Seromucinous Epithelial Tumor of Low Malignant Potential

[tigermom]

Hi,Dr I'm 32 years old. On April 2005, while I was 19 weeks pregnant, two complex cysts were discovered by ultrasound. 6.8cm cyst on right ovary. 3 cm cyst on left ovary. Both have thick slightly irregular sepatation. My Ob/Gyn said it's not cancerous and told me to have them removed by laparascopy after delivery of the baby. Since then, I had ultrasound every two months, the size of the two cysts had not changed. However, on October, 2 months after I gave birth to my son, another 2 cm cyst with 0.9cm nodule was discovered on left ovary.
On March 2006, i had the surgery. Unfortunately, the 6.8 cyst broke during the operation and my right ovary had unusual bleeding. The surgeon took a long time to stop the bleeding. He did not remove the cysts on the left ovary. He said these two cysts looked harmless. A month after the surgery, I was told by the surgeon that the cyst was borderline tumor. The disease was found"in a couple of areas, there is a tan brown mucousy lesion which measures 1.5x1.0x0.7cm and 2.0x1.0x1.0 cm."
On May 2006, I had a laparotomy, the gyn/oncologist explored my abdomen, removed the right ovary and tube, removed the two cysts from left ovary and also removed the appendix and omentum. According to the pathologist report, the two cysts on the left ovary also had borderline tumor on a few very tiny spot size of a rice. Everything else is fine. My question is:
1. Would you recommend using birth control pills to reduce the risk of reoccurence?
2. Would you recommend a hysterectomy later on?
3. Does it increase the risk if I get pregnant again. Thanks.

[Annekathryn Goodman, M.D.]

Dear Tigermom,

To summarize, you have experienced a malignancy called a borderline tumor of the ovary. Another term that has been used for this type of tumor is tumor of low malignant potential (LMP). Borderline tumors come from the epithelial lining of the ovary. This lining of the ovary can produce benign tumors (serous, mucinous, or endometrioid cell type cystadenomas), borderline tumors (serous, mucinous, endometriod) and invasive cancers (serous, mucinous, endometrioid, clear cell, undifferentiated cell types) Sometimes in the same ovary, one can find benign, borderline, and invasive epithelial cancers.

It sounds like you have had at least two separate borderline tumors, maybe more. Your right ovary is completely removed and you still have your left ovary. Therefore, you are at risk for the development of new borderline tumors in that remaining ovary. There is no data to suggest that pregnancy will stimulate the formation of these tumors. If you are interested in getting pregnant, I would recommend that you go ahead and try now. With only one ovary that may be smaller because of the removal of cysts, you may have some reduced fertility potential now.

Birth control pills have been associated with a reduction in risk of invasive epithelial ovarian cancers. I do not think we have good data to definitively say whether that is so for borderline tumors as well. However, if you are not trying to get pregnant, I think it is very reasonable to go on the pill.

A decision to do a hysterectomy would be based on many different factors. If you had a family history of breast, endometrial , and colon cancer, I would strongly recommend the removal of your uterus. This is because there is a genetic syndrome called Lynch syndrome that is associated with a 90% risk of endometrial cancer (cancer that comes form the lining of the uterus.)

Other reasons to remove the uterus include heavy bleeding, large painful fibroids, endometriosis, abnormal pap smears, precancers and cancers of the uterus, and  prolapse. In the absence of these indications, I do not recommend the removal of your uterus. I do recommend the removal; of your ovary once you have completed childbearing. It is not clear what the risk of invasive ovarian cancer is in women who have experienced borderline tumors. Interestingly the average age of women with invasive ovarian cancers is about 20 years older than for borderline tumors.

