Borderline Tumor Diagnosis and Management

[rainsunshine]

I have asked questions here before and I appreciate your time and kindness.

Again a brief summary of my history: I am a 38 years old nulligravid woman. I had sharp right flank pain in July 2008. Transvaginal ultrasound discovered a complex cyst involving the left ovary, a fibroid, and a paraplevic cyst involving the left kidney.  The paratubal cyst (near the fimbriated end) was removed Nov, 2008. NO staging was done.
The original pathology result is Serous Borderline Cystic Tumor. Capsule is Intact. Grade 1/3.

I took your advice and sent my pathology slides to Johns Hopkins for a second opinion. The result is Atypical Proliferative(borderline) serous tumor. I was told these tumors are not graded. I am confused because the tumor was originally graded as 1/3. Is this different practice in different hospitals? Also, no further info was provided such as tumor on external surface or Lymphatic channel/Vasular invasion. Do you think it is critical to get these details confirmed for management planning?

I am also wondering how certain do we know if a tumor is borderline by looking at the slides alone. Would the original block provide additional information? Will the way the pathology slides were cut make a difference? In other words, is it possible to get a different result if I were to send the original block instead of the slides for consultation?

The tumor is un-staged. How can we know the involvement of other organs and whether there are macro/ micro implants? Will a PET scan help? Are there any other tests (blood, pelvic fluid, urine, etc) available? Do I need a colonoscopy? I feel like I am left in the dark and dying for more info.

The tumor is paratubal rather than on the ovary. Does this mean it is at least stage II by definition as it is not limited to the inside of the ovary?

Is it possible the cyst involving the left kidney has something to do with the borderline tumor?  Do you recommend taking it out and biopsy?

[Annekathryn Goodman, M.D.]

Dear Hosnieh,
thank you for your question.
Most women with ovarian cancer who have a recurrence will have the recurrence within two years. (over 80%)
By five years, the majority of women who experience an ovarian cancer recurrence will have a recurrence (over 90%)
However even after five years from diagnosis, women are stil at risk for recurrent ovarian cancer.

The way ovarian cancer can recur is different after five years compared to before five years. After five years, a recurrence more commonly can be isolated. That means there can be a solitary lymph node with cancer, or a single spot in the spleen and so on.

It is very unusual for ovarian cancer to recur in the bone. It can happen but it is rare.
Therefore, for your mother, it is important to make sure that this lesion in her bone is not somehting else such as a new cancer or a noncanerous issue such as a fracture..

I agree with the plan to check further studies. Another option is to consider a biopsy.
I hope all works out
best wishes

[Hosnieh]

Dear Dr Goodman,
I need your expert opinion.
My mom was incidentally diagnosed by serous papillary cystadenocarcinoma of ovary in 2002 when she went to theatre for abnormal uterineDysfunctional uterine bleeding (dub)
Endometrial cancer
Fetal heart and uterine contraction monitor
Intrauterine device
Intrauterine growth restriction
Normal uterine anatomy (cut section)
Uterine anatomy
Uterine fibroids
Uterine prolapse bleeding, hence had TAH and BSO. FirstFirst progesterone mc10
First progesterone mc5
First-progesterone vgs 200
First-progesterone vgs 400 round of 6 course chemo with Doctaxel and carboplatin completed in Nov 2002. In Jan 2003,underwent second look surgery with omentectomy which revealed microresidual of tumor ,no gross tumor. Underwent 6 more cycle of chemo with Gemcitabine, carboplatine and mitoxantrone which was completed in March 2003. We never had CA125 prior to her firstFirst progesterone mc10
First progesterone mc5
First-progesterone vgs 200
First-progesterone vgs 400 operation . After chemo she was followed up by CA125, Ultrasound and 2 CT scans( last one in 2007 ), which were all normal.
Since Dec 2008 her CA125 started to raise slowly, it is now 70.
She does not have any abdominal symptom, but she has lost weight (6 kg in 2 months) which we put for her blood suger good control after struggling a bit. She newly started to complain of lower leg pain, some time so severe that she can not put weight on, her recent MRI, showed lytic lesions in T11, T12 and some enlarged nodes (Maximum size of 9 mm).   She does have terrible Tibial pain, and it is tender as well.
I am terrified with the fact of recurrence. I was told recurrence after 5 years is really unlikely.
She is going to be followed with another MRI and bone scan next week.
But I am desperate to have more information on this. I have looked into published papers, there is a real contraversies around the prognosis and resapond to treatment.
Please would you be kind enough to let me know if any one has a similar history or if our medical professional can kindly advise me.
I really appreciate your care and support.
Regards
Hosnieh

[Annekathryn Goodman, M.D.]

