Comparison of two fertility-sparing approaches for bilateral borderline ovarian tumours: a randomized controlled study

Fertility sparing treatment for bilateral borderline ovarian tumor: a case report and management strategy explication

A bilateral adnexal mass with suspected carcinosis could be a challenging experience for the gynecologist especially in fertile age and in patients with a desire for pregnancy. A 26-year-old patient who came to the outpatient clinical observation for bilateral, multilocular pelvic masses, with more than 4 papillary structures, color score 2, hypomobile compared to the uterus and rectum, respectively of 65 and 68mm in maximum diameter, free liquid in the abdomen and suspected of ovarian neoplasm. Positive tumor markers and a strong desire of a fertility sparing treatment (FST). A 2-step surgical approach managed to perform a diagnosis of bilateral ovarian borderline tumor with implants and a fertility sparing surgery. Harvesting and cryopreserving oocytes prior to the cytoreductive intervention was successfully performed.

Long-term surgical outcomes in pediatric ovarian neoplasms: 20-year single-center experience

PURPOSE

The management of pediatric ovarian neoplasms (ON) is based on finding a balance between adequate surgical treatment and future reproductive capacity. We aimed to evaluate long-term results of patients who underwent surgery for ON.

METHODS

A retrospective cohort study design was used. Medical records of patients with ON were reviewed. They were invited to participate in a telephone-based survey assessing complaints, menstrual status, and post-surgical recurrence.

RESULTS

Eighty-five patients were operated for ON between 1995 and 2015. Median age at surgery was 14.7 years. 62.4% of patients had ovary-sparing surgery (OSS). Median tumor size in oophorectomy group was significantly larger than OSS group (p = 0.029). Median length of follow-up was 5.1 years. Recurrent/metachronous disease was not significantly different between OSS and oophorectomy groups (p = 1.000). In OSS group, irregular menses (p = 0.004) and painful menses (p = 0.002) were significantly higher than oophorectomy group.

CONCLUSION

The main goal of treatment in pediatric ON is to find the right balance between adequate and appropriate tumor resection and maximal effort for fertility preservation. Our results showed no difference between oophorectomy and OSS in the terms of recurrence. Although irregular and painful menses were found to be significantly higher in the OSS group, longer follow-up and prospective studies are needed to clarify this issue.

Rapid and sensitive detection of ovarian cancer biomarker using a portable single peak Raman detection method

Raman spectroscopy (RS) is a widely used non-destructive technique for biosensing applications because of its ability to detect unique ‘fingerprint’ spectra of biomolecules from the vibrational bands. To detect these weak fingerprint spectra, a complex detection system consisting of expensive detectors and optical components are needed. As a result, surface enhanced Raman spectroscopy (SERS) method were used to increase the Raman signal multifold beyond 10¹² times. However, complexity of the entire Raman detection system can be greatly reduced if a short wavelength region/unique single spectral band can distinctly identify the investigating analyte, thereby reducing the need of multiple optical components to capture the entire frequency range of Raman spectra. Here we propose the development of a rapid, single peak Raman technique for the detection of epithelial ovarian cancers (EOC)s through haptoglobin (Hp), a prognostic biomarker. Hp concentration in ovarian cyst fluid (OCF) can be detected and quantified using Raman spectroscopy-based in vitro diagnostic assay. The uniqueness of the Raman assay is that, only in the presence of the analyte Hp, the assay reagent undergoes a biochemical reaction that results in product formation. The unique Raman signature of the assay output falls within the wavenumber region 1500–1700 cm⁻¹ and can be detected using our single peak Raman system. The diagnostic performance of our Raman system had 100.0% sensitivity, 85.0% specificity, 100.0% negative predictive value and 84.2% positive predictive value when compared to gold standard paraffin histology in a proof-of-concept study on 36 clinical OCF samples. When compared to blood-based serum cancer antigen 125 (CA125) levels, the Raman system-based assay had higher diagnostic accuracy when compared to CA125, especially in early-stage EOCs.

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.

MRI-Based Multiple Instance Convolutional Neural Network for Increased Accuracy in the Differentiation of Borderline and Malignant Epithelial Ovarian Tumors

BACKGROUND

Preoperative differentiation of borderline from malignant epithelial ovarian tumors (BEOT vs. MEOT) is challenging and can significantly impact surgical management.

PURPOSE

To develop a multiple instance convolutional neural network (MICNN) that can differentiate BEOT from MEOT, and to compare its diagnostic performance with that of radiologists.

STUDY TYPE

Retrospective study of eight clinical centers.

SUBJECTS

Between January 2010 and June 2018, a total of 501 women (mean age, 48.93 ± 14.05 years) with histopathologically confirmed BEOT (N = 165) or MEOT (N = 336) were divided into the training (N = 342) and validation cohorts (N = 159).

FIELD STRENGTH/SEQUENCE

Three axial sequences from 1.5 or 3 T scanner were used: fast spin echo T2-weighted imaging with fat saturation (T2WI FS), echo planar diffusion-weighted imaging, and 2D volumetric interpolated breath-hold examination of contrast-enhanced T1-weighted imaging (CE-T1WI) with FS.