[Grateful06]

Are there any studies on what happened decades later with women with borderline ovarian tumors who kept one or both ovaries?  It is interesting that you consider a borderline tumor a type of malignancy.  Does this mean we had cancer, but it was cured by surgery?  Or did we not have cancer?  I have had two borderline muconous cystadenomas removed, and still have my left ovary.  I don't know if I'll really "get" what it is or what it means for my future.  I just seem to get more confused.  I find myself doubting my decision to keep my left ovary at age 39, because my child bearing years are behind me.
Does a borderline tumor now mean ovarian cancer in later years?

[akg]

Your questions are right on!. It is very confusing. Borderline tumors really are a malignancy because they can spread (metastasize), recur, and in some cases, people do die from their borderline ovarian tumors. There is an old but very nice review of borderline tumors by Joseph Chambers called "Borderline Ovarian Tumors: A review of treatment" in the Yale Journal of Biology and Medicine; volume 62 pages 351-365 1989.

Luckily most borderline tumors are stage I and are cured by surgical removal. As we get more and more conservative in surgery for borderline tumors (that is, in young women it is rare to have a complete hysterectomy for this but that used to be the standard treatment 20 years ago.)- we wonder what risks young women with preserved ovaries will have 20 years later? I do not think any one knows yet.

Is the gene for making bordeline tumors the same as the one for making invasive ovarian cancers? No one knows but they definately can be both seen in the same ovary, Also women with the gene mutation for breast and ovarian cancer (BRCA 1) have a higher incidence of borderline tumors.

So on that slim data, I do lean towards suggesting that women with a history of borderline tumors who are done having their children, should consider removing the remaining ovary at some point.

[Grateful06]

Wow you are brilliant.  I think I can reconcile what you say and what my doc says, she is more "No, it is benign!" but I see that the potential of metasticizing is the key here.
I wish there were more studies, maybe I can offer my slides to study?  I've had two removed.  
Thank you for the site to this study, thank you for answering so many of my questions.  I am grateful.

[Bleason]

I just had a total Hyst with the removal of everything and the lymph nodes as well.  My doctor said my mass was low malignant potential tumor and that I have a 1 to 2 % chance in it coming back based on the stage of the tumor.  Is this similiar to what you are talking about?  Could it mastisize in another part of the body?  What kind of tests should I have to check for reoccurance?

[akg]

Hi There,
yes low malignant potential (LMP) is another term for borderline. The risk of recurrence is related to stage . Ask your doctor about the pathology report and what tissues (uterus/ ovaries/ tubes/lymph nodes/omentum etc were involved by this tumor.

[Joshua'sMom]

Hi! I am 28 years old and would like to share my situation with you and get your opinion. My GYN doctor found a 7.5 cm mass on my left ovary in Nov. 2005. We did "watchful waiting" for several months and it never disappeared. In fact, 2 more smaller cysts were disovered during one of the routine checks in Feb. 2006. My doctor thought all 3 of them were simple cysts because they appeared to be filled with fluid on the ultrasounds and none of them changed in size once they were discovered. I had the large one removed on March 9, 2006 and to our surprise, the pathology report revealied that it was a borderline ovarian tumor. My doctor did not remove the 2 smaller ones during the surgery because he throught they looked harmless (we didn't know anything was "borderline" at that time). He sent me to a GYN Oncologist for a consultation and this doctor recommended that I follow up with routine ultrasounds to make sure everything resolved. The Oncologist said removing my left ovary would be the best treatment to prevent recurrence but did not advise removing my left ovary immediately since my husband and I haven't decided whether we want more children.  I've been having follow-up ultrasound checks every 6-8 weeks since then. One of the  follow-up ultrasounds at the beginning of May showed that both of the small cysts were still there and I also have a new complex cyst on the right ovary. I went back for another ultrasound at the beginning of August and it revealed no change in status of the 2 remaining on my left ovary (which are about 1.5 cm each) and the complex one on my right ovary is now growing (it's around 3.5 cm). My doctor referred me back to the Oncologist for a consultation and they've already decided that I need to have the right complex cyst removed - the Oncologist said "watchful waiting" has been done long enough and it needs to be removed if it's growing. The Onocologist is planning to perform this surgery and said they will take this opportunity to closely examine the 2 that are being so persistent on the left ovary as well.

