Management Of Borderline Ovarian Tumors Research Articles

Management of Borderline Ovarian Tumors – state of the art

Borderline ovarian tumors (BOT) have invited controversy for decades. In the last couple of years research has showed a shift towards less aggressive treatment. This review summarizes the latest studies and therapeutic consequences thereof. Staging procedures are recommended in the setting of serous BOT, but controversial in the setting of mucinous BOT, where they may represent overtreatment. Surgical staging is limited to bilateral salpingo-oophorectomy, peritoneal cytology/biopsies and an omentecomy. Neither a hysterectomy nor lymphadenectomy should be undertaken. Conservative management should consist of a cystectomy or unilateral salpingo-oophrectomy in the setting of serous BOT and unilateral salpingo-oophrectomy in the case of mucinous BOT. Bilateral disease should be treated by bilateral cystectomy whenever possible. At present, there are no data to support the use of adjuvant treatment in any setting of BOT.

Conservative laparoscopic oophorectomy for borderline ovarian malignancy: A case report and review of the literature

Abstract We present the case of a 28-year-old nulligravida woman with a history of male factor infertility. A borderline ovarian tumor in the right ovary was accidentally discovered during the course of management of ectopic pregnancy as an outcome of in vitro fertilization (IVF). Considering the borderline tumor size, an attempt was made to preserve the left ovary and preserve fertility by using a laparoscopic oophorectomy procedure. The patient subsequently became pregnant by IVF trial. During the pregnancy, a left-sided cyst was noted in the left ovary at 14 week pregnancy and remains in stable tumor size on continuous ultrasounds with no symptoms till spontaneous vaginal delivery. Considering her desire to conceive again, several attempts of in vitro fertilization were performed, and after cryopreserved embryos, the laparoscopic left oophorectomy was performed 18 months after the delivery. The patient subsequently became pregnant again from the source of cryopreserved embryos. Our results show that meticulously planned, minimally invasive surgery – if combined with careful and regular follow-up – is an excellent option in the management of borderline ovarian tumors in women who desire to become pregnant.

New Pointers for Surgical Staging of Borderline Ovarian Tumors.

Surgical management of borderline ovarian tumors (BOTs) is similar to that of ovarian cancer apart from lymphadenectomy. However, the complete procedure including peritoneal washing, infracolic omentectomy and random peritoneal biopsies remains a subject of controversy especially in presumed early stage BOTs. To evaluate the prognostic value of complete surgical staging on recurrence rates, recurrence free (RFS) and overall survival (OS) in a multicentre cohort of BOTs. This retrospective multicentre study included 428 patients with BOTs diagnosed from January 1980 to December 2008. Survival estimates were based on Kaplan-Meier calculations and RFS defined as the time from the date of surgery to the date of recurrence. The median time of follow-up was 94.9 months (range: 60.00-207.3). The overall recurrence rate was 23.8 %. There was no difference in 5-year RFS between patients with and without complete surgical staging 78.1 % (95 % CI 68.9-88.6) and 70.9 % (95 % CI 64.6-77.8), (p = 0.0806). In the whole cohort, 5-year OS was higher for patients with complete surgical staging 98.4 % (95 % CI 96.8-1.0) and 93.8 % (95 % CI 88.1-1), (p = 0.0182) but this difference was not significant for patients with FIGO stage I 98.6 % (95 % CI 96.7-1) and 92.7 % (95 % CI 83.4-1.0), p = 0.1275, respectively. Complete staging surgery should be considered as a cornerstone treatment for patients with advanced stage BOT but not for those with stage I disease.

