|Year : 2015 | Volume
| Issue : 3 | Page : 646
Ovarian serous borderline tumors with noninvasive and invasive peritoneal implants: A case report each
Banushree C Srinivasamurthy1, Raj Kulandai Velu Ambedkar1, Nagarajan Krishnan2, Anand Shankar Rao Patil1
1 Department of Pathology, Sri Manakula Vinayagar Medical College, Puducherry, Tamil Nadu, India
2 Department of Radiology, Sri Manakula Vinayagar Medical College, Puducherry, Tamil Nadu, India
|Date of Web Publication||9-Oct-2015|
Banushree C Srinivasamurthy
Associate Professor, Department of Pathology, Indira Gandhi Medical College and Research Institute, Kathirkamam, Puducherry - 605 009
Source of Support: None, Conflict of Interest: None
Serous borderline tumors (SBT) are defined by the World Health Organization (WHO) as serous neoplasms that show epithelial proliferation greater than that seen in serous cystadenomas, as evidenced by cellular stratification, cytologic atypicality, and epithelial tufting, but which exhibit no evidence of "destructive stromal" invasion and can show extra-ovarian implants. Characterization of invasive peritoneal implants from patients with noninvasive serous ovarian tumors has important prognostic and treatment implications. Peritoneal implants have been classified as either noninvasive or invasive based on their histopathologic appearance. Three criteria were applied for the diagnosis of "invasive" implants: Invasion of underlying normal tissue, micropapillary architecture, and solid epithelial nests surrounded by clefts. We encountered two cases of unilateral ovarian serous borderline tumors with non-invasive peritoneal implants in a 43-year-old female, and invasive peritoneal implants in 76-year-old female.
Keywords: Invasive implants, non-invasive implants, ovary, peritoneal implants, serous borderline tumor
|How to cite this article:|
Srinivasamurthy BC, Ambedkar RK, Krishnan N, Patil AS. Ovarian serous borderline tumors with noninvasive and invasive peritoneal implants: A case report each. J Can Res Ther 2015;11:646
|How to cite this URL:|
Srinivasamurthy BC, Ambedkar RK, Krishnan N, Patil AS. Ovarian serous borderline tumors with noninvasive and invasive peritoneal implants: A case report each. J Can Res Ther [serial online] 2015 [cited 2020 May 27];11:646. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/646/147707
| > Introduction|| |
Taylor first described low malignant potential ovarian tumors (LMPOT) in 1929. This ovarian malignancy is defined by an epithelial tumor with a stratification of the epithelial lining, but with a lack of frank stromal invasion at pathologic examination. It has a less aggressive behavior than invasive epithelial ovarian tumors.  The prognosis of patients with a disease limited to the ovary is excellent, but patients with extra-ovarian spread have an uncertain prognosis and evolution.  The criteria for distinguishing invasive and noninvasive implants vary among investigators and can be difficult to apply.
Despite the absence of demonstrable stromal invasion in the primary tumors, extra-ovarian peritoneal implants are present in 30-40% of the patients and up to 30-40% of such patients die of their disease.  Serous borderline tumors have a disconcertingly high frequency of extraovarian disease. Peritoneal implants on serosal and omental surfaces are found at the time of initial operation in 20-46% of patients.  There is a very high correlation between exophytic tumor on the ovarian surface and synchronous implants. Almost two-thirds of patients whose ovarian tumor has an exophytic surface component have peritoneal implants, and 94% of patients with peritoneal implants have an exophytic surface component on their ovarian tumor. 
| > Case report|| |
Forty-three year old female presented with abdominal distention. Clinical examination revealed ascites and abdominal mass. Diagnosis of ovarian neoplasm was done by ultrasound. Patient underwent total abdominal hysterectomy and salphingo-oophorectomy with omental resection. Intra-operative peritoneal washings sent for cytological examination. Cytological diagnosis of papillary serous borderline tumour/low grade papillary serous carcinoma of ovary was given.
Received uterus with cervix and left ovary, tube and Right ovarian cyst with attached tube. Uterus measured 8 × 5 × 4 cm.
Left ovary measured 3.0 × 2.0 × 1.0 cm. Left tube measured 6.0 cm. Cut section was unremarkable.
Right ovarian cyst measured 11 × 7 × 5 cm. Surface showed exophytic papillary projections with focal microcystic area [Figure 1].
|Figure 1: Photograph-showing cystwall with papillary projections on surface|
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Separately sent fibro fatty omental tissue of the patient measure 8 × 4 × 2 cm, cut section showed specks of chalky white hard areas.
The cyst wall from right ovary showed broad focal complex papillary projections lined by columnar epithelium with focal microinvasion. The lining epithelium showed focal stratification with mild to moderate hyperchromatism and pleomorphism [Figure 2]. Psammoma bodies were seen in cyst wall and papillary core.
|Figure 2: Microphotograph (×10) H and E-showing exophytic papillary projections with focal stratification|
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Section from omentum showed papillary core with psammoma bodies lined by epithelium loosely adherent to subjacent fibro-fatty tissue without invading the surrounding structures [Figure 3]. Histopathological diagnosis of serous borderline tumor of ovary with non-invasive peritoneal implants was given.
|Figure 3: Photomicrography (×10) H and E-section from omentum showing psammoma bodies in papillary core|
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Seventy-six year old female presented with abdominal distention. Clinical examination revealed ascites and abdominal mass. Diagnosis of ovarian carcinoma was done by ultrasound. Patient underwent total abdominal hysterectomy and salphingo-oophorectomy with omental resection.
Received uterus with cervix and right ovary, tube and left ovarian cyst with attached tube. Uterus measured 7 × 5 ×2 cms.
