Ultrasound, physical examination, and CA 125 measurement for the detection of recurrence after conservative surgery for early borderline ovarian tumors

Surveillance procedures for patients treated for epithelial ovarian cancer: a review of the literature

Epithelial ovarian cancer is the leading cause of death from gynecological cancer in the Western countries. Approximately 20%–30% of patients with early-stage disease and 50%–75% of those with advanced disease who obtain a complete response following first-line chemotherapy will ultimately develop recurrent disease, which more frequently involves the pelvis and abdomen. Few formal guidelines exist regarding the surveillance of these patients, and there is no agreement in the literature about the type and timing of examinations to perform. Moreover, the objective of follow-up is unclear as recurrent epithelial ovarian cancer continues to be a therapeutic dilemma and quite all the relapsed patients will eventually die of their disease. The follow-up of asymptomatic patients generally include complete clinical history, serum cancer antigen (CA)125 assay, physical examination, and often ultrasound examination, whereas additional radiologic imaging techniques are usually performed when symptoms or signs appear.18Fluoro-2-deoxy-glucose (18FDG)–positron emission tomography (PET) has a sensitivity of 90% and a specificity of 85% approximately for the detection of recurrent disease, and this examination appears to be particularly useful for the diagnosis of recurrence when CA125 levels are rising and conventional imaging is inconclusive or negative. Recently, technologic advances have led to novel combined18FDG-PET/computed tomography (CT) devices, which perform contemporaneous acquisition of both18FDG-PET and CT images. The role of18FDG-PET/CT for the detection of recurrent ovarian cancer is very promising, and this technique may be especially useful for the selection of patients with late recurrent disease who may benefit from secondary cytoreductive surgery.

Results of the national survey of borderline ovarian tumors in Spain

MATERIAL AND METHODS

Retrospective multi-center analysis of women diagnosed with borderline ovarian tumor and treated between January 1990 and December 1997. A national survey was conducted, in which 457 patients from 27 centers corresponding to ten of Spain's autonomous communities were analyzed.

RESULTS

Four hundred fifty-seven women with borderline ovarian tumor were analyzed. The mean age of patients was 45.5+/-16.9 years. Of these, 390 patients (85.3%) were at stage I, 8 (1.8%) were at stage II and 36 (7.9%) at stage III. A bilateral tumor was observed in 63 women (13.8%). The mean tumor size was 14.2 cm and in 88 cases (19.3%) the tumor was on the surface of the ovary. Microinvasion was observed in 25 (5.5%) cases, and 29 women (6.3%) showed a micropapillary pattern. Study of the factors related to the appearance of peritoneal implants revealed positive tumor markers (OR 15.02: 1.9-32.9) and a tumor on the ovarian surface (OR 8.0: 1.8-127) to be independent risk factors. With respect to recurrence, the presence of peritoneal implants at the time of initial surgery (OR 3.4: 1.1-10.4) and signs of microinvasion in the anatomicopathological study (OR 5.5: 1.5-17.8) were found to be independent risk factors. The overall survival rate in our series was 97% with a mean follow-up of 88.3 months. The survival rate by stage was 97% for stage I, 100% for stage II and 97% for stage III.

CONCLUSIONS

Although borderline ovarian tumors have an excellent prognosis, they are not exempt from a risk of recurrence. Characterization of patients with borderline ovarian tumor is essential in order to prevent their evolution. Likewise, the taking on board of risk factors will enable more selective treatments to be offered in each case.

Borderline ovarian tumors: current concepts for prognostic factors and clinical management

Since their original description in 1929, our knowledge of the natural history and molecular pathology of borderline ovarian tumors (BOTs) has advanced most dramatically over the last decade. It has been estimated that at the time of abdominal exploration for a serous ovarian neoplasm, a BOT will be discovered in approximately 15% of cases. These tumors commonly affect women of reproductive age, have an excellent overall prognosis and the majority are cured with surgery. Nevertheless, a subset of patients with these tumors have an adverse clinical outcome and the molecular features of the associated tumor subtype is currently being defined. These data have caused some to place this more aggressive subtype of BOT, called micropapillary serous with invasive extraovarian implants, into the pathologic continuum with frankly invasive carcinomas. This chapter will explore advances in our understanding of the natural history, clinical and pathologic features of BOTs and will conclude with a discussion of the molecular prognostic factors that might be targets for future therapy. A special emphasis will be placed on points of agreement identified during a recent workshop on BOTs sponsored by the National Cancer Institute (NCI).

The management of borderline tumours of the ovary

PURPOSE OF REVIEW

The treatment of borderline ovarian tumours has been similar to that for their invasive counterparts for a long time. However, in view of the good prognosis for borderline ovarian tumours, their occurrence in a younger age group and the development of less invasive techniques, the question can be asked as to whether a more conservative treatment is warranted.

RECENT FINDINGS

Recent articles discuss the mode of surgery (laparotomy or laparoscopy), the possibility of fertility-sparing surgery, the need for restaging procedures and adjuvant therapy.

