{"paper_id":"57f1041d-1591-44f9-9903-190f21023e0a","body_text":"Asian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6749\nDOI:http://dx.doi.org/10.7314/APJCP .2014.15.16.6749\nAccompanying Pathologies with Borderline Ovarian Tumors\nAsian Pac J Cancer Prev, 15 (16), 6749-6754\nIntroduction\nBorderline ovarian tumors (BOTs) account for about \n10-20% of epithelial ovarian malignancies. These tumors \nhave epithelial proliferations with mild atypia and without \nstromal invasion except for micro-invasive variants \nthat have one or more foci of stromal invasion ≤3 mm \n(Seidman et al., 2004). \nBOTs diagnosed in young women tend to have better \nprognosis with 90%-100% survival rates (Ayhan et al., \n2005; Trope et al., 2012). Patients might present with \npelvic pain, abdominal fullness, increased urination or \ncystic mass diagnosed with imaging. Tumor markers \nincrease in roughly 25-60% of patients (Poncelet et al., \n2010). The risk of malignancy index (RMI) calculated \nby the serum levels of CA-125, ultrasonographic score, \nand menopausal status during patient evaluation is able \nto discriminate between benign and BOTs (Moolthiya \n1Department of Gynecologic Oncology, 3Department of Pathology, Zekai Tahir Burak Women’ s Health Education and Research \nHospital, Ankara, 2Department of Obstetrics and Gynecologic, Faculty of Medicine, Düzce University, Düzce, Turkey   *For \ncorrespondence: cetinkayanilufer@gmail.com\nAbstract\n Background: There are limited data in the literature related to concomitant genital or extra-genital organ \npathologies in patients with borderline ovarian tumors (BOTs). The aim of this study was to evaluate our \nexperience with 183 patients to draw attention to the accompanying organ pathologies with BOTs. Materials \nand Methods: One hundred eighty-three patients with BOTs, diagnosed and/or treated in our center between \nJanuary of 2000 and March of 2013 were evaluated retrospectively. Data related to age, tumor histology, lesion \nside, disease stage, accompanying incidental ipsilateral and/or contralateral ovarian pathologies, treatment \napproaches, and follow-up periods were investigated. Incidental gynecologic and non-gynecologic concomitant \norgan pathologies were also recorded. Results: The mean age at diagnosis was 40.6 years (range: 17-78). Ninety-\nfive patients (51%) were ≤40 years. A hundred and forty-seven patients (80%) were at stage IA of the disease. \nThe most common type of BOT was serous in histology. Non-invasive tumor implants were diagnosed in 4% and \nuterine involvement was found 2% among patients who underwent hysterectomies. There were 12 patients with \npositive peritoneal washings. Only 17 and 84 patients respectively had concomitant ipsilateral and concomitant \ncontralateral incidental ovarian pathologies. The most common type of uterine, appendicular and omental \npathologies were chronic cervicitis, lymphoid hyperplasia and chronic inflammatory reaction. Conclusions: \nAccording to our findings most of accompanying pathologies for BOT are benign in nature. Nevertheless, there \nwere additional malignant diseases necessitating further therapy. We emphasize the importance of the evaluation \nof all abdominal organs during surgery. \nKeywords: Borderline ovarian tumors - ovarian carcinoma - accompanying pathologies - staging - fertility sparing\nRESEARCH ARTICLE\nIs Target Oriented Surgery Sufficient with Borderline Ovarian \nTumors? - Role of Accompanying Pathologies\nTayfun Gungor1, Nilufer Cetinkaya1*, Hakan Yalcin1, Bulent Ozdal1, Emre Ozgu1, \nEralp Baser1, Nafiye Yilmaz1, Mete Caglar2, Sema Zergeroglu3, Salim Erkaya1\nand Yuenyao, 