Population-based cohort follow-up study of all patients operated for borderline ovarian tumor in western Sweden during an 11-year period

A Novel Case of Recurrent Mucinous Borderline Ovarian Tumor: Early Relapse and Fatal Outcome

Unlike ovarian carcinomas, borderline ovarian tumors (BOTs) are associated with a favorable prognosis: their recurrence rate is around 5–7%, and the survival rate is more than 97% when diagnosed early. There are only a few reports of recurrence and fatal outcomes. Herein, we report a novel case of recurrent mucinous BOT, with a literature review. A 63-year-old woman presented to a local doctor with abdominal fullness. She was diagnosed as having a polycystic tumor. The lesion was suspected to be a mucinous BOT (M-BOT) on magnetic resonance imaging. Upper and lower gastrointestinal endoscopy revealed no digestive cancerous lesions, and surgery was performed. Intra-operative diagnosis confirmed the diagnosis, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The final pathological diagnosis was non-invasive M-BOT (stage I c1 (T1c1N0M0)). The result of immunohistochemical staining supported the diagnosis of primary ovarian mucinous tumor.Four months after surgery, relapse occurred. Blood tests revealed an elevated carbohydrate antigen 19-9 level, and computed tomography revealed multiple liver metastases, peritoneal dissemination, left ureter infiltration, and carcinomatous peritonitis. Although the patient underwent chemotherapy, she died. This case of a very short progression-free and overall survival in stage I M-BOT indicates that some M-BOTs could result in fatal clinical outcomes despite diagnosis at an early stage. Frequent follow-up appointments after surgery could help detect relapse and increase survival in such cases.

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.

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.

Unilateral cystectomy and serous histology are associated with relapse in borderline ovarian tumor patients with fertility-sparing surgery: a systematic review and meta-analysis

PURPOSE

Surgical procedures, histological subtypes, and surgical approaches are involved in the recurrence of borderline ovarian tumors (BOTs), but whether those three factors affect relapse remains controversial. This study aimed to explore the effects of surgical procedures, histological subtypes, and surgical approaches on the relapse and pregnancy rates of BOT after fertility-preserving surgery (FPS) according to the patients' characteristics.

METHODS

A systematic search of PubMed, Embase, and the Cochrane library was conducted from their inception to November 2018. Studies that investigated the impact of surgical procedures, histological subtypes, and surgical approaches on the relapse and pregnancy rates in patients with BOT after FPS were eligible. The pooled odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.

RESULTS

Thirty-five studies involving a total of 2921 patients with BOT after FPS were included. The pooled ORs indicated that the risk of relapse was significantly increased in patients who underwent unilateral cystectomy or with serous BOT. There was no significant difference between laparoscopy and laparotomy on the risk of relapse. Surgical procedures, histological subtypes, and surgical approaches did not influence pregnancy rates.

CONCLUSIONS

Patients who underwent unilateral cystectomy or with serous BOT presented an excess risk of relapse after FPS, but the surgical approach did not affect the risk of relapse. The pregnancy rate is not affected by surgical procedures, histological subtypes, and surgical approaches.

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

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

Impact of surgical restaging on recurrence in patients with borderline ovarian tumors: A meta-analysis

OBJECTIVE

The benefits of restaging surgery for patients with a borderline ovarian tumor (BOT) discovered on initial surgery are debatable. We performed a meta-analysis to evaluate the role of restaging surgery on recurrence in patients with BOTs.

STUDY DESIGN

We systematically reviewed published studies comparing restaging surgery and incomplete surgery in BOT patients from January 1985 to December 2017. Endpoints were recurrence and mortality rates. Study design features that possibly affected participant selection, reporting of recurrence and death, and manuscript publication were assessed. For pooled estimates of the effect of restaging surgery on recurrence, fixed-effect meta-analytical models were used.

RESULTS

Of the 577 articles initially selected, four retrospective observational studies (Restaging group: 166 patients; Non-Restaging group: 394 patients) met our research criteria. No significant differences in terms of recurrence between the two groups were observed (pooled Peto Odds Ratio [OR] = 0.88; 95 % confidence interval [CI]: 0.41-1.92). The number of deaths was insufficient for statistical analysis.

CONCLUSIONS

This meta-analysis based on retrospective studies, suggests that restaging surgery does not significantly reduce recurrence in patients with BOT.

Mucinous borderline ovarian tumors with and without Intraepithelial Carcinoma: Differences in clinicopathologic features and fertility results

AIM

To investigate the clinicopathologic characteristic and fertility results of patients with mucinous borderline ovarian tumors (MBOTs), and the effects of intraepithelial carcinoma (IECA) on them.

METHODS

Fifty-two patients treated for MBOTs with or without IECA were retrospectively analyzed.

