Clinical management potential tumours of low malignancy

Hormone Replacement Therapy in Post-Menopause Hormone-Dependent Gynecological Cancer Patients: A Narrative Review

BACKGROUND

Advances in the treatment of gynecological cancer have led to improvements in survival but also an increase in menopausal symptoms, especially in young women with premature iatrogenic menopause.

METHODS

A narrative review was performed to clarify the possibility of prescribing hormone replacement therapy (HRT) after hormone-dependent gynecological cancers (ovarian cancer [OC], cervical adenocarcinoma [AC], and endometrial cancer [EC]).

RESULTS

HRT can be prescribed to patients with early-stage, grade I-II OC who experience bothersome menopausal symptoms non-responsive to alternative non-hormone therapy after optimal surgery. Caution should be exercised in administering HRT after serous borderline tumors and endometrioid OC, and HRT is not recommended in low-grade serous OC. HRT is not contraindicated in AC survivors. After surgery for EC, HRT can be prescribed in women with early-stage low-grade EC. There is not enough data to give indications to patients with advanced EC.

CONCLUSIONS

HRT can be discussed with patients, evaluating the risks and benefits of hormone-dependent gynecological cancer. Counseling should be performed by gynecologic oncologists experienced in the management of these patients.

Serous borderline ovarian tumours: an extensive review on MR imaging features

Serous borderline ovarian tumours (SBOTs) are an intermediate group of neoplasms, which have features between benign and malignant ovarian tumours and for which, fertility-sparing surgery can be offered. MRI in imaging of SBOTs is, therefore, crucial in raising the possibility of the diagnosis, in order to present the patient with the most appropriate treatment options. There are characteristic MRI features that SBOTs demonstrate. In addition, recent advanced techniques, and further classification into subtypes within the borderline group have been developed. The aim of this article is to review the MRI features of SBOT and provide the reporter with an awareness of the imaging tips and tricks in the differential diagnosis of SBOT.

Oncologic and reproductive outcomes of borderline ovarian tumors in Indian population

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In BOT Fertility sparing surgery is a safe procedure in early stage disease and should be performed in a young patient.

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Recurrences are more common in the cystectomy group as compared to oophorectomy (33% vs 6.2%; p = 0.03).

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Overall and Recurrence free survival is favourable and recurrences are always salvaged by surgery.

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Spontaneous conception and live birth rates after fertility sparing surgery in patients with BOT are modest (50%).

Borderline ovarian tumor (BOT) is characterized by atypical epithelial proliferation without stromal invasion and majority are diagnosed at early stages and in women of reproductive age group. A retrospective review of medical records of patients diagnosed with BOT and on regular follow up at All India Institute of Medical Sciences New Delhi, during a five-year study period from March 2014 to March 2019 was performed. Surgical treatment was classified as radical, fertility sparing surgery (FSS) or cystectomy. Surgical staging was defined as complete, partial or unstaged. Median age of seventy-five women was 32 years. Follow up period ranged from 22 to 61 months (median 36 m). Radical surgery was done in 34 (45.3%), FSS in 32 (42.6%) and cystectomy in 9 (12.0%) women. Complete surgical staging was performed in 22 (29.3%), partial staging in 23 (30.6%) and 30 (40%) were unstaged. During the follow up period, 98.7% patients were alive and 90.7% were free of recurrence. Median time to recurrence was 35 months. Recurrence rate was 33.3% in cystectomy vs 6.2% in oophorectomy (p = 0.03). All seven recurrences were in unstaged (six) or partially staged patient (one). Six recurrences in ovary were salvaged by surgery and recurrent disease was of borderline histology. Spontaneous conception and live birth rate was 42.1%. FSS is a safe procedure and should be considered in a young patient with early stage disease and desirous of future fertility. Spontaneous conception and live birth rates after fertility sparing surgery in patients with BOT are modest.

Can we safely forgo hysterectomy in non-fertility-sparing surgery for borderline ovarian tumors?

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In a cohort of patients with borderline ovarian tumor (BOT), rate of uterine involvement was 6.0%.

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In patients with BOT grossly confined to ovaries, rate of uterine involvement was 0%.

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Hysterectomy may be able to be safely excluded from non-fertility-sparing BOT surgery.

Forgoing hysterectomy as part of borderline ovarian tumor (BOT) staging is considered appropriate for fertility preservation. We evaluated whether forgoing hysterectomy may also be acceptable in non-fertility-sparing surgery by evaluating the frequency of uterine involvement and the rate of recurrence involving the uterus. A review of all BOTs at one institution over ten years (2009–2019) was performed. Patients with hysterectomy prior to BOT diagnosis were excluded. Data were abstracted from electronic medical records. Bivariate statistics were used to compare groups.

129 patients with BOT on final pathology were identified. 67 cases included hysterectomy. Reasons for no hysterectomy (n = 62) included fertility preservation (40), benign intraoperative frozen pathology (4), patient preference (3), comorbidities (7), and unknown (8). Four of 67 (6.0%) uterine specimens had non-invasive serosal implants, of which two had grossly visible uterine involvement and all four had grossly visible extrauterine peritoneal disease. 12 of 129 (9.3%) patients had documented recurrence, of which all had uterine preservation at the time of initial surgery. Of the 12 recurrences with uterus in situ, none were documented to involve the uterus, and all were composed of non-invasive implants. In patients with BOT grossly confined to ovaries at the time of surgery, we found no cases of uterine involvement. We found no cases in which microscopic uterine serosal involvement changed stage and no cases of recurrence involving the uterus. Hysterectomy may be able to be safely excluded from non-fertility-sparing surgery for BOTs, particularly when disease is grossly confined to the ovaries.

