Clinical behavior of borderline ovarian tumors: a study of 150 cases

Predicting Lymph Node Involvement in Borderline Ovarian Tumors with a Quantitative Model and Nomogram: A Retrospective Cohort Study

Purpose

This study aimed to establish a predictive model for lymph node involvement (LNI) in patients with borderline ovarian tumor (BOT) using clinicopathological factors.

Patients and Methods

We collected clinical data from consecutive patients who underwent lymphadenectomy for BOT between 2001 and 2018 and analyzed their clinicopathological features. Multivariate logistic regression was used to identify all independent risk factors associated with LNI; these were then incorporated into the prediction model.

Results

In total, we included 248 patients with BOT who were undergoing lymphadenectomy. These were divided into a training cohort (n=174) and a validation cohort (n=74). When considering histopathological data, 16 and 5 patients were identified to have LNI in the training and validation cohorts, respectively. Overall, 13.5% (21/156) patients with serous BOT had LNI while 0% (0/92) patients with non-serous BOT had LNI. We identified several predictors of LNI: the largest tumor being ≥ 12.2cm in diameter, the presence of lesions on the ovarian surface, and the presence of pelvic or abdominal lesions. We created a prediction model and nomogram that incorporated these three risk factors for serous BOT. The model achieved good discriminatory abilities of 0.951 and 0.848 when predicting LNI in the training and validation cohorts, respectively. The LNI-predicting nomogram had an area under curve (AUC) of 0.951 and generated well-fitted calibration curves.

Conclusion

Non-serous BOT may not require lymphadenectomy as part of surgical staging. The individual risk of LNI in patients with serous BOT can be accurately estimated using our prediction model and nomogram. The use of LNI criteria provides a practical way to support the clinician in making an optimal decision relating to surgical scope for patients with BOT.

Unilateral cystectomy and serous histology are associated with relapse in borderline ovarian tumor patients with fertility-sparing surgery: a systematic review and meta-analysis

PURPOSE

Surgical procedures, histological subtypes, and surgical approaches are involved in the recurrence of borderline ovarian tumors (BOTs), but whether those three factors affect relapse remains controversial. This study aimed to explore the effects of surgical procedures, histological subtypes, and surgical approaches on the relapse and pregnancy rates of BOT after fertility-preserving surgery (FPS) according to the patients' characteristics.

METHODS

A systematic search of PubMed, Embase, and the Cochrane library was conducted from their inception to November 2018. Studies that investigated the impact of surgical procedures, histological subtypes, and surgical approaches on the relapse and pregnancy rates in patients with BOT after FPS were eligible. The pooled odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.

RESULTS

Thirty-five studies involving a total of 2921 patients with BOT after FPS were included. The pooled ORs indicated that the risk of relapse was significantly increased in patients who underwent unilateral cystectomy or with serous BOT. There was no significant difference between laparoscopy and laparotomy on the risk of relapse. Surgical procedures, histological subtypes, and surgical approaches did not influence pregnancy rates.

CONCLUSIONS

Patients who underwent unilateral cystectomy or with serous BOT presented an excess risk of relapse after FPS, but the surgical approach did not affect the risk of relapse. The pregnancy rate is not affected by surgical procedures, histological subtypes, and surgical approaches.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Therapeutic Management of Early Stages]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning early stage borderline ovarian tumors (BOT).

METHODS

Bibliographical search in French and English languages by consultation of Pubmed, Cochrane, Embase, and international databases.