ASSESSMENT

Three monoparametric MICNN models were built based on T2WI FS, apparent diffusion coefficient map, and CE-T1WI. Based on these monoparametric models, we constructed an early multiparametric (EMP) model and a late multiparametric (LMP) model using early and late information fusion methods, respectively. The diagnostic performance of the models was evaluated using the receiver operating characteristic (ROC) curve and compared to the performance of six radiologists with varying levels of experience.

STATISTICAL TESTS

We used DeLong test, chi-square test, Mann-Whitney U-test, and t-test, with significance level of 0.05.

RESULTS

Both EMP and LMP models differentiated BEOT from MEOT, with an area under the ROC curve (AUC) of 0.855 (95% CI, 0.795-0.915) and 0.884 (95% CI, 0.831-0.938), respectively. The AUC of the LMP model was significantly higher than the radiologists' pooled AUC (0.884 vs. 0.797).

DATA CONCLUSION

The developed MICNN models can effectively differentiate BEOT from MEOT and the diagnostic performances (AUCs) were more superior than that of the radiologists' assessments.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

Fertility-Sparing Surgery for Ovarian Cancer

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

Second fertility preservation surgery for early relapse of seromucinous borderline ovarian tumors

•The initial diagnosis was endometriosis; however, the postoperative diagnosis was a seromucinous borderline ovarian tumor.•Women of reproductive age experienced an early relapse of seromucinous borderline ovarian tumor after surgery.•Transvaginal ultrasound was useful for early diagnosis of relapse.•A second fertility preservation surgery was performed, and fertility treatment without relapse was ongoing.

Analysis of Factors Influencing Relapse and Pregnancy in Patients with Borderline Ovarian Tumors

Objective: This retrospective study analyzed the factors affecting recurrence in patients after surgery with borderline ovarian tumors and postoperative recurrence and pregnancy after fertility-sparing surgery (FSS), to provide guidance for clinical treatment of borderline ovarian tumors and propose a therapeutic strategy for fertility protection.

Methods: A total of 415 patients with borderline ovarian tumors were initially operated on in the gynecology ward of Shengjing Hospital Affiliated with China Medical University from September 1, 2013, to September 1, 2019. Central pathology review and prospective follow-up were carried out. The clinical and pathological data were consulted through the medical record query system of our hospital. The recurrence and pregnancy of the patients were investigated through telephone follow-up and outpatient and inpatient medical records. The influence of clinical and pathological variables on recurrence and pregnancy were evaluated using univariate/multivariate analyses.

Results: In this study, 415 patients were collected, of which 21 lost follow-up, and a total of 394 eligible patients were included in the analysis. Among these patients, 25 patients relapsed with a recurrence rate of 6.3% and there were 196 patients with fertility-sparing surgery, of the 63 patients attempting to conceive, 35 were able to attain pregnancy with a pregnancy rate of 55.6%. All patients survived until the follow-up deadline. In univariate and multivariate analyses, FSS, FIGO stage, and micropapillary pattern were independent risk factors for recurrence of BOTs. FIGO stage, micropapillary pattern were independent risk factors for recurrence of BOTs with FSS. The risk of recurrence was not related to omentectomy nor postoperative chemotherapy. While omentectomy and chemotherapy had an impact on the pregnancy rate (P <0.05) and the pregnancy rate of patients without omentectomy or chemotherapy was higher.

Conclusion: Omentectomy did not affect recurrence and it is not recommended as a routine operation. Adjuvant chemotherapy does not reduce the recurrence rate. While omentectomy and chemotherapy had an impact on the pregnancy rate, and both of them should be carried out more carefully in patients with fertility requirements.

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.

Fertility preservation in women with malignant and borderline ovarian tumors: Experience of the French ESGO-certified center and pregnancy-associated cancer network (CALG)

OBJECTIVE

To describe strategy and results of fertility preservation (FP) in patients with malignant and borderline ovarian tumors.

METHODS

Consecutive cohort study of 43 women with malignant or borderline ovarian tumors who underwent FP between February 2013 and July 2019. The study was conducted in national expert center in Tenon University Hospital, Sorbonne University: French ESGO-certified ovarian cancer center and pregnancy-associated cancer network (CALG). Main outcome measure was FP technique proposed by multidisciplinary committee, FP technique used, time after surgery, number of fragments, histology and follicle density (if ovarian tissue freezing), number of expected, retrieved and frozen oocytes (if ovarian stimulation).

RESULTS

Pathological diagnosis was malignant epithelial ovarian tumor in five women (11.6%), rare malignant ovarian tumor in 14 (32.6%), borderline in 24 (55.8%), and mostly unilateral (79.1%) and stage I (76.7%). Mean age at diagnosis was 26.8 ± 6.9 years and mean tumor size 109.7 ± 61 mm. Before FP, mean AFC was 11.0 ± 6.1 and AMH levels were 2.7 ± 4.6 ng/mL. Six ovarian tissue-freezing procedures were performed (offered to 13). Twenty-four procedures of ovarian stimulation and oocyte freezing were performed after surgical treatment for 19 women (offered to 28) with a median interval of 188 days. The mean number of mature oocytes retrieved per stimulation was 12.4 ± 12.8. At least 10 mature oocytes were frozen for 52.6% of the women. No FP was offered to five women.

CONCLUSION

Oocyte and ovarian tissue cryopreservation should be offered to patients with malignant and borderline ovarian tumors. More data are needed to confirm ovarian stimulation and ovarian tissue grafting safety.

