Borderline ovarian tumors: French guidelines from the CNGOF. Part 2. Surgical management, follow-up, hormone replacement therapy, fertility management and preservation
Borderline ovarian tumors: French guidelines from the CNGOF. Part 2. Surgical management, follow-up, hormone replacement therapy, fertility management and preservation
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DOI：
10.1016/j.jogoh.2020.101966
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发表时间：
2021-01-15
影响因子：
1.9
通讯作者：
Darai, Emile
中科院分区：
文献类型：
--
作者：
Bourdel, Nicolas;Huchon, Cyrille;Darai, Emile
在边缘性卵巢肿瘤（BOT）的早期阶段（ES），如果手术没有肿瘤破裂的风险是可能的，那么腹腔镜手术与保护性提取建议剖腹手术（C级）。如果双侧浆液性ES BOT治疗的策略是保留生育力和/或内分泌功能，则建议在可能的情况下进行双侧Cybone治疗（B级）。在粘液性BOT治疗的情况下，建议采用保留生育力和/或内分泌功能的策略，进行单侧附件切除术（C级）。在粘液性BOT的情况下，在一个病人谁有一个初始的囊肿，单侧附件切除术是推荐的（C级）。在治疗患有初始膀胱炎的患者的浆液性ES BOT的情况下，采用保留生育力和/或内分泌功能的策略，如果手术和/或术后成像（参考超声检查或盆腔MRI）（C级）时没有可疑残留病变，则不建议进行附件切除术的再分期手术。对于浆液性或粘液性ES BOT，不建议常规子宫切除术（C级）。在ES BOT的情况下，不建议进行淋巴结切除术（C级）。对于ES BOT，仅当阑尾存在宏观病理学方面（C级）时才建议进行阑尾切除术。如果是浆液性BOT伴微乳头征，初次手术时腹腔检查不满意（C级），建议进行分期手术。如果只进行了阑尾切除术或阑尾未进行评估（C级），则建议对粘液性BOT进行分期手术。如果决定对ES BOT进行再分期手术，应执行以下程序：腹膜细胞学（C级），网膜切除术（文献中没有数据推荐应该进行哪种类型的网膜切除术）（B级），腹腔完全探查并进行腹膜活检（C级），阑尾可视化+/-病理性肉眼外观（C级）的阑尾切除术和粘液性BOT（C级）的单侧附件切除术。在BOT的晚期，不建议将淋巴结切除术作为常规手术（C级）。在晚期BOT的情况下，在希望怀孕的患者中，在多学科会议（C级）后可能会建议保守治疗，包括保留子宫和全部或部分卵巢。第二次手术旨在消除所有病变，如果最初没有进行，建议在晚期BOT（C级）的情况下。不建议在保守治疗（保留卵巢和子宫）后以及在实现对浆液性BOT（B级）的生育愿望后进行完成手术。BOT治疗后，由于中位复发时间（B级），建议随访5年以上。建议在治疗的BOT（B级）随访期间进行系统的临床检查。在CA 125水平初始升高的特定情况下，建议在随访期间监测CA 125（B级）。对于保守治疗（保留卵巢和子宫）的病例，建议在随访期间使用阴道内和经腹超声检查（B级）。如果生育年龄女性的BOT复发，可以再次建议保守治疗策略（C级）。如果存在非侵入性BOT植入物，希望保留生育能力的女性在首次非侵入性复发后可以考虑保守治疗（C级）。建议闭经12周后进行盆腔MRI检查，以诊断评分（C级）作为结论。由于已证实对胎儿有风险（C级），妊娠时注射钆应根据具体情况进行讨论。如果可行，妊娠期间应首选腹腔镜手术（C级）。应向BOT患者和育龄患者（C级）提供生殖专科医生的咨询。建议向患者提供手术治疗后卵巢储备功能下降风险的完整信息。建议在手术治疗疑似BOT（C级）之前评估卵巢储备。在可能的情况下，建议采取保守的手术策略以保留育龄妇女的生育能力（C级）。目前还没有关于BOT保守治疗后不孕症管理的具体数据。如果在BOT保守治疗后出现持续性不孕，则需要咨询专业生殖医生（C级）。在最佳治疗BOT的情况下，文献中没有证据表明禁忌使用辅助生殖技术（ART）。浆液性或粘液性BOT后不禁忌使用激素避孕（C级）。对于45岁以下的女性，在接受粘液性BOT治疗后，考虑到激素替代疗法（HRT）对心血管和骨骼风险的益处，以及粘液性BOT缺乏敏感性，建议提供HRT（C级）。在治疗粘液性BOT后，对于45岁以上的女性，没有理由禁忌使用HRT。HRT可用于更年期综合征，作为个体获益风险评估（C级）的一部分。(C)2020 Elsevier Masson SAS。All rights reserved.
In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C).In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C). (C) 2020 Elsevier Masson SAS. All rights reserved.