that mean that I will never get cervical cancer or HPV?A2. The vaccine covers the two most common oncogenic (cancer causing) strains of HPV which are HPV 16 and 18. These account for approximately 70% of cancers. However, there are many more strains out there which the vaccine does not cover.
3 Q3 What if I have cancer?A3. Most patients referred with an abnormal smear do not have cancer. The very small number that do tend to have early stage disease. The only way to know is to get tested. If there is a cancer, this can sometimes be treated with simple excisional treatments like a LLETZ under local anesthesia. Many patients with an early stage 1 cancer go on to have children afterwards.
References
1 1 https://www.gov.uk/guidance/cervical‐screening‐programme‐overview
3 3 Wuntakal R, Castanon A, Landy R, Sasieni P. How many preterm births in England are due to excision of the cervical transformation zone? Nested case control study. BMC Pregnancy Childbirth. 2015; 15:232. Published 2015 Sep 29. doi:10.1186/s12884‐015‐0664‐3
4 4 Kyrgiou M, Athanasiou A, Kalliala IE J, Paraskevaidi M, Mitra A, Martin‐Hirsch PPL, Arbyn M, Bennett P, Paraskevaidis E. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD012847. DOI: 10.1002/14651858.CD012847
20 The patient with previous borderline ovarian tumor
Arri Coomarasamy1, Kavita Singh2, and Jennifer Tamblyn1
1 University of Birmingham and Birmingham Women’s Hospital, Birmingham, UK
2 Pan-Birmingham Women’s Gynaecological Cancer Centre, City Hospital, Birmingham, UK
Case History: A 35‐year‐old woman was found to have a 7× 6 ×5 cm left‐sided complex ovarian cyst during an IVF workup. She had a laparoscopic left‐sided salpingo‐oophorectomy on the recommendation of a gynecologic oncology multidisciplinary team. The histology was reported as borderline ovarian tumor. Six months following the surgery, she re‐presented to the IVF unit requesting fertility treatment.
Background
Borderline ovarian tumors (BOTs) are a subgroup of epithelial ovarian tumors with low malignancy potential. Histologically, they are characterized by cellular proliferation and nuclear atypia, but in the absence of identifiable stromal invasions [1]. They account for 10–20% of all ovarian tumors, and are particularly common in women of reproductive age, with approximately one‐third of all BOTs occurring in women under the age of 40 years [1].
In women who have completed childbearing, the optimal treatment for BOT is considered to be hysterectomy, bilateral salpingo‐oophorectomy, omentectomy and multiple peritoneal biopsies [2]. However, as they often occur in women of reproductive age, and generally have excellent survival prognosis, fertility‐preserving surgery is usually offered to women suspected to have BOTs. Fertility preservation involves preservation of at least part of one ovary, and the uterus. Laparoscopy is often the standard approach for surgery. Although the rate of recurrence is higher following conservative surgery, this does not result in a higher mortality rate [3].
BOTs are bilateral in 25–50% of cases. In such women, the fertility‐preserving surgical option is either bilateral cystectomies or unilateral oophorectomy plus contralateral cystectomy [4]. In women who have had a cystectomy, the risk of further BOT is high, and oophorectomy could be considered once childbearing is completed.
Management options
Natural pregnancy rates of 32–65% have been reported in women with a history of fertility‐preserving surgery for BOTs [1,5,6]. A systematic review found conservative management of early stage BOT resulted in a pooled estimate for natural pregnancy rate of 54%, with a low risk of lethal recurrence (pooled estimate of 0.5%). In patients with advanced stage BOT, the natural pregnancy rate was lower at 34%, with a higher risk of lethal recurrence (pooled estimate of 2%) [7].
For those women who may require ovulation induction or IVF treatment, there is a theoretical concern that ovarian stimulation may be associated with an increased risk of recurrence of BOT or ovarian cancer. Although evidence is sparse, there is no clear evidence to support this association. Two experimental studies showed that estradiol and follicle stimulating hormone (FSH) have no adverse impact on cell proliferation [8,9]. A systematic review of studies of gonadotropin stimulation in women with a history of BOT identified 15 reports, including a total of 62 patients having 152 ovarian stimulation cycles, with a mean follow‐up of 52 months [10]. Live birth rate was 28% per stimulated cycle. The pooled recurrence rate was 19.4%, which is higher than the reported 11% recurrence rate for borderline ovarian tumors [11]. Despite the apparently higher recurrence rate, the survival in this group of women with gonadotropin stimulation is still excellent (100% at a median follow‐up period of 52 months). Notwithstanding these data, there may be a case for limiting the number of ovarian stimulation cycles in women with a history of BOT given the paucity and uncertainty of the available data [1]. Each case should be judged on its own merits.
The optimal time to try to conceive or have fertility treatment after fertility‐sparing surgery is unknown, although successful pregnancies have been achieved as early as 3 months after surgery [12,13]. Before any fertility treatment is initiated, the oncology team should be consulted to obtain clearance to proceed with the treatment. A pelvic ultrasound scan should be arranged to rule out ovarian cysts, which may indicate recurrence of BOT. CA125 has been found to be a useful tumor marker in diagnosing BOT recurrences [14,15], and should therefore be checked before fertility treatment.
After fertility treatment, the oncology multidisciplinary team may consider “completion surgery” to remove the remaining ovarian tissues and the uterus, particularly for those who had cystectomy (as opposed to oophorectomy), advanced stage disease, mucinous tumors or any evidence of peritoneal implants at the time of primary surgery [1].
Although fertility‐sparing surgery may offer the best chance of pregnancy for a woman with BOT, some women may benefit from fertility‐preserving techniques such as oocyte, embryo [16] or ovarian tissue freezing [6] or may require oocyte donation [17] or surrogacy. The role of the antral follicle count and anti‐Müllerian hormone serum levels in patients with BOT remains to be clarified.
A final consideration is whether fertility treatments, such as gonadotropins and clomiphene increase the risk of BOT. Although long‐term outcome data remain limited [18], a review suggested a potentially increased risk of BOT, especially following IVF [19].
Key points
Challenge: ART in a patient with a previous borderline ovarian tumor (BOT).
Background:
BOTs account for 10–20% of all ovarian tumors; approximately one‐third of these occur in women of reproductive age.
They have low malignancy potential.
Preservation of fertility is an important issue in the management of BOTs.
BOTs are bilateral in 25–50% of cases.
Fertility‐sparing surgery involves preservation of at least part of one ovary, and the uterus.
The recurrence risk (after conservative fertility‐sparing