Laparoscopic restaging of borderline ovarian tumours (BLOT): a retrospective study of 142 cases

Objectives

Primary objective: To analyse the impact of restaging, on recurrences and survival, in BLOT. Secondary objective: To cluster patients who could be exempted from restaging.

Study design

This retrospective study, included patients operated for a BLOT, between January 1990, and December 2007, in gynaecological surgery units of the University Hospital of Clermont-Ferrand.Two groups were evaluated: patients with and without optimal restaging.

Results

One hundred and forty-two patients were included. Optimal initial staging rate was 38.7% (n = 55). Among the eighty-seven women not initially staged, two groups were compared: restaged (n = 45) and non-restaged patients (n = 42). Mean follow-up was 80.5 months. Overall survival was 93.7%. Relapse rate was 7.7% (n = 11). Disease free survival (DFS) was 88% after a mean follow-up of 80.5 months. One death was noted.Optimal restaging rate was 31.7% (n = 45, 43 by laparoscopy). Mean follow-up was of 87.1 months among restaged patients, 84.5 months among non-restaged patients (p = 0.93).Relapse incidence was significantly higher in non restaged, than in restaged patients (p = 0.008). DFS was significantly longer among restaged than non-restaged patients, (p = 0.072). Younger age (p = 0.04), conservative treatment (p < 10⁻⁴) or non-diploidy (p = 0.04) increased the incidence of relapse.

Conclusions

When initial staging is missing, restaging improves the patients outcome in comparison to non-restaged groups. Laparoscopy is a valuable surgical option. This study suggests that a selected group of patients, older than 30 years old, submitted to a radical treatment, presenting a diploid, non micropapillar, mucinous BLOT, without visible implants during careful peritoneal inspection, could be exempted from restaging. They represented 11.6% of our population.     

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).

Results after conservative treatment of serous borderline tumours of the ovary with stromal microinvasion but without micropapillary pattern

The aim of this study was to assess the outcomes of women treated conservatively for a serous borderline ovarian tumour with stromal microinvasion (SBOT-SMI) but without micropapillary pattern. Ten women treated conservatively for a stage I ( n = 8) or stage IIIB ( n = 2) tumour were followed up. With a median follow-up duration of 62 months (range 7–117 months), five recurrences developed on the preserved ovary. All lesions were borderline recurrences (with noninvasive peritoneal implants in one). All women are currently disease free. Three women achieved a spontaneous pregnancy and three became pregnant after an in vitro fertilisation procedure. This study suggests that conservative treatment of SBOT-SMI is safe.     

Pregnancy rates after conservative treatment for borderline ovarian tumours: A systematic review

Borderline ovarian tumours account for 10–15% of all ovarian cancers, and there have been numerous studies indicating their excellent long-term prognosis. As this disease commonly affects younger women, the issue of fertility-preserving surgery is increasingly important.     

Long-term outcomes following conservative surgery for borderline tumor of the ovary: a large population-based study

OBJECTIVES: To examine outcomes in women treated with conservative surgery for borderline ovarian tumor in a large population-based cohort with long-term follow-up. METHODS: Women treated by conservative surgery for borderline tumor of the ovary from 1982-2004 within a large HMO setting were identified using electronic and tumor registry data. Chart review was performed when electronic data were incomplete. The indications for and outcomes from any subsequent gynecologic surgery and the risk of recurrent ovarian borderline and malignant tumor were determined. Risk factors for recurrence were analyzed using multivariate regression. RESULTS: Among one hundred and ninety-three patients identified, the average age was 33 (12-95), with 97% having apparent Stage I disease. Patients were followed with remaining ovarian tissue in situ for a mean of 6.9 years, with 59 women having 10 or more years of such observation. There were 21 recurrences with borderline tumor (11%) with a median time to first recurrence of 4.7 years; women treated by cystectomy recurred three times more often compared to women treated by oophorectomy (23% versus 7%). Two patients (1%) recurred with malignant disease involving remaining ovarian tissue, both within the first 3 years after surgery, with one death due to recurrence. During long-term follow-up, 19% of patients eventually underwent complete removal of ovarian tissue: in 8%, the surgery was prophylactic, in 5%, surgery was done for benign pathology, and in 6% for recurrent disease. CONCLUSIONS: In this population-based HMO setting, 11% of women treated with conservative surgery for borderline tumor recurred; however, half of these recurrences were successfully managed by repeat conservative surgery, with only 6% of women overall needing eventual complete removal of ovaries for recurrent disease. Patients treated by cystectomy were three times more likely to recur than those treated by oophorectomy. Malignant recurrences were rare, and while borderline recurrences often occurred more than 3 years after initial surgery, late malignant recurrences were not observed. These favorable long-term outcomes provide support for conservative surgery for these women.     

