Borderline Tumor

Borderline ovarian tumor.
Q. A woman comes with a history report of a borderline ovarian cyst. How will you manage.
Theory TOG

1. What is a boarderline ovarian tumor?
   Distinct pathological group of neoplasms that demonstrate higher proliferative activity but
   which do not show stromal invasion. Also known as tumors of low malignant potential.
   Constitute 10-15% of all epithelial ovarian neoplasms.
   Typically seen in younger women.
2. What is the 5 year survival rate?
   a. For stage I – 95%-97%.
   b. Stage III – 50-86%.
3. What are the risk factors?
   a. Younger women
   b. Nulliparous
   c. Lactation protective
   d. OCP is not protective
   e. No evidence of BRCA mutations increasing the risk.
   f. Mutation of BRAF/KRAS pathway (high grade P53)
4. What are the histological features
   a. Serous borderline are the most common type. (50%)
   b. B/L in 30%.
   c. Can be associated with extra ovarian lesions (implants) = can be invasive or
   non inasive.
   d. Mucinous borderline aconstitute 46%. Further classified into
   i. Intestinal 85%
   ii. Endocervical/ Mullerian 15%.

• Associated with peritoneal pseudomyxoma in 10% and can be
  indistinguishable from primary appendiceal tumors, necessacitating a
  thorough investigation of the GI tract with special attention to the
  appendix.
  e. Mixed, endometrioid, clear cell and brenner – 4%
  Histological features are defined by epithelial cellular profileration hreater than that seen in
  benign tumors. They have a stratified epithelium with varying degrees of nuclear atypia and
  increased mitotic activity and lack of stromal invasion.
  Diagnosis
  Borderline ovarian tumours are more likely to be asymptomatic and to be diagnosed as an
  incidental finding or at routine examination.
  Longer duration of symptoms.
  Pelvic pain, bloating, dyspareunia, menstrual irregularities, pressure symptoms.
  CA125 maybe raised. 19.9 maybe elevated in mucinous.
  RMI often low.
  TVS – cyst characteristics. Complexity.
  Doppler – intracystic blood flow
  A wide variety of appearances, ranging from unilocular cysts, minimally septate cysts with
  papillary projections and markedly septate lesions with plaque-like excrescences to solid
  lesions with exophytic papillary projections, can be demonstrated on magnetic resonance
  imaging (MRI).
  Management

1. Management depends on age, stage, potential desire for pregnancy and nature of
   peritoneal implants.
2. Standard management is similar to that of invasive ovarian cancer: namely, accurate
   staging and cytoreductive surgery where appropriate.
3. Where possible, ovarian tumours should be subjected to frozen section analysis.
4. If the frozen section is reported as borderline, for the older woman with no fertility
   concerns a complete staging should be undertaken, which should include:
   a. exploration of the entire abdominal cavity with peritoneal
   washings
   b. total abdominal hysterectomy
   c. bilateral salpingo-oophorectomy and infracolic mentectomy
   d. appendicectomy in the case of mucinous tumours.
   Approximately one-third of cases reported as borderline at frozen section are later
   reclassified as invasive tumours.
   no survival benefit has been shown with lymphadenectomy.
   When a borderline tumour is diagnosed on histology after primary surgery, a referral to the
   regional cancer centre followed by discussion at the local multidisciplinary team meeting
   may be useful.
   The role of restaging and completion surgery
   The decision to undertake further surgery will largely be determined by three factors: the
   histological subtype of borderline ovarian tumour, the completeness of the primary surgery
   and the fertility desires of the woman.
   Risk increases when there are invasive implants (31% vs 21%)
   Presence of DNA aneuploidy 19 fold risk.
   Restaging may be warranted for women with micropapillary tumours, invasive implants or
   DNA aneuploidy and those with no fertility concerns.
   There is less justification for further surgery for a woman who has undergone full
   laparotomy with inspection of all surfaces at primary surgery.
   The role of conservative surgery and subsequent fertility
5. For early stage – conservative surgery is an option. – defined as Surgery with
   complete staging but with preservation of the uterus and at least a part of one ovary
   to preserve fertility. Two common options
   a. Cystectomy
   b. Unilateral SO +/- infracolic omentectomy and peritoneal washings.
   c.
6. Counsell regarding risk of recurrence and subsequent fertility.Relapse rate
   a. Cystectomy – 12-58%
   b. SO- 0-20%
   c. Radical surgery – 2.5-5.7%.
   d. Counsell about the importance of long term follow up.
   e. No adverse effects on pregnancy on the disease or vice verca.
   f. Spontaneous fertility rate of 32-65%.
7. Need for removal of remaining ovary and uterus once the family is complete is
   debatable.
   a. Because recurrence is easily resectable, one can wait for the recurrence.
   b. But because of psychological stress women will chose to have definitive
   treatment upon family completion.
8. Role of laparoscopy -should ideally staged by a midline laparotomy.
9. Role of chemotherapy – No role for adjuvant chemotherapy.
10. Follow up .
    a. Done conservative surgery – clinical examination, TVS – every 3 months for 2
    years, every 6 months for next 2 years and annually thereafter

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