Serous and mucinous borderline ovarian tumours: differences in clinical presentation, high-risk histopathological features, and lethal recurrence rates

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

Fertility sparing treatment for bilateral borderline ovarian tumor: a case report and management strategy explication

A bilateral adnexal mass with suspected carcinosis could be a challenging experience for the gynecologist especially in fertile age and in patients with a desire for pregnancy. A 26-year-old patient who came to the outpatient clinical observation for bilateral, multilocular pelvic masses, with more than 4 papillary structures, color score 2, hypomobile compared to the uterus and rectum, respectively of 65 and 68mm in maximum diameter, free liquid in the abdomen and suspected of ovarian neoplasm. Positive tumor markers and a strong desire of a fertility sparing treatment (FST). A 2-step surgical approach managed to perform a diagnosis of bilateral ovarian borderline tumor with implants and a fertility sparing surgery. Harvesting and cryopreserving oocytes prior to the cytoreductive intervention was successfully performed.

Evaluation of Clinicopathologic Factors and Surgery Management on Borderline Ovarian Tumor Outcomes

Background: Borderline ovarian tumor (BOT) is a tumor most prevalent in young woman with desire to fertility. There are some controversies on the patient characteristic besides to the factors affecting the recurrence rate among different races. Objectives: The aim of this study is to evaluate clinicopathologic features of the tumor to discover the controversies on the topic. Methods: Medical data of the all referred patients to Motahari clinic from January 2010 till October 2020 were recorded. Patient clinicopathologic characteristics affecting on outcome were evaluated. By using SPSS software, data were tested by chi-square and fish exact test. Also, log rank test was used for survival analysis Results: Totally 145 patients were enrolled. 61.4% versus 38.6% of the patients underwent fertility sparing surgery and radical surgery respectively with common characteristics of mostly belong to stage 1A disease (61.8% vs. 66.1%), unilateral (93.3% vs. 89.3%), serous histology (51.7% vs. 66.1%). The characteristics were different in the aspects of age and tumor size. In the aspect of recurrence rate, higher FIGO stage, younger age, tumor size less than 10cm, performing laparoscopy and fertility sparing surgery were with higher rate of recurrence (P-value < 0.05) while histology type of the tumor, lateralization, micropapillary, microinvasion, noninvasive peritoneal implants, receiving adjuvant chemotherapy and performing lymphadenectomy were not statistically significant for recurrence (P-value > 0.05). Two patients had malignant transformation. Conclusions: Fertility sparing surgery was with more recurrence rate in borderline ovarian tumor patients. However, micropapillary, microinvasion were not significantly with higher recurrence rate in our study but they are challenging issues in border line ovarian tumors among different studies. Due to most prevalence of border line ovarian tumors in young women and desire of fertility preservation, we should notice more to clinicopathologic and surgery types affecting on recurrence of BOTs.

Prognosis and Prognostic Factors of Serous Borderline Tumor-Micropapillary Variant: Retrospective Study of 200 Patients with Long-Term Follow-Up

Objective

To determine the oncofertility outcomes and prognostic factors in a large series of serous borderline ovarian tumor-micropapillary variant (SBOT-M) with a long-term follow-up.

Methods

Consecutive patients with SBOT-Ms treated from two affiliated hospitals of the Chinese Academy of Medical Sciences were retrospectively reviewed. Prognostic factors on invasive recurrence, disease-free survival (DFS), and overall survival were analyzed, and outcomes of patients treated with conservative and radical surgery were compared.

Results

From 2000 to 2020, 200 patients were identified and followed. After a median follow-up of 68 months, 81 patients relapsed. In the multivariate analyses, younger age at diagnosis and conservative surgery that preserved fertility potential were independently associated with worse DFS (p = 0.018 and <0.001, respectively). Twenty-three patients experienced invasive recurrence, and seven died of progressive disease. Multivariate analysis showed that nulliparous and advanced FIGO stage were independently adversely associated with lethal recurrence (p = 0.022 and 0.029, respectively). Only advanced FIGO stage at diagnosis was associated with worse overall survival at univariate analysis (p = 0.02). Among 61 patients attempting conception, 37 achieved 44 pregnancies and resulted in 32 live births.

