Management of ovarian neoplasms

Gokul dev

Borderline ovarian tumors


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Histology and Cytology

According to Dietel and Hauptmann, the histology of borderline tumors is characterized by the following features: Epithelial multilayering of more than 4 cell layers Not more than 4 mitoses per 10 high-power field (HPF) Mild nuclear atypia Increase in nuclear/cytoplasmic ratio Slight to complex branching of epithelial papillae and pseudopapillae Epithelial budding and cell detachment into the lumen No destructive stromal invasion - A major component in differentiating malignant from borderline tumors Approximately 25% of borderline tumors have cell proliferations on the outer surface of the lesion, with no evidence of growth from the inner surface. Of these, approximately 90% develop peritoneal implants. Only 4% of cases with peritoneal implants do not have surface proliferation.

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Doppler Ultrasonography
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Preoperative transvaginal color Doppler ultrasonography has been used to assess the possibility of malignancy in ovarian masses. The rate of detection of intratumoral blood flow in borderline tumors (90%) is similar to that of malignant neoplasms (92%). The resistance and pulsatility indexes are also significantly reduced in carcinoma and borderline ovarian tumors compared with those of benign tumors. Although ultrasonography is useful in identifying the mass, this medium is not currently able to predict the final pathology of the tumor. It is neither sensitive nor specific enough to be used as a screening tool in the normal populations.

Foci Identification

} Computed

tomography (CT) scanning should be considered preoperatively to identify possible foci of metastasis. CT scanning can also be useful when following the patient in the future. Again, as with ultrasonography, there are no distinguishing characteristics that clearly identify a borderline ovarian tumor.

MRI Characteristics

Retrospective studies looking at MRI characteristics of known borderline tumors, revealed that serous borderline tumors were significantly smaller than mucinous borderline tumors. However, no other key imaging characteristics were identified that would distinguish borderline tumors from other ovarian tumors.

Treatment Parameters
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The accepted initial treatment of borderline ovarian tumors is surgical removal of the tumor and the performance of biopsies. However, the postoperative management protocol is far from clear. To date, no medical therapy has been shown to clearly improve outcomes. No consensus has been reached concerning treatment of patients with stage II-IV disease. Although these women still have high 5year survival rates compared with their counterparts with true malignant ovarian cancer, an increased stage is associated with a worse prognosis. However, stage (II vs III vs IV), type of surgery, postoperative treatment, postoperative platinum-based chemotherapy, and even the number of noninvasive implants have no effect on progression-free survival. Only age at diagnosis and the presence of invasive implants are shown to influence prognosis

Chemotherapy
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Various chemotherapy regimens have been used, but evidence is insufficient to determine exactly which therapy is indicated for borderline ovarian tumors. Many authors have used platinum-based agents, but with varying results. Some authors recommend platinum-based therapy for patients with invasive peritoneal implants because of their worse prognosis. Standard chemotherapy regimens for invasive ovarian cancer are used if any medical therapy is given. In patients without metastatic disease, chemotherapy is not indicated. An important area of research is postoperative chemotherapy. Little advantage has been reported after postoperative chemotherapy, but the number of patients studied has been small and the chemotherapeutic regimens used have been varied. The general consensus is that borderline tumors with noninvasive implants do not require any further therapy and should be observed. However, the benefit of treating tumors with invasive implants has been discussed. To date, no randomized data show a benefit.

Tumor Excision
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Given the excellent prognosis for borderline ovarian tumors, hysterectomy and contralateral oophorectomy are not necessary (if the ovary appears normal) if the patient wishes to preserve fertility. If the patient is beyond childbearing age, then hysterectomy is a reasonable option. Removal of a normal, contralateral ovary should be based on existing data regarding ovarian physiology. When a complex ovarian mass is discovered, surgery is often, if not always, indicated. Complete excision of the disease must be achieved if at all possible. Comprehensive staging should be a part of every operation. Although stage may or may not affect future treatment, it is of significant prognostic value and therefore is of value to the clinician and to the patient.

In most instances, surgery is curative for patients with confirmed stage I disease. If the tumor is unilateral and adjacent to normal tissue, unilateral cystectomy can be performed; however, inspection of the capsule for signs of rupture should be performed before resection. If no normal adjacent tissue is present, oophorectomy or salpingo-oophorectomy should be performed. If the contralateral ovary is normal in appearance, a biopsy should not be performed on the adjacent ovary because of the risk of ovarian failure (if fertility is an issue). Owing to the high association between surface proliferations and peritoneal implants, exploration of the peritoneum should be extensive and thorough. If possible, carefully evaluate and remove the implants. The type of implant (ie, invasive, noninvasive) should be noted by pathology, as it has significant prognostic value. Contraindications to surgery include medical reasons (ie, the patient is too great a surgical risk secondary to other medical problems) or patient refusal. Otherwise, the masses should be surgically removed.