Hi There
You should ask your doctor about the report. The important point is , it is confined
best wishes

[rainsunshine]

Dr. Goodman,

Thanks for your response. I will book an appointment with a genetic counselor.

I am puzzled as to why my pathology report below states the tumor extent is limited to the ovary while my tomor is contained to the left fallopian tube. could this be a mistake or it doesn't literally mean limited to ovary?

Since the tumor is origrnated from the ovary(?), is it possible the ovary itself is tomor free while it has already "spread" to the tube? or the likelyhood of a borderline tumor is currently developing in one or both of the ovaries is quite high???


Location: left ovary
Size: 2.4*2.2*1.2
Tumor on external surface: negative
Tumor capsule: received with intact wall
Extent: limited to ovary
Lymphatic channel/ vascular invasion: negative

thanks
rai

[Annekathryn Goodman, M.D.]

HI There
PET CT  is usually negative in low grade tumors so not helpful

ovulation induction drugs are not thought to cause ovarian cancer

family history is important and another reason to consider a full hysterectomy at some point.

You should get a consultation with a genetic counselor to discuss the benefit of genetic testing
best wishes

[rainsunshine]

Thanks Dr. Goodman!

I am trying to decide whether having a baby is feasible. At 38, the chance of getting pregnant without the help of fertility treatment is very low…I would be hesitate considering fertility drugs because it is a potential risk factor for recurrence. What is your opinion on fertility treatment? It would be nice to have a baby but I would like to know how much risk I am taking…I would say health is my first priority… Do you think I should have a time line? For example I would try for 6 months(?) to get pregnant if it doesn’t work out I’d better go back considering sugerically removal of ovaries and/or uterus.  

In a recent ultrasound in April 09, my uterus fibroid doubled in size (1.7*1.2*1.3cm to 3.3*2.7*3.1cm) compared to 6 months ago. A new fibroid was found (1.0*0.8*1.0cm). Also, there is a 0.6*0.8*0.7cm echogenic nodule with some increased Doppler flow along the anterior endometrium. Should I be concerned? Should this be managed as soon as possible?

Would you please elaborate a little more on why PET is not recommended? Is it because it not helpful in my situation? Or concerns about radiation?

I still feel bloated and urinate frequently 6 months after the surgery. My cycle is irregular (ranging from 28 to 40 days). I have been experiencing fatigue, back pain, abdominal discomfort, abnormal spotting after intercourse and in the middle of the cycle, and shortness of breath. What should I do to make sure everything is ok?

I had silicon breast implant in 1998. There are concerns about the rupture of the implants and this is currently under investigation. Could this be related to the borderline tumor?  

My family history of cancer: My grandmother died from stomach cancer and grand uncle died from bone cancer. Should I be concerned about family history of cancer? Do you recommend a BRCA1 and BRCA2 test?

I know some of my questions might sound crazy or irrelevant to you…but I am worried, scared and hope for the best at the same time.

Thanks again for all you help…you have no idea how much it means to me…
rainsunshine

[Annekathryn Goodman, M.D.]

Hi There
great questions!
I guess, the first thing I would ask you is: are you planning on having children? If so, then serial CA 125s and ultrasounds is probably all I would suggest at this time for a borderline tumor.

When you are done having kids, I would suggest going back surgically and considering either a full hysterectomy, removal of both ovaries and tubes or just the removal of the ovaries and tubes.

Yes more information can be obtained from the paraffin blocks but I would defer to the pathologists on that.(that is do the think they had enough slides to look at) I agree with Johns Hopkins. We usually do not assign a grade to a borderline tumor.

Without doing a full staging surgery,it is not possible to assign a stage .

no to PET scan
cysts on kidneys are normal and usually benign
colonoscopy - unless family history of colon cancer, start screening at age 50

best wishes