although causation has not been firmly established.
Almost all recurrences are again borderline ovarian tumors, with excellent survival prospects.
Management options:
Liaise with the gynecologic oncology team.
Pelvic ultrasound to rule out ovarian cysts before fertility treatment.
Serum marker: CA125
Aim to reduce the number of ART cycles as ovarian stimulation may increase recurrence.
Once fertility treatment is completed, the oncology team may consider “completion surgery,” particularly in women who had cystectomy (as opposed to oophorectomy), advanced stage disease, mucinous tumors and any evidence of peritoneal implants.
Answers to questions patients ask
1 Q1 What is a borderline ovarian tumor (BOT)? A1.A1. Borderline ovarian tumors result from the development of abnormal cells in the ovary. They are not cancerous, but are said to have low malignant potential, meaning they could possibility become cancerous in the long run. Approximately 10–20% of ovarian tumors are borderline, and they more commonly affect women of child‐bearing age.A small number of women who have been diagnosed with a BOT will be diagnosed at a more advanced stage where the disease has spread either to both ovaries or to the peritoneum (a layer of tissue covering the organs in the abdomen). These seedlings can be successfully removed surgically, but occasionally they may remain on this surface layer, for which you will be closely monitored by your consultant.
2 Q2 How are BOTs treated? A2.A2. As borderline ovarian tumors are slow growing, many of them are diagnosed at an early stage and can be cured by surgery. The best surgery for you will be agreed together with your oncologist and for a lot of women this will include important discussions about the fertility options.Most young women will have fertility sparing surgery, which will usually involve removal of one ovary or only the cyst. In about 1 in 20 women (5%), the tumor will come back (recurrence). Some women may be advised to have more definitive surgery following pregnancy based upon the type of disease and risk of recurrence. Most recurrent tumors can be easily cured by surgery with no impact on survival.For women who have completed their family or have more advanced disease, surgical removal of the womb, both tubes and ovaries may be advised. During surgery, the surgeon will closely look at the inside of the pelvis and abdomen and take small biopsies (small samples of tissue) from different areas.
3 Q3 Will I be able to get pregnant in future? A3.A4. Young women with early stage BOTs who have fertility sparing surgery have good chances of future natural pregnancy. Some women may require fertility treatment, such as IVF; the timing and safety of this will be planned together with the oncology doctor. Some women may benefit from fertility‐preservation, such as embryo freezing, which should be discussed when preparing for any surgery to treat BOTs.
References
1 1 Morice P. Borderline tumours of the ovary and fertility. Eur J Cancer. 2006; 42(2):149–58.
2 2 Morice P, Camatte S, Wicart‐Poque F, Atallah D, Rouzier R, Pautier P, et al. Results of conservative management of epithelial malignant and borderline ovarian tumours. Hum Reprod Update. 2003; 9(2):185–92.
3 3 du Bois A, Ewald‐Riegler N, de Gregorio N, et al. Borderline tumours of the ovary: a cohort study of the Arbeitsgmeinschaft Gynakologische Onkologie (AGO) Study Group. Eur J Cancer. 2013; 49:1905–14.
4 4 Palomba S, Zupi E, Russo T, Falbo A, Del NS, Manguso F, et al. Comparison of two fertility‐sparing approaches for bilateral borderline ovarian tumours: a randomized controlled study. Hum Reprod. 2007; 22(2):578–85.
5 5 Fauvet R, Poncelet C, Boccara J, Descamps P, Fondrinier E, Darai E. Fertility after conservative treatment for borderline ovarian tumors: a French multicenter study. Fertil Steril. 2005; 83(2):284–90.
6 6 Nam JH. Borderline ovarian tumors and fertility. Curr Opin Obstet Gynecol. 2010; 22(3):227–34.
7 7 Daraï E, Fauvet R, Uzan C, Gouy S, Duvillard P, Morice P. Fertility and borderline ovarian tumor: a systematic review of conservative management, risk of recurrence and alternative options. Hum Reprod Update. 2013; 19(2):151–66.
