Fertility after conservative treatment for borderline ovarian tumors: A French multicenter study

Reproductive outcomes in women opting for fertility preservation after fertility-sparing surgery for borderline ovarian tumors

PURPOSE

What are the reproductive outcomes of women who had fertility preservation (FP) using either oocyte or embryo vitrification after fertility-sparing surgery (FSS) for a borderline ovarian tumor (BOT)?

METHODS

A retrospective, single-center cohort study was conducted between January 2013 and December 2021. Patients with BOT who resorted to FP by vitrifying oocytes or embryos were included. Both clinical and reproductive parameters were reviewed. The primary outcome was live birth.

RESULTS

In total, thirteen patients who performed 31 FP cycles were included. Of those, six patients achieved eight live births after a mean follow-up period of 79 months. Three further pregnancies are still ongoing. All pregnancies/live births were obtained without using their cryopreserved oocytes or embryos.

CONCLUSION

Women who had FSS for BOT have favorable prospects of live offspring, even without the need to use their cryopreserved material. Fertility preservation in patients with BOT has to be considered as a tool to mitigate the risk of infertility that may arise in case of BOT recurrence requiring castrating surgery.

Fertility-sparing management of stage IIIC serous borderline ovarian tumor: A case report of a 20-year follow-up

Multimodal treatment, including assisted reproductive technology, is necessary in young patients with advanced borderline ovarian tumors. However, the details of long-term follow-up cases have not been reported. In this report, a 19-year-old patient presented with a stage IIIC serous borderline tumor. The patient underwent five fertility-sparing surgeries. The tumor did not respond to any of the three lines of chemotherapy administered. Serological and radiological responses were observed following hormonal treatment with leuprorelin, followed by a fourth surgery. Before the planned fifth surgery for complete resection of both adnexa, cryopreservation of the fertilized eggs was performed. At age 36, when the disease-free interval exceeded the previous one, we proposed embryo transfer; however, she declined fertility treatment. The patient had developed rheumatoid arthritis and childbirth not a priority. The patient had lived without any evidence of disease for 7 years following the last surgery and 20 years after the initial visit.

Reproductive Results in Cancer Survivors after Fertility Sparing Management: The Need for the Standardization of Definitions

In fertility-sparing management (FSM), two different issues can be distinguished: the risk of recurrence/death and the chance of childbearing. Survival is the principal outcome in oncology, and definitions of overall survival and progression-free survival are therefore well defined and widely accepted. The introduction of FSM to clinical practice was determined by the desire of young cancer patients to still have children. Initially, in small groups of patients, any pregnancy and/or childbirth were considered successes. Nowadays, FSM occupies an important place in cancer treatment, with thousands of young women treated successfully. However, in contrast to survival, no definition has been established for evaluating the reproductive outcomes of FSM. This review article evaluates the current pregnancy and birth rates of cancer patients. Differences between fertility-sparing and conservative treatment are analyzed, and improper and confusing interchangeable applications of these terms are pointed out. Additionally, various reasons for choosing FSM as a treatment method-which are not directly related to fertility preservation (treatment mismatch)-are presented. Uniform definitions of reproduction after FSM should be established to enable the comparison of results and facilitate the counseling of patients regarding the chances of reproduction.

The challenging management of borderline ovarian tumors (BOTs) in women of childbearing age

Borderline ovarian tumors (BOTs) account for approximately 15% of all epithelial ovarian cancers. In 80% of cases the diagnosis of BOTs is done at stage I and more than a third of BOTs occurs in women younger than 40 years of age wishing to preserve their childbearing potential; the issue of conservative surgical management (fertility-sparing treatment) is thus becoming of paramount importance. At early stages, the modalities of conservative treatment could range from mono-lateral cystectomy to bilateral salpingo-oophorectomy. Although cystectomy is the preferred method to promote fertility it can lead to an elevated risk of recurrence; therefore, an appropriate counseling about the risk of relapse is mandatory before opting for this treatment. Nevertheless, relapses are often benign and can be treated by repeated conservative surgery. Besides the stage of the disease, histological subtype is another essential factor when considering the proper procedure: as most mucinous BOTs (mBOTs) are more commonly unilateral, the risk of an invasive recurrence seems to be higher, compared to serous histotype, therefore unilateral salpingo-oophorectomy is recommended. In the appraisal of current literature, this review aims to gain better insight on the current recommendations to identify the right balance between an accurate staging and an optimal fertility outcome.

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

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

Fertility-Preserving Surgery of Borderline Serous Ovarian Tumors: A Case Report

Borderline ovarian tumors (BOTs) are tumors with low malignant potential and have an excellent prognosis. They are distinct by an epidemiological shift toward younger women. Fertility-sparing surgery is considered the gold standard in young patients presenting with BOTs. Spontaneous conception has been reported after conservative surgery with no enhanced risk of mortality or morbidity from disease progression during pregnancy.

