Survival Analysis of Borderline Ovarian Tumors: A 23-Year Retrospective Study in a Middle Eastern Cohort

Survival Analysis of Borderline Ovarian Tumors: A 23-Year Retrospective Study in a Middle Eastern Cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Survival Analysis of Borderline Ovarian Tumors: A 23-Year Retrospective Study in a Middle Eastern Cohort Sayna Abbaszadeh, Haleh Ayatollahi, Sedigheh Ghasemian, Hamid Reza Khalkhali, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7168557/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2025 Read the published version in BMC Women's Health → Version 1 posted 19 You are reading this latest preprint version Abstract Background Borderline ovarian tumors (BOTs) are non-invasive epithelial lesions with a generally favorable prognosis compared to invasive ovarian cancers. Given their prevalence among young women, balancing oncologic safety with fertility preservation is critical for clinical management. This study evaluates factors associated with survival in patients with BOTs over a long-term follow-up period. Materials and Methods This retrospective analysis reviewed data from 135 patients diagnosed with BOTs between 2000 and 2023 at healthcarefı facilities affiliated with Urmia University of Medical Sciences. Clinical and pathological data were extracted from patient records. Survival was estimated using the Kaplan–Meier method, and group comparisons were conducted with the Log-rank test. Results The mean patient age was 39.5 years; with most cases diagnosed at FIGO stage I. Conservative surgical management was performed in 65.2% of patients, while 34.8% underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO). Survival rates at 1, 3, 5, and 10 years were 100%, 99.2%, 98.3%, and 97.2%, respectively. No statistically significant differences in survival were observed based on age, tumor size, bilaterality, FIGO stage, or surgical approach. Conclusion BOTs generally exhibit a favorable clinical course, and conservative surgery appears safe and effective, particularly for younger women. The lack of association between certain pathological features and survival suggests that unnecessary surgical interventions should be avoided. Further prospective, multicenter studies are needed to validate these findings in diverse populations. Borderline ovarian tumors Hysterectomy Survival Rate Fertility Preservation Retrospective Study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Borderline ovarian tumors (BOTs), also known as low malignant potential tumors, are a histologically heterogeneous subset of epithelial ovarian neoplasms characterized by atypical epithelial proliferation without stromal invasion [1]. BOTs constitute less than 20% of all ovarian tumors and are predominantly serous or mucinous in histology. Unlike invasive epithelial ovarian cancers, BOTs exhibit a relatively indolent clinical course and a more favorable prognosis (2). As these tumors are frequently diagnosed in women of reproductive age, clinical management must balance oncologic safety with fertility preservation.[2, 3]. BOTs are typically diagnosed at an early stage, with epidemiological data indicating that approximately 70% of cases are FIGO stage I, 10% stage II, 19% stage III, and 1% stage IV [4, 5]. Prognosis is influenced by factors such as stage at diagnosis, histological subtype, reproductive history (e.g., parity and menopausal status), and surgical approach [6]. Stage I BOTs have excellent survival rates of 99% at 1 year and 97% at 5 years. However, survival decreases with advancing stage: stage II, 98% at 1 year and 90% at 5 years; stage III, 96% and 88%; and stage IV, 77% and 69% [7, 8]. Existing literature on BOTs has largely focused on individual prognostic factors. Some studies have examined surgical strategies and survival outcomes (9), others have investigated non-invasive implants (10), histopathological subtypes (11), or aspects of fertility history such as parity and reproductive planning (12). However, few studies have provided a comprehensive survival analysis that integrates demographic, reproductive, and treatment-related variables. This retrospective study aims to address this gap by offering a multidimensional assessment of short-term (1- and 3-year) and long-term (5- and 10-year) survival predictors in women diagnosed with BOTs between 2000 and 2023. Methods Study design This retrospective study involved patients diagnosed with borderline ovarian tumors (BOTs) who were treated at hospitals affiliated with Urmia University of Medical Sciences from 2000 to 2023. The study protocol received approval from the Institutional Ethics Committee for Human Research at Urmia University of Medical Sciences (Ethics Code: IR.UMSU.REC.1401.119) and was conducted in full compliance with the Declaration of Helsinki. The research team reviewed surgical pathology records from oncology departments of affiliated hospitals. Patients with BOTs were identified, and their clinical files and pathology slides were examined. Inclusion criteria required a confirmed BOT diagnosis based on histopathology reports, verified by a pathologist. Exclusion criteria included cases with incomplete clinical records or loss to follow-up for survival analysis. An initial review of records from 2000 to 2023 identified 183 BOT cases. Of these, 48 cases were excluded due to incomplete data or loss to follow-up. Ultimately, 135 patients were included in the final analysis. Data Collection and Statistical Analysis Data relevant to the survival analysis were obtained using a researcher-created checklist. The variables assessed included demographic characteristics (age at diagnosis, age group), clinical features (history of infertility, parity, tumor size, tumor location, tumor type, and FIGO stage), and treatment-related parameters (histopathological subtype and type of surgical intervention). Descriptive statistics, such as mean and standard deviation for numerical variables, and frequency distributions for qualitative variables, were utilized. The Kaplan–Meier method was employed to estimate the survival function, and differences between survival curves were evaluated using the Log-rank test. The final follow-up date for survival assessment was December 2023. All analyses were performed with a 95% confidence interval, and a p-value < 0.05 was considered statistically significant. Results The study initially enrolled 183 women who underwent surgery for borderline ovarian tumors (BOTs) between January 2000 and January 2023. Forty-eight patients were excluded due to incomplete data, leaving 135 patients with confirmed BOT diagnoses based on histopathology. Patients were classified by FIGO stage and tumor characteristics, as shown in Fig. 1 . Their ages ranged from 16 to 78 years (mean 39.5 ± 12.2 years). At diagnosis, most patients (85.2%) were in their reproductive years and premenopausal, while 14.8% were