Current Update On Borderline Ovarian Neoplasms Essay

Borderline ovarian tumours comprise an interesting group of non-invasive ovarian epithelial tumors with characteristic histology and variable tumour biological science. Borderline ovarian tumours typically manifest as low-stage disease in younger adult females with attendant first-class forecast. Borderline tumours are now considered to be precursors of low-grade ovarian malignant neoplastic diseases. Accurate diagnosing and theatrical production of boundary line tumours facilitates optimum patient direction peculiarly in patients wanting birthrate saving. Current Update On Borderline Ovarian Neoplasms Essay.

Introduction
Borderline ovarian tumours ( BOTs ) constitute up to 20 % of ovarian epithelial tumors. BOTs are histologically characterized as epithelial tumours with graded growing form but without stromal invasion. BOTs are a hetereogeneous disease with specific cell types that appear to arise or distinguish along different Mullerian epithelial tissue that line the fallopian tubing ( serous ) , endometrium ( endometrioid ) , endocervix ( mucinous ) , and vaginal nests ( clear cell ) . Howard Taylor is credited with the first usage of the term ‘semi-malignant tumours ‘ in 1929 to a subset of big ovarian tumours that chartered an faineant clinical class. However, BOTs were non considered a distinguishable entity until 1971. Since so, considerable contention has surrounded the definition and direction of BOTs due to puzzling tumour pathogenesis and vexing biological behaviour ( 1 ) . Although usage of the term ‘tumors of boundary line malignance ‘ is presently discouraged, tumours of low malignant potency and untypical proliferative tumour may be used as recognized equivalent word.

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Several surveies in the last 2 decennaries have demonstrated characteristic cytogenetics, epidemiology, natural history and biological behaviour of specific subtypes of boundary line ovarian tumours. It has been postulated that specific familial alterations contribute to the pathogenesis of BOTs every bit good as stepwise patterned advance to low-grade ovarian carcinomas. Although there is important convergence of imaging characteristics of BOTs with that of invasive epithelial malignant neoplastic diseases, imaging surveies play a major function in diagnosing, direction and surveillance of patients with BOTs.

Epidemiology
Borderline ovarian tumours typically affect white adult females during the 4th decennary. BOTs occur in adult females of generative age group ; up to 27 % of patients are aged less than 40 old ages.
Serous BOT ‘s ( SBT ‘s ) histories for about 65 % of all BOT ‘s. The patients with SBT ‘s are 10-15 years younger than those with serous carcinoma i.e. average age of 40 years Vs. 60 year. It is notable that 30-50 % SBT ‘s are bilateral.
The Mucinous BOT ‘s ( MBT ‘s ) history for approximately 32 % of all BOT ‘s. The enteric subtype histories for 85-90 % of MBT ‘s and staying are endocervical type. Current Update On Borderline Ovarian Neoplasms Essay.
The other uncommon BOT ‘s history for remainder of the 3 % of all BOT ‘s and consist of endometroid, clear cell and transitional cell ( Brenner ‘s ) assortments.

Taxonomy
Harmonizing to the 2003 World Health Organization categorization scheme, boundary line ovarian tumors are classified into serous, mucinous, endometroid, clear cell and Brenner ( transitional ) subtypes. Serous and mucinous tumors constitute & gt ; 95 % of boundary line tumours. Serous BOTs are biologically aggressive and may be associated with peritoneal ‘implants ‘ in up to 35 % of patients. Mucinous BOTs are farther classified into enteric and endocervical subtypes and may be associated with pseudomyxoma peritonei.
Table-1 Classification of Borderline tumour

Serous Tumors ( 65 % )

With Micro-invasion
Without Micro-invasion

Mucinous Tumors ( 32 % )

Intestinal type
Endocervical type

Assorted Tumors: ( 3 % )

