Surgical staging for epithelial ovarian tumors of low malignant potential

From January 1975 to December 1991, 34 patients with a diagnosis of epithelial ovarian tumors of low malignant potential (LMP) were admitted to the Istituto Nazionale Tumori of Milan. Eighteen of them (group 1) underwent complete staging laparotomy and retroperitoneal para-aortic and pelvic lymphadenectomy, as for ovarian cancer. In the remaining 16 cases (group 2), the surgical treatment ranged from unilateral oophorectomy to incomplete staging procedure. In group 1, nine patients (50%) were found to have retroperitoneal nodal involvement. In group 2, all patients had stage I disease. Patients were followed up for 20–222 months (mean 108, median 86). There were two recurrences in group 2 (after 5 years) and none in group 1 (NS). Currently all patients are alive and disease free. Nine of 18 group 1 patients were upstaged to stage III on the basis of lymph node involvement only. However, at least in this retrospective series, lymph node metastases did not affect prognosis or survival.     

Surgical staging in patients with ovarian tumors of low malignant potential

OBJECTIVE: To compare the outcomes of patients with ovarian tumors of low malignant potential who had complete surgical staging with those who were unstaged to determine whether the rate of recurrence or survival was affected by surgical staging. METHODS: A retrospective chart review was performed on 93 consecutive patients who had surgery for histologically confirmed tumors of low malignant potential between 1979 and 1997. Two cohorts of patients were identified: patients who had classic surgical staging (n = 48) versus those who were not staged (n = 45). Outcome data were recorded for patients and compared between the two groups. RESULTS: Early stage (I or II) disease was diagnosed in 31 of 48 patients who had surgical staging and 42 of 45 patients who were not staged (P =.001). In 17% of patients their stage was upgraded on the basis of surgical staging, as a result of retroperitoneal involvement in only 6% of those cases (three of 48 staged patients). During the study interval, the frozen section diagnosis of low malignant potential tumor of the ovary was changed to a final diagnosis of invasive cancer in eight other patients. There were three recurrences and two deaths in both the staged and unstaged low malignant potential groups. The average duration of follow-up was 6.5 +/- 4.2 years and was similar in the two groups. Overall 5-year survival was approximately 93% for all stages. CONCLUSION: Survival and recurrence rates were not significantly different between staged and unstaged patients who had surgery for low malignant potential tumors of the ovary.     

Operative staging and conservative surgery in the management of low malignant potential ovarian tumors

The medical records of 45- patients with intraoperative diagnosis of borderline or low malignant potential (LMP) ovarian tumor were reviewed to identify factors affecting intraoperative management. The correlation between gross and histologic staging was examined, as was the complication rate following surgery. Patient age and presence of qualifying pathologic terms on frozen section diagnosis were the only important factors relating to performance of surgical procedure. Surgical complications were closely associated with non-conservative surgery. Thirteen of 14 (92.8%) patients with significant complications had a hysterectomy. These 14 patients had staging procedures at essentially the same rate as the entire population. Thirteen of 45 patients (28.8%) thought to have LMP by frozen section had a different diagnosis on permanent review; 5 were benign and 8 were frankly malignant, confirming the limitations of frozen section in the diagnosis of LMP ovarian tumor. Of 40 with LMP or frankly malignant tumors 5(12.5%) were upstaged based on unsuspected histopathologic findings. These results indicate the need for a standard approach to staging in patients who are suspected to have an LMP ovarian tumor and should encourage the performance of conservative surgery when appropriate.     

Epithelial ovarian tumors of low malignant potential

The records of 31 women with ovarian tumors of low malignant potential were retrospectively reviewed to identify factors that determine the prognosis. Median follow-up was 51 months. Eighteen women had stage I disease. Twenty-three women (74%) had serous tumors, of which 46% were bilateral. Nine patients (29%) had concomitant endometriosis or endosalpingiosis. Two patients died of disease; both had mucinous tumors with extraovarian metastases at initial operation and inadequate pathologic sampling of their tumors. These results were combined with those of 970 women identified in previous reports to show that the rate of recurrence or persistence of ovarian tumors rises from 2% for women with stage I disease to 14% for those with stage III or IV disease, while mortality rises from 2 to 5%. Careful staging and pathologic sampling are important for establishing the prognosis. Testing of adjuvant therapy should be limited to patients with extraovarian disease.     

