Overin evre I sınırda tümörlerinde konservatif yaklaşım sonrası fertilite durumu

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Introduction
Borderline ovarian tumors are
known as low malignancy potential
tumors. They constitute 10-15% of
all epithelial ovarian malignancies.
Since approximately 80% of these
tumors are diagnosed at stage I or II
and the malignancy potency is low,
the prognosis is better than other
ovarian malignancies. Because they
are seen in the reproductive period,
preservation of fertility is an important issue in the management of these
tumors. We present a case of borderline ovarian tumor managed conservatively for future fertility.
Case Report
Twenty five-year-old nulliparous,
white female, married for 7 years
admitted to a center with irregular
menstrual bleeding. Her findings and
laboratory results in this first visit are
not available. She was given a long
course of oral contraceptive. After 2
years of treatment, at the control
examination she was told to have an230 · Aralýk 2006 · Gülhane TD Dede ve ark.
topathologic examination was reported as Grade I borderline tumor as
seen in Figure 1.
Figure 1. Papillae with cellular fibrous stroma
and lined by stratified epithelium, HEx200
Fifteen months after the second
laparotomy, she admitted to our
infertility center with the desire of
fertility. In April 2003 she was applied
an IVF-ICSI protocol. Although her
previous surgery might have caused a
dense pelvic adhesion, we made a
complete investigation for infertility
evaluation. At the third day of the
menstrual cycle the basal FSH was
2.14 and E2 was 175.75, indicating
adequate ovarian reserve. She was
applied an ICSI cycle because of male
factor infertility.
She was given a long GnRHa protocol using triptorelin asetat 0.1
(Decapeptyl, Erkim) for pituitary
suppression. After ten days of COH
using recFSH (Puregon, Organon)
we retrieved 11 mature oocytes.
Sperm concentration was 1X106 with
zero progressive motile sperm, 30%
motile sperm. Using ICSI we got 4
embryos. At the third day Grade I, 4
embryos (8,7,6,6 blastomer) were
transferred with Wallace Embriyo
Transfer catheter. The vaginal ultrasonography at the seventh week
showed two intrauterine gestational
sacs. The pregnancy was uneventful.
At January 18, 2004 she gave birth
with cesarean section at the 36th
week of gestation. She has twins. One
of them was 2450 g girl; the other was
2800 g girl. In cesarean section both
of two ovaries were seen normally.
We preferred cesarean section since
this was a multiple pregnancy after
IVF procedure.
After all she was called for control
examinations for three months, and
she was wanted to apply to the oncology clinic for the control of the
tumor.
Discussion
Borderline ovarian tumors account for 10-15% of all ovarian tumors.
Studies have consistently demonstrated the favorable prognosis of
these tumors. The overall 10-year
survival rate is 83-91%. Even patients
with stage III disease have a good
prognosis, with survival rates of 50-
86%. The borderline ovary tumors
tend to occur more frequently during
the reproductive age of the woman.
These tumors are seen in women
younger than 35-40 ages. For the
patients at these ages, the reproductivity is one of the most important
medical problems. In the study of
Seracchioli et al, there were six spontaneous pregnancies, and all went to
term (1). Despite the good outcomes,
this approach cannot be broadly recommended because of the lack of
complete staging to include pelvic
and para-aortic lymph node sampling. In such patients early surgical
treatment may provide a long-term
control for serous borderline tumor
of the ovary (1,2).
As reported in the study of
Donnez et al, an early and a well done
fertility sparing conservative surgery
may provide no recurrence in tumor
and will bring pregnancy (2). Unilateral salpingooophorectomy must be
considered as the first choice of conservative treatment in most patients,
because it seems to be associated with
lower recurrence rates. In their study,
all the patients conceived spontaneously, and the rate of pregnancy is
63.6%. In our case we used assisted
reproductive technology with IVFICSI long protocol because of male
factor. In the study of Camatte et al,
they used IVF protocol for persistent
infertility (3). They reported that of
17 women with stage II or III borderline ovarian tumor treated with fertility-preserving surgery, only two
women recurred and there were no
deaths at a median follow-up of 60
months. The same group reported on
pregnancy outcomes among their
entire cohort of 44 women treated
conservatively for borderline ovarian
tumors. There were 17 pregnancies
in 14 women. Fifteen were spontaneous, one patient was treated with
clomiphene citrate, and one woman
conceived after in-vitro fertilization
(IVF) (3).
As has already been discussed,
patients with borderline ovarian
tumors tend to be younger than
women with invasive ovarian cancer.
For many of these patients, fertility is
an important issue. Previous studies
have suggested the safety of conservative surgery with unilateral salpingo-oopherectomy or cystectomy for
patients with stage I borderline ovarian tumors. This observation has been
confirmed and even expanded to
include women with advanced-stage
disease. Zanetta et al. studied 339
women who were treated for borderline ovarian tumors. Although the
recurrence rate was higher for
women undergoing fertility-sparing
surgery (35/189 cases, 18.5%) compared with women undergoing hysterectomy and bilateral salpingooophorectomy (seven out of 150
cases, 4.7%) all but one women with
a recurrence of borderline tumor or
progression to carcinoma after conservative surgery were salvaged (4).
The preceding studies emphasize
the safety of conservative management for women with borderline
ovarian tumors, as long as fertilitypreserving surgery can remove all ofCilt 48 · Sayý 4 · Gülhane TD Fertility after stage I borderline tumor of the ovary · 231
the patient's visible disease. Whether
infertility treatment is safe in these
women is less clear, as too few
women have been studied to draw
valid conclusions (5).
Unilateral cystectomy may have
more chance of preserving a woman's
fertility compared to adnexectomy
because of the removal of less ovarian
tissue. Its greatest danger is the risk of
inadvertently leaving behind some
malignant cells (2).
In most of the borderline tumors
including both of the ovaries, the
recurrence rate is high. It was the
same in our case. Approximately one
and a half year after the surgery, we
found recurrence in the tumor. The
standard procedure for these tumors
is bilateral adnexectomy, hysterectomy and associated with often radiotherapy and chemotherapy as same as
their invasive counterparts. However
we made a conservative surgery. We
tried to preserve the ovaries with
extracting only the lesion and by
making a reconstruction to the
ovaries.
Young patients with ovarian
tumors of low malignant potential
usually undergo conservative surgery
because of the excellent prognosis of
these tumors. Patients wishing to
conceive after diagnosis occasionally
require ovulation induction, but data
regarding the safety of assisted reproductive technologies in this situation
remains unclear. In the study of
Beiner et al it is seen that ovulation
induction is a choice for pregnancy
after the diagnosis of a borderline
ovarian tumor (5).
If we have a pregnancy chance
even in the advanced tumors, as
reported in the study of Hoffman et
al (6), we have more advantages in
early stage ovarian serous borderline
tumors with conservative management and assisted reproductive technology.
In a very recent paper by
Fasouliotis et al, 3 term births out of
5 borderline tumor cases were presented (7). We wanted to add more
data pertinent to this issue.