Seidman J D, Kurman R J
Department of Pathology, Washington Hospital Center, DC 20010, USA.
Hum Pathol. 2000 May;31(5):539-57. doi: 10.1053/hp.2000.8048.
The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.
245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."
Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.
Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."
由于文献中的不一致和混淆，卵巢浆液性交界性肿瘤（SBTs）的行为及各种预后因素的意义尚不清楚且难以评估。最近的研究表明，原发性肿瘤的形态特征（有无微乳头特征）和腹膜“种植灶”（有无浸润特征）能够可靠地将SBTs分为良性和恶性类型。本综述的目的是检验两个假设。其一，SBTs所谓的恶性行为记录不充分；其二，原发性卵巢肿瘤和相关腹膜种植灶的形态特征足以将SBTs分为良性和恶性类型，从而无需该类别。
对245项报告了约18000例交界性卵巢肿瘤患者的研究进行了综述。在排除缺乏临床随访或因其他原因无法分析的系列研究后，剩下97份报告，包含4129例患者。除了复发和生存情况，我们还评估了腹膜种植灶的类型、微浸润、淋巴结受累、晚期复发以及进展为癌的情况，因为这些特征一直是“交界性恶性”或“低恶性潜能”概念的基础。
在回顾的4129例SBTs患者中，I期肿瘤平均随访6.7年后的年复发率为0.27%，无病生存率为98.2%，总体疾病特异性生存率为99.5%。晚期肿瘤患者的年复发率为2.4%。然而，大多数（69%）报告的复发没有病理记录，只有26例（占所有复发的8.4%）被记录为复发于充分取材的卵巢肿瘤。晚期肿瘤最可靠的预后指标是腹膜种植灶的类型。随访7.4年后，非浸润性腹膜种植灶患者的生存率为95.3%，而浸润性种植灶患者为66%（P <.0001）。原发性卵巢肿瘤中的微浸润与6.7年时100%的生存率相关，淋巴结受累与6.5年时98%的生存率相关。少数报告的IV期疾病、进展为浸润性癌和极晚期（>20年）复发的病例记录不充分。6项前瞻性随机试验中约373例患者平均随访6.7年，各阶段的生存率均为100%。
手术病理分期以及将卵巢外疾病分为浸润性和非浸润性种植灶是SBTs最重要的预后指标。I期肿瘤的生存率几乎为100%。非浸润性种植灶的晚期肿瘤生存率为95.3%，而浸润性种植灶的肿瘤生存率为66%。浸润性种植灶表现为癌，很可能发生转移。所谓非浸润性种植灶的确切性质尚不清楚，但它们表现为良性。原发性卵巢肿瘤中微乳头结构的存在是浸润性种植灶的有力预测指标。这些数据支持将具有微乳头结构的卵巢肿瘤指定为“微乳头浆液性癌”，而缺乏这些特征的肿瘤指定为“非典型增生性浆液性肿瘤”的建议。
