Therapeutic ART for borderline ovarian tumor

Abstract

Borderline ovarian tumors occur in about 10–16% of all epithelial ovarian tumors. However, it has a good prognosis when compared with other epithelial malignant tumors. Out of all the types, serous borderline tumor is the most common type, found bilateral in 30% of the cases. Management is tailored based on physical examination, radiological findings, and histopathology report. Even though the diagnosis is based on histopathological findings, pre-operative evaluation, especially in younger women, plays an important role in selecting less radical treatment. Here is a case of a borderline ovarian tumor, which was managed considering her age, marital, and fertility status.

INTRODUCTION

Borderline tumors, also known as tumors of low malignant potential, are highly proliferative and contain stratified epithelium with varying degrees of nuclear atypia without stromal invasion. It is seen in 10–15% of all epithelial ovarian neoplasms[¹] and has more than 90% survival rate. There are seven types: serous, mucinous, endometroid, clear cell, Brenner, mixed, and undifferentiated.[²] Out of all the types, serous borderline tumor is the most common type, found bilateral in 30% of the cases. Mucinous borderline tumor causes peritoneal pseudomyxoma in 10% of the cases. Even though the diagnosis is based on histopathological findings, pre-operative evaluation, especially in younger women, plays an important role in selecting less radical treatment.

CASE

This is a case report of a 25-year-old woman, Mrs NV, who is a known case of borderline ovarian tumor following active surveillance protocol for 2 years and came for assisted reproduction as advised. She had regular menstrual cycles lasting for 3–4 days for every 29 days. In 2015, she underwent laparoscopic ovarian cystectomy for abdominal mass, which was reported to be right ovarian mucinous cystadenoma. She was on follow-up for 2 years which was uneventful. While on regular follow-up, in 2017, a right ovarian cyst was noted for which magnetic resonance imaging (MRI (evaluation and tumor markers were done.

INVESTIGATIONS (2017)

Ca-125 was 443 U/mL; Ca-19.9 was 12,000 U/mL; CEA 106 ng/mL; LDH 212 IU/L; hCG 18.8 mIU/mL.

USG-14 cm right ovarian cyst with internal echoes and vascularity. Left adnexa and uterus-normal. MRI concurred with the ultrasound findings without evidence of peritoneal, nodal, or liver metastasis.

Oncologist opinion was sought and advised for staging laparotomy. In view of her young age and considering fertility options, a decision for intraoperative frozen section was made and taken up for laparotomy. Right ovary along with cyst was sent for frozen section, which reported as mucinous cystadenoma with intraepithelial carcinoma and focal microinvasion. Hence aiming for fertility preservation, left ovarian biopsy, peritoneal biopsy, and omental biopsy were done. Liver and paracolic gutters were inspected and no abnormality was found. The final biopsy report suggested borderline ovarian tumor. Hence, a second opinion was sought from the regional cancer center for pathology and further post-operative chemotherapy. Joint decision was made along with the medical oncologist to defer chemotherapy and to put her on strict surveillance protocol every 3 months for the next 2 years. Screening included MRI and tumor markers. She was advised for seek assisted reproduction when contemplating pregnancy. After an uneventful 2 years of follow-up, investigations were sent on day 2 of period and she was planned for assisted reproduction.

INVESTIGATIONS (2022)

AMH 4.63 ng/mL; TSH 2.80 µIU/mL; LH 2.66 mIU/mL; FSH 5.21 mIU/mL; prolactin 21.15 ng/mL; E2 45 pg/mL; Ca-125 5.5 U/mL; beta-hCG 1.70 mIU/mL. USG-uterus midposition, with APD 3.2 cm and ET 4.2 mm. Left ovarian volume 4 cc with antral follicle count of 16.

Husband semen analysis 46 million/mL concentration, total motility 45%, normal morphology 4% normozoospermia.

ART-ICSI was planned and she was stimulated using antagonist protocol with HP-HMG 300 IU for 6 days followed by 450 IU for 5 days. The follicular study was done and GnRh agonist trigger was given when dominant follicles reached >20 mm. Ovum pick up was done within 35 h of trigger. Fifteen oocytes were retrieved, out of which seven day 5 embryos were frozen.

DISCUSSION

Ovarian cancers are the second most common malignancy in women and also the leading cause of death among all gynecological malignancies. However, borderline ovarian tumors are the only group of cancers which have more than 90% survival rate. It occurs in 10–15% of all epithelial ovarian cancers in young and pre-menopausal age groups. Parity and lactation are protective, whereas OCP is non-protective. Diagnosis is through transvaginal ultrasound, and tumor markers such as Ca-125, Ca 19-9, and MRI as adjunct. There are no specific features to distinguish or exclusively diagnose borderline tumors (even with the help of IOTA) by imaging or blood investigations. They present as ovarian malignancy or as advanced disease with peritoneal implants involving the lymph nodes. They have solid components and thick septations in pre-operative imaging, raising the suspicion of malignancy.

The diagnosis is confirmed at the time of histopathology or frozen section only. The frozen section offers assistance in quick diagnosis on table and help decides further plan of action, especially in young women who is at peak of her reproductive phase. However in one-third of the cases, borderline tumors are reclassified as invasive. If the same is diagnosed in an older woman who has completed her family and not desiring future fertility, complete staging laparotomy though midline incision is the treatment of choice.

Conservative surgery is done by doing cystectomy, or unilateral salpingo-oophorectomy, with or without infracolic omentectomy and peritoneal washing in order to preserve fertility. Relapse is higher after cystectomy, in 12–58% of the cases, and recurs as borderline tumor only. There is no role for adjuvant chemotherapy. Follow-up is needed every 3 months for the first 2 years, every 6 months for the next 2 years, and annually thereafter. In the aforementioned case, without accurate diagnosis by the pathologist at the time of frozen section, her uterus and contralateral ovary would not have been retained. Hence, her fertility was preserved, and ART treatment was completed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.