Mucinous tumors of the ovary: diagnostic challenges at frozen section and clinical implications

Objective

Frozen section (FS) diagnosis of mucinous tumors of the ovary can be quite difficult due to the size of these tumors, heterogeneity and potential risk of metastasis from gastrointestinal (GI) neoplasms. Given the paucity of data on this subject, our objective was to determine the reliability of FS diagnosis in ovarian mucinous tumors.

Methods

A retrospective review of 73 consecutive ovarian mucinous tumors submitted for frozen section (FS) evaluation between January 2004 and November 2009 was conducted. FS and final pathology results, in addition to patient characteristics, were collected. Univariate analysis was performed evaluating predictors of FS reliability.

Results

The average tumor size was 19.7 cm (0.8-50 cm). The FS and final pathology diagnosis were concordant in 66% (48/73) of the cases. Of the 25 (34%) discordant cases, 8 (11%) were downgraded and 17 cases (23%) were upgraded. Of the 44 tumors interpreted as LMP on FS, 14 (32%) were malignant at final diagnosis (26% ovarian, 7% GI) and 8 (18%) were benign. Of the 23 benign tumors on FS, 13% were upgraded to either LMP or malignant at final diagnosis. Tumors with a malignant diagnosis on FS were 100% concordant with final diagnosis. Univariate analysis did not reveal any correlation with the FS diagnosis and patient age, tumor size or presence of bilateral disease.

Conclusions

Our study showed a 34% rate of discordance between FS and final diagnosis. Given that 5 cases (7%) were of GI origin, intraoperative assessment of the appendix should be performed in all mucinous ovarian tumors.     

卵巢交界性上皮性肿瘤30例临床与病理分析

回顾性分析我院及福建省安海、永春县等医院１９８３年６月－１９９３年６月期间经手术及病理证实的３０例卵巢交界性上皮性肿瘤的临床及病理特点。     

A retrospective study of 32 borderline ovarian tumours: the experience of a non-specialized centre

BACKGROUND: We evaluated the clinical features and treatment of patients with borderline ovarian tumors. METHODS: This was a retrospective review of the charts of 32 patients with borderline ovarian tumours that underwent surgery at the Department of Obstetrics and Gynaecology, Tzaneio General Hospital of Piraeus, over a 14-year period (1/1990-12/2003). RESULTS: Of the patients 62.5% were pre- or peri-menopausal. Mean age was 41.6 years. Five patients (15.63%) had undergone pelvic surgery (caesarean section not included) for unrelated reasons prior to the diagnosis of borderline tumour. Mean follow-up was 71.37 months and all patients showed up for their scheduled appointment during the first trimester of 2004. Pain was the presenting symptom in 37.5% (12/32) of patients. Twenty patients were diagnosed either by ultrasound (12.5%, 4/32) or during unrelated surgeries (50%, 16/32) and reported no relevant symptoms at the time of diagnosis. Treatment was conservative, comprised of either cystectomy (3/32), unilateral salpingo-oophorectomy (13/32), and unilateral salpingo-oophorectomy with myomectomy (1/32). Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed in 15 patients for unrelated conditions (uterine pathology). Mucinous borderline tumours were identified in 11 patients (34.38%), serous borderline tumours in 17 patients (53.12%), and nonserous-mucinous borderline tumours in four patients (12.5%). Omentectomy was performed in two cases, biopsy of the controlateral ovary was performed in five cases and peritoneal washing in eight cases. Restaging surgery was performed at the Metaxa Anticancer Piraeus Hospital in 11 patients (34.38%). One patient who did not undergo a restaging operation had a recurrence of the disease. CONCLUSION: Suboptimal staging remains a major problem during the initial operation in non-specialized centres in gynaecologic malignancies.     

Two cases of ectopic ovary and one case of potential ectopic ovary

Ectopic ovary is a rare gynecologic entity. A variety of synonymous terms such as ectopic ovary, supernumerary ovary, accessory ovary, and autoamputation of the ovary have been used to describe this condition. The etiology for ectopic ovary has not been elucidated, but several mechanisms have been proposed. They are categorized as either congenital (embryologically derived) or acquired. This report presents two cases of ectopic ovary resulting from different causes and one case of potential ectopic ovary.     

