Management of Borderline Serous Cystadenoma of the Left Ovary
For a borderline serous cystadenoma of the left ovary, perform surgical removal followed by observation without adjuvant chemotherapy, as these tumors have an excellent prognosis with over 80% five-year survival and do not benefit from postoperative therapy. 1
Initial Surgical Management
The surgical approach depends critically on the patient's age and fertility desires:
For Young Patients Desiring Fertility Preservation
Unilateral salpingo-oophorectomy (USO) of the left ovary is the recommended approach, preserving the uterus and right ovary for stage IA borderline tumors. 2 This fertility-sparing surgery is feasible and appropriate for select unilateral stage I tumors 2.
- Cystectomy alone (removing only the cyst while preserving the ovary) is acceptable but carries an 8-10% ipsilateral recurrence risk 1, 3, compared to approximately 6% recurrence with USO 4
- Despite higher recurrence rates, cystectomy remains a satisfactory option when it is the only way to preserve any ovarian tissue, particularly for bilateral disease or disease in a solitary ovary 2, 4
- The risk of invasive recurrence after fertility-sparing surgery is very low at only 0.5% 1
- Pregnancy rates are excellent with both approaches: 89.2% with USO and 85.7% with cystectomy 4
Surgical Staging Components
Comprehensive staging should include peritoneal washings, infracolic omentectomy, and multiple peritoneal biopsies 5, though the NCCN notes that comprehensive staging may not be necessary for select patients with borderline epithelial tumors 2.
Important caveat: Routine lymphadenectomy is NOT recommended for borderline tumors 6. Only remove suspicious or enlarged lymph nodes 2.
For Patients Not Desiring Fertility or Advanced Stage
Perform total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and complete resection of any macroscopic peritoneal lesions 5.
Post-Surgical Management
Observation is Standard
No adjuvant chemotherapy is recommended for borderline ovarian tumors, as they follow a clinically indolent course with good prognosis 1. The only exception where postoperative therapy may be considered is for serous borderline tumors with invasive peritoneal implants 6, though even this remains controversial with no proven benefit 1.
Surveillance Protocol
Long-term surveillance extending beyond 5 years is essential, as 70% of recurrences occur after 5 years and 30% after 10 years 1.
- Monitor CA-125 levels if they were elevated at diagnosis 1
- Regular imaging surveillance, particularly since recurrences are often detected by systematic ultrasonography 7
- Closer monitoring is required if invasive peritoneal implants were present 1
Management of Recurrence
Surgical re-excision is the treatment of choice for recurrent disease 1, 7.
- Less than 5% of borderline tumor recurrences progress to invasive cancer 1
- Most recurrences remain borderline in nature rather than becoming invasive carcinomas 1
- Fertility-sparing surgery can be repeated for recurrences in young patients who still desire pregnancy, provided the recurrence is non-invasive 7
- All patients with recurrences can be successfully treated with additional surgery 1
Critical Pitfalls to Avoid
Frozen section examination has lower-than-optimal accuracy for borderline tumors 6, so definitive surgical decisions should await final pathology when possible.
Involvement of the resection margin during cystectomy and removal of multiple cysts from one ovary are almost always associated with persistence or recurrence 3. If cystectomy is performed, ensure clear margins.
Incomplete staging increases recurrence risk 1, so ensure proper exploration of the abdominal cavity even when comprehensive lymphadenectomy is not needed.
A gynecologic oncologist should perform the primary surgery, as this is associated with improved outcomes (category 1 recommendation) 2.