Conclusions

In this series, patients with SBOT-M have an acceptable oncofertility outcomes. The use of conservative surgery was independently associated with worse DFS, but without an impact on neither invasive relapse nor on overall survival. Patients with advanced FIGO stages had a significantly higher risk of lethal recurrence and worse overall survival, suggesting that adequate staging surgery and intensive postoperative surveillance should be warranted.

Risk Factors for Recurrence of Borderline Ovarian Tumours after Conservative Surgery and Impact on Fertility: A Multicentre Study by the Francogyn Group

Introduction: Borderline ovarian tumours (BOT) represent 10–20% of epithelial tumours of the ovary. Although their prognosis is excellent, the recurrence rate can be as high as 30%, and recurrence in the infiltrative form accounts for 3% to 5% of recurrences. Affecting, in one third of cases, women of childbearing age, the surgical strategy with ovarian conservation is now recommended despite a significant risk of recurrence. Few studies have focused exclusively on patients who have received ovarian conservative treatment in an attempt to identify factors predictive of recurrence and the impact on fertility. The objective of this study was to identify the risk factors for recurrence of BOT after conservative treatment and the impact on fertility. Material and methods: This was a retrospective, multicentre study of women who received conservative surgery for BOT between February 1997 and September 2020. We divided the patients into two groups, the “R group” with recurrence and the “NR group” without recurrence. Results: Of 175 patients included, 35 had a recurrence (R group, 20%) and 140 had no recurrence (NR group, 80%). With a mean follow-up of 30 months (IQ 8–62.5), the overall recurrence rate was 20%. Recurrence was BOT in 17.7% (31/175) and invasive in 2.3% (4/175). The mean time to recurrence was 29.5 months (IQ 16.5–52.5). Initial complete peritoneal staging (ICPS) was performed in 42.5% of patients (n = 75). In multivariate analysis, age at diagnosis, nulliparity, advanced FIGO stage, the presence of peritoneal implants, and the presence of a micropapillary component for serous tumours were factors influencing the occurrence of recurrence. The post-surgery fertility rate was 67%. Conclusion: This multicentre study is to date one of the largest studies analysing the risk factors for recurrence of BOT after conservative surgery. Five risk factors were found: age at diagnosis, nulliparity, advanced FIGO stage, the presence of implants, and a micropapillary component. Only 25% of the patients with recurrence underwent ICPS. These results reinforce the interest of initial peritoneal staging to avoid ignoring an advanced tumour stage.

Second fertility-sparing surgery and fertility-outcomes in patients with recurrent borderline ovarian tumors

Background

At the time of recurrence, many borderline ovarian tumor (BOT) patients are still young with fertility needs. The purpose of this study is to evaluate the reproductive outcomes and recurrence rate of second fertility-sparing surgery (FSS) in women with recurrent BOTs.

Methods

Seventy-eight women of childbearing age diagnosed with recurrent BOTs from November 2009 to 2020 whose primary treatment was FSS were included.

Results

The FIGO stage I disease accounted for 46.2% and serous BOT accounted for 87.2% in the study group. Forty-seven patients underwent second FSS, and the remaining 31 underwent radical surgery (RS). Seventeen patients relapsed again after second surgery, but no malignant transformation and tumor-associated deaths were reported. Compared to FIGO stage I, the FIGO stage III tumors were more likely to relapse, but there was no statistical difference in pregnancy rate among patients with different stages. In the second FSS group, recurrence rate was higher in patients who underwent oophorocystectomy compared to patients with unilateral salpingo-oophorectomy (USO), but the pregnancy rate was similar. There was no significant difference in postoperative recurrence risk between USO and RS. The recurrence rate was not associated with operative route (laparoscopy or laparotomy), or lymphadenectomy, or postoperative chemotherapy. Among the 32 patients who tried to conceive, the pregnancy rate was 46.9% and live birth rate was 81.3%.

