Borderline ovarian tumours: Current concepts and management

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.

Use of ultrasound pattern recognition by expert operators to identify borderline ovarian tumors: a study of diagnostic performance and interobserver agreement

OBJECTIVE

To assess the accuracy and reproducibility of ultrasound 'pattern recognition' for the diagnosis of borderline ovarian tumors by asking experienced ultrasound operators to evaluate representative images of different types of adnexal tumor.

METHODS

Digitally stored static two-dimensional B-mode images of representative cases of benign, borderline and invasive malignant ovarian tumors were independently assessed by three expert sonologists who had not performed the original real-time ultrasound examination. The outcome measures included diagnostic accuracy and interobserver agreement in the diagnosis of benign, borderline or invasive malignant ovarian tumors.

RESULTS

One hundred and sixty-six cases were included in the final data analysis. A correct classification was made by all three experts in 83% of the primary invasive cancers, 76% of the benign masses and in 44% of the borderline malignant tumors (P < 0.01). The experts showed a tendency to misclassify borderline tumors as benign rather than primary invasive (ratio of 8 : 1 for Expert A, 4 : 1 for B and 6 : 1 for C). The interobserver agreement between any two experts was very good when they were tested for their ability to discriminate between invasive and non-invasive (benign and borderline) ovarian tumors (Cohen's kappa 0.85-0.88), but poorer for the discrimination between malignant (invasive and borderline) and benign tumors (kappa 0.70-0.78).

CONCLUSIONS

The accuracy of ultrasound diagnosis of borderline tumors is lower in comparison with benign and invasive malignant lesions. The diagnostic performance and interobserver agreement are better when the outcomes are dichotomized into non-invasive and invasive malignant lesions, as opposed to the traditional diagnosis of benign and malignant tumors.

Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery

OBJECTIVES

To assess the value of preoperative ultrasound examination in predicting the feasibility of intermediate-level laparoscopic surgery for benign adnexal masses.

METHODS

Symptomatic women with a clinical or ultrasound diagnosis of adnexal mass were offered a detailed transvaginal ultrasound scan in order to assess the feasibility of laparoscopic cystectomy/oophorectomy. In all cases an attempt was made to establish a likely histological diagnosis using the pattern recognition method. The selection criteria for laparoscopic surgery were: no ultrasound features suggestive of ovarian cancer, predominantly cystic lesion with no solid foci > 5 cm in mean diameter, no evidence of severe pelvic endometriosis or severe pelvic adhesions and dermoid cyst < 10 cm in mean diameter. Laparoscopic surgery was classified as successful if the mass was removed completely without resorting to a laparotomy.

RESULTS

One hundred and forty-three women were diagnosed with a total of 162 adnexal cysts. The final dataset consisted of 137 women (with 153 lesions), 113 (82.5%) of whom were selected for laparoscopy and 24 (17.5%) for laparotomy. On histological examination 152 (99.3%) cysts were benign and the remaining one (0.7%) was borderline. The operation was successfully completed laparoscopically in 107/113 (94.7%) cases. The preoperative ultrasound assessment predicted the successful outcome of laparoscopic surgery with a sensitivity of 98% (95% CI, 94-99%), specificity of 79% (95% CI, 60-90%), positive predictive value of 95% (95% CI, 89-98%), positive likelihood ratio of 4.58 (95% CI, 2.25-9.32) and negative likelihood ratio of 0.02 (95% CI, 0.01-0.09).

CONCLUSIONS

A detailed preoperative transvaginal ultrasound examination is a helpful tool for assessing the feasibility of intermediate-level laparoscopic surgery in women with benign adnexal lesions.

Accuracy of ultrasound subjective 'pattern recognition' for the diagnosis of borderline ovarian tumors

OBJECTIVES

To assess the value of pattern recognition for the preoperative ultrasound diagnosis of borderline ovarian tumors (BOTs).

METHODS

This was a prospective study of women who were referred to our regional cancer center with the diagnosis of an adnexal mass on a Level II (routine) gynecological ultrasound scan. Women with lesions of uncertain nature were referred for a Level III (expert) ultrasound scan in our tertiary center. The tumor pattern recognition method was used to differentiate between various types of ovarian tumors. Morphological features suggestive of BOTs were: unilocular cyst with a positive ovarian crescent sign and extensive papillary projections arising from the inner wall, or a cyst with a well defined multilocular nodule. The ultrasound findings were compared with the final histological diagnosis.

RESULTS

A total of 224 women with an adnexal mass of uncertain nature were referred for an expert scan, 166 (74.1%) of whom underwent surgery. In this group of women the final histological diagnoses were: 99 (60%) benign lesions, 32 (19%) invasive ovarian cancer and 35 (21%) BOTs. Using pattern recognition combining the different morphological features, a correct preoperative diagnosis of BOT was made in 24/35 (68.6%) women: area under the receiver-operating characteristics curve 0.812 (standard error 0.049; 95% CI, 0.716-0.908), sensitivity 0.69 (95% CI, 0.52-0.81), specificity 0.94 (95% CI, 0.88-0.97), positive likelihood ratio 11.3 (95% CI, 5.53-22.8) and negative likelihood ratio 0.34 (95% CI, 0.21-0.55).

CONCLUSIONS

Ultrasound diagnosis of BOTs is highly specific. However, typical features are absent in one-third of cases, which are typically misdiagnosed as benign lesions.

Faisabilité et limites du traitement cœlioscopique des tumeurs frontières de l'ovaire

Borderline ovarian tumours (BOT) are mainly diagnosed in young women with early stage disease. Due to the absence of specific pre operative criteria for BOT, a laparoscopy is usually performed. A review of the literature found no pejorative data on laparoscopic approach for BOT. Strict surgical procedures must be performed to avoid incomplete surgical staging, cells dissemination and port-site metastases. The limits of the laparoscopic management are the stage of disease and the tumour size. Laparoscopic treatment of BOT for women with early stage disease is feasible. This treatment should be evaluated in specialized centres for women with advanced stage diseases and/or peritoneal implants.