Management of Borderline Ovarian Tumors Based on Patient and Tumor Characteristics

Background: Borderline ovarian tumors are staged similarly to invasive ovarian tumors. Aims: We wanted to better understand which tumors were associated with disease recurrence. Methods: We performed a retrospective cohort analysis at a single institution between 1984 and 2005. Cases were confirmed by pathology report. Multivariate analysis was done to evaluate factors associated with recurrence. Results: 143 cases were identified. Mean follow-up was 73.5 months. The overall risk of recurrence was 12%. The hazard ratio for risk of recurrence was highest among seromucinous tumors at 4.04 and lowest among mucinous tumors at 0.53. Only 4% of mucinous tumors, 15.5% of serous tumors and 28.6% of seromucinous tumors recurred. 2% of mucinous tumors had an appendix positive for metastasis. No mucinous tumor had nodal disease. Conclusions: Based on our data, a low rate of appendiceal or lymph node involvement was observed in mucinous tumors, as was a low risk of recurrence. Less aggressive staging may be considered if a mucinous tumor is identified on frozen section with a normal-appearing appendix in the absence of pseudomyxoma peritonei. In patients with a serous or a seromucinous tumor, complete surgical staging is recommended.

Presentation and management of borderline ovarian tumors: Should mucinous tumors be managed differently?

Objective: Relatively little data exist on optimal surgical staging for mucinous borderline ovarian tumors. Surgical staging is not without complications; thus, a better understanding of the optimal staging for mucinous borderline ovarian tumors is needed.

Surgical management and perioperative morbidity of patients with primary borderline ovarian tumor (BOT).

e16535 Background: Surgery is the central aspect of clinical management in patients with borderline ovarian tumors (BOT). As patients have excellent overall prognosis after successful surgery, perioperative morbidity is a critical point for decision regarding the primary surgical approach. Methods: Clinical and surgical parameters of patients undergoing surgery for primary BOT at two gynecologic cancer centers between 1993 and 2008 were analyzed with regard to perioperative morbidity depending on the surgical approach (laparoscopy vs. laparotomy). Results: A total of 105 patients were analyzed (44 with primary laparoscopy [42%], 61 with primary laparotomy [58%]). Primary laparoscopy was often performed with diagnostic intention and resulted in complete surgical staging in only 9.1% with subsequent formal indication for re-staging procedures. In contrast, complete surgical staging was achieved in 47.5% at primary laparotomy (p < 0.001). Tumor rupture was significantly more frequent during laparoscopy compared to laparotomy (29.5% vs. 13.1%, p = 0.038) but no other intraoperative complications were seen in laparoscopic surgery in contrast to 7 of 61 laparotomies (0% vs. 11.5%, p = 0.020). Postoperative complication rates were similar in both groups (19.7% vs. 18.2%, p = 0.848). Conclusions: Irrespective of the surgical approach, surgical management of BOT has acceptable rates of perioperative complications and morbidity. Choice of initial surgical approach can therefore be made independent of complication-concerns. As the recently published large retrospective AGO ROBOT study observed similar oncologic outcome for both approaches, laparoscopy should be considered as the preferred surgical approach for staging of patients with BOT if this appears feasible in preoperative evaluation.

Survey of the management of borderline ovarian tumors in the United Kingdom

Borderline ovarian tumors (BOTs) represent approximately 10% of ovarian neoplasms and are a heterogeneous group of tumors with variable biological behaviour. The majority present with disease confined to the ovary and have an excellent prognosis after surgical removal. A small proportion subsequently has recurrent disease or progression to invasive cancer. Tumor recurrence can occur up to 20 years after surgical resection. There are no robust clinical, histological or molecular markers that distinguish high risk cases and no satisfactory treatment for patients with progressive disease. This results in great variability in management in different centres. We conducted a national survey on the management of borderline ovarian tumors in cancer centres representing different regions in the United Kingdom. In this article we review the literature for the current concepts in diagnosis, treatment and follow up of BOTs and we report the results of the survey of current practice in the United Kingdom. On that basis we provide recommendations for the management of pa-

The value of frozen section evaluation in the management of borderline ovarian tumors

