Borderline Ovarian Tumours Flashcards
(27 cards)
Definition
Epithelial ovarian tumours that have features between benign and malignant.
WITHOUT evidence of ovarian stromal invasion (distinguishes them from ovarian cancers).
Histological characteristics
Atypical epithelial proliferation
No stromal invasion
Can show papillary projections, stratified epithelium and nuclear atypia
Most common types: serous (most common), and mucinous
Less commonly: endometrioid, clear cell or Brenner types
Epidemiology if BOTs
- 15-20% of epithelial ovarian neoplasms
- 50-60% affect women <40y with median age 45-48
- 75% are stage 1 at time of diagnosis
Types of borderline tumours
- Serous 45-60%
- Mucinous 30-50%
- Seromucinous, endometroid, clear cell, Breener - 5-10%
- Invasive cancers that arise from borderline tumours are often low grade with low response to platinum based therapy
- Patients with invasive implants in the omentum or other sites are more likely to recur early
Clinical presentation
Often asymptomatic and found incidentally
If symptomatic:
- abdominal bloating, pelvic pain, palpable mass, increased abdominal girth,
Diagnosis BOT
Ultrasound: often shows complex cystic mass with papillary projections or septations
Tumour markers: Ca125 may be elevated, but less reliable than in invasive cancers
Definitive dx: histopathology after surgical removal
Ultrasounds features - BOT
- Multiloculated (40% of mucinous, 30% of serous)
- Solid/cystic components (40% of mucinous, 78% of serous)
- Internal papillations (40% of mucinous, 78% of serous)
- Thickened septa
- Bilateral
Tumour markers
- Ca125
–> elevated in 20-35% of stage 1 serous
–> elevated in 15-20% of mucunous (likely related to peritoneal irritation)
–> elevated in 80-90% of advanced serous tumours - Ca19-9
–> non specific for mucinous tumour
–> can be ovarian, pancreatic, gastric
Management of Early stage (Stage I)
- Fertility-sparing surgery is often possible:
–> unilateral SO
–> careful inspection of contralateral ovary and peritoneum - Complete surgical staging is important:
–> peritoneal washings
–> omental biopsy
–> peritoneal biopsies
Management of Advanced disease (stages II-III)
- More extensive surgery needed, but still often no need for chemo
- Adjuvant chemo not typically used, unless invasive implants are found
Staging (stage I)
(same as for epithelial ovarian cancer)
- Stage I = tumour confined to the ovaries (or fallopian tubes)
–> IA - one ovary/tubes involved, capsule intact, no tumour on surface, negative washings.
–> IB - both ovaries/tubes involved, capsule intact, no surface tumour, negative washings.
–> IC - one or both ovaries/tubes involved with any of the following:
—> IC1 surgical spill
—> IC2 capsule rupture before surgery or tumour on the surface
—> IC3 malignant cells in washings/ascites
Event though BOTs don’t invade, peritoneal washings can still be positive due to exfoliated cells
Staging - stage II
= pelvic extension (uterus or pelvic organs)
–> IIA - extension or implants on uterus and/or fallopian tubes/ovaries
–> IIB - extension to other pelvic tissues
Stage III
= peritoneal metastasis outside the pelvis and/or regional lymph node involvement:
IIIA1 - positive retroperitoneal LNs only
IIIA2 - microscopic peritoneal metastasis outside the pelvis (+/- nodes)
IIIB - macroscopic peritoneal metastasis </= 2cm
IIIC - macroscopic peritoneal metastasis >2cm (+/- nodes +/- capsule involvement)
***In BOTs, these ‘metastases’ are called implants, and they can be:
- non-invasive (most common) = good prognosis
- invasive = worse prognosis, behave more like carcinoma
How to surgically stage?
- Peritoneal washings (collect at the start, before manipulating the tumour)
- Careful inspection of the entire peritoneal cavity (diaphragms, omentum, bowel serosa, uterus, contralateral ovary, POD)
- Biopsies of any suspicious peritoneal lesions (or even random bx if no gross disease seen)
- Omentectomy
- +/- Appendicectomy (esp for mucinous)
- to rule out primary appendiceal tumour - LN sampling (controversial in BOTs)
- not routinely done unless nodes as suspicious
- BOTs can involve LNs, but this doesn’t significantly impact survival - Removal of the involved ovary/tubes +/- contralateral ovary if not fertility-sparing
Invasive vs non-invasive implants
In BOTs, esp serous types, tumour cells can ‘seed’ the peritoneum
Non-invasive implants
- most common (approx 85%)
- tumour cells sit on top of the peritoneum or within fibrous tissue, without destroying or infiltrating it
- associated with excellent prognosis
- these pts are often just monitored post op.