Clinical aspects of ovarian tumors of low malignant potential

A review of 21 cases of ovarian tumors of low-malignant potential diagnosed in our department over a period of 13 years was undertaken. Ninety percent of the patients presented with stage I disease. The average age at diagnosis (45 years) was younger than commonly found in patients with invasive epithelial cancer. Three patients received postoperative chemotherapy, and all of those were evaluated by second-look laparotomy. One of our patients with stage Ic serous tumor recurred with lung metastases. In two other patients with mucinous tumors, mucocele of the appendix was found. The five year survival in this series was 100%. Our study emphasizes the need for a prospective study to evaluate the value of adjuvant therapy in the various stages of these ovarian neoplasms.     

A retrospective study of 27 ovarian tumors of low malignant potential

INTRODUCTION: This study was undertaken to retrospectively review the fertility-sparing surgical treatment and long-term outcome of 27 patients with ovarian tumors of low malignant potential treated at the 1st Department of Obstetrics and Gynecology of Semmelweis University Faculty of Medicine between 1990 and 2000. MATERIALS AND METHODS: Between 1990 and 2000, 163 patients with epithelial ovarian tumors were diagnosed and treated. Of these, 27 patients were diagnosed as having low malignant potential (LMP) ovarian tumors. The authors evalutated the effect of histopathologic parameters (histologic type, grade of nuclear atypia, tumor size and tumor growth on the ovarian surface) and clinical parameters (age at diagnosis, stage of disease, and treatment modalities) on prognosis in this group of patients with a long observation time. We reviewed our experience to assess the safety of conservative surgical management of patients younger than age 40 with early stage disease, and to determine the long-term outcome of low malignant potential ovarian tumors. Medical records were reviewed on all 27 patients to determine age, gravidity, size of tumor, bilaterality, sites of extraovarian involvement, stage of disease and the operative procedure. Follow-up information was obtained from hospital records, and in some cases, by direct patient contact. Statistical comparisions were made by the chi2 test. RESULTS: The incidence of LMP tumors in our patient population was 16.5%. The patients ranged in age from 15 to 82 years (median, 45 years). The lesions were staged according to FIGO. The stage distribution was Stage IA in 20 patients, Stage IB in one patient, Stage IC in one patient, Stage IIA in one patient, Stage IIB in one patient, Stage IIC in one patient and Stage IIIA in two patients. The ovarian tumors ranged in size from 3 to 19 cm (median 9 cm) and 15% of the tumors were bilateral. All patients with LMP ovarian tumors were treated with primary surgery; those who were older than 40 (14 patients) were treated with total trans-abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), while patients younger than 40 with early stage disease (12 patients) who wished to retain their fertility potential were treated with fertility-sparing surgery, namely unilateral salpingo-oophorectomy (USO). One patient who was younger than 40 with a Stage IIIA LMP ovarian tumor was also treated with TAH and BSO. Follow-up information was available for all 27 patients with LMP ovarian tumors. Only those patients with a minimum of two years of follow-up were included. Follow-up information from two to ten years (median, 6 years; mean, 6.5 years) revealed that all 27 patients were alive. During the period of follow-up one patient who initially had stage IIIA disease developed recurrent tumor. Fifty percent of patients who underwent conservative fertility-sparing surgical treatment (6/12) subsequently conceived. CONCLUSIONS: This study confirms the excellent prognosis for patients with low malignant potential ovarian tumors. Conservative fertility-saving surgical treatment can be offered to young patients (< 40 years) with early stage (stage I-II) disease who wish to retain their fertility potential. Up to 50% of women in this study who underwent conservative surgery subsequently conceived. The long-term outcome of LMP ovarian tumors is extremely favorable, even when long-term follow-up is extended to ten years.     

Long-term follow-up of serous ovarian tumors of low malignant potential.