Fertility-Sparing Treatment for Early-Stage Cervical, Ovarian, and Endometrial Malignancies

Approximately 20% of gynecologic malignancies are diagnosed in reproductive-aged women, and standard-of-care surgical treatment often precludes future fertility. In early-stage disease, shared decision making about fertility-sparing medical and surgical approaches may give well-selected patients the opportunity to pursue their family-building goals without compromising long-term survival. Although future fertility is an important consideration for young women with cancer, rates of fertility-sparing procedures remain low. Moreover, because data on pregnancy rates and outcomes after fertility-sparing treatments are limited, it is challenging to counsel patients on realistic expectations. This review examines the critical oncologic outcomes of fertility-sparing approaches in early-stage gynecologic malignancies and highlights pregnancy outcomes in this population.

Fertility preservation after fertility-sparing surgery in women with borderline ovarian tumours

OBJECTIVE

To present a case series of women with borderline ovarian tumours (BOTs) who underwent oocyte vitrification in addition to fertility-sparing surgery.

STUDY DESIGN

Observational study of all women referred to a French fertility preservation unit between 2015 and 2019 for counselling regarding a fertility preservation (FP) strategy after BOT fertility-sparing surgery. All eligible women underwent one or more cycles of controlled ovarian stimulation (COS) using an antagonist protocol, followed by oocyte retrieval. Metaphase II (MII) oocytes were vitrified.

RESULTS

Twenty-five women with BOTs were referred during the study period. Among them, 11 women underwent at least one cycle of COS. One hundred and seven MII oocytes were vitrified. The mean number of vitrified MII oocytes per woman was 9.7 (standard deviation 5.2). Five live births were reported during follow-up of four women with vitrified oocytes: three spontaneous pregnancies, one in-vitro fertilization cycle with fresh embryo transfer, and one live birth after return of vitrified oocytes.

CONCLUSION

Conservative surgery for BOTs offers a high spontaneous pregnancy rate but has a higher risk of relapse than radical treatment. Furthermore, women who undergo conservative BOT surgery have a higher risk of surgery-induced premature ovarian failure. Oocyte cryopreservation after COS appears to be an effective technique after the conservative management of BOTs in women of reproductive age. Although the available short-term data are reassuring, further long-term studies evaluating the safety and cost-effectiveness of this systematic FP strategy after BOT fertility-sparing surgery are required.

Fertility preservation in borderline ovarian tumor patients and survivors

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

MRI-Based Machine Learning for Differentiating Borderline From Malignant Epithelial Ovarian Tumors: A Multicenter Study

BACKGROUND

Preoperative differentiation of borderline from malignant epithelial ovarian tumors (BEOT from MEOT) can impact surgical management. MRI has improved this assessment but subjective interpretation by radiologists may lead to inconsistent results.

PURPOSE

To develop and validate an objective MRI-based machine-learning (ML) assessment model for differentiating BEOT from MEOT, and compare the performance against radiologists' interpretation.

STUDY TYPE

Retrospective study of eight clinical centers.

POPULATION

In all, 501 women with histopathologically-confirmed BEOT (n = 165) or MEOT (n = 336) from 2010 to 2018 were enrolled. Three cohorts were constructed: a training cohort (n = 250), an internal validation cohort (n = 92), and an external validation cohort (n = 159).

FIELD STRENGTH/SEQUENCE

Preoperative MRI within 2 weeks of surgery. Single- and multiparameter (MP) machine-learning assessment models were built utilizing the following four MRI sequences: T₂ -weighted imaging (T₂ WI), fat saturation (FS), diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), and contrast-enhanced (CE)-T₁ WI.

ASSESSMENT

Diagnostic performance of the models was assessed for both whole tumor (WT) and solid tumor (ST) components. Assessment of the performance of the model in discriminating BEOT vs. early-stage MEOT was made. Six radiologists of varying experience also interpreted the MR images.

STATISTICAL TESTS

Mann-Whitney U-test: significance of the clinical characteristics; chi-square test: difference of label; DeLong test: difference of receiver operating characteristic (ROC).

RESULTS

The MP-ST model performed better than the MP-WT model for both the internal validation cohort (area under the curve [AUC] = 0.932 vs. 0.917) and external validation cohort (AUC = 0.902 vs. 0.767). The model showed capability in discriminating BEOT vs. early-stage MEOT, with AUCs of 0.909 and 0.920, respectively. Radiologist performance was considerably poorer than both the internal (mean AUC = 0.792; range, 0.679-0.924) and external (mean AUC = 0.797; range, 0.744-0.867) validation cohorts.

DATA CONCLUSION

Performance of the MRI-based ML model was robust and superior to subjective assessment of radiologists. If our approach can be implemented in clinical practice, improved preoperative prediction could potentially lead to preserved ovarian function and fertility for some women.

LEVEL OF EVIDENCE

Level 4.

TECHNICAL EFFICACY

Stage 2. J. Magn. Reson. Imaging 2020;52:897-904.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS AND CONCLUSION

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

CONCLUSION

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

[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).

