Abstract
Abstract
Introduction
Case
A 23-year-old nulliparous woman presented with amenorrhea. Ultrasound showed a mass with worrisome, complex features, such as septations, papillations, and solid components. A computed tomography scan revealed a 10×12 cm mass of the right ovary and a 1×2 cm mass on the splenic hilum. The patient underwent laparotomy. Gross inspection confirmed the presence of a right ovarian cystic tumor with solid components. It was necessary to excise the involved ovary completely in order to perform an appropriate frozen-section analysis. Moreover diffuse peritoneal implants were discovered, and a mass on the splenic hilum was identified. Intraoperative frozen-section analysis revealed mixed results— a borderline ovarian tumor (BOT) and an ovarian cystadenocarcinoma. Because the patient wished to preserve fertility and surgical treatment differs for these diverse clinical entities, it was decided to wait for the final histologic results before proceeding to excision of the uterus and contralataleral ovary. Accordingly, complete staging was performed, including biopsy specimens of the pelvic peritoneum (cul-de-sac, pelvic wall, and bladder peritoneum), abdominal peritoneum (paracolic gutters and diaphragmatic surfaces), omentum, intestinal serosa and mesentery, and retroperitoneal lymph nodes (pelvic and para-aortic).
The final histologic analysis revealed an ovarian carcinoma, in addition to the borderline ovarian tumor. Consequently, a secondary laparotomy was performed on the patient's third postoperative day. Excision of the uterus and contralataleral ovary was carried out. The patient was discharged after 4 days, her postoperative course was uneventful, and no recurrence has been noted 3 months after conclusion of 6 courses of chemotherapy with taxol and carboplatin. She tolerated treatment well, only experiencing minor side-effects. Computed tomography scans after chemotherapy showed no evidence of disease. Patient is currently on follow up appointments (3 monthly).
Discussion
When a complex ovarian mass is discovered, surgery is often, if not always, indicated. Definitive diagnosis of a pelvic mass requires visual inspection and histologic diagnosis.1,2
Frozen section is widely used in surgery for suspicious ovarian masses. It is usually necessary to excise the involved ovary completely, although there is no definite evidence of malignancy. 2
In the current case, intraoperative frozen-section analysis revealed mixed results—a borderline ovarian tumor and an ovarian cystadenocarcinoma.
Borderline ovarian tumors affect younger women, and these tumors are generally discovered earlier than other gynecologic malignancies. These also called adenocarcinomas of low malignant potential are usually associated with an excellent prognosis. 3
If these grade 0 carcinomas are unilateral, they may be treated by unilateral adnexectomy for women in their reproductive years. The opposite ovary should be inspected as well. 4
Even if peritoneal implants are identified, as in the current case, they are classified as invasive or noninvasive. Women with noninvasive peritoneal implants have no more than a mean of a 20% recurrence rate and a mean of a 7% mortality rate. 5
However, invasive epithelial ovarian tumors are treated with aggressive debulking, bilateral adnexectomy, and hysterectomy, regardless of age, even if inspection intraoperatively suggests that the disease may be confined to one ovary. 5
Yet, frozen-section examination of a tumor at the time of surgical intervention is considered to be necessary in order to decide the appropriate therapy for patients in the reproductive age group.
However, it should be kept in mind that BOTs produce the highest rate of false frozen-section results. 1 The sensitivity of the frozen section, to distinguish the benign and the malignant ovarian tumors, is 65%–97%, and its specificity is 97%–100%. In benign and invasive ovarian tumors, the reported accuracy of frozen-section analysis is between 90% and 96%. 1 Considering the reasonably high rate of false results of frozen section analyses, and the fact that the current patient was young and wished to preserve fertility, hysterectomy and contralateral oophorectomy were not performed until the final histologic results confirmed the presence of additional cancer.
Conclusions
In young women with early stage BOT, fertility-sparing surgery can often be performed, with removal of the uterus and contralateral ovary after childbearing is completed. If the patient is beyond childbearing age, then hysterectomy appears to be a reasonable option.2,6
The final histologic analysis for the current patient revealed ovarian carcinoma, in addition to the borderline ovarian tumor. So, a secondary laparotomy was performed, and excision of the uterus and contralataleral ovary was carried out. Optimal cytoreduction (residual disease <1 cm) was achieved, because it improves response to adjuvant chemotherapy and overall survival.
In the current case, handling the fertility-sparing issue was of great importance. Intraoperative frozen-section analysis was performed, a procedure widely recommended, according to conventional teaching. However, the conflicting results (ovarian cystadenocarcinoma and borderline ovarian tumor), revealed therapeutic dilemma: Should this patient undergo hysterectomy and contralateral adnexectomy—taking into consideration the most severe diagnosis (invasive cancer)—or not?
It was considered wise to individualize the surgical strategy for this patient, being hesitant to rely on the results of the intraoperative frozen-section analysis. Hence the final histologic results were awaited before operation was performed that would eradicate the patient's fertility, although this meant that she had to undergo an additional laparotomy.
Footnotes
Disclosure Statement
No competing financial conflicts of interest exist.