The biologic behavior of serous tumors of low malignant potential (LMP) is of significant interest, yet most large series lack extended follow-up. This study consists of 200 patients: 106 patients were diagnosed with serous tumors of LMP at our institution between 1979 and 1984 and an additional 94 patients were identified in the referred tumor registry. The patients ranged in age from 6 to 98 years (median, 34 years). The stage distribution was Stage I in 135 patients (67.5%), Stage II in 24 patients (12%), and Stage III in 41 patients (20.5%). Follow-up information from 4 to 27 years (median, 10 years; mean, 11.2 years) revealed 155 patients (77.5%) were alive without further evidence of disease and 11 patients (5.5%) died of unrelated conditions without recurrent tumor. Thirty-four patients (17%) developed recurrent neoplasms at 6 to 145 months (median, 26 months). Patients with Stage III disease developed recurrent neoplasms more commonly (54%) than did patients with Stage I or II disease (6 and 17%, respectively). Following treatment of recurrence, 15 patients are free of disease, 6 patients are alive with disease, and 13 (6.5% overall) patients have died of disease 1 to 15 years (median, 5 years) after their initial diagnosis. Mortality was also stage dependent: 0.7, 4.2, and 26.8% of patients with Stages I, II, and III disease, respectively, died secondary to tumors of LMP. Clinical life table analysis demonstrated 5-, 10-, and 15-, and 20-year survival rates for all stages of 97, 95, 92, and 89%, respectively. These findings confirm the excellent prognosis for patients with serous tumors of LMP, even when long-term follow-up is extended to 20 years. Additionally, these data suggest that those with more advanced or recurrent disease can enjoy extended survival.     

Retroperitoneal lymphatic involvement with epithelial ovarian tumors of low malignant potential

A comprehensive understanding of retroperitoneal lymphatic involvement is lacking in tumors of low malignant potential. This study was undertaken to evaluate retroperitoneal lymphatic involvement in patients with ovarian tumors of low malignant potential. One hundred seventy-one patients were diagnosed with epithelial ovarian tumors of low malignant potential between 1979 and 1989. Thirty-four (20%) of these patients underwent surgical staging which included lymph node sampling. The stage distribution was Stage I in 17 patients (50%), Stage II in 4 patients (12%), and Stage III in 13 patients (38%). The histology of the tumors was serous in 26 patients (76%), mucinous in 7 patients (21%), and seromucinous in 1 patient (3%). The incidence of retroperitoneal lymphatic involvement was 21%. The occurrence of positive pelvic and para-aortic nodes was 17 and 18%, respectively. Patients with localized intraperitoneal disease were upstaged in 22% of the cases based on retroperitoneal lymphatic involvement. Four of twenty-one patients (19%) with intraperitoneal disease confined to the ovary and two of six patients (33%) with intraperitoneal disease confined to the pelvis were upstaged to Stage III as a result of retroperitoneal lymphatic disease. Although the nodal status of patients did not significantly affect survival, those patients with localized intraperitoneal disease and nodal involvement had a higher incidence of recurrence which was statistically significant (P = 0.025). Accordingly, retroperitoneal lymph node sampling at the time of initial laparotomy may provide valuable prognostic information regarding recurrence in patients with tumors of low malignant potential.     

The role of laparoscopy in ovarian tumors of low malignant potential and early-stage ovarian cancer

Although it is feasible today to perform laparoscopic surgical staging and treatment of ovarian low malignant potential tumors and early-stage ovarian cancer safely, it is still generally agreed that a patient with ovarian cancer should have a laparotomy. Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, improper or delay in surgical staging, delay in therapy, and the possibility of port-site metastasis. On the other hand, laparoscopy has the advantages of being a minimally invasive surgery, with shorter hospitalization, decreased postoperative pain, and quicker return to normal daily activities. We review the current literature discussing the consequences of laparoscopic surgery in ovarian tumors of low malignant potential and early-stage ovarian cancer. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to list the concerns related to laparoscopic management of ovarian malignancies, to outline the accuracy of the diagnosis of low malignant potential (LMP) ovarian tumors on frozen section, and to summarize the data on the effect of capsule rupture on overall prognosis for patients with ovarian cancer.     

Epithelial ovarian tumors of low malignant potential: the role of microinvasion.

