Types of ovarian cysts

Question 1

Definition borderline tumour

Answer 1

Tumours of low malignant potential with higher proliferative activity but without stromal invasion

Noninvasive neoplasms that occasionally have intraperitoneal spread

Question 2

Six subtypes of borderline ovarian tumours

Answer 2

Serous (50%)
Mucinous (45%),

Less common: 
Endometrioid, 
clear cell, 
seromucinous, 
borderline Brenner tumor

Question 3

Describe malignant potential of borderline ovarian tumours

Answer 3

BOT can be associated with microinvasion, intraepithelial carcinoma, lymph node involvement, and non-invasive peritoneal implants

Question 4

Prognosis for BOT

Answer 4

• majority of BOT are limited to the ovary(ies) at presentation - 75% being diagnosed at FIGO stage I, compared to only 10% of ovarian carcinomas diagnosed at an early stage.

10-year survival of 97% for all stages combined

recurrences and malignant transformation can occur

• The 5-year survival rates for:
  
  • stage I borderline: vary from 95–97%.
  • stage III: 50–86%.
    The 10-year survival rates range from 70–80%, owing to late recurrence

Question 5

Treatment for Borderline ovarian tumours

Answer 5

• Complete surgical resection
• Surgical staging including omentectomy, peritoneal biopsies, cytology of peritoneal washings, and appendectomy in case of mucinous BOT
• Chemotherapy not indicated

Question 6

Serous borderline tumours

Answer 6

• Most common (50%)
• Often bilateral (30%)
• Share similar histological features to low grade serous carcinomas
• May be a spectrum of cystadenomas - BOT - low grade serous adenoma
• Can be associated with extra-ovarian lesions
  (also called implants), which can be invasive or non-invasive

Question 7

Mucinous borderline tumours

Answer 7

• Second most common (46%)
• Either intestinal (86%) or endocervical/mullerian
• 10% associated with peritoneal pseudomyxoma
• Can be indistinguishable from appendiceal tumours therefore also need to review appendix

Tumors are usually large, unilateral, and cystic with a smooth ovarian surface, composed of multiple cystic spaces with variable diameter.

The cysts are lined by columnar mucinous epithelium of gastric or intestinal differentiation, with papillary or pseudopapillary infoldings, and admixed goblet cells and neuroendocrine cells

Question 8

Risk factors for BOT

Answer 8

• Younger age
• Nulliparity

Protective:
- Lactation

No evidence of increased or decreased risk:

• BRCA mutation
• Contraceptive pill use

Question 9

Describe difference between two main types of ovarian ca and the relationship with BOT

Answer 9

• High grade serous has changes to P53

- Low grade serous due to mutations of BRAF/KRAS pathway- BOT are on this spectrum

Question 10

Histological features of BOT

Answer 10

Histological features are defined by epithelial cellular
proliferation greater than that seen in benign tumours.

Borderline ovarian tumours have a stratified
epithelium with varying degrees of nuclear atypia and increased mitotic activity; their lack of stromal invasion distinguishes them from invasive carcinomas

Question 11

Treatment for women with BOT:

• Desire to retain fertility
• No desire to retain fertility

Answer 11

1. Retain fertility:
   - Early stage? - conservative surgery
   - Late stage? - If invasive implants then complete surgery and follow up.
   If no invasive implants then consider conservative surgery with close follow up

Need to counsel re risk of recurrence and future fertility

Consider complete surgery after family complete

2. No desire to complete fertility:
   - Complete surgery with close follow up

Complete surgery:

• exploration of the entire abdominal cavity with peritoneal washings
• TAH-BSO
• infracolic omentectomy
• appendicectomy in the case of mucinous tumours

Conservative surgery:

Either cystectomy or USO + washings

Question 12

Tumour markers in BOT

Answer 12

Serum CA125 levels may be raised:
- may have a high level in 75% of
serous and 30% of mucinous borderline ovarian tumours.

CA19-9 levels are frequently raised in mucinous
borderline ovarian tumours.

Other tumour markers such as
CEA, CA15-3 and CA72-4 may help detection but are not specific and may be within normal limits or only minimally elevated.

RMI status often low as many borderline ovarian tumours occur in younger, premenopausal women,

Question 13

What to do if a BOT is identified after surgery

Answer 13

Referral to the regional cancer centre
followed by discussion at MDM.

Further management is planned according to the histology, grade, stage, DNA ploidy status (DNA aneuploidy carries higher risk of dying),
fertility preferences and completeness of primary surgery.

Question 14

Recurrence rates dependent on surgical management

Answer 14

• Cystectomy 12-58%
• USO 0-20%
• Radical surgery 2.7-5.7%

Question 15

Fertility outcomes after treatment of borderline ovarian tumours

Answer 15

no adverse effect of pregnancy on the disease or
vice versa.

Spontaneous fertility rates reported in literature
vary between 32–65%, with nearly half of the women treated conservatively conceiving spontaneously

Question 16

Role of laparoscopy in BOT

Answer 16

Risks:

• Rupture
• development of port-site metastases
• understaging of disease;
• higher risk of recurrence and worsened survival

Therefore should ideally be performed by laparotomy

Question 17

IOTA explanation of 6 cysts seen on USS

Answer 17

Simple cyst: unilocular, no internal material (anechoic), thin walled and avascular.

Corpus luteum: unilocular with peripheral vascularity (‘ring of fire’), second half of the cycle and associated with a secretory endometrium (unless there is a Mirena insitu). These often appear haemorrhagic.

Haemorrhagic cyst: unilocular, reticular pattern of fine thin intersecting lines (fibrin strands).

Endometrioma: homogeneous low-level internal echoes ‘ground glass’, minimal vascularity, smooth walled. Often bilocular, often bilateral.

Dermoid/teratoma: avascular, usually unilocular but with variable internal structure due to the differentiating cell types, most commonly hair (fine linear dots and dashes) and fluid levels (due to different fluid types). Classically dermoids have shadowing echogenic areas due to calcification.

Invasive malignancy: large irregular solid mass, highly vascular, usually no visible normal ovarian tissue remaining, ascites (defined by IOTA as fluid above the level of the uterine fundus to differentiate from physiological pelvic fluid commonly seen after ovulation).

Question 18

Management of haemorrhagic cyst

Answer 18

Haemorrhagic cysts often resolve spontaneously.

Repeat ultrasound in 2-3 months can be considered to ensure cyst resolution.

Ideally, this ultrasound should be performed just after a period to prevent confusion with a new corpus luteum.

Question 19

Endometriomas and Dermoids

Answer 19

Surgical removal

or

If not removed, should have annual follow up as there is a risk of malignant transformation, especially post menopause.