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Borderline ovarian tumours: a continuing conundrum?

Whereas benign and malignant primary tumours of the ovary are well understood clinically, the concept of borderline ones are less so. Of the epithelial tumours of the ovary, the concept is best described in serous tumours, and less so in the other types, largely because serous tumours can present with extra-ovarian nonmalignant spread at the time of diagnosis. The pathological diagnosis of a borderline tumour is essentially one of dysplasia, with no (or minimal) invasion, on good histological sampling of the ovary. In the area of ovarian serous tumours, this has been further complicated by the identification of the micro-papillary subset, and of serous epithelium involving other tissues (implants— invasive versus noninvasive) and what the diagnostic criteria are and what they mean biologically. The paper by Vasconcelos et al. (BJOG 2016) tries to answer this problem by a review of the available literature for pure cohort studies of borderline serous or mucinous ovarian tumours. Although identifying 2665 potential papers, ultimately only 54 papers met their criteria, highlighting the problem with obtaining high quality ‘pure’ studies. Their review of borderline serous versus borderline mucinous tumours with clinical outcomes suggests that the micro-papillary serous borderline pattern and micro-invasion were associated with a greater risk of lethal outcome than pure (‘ordinary’) borderline serous tumours. For mucinous tumours, the findings were by no means as clear cut, but would suggest no real difference, possibly as borderline mucinous tumours very rarely present with extra-ovarian spread at diagnosis. This paper adds to the growing, often contradictory, literature as to the significance of the serous micro-papillary pattern and outcome. It highlights the continuing problem of looking at clinical outcomes against the shifting sands of diagnostic criteria and application: many studies do not include a consistent pathological review, and everything else rests on this. The bulk of the literature does suggest that if pathological criteria are applied correctly, the serous micropapillary subtype and/or micro-invasion and/or the presence of extraovarian tissue involvement does identify a population at greater risk of recurrence/poor outcomes. The need for full staging is, however, essential in case the pathological diagnosis needs to be upgraded from borderline to true cancer. Why does this matter? The clinical dilemma of what do with women with a borderline ovarian tumour diagnosis is problematic in the extreme. Do these women warrant more aggressive treatment at diagnosis or can a watchful waiting policy be more appropriate? We still cannot predict which cases will/may progress with any certainty. The majority of these women are pre-menopausal, with many years of life ahead of them, and hence overtreatment may be just as harmful as under-treatment. The need for accurate pathology, and the distinction from a true low grade serous carcinoma, is vital but often very difficult. The need to exclude metastatic mucinous tumours from a primary ovarian one, even of borderline type, is well described. The questions are easy to raise, but answering them is and continues to be far harder.