Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

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.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC): New Approaches and Controversies on the Treatment of Advanced Epithelial Ovarian Cancer-Systematic Review and Meta-Analysis

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery has been extensively studied in patients with peritoneal carcinomatosis, and it holds promise as a therapeutic strategy, but its role remains elusive. The aim of this study was to assess the existing evidence for the use or not of HIPEC in primary debulking surgery (PDS), interval debulking surgery (IDS), and recurrent ovarian cancer (ROC), evaluated in terms of survival rates and post-surgical morbidity.

METHODS

Medline, Pubmed, Cochrane, and Medscape were systematically searched for any article comparing the use of HIPEC treatment with any other therapy in patients with ovarian cancer in PDS, IDS, and ROC. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. We only considered English-language published studies.

RESULTS

We included 14 studies, including two RCTs with a total of 1813 women, published between 2003 and 2023 with a recruitment period between 1998 and 2020. In PDS, there were no differences in progression-free survival (PFS) between HIPEC and controls [MD -5.53 months [95% CI -19.91 to 8.84 months]; I2 = 96%]. Conversely, in patients treated with NACT, pooled results showed a significant survival advantage in terms of progression-free survival (PFS) and overall survival (OS) in the combined HIPEC plus IDS group rather than surgery alone [PFS: MD 4.68 months (95% CI 3.49 to 5.86 months, I2 = 95%); OS: MD 11.81 months (95% CI 9.34 to 14.27 months); I2 = 97%]. Concerning ROC patients, pooled MD did not show either a significant PFS difference between intervention and controls [MD 2.68 months (95% CI 433 to 9.70 months); I2 = 95%], and OS significant difference (MD 6.69 months [95% CI -9.09 to 22.47 months]; I2 = 98%). Severe post-operative complications (≥grade 3) were available in 10 studies, accounting for 1108 women. Overall, there was a slightly but significantly increased risk with the combined approach compared to controls [RR 1.26 (95% CI 1.02 to 1.55); I2 = 0%].

CONCLUSIONS

The combination of HIPEC with cytoreductive surgery prolongs OS and PFS in advanced epithelial ovarian cancer after NACT with acceptable morbidity. However, additional trials are still needed to determine the effectiveness of HIPEC in primary and recurrence settings. In the era of personalized medicine, the correlation between the efficacy of HIPEC and biological and molecular findings represents a challenge for the future of ovarian cancer.

Evaluation of Borderline Ovarian Tumor Recurrence Rate after Surgery with or without Fertility-Sparing Approach: Results of a Retrospective Analysis

Borderline ovarian tumors (BOTs) comprise 15-20% of primary ovarian neoplasms and represent an independent disease entity among epithelial ovarian cancers. The present study (Clinical Trial ID: NCT05791838) aimed to report a retrospective analysis of the management and outcomes of 86 consecutive BOTs patients, 54 of which were at a reproductive age. All patients with BOTs undergoing surgical treatment from January 2010 to December 2017 were included. Data were retrospectively reviewed. High levels of Ca-125 were observed in 25.6% of the FIGO stage I patients and 58.3% of the advanced disease patients. Fertility-sparing surgery and comprehensive surgical staging were performed in 36.7% and 49.3% of the patients, respectively. Laparotomy was the most frequent surgical approach (65.1%). The most common diagnosis at frozen sections was serous BOT (50.6%). Serous BOTs have significantly smaller tumor diameters than mucinous BOTs (p < 0.0001). The mean postoperative follow-up was 29.8 months (range 6-87 months). Three patients experienced a recurrence, with an overall recurrence rate of 3.5% (10% considering only the patients who underwent fertility-sparing treatment). BOTs have low recurrence rates, with excellent prognosis. Surgery with proper staging is the main treatment. Conservative surgery is a valid option for women with reproductive potential.

Bilateral Ovarian Serous Borderline Tumor with Non-Invasive Endometrial Implants

Herein, we are presenting a case of a 33-year-old woman who presented to the emergency department complaining of persistent lower abdominal pain of one-day duration. Physical examination revealed abdominal tenderness with right lower quadrant rebound tenderness. Computed tomography abdomen/pelvis showed a 6 cm possible necrotic mass of the left ovary with moderate amount of complex ascites. A laparoscopic left oophorectomy with bilateral salpingectomy, right ovarian biopsy, and appendectomy were performed without complications. The cut surface of the left ovary showed a 9.7 cm × 8 cm × 4 cm ovarian mass, and the cut surface revealed multiple gray-tan friable papillary excrescence. Microscopic evaluation showed findings consistent with left and right ovarian serous borderline tumor (SBT). Subsequently, a tumor staging was conducted with total laparoscopic hysterectomy, pelvic and periaortic lymph node dissection, and omentectomy. The endometrium sections showed several small foci of SBT within the endometrial stroma, consistent with non-invasive implants of the endometrium. The omentum and lymph nodes were all negative for malignancy. SBTs associated with endometrial implants are very rare with only one case reported in the literature. Their existence can cause diagnostic challenges, and they should be acknowledged for early diagnosis and to plan for patient's treatment and outcome.

The impact of adjuvant antihormonal therapy versus observation on recurrence of borderline ovarian tumors: A retrospective cohort study

Objectives

Adjuvant management of borderline ovarian tumors (BOT) after surgical diagnosis and staging is not standardized. While many patients undergo observation alone, some providers have introduced the use of adjuvant antihormonal therapy for BOT, extrapolating from studies suggesting improvement in progression-free survival in the low-grade serous ovarian carcinoma population. We hypothesized that adjuvant antihormonal therapy after surgical diagnosis of BOT would improve progression-free survival compared to surveillance alone.

Methods

This is a retrospective review of BOT at one academic institution over thirteen years comparing management with antihormonal therapy, including aromatase inhibitors, progestins, and selective estrogen receptor modulators, to surveillance alone. Patients with concurrent malignancy were excluded. Data were abstracted from electronic medical records. Groups were compared by bivariate statistics.

Results

We identified 193 patients with BOT. Of these, 17 (8.8%) were treated with adjuvant antihormonal therapy and 24 (12.4%) recurred. Patients treated with antihormonal therapy were more likely to be obese (64.7% vs 37.9%, p = 0.032), have advanced-stage disease (70.6% vs 11.4%, p < 0.001), serous histotype (94.1% vs 59.4%, p = 0.005) or microinvasion (29.4% vs 9.7%, p = 0.030), and less likely to have undergone fertility-sparing surgery (18.8% vs 51.7%, p = 0.012). Use of antihormonal therapy was not associated with a difference in recurrence or survival.

Conclusions

This study is the first retrospective cohort review of adjuvant antihormonal therapy in BOT. We found that adjuvant antihormonal therapy for BOT is not associated with recurrence. While this single institution retrospective cohort study may lack the power to confirm or refute benefit, further studies could evaluate whether a subpopulation exists in whom antihormonal therapy is worthwhile.

Pulmonary metastases of a borderline ovarian tumor with multiple cystic formations: a case report

BACKGROUND

Metastatic lung tumors rarely present with cystic formations. This is the first report of multiple cystic formations in pulmonary metastases from mucinous borderline ovarian tumors written in English.