The prognosis of BOTs is very good; however, a small proportion of these tumors may recur and show malignant transformation. Timely follow-up of the patients is required for timely detection of any recurrence.

We are presenting here a case of a 23-year-old woman diagnosed with BOT. The patient was nulliparous and hence was the appropriate candidate for fertility-sparing surgery. She underwent unilateral salpingo-oophorectomy and is now on regular follow-up.

Fertility-Sparing Surgery for Ovarian Cancer

(1) Background: although most patients with epithelial ovarian cancer (EOC) undergo radical surgery, patients with early-stage disease, borderline ovarian tumor (BOT) or a non-epithelial tumor could be offered fertility-sparing surgery (FSS) depending on histologic subtypes and prognostic factors. (2) Methods: we conducted a systematic review to assess the safety and fertility outcomes of FSS in the treatment of ovarian cancer. We queried the MEDLINE, PubMed, Cochrane Library, and Cochrane (“Cochrane Reviews”) databases for articles published in English or French between 1985 and 15 January 2021. (3) Results: for patients with BOT, FSS should be offered to young women with a desire to conceive, even if peritoneal implants are discovered at the time of initial surgery. Women with mucinous BOT should undergo initial unilateral salpingo-oophorectomy, whereas cystectomy is an acceptable option for women with serous BOT. Assisted reproductive technology (ART) can be initiated in patients with stage I BOT if infertility persists after surgery. For patients with EOC, FSS should only be considered after staging for women with stage IA grade 1 (and probably 2, or low-grade in the current classification) serous, mucinous or endometrioid tumors. FSS could also be offered to patients with stage IC grade 1 (or low-grade) disease. For women with serous, mucinous or endometrioid high-grade stage IA or low-grade stage IC1 or IC2 EOC, bilateral salpingo-oophorectomy and uterine conservation could be offered to allow pregnancy by egg donation. Finally, FSS has a large role to play in patients with non- epithelial ovarian cancer, and particularly women with malignant ovarian germ cell tumors.

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

Background

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

Methods

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

Results

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

Conclusion

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

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature

OBJECTIVE

To compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.

DATA SOURCES

PubMed was searched from January 1, 1995, to May 29, 2020.

METHODS OF STUDY SELECTION

Studies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.

CONCLUSION

Fertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Fertility and prognosis of borderline ovarian tumor after conservative management: Results of the multicentric OPTIBOT study by the GINECO & TMRG group

OBJECTIVES

Description of fertility and prognosis of patients with borderline ovarian tumor (BOT) treated by fertility-sparing surgery through a longitudinal study from the French national cancer network.

METHODS

All consecutive patients diagnosed with BOT from the French National Network dedicated to Ovarian Malignant Rare Tumors from 2010 and 2017 were selected. In 2018, an update was made by sending a questionnaire regarding recurrence and fertility to patients aged under 43 years at diagnosis and treated conservatively. We compared the characteristics of the patients with/without recurrence and with/without live birth.

RESULTS

Fifty-two patients aged 18 to 42 years presented a desire of pregnancy. Thirty patients (58%) presented a FIGO IA tumor, and 20 patients were treated by bilateral cystectomies (38%). We observed at least one live birth for 33 patients (63%) and local recurrences in 20 patients (38%). Both recurrence and live birth in 17 patients (33%) were reported, with recurrence occurring before pregnancy, after a second fertility-sparing treatment, in half of the cases. No factors associated with recurrence or live birth in this study were identified. Moreover, in this population, both recurrence and live birth were independent of age, with a linear risk along time. Disease-free survival was worse for patients treated with bilateral cystectomy (n = 20, 38%), with no difference in terms of fertility.

CONCLUSION

Two third of the patients experienced life birth after conservation surgery. We did not highlight an age/time from surgery for which the risk of recurrence outweighs the chance of pregnancy and to radicalize surgery. Moreover, almost a quarter of the live birth occurred after recurrence, with no more further event to date in these patients. The results encourage to consider a second fertility-sparing surgery after local borderline recurrence in the case of pregnancy desire. All these decisions must be discussed in specialized multidisciplinary boards.

