COMMENTARY

Fertility-Preserving Surgery in Borderline Ovarian Tumors

Peter Kovacs, MD, PhD

Disclosures

February 13, 2018

Fertility Preservation in Cancer

Cancer treatment has changed significantly over the past decades. Surgery became less definitive, and new chemotherapeutic regimens and radiation therapy became more focused and less damaging for noninvolved organs. These changes have been paralleled with improved survival.[1]

Certain cancers are associated with young age, and cancers that are otherwise more common among older patients can also be detected in young people. Patients who have not started or completed childbearing not only have to face a diagnosis of cancer but have to consider remaining childless as a result of disease or its treatment.

Fertility preservation through assisted reproduction has undergone significant improvements. Oocyte, embryo, and ovarian tissue cryopreservation can be considered for most patients.[2] In addition to the tools of assisted reproductive technology, increasing evidence suggests that fertility-sparing surgery is safe for many patients affected by cancer.

Impact of Fertility-Sparing Surgery

A recent cohort study[3] evaluated the effect of fertility-sparing surgery in women with borderline ovarian tumors. Data were analyzed on 213 women with borderline ovarian tumors who were followed for a mean of 75 months. A majority (81%) of the cases involved stage I disease, 4% involved stage II, and 15% involved stage III. The tumor type of 140 patients was serous, and 69 had mucinous borderline ovarian tumors. The mean age of the women was 38.7 years, and 62% were under the age of 40 years at the time of diagnosis.

Fertility-sparing surgery was performed on 112 patients. Almost half of these patients had conservative surgery (cystectomy, partial oophorectomy) on the ovary that contained the tumor. Of 50 patients (24%) who were diagnosed with recurrences, 40 had undergone conservative surgery, and 10 had undergone radical surgery. Multivariate analysis found fertility-sparing surgery to be associated with recurrence (hazard ratio, 2.57; 95% confidence interval, 2.3-7.6).

Twenty women in the entire cohort died during follow-up; in 11 cases, the cause of death was related to the ovarian tumor. Six of 11 women who died of ovarian tumor had undergone conservative surgery. Fertility preservation was not associated with mortality. A total of 67 pregnancies were documented in 42 women.

Viewpoint

Borderline ovarian tumors are characterized by atypical cellular proliferation without stromal invasion. They are rare tumors and are detected at a younger age compared with invasive ovarian cancer. Most of these tumors are confined to the ovary and, in general, are associated with good prognosis. The stage of disease and histologic subtypes are key prognostic factors.[4]

Because borderline ovarian tumors are diagnosed in younger women, future health related to ovarian hormones as well the patient's reproductive needs have to be considered when treatment is discussed. Due to the generally good prognosis of these cases, conservative surgery during which the uterus and/or ovary(ies) are spared can be considered.[1,4]

This study has found that advanced stage at diagnosis and conservative surgery were associated with recurrence. Survival, however, was not influenced by fertility-sparing surgery. The subsequent chance to conceive is likely to be variable and depends on the patient's age, ovarian reserve, tubal status, and other pathologies. This study adds to our current knowledge and supports the use of conservative surgery for women with borderline ovarian tumors who wish to maintain fertility.

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