Fertility-sparing surgery for advanced serous primitive peritoneal borderline tumor. A safe and effective approach ? A case report and review of literature
Justine Pinckers, MD1, Katty Delbecque, MD2, Frédéric Kridelka MD&PhD1, Frédéric Goffin MD&PhD1*
1epartment of Obstetrics and Gynecology, CHU de Liège, University of Liège, avenue de l'hôpital 1, 4000 Liège, Belgium
2Department of Pathology, CHU de Liège, University of Liège, avenue de l'hôpital 1, 4000 Liège, Belgium
Frédéric Goffin, MD and PhD, Department of Obstetrics and Gynecology, CHU de Liège, University of
Liège, avenue de l'hôpital 1, 4000 Liège, Belgium
Figure 1: Photographs of diagnostic laparoscopy. (A) Peritoneal implants on left ovary (a), left hemi-uterus (b), right hemi-uterus (c), right ovary (d), sigmoid (e). (B) Peritoneal implants in the Douglas pouch (white arrow). (C) Peritoneal implants on the bladder (red arrow). (D) Implants on the right uterosacral ligament (black arrow).
Figure 2: Histopathological features of serous borderline ovarian tumours. A and B. Peritoneal non-invasive epithelial implant of serous borderline tumor. Mild cytologic atypia with clefting and micropapillary architecture (hematoxylin-eosin, original magnification, x200)
The patient strongly wanted to maintain her fertility. After multidisciplinary oncologic concertation, and after obtaining a second opinion from an international expert team, we proposed to proceed with cytoreductive surgery and preservation of fertility. Informed consent was obtained from the patient and her family concerning the increased risk of recurrence, and the lack of information concerning the fertility outcomes in such circumstances.
The surgery was performed by midline laparotomy. Given the multifocal locations of the peritoneal implants, large pelvic peritonectomy was performed with the conservation of the uterus, the ovaries and the Fallopian tubes. The surgery was completed by abdominal staging, including omentectomy, abdominal peritoneum resections (colic gutters, right diaphragm) and lymph node biopsies (resection limited to enlarged nodes in the pelvis and para-aortic areas). The cytoreduction was complete, without any macroscopic residual disease (R0). The surgery and the post-operative period proceed without complications. The definitive pathologic examination described the presence of non- invasive serous borderline implants on the pelvic peritoneum, the parieto-colic gutter peritoneum and the omentum. Nodes were negative. According to the FIGO classification, a stage IIIA2 was allocated. After multidisciplinary discussion, no adjuvant treatment was proposed but a closed gynecological follow-up was highly recommended. She was advised to proceed with her fertility wishes. She gets pregnant three times, spontaneously. She gave birth to healthy babies. The remission was documented after per-cesarean exploratory laparotomy for her first baby, two years after cytoreduction. Diagnostic biopsies showed a deciduose and no signs of recurrence. After almost 7 years of close follow up, the patient remains tumor-free according to radiological work-up and CA-125 monitoring.
Table 1: Published studies about oncological outcomes and fertility rates after fertility sparing surgery of stage II-III sBOT.
sBOT, serous Borderline ovarian tumor ; IOC, Invasive ovarian cancer ; inv impl, invasive implants ; DOD, Died of disease ; DID, died of intercurrent disease ; NR, not reported ; UIRS, Uni-institutional retrospective study ; MIRS, Multi-institutional retrospective study.
* invasive relapse including invasive ovarian cancer, invasive implants, others (lymph node invasion, ...).