SUMMARY

The ultimate goal in treating patients with borderline ovarian cancer is defining those patients with bad prognostic factors and risk for recurrence and who consequently require more aggressive therapy. A proper staging procedure is crucial to estimate the risk. Translational research might help identify borderline tumours with poor prognosis. Fertility-sparing surgery is often a good option in young patients with Fédération International de Gynécologie et Obstétrie (FIGO) stage I disease or in selected cases with noninvasive implants, since long-term survival does not seem to be negatively influenced by conservative surgery.

Fertility-sparing surgery and outcome in fertile women with ovarian borderline tumors and epithelial invasive ovarian cancer

OBJECTIVE

The aim was to evaluate the outcome of fertility-sparing treatment in ovarian borderline tumors and early invasive ovarian cancer.

MATERIALS AND METHODS

All women diagnosed with an ovarian borderline tumor or early invasive ovarian cancer who were treated with fertility-sparing surgery at the University Hospital in Lund between 1988 and 2002 were identified and included in the study (n=23).

RESULTS

During the follow-up period of a median 92 months, range 11-185 months, no relapse was found in the patients with Stage 1a tumors, including both borderline tumors (n=12) and invasive well-differentiated (n=9) and moderately differentiated (n=1) ovarian cancers. One patient with poorly differentiated ovarian cancer Stage 1c was 13 weeks' pregnant at the time of the primary operation. Although, unilateral oophorectomy was performed she insisted on continuing the pregnancy. At 37 weeks she had a cesarean section and the ovarian cancer was disseminated. Chemotherapy was given but she died less than a year later. None of the other patients received chemotherapy. In total, 30 children were born to 15 patients. Prophylactic removal of the remaining ovary+/-hysterectomy was accepted in only in six of the women after fulfilling their desire to have more children.

CONCLUSIONS

Young women with Stage 1a epithelial ovarian cancer and borderline tumors do not have to give up their fertility in order to receive successful and safe treatment of their disease. However, several of these patients do not accept the recommendation of prophylactic oophorectomy of the contralateral ovary and hysterectomy after completion of childbearing.

Borderline tumours of the ovary and fertility

Standard management of borderline ovarian tumours (BOT) is historically radical and based on hysterectomy, bilateral salpingo-oophorectomy and peritoneal staging. But, as 1/3 of BOTs are diagnosed in patients aged less than 40 years, treatments preserving fertility-potential (with preservation of the uterus and at least part of one ovary) has seen great developments in the last decade. Such treatments increase the rate of recurrences (between 15% and 35% depending on the type of conservative surgery), but without any impact on patient survival as most recurrent diseases are of the borderline type, easily curable and with excellent prognosis. The spontaneous pregnancy rate is nearly 50%. In case of persistent infertility, it seems that the use of ovarian induction or in vitro fertilization procedures could be proposed in selected cases. Follow-up is essential and based on clinical examination and routine ultrasonography. The interest of completion surgery (removal of the retained ovary) in patients who obtained pregnancy remains debated. In conclusion, conservative management of at least part of one ovary and uterus could be safely proposed at least to patients with early stage BOT, in order to preserve fertility-potential. The rate of recurrence is increased but without any impact on survival.

The accuracy of examination under anesthesia and transvaginal sonography in evaluating ovarian size

OBJECTIVE

To compare pelvic examination under anesthesia to transvaginal sonography (TVS) as a method for ovarian detection and measurement.

METHODS

Two hundred and eighty-nine ovaries from 151 women were evaluated. After induction of anesthesia, a complete pelvic examination and TVS were performed, and the ovaries were removed surgically. Ovarian dimensions generated sonographically and estimated on clinical examination were compared to those obtained from the measured surgical specimen.

RESULTS

Forty-four percent of ovaries were palpable clinically whereas 85% were visualized sonographically (P < 0.001). Right ovaries were palpable more frequently than left ovaries (P < 0.01). Ovaries were detected clinically in 30% of women > or = 55 years of age versus 51% of women <55 years of age (P < 0.05), in 9% of women weighing > or = 200 lb versus 55% of women weighing <200 lb (P < 0.001), and in 12% of women with a uterine weight > or = 200 g versus 51% of women with a uterine weight <200 g (P < 0.001). TVS was significantly more accurate than clinical examination in detecting ovaries in women with these high risk characteristics.

CONCLUSIONS

TVS is significantly more accurate than clinical examination in detecting ovaries and in defining their dimensions. Ovaries frequently are not palpable in women > or = 55 years of age, women who weigh > or = 200 lb, or women with an enlarged uterus (> 200 g). The addition of TVS to annual pelvic examination may be beneficial in women > or = 55 years of age who are overweight and therefore at high risk to develop ovarian cancer.

Conservative surgery for borderline ovarian tumors: a review

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Fertility-sparing surgery for ovarian low malignant potential tumors

OBJECTIVE

Ovarian low malignant potential (LMP) tumors have an excellent prognosis when treated by surgical resection. Conservative management usually involves leaving behind the uterus and contralateral adnexa to allow future childbearing. The purpose of this study was to determine the outcome of women treated with fertility-sparing surgery.

METHODS

All patients diagnosed with ovarian LMP tumors between 1984 and 2003 were identified at three institutions. Data were retrospectively extracted from clinical records.