Conclusion

Unilateral salpingo-oophorectomy is a safe procedure for FIGO stage I recurrent BOT patients with fertility needs, and can achieve a high postoperative pregnancy rate and live birth rate.

Role of MRI in characterizing serous borderline ovarian tumor and its subtypes: Correlation of MRI features with clinicopathological characteristics

PURPOSE

This study aimed to investigate the diagnostic value of MRI in serous borderline ovarian tumor (SBOT), and to determine the MRI features of SBOT and their correlations with clinicopathological characteristics.

MATERIALS AND METHODS

A total of 121 patients suspected of SBOT by preoperative MRI and then underwent surgery at our hospital were retrospectively reviewed. The accuracy of MRI in diagnosing SBOT was assessed. MRI features of the SBOT subtypes were compared and their correlations with clinicopathological characteristics were evaluated.

RESULTS

SBOT was confirmed by postoperative pathology in 95 patients, including 77 patients with conventional SBOT (SBOT-C) and 18 patients with micropapillary SBOT (SBOT-MP). The accuracy of MRI in diagnosing SBOT was 87.6%. Three MRI morphological patterns of SBOT were identified: (i) mainly solid, (ii) mainly cystic, and (iii) mixed. Branching papillary architecture and internal branching (PA&IB) structures corresponding to multiple branching papillary projections and internal fibrous stalks in tumors were observed in 69.7% of SBOTs on T2-weighted images. MRI findings were consistent with postoperative pathology. Compared with SBOT-C, patients with SBOT-MP were more likely to display elevated cancer antigen 125, bilateral tumors, peritoneal implantation, lymph node metastasis, and advanced tumor staging. No significant differences were observed in MRI features between SBOT-C and SBOT-MP groups.

CONCLUSION

MRI has good performance in diagnosing SBOT. MRI findings of SBOT are consistent with clinicopathological characteristics. The PA&IB structure is the characteristic MRI finding of SBOT. Compared to SBOT-C, SBOT-MP tends to display more aggressive clinical behavior, but their MRI features are similar.

Borderline epithelial ovarian tumors: what the radiologist should know

Ovarian borderline tumors are neoplasms of epithelial origin that are typically present in young patients and tend to have a less aggressive clinical course than malignant tumors. Accurate diagnosis and staging of borderline tumors has important prognostic and management implications (like fertility-sparing procedures) for women of child-bearing age. This article will review the sonographic, CT, and MRI features of borderline epithelial ovarian tumors with histopathologic correlation. Borderline tumors have less soft tissue and thinner walls/septations than malignant tumors. Serous borderline tumors more commonly have papillary projections, which can simulate the appearance of a sea anemone. Mucinous borderline tumors often are larger, multi-cystic, and more commonly unilateral. The borderline mucinous tumors may also present with pseudomyxoma peritonei, which can make it difficult to distinguish from malignant mucinous carcinoma. Ultrasound is usually the first-line modality for imaging these tumors with MRI reserved for further characterizing indeterminate cases. CT is best used to stage tumors for both locoregional and distant metastatic disease. Overall, however, the imaging features overlap with both benign and malignant ovarian tumors. Despite this, it is important for the radiologist to be familiar with the imaging appearances of borderline tumors because they can present in younger patients and may benefit from different clinical/surgical management.

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.

Status of Surgical Management of Borderline Ovarian Tumors in France: are Recommendations Being Followed? Multicentric French Study by the FRANCOGYN Group

Background

Borderline ovarian tumors (BOTs) are tumors with a favorable prognosis but whose management by consensus is essential to limit the risk of invasive recurrence. This study aimed to conduct an inventory of surgical practices for BOT in France and to evaluate the conformity of the treatment according to the current French guidelines.

Methods

This retrospective, multicenter cohort study included nine referral centers of France between January 2001 and December 2018. It analyzed all patients with serous and mucinous BOT who had undergone surgery. A peritoneal staging in accordance with the recommendations was defined by performance of a peritoneal cytology, an omentectomy, and at least one peritoneal biopsy.

