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

Ovarian tumors in the pediatric population: An update

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

Successful delivery after in vitro fertilization-embryo transfer in a woman with metachronous primary cancer of ovary and endometrium: a case report

BACKGROUND

The appearance of malignancies at various times in the same individual, excluding metastases of the initial primary cancer, is termed multiple primary cancers. Double primary gynecological cancers cause inevitable damage to female reproductive function, and the preservation of fertility in such patients remains a challenging issue as relatively few cases have been reported. This case report provides management options for dual primary ovarian and endometrial cancers, including the choice of ovulation induction protocols, considerations during pregnancy and parturition, with the aim of providing assistance to clinicians.

CASE PRESENTATION

We report a case of a 39-year-old woman with primary infertility and a medical history of right-sided ovarian mucinous borderline tumor with intraepithelial carcinoma, left-sided ovarian mucinous cystadenoma and endometrial cancer, who successfully conceived with in vitro fertilization-embryo transfer (IVF-ET) after three different ovulation induction protocols. During her pregnancy, she was complicated by central placenta praevia with placental implantation and eventually delivered a healthy female infant by caesarean section at 33 gestational weeks.

CONCLUSIONS

For patients with double primary gynecological cancers who have an intense desire for fertility, the most appropriate oncological treatment should be applied according to the patient's individual situation, and fertility preservation should be performed promptly. Ovulation induction protocol should be individualized and deliberate, with the aim of ensuring that the patient's hormone levels do not precipitate a recurrence of the primary disease during induction of ovulation and maximizing fertility outcomes. In addition, the risk of postpartum hemorrhage due to placental factors cannot be neglected in such patients.

Reproductive Results in Cancer Survivors after Fertility Sparing Management: The Need for the Standardization of Definitions

In fertility-sparing management (FSM), two different issues can be distinguished: the risk of recurrence/death and the chance of childbearing. Survival is the principal outcome in oncology, and definitions of overall survival and progression-free survival are therefore well defined and widely accepted. The introduction of FSM to clinical practice was determined by the desire of young cancer patients to still have children. Initially, in small groups of patients, any pregnancy and/or childbirth were considered successes. Nowadays, FSM occupies an important place in cancer treatment, with thousands of young women treated successfully. However, in contrast to survival, no definition has been established for evaluating the reproductive outcomes of FSM. This review article evaluates the current pregnancy and birth rates of cancer patients. Differences between fertility-sparing and conservative treatment are analyzed, and improper and confusing interchangeable applications of these terms are pointed out. Additionally, various reasons for choosing FSM as a treatment method-which are not directly related to fertility preservation (treatment mismatch)-are presented. Uniform definitions of reproduction after FSM should be established to enable the comparison of results and facilitate the counseling of patients regarding the chances of reproduction.

Identification of clinical and molecular features of recurrent serous borderline ovarian tumour

BACKGROUND

Serous borderline ovarian tumour (SBOT) is the most common type of BOT. Fertility sparing surgery (FSS) is an option for patients with SBOT, though it may increase the risk of recurrence. The clinical and molecular features of its recurrence are important and need to be investigated in detail.

METHODS

An internal cohort of 319 patients with SBOT was collected from Aug 1, 2009 to July 31, 2019 from the Obstetrics and Gynecology Hospital of Fudan University in China. An external cohort of 100 patients with SBOT was collected from Aug 1, 2009 to Nov 30, 2019 from the Shandong Provincial Hospital in China. The risk factors for the recurrence were identified by multivariate cox analysis. Several computational methods were tested to establish a prediction tool for recurrence. Whole genome sequencing, RNA-seq, metabolomics and lipidomics were used to understand the molecular characteristics of the recurrence of SBOT.

FINDINGS

Five factors were significantly correlated with SBOT recurrence in a Han population: micropapillary pattern, advanced stage, FSS, microinvasion, and lymph node invasion. A random forest-based online recurrence prediction tool was established and validated using an internal cohort and an independent external cohort for patients with SBOT. The multi-omics analysis on the original SBOT samples revealed that recurrence is related to metabolic regulation of immunological suppression.

INTERPRETATION

Our study identified several important clinical and molecular features of recurrent SBOT. The prediction tool we established could help physicians to estimate the prognosis of patients with SBOT. These findings will contribute to the development of personalised and targeted therapies to improve prognosis.

FUNDING

JL was funded by MOST 2020YFA0803600, 2018YFA0801300, NSFC 32071138, and SKLGE-2118 to Jin Li; JY was funded by the Initial Project for Young and Middle-aged Medical Talents of Wuhan City, Hubei Province ([2014] 41); HH was funded by MOST 2019YFA0801900 and 2020YF1402600 to He Huang; JS was funded by NSFC 22,104,080; CG was funded by Natural Science Foundation of Shanghai 20ZR1408800 and NSFC82171633; BL was funded by Natural Science Foundation of Shanghai 19ZR1406800.

