Borderline ovarian carcinomas account for about 16% of all epithelial ovarian malignancies. Of them most common is the serous subtype. It is a rare entity, difficult to differentiate from malignant carcinoma and good prognostic. Here we are reporting a case of serous borderline tumor in a 70 year old female treated with surgery alone and now on follow up.
Key findings:
The abstract reports a case of serous borderline ovarian tumor in a 70-year-old female. Borderline ovarian carcinomas, especially the serous subtype, represent a rare entity comprising 16% of all epithelial ovarian malignancies. Surgery alone was utilized for treatment, highlighting its efficacy and the importance of appropriate management in such cases.
What is known and what is new?
Borderline ovarian carcinomas, particularly the serous subtype, are recognized for their rarity, difficulty in differentiation from malignant carcinomas, and generally favorable prognosis. This abstract contributes a case report of a 70-year-old female diagnosed with a serous borderline tumor, emphasizing the ongoing importance of individualized treatment strategies and vigilant follow-up in managing such cases.
What is the implication, and what should change now?
The diagnosis of serous borderline ovarian tumors presents a challenge due to their resemblance to malignant carcinomas. This case underscores the importance of accurate diagnosis and appropriate management strategies. Moving forward, clinicians should emphasize thorough histopathological evaluation and consider multidisciplinary approaches to ensure optimal treatment and follow-up care for patients with borderline ovarian tumors.
Borderline ovarian tumors (BOT) are a type of ovarian epithelial tumors which are a heterogenous group of non-invasive tumors of uncertain malignant potential with characteristic histology [1]. BOT comprise about 16% of all epithelial ovarian malignancies [2]. BOTs differ significantly from ovarian carcinomas with regard to percentile distribution of tumor histotypes, lower FIGO stage at time of diagnosis, excellent overall prognosis even after recurrence, younger age distribution and need for fertility sparing.
Most common BOT is about 53.3% [3]. It usually affects women between the fourth and sixth decade of life and even younger [4]. It is difficult to diagnose pre operatively as the radiologic features of BOT resemble ovarian carcinoma or benign disease [5]. CA-125 is usually normal. This causes over treatment or under treatment. One important technique is use of the frozen section during surgery, but it has lower sensitivity and specificity and requires larger tissue samples and expertise [1].
Treatment is mainly surgery. As patients are usually of younger age and many are less than 40 years, conservative surgery or fertility sparing surgery is done. If this is not feasible or family is complete, a definitive surgery with hysterectomy and oophorectomy is done. There are high chances of recurrence with serous BOT but the recurrence is usually borderline type or a small malignant disease. It has good prognosis.Sherman et al. reported in a population-based analysis that the overall relative survival rate at 10 years was 96.9% ± 2.3% for serous BOTs [1].
Here we are reporting a case of serious BOT in a 70 year old female. It is a rare case scenario with tricky diagnosis and surgery as the mainstay of treatment.
A 70 year old postmenopausal, para four, female patient presented to our hospital with a complaint of abdominal discomfort for about four months. There were complaints of abdominal bloating and altered bowel habits. She visited the general outpatient department for these complaints several times. Since there was no relief with the medications, she was further diagnosed.
On examination there was no abdominal lump palpated. The blood counts and biochemistry was normal. An ultrasound of abdomen and pelvis was done suggestive of complex right adnexal cyst with endometrial polyp. A contrast enhanced computed tomography of abdomen was done suggestive of 80x77 mm cystic lesion in right ovary with 4 mm thickened medial wall and presence of septations within it. There was no pelvic or abdominal lymphadenopathy. No solid mural nodularity was seen. A probable diagnosis of right ovarian cystadenoma was made. CA-125 was 19 U/ml.
She was then operated at the gynecology department. Exploratory laparotomy proceed total abdominal hysterectomy with bilateral salpingo oophorectomy with omental biopsy with peritoneal fluid cytology was done. The histopathology examination was done. On gross examination, the right side ovary was converted into a smooth surface cyst measuring 7 cm in diameter. It was uniloculated with small areas showing solid area less than 5%. Cut section of the solid area shows multiple small cysts. Right ovary showed features of serous BOT. It was FIGO Stage IA with no pelvic implants. No micropapillary architecture was seen. There was no residual disease. It was a low grade serious BOT FIGO stage IA.
