The French National Gynaecological and Obstetrics and Gynaecology Hospital (CNGOF) guidelines for ovarian junction oncology (2020, lower part) || Surgery, follow-up, hormone replacement therapy, fertility protection and management

Abstract: For early junction ovarian tumors (ES BOTs), no risk of tumor rupture surgery is feasible, laparoscopic surgery using sealed bag is better than abdominal surgery (C-grade), early two-sided slurry BOTs patients, if organ function is to be preserved, feasible double-sided ovarian tumor excision (B-grade), and for two-sided mucus BOTs, one side attachment excision (C-grade) is recommended.
For patients who complete cyst excision, if it is early mucus BOTs, it is recommended to have side attachment excision (C-grade), slurry BOTs if organ function is required, imaging is not recommended when there is no residual lesions. Attachment (C-grade); early slurry or mucus BOTs are not recommended for routine hysterectomy (C-grade), not lymph node excision (C-grade), and are removed only if there is a significant lesion in the appendix (C-grade).
If it is micro papyrus BOTs, the initial surgical investigation is not sufficient to recommend re-surgery (C-grade), if mucus BOTs, only cyst removal, appendix has not been assessed, recommended re-surgery (C-level), the scope of surgery should include: abdomen Water cytology (C-level), large retina excision (B-level), peritina multi-point biopsy (C-level), appendectomy (C-level) and/- appendectomy (C-grade), mucus BOTs require one-sided attachment excision (C-level).
For late BOTs unconventionally recommended lymph node excision (C-grade), there are fertility requirements, after multidisciplinary discussion of feasible conservative surgical treatment, the retention of the uterus, part of the ovary tissue (C-grade), late BOTs if the initial surgery is not satisfied, recommended surgery to remove all diseased tissue (C-grade).
For slurry BOTs conservative treatment to complete post-fertility root surgery (B-grade), follow-up time should be more than 5 years (B-grade), follow-up period should be systematically checked (B-grade), if the preoperative CA125 elevated, it is recommended to monitor CA 125 changes (B-grade), if conservative surgical treatment, recommended by yin or abdominal ultrasound follow-up (B-grade), for young, relapsed and non-immersive implant patients, if fertility is to be retained, conservative surgical treatment (C-level) ), pelvic MRI examination is suitable for patients after 12 weeks of menopathy, a diagnostic score (C grade) should be made, because of the potential risk of radon to the fetus (C grade), if the application should be discussed after the selection, if feasible, pregnancy BOTs patients preferred laparoscopic surgery (C) level), to provide fertility guidance (C-level) for patients, should fully communicate the risk of reduced ovarian reserve after surgery, recommended preoperative evaluation of ovarian reserve function (C-grade), women of childbearing age if they need to retain fertility, if conditions permit, recommend conservative surgery (C-grade).
BOTs conservative treatment lack of infertility-related data, such as BOTs patients with persistent infertility after conservative surgery, should consult a reproductive specialist (C-level), may consider assisted reproductive technology (ART), whether slurry or mucus BOTs, The use of hormonal contraception is not taboo (C-level), due to poor mucus BOTs hormone sensitivity, patients under 45 years of age feasible hormone replacement therapy (HRT) to improve cardiovascular function and bone metabolism (C-level), women over 45 years of age are not HRT contraindication, if there are peri-menopaus symptoms, you need to weigh the pros and cons, carefully choose (C-level).
bots accounted for 10%-20% of all ovarian cortical tumors, the age of onset was 10 years earlier than ovarian cancer, the prognostication was good, the common histological type is slurry and mucus BOTs, the overall five-year survival rate of 95%, 10-year survival rate of 90%.
diagnosis is very difficult, understanding the ultrasound and MRI characteristics of BOTs can help to identify and diagnose good malignant tumors and determine surgical strategies.
bots patients with a young, well-prognostic, late pregnancy detection is the majority, there are fertility requirements of surgical tend to conservative.
late BOTs patients conservative surgery can still be selected, hysterectomy or appendectomy does not benefit from survival, preferably laparoscopic surgery, postoperative disease rate is small, the purpose is to eliminate lesions, without the need for complementary treatment.
phased or re-phased surgery must record FIGO stages and implant site, for patients who want to retain fertility, should consult a reproductive expert, inform patients that the risk of recurrence after conservative treatment is higher than cure surgery, and require long-term follow-up, recurrence time may be more than 10 years, and patients undergoing root treatment need to discuss the need for hormone replacement treatment.
this, the French National Hospital for Gynaecology and Obstetrics (CNGOF) has developed BOTs clinical practice and management guidelines aimed at improving the level of care and setting standards that follow the French National Health Service (HAS).
this paper focuses on BOTs surgical treatment, follow-up, hormone replacement therapy and fertility management.