Endometroid Tumors
Clear Cell Tumors
Transitional Cell Tumors: Brenner Tumor

Serous Borderline Tumors ( SBOT ‘s )
SBOT ‘s are tumours of low malignant potency exhibiting an untypical epithelial proliferation within a predominant cell types resembling those of the fallopian tubing. A typical SBOT purely follows the definition of BOT ‘s and does non demo any destructive invasion of stroma. However, a little subset of untypical SBOT ‘s besides exists, which may demo destructive stromal invasion and called as ‘SBOT ‘s with micro invasion ‘ . The average age for SBOT ‘s is 40yrs. The patients are normally symptomless or may show with abdominal expansion or pelvic hurting. In younger patients SBOT may be associated with sterility.
At the clip of presentation bulk of SBOT ‘s ( with or without micro invasion ) are confined to ovary ( Stage-I ) . However, some SBOT ‘s with micro invasion may hold peritoneal implants beyond the pelvic girdle in 10 % and have hepatic metastasis in 2.5 % instances. Pelvic and para-aortic lymph nodes are involved by SBOT in approximately 28 % of instances. Lymph nodal engagement appears to be without clinical significance ( 23, 24 ) and it does non adversely impact the overall endurance of patients with ovarian SBOT. Current Update On Borderline Ovarian Neoplasms Essay.
The alone term of ‘peritoneal implants ‘ is frequently described with SBOT ‘s with micro-invasion. The implants may be invasive or non invasive. Non invasive implants occur more normally ( 78 % ) than invasive implants ( 22 % ) . Bell and co-workers ( 25 ) used the term invasive ” to mention to invasion of underlying tissue ( omentum, intestine wall, etc. ) . Non-invasive lesions were stucked on ” the peritoneal surfaces, without invasion of implicit in tissue. The noninvasive implants are farther divided into epithelial type and desmoplastic type. Since a desmoplastic stromal response in other state of affairss is normally regarded as grounds of invasive malignant neoplastic disease, it is of import to acknowledge desmoplastic type of non-invasive implants by diagnosticians. Though the non-invasive implants have no negative influence on forecast but the invasive 1 is associated with hapless forecast, i.e. more than 50 % have returns and the 10 year endurance is merely approximately 35 % ( 26 ) . Histologically, the SBOT ‘s are divided into typical and micro papillose types. The typical signifiers makes up the huge bulk ( 90 % ) , while the micro-papillary signifier histories for little proportion ( 5-10 % ) . Serous surface boundary line tumour is another SBOT discrepancy demoing polypoid bulges formed by all right papillae with characteristics of SBOT occupy the outer surface of ovary. Micro-papillary serous carcinomas ( MPSC ) have higher frequences of bilateralism, surface ovarian engagement, advanced phase or excess ovarian disease at the clip of presentation, and invasive implants. ” It is suggested that most of the adult females with micro papillose tumour should ever hold a careful and ex-tended presenting laprotomy to seek for invasive disease outside the ovary ( 27 ) .
After the exclusion of MPSC and SBOT with invasive implants, the endurance of BOT ‘s confined to ovary is up to 99-100 % ( 33a ) . However, SBOT ‘s with peritoneal implants and distribution throughout the abdominal pit ( Stage-II-III ) may merely hold 55-75 % 5 year endurance. Recurrence rate in is about 15-20 % for SBOT ‘s.

Mucinous Borderline Tumors ( MBOT ‘s )
Mucinous tumours show some or all of epithelial cells incorporating intra-cytoplasmic mucin. MBOT ‘s are tumours of low malignant potency exhibiting an untypical epithelial proliferation of mucinous cells greater than that seen in their benign opposite number but without grounds of stromal invasion. They are farther subdivided into enteric and endocervical types. Current Update On Borderline Ovarian Neoplasms Essay.The enteric type ever contains some goblet cells and histories for 85-90 % of all MBOT ‘s ; the remaining is endocervical type. Endocervical type may be associated with abdominal or pelvic implants, which may be invasive in some of the instances. It ‘s interesting that in some instances these implants may originate from independent focal point of adenomyosis with in situ transmutation.
Most of the MBOT ‘s are confined to ovary at the clip of diagnosing and does clinically act similar to SBOT ‘s. The patients with these tumours seldom recur or die of disease.
Advanced phase MBOT ‘s have a mortality of about 50 % . It is really of import to except a metastatic adeno-carcinoma normally but non entirely from gastro-intestinal ( Usually appendiceal or colonic ) piece of land ; as a metastatic mucinous glandular cancer in the ovary, can mime non merely primary mucinous glandular cancer but besides mucinous BOT and even primary benign mucinous ovarian tumours. It is hard to separate these supernatural metastases from primary ovarian tumours.
A known presence of an extraovarian primary mucinous carcinoma is diagnostically utile. The immuno-histochemistry is besides of considerable value. In primary mucinous enteric ovarian tumours, cytokeratin ( CK ) 7 is virtually ever positive, and CK 20 is positive in about half of the instances ; on the other manus, in metastatic colorectal carcinomas, CK 20 is virtually ever positive and CK 7 negative ( 31 ) .
Syndrome of pseudomyxoma peritonei ( defined as the presence of mucinous ascites incorporating variable Numberss of mucinous cells and secretory organs ) is about ever the consequence of a ruptured low-grade mucinous tumour of the appendix and mucinous ascites in a patient with an evident mucinous enteric BOT should be considered strong presumptive grounds that the ovarian tumour really represents a metastasis ( 31 ) .

