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Borderline ovarian tumors: French guidelines from the CNGOF. Part 2. Surgical management, follow-up, hormone replacement therapy, fertility management and preservation - 16/01/21

Doi : 10.1016/j.jogoh.2020.101966 
Nicolas Bourdel a, Cyrille Huchon b, , Cendos Abdel Wahab c, Henri Azaïs d, Sofiane Bendifallah e, Pierre-Adrien Bolze f, g, Jean-Luc Brun h, Geoffroy Canlorbe d, Pauline Chauvet a, Elizabeth Chereau i, Blandine Courbiere j, Thibault De La Motte Rouge k, Mojgan Devouassoux-Shisheboran l, Caroline Eymerit-Morin m, n, Raffaele Fauvet o, Elodie Gauroy p, Tristan Gauthier q, Michael Grynberg r, Martin Koskas p, Elise Larouzee p, Lise Lecointre t, Jean Levêque a, i, Francois Margueritte q, Emmanuelle D’argent Mathieu e, Krystel Nyangoh-Timoh a, i, Lobna Ouldamer a, j, Jade Raad r, Emilie Raimond v, Rajeev Ramanah u, Lucie Rolland i, Pascal Rousset x, y, Christine Rousset-Jablonski w, z, A, Isabelle Thomassin-Naggara c, Catherine Uzan d, Marie Zilliox s, Emile Daraï e
a Service de Chirurgie Gynécologique, CHU de Clermont Ferrand, 1 Place Lucie Aubrac, 63 003, Clermont Ferrand, France 
b Service de gynécologie & obstétrique, GH Saint-Louis Lariboisière-Fernand Widal, Hôpital Lariboisière, Université de Paris, 2, rue Ambroise Paré, 75010, Paris, France 
c APHP.6 Service de Radiologie, Hôpital Tenon, 4 rue de la Chine, Faculté de Médecine UPMC, Sorbonne Université, 75020, Paris, France 
d AP-HP, Hôpital Pitié-Salpêtrière, service de chirurgie et oncologie gynécologique et mammaire, Faculté de Médecine UPMC, Sorbonne Université, 75013, Paris, France 
e Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Institut Universitaire de Cancérologie (IUC), Centre CALG (Cancer Associé à La Grossesse), UMRS-938, Faculté de Médecine UPMC, Sorbonne Université, 75020, Paris, France 
f Service de chirurgie gynécologique et oncologique, obstétrique, 165 Chemin du Grand Revoyet, 69310, Lyon Sud, Pierre Bénite, France 
g Université Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France 
h Service de Chirurgie Gynécologique, Centre Aliénor d’Aquitaine, Hôpital Pellegrin, 33076 Bordeaux, Société Française de Gynéco Pathologie, 81 rue verte, 76000, Rouen, France 
i Service de gynécologie obstétrique, Hopital Saint Joseph, 13005, Marseille, France 
j Centre Clinico-Biologique d’AMP, Pôle Femmes – Parents- Enfants, AP-HM, Hôpital de La Conception, 147 Bd Baille, 13005, Marseille, France 
k Département d’oncologie médicale, Centre Eugène Marquis, 35000, Rennes France 
l Institut de Pathologie multi-sites des HOSPICES CIVILS de LYON, Centre Hospitalier Lyon Sud, Centre de biologie et pathologie Sud, 165 Chemin du Grand revoyet, 69495 Pierre Bénite, Société Française de Gynéco Pathologie, 81 rue verte, 76000, Rouen, France 
m Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, HUEP, 4 rue de la Chine, 75020, Paris, UPMC Paris VI, Sorbonne Universities, France 
n Institut de Pathologie de Paris, 35 boulevard Stalingrad, 92240, Malakoff, France 
o Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire de Caen, 14000, Caen, France 
p Service de Gynécologie-Obstétrique, Hôpital Bichat, 46 Rue Henri Huchard, Université de Paris, 75018, Paris, France 
q Service de Gynécologie-Obstétrique, Hôpital Mère-Enfant, CHU Limoges, 8 av Dominique Larrey, 87042, Limoges, France 
r Service de Médecine de la Reproduction, Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92140, Clamart, France 
s Centre Hospitalier Universitaire Hautepierre, Hôpital de Hautepierre, CHRU Strasbourg, 1 avenue Molière, 67000, Strasbourg, France 
t Département de Gynécologie Obstétrique et Reproduction Humaine, 16, boulevard de Bulgarie, CHU Anne de Bretagne, UFR Médecine Université de Rennes 1, 35000, Rennes, France 
u Département de Gynécologie, Centre hospitalier universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37000, Tours, France 
v Département de Gynécologie Obstétrique, Institut Alix de Champagne, CHU Reims, 51100, Reims, France 
w Pôle Mère-Femme, CHU Besançon, 3 boulevard Fleming, 25000, Besançon, France 
x Service de Radiologie, Centre Hospitalier Lyon Sud, HCL, EMR 3738, 165 Chemin du Grand Revoyet, 69310, Lyon Sud, Pierre-Bénite, France 
y Université Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France 
z Centre Hospitalier Lyon Sud, Pierre-Bénite, France 
A Université Claude Bernard Lyon 1, EA 7425 Hesper, Health Service and Performance Research, Domaine Rockefeller, 8 Avenue Rockefeller, 69373, Lyon Cedex 8, France 

Corresponding author.

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Abstract

In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C). In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C).

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Keywords : Borderline ovarian tumor, Guidelines


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Vol 50 - N° 1

Article 101966- janvier 2021 Retour au numéro
Article précédent Article précédent
  • Borderline ovarian tumors: French guidelines from the CNGOF. Part 1. Epidemiology, biopathology, imaging and biomarkers
  • Cyrille Huchon, Nicolas Bourdel, Cendos Abdel Wahab, Henri Azaïs, Sofiane Bendifallah, Pierre-Adrien Bolze, Jean-Luc Brun, Geoffroy Canlorbe, Pauline Chauvet, Elisabeth Chereau, Blandine Courbiere, Thibault De La Motte Rouge, Mojgan Devouassoux-Shisheboran, Caroline Eymerit-Morin, Raffaele Fauvet, Elodie Gauroy, Tristan Gauthier, Michael Grynberg, Martin Koskas, Elise Larouzee, Lise Lecointre, Jean Levêque, Francois Margueritte, Emmanuelle Mathieu D’argent, Krystel Nyangoh-Timoh, Lobna Ouldamer, Jade Raad, Emilie Raimond, Rajeev Ramanah, Lucie Rolland, Pascal Rousset, Christine Rousset-Jablonski, Isabelle Thomassin-Naggara, Catherine Uzan, Marie Zilliox, Emile Daraï
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