RESULTS

Patients with IECA were more frequently observed at stage Ic (3/12 vs 1/40, P = 0.034) and accompanied by microinvasive carcinoma (3/12 vs 1/40, P = 0.034). The detected rate of IECA by intraoperative frozen section (5/12, 41.7%) was much lower than that of MBOTs (82.5%, P = 0.010). About 61.5% patients in our study underwent fertility-sparing surgery. Follow-up information was retained completely in 41 patients. And all four tumor recurrences were observed (9.8%) in conservative surgery group in 66 months, though there was no statistical association (P = 0.280). There were three patients who recurred more than once, even one occurred tumor-related death. Only one recurrent patient was in IECA group (P > 0.05). However, patients with IECA were more likely to receive adjuvant chemotherapy (3 of 12 vs 0 of 40, P = 0.010) and surgical staging (75% vs 52.5%, P = 0.200). As for fertility results, nine patients wished to be pregnant and seven of them (77.8%) were successful.

CONCLUSION

For young patients with MBOTs, fertility results are satisfactory after conservative surgery. But patients should be fully informed about the relative high recurrent rate. And IECA has no statistical negative effects on MBOTs till now, but a long-term follow-up is required.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Diagnosis and Management of Recurrent Borderline Ovarian Tumours]

OBJECTIVE

To provide recommendations for the diagnosis and management of the recurrence of Borderline Ovarian Tumour (BOT).

METHODS

Literature review by consulting Pubmed, Medline and Cochrane databases.

RESULTS

In the case of BOT, most of recurrences are a new BOT without invasive contingent (LE2). In the case of bilateral BOT, bilateral cystectomy is associated with a shorter recurrence time compared to unilateral oophorectomy and contralateral cystectomy (LE2). In recurrent serous BOT, cysts are usually fluid thin-walled with vegetation, corresponding in the IOTA classification to a solid unilocular cyst (LE2). A size of the cyst less than 20mm is not a sufficient to eliminate the diagnosis of recurrent serous BOT (LE2). Recurrence of mucinous BOT predominantly appears as multilocular or as solid multilocular cysts (LE4). In the case of ovarian preservation, recurrences are most often observed on the preserved ovary(s) (LE2). Non-invasive peritoneal recurrence after initial radical treatment including bilateral hysterectomy and adnexectomy is possible, mainly in patients initially diagnosed with stage II or III BOT with non-invasive peritoneal implant (LE3). Most BOT recurrences are asymptomatic, but clinical examination may allow diagnosis of recurrence (LE2). The normality of the CA 125 dosage does not rule out the diagnosis of recurrent BOT (LE2). A second conservative treatment in the event of recurrence of BOT entails the risk of new recurrence (LE2) with no impact on survival (LE4). Totalization of the adnexectomy in case of recurrence of BOT reduces the risk of new recurrence (LE2). Conservative treatment does not increase the risk of recurrence with non-invasive peritoneal implants (LE4). Conservative treatment may be offered after a first non-invasive recurrence in young women who wish to preserve their fertility (gradeC). In the absence of infiltrating tumor, chemotherapy is not indicated. The only cases for which chemotherapy can be considered are those for which there is an infiltrative component in addition to TFO.

[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.

Impact of age on clinicopathological features and survival of epithelial ovarian neoplasms in reproductive age

BACKGROUND

Little is known about the effect of age on the prognosis of epithelial ovarian neoplasms. In the reproductive age, fertility-sparing surgery had been widely implemented. This study aimed to elucidate impact of age on the clinicopathologic characteristics and survival of epithelial ovarian neoplasms in the reproductive age.

METHODS

The clinical records of patients diagnosed as epithelial ovarian cancer or epithelial borderline ovarian tumor at the age of 40 years or younger at multiple institutions in the Tokai Ovarian Tumor Study Group were reviewed retrospectively. All patients were stratified into two age groups: group A (≤ 30 years) and group B (31-40 years). Univariate and multivariate analyses were performed to evaluate overall survival and disease-free survival.

RESULTS

A total of 583 patients (325 patients: cancer, 258 patients: borderline) were included. The median follow-up time was 62.0 months (range 1-270 months). Compared with group B, group A had a significantly higher rate of borderline tumor (66.7% vs. 32.7%, p < 0.001); stage I disease (85.9% vs. 70.4%, p < 0.001); mucinous type (69.2% vs. 35.6%, p < 0.001); conservative surgery (83.8% vs. 41.6%, p < 0.001); no adjuvant chemotherapy (67.2% vs. 44.7%, p < 0.001); and CA125 ≤ 35 U/mL (39.4% vs. 28.8%, p < 0.05). There was a significant difference in the overall survival (p = 0.0051) and the disease-free survival (p = 0.0039) between the two groups. Multivariate analysis revealed that the independent prognostic factors for the overall survival were age, stage, histology, and ascitic fluid cytology.