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.

Comparison between laparoscopy and laparotomy in the surgical re-staging of granulosa cell tumors of the ovary

OBJECTIVE

To evaluate the role of laparoscopic (LPS) and laparotomic (LPT) re-staging in patients with incompletely surgically staged ovarian granulosa cell tumors (OGCT).

METHODS

We conducted a medical chart retrospective analysis of all patients with sex cord stromal tumors (SCSTs) who were managed in our division between March 1994 and March 2017. After a complete review of surgical and pathological notes, patients with incomplete staging were restaged according to the FIGO guidelines. Statistical analysis was conducted using Statistical Package version 20.0 for Windows (SPSS, Inc., Chicago, Illinois).

RESULTS

Out of a total of 170 patients SCSTs, 84 patients (49,5%) received primary surgery that included a hysterectomy; 86 patients (50,5%) underwent fertility-sparing surgery. Eighty-one patients (48%) with diagnosis of OGCT were incompletely surgically staged at another institution. We evaluated our results in terms of laparoscopic approach (56 patients) and open treatment (25 patients). Among the IA patient's group, 1 was upstaged to IIB stage and 2 to IIIB; among patients with IC stage, 1 was upstaged to IIA, 2 to IIB and 1 to IIIB stage. Adjuvant chemotherapy was given to the upstaged patients with final stage IIB-IIIC. No statistically significant difference between laparoscopy and open-surgery was detected in terms of upstaged patients after second surgery (p = 0,36).

CONCLUSION

According to our series, laparoscopic restaging compared to the open approach seems to be a feasible and efficient technique to complete surgical staging in patients with GCTs incorrectly staged. Surgical restaging seems to upstage a considerable number of OGCT, mainly in the initial stage IC group of patients. However, the impact of restaging on final outcome and survival remains to be demonstrated.

Apparent diffusion coefficients measured using different regions of interest in differentiating borderline from malignant ovarian tumors

Background

Apparent diffusion coefficients (ADCs) measured using different regions of interest (ROIs) are widely used in differentiating ovarian tumors.

Purpose

To evaluate the diagnostic performance of ADCs with different ROIs in differentiating borderline ovarian tumors (BOTs) from malignant ovarian tumors (MOTs).

Material and Methods

Thirty-five BOTs and 54 MOTs who underwent diffusion-weighted magnetic resonance imaging (MRI) were evaluated retrospectively. ADC values were independently measured using five ROI methods: round; rectangle; hot-spot; edge drawing; and five sample ROIs. The inter- and intraclass correlation coefficients (ICCs), one-way analysis of variance, receiver operating characteristic curve analysis, and unpaired t-tests were used to perform the statistical analyses.

Results

The measurement reproducibility of the minimum ADC and mean ADC values were good or excellent for BOTs and MOTs (ICC = 0.70–0.95). The minimum and mean ADC value by the edge drawing ROI were significantly higher than those of the other ROI methods (both P < 0.05). The area under the curve (AUC) of the minimum ADC value was less than that of the mean ADC value from the five ROI methods, whereas the AUCs of the mean ADC values from the round ROI and five sample ROIs were significantly larger than those of the other ROI methods ( P < 0.05). The minimum and mean ADC values from the five ROI methods showed significant differences between BOTs and MOTs (all P < 0.05).

Conclusion

The ROI shape influences the diagnostic performance of ADC value for differentiating BOTs from MOTs. The mean ADC values from the round ROI and five sample ROIs have better diagnostic efficiency.

A Rare Case of Ovarian Serous Borderline Tumor with Brain Metastasis

Background. Serous borderline tumor represents a group of noninvasive tumor of the ovary bridging between benign serous cystadenoma and serous carcinoma. They are commonly seen in younger women and usually have an excellent outcome but seldom show local recurrence (J. F. Leake et al. 1991). Metastasis to the lymph nodes has rarely been reported (M. D. Chamberlin et al., 2001; M. B. Verbruggen et al., 2006). Moreover, the brain is exceptionally a rare metastatic site for ovarian tumor. There is one case of an advanced staged SBT with micropapillary pattern metastasis to the brain recently and by far it is the most distant metastasis reported (M. D. Martin et al., 2017). However, to the best of our knowledge, no report has been documented for a recurrent stage 1 typical SBT metastasizing to the brain.

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.

Utility of DWI with quantitative ADC values in ovarian tumors: a meta-analysis of diagnostic test performance

Background Diffusion-weighted imaging (DWI) and quantitative apparent diffusion coefficient (ADC) values are widely used in the differential diagnosis of ovarian tumors. Purpose To assess the diagnostic performance of quantitative ADC values in ovarian tumors. Material and Methods PubMed, Embase, the Cochrane Library, and local databases were searched for studies assessing ovarian tumors using quantitative ADC values. We quantitatively analyzed the diagnostic performances for two clinical problems: benign vs. malignant tumors and borderline vs. malignant tumors. We evaluated diagnostic performances by the pooled sensitivity and specificity values and by summary receiver operating characteristic (SROC) curves. Subgroup analyses were used to analyze study heterogeneity. Results From the 742 studies identified in the search results, 16 studies met our inclusion criteria. A total of ten studies evaluated malignant vs. benign ovarian tumors and six studies assessed malignant vs. borderline ovarian tumors. Regarding the diagnostic accuracy of quantitative ADC values for distinguishing between malignant and benign ovarian tumors, the pooled sensitivity and specificity values were 0.91 and 0.91, respectively. The area under the SROC curve (AUC) was 0.96. For differentiating borderline from malignant tumors, the pooled sensitivity and specificity values were 0.89 and 0.79, and the AUC was 0.91. The methodological quality of the included studies was moderate. Conclusion Quantitative ADC values could serve as useful preoperative markers for predicting the nature of ovarian tumors. Nevertheless, prospective trials focused on standardized imaging parameters are needed to evaluate the clinical value of quantitative ADC values in ovarian tumors.

