Prognostic Factors for Patients with Advanced-Stage Serous Borderline Tumors of the Ovary

Abstract & Commentary

Synopsis: In this series, the only prognostic factor for patients with advanced-stage borderline tumor is the type of peritoneal implant. More patients died of the treatment’s complications than of the disease itself. The patients’ prognosis with noninvasive implants seems to be excellent, and conservative management could be discussed in younger patients.

Source: Morice P, et al. Ann Oncol. 2003;14:592-598.

The ovarian malignancy, low malignant potential ovarian tumors (LMPOT) are defined by an epithelial tumor with a stratification of the epithelial lining, but with a lack of frank stromal invasion at pathological examination. It has a much less aggressive behavior than typical invasive epithelial ovarian cancer. The prognosis of patients with disease limited to the ovaries is excellent, but there are some patients with extra-ovarian spread. The histologic subtype is also important, as patients with mucinous borderline tumors and peritoneal extension (pseudomyxoma peritonei) are different. LMPOT account for approximately 15% of epithelial ovarian cancers with approximately 4000 patients diagnosed annually. The average age is 49 years, with the highest frequency of cases occurring in the 15-29 age group. These tumors may occur in a background of benign neoplasia and/or in association with areas of invasive disease.1 Therefore, a thorough sampling of the primary tumor is critical to the establishment of an accurate diagnosis. The term "microinvasion" has been applied to cases that appear to bridge the definitions of LMPOT and invasive lesions. The prognosis is similar to noninvasive lesions.2

Comment by Stuart M. Lichtman, MD, FACP

This paper is a current review of a series including patients with advanced-stage serous borderline tumors of the ovary. This is the second largest series of patients with advanced-stage LMPOT. Their charge was to determine the prognosis of patients with serous LMPOT associated with peritoneal implants, as well as proposing an adequate treatment for these patients. The results were an analysis of 80 patients with a median age of 32 years. Most patients had elevated CA125 levels with a mean of 183 U/L. Twenty-nine patients had stage II disease, and 51 had stage III disease. Sixty-five patients had noninvasive implants, and 15 had invasive implants. Sixty-five patients had what was considered radical surgery, and 46 received some form of adjuvant treatment. This included radiation in 6 patients and chemotherapy to 32 patients. In 8 patients both treatments were given. Twenty-six of the chemotherapy patients received a platinum-containing regimen. Fifteen patients had recurrences with a median delay for recurrences of 23 months. Six patients had peritoneal recurrences with invasive disease. Four were observed in the patients with invasive implants and 2 in the patients with noninvasive implants. Their analysis showed that the rate of developing invasive disease is related to whether the patients had invasive peritoneal implants and the time of initial diagnosis (31% with invasive vs 2% with noninvasive; P < .002). Another entity has been described in patients with peritoneal implants associated with borderline tumor called micropapillary serous carcinoma (MPSC). It is more often, but not exclusively, associated with invasive implants.

In this study, the presence of stromal microinvasion was not an adverse prognostic factor. However, the rate of recurrence is increased (23% vs 3.5%; P = .023). In another review, the overall survival of patients with microinvasion is 100%.3 Morice and colleagues concluded that in patients with a good prognosis (borderline ovarian tumor with noninvasive implants) conservative surgery and total resection of the peritoneal implants were warranted. The role of chemotherapy is questionable and in some series more patients died from complications of the adjuvant treatment than from progression of the disease. In patients with invasive implants Morice et al have recommended chemotherapy after surgery.

This paper discussed a histologic subtype of malignant ovarian tumors, which is often not diagnosed. Recognition of this clinical syndrome is important, as patients generally have an excellent prognosis usually with the need for chemotherapy. This will avoid overtreatment in this generally younger patient population. The clinicians must work in closed association with the pathologist to ensure an accurate diagnosis. Conservative management seems appropriate in the vast majority of cases. The increased relapse rate of invasive implants may make one consider adjuvant chemotherapy. However the true benefit of these treatments has not yet been proven.

Dr. Lichtman is Associate Professor of Medicine, NYU School of Medicine, Division of Oncology; Don Monti Division of Medical Oncology, North Shore University Hospital, Manhasset, NY.

References

1. Menzin AW. Oncology (Huntingt). 2000;14:897-902.

2. Bell DA, Scully RE. Hum Pathol. 1990;21:397-403.

3. Seidman JD, Kurman RJ. Am J Surg Pathol. 1996;20: 1331-1345.