Fertility preservation in borderline ovarian tumor patients and survivors

Borderline ovarian tumors (BOTs) represent around 15% of all epithelial ovarian cancer. Around one third of those patients is under 40 and has not completed childbearing when the tumor is diagnosed. Cancer survivors are more and more concerned about their future fertility since a large proportion of those with BOTs are young. Whatever the tumor stage, information regarding future fertility after treatment and fertility preservation (FP) options must be delivered to all patients before treatment. A multidisciplinary team will discuss and propose personalized treatment and FP strategies. Nowadays, the FP options offered to patients with BOT are the followings: i) minimal invasive conservative surgery, ii) oocyte cryopreservation after controlled ovarian stimulation (COS) or in vitro maturation (IVM) and iii) ovarian tissue cryopreservation. Generally, the most common strategy to preserve future fertility is represented by minimal invasive conservative surgery. However, with the remarkable success and evolution of assisted reproductive technologies (ART) - notably progress and efficiency in COS and oocyte vitrification - have led to offer another potential approach for FP consisting in oocyte cryopreservation. Several COS protocols, such as random start or dual stimulation associating tamoxifen or aromatase inhibitors with gonadotropins provide similar results when compared to standard protocols while providing safety by minimizing the risk of high estrogen exposure. When COS is contraindicated, oocyte cryopreservation can still be possible throw IVM. Even though, oocyte competence after IVM is lower than that obtained after COS. A less used approach is cryopreservation of ovarian tissue, consisting in freezing ovarian cortex fragments for a future thawing and graft. Some concerns and limitations regard the ovarian cortex graft and the risk of reintroducing malignant cells once performed. Nonetheless, the latter it is the only option in prepubertal patients.

Borderline ovarian tumours: management in the era of fertility-sparing surgery

Borderline ovarian tumours (BOTs) are ovarian neoplasms characterised by epithelial proliferation, variable nuclear atypia and no evidence of destructive stromal invasion. BOTs account for approximately 15% of all epithelial ovarian cancers. Due to the fact that the majority of BOTs occur in women under 40 years of age, their surgical management often has to consider fertility-sparing approaches. The aim of this mini-review is to discuss the state of the art of fertility-sparing surgery for BOTs with a specific focus on the extent of surgery, post-operative management and fertility.

Borderline ovarian tumors in pregnancy

Borderline ovarian tumors (BOTs) are common in women in their reproductive years. In more than one-third of patients tumors are detected at the age of 15–29, the average age at initial diagnosis is 40. The study was aimed to improve methods for BOTs diagnosis in pregnancy and to determine the possibilities of organ preservation treatment. A group of 300 pregnant women with various tumor-like formations and ovarian tumors was examined. Of them, 25 patients had borderline epithelial tumors (22 patients had serous and 3 patients had mucinous tumors). Ultrasound examination together with blood serum CА-125, sFas, VEGF and IL6 level assessment were performed prior to surgery. The results obtained were compared with the results of morphological studies. Organ preservation and radical surgical treatment were carried out, and chemotherapy, if necessary. Perinatal outcomes were studied when performing the cross-comparison. It was discovered, that ultrasonography and logistic regression analysis made it possible to distinguish between benign ovarian tumors, BOTs and malignant ovarian tumors. The levels of VEGF above the 500 pg/ml, IL6 above the 8.1 pg/ml and CА-125 above the 300 U/ml indicated the high probability of malignant ovarian tumors in pregnant women. Only the morphological study of ovarian tissue, obtained regardless of surgical methods, ensured understanding of the ovarian tumor’s true nature during pregnancy. At the same time, in three pregnant women with ovarian tumors, the morphological examination revealed some tissue areas common both for BOTs and malignant ovarian tumors. Thus, the predominance of the tumor early stages, relatively mild course and, favorable prognosis in patients with BOTs make it possible to use gentle surgical treatment making it possible to preserve menstrual function and fertility.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Fertility]

OBJECTIVES

Borderline ovarian tumours (BOT) represent around 15% of all ovarian neoplasms and are more likely to be diagnosed in women of reproductive age. Overall, given the epidemiological profile of BOT and their favourable prognosis, ovarian function and fertility preservation should be systematically considered in patients presenting these lesions.

METHODS

The research strategy was based on the following terms: borderline ovarian tumour, fertility, fertility preservation, infertility, fertility-sparing surgery, in vitro fertilization, ovarian stimulation, oocyte cryopreservation, using PubMed, in English and French.

RESULTS AND CONCLUSIONS

Fertility counselling should become an integral part of the clinical management of women with BOT. Patients with BOT should be informed that surgical management of BOT may cause damage ovarian reserve and/or peritoneal adhesions. Nomogram to predict recurrence, ovarian reserve markers and fertility explorations should be used to provide a clear and relevant information about the risk of infertility in patients with BOT. Fertility-sparing surgery should be considered for young women who wish preserving their fertility when possible. There is insufficient evidence to claim a causal relation between controlled ovarian stimulation (COS) and BOT. However, in case of poor prognosis factors, the use of COS should be considered cautiously through a multidisciplinary approach. In case of infertility after surgery for BOT, COS can be performed without delay, once histopathological diagnosis of BOT is confirmed. There is insufficient consistent evidence that fertility drugs and COS increase the risk of recurrence of BOT after conservative management. The conservative surgical treatment can be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. In women with BOT recurrence in a single ovary and in women with bilateral ovarian involvement when the conservative management is not possible, other fertility preservation strategies are available, but still experimental.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS AND CONCLUSION

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

CONCLUSION

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

Uncommon borderline ovarian tumours: A clinicopathologic study of seventeen patients

Objective

To evaluate uncommon types of borderline ovarian tumors (BOT) and define the clinical, surgical, and pathologic features.