RESULTS

Considering management of early stage BOT, if surgery is possible without a risk of tumor rupture, the laparoscopic approach is recommended compared to laparotomy (Grade C). In BOT, it is recommended to take all the measures to avoid tumor rupture, including the peroperative decision of laparoconversion (Grade C). In BOT, extraction of the surgical specimen using an endoscopic bag is recommended (Grade C). In case of early stage, uni or bilateral BOT, suspected in preoperative imaging in a postmenopausal patient, bilateral adnexectomy is recommended (Grade B). In cases of bilateral BOT and desire of fertility preservation, a bilateral cystectomy is recommended (Grade B). In case of mucinous BOT and desire of fertility preservation, it is recommended to perform a unilateral adnexectomy (Grade C). In case of endometrioid BOT and desire of fertility preservation, it is not possible to establish a recommendation of treatment choice between cystectomy and unilateral adnexectomy. In case of mucinous BOT at definitive histological analysis in a woman of childbearing age who had an initial cystectomy, surgical revision for unilateral adnexectomy is recommended (Grade C). In the case of serous BOT with definitive histological analysis in a woman of childbearing age who has had an initial cystectomy, it is not recommended to repeat surgery for adnexectomy in the absence of residual suspicious lesion during initial surgery and/or on postoperative imaging (referent ultrasound or pelvic MRI) (Grade C). An omentectomy is recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous analysis or suspected on preoperative radiological elements (Grade B). There is no data in the literature to recommend the type of omentectomy to be performed. If restaging surgery is decided for a presumed early stage BOT, an omentectomy is recommended (Grade B). Multiple peritoneal biopsies are recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous or suspected on preoperative radiological elements (Grade C). In case of restaging surgery for a presumed early stage BOT, exploration of the abdominal cavity should be complete and peritoneal biopsies should be performed on suspicious areas or systematically (Grade C). A primary peritoneal cytology is recommended in order to achieve complete initial surgical staging when BOT is suspected on preoperative radiological elements (Grade C). In case of restaging surgery for presumed early stage BOT, a first peritoneal cytology is recommended (Grade C). For early serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (Grade C). For early stage endometrioid BOT, and in the absence of a desire to maintain fertility, hysterectomy is recommended for initial surgery or if restaging surgery is indicated (Grade C). For endometrioid-type early stage BOT, if there is a desire for fertility preservation, the uterus may be retained subject to good evaluation of the endometrium by imaging and endometrial sampling (Grade C). In case of surgery (initial or restaging if indicated) for early stage BOT, it is recommended to evaluate the macroscopic appearance of the appendix (Grade B). In case of surgery (initial or restaging if indicated) for early stage BOT, appendectomy is recommended only in case of macroscopically pathological appearance of the appendix (Grade C). Pelvic and lumbar aortic lymphadenectomy is not recommended for initial surgery or restaging surgery for early stage BOT regardless of histologic type (Grade C). In case of BOT diagnosed on definitive histology, the indication of restaging surgery should be discussed in Multidisciplinary Collaborative Meeting. For presumed early stage BOT, it is recommended to use the laparoscopic approach to perform restaging surgery (Grade C). Restaging surgery is recommended for serous BOT with micropapillary appearance and unsatisfactory abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended in case of mucinous BOT if only a cystectomy has been performed or the appendix has not been visualized, then a unilateral adnexectomy will be performed (Grade C). If a restaging surgery is decided in the management of a presumed early stage BOT, the actions to be carried out are as follows: a peritoneal cytology (Grade C), an omentectomy (there is no data in the literature recommending the type of omentectomy to be performed) (Grade B), a complete exploration of the abdominal cavity with peritoneal biopsies on suspect areas or systematically (Grade C), visualization of the appendix± the appendectomy in case of pathological macroscopic appearance (Grade C), unilateral adnexectomy in case of mucinous TFO (Grade C).

Prognostic Factors for Recurrence After Fertility-Preserving Surgery in Patients With Borderline Ovarian Tumors: A Systematic Review and Meta-analysis of Observational Studies

OBJECTIVE

The aim of this study was to find the unfavorable prognostic factors for recurrence after fertility-preserving surgery (FPS) in patients with borderline ovarian tumors (BOTs).

METHODS

To perform a meta-analysis to compare the recurrence rates of BOT patients after FPS according to different prognostic factors, we searched PubMed, EMBASE, and Cochrane for observational studies. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with a fixed-effects model.

RESULTS

We analyzed 32 studies that included 2691 BOT patients who underwent FPS, 383 patients of whom had a relapse in the follow-up. In meta-analysis, risks associated with recurrence in patients with unilateral cystectomy (OR, 2.49; 95% CI, 1.86-3.33) or serous borderline ovarian tumors (OR, 3.15; 95% CI, 1.97-5.02) were significantly increased, and there was no significantly increased OR for patients with laparoscopy compared with those with laparotomy (OR, 0.96; 95% CI, 0.57-1.60).

CONCLUSIONS

Unilateral cystectomy (19.4%) and serous BOTs (19.2%) are significantly associated with higher recurrence rates, and no negative impact of laparoscopy on recurrence can be demonstrated when compared with laparotomy in the meta-analysis.

The feasibility of fertility-sparing surgery in treating advanced-stage borderline ovarian tumors: A meta-analysis

OBJECTIVE

To evaluate the feasibility of fertility-sparing surgery in treating advanced-stage borderline ovarian tumors (BOTs).

MATERIALS AND METHODS

The databases of PubMed, Cochrane Library, EMbase, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Weipu (Chinese), and Wanfang (Chinese) were searched using the keywords "advanced-stage borderline ovarian tumors", "fertility-sparing surgery", "conservative surgery", and "borderline ovarian tumor" to collect the clinical controlled trails (CCTs) regarding fertility-sparing surgery for the treatment of advanced-stage BOT. The references of those CCTs were also searched manually. Data extraction and quality assessment were done using Review manager Version 5.1 and R software Version 2.11.1.