2009; Arun-Muthuvel and Jaya, 2014). \nModified cutoff values of CA-125 and RMI score were \nreported to result in a better prediction of malignancy, at \nthe cost of reduced sensitivity in patients with ovarian \nmasses (Winarto et al., 2014). Furthermore, tissue levels \nof CA-125 and HE4 proteins were reported to be higher \nin ovarian malignancies than in benign lesions (Devan et \nal., 2013) and elevated CA-125 levels in blood is known \nto predict tumor burden (Li et al., 2012). \nBOTs are surgically staged according to the \nInternational Federation of Gynecology and Obstetrics \n(FIGO) 2009 staging system. Most patients with BOTs \nare diagnosed as stage I of the disease. However, BOTs \nmight have invasive or non-invasive implants spreading \nonto the surrounding pelvic or abdominal organs and \nif present increase the stage of disease (Menczer et al., \n2012). Surgical treatment is the same as for malignant \novarian tumors but there is no difference in the recurrence \n\nTayfun Gungor et al\nAsian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6750\nor survival rate whether lymphadenectomy is performed \nor not. Therefore, lymphadenectomy can be postponed \n(Kanat-Pektas et al., 2011b). Laparoscopic surgery is a \nsuitable choice in early stages of the disease (Tinelli et \nal., 2009). Protection of fertility by preserving the uterus \nand contralateral ovary is preferable for young patients \n(Karimi Zarchi et al., 2011). Unilateral oophorectomy \nor cystectomy are safe options for the stage I disease if \ncareful follow-up of the patient is possible (Tinelli et al., \n2006; Yinon et al., 2007; Park et al., 2009). However, \nthe recurrence rate is 12%-58% after cystectomy (Trope \net al., 2012). Hysterectomies with bilateral salpingo-\noophorectomy are performed in women at more advanced \nages (Menczer et al., 2012). The accuracy of intraoperative \nfrozen section for the diagnosis of ovarian masses is high \n(Suprasert et al., 2008). However, the sensitivity of the \nfrozen section for BOTs is about 45%-64% (Wu et al., \n2009; Poncelet et al., 2010), which means that some \npatients are diagnosed in permanent pathology. Because \nit is known that lymph node involvement might be 20% \nin stage I serous BOTs (Trope et al., 2012), restaging \nsurgery is questionable. \nSpontaneous pregnancies usually occur after \nconservative surgery and pregnancy outcomes are known \nto be promising (Nam, 2010). Young age at diagnosis, \nnon-serous histology and unilateral cystectomy are known \nto be associated with favorable reproductive outcomes in \nwomen on whom conservative surgery was performed \n(Kanat-Pektas et al., 2011a).\nBOT’s are relatively resistant to chemotherapy and \nthere is little effect on long-term survival in advanced \nstage disease due to their low-malignant potential (Trope \net al., 2012). Micro-invasive or micro-papillary histology, \nconservative procedures like cystectomy or unilateral \nsalpingo-oophorectomy, cyst rupture, advanced stage \ndisease and the presence of tumor implants are prognostic \nfactors affecting recurrence (Wu et al., 2009).\nThere are numerous papers in the literature related \nwith the diagnosis, treatment options, postoperative \nsurveillance, recurrence and prognostic factors of \nBOTs. However, there are limited data concerning the \naccompanying organ pathologies with BOTs in these \npatients (Kanat-Pektas et al., 2010). The aim of this study \nwas to evaluate our experience with 183 patients having \nbeen diagnosed with BOTs and to draw attention to \nconcomitant ipsilateral and contralateral ovarian, uterine, \nomental, appendiceal, lymph nodal, peritoneal or non-\ngynecologic organ abnormalities.