salpingo-oophorectomy was performed. Her postoperative course was uncomplicated. She de- livered a 2200 gm male infant on October 20, 1994 with Apgars ...
Arch Gynecol Obstet (1996) 258: 105-108
Gynecology and Obstetrics
Parovarian borderline malignancy in pregnancy B. A. Fine I, P. T. Valente 1' 2, B. Schroeder 1 1 Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, Division of Gynecologic Oncology, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7836, USA 2 Department of Pathologie, The University of Texas Health Science Center at San Antonio, Division of Gynecologic Oncology, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7836, USA
Abstract. A patient with a recurrent p a r o v a r i a n p a p i l l a r y serous tumors o f low malignant potential d i a g n o s e d during p r e g n a n c y is p r e s e n t e d and the m a n a g e m e n t o f these tumors during p r e g n a n c y is discussed.
Key words: P a r o v a r i a n - L o w m a l i g n a n t potential - P r e g n a n c y Introduction O v a r i a n tumors o f b o r d e r l i n e m a l i g n a n t potential c o m p r i s e 1 5 - 2 0 % o f epithelial ovarian c a r c i n o m a s with a r e p o r t e d i n c i d e n c e o f up to 35% during p r e g n a n c y (Dgani, 1989). T u m o r s of b o r d e r l i n e m a l i g n a n t potential are a s s o c i a t e d with 5 0 - 1 0 0 % 5 - y e a r survival d e p e n d i n g on the stage o f disease. A patient with a recurrent p a p i l l a r y serous p a r o v a r i a n t u m o r o f low m a l i g n a n t potential d i a g n o s e d during p r e g n a n c y is p r e s e n t e d and discussed.
Case report A 25-year-old gravida 3 at 23 weeks gestation had a level II ultrasound performed in August 1994 for an elevated alpha-fetoprotein. An incidental finding at the time of ultrasound was a 4.8 x 5.6 x 5.7 cm complex left adnexal mass. The patient was asymptomatic. Review of the patient's medical history revealed a previous laparoscopy for a parovarian cyst on April 10, 1992. Although the cyst appeared benign, final pathology was that of a papillary serous tumor of low malignant potential. She subsequently underwent a staging procedure with pelvic and abdominal washings and peritoneal biopsies, all of which were negative for disease on June 6, 1992. She was most recently seen in January 1994, seven months prior to the sonogram, and found to be free of disease by exam with a normal CA-125. On August 24, 1994, she underwent an exploratory laparotomy with pelvic and abdominal washings, diaphragm scrapings, biopsy of uterine serosal nodules, omentectomy, left salpingooophorectomy, and initial right ovarian cystectomy. Frozen section of the left ovary and right
Correspondence to: B. A. Fine
B. A, Fine et al.:
Fig. 1. Low magnification shows a parovarian papillary serous tumor of low malignant potential. Note the complex papillary structure and absence of invasion. Arrow indicates smooth muscle of the broad ligament. (H & E, x400)
Fig. 2. High magnification of the ovarian recurrence reveals prominent "tufting" of epithelial cells characteristic of serous borderline tumors. (H & E, xl000)
Parovarian borderline malignancy
ovarian cyst demonstrated papillary serous tumors of low malignant potential. Therefore, a right salpingo-oophorectomy was performed. Her postoperative course was uncomplicated. She delivered a 2200 gm male infant on October 20, 1994 with Apgars 81 and 95. The infant is doing well and the patient remains without evidence of disease on exam and her most recent CA-125 in September 1995 was 18 u/ml. The parovarian cyst removed 2 years and 4 months previously had measured 2.0 x 1.5 x 1.5 cm and was lined with minute papillary excrescences. Microscopically, the papillary configuration and epithelial stratification were characteristic of a serous tumor of low malignant potential (Fig. 1). The right and left ovarian cysts resected subsequently measured approximately 5 cm and 8 cm in diameter, respectively. They were lined by similar papillary tumor diagnostic of serous tumor of low malignant potential. Epithelial stratification, tufting, and nuclear atypism were prominent (Fig. 2).
