Conservative surgery - Prof. Dr. Fuat Demirkıran

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
More frequent in western regions
More frequent in eastern regions
One of third bilateral
usually unilateral
60% of them stage I disease
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
Evolution of and discrepancies in current
classifications of serous borderline ovarian tumours.
micropapillary pattern
Invasive implant
Non –invasive implant
Stromal Microinvasion
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=lowgrade serous carcinoma. HGSC=high-grade serous carcinoma. *Without micropapillary pattern.
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
Peritoneal Implants
Non –invasive implant
Invasive implant
At serous BOT
15-40 % extra-ovarian implant
Recurrance rate 8%
Mortality rate %4
Reccurance rate 29%
Mortality rate 25%
İmplant Olasılığını Etkileyen Faktörler
Cusido M., Gynecol Oncol, 2007
Stromal Microinvasion
In 12 series of serous BOTs with microinvasion (n=133)
Recurrence rate 15 % (20/133)
35% (seven of 20) with invasive disease at recurrence
Rate of disease-related death is 6%
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
bilateral tm
USO + cystectomy
Bilateral cystectomy
with peritoneal staging
Interventions for the treatment of borderline ovarian
tumours (Review) The Cochrane Collaboration and published in The Cochrane
Library 2010, Issue 9
Open abdominal surgery
Endoscopic Surgery
Frozen section
Conservative surgery for aerly stage disease
n: 339
Conservative surgery (n: 189) and Radical Surgery (n:150)
Median Follow-up 70 months
Conservative S.
Radical S.
Conservative S.
Stage II-III Radical
N:56 , 17%
Stage I
n:283, 83%
Zaneta ve ark J Clin Oncol 2001
n: 62
42 pts (67%) …….USO
13 “ (21%)……..UC
5 “ (8 %)…….. USO CC
2 “ (4 % )………CC
Mean follow-up 44 months
Recurrence rate 7%
39 pts. with stage II-III BOT
11 of them underwent USO
28 “ “
Median follow-up 57 months
Recurrence rate 56%
5 yrs.
10 yrs.
Literature review of recurrence rate in advanced-stage
ovarian borderline tumor (in particular with invasive
implants) with conservative treatment.
Recurrence rate 14%
Recurrence rate 44%
Conservative surgery at the presence of implants
The prognosis of patients with noninvasive
implants remains good and conservative surgery can
be considered in such patients
(if implants are totally resected).
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
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
Mean follow-up 109 mounts
32 stage I, 12 stage II-III
Recurrance localization after conservative surgery
110 unilateral salpingo-oophorectomy
50 cystectomy
24 bilateral cystectomies
5 Other combinations
n: 189
55% in contralateral ovary
40% in same ovary after cystectomy
5% in extrapelvic region
Zaneta ve ark J Clin Oncol 2001
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
Reports on patients with a previous history of borderline ovarian
tumor who underwent ovarian hyperstimulation
(OS) and/or oocyte retrieval (OR) for assisted conception
Recurrence rate 19%
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
ART rate 16%
Pregnancy rate 48%
The recurrence rate 16%
5 recorded disease-related deaths.
young age at diagnosis.
high overall survival rate
80%of them early stage
conservative surgery for all stages
ovarian stimulation after surgery