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.

Ovarian borderline tumors in the 2014 WHO classification: evolving concepts and diagnostic criteria

Borderline ovarian tumors (BOT) are uncommon but not rare epithelial ovarian neoplasms, intermediate between benign and malignant categories. Since BOT were first identified >40 years ago, they have inspired controversies disproportionate to their incidence. This review discusses diagnostic criteria for the histologic subtypes of BOT, highlighting areas of diagnostic challenges, ongoing controversies, and changes in terminology implemented by the recent 2014 WHO Classification of Tumours of the Female Genital Organs. Emerging knowledge supports the notion that subtypes of borderline ovarian tumors comprise distinct biologic, pathogenetic, and molecular entities, precluding a single unifying concept for BOT. Serous borderline tumors (SBT) share molecular and genetic alterations with low-grade serous carcinomas and can present at higher stages with peritoneal implants and/or lymph node involvement, which validates their borderline malignant potential. All other (non-serous) subtypes of BOT commonly present at stage I confined to the ovary(ies) and are associated with overall survival approaching that of the general population. An important change in the WHO 2014 classification is the new terminology of non-invasive implants associated with SBT, as any invasive foci (previously called “invasive implants”) are now in line with their biological behavior considered peritoneal low-grade serous carcinoma (LGSC). The controversy regarding the terminology of non-serous borderline tumors, called by some pathologists “atypical proliferative tumor” in view of their largely benign behavior, has not been resolved. The concepts of intraepithelial carcinoma and microinvasion may evolve in further studies, as their presence appears to have no prognostic impact and is subject to considerable inter-observer variability.

Ultrasonographic diagnosis and longitudinal follow-up of recurrences after conservative surgery for borderline ovarian tumors

BACKGROUND

Borderline ovarian tumors are generally diagnosed in young women. Because of the young age of patients at first diagnosis and at recurrence, and given the good prognosis of borderline ovarian tumors, a conservative surgical approach in those women who wish to preserve their fertility is advised. In this scenario, transvaginal ultrasound examination plays a key role in the detection of borderline ovarian tumor recurrence, and in assessment of amount of normal functioning parenchyma remaining. To date, no data are available about the natural history of borderline ovarian tumor recurrence.

OBJECTIVE

The aim of the study was to determine growth rate of recurrent ovarian cysts by a scheduled follow-up by ultrasound examination, in women previously treated with fertility-sparing surgery due to borderline ovarian tumors.

STUDY DESIGN

In this prospective observational study, we collected data from 34 patients previously treated with fertility-sparing surgery due to borderline ovarian tumors, who had a suspicious recurrent lesion. The patients underwent transvaginal ultrasonographic examination every 3 months, until the clinical setting recommended proceeding with surgery. According to cyst size at study entry, they were categorized into 3 groups: ≤10 mm, 10-20 mm, and >20 mm. Summary statistics for cyst size, growth rate, and the probability of remaining within the same dimension category at first ultrasound during the follow-up were also obtained. For each cyst the growth rate was calculated as the slope of the linear interpolation between 2 consecutive measurements.

RESULTS

Follow-up timing (P < .001), cyst size (P < .001), and micropapillary pattern (P < .001) were factors significantly affecting the cyst growth both in univariate and multivariate analysis. According to size category at first ultrasound, growth rate ranges from a minimum of 0.06 mm/mo for cysts <10 mm up to 1.92 mm/mo for cysts >20 mm. The final histology of all recurrent lesions confirmed the same histotype of primary borderline ovarian tumors.

CONCLUSION

This article represents the first observational study that describes the trend in the growth rate of borderline ovarian tumor recurrence in relation to their size detected at the first ultrasound examination. The findings of this study seem to confirm, in selected patients, that a thorough ultrasonographic follow-up of borderline ovarian tumor recurrence has proven to be safe and feasible. The final goal of such management is to maximize the impact on fertility potential of these young women without worsening their prognosis.

Borderline ovarian tumors: clinical characteristics, management, and outcomes - a multicenter study

Background

The optimal surgical management and staging of borderline ovarian tumors (BOTs) are controversial. Institutions have different surgical approaches for the treatment of BOTs. Here, we performed a retrospective review of clinical characteristics, surgical management and surgical outcomes, and sought to identify variables affecting disease-free survival (DFS) and overall survival (OS) in patients with BOTs.

Methods

A retrospective review of ten gynecological oncology department databases in Turkey was conducted to identify patients diagnosed with BOTs. The effects of type of surgery, age, stage, surgical staging, complete versus incomplete staging, and adjuvant chemotherapy were examined on DFS and OS.

