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 Mucinous More 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 % 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 regimens and paclitaxel) MBOT with stromal microinvasion§ Conservative treatment of SBOT; use of (re)staging surgery

Treatment of BOT

Conservative Surgery Fertility-sparing Surgery Who desire to preserve fertility unilateral bilateral tm USO USO + cystectomy Bilateral cystectomy Interventions for the treatment of borderline ovarian tumours (Review) The Cochrane Collaboration and published in The Cochrane Library 2010, Issue 9 USO + cystectomy Bilateral 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 I n:283, 83% Stage II-III N:56, 17% Zaneta ve ark J Clin Oncol 2001 Conservative surgery for aerly stage disease n: 339

42 pts (67%) …….USO 13“ (21%)……..UC 5 “ (8 %)…….. USO CC 2 “ (4 % )………CC Mean follow-up 44 months Recurrence rate 7% n: 62

39 pts. with stage II-III BOT 11 of them underwent USO 28 “ “ “ CYSTEC. 39 pts. with stage II-III BOT 11 of them underwent USO 28 “ “ “ CYSTEC. 5 yrs. 10 yrs. Median follow-up 57 months Recurrence rate 56%

Recurrence rate 14% 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 the Survival rate the survival of patients is not affected by the use of conservative surgery

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:20 55% in contralateral ovary 40% 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 women Control 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% 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%

Conclusion young age at diagnosis. high overall survival rate 80%of them early stage conservative surgery for all stages ovarian stimulation after surgery