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

OBJECTIVE

To determine the place of imaging and the performance of different imaging techniques (transvaginal ultrasound with or without Doppler, scoring, CT, MRI) to differentiate benign tumour, borderline ovarian tumour (BOT) and malignant ovarian tumor. Differentiate the histological subtypes of BOT (serous, sero-mucinous, mucinous) and prediction in imaging of the possibility of conservative treatment.

METHODS

The research was carried out over the last 16 years using the terms "MeSH" based on the query of the Medline® database and supplemented by the review of references contained in the meta-analyzes, systematic reviews and original articles included.

RESULTS

Endo-vaginal and suprapubic ultrasonography is recommended for analysis of an ovarian mass (grade A). In the case of ultrasound by a referent, subjective analysis is the recommended technique (grade A). In case of echography by a non-referent, the use of "Simple Rules" is recommended (grade A) and should be best combined with subjective analysis to rejoin the performance of a sonographer refer (grade A). In cases of undetermined ovarian lesions in endovaginal ultrasound and suprapubic ultrasound, it is recommended to perform a pelvic MRI (grade A). The MRI protocol should include T2, T1, T1 sequences with fat saturation, diffusion, injected dynamics, and after gadolinium injection (grade B). To characterize an MRI-adnexal image, it is recommended to include a risk score for malignancy (ADNEX-MR/O-RADS) (grade C) in the report and to formulate an anatomopathological hypothesis (Grade C). The predictive signs of benignity in front of a cyst with endocystic vegetations are the low number, the small size, the presence of calcifications and the absence of Doppler flow in case of size greater than 10mm in echography (LP 4) and a curve of type 1 MRI (LP4). MRI is recommended for suspicious lesions of BOT in ultrasound (grade B) or indeterminate lesions in ultrasound (grade A). There is no data to support the usefulness of CT or PET-CT for BOT. Morphological criteria in ultrasound and MRI exist to differentiate BOT from invasive tumors regardless of grade (NP 2). Pelvic MRI is recommended to characterize a tumor suggestive of ultrasound BOT (grade C). No recommendations can be made about the use of combined ultrasound, biological, and menopausal status scores for the diagnosis of BOT. The diagnostic performance of imaging to detect peritoneal implants of BOT is not known. The assessment of the invasiveness of peritoneal implants of imaging BOT has not been evaluated. The association of macroscopic signs in MRI makes it possible to differentiate the different subtypes - serous, sero-mucinous and mucinous (intestinal type) - of BOT, despite the overlap of certain presentations (LP3). The analysis of macroscopic MRI signs must be performed to differentiate the different subtypes of TFO (grade C). No recommendation can be made on imaging prediction of the possibility of conservative BOT treatment.

New sonographic marker of borderline ovarian tumor: microcystic pattern of papillae and solid components

OBJECTIVE

To describe and evaluate the utility of a new sonographic microcystic pattern, which is typical of borderline ovarian tumor (BOT) papillary projections, solid component(s) and/or septa, as a new ultrasound marker that is capable of distinguishing BOT from other adnexal masses, and to present/obtain histologic confirmation.

METHODS

In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who had undergone preoperative transvaginal ultrasound (TVS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations, associated with solid component(s), papillary projections and/or septa. From the same cases, histopathologic slides of each BOT were examined for presence of any of these microcystic features which had been identified on TVS. To confirm that the microcystic TVS pattern is unique to BOTs, we also selected randomly from our ultrasound and surgical database 20 cases of epithelial ovarian cancer and 20 cases of benign cystadenoma, for review by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to determine whether the association between microcystic tissue pattern and BOT has been described previously.

RESULTS

Included in the final analysis were 62 patients (67 ovaries) with preoperative TVS and surgically confirmed BOT on pathologic examination. The mean patient age at surgery was 39.8 years. The mean BOT size at TVS was 60.7 mm. Of the 67 BOTs, 47 (70.1%) were serous, 15 (22.4%) were mucinous and five (7.5%) were seromucinous. We observed on TVS a microcystic pattern in the papillary projections, solid component(s) and/or septa in 60 (89.6%) of the 67 BOTs, including 46 (97.9%) of the 47 serous BOTs, 11 (73.3%) of the 15 mucinous BOTs and three (60.0%) of the five seromucinous BOTs. On microscopic evaluation, 60 (89.6%) of the 67 samples had characteristic 1-3-mm fluid-filled cysts similar to those seen on TVS. In seven cases there was a discrepancy between sonographic and histologic observation of a microcystic pattern. The 20 cystadenomas were mostly unilocular and/or multilocular and largely avascular. None of them or the 20 epithelial ovarian malignancies displayed microcystic characteristics, either on TVS or at histology. On review of 23 published articles in the English medical literature, containing 163 sonographic images of BOT, we found that, while all images contained it, there was no description of the microcystic tissue pattern.

CONCLUSION

We report herein a novel sonographic marker of BOT, a 'microcystic pattern' of BOT papillary projections, solid component(s) and/or septa. This was seen in the majority of both serous and mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of benign entities and malignancies, the microcystic appearance seems to be unique to BOTs. No similar description has been published previously. Utilization of this new marker should help to identify BOT correctly, discriminating it from ovarian cancer and benign ovarian pathology, and should ensure appropriate clinical and surgical management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Borderline Ovarian Tumors: Fifteen Years' Experience at a Scottish Tertiary Cancer Center

OBJECTIVES

Since the recognition of borderline ovarian tumors (BOTs) in the 1970s, the management of this subset of epithelial ovarian tumors has presented a challenge to clinicians. The majority present at an early stage, but their diagnosis is often only made following surgery, hence the heterogeneity of surgical management. Borderline ovarian tumors are morphologically diverse, and their behavior is subsequently also heterogeneous. We aimed to assess recurrence rates and the rate of malignant transformation in patients diagnosed with BOT. Secondary objectives included a review of current management and assessment of tumor markers, stage, cyst dimensions, and the presence of micropapillary features as prognostic indicators of recurrence.

