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Role of fertility-sparing surgery and further prognostic factors in borderline tumors of the ovary
  1. Timo Westermann1,
  2. Edin Karabeg1,
  3. Florian Heitz1,2,
  4. Alexander Traut1,
  5. Helmut Plett1,2,
  6. Malak Moubarak1,
  7. Julia Welz1,
  8. Sebastian Heikaus3,
  9. Sigurd Lax4,
  10. Andreas du Bois1 and
  11. Philipp Harter1
    1. 1Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
    2. 2Department of Gynecology, European Competence Center for Ovarian Cancer, Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
    3. 3Center of Pathology Essen-Mitte, ZPEM, Essen, Germany
    4. 4Pathology, General Hospital Graz II, Location West; Styrian Hospital Corporation and Medical University of Graz, Graz, Austria
    1. Correspondence to Dr Timo Westermann, Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen 45136, Germany; tywest{at}


    Objective Borderline tumors of the ovary are a rare group of ovarian neoplasms with distinctive histological features. Considering their favorable prognosis and occurrence at a younger age, fertility-sparing surgery may be considered. Several risk factors have been identified as contributing to a higher recurrence rate, while the impact of pathohistological features varies in the literature. This study aimed to analyze risk factors for recurrence in patients with borderline tumors of the ovary.

    Methods Analysis included patients treated with first diagnosis of a borderline tumor at our center between January 1997 and December 2022 to analyze disease-free survival and to identify the role of fertility-sparing surgery, defined as preservation of at least one ovary, pathohistological features, and other prognostic factors for relapse. All stages classified according to the International Federation of Gynecology and Obstetrics (FIGO) were included.

    Results Among 507 patients, 26 patients (5.2%) had a recurrence, with 21 (4.1%) showing borderline histology and 5 (1%) with invasive relapses. Recurrence rate was higher following fertility-sparing surgery (p<0.0001). Median follow-up period was 49.2 (range 42.0–57.6) months. Among 153 patients (30.2%) who had fertility-sparing surgery, 21 (13.7%) experienced a recurrence (including one invasive relapse). Fertility-sparing surgery (HR 20; 95% CI 6.9 to 60; p<0.001), FIGO stage I with bilateral presence of tumor (HR 6.4; 95% CI 1.3 to 31; p=0.020), FIGO stage II (HR 15; 95% CI 3.4 to 68; p<0.001), FIGO stages III-IV (HR 38; 95% CI 10 to 140; p<0.001) in comparison with FIGO stage I with unilateral tumor, microinvasion (HR 8.6; 95% CI 2.7 to 28; p<0.001), and micropapillary growth patterns (HR 4.4; 95% CI 1.8 to 10; p=0.001) were identified as independent risk factors for recurrence in multivariate analysis. None of these factors were associated with an increased risk of disease-related death.

    Conclusions Our study showed that although a fertility-preserving approach is associated with increased recurrence rates of a borderline tumor, it does not affect overall survival and can therefore be regarded as oncologically safe for patients desiring to preserve fertility. Additionally, presence of micropapillary patterns and microinvasion were identified as prognostic risk factors.

    • Ovarian Diseases
    • Ovarian Cancer
    • Gynecologic Surgical Procedures
    • Cytoreduction surgical procedures
    • Adnexal Diseases

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    • Contributors TW and PH designed and supervised the project. TW, EK, and AT worked on follow-up data. AT handled technical details, and was responsible for numerical calculations. TW wrote the manuscript with the input of all authors. PH, AdB, HP, MM, EK, and FH revised the data and the manuscript. SH conducted most of the pathology and SL performed the majority of the expert review of pathology. TW is responsible for the overall content as guarantor. All authors provided critical feedback and contributed to the research and manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests TW: nothing to disclose. FH: consulting fees: AstraZeneca, GSK, Roche, Tesaro. AdB: consulting fees: Roche, BIOCAD, Astra Zeneca, Zodiac, GSK/Tesaro, Amgen, Clovis, Genmab/Seattle Genetics, MSD; honoraria: Roche, Astra Zeneca, GSK/Tesaro, Clovis, BIOCAD, Zodiac, Amgen. SL: honoraria for lectures and participation in advisory boards from GSK, MSD, Astra Zeneca, Janssen, Novartis, Pharma-Mar. PH: honoraria: Amgen, Astra Zeneca, GSK, Roche, Sotio, Stryker, Zai Lab, MSD, Clovis, Eisai, Mersana, Exscientia; consulting fees: Astra Zeneca, Roche, GSK, Clovis, Immunogen, MSD, Miltenyi, Novartis, Eisai; grants: Astra Zeneca, Roche, GSK, Genmab, Immunogen, Seagen, Clovis, Novartis (all institutional); support for attending meetings: Astra Zeneca. EK, AT, HP, MM, JW, SH: nothing to disclose.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.