Discussion Ovarian tumors infrequently complicate pregnancy; however, their diagnosis and management can be challenging. The reported incidence of surgical exploration for an adnexal mass in pregnancy approximates 0.1% and less than 5% of ovarian tumors complicating pregnancy are malignant. The literature indicates that up to 35 % of malignant ovarian tumors may be of borderline malignancy (Dgani, 1989). These tumors comprise 15-20% of all epithelial ovarian tumors. The importance of a correct histologic diagnosis becomes paramount when the survival of borderline tumors is compared to invasive epithelial ovarian tumors. Five-year survival rates of 90-100% for stage I and II borderline malignancies and 50-60% for advanced stage borderline malignancies are reported in contrast to 60-90% and 15-20%, respectively, for the invasive counterpart. Clinically, the patient with a borderline malignancy has a younger average age at diagnosis than a patient with an invasive tumor. Also characteristic of patients with carcinomas of low malignant potential is that of an indolent course accounting for the improved survival compared to invasive disease even in advanced stages. The impact of any ovarian tumor on a pregnancy, regardless of histology, can be detrimental. Torsion, rupture of the cyst, infection, and obstruction of labor are well recognized potential complications. It is generally accepted that operative intervention be the optimal method of treatment. Timing of the surgical procedure has been a controversial issue. However, the early second trimester provides minimal mechanical barriers secondary to uterine enlargement and, at this time, the corpus luteum is no longer essential to maintain the pregnancy. This patient presents with a bilateral ovarian recurrence of a parovarian borderline malignancy. Only a few cases of a parovarian primary borderline malignancy have been reported (Seltzer, 1988). Parovarian cysts may be of mesothelial, paramesonephric, or mesonephric origin. They are found in the mesosalpinx, between the fallopian tube and the ovarian hilum. Malignant parovarian tumors are extremely rare. The appropriate surgical management of the patient presented is less well defined. Recommendations for surgical staging of ovarian carcinomas of low malignant potential have not taken into account the gravid patient and her desire to continue the pregnancy. The standard surgical procedure for a non-gravid patient who does not desire future fertility would consist of a complete staging laparotomy with a total abdominal hysterectomy and bilateral salpingo-oophorectomy. For patients with a Stage IA lesion, desiring to preserve fertility, uterine and contralateral ovar-
B.A. Fine et al.:
ian retention is an option. The patient desired to continue the pregnancy and the staging procedure performed demonstrated no evidence of metastatic disease. Nodal dissection was not performed and the uterus remained in situ. In contrast to this conservative management following a recurrence, in the nongravid patient, many oncologists advocate completion of the staging procedure and a total abdominal hysterectomy. The significance of surgical staging is evident upon review of the findings of Yazigi et al. (1988). Twenty-four percent of patients with presumed stage I or stage II disease were upstaged to stage III as a result of the staging procedures, and 33% of those patients whose staging procedure included a lymph node dissection had positive lymph nodes. Previously, it was felt that patients with invasive implants did poorly compared to those with benign or borderline peritoneal disease. However, Gershenson and Silva (1990) found no difference in survival of patients with invasive and noninvasive implants. They concluded that the discrepancy between their findings and those of prior studies may have resulted from postoperative therapy and that randomized studies were needed to resolve this issue. Regardless of the extent of the surgical procedure performed, close follow-up is needed to ensure early detection of a late recurrence. As always, wishes of the patient are of paramount importance.
References 1. Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M (1989) Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984. Gynecol Oncol 33:326-331 2. Gershenson DM, Silva EG (1990) Serous ovarian tumors of low malignant potential with peritoneal implants. Cancer 65:578-585 3. Seltzer VL, Molho I, Fougner A, Hong P, Kereszti B, Gero M, and Spitzer M (1988) Parovarian Cystadenocarcinoma of Low-Malignant Potential. Gynecol Oncol 30:216-221 4. Yazigi R, Sandstad J, Munoz AK (1988) Primary staging in ovarian tumors of low malignant potential. Gynecol Oncol 31:402-408