Assorted Borderline Tumor
Other uncommon assortments of BOT ‘s consist ; endometroid, clear cell and transitional cell ( Brenner ‘s ) assortments. Endometroid BOT ‘s resemble the correspondent endometroid tumours originating from uterine principal. These are ovarian tumours of low malignant potency composed of untypical or histologically malignant endometroid type secretory organs or cysts with absence of stromal invasion. They appear to be derived from surface epithelial tissue of ovary or adenomyosis. The patient age ranges between 22-77 year. The tumours are preponderantly one-sided. As described above the Endometroid BOT ‘s are known to transform into carcinomas. The forecast is first-class and recurrences/metastasis is rare. Current Update On Borderline Ovarian Neoplasms Essay.
Clear cell BOT ‘s are ovarian tumours of low malignant potency composed of untypical or histologically malignant secretory organs or cysts lined by clear or hobnail cells set in a dense hempen stroma with absence of stromal invasion. It has a average age of 65 years at presentation. These tumours have benign class following remotion of ovary. Clear cell BOT ‘s are besides known to transform into matching carcinomas.
Borderline Brenner ‘s tumours are ovarian transitional cell tumours of low malignant potency with untypical or malignant characteristics of epithelial tissue but missing stromal invasion. Merely 3-5 % of Brenner ‘s tumours are marginal.

Staging of BOT ‘s
BOT ‘s follow a similar theatrical production system that of ovarian epithelial carcinomas. The theatrical production is surgical and the suggested guidelines include biopsy specimen from omentum, enteric serosa/mesentery, pelvic peritoneum including cul-de-sac, vesica peritoneum and pelvic wall ; abdominal peritoneum including para colic trough and diaphragmatic surface ; and retroperitoneal nodes ( 3 ) . The FIGO theatrical production for ovarian tumours is summarized in table-2.

