Balancing Fertility and Oncologic Outcomes: Can We Have Our Cake and Eat It Too?

During the last decade, gynecologic oncologists and pathologists have begun to reconsider which clinical and pathologic factors effect outcomes in patients with borderline tumors of the ovary. These tumors of low malignant potential lack the deep stromal invasion ([ 5m m or [10 mm 2 ) of their invasive carcinoma counterparts. And unlike epithelial carcinomas, which have six different subtypes (serous, endometrioid, mucinous, clear cell, transitional, and undifferentiated), borderline tumors of the ovary are almost exclusively either serous or mucinous. Serous borderline tumors tend to be smaller than their mucinous counterparts and rarely have areas of invasive carcinoma in the same specimen. Furthermore, they seldom recur once removed; however, when they do, they typically return as recurrent borderline histology and rarely undergo malignant transformation into low-grade serous carcinoma. It is exceedingly rare for a serous borderline tumor to recur as a high-grade carcinoma. Mucinous borderline tumors, on the other hand, seem to be a step along the continuum from normal to invasive mucinous carcinoma. Pathologic specimens may have areas of normal ovary, benign mucinous cystadenoma, borderline tumor, and high-grade invasive mucinous carcinoma side by side with one another. Because these neoplasms often can be [10 cm in size at surgical resection, making frozen section exclusion of invasive carcinoma difficult, most gynecologic oncologists perform a modified staging procedure, which includes appendectomy for all mucinous neoplasms (benign or borderline) in the event that final pathology returns an invasive carcinoma. In this month’s issue of Annals of Surgical Oncology, Koskas and colleagues 1 report their single institution experience with mucinous borderline tumors of the ovary. This study reviewed a large cohort of 97 patients seen during a 7-year period from 1997‐2004. The authors found that 9% of patients recurred as invasive carcinoma within 5 years of initial therapy. At 10 years follow-up, that number had increased to 13%. This important finding of malignant transformation is significantly higher than what has been reported in the literature to date. Many of these patients had undergone only an ovarian cystectomy in an effort to preserve fertility. The authors challenge the traditional philosophy that borderline tumors of the ovary are relatively benign and that even when they do recur they tend to be indolent with minimal effect on mortality. In addition, they suggest that cystectomy is likely insufficient treatment of borderline tumors and recommend at least complete oophorectomy. Although retrospective in nature, this study has many strengths. Most importantly, all pathologic specimens were reviewed at their institution. Because 80% of mucinous tumors of the ovary are extraovarian in origin, it is imperative that these specimens are centrally