CASE PRESENTATION

A 41-year-old woman underwent left adnexectomy + partial omentectomy + para-aortic lymphadenectomy for a left ovarian tumor 4 years ago. The pathological finding was mucinous borderline ovarian tumor with a microinvasion. A chest computed tomography performed 3 years after surgery revealed multiple cystic lesions in both lungs. After 1-year follow-up, the cysts increased in size and wall thickness. Subsequently, she was referred to our department with multiple cystic lesions in both lungs. No laboratory findings indicated infectious diseases or autoimmune disorders that could cause cystic lesions in both lungs. Positron emission tomography showed slight accumulation in the cyst wall. Partial resection of the left lower lobe was performed to confirm the pathological diagnosis. The diagnosis was consistent with pulmonary metastases from a previous mucinous borderline ovarian tumor.

CONCLUSIONS

This is a rare case of lung metastases from a mucinous borderline ovarian tumor presenting with multiple lesions with cystic formation. Pulmonary cystic formations in patients with a borderline ovarian tumor should be considered as possible pulmonary metastases.

Lymph Node Involvement in Recurrent Serous Borderline Ovarian Tumors: Current Evidence, Controversies, and a Review of the Literature

Borderline ovarian tumors (BOTs) account for 10-20% of epithelial ovarian neoplasms. They are characterized by their lack of destructive stromal invasion. In comparison to invasive ovarian cancers, BOTs occur in younger patients and have better outcome. Serous borderline ovarian tumor (SBOT) represents the most common subtype of BOT. Complete surgical staging is the current standard management but fertility-sparing surgery is an option for SBOT patients who are at reproductive age. While most cases of SBOTs have an indolent course with favorable prognosis, late recurrence and malignant transformation can occur, usually in the form of low-grade serous carcinoma (LGSC). Thus, assessment of the recurrence risk is essential for the management of those patients. SBOTs can be associated with lymph node involvement (LNI) in up to 30% of patients who undergo lymph node dissection at diagnosis, and whether LNI affects prognosis is controversial. The present review suggests that recurrent SBOTs with LNI have poorer oncological outcomes and highlights the biases due to the scarcity of reports in the literature. Preventing SBOTs from recurring and becoming invasive overtime and a more profound understanding of the underlying mechanisms at play are necessary.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diffusion-weighted imaging-based radiomics in epithelial ovarian tumors: Assessment of histologic subtype

Background

Epithelial ovarian tumors (EOTs) are a group of heterogeneous neoplasms. It is importance to preoperatively differentiate the histologic subtypes of EOTs. Our study aims to investigate the potential of radiomics signatures based on diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps for categorizing EOTs.

Methods

This retrospectively enrolled 146 EOTs patients [34 with borderline EOT(BEOT), 30 with type I and 82 with type II epithelial ovarian cancer (EOC)]. A total of 390 radiomics features were extracted from DWI and ADC maps. Subsequently, the LASSO algorithm was used to reduce the feature dimensions. A radiomics signature was established using multivariable logistic regression method with 3-fold cross-validation and repeated 50 times. Patients with bilateral lesions were included in the validation cohort and a heuristic selection method was established to select the tumor with maximum probability for final consideration. A nomogram incorporating the radiomics signature and clinical characteristics was also developed. Receiver operator characteristic, decision curve analysis (DCA), and net reclassification index (NRI) were applied to compare the diagnostic performance and clinical net benefit of predictive model.

Results

For distinguishing BEOT from EOC, the radiomics signature and nomogram showed more favorable discrimination than the clinical model (0.915 vs. 0.852 and 0.954 vs. 0.852, respectively) in the training cohort. In classifying early-stage type I and type II EOC, the radiomics signature exhibited superior diagnostic performance over the clinical model (AUC 0.905 vs. 0.735). The diagnostic efficacy of the nomogram was the same as that of the radiomics model with NRI value of -0.1591 (P = 0.7268). DCA also showed that the radiomics model and combined model had higher net benefits than the clinical model.

Conclusion

Radiomics analysis based on DWI, and ADC maps serve as an effective quantitative approach to categorize EOTs.

MRI of Borderline Epithelial Ovarian Tumors: Pathologic Correlation and Diagnostic Challenges

Borderline epithelial ovarian tumors are a distinct pathologic entity characterized by increased epithelial proliferation and nuclear atypia, but without frank stromal invasion. Borderline tumor (BT) is now considered to represent an intermediate phase in the stepwise progression from benign to malignant ovarian epithelial tumor. Since BTs commonly manifest at early stages in women of reproductive age and are associated with a good prognosis, making the correct diagnosis is important in determining whether a patient is a candidate for fertility-sparing surgery. There are six histologic BT subtypes (serous, mucinous, seromucinous, endometrioid, clear cell, and Brenner), and each has different MRI features, reflecting their unique histologic architectures. Radiologists should be aware of the MRI features that can suggest BTs. These features include a hyperintense papillary architecture with hypointense internal branching, which can be observed with serous and seromucinous BTs on T2-weighted images; aggregates of microcysts that have hypointensity on T2-weighted images and reticular enhancement on contrast-enhanced T2-weighted images, which can be seen with mucinous BTs; and moderately high signal intensity on diffusion-weighted images along with relatively high apparent diffusion coefficient values, which can be observed regardless of the histologic subtype. Nevertheless, because the imaging features of BTs overlap with those of many benign lesions (eg, cystadenoma and cystadenofibroma, decidualized endometriosis, and polypoid endometriosis) and malignant tumors (ovarian cancers and metastases), histologic confirmation is required for the final diagnosis. Special emphasis is placed on the MRI features of BTs, pathologic correlation, and the challenges related to diagnosis. ^©RSNA, 2022.

Borderline ovarian tumor and MRI evaluation of a case report

Borderline ovarian tumors or atypical proliferative tumors are abnormal cells that arise from ovarian epithelium in contrast to ovarian cancers which form from stroma, the supportive tissue of ovaries. They are not invasive and tend to grow slowly. Many patients with BOTs are asymptomatic, while others have nonspecific symptoms like abdominal pain or abdominal distension. The absence of symptoms makes Borderline Ovarian Tumor hard to diagnose until it is in an advanced size or stage. Very rarely, the borderline tumor cells change into cancer cells. It usually affects patients at the reproductive age, for whom preserving the childbearing potential plays a very important role.

In this report, we present the case of 58-year-old female patient who is presented to the neurosurgeon's office with complaints of lower abdominal pain. Incidentally while investigating the intervertebral discs through a lumbar MRI, an abnormal finding was present in the coronal view, where a mass was noted on the lower right adnexal region of the abdomen. The patient was referred to a gynecologist for further investigations,

This case report emphasizes the high sensitivity and specificity of contrast MRI in the diagnosis of various pelvic pathologies in female patients.

Plasma cfDNA methylation markers for the detection and prognosis of ovarian cancer

Background

Plasma cell-free DNA (cfDNA) methylation has shown the potential in the detection and prognostic testing in multiple cancers. Herein, we thoroughly investigate the performance of cfDNA methylation in the detection and prognosis of ovarian cancer (OC).