\nMaterials and Methods\nThe present study was approved by the Institutional \nReview Board of Zekai Tahir Burak Women’ Health \nEducation and Research Hospital where the study was \nconducted.\n183 patients with BOTs, diagnosed and/or treated in \nour center between January of 2000 and March of 2013 \nwere included in the study. Clinical and pathological \ndata were reviewed retrospectively. Permanent pathology \nreports of patients were analyzed and concomitant \npathologic lesions with BOTs were characterized. \nFrom the hospital records of the 183 patients, data \nrelated with age, type of surgery, disease stage, primary \nBOT lesion side, tumor diameter, tumor histology, \naccompanying ipsilateral and contralateral ovarian lesions \ndiagnosed incidentally, results of peritoneal washings, \npresence of and characteristics of tumor implants, \ndissected lymph node counts were reviewed. Furthermore, \ncoexistent pathologies of the uterus, lymph nodes, \nomentum, appendix and peritoneum were evaluated. Also \nthe presence of non-gynecological pathologies were noted. \nThe mean postoperative follow-up periods, data related \nwith the disease recurrence and conditions necessitating \nrecurrent operations were commentated as secondary \ninferences.\nThe patients were staged surgically according to FIGO \n2009 guidelines for ovarian carcinoma. Comprehensive \nsurgical staging with peritoneal sampling, total abdominal \nhysterectomy, bilateral salpingo-oophorectomy, pelvic \nand para-aortic lymphadenectomy, appendectomy and \nomentectomy were performed in patients who were \npostmenopausal, completed their fertility or had additional \ndisease that require extensive surgery. Fertility sparing \nsurgery was performed in the form of unilateral salpingo-\noopherectomy (USO), cystectomy, USO with contralateral \novarian biopsy, USO with contralateral cystectomy, \ncystectomy with contralateral ovarian biopsy and bilateral \novarian biopsy in patients who were premenopausal or \nwish to preserve their fertility.\nStatistical analysis\nThe statistical analysis was performed with SPSS for \nMac version 20 (SPSS for Mac Inc., Chicago, IL, US). \nWe computed descriptive statistics (mean and range). An \nindependent samples t test was performed to compare the \ndifference between the tumors’ histologic types.\nResults \nA total of 183 patients were diagnosed. The mean age \nat diagnosis was 40.6 (range: 17-78). Ninety-five patients \n(51%) were ≤40 years. A total of 91 hysterectomies, 176 \nperitoneal fluid washings, 153 appendectomies, 163 \nomentectomies and 159 pelvic & para-aortic lymph node \ndissections were performed.\nComprehensive surgical staging was performed \non 91 patients (49%). There were 14 patients in the \ncomprehensive staging surgery group that were ≤40 \nTable 1. Data for Ovarian Tumors \nLocation   Total\nRight Ovary Serous Bot 67 113\n Serous Micro-Invasive Bot  5 \n Serous Micro-Papillary Bot 2 \n Mucinous Bot 33 \n Endometrioid Bot 5 \n Clear Cell Bot 1 \nLeft Ovary Serous Bot 59 93\n Serous Micro-Invasive Bot 3 \n Serous Micro-Papillary Bot 1 \n Mucinousbot 27 \n Mucinous Micro-Invasive Bot 1 \n Brenner Bot 2 \nTotal   206\n\nAsian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6751\nDOI:http://dx.doi.org/10.7314/APJCP .2014.15.16.6749\nAccompanying Pathologies with Borderline Ovarian Tumors\nyears old and had hysterectomies due to concomitant \nuterine pathologies. The reasons for the hysterectomies \nwere secondary dysmenorrhea and abnormal uterine \nbleeding due to giant or multiple myoma, adenomyosis, \nendometrial polyps or simple