Primary retroperitoneal mucinous borderline tumor: a case report

BACKGROUND: Primary retroperitoneal mucinous borderline tumors are rare. These tumors can be present in women with otherwise normal pelvic anatomy. CASE: A 22-year-old woman with abdominal pain was found to have a large midline mass superior to the uterus with ascites. In surgery, a large mass was arising from the sigmoid mesentery. The pelvis was normal on inspection. Final pathology of the mass revealed borderline tumor (tumor of low malignant potential) and focus of ovarian tissue. CONCLUSION: This is a case report of primary retroperitoneal mucinous borderline tumor. The gynecologic oncologist should be aware of primary retroperitoneal tumors and the differential diagnosis.     

Malignant mixed mullerian tumour of the ovary: prognostic factor and response of adjuvant platinum-based chemotherapy

OBJECTIVES: The purpose of the present study was to analyse retrospectively the data of a series of patients presenting to our unit with malignant mixed mullerian tumour (MMMT) of the ovary to identify the prognostic factors and relate them to survival. The role of platinum-based chemotherapy in the adjuvant treatment of this tumour was also evaluated. METHODS: All patients diagnosed with MMMT of the ovary from 1987 to 2000 were identified from the gynaecological tumour registry of King George V Hospital, Australia. The effect of clinical and histopathological variables on survival was analysed. The response of platinum-based adjuvant chemotherapy after surgery was also evaluated. RESULTS: Twenty patients with MMMT of the ovary were identified. Of the six patients with measurable disease, two (33%) had complete response after adjuvant platinum-based chemotherapy. The median survival of all patients was 8 months, while that of the patients receiving adjuvant platinum-based chemotherapy was 23 months. Women who were older (> 65 years) had a significantly worse survival rate than those who were younger (P = 0.02). The patients with optimal debulking had a better median survival than those with suboptimal debulking, but this difference was not statistically significant (P = 0.21). Sarcomatous component (homologous vs heterologous) was not found to be a significant prognostic factor for predicting survival. CONCLUSIONS: Malignant mixed mullerian tumour of the ovary is a rare and aggressive gynaecological tumour. The current study indicates that patient age was a significant prognostic factor for survival and surgical cytoreduction combined with platinum-based chemotherapy is the most effective management regimen identified to date to treat MMMT of the ovary.     

Paratubal borderline tumor diagnosed in the adolescent period: a case report and review of the literature

Background

Borderline paratubal cysts are rare entities. These tumors are identified as epithelial proliferation without stromal invasion.

Case

A 19-year-old virgin patient was admitted to our clinic with abdominal pain and nausea. The sonographic evaluation showed a left adnexal mass 89 × 80 mm in diameter with solid tissue projections. Doppler examination revealed no significant blood supply. At surgery, a torsed left paratubal cyst 10 cm in diameter and normal bilateral ovaries were encountered. Cystectomy was performed and of frozen section revealed a borderline Fallopian tube neoplasm. Final pathology review was reported as a serous borderline paratubal tumor.

Conclusion

The evaluation of the structure of cyst by ultrasound and the performance of intraoperative frozen section analysis are two important issues to diagnose the nature of a cyst. Fertility-sparing surgery is the main point of management.     

Role of minimally invasive surgery in complex adnexal tumours and ovarian cancer

Ovarian cancer is one of the most common causes of cancer-related death in women. Adnexal masses are frequently diagnosed during reproductive age and often require surgical removal. The risk of malignancy when dealing with a complex adnexal mass should be defined prior to surgery and several scoring systems may be useful for this purpose. Laparoscopic management of ovarian tumours allows a minimally invasive approach with respect to several oncological assumptions. In the last decade concerns have been raised regarding the risk of cyst rupture and tumour spillage as a consequence of the laparoscopic technique itself both in early and advanced stages of ovarian cancer. Although limited data have been reported in the literature on the use of minimally invasive techniques in ovarian cancer, the clear benefits of this approach must be balanced with the potential hazards in different clinical situations. Laparoscopic staging in borderline tumours and presumed early-stage ovarian cancer performed by a laparoscopic oncologist seems to be safe and effective when compared to laparotomy. The precise role of laparoscopy in patients with more advanced cancer is still to be defined, and the risk of suboptimal surgery should never outweigh the potential benefits of minimally invasive surgery. Thus, a tailored prediction of optimal laparoscopic debulking is mandatory in these patients.     

