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Ovarian Low Malignant Potential Tumors Treatment (PDQ®): Treatment - Health Professional Information [NCI]

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General Information About Ovarian Low Malignant Potential Tumors

Incidence and Mortality

Tumors of low malignant potential (i.e., borderline tumors) account for 15% of all epithelial ovarian cancers. Nearly 75% of these tumors are stage I at the time of diagnosis. These tumors must be recognized because their prognosis and treatment is clearly different from the frankly malignant invasive carcinomas.

A review of 22 series (953 patients) with a mean follow-up of 7 years revealed a survival rate of 92% for patients with advanced-stage tumors, if patients with so-called invasive implants were excluded. The cause of death was determined to be benign complications of disease (e.g., small bowel obstruction), complications of therapy, and only rarely (0.7%), malignant transformation.[1] In one series, the 5-, 10-, 15-, and 20-year survival rates of patients with low malignant potential tumors (all stages), as demonstrated by clinical life table analysis, were 97%, 95%, 92%, and 89%, respectively.[2] In this series, mortality was stage dependent: 0.7%, 4.2%, and 26.8% of patients with stages I, II, and III, respectively, died of disease.[2] Another large study showed early stage, serous histology, and younger age to be associated with a more favorable prognosis.[3] In contrast to the excellent survival rates for early-stage disease reported above, the Federation Internationale de Gynecologie et d'Obstetrique Annual Report (#21) included 529 patients with stage I tumors with a 5-year actuarial survival rate of 89.1%. Similarly, good survival was found in a large prospective study.[4] Nonetheless, these survival rates are clearly in contrast with the 30% survival rate for invasive tumors (all stages).

Endometrioid Tumor

The less common endometrioid tumor of low malignant potential should not be regarded as malignant because it seldom, if ever, metastasizes. Malignant transformation can, however, occur and may be associated with a similar tumor outside of the ovary; such tumors are the result of either a second primary or rupture of the primary endometrial tumor.[5]

References:

  1. Kurman RJ, Trimble CL: The behavior of serous tumors of low malignant potential: are they ever malignant? Int J Gynecol Pathol 12 (2): 120-7, 1993.
  2. Leake JF, Currie JL, Rosenshein NB, et al.: Long-term follow-up of serous ovarian tumors of low malignant potential. Gynecol Oncol 47 (2): 150-8, 1992.
  3. Kaern J, Tropé CG, Abeler VM: A retrospective study of 370 borderline tumors of the ovary treated at the Norwegian Radium Hospital from 1970 to 1982. A review of clinicopathologic features and treatment modalities. Cancer 71 (5): 1810-20, 1993.
  4. Zanetta G, Rota S, Chiari S, et al.: Behavior of borderline tumors with particular interest to persistence, recurrence, and progression to invasive carcinoma: a prospective study. J Clin Oncol 19 (10): 2658-64, 2001.
  5. Norris HJ: Proliferative endometrioid tumors and endometrioid tumors of low malignant potential of the ovary. Int J Gynecol Pathol 12 (2): 134-40, 1993.

Stage Information for Ovarian Low Malignant Potential Tumors

The Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) Staging

FIGO and the American Joint Committee on Cancer have designated staging to define ovarian low malignant potential tumors; the FIGO system is most commonly used.[1,2]