Results

The study included 332 patients. A laparoscopy was performed in 79.5% of the cases. Treatment was conservative in 31.9% of the cases. The recurrence rate was significantly increased after conservative treatment (17.3% vs 3.1%; p < 0.001). Peritoneal cytology was performed for 95.5%, omentectomy for 83.1%, and at least one biopsy for 82.2% of the patients. The overall recurrence rate was 7.8%, and the recurrence was invasive in 1.2% of the cases. No link was found between the recurrence rate and the conformity of peritoneal staging. The overall rate of staging noncompliance was 22.9%.

Conclusion

The current standards for BOT management seem to be well applied.

Multimodality imaging review of complex pelvic lesions in female pelvis

Complex pelvic lesions can originate from various anatomical structures in the pelvis and pose a diagnostic dilemma due to a wide range of possible diagnoses. Accurate characterisation of these lesions would often require an algorithmic approach, which incorporates clinical findings, sequential use of multiple imaging modalities and a multiparametric approach. This approach usually aims at identifying key imaging features, which aid in anatomical localisation, morphology and tissue characterisation. There have been various attempts to standardise the lexicon used for describing adnexal masses in female patients; stratify their risk of cancer and suggest appropriate next steps in the management pathway. Through this review, we extend this approach to complex pelvic masses in female pelvis in general and will focus on optimal use of different imaging modalities to arrive at definitive diagnosis or meaningful differential diagnosis. We will also discuss potential pitfalls of imaging diagnosis and common mimics.

Ovarian mucinous neoplasms, intestinal type, in premenopausal patients, develop in abnormal ovaries

Although several studies have addressed different aspects of mucinous neoplasms arising in the ovary, such as their clinicopathologic features, immunohistochemical profile, and molecular characteristics, no study has presented an analysis of the ovarian tissue where these neoplasms arise. In this study, we included 196 cases of intestinal-type ovarian mucinous neoplasms in premenopausal patients. Our main goal was to perform a rigorous examination of the ovarian tissue surrounding these neoplasms. We also reviewed the clinicopathologic features of these cases. For comparison, the background ovarian tissue in 85 cases of ovarian serous neoplasm and in 29 cases of metastatic neoplasms to the ovary, as well as 57 normal ovaries, was examined. All the patients in this study, which included those with mucinous and with serous neoplasms primary in the ovary, those with metastatic tumors to the ovaries, and those with normal ovaries, were also premenopausal. Patients affected by ovarian mucinous neoplasms ranged in age from 13 to 52 years (median = 36 years). Nulligravidity was seen in 50%, 32%, and 22% of patients with mucinous carcinomas, mucinous borderline neoplasms, and mucinous cystadenomas, respectively. Ovarian mucinous intestinal neoplasms arise in abnormal ovaries characterized by two important features: (1) an abnormal ovarian cortex, seen in 95% of the cases, which is hypocellular or with no distinction between the cellular cortex and medulla, and (2) a remarkable paucity of primordial follicles. The abnormalities detected in the background ovarian tissue might provide insights into the tumorigenesis of these neoplasms and might facilitate their distinction from metastasis to the ovary, in premenopausal patients.

Risk factors for recurrence of borderline ovarian tumors in France: A multicenter retrospective study by the FRANCOGYN group

INTRODUCTION

Borderline ovarian tumors (BOTs) although rare, have shown an increase in the incidence worldwide. Although the survival rate is high, the recurrence rate is estimated to be between 5% and 34%. The objective of this study was to identify risk factors for recurrence of BOTs.

METHODS

This retrospective multicenter study included 493 patients treated surgically for BOT between January 2001 and December 2018.

RESULTS

Thirty-seven patients showed recurrence (group R, 7.5%), while 456 did not (group NR, 92.5%). With an average follow-up of 30.5 months (1-276), the overall recurrence rate was 7.5%. Recurrence rates for the BOT and invasive types were 5.7% (n = 28) and 1.4% (n = 7), respectively. The mean time to recurrence was 44.1 (3-251) months. Univariate analysis showed that age at diagnosis, type of surgical procedure, histological type, and FIGO stage were factors influencing recurrence. Multivariate analysis showed that the risk factors for recurrence of BOT were conservative treatment (OR = 7 [95% CI 3.01-16.23]; p < 0.05) and advanced FIGO stage (OR = 5.86 [95% CI 2.21-15.5]; p < 0.05).

