Management of stage-I borderline ovarian tumors

Management of Borderline ovarian tumors (BOT): results of a retrospective, single center study in Switzerland

BACKGROUND

Borderline tumors are malignant epithelial ovarian tumors with a very low incidence. Thus experience in diagnostics and treatment is still rare. The aim of this study was to present and analyze data of women with borderline ovarian tumor (BOT) regarding clinical features, histological characteristics, diagnostics and treatment management.

METHODS

In this single center retrospective study women with BOT treated at the Departement of Gynecology and Obstetrics at the Kantonsspital Luzern between 2011 and 2018 were analyzed according to their clinical and histological reports.

RESULTS

A total of 42 women were enrolled. The median age was 58.5 with a range from 26 to 85, of which 31 (73.8%) were postmenopausal. Regarding the histological subtypes, 23 women (54.8%) had serous and 15 (35.7%) had mucinous BOT. Seromucinous histology was found in 3 patients (7.1%) and endometrioid in 1 woman (2.4%), respectively. All women underwent surgery. In a total of 39 women (92.9%) a complete surgical staging for BOT was performed. In 29 women (69.0%) staging was performed by laparoscopy, 13 (31.0%) underwent laparotomy. The mean follow up was 52 months (range = 16.3-101.4 months). During this period two patients, initially diagnosed in FIGO stage 1, recurred after 21.7 and 44 months, respectively, the second woman died after 53 months because of the BOT.

CONCLUSION

In the present study women were treated according to the international therapy recommendations and the rate of recurrence was very low. The most common risk factors for relapse are known to be FIGO stage, incomplete staging and peritoneal implants but were not present in our group. Thus further studies are necessary to investigate additional recurrence risks.

Endometrioid Borderline Ovarian Tumor: Clinical Characteristics, Prognosis, and Managements

BACKGROUND

Endometrioid borderline ovarian tumor (EBOT) is a rare subtype of borderline ovarian malignancies. This study was designed to determine the prognosis of a series of EBOT.

METHODS

This is a retrospective review of patients with EBOT treated in or referred to our institutions and a centralized, histological review by a reference pathologist. Data on the clinical characteristics, management (surgical and medical), and oncologic outcomes of patients were required for inclusion.

RESULTS

Forty-eight patients were identified. Median age was 52 years (range 14-89). Fourteen patients underwent a conservative surgery and 32 a bilateral salpingo-oophorectomy (unknown in 2 cases). Two patients had bilateral tumors. Forty-three patients had stage I disease, and five patients had stage II disease (10%). Stromal microinvasion and intraepithelial carcinoma was observed in 6 (12%) and 13 (27%) patients respectively. Endometriosis was histologically associated in 12 patients (25%). Synchronous endometrial disease was found in 7 (24%) of 29 patients with endometrial histological evaluation. The median follow-up was 72 months (range 6-146). Two patients developed a recurrence after cystectomy in form of borderline disease (5%). No death related to EBOT occurred.

CONCLUSIONS

Peritoneal restaging surgery should be performed if not realized initially, because 5% of EBOTS are diagnosed at stage II-III. Fertility-sparing surgery seems a safe option in selected patients. Because synchronous endometrial diseases, including endometrial carcinoma are frequent, systematic hysterectomy (or endometrial sampling in case of fertility-sparing surgery) is mandatory. Prognosis is generally excellent. Recurrence is a rare event (6%), but it can occur in the form of invasive disease.

Clear Cell Borderline Ovarian Tumor: Clinical Characteristics, Prognosis, and Management

BACKGROUND

Clear cell borderline ovarian tumor (CCBOT) is one of the rarest subtypes of borderline ovarian malignancies. The aim of this study was to determine the prognosis of a series of CCBOT.

PATIENTS AND METHODS

A retrospective review of patients with CCBOT treated or referred to our institutions. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion.

RESULTS

Nineteen patients were identified. Median age was 62 (range 36-83) years. Four patients underwent a conservative surgery and 14 a bilateral salpingo-oophorectomy +/- hysterectomy (unknown in 1 case). One patient had bilateral tumor, and all cases were stage-I disease. All CCBOTs showed an adenofibromatous pattern. Stromal microinvasion was observed in seven cases and intraepithelial carcinoma in two cases. Endometriosis was histologically associated in one case. The median follow-up was 76 (range 6-231) months. No recurrence occurred. Two patients died of intercurrent disease.

CONCLUSIONS

Peritoneal staging procedures should always be associated, but restaging surgery could be omitted if there was no suspicious lesion in the peritoneum during initial surgery, since all patients reported had stage-I disease. Fertility-sparing surgery appears to be a safe alternative in young patients. Synchronous endometrial disorders with atypia are infrequent. Prognosis is generally excellent, and long-term risk of recurrence is low. The two recurrences described in literature occurred in stage-IC diseases, highlighting the importance of avoiding perioperative rupture.

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.

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.

Pregnancy after laparoscopic bilateral partial ovarian decortication for stage IC borderline ovarian tumour

BACKGROUND

Fertility preservation techniques are a growing area of research as more women in the reproductive age group develop gynaecologic cancers. We report here a novel technique of fertility preservation used in the treatment of a patient with borderline ovarian tumour.