Table 1. Definitions of FIGO Stage Ia
StageDefinition
a Adapted from the Fédération Internationale de Gynécologie et d'Obstétrique.[1]
ITumor confined to ovaries or fallopian tube(s).
IATumor limited to one ovary (capsule intact) or fallopian tube; no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or peritoneal washings.
IBTumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or peritoneal washings.
ICTumor limited to one or both ovaries or fallopian tubes, with any of the following:
IC1: Surgical spill.
IC2: Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface.
IC3: Malignant cells in the ascites or peritoneal washings.
Table 2. Definitions of FIGO Stage IIa
StageDefinition
a Adapted from the Fédération Internationale de Gynécologie et d'Obstétrique.[1]
IITumor involves one or both ovaries or fallopian tubes with pelvic extension (below the pelvic brim) or primary peritoneal cancer.
IIAExtension and/or implants on uterus and/or fallopian tubes and/or ovaries.
IIBExtension to other pelvic intraperitoneal tissues.
Table 3. Definitions of FIGO Stage IIIa
StageDefinition
a Adapted from the Fédération Internationale de Gynécologie et d'Obstétrique.[1]
IIITumor involves one or both ovaries or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes.
IIIA1Positive retroperitoneal lymph nodes only (cytologically or histologically proven):
IIIA1(I): Metastasis ≤10 mm in greatest dimension.
IIIA1(ii): Metastasis >10 mm in greatest dimension.
IIIA2Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes.
IIIBMacroscopic peritoneal metastasis beyond the pelvis ≤2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes.
IIICMacroscopic peritoneal metastasis beyond the pelvis >2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes (includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ).
Table 4. Definitions of FIGO Stage IVa
StageDefinition
a Adapted from the Fédération Internationale de Gynécologie et d'Obstétrique.[1]
IVDistant metastasis excluding peritoneal metastases.
IVAPleural effusion with positive cytology.
IVBParenchymal metastases and metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity).

References:

  1. Berek JS, Renz M, Kehoe S, et al.: Cancer of the ovary, fallopian tube, and peritoneum: 2021 update. Int J Gynaecol Obstet 155 (Suppl 1): 61-85, 2021.
  2. Ovary, fallopian tube, and primary peritoneal carcinoma. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. Springer; 2017, pp 681-90.

Early-Stage Ovarian Low Malignant Potential Tumors

The value of complete staging has not been demonstrated for early-stage cases, but the opposite ovary should be carefully evaluated for evidence of bilateral disease. Although the impact of surgical staging on therapeutic management is not defined, in a study, 7 of 27 patients with presumed localized disease were upstaged following complete surgical staging.[1] In two other studies, 16% and 18% of patients with presumed localized tumors of low malignant potential were upstaged as a result of a staging laparotomy.[2,3] In one of these studies, the yield for serous tumors was 30.8% compared with 0% for mucinous tumors.[4] In another study, patients with localized intraperitoneal disease and negative lymph nodes had a low incidence of recurrence (5%), whereas patients with localized intraperitoneal disease and positive lymph nodes had a statistically significantly higher incidence of recurrence (50%).[5]

In early-stage disease (stage I or II), no additional treatment is indicated for a completely resected tumor of low malignant potential.[6] When a patient wishes to retain childbearing potential, a unilateral salpingo-oophorectomy is adequate therapy.[7,8] In the presence of bilateral ovarian cystic neoplasms, or a single ovary, a partial oophorectomy can be employed when fertility is desired by the patient.[9] Some physicians stress the importance of limiting ovarian cystectomy to stage IA patients in whom the margins of the cystectomy specimens are free of tumor.[4] In a large series, the relapse rate was higher with more conservative surgery (cystectomy > unilateral oophorectomy > TAH, BSO); differences, however, were not statistically significant, and survival was nearly 100% for all groups.[5,10] When childbearing is not a consideration, a total abdominal hysterectomy and bilateral salpingo-oophorectomy is appropriate therapy. Once a woman has completed her family, most, but not all,[4] physicians favor removal of remaining ovarian tissue as it is at risk of recurrence of a borderline tumor, or even rarely, a carcinoma.[2,7]

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

References:

