Description of a case report of an intestinal-type ... - Cancer Therapy

Longo et al: Description of a case report of an intestinal-type mucinous borderline ovarian tumor
Surgery is the cornerstone in the management of
BOTs, but many issues exist on the extent of the staging
procedure and the optimal surgical approach, including the
use of laparoscopy, conservative surgery, and
retroperitoneal lymph nodes dissection. Considering the
clinical relevance of the stage in deciding treatment
options, a careful inspection of the entire abdominal cavity
with peritoneal washing, infracolic omentectomy, removal
of all macroscopic suspicious peritoneal lesions, multiple
peritoneal biopsies, and, for MBOTs, appendectomy, are
mandatory (Cadron et al, 2007). Unfortunately, complete
staging is only performed in 50% or fewer patients, even
though the pelvic peritoneum and abdominal peritoneum
are involved in 58% and 48% of patients, respectively
(Menzin et al, 2000; Cadron et al, 2007). Furthermore,
invasive implants are present in pelvic peritoneum and
abdominal peritoneum in 9% and 14% of patients,
respectively. The omentum is involved in 39% of patients,
and in 9% of patients, these implants are invasive (Jones,
2006; Cadron et al, 2007).
Because younger women are more likely to develop
BOTs, an important issue is the appropriateness of
conservative surgery with fertility preservation for stage I
disease or for BOTs with noninvasive implants. According
to results of retrospective studies comparing conservative
vs more radical approach, it seems reasonable to perform
conservative surgery (ie, salpingo-oophorectomy with
infracolic omentectomy and multiple peritoneal biopsies
and cytology) only for stage I disease (Cadron et al,
2007).Considering the increased risk of developing
persistent invasive implants or recurrence, patients with
invasive implants should be treated with radical surgery.
In case of extraovarian recurrence with invasive implants
after conservative therapy, extensive cytoreductive surgery
remains the treatment option of choice (Cadron et al,
2007). The advantage of retroperitoneal lymph node
sampling is questionable in patients with BOTs and
lymphadenectomy can be omitted, even for the advanced
disease, because it does not affect the recurrence or
survival rate (Cho et al, 2006; Cadron et al, 2007). A
recent prospective study conducted in 57 women with
BOTs, para-aortic and pelvic node dissection was not
correlated to any survival advantage (Pirimoglu et al,
2008).
Laparoscopy seems to be feasible in BOTs of
moderate size (diameter below 10 cm), to give fewer
complications and a shorter hospitalization (Cadron et al,
2007; Daraï et al, 2007; Ødegaard et al, 2007). However,
many potential concerns remain unmet, including the
chance of tumor rupture, the development of port site
metastases, and finally a potentially increased number of
patients with unstaged or inappropriately staged tumors.
Future, prospective studies with a long-term follow-up are
needed to determine the ultimate recurrence risk as well as
fertility rates of this procedure as compared to laparotomy
(Cadron et al, 2007).
Chemotherapy should be reserved only for
progressive disease that does not respond to surgical
management (Cadron et al, 2007).
Finally, another important issue is the intraoperative
frozen section (IFS) diagnosis of BOTs. A recent
retrospective analysis comparing IFS analysis and
definitive histology showed an agreement between these
two procedures in 69/96 (71.9%) patients, yielding an
overall sensitivity and a positive predictive value of 75.0%
and 94.5%, respectively. Underdiagnosis and
overdiagnosis occurred in 27/96 (28%) and 0/96 (0%)
patients, respectively. The authors concluded that surgical
management based on IFS diagnosis should be used with
caution in BOT patients (Tempfer et al, 2007).
In our case, considering tumor dimensions, the
menopausal status and the lack of peritoneal implants and
locoregional lymph nodes involvement, the patient
underwent radical surgical tumor resection without other
adjuvant treatments. After a follow up of 19 months, the
patient is alive, in good clinical conditions, and diseasefree
References
Acs G (2005) Serous and mucinous borderline (low malignant
potential) tumors of the ovary. Am J Clin Pathol
123(Suppl), S13-S57.
Cadron I, Leunen K, Van Gorp T, Amant F, Neven P, Vergote I
(2007) Management of borderline ovarian neoplasms. J Clin
Oncol 25, 2928-37.
Cho YH, Kim DY, Kim JH, Kim YM, Kim KR, Kim YT, Nam
JH (2006) Is complete surgical staging necessary in patients
with stage I mucinous epithelial ovarian tumors? Gynecol
Oncol 103, 878-82.
Daraï E, Tulpin L, Prugnolle H, Cortez A, Dubernard G (2007)
Laparoscopic restaging of borderline ovarian tumors. Surg
Endosc 21, 2039-43.
Guerrieri C, Hogberg T, Wingren S, Fristedt S, Simonsen E,
Boeryd B (1994) Mucinous borderline and malignant tumors
of the ovary. A clinicopathologic and DNA ploidy study of
92 cases. Cancer 74, 2329-40.
Hart WR (2005a) Borderline epithelial tumors of the ovary. Mod
Pathol 18(Suppl 2), S33-S50.
Hart WR (2005b) Mucinous tumors of the ovary: a review. Int J
Gynecol Pathol 24, 4-25.
Jones MB (2006) Borderline ovarian tumors: current concepts for
prognostic factors and clinical management. Clin Obstet
Gynecol 49,517-25.
Kaern J, Tropé CG, Abeler VM (1993) A retrospective study of
370 borderline tumors of the ovary treated at the Norwegian
Radium Hospital from 1970 to 1982: a review of
clinicopathologic features and treatment modalities. Cancer
71, 1810-20.
Kikkawa F, Nawa A, Kajiyama H, Shibata K, Ino K, Nomura S
(2006) Clinical characteristics and prognosis of mucinous
tumors of the ovary. Gynecol Oncol 103, 171-5.
Kliman L, Rome RM, Fortune DW (1986) Low malignant
potential tumors of the ovary: a study of 76 cases. Obstet
Gynecol 68, 338-44.
Lee KR, Scully RE (2000) Mucinous tumors of the ovary: a
clinicopathologic study of 196 borderline tumors (of
intestinal type) and carcinomas, including an evaluation of
11 cases with “pseudomyxoma peritonei”. Am J Surg
Pathol 24, 1447-64.
Ludwick CL, Gilks CB, Miller D, Yaziji H, Clement PB (2005)
Aggressive behavior of stage 1 ovarian mucinous tumors
lacking extensive infiltrative invasion: a report of four cases
and review of the literature. Int J Gynecol Pathol 24, 205-
17.
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