Material and Methods

Seventeen patients who were treated in our hospital between 1990 and 2017 were identified. Patients’ data were collected from the gynecologic oncology clinic electronic database, patients’ files, and pathology reports. Conservative surgery was defined as preservation of the uterus and at least part of one ovary.

Results

The mean age was 47 (range, 22-70) years. Based on histopathologic tumor type, there was mixed tumor in five (29.4%) patients, endometrioid-type in nine (52.9%), seromusinous-type in two (11.8%), and Brenner-type in one (5.9%). Conservative surgery was performed in 4 patients. Two patients with endometrioid BOT had synchronous endometrial pathology, including one (11%) patient with endometrial cancer, one (11%) with endometrial hyperplasia without atypia, and 3 (33%) patients had endometriosis. The median follow-up was 19 (range, 1-137) months. No recurrence was observed during the follow-up period.

Conclusion

In our small volume case series, it could be said that non-serous/non-mucinous BOT has excellent prognosis. However, endometrial pathology should be checked in endometrioid type.

Cancer Treatment-Related Infertility: A Critical Review of the Evidence

Cancer treatments may compromise the fertility of children, adolescents, and young adults, and treatment-related infertility represents an important survivorship issue that should be addressed at diagnosis and in follow-up to ensure optimal decision-making, including consideration of pursuing fertility preservation. Risk of infertility varies substantially with patient and treatment factors. The ability to accurately assess fertility risk for many patients is hampered by limitations of the current literature, including heterogeneity in patient populations, treatments, and outcome measures. In this article, we review and synthesize the available data to estimate fertility risks from modern cancer treatments for both children and adult cancer survivors to enable clinicians to counsel patients about future fertility.

Short-term Outcomes and Pregnancy Rate After Laparoscopic Fertility-Sparing Surgery for Borderline Ovarian Tumors: A Single-Institute Experience

Objective

We investigated the short-term outcomes and pregnancy rate after a laparoscopic approach to fertility preservation in patients with borderline ovarian tumors (BOTs).

Methods

Clinic-pathologic variants of patients with BOTs who underwent conservative surgery at the Tianjin Central Hospital of Obstetrics and Gynecology between January 2009 and July 2015 were retrospectively analyzed.

Results

Among 211 patients with BOTs, 74 (35.1%) received conservative surgery (44 cases using a laparoscopic approach and 30 cases using a laparotomy approach). The mean age of the laparotomy group was significantly younger than that of the laparoscopic group (P = 0.024). The maximal longitude of the tumor in the laparotomy group was significantly longer than that in the laparoscopic group (P < 0.001). The number of incomplete surgery cases in the laparoscopic group was significantly greater than that in the laparotomy group (P < 0.001). The 2 groups showed no significant differences in gravidity and parity before surgery, abnormality of serum tumor makers, tumor lateralities, ascites, histology, duration of follow-up, pregnancy rate after surgery, or postoperative recurrence. Total recurrent rate was 6.7% (5/74). Two cases in laparotomy group and 3 cases in laparoscopic group relapsed respectively. There was no significant difference of recurrent rate between the 2 groups. The total pregnant rate was 33.8% (25/74). Nine patients (30%) in the laparotomy group and 16 patients (36.4%) in the laparoscopic group became pregnant during follow-up respectively. There were no significant differences in the postoperative durations of pregnancy, pregnancy type, age at pregnancy, tumor lateralities, ascites, or type of pathology between 2 groups. The pregnancy rate of incomplete surgery cases in laparoscopic group was significantly higher than that of laparotomy group (P = 0.011). No recurrence occurred among the pregnant cases.

Conclusions

A comprehensive laparoscopic surgery was not performed in incomplete surgery patients undergoing complete exploration. Good short-term outcomes and pregnancy were observed in patients receiving conservative laparoscopic surgery for BOTs, especially in patients receiving incomplete conservative laparoscopic surgery.

Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part I: Indications for fertility preservation

Purpose

Most guidelines about fertility preservation are predominantly focused on scientific evidence, but are less practically orientated. Therefore, practically oriented recommendations are needed to support the clinician in daily practice.