Neuroendocrine Tumors: Clinical, Histological and Immunohistochemical Perspectives and Case Report-Mature Teratoma in a 16-Year-Old Girl

A mature teratoma is a germinal neoplasm that differentiates from embryonic multipotent cells into three germ layers. There may also be glandular tissue. The literature describes a total of 658 cases of ovarian neuroendocrine neoplasms, mainly in women over 40 years of age. The authors, together with a systemic review, present a case of a 16-year-old girl diagnosed with and treated for a neuroendocrine tumor. Case description: A 16-year-old girl visited the Paediatric Gynaecology Outpatient Clinic because of abdominal pains that intensified during menstruation. Standard painkillers and diastolic drugs were ineffective. An ultrasound examination revealed a large tumor with a heterogeneous structure in her right ovary. A sparing operation was carried out. During laparotomy, the lesion was enucleated, leaving healthy tissue. Histopathological examination revealed the typical features of teratoma, as well as the coexistence of a G1 neuroendocrine tumor. Immunohistochemical examination (IHC) showed the presence of markers characteristic for this type of tumor. The patient requires constant monitoring in the Endocrinology and Oncological Gynaecology Clinic. Conclusion: Tissue of neuroendocrine neoplasm within a teratoma is rare in this age group of patients; thus, there are currently no standards for long-term follow-up. This case adds to the body of evidence and demonstrates a possible good prognosis with non-aggressive behavior in G1 neuroendocrine tumors and teratomas in young patients.

Prognostic score model-based signature genes for predicting the prognosis of metastatic skin cutaneous melanoma

PURPOSE

Cutaneous melanoma (SKCM) is the most invasive malignancy of skin cancer. Metastasis to distant lymph nodes or other system is an indicator of poor prognosis in melanoma patients. The aim of this study was to identify reliable prognostic biomarkers for SKCMs.

METHODS

Four RNA-sequencing datasets associated with SKCMs were downloaded from the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) database as well as corresponding clinical information. Differentially expressed genes (DEGs) were screened between primary and metastatic samples by using MetaDE tool. Weighted gene co-expression network analysis (WGCNA) was conducted to screen functional modules. A prognostic score (PS)-based predictive model and nomogram model were constructed to identify signature genes and independent clinicopathologic factors.

RESULTS

Based on MetaDE analysis and WGCNA, a total of 456 overlapped genes were identified as hub genes related to SKCMs progression. Functional enrichment analysis revealed these genes were mainly involved in the hippo signaling pathway, signaling pathways regulating pluripotency of stem cells, pathways in cancer. In addition, eight optimal DEGs (RFPL1S, CTSV, EGLN3, etc.) were identified as signature genes by using PS model. Cox regression analysis revealed that pathologic stage T, N and recurrence were independent prognostic factors. Three clinical factors and PS status were incorporated to construct a nomogram predictive model for estimating the three years and five-year survival probability of individuals.

CONCLUSIONS

The prognosis prediction model of this study may provide a promising method for decision making in clinic and prognosis predicting of SKCM patients.

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.

Anaesthetic considerations for fertility-sparing surgery and uterine transplantation

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

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature

OBJECTIVE

To compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.

DATA SOURCES

PubMed was searched from January 1, 1995, to May 29, 2020.

METHODS OF STUDY SELECTION

Studies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.

CONCLUSION

Fertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.

Ultraconservative, Fertility Sparing Treatment of Bilateral Borderline Ovarian Tumors: A Case Report of a 26-Year-Old, 0-Gravida with an Endometrioid Borderline Ovarian Tumor of the Right Ovary and a Sero-Mucinous Borderline Ovarian Tumor of the Left Ovary and a Review of the Literature

Endometrioid borderline ovarian tumors are rare, entailing a lack of data on their natural history as well as the safety of conservative and ultraconservative surgical management, especially in cases with bilateral borderline ovarian tumors including one of endometrioid differentiation. Therefore, we present such a case and provide a review of the literature on endometrioid borderline ovarian tumors. We report the case of a 26-year-old, 0-gravida with an endometrioid borderline ovarian tumor of the right and a sero-mucinous borderline ovarian tumor of the left ovary treated by fertility sparing, ultraconservative surgery with bilateral cystectomy, completed by staging procedures including omentectomy and peritoneal sampling, as well as endometrial sampling by means of curettage. Reviewing the literature and taking into account the course of our case, we propose the feasibility of an ultraconservative management, including endometrial sampling, in young patients with bilateral borderline ovarian tumors including one of endometrioid differentiation who desire to preserve fertility, followed by a closely monitored follow-up.

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: 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).

Outcomes of fertility-sparing surgery for stage II and III serous borderline ovarian tumors

Objective

This study was performed to assess the feasibility of conservative treatment for stage II or III serous borderline ovarian tumors (BOTs).

Methods

Twenty-one patients were treated conservatively for advanced serous BOTs from 2006 to 2017. Two patients were lost to follow-up. The patients’ clinical status, surgical results, fertility results, and oncological outcomes were collected.

