OQ: LCOH Ovarian Cancer Flashcards
What are the histologic criteria for borderline tumors?
histologic criteria- nuclear atypia >10% of tumor epithelium, stratified epithelium, microscopic papillary projections, absence of stromal invasion.
What is the recurrence risk of serous borderline and what percentage of recurrences are malignant?
- stage 1: <5%
- Stage II-IV- 20%
- overall 10-15%
staging can upstage up to 47%, but doesn’t alter survival
What surgery would you do if frozen section shows borderline tumor of the ovary?
- USO/cystectomy (fertility desired)
- Washings, cytology of the diaphragm, omental biopsy , resection of mets rather than full staging for EOC
- OK to omit LND: meta-analysis 6.5yr survival =98% (Lesieur et al Am J OB GYN 2011;204(5):438)
What surgery would you do if frozen section shows borderline tumor of the ovary and she has bilateral tumors and desires fertility? What are the general risks of recurrence of cystectomy vs. USO?
- remove the more suspicious lesions first and send for frozen section- if borderline, then contralateral cystectomy or oophorectomy
- best if USO and contralateral cystectomy- less recurrence than b/l contralateral cystectomies
Bilateral tumors: USO + contralateral cystectomy vs bilateral cystectomy => no difference in recurrence rate 60%vs59% although recurrence was SOONER 16mo vs 48mo and multiple recurrences were more likely [ Palomba et al. Hum Reprod 2007;22(2):578-85
higher risk of recurrence : cystectomy (30%), vs USO (11%), VS bso (1.7%)
No difference in survival- recurrent disease can be salvaged
Borderline tumors, Lscope vs Ex LAP?
=> increased rupture risk but no difference in recurrence (Maneo et al Gyn ONc 2004;94(2):387 Desfeux et al Gyn onc 2005;98(3):390]
Mucinous LMP tumor on frozen section, how would you treat (24 yo vs 49 yo)?
USO/cystectomy staging vs TAH BSO staging
Appendix does not have to be removed, if grossly normal (See below)
NCCN 2021 – recommend appx ( mucinous adenoca)
Patient with 7cm ovary, s/p USO by generalist and final path showing borderline tumor?
Imaging, surveillance, tumor markers
Borderline tumor with micropapillary invasion, omental implants, invasive implants, when do you give chemotherapy?
Chemo only for invasive implants, it’s equivalent to LGSOV.
Patient with 7cm ovary, s/p USO by generalist and final path showing borderline tumor? How would you follow and counsel the pt?
US , tumor markers
Recurrence risk 7-30% (fertility-sparing), higher if pt had cystectomy but no diff in OS
For st I (s/p USO or cystectomy) RR 13% borderline, 1.6% ca
USO vs cystectomy ~95% DFS
Time-to-recurrence 2.6yrs (cystectomy) vs 7 yrs USO
What are characteristic differences b/w borderline tumor and frank ovarian cancer
Stromal Invasion < 5mm, focus of microinvasion is <10mm2
Do you recommend completion surgery for borderline tumor?
Category 2B
No difference in survival reported, especially for serous. For mucinous some experts suggest completions due to risk of recurrence as mucinous carcinoma (Prat J et al Ann Onc 2014 25(7)1255-8)
2% risk of invasive carcinoma is too low to justify completion surgery (DFS 99.6% st I; 96% st II, 89% st III) Zanetta et al. JCO 2001;19(10):2658; TInelli et al meta analysis Gyn Onc 2006;100(1):185)
3 year recurrence after borderline, what is likely histology? How would you manage?
Borderline , LGSOC (4%). Imaging, surgery with full staging
How do you manage low=grade serous carcinoma?
St I - selected pts may undergo USO ( fertility-sparing surgery)
Still need genetic testing just like HGSOC bc 5.7% of BRCA ½
GOG 182 (Fader et al OB GYN 2013;122 (2 Pt 1):225 ancillary data analysis
Objective: clinicopathologic variables associated with survival in LGSOC, ph III
Primary cytoreduction: improves both Median PFS and OS 97mo (R0) vs 35mo (R1)
R0 is important, as ORR to chemotx is 23% vs 90% for HGSOC. RR to NACT 11% vs75% HGSOC
Measurable residual dz postop shows the same HR for death (HR 2.12) as for pts with HGSOC
LGSOV, do you give chemotherapy and why or why not?
No known benefits to IP or dose-dense T/C. IC is observe vs. chemo vs. hormonal (2B), II-IV is chemo vs. hormonal (2B), IC-IV needs maintenance chemotherapy.
BEV: recurrent dz – YES (39-48% RR, 62% CBR)!
NO data to support BEV in the 1st line setting (ICON7 subgroup analysis), although I believe LGSOV was included in 218.
Maintenance vs Observation for st II-IV LGSOV?
Retrospective single institution data – improved PFS 65 mo vs 26mo, trend but not sig towards improved OS (116vs 103mo)
St II-IV pts: surgery (27 pts )-> adjuvant endocrine tx ( no chemo)
Retrospective study – endocrine tx (AI, tamoxifene) instead of adjuvant chemotx postop 3yr PFS 79%, 3yrOS 93%; RR 22%
