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The Management of Borderline Ovarian Tumors in Young Nulliparous Women

11/1/2017 - Erica L. Berry D.O., FACOG


Mentor: Maureen E. Farrell M.D., FACOG
Editor: Abimbola O. Famuyide MBBS, FRCOG, FACOG

Published 11/1/17

 

 Borderline ovarian tumors, also known as low-malignant potential (LMP) tumors, make up nearly 20% of ovarian epithelial cancers and have an excellent prognosis regardless of stage at diagnosis. Borderline ovarian tumors are typically diagnosed in women during their 40’s, significantly earlier than invasive carcinomas. These tumors have not been shown to have hereditary component.

Pelvic ultrasonography is considered the gold standard for characterization of a suspected ovarian mass. LMP tumors often share ultrasound findings with malignant tumors including papillary projections, thickened septations, and multicystic components. However, a significant percentage of borderline tumors present as unilocular cysts on ultrasound, and close to 80% of LMP tumors are initially managed by gynecologic specialists.

Surgery is the recommended management for borderline ovarian tumors. The choice between a laparoscopic or open approach is made most importantly on the size of the mass, as well as prior surgical history and skill level of the primary surgeon. A laparoscopic approach is reasonable and preferred in most patients. If an open approach is chosen, then a midline vertical incision is necessary if surgical staging in the upper abdomen becomes necessary.

Most gynecologic surgeons diagnose a borderline ovarian tumor in one of two common scenarios. One occurs when a young nulliparous patient is taken for surgical excision of a suspected benign pelvic mass and the intraoperative frozen section unexpectedly shows borderline elements. In the other, a young nulliparous patient is taken for suspected benign pelvic mass excision and an intraoperative pathologic analysis was either not obtained or the final pathology upgraded a previously benign diagnosis from the intraoperative frozen section assessment. Preoperative counseling of young nulliparous patients should include management in the event that a borderline or malignant tumor is diagnosed during surgery or immediate postoperative period. Intraoperatively, peritoneal washings should be performed prior to pelvic mass excision, and the mass should be excised intact without spillage into the peritoneal cavity. Premenopausal patients who have not completed childbearing may undergo unilateral adnexectomy with preservation of the uterus and the contralateral ovary.

Intraoperative or post-operative consultation should be obtained from a gynecologic oncologist to determine the need for additional surgery. Intraoperatively, the pelvis and abdominal viscera need to be carefully inspected to exclude any visible invasive disease and suspicious areas must be biopsied. In the event that only a cystectomy is performed and final pathology results are consistent with LMP tumor, a gynecologic oncologist can counsel the patient regarding reoperation to remove the affected adnexa with possible surgical staging. Although the weight of evidence does not support routine surgical staging of LMP tumors, the National Comprehensive Cancer Network (NCCN) provides detailed algorithms for limited versus comprehensive surgical staging and post-surgical care of borderline ovarian tumor patients. Borderline ovarian tumor staging procedures typically include hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, omentectomy, diaphragm stripping, and removal of any visible disease. Lymph node sampling is not typically performed in the staging of LMP tumors, but can be considered in select cases.

Fertility-sparing surgical management of borderline ovarian tumors in young nulliparous women is preferred, and should be planned unless the patient decides otherwise. Relapse rates of up to 15% have been noted with fertility-sparing surgery, but relapse is highly curable with reoperation and contralateral adnexectomy.

Further reading:
Sherif, A.M., et al. Staging for low malignant potential ovarian tumors: a global perspective. Am J Obstet Gynecol 2016; 215: Vol 2: 153-168.
Morgan, J.L., et al. Ovarian cancer version 1.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2016;14: 1134-1163.

Evaluation and management of adnexal masses. Practice Bulletin No. 174. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128: 210–26.

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