Staging surgery for Serous borderline tumor?

Hello - I am 40. No children. For three years, my gyn watched a 3-4cm mass on my left ovary and did not recommend removal. I was having a lot of pain and didn't feel right about waiting any longer, so I went to another doc. was suspected to be a dermoid. During surgery, "Posterior cul-de-sac demonstrated ...endometriosis ... as well as left ovarian fossa adhesions, leakage of dermoid material, oily material from the left ovary. The left and right fimbriated ends appeared to be slightly phimotic. There were no other adhesions except for the small loop bowel adhesions between the left uterosacral ligament in the sigmoid. Appendix was normal. Liver was normal. We initially started with lysing the left ovarian ahesions with sharp  cautery, and the ovary was then mobilized anteriorly, and we scored the antimesenteric border of the ovary. The cyst was then shelled out under sharp and blunt dissection. The cyst was removed through the 10mm port. The base appeared to ooze at the hilum...tubes with carmine dye, both spilled....reinspected left ovary, cauterized hilim, 3 small areas...Peritoneum was irrigated with 3L of lactated ringer's to remove the dermoid material." My doctor was shocked when the pathology report came back to be a serous borderline tumor LMP rather than a dermoid. (I do not yet have a copy of the pathology report to give you a verbatim.) Also, recent ultrasounds since the surgery reveal that a mass on my right ovary, which was initially thought to be a cyst, has not changed in at several months. Oncologists have reviewed my pathology report, and according to my regular gyn, have not recommended staging, only genetics counseling. Everything I have read (particularly from the National Cancer Institute) has indicated that staging should be done after diagnosis of a borderline tumor. I am especially curious about this since my tumor was leaking, I have scar tissue from it, and the wash from my surgery was not reviewed by a pathologist.Should I seek staging?

[Annekathryn Goodman, M.D.]

Hi There,
thank you for your question.  Sharon - thank you for your comments.

I guess, my first question to you is: are you trying to have children? if so, you should see a fertility doctor (reproductive endocrinologist) very soon to have an honest assessment of your ovarian function.

At age 40, ovarian function is much lower. and the ability to conceive drops. By 45 , most women who want to try to get pregnant need alot of help including donor egg.

I ask that because, I would recommend that you have that whole ovary removed.

Depending on various factors, your options include:
1-close follow up with CA 125 and ultrasound checks. I would only suggest this if you are actively trying to get pregnant.
2-a second surgery with the complete removal of that ovary and fallopian tube
3-a complete hysterectomy, removal of both ovaries and fallopian tubes

the decision on choice 2 versus three depends on factors such as how much endometriosis there is. The cure of endometriosis is complete removal of the uterus (the source of the endometriosis) and other risk factors for ovarian cancer such as family history, breast cancer, genetic risk.

now the issue of staging: you have to ask why is staging important? how does it change your management? Staging is not therapeutic. It is diagnostic. So if you had an invasive ovarian cancer, staging (lymph node biopsies, washings, omentectomy, diaphragmatic biopises), is important. It gives information about risk of recurrence.And we base decisions about chemotherapy on risk of recurrence. And decisions about IV versus intraperitoneal cancer is also based on this information.

But borderline malignancies are not treated with chemotherapy.  So ultimately the only therapy is surgical removal of the lesion.
best wishes

[Sharon2714]

w0w i would say so ... probably best to seek the opinion of a gyn/onc and make sure u arent piece mealing this ... unless u specifically wanted fertility sparing surgery .. either way the gyn/onc is the way to go ... i had mine out all at once and totally do not regret it ... although they are LMP if they are not properly treated they can still kill .. sadly .. good luck

[Sharon2714]

oops i was looking at the wrong forum .. but i still think u need to see the gyn/onc .. good luck

[zoeb333]

Dr. Goodman,

Thanks so much for your reply. To answer your question, I asked about staging in order to help me make a decision about getting pregnant. That is, if my tumor cells have advanced, do I really want to risk a pregnancy?

My husband and I are only children. (Though I have some distant half-siblings). We have no support system. His mother lives far away, my father is dead (heart disease), and my mother is elderly. Part of the reason I have no family is that on my mother's side, they have all died from cancer. My mom is the youngest of 6, and all her siblings died from either reproductive, colon or lung cancers. My mom herself had her uterus out when she delivered me (due to uterine cancer.) (I am planning to ask my genetics counselor about testing for Lynch syndrome.) In my view, it would be irresponsible to bring a child into this world which I may not be able to care for if I could develop advanced disease.

I have scheduled a second opinion with a gyn/onc at a reputable institution in my city. I plan to ask him whether or not the pathology report indicated if my tumor cells are estrogen-receptive. Am I correct in assuming that would put me at higher risk with pregnancy? That would also influence my decision to get pregnant.

While having children would be nice, I have to confess that I don't have a burning desire to do so in light of everything that is happening to me. My instincts are telling me to get everything out. Yes, I would like kids. But I am older, and the risks seem to be too many. I have a full life with advanced degrees, a career, and would maybe use the years ahead of me toward bettering the world instead of raising a kid. I'm trying to have a good outlook, and my husband is supportive.

So, knowing this, would you still recommend having the ovary taken out? What about the growth on the right ovary? Would you recommend taking the entire right ovary at first pass, or simply biopsy first? What other questions should I be asking my gyn/onc? Other than Lynch, what should I be tested for genetically? BRCA?

Thanks for your responses!

[zoeb333]

I forgot to comment on the endometriosis....

The gyn who did the surgery said that it was just Stage 1, and they couldn't remove it because of the location. Some adhesions were on a blood vessel, and on the uterine ligament. The adhesions in the area of the left ovary were from scar tissue that had formed around the leaking tumor, not the endo.

Are the endo lesions on the vessel and ligament in a "dangerous" place? If I do have an oophorectomy, should the uterus be taken also given the endometriosis locations?

[Annekathryn Goodman, M.D.]

Hi there,
thank you for your additional comments.
a genetic counselor will have the expertise to recommend which gene mutations to evaluate based on a full family tree.

from what you have just told me, I would lean towards a full hysterectomy and removal of both ovaries and tubes.

there is no robust data to suggest that estrogen stimulates borderline tumors.

good luck on this journey. it sounds like you will carefully weigh your options and make a decision that that is right for you

[zoeb333]

A related discussion, Follow-up was started.