, surgery in early patients1 Surgery There is no evidence of adverse effects of laparoscopic surgery on prognostication (LE4), although the lump size is large, laparoscopic surgery seems to be more suitable for early patients (LE4).
studies have shown that tumor rupture increases the risk of recurrence, tumor volume is the main predictor of rupture (LE4), tumor rupture is also associated with surgery, tumor excision rupture risk is higher than attachment excision.
Therefore, early BOTs patients do not have the risk of tumor rupture, preferred laparoscopic surgery (C-grade), surgery should take a comprehensive precaution to avoid the occurrence of rupture (C-grade), it is recommended to use a sealed bag (C-grade).
2 The risk of recurrence after initial surgery simple tumor excision is higher than that of attachment excision (LE2), even more so with slurry BOTs, where most relapses occur in non-immersive planting areas (LE2).
One-sided or two-sided ESBOTs, if no organ function is required, feasible two-sided attachment excision (B-grade), two-sided slurry liquid ESBOTs if organ function is required, viable two-sided tumor excision (B-level);
Mucus ESBOTs patients who perform only tumor excision for the first time, regardless of whether organ function is retained, are recommended for re-surgical removal of attachments (C-grade), while in the same case, if ultrasound or MRI does not detect suspected residual lesions, re-surgery (C-grade) is not recommended.
3 Large retinal excision Study data show that the rate of hidden metastasis in ES BOTs patients is about 1.5%-10% (LE4), and that large retinal excision is associated with no progression lifetime, but there is no regulation (LE2) for the type of large mesh excision (biopsy, sub-colonectomy, or gastric bent excision).
Therefore, as an important component of the complete surgical phase, it is recommended to remove the large retina (B-grade), there is no consistent recommendation for the type of large retinal excision, ES BOTs patients need to re-surgery, it is recommended to remove the large retina (B-grade).
4 Peritina implantation stove Study found that the occurrence rate of hidden peritometrial implantation in ES BOTs patients was 0% to 15%, and the occurrence rate of immersion implantation in biopsy specimens was 1.4%-3.7% (LE4), but the type and number of peritina biopsies were not specified in the literature.
For slurry BOTs, micro papyrus type is associated with immersion implantation (LE4), it is recommended that the peritometrium multi-point biopsy to complete a comprehensive phased operation (C-level), if the need for re-surgery, should be a full abdominal cavity detection, in the suspect area or routine peritonal multi-point biopsy (C-level).
5 Abdominal rinse liquid ES BOTs patients with a positive rate of 1.4% to 13.4% (LE4), it is recommended to carry out routine celiac flushing fluid cytological examination to achieve full surgical phase (C-level), if re-surgery is required, it is recommended that abdominal flushing fluid examination (C-grade).
6 Hysterectomy Early slurry and mucus BOTs patients with uterine metastasis rate of less than 2% (LE4), routine hysterectomy is not related to prognosis (LE4), hysterectomy (C-grade) is not recommended; 52% of patients found endometrial abnormalities, half of which had leaching lesions (LE4), and hysterectomy (C-grade) was recommended, but the uterus could be retained if fertility was to be preserved, but a comprehensive assessment (C-grade) was required through imaging and endometrial sampling.
7 Appendectomy ES BOTs patients with a normal-looking appendix transfer rate of less than 3% (LE4), regardless of any histological type, for initial or re-surgery, it is recommended to evaluate the appendix (B-grade), only in the event of an appendix abnormality need to be removed (C-grade).
8 Lymph node excision Is not related to prognosis (LE4) in patients with ES BOTs, pelvic and/or abdominal aorta side lymph node excision, regardless of any histological type, pelvic and/or abdominal aorta side lymph node excision should not be routine (C-grade).
9 Re-surgery ES BOTs Patients If re-operated, 15% of slurry BOTs patients had FIGO phased up, while mucus patients had less than 5% phased increase (LE2).
As a result, slurry-based BOTs (especially micro-nipple type) are a risk factor for FIGO phased increase (LE4), and it is feasible to choose laparoscopic laparoscopy (LE4) again, although the recurrence rate (RFS) has improved, but re-surgery does not affect overall survival (LE3).
the evidence of re-surgery is that the first operation did not fully explore the abdominal cavity, may miss the suspect lesions (LE3), should be discussed in a multidisciplinary manner, laparoscopic surgery is the preferred treatment (C-grade).
