TOG - Management of borderline ovarian tumours

Question 1

What is the definition of borderline ovarian tumours?

Answer 1

Demonstrate higher proliferative activity compared with benign neoplasms but do not show stromal invasion

Question 2

What % of all epithelial ovarian neoplasms are borderline tumours?

Answer 2

10-15%

Question 3

What are the 5 year survival rates for borderline ovarian tumours?

Answer 3

Stage I - 95-97%

Stage III - 50-86%

Question 4

What is the 10 year survival rate for borderline ovarian tumours?

Answer 4

70-80%

Question 5

What are the risk/protective factors for borderline ovarian tumours?

Answer 5

Younger tend to be affected
Parous - reduced risk
Lactation - protective
COCP not protective
No increase in BRCA

Question 6

Which mutation is associated with borderline ovarian tumours?

Answer 6

BRAF/KRAS pathway

invasive tends to be p53

Question 7

What is the most common histological type of borderline ovarian tumour?

Answer 7

Serous (50%) bilateral in 30%
May have extra-ovarian implants which may or may not be invasive

Mucinous (46%)
Mixed, endometrioid, clear cell, Brenner (4%)

Question 8

What are the histological features of borderline ovarian tumours?

Answer 8

• Epithelial proliferation > that seen in benign tumours
• Stratified epithelium, varying degrees nuclear atypia and increased mitotic activity
• LACK STROMAL INVASION distinguishes from invasive carcinoma

Question 9

What are the subtypes of mucinous borderline ovarian tumours?

Answer 9

Intestinal 85%

Endocervical/mullerian types 15%

Question 10

Which borderline ovarian tumour is associated with peritoneal pseudomyxoma and in what %?

Answer 10

Mucinous
10%
Indistinguishable from primary appendiceal tumours therefore investigation of GIT crucial

Question 11

Tumour markers are raised in what % of borderline ovarian tumours?

Answer 11

Ca125 raised in 75% serous and 30% mucinous

May have raised Ca19-9 in mucinous

Question 12

What should be involved in laparotomy in an older woman with no fertility concerns if a frozen section is reported as borderline?

Answer 12

• Exploration of cavity with peritoneal washings
• TAH and BSO
• Infracolic omentectomy
• Appendicectomy in the case of mucinous tumours
• Consider lymphadenectomy - no survival benefit but may be upgraded to invasive therefore fully staged

Question 13

How many cases reported as borderline at frozen section are later reclassified as invasive tumours?

Answer 13

1/3

Question 14

What increases the chance of risk of recurrence as invasive disease in borderline ovarian tumours?

Answer 14

• Presence of invasive implants (31 vs 21% over 5 yrs)

- DNA aneuploidy - 19x risk of dying

Question 15

What are the options for borderline ovarian tumour management in women with early-stage disease who are keen to retain their fertility?

Answer 15

Conservative surgery

• Complete staging
• Preservation of uterus and at least part of 1 ovary

i.e. cystectomy or unilateral salpingo-oophorectomy
+/- infracolic omentectomy and peritoneal washings

Debatable whether completion surgery after completion of family

Question 16

What are spontaneous fertility rates following conservative treatment of borderline ovarian tumours?

Answer 16

32-65%

No evidence recurrence 2dry to fertility drugs - but advise limitation of no of stimulation cycles

Question 17

What are the concerns with laparoscopic approach for treatment of borderline ovarian tumours?

Answer 17

• Cyst rupture
• Port-site metastases
• Understaging of disease

Question 18

What is the role of chemotherapy in borderline ovarian tumours?

Answer 18

None - but may be considered in recurrence that is not amenable to resection

Question 19

What is the incidence of invasive disease at recurrence of borderline ovarian tumours?

Answer 19

8-73%

Question 20

What is the recommended follow up following treatment of borderline ovarian tumours?

Answer 20

Every 3/12 for first 2 years
Every 6/12 for 2 years
then annually