Do you think it is possible that the complex one on the right ovary is related to the borderline cancer? And what is your opinion about the 2 that have been so persistent on the left ovary since they are right next to where the tumor was? My doctor said they could be an outgrowth of the tumor but they don't seem to be growing in size.  Is there a cause for concern even if they don't grow?

I really appreciate any feedback you can provide. I agree with the others on this forum that "borderline" is very confusing and it's quite scary to think that some of the cells could still be in my body.

Thanks for your response!!

[akg]

Hi, Thank you for the detailed note. I completely agree with your oncologist. These tumors are very slow growing and in fact may not change in size over many months or even years. That is why even in the presence of a borderline tumor, one can wait a bit before removing it. You do run the risk of losing your ovaries with more surgery at your young age. However because the cyst on the right is growing, that is a good reason to go ahead with surgery.
Yes it can be very scary but borderline tumors are very effectively treated by surgery. It sounds like you have good people watching over.
take care

[Joshua'sMom]

Thank you so much for the feedback! Yes, I agree that I have great doctors looking after me. I have a consultation and pre-op scheduled for next week. I trust everything will go well! Thanks again. This site is very helpful and I appreciate your time. Take care.

[Jack's mom]

Hello. I'm 28 and was diagnosed with a LMP tumor when I was 23. At that time I had my right ovary and fallopian tube removed and was staged at stage IC. The only reason I was at that stage was because some of the fluid from inside the tumor spilled out into the abdominal cavity (which is a scary thought to stay the least). I was told that removing my remaining ovary was inevitable; that boderline cancers were non-aggressive, but usually returned. I had a CT scan done this past May that revealed a mass on the inside of my left ovary. We're waiting for my period now to determine whether this mass is functional or not. If it shrunk or went away, I was advised to get pregnant ASAP if I want more kids. If it has grown or still looks suspicious, my doc wants to remove everything...uterus included. I did get a second opinion from a fertility specialist. He said that he could assist my oncologist during surgery so they could together attempt to keep part of my left ovary intact and just remove the mass. However, this is difficult since it is inside the ovary. I find the entire ordeal to be confusing. One day I feel like it's no big deal, the next day I'm worried that I'm not going to see my son grow up. It's awful!! I don't want to have everything taken out so early. I don't want to go through menopause this young. It's hard to handle, but it's reassuring to know that there are other people out there with similar problems and concerns. At least we know we're not alone! My best to everyone. take care of yourselves!

[jcrupp]

Hi, this past June (2006) I had my left ovary, fallopian tube, a borderline malignant tumor the size of a raquetball, and the omentum the tumor had attached to removed.  The tumor had caused a noticable inflammatory response to the left side of my abdomen and the lymph node in my left groin.  As a result of the findings from this first surgery, I chose to have a full hysterectomy in August 2006.  The pathology report identified another borderline growth about a centimeter in diameter in the right ovary.  (I am 34 years old and my husband and I had completed our family--so that was not an issue.  I am also a nurse, so I know the effects of early menospause and chose that over the stress of the unknown GYN future.)  My question is:  Where do I go from here?  I just returned from my 6 week post-op appointment and my dr. suggested a CT scan of my abdomen in 6 months.  After that, he said he was not sure what the next step should be due to the lack of research on borderline malignant tumors.  He said he would continue to do some research and told me to do the same.  Thank you.

