Borderline tumor
The latest findings underscore the importance of full staging in both radical and conservative surgery, to choose the most comprehensive treatment and obtain an accurate prognosis.
In addition, the article aims to review follow-up guidelines and to clarify the main prognostic factors that affect recurrence and survival of these patients.
In some studies, an increase in the incidence (two to four times greater) of serous BOT in women undergoing assisted reproduction techniques has been observed.
[4] Some patients with BOT (16–30%) are asymptomatic when diagnosed and the discovery is incidental; nevertheless, when there are symptoms these are often non-specific, similar to other adnexal tumours, such as pelvic pain or abdominal distension.
In addition, in advanced stages, these may be associated with lymphatic involvement in about 27% of cases, including the following in descending order of frequency: pelvic, omental and mesenteric, and paraaortic and supradiaphragmatic regions.
[4] These tend to be larger than serous BOT and have either a unilocular or multilocular cystic structure, with fine septa in their interior and intramural nodules.
The histological criteria for diagnosis are: epithelial cell proliferation, stratified epithelium, microscopic papillary projections, cellular pleomorphism, nuclear atypia, and mitotic activity.
[4] The surgical treatment of BOT depends on the age of the patient, their reproductive wishes, the stage at diagnosis, and the presence or absence of invasive implants.
[4] Surgical staging is based on operative findings, and consists in carrying out all procedures in the standardised clinical guides explained below, either in a first surgery or a second, if required, although there is a great deal of controversy around a second because it does not appear to affect patient survival.
Theoretically, long-term survival would be diminished in patients with non-optimal staging with invasive implants, although the data do not seem to be statistically significant in the literature, probably due to the good overall prognosis of BOT and the low number of cases of each series.
[4] In spite of the fact that only 15% of unilateral tumours are associated with peritoneal extension, compared with 56% for bilateral, and with both radical and conservative surgeries as objectives, it would seem the most sensible course would be to perform complete surgical staging.
[4] In postmenopausal women, and in those who have fulfilled their reproductive wishes, the following standardised procedures will be carried out: a thorough exploration of the abdominal cavity, bilateral salpingo-oophorectomy, total hysterectomy, inframesocolic omentectomy, peritoneal lavage to obtain samples for cytology, resection of macroscopically suspicious lesions, and multiple peritoneal biopsies (including omentum, intestinal serosa, mesentery, pelvic, and abdominal peritoneum), although this practice is in disuse due to its low sensitivity and the apparent lack of utility of randomised biopsies where no suspicious lesions are present.
[4] In addition, in cases of mucinous BOT, appendectomies are performed to exclude ovarian metastasis whose origin is a primary carcinoma of the appendix.
In addition, cystectomy, which produces an increased risk of recurrence on the ipsilateral ovary (31%), should be carried out only on women with bilateral tumours, with only one ovary, or on those patients who are extremely young, such that a loss of a large mass of ovarian tissue might negatively affect their fertility later on (though recent studies have obtained excellent fertility results in patients treated with unilateral salpingo-oophorectomy).
In spite of this, most of the studies were carried out retrospectively, so that if the laparoscopy is performed by a trained specialist, it provides such benefits as lower morbidity and fewer postsurgical adhesions, as well as less pain and a shorter hospital stay.
In addition, the possibility of the co-existence of benign, borderline, and invasive cancer areas has been described in mucinous BOTs especially of the intestinal type, which implies that they should be carefully examined, given their great volume in some cases, and the treatment of choice will be salpingo-oophorectomy.
This treatment will only be indicated for those patients with BOTs with a high risk of recurrence (invasive implants, microinvasion, micropapillary patterns, or intracystic carcinoma).
However, there is also the possibility of performing the radical surgery sooner because of the psychological impact produced by waiting for the relapse to occur, even risking recurrence in the form of an invasive tumour.
[4] There are two types of surgical treatment (Table 2) for the ipsilateral ovary:[4] When an extra-ovarian borderline or invasive relapse occurs, cytoreductive surgery as with primary ovarian cancer should be carried out.
[4] Follow-up visits should include clinical exploration, transvaginal ultrasound, and Ca125 levels, even though some authors have suggested adding Ca19.9 since it appears that some mucinous tumours do not mark Ca125.
(a) Sometimes mucinous cells with voluminous cytoplasm can mimic goblet cells. Admixed lightly eosinophilic ciliated cells are almost always identifiable.
(b) Background of prominent neutrophilic infiltration. Admixture of mucinous cells, eosinophilic cells, and some clear cells, with mild or moderate nuclear atypia and stratifications.
(c) Indifferent cells with abundant eosinophilic cytoplasm.
(d) Endometrioid type epithelium.
(e) Squamous epithelium.
(f) Clear cells. Focal hobnail appearance is also seen (right lower corner). [ 5 ]