8 8 Tourgeman DE, Lu JJ, Boostanfar R, Amezcua C, Felix JC, Paulson RJ. Human chorionic gonadotropin suppresses ovarian epithelial neoplastic cell proliferation in vitro. Fertil Steril. 2002; 78(5):1096–9.
9 9 Basille C, Olivennes F, Le Calvez J, Beron‐Gaillard N, Meduri G, Lhommé C, et al. Impact of gonadotrophins and steroid hormones on tumour cells derived from borderline ovarian tumours. Hum Reprod. 2006; 21(12):3241–5.
10 10 Denschlag D, von Wolff M, Amant F, Kesic V, Reed N, Schneider A, et al. Clinical recommendation on fertility preservation in borderline ovarian neoplasm: ovarian stimulation and oocyte retrieval after conservative surgery. Gynecol Obstet Invest. 2010; 70:160–5.
11 11 Suh‐Burgmann E. Long‐term outcomes following conservative surgery for borderline tumor of the ovary: a large population‐based study. Gynecol Oncol. 2006; 103(3):841–7.
12 12 Uzan C, Kane A, Rey A, Gouy S, Duvillard P, Morice P. Outcomes after conservative treatment of advanced‐stage serous borderline tumors of the ovary. Ann Oncol. 2010; 21(1):55–60.
13 13 Boran N, Cil AP, Tulunay G, Ozturkoglu E, Koc S, Bulbul D, et al. Fertility and recurrence results of conservative surgery for borderline ovarian tumors. Gynecol Oncol. 2005; 97(3):845–51.
14 14 Zanetta G, Rota S, Chiari S, Bonazzi C, Bratina G, Mangioni C. Behavior of borderline tumors with particular interest to persistence, recurrence, and progression to invasive carcinoma: a prospective study. J Clin Oncol. 2001; 19(10):2658–64.
15 15 Zanetta G, Rota S, Lissoni A. Ultrasound, physical examination and CA125 measurement for the detection of recurrence after conservative surgery for early borderline ovarian tumours. Gynecol Oncol. 2001; 81:63–6.
16 16 Gallot D, Pouly JL, Janny L, Mage G, Canis M, Wattiez A, et al. Successful transfer of frozen‐thawed embryos obtained immediately before radical surgery for stage IIIa serous borderline ovarian tumour: case report. Hum Reprod. 2000; 15(11):2347–50.
17 17 Lawal A, B‐Lynch C. Borderline ovarian cancer, bilateral surgical castration, chemotherapy and a normal delivery after ovum donation and in vitro fertilisation‐embryo transfer. Br J Obstet Gynaecol. 1996; 103:931–2.
18 18 Bjørnholt S, Kjaer S, Nielsen T, Jensen A. Risk for borderline ovarian tumours after exposure to fertility drugs: results of a population‐based cohort study. Hum Reprod. 2015; 30(1):222–31.
19 19 Rizzuto I, Behrens R, Smith L. Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Cochrane Database Syst Rev. 2013;( 8), CD008215.
21 The patient with an endometrioma
Spyros Chouliaras1 and Luciano G. Nardo2
1 Sidra Medicine; and Weill Cornell Medicine, Doha, Qatar
2 Reproductive Health Group, Daresbury and Manchester Metropolitan University, Manchester, UK
Case History 1: A 35‐year‐old woman with a history of primary infertility was seen in the reproductive medicine clinic. Her anti‐Müllerian hormone (AMH) and the semen analysis of her partner were within normal range. Transvaginal pelvic ultrasound scan found she had bilateral ovarian cysts with features of endometriomas (low‐level echoes). The left ovarian cyst measured 2.8 × 2.5 × 2.3 cm and the right ovarian cyst measured 3.7 × 2.5 × 2.4 cm.
Case History 2: A 40‐year‐old woman with a 3 year history of primary infertility is known to suffer from endometriosis. She had a laparoscopic right ovarian cystectomy 2 years previously.