OBJECTIVE: To identify prognostic factors that may be used to predict an aggressive disease course and poor outcome in patients with epithelial ovarian tumors of low malignant potential (borderline tumors). METHODS: Data on 126 patients with ovarian borderline tumors were analyzed with regard to demographic characteristics, staging, presence of microinvasion, duration of follow-up, recurrence rate, rate of recurrence as invasive disease, mortality rate, preoperative and postoperative CA-125, and treatment. Chi-square and Fisher exact tests were used to evaluate proportions for statistical significance. Disease-free and overall survival was calculated by using the Kaplan-Meier method and log-rank test. RESULTS: Patients were followed for a median of 39.0 months (mean 47.8 months). Seven patients (5.6%) had recurrent disease. Advanced stage disease and microinvasion were associated with significantly higher recurrence and mortality rates than were stage I/II disease and borderline tumors without microinvasion, respectively. Two of 13 (15%, 95% CI 8.7, 21.3) patients with microinvasion died of recurrent invasive cancer, whereas only 1 out of 113 patients without microinvasion died of recurrent borderline tumor (OR 20.4, 95% CI 1.2, 239). All 3 patients with an aggressive disease course and poor outcome had increasing CA 125 levels at the time of recurrence. CONCLUSION: Certain patients with microinvasion may be at higher risk for recurrence as invasive disease and may require different treatment strategies. CA 125 monitoring may have a role in early detection of recurrence in patients with aggressive disease.     

Epithelial ovarian neoplasms of low malignant potential

This report presents 13 patients with epithelial ovarian neoplasms of low malignant potential. Ten patients had serous tumors, 1 had a mucinous tumor, and 2 had endometrioid tumors. Two had Stage I disease, 4 had Stage II disease, and 7 had Stage III disease. All were treated with melphalan. Second-look laparotomy was performed in 11 patients and 1 patient required subsequent exploratory laparotomy. None achieved histologic confirmation of cure. Five patients continued treatment with melphalan and underwent third-look laparotomy with findings of persistent disease. Seven patients are alive without clinically detectable evidence of disease. Four patients died of their disease and 2 patients died of melphalan-induced acute leukemia.     

Epithelial ovarian carcinoma of low malignant potential

The records of 94 patients with epithelial ovarian carcinoma of low malignant potential were examined. These records were contributed by Walter Reed Army Medical Center, Naval Hospital, Bethesda, MD, and Naval Hospital, Portsmouth, VA. A review of microscopic sections from each of the 94 tumors confirmed that these were lesions of low malignant potential. The tumors occurred in patients of a younger age than that generally described for invasive epithelial ovarian carcinoma. Forty-seven of 94 patients had stage I disease. The corrected five- and ten-year survival rates were 95 and 87%, respectively. Adjunctive postoperative therapy may not influence survival.     

Ovarian epithelial tumors of low malignant potential

Forty-one patients with epithelial ovarian tumors of low malignant potential are discussed. Twenty-three patients presented with Stage I, four with Stage II and 14 with Stage III disease. All patients with Stage I disease were solely treated surgically. Twelve patients with Stage II and III disease also received postoperative chemotherapy. Four of ten patients had persistent disease at second look laparotomy. Chemotherapy was not used in six patients with Stage II and III disease when the tumor was considered to have been removed completely. Forty of the 41 patients are currently alive and free of disease at two to nine years of follow-up study. Vigorous and, at times, multiple surgical procedures remain the primary treatment of ovarian tumors of low malignant potential.     

Evidence for the efficacy of adjuvant therapy in epithelial ovarian tumors of low malignant potential

During the 10-year period from January 1975 through December 1985, 48 patients with low malignant potential epithelial ovarian tumors were treated on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. No patients were lost to follow-up and the mean duration of follow-up was 42 months. Twenty-nine patients were Stage I, 5 patients were Stage II, 11 patients were Stage III, 1 patient was Stage IV, and 2 patients were unstaged. Patients were divided into those with no residual disease after initial surgical treatment (29), microscopic residual disease (7), and gross residual disease (12). No patient without residual disease died from cancer. Of the 19 patients with residual disease, all received adjunctive chemotherapy alone, radiation therapy alone, or a combination of both. Three of 19 patients died from cancer. Twelve patients with residual disease were found to be free of disease at second-look surgical reassessment following adjunctive therapy. This review indicates that adjunctive therapy can eradicate residual disease in patients with epithelial ovarian tumors of low malignant potential.     

An assessment of pathologic features and treatment modalities in ovarian tumors of low malignant potential

Sixty-eight patients with epithelial ovarian tumors of low malignant potential treated at the University of Michigan Medical Center were reviewed for clinical and pathologic features related to recurrence or death. The ovarian tumor of low malignant potential represented 12.6% of all ovarian cancers and 22% of all serous or mucinous tumors. Thirty-four patients were stage I (50%), 13 were stage II (19%), 17 were stage III (25%), two patients could not be staged, and two patients developed ovarian tumor of low malignant potential in a residual ovary. The risk of recurrence was significantly related to stage III disease (P = .023), high nuclear atypia (P = .020), and high grade (P = .017); and was unrelated to capsular status, the presence of psammoma bodies, nucleoli, cribriform pattern, stratification, cystadenofibroma, tumor size, or spillage at surgery. Therapy in all stages included observation, chemotherapy, or radiotherapy. There was one recurrence in 47 patients with stages I-II, and 11 recurrences in 17 patients with stage III disease. The ovarian tumor of low malignant potential carries an extremely favorable prognosis in stage I and II regardless of therapy. Radiotherapy appeared to extend disease-free survival in stage III disease, and future randomized studies should consider this treatment modality.     