Tumorigenesis and oncogenesis:
Harmonizing to the classical position of ovarian carcinogenesis ” , the BOT ‘s may stand for intermediate phase between benign and malignant lesions, but familial profile paradoxically indicates that some BOT ‘s have small capacity to transform into a malignant phenotype.
Out of all histologic assortments the most discussed and most evaluated is serous BOT ‘s, likely because of its highest frequence in pattern. Ortiz et Al. have compared mutational profiles of p53 and KRAS cistrons in Serous BOT ‘s and the subsequent serous carcinomas from the same patients and found that Serous BOTs were molecular genetically different from the serous carcinomas ( 4 ) . Loss of heterozygosity on the long arm of the inactivated X-chromosome is characteristically seen in SBOT ‘s but rare in carcinomas. Current Update On Borderline Ovarian Neoplasms Essay.
It is now accepted that some boundary line tumours are precursors of invasive carcinoma, and others are non.
Kurman and Shih ( 5, 6, 7 ) have late described ‘Model of Ovarian Carcinogenesis ‘ proposing two distinguishable tracts of tumorigenesis taking to the development of invasive low class ( type-I ) micro-papillary serous carcinoma ( MPSC ) and usual high class ( type-II ) serous carcinoma ( 5, 6, 7 ) . New ‘dualistic ‘ theoretical account of serous carcinogenesis, explains the deficiency of association of Serous BOTs with the usual type of serous carcinoma on the one manus and the occasional malignant behavior of serous BOTs on the other manus.
In first tract, the sequence mimics the colorectal adeno-carcinoma sequence, where the carcinoma evolves through a continuum of histologically recognizable precursor lesions. The precursor or usual type of benignantly acting serous BOT is termed as Atypical Proliferative Serous Tumor ( APST ) ” ( 8 ) and during tumour patterned advance, the invasive MPSCs develop from APSTs with the non-invasive MPSCs stand foring a transitional measure in this patterned advance. Foci of invasion can develop in these non-invasive tumours and when they overgrow the non-invasive constituent, it called as invasive MPSC.
In the 2nd tract ; top-quality serous carcinomas develop quickly, presumptively from inclusion cysts or ovarian surface epithelial tissue ( de novo without any precursors ) .
This Manichaean theory explains that why some BOT ‘s are precursors of malignance but others are non.
Serous BOT ‘s hence may transform into low class serous carcinoma following cysadenoma-borderline tumor-carcinoma sequence. Genes of the RAF household, mediate cellular responses to growing signals, encode kinases that are regulated by RAS and take part in the RAS/RAF/MEK/ERK/MAP-kinase tract. The high prevalence of B-RAF/ K-RAS mutants in SBOT ‘s in contrast to serous carcinomas indicates that the mitogenic RAS-RAF-MEK-ERK-MAP kinase tract is important for the pathogenesis of SBOT’s.. There are strong groundss that ERK inhibitor Dusp-4 and u PA -inhibitor serpina-5 are chiefly responsible for faineant behaviour of SBOT ‘s. These tumour suppresser cistrons in bend affect other cistrons modulating peptidase activity, such as MMP-9 ( Matrix Metallo-peptidase 9 ) , which are responsible for debasement of proteins in the extracellular matrix.Current Update On Borderline Ovarian Neoplasms Essay.  Destructive stromal invasion due to the activation of MMP-9 in serous carcinoma is likely related to loss of ERK and u PA -inhibition and down ordinance of Dusp-4 and serpina-5. ( *Nathalie et Al )
Non serous boundary line tumours are frequently associated with their corresponding carcinomas, therefore stand foring an intermediate phase in the stepwise patterned advance to carcinoma
Mucinous boundary line tumours are known to follow cysadenoma-borderline tumor-carcinoma sequence and transform into mucinous carcinoma. KRAS and TP53 mutational activation are associated with passage from mucinous boundary line tumour to carcinoma.
Endometriosis and endometroid adenofibromas are the precursors of endometroid cell boundary line tumours. The endometroid BOT ‘s have possible to come on to invasive carcinoma. Though the clear cell BOT ‘s besides have similar precursors like endometroid BOT ‘s but molecular grounds for the stepwise patterned advance to carcinoma is missing. Molecular characteristics like loss of heterozygosity or mutants in PTEN, & A ; szlig ; -catenin cistron mutants, and microsatellite instability have been described with endometroid tumour patterned advance.
Similarly, KRAS mutants and microsatellite instability have been expressed with clear cell pathogenesis.
Brenner ‘s tumours are the precursors of Brenner ‘s BOT ‘s and may come on to malignant Brenner ‘s carcinoma. However, associated molecular and genic alterations in tumour patterned advance have yet non been described.

