evaluation of various parameters such as signs symptoms and above all age. Moreover, we believe that, for a correct diagnosis and for the best fertility sparing treatment, it is also extremely important to refer to a gynecological oncology unit with an expert surgeon.

Imaging in gynecological disease (12): clinical and ultrasound features of invasive and non-invasive malignant serous ovarian tumors

OBJECTIVES

To describe clinical and ultrasound features of different subclasses of malignant serous ovarian tumors according to the World Health Organization 2014 classification.

METHODS

Patients with a histological diagnosis of borderline tumor (BOT), non-invasive and invasive low-grade serous carcinoma (LGSC) and high-grade serous carcinoma (HGSC), who had undergone preoperative ultrasound examination, were retrospectively identified from two ultrasound centers. The masses were described using the terms of the International Ovarian Tumor Analysis Group.

RESULTS

Sixty-four (15.8%) women had a serous BOT, 11 (2.7%) a non-invasive LGSC, 31 (7.6%) an invasive LGSC and 300 (73.9%) had a HGSC. The vast majority of BOTs (82.3%) and non-invasive LGSCs (90.9%) were Stage I according to the International Federation of Gynecology and Obstetrics (FIGO) classification scheme, whereas most invasive LGSCs (74.2%) and HGSCs (74.0%) were FIGO Stage III. On ultrasound examination, most borderline lesions were described as unilocular-solid (54.7%) or as multilocular-solid (29.7%) cysts. Papillary projections were present in 52 (81.3%) BOTs. Most non-invasive LGSCs (63.6%) were multilocular-solid cysts and 81.8% had papillary projections. Invasive LGSCs were multilocular-solid cysts in 54.8% of cases, and papillary projections were present in 32.3% of lesions. HGSCs were multilocular-solid (32.7%) or solid (64.0%) masses, with papillary projections in only 7% of cases.

CONCLUSIONS

Papillary projections were the most typical ultrasound feature of non-invasive (borderline and low-grade) malignant serous tumors, while the presence of solid components but few, if any, papillations was the most representative feature of invasive (low-grade and high-grade) serous tumors. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Borderline tumors of the ovary: A clinicopathological study

Objective:

To report experience with borderline ovarian tumors (BOTs) in a developing country like Pakistan with limited resources and weak database of health system.

Methods:

Patients with BOTs managed at Shaukat Khanum Cancer hospital, Lahore, Pakistan from 2004 to 2014 were included and reviewed retrospectively. Data was recorded on histopathological types, age, CA-125, stage of disease, treatment modalities and outcomes.

Results:

Eighty-six patients with BOT were included with a median age of 35 years. Forty-two (49%) patients had serous BOTs and 43 (50%) had mucinous BOTs, while one (1%) had mixed type. Using FIGO staging, 80 patients had stage I; two patients had IIA, IIB and stage III each. Median follow-up time was 31.5 months. All patients had primary surgery. Seventy (81%) patients underwent complete surgical resection of tumor. Forty-three (50%) patients had fertility preserving surgery. Seventy-three (85%) patients remained in remission. Recurrent disease was observed in 13 (15%) patients. Median time to recurrence was 22 months. On further analysis, age above forty years, late stage at diagnosis and incomplete surgery were significantly associated with invasive recurrence.

Conclusion:

Despite a low malignant potential, relapses may occur in patients above forty years of age, incomplete surgery and staging information and advanced stage at presentation. Fertility sparing surgery should be considered in young patients. Complete excision of tumor and prolonged follow-up are advised because recurrence and transformation to invasive carcinoma may occur.

Relapse and disease specific survival in 1143 Danish women diagnosed with borderline ovarian tumours (BOT)

OBJECTIVE

The aim of the study was to evaluate the rate of relapse as well as disease-free, overall, and disease-specific survival in women with borderline ovarian tumour (BOT). Furthermore, the study aims to identify the clinical parameters correlated to relapse.

METHODS

National clinical data of women diagnosed with BOT from January 2005 to January 2013 constituted the basis for our study population. The prognostic influence of clinical variables was evaluated using univariate and multivariate analyses.

RESULTS

A total of 1143 women were eligible for analysis, with 87.9% in FIGO stage I and 12.1% in FIGO stages II-IV. Relapse of BOT was detected in 3.7%, hereof 40.5% with malignant transformation. The five-year disease-free survival was 97.6% in FIGO stage I and 87.3% in FIGO stages II-IV. Younger age, laparoscopic surgical approach, fertility sparing surgery, FIGO stages II-IV, bilateral tumour presence, serous histology, implants and microinvasion of the tumour were significantly associated with relapse in univariate analyses. The overall five-year survival rate was 92.2% in FIGO stage I and 89.0% in FIGO stages II-IV. Out of 77 deaths in total, only seven women died from BOT.

CONCLUSIONS

A general favourable prognosis in women with BOT was confirmed in our study. Our findings indicate that systematic, long-term follow-up does not seem necessary in women treated for FIGO stage IA BOT with no residual disease or microinvasion.