postmenopausal. Additionally, 6.7% reported long-term use of oral contraceptive pills (OCPs). Regarding pregnancy history, 25.9% had never been pregnant, 37.8% had one or two pregnancies, and 36.3% had three or more pregnancies. Histopathological findings indicated that serous tumors were the most common (57.8%), followed by mucinous tumors (41.5%). Only one case (0.7%) was an endometrioid tumor. Most patients (84.4%) had unilateral tumors, with bilateral involvement in 15.6% of cases. According to FIGO staging, the majority of patients (94%) were diagnosed at Stage I, with only a small portion diagnosed at Stages II and III, each representing 3% of the cases. In terms of surgical treatment, 65.2% of the patients received conservative surgery, whereas 34.8% underwent total abdominal hysterectomy combined with bilateral salpingo-oophorectomy (TAH + BSO) .Microscopically, micro invasion was reported in 11.9% of cases, while it was absent in 88.1%. The mean tumor size was 13.37 ± 7.02 cm, with sizes ranging from 3 to 40 cm. Tumor size distribution showed that 48.9% of tumors measured between 10 to 20 cm, 37% were smaller than 10 cm, and 14.1% exceeded 20 cm. The patients were followed for a period ranging from 15 to 237 months, with a mean follow-up duration of 99.05 ± 54.2 months. During the follow-up period and the course of the study (from 2000 to 2023), only 3 out of 135 patients (2.2%) had died. The overall survival function was estimated using the Kaplan–Meier method. The mean overall survival time was 231.9 ± 2.8 months (95% CI). The 1-, 3-, 5-, and 10-year survival rates were reported as 100%, 99.2%, 98.3%, and 97.2%, respectively, Fig. 2 . The average survival time for patients aged under 30, 30–50, and over 50 years was 106.3 ± 8.9 months (95% CI: 88.8–123.9), 103.8 ± 6.4 months (95% CI: 91.3–116.4), and 86.2 ± 10.5 months (95% CI: 69.2–109.7), respectively. According to the Log-rank test, there was no statistically significant difference in survival among the different age groups (P = 0.44), as shown in Fig. 3 . The average survival time for patients with tumors larger than 20 cm was 90.9 ± 14.7 months (95% CI: 62.1–119.8), which was shorter compared to patients with tumors smaller than 10 cm (107.8 ± 4.7 months, 95% CI: 93.3–126.4) and those with tumors measuring between 10 and 20 cm (98.8 ± 4.6 months, 95% CI: 83.4–111.4). According to the results of the Log-rank test, there was no statistically significant difference in survival based on tumor size (P = 0.752), as shown in Fig. 4 . The average survival time for patients with unilateral tumors was 100.4 ± 7.5 months (95% CI: 62.1–119.8). In comparison, patients with bilateral borderline ovarian tumors had a mean survival time of 99.9 ± 7.7 months (95% CI: 76.1–126.8). However, the Log-rank test indicated that this difference was not statistically significant (P = 0.969), as shown in Fig. 5 . The overall survival of patients with borderline ovarian tumors at FIGO stages I to III showed no statistically significant difference between the three groups based on the Log-rank test (P = 0.746). However, due to the limited number of patients in stage III, an accurate assessment for this group was not feasible, as shown in Fig. 6 . The average survival time for patients who underwent TAH + BSO surgery was 91.4 ± 1.8 months (95% CI: 75.3–107.3), while for those who underwent conservative surgery it was 105.4 ± 4.5 months (95% CI: 94.1–116.8). Although survival was longer in the conservative surgery group, this difference was not statistically significant based on the Log-rank test (P = 0.199), as shown in Fig. 7 . The average survival time for patients with serous tumors was 108.5 ± 5.6 months (95% CI: 95.3–121.3), while for those with mucinous tumors it was 89.4 ± 7.6 months (95% CI: 77.1–101.8). Although patients with serous tumors had a longer survival, this difference was not statistically significant according to the Log-rank test (P = 0.069), as shown in Fig. 8 . Discussion Borderline ovarian tumors (BOTs) are a heterogeneous group of ovarian lesions characterized by atypical epithelial proliferation without stromal invasion [1]. their prognosis primarily depends on the stage at diagnosis and histopathological features, with most studies reporting favorable outcomes [9]. BOTs frequently diagnosed at early stages, contributing to high survival rates. However, like invasive ovarian carcinomas, BOTs can spread to the peritoneum and lymph nodes, necessitating the identification of risk factors for aggressive recurrence or disease-related mortality [10]. This retrospective study investigated survival rates and associated factors in 135 patients with BOTs referred to the gynecologic oncology department at Urmia University of Medical Sciences between 2000 and 2023. We followed Patients for 15 to 237 months (mean 99.05 ± 54.2 months). A key strength of this study is its comprehensive analysis of survival based on demographic, reproductive, and treatment-related variables, with the extended follow-up period enabling robust evaluation of long-term outcomes. Our findings indicate that most BOTs were serous (57.8%), followed by mucinous (41.5%), with the majority being unilateral and diagnosed at FIGO stage I. These results align with studies identifying serous BOTs as the most common subtype [11, 12]. In contrast, a large cohort study by Karlsen et al. reported nearly equal prevalence of serous and mucinous BOTs [13]. while other studies noted a higher prevalence of mucinous BOTs [14], These variations may be attributed to geopolitical and demographic factors, including ethnicity, environmental exposures, and lifestyle differences. Notably, serous BOTs are more prevalent in Middle Eastern populations, whereas mucinous BOTs predominate in East Asian populations [15]. This study found that patients with serous borderline ovarian tumors (BOTs) had higher survival rates than those with mucinous BOTs, though this difference was not statistically significant. These findings align with some studies [16, 17], while others report a significant difference [18], possibly due to variations in disease stage across study populations. Additionally, certain studies suggest that mucinous BOTs have a greater potential for malignant transformation and progression to invasive carcinoma [19, 20]. This study demonstrates that BOTs are distinct from invasive ovarian cancers. The lack of significant survival differences based on clinic pathological factors, such as tumor size or bilaterality, suggests that molecular and genetic features may be more reliable predictors of recurrence or survival [21]. Overall survival among patients with BOTs at FIGO stages I to III showed no statistically significant differences. This contrasts with studies reporting lower 5-year survival rates with advancing disease stage, typically due to increased mortality risk at higher stages [13, 22]. A possible explanation for the lack of a