Different routes of progesterone administration and polycystic ovary syndrome: A review of the literature

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in woman of reproductive age. Although extensive studies have been performed in past decades to investigate the pathobiological mechanisms underlying the unset of this disease, its etiology remains unknown. Progesterone is a hormone of paramount importance in ovulation, implantation and luteal phase support. Low levels of progesterone have been found in the early luteal phase in PCOS patients. Granulosa cells from polycystic ovaries show an altered progesterone production. Moreover, the lack of cyclical exposure to progesterone may have a role in the development of the gonadotropin and androgen abnormalities found in PCOS patients. Ovulation failure and progesterone deficiency may facilitate the hypothalamic–pituitary abnormalities causing the associated disordered luteinizing hormone secretion in PCOS. Progesterone may be administered to PCOS patients in the following cases: to induce withdrawal bleeding, to suppress secretion of luteinizing hormone, in ovulation induction in clomiphene citrate-resistant patients and in luteal phase support in assisted reproduction. We discuss the pharmacologic characteristics of the different routes of progesterone administration with reference to these diverse indications, the therapeutic objectives and patient compliance.     

Safety of conservative management and fertility outcome in women with borderline tumors of the ovary

OBJECTIVE: To assess the safety of fertility-sparing treatment and the remaining chance of childbearing after surgery. DESIGN: Retrospective clinical study. DESIGN: Gynecology department of a university teaching hospital. PATIENT(S): Seventy-five women underwent surgical management in our institution between 1986 and 2001 for borderline tumors of the ovary. INTERVENTION(S): Fifty-nine patients were treated by radical, fertility-compromising surgery. The remaining 16 patients underwent conservative surgery, preserving the uterus and at least some functional ovarian tissue. Seven unilateral adnexectomies, one simple cystectomy, and two adnexectomies associated with contralateral cystectomy were performed. MAIN OUTCOME MEASURE(S): Recurrence, survival, and pregnancy rates. RESULT(S): The observed recurrence rates after radical and conservative surgery were 0.0% and 18.7%, respectively. No disease-related deaths occurred in any group; there is no significant difference in survival rates. We can report 12 pregnancies in 7 of 11 women who underwent fertility-sparing management and who wished to become pregnant. CONCLUSION(S): In certain circumstances, conservative management offers a safe solution for borderline tumors of the ovary. Recurrence is noted significantly more often after this type of treatment, but all cases of recurrent disease can be detected with close follow-up and can be treated accordingly. No significant change in survival rates was found. Moreover, the pregnancy rate in women desiring pregnancy, those treated conservatively, was as high as 63.6%.     

Yolk sac tumours of the ovary: Evaluation of clinicopathological features and prognostic factors

Objective

To evaluate the clinicopathological prognostic features, factors and outcomes of chemotherapy in ovarian yolk sac tumours (YST).

Study design

We reviewed the medical records of 32 women with ovarian YST treated from 1990 to 2006 at two centres.

Results

The median follow-up was 36 months. The median age was 22 (range, 9–68). Two patients were postmenopausal. The most common symptoms at diagnosis included abdominal swelling or mass (72%) and abdominopelvic pain (62%). The location of the tumour was bilateral in 2 cases. Eight patients were in stage I, 4 patients in stage II, 17 patients in stage III, and 3 patients in stage IV. Eighteen patients underwent unilateral salpingo-oophorectomy, two bilateral salpingo-oophorectomy and two cystectomy, while 10 patients had total abdominal hysterectomy and two bilateral salpingo-oophorectomy. Of 32 patients who received postoperative chemotherapy, 27 were treated with a bleomycin/etoposide/cisplatin (BEP) regimen. Seventy-two percent of patients were alive at the last follow-up visit. Ten (31%) patients suffered from a recurrence of the disease with a median time to recurrence of 8 months (range, 6–28 months). The most common site of recurrence was the intra-abdominal space, with 8 patients. Only one patient who had recurrence could be salvaged. Fertility-sparing surgery was found at least as effective as radical surgery. While age, histology (mixed vs. pure), stage, tumour size, ascites, and marker levels were not found as prognostic factors, the presence of residual tumour (P = 0.014) and BEP chemotherapy (P = 0.016) were significant prognostic factors in univariate analysis.

Conclusions

In patients with ovarian YST, fertility-sparing surgery is as effective as radical surgery. Optimal cytoreductive surgery and standard BEP regimen are the most decisive prognostic factors. In these tumours, adjunctive therapeutic modalities to eradicate intra-abdominal disease and effective salvage therapy strategies are needed.