Results

In total, 733 patients with BOTs were included in the analysis. Most of the staged cases were in stage IA (70.4 %). In total, 345 patients underwent conservative surgeries. Recurrence rates were similar between the conservative and radical surgery groups (10.5 % vs. 8.7 %). Furthermore we did not find any difference between DFS (HR = 0.96; 95 % confidence interval, CI = 0.7–1.2; p = 0.576) or OS (HR = 0.9; 95 % CI = 0.8–1.1; p = 0.328) between patients who underwent conservative versus radical surgeries. There was also no difference in DFS (HR = 0.74; 95 % CI = 0.8–1.1; p = 0.080) or OS (HR = 0.8; 95 % CI = 0.7–1.0; p = 0.091) between complete, incomplete, and unstaged patients. Furthermore, receiving adjuvant chemotherapy (CT) for tumor stage ≥ IC was not an independent prognostic factor for DFS or OS.

Conclusions

Patients undergoing conservative surgery did not show higher recurrence rates; furthermore, survival time was not shortened. Detailed surgical staging, including lymph node sampling or dissection, appendectomy, and hysterectomy, were not beneficial in the surgical management oF BOTs.

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.

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.

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.

Hereditary risk evaluation for borderline ovarian tumors based on immunohistochemistry

Objectives

Borderline ovarian tumors (BOT) are premalignant lesions. Approximately 10% of all epithelial ovarian cancers are known to be hereditary with hereditary breast and ovarian cancer (HBOC) accounting for approximately 90% of cases; the remaining 10% are attributable to Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC). The aim of our study is to estimate this risk based on screening immunohistochemistry (IHC).

Methods

Thirty-four patients diagnosed with BOT were identified. Family history, clinical characteristics, and IHC data (breast cancer 1, early onset [BRCA1], breast cancer 2, early onset [BRCA2], mutS homolog 2 [MSH2], mutL homolog 1 [MLH1]) were collected for all cases from the patients' medical charts. Nuclear staining of the tumor was scored as negative and positive.

Results

Among 32 patients, 14 (44%) had serous type and 18 (56%) had mucinous type. The mean patient age was 44 years (range 19-86).The number of patients with weak IHC staining for MSH2 and BRCA2 was 1 (3%) and 6 (19%) respectively. The median follow up was 21.8 months.

Conclusion

According to the results, we discovered that 3% and 19% of patients with BOT had a risk of hereditary cancer based on IHC analysis respectively. This pilot study may help clinician to counsel effectively for confirmative tests.

Borderline tumours of the ovary, current controversies regarding their diagnosis and treatment

Borderline ovarian tumours generally affect women of reproductive age. The positive prognosis is related to the fact that over 80% of cases are diagnosed at an early stage of the disease. Although radical surgery is the standard of care for this disease, fertility-sparing surgery can be performed in selected cases. Since it was first described in 1929, the knowledge of the molecular and histologic characteristics has been significantly improved. In this review, advances in the clinical behaviour, pathologic characteristics, prognostics factors, and different strategies of treatment are discussed.

Ovarian epithelial tumors and reproductive factors: a systematic review

PURPOSE

The aim of this systematic review is to summarize the current knowledge about the etiology and pathogenesis of borderline tumors ovarian cancer with special emphasis on the role of endocrine treatments and reproductive factors to establish a foundation for future studies.

METHODS

We performed a systematic review on the relation between ovarian epithelial tumors (OET) and reproductive factors using the keywords: ovarian cancer, ovarian tumor, ovarian borderline tumor, age at menarche, age at menopause, parity, infertility, PCO syndrome, oral contraception, menopausal hormone therapy, fertility treatment. Totally, 3,290 abstracts were scanned for their relevance in this publication and 127 were finally included.

RESULTS

The incidence of ovarian epithelial cancer and ovarian borderline tumors is influenced by certain reproductive factors. The strongest protective effects are conferred by parity and use of oral contraceptive pills. Recent molecular biologic and histopathologic studies prove that OET represent a diverse group of tumors, each histologic type with a different genetic background. This is at least partly reflected in epidemiologic and clinical studies showing different risk modulating effects of reproductive factors and endocrine therapies on OET.

CONCLUSIONS

The etiology and pathogenesis of ovarian cancer are still not fully understood. None of the so far proposed hypothesis on the development of OET can fully account for the epidemiologic and clinical findings in the context of reproductive factors and OET development. Further research approaches are warranted and need to put more weight on the clinical and genetical diversity of OET to yield a more detailed insight into their pathogenesis.

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.

Clinical significance of microinvasion in borderline ovarian tumors and its impact on surgical management

OBJECTIVE

The aims of this study were to evaluate the rate of recurrences in borderline ovarian tumors (BOTs) with microinvasion and to evaluate the possibility to enlarge fertility-sparing surgery in this group of patients.

METHODS

Between 1985 and 2010, 209 patients with BOTs were retrospectively divided into 2 groups: group 1 consisted of 28 women with microinvasive BOTs; group 2 consisted of 181 with BOTs without microinvasion. All of the patients were submitted to surgical treatment: in group 1, 10 patients underwent cystectomy (CYS), 11 patients underwent monolateral salpingo-oophorectomy (MSO), and 7 patients underwent bilateral oophorectomy with or without total hysterectomy (BSO); in group 2, 34 patients underwent CYS, 58 patients underwent MSO, and 89 patients underwent BSO. Specific prognostic factors such as stage, surgical approach, intraoperative spillage, histology, exophytic tumor growth, and endosalpingiosis were analyzed. Tumor recurrence rate and overall and disease-free survivals were evaluated.

RESULTS

After a mean follow-up of 53 months, relapses occurred in 21.4% of the cases in group 1 and in 12.7% of the cases in group 2 (P = 0.21). The prognostic factors had no significant differences in the 2 groups. Relapses after CYS, MSO, and BSO were observed in 30%, 27.3%, and 0%, respectively, in group 1 and in 29.4%, 12.1%, and 6.7%, respectively, in group 2. Progression-free survival was significantly longer in BOTs compared to microinvasive BOTs (P = 0.041), but overall survival did not differ.