Imaging modes and techniques
The ability to separate boundary line from early phase malignance and precise preoperative theatrical production, may assist many of immature patients with uncomplete households necessitating birthrate preservation. However, on the other manus inaccurate pre-operative diagnosing of marginal tumour on the footing of imaging or any other work-up may ensue in colored uncomplete surgical resection and theatrical production ; discharge of patient without proper intervention.
On imaging all ovarian tumours are normally cystic, solid-cystic or preponderantly solid in nature. Universally accepted imaging hints proposing malignance are bilateralism of lesion, large size of lesion ( transcending 4cm ) , thick internal septations ( & gt ; 2mm ) , preponderantly solid lesion and contrast sweetening of wall, septate and solid constituents.
Unfortunately, both BOT ‘s and early phase ovarian malignance have some or the other overlapping characteristics on imagination and imagination have limited clinical public-service corporation in pre-operative diagnosing of BOT ‘s ( 3 ) . Current Update On Borderline Ovarian Neoplasms Essay.
Ultrasonography
The Ultrasonography ( US ) is the primary showing imaging mode in the rating of any suspected annexal mass ( 10,11 ) and to test its returns. Use of colour and spectral Doppler US may supply extra information on angio-architectural inside informations. However, it has been shown that both US and Color Doppler have limited function in word picture of ovarian boundary line tumours. Exacoustos ( 12 ) et al published a retrospective survey on 33 adult females with histologically proved diagnosing of BOT ‘s and concluded that though the most frequent diagnostic characteristic on US imagination was the presence of papillae within the cyst but neither papillae nor other sonographic characteristics constituted extremely sensitive sonographic markers of BOT ‘s.
US is limited by both patient and operator related factors like forte preparation of the sonographer, the patient ‘s menopausal position and the deficiency of specific sonographic diagnostic standards, in accurate word picture of ovarian tumor.
It is now good accepted that on ultrasound, the lesion is categorized merely into ‘benign ‘ and ‘non-benign ‘ tumours ( really dwelling both malignant and marginal tumours ) . The Color Doppler survey reveals increased blood flow in ‘non-benign ‘ tumours with lower RI and PI. However, none of the grey scale US or Color Doppler can segregate ‘non-benign ‘ into BOT ‘s and malignant lesions.
Hazard of Malignancy Index ( RMI )
Hazard of Malignancy Index ( RMI ) is calculated with the combination of transvaginal ultrasound scrutinies ( US ) , CA-125 degree in blood and menopausal position. A cut off of 200 is taken important to know apart a benign pelvic mass from an ovarian malignant neoplastic disease ( 13 ) . However, it is notable that the CA 125 may or may non be elevated in instance of BOT ‘s.
Cross sectional Imaging
Research workers have reported diagnostic truths of 91-93 % and 89.15 % with MR ( 14,15 ) and MDCT imagination ( 16 ) severally, to qualify annexal multitudes into benign and malignant lesions. Current Update On Borderline Ovarian Neoplasms Essay.Presently, the sonographically undetermined lesions require MR imaging to qualify it farther ; and both MR and MDCT can be used in patients with known ovarian malignances to observe peritoneal metastasis and supply preoperative planning and theatrical production. It is notable that pre-operative segregation of BOT ‘s and early malignances is the most of import important issue on imaging and none of the MR or MDCT have been shown encouraging consequences.
PET-CT
PET-CT, which reveals the functional alterations in the tumour instead than the anatomy, has shown assuring diagnostic value to know apart between benign disease and ovarian malignant neoplastic disease and for turn uping distant metastases. Unfortunately, marginal tumours were interpreted as benign on PET/CT ( 17 ) .

Individual subtypes with imaging findings
Serous Borderline Tumor
Macroscopically and on imagination, SBOT ‘s ( with or without microinvasion ) may be cystic ( Uni or Multilocular ) with variable Numberss of septations, may demo solid constituents or papillose projections from cyst wall or septations, both intra or extracystic bulges ( sometimes giving rise to predominant solid visual aspect ) or a combinations of any of these characteristics. Contrary to carcinomas, SBOT ‘s normally lack mortification and bleeding ( 26 ) .
SBOT ‘s should be suspected when a preponderantly cystic tumour is associated with legion endocystic or exocystic floras that present moderate sweetening during dynamic contrast enhanced MRI without an associated solid part.
MR visual aspect of serous and mucinous BOT ‘s has late been classified into four morphological groups by Bent et Al ( 28 ) .The categorization grouped BOT ‘s harmonizing to the presence and figure of septations, presence of solid constituents and papillose projections, and heightening form. Bent ‘s group 1 & A ; 2 lesions were preponderantly but non entirely serous BOT ‘s. The group -1 lesions were unilocular ( without septations ) and shown heightening intracystic papillose projections originating from cyst wall. The group-2 & A ; 3 lesions were multi-cystic with internal septations. However, the group-2 lesions had & lt ; 5 figure of septae, while group-3 had & gt ; 5 septations. Current Update On Borderline Ovarian Neoplasms Essay. The group-2 lesions had intracystic heightening frond like or papillose solid constituents originating from septations and cyst wall. The group-3 lesions were described as preponderantly mucinous BOT ‘s, though merely 57 % of tumours were really mucinous in beginning. These lesions typically had non-enhancing mucinous globules in dependent portion, intracystic/Plaque like inspissating and changing grade of cyst and septate wall thickness. The group-4 lesion were described as entirely serous in nature, demoing heightening and preponderantly solid visual aspect due to environing external Brassica oleracea botrytis like projections originating from cardinal cystic focal point. Bent ‘s morphological categorization is alone but does n’t qualify any of the BOT ‘s with assurance. As per the categorization the findings in a specific group are implicative of a specific histologic group but non diagnostic. The imagination characteristics are overlapping within assorted groups every bit good as with early phase carcinoma and the false positive/negative rates could be important.
Characteristic imagination characteristics of SBOT ‘s with invasive implants have been described by Tsuyoshi et Al ( 29 ) , which are parallels to Bent ‘s group-4 lesions. The macroscopic visual aspect of the tumour showed profuse papillose projections dwelling of many cysts punching and widening far beyond the ovarian capsule without a solid constituent. The lesion had high signal strength on the contrast-enhanced T1-weighted image and a big portion of the lesion had H2O signal strength on the T2-weighted image, proposing the absence of an obvious solid portion ( 18, 30 ) .