endometrial hyperplasia \nwithout atypia. Fertility-sparing surgery with unilateral \nsalpingo-oophorectomy or cystectomy, with or without \ncontralateral ovarian biopsy, was performed in 48% \nof the patients (n: 89). The mean age of the patients in \nthe fertility-sparing group was significantly lower than \npatients in comprehensive surgical staging group -30 years \n(range: 17-45) and 50 years (range: 31-78) respectively. \nLymph node dissection was done in 76% of these patients \n(n: 68). Furthermore, unilateral salpingo-oopherectomy \n(USO), cystectomy, USO with contralateral ovarian \nbiopsy, USO with contralateral cystectomy, cystectomy \nwith contralateral ovarian biopsy and bilateral ovarian \nbiopsy were performed in 38, 18, 27, 3, 2 and 1 patient \nrespectively. \nThe patients that had complete surgical staging or \nfertility sparing surgery with lymph node dissection were \noperated on using a midline abdominal incision. Patients \nthat had fertility sparing surgery without lymph node \ndissection (n: 21) were operated on using a pfannenstiel \nincision. These patients all had negative preoperative \ntumor markers. \nThe disease stages at surgery were stage IA (80%, n: \n147), stage IB (9%, n: 17), stage IC (1%, n: 3), stage IIC \n(2%, n: 4) and stage IIIC (6%, n: 12) respectively. The \nmost common type of BOT was serous in histology with \n18% bilateralism followed by mucinous, endometrioid, \nBrenner and clear cell. Another patient had synchronous \nright-sided serous micro-invasive and left sided mucinous \nBOT on separate ovaries. Ninety patients (49%) had \nunilateral right and 70 patients (38%) had unilateral left \nsided BOT. Twenty-three patients’ BOT lesions were \nbilateral (12%). Serous BOT was the leading (91%) \nhistologic type in bilateral tumors. There were 113 \nBOTs on the right ovary and 93 BOTs on the left ovary. \nNumber of patients and ovarian lesions in respect to \ntumor localizations and histological characteristics are \nsummarized in Tables 1 and 2.\nThe mean tumor diameter was 9.4 cm (range: 1-27), \n14.8 cm (range: 3-38), 7.6 cm (range: 0.8-13), 10.5 cm \n(range: 9-12) in serous, mucinous, endometrioid and \nBrenner type BOT respectively. The tumor diameter \nof the clear cell BOT was 13 cm. Mucinous BOTs had \nsignificantly larger tumor diameters than the serous BOTs \n(P<0.0001). \nThere were 12 patients (6%) with positive peritoneal \nwashings. The cytology reports of 9 patients were \ncorrelated with serous BOT and 3 patients’ reports were \ncorrelated with malignancy (2 with bilateral serous \nand one with bilateral mucinous BOTs). Hemorrhagic \ncontaminations, mesothelial proliferations or subacute \ninflammatory reactions were other subtle changes. \nNon-invasive tumor implants were diagnosed in 9 \npatients (4%); 5 with serous, 2 with serous micro-papillary \nand 2 with mucinous BOTs. Implants were mostly located \non the Douglas pouch, uterine or tubal serosa, bladder \nserosa, sigmoid mesocolon, omentum, small intestine \nmesentery and the area surrounding the ureter. \nThe mean number of dissected lymph nodes was \n56.98 (range: 12-173). Of the 159 patients’ lymph node \ndissections, only 10 (6%) had lymph node abnormalities \nother than lymphoid hyperplasia. Four of these patients had \nbenign glands, lined by tubal-type epithelium (also called \nendosalpingiosis); 3 had benign inclusional glandular \nimplants; 2 showed the presence of serous BOTs; and \none, who had synchronous serous adenocarcinoma on \nthe contralateral ovary, had tumor-positive lymph nodes. \nOf the 90 patients who had right unilateral BOTs and \nthe 70 patients who had left unilateral