METHODS

This retrospective cohort study included all patients treated with BOT between 2000 and 2015 in the southeast region of Scotland. Clinical, surgicopathological, and follow-up data were collated. Data were analyzed with reference to recurrence and malignant transformation.

RESULTS

Two hundred seventy-five patients underwent treatment for BOT in the study period. Surgical management was highly variable. A diagnosis of recurrent/persistent BOT or ovarian malignancy following initial treatment of BOT was rare, with only 12 (4%) of 275 cases. There were 7 cases (3%) of ovarian malignancy. Advanced International Federation of Gynecology and Obstetrics stage was the most prominent prognostic factor. Elevated preoperative serum CA-125 and the presence of micropapillary features correlated with advanced stage at presentation. With a lack of clear guidance, follow-up was highly variable with a median of 43 months (0-136 months).

CONCLUSIONS

To our knowledge, this study is the largest BOT cohort in the United Kingdom. Recurrent disease is rare in optimally staged, completely resected, early-stage BOT, without high-risk features. Caution is needed in women electing not to undergo completion staging after diagnosis and in those opting for a fertility-preserving approach. Thorough informed consent and clear plans for surveillance and follow-up are needed with consideration of delayed completion surgery as appropriate.

Utero-ovarian preservation and overall survival of young women with early-stage borderline ovarian tumors

PURPOSE

To examine survival of women who had uterine and ovarian preservation during surgical treatment for early-stage borderline ovarian tumors (BOTs).

METHODS

The Surveillance, Epidemiology, and End Results Program was used to identify women aged < 50 years with stage I BOTs who underwent ovarian conservation at surgical treatment between 1988 and 2003. Survival outcomes were examined based on the use of concurrent hysterectomy at surgery.

RESULTS

Among 6379 cases of BOT, there were 1065 women who had utero-ovarian preservation at surgery, and there were 52 women who had hysterectomy with ovarian preservation alone. Women who had uterine preservation were more likely to be single and diagnosed in recent years (both, P < 0.05). On univariable analysis, women who had utero-ovarian preservation had cause-specific survival similar to those who had ovarian preservation alone without uterine preservation (10-year rates: 99.2% versus 98.1%, P = 0.42); however, overall survival was higher in the utero-ovarian preservation group compared to the hysterectomy group (95.8% versus 87.6%, P < 0.001). On multivariable analysis, utero-ovarian preservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.35, 95% confidence interval 0.15-0.79, P = 0.012). Cardiovascular disease mortality was lower in the utero-ovarian preservation group compared to the hysterectomy group, but it did not reach statistical significance (20-year cumulative rate, 0.8% versus 3.0%, P = 0.29).

CONCLUSION

Our study suggests that utero-ovarian preservation for young women with early-stage BOTs may be associated with improved overall survival compared to ovarian preservation alone without affecting BOT-related survival outcome.

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review

BACKGROUND

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review.

RESULTS

Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence.

CONCLUSIONS

Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly 3-4).

A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility

STUDY OBJECTIVE

To develop a predictive score for ovarian malignancy to avoid unnecessary adnexectomy in cases of adnexal mass in pediatric and adolescent girls.

DESIGN

A population-based retrospective study on girls who underwent surgery for an ovarian mass with normal levels of human chorionic gonadotrophin and alpha fetoprotein between 1996 and 2016.

SETTING

Rennes University Hospital, Rennes, France.

PARTICIPANTS

Eighty-one patients who received surgery for ovarian tumor.

MAIN OUTCOME MEASURES

The main outcome measure was the rate of malignant and borderline tumor. A preoperative scoring system was constructed after multivariate analysis.

RESULTS

The rate of malignant ovarian tumor was 6/81 (7%), borderline tumor was 7/81 (9%) (ie, outcome measure: 16%), and benign tumor was 84%. In a univariate analysis, the characteristics significantly associated with malignancy were early puberty, palpable mass, size and content of the tumor, and positive epithelial tumor markers (carcinoma antigen 125, carcinoembryonic antigen, and carcinoma antigen 19-9). The predictive malignancy score was on the basis of 2 variables obtained after multivariate analysis: tumor size and cystic content. The score defined 3 groups at risk for malignancy: low risk, middle-risk, and high-risk. The sensitivity for detecting malignancy was 1.3% (95% confidence interval [CI], 0.1-18.4), 26.2% (95% CI, 11.6-49.0), and 53.1% (95% CI, 29.1-75.8), respectively.

CONCLUSION

We set up a simple predictive score of malignancy on the basis of objective criteria to help decision-making on whether or not ovarian-sparing surgery is feasible in case of children and adolescents with ovarian tumors and normal human chorionic gonadotrophin and alpha fetoprotein levels while ensuring oncologic safety.

