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Fertility-sparing
surgery in
borderline and
non epithelial
ovarian tumors:
State of the Art
ESGO 2013
Liverpool
Giorgia Mangili MD
Cristina Sigismondi MD
IRCCS Ospedale San Raffaele, Milan
Gynecology Oncology Department
Prof. M.Candiani The presenter has no conflict of interest to declare.
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Borderline Ovarian Tumors
(BOT)
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Borderline Ovarian Tumors:
Early Stage
Unilateral Salpingo-oophorectomy + peritoneal staging

Fertility-sparing treatment:
INDIPENDENT PROGNOSTIC FACTOR FOR RECURRENCE

Rate of recurrence
0-5% Radical Surgery
0-25% Unilateral salpingo-oophorectomy
10-42% Cystectomy
NO IMPACT ON SURVIVAL

Risk of lethal recurrence < 0.05%
Daraï et al. Hum Reprod Update. 2013
Du Bois et al. Eur J Cancer. 2013
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Serous Borderline Ovarian Tumors
Median
Age
I st
II st
III st
Cystectomy 18
30
13
0
5
6 (33%)
2
0
28
38
21
3
4
2 (7%)
0
2 DOC
N°
USO
Relapses Progression Deaths
Radical
surgery
53
53
41
1
11
1 (1.8%)
1
7 DOC
1 DOD
Total
99
40
75
4
20
9 (9%)
3
10
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Bilaterality in Borderline Ovarian
tumors
BILATERAL CYSTECTOMY (experimental group, n = 15)
versus
SALPINGO-OOPHORECTOMY AND CYSTECTOMY (control group, n = 17)
 No difference in cumulative recurrence rate
 Shorter time to first recurrence and higher rate of radical treatment
 Better reproductive outcomes
Human Reproduction. 2010
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 26 patients
 All patients had a borderline histology at first recurrence
 11 patients relapsed at least twice
 2 patients had an invasive histology at 2-3 recurrence (1 DOD)
“Fertility-preserving surgery remains a valuable alternative in young
patients with recurrent BOT, in the form of a non-invasive ovarian
lesion, who wish to start a pregnancy.”
Human Reproduction. September 25, 2013
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Advanced Stages BOT
Fertility-sparing Treatment
N. of
conservative
treatments
N. Non
invasive
implants
N.
Invasive
implants
N. Ns
implants
Relapses
Deaths
Zanetta, 2001
25
15
7
2
10
0
Prat, 2002
10
9
1
3
1 (invasive
imp.)
Longacre, 2005
21
NR
NR
NR
5
0
De Iaco, 2009
21
NR
NR
NR
4
0
Uzan, 2010
41
37
3
1
22
1 (non
invasive imp.)
Viganò, 2010
10
10
6
0
Song, 2011
5
1
0
50 (38%)
2 (1.4%)
Series
Total
132
69
11
3
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Stromal Ovarian Tumors
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Granulosa cell tumors
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Fertility-sparing Surgery in
Granulosa Cell Tumors