RESULTS

Four studies involving 74 patients were included. The results of meta-analysis showed that: (1) compared with radical surgery, the recurrence of the fertility-sparing surgery during the follow time is higher with significant difference [odds ratio (OR)=3.87, 95% confidence interval (CI) (1.20,12.44), p=0.02]; (2) the difference of survival rate between the two groups was not significant [5-year survival: OR=0.85, 95%CI (0.03, 23.82), p=0.92; 7-year survival: OR=0.80, 95%CI (0.08, 8.41), p=0.85]; and (3) concerning fertility results in fertility-sparing surgery, 18 patients tried to become pregnant, 15 pregnancies were achieved in the 11 patients, 11 full-term deliveries.

CONCLUSION

The rate of ovarian recurrence in patients who underwent conservative treatment was higher than in patients with radical treatment, but it did not affect patient survival; fertility-sparing surgery could be induced to preserve the fertility potential of young patients.

Staging for low malignant potential ovarian tumors: a global perspective

OBJECTIVE

We describe current evidence for staging low malignant potential ovarian tumors and their conformity to current consensus guidelines and practice from an international perspective.

DATA SOURCES

A search of MEDLINE, EMBASE, and SCOPUS databases was conducted for articles published between January 1990 and April 2015.

STUDY ELIGIBILITY CRITERIA

Studies on low malignant potential ovarian tumors that evaluated the prognostic value of disease stage, staging vs no staging, complete vs incomplete staging, or discrete components of staging were eligible. Studies that described only crude survival rates were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Eligible studies were categorized according to their outcome (disease stage, staging procedure, or discrete staging elements). Data were abstracted using a standard form. Inconsistencies on data abstraction were resolved by consensus among the authors. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1116 studies, 702 were excluded for irrelevance and 364 for not meeting inclusion criteria. Nine studies were excluded for describing crude survival rates without a comparative conclusion. We found that studies supporting the value of defining disease stage or staging procedures (mostly conducted in northern Europe) included more patients than studies that did not find disease stage or staging useful (predominantly from North America, 4072 vs 3951). Disease stage correlated with survival in 13 of 25 studies, whereas none of the studies that evaluated the value of staging found it beneficial (9 studies, 1979 patients). Studies that evaluated isolated components of staging found no benefit to these procedures. Regional guidelines and consensus reviews drew conclusions based on a limited number of studies that generally originated from the same region.

CONCLUSIONS

Although the correlation of stage with survival was mixed, performing staging procedures for low malignant potential ovarian tumors is not supported by the best available evidence. Guidelines in support of staging based their recommendations on a few regional studies and conflict with better-quality data that do not support staging procedures. An international consensus statement is needed to standardize the surgical management of low malignant potential ovarian tumors.

Conservative surgery in ovarian borderline tumours: a meta-analysis with emphasis on recurrence risk

BACKGROUND

Recent reports have stirred the debate regarding the optimal conservative treatment for both serous and mucinous borderline ovarian tumour (BOT). The aim of this study is to examine the optimal oncological approach of conservative surgery in unilateral BOT (cystectomy (C) versus unilateral salpingo-oophorectomy (USO)) and in bilateral BOT (bilateral C (BC) versus USO+contralateral C (CC)), as well as fertility outcomes.

MATERIALS AND METHODS

The PubMed database and Cochrane Library were searched using the search terms (((Borderline) OR (low malignant potential)) AND (ovarian)) AND ((tumour) OR (cancer)) AND (((fertility sparing) OR (conservative)) AND surgery).

RESULTS

We analysed 39 studies that included 5105 women (2624 patients with serous-, 2120 patients with mucinous- and the remaining with other types of BOT), 2752 of which underwent conservative surgery (817 underwent C, 89 BC, 1686 USO and 118 USO+CC). Eight studies included only stage I patients, in 14 studies more than 90% of patients were stage I and five studies included only late-stage patients. Seven studies included only patients with serous borderline ovarian tumour (sBOT) and two only mucinous borderline ovarian tumour (mBOT). A total of 296 patients with non-invasive-, 76 patients with invasive- and 50 patients with unspecified implants were pooled. Of the patients undergoing C, BC, USO and USO+CC the pooled recurrence estimates were respectively 25.3%, 25.6%, 12.5% and 26.1%. In meta-analysis, USO was significantly favored over C with an OR for recurrence reduction=2200, 95% CI=0.793-2.841 and p<0.0001. The pooled recurrence estimate as invasive ovarian cancer was 15.4% and the pooled 95% CI was 0.120-0.196. The cumulative pregnancy rate was 55.7% with 45.4% for USO and 40.3.0% for C.