Methods

The OC-specific differentially methylated regions (DMRs) were identified by sequencing ovarian tissue samples from OC (n = 61), benign ovarian disease (BOD, n = 49) and healthy controls (HC, n = 37). Based on 1,272 DMRs, a cfDNA OC detection model (OC-D model) was trained and validated in plasma samples from patients of OC (n = 104), BOD (n = 56) and HC (n = 56) and a prognostic testing model (OC-P model) was developed in plasma samples in patients with high-grade serous OC (HG-SOC) in the training cohort and then tested the rationality of this model with International Cancer Genome Consortium (ICGC) tissue methylation data. Mechanisms were investigated in the TCGA-OC cohort.

Findings

In the validation cohort, the cfDNA OC-D model consisting of 18 DMRs achieved a sensitivity of 94.7% (95% CI: 85.4%‒98.9%) at a specificity of 88.7% (95% CI: 78.7%‒94.9%), which outperformed CA 125 (AUC: 0.967 vs 0.905, P = 0.03). Then the cfDNA OC-P model consisting of 15 DMRs was constructed and associated with a better prognosis of HG-SOC in multivariable Cox regression analysis (HR: 0.29, 95% CI, 0.11‒0.78, P = 0.01) in the training cohort, which was also observed in the ICGC cohort using tissue methylation (HR: 0.56, 95% CI, 0.32‒0.98, P = 0.04). Investigation into mechanisms revealed that the low-risk group had higher homologous recombination deficiency and immune cell infiltration (P < 0.05).

Interpretation

Our study demonstrated the potential utility of cfDNA methylation in the detection and prognostic testing in OC. Future studies with a larger population are warranted.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.

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.

T2-weighted MRI-based radiomics for discriminating between benign and borderline epithelial ovarian tumors: a multicenter study

Background

Preoperative differentiation between benign and borderline epithelial ovarian tumors (EOTs) is challenging and can significantly impact clinical decision making. The purpose was to investigate whether radiomics based on T2-weighted MRI can discriminate between benign and borderline EOTs preoperatively.

Methods

A total of 417 patients (309, 78, and 30 samples in the training and internal and external validation sets) with pathologically proven benign and borderline EOTs were included in this multicenter study. In total, 1130 radiomics features were extracted from manually delineated tumor volumes of interest on images. The following three different models were constructed and evaluated: radiomics features only (radiomics model); clinical and radiological characteristics only (clinic-radiological model); and a combination of them all (combined model). The diagnostic performances of models were assessed using receiver operating characteristic (ROC) analysis, and area under the ROC curves (AUCs) were compared using the DeLong test.

Results

The best machine learning algorithm to distinguish borderline from benign EOTs was the logistic regression. The combined model achieved the best performance in discriminating between benign and borderline EOTs, with an AUC of 0.86 ± 0.07. The radiomics model showed a moderate AUC of 0.82 ± 0.07, outperforming the clinic-radiological model (AUC of 0.79 ± 0.06). In the external validation set, the combined model performed significantly better than the clinic-radiological model (AUCs of 0.86 vs. 0.63, p = 0.021 [DeLong test]).

Conclusions

Radiomics, based on T2-weighted MRI, can provide critical diagnostic information for discriminating between benign and borderline EOTs, thus having the potential to aid personalized treatment options.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01264-x.

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.

Develop a nomogram to predict overall survival of patients with borderline ovarian tumors

BACKGROUND

The prognosis of borderline ovarian tumors (BOTs) has been the concern of clinicians and patients. It is urgent to develop a model to predict the survival of patients with BOTs.

AIM

To construct a nomogram to predict the likelihood of overall survival (OS) in patients with BOTs.

METHODS

A total of 192 patients with histologically verified BOTs and 374 patients with epithelial ovarian cancer (EOC) were retrospectively investigated for clinical characteristics and survival outcomes. A 1:1 propensity score matching (PSM) analysis was performed to eliminate selection bias. Survival was analyzed by using the log-rank test and the restricted mean survival time (RMST). Next, univariate and multivariate Cox regression analyses were used to identify meaningful independent prognostic factors. In addition, a nomogram model was developed to predict the 1-, 3-, and 5-year overall survival of patients with BOTs. The predictive performance of the model was assessed by using the concordance index (C-index), calibration curves, and decision curve analysis (DCA).

RESULTS

For clinical data, there was no significant difference in body mass index, preoperative CA199 concentration, or tumor localization between the BOTs group and EOC group. Women with BOTs were significantly younger than those with EOC. There was a significant difference in menopausal status, parity, preoperative serum CA125 concentration, Federation International of gynecology and obstetrics (FIGO) stage, and whether patients accepted postoperative adjuvant therapy between the BOT and EOC group. After PSM, patients with BOTs had better overall survival than patients with EOC (P value = 0.0067); more importantly, the 5-year RMST of BOTs was longer than that of EOC (P value = 0.0002, 95%CI -1.137 to -0.263). Multivariate Cox regression analysis showed that diagnosed age and surgical type were independent risk factors for BOT patient OS (P value < 0.05). A nomogram was developed based on diagnosed age, preoperative serum CA125 and CA199 Levels, surgical type, FIGO stage, and tumor size. Moreover, the c-index (0.959, 95% confidence interval 0.8708–1.0472), calibration plot of 1-, 3-, and 5-year OS, and decision curve analysis indicated the accurate predictive ability of this model.

CONCLUSION

Patients with BOTs had a better prognosis than patients with EOC. The nomogram we constructed might be helpful for clinicians in personalized treatment planning and patient counseling.

Quantitative analysis of the MRI features in the differentiation of benign, borderline, and malignant epithelial ovarian tumors

Objective

This study aims to investigate the value of the quantitative indicators of MRI in the differential diagnoses of benign, borderline, and malignant epithelial ovarian tumors (EOTs).

Materials and methods

The study population comprised 477 women with 513 masses who underwent MRI and operation, including benign EOTs (BeEOTs), borderline EOTs (BEOTs), and malignant EOTs (MEOTs). The clinical information and MRI findings of the three groups were compared. Then, multivariate logistic regression analysis was performed to find the independent diagnostic factors. The receiver operating characteristic (ROC) curves were also used to evaluate the diagnostic performance of the quantitative indicators of MRI and clinical information in differentiating BeEOTs from BEOTs or differentiating BEOTs from MEOTs.

Results

The MEOTs likely involved postmenopausal women and showed higher CA-125, HE4 levels, ROMA indices, peritoneal carcinomatosis and bilateral involvement than BeEOTs and BEOTs. Compared with BEOTs, BeEOTs and MEOTs appeared to be more frequently oligocystic (P < 0.001). BeEOTs were more likely to show mild enhancement (P < 0.001) and less ascites (P = 0.003) than BEOTs and MEOTs. In the quantitative indicators of MRI, BeEOTs usually showed thin-walled cysts and no solid component. BEOTs displayed irregular thickened wall and less solid portion. MEOTs were more frequently characterized as solid or predominantly solid mass (P < 0.001) than BeEOTs and BEOTs. The multivariate logistic regression analysis showed that volume of the solid portion (P = 0.006), maximum diameter of the solid portion (P = 0.038), enhancement degrees (P < 0.001), and peritoneal carcinomatosis (P = 0.011) were significant indicators for the differential diagnosis of the three groups. The area under the curves (AUCs) of above indicators and combination of four image features except peritoneal carcinomatosis for the differential diagnosis of BeEOTs and BEOTs, BEOTs and MEOTs ranged from 0.74 to 0.85, 0.58 to 0.79, respectively.

