What is the management of incidental low-grade serous carcinoma (LGSC) of the ovary after oophorectomy for torsion with surgical spill?

Management of Incidental Low-Grade Serous Carcinoma of the Ovary Post Oophorectomy with Surgical Spill

Peritoneal restaging surgery is mandatory for incidental low-grade serous carcinoma of the ovary following oophorectomy with surgical spill, even if it does not alter the indication for adjuvant chemotherapy. 1

Surgical Management

Initial Assessment

• The surgical spill during oophorectomy for torsion has upstaged this case to at least IC2, which significantly impacts management decisions
• Low-grade serous carcinoma (LGSC) has distinct clinical behavior compared to high-grade serous carcinoma, with generally lower chemosensitivity 1, 2

Recommended Surgical Approach

1. Complete peritoneal restaging surgery including:

   • Total hysterectomy and contralateral salpingo-oophorectomy (unless fertility preservation is desired)
   • Omentectomy
   • Peritoneal biopsies from pelvis, paracolic gutters, and diaphragm
   • Aspiration of peritoneal fluid or peritoneal lavage for cytology 1

2. Lymph node assessment:

   • Systematic pelvic and para-aortic lymph node dissection up to the left renal vessel origin 1
   • However, lymph node dissection may be avoided if nodal status would not alter management 1

3. Special considerations:

   • For young patients desiring fertility preservation, unilateral salpingo-oophorectomy with complete staging may be considered only in fully staged FIGO stage I disease 1
   • However, with surgical spill having occurred, this case is already beyond stage IA, limiting fertility-sparing options

Systemic Therapy

Adjuvant Chemotherapy

• For low-grade serous carcinoma stage IB/IC (which applies in this case due to surgical spill):

  • Adjuvant chemotherapy is recommended but can be considered optional in fully staged patients 1
  • When administered, acceptable regimens include:
    • Carboplatin alone (6 cycles) OR
    • Carboplatin/paclitaxel (minimum 3 cycles) 1

• Important caveat: LGSC is relatively chemoresistant compared to high-grade serous carcinoma, with lower response rates to standard platinum-based regimens 2, 3

Hormonal Therapy

• Most LGSC expresses estrogen receptors (96% in some studies) 4
• Consider hormonal maintenance therapy following adjuvant chemotherapy, particularly in cases with residual disease 2
• Options include letrozole, anastrozole, or tamoxifen 5, 4
• Some studies suggest promising outcomes with primary cytoreductive surgery followed by hormonal monotherapy without chemotherapy 4

Prognostic Factors and Follow-up

Key Prognostic Factors

• Residual disease status after surgery is the most important prognostic factor 6
• Complete cytoreduction to no visible residual disease significantly improves survival 3, 6
• Other factors affecting prognosis include:
  • Age at diagnosis
  • Hormonal receptor expression
  • Ki-67 proliferation index 3

Follow-up Recommendations

• Regular clinical assessment with tumor marker monitoring
• Imaging surveillance with CT or MRI as clinically indicated
• Long-term follow-up is essential due to the indolent but persistent nature of LGSC 3, 7

Important Caveats

1. Surgical spill significance: The surgical spill that occurred during oophorectomy for torsion has important staging and treatment implications, automatically classifying this as at least stage IC2 1

2. Histopathological confirmation: Ensure expert gynecologic pathology review to confirm LGSC diagnosis, as treatment differs significantly from high-grade serous carcinoma 1, 3

3. Chemotherapy limitations: Despite being standard of care, platinum-based chemotherapy has limited efficacy in LGSC compared to high-grade serous carcinoma 2, 3

4. Surgical expertise: Complete cytoreduction should be performed by experienced gynecologic oncologists to maximize the chance of achieving no residual disease 6

5. Emerging therapies: Consider clinical trials investigating targeted therapies (particularly MEK inhibitors) or immunotherapy for LGSC, as these represent promising approaches for this specific histologic subtype 2, 3