[akg]

Hi There,
You have had the right treatment. I would recommend a check up and CA 125 blood test every three months for the first year. If everything is stable, in the second year, I would do checkup and CA 125 blood work every 6 months. It is very rare for borderline tumors to recur. If that happens, one usually remove the recurrence surgically.
best wishes

[Joshua'sMom]

Hi, again! I wanted to give you an update on my situation and I am requesting your opinion. I had the mass removed from my right ovary last week on Sept. 25th. The Oncologist fully removed it laparoscopically without damaging my ovary (it measured 2.8 x 3.5 cm). Also during the surgery she noticed some tissue on the back on my right ovary that looked abnormal so she biopsied it. She saw this same tissue on the inside and outside of my ovary. Both were sent to pathology and the results showed that the mass was another borderline tumor and the tissue also had borderline cells in it. She has recommended that I undergo another surgery to have my entire right ovary and fallopian tube removed and has scheduled this for Oct. 30th. She said there is no question about this and that it needs to be removed to keep these cells from shedding anywhere else (she said the tissue is not contained like the tumor was).

My doctor feels confident that my left ovary is stable for now even though the 2 masses that have been there since my first surgery (which removed a borderline tumor from the left ovary in March of this year) have not grown in size.

Have you ever seen a case like this before? I didn't realize that borderline cells could invade issue, I thought only tumors were considered borderline. Also, would my right ovarian tumor/tissue be considered a recurrence of borderline cancer or could it be related to the other 2 masses that are being left alone at this point? Thank you so much for any clarification you can provide. It's been a rough 7 months dealing with 2 surgeries and I am not looking forward to the third one in a few weeks but I certainly want whatever contains these cells taken out!

Thank your for your time!

[akg]

Hi There,
Yes it does sound like you have had a recurrence of your borderline tumor. This is very common especially if a person has what we call "conservative surgery". That is the whole ovary is not removed. When you have completed your family, you should consider the full removal of your ovaries, tubes, and maybe your uterus. You should ask your doctor about this as well. That is alot of surgery to go through in less than  a year.
good luck to you.

[Joshua'sMom]

Thank you so much for your feedback. I will talk to my doctor about having my uterus removed as well as my left ovary. She has already mentioned removing my left ovary when we have decided we are done having children.

Have you seen borderline cells appear in ovarian tissue before? I was thinking only tumors were considered borderline. It does make me nervous that some of these cells could be shedding elsewhere in my body. What are the chances that these cells could form another type of tumor on another organ, etc.?

Thanks for any clarification you can provide once again!

[sisterlove]

Hi I am new to this site....  I have read some things that were posted on here and I too have questions and am hoping to get some answers or at least more than I am being given...

I am 28 now but back in April of 2003 I was still 24 and I had a tubaligation done (decided we were done with our family 2 boy & girl).  Prior to the surgery the doctor had told me that I had to sign a release allowing them to remove any other objects they might have found while doing the surgery...  So I was surprised when she showed me pictures of the surgery and my ovaries to see a nickle sized bubble sticking out of my left ovary.  But the dr told me that was normal while menstruating to have a cyst and it would dissolve within a couple of weeks.  I felt uncomfortable about it then but I felt confident with my Dr.'s comments so I went on with life...

Progressively over the years I have noticed many changes that I thought were just associated with the tubal.  Such as miserable periods extremely heavy and painful which I hadn't experienced before. And plain out uncomfortable in the pelvic area.  And for the last year I would say extrmeley uncomfortable on a daily basis.. Bloated and painful ..  I can even feel a large lump in the left side... On my routine physical a new dr told me that I needed to get an ultrasound as she felt a fibroid so oct 3rd I had my ultrasound.  The dr asst. called yesterday and is referring me to an OBGYN to discuss the results with me but I got out of her that I had 2 cysts on my left ovary...  I am scared... I know everyone tells me oh it is normal and they will just give you bc pills and it will go away but I am really scared..  I don't have a good feeling.  
What are my options?  What questions should I be asking... I don't want to play a waiting game... I cannot even wear jeans that are slighly tight anymore or I am so swollen inside when I take them off I am doubled over.. Intimacy is sometimes just unbearable..(but I don't say anything)  

Does anyone have any advice?
I am grateful for any ideas or help! :)
Thank you

[Deb2009]

A related discussion, borderlin ovarian cancer serous was started.