significant association in our study is that the majority of patients were diagnosed at stage I, while the number of cases identified at stage III was too small to yield reliable comparisons. This limited representation of advanced-stage cases is considered one of the main limitations of our study. In this study, the average age of patients was around 40 years, with most individuals falling within the 30 to 50-year age range. However, a broad age distribution was noted. This observation aligns with the findings of some previous studies [12, 22]. In contrast, other research has indicated a higher average age at diagnosis compared to the current study [13, 23], while some have reported a lower average age at diagnosis[14]. Overall, variations in sample selection methods and cultural differences in health-seeking behaviors—particularly regarding the early versus late detection of ovarian tumors—may explain these discrepancies. In the present study, no significant difference in survival was observed between different age groups. However, the findings of some previous studies contradict this [3, 16], which may be attributed to the age-dependent risk of malignant transformation in cases of recurrent borderline ovarian tumors. We found no significant difference in mean survival rates between patients undergoing total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO) and those receiving conservative surgery. This result is consistent with findings from some previous studies[11, 24]. For example, a study by Joseph Menczer et al., which included 225 patients with borderline ovarian tumors—147 of whom were at FIGO stages II–III and underwent hysterectomy—reported no significant difference in overall survival tumors[24]. These findings question the therapeutic necessity of hysterectomy in managing advanced-stage borderline ovarian tumors. Future research should focus on multicenter, prospective studies with larger sample sizes to improve the generalizability of results. Additionally, parallel studies could investigate the psychological aspects and quality of life associated with patient outcomes. Conclusion The results demonstrate that patients with borderline ovarian tumors, particularly those diagnosed at early stages and treated with conservative surgery, exhibit highly favorable survival rates. No significant differences in survival outcomes based on age, tumor size, bilaterality, or FIGO stage indicate that traditional pathological criteria may not reliably predict prognosis in these patients. Moreover, the absence of survival benefits in patients undergoing Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH + BSO) supports the safety and efficacy of conservative surgical approaches, especially for younger women. These findings advocate for individualized, less invasive surgical strategies for eligible patients, reducing the risk of unnecessary complications associated with extensive procedures. Additionally, the lack of a significant correlation between tumor size, bilaterality, and survival outcomes provides a rationale for minimizing overtreatment in this patient population. This insight can guide gynecological oncologists in tailoring treatment decisions that balance oncologic safety with patients’ reproductive goals. For future research, prospective multicenter studies with larger sample sizes are recommended to validate these findings across diverse populations. Furthermore, qualitative studies exploring the psychological impact, decision-making processes, and quality of life of patients undergoing various surgical treatments could enhance our understanding of borderline ovarian tumor management. Abbreviations BOTs - Borderline ovarian tumors BSO- Bilateral Salpingo-oophorectomy TAH – Total Abdominal Hysterectomy Declarations Acknowledgements The authors thank the Oncology Center of Urmia University of Medical Sciences for data collection. Author contributions Sayna Abbaszadeh, Haleh Ayatollahi, Sedigheh Ghasemian designed the study. Sayna Abbaszadeh collected the data. Hamid Reza Khalkhali analyzed the data, with assistance from Sayna Abbaszadeh, Alireza Babajani in understanding and interpreting theresults. Alireza Babajani wrote the final manuscript, with revisionsfrom all authors. All authors approved the final version. Funding This study was financially supported by Urmia University of Medical Sciences funded this research. Data availability Research data are available upon formal request and a privacy statement from the corresponding author. Ethics approval and consent to participate The study protocol was approved by the Institutional Ethics Committee for Human Research at Urmia University of Medical Sciences (Ethics Code: IR.UMSU.REC.1401.119). The data were extracted from the records of patients who participated in the study after being informed about the study objectives, stating confidentiality of the information, and providing written informed consent. Competing interests The authors declare no competing interests. References Ricotta G, Maulard A, Genestie C, Pautier P, Leary A, Chargari C, et al. Brenner Borderline Ovarian Tumor: A Case Series and Literature Review. Ann Surg Oncol. 2021;28(11):6714-20. du Bois A, Ewald-Riegler N, de Gregorio N, Reuss A, Mahner S, Fotopoulou C, et al. Borderline tumours of the ovary: A cohort study of the Arbeitsgmeinschaft Gynäkologische Onkologie (AGO) Study Group. Eur J Cancer. 2013;49(8):1905-14. Trillsch F, Mahner S, Woelber L, Vettorazzi E, Reuss A, Ewald-Riegler N, et al. Age-dependent differences in borderline ovarian tumours (BOT) regarding clinical characteristics and outcome: results from a sub-analysis of the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) ROBOT study. Ann Oncol. 2014;25(7):1320-7. Harter P, Gershenson D, Lhomme C, Lecuru F, Ledermann J, Provencher DM, et al. Gynecologic Cancer InterGroup (GCIG) consensus review for ovarian tumors of low malignant potential (borderline ovarian tumors). Int J Gynecol Cancer. 2014;24(9 Suppl 3):S5-8. Ness RB, Cramer DW, Goodman MT, Kjaer SK, Mallin K, Mosgaard BJ, et al. Infertility, fertility drugs, and ovarian cancer: a pooled analysis of case-control studies. Am J Epidemiol. 2002;155(3):217-24. Plett H, Harter P, Ataseven B, Heitz F, Prader S, Schneider S, et al. Fertility-sparing surgery and reproductive-outcomes in patients with borderline ovarian tumors. Gynecol Oncol. 2020;157(2):411-7. Gershenson DM. Is micropapillary serous carcinoma for real? Cancer. 2002;95(4):677-80. Morice P, Camatte S, Rey A, Atallah D, Lhommé C, Pautier P, et al. Prognostic factors for patients with advanced stage serous borderline tumours of the ovary. Ann Oncol. 2003;14(4):592-8. Trimble CL, Kosary C, Trimble EL. Long-term survival and patterns of care in women with ovarian tumors of low malignant potential. Gynecologic oncology. 2002;86(1):34-7. Sun Y, Xu J, Jia X. The diagnosis, treatment, prognosis and molecular pathology of borderline ovarian tumors: current status and perspectives. Cancer management and research. 