- Borderline ovarian tumors, also known as tumors of low malignant potential, are noninvasive epithelial ovarian neoplasms with an intermediate behavior between benign cystadenomas and invasive carcinomas. - They account for 14-15% of primary ovarian neoplasms and are most commonly serous histology. The majority are diagnosed at stage I and have an excellent prognosis with five-year survival rates of 99% for stage I disease. - Treatment involves surgical staging and tumor debulking. For apparent unilateral stage I disease, conservative surgery such as salpingo-oophorectomy may be considered. Bilateral salpingo-oophorectomy is recommended for bilateral tumors. Chemotherapy is not routinely used except in

1. Dr Sumit Kumar
Assistant professor
NEIGRIHMS, Shillong

2. Borderline tumors of the ovary also called
tumors of low malignant potential.
Defined histologically by atypical epithelial
proliferation without stromal invasion.
The behaviour distinct from low-grade ovarian
carcinoma,That why considered a distinct
clinical entity.

3. Borderline ovarian epithelial neoplasms are noninvasive neoplasms that
occasionally have intraperitoneal spread.
Behavior :intermediate between benign cystadenomas and invasive
carcinomas.
Also named as atypical proliferative, and tumors of low malignant potential.
Borderline neoplasm term adopted into theWorld Health Organization (WHO)
classification.
Borderline tumors account for 14 to 15 % of all primary ovarian neoplasms.
Histology
 Serous (mc)-65-70%
 Mucinous –approx. 11%
 Endometrioid
 Clear-cell
 Transitional cell (brenner) borderline tumors

4.  Serous borderline tumors — Among ovarian borderline
tumors, approximately 65 to 70 percent are serous histology,
and borderline tumors account for an estimated 15 to 20 percent
of all ovarian serous neoplasms [6-8].
 In the vast majority of patients, serous borderline tumors are
confined to the ovary at the time of diagnosis [9,10].
Approximately 70 percent of cases are diagnosed at stage I [11].
However, up to 50 percent of the time, serous borderline tumors
are bilateral [9,10].
 Micropapillary features are present in 10 to 15 percent of serous
borderline tumors, as well as in other types of benign and
malignant serous ovarian tumors. The presence of
micropapillary features is associated with an increased likelihood
of both invasive peritoneal implants and of recurrence [12].
 Mucinous borderline tumors — Mucinous tumors are the other
common histologic type of borderline ovarian neoplasm; they
account for approximately 11 percent of borderline tumors [13].
At diagnosis, the great majority are stage I (100 percent in one
study of 15 patients
Characteristic Serous Borderline Tumor Mucinous Borderline Tumor
Histological Type Serous epithelium Mucinous epithelium
Age at Diagnosis Typically younger age (40s) Wider age range (30s-70s)
Bilaterality More commonly bilateral (20-30%) Can be unilateral or bilateral (10-15%)
Association with Endometriosis Not typically associated May be associated with endometriosis
Tumor Behavior Low malignant potential Low malignant potential
Ascites Less common More common
Pseudomyxoma Peritonei Rare Associated in some cases
Recurrence Rate Generally lower recurrence rate Slightly higher recurrence rate
Response to Chemotherapy Limited response Limited response
Fertility Preservation More common for fertility preservation Considered for fertility preservation
Prognosis Generally favorable prognosis Generally favorable prognosis
Management Differences
Bilateral cases more common, may require bilateral
surgery
Bilateral cases less common, usually treated with
unilateral surgery

5.  Approximately one-third of patients diagnosed with a borderline
ovarian tumor are younger than 40 years of age .
 The majority of cases are diagnosed at stage I.
Risk Factor Association with BorderlineTumors
Age <40 1/3 of patients
Stage at Diagnosis Majority at stage I (70%)
Infertility Increased risk with unknown cause
Ovulation Induction Mixed findings
BRCA Gene Mutations Uncertain association
Postmenopausal HormoneTherapy Mixed data

6. The clinical presentation of borderline ovarian tumors is the same as
for other adnexal masses
Symptoms may include:
• Pelvic or abdominal pain or pressure Dyspareunia
• unlikely to present with ascites, bowel obstruction, pleural effusion, or venous
thromboembolism.
Suspect a borderline tumor in a younger patient with a relatively
asymptomatic ovarian cyst that has evidence of internal papillary growth on
ultrasound.

7. Diagnostic evaluation same as for ovarian carcinoma
Serum CA 125 does not appear to be a useful test.
Pelvic ultrasound not differentiate borderline tumor from a benign or invasive ovarian neoplasm.
The standard procedure for suspected malignant ovarian mass is to remove the ovary intact and
send it for frozen section.
If suspect benign or borderline mass, a cystectomy may be performed.
If both ovaries are involved, the lesion that appears more suspicious should be removed and sent
for frozen pathology.
If the histology shows a borderline neoplasm or invasive disease, staging is performed, which may
include ovarian conservation.
The sonographic appearance of borderline ovarian tumors ranges from unilocular
cysts to masses with both solid and fluid components; papilla are common.