  1. Yazigi R, Sandstad J, Munoz AK: Primary staging in ovarian tumors of low malignant potential. Gynecol Oncol 31 (3): 402-8, 1988.
  2. Snider DD, Stuart GC, Nation JG, et al.: Evaluation of surgical staging in stage I low malignant potential ovarian tumors. Gynecol Oncol 40 (2): 129-32, 1991.
  3. Leake JF, Rader JS, Woodruff JD, et al.: Retroperitoneal lymphatic involvement with epithelial ovarian tumors of low malignant potential. Gynecol Oncol 42 (2): 124-30, 1991.
  4. Piura B, Dgani R, Blickstein I, et al.: Epithelial ovarian tumors of borderline malignancy: a study of 50 cases. Int J Gynecol Cancer 2 (4): 189-197, 1992.
  5. Leake JF, Currie JL, Rosenshein NB, et al.: Long-term follow-up of serous ovarian tumors of low malignant potential. Gynecol Oncol 47 (2): 150-8, 1992.
  6. Tropé C, Kaern J, Vergote IB, et al.: Are borderline tumors of the ovary overtreated both surgically and systemically? A review of four prospective randomized trials including 253 patients with borderline tumors. Gynecol Oncol 51 (2): 236-43, 1993.
  7. Kaern J, Tropé CG, Abeler VM: A retrospective study of 370 borderline tumors of the ovary treated at the Norwegian Radium Hospital from 1970 to 1982. A review of clinicopathologic features and treatment modalities. Cancer 71 (5): 1810-20, 1993.
  8. Lim-Tan SK, Cajigas HE, Scully RE: Ovarian cystectomy for serous borderline tumors: a follow-up study of 35 cases. Obstet Gynecol 72 (5): 775-81, 1988.
  9. Rice LW, Berkowitz RS, Mark SD, et al.: Epithelial ovarian tumors of borderline malignancy. Gynecol Oncol 39 (2): 195-8, 1990.
  10. Casey AC, Bell DA, Lage JM, et al.: Epithelial ovarian tumors of borderline malignancy: long-term follow-up. Gynecol Oncol 50 (3): 316-22, 1993.

Advanced-Stage Ovarian Low Malignant Potential Tumors

Patients with advanced disease should undergo a total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, node sampling, and aggressive cytoreductive surgery. Patients with stage III or IV disease with no gross residual tumor have had a 100% survival rate in some series regardless of the follow-up duration.[1,2] The 7-year survival rate of patients with gross residual disease was only 69% in a large series [3] and appears to be inversely proportional to the length of follow-up.[3]

For patients with more advanced-stage disease and microscopic or gross residual disease, chemotherapy and/or radiation therapy are not indicated. Scant evidence exists that postoperative chemotherapy or radiation therapy alters the course of this disease in any beneficial way.[1,3,4,5,6] In a study of 364 patients without residual tumor, adjuvant therapy had no effect on disease-free or corrected survival when stratified for disease stage.[7] Patients without residual tumor who received no adjuvant treatment had a survival rate equal to or greater than the treated groups. Currently, no controlled studies have compared postoperative treatment with no treatment.

In a review of 150 patients with borderline ovarian tumors, the survival of patients with a residual tumor of less than 2 cm was significantly better than survival for those with a residual tumor from 2 to 5 cm and more than 5 cm.[8] Whether invasive implants imply a worse prognosis remains an unsettled question. Some investigators have correlated invasive implants with poor prognosis, [9] while others have not.[2,10] Some studies have suggested that it may be possible to use DNA ploidy of the tumors to identify those patients who will develop aggressive disease.[11,12] A study could not correlate DNA ploidy of the primary serous tumor with survival but found that aneuploid invasive implants were associated with a poor prognosis.[13] Currently, no evidence indicates that treatment of patients with aneuploid tumors would have an impact on survival. No significant association was found between p53 and HER-2/neu overexpression and tumor recurrence or survival.[14]

In the face of clinical progression, further tumor reductive surgery followed by chemotherapy is certainly indicated. If the symptom-free interval is long, using chemotherapy after a secondary cytoreductive procedure is not advisable. If, on the other hand, the disease symptomatically recurs rapidly, chemotherapy may be beneficial. Reports have surgically documented the efficacy of chemotherapy on some patients with microscopic or gross residual disease.[15,16] A Gynecologic Oncology Group study used melphalan chemotherapy for patients with progressive disease and used cisplatin for melphalan failures.[17]

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

References:

