Conservative Management of Borderline Ovarian

Tumor Prof. Dr. Fuat Demirkıran

I.U Cerrahpaşa School of Medicine.Department of OB&GYN

Division Of Gynocol Oncol April 2013 Beirut

Differences in Epidemiologic Features of Serous and Mucinous BOT

Serous MucinousMore frequent in western regions

One of third bilateral

60% of them stage I disease

More frequent in eastern regions

usually unilateral

70% of them stage I disease

Intestinal (comprising 85–90%) type ** extraovarian spread in only 2% of patients. ** more frequently unilateral.

Mullerian (or endocervical) lesions type ** bilateral in as many as 40% of cases. ** coexists with pelvic endometriosis in 20 – 30% of patients, including a serous componenet

Non –invasive implant

Invasive implant

AFIP=Air Forces Institute of Pathology. NCI=National Cancer Institute. NIH=National Institutes of Health. MPSC=micropapillary serous carcinoma. APST=atypical proliferative serous tumour. LGSC=low-grade serous carcinoma. HGSC=high-grade serous carcinoma. *Without micropapillary pattern.

Evolution of and discrepancies in current classifications of serous borderline ovarian tumours.

micropapillary pattern Stromal Microinvasion

micropapillary pattern in serous BOT

..not only morphological criteria

..associated with greater frequency of bilateral tumors

..associated with higher rate of surface involvement

..associated with higher rate of invasive peritoneal implants

At serous BOT

15-40 % extra-ovarian implant

Non –invasive implant Invasive implant

Recurrance rate 8%Mortality rate %4

Peritoneal Implants

Reccurance rate 29%Mortality rate 25%

İmplant Olasılığını Etkileyen Faktörler

n:457

Cusido M., Gynecol Oncol, 2007

Stromal Microinvasion

In 12 series of serous BOTs with microinvasion (n=133)

Recurrence rate 15 % (20/133)

Rate of disease-related death is 6%

35% (seven of 20) with invasive disease at recurrence

Data indicate that microinvasion is a prognostic factor for serous borderline ovarian tumours.

Potential prognostic factors for BOTs Prognostic factors

• SBOT with implants (worse in case of invasive implants)• Peritoneal residual disease

Debatable prognostic factors• Micropapillary patterns (but not as an independent factor)• MBOT with intraepithelial carcinoma• MBOT treated with cystectomy• SBOT with stromal microinvasion

Not prognostic factors• Nodal spread• Laparoscopic approach‡• Use of adjuvant treatment (conventional chemotherapy: platinum-based regimensand paclitaxel)• MBOT with stromal microinvasion§• Conservative treatment of SBOT; use of (re)staging surgery

Treatment of BOT

Conservative Surgery Fertility-sparing SurgeryConservative Surgery Fertility-sparing Surgery

Who desire to preserve fertility

unilateral bilateral tmbilateral tm

USO USO + cystectomyBilateral cystectomy

Interventions for the treatment of borderline ovariantumours (Review) The Cochrane Collaboration and published in The Cochrane Library 2010, Issue 9

USO + cystectomyBilateral cystectomy

with peritoneal staging

Open abdominal surgery

Endoscopic Surgery

Frozen section

(28%)

Conservative surgery (n: 189) and Radical Surgery (n:150) Median Follow-up 70 months

Surgery Recurence DFS

Conservative S. 40% 100%Radical 13% 85%

Conservative S. 15% 99%Radical S. 2.5% 100%

Stage In:283, 83%

Stage II-IIIN:56 , 17%

Zaneta ve ark J Clin Oncol 2001

Conservative surgery for aerly stage diseasen: 339

42 pts (67%) …….USO13“ (21%)……..UC 5 “ (8 %)…….. USO CC 2 “ (4 % )………CC

Mean follow-up 44 monthsRecurrence rate 7%

n: 62

39 pts. with stage II-III BOT

11 of them underwent USO28 “ “ “ CYSTEC.

39 pts. with stage II-III BOT

11 of them underwent USO28 “ “ “ CYSTEC.

5 yrs. 10 yrs.

Median follow-up 57 monthsRecurrence rate 56%

Recurrence rate 14% Recurrence rate 14% Recurrence rate 44% Recurrence rate 44%

Literature review of recurrence rate in advanced-stage ovarian borderline tumor (in particular with invasive

implants) with conservative treatment.

The prognosis of patients with noninvasive implants remains good and conservative

surgery can be considered in such patients (if implants are totally resected).

Conservative surgery at the presence of implants

The prognosis of patients with invasive implants is much poorer in the literature.

So, it should be more reluctant to propose conservative treatment to patients with

invasive implants.

Impact of Conservative Surgery on theSurvival rate

the survival of patients is not affected by the use of conservative surgery

1116 69 129 4

The relation between type of conservative surgery and recurrance rate

32 stage I, 12 stage II-III

Mean follow-up 109 mounts

110 unilateral salpingo-oophorectomy

50 cystectomy

24 bilateral cystectomies

5 Other combinations

Recurrance localization after conservative surgery

n:2055% in contralateral ovary40% in same ovary after cystectomy 5% in extrapelvic region

Zaneta ve ark J Clin Oncol 2001

n: 189

Ovarian Stimulation and IVF after Conservative Surgery

cohort study of 19,146 subfertile womenControl group 6963 subfertile women

a median follow up of 15 years, a total of 77 ovarian malignancies were observed in the cohort (42 EOC and 35

BOT

RR was 1.67 for EOC and 4.25 for BOT

The conclusion was that IVF increases the risk of BOT.

Burger CW, Gynecol Oncol 2009

Recurrence rate 19% Recurrence rate 19%

Reports on patients with a previous history of borderline ovarian tumor who underwent ovarian hyperstimulation(OS) and/or oocyte retrieval (OR) for assisted conception

923/2479 patients treated by conservative surgery

95% pts. with stage I or stage II disease 5% pts with stage III disease.20 women underwent ovarian stimulation and/or IVF

The recurrence rate 16% 5 recorded disease-related deaths.

ART rate 16%Pregnancy rate 48%

Conclusionyoung age at diagnosis.

high overall survival rate

80%of them early stage

conservative surgery for all stages

ovarian stimulation after surgery