BOT, only 12 and 5 \npatients respectively had concomitant ipsilateral incidental \novarian pathology. Moreover, of the 90 patients who had \nright unilateral BOTs only 53 patients had concomitant \ncontralateral incidental ovarian pathology and of the 70 \npatients who had left unilateral BOTs only 31 patients had \nit. Table 3 and 4 presents the accompanying ipsilateral and \ncontralateral incidental ovarian pathologies with BOTs. \nTable 2. Pathological Diagnoses of Ovarian Tumors \nIncidental Ipsilateral Ovarian Lesions   \nPrimary Right Ovarian Tumors  Incidental Right Ovarian Lesions \n   Serous Bot 6    Endosalpingiosis 2\n     Cystadenofibroma 1\n     Endometrioma 1\n     Serous Cystadenoma, Endometrioma 1\n     Synchronous Intra-Ovarian Serous Bot 1\n   Mucinous Bot 3    Endometrioma 1\n     Mucinous Cystadenoma, Mucinous Adenocarcinoma 1\n     Endometrioma, Mature Cystic Teratoma 1\n   Endometrioid Bot 2    Endometrioid Carcinoma 1\n     Endometrioid Carcinoma, Endometrioid Adenofibroma 1\n   Clear Cell Bot 1    Clear Cell Carcinoma, Endometrioma, Adenofibroma 1\nTotal   12\nPrimary Left Ovarian Tumors  Incidental Left Ovarian Lesions \n   Serous Bot 2    Endometrioma 2\n   Mucinous Bot 2    Mucinous Cystadenocarcinoma 1\n     Benign Brenner Tumor 1\n   Brenner Bot 1    Benign Brenner Tumor 1\nTotal   5\n\nTayfun Gungor et al\nAsian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6752\nThere were no concomitant ovarian pathologies for the 2 \nBrenner BOT on left or right ovary. Follicular cyst, corpus \nluteum and inclusional cyst were the other benign findings \ndiagnosed in paraffin blocs of the ovarian specimens. \nHysterectomies were performed on 91 patients. \nFive patients had normal appearing uterine specimens \nwith proliferative or secretory endometrial lining. \nThe most common types of uterine pathologies were \nchronic cervicitis (63.7%, n: 58) followed by myoma \nuteri (37.3%, n: 34) and adenomyosis (24.1%, n: 22). \nThirteen patients had concomitant endometrial polyps, 4 \npatients had low-grade and 2 had high-grade squamous \nintraepithelial lesions. Three patients-one with bilateral \nserous BOTs, one with bilateral micro-papillary serous \nBOTs and one with bilateral mucinous BOTs-had \ntubal, para-tubal and/or uterine serosal non-invasive \nimplants. The concomitant uterine pathologies of \nanother 4 patients with serous BOTs were: degenerated \nplacental tissues (BOT was diagnosed during cesarean \nsection), bilateral adnexal endosalpingiosis, para-tubal \nserous carcinoma at the same site as the BOT and tubal \nmalign mixed mullerian tumor (MMMT) involvement \nof clear-endometrioid-leiomyosarcoma histology due to \naccompanying contralateral ovarian MMMT. A chronic \ngranulomatous lesion in the endometrium and on the \ncervix with bilateral tubal salpingitis folicularis due to \nTuberculosis was another entity that accompanied the \nunilateral Brenner BOT-Benign Brenner combination. \nSalpingitis, serosal endometriotic implants, endometritis \nand simple hyperplasia without atypia were the other less \nencountered uterine lesions.\nThe appendectomy specimens of 88 patients had \nnormal histology (57.5%). The most common types \nof appendix pathology were lymphoid hyperplasia \n(18.9%, n: 29, one with local peritonitis) followed by \nperi-appendicitis (13.7%, n: 21) and luminal obliteration \n(7.1%, n: 11). Only one patient had acute inflammation \nof the appendix. A case with bilateral mucinous BOTs \nhad incidental appendiceal mucinous cyst-adenoma \nand large spread peritoneal, omental mucinous tumor \nimplantation, which resulted in Disseminated Peritoneal \nAdenomucinosis. Another patient who had unilateral \nserous BOT also had a 1.5 cm insular type appendiceal \ncarcinoid tumor. Endosalpingiosis, the presence of a \nreactive lymph node and enterobiasis infection were the \nother less encountered types of appendiceal lesions.