Methods

A selective literature search was performed based on the clinical and scientific experience of the authors, focussing on the most relevant diseases and gynaecological cancers. This article (Part I) provides information on topics that are essential for the fertility preservation indication, such as disease prognosis, disease therapy and its associated risks to fertility, recommending disease-specific fertility preservation measures. Part II specifically focusses on fertility preservation techniques.

Results

In breast cancer patients, fertility preservation such as ovarian tissue and oocyte cryopreservation is especially recommended in low-stage cancer and in women < 35 years of age. In Hodgkin’s lymphoma, the indication is mainly based on the chemotherapy regime as some therapies have very low, others very high gonadotoxicity. In borderline ovarian tumours, preservation of fertility usually is achieved through fertility sparing surgery, ovarian stimulation may also be considered. In cervical cancer, endometrial cancer, rheumatic diseases and other malignancies such as Ewing sarcoma, colorectal carcinoma, non-Hodgkin lymphoma, leukaemia etc., several other factors must be considered to enable an individual, stage-dependent decision.

Conclusion

The decision for or against fertility preservation depends on the prognosis, the risks to fertility and individual factors such as prospective family planning.

Fertility preservation in women with borderline ovarian tumors - how does it impact disease outcome? A cohort study

INTRODUCTION

Borderline ovarian tumors are typically indolent neoplasms. Since many are diagnosed in younger women, fertility conservation is an important consideration and has been advocated based on retrospective data. The objective of this study was to identify features impacting on recurrence and survival in a series of borderline ovarian tumors, and to assess the safety of a fertility-sparing approach.

MATERIAL AND METHODS

A historical cohort study of consecutive borderline ovarian tumors cases treated at a single institution over 30 years (1981-2011). Data on surgical approach (fertility-sparing or otherwise), disease stage, CA125 levels, histological features, adjuvant treatment and follow-up data were collected. Recurrence and survival were assessed using the Kaplan-Meier method and associations with the variables of interest were evaluated using a multivariate Cox proportional hazards model.

RESULTS

213 patients were included. Of 132 women age 40 years and below at diagnosis, 112 (85%) had a fertility-sparing procedure and 60 (46%) had conservation of an involved ovary. Fifty patients (24%) developed recurrences; fertility preservation (hazard ratio = 2.57; 95% confidence interval 1.1-6; p = 0.029) and advanced stage (hazard ratio = 4.15; 95% confidence interval 2.3-7.6; p < 0.001) were independently associated with recurrence on multivariate analysis. Eleven (5%) patients died of their disease. Fertility preservation was not associated with compromised survival.

CONCLUSIONS

Borderline ovarian tumors carry a good prognosis overall. Fertility preservation is associated with a higher risk of disease relapse; however, as most relapses are localized and may be salvaged with surgical treatment, overall survival is not compromised.

Management of Borderline Ovarian Tumors-Still a Gray Zone

Borderline ovarian tumors (BOTs) are a heterogeneous group of non-invasive epithelial ovarian tumors that occur at a younger age, present in early stage, frequently associated with infertility but are easily curable. Although they may have symptomatic long-term recurrences, they have an excellent prognosis in spite of peritoneal spread. Among the epithelial tumors of the ovary, BOTs fall in the spectrum lying between cystadenomas (benign) and cystadenocarcinomas (malignant). Their oncological behavior is more aggressive than benign ovarian tumors but relatively less than that of malignant ovarian tumors. Since the age group affected is usually young females, preservation of fertility is an important aspect of treatment protocol. Although the management of these tumors has been extensively discussed, it still remains a controversial gray zone. In this review, epidemiology, pathogenesis, histologic subtypes, various surgical approaches, follow-up, and management of recurrence have been discussed. Choosing the best treatment still poses a challenge for the treating oncosurgeon.

Oncologic and obstetric outcomes of conservative surgery for borderline ovarian tumors in women of reproductive age

Objective

To compare the oncologic and obstetric outcomes in reproductive-age females with borderline ovarian tumors (BOTs) treated with cyst enucleation (CE) or unilateral salpingo-oophorectomy (USO).

Methods

The medical records of patients with BOTs treated between 1998 and 2014 were retrospectively reviewed. The recurrence rates in the USO and CE groups were compared, and the postoperative obstetric outcomes were assessed via telephone survey.

Results

Eighty-nine patients with BOTs underwent USO, and 19 underwent CE. Of these, six patients had recurrent BOTs. The recurrence rate was significantly lower in the USO group (3/89, 3.4%) than in the CE group (3/19, 15.8%) (P=0.032). All patients with recurrent disease were successfully treated with further surgery. Of the 76 patients interviewed by telephone, 71 (93.4%) resumed regular menstruation after surgery. Twenty-six of the 32 patients (81.3%) who attempted to conceive had successful pregnancies. USO (19/24, 79.2%), like CE (7/8, 87.5%), resulted in favorable pregnancy rates for patients with BOTs.

