■ ORIGINAL ARTICLE ■

MANAGEMENT OF OVARIAN BORDERLINE MALIGNANCY

Hung-Yaw Chang*, Hao Lin, Chan-Chao Changchien, Shiuh-Young Chang

Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

SUMMARY
Objective: Ovarian tumors of borderline malignancy are not as aggressive as, and tend to occur in younger
patients than, their invasive counterparts. We retrospectively reviewed our experience to assess the safety of
conservative management of patients with limited disease.
Materials and Methods: The clinical and pathologic records of 57 patients with ovarian borderline malignant
tumors from 1988 to 1998 were identified from the database of the Chang Gung Memorial Hospital, Taiwan.
The International Federation of Gynecology and Obstetrics staging was retrospectively assigned, follow-up
information was obtained, and clinicopathologic correlations were made.
Results: Forty-three of the 57 patients (75.4%) were at stage Ia, six (10.5%) were at stage Ib, seven (12.3%)
were at stage Ic, and only one (1.8%) was at stage IIIc. Forty-three patients (75.4%) had mucinous cystadenoma
of borderline malignancy, while 14 (24.6%) had the serous type. Twenty-eight patients (49.1%) underwent
total abdominal hysterectomy and bilateral salpingo-oophorectomy or bilateral oophorectomy. Twenty-four
patients (42.1%) were treated with unilateral oophorectomy or unilateral salpingo-oophorectomy. Two patients
(3.5%) underwent debulking surgery. Five patients (8.8%) underwent enucleation of the ovarian tumor. Five
patients (8.8%) received chemotherapy after surgery. The median follow-up period was 44 months, and no
recurrence was found.
Conclusions: Conservative procedures appear to be warranted in young patients with clinically localized disease,
which might preserve fertility and decrease surgical morbidity. [Taiwanese J Obstet Gynecol 2004;43(1):16–19]

Key Words: conservative treatment, ovarian borderline malignancy, ovarian cancer

Introduction longer survival. In addition, the mean age of occurrence

Ovarian tumors of borderline malignancy (low malignant
potential) constitute approximately 10–15% of ovarian
carcinomas [1]. The majority of borderline ovarian
tumors are of the serous or mucinous histologic type.
Compared with frankly invasive ovarian tumors,
borderline ovarian tumors behave more indolently and
are characterized by an earlier stage at presentation and
*Correspondence to: Dr. Hung-Yaw Chang, Department of Obste-
trics and Gynecology, Chang Gung Memorial Hospital, 123
Ta-Pei Road, Niaosung, Kaohsiung, Taiwan.
E-mail: chy22@adm.cgmh.org.tw
Received: February 25, 2003
Revised: July 18, 2003
Accepted: October 2, 2003
of borderline tumors is nearly 10 years younger than
that of invasive tumors [2]. In view of their biologically
less aggressive behavior or low malignant potential,
conservative treatments have been attempted recently
in order to preserve fertility and avoid morbidity [3,4].
According to a survey of the Society of Gynecologic
Oncologists (SGO), 97% of respondents advocated
surgical staging as surgical management for borderline
ovarian tumors [5]. Diversity exists in the surgical
management of borderline ovarian tumors between
conservative treatment and complete surgical staging.
In an effort to provide more information about the
appropriateness of conservative surgical management
in early ovarian borderline malignancies, we conducted
a retrospective, 10-year review of patients with borderline
tumors to study the clinical characteristics of patients
and their outcomes.