8.  Borderline ovarian neoplasm is a histologic
diagnosis.

9. STAGING AND
SURGICAL
TREATMENT
:Borderline
Pregnancy
Desired
Not desired
TH & BSO, peritoneal washing,
omentectomy, and resection of
grossly visible metastases
Conservative
surgery
• Staging same as invasive tumor
Lymphadenectomy in patients with borderline tumors usually not required
Metanalysis
97 studies (4000 pt.)
98% survival at 6.5 Yrs in patients with lymph node involvement

10. • Choice of surgery should be individualized.
• Approximately 1/3 of cases in patients <40 years old.
• Desire for fertility preservation or avoiding premature
menopause.
• Good prognosis (Stage I five-year survival is 99%).
• Recurrence risk after conservative surgery: 7-30%.
• Systematic review and meta-analysis data (120 studies):
• USO or Ovarian Cystectomy in Stage I:
• Borderline recurrence rate: 13%
• Recurrence with malignant disease: 1.6%
• Death rate: 0.5%

11. Study
• Comparison of Unilateral Salpingo-Oophorectomy (USO) vs.
Ovarian Cystectomy
• Retrospective Study with 193 Patients
• Five-Year Disease-Free Survival Rate: USO - 95%,
Cystectomy - Data Limited
• Recurrence Rates and Timing:
• USO: 7% recurrence, Median time to recurrence: 4.8 years
• Cystectomy: 23% recurrence, Median time to recurrence: 2.6
years

12. • Recurrence and Management of Borderline Disease:
• Recurrence requires surgical resection, typically full staging.
• Borderline recurrences not associated with mortality.
• Fertility preservation may be considered even after recurrence.
• Advanced-Stage Disease:
• Total Abdominal Hysterectomy and BSO (TAH-BSO) more effective.
• Risk of progression to invasive disease clinically significant.
• Advantages of Comprehensive Staging:
• Detection of advanced-stage disease.
• Identification of occult invasion.
• Better information for prognostic counseling.
• Imaging for Residual Disease Assessment:
• CT with contrast may be useful post-surgery.
 Note: Comprehensive staging provides critical information and
helps in appropriate management decisions for borderline ovarian
tumors.

13. • Fertility Preservation:
• Unilateral stage I borderline ovarian tumors can be managed with
ovary-sparing surgery for patients desiring fertility preservation.
• Appendectomy is considered for mucinous tumors.
• Incidental Discovery:
• Borderline tumors found incidentally during benign ovarian mass
surgery may undergo conservative surgery with optional biopsies.
• Peritoneal washings and appendectomy are considered for
mucinous tumors.
• Completion Surgery Controversy:
• Completing surgery after childbearing for remaining ovaries is
debated; some guidelines recommend it, but low recurrence rates
may make it unnecessary.
• Preoperative Consultation:
• Patients suspecting ovarian borderline tumors or malignancies and
desiring fertility preservation should seek a consultation

14. Bilateral tumors — For patients with bilateral ovarian borderline tumors,
oophorectomy on one side and cystectomy on the other is the usual treatment
approach.
Treatment
Approach
Recurrence
Rate (%)
Time to
Recurrence
(months)
Multiple
Recurrences
(%)
Invasive
Recurrences
(%)
Fertility
Outcomes (%)
Unilateral
Oophorectomy
+ Contralateral
Cystectomy
(Standard
Surgery)
59 48 0 0 53
Bilateral
Cystectomy
(Ultraconservat
ive)
60 16 23 0 93
Table Content:
Note: A randomized trial of patients with bilateral ovarian borderline tumors compared standard surgery (unilateral
oophorectomy + contralateral cystectomy) to an ultraconservative approach (bilateral cystectomy).

15.  Chemotherapy is rarely recommended for
borderline ovarian tumors, especially in
early stages.
 Its use in more advanced cases is
controversial, with no clear survival benefit
observed, and it is generally considered
only if invasive implants are identified.
 Other investigational hormonal or targeted
therapies may hold potential for treatment.

16.  Posttreatment surveillance —same as other type
 Future pregnancy —SAFE
Fertility treatments, such as ovulation induction, also
appear to be safe, if indicated.
 Hormone therapy —offer postmenopausal patients hormone
therapy after comprehensive counselling about risks and
benefits because some data suggest that hormone therapy
is a risk factor for developing the disease.
Endometrioid borderline like endometriosis, be stimulated to grow by estrogens;
so avoid estrogens
A systematic review of 120 studies reported a 54 % pregnancy rate at 3 to 6
years in patients treated conservatively for borderline tumors.

17. Ovarian borderline tumors are atypical epithelial proliferation without
stromal invasion.
14 to 15 % of ovarian epithelial tumors.
The majority are serous, approx75% of patients in stage I disease; 25 to
50 % B/L.
Mucinous tumors,90% in stage I and less than 10% B/L.
CA 125 does not reliably predict borderline histology.
STAGING same as other ovarian neoplasms
Complete staging withTH and BSO is required for patients with stage II
or higher disease.

18. For apparent U/L stage I borderline ovarian tumor, salpingo-oophorectomy of
the affected ovary, pelvic washings, an omental biopsy, and a biopsy of any
peritoneal lesions rather than full staging for ovarian cancer (Grade 2C).
BSO is required in patients with bilateral borderline ovarian tumors.
No use of adjuvant chemotherapy early-stage disease.
Some recommend chemotherapy after aggressive surgical debulking only if
invasive implants are identified (Grade 1B).
Borderline tumors have an excellent prognosis

19. D/D