Right ovary measured 2.0 × 2.0 × 1.0 cm. right tube measured 5.0 cm. Cut section-unremarkable.
Left cystic ovarian mass measured 12 × 10 × 6 cm. Cut section showed uniloculated cyst filled with serous fluid. Inner cyst wall showed multiple foci of papillary excrescence with friable areas [Figure 4].
|Figure 4: Photograph-showing hysterectomy specimen with left ovarian cyst. Cut section of Inner left ovarian cyst wall showing multiple foci of papillary excrescence|
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Separately sent fibro fatty omental tissue measured 5 × 2.5 × 1 cm. Cut section showed multiple foci of solid grey white tissue.
Left ovarian cyst wall showed elongated fibrous papillae with hierarchical branching covered byproliferating epithelial cells with tufting, low grade atypia and without stromal invasion [Figure 5].
|Figure 5: Photomicrograph (×10) H and E-section from left ovarian cyst wall showing elongated fibrous papillae with hierarchical branching covered by proliferating epithelial cells with tufting, low grade atypia and without stromal invasion|
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Section from omentum showed papillary core and solid epithelial nest surrounded by cleft invading the underlying adipose tissue [Figure 6].
|Figure 6: Photomicrograph (×10) H and E-Section from omentum showing papillary core and solid epithelial nest surrounded by cleft invading the underlying adipose tissue|
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| > Discussion|| |
The most challenging issues for serous tumors include the criteria and clinical behavior of stromal microinvasion; the high prevalence of synchronous extraovarian disease; the classification and histopathologic features of associated peritoneal tumor implants, especially invasive implants; and the prognostic significance of micropapillary tumors.  Peritoneal implants have been classified into invasive and noninvasive categories with noninvasive peritoneal implants subclassified as epithelial and desmoplastic or both.  Desmoplastic implants may also involve the surface of the ovary and the walls of cysts where they may bridge adjacent papillary processes. Such "auto-implants" must be distinguished from true stromal invasion in ovarian serous carcinomas.  Serous borderline ovarian tumors are unique neoplasms that may behave in an aggressive fashion with associated peritoneal "implants" and regional lymphadenopathy. Because women with extraovarian spread of disease have a very good prognosis, the peritoneal lesions are classified as implants instead of metastases.  Ovarian serous borderline neoplasm with non-invasive implants traditionally have been considered to be nonaggressive tumors associated with an excellent prognosis. However, in 2006, Silva et al., studied and followed-up 80 cases of advanced-stage serous borderline tumor of ovary with non-invasive implants for many years and found recurrence in 35 (44%) patients.  In 2007, Russel Hogg et al., studied 46 patient with serous borderline tumor. 13 of 46 (28%) serous borderline tumors had a micropapillary pattern, 12 (26%) had evidence of microinvasion and 19 (41%) had extraovarian implants, of which one (5%) was invasive. Three of 46 (7%) of serous borderline tumors recurred, all were originally advanced stage.  K-RAS mutations are the most frequent molecular genetic alteration in serous ovarian tumors of borderline malignancy. The demonstration of K-RAS mutations in Müllerian inclusion cysts and implants of SBOT suggests that K-RAS mutations represent a pivotal event during neoplastic transformation of ovarian and extraovarian serous epithelium.  The pathologist has an important role in assessment of the borderline nature of ovarian tumors and in the identification of high-risk criteria, most of which are histological. Reproducibility of the histological interpretation of some of these potential criteria e. g., classification of peritoneal implants (particularly in desmoplastic subtype), stromal microinvasion, micro-papillary patterns remains unclear, and should be investigated. 
| > References|| |
Taylor HC. Malignant and semi-malignant tumors of the ovary. Surg Gynecol Obstet 1929;48:204-30.
Kaern J, Trope 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 1993;71:1810-20.
Bell DA, Weinstock MA, Scully RE. Peritoneal implants of ovary serous borderline tumors: Histologic features and prognosis. Cancer 1988;62:2212-22.
Kennedy AW, Hart WR. Ovarian papillary serous tumors of low malignant potential (serous borderline tumors). A long term follow-up study, including patients with microinvasion, lymph node metastasis, and transformation to invasive serous carcinoma. Cancer 1996;78:278-86.
Segal GH, Hart WR. Ovarian serous tumors of low malignant potential (serous borderline tumors). The relationship of exophytic surface tumor to peritoneal "implants". Am J Surg Pathol 1992;16:577-83.
Hart WR. Borderline epithelial tumours of ovary. Mod Pathol 2005;18:S33-50.
Rollins SE, Young RH, Bell DA. Autoimplants involving serous borderline tumors of the ovary: A clinicopathologic study of 30 cases. Mod Pathol 2004;17:213A.
Lalwani N, Shambhogue AK, Vikram R, Nagar A, Jagirdar J, Prasad SR. Current update on borderline ovarian neoplasms. AJR Am J Roentgenol 2010;194:330-6.
Silva EG, Gershenson DM, Malpica A, Deavers M. The recurrence and the overall survival rates of ovarian serous borderline neoplasms with non-invasive implants is time dependent. Am J Surg Pathol 2006;30:1367-71.
Hogg R, Scurry J, Kim SN, Friedlander M, Hacker N. Microinvasion links ovarian serous borderline tumor and grade 1 invasive carcinoma. Gynaecol Oncol 2007;106:44-51.
Diebold J, Seemuller F, Lohrs U. K-RAS mutations in ovarian and extraovarian lesions of serous tumors of borderline malignancy. Lab Invest 2003;83:251-8.
Morice P, Uzan C, Fauvet R, Gouy S, Duvillard P, Darai E. Borderline ovarian tumour: Pathological diagnostic dilemma and risk factors for invasive or lethal recurrence. Lancet Oncol 2012;13:e103-15.
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