CONCLUSION

In epithelial ovarian neoplasms, younger patients had a survival advantage over older patients.

Trends in incidence, treatment and survival of borderline ovarian tumors in the Netherlands: a nationwide analysis

Background: Population-based data on borderline ovarian tumors (BOTs) are scarce and information regarding recent trends in incidence, treatment and survival is lacking. The purpose of this study was to analyze these trends in the Netherlands and to assess the risk of developing a subsequent invasive ovarian tumor. Material and methods: All consecutive patients diagnosed with BOTs between 1993 and 2016 (n = 7113) were identified from the Netherlands Cancer Registry (NCR). Annual age-adjusted incidence rates were calculated. Relative survival (RS) analyses and multivariable analyses estimating excess mortality were conducted. Patients with a subsequent invasive ovarian tumor were identified by the NCR. Results: Age-adjusted incidence increased from 2.1/100,000 person-years in 1993 to 4.2/100,000 in 2011, after 2011 the incidence declined. The proportion of bilateral tumors decreased over time from 16% in 1993-1998 to 11% in 2005-2010 and remained stable onwards. Survival improved over time (excess mortality ratio_adjusted 2011-2016 versus 1993-1998: 0.25; 95%CI: 0.13-0.47). Five-year RS increased from 91% in 1993-1998 to 98% in 2011-2016 and 10-year RS from 88% in 1993-1998 to 96% in 2005-2010. Fewer patients were treated with chemotherapy (4.4% in 1993-1998 versus 0.7% in 2011-2016). During a median follow-up time of 8 years, 0.9% developed a subsequent invasive ovarian carcinoma. Conclusions: The incidence of BOTs increased over time from 1993 until 2010 but declined since 2011. This decline may be partly due to changes in the classification of gynecological tumors, as serous BOTs are now more often diagnosed as low grade serous ovarian cancers. Survival is high and has improved since 1993. The risk of a subsequent invasive ovarian carcinoma seems low.

Borderline tumours of the ovary: Common practice in the Netherlands

Objectives

Discordance between frozen section diagnosis and the definite histopathological diagnosis and the fact that the frozen section result is not always unambiguous, may contribute to differences in clinical practice regarding perioperative treatment and follow-up of borderline ovarian tumours (BOTs) patients amongst gynaecologic oncologists, which may lead to over- and undertreatment. The aim of the study was to map the Dutch gynaecologists' preferred treatment and follow-up strategy in case of BOTs.

Methods

A questionnaire was sent to all Dutch gynaecologists involved in ovarian surgery with perioperative frozen section analysis, and the outcomes were assessed using descriptive statistics.

Results

Nearly half of the respondents (41.0%) would not perform a staging procedure in case of a BOT. In case of an ambiguous frozen section diagnosis, tending towards invasive carcinoma, a considerable number (sBOT 56.4%; mBOT 30.8%) would perform a lymph node sampling as part of the staging procedure. A relaparotomy/relaparoscopy, to perform a lymph node sampling in case of a serous or mucinous carcinoma after a BOT frozen section diagnosis, would be performed by 97.4% and 48.7% of the respondents, respectively.

Conclusions

A considerable number of gynaecologists would perform a staging procedure that is recommended for ovarian cancer in case of an ambiguous BOT frozen section diagnosis, especially for serous tumours. In addition, nearly all gynaecologists would perform a second procedure including a lymph node sampling in case of a serous invasive carcinoma after a BOT frozen section diagnosis, which applies to half of the gynaecologists in case of a mucinous carcinoma.

•

In case of an unambiguous frozen section BOT diagnosis, a staging procedure is omitted by nearly half of the gynaecologists.

•

When the frozen section BOT diagnosis is ambiguous, a full ovarian cancer staging procedure is frequently performed.

•

Most gynaecologists perform a second procedure to complete staging when definitive diagnosis shows invasive ovarian cancer.

•

Full staging is performed more frequently in case of serous histopathology, when compared to mucinous tumours.

The impact of clinicopathologic and surgical factors on relapse and pregnancy in young patients (≤40 years old) with borderline ovarian tumors

BACKGROUND

Fertility sparing surgery has been extensively performed among patients with borderline ovarian tumors due to their age and favorable prognosis. Nevertheless, the prognosis and obstetric outcomes in these patients remain uncertain. Thus, the current study was carried out to evaluate the oncological safety and fertility benefits of different fertility sparing surgery subtypes and various clinicopathological parameters.

METHODS

Young borderline ovarian tumor patients with an age of ≤40 years, who were admitted and treated in Zhejiang Cancer Hospital from January 1996 to December 2016, were enrolled in this study and reviewed retrospectively. The prognostic and obstetric effects of clinicopathological and surgical variables were evaluated using univariate/multivariate analyses and survival curves.