DISCUSSION

To the best of our knowledge, this multicenter study was one of the largest studies on the risk factors for BOT recurrence. Conservative treatment and advanced FIGO stage were identified as risk factors for BOT recurrence. These results reinforce the need for restaging of patients who did not have an optimal initial surgical staging so as not to avoid missing a tumor in the advanced stage. Referral to a surgical oncology center is suggested to optimize overall patient management.

[Borderline ovarian tumours: CNGOF Guidelines for clinical practice - Biopathology of ovarian borderline tumors]

OBJECTIVES

Ovarian borderline tumors (OBT) represent a heterogeneous group of lesions with specific management for each histological subtype. Thus, the correct histological diagnosis is mandatory.

MATERIAL AND METHODS

References were searched by PubMed from January 2000 to January 2018 and original articles in French and English literature were selected.

RESULTS AND CONCLUSIONS

OBT should be classified according to the last WHO classification. Any micro-invasion (foci<5mm) or microcarcinoma (foci<5mm with nuclear atypia and desmoplastic stromal reaction) should be indicated in the pathology report. In case of serous OBT, variants (classical or the micropapillary/cribriform) should be indicated (grade C). The peritoneal implants associated with OBT, should be classified as invasive or noninvasive, according to the extension into the underlying adipous tissue. If no adipous tissue is seen the term undetermined should be used (grade B). In case of mucinous OBT bilateral and/or with peritoneal implants or peritoneal pseudomyxoma a search for primitive gastrointestinal, appendiceal or biliopancreatic tumor should be performed (grade C). In case of OBT, a thorough sampling of the tumor is recommended, with 1 block/cm and 2 blocks/cm in case of mucinous OBT, serous OBT micropapillary variant, OBT with intraepithelial carcinoma or/and micro-invasion. Peritoneal implants should be examined in toto. Omentum without macroscopic lesion should be sampled in 4 to 6 blocks (grade C). In case of ovarian cyst suspicious for OBT, fine needle aspiration is not recommended (grade C). In case of ovarian tumor suspicious for OBT, intraoperative examination should be performed by a gynecological pathologist (grade C).

Fertility preservation after fertility-sparing surgery in women with borderline ovarian tumours

OBJECTIVE

To present a case series of women with borderline ovarian tumours (BOTs) who underwent oocyte vitrification in addition to fertility-sparing surgery.

STUDY DESIGN

Observational study of all women referred to a French fertility preservation unit between 2015 and 2019 for counselling regarding a fertility preservation (FP) strategy after BOT fertility-sparing surgery. All eligible women underwent one or more cycles of controlled ovarian stimulation (COS) using an antagonist protocol, followed by oocyte retrieval. Metaphase II (MII) oocytes were vitrified.

RESULTS

Twenty-five women with BOTs were referred during the study period. Among them, 11 women underwent at least one cycle of COS. One hundred and seven MII oocytes were vitrified. The mean number of vitrified MII oocytes per woman was 9.7 (standard deviation 5.2). Five live births were reported during follow-up of four women with vitrified oocytes: three spontaneous pregnancies, one in-vitro fertilization cycle with fresh embryo transfer, and one live birth after return of vitrified oocytes.

CONCLUSION

Conservative surgery for BOTs offers a high spontaneous pregnancy rate but has a higher risk of relapse than radical treatment. Furthermore, women who undergo conservative BOT surgery have a higher risk of surgery-induced premature ovarian failure. Oocyte cryopreservation after COS appears to be an effective technique after the conservative management of BOTs in women of reproductive age. Although the available short-term data are reassuring, further long-term studies evaluating the safety and cost-effectiveness of this systematic FP strategy after BOT fertility-sparing surgery are required.

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.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Epidemiology and Risk Factors of Relapse, Follow-up and Interest of a Completion Surgery]

OBJECTIVE

To provide clinical practice guidelines from the French college of obstetrics and gynecology (CNGOF) based on the best evidence available, concerning epidemiology of recurrence, the risk or relapse and the follow-up in case of borderline ovarian tumor after primary management, and evaluation of completion surgery after fertility sparing surgery.