Mucinous Borderline Tumor
Macroscopically and on imagination, both assortments of MBOT ‘s may be larger ( twice the size of SBOT ‘s ) , multi-locular or unilocular cystic multitudes incorporating watery or syrupy mucoid stuff. Bleeding, mortification and solid or papillose countries may besides be apparent in both of the assortments. However, the endocervical MBOT ‘s are paucilocular, show exophytic form ( make non esteem ovarian capsule ) , normally smaller than enteric types and bilateral in important instances ( 40 % ) .
In Bent ‘s categorization the imaging findings of group-3 are implicative of MBOT ‘s. They are described to hold big figure of septae ( & gt ; 5 ) and variable thickness of cyst wall and sepate. Intracystic plaque like inspissating was entirely seen in these lesions. Interestingly, approximately 43 % of ‘characteristic ‘ group-3 lesions were really non MBOT ‘s in their ain survey hence these imaging findings can non confidently qualify the lesions.
Bazot et ( 18 ) described that mucinous BOT ‘s unambiguously have multilocular cystic mass has legion septa incorporating fluids of different signal strengths on T1- or T2-weighted MR images and endocystic floras demoing delayed consumption of contrast medium. Current Update On Borderline Ovarian Neoplasms Essay. On T1W images the mucinous constituent shows high signals ( 32 ) .However, it has been described that SBOT ‘s may on occasion hold mucinous fluid within the cysts ( 26 ) .
Endometroid SBOT ‘s are Macroscopically, these tumours range in size from 2-40cms and demo solid to preponderantly solid with cystic countries ( few millimeter -8cm cysts ) .Larger tumours may hold bleeding and mortification.
Brenner ‘s Macroscopically, they are big with a average diameter of 16-20cm. They may hold solid or multi-cystic constituent with papillose or polypoid multitudes. They are normally one-sided and frequently confined to ovary at the clip of presentation, hence show good forecast.
It is evident that even these uncommon assortments of BOT ‘s do non demo any characteristic characteristic and may resemble with other BOT ‘s every bit good as early phase carcinomas. Almost all the classically described marks of malignance like septations, solid constituents, implants, nodal metastasis, bilateralism and ascites are shared by certain subsets of BOT ‘s.

Imaging progresss
Recently, a few of the newer techniques and surveies have shown some of the encouraging consequences in pre-operative word picture of ovarian tumours. However, none of them is able to segregate BOT ‘s and early malignances with high degree of assurance and diagnostic truth but they may hold a futuristic potency and application.
The most discussed in recent literature is ‘Dynamic MR imaging ‘ , which has evaluated characteristics of Benign, Borderline and Malignant lesions and shown some encouraging consequences ( 18, 19, 20 ) . Bazot et Al ( 18 ) have described a alone manner of segregating benign, boundary line and malignant tumours on dynamic MR imagination. They evaluated ovarian tumours during the arterial stage ( 30 s ) of dynamic MRI and on post-contrast MR images ( & gt ; 4 min ) . The time-intensity curves of BOTs were compared with those of normal outer myometrium. The curves demoing a gradual addition without a chiseled extremum were good correlated to benign ovarian tumours, the curves with moderate initial sweetening followed by a tableland largely represented boundary line ovarian tumours. The carcinomas had intense initial sweetening get downing even before myometrial sweetening. Current Update On Borderline Ovarian Neoplasms Essay.
‘Virtual spherical tissue trying ‘ ( 21 ) utilizing three-dimensional ( 3D ) ultrasound power Doppler angiography to heighten distinction between normal and diseased ovaries is another newer technique which may hold futuristic potency. Vascularity indices for both 1-cm3 spherical samples and whole dense parts of the ovaries were compared in assorted groups. Spherical 1-cm3 sampling achieved a higher grade of favoritism between the groups compared with the whole solid-part attack. Kudla et Al concluded that spherical 1-cm3 sampling of ovarian tissue with 3D ultrasound power Doppler angiography is a sensitive and promising attack to distinguish between assorted ovarian tumours ( including boundary line tumours and malignances ) and normal ovaries.
Another prospective attack with futuristic applications can be development of discordant MRI-PET imagination, which may assist distinguish boundary line from malignant ovarian tumours. Jung et Al ( 22 ) have described a retrospective survey of 8 patients with pathologically confirmed boundary line ovarian tumours ( BOT ) who underwent MRI and FDG-PET before surgical theatrical production. Though MR findings were compatible with malignant ovarian tumours but
PET imagination was implicative of benign nature. This discordance of two imaging modes may segregate BOT ‘s from malignant tumours.