RESULTS

A total of 92 eligible patients were enrolled in the analysis. Among these patients, 22 (24%) patients showed recurrence after a median follow-up of 46.5 months. Within the fertility sparing surgery group, patients at advanced stage (≥stage II), of serous type, with micropapillary and bilateral tumors were associated with a higher recurrence rate and a shorter recurrence interval. In terms of different modalities of fertility sparing surgery, adnexectomy was remarkably favored over cystectomy-including (P = 0.012); unilateral salpingo-oophorectomy had better prognosis than cystectomy and bilateral cystectomy was favored over unilateral salpingo-oophorectomy+contralateral cystectomy. Univariate Cox regression analysis indicated that the International Federation of Gynecology and Obstetrics stage (≥Stage II), the presence of bilateral and micropapillary lesions, and the application of cystectomy-including surgery were correlated with poorer disease-free survival, while the mucinous type of borderline ovarian tumors was related to improved disease-free survival. In this study, a total of 22 patients attempted to conceive and 15 (68%) of these patients achieved successful pregnancy.

CONCLUSIONS

Unilateral salpingo-oophorectomy and bilateral cystectomy should be recommended as the preferred choice of treatment for young patients with unilateral and bilateral borderline ovarian tumor who desire to preserve fertility. In addition, borderline ovarian tumor patients at advanced stage (≥stage II), of serous type, with micropapillary and bilateral tumors should pay more attention to the risk of recurrence. Therefore, these patients should choose fertility sparing surgery carefully and attempt to achieve pregnancy as soon as possible.

Age-dependent difference in impact of fertility preserving surgery on disease-specific survival in women with stage I borderline ovarian tumors

Background

This study was to determine age-specific impact of fertility preserving surgery on disease-specific survival in women with stage I borderline ovarian tumors (BOTs). Patients diagnosed during 1988–2000 were selected from The Surveillance, Epidemiology, and End Results (SEER) database. The age-specific impact of fertility preserving surgery and other risk factors were analyzed in patients with stage I BOTs using Cox proportion hazard regression models. Data from our hospital were collected during 1996–2017 to determine the prevalence of patients who had undergone fertility preserving surgery.

Results

Of a total 6295 patients in the SEER database, this study selected 2946 patients with stage T1 BOTs who underwent fertility preserving or radical surgery. Their median age at diagnosis was 45.0 years and the median follow-up time was 200 months. Fertility preserving surgery was performed in 1000/1751 (57.1%) patients < 50 years and in 1,81/1195 (15.1%) patients ≥50 years. Fertility preserving surgery was significantly associated with worse disease-specific survival only in patients ≥50 years. Increased age, stage T1c and mucinous histology were risk factors for overall patients or patients ≥50 years, but not for < 50 years. Data from our hospital showed that fertility preserving surgery was performed in 53.9 and 12.3%patients < 50 and ≥ 50 years with stage I disease, respectively.

Conclusion

Fertility preserving surgery is safe for women < 50 years with early staged BOTs, but it may decrease disease-specific survival in patients ≥50 years. Conservative surgery is performed at a relatively high rate in patients ≥50 years.

Electronic supplementary material

The online version of this article (10.1186/s13048-018-0423-y) contains supplementary material, which is available to authorized users.

Long-term Behavior of Serous Borderline Tumors Subdivided Into Atypical Proliferative Tumors and Noninvasive Low-grade Carcinomas: A Population-based Clinicopathologic Study of 942 Cases