MATERIAL AND METHODS

English and French review of literature from 2000 to 2019 based on publications from PubMed, Medline, Cochrane, with keywords borderline ovarian tumor, low malignant potential, recurrence, relapse, follow-up, completion surgery. From 2000 up to this day, 448 references have been found, from which only 175 were screened for this work.

RESULTS AND CONCLUSION

Overall risk of recurrence with Borderline Ovarian Tumour (BOT) may vary from 2 to 24% with a 10-years overall survival>94% and risk of invasive recurrence between 0.5 to 3.8%. Age<40 years (level of evidence 3), advanced initial FIGO stage (LE3), fertility sparing surgery (LE2), residual disease after initial surgery for serous BOT (LE2), implants (invasive or not) (LE2) are risk factors of recurrence. In case of conservative treatment, serous BOT had a higher risk of relapse than mucinous BOT (LE2). Lymphatic involvement (LE3) and use of mini invasive surgery (LE2) are not associated with a higher risk of recurrence. Scores or Nomograms could be useful to assess the risk of recurrence and then to inform patients about this risk (gradeC). In case of serous BOT, completion surgery is not recommended, after conservative treatment and fulfillment of parental project (grade B). It isn't possible to suggest a recommendation about completion surgery for mucinous BOT. There is not any data to advise a frequency of follow-up and use of paraclinic tools in general case of BOT. Follow-up of treated BOT must be achieved beyond 5 years (grade B). A systematic clinical examination is recommended during follow-up (grade B), after treatment of BOT. In case of elevation of CA-125 at diagnosis use of CA-125 serum level is recommended during follow-up of treated BOT (grade B). When a conservative treatment (preservation of ovarian pieces and uterus) of BOT is performed, endovaginal and transabdominal ultrasonography is recommended during follow-up (grade B). There isn't any sufficient data to advise a frequency of these examinations (clinical examination, ultrasound and CA-125) in case of treated BOT.

CONCLUSION

Risk of relapse after surgical treatment of BOT depends on patients' characteristics, type of BOT (histological features) and modalities of initial treatment. Scores and nomogram are useful tools to assess risk of relapse. Follow-up must be performed beyond 5 years and in case of peculiar situations, use of paraclinic evaluations is recommended.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Surgical Management of Advanced Stages of Borderline Ovarian Tumours]

OBJECTIVE

To evaluate the surgical management of borderline ovarian tumors (BOT) in the framework of recommendations for clinical practice made by the National College of Obstetricians and Gynecologists (CNGOF) METHODS: This is a comprehensive review of the literature on the advanced stages of BOT. Bibliographic selection was conducted in PubMed from 2007 to 2019 inclusive, selecting publications in English and French. Articles were selected on the basis of the title, then the abstract and finally the full article. The levels of evidence of the studies were defined according to the scale proposed by the High Authority of Health (HAS).

RESULTS

By analogy with epithelial ovarian cancer, in case of preoperative suspicion or after a postoperative diagnosis of advanced BOT, the patient must be referred to an expert centre in ovarian cancer (gradeC). There is no data from the literature to conclude that a hysterectomy should be performed routinely, however, the goal in the advanced stages of BOT is no tumor residue (gradeC). In advanced stages of BOT, systematic lymphadenectomy is not recommended, but excision of suspected lymph node on preoperative and intraoperative evaluation, for curative purposes, may be discussed to obtain no residual disease (gradeC). It is recommended to describe peritoneal carcinomatosis before any excision as well as tumor residues at the end of surgery (grade B). The use of a peritoneal carcinomatosis score to evaluate tumor burden such as the "Peritoneal Carcinosis Index" (PCI) is recommended (gradeC). For advanced stages of BOT, a conservative treatment with at least the preservation of the uterus and an ovarian fragment in a patient wishing a pregnancy may be proposed after Multidisciplinary Concertation Meeting (GradeC). Contralateral ovary biopsy is not recommended in advanced stage BOT (GradeC) but restaging surgery associated with removal of all tumor lesions is recommended when not performed initially (GradeC). It is not possible to make a recommendation on chemotherapy indication in advanced stages even with invasive implants.

