What is the appropriate work‑up, surgical staging, adjuvant therapy, and follow‑up for a borderline ovarian tumor in a 35‑year‑old woman who wishes to preserve fertility?

Management of Borderline Ovarian Tumor in a 35-Year-Old Woman Desiring Fertility Preservation

For a 35-year-old woman with a borderline ovarian tumor who wishes to preserve fertility, perform unilateral salpingo-oophorectomy with resection of all visible disease, followed by observation without adjuvant chemotherapy if no invasive implants are present. 1

Initial Surgical Approach

Fertility-sparing surgery is the cornerstone of management for young women with borderline ovarian tumors. 1

• Perform unilateral salpingo-oophorectomy (USO) preserving the uterus, contralateral ovary, and contralateral fallopian tube with resection of all residual disease 1
• Obtain peritoneal washings for cytologic examination 1
• Perform peritoneal biopsies of any suspicious lesions to identify invasive versus non-invasive implants 2
• Omentectomy and lymphadenectomy do not improve survival and are not routinely recommended, though lymph node evaluation may be considered case-by-case 1
• The NCCN deleted comprehensive surgical staging as a routine recommendation in 2016 because data show no survival benefit, although upstaging can occur 1

Critical surgical principle: All visible disease must be resected during the initial procedure 1

Work-Up and Pathologic Assessment

The single most critical prognostic factor is whether peritoneal implants are invasive or non-invasive 2

• Non-invasive implants lack destructive invasion and carry a favorable prognosis 2
• Invasive implants show crowded epithelial nests with haphazard arrangement and predict adverse outcomes 2
• Invasive implants must be confirmed by at least two pathologists, preferably including a gynecologic pathology specialist 2
• When invasive implants are identified, the diagnosis becomes "extra-ovarian low-grade serous carcinoma" per WHO 2014 criteria 2

Adjuvant Therapy Decision Algorithm

The presence or absence of invasive implants determines all post-operative management. 1

If NO Invasive Implants Present:

• Observation is the preferred strategy (Category 2B recommendation) 1
• Postoperative chemotherapy has no demonstrated benefit in patients without invasive implants 1
• Five-year survival exceeds 80% with observation alone 1

If Invasive Implants ARE Present:

• Carboplatin plus paclitaxel OR carboplatin plus docetaxel is recommended (Category 2A) 1
• Use the same regimens as for grade 1 (low-grade) serous ovarian carcinoma 1
• Observation alone is a weaker option (Category 3 recommendation) for invasive implants 1
• The benefit of chemotherapy remains controversial even with invasive implants, as the significance is still under investigation 1

Important nuance: The NCCN upgraded chemotherapy for invasive implants from Category 2B to Category 2A in 2016, reflecting increased consensus despite ongoing controversy about benefit 1

Follow-Up Protocol

Prolonged surveillance is mandatory because borderline tumors can recur up to 20 years after diagnosis. 3, 4

• Monitor with routine ultrasound examinations of the remaining ovary 1
• After childbearing is completed, strongly consider completion surgery (removal of remaining ovary, uterus, and contralateral tube) as a Category 2B recommendation 1
• The most important negative prognostic factor for recurrence is conservative surgery itself, though recurrences are typically borderline-type and easily curable without impact on survival 3

Management of Relapse

If clinical relapse occurs:

• Perform surgical evaluation and debulking if appropriate 1
• If low-grade invasive carcinoma or invasive implants from borderline tumor are found, treat as grade 1 (low-grade) serous ovarian cancer 1
• If high-grade invasive carcinoma develops, treat according to high-grade epithelial ovarian cancer protocols 1

Critical Pitfalls to Avoid

• Never perform fine needle aspiration or transvaginal aspiration of ovarian masses—this is absolutely contraindicated 5
• Do not assume frozen section diagnosis is definitive; accuracy is lower than optimal, and final pathology may reveal different findings 6
• Avoid routine lymphadenectomy, as it provides no survival benefit 1
• Do not delay referral to a gynecologic oncologist; these patients should be evaluated by a specialist 1

Special Considerations for This Patient

• At age 35, fertility preservation is entirely appropriate and does not compromise oncologic outcomes for stage I disease 1, 3, 6
• Approximately 65-70% of serous borderline tumors present as stage I disease 6
• Borderline tumors occur most commonly in younger women, with approximately one-third diagnosed under age 40 7
• Conservative surgery carries a small risk of tumor developing in the contralateral ovary, but this is manageable with surveillance 8