2020:3651-9. 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Reproductive and obstetrical outcomes with the overall survival of fertile-age women treated with fertility-sparing surgery for borderline ovarian tumors in Sweden: a prospective nationwide population-based study. Fertility and sterility. 2021;115(1):157-63. Song T, Lee YY, Choi CH, Kim TJ, Lee JW, Bae DS, et al. Histologic distribution of borderline ovarian tumors worldwide: a systematic review. J Gynecol Oncol. 2013;24(1):44-51. Kalapotharakos G, Högberg T, Bergfeldt K, Borgfeldt C. Long-term survival in women with borderline ovarian tumors: a population-based survey of borderline ovarian tumors in Sweden 1960-2007. Acta Obstet Gynecol Scand. 2016;95(4):473-9. Song T, Lee Y-Y, Choi CH, Kim T-J, Lee J-W, Kim B-G, et al. Prognosis in Patients With Serous and Mucinous Stage I Borderline Ovarian Tumors. International Journal of Gynecological Cancer. 2012;22(5):770-7. Fischerova D, Zikan M, Dundr P, Cibula D. Diagnosis, treatment, and follow-up of borderline ovarian tumors. Oncologist. 2012;17(12):1515-33. Lalwani N, Shanbhogue AK, Vikram R, Nagar A, Jagirdar J, Prasad SR. Current update on borderline ovarian neoplasms. AJR Am J Roentgenol. 2010;194(2):330-6. Bonadio RC, de Siqueira Santos AG, Estevez-Diz MDP. Borderline ovarian tumors: a review of its biology, molecular profile, and management. Brazilian Journal of Oncology. 2024;20(continuous publication). Silva EG, Gershenson DM, Malpica A, Deavers M. The recurrence and the overall survival rates of ovarian serous borderline neoplasms with noninvasive implants is time dependent. Am J Surg Pathol. 2006;30(11):1367-71. Loizzi V, Selvaggi L, Leone L, Latorre D, Scardigno D, Magazzino F, et al. Borderline epithelial tumors of the ovary: Experience of 55 patients. Oncol Lett. 2015;9(2):912-4. Sahin F, Aktürk E, Günkaya OS, Özdemir S, Konal M, Genç S, et al. Borderline ovarian tumors: twenty years of experience at a tertiary center. Anatolian Current Medical Journal. 2023;5(3):196-200. Menczer J, Chetrit A, Sadetzki S. The effect of hysterectomy on survival of patients with borderline ovarian tumors. Gynecol Oncol. 2012;125(2):372-5. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7168557","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":505449111,"identity":"6a46fac3-e248-4ca2-ac15-e2c620cd4258","order_by":0,"name":"Sayna 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location.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/de55bafe23e966adc1a89b6c.png"},{"id":89988528,"identity":"11695d57-fed6-4405-bf2d-fd721499428e","added_by":"auto","created_at":"2025-08-27 07:04:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23334,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival of the studied patients.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/6f7c8ef265852798952808e2.png"},{"id":89988533,"identity":"6a0fa538-f9ed-4239-82cd-0688fb62edb3","added_by":"auto","created_at":"2025-08-27 07:04:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40621,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival of the studied patients stratified by age groups at the time of surgery\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/3e7199ae0c0db5b82a082a26.png"},{"id":89988537,"identity":"dfd4b3c7-f961-4ead-9731-ee1ce5ae06a9","added_by":"auto","created_at":"2025-08-27 07:04:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":43078,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival of patients stratified by initial tumor size\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/85af3a2f3af857f7bdbec096.png"},{"id":89988545,"identity":"36888c93-2667-490c-ab5e-fbec09b33c13","added_by":"auto","created_at":"2025-08-27 07:04:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":33788,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival according to tumor location in the studied patients.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/4335232704d47bf57c8d1942.png"},{"id":89988538,"identity":"0db6d75b-97ae-4d54-aaf2-c623cc54d6f3","added_by":"auto","created_at":"2025-08-27 07:04:34","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":33563,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival stratified by tumor stage in the studied patients.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/f5fd30bdd1479c109b831881.png"},{"id":89988551,"identity":"88543ed3-3882-4b0a-91c7-a1c0c6f77123","added_by":"auto","created_at":"2025-08-27 07:04:34","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":37253,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival stratified by surgical technique in the studied patients\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/43e89c22b936326f32f8d122.png"},{"id":89990428,"identity":"3c19e56e-2d2b-4b78-a80a-a7f86a944d04","added_by":"auto","created_at":"2025-08-27 07:12:34","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":127387,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival based on tumor histopathology in the studied patients.\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/e4d90d8a1c1c2db5b23ac367.png"},{"id":98245251,"identity":"6070782a-f58b-458b-9614-8613c69d8bcb","added_by":"auto","created_at":"2025-12-15 16:17:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":759918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7168557/v1/3bd6b221-f097-4abd-b968-e0d661994d32.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Survival Analysis of Borderline Ovarian Tumors: A 23-Year Retrospective Study in a Middle Eastern Cohort","fulltext":[{"header":"Background","content":"\u003cp\u003eBorderline ovarian tumors (BOTs), also known as low malignant potential tumors, are a histologically heterogeneous subset of epithelial ovarian neoplasms characterized by atypical epithelial proliferation without stromal invasion [1]. BOTs constitute less than 20% of all ovarian tumors and are predominantly serous or mucinous in histology. Unlike invasive epithelial ovarian cancers, BOTs exhibit a relatively indolent clinical course and a more favorable prognosis (2). As these tumors are frequently diagnosed in women of reproductive age, clinical management must balance oncologic safety with fertility preservation.[2, 3].\u003c/p\u003e\u003cp\u003eBOTs are typically diagnosed at an early stage, with epidemiological data indicating that approximately 70% of cases are FIGO stage I, 10% stage II, 19% stage III, and 1% stage IV [4, 5]. Prognosis is influenced by factors such as stage at diagnosis, histological subtype, reproductive history (e.g., parity and menopausal status), and surgical approach [6]. Stage I BOTs have excellent survival rates of 99% at 1 year and 97% at 5 years. However, survival decreases with advancing stage: stage II, 98% at 1 year and 90% at 5 years; stage III, 96% and 88%; and stage IV, 77% and 69% [7, 8].