Conclusion

In this study, the characteristics of MRI can provide objective quantitative indicators for the accurate imaging diagnosis of three categories of EOTs and are helpful for clinical decision-making. Among these MRI characteristics, the volume, diameter, and enhancement degrees of the solid portion showed good diagnostic performance.

Cancer Patient Tissueoid with Self-Homing Nano-Targeting of Metabolic Inhibitor

The current paradigm of cancer medicine focuses on patient- and/or cancer-specific treatments, which has led to continuous progress in the development of patient representatives (e.g., organoids) and cancer-targeting carriers for drug screening. As breakthrough concepts, i) living cancer tissues convey intact profiles of patient-specific microenvironmental signatures. ii) The growth mechanisms of cancer mass with intense cell-cell interactions can be harnessed to develop self-homing nano-targeting by using cancer cell-derived nanovesicles (CaNVs). Hence, a tissueoid model of ovarian cancer (OC) is developed by culturing OC patient tissues in a 3D gel chip, whose microchannel networks enable perfusion to maintain tissue viability. A novel model of systemic cancer responses is approached by xenografting OC tissueoids into ischaemic hindlimbs in nude mice. CaNVs are produced to carry general chemotherapeutics or new drugs under pre/clinical studies that target the BRCA mutation or energy metabolism, thereby increasing the test scope. This pioneer study cross-validates drug responses from the OC clinic, tissueoid, and animal model by demonstrating the alignment of results in drug type-specific efficiency, BRCA mutation-dependent drug efficiency, and metabolism inhibition-based anti-cancer effects. Hence, this study provides a directional foundation to accelerate the discovery of patient-specific drugs with CaNV application towards future precision medicine.

Undifferentiated Carcinoma After Laparoscopic Surgery for a Cystic Ovarian Tumour: A Case Study

BACKGROUND

Laparoscopic surgery for malignant tumours occasionally results in recurrence at the trocar insertion site or port-site metastasis (PSM). We report on a patient requiring emergency laparoscopic surgery for an ovarian tumour with a review of the relevant literature.

CASE REPORT

A 42-year-old woman developed sudden abdominal pain and underwent laparoscopic right adnexectomy because of a suspected ovarian cystic tumour rupture. The postoperative histological diagnosis was a mucinous borderline ovarian tumour; however, an undifferentiated carcinoma was detected at the port site eight months after the initial surgery. The histopathological diagnosis of the abdominal wall tumour at the port site differed from intraoperative pathological findings, which was contradictory to PSM definition. Postoperatively, she received three systemic chemotherapy courses but died consequent to tumour metastasis.

CONCLUSION

This is an atypical PSM case with histopathological differences from the initial tumour. Careful preoperative diagnosis and intraoperative attention are essential in such cases.

Diagnosis of Ovarian Neoplasms Using Nomogram in Combination With Ultrasound Image-Based Radiomics Signature and Clinical Factors

Objectives: To establish and validate a nomogram integrating radiomics signatures from ultrasound and clinical factors to discriminate between benign, borderline, and malignant serous ovarian tumors. Materials and methods: In this study, a total of 279 pathology-confirmed serous ovarian tumors collected from 265 patients between March 2013 and December 2016 were used. The training cohort was generated by randomly selecting 70% of each of the three types (benign, borderline, and malignant) of tumors, while the remaining 30% was included in the validation cohort. From the transabdominal ultrasound scanning of ovarian tumors, the radiomics features were extracted, and a score was calculated. The ability of radiomics to differentiate between the grades of ovarian tumors was tested by comparing benign vs borderline and malignant (task 1) and borderline vs malignant (task 2). These results were compared with the diagnostic performance and subjective assessment by junior and senior sonographers. Finally, a clinical-feature alone model and a combined clinical-radiomics (CCR) model were built using predictive nomograms for the two tasks. Receiver operating characteristic (ROC) analysis, calibration curve, and decision curve analysis (DCA) were performed to evaluate the model performance. Results: The US-based radiomics models performed satisfactorily in both the tasks, showing especially higher accuracy in the second task by successfully discriminating borderline and malignant ovarian serous tumors compared to the evaluations by senior sonographers (AUC = 0.789 for seniors and 0.877 for radiomics models in task one; AUC = 0.612 for senior and 0.839 for radiomics model in task 2). We showed that the CCR model, comprising CA125 level, lesion location, ascites, and radiomics signatures, performed the best (AUC = 0.937, 95%CI 0.905-0.969 in task 1, AUC = 0.924, 95%CI 0.876-0.971 in task 2) in the training as well as in the validation cohorts (AUC = 0.914, 95%CI 0.851-0.976 in task 1, AUC = 0.890, 95%CI 0.794-0.987 in task 2). The calibration curve and DCA analysis of the CCR model more accurately predicted the classification of the tumors than the clinical features alone. Conclusion: This study integrates novel radiomics signatures from ultrasound and clinical factors to create a nomogram to provide preoperative diagnostic information for differentiating between benign, borderline, and malignant ovarian serous tumors, thereby reducing unnecessary and risky biopsies and surgeries.

Serous Borderline Ovarian Tumor Diagnosis, Management and Fertility Preservation in Young Women

Borderline ovarian tumors (BOT) represent about 10 to 20 percent of all epithelial tumors of the ovary. They constitute intermediate lesions between benign ovarian cysts and invasive carcinomas. They often occur in young women of reproductive age, and, albeit with a favorable prognosis, it may recur on the ipsilateral or contralateral ovary. Controversies surround the diagnostic criteria used for their assessment, and the optimal management to minimize their risk of recurrence and/or transformation into malignant carcinoma. Fertility preservation (FP) is considered a priority in the management of these patients, and studies aim at finding the safest and most effective way to help women with BOT history conceive with minimal risk. We present the experience of a single institution in managing three cases of serous BOT in young nulliparous women, followed by a thorough review of the existing literature, highlighting controversies and exploring the possible FP techniques for these women.

