What is ovarian junctional tumor?

I have received a lot of questions about ovarian junctional tumors, not only from patients and families, but also from professional obstetricians and gynecologists. Therefore, I would like to publish here the article written by me together with my colleague Li Yi (who also opened the consultation webpage) and Professor Shen Danhua, director of the Department of Pathology, for your reference only, and may also help patients and families to solve one or two problems. 1. Ovarian junctional tumor is an ovarian epithelial tumor with malignant potential between benign adenoma and cancer. 2. The pathological manifestation is complex proliferation of tumor epithelium, accompanied by mild-moderate atypia of cells and structures, and such structures should account for at least 10% of the tumor. The tumor does not show interstitial infiltration beyond the microinfiltration range. 3. The overall prognosis of the tumor is good. For young patients with the requirement of preserving reproductive function, conservative surgery is feasible. For patients without fertility requirements, the standard procedure is to perform total hysterectomy, double adnexa, greater omentum, appendectomy and multi-point biopsy of peritoneum after retention of abdominal irrigation fluid. It is not necessary to routinely remove the pelvic and abdominal lymph nodes. 4.Patients with no tumor residue and no peritoneal infiltration after surgery do not need to receive adjuvant therapy; chemotherapy should be used with milder PC regimen and the course of treatment should not be too concentrated. 5. The most important prognostic factor is the nature of the extra-ovarian lesion, and the type of peritoneal implantation is the main prognostic factor in stage II and III patients. The size of the residual postoperative lesion also has prognostic significance. Pathogenetic features The etiology of ovarian junctional tumors is unclear; it is currently thought to arise from specialized peritoneal or derivatives on the ovarian surface and from epithelial inclusion cysts. Epidemiological investigations have shown a higher risk in uncomplicated than in menstruating women, with breastfeeding as a protective factor, but oral contraceptives are not protective. Its exact incidence is unknown, and it has been estimated to be stable in recent years at 2/100,000 woman-years. Plasmacytosis is the most common (65%), followed by mucinous (30%). The age of onset of ovarian plasmacytotic junctional tumors is slightly higher than that of benign plasmacytotic cystadenomas and 10-15 years lower than that of plasmacytotic carcinomas (45 and 60 years, respectively). About 50% of plasmacytic junctional tumors of the ovary are unilateral and 30% bilateral. In contrast, mucinous junctional tumors are approximately 8% bilateral. 30% of ovarian plasmacytoma junctional tumors have tumors on the ovarian surface and 66.7% have peritoneal implants. The vast majority of junctional tumors are stage I (50% to 80%). The prognosis of ovarian junctional tumors is much better compared to ovarian cancer at the same clinical stage, with a 5-year survival rate of 96% for stage I patients and an average of about 92% for all other stages. Clinical diagnosis The accuracy of preoperative diagnosis of ovarian junctional tumors is not high, and the correct diagnosis is mainly based on pathological histological examination. Pathological diagnostic criteria: For a long time, there have been different opinions on the pathological diagnostic criteria of ovarian junctional tumors. After more than 30 years of exploration, the understanding of its nature has been gradually deepened, especially the working meeting on ovarian junctional tumors held in Bethesda, Maryland, USA on August 27-28, 2003, which achieved a more consistent opinion on certain pathological differences of ovarian junctional tumors. In particular, pathologic diagnostic concepts such as micropapillary plasmacytic junctional tumors, microinfiltration of the mesenchyme, intraepithelial carcinoma, and peritoneal implantation were introduced to provide a basis for the treatment of junctional tumors. Ovarian junctional tumors can be divided into plasmacytotic, mucinous, endometrioid, clear cell, Brenner and other types according to epithelial types, among which the first two types are the most common. The following is a key overview of these two types of junctional tumors and the pathological features of junctional tumors proposed in recent years. (a) Pathological diagnosis of plasmacytotic junctional tumor (SBOT): Generally, the tumor is cystic and papillary in shape, with a diameter ranging from 2-25 cm, averaging 10 cm, and the surface of the tumor can appear as an exophytic papilla. SBOT can be divided into two types according to different cellular and histological structures: typical SBOT and micropapillary SBOT. 1. Typical SBOT: It accounts for 90% of plasmacytic junctional tumors, with typical branching papillae structure, papillae covered with multiple layers of epithelial cells, and nuclei with only mild to moderate atypia, usually without nuclear division images, or with only a few nuclear division images, but usually without pathological nuclear division images. There is usually no pathological nuclear division. Interstitial microinfiltrative foci may be present, and sand granules can often be seen in the cyst fluid and interstitium. Micro papilla type SBOT: It accounts for 5%-10% of plasmacytotic junctional tumors. Microscopically, elongated “micro papillae” can be seen directly from the cyst wall or large fibrous or edematous papillae in the form of non-branching, forming “jellyfish head”-like manifestations. The papillae contain little or no connective tissue in their axis and are most often covered with cuboidal cells. The slender papillae are at least five times as long as they are wide. Fibrovascular axes surrounded by