\nThe omentectomy specimens of 129 patients (79.1%) \nhad normal histology as a mature adipose tissue. Chronic \ninflammatory reaction (6.1%, n: 10), a reactive lymph \nnode (4.9%, n: 8), subacute peritonitis (2.4%, n: 4), \nmesothelial proliferation (1.8%, n: 3) and inclusional \ngland implantation (1.2%, n: 2) were the most commonly \nTable 3. Tumor Types Encountered  \nIncidental Contralateral Ovarian Lesions   \nPrimary Right Ovarian Tumors  Incidental Left Ovarian Lesions \nSerous Bot 34    Serous Bot 18\n     Serous Cystadenoma 7\n     Endometrioma 5\n     Endometrioid Carcinoma 1\n     Ovarian Malign Mixed Mullerian Tumor 1\n     Adenofibroma 1\n     Fibromatous Nodule 1\nSerous Micro-Invasive Bot 3    Serous Bot 1\n     Serous Micro-Invasive Bot 1\n     Mucinous Bot 1\nSerous Micro-Papillary Bot 1    Serous Micro-Papillary Bot 1\nMucinous Bot 13    Endometrioma 4\n     Mucinous Cystadenoma 4\n     Serous Cystadenoma 3\n     Mucinous Bot 1\n     Fibroma 1\nEndometrioid Bot 2    Endometrioma, Endometrioid Carcinoma 1\n     Adenofibroma 1\nTotal   53\nPrimary Left Ovarian Tumors     Incidental Right Ovarian Lesions \nSerous Bot 26    Serous Bot 18\n     Serous Cystadenoma 3\n     Serous Carcinoma 2\n     Serous Micro-Invasive Bot 1\n     Ovarian Micro Abscess 1\n     Endometrioma  1\nSerous Micro-Invasive Bot 1    Serous Micro-Invasive Bot 1\nSerous Micro-Papillary Bot 1    Serous Micro-Papillary Bot 1\nMucinous Bot 3    Mucinous Bot 1\n     Mature Cystic Teratoma, Mucinous Cyst 1\n     Serous Micro-Invasive Bot 1\nTotal   31\n\nAsian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6753\nDOI:http://dx.doi.org/10.7314/APJCP .2014.15.16.6749\nAccompanying Pathologies with Borderline Ovarian Tumors\nencountered lesions. Only 3 patients (1.8%) had non-\ninvasive omental BOT implants. Metastasis from \ngastric carcinoma (0.6%), mucinous tumor infiltration \n(0.6%) due to disseminated peritoneal adenomucinosis, \nendosalpingiosis and chronic granulomatous process \naccompanying bilateral mucinous BOT were the other \nless encountered omental lesions.\nIn addition to the aforementioned conditions, there \nwere three patients who had bilateral serous BOTs and \nextra-ovarian incidental pathologies. The first patient \nhad pathologically confirmed renal methanephric \nadenoma that was diagnosed during follow-up period \nshortly after the staging surgery. The second patient had \nsynchronous lymhoepithelioma type gastric carcinoma, \nwhich was diagnosed per-operatively during staging \nsurgery, and she also had a pelvic cyst diagnosed as \nhydatic cyst in permanent pathology. The third patient \nhad diffuse noninvasive peritoneal serous BOT implants \nwith retroperitoneal desmoplasia and sarcomatous mural \nnodules with increased mitosis and necrosis accompanying \nadnexal tumor mass. Furthermore, another patient with \nunilateral mucinous BOT had a suspicious peritoneal \nbiopsy, which revealed accessory spleen and Meckel \ndiverticulum was another incidental condition associated \nwith unilateral serous BOT.