Prognostic similarity between ovarian mucinous carcinoma with expansile invasion and ovarian mucinous borderline tumor: A retrospective analysis

There is a similarity of histological features and survival between ovarian mucinous carcinoma (MC) with expansile invasion and ovarian mucinous borderline tumor (MBT). The aim of this study was to compare the clinical outcomes of MC with expansile invasion with those of MBT based on the 2020 World Health Organization (WHO) criteria.A pathological review was performed on patients with MC, ovarian MBT, and seromucinous borderline tumors that underwent surgery at our hospital between 1984 and 2019. Clinicopathological features were compared retrospectively between MC with expansile invasion and MBT.Among 83 cases of MC, 85 cases of MBT, and 12 cases of seromucinous borderline tumor, 25 MC cases with expansile invasion and 98 MBT cases were included through review. MC cases with expansile invasion were diagnosed with advanced International Federation of Gynecology and Obstetrics (FIGO) stages more frequently (P = .02) than that of MBT cases. In addition, patients with MC with expansile invasion received adjuvant chemotherapy more often (P < .01) than that of patients with MBT. There were no statistically significant differences in recurrence rate (P = .10) between MC with expansile invasion and MBT. Progression-free survival (PFS) was worse in MC cases with expansile invasion than that in MBT cases (P = .01). However, a multivariate analysis for PFS showed that histological subtype, FIGO stage, and adjuvant chemotherapy were not an independent prognostic factor.The prognostic outcome of MC with expansile invasion might mimic those of MBT. These results showed ovarian borderline tumor treatment could be applied to MC treatment.

Is cystectomy an option as conservative surgery for young patients with borderline ovarian tumor? A multi-institutional retrospective study

OBJECTIVE

To investigate the impact of cystectomy for borderline ovarian tumor (BOT) on tumor recurrence compared with salpingo-oophorectomy using inverse probability of treatment weighting (IPTW).

METHODS

A central pathologic review and a search of the medical records from 14 collaborating institutions from 1986 to 2017 identified 4708 women with a malignant ovarian neoplasm. Data for young women with Stage I BOT were extracted. To compare recurrence-free survival between the surgery groups, Cox regression analyses and the IPTW-adjusted Kaplan-Meier method were employed.

RESULTS

During a median follow-up of 62.0 (1.2-270.4) months, 10 of the 285 patients identified (3.5%) developed recurrence. In multivariate analysis, the practice of cystectomy was not a significant prognostic indicator of recurrence-free survival (hazard ratio [95% confidence interval] 1.276 [0.150-10.864]; P = 0.823). In the IPTW-adjusted cohort, the 5-year recurrence-free survival rates were 95.8% and 96.0% in patients receiving cystectomy and salpingo-oophorectomy, respectively (P = 0.378).

CONCLUSION

If patients are selected appropriately, cystectomy in itself may not increase tumor recurrence in young women with early-stage BOT. A large-scale prospective clinical study is necessary to validate this finding.

Factors Influencing the Discordancy Between Intraoperative Frozen Sections and Final Paraffin Pathologies in Ovarian Tumors

Aim

To retrospectively investigate the pre-operative clinical factors and ultrasonographic features that influence the accuracy of the intraoperative frozen section (IFS) of ovarian tumors.

Patients and methods

Women with ovarian tumors that underwent IFS in one tertiary medical center were recruited from January 2010 to December 2018. Demographic and clinical data of these women were retrieved from medical records in the hospital's centralized database.

Results

A total of 903 ovarian tumors were enrolled, including 237 (26.2%) benign, 150 (16.6%) borderline tumor, and 516 (57.2%) malignant. The overall accuracy of IFS among all specimens was 89.9%. The sensitivities of IFS in diagnosing borderline tumors (82.0%) and malignant tumors (88.2%) were lower than in diagnosing benign tumors (98.7%, p <0.001, Z-test). The specificity of diagnosing malignant tumors (99.7%) was significantly higher than that of diagnosing benign tumors (94.7%, p <0.001, Z-test). The group with discordant IFS and final paraffin pathology (FPP) had younger age (47.2 ± 14.0 vs. 51.5 ± 11.8 years, p = 0.013, Mann-Whitney U test), and higher percentage of early-stage disease (85.2% vs. 65.1%, p = 0.001, chi-square test) and mucinous (39.3% vs. 3.3%) and endometrioid histologic types (34.4% vs. 20.2%) than the concordant group (all by chi-square test). Menopause (OR 0.34, 95% CI 0.15-0.76, p = 0.009), multicystic tumor in ultrasound (OR 2.14, 95% CI 1.14-4.01, p = 0.018), and ascites existence (OR 0.33, 95% CI 0.14-0.82, p = 0.016) were factors related to the discordant IFS by multivariate analysis.

Conclusions

IFS has good accuracy in the diagnosis of ovarian tumors. We recommend more frozen tissue sampling for sonographic multicystic tumors in premenopausal women to improve the accuracy of IFS.

Nationwide population-based study of prevalence and trend of borderline ovarian tumors in the Republic of Korea

Borderline ovarian tumors (BOTs) represent noninvasive tumors with uncertain malignant potential. They have a favorable prognosis although they can also recur or be fatal. There are limited population-based data on BOTs, its incidence and surgical treatment approach. We sought to analyze these trends in South Korea between 2014 and 2018. Data from patients diagnosed with BOT between 2014 and 2018 were obtained from the Health Insurance Review and Assessment Service/National Inpatient Sample in South Korea. Treatment was analyzed by using codes including adnexal surgery with or without hysterectomy. Data from 4,636,542 women were entered into the database between 2014 and 2018. Data from 5,109 women with BOT, and 537 women with surgery were extracted for analysis. The highest prevalence of BOT occurred in women 40–44 years old. In logistic regression analysis, age was significantly correlated with the prevalence of BOT (p < 0.05). The prevalence of BOT was lower in individuals over 50 than it was in those under 50 years (odds ratio (OR), 0.400 in 2014; OR, 0.457 in 2015; OR, 0.419 in 2016; OR, 0.355 in 2017; OR, 0.347 in 2018). The prevalence of BOT varies significantly with age, and is most common in women in their 40 s.

Borderline ovarian tumor in pregnancy: can surgery wait? A case series

PURPOSE

To study the characteristics of borderline tumors (BOT) diagnosed during pregnancy, as either first diagnosis or relapse, to evaluate safety of expectant management.

METHODS

15 women affected by BOT during pregnancy were included, to evaluate clinical and histo-pathological characteristics. Age of patient, parity, gestational age, follow-up time, size of tumor, surgical approach, type and timing of surgery, FIGO stage, and histologic type were obtained through retrospective review.

RESULTS

All patients except one were diagnosed with serous BOT (BOTs). Median follow-up time was 147 ± 57 months. Eight women received first diagnosis of BOT and seven had diagnosis of BOT recurrence during pregnancy, including three with a second relapse and four with a third relapse. BOT were diagnosed at FIGO stage I in most patients (75%) of the first group and in 14.3% of the second group, respectively. Micropapillary pattern was present in 71.4% of patients with first diagnosis of BOT, but only in 14.2% in case of relapse. All relapses were BOTs. No patient with BOT and concomitant pregnancy developed an invasive recurrence later. Overall, 24 relapses occurred in 10 patients (66.7%). Altogether 24 pregnancies occurred during follow-up, with a high livebirth rate (91.6%) and only 2 spontaneous miscarriages.

CONCLUSION

According to our experience, an "expectation management" could be a safe option in case of both relapse of BOTs during pregnancy and first suspicion of BOT in pregnant women at advanced gestational age.

