Recurrence characteristics and clinicopathological results of borderline ovarian tumors - BMC Women's Health - BMC Blogs Network

BOTS are tumors with low malignancy potential. It has been proven that although they have a good prognosis, they also have a notable recurrence rate. In this study, 286 patients with BOTs were followed up for 10–109 months, and pathology revealed that BOTs recurred in 40 patients, which gives a recurrence rate of 13.9%. Qian Zhang et al. [7] reported a lower recurrence rate of 9.2% but the recurrence rate in this study is consistent with other research. BOTs are mostly found in women of childbearing age and often only found during a physical examination due to the absence of clinical symptoms in the early stages. The present study revealed that the median age of the onset of BOTs was 42.06 ± 14.97 years. Asymptomatic pelvic masses were found in 62.9% of the asymptomatic patients through physical examination, while abnormal uterine bleeding, urinary frequency, and urgent urination occurred in only 7.1% and 3.6% of patients. The number of patients who experienced pain in the lower abdomen and abdominal distension and discomfort was slightly higher. However, these symptoms are not characteristic symptoms of BOTs, so they are easily overlooked. Annual physical examinations are clearly important.

The treatment of BOTs is based on the National Comprehensive Cancer Network (NCCN) guidelines, and gives thorough consideration to the characteristics of the disease, as well as the patient's age and her desire to remain fertile [8]. There are two possible types of operation. The first is a conservative operation, which retains at least part of the uterus and unilateral ovary. It is suitable for younger patients with reproductive or endocrine requirements. The operation methods include unilateral tumor removal, bilateral tumor removal, unilateral adnexectomy, and unilateral adnexectomy + contralateral focus resection, and comprehensive staging of fertility preservation [9]. The second is a radical operation, which means, at the least, a hysterectomy and bilateral adnexectomy, omentectomy, and peritoneal washings/biopsies, including a comprehensive staging of ovarian cancer [9]. Borderline tumors have a good prognosis and a low recurrence rate, and if they do recur, they mostly remain borderline. That is to say, malignant transformation is rare, but there is still a risk of recurrence, disease progression, and death. Recurrence almost always occurs in the reserved ovary; therefore, the management of BOTs is controversial [10]. The present study has found that the recurrence rate in a conservative operation is higher than that of a radical operation (21.3% vs. 1.8%, P < 0.001), and multivariate analysis results indicate that conservative surgery is an independent risk factor for the recurrence of BOTs. As conservative surgery only removes the areas affected by the tumor, it is easy to ignore the seemingly unaffected parts. If the tumor is potentially cancerous, or cancer has occurred, the tumors are likely to have invaded other parts of the reproductive system [11]. However, for patients with fertility requirements, especially young patients, the radical operation will greatly affect their quality of life. One study revealed that not only does postoperative chemotherapy not necessarily improve patients' prognosis, but it can also lead to complications and increase the mortality rate. Therefore, chemotherapy is generally not recommended [11, 12]. The investigators believe that it is necessary to be cautious about only operating on patients conservatively, and stress that follow-up after the operation is essential, and a radical operation should be considered as early as possible after the birth of a child.

In a previous study, postoperative pathology revealed that the recurrence rate was higher in patients with micropapillary and microinvasion tumors [13], which have been proven to be related to a variety of malignant tumors, ovarian cancer being one of them [14]. One scholar considers that when the composition of a micropapillary tumor is less than 25% or less than 10%, the severity of the lymphatic invasion and lymph node metastasis is also significantly higher than that of patients without micropapillary tumors. Therefore, as long as the tumor has micropapillary components, it should be diagnosed as invasive micropapillary carcinoma [14], and this is why clinicians should pay attention to micropapillary and microinvasion tumors. Calcified psammoma bodies refer to calcified bodies with concentric circles, and calcified psammoma bodies can be detected in serous cystadenocarcinoma and serous mucinous carcinoma of the ovary [15]. Whether calcified psammoma bodies are related to recurrence is still a controversial theory. One study concluded that the formation of calcified sand bodies, which need to be formed under the condition of better cell differentiation, is slow. This indicates that the biological behavior of a tumor that can form calcified psammoma bodies is an improvement. Therefore, calcified psammoma bodies may also be an indicator of good tumor biological behavior [16]. However, the present study has revealed that micropapillary, microinvasion, and calcification of psammoma bodies in patients were related to recurrence. It suggests that short-term and long-term follow-up are extremely important for patients with pathologically confirmed micropapillary, microinvasion, and calcified sand bodies, and especially for those who have undergone conservative surgery. It is recommended that a radical operation should be performed as early as possible for patients who have had a conservative operation and who have completed their reproductive plans.

Almost all recurrences occur in the pelvic cavity, and recurrences outside the ovary are rare. Furthermore, patients with BOTs at the late FIGO stage are prone to experience recurrence. A study revealed that FIGO staging was an independent risk factor for the recurrence of BOTs. The higher the FIGO stage, the greater the potential of tumor recurrence [17]. This is consistent with the results of this study. CA125 is a commonly used clinical marker for monitoring ovarian cancer and is of great significance in diagnosing and treating ovarian cancer. However, it remains controversial whether it is related to the recurrence of borderline tumors [18]. The present study demonstrated that CA125 was related to it. Indeed, further multivariate analysis showed that CA125 is an independent risk factor for the recurrence of BOTs, and the risk of recurrence was significantly higher in patients with elevated CA125. Therefore, the investigators used the CA125 level as a screening and postoperative re-examination monitoring index for patients with BOTs, and paid special attention to patients with elevated CA125 levels.

Despite being more detailed and comprehensive in terms of data than previous studies, there are some limitations to this study. Although the medical records were well preserved, and the case records such as height, weight, menstruation cycle, body mass index, and pathological data were detailed, because this study was retrospective, some data were still unavailable. Second, although the sample size in this study was not small, the larger it is, the more reliable the findings are. Moreover, the samples in this study were collected from two hospitals, and the levels of examination, operation, intraoperative freezing, and postoperative pathological tests of the medical professionals in the different hospitals may have been affected by this to some extent. In addition, the recurrence time of this disease is mostly within 10–20 years, so the short follow-up time of patients may also have influenced the analysis results in this study.

In summary, this disease has an early onset, a good prognosis, and a low recurrence rate, and tumors are mostly borderline after recurrence. Since patients can survive for a long time, it is desirable to retain fertility function. However, because it has a certain recurrence rate, canceration rate, and mortality rate, the investigators recommend that patients with any of the above recurrence risk factors should be followed up for a long time [8]. Patients without follow-up opportunities or patients who have undergone conservative surgery and completed their reproductive plans should consider undergoing radical surgery to avoid any recurrence and the possibility of death.