CONCLUSION

Cystectomy in unilateral serous BOT is significantly associated with a higher recurrence rate, albeit no impact on survival can be demonstrated. Whether this is related to the duration of follow-up, remains to be proven. Nonetheless, recent data seem to suggest that USO is advisable in the case of mucinous BOT. On the contrary, a more conservative approach (BC) should be definitively favored in bilateral BOT, which is almost always serous, because no significant difference is seen in terms of recurrence rate when compared to USO+CC.

Limited efficacy of platinum-based adjuvant treatment on the outcome of borderline ovarian tumors

Adjuvant treatment of borderline ovarian tumors (BOT) remains highly debatable. This article evaluates the benefits of platinum-based adjuvant treatment in patients with BOT. The PubMed and Cochrane Library databases were systematically searched for articles using the terms ((Borderline) OR (low malignant potential) AND (ovarian)) AND ((tumor) OR (cancer)) AND ((follow-up) OR (survival) OR (treatment) OR (chemotherapy) OR (adjuvant treatment)). We identified 31 articles including 4965 patients. Together, 592 patients presented non-invasive-, 244 invasive- and 77 unspecified implants. Central pathological examination was performed in 23 studies. Nine studies included more than 90% stage I patients, while 11 included only advanced stage patients. Nineteen studies reported patients undergoing complete cytoreduction, ten reported response rates and eight compared survival outcomes. All studies provided information regarding either mortality or recurrence rates. A meta-analysis of the 13 studies providing separate mortality data for both treatment groups, including 2206 women, favored surgical treatment only (OR=7.44; 95% CI=3.39-16.32; p<0.0005) albeit with moderate heterogeneity of the studies (I(2)=35.0%) but no asymmetry (Egger's test p=0.44). Regarding survival data, 4 studies reported no difference between groups. In the adjuvant setting, 4 reported worse outcome and 1 reported a nonsignificant trend to worse outcome. At present, there is no evidence to support the use of adjuvant treatment in patients with BOT.

Histologic distribution of borderline ovarian tumors worldwide: a systematic review

Objective

The histologic types of borderline ovarian tumors (BOTs) exhibit striking differences in clinical behavior and prognosis. Yet, there is no information available on the histologic distribution of BOTs according to geographic region. The purpose of this study was to systematically review this issue worldwide.

Methods

A comprehensive search of the literature was conducted using electronic databases. Studies were eligible if BOTs were investigated and the histologic distribution of the data was shown. The studies were grouped by geographic region and totaled by country.

Results

Of 487 potentially relevant studies, 51 met our inclusion criteria, as follows: 8 studies from North America (2 countries); 26 studies from Europe (14 countries); 7 studies from the Middle East (3 countries); and 10 studies from East Asia (5 countries). The histologic distribution of BOTs was considerably different in different parts of the world, but follows specific patterns. In general, serous-type BOTs were the predominantly identified histology in North America, the Middle East, and Europe, while mucinous-type BOTs predominated in East Asia.

Conclusion

Significant geographic variation is evident among BOT histology in different parts of the world. More research is needed to understand this phenomenon.

Borderline ovarian tumors: a study of 100 cases from a Tertiary Care Hospital

AIM OF THE STUDY

The purpose of the study was to evaluate patients with borderline ovarian tumors.

MATERIAL AND METHODS

Clinical features, treatment and survival status of 100 patients with borderline ovarian tumors were retrospectively evaluated between 1998 and 2007.

RESULTS

Patients' mean age was 37.75 years (range: 15-72); 22 of them were postmenopausal. Histopathological diagnoses were serous, mucinous, endometrioid and clear cell in 54%, 41%, 2% and 3% of the patients, respectively; 70 patients had stage IA disease, 8 were at stage IB, 16 at stage IC, 2 at stage IIIA, 3 at stage IIIB and 1 at stage IIIC. Restaging laparotomies were performed on 19 patients; fertility-sparing surgery was performed on 52 patients; 2 patients received chemotherapy because of advanced-stage disease. All patients are currently alive. The 5-year disease-free survival rate for 71 cases was 100%.

CONCLUSIONS

Borderline ovarian tumors have excellent prognoses, and fertility-conserving surgery can be performed in young patients with early-stage disease.

Prognostic value of lymph node involvement in ovarian serous borderline tumors

OBJECTIVE

This study was conducted to evaluate the prognosis value of lymph node involvement (LN positive) lymph node involvement for borderline ovarian tumor (BOT).