\u003c/p\u003e\u003cp\u003eExisting literature on BOTs has largely focused on individual prognostic factors. Some studies have examined surgical strategies and survival outcomes (9), others have investigated non-invasive implants (10), histopathological subtypes (11), or aspects of fertility history such as parity and reproductive planning (12). However, few studies have provided a comprehensive survival analysis that integrates demographic, reproductive, and treatment-related variables. This retrospective study aims to address this gap by offering a multidimensional assessment of short-term (1- and 3-year) and long-term (5- and 10-year) survival predictors in women diagnosed with BOTs between 2000 and 2023.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective study involved patients diagnosed with borderline ovarian tumors (BOTs) who were treated at hospitals affiliated with Urmia University of Medical Sciences from 2000 to 2023. The study protocol received approval from the Institutional Ethics Committee for Human Research at Urmia University of Medical Sciences (Ethics Code: IR.UMSU.REC.1401.119) and was conducted in full compliance with the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003eThe research team reviewed surgical pathology records from oncology departments of affiliated hospitals. Patients with BOTs were identified, and their clinical files and pathology slides were examined. Inclusion criteria required a confirmed BOT diagnosis based on histopathology reports, verified by a pathologist. Exclusion criteria included cases with incomplete clinical records or loss to follow-up for survival analysis. An initial review of records from 2000 to 2023 identified 183 BOT cases. Of these, 48 cases were excluded due to incomplete data or loss to follow-up. Ultimately, 135 patients were included in the final analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection and Statistical Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData relevant to the survival analysis were obtained using a researcher-created checklist. The variables assessed included demographic characteristics (age at diagnosis, age group), clinical features (history of infertility, parity, tumor size, tumor location, tumor type, and FIGO stage), and treatment-related parameters (histopathological subtype and type of surgical intervention). Descriptive statistics, such as mean and standard deviation for numerical variables, and frequency distributions for qualitative variables, were utilized.\u003c/p\u003e\u003cp\u003eThe Kaplan–Meier method was employed to estimate the survival function, and differences between survival curves were evaluated using the Log-rank test. The final follow-up date for survival assessment was December 2023. All analyses were performed with a 95% confidence interval, and a p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study initially enrolled 183 women who underwent surgery for borderline ovarian tumors (BOTs) between January 2000 and January 2023. Forty-eight patients were excluded due to incomplete data, leaving 135 patients with confirmed BOT diagnoses based on histopathology. Patients were classified by FIGO stage and tumor characteristics, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Their ages ranged from 16 to 78 years (mean 39.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2 years). At diagnosis, most patients (85.2%) were in their reproductive years and premenopausal, while 14.8% were postmenopausal. Additionally, 6.7% reported long-term use of oral contraceptive pills (OCPs). Regarding pregnancy history, 25.9% had never been pregnant, 37.8% had one or two pregnancies, and 36.3% had three or more pregnancies.\u003c/p\u003e\u003cp\u003eHistopathological findings indicated that serous tumors were the most common (57.8%), followed by mucinous tumors (41.5%). Only one case (0.7%) was an endometrioid tumor. Most patients (84.4%) had unilateral tumors, with bilateral involvement in 15.6% of cases.\u003c/p\u003e\u003cp\u003eAccording to FIGO staging, the majority of patients (94%) were diagnosed at Stage I, with only a small portion diagnosed at Stages II and III, each representing 3% of the cases. In terms of surgical treatment, 65.2% of the patients received conservative surgery, whereas 34.8% underwent total abdominal hysterectomy combined with bilateral salpingo-oophorectomy (TAH\u0026thinsp;+\u0026thinsp;BSO) .Microscopically, micro invasion was reported in 11.9% of cases, while it was absent in 88.1%. The mean tumor size was 13.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.02 cm, with sizes ranging from 3 to 40 cm. Tumor size distribution showed that 48.9% of tumors measured between 10 to 20 cm, 37% were smaller than 10 cm, and 14.1% exceeded 20 cm.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patients were followed for a period ranging from 15 to 237 months, with a mean follow-up duration of 99.05\u0026thinsp;\u0026plusmn;\u0026thinsp;54.2 months. During the follow-up period and the course of the study (from 2000 to 2023), only 3 out of 135 patients (2.2%) had died. The overall survival function was estimated using the Kaplan\u0026ndash;Meier method. The mean overall survival time was 231.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 months (95% CI). The 1-, 3-, 5-, and 10-year survival rates were reported as 100%, 99.2%, 98.3%, and 97.2%, respectively, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe average survival time for patients aged under 30, 30\u0026ndash;50, and over 50 years was 106.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 months (95% CI: 88.8\u0026ndash;123.9), 103.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 months (95% CI: 91.3\u0026ndash;116.4), and 86.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 months (95% CI: 69.2\u0026ndash;109.7), respectively. According to the Log-rank test, there was no statistically significant difference in survival among the different age groups (P\u0026thinsp;=\u0026thinsp;0.44), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe average survival time for patients with tumors larger than 20 cm was 90.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7 months (95% CI: 62.1\u0026ndash;119.8), which was shorter compared to patients with tumors smaller than 10 cm (107.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 months, 95% CI: 93.3\u0026ndash;126.4) and those with tumors measuring between 10 and 20 cm (98.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 months, 95% CI: 83.4\u0026ndash;111.4). According to the results of the Log-rank test, there was no statistically significant difference in survival based on tumor size (P\u0026thinsp;=\u0026thinsp;0.752), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe average survival time for patients with unilateral tumors was 100.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 months (95% CI: 62.1\u0026ndash;119.8). In comparison, patients with bilateral borderline ovarian tumors had a mean survival time of 99.