RESULTS

Thirty-eight (15%) of 249 women with LMP tumors underwent fertility-sparing surgery. Twenty-three were nulliparous and four primiparous. Thirty-three (87%) underwent unilateral salpingo-ophorectomy and five (13%) cystectomy. Fourteen patients also had contralateral cystectomy or biopsy. Thirty-four (89%) were stage I, one (3%) stage II and three (8%) stage III. Most tumors had serous (55%) or mucinous (42%) histology. No patients received adjuvant therapy. Six (16%) of 38 recurred after a median follow-up of 26 months: five in the remaining ovary were salvaged with surgical resection alone, and none died from recurrent LMP tumor. Five women delivered six term infants during post-treatment surveillance.

CONCLUSION

Fertility-sparing surgery for ovarian LMP tumors is an option for motivated patients. Preservation of the contralateral adnexa increases the risk of recurrence, but surgical resection is usually curative.

The value of detection of normal ovarian tissue (the 'ovarian crescent sign') in the differential diagnosis of adnexal masses

OBJECTIVE

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions.

METHODS

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.

RESULTS

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.

CONCLUSION

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

High preoperative plasma concentration of tissue plasminogen activator (tPA) is an independent marker for shorter overall survival in patients with ovarian cancer

OBJECTIVE

The objective was to evaluate the preoperative blood concentration of tissue plasminogen activator (tPA) as a discriminator between malignant and benign ovarian tumors, and as a potential marker of postoperative prognosis in patients with ovarian cancer.

METHODS AND MATERIAL

The concentration of tPA was assayed with ELISA (Imulyse Biopool) in preoperative plasma samples obtained from 111 patients with adnexal lesions. Tumors were classified as benign (n = 25), borderline malignant (n = 11), well-differentiated (G1, n = 22), moderately differentiated (G2, n = 11), and poorly differentiated malignant (G3, n = 42). The median follow-up time of patients with malignant tumors was 5.6 years (range 2.1-13.2 years) and 37 patients died during the follow-up period.

RESULTS

Patients with moderately and poorly differentiated tumors had higher levels of plasma tPA compared to those with well-differentiated tumors (P = 0.004 and P = 0.005). No significant differences in the plasma tPA levels were observed between patients with benign, borderline, and well-differentiated tumors. The tPA levels were not different between stages nor within stage Ia-c. In a multivariate Cox proportional hazards model including stage, grade, age, and plasma tPA dichotomized at the median (> or =9 vs <9 ng/mL), high levels of tPA were significantly associated with shorter survival: HR = 4.4 (95% CI 2.0-9.8, P = 0.0003). In the univariate analyze high levels of tPA showed HR = 4.5 (95% CI 2.1-9.6, P = 0.0003).

CONCLUSIONS

High concentration of plasma tPA was an independent marker for poor prognosis in patients with ovarian cancer in our study. Plasma tPA did, however, not discriminate between benign and malignant adnexal lesions.

Borderline ovarian tumours: a review of the recent literature

PURPOSE OF REVIEW

Borderline tumors of the ovary are seen commonly in obstetrics and gynecology practices. This review will outline the most recent information regarding the epidemiology, molecular pathogenesis, pathology, and clinical management of these tumors.

RECENT FINDINGS

In the past, borderline ovarian tumors and invasive ovarian cancer were studied together, under the presumption that they represent a continuum of disease. This view is coming into question based on both epidemiological and molecular biological studies. Pathologists are increasingly able to identify poor prognostic histological features. This has not yet been translated into improved non-surgical therapy. Surgical management to excise all visible tumor remains the cornerstone of therapy. Because borderline ovarian tumors often occur in reproductive-age women, fertility is an important issue. Conservative surgery is safe in carefully selected patients.

SUMMARY

Our growing understanding of the relatively benign natural history of borderline ovarian tumors has allowed us to be more conservative in their surgical management, preserving fertility in many young women. A few women will be affected by a more virulent form of the disease with the potential to recur and cause death. The pathological features that identify patients with a poor prognosis are progressively being elucidated. Surgery remains the most effective therapy for these patients. Effective non-surgical therapies have yet to be identified. Hopefully, as molecular biological studies continue to expand our understanding of this disease as probably a separate carcinogenic process from invasive ovarian cancer, we will be able to employ this knowledge to design novel adjuvant therapies.

The cystic adnexal mass: patient selection, surgical techniques and long-term follow-up

The continuous change in the treatment and management of ovarian tumours is an excellent example of the changes that have occurred in gynaecological laparoscopic surgery. This paper evaluates the management of the adnexal mass in 2001. Second, it reviews ovarian tumours treated at the Department of Obstetrics and Gynaecology, University of Kiel, between January 1997 and December 1998, and the place of laparoscopy in the management of these lesions. Third, the review attempts to give an insight into the long-term follow-up of patients treated laparoscopically for the removal of ovarian cysts. Finally, a retrospective survey is given of the clinical pathology and prognostic features of adnexal masses operated on during pregnancy. With regard to long-term follow-up, no difference was found between laparoscopic or laparotomic treatment of ovarian tumours.