sieve-like epithelium or a mixture of micropapillae and sieve-like structures are also included in this type. In most cases, micropapillary SBOT can coexist with typical SBOT, therefore, at least one contiguous area consisting of either micropapillary or sieve structures or both, with a maximum diameter >5 mm, should be present in a single section to diagnose micropapillary SBOT. in addition. The following two points should be noted in the diagnosis of micropapillary type SBOT: firstly, micropapillary type SBOT cannot show interstitial microinfiltration, and once interstitial infiltration appears, it should be diagnosed as plasmacytoma. Secondly, nuclear heterogeneity in micropapillary SBOT is generally mild to moderate, and if severe heterogeneity is present, the possibility of papillary plasmacytoma should also be considered. In addition to the histomorphological differences between the two types of SBOT, there are also differences in clinical prognosis. Most studies suggest that micropapillary SBOT is more likely to develop invasive peritoneal implantation than typical SBOT and has a shorter interval to recurrence. Thus, it is considered a special type of low-grade malignant plasmacytoma, and some authors even call it non-invasive micropapillary plasmacytoma. However, the vast majority of gynecologic pathologists still place micropapillary-type tumors without interstitial infiltration in junctional plasmacytoma. However, it is worth noting that adequate sampling should be done for this type of lesion, except for the presence of infiltrative lesions, and attention should be paid to the heterogeneity of the nuclei. If these two points are ignored, there is a risk of missing some plasmacytoma, leading to inadequate clinical treatment (b) Pathologic diagnosis of mucinous junctional tumor (MBOT) Mucinous junctional tumor of ovary (MBOT) has the same criteria as SBOT diagnosis: complex proliferation of mucinous epithelium, with more pronounced cellular and structural atypia than cystadenoma, and this structure should account for at least 10% of the tumor. MBOT can be divided into two types: intestinal and endocervical (Mullerian). The intestinal type MBOT is a unilateral mass in more than 90% of cases, and the tumor is large, with an average diameter of 17 cm. The cut surface is multifocal and contains aqueous or mucus-like contents with a smooth peritoneum. Microscopically, the tumor was seen to consist of capsules and glands of variable size. The overlying epithelium was a complex proliferating intestinal type mucous epithelium, which could form bridging and complex structures, and could have villi and papillary protrusions. Even in the same tumor, the degree of nuclear anisotropy and nuclear schizophrenia are highly variable, usually mild to moderate, and interstitial microinfiltrates may be present. In contrast to intestinal MBOT, endocervical type is much less common, accounting for about 5%-15% of MBOT, and is more closely related to SBOT clinically and pathologically, both in terms of histology and morphology of implantation. 13%-40% of tumors are bilateral, with an average tumor diameter of 7-8 cm. 8cm . The general structure is more similar to that of SBOT of the ovary, and the tumor can be either an intracapsular growth or an exophytic structure. Microscopically the tumor may consist of a mixture of cervical-type mucinous epithelium and plasma (ciliated) epithelium, often mixed with a small number of other cell types (e.g., endometrioid, squamous epithelium or eosinophils). It often shows complex graded papillae with epithelial cells arranged in complex layers or tufts. Nuclear anisotropy is generally mild to moderate, with an uncommon split image and a high neutrophil infiltration . Like SBOT, cervical MBOT may show micropapillary structures, interstitial microinfiltrates and lymph node involvement, but is not associated with peritoneal pseudomucinous tumors. MBOT can be accompanied by intraepithelial carcinoma, defined by certain areas of MBOT showing cytologic features of carcinoma without interstitial infiltration. However, the criteria for its diagnosis are still somewhat controversial, with some investigators considering mucinous junctional tumors to be diagnostic of intraepithelial carcinoma when they show one or more of the following features: moderate to highly cellular heterogeneous epithelial complexes of 4 or more layers, sieve-like or papillary hyperplasia without mesenchyme in the glandular lumen. However, the currently agreed criteria for the diagnosis of intraepithelial carcinoma are: the presence of cytologic heterogeneity should be severe (grade 3). In contrast, for having excessive epithelial stratification and other complex intracapsular growth structures but lack of severe cellular anisotropy, it should still be considered as a junctional tumor and should not be diagnosed as intraepithelial carcinoma. (iii) Peritoneal implantation Ovarian plasmacytic junctional tumors are frequently associated with a higher frequency of extra-ovarian lesions. Approximately 20%-46% of SBOTs present with pelvic-abdominal plasma membrane and omental surface implantation. Peritoneal implants are divided into infiltrative and non-invasive implants. (1) Infiltrative implantation: Histologically, it appears as a haphazard proliferation of epithelium that irregularly extends into and disrupts the normal tissue beneath the peritoneum. The implantation foci often consist of elongated papillae, glands, small solid nests of cells or sieve-like epithelial nests. The cells are usually mildly to moderately heterogeneous, sometimes with severe heterogeneity, like high-grade plasmacytoma. (2) Non-invasive implants are morphologically subdivided into two types: epithelial implants with epithelial hyperplasia but no mesenchymal reaction and pro-fibrogenic implants accompanied by obvious mesenchymal reaction. The epithelial type is