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Preserving Fertility in Borderline Ovarian Cancer

This retrospective study of 25 women who underwent fertility-sparing surgery for the treatment of borderline ovarian carcinoma was conducted to investigate the survival and fertility outcome of these patients.

The median age of study subjects was 29 years. Nineteen were treated with unilateral adnexectomy, 5 had unilateral adnexectomy with contralateral cystectomy, and 1 had unilateral cystectomy. The uterus and at least one portion of one ovary were preserved in each patient. Complete surgical staging was possible in 14 women of whom 10 were diagnosed with

stage IA disease, 3 with stage IC, and 1 with IIIA. Histologic results for all 25 patients included 11 mucinous tumors, 11 serous, and 3 mixed tumors. None of the 25 patients were treated with chemotherapy in addition to surgery. After a median follow up of 80 months (range, 4–157 months), there were no recurrences of ovarian

Cancer. One patient was diagnosed with lymphoma 5 months after she was treated for borderline ovarian cancer. After treatment with vincristine, doxorubicin, and cyclophosphamide, she was alive without evidence of disease at 34 months. Of the 15 patients whose fertility status was known, 6 had attempted pregnancy. Of these, 5 became pregnant and delivered normal healthy babies at term. One each of these women had stage IA, stage IC, or stage IIIA disease and 2 were unstaged. The sixth patient achieved pregnancy with in vitro fertilization but had a spontaneous abortion in the first trimester. Chan J, et al. J Reprod Med 2003;48:756–760

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malignant potential or borderline epithelial ovarian tumors are usually confined to one ovary or the other, not both, and rarely recur or lead to the death of the patient. The diagnosis and management of these lesions has been recently reviewed by Crispens (Curr Opin Obstet Gynecol 2003;15:39). Although it is generally recommended that women with borderline ovarian tumors be treated by removal of both ovaries and the uterus, as well as staging biopsies, most experts agree that women who desire to retain their fertility can be safely managed by removal of the affected ovary alone, or even just the cystic

tumor itself, preserving most or all of both ovaries. The study noted above from the University of California at Irvine strongly supports this concept. No patient developed a recurrence during a median follow up of 80 months despite conservative surgery and no postoperative chemotherapy or radiation therapy. Similar results were reported from Italy in a series of 19 women with borderline tumors who were managed by laparoscopic oophorectomy (8) or cystectomy (11) (Seracchioli et al. Fertil Steril 2001;76:999). These women all underwent “second-look

laparoscopy” at 6 months to evaluate their status and only one patient—originally treated by cystectomy for a borderline serous tumor—was found to have evidence of recurrence on follow up. She was treated by a repeat cystectomy for a 3-cm cystic borderline tumor in the same ovary. The authors advised placing the tumor in a bag (while removing it) to reduce the risk of tumor spillage if

cyst rupture occurred; but at the same time, they point out that several studies have shown no adverse effect of cyst rupture at the time of surgery (Sjovall et al. Int J Gynecol Cancer 1994;4:333).
The most important argument for a careful technique to prevent spillage and for accurate staging is the uncertainty of the diagnosis at the time of surgery. Although most of these tumors appear

benign to the surgeon, it is possible that the small 6-cm cyst will be a cancer on microscopic examination; and even when the 10-cm tumor is diagnosed as a borderline

lesion on frozen section, it is not unusual that careful study of more sections will upgrade the diagnosis the next day to a well-differentiated serous carcinoma. In these cases, accurate staging could save the patient additional surgery or chemotherapy.

However, what should be done if staging is incomplete and the final diagnosis is borderline? Because no postoperative therapy is recommended and survival is excellent even when “

metastatic” borderline ovarian lesions are diagnosed, reoperation for staging is not necessary. A careful review of the pathology is indicated and close follow up is important. In Chan’s study noted above, incomplete staging was noted in 11 patients who were managed conservatively with excellent results. Various studies have followed patients by ultrasound, computed tomography scan, and second-look laparoscopy. The less-invasive techniques are probably adequate because survival approaches 100% even when recurrent “metastatic” borderline lesions are diagnosed and removed.

Although pregnancy is not always attempted postoperatively in women treated conservatively, there is good evidence that these pregnancies are normal, and there is no convincing evidence that pregnancy adversely affects the risk of ovarian tumor recurrence. Although Papadimitriou et al. reported 5 recurrences after pregnancy, over 120 pregnancies have been reported in the literature with no other recurrences (Eur J Gynaecol Oncol 1999;2:94). Conservative, fertility-preserving surgery for borderline epithelial ovarian tumor is a safe and reasonable management approach.—HWJ)