Ovarian serous borderline tumors (SBTs) have been the subject of considerable controversy, particularly with regard to terminology and behavior. It has been proposed that they constitute a heterogenous group of tumors composed, for the most part, of typical SBTs that are benign and designated "atypical proliferative serous tumor (APST)" and a small subset of SBTs with micropapillary architecture that have a poor outcome and are designated "noninvasive low-grade serous carcinoma (niLGSC)". It also has been argued that the difference in behavior between the 2 groups is not due to the subtype of the primary tumor but rather the presence of extraovarian disease, specifically invasive implants. According to the terminology of the 2014 WHO Classification, typical SBTs are equivalent to APSTs and SBTs displaying micropapillary architecture are synonymous with niLGSC. In addition, "invasive implants" were renamed "low-grade serous carcinoma" (LGSC). The argument as to whether it is the appearance of the primary tumor or the presence of extraovarian LGSC that determines outcome remains unsettled. The current study was initiated in 2004 and was designed to determine what factors were predictive of outcome, with special attention to the appearance of the primary tumor (APST vs. niLGSC) and that of the extraovarian disease (noninvasive vs. invasive implants). Our study is population based, involving the entire female population of Denmark. None of the women in the study were lost to follow-up, which ranged up to 36 years (median, 15 y). All the microscopic slides from the contributing hospitals were rereviewed by a panel of 2 pathologists (R.V. and R.J.K.) who were blinded to the follow-up. After excluding those that were not SBTs by the pathology panel, as well as cases with a prior or concurrent cancer or undefined stage, 942 women remained, of which 867 were APSTs and 75 were niLGSCs. The median patient age was 50 years (range, 16 to 97 y). Eight hundred nine women (86%) presented with FIGO stage I disease, whereas 133 (14%) had advanced stage disease. Compared with APSTs, niLGSC exhibited a significantly greater frequency of bilaterality, residual gross disease after surgery, microinvasion/microinvasive carcinoma, advanced stage disease, and invasive implants at presentation (P-values <0.003). Because the cause of death is difficult to accurately ascertain from death certificates, we used development of invasive serous carcinoma as the primary endpoint as following development of carcinoma, the mortality is very high. In the entire cohort, subsequent development of carcinoma occurred in 4%, of which 93% were low grade and 7% high grade (median time, 10 y; range, up to 25 y). After adjusting for age at and time since diagnosis of APST or niLGSC, occurrence of subsequent carcinoma was significantly higher with niLGSC than APST among all stages combined (hazard ratio [HR]=3.8; 95% confidence interval [CI], 1.7-8.2). This difference was still significant for stage I but not advanced stage cases. Moreover, all-cause mortality was not statistically significantly different between APST and niLGSC. Of all women with advanced stage disease, 114 (86%) had noninvasive implants, whereas 19 (14%) were invasive. Noninvasive implants were significantly associated with subsequent development of carcinoma (HR=7.7; 95% CI, 3.9-15.0), but the risk with invasive implants was significantly higher (HR=42.3; 95% CI, 16.1-111.1). In conclusion, although invasive implants are the most important feature in predicting an adverse outcome, subclassification into APST and niLGSC is important as it stratifies women with respect to risk for advanced stage disease and invasive implants for all women and development of serous carcinoma for stage I cases.

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.

Long-term Behavior of Serous Borderline Tumors Subdivided Into Atypical Proliferative Tumors and Noninvasive Low-grade Carcinomas: A Population-based Clinicopathologic Study of 942 Cases

Ovarian serous borderline tumors (SBTs) have been the subject of considerable controversy, particularly with regard to terminology and behavior. It has been proposed that they constitute a heterogenous group of tumors composed, for the most part, of typical SBTs that are benign and designated "atypical proliferative serous tumor (APST)" and a small subset of SBTs with micropapillary architecture that have a poor outcome and are designated "noninvasive low-grade serous carcinoma (niLGSC)". It also has been argued that the difference in behavior between the 2 groups is not due to the subtype of the primary tumor but rather the presence of extraovarian disease, specifically invasive implants. According to the terminology of the 2014 WHO Classification, typical SBTs are equivalent to APSTs and SBTs displaying micropapillary architecture are synonymous with niLGSC. In addition, "invasive implants" were renamed "low-grade serous carcinoma" (LGSC). The argument as to whether it is the appearance of the primary tumor or the presence of extraovarian LGSC that determines outcome remains unsettled. The current study was initiated in 2004 and was designed to determine what factors were predictive of outcome, with special attention to the appearance of the primary tumor (APST vs. niLGSC) and that of the extraovarian disease (noninvasive vs. invasive implants). Our study is population based, involving the entire female population of Denmark. None of the women in the study were lost to follow-up, which ranged up to 36 years (median, 15 y). All the microscopic slides from the contributing hospitals were rereviewed by a panel of 2 pathologists (R.V. and R.J.K.) who were blinded to the follow-up. After excluding those that were not SBTs by the pathology panel, as well as cases with a prior or concurrent cancer or undefined stage, 942 women remained, of which 867 were APSTs and 75 were niLGSCs. The median patient age was 50 years (range, 16 to 97 y). Eight hundred nine women (86%) presented with FIGO stage I disease, whereas 133 (14%) had advanced stage disease. Compared with APSTs, niLGSC exhibited a significantly greater frequency of bilaterality, residual gross disease after surgery, microinvasion/microinvasive carcinoma, advanced stage disease, and invasive implants at presentation (P-values <0.003). Because the cause of death is difficult to accurately ascertain from death certificates, we used development of invasive serous carcinoma as the primary endpoint as following development of carcinoma, the mortality is very high. In the entire cohort, subsequent development of carcinoma occurred in 4%, of which 93% were low grade and 7% high grade (median time, 10 y; range, up to 25 y). After adjusting for age at and time since diagnosis of APST or niLGSC, occurrence of subsequent carcinoma was significantly higher with niLGSC than APST among all stages combined (hazard ratio [HR]=3.8; 95% confidence interval [CI], 1.7-8.2). This difference was still significant for stage I but not advanced stage cases. Moreover, all-cause mortality was not statistically significantly different between APST and niLGSC. Of all women with advanced stage disease, 114 (86%) had noninvasive implants, whereas 19 (14%) were invasive. Noninvasive implants were significantly associated with subsequent development of carcinoma (HR=7.7; 95% CI, 3.9-15.0), but the risk with invasive implants was significantly higher (HR=42.3; 95% CI, 16.1-111.1). In conclusion, although invasive implants are the most important feature in predicting an adverse outcome, subclassification into APST and niLGSC is important as it stratifies women with respect to risk for advanced stage disease and invasive implants for all women and development of serous carcinoma for stage I cases.