Identification of factors that impact recurrence in patients with borderline ovarian tumors

Background

The lack of consensus around best practices for management of borderline ovarian tumors (BOT) is, in part, to the lack of available data and of clarity in interpreting relationships among various factors that impact outcomes. The objective of this study was to identify clinicopathological factors that impact prognosis of patients with borderline ovarian tumors (BOT) and to address features of this disease with the objective of providing clarity in decision making around management of BOT.

Results

A total of 178 BOT patients were included in this study, with a median age of 43 years and a median follow-up time of 37 months. Thirty-two (18.0%) recurrences and 5 (2.8%) deaths were observed in this study group. Multivariate analysis showed that fertility-preserving surgery (P = 0.0223 for bilateral cystectomy) and invasive implants (P = 0.0030) were significantly associated with worse PFS, whereas lymphadenectomy (P = 0.0129) was related to improved PFS. No factors were found to be associated with OS due to the limited number of deaths. In addition, patients with serous BOT more commonly had abnormal levels of CA125, while patients with mucinous BOT more commonly had abnormal levels of CEA. Patients with abnormal levels of CA125, or CA19-9, or HE4 had significantly larger tumor sizes.

Conclusions

Our study reveals the impact of certain types of fertility-preserving surgery, lymphadenectomy and invasive implants on PFS of BOT patients. Blood cancer markers may be associated with histology and size of BOT. Our findings may assist in selection of optimum treatment for BOT patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13048-017-0316-5) contains supplementary material, which is available to authorized users.

Role of Imaging Tools for the Diagnosis of Borderline Ovarian Tumors: A Systematic Review and Meta-Analysis

Borderline ovarian tumors (BOTs) have a low malignant potential and occur most often in young women. Its preoperative diagnosis can improve surgical strategy and reproductive approach. This study systematically reviews the literature for the accuracy of transvaginal ultrasound (TVUS), magnetic resonance (MRI), and computed tomography (CT) in the diagnostic of BOTs. We conducted a search in PubMed/Medline of articles in English from the last 5 years and included 14 studies for systematic review, 9 of them in the meta-analysis. The pooled sensibility and specificity was respectively 77.0% and 83.0% for TVUS (5 studies) and 85% and 74% for MRI (4 studies) in differentiating benign from malignant BOTs. CT and positron emission tomography (PET)-CT techniques were heterogeneous between studies, so a meta-analysis was not performed for the 4 studies on CT and PET-CT. However, these 4 studies have also shown a high accuracy in differentiating BOTs from malignant ovarian cancers.

Etiology of Ascites and Pleural Effusion Associated with Ovarian Tumors: Literature Review and Case Reports of Three Ovarian Tumors Presenting with Massive Ascites, but without Peritoneal Dissemination

Borderline ovarian tumors are benign but relatively large tumors that are often initially mistaken as ovarian cancers. We report three cases of stage I borderline ovarian tumors having massive ascites that we (preoperatively) suspected of being advanced ovarian cancer. The three patients (35, 47, and 73 years old) reported feeling fullness of the abdomen before consulting their gynecologist. By CT scan, they were diagnosed with a pelvic tumor accompanied by massive ascites, the diameters of which were 11, 20, and 11 cm, respectively. Postsurgical pathology showed all were stage I borderline ovarian tumors without dissemination; two were mucinous and one was serous. The amount of ascites was 6,300, 2,600, and 3,600 mL, respectively, and was serous in all. Cytodiagnosis of the ascites found that one was positive for tumor cells and two were negative. After resection of the mass, the ascites disappeared in all three cases. No pleural effusion was present at any time. The literature is reviewed concerning ascites and pleural effusions linked to ovarian tumors, and a supposition is forwarded of why pleural effusion presents sporadically in these cases.

Ultrasound diagnosis of serous surface papillary borderline ovarian tumor: A case series with a review of the literature

Serous surface papillary borderline ovarian tumors (SSPBOTs) are a rare morphologic variant of serous ovarian tumors that are typically confined to the ovarian surface, while the ovaries themselves tend to appear normal in size and shape. In this report, we describe the findings from five premenopausal women diagnosed with SSPBOTs, in whom ultrasound showed grossly normal ovaries that were partially or wholly covered with irregular solid tumors. In all five cases, histologic examination showed evidence of borderline serous tumors. These findings demonstrate that SSPBOTs can be diagnosed on a preoperative sonographic examination, which could facilitate conservative, fertility-sparing surgery in young women affected by this condition.

Fertility-sparing management of gynecological cancers

Fifteen to 21% of women diagnosed with genital tract tumors are younger than 40. Adequate counseling of these patients must be conducted to decide whether fertility-sparing treatment is allowed and what would be the oncological, fertility and obstetrical outcomes. We performed a comprehensive PubMed literature search using the terms "Uterine Cervical Neoplasms"[Mesh], "Trachelectomy", "Endometrial Neoplasms"[Mesh], "Ovarian Neoplasms"[Mesh] and "Fertility"[Mesh]. The following review reports available evidence for the conservative management of cervical, endometrial and ovarian cancer. Data regarding the selection of patients, surgical techniques, obstetrical issues and cancer prognosis are summarized. The level of evidence is low in most of the available reports. The therapeutic options presented in this paper should not therefore be considered as a standard of care. Nevertheless, fertility-sparing treatments of gynecological malignancies should be discussed in a multidisciplinary team and suggested to eligible patients who are younger than 40 and wish to become pregnant further.

