eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Borderline Ovarian Cancer: Treatment

Author: Andrew E Green, MD, BA, BS, Consulting Staff, Southeastern Gynecologic Oncology, LLC, Northeast Georgia Medical Center
Contributor Information and Disclosures

Updated: Jan 15, 2008

Treatment

Medical Therapy

No consensus has been reached concerning treatment of patients with stage II-IV disease. While they still have high 5-year survival rates compared to their malignant counterparts, 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.

Various chemotherapy regimens have been used, but evidence is insufficient to determine exactly which therapy is indicated. 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.

Surgical Therapy

Complete excision of the disease must be achieved if at all possible. Comprehensive staging, as described above, 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 both clinician and patient. In one study, 77% of patients with invasive peritoneal implants also had noninvasive implants. Comprehensive debulking and staging decreases the chance of a sampling error that could result in an inaccurate diagnosis and prognosis.

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. The type of implant has significant prognostic value.

Postoperative Details

While not routine, static DNA cytometry can be performed on the specimens. Approximately 95% of tumors have diploid DNA. This finding is almost always associated with excellent prognosis. If the tumor is aneuploid, the recurrence rate is high. Some authors suggest treating these as low-grade invasive carcinoma (aka, micropapillary carcinoma). 

With the advent of microarray technology, the actual characterization of the tumor genome can now be studied. Some preliminary work is starting to emerge in the invasive forms of ovarian cancer; however, little has been done on borderline ovarian cancer, mostly because of its low incidence and good prognosis. Some data suggest that invasive tumors discovered at low stages and borderline tumors, especially those with invasive implants, share genetic expression profiles. However, the significance of this has not been determined.

Conflicting data exist with respect to overexpression of various oncogenes and tumor suppressor genes. While p53 positivity and Her-2 overexpression in invasive cancer were associated with a worse prognosis, the same gene profile conferred a survival advantage in borderline tumors.

Complications

Most of the complications of this disease are caused by the operation itself, subsequent therapy, or recurrence. Without comprehensive surgical staging, the prognosis for an individual patient is difficult to predict.

In one study of stage I disease, all recurrences appeared in patients who were inadequately staged. Many, if not all, of these patients probably did not actually have stage I disease.

Pathologic diagnosis is difficult to confirm by frozen section. Borderline tumors are correctly diagnosed 58-86% of the time by frozen section, depending on the experience of the pathologist and the site of the operation (eg, tertiary care vs community hospital). However, in one study at a tertiary referral center, benign disease was excluded in 94% of cases subsequently diagnosed as borderline tumor. Thus, the proper operation and staging procedures could have been performed during the initial operation in most cases even though the diagnosis by frozen section was not completely accurate.

Another major source of complications is that of postoperative chemotherapy. In one series of 28 borderline tumor–related deaths, 2 patients died of radiation-associated complications, 9 of chemotherapy-associated complications, 8 of bowel obstruction, and 8 of invasive carcinoma. This led the authors to suggest that most patients with borderline tumors died with the disease rather than of the disease.

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