CONCLUSIONS

Although exploratory, our data suggest that BOTs with microinvasion present earlier relapses, but overall incidence of relapses and overall survival do not differ significantly from BOTs without microinvasion. Fertility-sparing surgery is feasible in this group of patients, but strict follow-up has to be suggested.

Ultrasonographic markers and preoperative CA-125 to distinguish between borderline ovarian tumors and stage I ovarian cancer

OBJECTIVE

Preoperative evaluation of ovarian masses has become increasingly important for optimal planning of treatment. The aim of this study was to assess the role of preoperative serum cancer antigen 125 (CA-125) levels in correlation with ultrasonographic features in order to distinguish between borderline ovarian tumors (BOTs) and stage I epithelial ovarian carcinoma (EOC).

DESIGN

Retrospective study.

SETTING

Tertiary University Hospital.

POPULATION

We reviewed all women with BOTs and stage I EOC from January 2000 to December 2010. Data from 165 women (66 BOTs and 99 stage I EOC) were analyzed.

METHODS

Multivariable logistic regression with stepwise selection of variables was used to determine which clinical variables, ultrasound features and CA-125 level were independently associated with invasiveness.

MAIN OUTCOME MEASURES

Utility of ultrasonographic markers and CA-125 in the preoperative differential diagnosis between BOTs and stage I EOC.

RESULTS

Women with CA-125 > 100 IU mL(-1) had almost three times greater likelihood of belonging in the EOC group [odds ratio (OR) 3.02; confidence interval (CI) 95%: 1.13-8.12]. Furthermore, the presence of large solid component (≥20% of the tumor comprised of solid components) was associated with 4.25 times greater odds of it to representing ovarian cancer rather than a BOT (OR 4.25; 95% CI: 2.05-8.82). In contrast, the presence of papillary projections was associated with a 73% lower likelihood of EOC (OR 0.27; 95% CI: 0.13-0.58).

CONCLUSIONS

Preoperative CA-125 > 100 IU mL(-1) combined with the presence of a large solid component and the absence of papillary projections seems to improve the discriminative ability in favor of stage I EOC.

Fertility-sparing surgery for borderline ovarian tumors: oncologic safety and reproductive outcomes

INTRODUCTION

To evaluate the oncological safety and reproductive outcomes of patients with borderline ovarian tumors (BOTs) treated with fertility-sparing surgery.

METHODS

Patients with BOTs who underwent radical or fertility-sparing surgery between 1997 and 2009 were identified from an institutional database. The recurrence rates were compared between the 2 surgery groups. To compare the reproductive outcomes, all patients who underwent fertility-sparing surgery were interviewed by telephone.

RESULTS

One hundred forty-three patients underwent radical surgery, and 155 patients underwent fertility-sparing surgery. After a median interval of 38 months from the initial surgery (range, 10-77 months), 19 patients had a recurrence. The recurrence rate was similar in the radical and fertility-sparing surgery groups (4.9% and 7.7%, respectively; P = 0.280). In the fertility-sparing surgery group, however, the main site of recurrence was the remaining ovary that was successfully salvaged with a second round of fertility-sparing surgery. Of 51 patients who attempted to conceive, 45 patients (88.2%) were successful and resulted in 54 term deliveries.

CONCLUSIONS

Fertility-sparing surgery for BOTs is safe and can result in future pregnancies, suggesting that such surgery should be considered for young patients who desire preservation of fertility.

Fertility outcome after conservative surgery for borderline ovarian tumors: a single center experience

OBJECTIVE

The present study aims to document the experience of a single center on the reproductive outcome of a cohort of women who were treated with conservative surgery for borderline ovarian tumors and to specify whether their fertility potential is associated with age, tumor histology and surgery type.

METHODS

A total of 55 women who had undergone conservative surgery for borderline ovarian tumors between January 1999 and January 2009 were eligible. Recurrence rate, fertility outcome and the number of pregnancies were analyzed retrospectively.

RESULTS

Among the study group, 11 women were not sexually active both at the time of surgery and during the follow-up period. Thus, a total of 44 patients attempted pregnancy after conservative surgery and 52.3% of them (23 out of 44) were able to conceive either spontaneously or by in vitro fertilization. The ability to conceive was shown to be associated with age, tumor histology and type of conservative surgery. As expected, the fertility potential correlated positively with decreasing age (correlation coefficient = 0.705, p = 0.001). Moreover, the existence of non-serous histology and the implementation of unilateral cystectomy were found to be associated with the ability to reach a clinical pregnancy (correlation coefficient = 0.585, p = 0.001 and correlation coefficient = 0.587, p = 0.001, respectively).

CONCLUSIONS

The primary treatment of borderline ovarian tumors refers to conservative surgery. Younger age, non-serous histology and unilateral cystectomy appear to be associated with favorable reproductive outcome in women who undergo conservative surgery for borderline malignancy of ovary.

Risk factors for recurrence of ovarian borderline tumors

OBJECTIVE

The objective of this study was to identify clinicopathologic features that are associated with an increased risk of recurrence for borderline ovarian tumors (BOT).

METHODS

We performed a retrospective review of all patients treated for BOT at our institution from 1979 to 2008. Progression-free survival (PFS) was defined as the time of diagnosis to time of recurrence/death or last follow-up. The Kaplan-Meier method was used to calculate the PFS rate and the Wilcoxon-Gehan test was performed to identify prognostic factors.