Conclusion

USO is a suitable fertility-preserving surgery for women with BOTs. CE is also an acceptable option for select patients.

Mucinous borderline ovarian tumors: Analysis of 75 patients from a single center

OBJECTIVE

To analyze the clinicopathologic features, recurrence and survival rates, reproductive history, and treatment of patients with mucinous borderline ovarian tumors (mBOTs).

MATERIAL AND METHODS

Patients with a diagnosis of mBOT were evaluated retrospectively. Patients with borderline ovarian tumors other than mucinous type and concomitant invasive cancer were excluded.

RESULTS

A total of 75 patients were identified. Median age was 38 years. The most common symptom was pain (42.7%). Median CA-125 level was 23.5 IU/mL (range, 1-809 IU/mL). Median tumor size was 200 mm (range, 40-400 mm), and 6.7% of mBOTs were bilateral. Thirty-six (48%) patients underwent staging surgery. Two patients (5.9%) had nodal involvement. One patient received platinum-based adjuvant chemotherapy. One (1.3%) patient had recurrence. None of the patients died because of the ovarian tumor. A total of 43 patients had conservative surgery.

CONCLUSION

Prognosis of mBOTs is excellent, and fertility-sparing surgery should be considered in the reproductive age group. Furthermore, the necessity of staging surgery is controversial.

Assisted reproductive techniques after fertility-sparing treatments in gynaecological cancers

BACKGROUND

The trend toward late childbearing has made fertility preservation a major issue for women who face gynecological cancer. New techniques in assisted reproductive medicine enable conception after primary treatment of these cancers. Here, we aimed to review the efficacy and safety of assisted reproductive techniques (ART) after fertility-preserving treatment of gynaecological cancers.

METHODS

We conducted a systematic literature review of both prospective and retrospective studies in the PubMed, EMBASE, CENTRAL and SciSearch databases. In the retrieved studies, we evaluated live births, clinical pregnancies, overall survival and disease-free survival.

RESULTS

We identified many prospective and retrospective studies on this topic, but no relevant randomized clinical trials. Fertility-sparing treatments with safe oncological outcomes are feasible in endometrial, cervical and ovarian cancer cases. After cancer treatment, ART seem safe and show variable obstetrical outcomes.

CONCLUSIONS

After fertility-preserving treatment for gynaecological cancers, ART can enable pregnancy to be achieved with apparent oncological safety. The success of such procedures should directly impact clinical practice and management of those patients who require fertility-sparing treatment.

Controversies in borderline ovarian tumors

Borderline ovarian tumors (BOTs) represent about 15% to 20% of all ovarian malignancies and differ from invasive ovarian cancers (IOCs) by many characters. Historically, standard management of BOT is peritoneal washing cytology, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, complete peritoneal resection of macroscopic lesions; in case of mucinous BOTs, appendectomy should be performed. Because BOTs are often diagnosed at earlier stage, in younger age women and have better prognosis, higher survival rate than IOCs, fertility-sparing surgery is one of the option to preserve childbearing capacity. The study of such conservative surgery is being released, and still controversial. After surgery, pregnancy and ovarian induction followed by in vitro fertilization are also significant issues. In surgery, laparoscopic technique can be used by a gynecologic oncology surgeon. So far postoperative chemotherapy, radiotherapy and hormone therapy are not recommended. We will discuss controversial issues of BOTs on this review and present the outline of the management of BOTs.

Fertility sparing treatment in borderline ovarian tumours

Borderline ovarian tumours are low malignant potential tumours. They represent 10-15% of all epithelial ovarian malignancies. Patients with this type of tumour are younger at the time of diagnosis than patients with invasive ovarian cancer. Most of them are diagnosed in the early stages and have an excellent prognosis. It has been quite clearly established that the majority of borderline ovarian tumours should be managed with surgery alone. Because a high proportion of women with this malignancy are young and the prognosis is excellent, the preservation of fertility is an important issue in the management of these tumours. In this systemic review of the literature, we have evaluated in-depth oncological safety and reproductive outcomes in women with borderline ovarian tumours treated with fertility-sparing surgery, reviewing the indications, benefits, and disadvantages of each type of conservative surgery, as well as new alternative options to surgery to preserve fertility.

Surgical staging and prognosis in serous borderline ovarian tumours (BOT): a subanalysis of the AGO ROBOT study

BACKGROUND

Incomplete surgical staging is a negative prognostic factor for patients with borderline ovarian tumours (BOT). However, little is known about the prognostic impact of each individual staging procedure.

