Surgical Management

In general, as in malignant ovarian cancer, there should be a maximal surgical effort to remove as much tumor as possible from women with extraovarian tumors and to assess the extent and need for further staging procedures based on patient characteristics in women whose disease appears confined to the ovary.

Intraoperative Frozen Section

Most often the diagnosis of an ovarian borderline tumor is not known preoperatively, and a frozen section is obtained to establish a definitive diagnosis to guide the nature and extent of surgery required. In general, the pathologic analysis of frozen section to differentiate invasive and noninvasive ovarian tumors demonstrates a sensitivity between 65% and 97% and a specificity of 97% to 100%, as shown on a recent metaanalysis.27 In borderline tumors, especially large mucinous tumors, that same differentiation may be more difficult. Tempfer and colleagues28 found that none of their patients was overdiagnosed (defined as a frozen section with borderline or malignant pathology and a subsequent final benign pathology). In contrast, they also found underdiagnosis in almost one third of patients. This was defined as frozen read as normal and final pathology with borderline, or as a frozen diagnosis of borderline and a final malignant pathology. Of note, nearly all the missed underdiagnoses were borderline tumors and not invasive cancers. Increasing tumor size was also a factor in missing the correct diagnosis. In summation, frozen section may lend important information but must be interpreted with caution, especially in centers without gynecologic pathologists.

Extent of Surgery

Women with borderline tumors tend to be younger and often do not have a known diagnosis preoperatively. For women who do not desire future pregnancy, most experts would recommend a bilateral salpingo-oophorectomy, hysterectomy, and staging if indicated (see text that follows). For women who desire reproductive capability, several studies indicate the safety of fertility-sparing surgery with a unilateral oophorectomy or even simple cystectomy if the other ovary and remainder of the surgical exploration are normal.3,28-32 The performance of fertility sparing surgery does not seem to adversely impact overall survival but does consistently increase recurrence rates in multiple retrospective reviews.17,29-32 A French study compared cystectomy versus unilateral salpingo-oophorectomy versus bilateral salpingo-oophorectomy and recurrence rates in 313 women with borderline tumors; found were significantly increased recurrence rates with the more limited excisions (30% versus 11% versus 1.7%, respectively; P < .001).32 Morris and associates29 reviewed 43 patients with borderline tumors treated with fertility-sparing surgery and found that 50% of the women attempting pregnancy conceived (12 of 24 patients for a total of 25 pregnancies) and that the recurrence rate for the entire population was 32%. The recurrence rate of borderline tumors was higher in women treated with cystectomy compared with those treated with oophorectomy (58% versus 23%; P < .04). Similarly, Suh-Burgmann30 found a recurrence rate of 11% in 193 patients treated with conservative surgery with a mean time to recurrence of 4.7 years. Women initially treated with cystectomy were three times more likely to have a recurrence of borderline tumors than women undergoing oophorectomy.30 In summation, women can safely elect to maintain fertility but must understand the potential increased risk of recurrence and need for additional surgery.

Staging

The role of complete surgical staging for borderline tumors remains controversial. Complete staging would include bilateral salpingo-oophorectomy, hysterectomy, washings, omentectomy, peritoneal biopsies, and lymph node dissection. Proponents of full staging argue that frozen section is unreliable and that if a cancer is found, definitive staging enables a rational adjuvant treatment decision. Furthermore, they contend that full staging will upstage up to 50% of apparent stage I borderline tumors. Opponents of full staging for all patients argue that there is no survival advantage in accurately assessing stage of borderline tumors owing to the lack of evidence for effective adjuvant therapy and that staging may add surgical morbidity (especially if it requires a second surgery to accomplish). Winter and colleagues33 analyzed 93 consecutive patients with borderline tumors and found that full surgical staging upstaged patients 17% of the time but that retroperitoneal involvement was found only 6% of the time. Furthermore, the overall survival and recurrence rates did not differ between staged and unstaged patients.

Similarly, Longacre and associates16 found that one third of women undergoing nodal dissection for borderline tumors had positive nodes, but they did not find any significant difference in survival based on nodal status. Finally, a French multicenter study evaluated 360 women with borderline tumors and assessed the impact of surgical restaging of 54 women.34 The researchers found no impact on survival, but they did find a 14.8% rate of upstaging. This was more common in serous tumors and in women undergoing cystectomy at the initial surgery.34 In summation, surgical decisions must be made for individual patients and must take into account future fertility wishes, impact on future treatment decisions, and potential surgical morbidity.

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