Conservative surgery in ovarian borderline tumours: a meta-analysis with emphasis on recurrence risk

BACKGROUND

Recent reports have stirred the debate regarding the optimal conservative treatment for both serous and mucinous borderline ovarian tumour (BOT). The aim of this study is to examine the optimal oncological approach of conservative surgery in unilateral BOT (cystectomy (C) versus unilateral salpingo-oophorectomy (USO)) and in bilateral BOT (bilateral C (BC) versus USO+contralateral C (CC)), as well as fertility outcomes.

MATERIALS AND METHODS

The PubMed database and Cochrane Library were searched using the search terms (((Borderline) OR (low malignant potential)) AND (ovarian)) AND ((tumour) OR (cancer)) AND (((fertility sparing) OR (conservative)) AND surgery).

RESULTS

We analysed 39 studies that included 5105 women (2624 patients with serous-, 2120 patients with mucinous- and the remaining with other types of BOT), 2752 of which underwent conservative surgery (817 underwent C, 89 BC, 1686 USO and 118 USO+CC). Eight studies included only stage I patients, in 14 studies more than 90% of patients were stage I and five studies included only late-stage patients. Seven studies included only patients with serous borderline ovarian tumour (sBOT) and two only mucinous borderline ovarian tumour (mBOT). A total of 296 patients with non-invasive-, 76 patients with invasive- and 50 patients with unspecified implants were pooled. Of the patients undergoing C, BC, USO and USO+CC the pooled recurrence estimates were respectively 25.3%, 25.6%, 12.5% and 26.1%. In meta-analysis, USO was significantly favored over C with an OR for recurrence reduction=2200, 95% CI=0.793-2.841 and p<0.0001. The pooled recurrence estimate as invasive ovarian cancer was 15.4% and the pooled 95% CI was 0.120-0.196. The cumulative pregnancy rate was 55.7% with 45.4% for USO and 40.3.0% for C.

CONCLUSION

Cystectomy in unilateral serous BOT is significantly associated with a higher recurrence rate, albeit no impact on survival can be demonstrated. Whether this is related to the duration of follow-up, remains to be proven. Nonetheless, recent data seem to suggest that USO is advisable in the case of mucinous BOT. On the contrary, a more conservative approach (BC) should be definitively favored in bilateral BOT, which is almost always serous, because no significant difference is seen in terms of recurrence rate when compared to USO+CC.

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.

Nomogram to predict recurrence in patients with early- and advanced-stage mucinous and serous borderline ovarian tumors

OBJECTIVE

Recurrence prediction is a cornerstone of patient management for borderline ovarian tumors. This study aimed to develop a nomogram predicting the recurrence probability in individual patients who had received primary surgical treatment.

STUDY DESIGN

This retrospective multicenter study included 186 patients with borderline ovarian tumor diagnosed from January 1980 through December 2008. A multivariate logistic regression analysis of selected prognostic features was performed and a nomogram to predict recurrence was constructed. The nomogram was internally validated.

RESULTS

The overall recurrence rate was 34.4% (64/186), with noninvasive and invasive forms in 29% (54/186) and 5.4% (10/186) of cases, respectively. International Federation of Gynecology and Obstetrics stage, age at diagnosis, histologic subtype, completeness of surgery, and type of surgery (radical vs fertility sparing) were associated with an increased risk of recurrence and were included in the nomogram. The predictive model had a concordance index of 0.78 (95% confidence interval, 0.76-0.80) and 0.77 (95% confidence interval, 0.75-0.79) before and after the 200 repetitions of bootstrap sample corrections, respectively, and showed good calibration.

CONCLUSION

Our results support the use of the present nomogram based on 5 clinical and pathological characteristics to predict recurrence probability with a high concordance, hence to inform patients on surgical management. External validation is required to recommend this nomogram in routine practice.

[Unilateral borderline ovarian tumor and unilateral adenexectomy?]

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

[Presumed ovarian benign tumors and fertility]

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology.

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.

Histologic distribution of borderline ovarian tumors worldwide: a systematic review

Objective

The histologic types of borderline ovarian tumors (BOTs) exhibit striking differences in clinical behavior and prognosis. Yet, there is no information available on the histologic distribution of BOTs according to geographic region. The purpose of this study was to systematically review this issue worldwide.

Methods

A comprehensive search of the literature was conducted using electronic databases. Studies were eligible if BOTs were investigated and the histologic distribution of the data was shown. The studies were grouped by geographic region and totaled by country.

Results

Of 487 potentially relevant studies, 51 met our inclusion criteria, as follows: 8 studies from North America (2 countries); 26 studies from Europe (14 countries); 7 studies from the Middle East (3 countries); and 10 studies from East Asia (5 countries). The histologic distribution of BOTs was considerably different in different parts of the world, but follows specific patterns. In general, serous-type BOTs were the predominantly identified histology in North America, the Middle East, and Europe, while mucinous-type BOTs predominated in East Asia.

Conclusion

Significant geographic variation is evident among BOT histology in different parts of the world. More research is needed to understand this phenomenon.

Is MRI a useful tool to distinguish between serous and mucinous borderline ovarian tumours?