CASE

A 29-year-old woman with stage I borderline ovarian tumour was referred to our tertiary level hospital. She had a history of infertility and requested fertility preservation be considered in treatment decisions. We performed bilateral laparoscopic partial decortication of the ovaries, and the patient successfully conceived spontaneously following the procedure.

CONCLUSION

Fertility-preserving surgery should be an option for young women with borderline ovarian tumours who wish to retain fertility. Removing abnormal ovarian tissue may restore fertility. The laparoscopic approach is safe and feasible for these patients.

Fertility and borderline ovarian tumor: a systematic review of conservative management, risk of recurrence and alternative options

BACKGROUND

The aim of this systematic review was to evaluate the fertility outcome after borderline ovarian tumor (BOT) management and the results of conservative management, risk of recurrence and alternative options.

METHODS

The search strategy was based on relevant terms concerning BOT using Medline and the Central Cochrane Library. Both early and advanced stages of serous and mucinous BOT were included, but not rare entities such as endometrioid, Brenner or clear-cell BOT because of their low incidence. We considered all articles-case reports, original studies, meta-analyses and reviews-in English and French.

RESULTS

Overall, 230 articles were screened of which 120 were retained for review. Most pregnancies were spontaneous but some data were obtained from studies analyzing the contribution of assisted reproductive technology (ART). However, not all studies differentiated spontaneous pregnancy from those obtained after fertility treatment including ovulation induction, intrauterine insemination and IVF. Conservative management of early stage BOT resulted in a pooled estimate for spontaneous pregnancy rate of 54% with a low risk of lethal recurrence (pooled estimate: 0.5%). In patients with advanced stage BOT, the spontaneous pregnancy rates was lower (34% in the single series reporting pregnancy rate in this context) and the risk of lethal recurrence increased (pooled estimate: 2%).

CONCLUSIONS

This systematic review underlines that fertility subsequent to treatment of BOT depends mainly on histology and initial staging to distinguish early from advanced stages. In patients with advanced stage BOT, several alternative options to conservative management are available to allow patients to conceive without compromising their prognosis.

Management and prognosis of clear cell borderline ovarian tumor

BACKGROUND

The clear cell borderline ovarian tumor (CCBOT) of the ovary is a rare tumor accounting for less than 1% of BOT. Fewer than 25 cases have been reported in the literature (including details on clinical management and outcomes). The aim of this study was to determine the prognosis of a series of CCBOTs collected in 2 reference centers.

PATIENTS AND METHODS

This was a retrospective review of patients with CCBOT treated or referred to our institutions. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion.

RESULTS

Twelve patients were identified between 2000 and 2010. The median age of patients was 68 years (range, 36-83 years). Two had been treated conservatively and 9 radically (data unknown in 1). The tumor was unilateral in 11 cases. All patients had stage I disease. All cases were CCBOT with an adenofibromatous pattern. Stromal microinvasion or intraepithelial carcinoma was histologically associated in 2 and 3 cases, respectively. Four of the 12 patients had synchronous endometrial disorders (but no endometrioid carcinoma). No cases were histologically associated with endometriosis. Four patients were lost to follow-up. Among 8 other patients, after a median period of 28 months (range, 2-129 months), no recurrence had occurred (1 patient had died of another disease).

CONCLUSION

Clear cell borderline ovarian tumor carries a good prognosis. All tumors are stage I; therefore, surgical staging is not necessary in most of the cases. Conservative treatment could be proposed to young patients, but uterine curettage would then be required in cases of uterine preservation.

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 patients with BOTs.

Recommendations of the Fertility Task Force of the European Society of Gynecologic Oncology about the conservative management of ovarian malignant tumors

In young patients with borderline ovarian tumor a conservative treatment approach does not seem to have a significant impact on survival, and the outcome regarding fertility is good in general. It can be considered even if noninvasive peritoneal implants are discovered at the time of the initial surgery. In contrast, in patients with epithelial ovarian cancer, conservative surgery should be considered only in adequately staged patients, with a stage IA grade 1 (and probably 2) serous, mucinous or an endometrioid tumor, including a careful follow-up. Such an approach could also probably be discussed in stage IC grade 1 disease.In patients with nonepithelial malignant ovarian tumors, conservative surgery is also feasible, particularly in patients with malignant germ cell tumors because of their high chemosensitivity leading to an excellent prognosis in general.

Prognostic factors of a large retrospective series of mucinous borderline tumors of the ovary (excluding peritoneal pseudomyxoma)

BACKGROUND

To determine the prognosis and prognostic factors in a large series of mucinous borderline tumors of the ovary (MBOT).

MATERIALS AND METHODS

A retrospective review of patients with MBOT treated or referred to our institution. Three inclusion criteria were defined: (1) centralized histological review by our expert pathologist, (2) exclusion of peritoneal pseudomyxoma and any synchronous malignant tumor in the abdominal cavity, and (3) available data on the management and outcomes of patients.