RESULTS

A total of 266 patients were identified. The median age was 43 years (range, 15-94 years). The majority of patients (68.4%) had FIGO stage I disease and serous histology (73.7%). Only 23 (8.6%) patients developed recurrent disease. The median PFS was 19 years and the median follow-up was 4 years. Abnormal baseline CA-125 (>35 U/ml), advanced stage, age at diagnosis, and invasive implants were associated with decreased PFS. Of the 196 patients with serous BOT, those with a micropapillary pattern had a 3-year PFS of 75.9% (95%CI, 55.6-87.8) compared with 94.3% (95% CI, 88.4-97.3) for patients without micropapillary pattern (P<0.001).

CONCLUSION

Age at diagnosis, an elevated preoperative CA-125, invasive implants, and micropapillary histology were clinical factors associated with increased risk of recurrence in women with BOT. Including these clinicopathologic features will likely identify patients at higher risk for recurrence, for whom development of new treatment strategies would be appropriate.

Clinical management of borderline ovarian tumors

Borderline ovarian tumors (BOTs) are epithelial tumors of the ovaries characterized by cellular proliferation and nuclear atypia but without an infiltrative growth pattern. As they frequently affect younger patients the clinical management is complicated by considerations such as preserving fertility and reducing postoperative morbidity. Over the past several decades surgical therapy has shifted from a radical approach to more conservative treatment. There are various modes of surgery applied to the patients. All these developments have to be considered from an oncologic standpoint as BOTs represent a potentially malignant disease. Oncologic safety, as well as patients' desires and expectations, have to be balanced to reach the most appropriate treatment for BOTs. For this reason current literature will be discussed in this review to give a thorough overview of this topic and to develop recommendations for the surgical management of these patients. Open questions will be identified to elaborate the need for future surveys and research.

Ten years experience in the management of borderline ovarian tumors at Tom Baker Cancer Centre

OBJECTIVE

The aim of this study was to review the clinical outcomes of patients with borderline ovarian tumors (BOTs) at Tom Baker Cancer Centre (TBCC) and to assess the value of surgical staging.

METHODS

This retrospective study included 138 patients treated for BOTs at TBCC between January 1994 and December 2005. Patients were divided into two groups: group I with complete surgical staging (n = 89) and group II with incomplete surgical staging (n = 49). This population-based study identified patients using the Alberta Cancer Registry. Charts were reviewed by a single person. Data extracted included demographic information and prognostic factors such as age, histological type, laterality of the cyst, presence of microinvasion, and the type of surgical procedure. Data were extracted and entered into a study database for analysis. Overall survival and overall recurrence-free survival of both groups were calculated using the Kaplan-Meier method. Risk factors for recurrence were analyzed using Cox regression analysis.

RESULTS

A total of 138 patients were enrolled, with a mean age of 46 years. The median follow-up time was 37 months. The most common histological type of BOT was the serous type found in 70 (50.7%) patients. Microinvasion was identified in four (2.9%) patients. Twelve patients were found to have implants as result of the staging procedure; two of them were invasive implants and both required chemotherapy. Forty-three (31%) patients had conservative surgery and 95 (68.8%) patients had non-conservative surgery. Nine (6.5%) patients experienced recurrence: five (5.6%) patients in group I versus four (8.2%) patients in group II. The presence of microinvasion is the risk factor for recurrence (P = 0.013).

CONCLUSIONS

The indications for restaging surgery remain controversial, as there was no difference in recurrence rates observed between the study groups. However, surgical staging is important for identifying invasive extraovarian implants that need to be treated with chemotherapy. For patients who have conservative surgery, close- and long-term follow-up is required.

The role of restaging borderline ovarian tumors: single institution experience and review of the literature

BACKGROUND

Borderline ovarian tumors (BOTs) are a histological category of epithelial ovarian tumors and 70% of them are early diagnosed (stage I). Since early stage is the most important prognostic factor, restaging procedure could be justified. This study aims to evaluate the role of restaging surgery in the management of patients with borderline ovarian tumors referred to our Institution after being incompletely surgically staged in other hospitals.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients with BOT who were referred to our centre to undergo restaging procedure. From December 1995 to May 2008, 186 patients were treated for BOT and 70 patients met the inclusion criteria. Data collected included patients' age, primary and re-staging surgery details, FIGO stage after first and second procedure, pathological findings, and follow-up data.

RESULTS

FIGO stage after primary surgery was IA in 46 patients (68.6%), IB in 7 patients (10.4%), IC in 12 patients (17.9%, 6 due to ruptured cyst), IIA in 1 patient (1.4%), IIB in 1 patient (1.4%), III B in 2 patients (2.8%), and IIIC in 1 patient (1.4%). Among stage I patients (representing 97% of all patients), 12.3% (8 patients) were up-staged. The upstaging rate among serous tumors was 16.2%, and 4% among mucinous tumors. The mean follow-up time was 60.4 months from restaging surgery (SD 30.6 months). We observed 8 primary recurrences of the disease and 3 second recurrences.

CONCLUSIONS

There were no differences in terms of overall survival between patients who were upstaged and those who were not. Restaging procedure does not seem to have a significant impact on the management of patients diagnosed with borderline ovarian tumors, especially in mucinous subtype and apparent FIGO stage higher than I.

Complete lymph node dissection: is it essential for the treatment of borderline epithelial ovarian tumors?

OBJECTIVE

The present study aims to compare the clinical and reproductive outcomes of women who have undergone lymph node dissection with those who have not and to discuss the indications for retroperitoneal evaluation in the treatment of borderline ovarian tumors.