Management of BOT ‘s and algorithms for followup: ( Refer fig.2 & A ; 3 )
Any adult female with a leery adnexal mass is foremost evaluated with transvaginal US. The findings with high leaning of ovarian malignant neoplastic disease is explored through laprotomy and entire hysterectomy with bilateral salpingoophorectomy, bilateral pelvic and para-aortic lymphadenectomy and selected peritoneal biopsies.
If the transvaginal US is non exactly determined, one may choose for an MRI for farther rating.Current Update On Borderline Ovarian Neoplasms Essay.  However, in most of the instances both benign and BOT ‘s require confirmatory and concluding diagnosing by diseased rating after surgical deletion. Midline laprotomy is preferred over laparoscopic attack due to chance of underestimate of theatrical production, chance of port site metastasis and opportunities of cyst rupture and spillage during the process. Adequate theatrical production is must to find forecast.
If the postoperative histopathology suggests BOT without invasion, peritoneal seeding or distant metastasis, no farther intervention is required. However, advanced phase disease requires combination of cyto-reduction surgery and Pt based chemotherapy.

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Barakat et Al ( 33 ) have shown complete clinical response in advanced phase BOT ‘s with microscopic residuary disease treated with chemotherapy. Recurrences occur on norm in 10-15 % of SBOT ‘s. Optimal or complete surgical deletion of the returns had a better response to chemotherapy and better overall endurance.
Patient with suspected BOT is as per the pre-operative work-up and wanting birthrate saving may choose for cystectomy or salpingo-oophorectomy alternatively of entire hysterectomy.
Morris et Al ( 31 ) reviewed 43 adult females undergone conservative surgeries ( cystectomies or ovariectomies ) for BOT ‘s. Women undergoing ovarian cystectomy were more likely to necessitate extra surgeries ( 63 % vs. 40 % ) in the hereafter and more likely to repeat ( 75 % vs. 24 % ) , when compared with adult females undergoing ovariectomies. 41 out of 43, survived and 24 attempted gestations and 50 % were successful. About one tierce of the cautiously treated patients conceived but it was at the disbursal of statistically important greater return frequence. Hence, patients with cystectomies require close surveillance because of the hazard of return and demand for future surgery.
In advanced staged marginal tumours or BOT ‘s with invasive implants ; a extremist surgery is suggested due to high hazard of returns as invasive ovarian carcinomas. In add-on, appendicectomy is frequently suggested along with extremist surgery in instance of mucinous BOT ‘s. Current Update On Borderline Ovarian Neoplasms Essay.
Lymphadenectomy does non hold any impact over endurance or return, therefore non recommended in instance of BOT ‘s.
Follow-up is normally done with combination of clinical scrutiny, transvaginal US and CA 125 degrees. During initial two old ages follow up is required at every 3 months. The frequence so becomes half annually and annually between 3rd to fifth old ages and after 5th twelvemonth severally. ( Refer fig-3 )
The most of import predictive factor is phase at the clip of diagnosing. All stage-I BOT ‘s have first-class forecast irrespective of implants and lymph node engagement. However, the presence of invasive implants is associated with higher return rate. Primary BOT ‘s or implants with aneuploidy have greater opportunities of deceasing of disease in comparing of diploid tumours.
Decision
Borderline ovarian tumours are a alone subset of epithelial tumors that affect younger adult females in generative age group, charter an faineant class and demo first-class forecast. Borderline tumours typically manifest as complex cystic multitudes with mural nodularity and septations. The imaging findings are identical from invasive ovarian carcinomas. Accurate diagnosing and theatrical production is the basis to optimal patient direction. Fertlity saving surgery may do in patients with tumours confined to the ovary. Extremist surgery is recommended in patients with advanced disease. Long term surveillance is recommended to document and handle late returns. Current Update On Borderline Ovarian Neoplasms Essay.