AIM

To analyse the morphological magnetic resonance imaging (MRI) features of borderline ovarian tumours (BOT) and to evaluate whether MRI can be used to distinguish serous from mucinous subtypes.

MATERIALS AND METHODS

A retrospective study of 72 patients who underwent BOT resection was undertaken. MRI images were reviewed blindly by two radiologists to assess MRI features: size, tumour type, grouped and irregular thickened septa, number of septa, loculi of different signal intensity, vegetations, solid portion, signal intensity of vegetations, normal ovarian parenchyma, and pelvic ascites. Statistical analysis was performed using Mann-Whitney and Fisher's exact tests. Logistic regression analysis was used to assess the predictive value of the MRI findings for histological subtypes.

RESULTS

At histology, there were 33 serous BOT (SBOT) and 39 mucinous BOT (MBOT). Predictive MRI criteria for SBOT were bilaterality, predominantly solid tumour, and the presence of vegetations, especially exophytic or with a high T2 signal (p < 0.01), whereas predictive MRI criteria for MBOT were multilocularity, number of septa, loculi of different signal intensity, and grouped and irregular thickened septa (p < 0.01). Using multivariate analysis, vegetations were independently associated with SBOT [odds ratio (OR) = 29.5] and multilocularity with MBOT (OR = 3.9).

CONCLUSION

Vegetations and multilocularity are two independent MRI features that can help to distinguish between SBOT and MBOT.

Evaluation of selected ultrasonographic parameters and marker levels in the preoperative differentiation of borderline ovarian tumors and ovarian cancers

Abstract

Objectives

In young patients with borderline tumors the fertility-sparing treatment is indicated, thus the preoperative investigation is important. The aim of this study was to perform a comparative assessment of sensitivity and specificity of selected ultrasonographic and clinical parameters for the diagnoses of borderline tumors and ovarian cancers.

Methods

We retrospectively analyzed 57 patients who underwent surgical treatment in the Maria Sklodowska-Curie Memorial Cancer Center from Jan 01, 2008 to Dec 31, 2009. Ovarian cancers were diagnosed in 41 patients, and borderline ovarian tumors in 16 patients. Statistical model was developed to determine independent predictive factors that would be useful in preoperative differentiation between both tumors. The model included the following factors: menopausal status, tumor morphology, wall thickness (including outgrowths), septal thickness, echogenicity, resistive index, serum CA-125 level, and free fluid in the peritoneal cavity.

Results

Based on the statistical model developed, independent predictive factors in the differentiation between ovarian cancers and borderline tumors included the menopausal status (P = 0.005), tumor echogenicity (P = 0.047) and the presence of free fluid in the Douglas pouch (P = 0.043). With the cutoff value of 13 (with scores below 13 indicating a borderline ovarian tumor, and scores of ≥13 indicating ovarian cancer), sensitivity was 90.2 % and specificity was 87 %.

Conclusions

Our proposed model of preoperative evaluation has a sensitivity of 90 % in the differentiation between ovarian cancers and borderline tumors. When combined with intraoperative findings, it allows optimal surgical therapeutic decisions to be made in patients with borderline ovarian tumors.

Assessing gonadal function after childhood ovarian surgery

PURPOSE

We aimed to assess the late effects of ovarian salvage or oophorectomy on gonadal function and fertility as measured by menstrual regularity.

METHODS

We performed a 10-year retrospective review of females aged 20 years or younger who required surgery to treat an ovarian disorder. A mail survey was distributed to these patients to evaluate the effects of ovarian surgery on menarche, menstrual regularity, and pregnancy.

RESULTS

A total of 180 females had surgery to treat an ovarian disorder. Eighty-six of these underwent unilateral oophorectomy (48%), whereas 94 (52%) had an ovary sparing procedure. Eighty-one patients (45%) returned completed surveys. Of the respondents, 44 had oophorectomy, and 37 had ovarian salvage. Ages of menarche were similar between surgical groups. Symptoms of menstrual irregularity differed most significantly according to painful menses (oophorectomy, 27.3%; salvage, 59.5%; P < .04). Interestingly, continuation of regular menses after surgery was higher in the oophorectomy group (oophorectomy, 70%; salvage, 15%; P = .013).

CONCLUSIONS

Unilateral oophorectomy does not appear to impair late gonadal function when compared with ovarian salvage. Surprisingly, oophorectomy appears to maintain more normal ovarian activity as estimated by menstrual regularity. Oophorectomy may be performed without apparent adverse effect on gonadal activity.

[Cancer, fertility preservation and gonadotropins]

The recent emergence of oncofertility raises the question of ovarian stimulation and its risks when performed for oocyte or/and embryo cryopreservation in a fertility preservation program. The relation between ovarian stimulation and cancer has been marked by the possible direct or indirect tumorigenic role for pituitary gonadotrophins in the tumorogenesis. Although the growth of many gonadal and extragonadal tumors is stimulated by gonadal sex hormones, whose production is regulated by gonadotrophins, there is still a lack of data to consider FSH and LH as tumor promoters. The purpose of this brief review is to present on one hand, the questions raised by the administration of exogenous gonadotrophins in cancer patients and on the other, to evaluate both experimental and clinical data about the possible relation between gonadotrophins and tumorogenesis.

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

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