Oncofertility outcomes after fertility-sparing treatment of bilateral serous borderline ovarian tumors: results of a large retrospective study

STUDY QUESTION

What are the oncofertility outcomes of young women (≤40 years old) with bilateral serous borderline ovarian tumors (SBOTs) after fertility-sparing surgery?

SUMMARY ANSWER

Fertility preservation with the bilateral ovarian cystectomy procedure is feasible for bilateral SBOTs, with an acceptable oncological outcome and worthwhile pregnancy rates.

WHAT IS KNOWN ALREADY

Fertility-sparing approaches are becoming the standard management of young patients with unilateral SBOTs and other borderline histological subtypes. However, there is a paucity of evidence to dictate the best management in bilateral SBOTs.

STUDY DESIGN, SIZE, DURATION

This was a retrospective observational study performed at the Peking Union Medical College Hospital in Beijing, China, between January 1999 and January 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ninety-four women (≤40 years old) with pathologically confirmed bilateral SBOTs were included. Following preoperative counseling, patients self-selected into one of three treatment modalities: bilateral ovarian cystectomy (n = 48), unilateral adnexectomy plus contralateral cystectomy (UAC; n = 31), and radical surgery (n = 15). Univariate and multivariate analyses were used to determine the clinical and pathological features associated with disease-free survival and reproductive outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

During the median follow-up of 64 months (range, 4-243 months), 61 patients (65%) developed relapse, including 3 (20%) in the radical group, 26 (84%) in the UAC group and 32 (67%) in the bilateral cystectomy group. In the multivariate analyses, preoperative CA-125>300 U/mL, fertility preservation and micropapillary pattern were independently associated with adverse disease-free survival (P = 0.001, 0.03 and 0.026, respectively). Fourteen patients (15%) experienced invasive recurrence, and three (3%) died of progressive disease. The micropapillary pattern was significantly associated with invasive evolution risk (P = 0.006). Of the 49 patients who attempted to conceive, 23 (47%) achieved 27 pregnancies (24 spontaneous and three after IVF-ET), resulting in 19 live births. There was no significant difference in disease-free survival (P = 0.13) or pregnancy rate (41 vs. 50%, P = 0.56) between the UAC and bilateral procedures.

LIMITATIONS, REASONS FOR CAUTION

As a retrospective study conducted in a referral center, inherent biases exist. The nonrandom allocation to treatment groups and relatively small number of patients attempt to conceive might limit the statistical power of our findings. Only 41 patients (43.6%) received complete staging during their initial surgeries, so an underestimation bias in terms of the FIGO stage and extraovarian implants might have occurred.

WIDER IMPLICATIONS OF THE FINDINGS

The ultraconservative bilateral ovarian cystectomy procedure should be proposed in bilateral SBOTs when technically feasible. Invasive evolution occurs frequently in these women, and intense follow-up and oncofertility counseling are warranted, especially for those with micropapillary patterns.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Salpingo-oophorectomy versus cystectomy in patients with borderline ovarian tumors: a systemic review and meta-analysis on postoperative recurrence and fertility

BACKGROUND

To compare the postoperative recurrence and fertility in patients with borderline ovarian tumors (BOTs) who underwent different surgical procedures: salpingo-oophorectomy versus cystectomy.

METHODS

Potentially relevant literature from inception to Nov. 06, 2020, were retrieved in databases including Cochrane Library, EMBASE (Ovid), and MEDLINE (Pubmed). We applied the keywords "fertility-sparing surgery," or "conservative surgery," or "cystectomy," or "salpingo-oophorectomy," or "oophorectomy," or "adnexectomy," or "borderline ovarian tumor" for literate searching. Systemic reviews and meta-analyses were performed on the postoperative recurrence rates and pregnancy rates between patients receiving the two different surgical methods. Begger's methods, Egger's methods, and funnel plot were used to evaluate the publication bias.

RESULT

Among the sixteen eligible studies, the risk of recurrence was evaluated in all studies, and eight studies assessed the postoperative pregnancy rates in the BOT patients. A total of 1839 cases with borderline ovarian tumors were included, in which 697 patients (37.9%) received unilateral salpingo-oophorectomy and 1142 patients (62.1%) underwent unilateral/bilateral cystectomy. Meta-analyses showed that BOT patients with unilateral/bilateral cystectomy had significantly higher recurrence risk (OR=2.02, 95% CI: 1.59-2.57) compared with those receiving unilateral salpingo-oophorectomy. Pooled analysis of four studies further confirmed the higher risk of recurrence in patients with cystectomy (HR=2.00, 95% CI: 1.11-3.58). In addition, no significant difference in postoperative pregnancy rate was found between patients with the two different surgical procedures (OR=0.92, 95% CI: 0.60-1.42).

CONCLUSION

Compared with the unilateral/bilateral cystectomy, the unilateral salpingo-oophorectomy significantly reduces the risk of postoperative recurrence in patients with BOT, and it does not reduce the pregnancy of patients after surgery.

TRIAL REGISTRATION

PROSPERO CRD42021238177.

Dysregulated Immunological Functionome and Dysfunctional Metabolic Pathway Recognized for the Pathogenesis of Borderline Ovarian Tumors by Integrative Polygenic Analytics

The pathogenesis and molecular mechanisms of ovarian low malignant potential (LMP) tumors or borderline ovarian tumors (BOTs) have not been fully elucidated to date. Surgery remains the cornerstone of treatment for this disease, and diagnosis is mainly made by histopathology to date. However, there is no integrated analysis investigating the tumorigenesis of BOTs with open experimental data. Therefore, we first utilized a functionome-based speculative model from the aggregated obtainable datasets to explore the expression profiling data among all BOTs and two major subtypes of BOTs, serous BOTs (SBOTs) and mucinous BOTs (MBOTs), by analyzing the functional regularity patterns and clustering the separate gene sets. We next prospected and assembled the association between these targeted biomolecular functions and their related genes. Our research found that BOTs can be accurately recognized by gene expression profiles by means of integrative polygenic analytics among all BOTs, SBOTs, and MBOTs; the results exhibited the top 41 common dysregulated biomolecular functions, which were sorted into four major categories: immune and inflammatory response-related functions, cell membrane- and transporter-related functions, cell cycle- and signaling-related functions, and cell metabolism-related functions, which were the key elements involved in its pathogenesis. In contrast to previous research, we identified 19 representative genes from the above classified categories (IL6, CCR2 for immune and inflammatory response-related functions; IFNG, ATP1B1, GAS6, and PSEN1 for cell membrane- and transporter-related functions; CTNNB1, GATA3, and IL1B for cell cycle- and signaling-related functions; and AKT1, SIRT1, IL4, PDGFB, MAPK3, SRC, TWIST1, TGFB1, ADIPOQ, and PPARGC1A for cell metabolism-related functions) that were relevant in the cause and development of BOTs. We also noticed that a dysfunctional pathway of galactose catabolism had taken place among all BOTs, SBOTs, and MBOTs from the analyzed gene set databases of canonical pathways. With the help of immunostaining, we verified significantly higher performance of interleukin 6 (IL6) and galactose-1-phosphate uridylyltransferase (GALT) among BOTs than the controls. In conclusion, a bioinformatic platform of gene-set integrative molecular functionomes and biophysiological pathways was constructed in this study to interpret the complicated pathogenic pathways of BOTs, and these important findings demonstrated the dysregulated immunological functionome and dysfunctional metabolic pathway as potential roles during the tumorigenesis of BOTs and may be helpful for the diagnosis and therapy of BOTs in the future.