16 Taiwanese J Obstet Gynecol • March 2004 • Vol 43 • No 1


Materials and Methods
Fifty-seven patients with a diagnosis of borderline ovarian
tumor who were seen at Chang Gung Memorial Hospital,
Taiwan, from 1988 to 1998, were identified using the
database of the institution and that of the Department
of Pathology. Detailed information regarding patient
age, blood type, initial symptoms, serum level of tumor
markers, treatment, and follow-up were extracted from
the medical records. The diagnosis of borderline tumors
of the ovary was defined by published histologic criteria
[6,7]. Based on the surgical notes and pathologic reports,
tumor stage was defined using International Federation
of Gynecology and Obstetrics criteria [8].
Results
Patient characteristics
The age at presentation ranged from 17 to 80 years,
with 70.2% of patients being premenopausal. The mean
age was similar in the serous (43.6 years) and mucinous
groups (43.7 years). Patients had a mean age at
menarche of 14.6 years (range, 12–18 years). The mean
number of gestations was 3.12 (range, 0–10), and 15
(26.3%) patients were nulligravida.
All 57 patients had undergone pelvic surgery, and no
diagnosis of borderline tumor had been made before
the operation. The mean and median follow-up times
were 44.9 and 44.0 months, respectively.
Presenting symptoms
Low abdominal pain and a palpable pelvic mass led the
presenting symptoms in 41 patients (71.9%). Three pa-
tients (5.3%) presented with dysmenorrhea, six (10.5%)
with abdominal distension due to ascites or tumor
mass, and three (5.3%) with postmenopausal bleeding
for 1 to 4 months. Two patients (3.5%) came for help
due to primary infertility, and one patient (1.8%) was
diagnosed during pregnancy.
Surgical treatment
All 57 patients had their primary surgery without grossly
detected residual disease. The types of primary surgical
procedures are shown in Table 1. Peritoneal washings
were performed in 12 patients: only two had atypical
cells, while the other 10 were negative for malignant
cells. Nine patients underwent omentectomy and all
were negative for tumors. Pelvic and para-aortic lymph
nodes were sampled in two patients, none of which
showed tumor invasion. Most patients did not receive
complete staging work-up when the tumor was confined
to the ovaries, and palpation of the pelvic lymph node
and omentum was negative.
Taiwanese J Obstet Gynecol • March 2004 • Vol 43 • No 1
Management of Ovarian Borderline Malignancy
Histopathologic type
All 57 patients had either serous or mucinous borderline
tumors of the ovary. Forty-three of the 57 patients
(75.4%) had mucinous borderline ovarian tumors and
14 (24.6%) had serous borderline tumors. In seven
patients, the tumors, which ruptured during surgery,
were staged Ic. Six patients’ bilateral ovarian borderline
tumors (three mucinous and three serous) were staged
Ib. One patient had extra-ovarian disease with omental
metastasis, staged IIIc.
Fifty-three of the 57 patients had frozen sections
taken. Diagnoses of borderline tumors by frozen and
permanent pathology were consistent in 77.3% of cases.
Twelve patients were under-diagnosed to have benign
lesions by frozen section.
The mean overall diameter was 17.2 cm (range, 3–
50 cm) for serous and 18.8 cm for mucinous tumors.
CA-125 values
Preoperative CA-125 values were available in 42 of
57 patients. CA-125 values were more than 35 IU/mL
in 50% of mucinous tumors (mean, 88.0 IU/mL) as
opposed to 75% of serous tumors (mean, 95.4 IU/mL).
Adjuvant therapy
Five of the 57 patients received adjuvant systemic
chemotherapy using a regimen of cisplatin, adriamycin
and cyclophosphamide for 3 to 5 cycles. We performed
physical examination, serum CA-125 test, and pelvic
ultrasound examination during follow-up, but found
no recurrence in any of the 57 patients.
Discussion
Borderline tumors of the ovary tend to occur at a
younger age than their invasive counterparts [9]. In the
current study, the mean age at diagnosis was 43.7 years,
with 70.2% of patients presenting prior to menopause,
and 42.1% of patients presenting prior to the age of 40
Table 1. Primary surgical procedures for ovarian
borderline tumors
Stage
Ia Ib Ic IIIc
Cystectomy 15 0 0 0
Unilateral oophorectomy 21 0 3 0
Bilateral oophorectomy 11 1 0 0
Abdominal total hysterectomy +
bilateral oophorectomy 16 5 4 1
(+ staging procedures)
17
H.Y. Chang, et al
years. The mean age at diagnosis is less than in some