Staging procedures in patients with mucinous borderline tumors of the ovary do not reveal peritoneal or omental disease

OBJECTIVES

Staging in case of a borderline tumor of the ovary (BOT) is a controversial issue. Upstaging is not uncommon, but this occurs especially with presumed stage I serous borderline tumors. There are only a few documented cases of BOTs of non-serous histology that were not confined to the ovary. The aim of this study was to assess the incidence of non-invasive and invasive implants in the omentum and other (extra)pelvic peritoneal surfaces in patients with a mucinous BOT (mBOT).

METHODS

A retrospective cohort study was performed in three hospitals in the Netherlands. All patients with a histopathological diagnosis of mBOT diagnosed from January 1st 1990 to December 1st 2015 were identified and included when the inclusion criteria were met.

RESULTS

In total, 74 patients were included. Of these 74 patients, 46 (62.2%) underwent a staging procedure. In 12 (26.1%) patients, only omental tissue was obtained, in 32 (69.6%) patients, omental tissue and peritoneal biopsies were obtained and in two (4.3%) patients, only peritoneal biopsies were obtained. No implants were seen upon microscopic examination in any of the patients. Two patients (3%) developed a recurrence.

CONCLUSIONS

Because no extra-ovarian disease was found, staging procedures in the case of an mBOT may be omitted. However, the actual perioperative decision for staging or not should be taken in the context of a frozen section diagnosis, which is not always accurate and straightforward. Recurrence with malignant disease is rare after mBOT. The value of post-treatment surveillance seems limited after bilateral salpingo-oophorectomy.

Fertility-sparing surgery for young patients with borderline ovarian tumors (BOTs): single institution experience

BACKGROUND

Fertility-sparing surgery for patients with borderline ovarian tumors (BOTs) is still controversial. This study aimed to evaluate the oncological safety and fertility benefits in conservative surgery,as well as efficiency of surgical procedures and approaches.

RESULTS

In total 122 patients with BOTs, four types of fertility-sparing surgery were performed: unilateral adnexectomy (UA, n = 47), unilateral cystectomy (UC, n = 59), unilateral adnexectomy + contralateral cystectomy (UA + CC, n = 7) and bilateral cystectomy (BC, n = 9). Fifty-two (42.6 %) patients had undergone laparoscopy, while 70 (57.4 %) had undergone laparotomy. After a median follow-up of 58.0 months, eight patients (6.6 %) relapsed in average of 25.9 months. Only one patient progressed to invasive cancer. None died within our observational period. Univariate analysis showed that patients with elevated CA125, bilateral tumors, extra-ovary tumor or mucinous type tended to replase in shorter time (p < 0.05). Among all cases, 45 patients attempted to conceive and 34 (75.6 %) patients had successful pregnancy. The recurrence rates were successively increased (2.1 %, 6.8 %, 14.3 %, and 22.2 %), the recurrence interval were shortened (48.0, 25.3, 26.0 and 21.2 months) and the subsequent fertility rates were 76.9 %, 77.3 %, 66.7 % and 71.4 % in UA, UC, UA + CC, and BC groups, respectively. As for surgical approaches, three patients (5.8 %) relapsed in 26.3 months in the laparoscopy group and five (7.1 %) in 25.5 months in the laparotomy group. The subsequent fertility rate was higher in laparoscopy group (88.9 %) than in laparotomy group (66.7 %). In our study, 38 patients underwent staging surgery. Two patients (5.3 %) recurrent in average of 21.0 months, and the subsequent pregnancy rate of staging surgery group was 61.5 %. Twelve patients received adjuvant chemotherapy but they didn't get any benefit from it, both in term of recurrence (8.3 %, 26.0 months) and subsequent pregnancy rate (75.5 %).

CONCLUSION

Fertility-sparing surgery is safe and beneficial for most young BOTs. UA through laparoscopy should be recommended as the first choice. To the patients with bilateral tumors, elevated CA125, extra-ovary tumor or mucinous type, conservative surgery should be carefully chosen and subsequent pregnancy should be attempted in short term. In addition, the benefit of comprehensive surgical staging is to be further investigated and adjuvant chemotherapy is not recommended.

