Latest data on fertility-sparing surgery

This study was published in December 2016 and is available online (open access).

It’s the first prospective cohort of women who, after a BOT diagnosis, initially underwent fertility-sparing surgery (FFS). All participants (34 women) experienced recurrence.  

They received high quality follow up – including 2 experienced ultrasound examiners, with 15 years of experience in gynecological oncology ultrasound —> this is important: each woman had TWO EXPERIENCED sonographers examine her at each follow-up visit.

The study offers important insights into how to support women who wish to preserve their fertility, without increasing their risk of disease.  

All women eventually underwent completion surgery.

Key findings from this study (of 34 women):

• The women who participated had undergone fertility-sparing (conservative) surgery at time of diagnosis [NB: this isn’t always an option – the criteria for being eligible for FSS are listed below]

• These women had a suspicious recurrent lesion at follow-up transvaginal ultrasound examination, with no indication for immediate surgical treatment

• All were followed up for at least 3 months before undergoing surgery

• Importantly:  all examinations were performed by 2 experienced ultrasound examiners, with 15 years of experience in gynecological oncology ultrasound.  This is critical and really important to note: these women had top-notch sonographers and TWO of them.  We don’t all have access to this and the authors of the study make it very clear that this is critical  

• FSS with thorough ultrasonographic follow-up – i.e. transvaginal ultrasonographic examination every 3 months, conducted by expert sonographers – is safe and feasible FOR SOME WOMEN

• ALL WOMEN did then undergo completion surgery

• The data suggests that the rate of growth of new cysts is a key predictor for how long further surgery can be delayed: this is where your expert, experienced sonographers come in

• Important to note: this is a small study – small number of women AND a short follow-up period AND with access to high-quality sonography: more research needed with longer follow-up to be able to comment on the longer term prognosis

All women initially underwent fertility-sparing surgery (FSS); what exactly is FSS?

Fertility-sparing surgery
(FSS) is defined as the preservation of
the uterus and of at least part of 1 ovary
with a complete staging procedure. 

Although this strategy has proven to be
safe and feasible,recurrences have been
described in 5-56% of cases.

Hence, a
close follow-up based on scheduled
pelvic ultrasounds is mandatory for
early identification of any relapse after
FSS.

How long before they needed further surgery?

• The women were followed up by TV ultrasound for a median time of 9.8 months before further surgery
• Some women in the study needed further surgery as early as 3 months after initial surgery, some as late as 54 months.  But 9.8 months was the median.

Who were these women?

They were young patients who wanted to preserve their fertility but had no immediate pregnancy
plan.  They also had to meet the following criteria:

• no evidence of metastasis
• no
  ascites
• maximum diameter of the
  suspected recurrent lesion <40 mm
• presence of healthy ovarian tissue adjacent
  to the tumor (namely “ovarian
  crescent sign”)
• negative tumor
  marker (CA125, CA19.9). 

What happened when they experienced a recurrence?

In case of recurrence, patients were offered a further FSS
if the following criteria were met: 

• desire of pregnancy
• patient’s request
  due to subjective anxiety
• tumor
  markers above the upper normal limit
• rapidly increased growth rate of the cyst
  defined as doubling of tumor dimension
  in 3 months
• cyst size 40 mm. 

Did they undergo completion surgery?

Yes.  Surgery (”completion” surgery) was performed on all the women who participated in the study due to any of the following:

• patients’ choice OR
• no more
  pregnancy desire due to age OR
• no more
  evidence of disease-free ovarian tissue OR
• presence of ascites OR
• detection of
  peritoneal implants

Who were the women in the study?

All patients
were premenopausal and age <40
years except 1. 

Median time from primary
diagnosis to diagnosis of suspicious
BOT recurrence was 34.1 months. 

The
primary tumor was serous BOT in 32
(94.1%) patients and mucinous endocervical
type in 2 (5.8%) patients. 

At the diagnosis of the primary tumor,
23 (67.6%) patients were FIGO stage II
and III, with invasive implants in 4
(11.8%) cases (Table 1). 

In 14 (41.2%)
patients micropapillarity pattern was
described at initial pathology. 

Of these 34 patients, 16 underwent
cystectomy at first surgery therefore
preserving both ovaries, whereas 16 had
a monolateral salpingo-oophorectomy
and 2 a monolateral salpingooophorectomy
with contralateral excision
of a borderline cyst. 

Recurrences were almost all monolateral
(71.8%). Namely, recurrence was
detected on the same ovary already treated by conservative surgery at the
first diagnosis in 8 (20.5%) patients, on
the contralateral ovary in 20 (51.2%)
patients, and bilaterally in 11 (28.2%)
patients.