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 months (95% CI: 76.1\u0026ndash;126.8). However, the Log-rank test indicated that this difference was not statistically significant (P\u0026thinsp;=\u0026thinsp;0.969), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe overall survival of patients with borderline ovarian tumors at FIGO stages I to III showed no statistically significant difference between the three groups based on the Log-rank test (P\u0026thinsp;=\u0026thinsp;0.746). However, due to the limited number of patients in stage III, an accurate assessment for this group was not feasible, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe average survival time for patients who underwent TAH\u0026thinsp;+\u0026thinsp;BSO surgery was 91.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 months (95% CI: 75.3\u0026ndash;107.3), while for those who underwent conservative surgery it was 105.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 months (95% CI: 94.1\u0026ndash;116.8). Although survival was longer in the conservative surgery group, this difference was not statistically significant based on the Log-rank test (P\u0026thinsp;=\u0026thinsp;0.199), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThe average survival time for patients with serous tumors was 108.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 months (95% CI: 95.3\u0026ndash;121.3), while for those with mucinous tumors it was 89.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 months (95% CI: 77.1\u0026ndash;101.8). Although patients with serous tumors had a longer survival, this difference was not statistically significant according to the Log-rank test (P\u0026thinsp;=\u0026thinsp;0.069), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBorderline ovarian tumors (BOTs) are a heterogeneous group of ovarian lesions characterized by atypical epithelial proliferation without stromal invasion [1]. their prognosis primarily depends on the stage at diagnosis and histopathological features, with most studies reporting favorable outcomes [9]. BOTs frequently diagnosed at early stages, contributing to high survival rates. However, like invasive ovarian carcinomas, BOTs can spread to the peritoneum and lymph nodes, necessitating the identification of risk factors for aggressive recurrence or disease-related mortality [10].\u003c/p\u003e\u003cp\u003eThis retrospective study investigated survival rates and associated factors in 135 patients with BOTs referred to the gynecologic oncology department at Urmia University of Medical Sciences between 2000 and 2023. We followed Patients for 15 to 237 months (mean 99.05\u0026thinsp;\u0026plusmn;\u0026thinsp;54.2 months). A key strength of this study is its comprehensive analysis of survival based on demographic, reproductive, and treatment-related variables, with the extended follow-up period enabling robust evaluation of long-term outcomes.\u003c/p\u003e\u003cp\u003eOur findings indicate that most BOTs were serous (57.8%), followed by mucinous (41.5%), with the majority being unilateral and diagnosed at FIGO stage I. These results align with studies identifying serous BOTs as the most common subtype [11, 12]. In contrast, a large cohort study by Karlsen et al. reported nearly equal prevalence of serous and mucinous BOTs [13]. while other studies noted a higher prevalence of mucinous BOTs [14], These variations may be attributed to geopolitical and demographic factors, including ethnicity, environmental exposures, and lifestyle differences. Notably, serous BOTs are more prevalent in Middle Eastern populations, whereas mucinous BOTs predominate in East Asian populations [15].\u003c/p\u003e\u003cp\u003eThis study found that patients with serous borderline ovarian tumors (BOTs) had higher survival rates than those with mucinous BOTs, though this difference was not statistically significant. These findings align with some studies [16, 17], while others report a significant difference [18], possibly due to variations in disease stage across study populations. Additionally, certain studies suggest that mucinous BOTs have a greater potential for malignant transformation and progression to invasive carcinoma [19, 20].\u003c/p\u003e\u003cp\u003eThis study demonstrates that BOTs are distinct from invasive ovarian cancers. The lack of significant survival differences based on clinic pathological factors, such as tumor size or bilaterality, suggests that molecular and genetic features may be more reliable predictors of recurrence or survival [21].\u003c/p\u003e\u003cp\u003eOverall survival among patients with BOTs at FIGO stages I to III showed no statistically significant differences. This contrasts with studies reporting lower 5-year survival rates with advancing disease stage, typically due to increased mortality risk at higher stages [13, 22]. A possible explanation for the lack of a significant association in our study is that the majority of patients were diagnosed at stage I, while the number of cases identified at stage III was too small to yield reliable comparisons. This limited representation of advanced-stage cases is considered one of the main limitations of our study.\u003c/p\u003e\u003cp\u003eIn this study, the average age of patients was around 40 years, with most individuals falling within the 30 to 50-year age range. However, a broad age distribution was noted. This observation aligns with the findings of some previous studies [12, 22]. In contrast, other research has indicated a higher average age at diagnosis compared to the current study [13, 23], while some have reported a lower average age at diagnosis[14]. Overall, variations in sample selection methods and cultural differences in health-seeking behaviors\u0026mdash;particularly regarding the early versus late detection of ovarian tumors\u0026mdash;may explain these discrepancies. In the present study, no significant difference in survival was observed between different age groups. However, the findings of some previous studies contradict this [3, 16], which may be attributed to the age-dependent risk of malignant transformation in cases of recurrent borderline ovarian tumors.\u003c/p\u003e\u003cp\u003eWe found no significant difference in mean survival rates between patients undergoing total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH\u0026thinsp;+\u0026thinsp;BSO) and those receiving conservative surgery. This result is consistent with findings from some previous studies[11, 24]. For example, a study by Joseph Menczer et al., which included 225 patients with borderline ovarian tumors\u0026mdash;147 of whom were at FIGO stages II\u0026ndash;III and underwent hysterectomy\u0026mdash;reported no significant difference in overall survival tumors[24]. These findings question the therapeutic necessity of hysterectomy in managing advanced-stage borderline ovarian tumors.