STUDY DESIGN

This was a retrospective study on 49 patients treated at our institution for advanced-stage serous BOT (International Federation of Gynecology and Obstetrics [FIGO] III or IV). Pathological characteristics and survival were compared according to the lymph node status. The same analysis was performed on 1503 patients of the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

In our institution, 14 patients were LN positive. Eight patients have been upstaged after lymph node dissection. No patient has died during follow-up (median 53 months). LN positivity was not associated with recurrence. In the SEER registry, 93 patients (6.2%) had LN positivity. These patients were younger and with more advanced local extension. Survival curves were similar after adjustment for FIGO stage.

CONCLUSION

Lymph node involvement does not appear as a prognosis factor for advanced-stage BOT.

Preservation of ovarian function, reproductive ability and emotional attitudes in patients with malignant ovarian tumors

OBJECTIVES

Although cancer is predominantly a disease of aging, an increasing number of women survive malignancies before or during their reproductive years, which may interfere with their fertility potential. Although a variety of studies have tried to document the impact of conservative treatment aimed at preserving ovarian function and reproductive ability, little information has been available regarding survivors' attitudes, emotions, and choices to have children. The aim of this study is to evaluate the reproductive history, experiences, attitudes, and emotions with regard to having children in conservatively treated patients with Stage I epithelial ovarian cancer, any stage LMP tumors, malignant ovarian germ cell tumors (MOGCTs) and Stage I sex cord-stromal tumors (SCSTs).

STUDY DESIGN

Between 1986 and 2000, a total of 75 patients with primary malignant ovarian tumors underwent conservative treatment. Out of 75 patients in the study, 14 women (19%) presented Stage I epithelial ovarian cancer, 23 (31%) LMP tumors, 33 (43%) MOGCTs, and five (7%) SCSTs. Information was obtained from medical records and from a questionnaire mailed to all patients who were at least 15 years old at the time of the diagnosis (68 subjects). Median time of follow-up was 102 months (35-192 months). There were four (5.2%) clinical recurrences within 35 months. Only 20 patients (49%) had tried to conceive after the completion of their treatment; of these, 15 women (75%) succeeded and delivered 19 healthy children. Seventy percent (32/41) of the respondents claimed that their disease did not have any impact on their desire to have children. Whereas 51% (21/41) fear that their ovarian disease could have damaged their reproductive potential, 76% (31/41) are not concerned about the effects of the treatment they received on offspring. The impact of the disease on the patients' attitudes toward life was reported as positive.

CONCLUSION

The results from our study, in agreement with the data from the literature, confirm that management of Stage I (grade 1, grade 2) epithelial ovarian cancer, any stage LMP tumors, MOGCTs and Stage I SCSTs with fertility-sparing surgery is a safe, practicable treatment option. Though preliminary, this survey provides insight into the attitudes and experiences of young women ovarian cancer survivors regarding fertility.

Expression profiling of mucinous tumors of the ovary identifies genes of clinicopathologic importance

PURPOSE

To elucidate the molecular mechanisms contributing to the unique clinicopathologic characteristics of mucinous ovarian carcinoma, global gene expression profiling of mucinous ovarian tumors was carried out.

EXPERIMENTAL DESIGN

Gene expression profiling was completed for 25 microdissected mucinous tumors [6 cystadenomas, 10 low malignant potential (LMP) tumors, and 9 adenocarcinomas] using Affymetrix U133 Plus 2.0 oligonucleotide microarrays. Hierarchical clustering and binary tree prediction analysis were used to determine the relationships among mucinous specimens and a series of previously profiled microdissected serous tumors and normal ovarian surface epithelium. PathwayAssist software was used to identify putative signaling pathways involved in the development of mucinous LMP tumors and adenocarcinomas.

RESULTS

Comparison of the gene profiles between mucinous tumors and normal ovarian epithelial cells identified 1,599, 2,916, and 1,765 differentially expressed in genes in the cystadenomas, LMP tumors, and adenocarcinomas, respectively. Hierarchical clustering showed that mucinous and serous LMP tumors are distinct. In addition, there was a close association of mucinous LMP tumors and adenocarcinomas with serous adenocarcinomas. Binary tree prediction revealed increased heterogeneity among mucinous tumors compared with their serous counterparts. Furthermore, the cystadenomas coexpressed a subset of genes that were differentially regulated in LMP and adenocarcinoma specimens compared with normal ovarian surface epithelium. PathwayAssist highlighted pathways with expression of genes involved in drug resistance in both LMP and adenocarcinoma samples. In addition, genes involved in cytoskeletal regulation were specifically up-regulated in the mucinous adenocarcinomas.