Invasive implants
- tumour cells invade underlying tissues, like subperitoneal fat or muscle
- behave more like low-grade serous carcinoma
associated with higher recurrence and worse survival
- may alter management:
–> some consider adjuvant therapy or closer follow up
–> potentially more aggressive surgical approach if found intra-op
Serous BOTs (histological and prognostic features)
Histological features:
- papillary architecture
- frequently bilateral (approx 30%)
- can have peritoneal implants:
–> may be non-invasive or invasive
- may have a micropapillary variant -> associated with a more aggressive behaviour
Prognostic features:
- stage at dx: most are stage I, but higher-stage still has good prognosis
- implants: key prognostic feature: non-invasive = good, invasive = worse
- micropapillary pattern = associated with higher risk of invasive implants and recurrence
- fertility-sparing surgery: higher recurrence rate, but no clear impact on overall survival (So still safe!)
- LN involvement: may occur, but doesn’t significantly worsen prognosis
- Survival >95% 10-year survival in non-invasive disease
** Key point = prognosis mainly depends on implant type (invasive vs non-invasive) and micropapillary pattern **
Mucinous BOTs
Histological features:
- often unilateral
- very large tumours (>20cm common)
- rarely associated with peritoneal implants
- can be intestinal-type or endocervical type (less common)
- possible confusion with primary GI tumours - appendiceal check often recommended
Prognostic features:
- stage at dx: most are stage I, confined to one ovary
- implants = rare (<10%), usually non-invasive (rare, but if invasive implants present = poor prognosis)
- recurrence = usually locally (ovary), esp after conservative surgery (and usually still borderline)
- intraepithelial carcinoma or microinvasion - not clearly linked to worse outcomes, but may warrant closer follow up
- survival = excellent in stage I (nearly 100%), but much worse if peritoneal spread present
** Key point: prognosis is excellent if confined to the ovary; advanced-stage mucinous BOT behaves more aggressively than serous BOT, often with poor outcomes **
Prognostic factors - serous
- Conservative surgery (cystectomy) = recurrence rate of 15-50% but survival unchanged
- Micropapillary architecture (ovarian tumour/microinvasive, impants)
- Grade not significant
- Invasive implants: 66% survival at 7.4 years
- Non-invasive implants: 95% survival at 7.4 years
Prognostic factors - mucinous tumours
- extra-ovarian tumours
- pseudomyxoma peritoneii
- implants: invasive/non invasive
- invasive foci within the tumour: intraepithelial carcinoma
- grade, intestinal and endocervical subtype probably not significant
- IHC (immunohistochemistry) can aid with deciding if primary ovarian in origin or potential for GIT association
- think metastatic - bowel/gastric - scopes
What is intraepilelial carcinoma (IEC)?
- Foci of high-grade nuclear atypia confined to the epithelial layer, without stromal invasion
- Often associated with mucinous BOTs
- May suggest a step toward carcinoma
- some reports show higher recurrence or progression rates
- but not enough to mandate adjuvant therapy
- warrant closer follow up
- rare in serous BOT
** Think of IEC in mucinous BOT as a ‘red flag’ for malignant potential, esp in large tumours **
Micropapillary Serous (variant of serous BOT)
- Serous borderline tumours whose primary tumour contains areas of filiform or cribiform formations or both
- Higher frequency of exophytic surface tumour, invasive rather than non-invasive implants, bilateral ovarian tumours, higher recurrence rates, and higher mortality rates.
- may progress to low grade serous cancers
- not BRCA
- often not chemosensitive
Treatment - surgical
- Full staging not usually required
- Can be performed laparoscopically
- If fertility not required - TAH + BSO
- If stage 1 and wanting to preserve fertility
–> if only one side affected -> USO
–> if both sides –> bilateral partial oophorectomies/cystectomies - Always perform washings and omental biopsy in addition
- Aim to be as conservative as possible: can always go back and take out more, but can’t put things back
- May be aided by frozen section intra-op
- 50% who have a cystectomy will require further surgery
- No role for routine bx of normal contralateral ovary
- No need to remove appendix if looks normal
Treatment - Adjuvant
- No evidence that adjuvant therapy is beneficial unless:
–> invasive impants
–> response is low overall - Consider adjuvant hormonal therapy for recurrent or metastatic borderline ovarian tumours and low grade serous carcinoma
Prognosis BOTs overall
- 10 year survival is 95% (stage I)
–> event advanced stages have good outcomes unless invasive implants are present - Recurrence rates
–> cystectomy - 10-30%
–> oophorectomy - 1% - Development of invasive cancer
–> usually low grade with poor response to platinum based therapy
–> uncommon early recurrence with high grade cancer that may benefit from chemotherapy
