• © 2003 by American Society of Clinical Oncology

Unusual Abdominal and Pelvic Tumors

CASE 2. SPONTANEOUS REGRESSION OF PERITONEAL IMPLANTS IN BORDERLINE OVARIAN TUMOR AFTER SALPINGO-OOPHORECTOMY

A 49-year-old woman, with a history of right salpingo-oophorectomy for ovarian borderline tumor 20 years previously, underwent a laparoscopic procedure for pelvic pains. A suspicious tumor on the left ovary, with numerous peritoneal implants on the pelvic cavity and a myoma, were found during the laparoscopy. A conversion to laparotomy was performed to carry out a left salpingo-oophorectomy, myomectomy, and peritoneal biopsies. Histologic examinations revealed the presence of serous borderline tumor of the ovary with micropapillary component, positive peritoneal cytology, and noninvasive peritoneal implants (Fig 1⇓). At the end of surgical procedure, residual disease was persistent on the peritoneum of the pelvic cavity (numerous peritoneal implants from 1 to 5 mm). A radical surgery (hysterectomy and resection of the peritoneal implants) was proposed, but was refused by the patient. A second-look resection of residual peritoneal implants was planned using a laparoscopic approach 6 months following the salpingo-ooporectomy. At that time, the clinical examination, CA125 antigen level, and abdominopelvic computed tomography scan were normal. During the laparoscopic procedure, we noted an adhesion of the omentum to the uterine scar of myomectomy with 2 peritoneal implants of 2 mm. On the peritoneum of the pelvic cavity an important regression of the peritoneal implants was observed. Several implants of 1 mm were found on the Douglas pouch, on the peritoneum of the broad ligament and on the surface of the peritoneum of the bladder. Large peritonectomies were performed with a partial omentectomy by laparoscopy. There was no residual tumor at the end of this surgical procedure. Histologic examination revealed the presence of only two small, noninvasive implants on the omentum. Calcospherites with fibrosis were found on the surface of the peritoneum, but residual peritoneal implants were absent (Fig 2⇓).

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Fig 1.

Noninvasive implants on the peritoneum removed during initial surgery (hematoxylin and eosin, magnification ×50).

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Fig 2.

Aspect of peritoneal lesion removed during second-look surgery. Calcospherites with fibrosis were found on the surface of the peritoneum, but without residual tumoral implants (hematoxylin and eosin, magnification ×100).

Peritoneal implants from borderline ovarian tumor are defined as invasive or noninvasive depending on the presence or absence of stroma infiltration. The rate of recurrence with invasive disease is 31% in patients with invasive peritoneal implants versus 2% in patients with noninvasive implants.¹ Prognosis of patients with noninvasive implants is good. Peritoneal implants are not chemosensitive lesions. The most important therapy is surgery with resection of all macroscopic disease.² As in patients with ovarian carcinoma, such surgery may involve large resection of the peritoneum with eventually bowel resection in cases of extensive peritoneal implants. Such “debulking” surgery is associated with high morbidity, which could be unacceptable particularly in young patients with noninvasive implants treated conservatively to preserve fertility. Our observation of spontaneous regression of peritoneal implants following resection of the ovarian tumor is exceptional and has important management implications. It could suggest that in young patients with noninvasive implants confirmed by multiple peritoneal biopsies, if the surgery needed to achieve a complete resection of implants would be too aggressive (bowel resection) or unacceptable by the patient, it would be advisable to propose a simple resection of the ovarian tumor with a second look surgery several weeks after this initial operation.

The pathogenesis of peritoneal implants is debated: some authors think that peritoneal implants are “metastases” from the ovarian tumor³ whereas others think that peritoneal and ovarian tumors arise independently in response to the same tumorigenic agents.⁴ A recent important study using clonality testing (based on inactivation of X chromosome) in patients with ovarian borderline tumor and peritoneal implants suggests that peritoneal implants and the ovarian borderline tumor arise independently.⁵ Our case suggests that the clinical behavior of peritoneal implants is related to the primary ovarian tumor possibly due to the secretion of prosurvival factors.