CONCLUSIONS

These data provide a useful basis for understanding the molecular events leading to the development and progression of mucinous ovarian cancer.

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.

Innovations in fertility preservation for patients with gynecologic cancers

OBJECTIVE

To review options for fertility preservation in women with gynecologic cancers.

DESIGN

Literature review.

RESULT(S)

We discuss the data regarding cancer treatment and fertility outcomes and current controversies for women with gynecologic cancers.

CONCLUSION(S)

Gynecologic cancers represent 12%-15% of cancers affecting women, and 21% of these are diagnosed in women of reproductive age. Current advances in our understanding of these diseases, along with improved multimodality treatment, allow for consideration of fertility options. For some women with gynecologic cancers, fertility-sparing treatment might be appropriate.

Recurrence and prognostic factors in borderline ovarian tumors

OBJECTIVE

The purpose of this study was to evaluate the survival estimates and clinico-pathological variables in patients treated for borderline ovarian tumors.

METHODS

The patients treated for borderline ovarian tumors were evaluated retrospectively. Data were obtained from hospital records and special gynecologic oncology forms.

RESULTS

Overall, 100 patients were evaluated. The mean age at the time of diagnosis was 41.7 (range, 19-84). Seventy one (71%) patients underwent surgical staging including 49 (49%) of them with comprehensive surgical staging, 22 (22%) with fertility-sparing surgery. Only 30 (30%) patients were unstaged. The histopathological diagnosis was serous, mucinous, and the other types of borderline ovarian tumor in 54 (54%), 39 (39%), and 7 (7%) of the patients, respectively. Seventy patients had stage IA (70%), 10 had stage IB (10%), 9 had stage IC (9%), 3 had stage IIIA (3%), and 8 had stage IIIC (8%) disease. The stage of only four patients in which disease confined to ovary was upgraded as stage IIIC following surgical staging procedure. The recurrence rate was found 3% (3). The overall disease-free survival rates of BOT in surgically staged (comprehensive, fertility-sparing surgery) and unstaged patients were 97.92%, 95.00%, and 96.30%, respectively. But, the overall tumor-free survival was significantly found to be decreased in cases of young age (<30 years old), performing fertility-sparing surgery and presence of micropapillary architecture or peritoneal implants. Overall survival rates of BOT in surgically staged (comprehensive, fertility-sparing surgery) and unstaged patients were 97.9%, and 100% and 100%, respectively.

CONCLUSION

Low malignant potential ovarian tumors have excellent survival, and the patients can be treated safely by conservative surgery.

Fertility preservation options for female patients with malignancies

PURPOSE OF REVIEW

Preservation of fertility in female patients diagnosed with cancer has recently been an area of intensive investigation. This review summarizes available options and discusses recently published data concerning experimental methods. Specific strategies for fertility preservation in women with gynecologic malignancies are also presented.

RECENT FINDINGS

Success with ovarian stimulation protocols using tamoxifen or aromatase inhibitors has recently been reported for women with breast cancer who attempt embryo cryopreservation prior to chemotherapy. The first embryo transfer using oocytes retrieved from cryopreserved ovarian tissue implanted at a heterotopic location, the first pregnancy following orthotopic transplantation of cryopreserved ovarian tissue, and increasing success with oocyte cryopreservation were also reported.

SUMMARY

Fertility preservation in female patients with cancer has become an important health issue due to increasing survival rates and delayed childbearing especially in Western countries. Radical vaginal trachelectomy for cervical cancer, conservative surgery for ovarian tumors, and progestin treatment in endometrial cancers may be considered at early stages in order to preserve fertility. Embryo cryopreservation is an established technique that is available for fertility preservation, providing a delay in the initiation of chemotherapy or radiotherapy is acceptable, and a partner or donor sperm is available. Additional techniques that could be offered after counseling the patient about their experimental nature include oocyte cryopreservation, ovarian cryopreservation, and gonadotropin-releasing hormone agonist co-treatment with chemotherapy. Improvement of these techniques as well as better characterization of their success rates and risks await further investigation.

