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11/1/2017

The Management of Borderline Ovarian Tumors

Borderline ovarian tumors, previously known as low-malignant potential (LMP) tumors, make up nearly 20% of ovarian epithelial cancers and have an excellent prognosis regardless of stage at diagnosis. Borderline ovarian tumors are typically diagnosed in patients during their 40’s, significantly earlier than invasive carcinomas. These tumors have not been shown to have a hereditary component.

Borderline tumors often share ultrasound findings with malignant tumors including papillary projections, thickened septations, and multicystic components. However, a significant percentage of borderline tumors present as unilocular cysts on ultrasound, and close to 80% of borderline tumors are initially managed by gynecologic specialists.

Surgery is the recommended management for borderline ovarian tumors. The choice between a laparoscopic or open approach is based on the size of the mass, as well as prior surgical history and experience of the primary surgeon. A laparoscopic approach is reasonable and preferred in most patients with a focus on avoiding spillage. If an open approach is chosen, then a midline vertical incision may be necessary if surgical staging in the upper abdomen is indicated.

Most gynecologic surgeons diagnose a borderline ovarian tumor either with intraoperative frozen section or on final operative pathology. Intraoperatively, peritoneal washings should be performed prior to pelvic mass excision, and the mass should be excised intact without spillage into the peritoneal cavity. Premenopausal patients who have either not completed childbearing, or who wish to avoid the symptoms and health risks of premature menopause may undergo unilateral adnexectomy or cystectomy with preservation of the uterus and the contralateral ovary. Of note, agreement between frozen and final pathology has been reported to be a low as 55%, so the need to make management decisions after incomplete staging is relatively common.

Intraoperative or post-operative consultation should be obtained from a gynecologic oncologist to determine the need for additional surgery. Intraoperatively, the pelvis and abdominal viscera need to be carefully inspected to exclude any visible invasive disease.  Suspicious areas must be biopsied. Although evidence does not support routine surgical staging of borderline tumors, the National Comprehensive Cancer Network (NCCN) provides detailed algorithms for limited versus comprehensive surgical staging and post-surgical care of borderline ovarian tumor patients. Borderline ovarian tumor staging procedures typically include hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, omentectomy, diaphragm stripping, and removal of any visible disease. Lymph node sampling is not typically performed in the staging of borderline tumors, but can be considered in select cases. In the event that only a cystectomy is performed and final pathology results are consistent with borderline tumor, a gynecologic oncologist can counsel the patient regarding possible reoperation to remove the affected adnexa with possible surgical staging vs. surveillance.

Fertility-sparing surgical management of borderline ovarian tumors in patients who desire future fertility is preferred, and should be planned unless the patient decides otherwise. Patients under 40 who prefer to avoid the symptoms and effects of surgical menopause can also be offered conservative surgery Relapse rates of up to 15% have been noted with unilateral oophorectomy and up to 30% with unilateral cystectomy, but relapse is typically borderline rather than malignant and is highly curable with reoperation. Cystectomy preserves the maximum amount of ovarian stroma, the benefits of which must be weighed against the morbidity of additional treatment of recurrence. Providers should use patient centered, shared decision making when counseling patients on their management options.

Further reading:

Morgan RJ Jr, Armstrong DK, Alvarez RD, et al. Ovarian Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016 Sep;14(9):1134-63.

Renaud EJ, Sømme S, Islam S, et. al. Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review. J Pediatr Surg. 2019 Mar;54(3):369-377. doi: 10.1016/j.jpedsurg.2018.08.058. Epub 2018 Sep 6. PMID: 30220452.

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016 Nov;128(5):e210-e226. Reaffirmed 2021.

 

Originally titled The Management of Borderline Ovarian Tumors in Young Nulliparous Women; Renamed July 2022

Initial Approval November 2017, Revised May 2019; Revised January 2021, Revised and renamed July 2022

 

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