Results

The patients’ median age at surgery was 28 years (range, 22–37 years). The median follow-up interval was 74 months (range, 16–214 months). Among the 19 patients who were followed up, 8 had stage II tumors and 11 had stage III tumors. Sixteen patients had noninvasive peritoneal implants. Two patients developed tumor metastasis to the fallopian tubes and one developed metastasis to the pelvic lymph nodes and omentum. The total recurrence rate was 26.3%. Seventeen (89.5%) patients were nulliparous. Four of 10 patients who wished to preserve their fertility obtained natural pregnancy. No patients died of their disease.

Conclusions

This study supports the efficacy of conservative treatment for advanced BOTs with respect to its favorable fertility result. The overall prognosis is not changed by conservative treatment.

Clinical Predictors of Recurrence and Prognostic Value of Lymph Node Involvement in the Serous Borderline Ovarian Tumor

AIM

This study was aimed to evaluate the risk factors of recurrence and the value of nodal involvement in patients with serous borderline ovarian tumors (SBOT).

METHODS

Two hundred twenty-five patients who underwent surgery and were diagnosed with SBOT were retrospectively studied. Univariate and multivariate analyses were used to assess the risk factors for recurrence. Patients' clinical pathologic characteristics were compared between the patients who presented lymph node involvement and those who did not. The significant values of lymph condition influencing 5-year disease-free survival were also evaluated by statistical analysis.

RESULTS

Both univariate and multivariate analyses showed that risk factors for recurrence were micropapillary (P = 0.021), fertility-preserving surgery (P = 0.014), and laparoscopic approach (P = 0.009). Of these 112 patients on whom lymphadenectomy was performed, 17 cases showed lymph node positive, whereas the remaining 95 patients did not. Significant differences in terms of lymph node numbers (P < 0.0001), invasive implant (P = 0.022), and International Federation of Gynecology and Obstetrics staging (P < 0.0001) were observed between the 2 groups of lymphatic node involved or not. Kaplan-Meier curves of 5-year disease-free survival revealed that there were no significant differences either between groups of lymphatic node involved or not (P = 0.778) and groups of removed nodes whether more than 10 or not (P = 0.549).

CONCLUSIONS

Micropapillary, fertility-preserving, and laparoscopic approach were factors significantly affecting the recurrence of SBOT by both univariate and multivariate analysis. Lymph node metastasis did not seem to be correlated to a worse prognosis of SBOT.

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.

Prognostic Factors for Recurrence After Fertility-Preserving Surgery in Patients With Borderline Ovarian Tumors: A Systematic Review and Meta-analysis of Observational Studies

OBJECTIVE

The aim of this study was to find the unfavorable prognostic factors for recurrence after fertility-preserving surgery (FPS) in patients with borderline ovarian tumors (BOTs).

METHODS

To perform a meta-analysis to compare the recurrence rates of BOT patients after FPS according to different prognostic factors, we searched PubMed, EMBASE, and Cochrane for observational studies. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with a fixed-effects model.

RESULTS

We analyzed 32 studies that included 2691 BOT patients who underwent FPS, 383 patients of whom had a relapse in the follow-up. In meta-analysis, risks associated with recurrence in patients with unilateral cystectomy (OR, 2.49; 95% CI, 1.86-3.33) or serous borderline ovarian tumors (OR, 3.15; 95% CI, 1.97-5.02) were significantly increased, and there was no significantly increased OR for patients with laparoscopy compared with those with laparotomy (OR, 0.96; 95% CI, 0.57-1.60).

CONCLUSIONS

Unilateral cystectomy (19.4%) and serous BOTs (19.2%) are significantly associated with higher recurrence rates, and no negative impact of laparoscopy on recurrence can be demonstrated when compared with laparotomy in the meta-analysis.

Using quality improvement methodology to improve ovarian salvage for benign ovarian masses

PURPOSE

Most ovarian masses in children are benign and potentially amenable to ovarian salvage surgery (OSS). Despite the common use of OSS among pediatric and adolescent gynecologists (PAG) in recognition of reproductive and hormonal health advantages, this technique is not commonly performed by pediatric surgeons. The aim of this quality improvement (QI) initiative was to improve our institutional rate of OSS for benign ovarian masses.

METHODS

Baseline data were obtained retrospectively from surgical procedures performed for benign ovarian masses between January 2012 and February 2016. Designed interventions to improve the rate of OSS included the development of an ovarian mass algorithm, standardization of radiologic templates, multidisciplinary analyses of ovarian procedures, and implementation of a training model for performing OSS. Procedures performed for benign ovarian masses from March 2016 to February 2017 comprised the process stage.

RESULTS

Our institutional baseline OSS rate was 28.8%. After implementation of the institutional algorithm, a single oophorectomy was performed for a benign mass, increasing the OSS rate to 96%. There have been no missed ovarian malignancies.

CONCLUSIONS

Utilizing preoperative risk assessment, QI methodology and multidisciplinary collaboration resulted in improved OSS rates for benign ovarian masses with no evidence of missed ovarian malignancies.

LEVEL OF EVIDENCE

Level II. This is a prospective comparative study, with comparison to a retrospective cohort. This is a quality improvement initiative without randomization.

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.