To evaluate the accuracy of a frozen section and to analyze the factors affecting frozen section results in cases of borderline ovarian tumors (BOTs). The files and pathological reports of 82 cases diagnosed with BOT at our clinic, between January 1994 and June 2009, have been retrospectively evaluated. The frozen section results were compared to the permanent paraffin section results. Accuracy, overdiagnosis, and underdiagnosis rates were estimated. The factors affecting the diagnosis were also evaluated using logistic regression analysis. The mean age was 40.16 ± 14.01 years. Of the patients, 47.6% had serous and 42.7% had mucinous histology. About 90% of the cases were in stage I. The rate of correct diagnosis with frozen section was 69.5%. The rates of overdiagnosis and underdiagnosis were 1.2 and 29.3%; respectively. The factors affecting the diagnosis were determined as, the dimension of the ovarian mass (P = 0.005), presence of a solid component (P = 0.000), preoperative CA 125 value (P = 0.016), and intraoperative rupture of the ovarian cyst (P = 0.049). In the frozen section evaluation of BOTs, the underdiagnosis that restricts the diagnostic performance of the method seems to be a major problem. A more careful approach is therefore needed, while choosing a proper surgical technique during laparotomy for ovarian masses. In order to reduce the false diagnosis and surgical morbidity, the frozen section analysis should be applied by experienced pathologists and the possible predictive factors affecting a false diagnosis should carefully be taken into consideration.

Ten years experience in the management of borderline ovarian tumors at Tom Baker Cancer Centre

The aim of this study was to review the clinical outcomes of patients with borderline ovarian tumors (BOTs) at Tom Baker Cancer Centre (TBCC) and to assess the value of surgical staging. This retrospective study included 138 patients treated for BOTs at TBCC between January 1994 and December 2005. Patients were divided into two groups: group I with complete surgical staging (n = 89) and group II with incomplete surgical staging (n = 49). This population-based study identified patients using the Alberta Cancer Registry. Charts were reviewed by a single person. Data extracted included demographic information and prognostic factors such as age, histological type, laterality of the cyst, presence of microinvasion, and the type of surgical procedure. Data were extracted and entered into a study database for analysis. Overall survival and overall recurrence-free survival of both groups were calculated using the Kaplan-Meier method. Risk factors for recurrence were analyzed using Cox regression analysis. A total of 138 patients were enrolled, with a mean age of 46 years. The median follow-up time was 37 months. The most common histological type of BOT was the serous type found in 70 (50.7%) patients. Microinvasion was identified in four (2.9%) patients. Twelve patients were found to have implants as result of the staging procedure; two of them were invasive implants and both required chemotherapy. Forty-three (31%) patients had conservative surgery and 95 (68.8%) patients had non-conservative surgery. Nine (6.5%) patients experienced recurrence: five (5.6%) patients in group I versus four (8.2%) patients in group II. The presence of microinvasion is the risk factor for recurrence (P = 0.013). The indications for restaging surgery remain controversial, as there was no difference in recurrence rates observed between the study groups. However, surgical staging is important for identifying invasive extraovarian implants that need to be treated with chemotherapy. For patients who have conservative surgery, close- and long-term follow-up is required.

Clinical management of borderline ovarian tumors

Borderline ovarian tumors (BOTs) are epithelial tumors of the ovaries characterized by cellular proliferation and nuclear atypia but without an infiltrative growth pattern. As they frequently affect younger patients the clinical management is complicated by considerations such as preserving fertility and reducing postoperative morbidity. Over the past several decades surgical therapy has shifted from a radical approach to more conservative treatment. There are various modes of surgery applied to the patients. All these developments have to be considered from an oncologic standpoint as BOTs represent a potentially malignant disease. Oncologic safety, as well as patients’ desires and expectations, have to be balanced to reach the most appropriate treatment for BOTs. For this reason current literature will be discussed in this review to give a thorough overview of this topic and to develop recommendations for the surgical management of these patients. Open questions will be identified to elaborate the need for future surveys and research.