Borderline epithelial tumors of the ovary

The concept and terminology of borderline epithelial tumors of the ovary have been controversial for over a century, in spite of the acceptance of a borderline category in almost all current classifications of ovarian tumors. Typically, borderline tumors are noninvasive neoplasms that have nuclear abnormalities and mitotic activity intermediate between benign and malignant tumors of similar cell type. Borderline tumors of all surface epithelial cell types have been studied. The most common and best understood are serous borderline tumors and mucinous borderline tumors of intestinal type, which are the subject of this review. Some of the most challenging issues for serous tumors include: the criteria and clinical behavior of stromal microinvasion; the high prevalence of synchronous extraovarian disease; the classification and histopathologic features of associated peritoneal tumor implants, especially invasive implants; and, the prognostic significance of micropapillary tumors. The mucinous borderline tumors of intestinal type have a different set of considerations, including: their frequently heterogeneous composition with coexisting benign, borderline and malignant elements; the classification and significance of accompanying noninvasive carcinoma; the recognition of stromal invasion, including microinvasion and expansile invasion; and, the historically misunderstood relationship to pseudomyxoma peritonei. All of these issues are discussed in this presentation, as are the important gross and microscopic features of serous and mucinous borderline tumors and pertinent information on their treatment and prognosis.

Serous borderline (low malignant potential, atypical proliferative) ovarian tumors: Workshop perspectives

Although the category of serous borderline ovarian tumor (S-BOT) was established more than 30 years ago, the nomenclature and prognostic significance of various histological features of these neoplasms continues to engender controversy. The Borderline Ovarian Tumor Workshop was held in Bethesda, MD, in August 2003 in an attempt to examine the existing data, establish areas of agreement, and identify areas needing further investigation. This report addresses 6 areas of controversy regarding S-BOT: (1) tumors with and without a micropapillary architecture (typical vs micropapillary type), (2) peritoneal implants, (3) stromal microinvasion, (4) ovarian surface involvement, (5) lymph node involvement, and (6) recurrent tumors. Each of these issues is addressed by summarizing the data in the literature on which the discussions were based, areas of agreement that emerged, divergent opinions and the reasoning behind them, and the conclusions of the participants with recommended nomenclature.

Impact of surgical staging in patients with macroscopic “stage I” ovarian borderline tumours: analysis of a continuous series of 101 cases

The aim of this study was to assess the patient's clinical outcome following complete or incomplete surgical staging in cases treated for an early stage low-malignant-potential ovarian tumour (LMPOT). One-hundred and one patients treated between 1965 and 1998 for a early stage I LMPOT were reviewed according to whether the initial surgical staging was complete (Group 1/defined by peritoneal cytology + peritoneal biopsies + infracolic omentectomy) or incomplete (Group 2/omission of at least one of the peritoneal staging procedures described above). Complete and incomplete surgical stagings were carried out in 48 (48%) and 53 (52%) patients, respectively. Four (8%) LMPOT recurrences were observed in Group 2, all following conservative management, but there were no recurrences in Group 1. No relapses with invasive carcinoma or peritoneal disease and no tumour-related deaths were observed. The absence of complete peritoneal staging in patients with an apparent "stage I" LMPOT increased the recurrence rate. However, this surgical restaging (in cases of incomplete initial surgery) does not modify the survival of patients with apparent "stage I" LMPOT misdiagnosed during the initial surgery. This procedure could probably be omitted: (1) if the peritoneum is clearly reported as "normal" during the initial surgery; (2) in the absence of a micropapillary pattern; and (3) if the patient agrees to be carefully followed-up.

Allelic loss at 19q12 and Xq11-12 predict an adverse clinical outcome in patients with mucinous ovarian tumours of low malignant potential

Ovarian tumours of low malignant potential (LMP) are intermediate between adenomas and ovarian carcinomas. These tumours are often associated with a significantly better prognosis than ovarian carcinomas. However, a subset of these tumours can progress and become lethal. In order to seek sensitive diagnostic tools for monitoring patients after surgical operation, we performed a genome-wide scan for loss of heterozygosity (LOH) in 41 mucinous LMPs using 91 polymorphic microsatellite markers at an average interval of 50 cM across all of the human chromosomes and 25 LOH markers reportedly associated with ovarian carcinoma. In addition, we assessed whether clinicopathological parameters, microvessel density, Ki-67 labeling index, apoptotic index or p53 overexpression would be useful for predicting the postoperative outcome of LMP patients. Of the 116 markers examined, 19q12 and Xq11-12 showed significant correlation between postoperative progression-free survival time and LOH status (P<0.05). Patients with a high Ki-67 labeling index had a significantly poorer progression-free survival time than those with lower levels (P=0.042). Other clinicopathological factors and immunohistochemical analysis had no correlation with progression-free survival time in this series of patients. When the combination of LOH at 19q12 and/or Xq11-12 was assessed using Cox's regression analysis, patients with tumours that showed LOH at these positions were at greatest risk of progression (P=0.0073). These findings suggest that the identification of LOH at 19q12 and/or Xq11-12 in former mucinous LMP sites should alert the clinician to the presence of a potentially aggressive lesion in the coelomic epithelium, even if a distinction between second primary tumours or recurrence could not be determined.

