Images by Carinelli, EIO.
Borderline ovarian tumors
Definition
Borderline ovarian tumors
(BOTs) are epithelial tumors
with a low grade of
malignancy.
They are defined as epithelial
tumors with a stratification of
the epithelial lining, but with a
lack of frank stromal invasion.
Consequently they show low
potential to invade or
metastasise.
BOTs account for 10–15 % of epithelial ovarian tumors.
The incidence of BOTs is estimated to be 4.8/100 000
women per year.
These tumors occur in younger women, with almost 30% of
patients younger than 40 years, and they are often
diagnosed in an earlier stage of the disease than invasive
carcinomas.
About 80% of women with BOT present with stage I
disease.
More than 95% of BOTs are either of serous or mucinous
histotype. Other rare types are endometrioid, clear cell, and
Brenner tumors.
Borderline ovarian tumors
Incidence
BOTs seem to arise from cortical inclusion cysts of the
ovarian epithelium, that are exposed to metaplastic and
dysplastic transformation into BOT.
Mutations in BRAF and KRAS characterise the non-
invasive serous tumours and invasive low grade serous
carcinoma and mutations in both genes occur early in
tumour progression.
PrognosisWhen the disease is diagnosed at stage I, prognosis is
excellent and fertility-sparing conservative treatments
for BOT should be offered to young women.
Therefore accurate preoperative diagnosis is of utmost
importance for planning appropriate management.
Borderline ovarian tumors
Pathogenesis
In some cases BOTs can be associated with extra
ovarian disease, defined as ‘implants’ rather than
metastases. The prognosis in these cases in worse.
These implants are
further sub-classified as
invasive or non-
invasive, and require
different treatment.
Image by Franchi D, Mancari R - EIO
Borderline ovarian tumors
Prognosis (2)
Serous borderline tumors (sBOT)
sBOT form bilateral (30–40%) large cystic and/or solid masses
with papillary epithelial structures. The inner layer of the cyst is
composed of confluent papillae of different dimensions.
Mucinous borderline tumors (mBOT)
mBOT have been subclassified into two clinico-pathologic
forms: gastrointestinal-type and endocervical-like tumors.
Gastrointestinal type tumours account for 85–90% of mBOTs
and they have similar histologic features to primary mucinous
carcinomas of the appendix, appearing mainly as cystic
masses.
Endocervical-like tumours show a morphology similar to serous
borderline tumours.
Borderline ovarian tumors
Prognosis (2)
Image by Franchi D - EIO
Borderline ovarian tumors
Serous borderline ovarian tumor with
evidence of disease on the ovarian
surfaceImage by Franchi- EIO
Borderline ovarian tumors
sBOT
sBOTs and endocervical-type mBOTs have similar sonographic
features. Compared with the intestinal-type mBOTs, these tumors
are characterised by a smaller maximum diameter, fewer locules
(they are usually unilocular-solid lesions) with a positive ovarian
crescent sign, a higher number of papillary excrescences within
the lesions and a higher rate of vessels inside the papillations.
Solid morphology is very rare in both groups of lesion.
Intestinal-type mBOTs are usually unilateral, large, multilocular
tumors with a smooth capsule and no clear definition of solid tissue
or papillary projection. A multilocular nodule arising from the inner
cyst wall (‘honeycomb nodule’) can be detected.
Borderline ovarian tumors
Ultrasound characteristics
Unilocular-solid cysts or multilocular-solid cysts
Multiple papillary projections
with irregular surface
Ovarian Crescent sign
Image by Franchi - EIO
Borderline ovarian tumorsMorphological features suggestive of
serous type or endocervical type BOT
Image by Franchi - EIO
Borderline ovarian tumorsUltrasound characteristics: typical
appearance
Image by Franchi - EIO
Borderline ovarian tumors
sBOTS
Clip by Franchi EIO
Borderline ovarian tumors
sBOTS
Images by Franchi EIO
Borderline ovarian tumor with extra
ovarian disease
Borderline ovarian tumors
sBOTS
• Multilocular Cysts in 55% of cases
• > 10 locules in 80% of cases
• Honeycomb nodule present in 50% of cases
• Thick echogenic fluid content
Image by Franchi - EIO
Borderline ovarian tumorsMorphological features suggestive of
intestinal type borderline tumor
Honeycomb nodule
Images by Franchi EIO
Borderline ovarian tumors
mBOTS
Clip by Franchi - EIO
Borderline ovarian tumors
mBOTS
The symptoms of BOTs may be absent and the
diagnosis can be infrequent when the lesion
has a small diameter. This occurence is more
frequent with endocervical-type mBOTs and
sBOTs.
Symptoms are related to the presence of an
abdominal or pelvic mass with huge
dimensions, with bloating and pain being the
usual presentation.
Borderline ovarian tumors
Clinical symptoms
Due to the younger age of presentation of BOTs, a
correct preoperative diagnosis is of the utmost
importance in the management of these patients, who
may benefit from conservative treatment .
In these cases, ultrasound allows careful follow up of
the patient, as it is able to detect very small
recurrences within normal ovarian parenchyma. This
makes it possible to perform repeated fertility sparing
surgery.
Borderline ovarian tumors
Conclusion