Comparison of Laparoscopic and Laparotomic Surgery for Borderline Ovarian Tumor

Study Objective: To compare the surgical and survival outcomes after surgery by laparoscopy or laparotomy for borderline ovarian tumors. Design: Retrospective analysis. Setting: Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea. Patients: Three hundred thirty six patients with borderline ovarian tumor. Intervention: Laparoscopic or laparotomic surgical management for borderline ovarian tumor. Measurements and Main Results: Of 336 patients with borderline ovarian tumor, 245 patients underwent laparoscopic surgery and 91 patients underwent laparoscopic surgery from 1997 to 2009. Age, parity, and body mass index was similar between the two surgery groups. Menopausal women was more in laparoscopy group. Mean tumor size was higher in laparotomy group. FIGO stage, histologic type, bilaterality of tumor, microinvasion, micropapillary pattern, invasive implant, intraoperative tumor rupture, malignant ascites or cytology, and preoperative CA 125 level were not different between the two surgery groups. However, conservative management, use of ovarian cystectomy were more common in laparoscopy group, and comprehensive surgical staging including lymph node dissection and omentectomy were more common in laparotomy group. After mean follow-up time of 56 months (range, 3–132 months), recurrence rate (5.1% vs 4.2%, p = 0.763) and death rate (1.7% vs 1.4%, p = 0.864) were not different between the two surgery groups. Five year disease-free survival was 94% and 98%, respectively (p = 0.8827), and 5-year overall survival rate was 98% in both groups (p = 0.9643). Conclusion: Laparoscopic surgery for borderline ovarian tumor was feasible in most cases. Although comprehensive staging procedure was less frequently used and comservative management was adopted more frequently, the survival was not compromised. Laparoscopic surgery may be a safe and reasonable alternative to laparotomic surgery in the management of borderline ovarian tumor.

Current management of borderline ovarian tumors: A multicenter survey of 323 clinics in Germany, on behalf of the North-Eastern German Society of Gynecological Oncology (NOGGO)

e16568 Background: The aim of this survey was to analyze the standard of care in diagnostic, surgery, chemotherapy and aftercare management of patients with Borderline tumor of the ovary (BOT) in Germany. Methods: A structured questionnaire comprising different dimensions of treatment of BOT was sent to all 1,114 gynecological departments in Germany. The questionnaire could be returned anonymously. Results: The overall response rate was 29.0% (323 departments). The most departments were on secondary care (71.8%), tertiary care (23.2%) or university hospital (5.0%) level. The most clinicians performed not more than 5 BOT operations (89.2%) per year. 93.2% of the gynecological departments used additional preoperative diagnostic procedures to the classical bimanual examination and vaginal ultrasound in a case of unclear ovarian tumor: CA-125 or CEA detection (95%), CT-scan (76%), Doppler ultrasound (66%), MRI (36%), or PET-CT (1.7%) techniques. In university hospitals (87%), tertiary care (80%), secondary care (68%) and most of the general practitioners’ hospitals (64%) a regular fresh frozen section was the intraoperative diagnostic standard. For diagnosis of BOT mostly laparotomy (48%) and laparoscopy (15%) were performed, whereas 19% used a diagnostic laparoscopy, followed by laparotomy for completion in a second intervention or switch from laparoscopy to laparotomy in the primary surgical session (18%). In young women with desire to preserve fertility clinicians performed much seldom unilateral salpingo-oophorectomy (92%) and only in 53% biopsies of the contra lateral ovary and in 67% peritoneal biopsies. Generally biopsies of the contra lateral ovary were performed in 4% to 53% of all patients. Chemotherapy was the second therapy option (64%) after surgery (97%) for BOT, mostly favored in “high-risk” patients with tumor residual, micro invasion or invasive implants. Conclusions: These data demonstrate a high clinical unsureness in the clinical management of borderline tumors of the ovary. No significant financial relationships to disclose.

Surgical management of borderline ovarian tumors: The role of fertility-sparing surgery