RESULTS

From 1997 to 2004, 97 patients fulfilled inclusion criteria (95 stage I and 2 stage II disease). Of these, 9 patients had endocervical-like subtypes, 8 patients had stromal microinvasion, and 24 had intraepithelial carcinoma. Radical and conservative surgeries were performed, respectively, in 28 and 69 patients. After a median follow-up of 48 months, 13 patients had developed 14 recurrences: 7 were borderline and 7 were invasive lesions. The probability of recurrence in the form of carcinoma 5 and 10 years after the diagnosis was, respectively, 9 and 13%. The only prognostic factor for recurrence attaining statistical significance was the use of a cystectomy (compared with other surgeries relative risk [RR] = 5.6; P = 0.003; compared with salpingo-oophorectomy RR = 5.5; P = 0.012).

CONCLUSIONS

In the present series of 97 MBOT, mainly early-stage disease and excluding peritoneal pseudomyxoma, the cumulative risk of recurrence in the form of invasive carcinoma at 10 years was 13%. MBOT do not appear to be such a "safe" disease. The only prognostic factor for recurrence was the use of a cystectomy, suggesting that a salpingo-oophorectomy should be preferred in cases of conservative treatment.

[Ovarian low malignant potential tumor: how to preserve fertility?]

Ovarian low malignant potential tumor account for 10 to 20 percent of ovarian epithelial tumors. They differ from typical ovarian cancers in that they do not grow into the ovarian stroma. Likewise, if they spread outside the ovary, for example, into the abdominal cavity, they do not usually grow into the lining of the abdomen. These cancers tend to affect women at a younger age than the typical ovarian cancers and are less life-threatening than most ovarian cancers. Guidelines for surgical treatment of borderline ovarian tumors are similar to those for ovarian cancer and include hysterectomy with bilateral salpingo-oophorectomy. However, patients with borderline ovarian tumors tend to be younger than women with invasive ovarian cancer. For many of these patients, fertility is an important issue. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Despite infrequent data, this observation has been expanded to include women with advanced-stage disease. Recurrence is noted more often after this type of treatment, but does not seem to have a negative effect on survival. Management of conservative treatment (complete staging, cystectomy or oophorectomy, oophorectomy or adnexectomy) are still under debate since none avoids the malignant transformation risk. Thus, close follow-up is mandatory and the optimal moment for final oophorectomy remains unclear. When ovarian preservation is impossible, oocyte/ovarian cryopreservation or emergency ovarian induction before the surgical procedure to obtain embryos are promising but still under evaluated options.

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.

Pregnancy rates after conservative treatment for borderline ovarian tumours: a systematic review

Borderline ovarian tumours account for 10-15% of all ovarian cancers, and there have been numerous studies indicating their excellent long-term prognosis. As this disease commonly affects younger women, the issue of fertility-preserving surgery is increasingly important. A systematic review of the literature, searching the relevant electronic databases was performed analysing conservative surgery, borderline ovarian tumours and pregnancy rates/fertility outcome. Overall, 19 studies met the inclusion criteria. From these studies, 2479 patients had borderline ovarian tumours of which 923 (37%) patients were treated by conservative surgery. Nine studies recorded data regarding pregnancy outcome. A pregnancy rate of 48% was calculated on these data, where recorded, analysing the number of women wanting to conceive and the actual number of pregnancies achieved. The recurrence rate after conservative treatment was 16% with only five recorded disease-related deaths. Knowledge of the pregnancy rates is important to permit appropriate counselling of women diagnosed with this malignancy.

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.

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.

Cystic clear cell tumor of borderline malignancy of the ovary lacking fibromatous components: report of two cases and a possible new histological subtype

BACKGROUND

All of the ovarian borderline clear cell tumors ever reported had, without exception, an adenofibromatous pattern.

CASE

We report two cases of borderline cystic clear cell tumor of the ovary without apparent invasive lesions or adenofibromatous components.

CONCLUSION

This is the first report of cystic clear cell tumors of borderline malignancy, indicating a possible new histological subtype.

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.

Fertility and recurrence results of conservative surgery for borderline ovarian tumors

OBJECTIVES

To evaluate the fertility and recurrence outcomes in women treated with fertility-sparing surgery for borderline ovarian tumors.

METHODS

A total of 142 patients with borderline ovarian tumors managed surgically from 1993 to 2004 were identified from gynecologic oncology and pathology files of SSK Ankara Maternity and Women's Health Teaching Hospital. Sixty-two of those patients who had conservative surgery were eligible for the study. Information was acquired by retrospective medical record review and patient interview.

RESULTS

The observed recurrence rates after radical and fertility-sparing surgery were 0.0% and 6.5%, respectively. Four patients from the conservative surgery group developed recurrence, in contrast to none of the patients from the non-conservative surgery group. No disease-related deaths occurred in any group. In the conservatively managed group, ten women had successful pregnancies, with a total of 10 live births and 3 abortions. The mean duration of follow-up for the conservative surgery group was 44.3 months (range, 3-128).

CONCLUSION

Fertility-sparing surgery for borderline ovarian tumors should be considered for women in the reproductive age group who desire preservation of fertility. Recurrence is noted significantly more often after this type of treatment and close follow-up is needed to detect recurrent disease.