METHODS

The present study investigated 123 women who were finally diagnosed with borderline epithelial ovarian tumors at the study center between January 1999 and January 2009. A total of 68 patients (55.3%) were found to have a complete surgical staging procedure.

RESULTS

The patients who underwent complete lymph node dissection were significantly younger than those who did not have lymphadenectomy. Thus, the ratio of postmenopausal women was significantly higher among those in whom retroperitoneal evaluation was performed. As expected, the intraoperative blood loss was significantly more and the hospital stay was significantly longer in patients who underwent complete lymph node dissection. Also, the non-serous borderline ovarian tumors were significantly more frequent in the latter patient group. However, overall and disease-free survival spans were found to be statistically similar for both study groups as well as the recurrence rate.

CONCLUSIONS

Retroperitoneal evaluation can be spared in every woman with borderline ovarian tumor unless she is to undergo complete surgical staging procedure because of high recurrence risk, advanced stage disease or personal choice.

Phase II trial of the histone deacetylase inhibitor belinostat in women with platinum resistant epithelial ovarian cancer and micropapillary (LMP) ovarian tumours

AIM

Micropapillary/borderline (LMP) ovarian tumours are rarely included in clinical trials and are intrinsically resistant to radiation and chemotherapy. Platinum resistant epithelial ovarian cancer (EOC) has a poor prognosis. The histone deacetylase inhibitor belinostat demonstrated antitumour activity in pre-clinical ovarian cancer models.

METHODS

A phase II study was performed to evaluate the activity of belinostat in two patient populations: women with metastatic or recurrent platinum resistant (progression within 6 months) EOC and LMP ovarian tumours, both groups had received no more than 3 prior lines of chemotherapy. Belinostat 1000 mg/m(2)/d was administered iv days 1-5 of a 21 d cycle. Peripheral blood mononuclear cells (PBMCs) and tumour biopsies, where possible, for correlative studies were obtained prior to and following treatment.

RESULTS

Eighteen patients with EOC and 14 patients with LMP tumours were enrolled on study. Belinostat was well tolerated with no grade four toxicity (179 cycles). Grade 3 toxicity consisted of thrombosis (3 patients), hypersensitivity (1) and elevated ALP (1). One patient with LMP tumour had a partial response (unconfirmed) and 10 had stable disease (SD), 3 were non-evaluable. Median progression-free survival (PFS) was 13.4 months (95% confidence interval (CI), 5.6--not reached). Best response in patients with EOC was SD (nine patients) and median PFS was 2.3 months (95% CI, 1.2-5.7 months). An accumulation of acetylated histones H3 and H4 was noted in PBMCs and in tumour tissue.

CONCLUSIONS

Belinostat is well tolerated in both patient groups and shows some activity in patients with micropapillary (LMP) disease.

Current update on borderline ovarian neoplasms

OBJECTIVE

Borderline ovarian tumors comprise a unique group of noninvasive ovarian neoplasms with characteristic histology and variable tumor biology that typically manifest as low-stage disease in younger women with resultant excellent prognosis.

CONCLUSION

Borderline tumors are considered to be precursors of low-grade ovarian cancers. Accurate diagnosis and staging facilitate optimal patient management particularly in patients desiring to preserve fertility.

Borderline ovarian tumors and extended patient follow-up: an individual institution's experience

INTRODUCTION

Borderline tumors of the ovary (BOT) comprise nearly 20% of all ovarian malignancies and are associated with a favorable prognosis. However, since these lesions can present with malignant features and recur, a further evaluation of appropriate patient management and long-term follow-up is warranted.

METHODS

We report a physician group's retrospective experience treating BOT patients at a single institution. Patient demographics, disease pathology, treatment type (surgery, chemotherapy), and patient surveillance (e.g., disease-free survival (DFS), overall survival, follow-up via CA-125/radiology/physical exam) data were reviewed in all cases.

RESULTS

In the present study, 78 BOT patients treated from April 2001 until February 2009 were identified and confirmed via pathologic diagnosis. The majority (87%) underwent surgery, although nearly 13% of patients also received adjuvant chemotherapy. In the study population, 12% of the patients developed progressive disease, which was primarily detected via CA-125 and physical exam/disease symptomatology. DFS for these patients was 38 months. Recurrent disease was significantly related to the administration of chemotherapy (P = 0.0024) and prolonged time since initial treatment (P < 0.001).

DISCUSSION

Since BOT can be aggressive and eventually recur, continued (i.e., long-term) surveillance with CA-125 evaluation and physical examination should be considered for optimal patient follow-up.

[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.

Nuclear cyclin B1 is overexpressed in low-malignant-potential ovarian tumors but not in epithelial ovarian cancer

OBJECTIVE

To investigate the role of cyclin G1 and cyclin B1 in ovarian tumorigenesis.

STUDY DESIGN

We examined cyclin B1 and G1 expression in 58 epithelial ovarian cancer, 18 low-malignant-potential ovarian tumors, and 6 normal ovarian epithelium samples using immunohistochemistry. We also examined cyclin G1 and p53 expression in 7 epithelial ovarian cancer cell lines using Western blot analysis.

RESULTS

Nuclear cyclin B1 expression was significantly higher in low-malignant-potential tumors than in normal ovarian epithelium. There was no difference in nuclear or cytoplasmic cyclin B1 or cyclin G1 expression between epithelial ovarian cancer and normal ovarian epithelium. Cyclin G1 and B1 expression was not associated with p53 expression or clinicopathologic features in patients with epithelial ovarian cancer or low-malignant-potential tumors.