Objective To evaluate the recurrence, survival, and pregnancy outcomes of patients with borderline ovarian tumors (BOT) treated with fertility-sparing surgery. Methods The medical records of patients with BOT who underwent surgery between 1989 and 2008 were retrospectively reviewed. Outcomes were compared between groups that underwent radical or fertility-sparing surgery. Fertility-sparing surgery was defined as the preservation of the uterus and ovarian tissue in one or both adnexa. Results During the study period, 360 patients with BOT were identified; of these, 344 had stage I, one had stage II, and 15 had stage III disease. A total of 176 patients underwent radical surgery (23 laparoscopically and 153 laparotomically), and 184 underwent fertility-sparing surgery (48 laparoscopically and 136 laparotomically). After surgery, 45 patients received adjuvant chemotherapy. After a median follow-up time of 70 months (range, 3–216 months), 18 patients had recurrent disease and 5 died of disease. The recurrence rate was similar in the radical and fertility-sparing surgery groups (4.9% vs. 5.1%, p = 0.923). In the fertility-sparing surgery group, however, the most common site of recurrence was the remaining ovarian tissue which was successfully salvaged with a second round of fertility-sparing surgery. Multivariate analysis showed no difference in disease-free survival between groups that underwent radical or fertility-sparing surgery ( p = 0.651). To date, there have been 34 full-term deliveries by women in the fertility-sparing surgery group. Conclusions Fertility-sparing surgery for patients with BOT is safe and can permit future pregnancy, suggesting that such surgery should be considered for young patients who wish to preserve fertility.

Tumeurs borderline de l’ovaire : état des lieux

Borderline ovarian tumors account for 15–20% of all ovarian epithelial tumors and are diagnosed primarily in young women who want to preserve their childbearing potential. Due to the absence of specific preoperative criteria, diagnosis is often made during surgery or after the anatomopathologic examination. The management of borderline ovarian tumors with early stage is well-known and conservative surgery must be chosen as much as possible. Laparoscopic approach is possible for these tumors, allowing diagnosis, staging and also treatment. For advanced stage, laparotomy is still recommended. Staging must be performed during the initial surgery because tumor stage is one of the most relevant prognostic factors. Restaging operation should be discussed when complete staging was not made during initial surgery. Because his prognostic and therapeutic impacts are not proved, restaging surgery remains controversial. For that reason, it seems important to define clinical and histological criteria for patients with a high risk of upstaging.

Six cases with borderline ovarian tumors diagnosed after laparoscopic cystectomy for benign ovarian tumors

Objective: The laparoscopic management of borderline ovarian tumors is controversial. We examined the outcomes of six cases with borderline ovarian tumors diagnosed after laparoscopic cystectomy for benign ovarian tumors.Methods: Among 127 patients who were treated by laparoscopic cystectomy for benign ovarian tumors between 1998 and 2006 at the University of the Ryukyus Hospital, 6 women were pathologically-diagnosed with borderline ovarian tumors. We retrospectively investigated the clinical outcomes of these patients.Results: The mean age was 42.5±23.3 years (range, 23-74 years), and the tumor size was 15.7±6.5 cm (range, 8.1-25.0 cm) . Laparoscopic cystectomy was performed in four cases who wished to preserve fertility. The remaining two postmenopausal women were treated by laparoscopic bilateral salpingo-oophorectomy. All six cases had stage Ic (b) tumor due to intraoperative tumor rupture (three mucinous, two serous, and one carcinoid) . All of the patients were surveyed without re-laparotomy for surgical staging or postoperative chemotherapy. Two of 4 women who desired pregnancy became pregnant within 1 year, and 3 recurrences as borderline tumors occurred in patients treated by laparoscopic cystectomy, 3, 14, and 21 months after the initial laparoscopic surgery. Two recurrent patients underwent laparoscopic oophorectomy, and the other recurrence was treated by salpingo-oophorectomy and lymph node sampling. The patients remained disease-free for 44, 27, and 56 months.Conclusions: Although long-term follow-up is indispensable, patients with borderline ovarian tumors can safely undergo conservative surgery.

Management of Borderline Ovarian Neoplasms

Over the last decades, the management of borderline ovarian tumors (BOTs) has changed from radical surgery to more conservative therapy as a result of the need for fertility-sparing surgery and the increasing use of laparoscopy. The question is whether this is good clinical practice from an oncologic point of view. Here, recent literature regarding management of borderline ovarian neoplasms is reviewed, and oncologic concerns are discussed with emphasis on the mode of surgery and the possibility of fertility-sparing surgery and its consequences. Proper staging is defined as an exploration of the entire abdominal cavity with peritoneal washings, infracolic omentectomy, and multiple peritoneal biopsies as the cornerstone of a successful treatment, and this is only possible through a midline incision. For stage I disease, conservative surgery consisting of unilateral salpingo-oophorectomy or cystectomy in case of bilateral ovarian involvement or when the disease develops in the only remaining ovary is a valuable alternative in a number of young patients who want to preserve their fertility. Patients with advanced-stage disease or who are finished childbearing are treated with radical surgery consisting of peritoneal washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, complete peritoneal resection of macroscopic lesions, or multiple peritoneal biopsies; in case of mucinous BOTs, patients also are treated with an appendectomy.