Long-term survival in women with borderline ovarian tumors: a population-based survey of borderline ovarian tumors in Sweden 1960-2007

INTRODUCTION

We conducted an evaluation of incidence and survival of women with borderline ovarian tumors in Sweden.

MATERIAL AND METHODS

All women diagnosed with borderline ovarian tumor in the Swedish Cancer Register 1960-2007 (n = 6252) combined with follow up in the Swedish Death Registry to 1 July 2009 were included. Estimation of age-standardized relative survival rate according to time periods for diagnosis.

RESULTS

The incidence of borderline ovarian tumors increased during the study period, with a steep increase during the 1980s. The age standardized 5-year relative survival including all borderline tumors diagnosed 2000-07 was 97% (95% CI 92-99%). In women aged ≤64 years, the 10-year relative survival related to age at diagnosis of borderline tumors ranged from 95 to 98% and was 89% in women aged 65-74 years. In a multivariable analysis including age and decade of diagnosis relative survival for every decade increased. The 10-year relative survival in women with mucinous and serous borderline tumors did not differ significantly (p = 0.121).

CONCLUSIONS

Results of the present study are reassuring about long-term survival in women with borderline ovarian tumors. The age-standardized relative survival rate increased across time periods for diagnosis. There was no difference in long-term survival between mucinous and serous borderline ovarian tumors.

A meta-analysis on the impact of platinum-based adjuvant treatment on the outcome of borderline ovarian tumors with invasive implants

BACKGROUND

Treatment of borderline ovarian tumors (BOTs) remains contentious, and there is no consensus regarding therapy for BOTs with invasive implants (BOTi). The benefits of platinum-based adjuvant treatment were evaluated in patients with BOTi at primary diagnosis.

METHODS

The PubMed database was systematically searched for articles using the following terms: ((borderline) OR (low malignant potential) AND (ovarian)) AND ((tumor) OR (cancer)) AND (invasive implants) AND ((follow-up) OR (survival) OR (treatment) OR (chemotherapy) OR (adjuvant treatment) OR (surgery) OR (surgical treatment)).

RESULTS

We identified 27 articles including 3,124 patients, 181 with invasive implants. All studies provided information regarding mortality or recurrence rates. Central pathological examination was performed in 19 studies. Eight studies included more than 75% stage I patients; 7 included only advanced-stage patients, and 14 included only serous BOT. The pooled recurrence estimates for both treatment groups (adjuvant treatment: 44.0%, upfront surgery: 21.3%) did not differ significantly (p = .114). A meta-analysis of the 6 studies providing separate mortality data for both treatment groups favored surgical treatment only, but this difference did not reach statistical significance (.05 < p < .1; odds ratio: 0.33; 95% confidence interval: 0.09-1.71; p = .086). We were unable to pool the results of the included studies because not all studies registered events in both treatment groups. Egger's regression indicated low asymmetry of the studies (p = .39), and no heterogeneity was found (I(2) = 0%).

CONCLUSION

We did not find evidence supporting platinum-based adjuvant therapy for BOT with invasive implants.

Limited efficacy of platinum-based adjuvant treatment on the outcome of borderline ovarian tumors

Adjuvant treatment of borderline ovarian tumors (BOT) remains highly debatable. This article evaluates the benefits of platinum-based adjuvant treatment in patients with BOT. The PubMed and Cochrane Library databases were systematically searched for articles using the terms ((Borderline) OR (low malignant potential) AND (ovarian)) AND ((tumor) OR (cancer)) AND ((follow-up) OR (survival) OR (treatment) OR (chemotherapy) OR (adjuvant treatment)). We identified 31 articles including 4965 patients. Together, 592 patients presented non-invasive-, 244 invasive- and 77 unspecified implants. Central pathological examination was performed in 23 studies. Nine studies included more than 90% stage I patients, while 11 included only advanced stage patients. Nineteen studies reported patients undergoing complete cytoreduction, ten reported response rates and eight compared survival outcomes. All studies provided information regarding either mortality or recurrence rates. A meta-analysis of the 13 studies providing separate mortality data for both treatment groups, including 2206 women, favored surgical treatment only (OR=7.44; 95% CI=3.39-16.32; p<0.0005) albeit with moderate heterogeneity of the studies (I(2)=35.0%) but no asymmetry (Egger's test p=0.44). Regarding survival data, 4 studies reported no difference between groups. In the adjuvant setting, 4 reported worse outcome and 1 reported a nonsignificant trend to worse outcome. At present, there is no evidence to support the use of adjuvant treatment in patients with BOT.