CONCLUSION

The weakness of the literature and the retrospective nature of BOT advanced stage studies limit the grade of the recommendations.

Histopathological Patterns of Microinvasion in Ovarian Serous Borderline Tumors

Stromal microinvasion in ovarian serous borderline tumors can take various aspects, some of which are difficult to identify. Thus, the identification of stromal microinvasion is relatively simple for typical intracystic papillary proliferations such as serous borderline tumors, but may be difficult for tumors with glandular component. The study analyzed 14 cases of ovarian serous borderline tumors diagnosed in patients with mean age of 47,1 years. Histopathologically all tumors corresponded to typical forms in which we identified only two cases of stromal microinvasion. In one case, microinvasion was of eosinophilic type, and in the other case was observed a glandular and micropapillary pattern, being associated with the noninvasive peritoneal implants.

Safety and fertility outcomes after the conservative treatment of endometrioid borderline ovarian tumours

Background

Because of the rarity of endometrioid borderline ovarian tumours (EBOTs), there is a paucity of data concerning the natural history and prognosis of this condition. Thus, the objective of our study was to establish the feasibility of fertility preservation in young women with EBOTs, as well as their oncological and reproductive outcomes.

Methods

Consecutive patients with EBOTs, treated at a tertiary referral centre during a span of 22 years, were retrospectively analysed. Recurrence-free interval, as well as its association with the type of surgery and with other clinical and pathological features, was assessed using the Kaplan-Meier and Cox proportional hazards methods.

Results

Of the 59 patients studied, the median follow-up time was 30 months (range, 6–177 months). Nine (15.3%) patients developed 13 recurrences 6–137 months after the initial surgeries, including three patients (5.1%; n = 3/59) who developed six invasive recurrences 8, 18 and 68 months after their initial surgeries. Conservative surgery showed a tendency towards a high recurrence rate (17.2% versus 13.3%); however, this difference was not significant (p = 0.45). The 5-year recurrence-free survival rate was significantly higher in the oophorectomy group than in the cystectomy group (p = 0.001). Cox regression analysis showed that none of the variables assessed were associated with an increased hazard ratio for recurrence, except for a younger age at diagnosis (p = 0.021). Of 20 patients who attempted to conceive, three pregnancies among two patients (10.0%) resulted in two live births.

Conclusions

Conservative surgery with unilateral adnexectomy can be proposed for young women with EBOTs with fertility desire; however, the reproductive result is not satisfactory. In addition, careful evaluations of the endometria should be offered during the initial surgery and follow-up period.

Trial registration

Retrospectively registered.

Ultrasound-Guided Laparoscopic Ovarian Wedge Resection in Recurrent Serous Borderline Ovarian Tumours

Objective

The aim of this study was to demonstrate the use of intraoperative ultrasound-guided ovarian wedge resection in the treatment of recurrent serous borderline ovarian tumors (sBOTs) that are too small to be visualized laparoscopically.

Methods

This was a prospective analysis of all women with recurrent sBOTs that were not visible laparoscopically, who underwent intraoperative ultrasound-guided ovarian wedge resection between January 2015 and December 2016 at the West London Gynaecological Cancer Centre, Imperial College NHS Trust, London, United Kingdom.

Results

We evaluated 7 patients, with a median age of 35 years (range, 28–39 years). Six women were nulliparous, whereas 1 woman had a single child. Previous surgical intervention left 5 women with a single ovary, whereas the remaining 2 had previous ovarian-sparing surgery. The median size of recurrence was 18 mm (range, 12–37 mm). All women underwent uncomplicated intraoperative guided ovarian wedge resections. Histological assessment confirmed sBOT in all 7 cases. Six of the women remain disease-free. One woman recurred postoperatively with her third recurrence, who previously had bilateral disease and noninvasive implants with microinvasive disease and micropapillary pattern. No cases progressed to invasive disease. The median follow-up time was 12 months (range, 1–20 months). One pregnancy has been achieved postoperatively but resulted in miscarriage.