Surgery of borderline tumors of the ovary: retrospective comparison of short‐term outcome after laparoscopy or laparotomy

Laparoscopic management of borderline ovarian tumors is controversial. To retrospectively compare outcome after surgery by laparoscopy or laparotomy for borderline tumors. Ovarian tumors from all women operated at Ullevål University Hospital during a five-year period were re-evaluated histologically. Patients with borderline FIGO (International Federation of Gynaecology and Obstetrics) stage I tumors were retrospectively compared regarding surgery outcome following laparoscopy or laparotomy. Histological re-evaluation revealed only 3 misclassifications in 608 patients. Borderline tumors represented 36% of epithelial ovarian malignancies. The 107 borderline stage I included 52 serous, 53 mucinous, and 2 endometrioid tumors. Thirty-eight patients were operated on primarily by laparoscopy and 69 by laparotomy (including 14 women starting with laparoscopy). In the laparoscopy group, more women were premenopausal (63% versus 35%, p=0.01) and median tumor diameter was smaller (8.6 versus 16.4 cm, p<0.001) as compared to the laparotomy group. When tumor diameter exceeded 10 cm, intraoperative tumor rupture was significantly more frequent during laparoscopy than during laparotomy (p=0.01). Less postoperative complications were seen after laparoscopic operations (p=0.034), but laparoscopic surgeries were less extensive, without hysterectomy, as compared to laparotomy. During the 14-78 months follow-up time, no relapse occurred in either group. After fertility-sparing surgery, there was no statistical significant difference regarding successful pregnancies between the two groups. Laparoscopic treatment of borderline ovarian tumors is feasible if tumor is of moderate size (diameter below 10 cm), gives fewer complications, and shorter hospital stay. Long-term follow-up of larger materials is needed to determine the ultimate recurrence risk as well as fertility rates.

Pregnancy outcome and recurrence after conservative laparoscopic surgery for borderline ovarian tumors

The aim of this study was to evaluate the safety and efficacy of conservative laparoscopic management of borderline ovarian tumors, and to assess pregnancy outcome and recurrence after fertility-sparing surgery. From 1995 to 2005, 43 patients of reproductive age presented with adnexal mass, which was subsequently diagnosed as a borderline tumor of the ovary. These patients were treated by conservative laparoscopic surgery, with intraoperative staging of the disease. Patients were evaluated every 3 months for the first 2 years, and then every 6 months thereafter, to determine the best modality for following patients after conservative surgery. Three (7%) patients developed a recurrence after conservative treatment. Among the 43 patients who had conservative surgery, 21 (49%) became pregnant during the follow-up period; 12 (57%) conceived spontaneously, and the remaining 9 (43%) patients underwent caesarean section. In our opinion, conservative laparoscopic treatment of borderline ovarian tumors is an appropriate and reasonable therapeutic option for young women with low-stage disease who wish to preserve their childbearing potential, because the fertility results are encouraging. Recurrence can be noted after this type of treatment, but the cases of recurrent disease can be detected with close follow-up and treated accordingly. Careful selection of candidates for this kind of treatment is, of course, necessary, and close follow-up is required.

Management of borderline ovarian tumors: Results of an Italian multicenter study

Management of borderline ovarian tumors: Results of an Italian multicenter study

Laparoscopy Vs. Laparotomy For The Surgical Management Of Borderline Ovarian Tumors (Bot)

Laparoscopy Vs. Laparotomy For The Surgical Management Of Borderline Ovarian Tumors (Bot)