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Are Fertility-Sparing Procedures Safe for Women with Ovarian Borderline Tumors? Probably.
Abstract & Commentary
By Robert L. Coleman, MD, Associate Professor, University of Texas; M.D. Anderson Cancer Center, Houston TX, is Associate Editor for OB/GYN Clinical Alert
Dr. Coleman is on the speaker’s bureau for GlaxoSmithKline, Bristol Myers Squibb, and Ortho Biotech.
Synopsis: Fertility-sparing surgery for ovarian LMP tumors is an option for motivated patients. Preservation of the contralateral adnexa increases the risk of recurrence, but surgical resection is usually curative.
Source: Rao GG, et al. Fertility-sparing surgery for ovarian low malignant potential tumors. Gynecol Oncol. 2005;98:263-266.
It has been well documented that women diagnosed with low malignant potential (LMP) tumors have an excellent prognosis with few recurrences identified in those undergoing definitive resection. However, many of these cases occur in women of childbearing age in whom fertility may be desired. Limited evidence to date has suggested that subtotal resection is not associated with worsening prognosis although recurrence risk is increased. In evaluation of this objective, Rao and colleagues examined the outcomes of 38 patients with LMP tumors who underwent fertility-sparing operations as primary management of their disease. Most had unilateral oophorectomy; 5 underwent cystectomy only. Although formal staging wasn’t obtained in all cases, only 4 were not apparent stage I. No patients received adjuvant therapy. At a median 26 months of follow-up 6 patients had recurred (16%); 5 in a remaining ovary, in which all were cured following subsequent resection. Five women delivered 6-term infants during post-treatment surveillance. Rao and colleagues conclude that given these characteristics, well-informed patients might safely choose surgical therapy which preserves their fertility. Although recurrence may be experienced, surgical resection is generally curable.
Most women diagnosed with an ovarian malignancy have invasive, advanced-staged disease requiring aggressive cytoreduction and adjuvant chemotherapy. The track record in successful management for these patients is well described and while improving, is, in general, poor. On the other end of this spectrum, tumors of low malignant potential are characterized by limited extra-ovarian disease at presentation, long periods of disease-free survival and infrequent need for systemic adjuvant therapies. While some of these tumors can be fatal, particularly in those patients in whom inoperable disease attains a progressive or an invasive phenotype, the majority follows a more benign course compared to their invasive counterpart. Surgical staging studies of women with these neoplasms have documented that thorough abdominal and pelvic sampling will upstage approximately 20% of apparent stage I cases.1-4 However, it has been increasingly documented that re-operating to formally stage a patient with a surprise LMP final pathological diagnosis is of little value. Nonetheless, receiving the diagnosis of LMP intraoperatively generally promulgates formal surgical staging as subsequent upgrading to invasive disease can occur in 5-30%. In patients with unstaged invasive lesions the stakes are higher; and the management considerations in this situation are to re-operate for formal staging or empiric multi-agent chemotherapy. With these caveats, a young woman undergoing surgical exploration for adnexal pathology should have a discussion that not only incorporates the possibility of cancer but also the procedures to be undertaken in this situation. For the motivated patient who understands the attendant risks of subtotal resection in the event of LMP, fertility-sparing procedures are an option. Data from the current series as well as others would support this management pathway.5 Staging biopsies are still obtained but resection of all fertility organs may be omitted. The decision to remove these retained organs after childbearing is less definitive but generally recommended if it is an organ responsible for persistent or recurrent disease. Advanced reproductive techniques are redefining what "fertility-sparing" entails. A retained uterus without ovaries permits surrogacy, as well as subcutaneously implanted ovarian tissue in the absence of ovaries or a uterus. Such extremes are infrequently encountered but underscore pre-operative counseling necessary for women with adnexal masses in whom, prospective education can maximize options for fertility-desiring women.