Conclusions

Continuous intraoperative ultrasound can be used to facilitate complete tumor excision in recurrent sBOT while minimizing the removal of ovarian tissue in women with recurrent sBOT. It is essential that surgical techniques evolve simultaneously with diagnostic imaging modalities to enable surgeons to treat such pathology.

A nationwide study of ovarian serous borderline tumors in Denmark 1978-2002. Risk of recurrence, and development of ovarian serous carcinoma

OBJECTIVE

Absolute risk and risk factors for recurrence and ovarian serous carcinoma following ovarian serous borderline tumors (SBTs) is not well-established.

METHODS

We included all women with SBTs in Denmark, 1978-2002. Diagnoses were confirmed by centralized pathology review and classified as atypical proliferative serous tumor (APST) or noninvasive low-grade serous carcinoma (LGSC). Implants were classified as noninvasive or invasive. Medical records were collected and reviewed, and follow-up was obtained. Subsequent diagnoses were also confirmed by centralized pathology review. We examined absolute risk and risk factors for recurrent APST and serous carcinoma using Cox regression.

RESULTS

The absolute serous carcinoma risk after, respectively, 5 and 20years was 5.0% and 13.9% for noninvasive LGSC, and 0.9% and 3.7% for APST. Serous carcinoma risk was significantly higher following noninvasive LGSC compared with APST among stage I patients/patients without implants (HR=5.3; 95% CI: 1.7-16.3), whereas no significant association with tumor type was found in advanced stage patients/patients with implants. Advanced stage - notably invasive implants - bilaterality, surface involvement, and residual disease increased serous carcinoma risk. However, women with stage I APST also had a higher risk than the general population.

CONCLUSIONS

This largest population-based cohort of verified SBTs revealed that women with noninvasive LGSC are significantly more likely to develop serous carcinoma than women with APST, which could not entirely be explained by invasive implants. Although invasive implants was a strong risk factor for serous carcinoma, even women with stage I APST were at increased risk compared with the general population.

Fertility Preservation Is Safe for Serous Borderline Ovarian Tumors

Objectives

This study aimed to determine the overall survival (OS) and progression-free interval and the influence of fertility-preserving surgery (FPS) versus radical surgery (RS) in patients with serous borderline ovarian tumor (BOT).

Methods

Clinical parameters of patients with serous BOT treated between 1993 and 2013 in one institution were retrospectively investigated. All tumors were examined by one pathologist with experience in gynecological pathology.

Results

One hundred thirty-two patients with serous BOT (inclusive 16 microinvasive) were analyzed (45% were ≤40 years), with a median follow-up of 6 years. Thirty-two percent (42/132) of the patients received FPS; 14% (18/132) relapsed (invasive or borderline). The 5-year progression-free survival was 89%. The risk of recurrence was higher in patients 40 years or younger (P = 0.019), after FPS (P = 0.002), in patients with a higher International Federation of Gynecology and Obstetrics (FIGO) stage (P = 0.016), for bilateral BOT (P = 0.0132), and for the micropapillary variant (P = 0.067). The OS at 5 years was 97%. There was no statistically significant difference in OS between FPS and RS [all (6 of 90) patients, except for 1, with RS died]. One patient died of relapsed BOT. Among the recurrences, low-grade invasive carcinoma was diagnosed in 4 patients. Three of these 4 patients were originally operated radically, 2 had a micropapillary variant FIGO stage III, and 1 had a papillary pattern FIGO stage II with microinvasion; all 3 had noninvasive implants and are alive. One patient with a micropapillary variant, FIGO stage IIIC with microinvasion and invasive implants, received FPS and died of disease.

Conclusions

The risk of recurrence is higher after FPS compared with RS; however, no influence on OS was observed. This was because most of the patients relapsed as BOT. Fertility preservation is justified in young patients with serous borderline tumors.

Fertility preservation in women with cervical, endometrial or ovarian cancers

Background

Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance.

Outcomes

Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery.

Conclusions

Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.