A nationwide study of serous "borderline" ovarian tumors in Denmark 1978-2002: centralized pathology review and overall survival compared with the general population

OBJECTIVE

To describe the study population and estimate overall survival of women with a serous "borderline" ovarian tumor (SBT) in Denmark over 25 years relative to the general population.

METHODS

The Danish Pathology Data Bank and the Danish Cancer Registry were used to identify 1487 women diagnosed with SBTs from 1978 to 2002. The histologic slides were collected from Danish pathology departments and reviewed by expert pathologists and classified as SBT/atypical proliferative serous tumor (APST) or noninvasive low-grade serous carcinoma (LGSC). Associated implants were classified as noninvasive or invasive. Medical records were collected from hospital departments and reviewed. Data were analyzed using Kaplan-Meier and relative survival was estimated with follow-up through September 2, 2013.

RESULTS

A cohort of 1042 women with a confirmed SBT diagnosis was identified. Women with stage I had an overall survival similar to the overall survival expected from the general population (p=0.3), whereas women with advanced stage disease had a poorer one (p<0.0001). This was evident both in women with noninvasive (p<0.0001) and invasive implants (p<0.0001). Only among women with advanced stage, overall survival of women with SBT/APST (p<0.0001) and noninvasive LGSC (p<0.0001) was poorer than expected from the general population.

CONCLUSIONS

To date this is the largest nationwide cohort of SBTs where all tumors have been verified by expert pathologists. Only in women with advanced stage SBT, overall survival is poorer than in the general population which applies both to women with noninvasive and invasive implants as well as to women with SBT/APST and noninvasive LGSC.

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.

High preoperative blood levels of HE4 predicts poor prognosis in patients with ovarian cancer

Abstract

The aim of this study was to assess the clinical value of preoperative blood levels of HE4 as a predictor of overall survival in patients with ovarian cancer and to validate previous data of HE4 and the ROMA algorithm including HE4 and CA125 in discriminating benign and malignant ovarian tumors.

Experimental design

The preoperative plasma levels of HE4 and CA125 were analyzed with ELISA in 312 patients with adnexal lesions. Tumors were classified as benign (n= 206), borderline (i.e. low malignant potential tumors) (n= 25), and well (n= 14), moderately (n= 15), and poorly (n= 51) differentiated malignant.

Results

In univariate Cox regression analyses high levels (dichotomized at the median) of HE4, CA125, increased age (continuous variable), advanced-stage of disease 2–4, histological grade 3 and non-optimal tumor debulking at primary surgery were all significantly associated with shorter overall survival. A multivariate Cox regression model including pre-operative available covariates HE4 and CA125 both dichotomized at median in addition to age as continuous variable showed that high levels of HE4 was an independent prognostic marker for worse prognosis HR 2.02 (95% CI 1.1-3.8). In postmenopausal women the ROMA algorithm gave the highest AUC of 0.94 (95% CI, 0.90-0.97) which was higher than the separate markers HE4 AUC 0.91 (95% CI 0.86-0.95) and CA125 AUC 0.91(95% CI 0.87-0.96).

Conclusions

High concentration of plasma HE4 is an independent preoperative marker of poor prognosis in patients with ovarian cancer. The algorithm ROMA discriminates in postmenopausal women between malignant and benign tumors with an AUC of 0.94.

Borderline tumors of the ovary: clinical course and prognostic factors

BACKGROUND

The prognosis in borderline tumors of the ovary (BOT) is generally favorable. However, some patients experience recurrence, and mortalities occur. There is a need to better characterize prognostic factors to be considered for individualized treatment planning.

PATIENTS AND METHODS

The data of 158 consecutive patients who underwent surgery for BOT at a tertiary referral center for gynecologic oncology between 1997 and 2008 were retrospectively analyzed.

RESULTS

Most patients had early stage disease, and advanced stages FIGO II/III only occurred in 23.4%. Serous histology was most frequent (68%), followed by mucinous histology (22%). All patients received surgery as initial treatment with no adjuvant systemic therapy. 37 patients (40.7% of the patients under the age of 50) had fertility-sparing surgery (FSS). Recurrent disease occurred in 18 (11.4%) patients, and 4 (2.5%) patients died. Independent risk factors for recurrence were FIGO stages > I (hazard ratio (HR) 37.1; 95% confidence interval (CI) 4.5-155.5), tumor rupture (HR 12.4; 95% CI 1.5-61.5), incomplete staging (HR 5.9; 95% CI 1.6-21.3), and FSS in patients < 50 years (HR 8.0; 95% CI 2.0-31.6).

CONCLUSION

Intraoperative tumor rupture, incomplete staging, and FSS - all influenced by the surgeon - may impose a substantial recurrence risk. Therefore, careful counseling and balancing of risk and benefit are mandatory before therapy is applied, especially if FSS is planned.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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