\nThe mean postoperative follow-up period was 20.4 \nmonths (range: 6-78 months). During the follow-up \nperiod, 15 patients that had accompanying malignancy, \nperitoneal implants and/or lymph node positivity had \npost-operative chemotherapy. Disease recurrence was seen \nin 5 of the 183 patients, indicating an overall recurrence \nrate of 2.7%. All of the recurrences except one were \ndiagnosed after fertility sparing surgery. Recurrent tumors \nhad serous histology. Contralateral ovarian recurrence was \nseen in two patients who had had USO previously. One \npatient who had previously had a cystectomy experienced \nipsilateral ovarian recurrence. Another patient with a \nhistory of cystectomy and chemotherapy due to serous \nBOT with implants had recurrent benign ovarian cyst and \npelvic non-invasive BOT implants. There was only one \npatient in the comprehensive surgery group whose disease \nrecurred after debulking surgery. Recurrence was in the \nform of bilateral cystic masses simulating slowly enlarging \nlymphocysts with normal tumor markers.\nDuring the follow-up period, only 9 patients had \nsecondary operations: five due to disease recurrence, one \nwith recurrent serous ovarian malignancy with a history of \nserous BOT and concomitant serous ovarian malignancy, \none with benign ovarian cyst on the contralateral ovary \nwith mucinous BOT history, one with bilateral benign \novarian cyst with a history of serous BOT and another due \nto the formation of a 10cm lymphocyst with a history of \nmucinous BOT. Only two patients from the comprehensive \nsurgery group had secondary surgery.\nDiscussion\nIn our study, we evaluated a large data pool of 183 \npatients diagnosed as borderline epithelial ovarian tumor. \nThere were 95 patients (51%) aged ≤40. Our results \nindicate that BOTs tend to be diagnosed at a younger \nage, which is consistent with the literature (Gotlieb et \nal., 2005; Romagnolo et al., 2006). Serous BOTs were \nmore numerous than mucinous ones and endometrioid, \nBrenner and clear cell BOTs were diagnosed relatively \ninfrequently. Bilateral tumors more commonly had serous \nhistology, and mucinous tumors were larger than serous \nones. These results were compatible with the literature \n(McCluggage, 2010; Messalli et al., 2013). \nThere might be accompanying genital and extra-\ngenital organ pathologies with BOTs (Gungor et al., 2011). \nHowever the data in the literature related with this topic is \nquite limited and the issue is addressed only in several case \nreports. According to our study, most of the accompanying \npathologies with BOTs were ovarian in origin and benign \nin nature. Serous cystadenoma, endometrioma, mucinous \ncyst, adenofibroma and mature cystic teratoma were the \nmost commonly encountered ovarian lesions concomitant \nto BOTs. Nevertheless, we demonstrated that there could \nbe additional malignant tumor foci within the BOTs. \nSuch as, serous, mucinous, endometrioid or clear cell \ncarcinoma. Based on our findings, the minimum tumor \ndiameters of the incidental ipsilateral and contralateral \novarian malignancies accompanying to BOTs were \nreported to be 8 mm and 1.2 cm respectively. Furthermore \nwe also demonstrated the presence of malignant tumors \nthat had different cellular in origins. Such as, gastric \ncarcinoma, appendiceal carcinoid and mixed Mullerian \ntumor. The complex association of BOTs with genital \nor extra-genital organ pathologies leads to figure out the \nimportance of the tissue sampling during operation and the \nmacroscopic evaluation of the sampled tissue after surgery. \nOvarian serous carcinoma, endometrioid carcinoma, \novarian malign mixed Mullerian tumor, mucinous \ncarcinoma and clear cell carcinoma were associated with \nBOTs as ipsilateral or contralateral incidental coexistent \novarian lesions. The presence of invasive disease required \ntreatment manipulation against malignancy in these \npatients. Nearly 66% of patients that required postoperative \nchemotherapy had the incidental concomitant ovarian, \npara-tubal or gastric malignancy and the other 13% had \nthe incidental contralateral ovarian micro-invasive BOTs.