CONCLUSION

Our data demonstrated that nuclear cyclin B1 is overexpressed in low-malignant-potential tumors, which may contribute to the development of low-malignant-potential tumors. Cyclin B1 and G1 may not be suitable targets for epithelial ovarian cancer treatment.

Recent Developments on the Significance and Pathogenesis of Lymph Node Involvement in Ovarian Serous Tumors of Low Malignant Potential (Borderline Tumors)

In approximately 27% of patients that were surgically staged for ovarian serous borderline tumors (ovarian serous tumors of low malignant potential), regional lymph nodes, most commonly the pelvic and paraaortic groups, display morphologically similar epithelial clusters. Lymph nodes above the diaphragm may also be involved. Lymph node involvement does not adversely impact the overall survival of patients with ovarian serous borderline tumors, but there is controversy as to whether this finding is associated with a decrease in recurrence-free survival. Nodular aggregates of epithelium greater than 1 mm in maximum dimension, as compared with all other patterns of nodal involvement, have been associated with reduced recurrence-free survival. The lymph nodes may also be the site of recurrence and/or progression to carcinoma of an ovarian serous borderline tumor. Recent molecular and morphologic data suggest that although most nodal implants are indeed metastatic from their synchronous ovarian neoplasms, a small subset arise de novo from nodal endosalpingiosis. The precise mechanistic basis for how these noninvasive neoplasms achieve nodal metastases is unclear. However, because most patients with nodal metastases also have peritoneal implants, tumors that are ovary-confined and without ovarian surface involvement are rarely associated with nodal involvement, microinvasive borderline tumors frequently display lymphatic vessel involvement yet show a remarkably low frequency of nodal involvement, in conjunction with the recent finding that node-positive and node-negative tumors display no significant differences in lymphatic vessel density, suggest that the route of spread to lymph nodes in most cases is via the peritoneal and not tumoral lymphatics.

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.

Placental Pathology and Clinical Outcomes in a Cohort of Infants Admitted to a Neonatal Intensive Care Unit

BACKGROUND

Placental pathology predicts persistent neurological impairment, even in normally grown infants. However, few studies have linked placental pathology with neonatal outcomes in a large population.

METHODS

We matched the clinical outcomes of a cohort of neonates admitted to a neonatal intensive care unit (NICU) with placental pathology, where available, and examined (by multivariable logistic regression) the relationship between placental pathologies and these outcomes. The outcomes included neonatal death, necrotizing enterocolitis, and intraventricular hemorrhage > or = grade 3. A forward selection model (10% significance level for entry) was used after adjusting for onfounding factors.

RESULTS

A detailed gross and microscopic pathological report was available for 1296 eligible infants (64%). Specific placental features were associated with specific neonatal outcomes. The Canadian Neonatal Network has previously determined that specific changes in the pattern of neonatal care can alter the incidence and severity of these outcomes. In the placentas from pregnancies delivering small for gestational age infants who were subsequently admitted to NICU, two different patterns of placental pathologies were found, one ischemic and the other inflammatory.

CONCLUSION

Frozen section examination of placentas may facilitate more timely delivery of tailored neonatal therapy.

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.

Conserving fertility in the management of gynaecological cancers

The quality of cancer treatment is judged by both morbidity and mortality. Patients benefit if morbidity is reduced without compromising mortality. This applies particularly for women who develop gynaecological malignancy during their childbearing years where curative treatment also renders them infertile. This study reviews the increasing role of fertility-sparing surgery in such women. A literature search was undertaken using PubMed, entering the terms endometrial cancer, cervical cancer and ovarian cancer in conjunction with the terms fertility and fertility sparing. Each relevant identified paper was reviewed, references checked and results collated to provide an evidence-based summary of fertility-sparing treatments for gynaecological malignancy. Fertility-sparing surgery is appropriate in many circumstances, and all doctors who advise young women with gynaecological malignancy should be aware of these possibilities. However, data are relatively sparse in many situations, and careful counselling and balanced guidance are essential if patients are to understand the full implications of their choices.

Recurrence and prognostic factors in borderline ovarian tumors

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound features of different histopathological subtypes of borderline ovarian tumors

OBJECTIVE

To describe the gray-scale sonographic and color Doppler imaging features of the most common histopathological subtypes of borderline ovarian tumors.

METHODS

We analyzed retrospectively the preoperative transvaginal sonographic reports of patients with a histological diagnosis of borderline ovarian tumor. All patients were scanned consecutively by two of the investigators using transabdominal and transvaginal gray-scale imaging to assess the morphology and color Doppler to obtain indices of the blood flow. Sonographic findings were compared to histopathological data.

RESULTS

A total of 113 consecutive cases were reviewed from two referral centers for gynecological oncology. At histological examination 50 tumors (44%) were classified as being serous borderline ovarian tumors (SBOT), 61 (54%) were mucinous borderline ovarian tumors (MBOT) (42 intestinal type and 19 endocervical type), and two patients (2%) presented with borderline endometrioid tumors. SBOTs and endocervical-type MBOTs had very similar sonographic features and a smaller diameter, fewer locules (usually unilocular-solid lesions) and a higher color score than intestinal-type MBOTs. Intestinal-type MBOTs were characterized by a significantly higher percentage of lesions with > 10 locules when compared with the endocervical-type MBOTs.

CONCLUSION

Intestinal-type MBOTs have different sonographic features from other common borderline ovarian tumors.