Unilateral salpingo-oophorectomy

Peritoneal staging

Endometrial biopsy

NO contralateral biopsy

NO lymphadenectomy
Conservative surgery can be offered to
young women who desire to retain fertility
Colombo et al. J Clin Oncol. 2007
Thrall et al. Gynecol Oncol. 2012
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Sertoli-Leydig Cell Tumors
Authors
N.
Stage I
Conservative
surgery
Young and Scully 1985
207
202 (97.6%)
143 (69%)
Gui 2012
40
40 (100%)
28 (70%)
Sigismondi 2012
21
18 (86%)
11 (52%)
Bath 2013
15
13 (86.7%)
13 (86%)
Weng 2013
23
18 (78%)
11 (47%)
No difference in survival rate between conservative and
radical surgery
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Malignant germ cell ovarian
tumors (MOGCT)
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Fertility-sparing Surgery in MOGCT
CONSERVATIVE SURGERY + PEB
Except for Stage IA dysgerminoma and stage I immature teratoma
Study
Conservative
Demolitive
Total Patient n°
Patient n°
Survival n°(%)
Patient n°
Survival n°(%)
Creasman et al. 1979
32
19 (59.3%)
19/19 (100%)
13 (40.6%)
11/13 (85%)
Gershenson et al. 1983
21
15 (71.4%)
12/15 (80%)
6 (28.5%)
3/6 (50%)
Schwartz 1984
19
17 (89.4%)
17/17 (100%)
2 (10.5%)
2/2 (100%)
Zanetta et al. 2001
169
138 (81.6%)
135/138 (98%)
31 (18.3%)
27/31 (87%)
Khi et al.2002
49
43 (93.4%)
43/43 (100%)
6 (13%)
6/6 (100%)
Chan et al. 2008
535
313 (58.5%)
306/313 (98%)
222 (41.5%)
212/222 (96%)
Tangjitgamol et al. 2010
124
89 (71. 7%)
83/89 (93%)
35 (28.2%)
32/35(91%)
Mangili et al. 2011
123
92 (74.8%)
84/92 (91%)
31 (25.2%)
25/31 (81%)
Total
1072
726 (68%)
699 (96%) 346 (32%)
318 (91%)
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Bilateral MOGCT
 Bilaterality 4.3% (dysgerminoma 15%)
If CYS is not
possible?
 USO+CYS+staging
Residual disease could be
intentionally left in order to spare
fertility
3 patients reported
(2 OSR, 1 Vicus et al Gyn Onc 2010)
 XY disgenetic gonads  bilateral gonadectomy, spare the uterus!
2 patients conceived through IVF with donor oocyte
Mangili et al. Gyn ecol Oncol. 2011
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Fertility Outcome in MOGCT
 Small number of patients
 Short follow-up
 Young patients
Premature ovarian
failure 3%
Study
n°
n° getting pregnancy
Pektasides et al.
17
5/17 (29.4%)
Brewer et al
14
3/14 (21.4%)
Mitchell et al.
26
11/26 (42%)
Low et al.
74
16/74 (21.6%)
Zanetta et al.
138
32/138 (23.1%)
Tangir et al.
64
29/64 (45.3%)
Boran et al.
23
6/23 (26%)
de La Motte Rouge et al.
41
12/41 (29.2%)
Cicin et al.
29
7/29 (24.1%)
Zanagnolo et al.
75
15/75 (20%)
Weinberg et al.
22
10/22 (45.4%)
Mangili et al.
92
12/92 (13%)
Total
615 158/615 (25.7%)
+ Reproductive function assessment after
surgery plus chemotherapy for Germ Cell
Ovarian Tumors: novel clues deriving
from the field of fertility preservation
Age
Tumor
characteristics
16
Mixed germ cell
tumor
Stage
Treatment
AMH
(ng/ml)
IIIIC
USO+ ovarian
biopsy+ staging+
BEP
0.1
IIB
USO+ CYS+
staging+ BEP
0.7
Dysgerminoma
IC
USO+BEP
2.3
Dysgerminoma
IV
18
Mixed germ cell
tumor
21
23
USO+BEP
Oocytes
cryopreservation
2.7
Ottolina et al. Submitted
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The Fertility Window
Evaluation of ovarian reserve
Spontaneous
conception/
ART
Ovarian reserve
AMH
DESIRE FOR
PREGNANCY
La Marca et al. Eur J Obstet Gynecol Reprod Biol. 2012
Preservation of
fertility
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Conclusions
 Fertility-sparing
surgery in borderline ovarian tumors and
non epithelial ovarian cancers is feasible

The fertility window may be shortened by oncological
treatments
 Reproductive
required
function&Oncological follow-up is
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Thank you!
ginecologia.oncologica@hsr.it
mangili.giorgia@hsr.it