other series [10,11], with no difference in the age of
patients with mucinous or serous types of tumors.
Unlike previous studies [7,10,12], mucinous borderline
tumors (75.4%) were more common than serous
borderline tumors (24.6%) in our study. This may have
been due to the early stage of the tumors in our series,
as serous borderline tumors are more often found in
advanced disease [7,10,12].
CA-125 was elevated in 57% (24/42) of patients.
Preoperatively, serous tumors of borderline malignancy
were associated with elevated CA-125 levels in 75% of
patients compared with 50% of patients with mucinous
tumors. A previous study also found that a higher
proportion of serous tumors was associated with
elevated CA-125 (75% serous, 30% mucinous) [13].
Primary surgical treatment of borderline tumors
follows the guidelines for invasive carcinomas, and
includes total abdominal hysterectomy, bilateral
salpingo-oophorectomy, omentectomy, and peritoneal
washing. In advanced stages, tumor debulking is per-
formed, but lymph node sampling has not been part of
the standard procedure. In young fertile women with
early stage tumors, limited surgery with fertility pre-
servation has been performed. The surgical approach
now tends to be less aggressive for early stage tumors.
Borderline ovarian tumors behave more indolently
than frankly invasive ovarian tumors. Patients with
borderline tumors are characterized by a younger age at
diagnosis, an earlier stage at presentation, and longer
survival [14–16]. In recent times, less radical surgery has
been used more often in limited disease of borderline
tumors not only because of the desire to preserve fertility,
but also for the lower morbidity that can be achieved
without radical operation and staging. In this series, no
recurrence was found with or without radical operation
and staging. Recurrence was reported in 10–15% of
early stage borderline ovarian tumors in a previous
study [17,22]. However, a low recurrence rate (2.5%)
for stage I borderline ovarian tumors has been reported
in another series [16]. Late recurrence may occur, but
the interval between initial treatment and recurrence
was 6 to 36 months in one series [19].
According to a survey among members of the SGO,
97% of respondents advocated surgical staging [5]. In
our study, complete staging procedures were performed
in two patients, 12 patients had washings, nine had
omentectomy, and two had pelvic para-aortic lymph
node sampling. All of the previous staging surveys re-
vealed negative findings. None of the other patients had
staging work-up except for complete tumor excision.
Survival and recurrence did not differ between those
patients who underwent conservative treatment and
18
Table 2. Incidence of recurrence after conservative
and aggressive treatment and staging procedures
Case Number Recurrence
Conservative treatment* 29 0
Aggressive treatment† and
staging procedures‡ 28 0
*Conservative treatment included cystectomy and unilateral oophorectomy
with or without salpingectomy; †aggressive treatment included total abdominal
hysterectomy and bilateral oophorectomy with or without salpingectomy;
‡
staging procedures included omentectomy, pelvic or para-aortic lymph node
sampling, and peritoneal biospy.
those who underwent radical surgery and staging pro-
cedures (Table 2). Thus, our experience may indicate
that complete surgical staging with radical procedures
may not be necessary in patients with limited borderline
ovarian tumors without palpable pelvic lymph nodes or
omental tumors. The prognosis for patients with
borderline ovarian tumors without nodal involvement is
excellent. Routine lymphadenectomy should not be
performed in patients with early stage disease [20,21].
However, the follow-up period in our study is not long
enough, and a longer duration of follow-up would be
required to make such a conclusion.
The management of borderline ovarian tumors is
still evolving. The main suggestion for patients with
borderline tumors is that they should not be managed
with an overly aggressive approach [23]. Continued ad-
vances in the application of molecular genetic analysis
may help to identify tumors which are likely to contain
areas of malignant transformation from those likely
to have aggressive behavior. Individualized treatment
based on these analyses can minimize over-treatment of
these diseases [24].
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