She kept on following up. She has completed two three monthly follow ups and is disease free.
Borderline ovarian tumors (BOT) are a type of ovarian epithelial tumors which are a heterogenous group of non-invasive tumors of uncertain malignant potential with characteristic histology [1]. They constitute about 16% of all epithelial ovarian tumors. They are mostly bilateral (30-50%) [2]. The BOTs are mainly classified further into serous (53%), mucinous (42.5%) and other uncommon variants like endometrioid, clear cell, transitional cell or mixed epithelial tumors (4.2%) [3]. They affect women in the fourth or fifth decade or even younger [4].
Our patient was a 70 year old female, which was higher than the usual age group for serious BOT. The histology was serous BOT without any micropapillary variant or pelvic implants.
Serous BOT are further subclassified into typical serous borderline (90%) and borderline tumors with micropapillary pattern (5-10%).Some histological features of serous BOT vary with the subtype like, peritoneal implants present in 35% of patients. Their incidence is increased with micropapillary variants [1].
Serious BOTs are usually diagnosed at an early stage. About 75% of patients are diagnosed at stage I. The main clinical presentation is abdominal pain or discomfort, bleeding per vaginum or asymptomatic who are detected as a mass in the pelvis. The serous BOT is difficult to differentiate from benign and malignant ovarian tumors. Ultrasound is the best modality to detect serous BOT. Color Doppler and grayscale are usually done for added details. However, even with these modalities and expertise of the ultrasonologist it is difficult to accurately diagnose serious BOT. The antigen CA-125 is usually negative in serous BOT. The serous BOT are usually diagnosed as a mass in the pelvis and the histology is usually established after or during surgery [1]. Computed Tomography, Magnetic Resonance Imaging and Positron Emission Tomography have an uncertain role in diagnosis of serous BOT. Frozen section analysis during surgery can help establish the diagnosis of serous BOT, but its sensitivity and specificity is low and requires expertise [1].
In our patient, ultrasound was suggestive of a complex right adnexal cyst with endometrial polyp. But in contrast to enhanced computed tomography of the abdomen, it was right serous cystadenoma. CA-125 was 19 U/ml.
The main treatment of serous BOT is conservative surgery as the patients are of younger age group and fertility sparing is required. It involves the preservation of the uterus and at least part of one ovary, with surgical staging. Biopsy of contralateral ovary is not usually done as it causes adhesions and infertility. However, conservative surgery is associated with higher recurrence chances that is, 10-20% vs 5% with radical surgery. Thus authors recommend radical surgery with oophorectomy and hysterectomy, once family is completed. There is no established role of adjuvant therapy, that is, chemotherapy or radiation therapy. Some studies even suggest that use of adjuvant therapy is negative prognostic as it increases toxicity [1].
In our patient as there was no need for fertility sparing so a radical surgery was done. It was FIGO stage IA. No adjuvant therapy was given. The patients of serous BOT are kept on follow up after surgery. Three monthly for the first two years and biannually for 3-5 years [6].
The serous BOT have a good prognosis. Sherman et al, reported in a population-based analysis that the overall relative survival rate at 10 years was 96.9% ± 2.3% for serous BOTs and survival rate at 10 years for advanced serous BOTs was 89.9% ± 5.3%. However, they are recurrent (11% chances) or may turn malignant (20-30%). The negative prognostic factors are not well defined in any study for serous BOT. Advanced stage, presence of micropapillary variant and pelvic implants, conservative surgery, and use of adjuvant therapy are probable negative prognostic factors for serous BOT [1].
In our patient, it was early FIGO stage IA, no micropapillary variant was present, and no pelvic implants were there on histology. Definitive surgery was done. No adjuvant therapy was given. She is on follow up and has completed two three monthly follow ups and stands disease free as of now.
The serous BOT are rare, good prognostic tumors. However, there are fewer studies for diagnosing them correctly from malignant or benign ovarian tumors. This causes under or over treatment and affects survival negatively. More studies are needed in future for effective diagnosis and thus treatment of serous BOT.
Funding: No funding sources.
Conflict of interest: None declared.
Ethical approval: The study was approved by the Institutional Ethics Committee of Shri Lal Bahadur Shastri Medical College
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