\u003c/p\u003e\u003cp\u003eFuture research should focus on multicenter, prospective studies with larger sample sizes to improve the generalizability of results. Additionally, parallel studies could investigate the psychological aspects and quality of life associated with patient outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results demonstrate that patients with borderline ovarian tumors, particularly those diagnosed at early stages and treated with conservative surgery, exhibit highly favorable survival rates. No significant differences in survival outcomes based on age, tumor size, bilaterality, or FIGO stage indicate that traditional pathological criteria may not reliably predict prognosis in these patients. Moreover, the absence of survival benefits in patients undergoing Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH\u0026thinsp;+\u0026thinsp;BSO) supports the safety and efficacy of conservative surgical approaches, especially for younger women. These findings advocate for individualized, less invasive surgical strategies for eligible patients, reducing the risk of unnecessary complications associated with extensive procedures.\u003c/p\u003e\u003cp\u003eAdditionally, the lack of a significant correlation between tumor size, bilaterality, and survival outcomes provides a rationale for minimizing overtreatment in this patient population. This insight can guide gynecological oncologists in tailoring treatment decisions that balance oncologic safety with patients\u0026rsquo; reproductive goals.\u003c/p\u003e\u003cp\u003eFor future research, prospective multicenter studies with larger sample sizes are recommended to validate these findings across diverse populations. Furthermore, qualitative studies exploring the psychological impact, decision-making processes, and quality of life of patients undergoing various surgical treatments could enhance our understanding of borderline ovarian tumor management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOTs - Borderline ovarian tumors\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;BSO- Bilateral Salpingo-oophorectomy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTAH \u0026ndash; Total Abdominal Hysterectomy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors thank the Oncology Center of Urmia University of Medical Sciences for data collection.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eSayna Abbaszadeh, Haleh Ayatollahi, Sedigheh Ghasemian designed the study. Sayna Abbaszadeh collected the data. Hamid Reza Khalkhali analyzed the data, with assistance from Sayna Abbaszadeh, Alireza Babajani in understanding and interpreting theresults. Alireza Babajani wrote the final manuscript, with revisionsfrom all authors. All authors approved the final version.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was financially supported by Urmia University of Medical Sciences funded this research.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eResearch data are available upon formal request and a privacy statement from the corresponding author.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Ethics Committee for Human Research at Urmia University of Medical Sciences (Ethics Code: IR.UMSU.REC.1401.119). The data were extracted from the records of patients who participated in the study after being informed about the study objectives, stating confidentiality of the information, and providing written informed consent.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRicotta G, Maulard A, Genestie C, Pautier P, Leary A, Chargari C, et al. Brenner Borderline Ovarian Tumor: A Case Series and Literature Review. Ann Surg Oncol. 2021;28(11):6714-20.\u003c/li\u003e\n\u003cli\u003edu Bois A, Ewald-Riegler N, de Gregorio N, Reuss A, Mahner S, Fotopoulou C, et al. Borderline tumours of the ovary: A cohort study of the Arbeitsgmeinschaft Gyn\u0026auml;kologische Onkologie (AGO) Study Group. Eur J Cancer. 2013;49(8):1905-14.\u003c/li\u003e\n\u003cli\u003eTrillsch F, Mahner S, Woelber L, Vettorazzi E, Reuss A, Ewald-Riegler N, et al. Age-dependent differences in borderline ovarian tumours (BOT) regarding clinical characteristics and outcome: results from a sub-analysis of the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) ROBOT study. Ann Oncol. 2014;25(7):1320-7.\u003c/li\u003e\n\u003cli\u003eHarter P, Gershenson D, Lhomme C, Lecuru F, Ledermann J, Provencher DM, et al. Gynecologic Cancer InterGroup (GCIG) consensus review for ovarian tumors of low malignant potential (borderline ovarian tumors). Int J Gynecol Cancer. 2014;24(9 Suppl 3):S5-8.\u003c/li\u003e\n\u003cli\u003eNess RB, Cramer DW, Goodman MT, Kjaer SK, Mallin K, Mosgaard BJ, et al. Infertility, fertility drugs, and ovarian cancer: a pooled analysis of case-control studies. Am J Epidemiol. 2002;155(3):217-24.\u003c/li\u003e\n\u003cli\u003ePlett H, Harter P, Ataseven B, Heitz F, Prader S, Schneider S, et al. Fertility-sparing surgery and reproductive-outcomes in patients with borderline ovarian tumors. Gynecol Oncol. 2020;157(2):411-7.\u003c/li\u003e\n\u003cli\u003eGershenson DM. Is micropapillary serous carcinoma for real? Cancer. 2002;95(4):677-80.\u003c/li\u003e\n\u003cli\u003eMorice P, Camatte S, Rey A, Atallah D, Lhomm\u0026eacute; C, Pautier P, et al. Prognostic factors for patients with advanced stage serous borderline tumours of the ovary. Ann Oncol. 2003;14(4):592-8.\u003c/li\u003e\n\u003cli\u003eTrimble CL, Kosary C, Trimble EL. Long-term survival and patterns of care in women with ovarian tumors of low malignant potential. Gynecologic oncology. 2002;86(1):34-7.\u003c/li\u003e\n\u003cli\u003eSun Y, Xu J, Jia X. The diagnosis, treatment, prognosis and molecular pathology of borderline ovarian tumors: current status and perspectives. Cancer management and research. 2020:3651-9.\u003c/li\u003e\n\u003cli\u003eSharami SRY, Farhadifar F, Tabatabaei R. Recurrence and 5-year survival rate in patients with borderline ovarian tumors and related factors in Kurdistan. European journal of translational myology. 2022;33(1):10779.\u003c/li\u003e\n\u003cli\u003eKarimi Zarchi M, Mehdizadeh Kashi A, Allahqoli L, Sadat Tabatabai R, Shamsi F, Hashemian Asl N. The Recurrence and 5-Year Survival Rates in Patients with Borderline Ovarian Tumors in Yazd from 2006 to 2016. Journal of Obstetrics, Gynecology and Cancer Research. 2022;4(2):57-61.\u003c/li\u003e\n\u003cli\u003eKarlsen NMS, Karlsen MA, H\u0026oslash;gdall E, Nedergaard L, Christensen IJ, H\u0026oslash;gdall C. Relapse and disease specific survival in 1143 Danish women diagnosed with borderline ovarian tumours (BOT). Gynecologic oncology. 2016;142(1):50-3.\u003c/li\u003e\n\u003cli\u003eJohansen G, Dahm-K\u0026auml;hler P, Staf C, R\u0026aring;destad AF, Rodriguez-Wallberg KA. Reproductive and obstetrical outcomes with the overall survival of fertile-age women treated with fertility-sparing surgery for borderline ovarian tumors in Sweden: a prospective nationwide population-based study. Fertility and sterility. 