METHODS

Clinical parameters of 950 patients with BOT (confirmed by central reference pathology) treated between 1998 and 2008 at 24 German AGO centres were analysed. In 559 patients with serous BOT and adequate ovarian surgery, further recommended staging procedures (omentectomy, peritoneal biopsies, cytology) were evaluated applying Cox regression models with respect to progression-free survival (PFS).

RESULTS

For patients with one missing staging procedure, the hazard ratio (HR) for recurrence was 1.25 (95%-CI 0.66-2.39; P=0.497). This risk increased with each additional procedure skipped reaching statistical significance in case of two (HR 1.95; 95%-CI 1.06-3.58; P=0.031) and three missing steps (HR 2.37; 95%-CI 1.22-4.64; P=0.011). The most crucial procedure was omentectomy which retained a statistically significant impact on PFS in multiple analysis (HR 1.91; 95%-CI 1.15-3.19; P=0.013) adjusting for previously established prognostic factors as FIGO stage, tumour residuals, and fertility preservation.

CONCLUSION

Individual surgical staging procedures contribute to the prognosis for patients with serous BOT. In this analysis, recurrence risk increased with each skipped surgical step. This should be considered when re-staging procedures following incomplete primary surgery are discussed.

[Unilateral borderline ovarian tumor and unilateral adenexectomy?]

To perform an adnexectomy in case of unilateral borderline tumor must consider the risk of recurrence, the preservation of fertility, and to integrate a global comprehensive management of a couple. Adnexectomy can be considering as a legitimate option when the woman desire a pregnancy. The risk of recurrence is low and the global survey high. Identification of woman with a high risk of recurrence is necessary. Adnexectomy can be considering as a legitimate option to preserve fertility in case of unilateral tumor. However, ovarian reserve data are missing after the surgery. Adnexectomy can be considering for the management of infertile woman with unilateral borderline tumor. IVF can be performed in the absence of any poor prognosis factor. Management with ovarian cryopreservation and In vitro Maturation remain unclear.

Prognostic factors for recurrence after conservative treatment in a series of 119 patients with stage I serous borderline tumors of the ovary

BACKGROUND

The aim of this study was to evaluate prognostic factors for recurrence after conservative treatment of a large series of 'apparent' stage I serous borderline ovarian tumors (SBOTs).

PATIENTS AND METHODS

A review of 119 patients treated conservatively between 2000 and 2009 with follow-up data. All pathological slides were reviewed by the same expert pathologist. Prognostic factors for recurrence were studied (age, histological subtypes and surgical procedure).

RESULTS

Conservative surgical procedures were: unilateral cystectomy (n = 43, 36%); unilateral adnexectomy (UA; n = 50, 42%); bilateral cystectomies (n = 11, 9%) and UA + contralateral cystectomy (n = 15, 13%). Stromal microinvasion and/or a micropapillary pattern was present in 21 (18%) and 13 (11%) patients, respectively. With a median follow-up of 45 months, 38 (32%) patients relapsed (10 also had peritoneal disease in the form of noninvasive implants at the first recurrence). In 2 of these 38 patients, progression-to-invasive disease occurred at the second and third relapse (one patient died to the recurrence). Three prognostic factors for recurrence were identified in the univariate analysis: a young age (< or >30 years old), the type of conservative treatment (adnexectomy versus cystectomy) and tumor bilaterality. In the multivariate analysis, only age remained statistically significant.

CONCLUSION

In this series (the largest reported, to date, on recurrences after the conservative management of stage I SBOT), the risk of relapse was not related to tumor histological subtypes (micropapillary and stromal microinvasion) nor to the use of complete staging surgery. Invasive recurrences were very rare in stage I SBOT, but did occur. A young age, tumor bilaterality and the use of a cystectomy were identified as risk factors for recurrence, suggesting that management of fertility preservation (particularly in very young patients) should be associated with a meticulously conducted follow-up.

External multicentre validation of a nomogram predicting the risk of relapse in patients with borderline ovarian tumours

Background:

The Obermair nomogram was recently developed to predict the risk of relapse in patients with borderline ovarian tumours (BOTs) based on five readily available clinical, biological, and pathological characteristics. We set out to externally validate and assess its robustness using a multi-institutional BOT database.

Methods:

All consecutive patients treated for BOTs in the two participating centres between January 1980 and December 2008 and who had all the nomogram variables documented were identified for analysis.

Results:

Three hundred and fourteen eligible patients were identified and used for external validation analysis. The median follow-up and initial relapse time were 46.43 (range: 0.1–360) and 66.64 (range: 8–77) months, respectively. The nomogram concordance index was 0.54 (95% CI, 0.52–0.56). The correspondence between the actual relapse and the nomogram predictions suggests a limited calibration of the nomogram in the validation cohort.