  1. Barnhill D, Heller P, Brzozowski P, et al.: Epithelial ovarian carcinoma of low malignant potential. Obstet Gynecol 65 (1): 53-9, 1985.
  2. Bostwick DG, Tazelaar HD, Ballon SC, et al.: Ovarian epithelial tumors of borderline malignancy. A clinical and pathologic study of 109 cases. Cancer 58 (9): 2052-65, 1986.
  3. Leake JF, Currie JL, Rosenshein NB, et al.: Long-term follow-up of serous ovarian tumors of low malignant potential. Gynecol Oncol 47 (2): 150-8, 1992.
  4. Casey AC, Bell DA, Lage JM, et al.: Epithelial ovarian tumors of borderline malignancy: long-term follow-up. Gynecol Oncol 50 (3): 316-22, 1993.
  5. Tumors of the ovary: neoplasms derived from coelomic epithelium. In: Morrow CP, Curtin JP: Synopsis of Gynecologic Oncology. 5th ed. Churchill Livingstone, 1998, pp 233-281.
  6. Sutton GP, Bundy BN, Omura GA, et al.: Stage III ovarian tumors of low malignant potential treated with cisplatin combination therapy (a Gynecologic Oncology Group study). Gynecol Oncol 41 (3): 230-3, 1991.
  7. Kaern J, Tropé CG, Abeler VM: A retrospective study of 370 borderline tumors of the ovary treated at the Norwegian Radium Hospital from 1970 to 1982. A review of clinicopathologic features and treatment modalities. Cancer 71 (5): 1810-20, 1993.
  8. Tamakoshi K, Kikkawa F, Nakashima N, et al.: Clinical behavior of borderline ovarian tumors: a study of 150 cases. J Surg Oncol 64 (2): 147-52, 1997.
  9. Bell DA, Scully RE: Serous borderline tumors of the peritoneum. Am J Surg Pathol 14 (3): 230-9, 1990.
  10. Michael H, Roth LM: Invasive and noninvasive implants in ovarian serous tumors of low malignant potential. Cancer 57 (6): 1240-7, 1986.
  11. Friedlander ML, Hedley DW, Swanson C, et al.: Prediction of long-term survival by flow cytometric analysis of cellular DNA content in patients with advanced ovarian cancer. J Clin Oncol 6 (2): 282-90, 1988.
  12. Kaern J, Trope C, Kjorstad KE, et al.: Cellular DNA content as a new prognostic tool in patients with borderline tumors of the ovary. Gynecol Oncol 38 (3): 452-7, 1990.
  13. de Nictolis M, Montironi R, Tommasoni S, et al.: Serous borderline tumors of the ovary. A clinicopathologic, immunohistochemical, and quantitative study of 44 cases. Cancer 70 (1): 152-60, 1992.
  14. Eltabbakh GH, Belinson JL, Kennedy AW, et al.: p53 and HER-2/neu overexpression in ovarian borderline tumors. Gynecol Oncol 65 (2): 218-24, 1997.
  15. Fort MG, Pierce VK, Saigo PE, et al.: Evidence for the efficacy of adjuvant therapy in epithelial ovarian tumors of low malignant potential. Gynecol Oncol 32 (3): 269-72, 1989.
  16. Gershenson DM, Silva EG: Serous ovarian tumors of low malignant potential with peritoneal implants. Cancer 65 (3): 578-85, 1990.
  17. Barnhill DR, Kurman RJ, Brady MF, et al.: Preliminary analysis of the behavior of stage I ovarian serous tumors of low malignant potential: a Gynecologic Oncology Group study. J Clin Oncol 13 (11): 2752-6, 1995.

Changes to This Summary (12 / 22 / 2021)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Stage Information for Ovarian Low Malignant Potential Tumors

Added Berek et al. as reference 1.

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of ovarian low-malignant potential tumors. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

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Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Ovarian Low Malignant Potential Tumors Treatment are:

  • Franco M. Muggia, MD (New York University Medical Center)
  • Marina Stasenko, MD ()

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

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PDQ® Adult Treatment Editorial Board. PDQ Ovarian Low Malignant Potential Tumors Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/ovarian/hp/ovarian-low-malignant-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389466]

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Last Revised: 2021-12-22

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