If it is slurry BOTs, micro nipple type, the initial surgical detection is not sufficient, it is recommended to perform re-surgery (C-grade);
The following steps are required for re-surgery: celiac flushing fluid cytological examination (C-grade), large retina excision (B-grade), comprehensive detection of the abdominal cavity, multi-point biopsy (C-level) for suspect areas or lines of the peritometrium, appendectomy/appendectomy (C-level), mucus BOTs line one-sided attachment excision (C-level).
, the treatment of advanced BOTs (AS BOTs) in patients with advanced stages refers to patients who have exceeded phase II of FIGO and should be referred to the Ovarian Tumor Management Center for treatment (C-grade).
1 Prognosis The risk of recurrence of AS BOTs increases in stages (LE3), lesion residues are risk factors for recurrence (LE4), leaching implantation is a risk factor for recurrence and death, the effects of histological subtypes on prognosis are unclear, and micro pap nipple subtypes appear to be associated with peritina cultivation (LE3), but there is insufficient evidence of their prognostic value.
2 Surgical treatment has sufficient evidence that AS BOTs patients should be preferred for surgical treatment, the value of hysterectomy is not confirmed, surgery is designed to remove all tumor residues, lymph node removal does not affect overall survival (LE4), not recommended routine excision (C-grade).
similar to endotopic ovarian cancer, all suspect lesions should be removed to achieve R0.
All perional cancer changes (Grade C) should be recorded in detail using the Periary Cancer Index (PCI), surgical records should indicate tumor residues (size, location, and causes of non-removal), and PCI is recommended for objective assessment of tumor load (C-grade).
a lateral ovary biopsy (C-grade) is not recommended for patients with fertility requirements, and if the initial surgical tumor is not removed thoroughly, re-surgery (C-grade) is recommended.
3 complementary therapy there is insufficient evidence to support the role of chemotherapy in late-stage BOTs, even for immersive implantation.
4 Complementary Comprehensive Surgery There is no study evaluating the role of conservative post-surgery complementary comprehensive surgery in BOTs patients, and for patients with slurry BOTs, there is no evidence to support the need for complementary comprehensive surgery (LE2) after conservative surgery, and it is not recommended for patients with plasma BOTs who undergo conservative surgery (retention of ovaries and uterus), and for patients with mucus BOTs who undergo comprehensive surgery (B-grade) after childbirth.
5 Follow-up Literature reported significant differences in recurrence times (39 to 55 months), an average of 49 to 63 months (LE2), no prospective studies or randomized trials compared the impact of different follow-up methods on survival.
for the diagnosis of recurrence, the sensitivity of the system was 57% (LE2), the tumor marker was 33%-66.6% (LE2), and the ultrasound was 83.5%-100% (LE2).
In view of the BOTs recurrence time delay, follow-up time should be more than 5 years (B-level), pay attention to the system check body (B-grade), if the initial CA125 elevated, it is recommended to use CA125 follow-up, conservative surgery can be used after vaginal and abdominal ultrasound follow-up (B-level), there is no clear time interval for review in the literature.
3. The diagnosis and treatment of BOTs recurrence 1 recurrence time and type Most BOTs recurrence is non-immersive (LE2), for two-sided BOTs, double-sided tumor resection time is shorter (LE2) than one-sided ovary excision and lateral tumor resection, the patient should be fully informed, but in most cases recurrence is still BOTs.
2 The recurrence of plasma-liquid BOTs usually corresponds to thin-walled, cystic, fixed single-room cysts (LE2) in the IOTA classification, and cysts less than 2cm may also be relapses (LE2);
3 If the ovaries are retained, in-place recurrence is most common (LE2), while after root-and-treat surgery (e.g. after uterus and double-sided attachment excision) mostly non-immersive recurrence of the peritometrium, commonly found in stage II or stage III peritometrium non-immersive implantation BOTs patients (LE3).
4 Diagnosis Most BOTs recurrences have no obvious symptoms and are only detected by the body (LE2), and CA125 test sensitivity is low, even if normal, the possibility of recurrence (LE2) cannot be ruled out.
5 Surgical treatment bots recurrence, if conservative surgery is chosen, the risk of recurrence is high, but does not affect survival (LE3), the removal of both sides of the attachment can reduce the risk of recurrence (LE3).
Therefore, women of childbearing age should be fully informed of the risk of recurrence of conservative surgery (C-grade), according to the initial treatment and the characteristics of recurrence, individualized choice of re-surgery, conservative surgery will not increase the risk of non-immersive recurrence of the peritometrium (LE4).