Conclusion:

This external validation study of the Obermair nomogram showed limitations in its generalisability to a new and independent patient population.

Imaging in gynecological disease (8): ultrasound characteristics of recurrent borderline ovarian tumors

OBJECTIVES

To describe the sonographic characteristics of borderline ovarian tumor (BOT) recurrence.

METHODS

From the databases of five ultrasound centers, we retrospectively identified 68 patients with histological diagnosis of recurrent BOT who had undergone preoperative ultrasound examination. All recurrences were detected during planned follow-up ultrasound examinations. Recurrent lesions were described using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group.

RESULTS

Sixty-two patients had a serous BOT recurrence and six a mucinous BOT recurrence. All patients except one were premenopausal, 84% of them being < 40 years old. All but one patient were asymptomatic at diagnosis of the recurrence. Fertility-sparing surgery of the recurrent tumor was performed in 57/68 (84%) patients. The most frequent ultrasound feature of recurrent serous BOT was a unilocular solid cyst (49/62, 79%) and almost half of the recurrent serous BOTs (29/62, 47%) had multiple papillary projections. In 89% of the recurrent serous BOTs there was at least one papillation with irregular surface and in 73% there was at least one papillation vascularized at color Doppler examination. Recurrent mucinous BOTs appeared mainly as multilocular or multilocular solid cysts (5/6, 83%).

CONCLUSION

Sonographic features of recurrent BOT resemble those described by others for different subtypes of primary BOT.

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.

Diagnosis, treatment, and follow-up of borderline ovarian tumors

Borderline ovarian tumors represent a heterogeneous group of noninvasive tumors of uncertain malignant potential with characteristic histology. They occur in younger women, are present at an early stage, and have a favorable prognosis, but symptomatic recurrence and death may be found as long as 20 years after therapy in some patients. The molecular changes in borderline ovarian tumors indicate linkage of this disease to type I ovarian tumors (low-grade ovarian carcinomas). The pathological stage of disease and subclassification of extraovarian disease into invasive and noninvasive implants, together with the presence of postoperative macroscopic residual disease, appear to be the major predictor of recurrence and survival. However, it should be emphasized that the most important negative prognostic factor for recurrence is just the use of conservative surgery, but without any impact on patient survival because most recurrent diseases are of the borderline type-easily curable and with an excellent prognosis. Borderline tumors are difficult masses to correctly preoperatively diagnose using imaging methods because their macroscopic features may overlap with invasive and benign ovarian tumors. Over the past several decades, surgical therapy has shifted from a radical approach to more conservative treatment; however, oncologic safety must always be balanced. Follow-up is essential using routine ultrasound imaging, with special attention paid to the remaining ovary in conservatively treated patients. Current literature on this topic leads to a number of controversies that will be discussed thoroughly in this article, with the aim to provide recommendations for the clinical management of these patients.

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.

Paratubal borderline tumor diagnosed in the adolescent period: a case report and review of the literature

BACKGROUND

Borderline paratubal cysts are rare entities. These tumors are identified as epithelial proliferation without stromal invasion.

CASE

A 19-year-old virgin patient was admitted to our clinic with abdominal pain and nausea. The sonographic evaluation showed a left adnexal mass 89 × 80 mm in diameter with solid tissue projections. Doppler examination revealed no significant blood supply. At surgery, a torsed left paratubal cyst 10 cm in diameter and normal bilateral ovaries were encountered. Cystectomy was performed and of frozen section revealed a borderline Fallopian tube neoplasm. Final pathology review was reported as a serous borderline paratubal tumor.

CONCLUSION

The evaluation of the structure of cyst by ultrasound and the performance of intraoperative frozen section analysis are two important issues to diagnose the nature of a cyst. Fertility-sparing surgery is the main point of management.

Fertility preserving options in patients with gynecologic malignancies

A proportion of reproductive age women are affected by gynecologic malignancies. This patient population is faced with difficult decisions, related to their cancer care and treatment, as well as future childbearing potential. Therefore, it is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer. In addition to understanding the surgical approaches available, providers should be able to counsel patients regarding their eligibility for and the indications and limitations of fertility sparing therapy for gynecologic cancer, allowing for appropriate referrals. A comprehensive PUBMED literature search was conducted using the key words "fertility preservation," "cervical cancer," "endometrial cancer," "ovarian cancer," "borderline tumor of the ovary," "germ cell tumor," "obstetrical outcomes," "chemotherapy," and "radiation." The following review summarizes fertility sparing options for patients with cervical, ovarian and endometrial cancer, with an emphasis on appropriate patient selection, oncologic, and obstetric outcomes.