Anaesthetic considerations for fertility-sparing surgery and uterine transplantation

A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation. Regardless of clinical indication, women now have the reproductive autonomy to make fully informed decisions regarding their future fertility. In particular, there has been an increasing interest and demand among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is it important to understand the surgical procedures now undertaken, but also the intra-operative management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also describes important anaesthetic challenges including peri-operative care for women undergoing complex fertility-sparing surgeries such as uterus transplantation.

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

•

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

•

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

•

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.

Role of Retinoblastoma Protein Family (Rb/p105 and Rb2/p130) Expression in the Histopathological Classification of Borderline Ovarian Tumors

Borderline ovarian tumors (BOT) are uncommon but not rare epithelial ovarian neoplasms, intermediate between benign and malignant categories. 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. The identification of valuable markers for the diagnosis and classification of these tumors is in need. Among the molecular candidates, the Retinoblastoma (Rb) family members Rb/p105 and Rb2/p130 seem to play a pivotal role in ovarian cancer. In particular, Rb/p105, when in the unphosphorylated form, acts as a growth suppressor controlling cell cycle and tumor progression; whereas, the phosphorylated form activates gene transcription and cellular proliferation. While Rb/p105 is ubiquitously confined to the nuclei of cycling and quiescent cells, Rb2/p130 activity is also regulated by intracellular localization. According to this, Rb family members could represent a novel marker in diagnosis and classification risk for patients with BOT. In this study, we evaluated the expression and subcellular localization of proteins of the retinoblastoma (Rb) gene family in 65 ovarian borderline tumors. Statistically significant differences were found in nuclear and cytoplasmic expressions of Rb/p105 and Rb2/p130 according to different examined histotypes. In detail, the nuclear expression of Rb/p105 and Rb2/p130 was more frequently detected in serous (84.6%) than sero-mucinous (42.1%) and mucinous (50%) types. Conversely, the cytoplasmic expression of Rb2/p130 was not detected in serous tumors and frequently observed in mucinous subtypes (80%). Our findings suggest that Rb proteins do not play a key role in the tumor progression of serous borderline tumors since any cases showed cytoplasmic localization. By contrast, the observed higher cytoplasmic expression of Rb2/p130 in intestinal mucinous BOTs is indicative of Rb protein family involvement in the cancerogenesis pathway of mucinous ovarian tumors. Also, mucinous BOTs of intestinal-type, exhibiting low nuclear and high cytoplasmic levels of Rb2/p130 might potentially be considered a high-risk category of malignant evolution. Further studies on larger series are needed to clarify how BOTs could be stratified in different prognostic groups according to their Rb proteins immunohistochemical profile.

Malignant Transformation of a Borderline Ovarian Tumor With Pulmonary and Pleural Metastases After Years of Latency: A Case Report and Literature Review

Borderline ovarian tumor (BOT) refers to a distinct tumor of the ovary of epithelial origin and typically has a favorable prognosis. However, these tumors are not exempt from risks of recurrence and malignant transformation, which can arise from the remaining ovarian tissue, peritoneal implants, or distant localization. Here, we report a case of a mucinous BOT with multiple pulmonary cystic nodules without evidence of pulmonary metastasis even after two fine needle biopsies. Staging surgery was performed, and no evidence of peritoneal implants or invasion to adjacent organs found. At the end of the 7-year monitored follow-up after surgery, the pulmonary lesions were found to be increased in size. The transbronchial lung biopsy and pleural biopsy confirmed transformation into malignant mucinous adenocarcinoma with pleural metastasis. In the current case, we observed potential pulmonary metastasis of the BOT with malignant transformation and a latency as long as 7 years, which reminds us that multiple pulmonary cystic changes in patients with BOTs should be screened carefully to evaluate the pulmonary involvement of BOTs and potentially false-negative results after fine needle biopsy. Thus, a thorough check-up for complete staging of the disease and a close long-term follow-up to monitor potential recurrence and malignant transformation are advised.

Reproductive and obstetrical outcomes with the overall survival of fertile-age women treated with fertility-sparing surgery for borderline ovarian tumors in Sweden: a prospective nationwide population-based study

OBJECTIVE

To assess the efficacy of fertility-sparing surgery (FSS) in terms of reproductive outcomes by following FSS for borderline ovarian tumors (BOTs) and comparing the safety of FSS versus radical surgery (RS).

DESIGN

Nationwide cohort study based on prospectively recorded data.

SETTING

Sweden.

PATIENT (S)

All women of reproductive age (18-40 years) treated in Sweden for stage I BOT with the use of FSS or RS from 2008 to 2015, identified in the Swedish Quality Registry for Gynecologic Cancer (SQRGC).

INTERVENTIONS (S)

FSS or RS.

MAIN OUTCOME MEASURE (S)

Reproductive outcomes: natural conception, use of assisted reproductive technology (ART), live birth and obstetrical outcomes. Safety outcome: overall survival (OS) rates, comparing women undergoing FSS versus RS. The FSS cohort was linked to the Swedish Medical Birth Register to identify all women who had given birth after FSS and to obtain detailed obstetrical data. For information on ART treatment, the National Quality Registry for Assisted Reproduction was consulted. OS rate comparisons were conducted by means of Kaplan-Meier estimates.

RESULT (S)

Of the 277 women with BOTs, 213 (77%) underwent FSS, 183 (86%) unilateral salpingo-oophorectomy, and 30 (14%) cystectomy. Following FSS, 50 women gave birth to 62 healthy children, 8% of which were preterm. Only 20 (9%) of the women underwent ART treatment. OS was similar in women treated with FSS and RS.

CONCLUSION (S)

Natural fertility was maintained after FSS; only 9% required ART treatment. FSS was also deemed to be equivalent to RS regarding survival outcome.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CPH-I and HE4 Are More Favorable Than CA125 in Differentiating Borderline Ovarian Tumors from Epithelial Ovarian Cancer at Early Stages

Aim

To evaluate the diagnosis value of serum human epididymis protein 4 (HE4), cancer antigen 125 (CA125), the Risk of Ovarian Malignancy Algorithm (ROMA), and Copenhagen Index (CPH-I) at early stages for differentiating borderline ovarian tumors from epithelial ovarian cancer.

Methods

We recruited 144 borderline ovarian tumors in FIGO stages I and II (BOT I+II), 108 epithelial ovarian cancers in FIGO stages I and II (EOC I+II), and 238 benign ovarian tumor patients with surgical treatment in the retrospective study. The concentration of HE4 and CA125 and the values of CPH-I and ROMA were assessed separately.