2021;115(1):157-63.\u003c/li\u003e\n\u003cli\u003eSong T, Lee YY, Choi CH, Kim TJ, Lee JW, Bae DS, et al. Histologic distribution of borderline ovarian tumors worldwide: a systematic review. J Gynecol Oncol. 2013;24(1):44-51.\u003c/li\u003e\n\u003cli\u003eKalapotharakos G, H\u0026ouml;gberg T, Bergfeldt K, Borgfeldt C. Long-term survival in women with borderline ovarian tumors: a population-based survey of borderline ovarian tumors in Sweden 1960-2007. Acta Obstet Gynecol Scand. 2016;95(4):473-9.\u003c/li\u003e\n\u003cli\u003eSong T, Lee Y-Y, Choi CH, Kim T-J, Lee J-W, Kim B-G, et al. Prognosis in Patients With Serous and Mucinous Stage I Borderline Ovarian Tumors. International Journal of Gynecological Cancer. 2012;22(5):770-7.\u003c/li\u003e\n\u003cli\u003eFischerova D, Zikan M, Dundr P, Cibula D. Diagnosis, treatment, and follow-up of borderline ovarian tumors. Oncologist. 2012;17(12):1515-33.\u003c/li\u003e\n\u003cli\u003eLalwani N, Shanbhogue AK, Vikram R, Nagar A, Jagirdar J, Prasad SR. Current update on borderline ovarian neoplasms. AJR Am J Roentgenol. 2010;194(2):330-6.\u003c/li\u003e\n\u003cli\u003eBonadio RC, de Siqueira Santos AG, Estevez-Diz MDP. Borderline ovarian tumors: a review of its biology, molecular profile, and management. Brazilian Journal of Oncology. 2024;20(continuous publication).\u003c/li\u003e\n\u003cli\u003eSilva EG, Gershenson DM, Malpica A, Deavers M. The recurrence and the overall survival rates of ovarian serous borderline neoplasms with noninvasive implants is time dependent. Am J Surg Pathol. 2006;30(11):1367-71.\u003c/li\u003e\n\u003cli\u003eLoizzi V, Selvaggi L, Leone L, Latorre D, Scardigno D, Magazzino F, et al. Borderline epithelial tumors of the ovary: Experience of 55 patients. Oncol Lett. 2015;9(2):912-4.\u003c/li\u003e\n\u003cli\u003eSahin F, Akt\u0026uuml;rk E, G\u0026uuml;nkaya OS, \u0026Ouml;zdemir S, Konal M, Gen\u0026ccedil; S, et al. Borderline ovarian tumors: twenty years of experience at a tertiary center. Anatolian Current Medical Journal. 2023;5(3):196-200.\u003c/li\u003e\n\u003cli\u003eMenczer J, Chetrit A, Sadetzki S. The effect of hysterectomy on survival of patients with borderline ovarian tumors. Gynecol Oncol. 2012;125(2):372-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Borderline ovarian tumors, Hysterectomy, Survival Rate, Fertility Preservation, Retrospective Study","lastPublishedDoi":"10.21203/rs.3.rs-7168557/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7168557/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBorderline ovarian tumors (BOTs) are non-invasive epithelial lesions with a generally favorable prognosis compared to invasive ovarian cancers. Given their prevalence among young women, balancing oncologic safety with fertility preservation is critical for clinical management. This study evaluates factors associated with survival in patients with BOTs over a long-term follow-up period.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003eThis retrospective analysis reviewed data from 135 patients diagnosed with BOTs between 2000 and 2023 at healthcarefı facilities affiliated with Urmia University of Medical Sciences. Clinical and pathological data were extracted from patient records. Survival was estimated using the Kaplan\u0026ndash;Meier method, and group comparisons were conducted with the Log-rank test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean patient age was 39.5 years; with most cases diagnosed at FIGO stage I. Conservative surgical management was performed in 65.2% of patients, while 34.8% underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH\u0026thinsp;+\u0026thinsp;BSO). Survival rates at 1, 3, 5, and 10 years were 100%, 99.2%, 98.3%, and 97.2%, respectively. No statistically significant differences in survival were observed based on age, tumor size, bilaterality, FIGO stage, or surgical approach.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBOTs generally exhibit a favorable clinical course, and conservative surgery appears safe and effective, particularly for younger women. The lack of association between certain pathological features and survival suggests that unnecessary surgical interventions should be avoided. Further prospective, multicenter studies are needed to validate these findings in diverse populations.\u003c/p\u003e","manuscriptTitle":"Survival Analysis of Borderline Ovarian Tumors: A 23-Year Retrospective Study in a Middle Eastern Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 07:04:28","doi":"10.21203/rs.3.rs-7168557/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T00:03:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-31T12:22:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-31T06:51:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-30T11:23:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T14:06:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325973946618579712508594011051597484867","date":"2025-08-25T20:24:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235442813343933379434779080780429450336","date":"2025-08-24T20:11:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6856932058792334846907313289109153936","date":"2025-08-24T08:15:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134293851688748562740908881640301013268","date":"2025-08-24T07:51:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T11:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24924996504037972661167844070083576355","date":"2025-08-20T02:34:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T18:53:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293582819038677080645246496329174762526","date":"2025-08-19T08:17:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254319466313317398460167048009634164261","date":"2025-08-18T23:30:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-18T21:36:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-30T09:42:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-30T05:09:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-30T05:08:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-07-20T08:45:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd6ae50e-ff38-4223-9a24-3e496e95b9fb","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:13:58+00:00","versionOfRecord":{"articleIdentity":"rs-7168557","link":"https://doi.org/10.1186/s12905-025-04183-3","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2025-12-12 15:58:10","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-08-27 07:04:28","video":"","vorDoi":"10.1186/s12905-025-04183-3","vorDoiUrl":"https://doi.org/10.1186/s12905-025-04183-3","workflowStages":[]},"version":"v1","identity":"rs-7168557","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7168557","identity":"rs-7168557","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}