Long-term survival and patterns of care in women with ovarian tumors of low malignant potential

OBJECTIVES: The objectives of this study were to ascertain long-term survival and patterns of care among women diagnosed with ovarian tumors of low malignant potential (LMP) in a population-based data set. METHODS: Using the NCI's Surveillance, Epidemiology, and End Results (SEER) database, we identified 2818 women diagnosed with ovarian tumors of low malignant potential between 1988 and 1997. RESULTS: By FIGO stage, 10-year relative survival was as follows: stage I, 99%; stage II, 98%; stage III, 96%; and stage IV 77%. One-quarter of women with stage I disease underwent partial or unilateral oophorectomy only, while women with more advanced disease commonly underwent omentectomy, unilateral or bilateral oophorectomy, and hysterectomy. Adjuvant chemotherapy was given to about 30% of women with stage III and IV disease. Radiation therapy was rarely used. We observed no significant changes in primary surgery or adjuvant treatment over time. CONCLUSIONS: The diagnosis of an ovarian tumor of LMP conveys a relatively benign prognosis. Conservative surgery should be considered in younger women with early-stage disease. There are insufficient data to support a role for adjuvant chemotherapy for women with advanced disease.     

The significance of comprehensive staging surgery in malignant ovarian germ cell tumors

Objective

To evaluate the clinical significance of fertility-preserving comprehensive staging surgery (CSS) in the treatment of malignant ovarian germ cell tumors (MOGCTs).

Methods

A total of 92 cases of MOGCTs were retrospectively reviewed.

Results

Forty-six patients (50%) received CSS, which includes ipsilateral adnexectomy + omentectomy + retroperitoneal lymphadenectomy (appendectomy and multiple biopsies as required). Forty-six patients (50%) received USO, which includes ipsilateral adnexectomy + clinical intraoperative evaluation (including retroperitoneal lymph nodes, great omentum, peritoneal, and contralateral ovary), biopsy of suspicious sites, and excision of all visible lesions. The mean operation time (177.0 vs. 114.8 min; p < 0.0001) and the mean intraoperative blood loss (499.1 ml vs. 112.9 ml; p = 0.04) were significantly higher in the CSS group compared to those in the USO group. The complication rate (17.4% vs 0%, p = 0.003), the relapse rate (10.9% vs 2.2%, p = 0.102) and the mortality rate (4.3% vs 2.2%, p = 0.500) were higher in the CSS group compared to those in the USO group. The difference in complication rate was statistically significant. The overall 5 year survival rates were 92% and 97% in the CSS and USO groups, respectively (p = 0.575). Tumor-free survival rates at 5 years were 87% and 97% in the CSS and USO groups, respectively (p = 0.115).

Conclusions

The benefit of fertility-preserving CSS to MOGCT patients was not greater than that of USO. It is safer and more effective to perform ipsilateral adnexectomy + clinical intraoperative exploration surgery (including retroperitoneal lymph nodes, great omentum, peritoneal, and contralateral ovary), biopsy of suspicious sites, excision of all visible lesions, and adjuvant chemotherapy.     

Ovarian carcinoma of low malignant potential: staging and treatment

A review of 65 cases of ovarian carcinoma of low malignant potential registered at the Manitoba Cancer Treatment and Research Foundation over a 7 1/2-year period was undertaken. Eighty-four percent of patients presented with Stage I disease, which was confirmed by primary staging laparotomy in 25%. The average age at diagnosis was younger than that commonly found in patients with invasive carcinoma. Fourteen patients received postoperative chemotherapy, of whom 10 were evaluated with second-look laparotomy. No patient with macroscopic residual disease after initial surgery was cured by chemotherapy. This report emphasizes the need for a prospective controlled study to evaluate adjunctive chemotherapy in the treatment of these tumors.