Results

The HE4 level and ROMA and CPH-I values of EOC I+II were all higher than that of BOT I+II and benign groups whether in all, pre-, or postmenopausal groups (P < 0.01). When distinguishing BOT I+II from EOC I+II, the AUC-ROC of CPH-I and HE4 were bigger than CA125 (P < 0.001), while the CPH-I has the highest sensitivities in all and postmenopausal groups (78.7%, 85.1%), and HE4 has the highest specificity and PPV (90.91%, 88.64%) in postmenopausal groups. Under pathological stratification, HE4, ROMA, and CPH-I of the serous EOC I+II were higher than that of BOT I+II (P < 0.001) and the AUC of the three indices were significantly bigger than CA125 (P < 0.001). However, the concentration of HE4 and CA125 and the values of CPH-I and ROMA have no significant difference between the two endometrioid subgroups. The index with the highest sensitivity and NPV among the four indices of different pathological subtype groups was CPH-I, and the index with the highest specificities and PPV was HE4.

Conclusion

CPH-I was more valuable than CA125 for differentiating BOT I+II from EOC I+II regardless of menopausal status, while HE4 might be better than CA125 for postmenopausal subgroups. HE4 and CPH-I were more favorable than CA125 for differentiating BOT I+II from EOC I+II in the case of unknown pathology or in serous type.

Recurrence rate and associated factors of borderline ovarian tumors in the south of Vietnam

AIM

This study aimed to determine the recurrence rate and related risk factors of borderline ovarian tumors (BOT).

METHODS

We conducted a retrospective cohort study with 433 patients who were surgically treated for primary BOT at Tu Du Hospital from 11/2008 to 09/2015. We used the life table method to estimate the cumulative recurrence rate. We used the log-rank test and Cox proportional hazard model to determine recurrence-associated factors.

RESULTS

Median follow-up time was 43 months (range: 3-105 months). Eighteen patients developed recurrence. The cumulative BOT recurrence rates at year 1, 2, 3 and 4 were 1.2% (95% confidence interval [CI] = 0.5-2.8), 3.0% (95% CI = 1.7-5.2), 4.6% (95% CI = 2.9-7.4), and 5.1% (95% CI = 3.2-8.0), respectively. In the final multivariate model, a higher recurrence rate was significantly associated with primary tumor stages (stage I vs stages II and III, hazards ratio [HR] = 4.44, 95% CI = 1.60-12.38), pre-operative tumor's capsule rupture (HR = 4.14, 95% CI = 1.78-9.64), and cystectomy (HR = 5.33, 95% CI = 1.43-19.91).

CONCLUSION

The overall BOT recurrence rate in women in southern Vietnam was moderate. Primary tumor stage, capsule rupture, and cystectomy were main factors associated with BOT recurrence. Appropriate follow-up strategies for patients with high-risk factors are needed for early detection and management of recurrence.

A rat model of serous borderline ovarian tumors induced by 7,12-dimethylbenz[a]anthracene

Serous borderline ovarian tumors (SBOTs) behave between benign cystadenomas and carcinomas, and the effective detection and clinical management of SBOTs remain clinical challenges. Because it is difficult to isolate and enrich borderline tumor cells, a borderline animal model is in need. 7,12-dimethylbenz[a]anthracene (DMBA) is capable of inducing the initiation, promotion, and progression of serous ovarian tumors. This study aims to investigate the proper dosage and induction time of DMBA for rat models of SBOTs, and explore their morphological features demonstrated by magnetic resonance (MR) imaging and molecular genetic characteristics. Rats were randomly divided into six groups (1 mg/70 D, 2 mg/70 D, 3 mg/70 D, 2 mg/50 D, 2 mg/90 D, and 2 mg/110 D). The 3 mg/70 D group induced the most SBOTs (50.0%, 12/24). The micropapillary projections were shown on MR imaging, which was the characteristic of SBOTs. The Cyclin D1 characterizing an early pathogenetic event strongly expressed in induced serous benign tumors (SBTs). The immunoreactivity staining scores of P53 expression significantly increased from SBTs, SBOTs to serous ovarian carcinomas (SCAs), which elucidate that P53 might be a promising biomarker to grade serous ovarian tumors. Based on morphological and molecular genetic similarities, this rodent SBOT model was suitable for investigating the pathogenesis of serous ovarian tumors and developing an early detection strategy.

Preservation of Fertility or Ovarian Function in Patients with Breast Cancer or Gynecologic and Internal Malignancies

Because of the efficacy of systemic therapies, neoplasias which occur in pediatric and adolescent patients and in young adults have high cure rates. This means that fulfilling their wish to have children has become a more pressing concern, particularly among young women with malignant tumors. Premature ovarian failure is also a not insignificant problem as it has a lasting detrimental effect on quality of life. Every oncology patient who may potentially wish to have children should be informed about their options for preserving fertility prior to starting treatment. The rates of patient who received detailed briefing on this point remain low. This review presents the effects of different chemotherapeutic drugs on gonadal function together with an overview of currently valid recommendations on fertility preservation. Risk groups are defined and the specific approaches for malignancies of various organ systems are described. Cryopreservation of oocytes, fertilized embryos and ovarian tissue are fertility-preserving options for girls/young women. The data on the benefits of administering GnRH analogs for ovarian protection prior to starting chemotherapy are not clear. In postpubertal boys or male cancer patients, the standard approach is to cryopreserve sperm before starting therapy. The cryopreservation of testicular tissue is possible for prepubertal boys, however in-vitro sperm maturation is still in its experimental stages. This review also presents existing drug options for the preservation of ovarian function in oncology patients prior to chemotherapy, particularly for patients with (hormone-sensitive) breast cancer, and looks at the special issues of fertility-preserving surgery and radiation therapy in patients with gynecologic malignancies.

Borderline tumors of the ovary: A clinicopathological study

Objective:

To report experience with borderline ovarian tumors (BOTs) in a developing country like Pakistan with limited resources and weak database of health system.

Methods:

Patients with BOTs managed at Shaukat Khanum Cancer hospital, Lahore, Pakistan from 2004 to 2014 were included and reviewed retrospectively. Data was recorded on histopathological types, age, CA-125, stage of disease, treatment modalities and outcomes.

Results:

Eighty-six patients with BOT were included with a median age of 35 years. Forty-two (49%) patients had serous BOTs and 43 (50%) had mucinous BOTs, while one (1%) had mixed type. Using FIGO staging, 80 patients had stage I; two patients had IIA, IIB and stage III each. Median follow-up time was 31.5 months. All patients had primary surgery. Seventy (81%) patients underwent complete surgical resection of tumor. Forty-three (50%) patients had fertility preserving surgery. Seventy-three (85%) patients remained in remission. Recurrent disease was observed in 13 (15%) patients. Median time to recurrence was 22 months. On further analysis, age above forty years, late stage at diagnosis and incomplete surgery were significantly associated with invasive recurrence.

Conclusion:

Despite a low malignant potential, relapses may occur in patients above forty years of age, incomplete surgery and staging information and advanced stage at presentation. Fertility sparing surgery should be considered in young patients. Complete excision of tumor and prolonged follow-up are advised because recurrence and transformation to invasive carcinoma may occur.