\nWe observed that peritoneal fluid abnormality, lymph \nnode positivity and uterine involvement with BOTs were \n6%, 6% and 2% respectively. Uterine pathologies were \ngenerally benign in nature except for patients with cervical \nsquamous intraepithelial lesions, para-tubal serous \ncarcinoma and tubal malign mixed Mullerian tumors. \nFurthermore, the omentum and appendix were the less \nencountered organs with pathologies concomitant to BOTs \nand the presence of the BOT implants on the omentum \nand the carcinoid tumor of the appendix were their most \nremarkable pathologies. \nTo our knowledge this study is the only one in the \nliterature that evaluates a large data pool of patients to \npoint out the concomitant organ pathologies with BOTs. In \nspied of its retrospective nature based on the results of our \nstudy, we emphasize the importance of the visualization \nand palpation of all abdominal organs during staging \nsurgery for BOTs. The surgeon’s ability to recognize \nsuspicious areas and request a biopsy during surgery \nenables incidental pathologies to be diagnosed, which \n\nTayfun Gungor et al\nAsian Pacific Journal of Cancer Prevention, Vol 15, 2014\n6754\n0\n25.0\n50.0\n75.0\n100.0\nNewly diagnosed without treatment \nNewly diagnosed with treatment \nPersistence or recurrence\nRemission\nNone\nChemotherapy\nRadiotherapy\nConcurrent chemoradiation\n10.3\n0\n12.8\n30.0\n25.0\n20.3\n10.1\n6.3\n51.7\n75.0\n51.1\n30.0\n31.3\n54.2\n46.8\n56.3\n27.6\n25.0\n33.1\n30.0\n31.3\n23.7\n38.0\n31.3\n0\n25.0\n50.0\n75.0\n100.0\nNewly diagnosed without treatment \nNewly diagnosed with treatment \nPersistence or recurrence\nRemission\nNone\nChemotherapy\nRadiotherapy\nConcurrent chemoradiation\n10.3\n0\n12.8\n30.0\n25.0\n20.3\n10.1\n6.3\n51.7\n75.0\n51.1\n30.0\n31.3\n54.2\n46.8\n56.3\n27.6\n25.0\n33.1\n30.0\n31.3\n23.7\n38.0\n31.3\n0\n25.0\n50.0\n75.0\n100.0\nNewly diagnosed without treatment \nNewly diagnosed with treatment \nPersistence or recurrence\nRemission\nNone\nChemotherapy\nRadiotherapy\nConcurrent chemoradiation\n10.3\n0\n12.8\n30.0\n25.0\n20.3\n10.1\n6.3\n51.7\n75.0\n51.1\n30.0\n31.3\n54.2\n46.8\n56.3\n27.6\n25.0\n33.1\n30.0\n31.3\n23.7\n38.0\n31.3\nmight have a positive effect on the patients’ survival. \nAlso it must be remembered that fertility-sparing surgery \nin patients with BOTs and the presence of incidental \nmalignancies impact on the disease recurrence. \nPatient follow-up after detection of accompanying \npathologic conditions must be individualized. Such as, the \npresence of a concomitant squamous cell intraepithelial \nlesion must preclude Pap test screening for early detection \nof invasive squamous cell pathologies originating from \nthe vaginal cuff or the vagina itself. Close monitoring \nafter primary therapy is essential for the diagnosis of \ndisease recurrence. Benign pathologies might be seen \non close follow-up. However, malignant processes or \nrecurrent BOTs are need to be diagnosed, especially after \ninvasive serous tumors or serous BOTs with invasive or \nnon-invasive tumor implants such as those that occurred \nin our study. However, further prospective studies with \nlarger numbers and detailed documentations of the \naccompanying pathologies with BOTs are needed to more \nclearly delineate this issue.\nReferences\nArun-Muthuvel V , Jaya V (2014). Pre-operative evaluation of \novarian tumors by risk of malignancy index, CA125 and \nultrasound. 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