Lymph node disorders and prognostic value of nodal involvement in patients treated for a borderline ovarian tumor: an analysis of a series of 42 lymphadenectomies

BACKGROUND

The aim of this study is to evaluate the rate and the clinical outcomes of lymph node involvement in patients treated for borderline ovarian tumor (BOT).

STUDY DESIGN

Forty-two patients were treated for BOT with a procedure that included lymphadenectomy. Twenty-four patients underwent a pelvic lymphadenectomy, 6 a paraaortic lymphadenectomy, and 12 both procedures. Thirty-two patients underwent systematic lymphadenectomy, five because of associated cancer (uterine cervix or corpus) and five because of bulky nodes discovered during the surgical procedure.

RESULTS

An endosalpingiosis was present in 11 (26%) patients who underwent lymphadenectomy. Eight patients had nodal involvement related to the BOT. All patients with nodal involvement had serous BOT with peritoneal implants. None of the patients with a mucinous tumor had nodal involvement. None of the patients with early-stage disease (without peritoneal disease) had nodal involvement discovered after routine lymphadenectomy. None of the patients with nodal involvement died of borderline tumor. One patient died of a complication of adjuvant therapy (leukemia after chemotherapy).

CONCLUSIONS

The prognosis of patients with borderline tumors of the ovary and nodal involvement is excellent. Routine lymphadenectomy should not be performed in patients with early-stage disease. This procedure should be carried out in patients with serous tumor and enlarged lymph nodes.

Micropapillary serous ovarian carcinoma: surgical management and clinical outcome

OBJECTIVES

The objectives of this study were to characterize the prognostic features of micropapillary serous ovarian carcinoma (MPSC), examine the clinical impact of surgical staging, and define the role of cytoreductive surgery for patients with advanced disease.

METHODS

Fifty-one patients with MPSC were identified from hospital and tumor registry databases. Demographic, operative, pathologic, and follow-up data were abstracted retrospectively. Survival curves were generated using the Kaplan-Meier method, and statistical comparisons were performed using the log rank test, logistic regression analysis, and the Cox proportional hazards regression model.

RESULTS

The median age at diagnosis was 45 years, and follow-up extended to a median of 43.0 months. Stage I/II disease was present in 25.5% of patients and no disease-related deaths were observed in this group. Stage III disease was discovered in 29.4% of patients with tumor clinically confined to the ovaries. Stage III/IV disease (74.5% of cases) was associated with median progression-free and overall survival times of 32.8 and 114.2 months, respectively. Menopausal status and the anatomic extent of disease were significantly associated with survival outcome. However, the strongest independent predictor of survival for patients with advanced disease was the amount of residual tumor. Median overall survival for patients with optimal cytoreduction (residual disease </=1 cm) was 115.4 months compared to 43.1 months for those with >1 cm residual tumor (P < 0.0002).

CONCLUSIONS

MPSC carries a significant risk of extraovarian spread; however, adequately sampled Stage I/II disease is associated with a favorable prognosis. Optimal cytoreduction is associated with improved survival and should be the primary therapeutic objective for patients with advanced-stage MPSC.

Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors

OBJECTIVE

To assess clinical outcome and fertility in patients treated conservatively for a low malignant potential (LMP) ovarian tumor.

DESIGN

Retrospective study.

SETTING

Gynecologic oncology department of a cancer care center in France.

PATIENT(S)

Forty-four patients treated with conservative management for a stage I (n = 32) or stage II or III (n = 12) LMP tumor.

INTERVENTION(S)

Thirty-three patients had unilateral adnexectomy and 11 had cystectomy. Cystectomy was bilateral in 1 patient and was done in conjunction with contralateral adnexectomy in 5 patients.

MAIN OUTCOME MEASURE(S)

Tumor recurrence and pregnancy rates.

RESULT(S)

Tumor recurrence rates after radical surgery (hysterectomy with bilateral salpingo-oophorectomy), adnexectomy, and cystectomy were 5.7%, 15.1%, and 36.3%, respectively (P<.01). Among patients who initially received conservative treatment, tumors did not recur in the form of invasive carcinoma. Five patients who had recurrence underwent repeated conservative management; these patients are alive and free of disease. Seventeen pregnancies (of which 15 were spontaneous) occurred in 14 patients; 13 pregnancies occurred in patients with stage I disease and 4 occurred in patients with stage III disease.

CONCLUSION(S)

Conservative management of LMP tumor significantly increases the risk of recurrence but does not affect overall survival. Such management offers even patients with advanced disease the chance to have spontaneous pregnancy. Conservative management might be proposed in young patients who wish to preserve their fertility, but careful follow-up will be required to detect tumor recurrence.