characterized by papillary hyperplasia of plasmacytoid epithelium located on the peritoneal surface or in smoothly bordered mesothelial depressions, with no invasion of the underlying tissue, insignificant cellular anisotropy, no nuclear schizophrenia, and often visible sarcoid bodies. The implantation lesions of this type resemble those of their ovaries. The pro-fibrogenic type is characterized by proliferating granulation tissue-type fibroblasts that form plaque-like structures on the peritoneal surface with small papillae, glands and gland-like structures, individual cells, and nests of small cells. Some investigators have suggested that these glandular components are more like reactive mesothelial hyperplasia. Both types of non-invasive implants described above can co-exist. Regardless of the type of noninvasive implant, it does not affect the 10-year survival rate. There has been debate as to whether the peritoneal implantation lesion is a true implantation (i.e., tumor cells shed from the ovarian tumor that continue to grow on the peritoneal surface) or a primary peritoneal tumor independent of the ovary. It has been suggested that the “peritoneal implantation” in combination with ovarian SBOT may be a lesion of second Müllerian system origin, which may or may not be the same as the ovarian lesion. However, some clinicopathologic studies have shown that patients with exophytic SBOT with involvement of the ovarian surface and micropapillary SBOT have a higher risk of peritoneal implantation than patients with intracapsular SBOT, suggesting that, at least in some cases, peritoneal implantation is a true implantation. Regardless of whether the peritoneal lesion is a multicentric primary lesion or a post-implantation lesion, the type of implantation is extremely important in determining prognosis. Infiltrative implants have a poor prognosis, with more than 50% having recurrence and a 10-year survival rate of approximately 35%. Bell et al. reported a recurrence rate of 65% for infiltrative peritoneal implants and only 14% for non-infiltrative implants. seidman counted 4129 cases of junctional plasmacytoma with a 7.4-year (median) follow-up and the survival rate was 95% for non-infiltrative peritoneal implants, while it dropped to 66% for infiltrative peritoneal implants. Therefore, clinicians should carefully perform multi-point biopsies of the peritoneal cavity at the time of surgery to look for lesions, and infiltrative implants in plasmacytotic junctional tumors are the only cause of death, and only such patients require chemotherapy. (iv) Interstitial microinfiltrates Ovarian junctional tumors can be associated with interstitial microinfiltrates, with the highest percentage of interstitial microinfiltrates occurring in SBOT, with approximately 10%-15% of SBOT containing interstitial microinfiltrates. Microinfiltrative foci are very small and usually do not cause significant interstitial reaction. The term “borderline tumors with microinvasion” should be used in the diagnosis instead of “mciroinvasison borderline tumors”. The term “borderline tumors” is used instead of “mciroinvasison borderline tumors”. The first two forms are mainly seen in SBOT and the second in MBOT. The first form is characterized by the presence of single cells or clusters of cells or nests in the papillary fibrous or intracapsular mesenchyme of the tumor. These tumor cells are mildly to moderately heterogeneous and have abundant eosinophilic cytoplasm. The surrounding mesenchyme is generally normal or has mild fibrous tissue hyperplasia. Most of the reported interstitial microinfiltrates are of this type. The second type is rare. The microscopic features are: small nests of solid cells or micropapillae infiltrating into the interstitium, which are often surrounded by clear spaces or fissures. Sieve-like structures as well as rounded aggregated papillae resembling infiltrating low-grade plasmacytoma may also be seen in them. Type III: Infiltration of the interstitium with single cells or glands composed of mucinous epithelial cells and small clusters/nests; the infiltrating foci are often surrounded by clear spaces, irregular glands with irregular margins, and are often accompanied by interstitial edema, fibroblast hyperplasia, and inflammatory cell infiltration. The size criteria for microinfiltrate foci are inconclusive. The initial diagnostic criteria for microinfiltrates in SBOT were proposed as a single infiltrate with a maximum diameter of ≤3 mm, and later on, an area of ≤10 mm2. Some investigators still use the same criteria as SBOT, that is, the maximum diameter of infiltrating foci does not exceed 3 mm and the area does not exceed 10 mm2, but some investigators use different size criteria, but it is generally accepted that if the maximum diameter of microinfiltrating foci does not exceed 5 mm and the cellular anisotropy does not reach severe (high grade), the prognosis is very good. When the tumor is mainly composed of MBOT, but the infiltrating foci in it have a maximum diameter >5 mm, it can be diagnosed as mucinous junctional tumor with mucinous carcinoma component, and the size of the carcinoma foci should be indicated to alert the clinician’s attention. (V) Lymph node involvement Lymph node involvement refers to the presence of epithelial hyperplasia in lymph nodes similar to ovarian junction, usually involving pelvic or para-aortic lymph nodes. Regional lymph node involvement has been reported in 7-23% of SBOT patients undergoing lymph node sampling. These lesions may be true metastases in the lymphatic sinuses, mesothelial cells in the sinuses mistaken for tumor cells, or primary ovarian plasmacytic junctional tumors originating from Mullerian inclusion glands. Thus, it cannot be confirmed whether lymph node involvement is clonally related to the ovarian tumor or an independent lesion, and patients with lymph node involvement have not affected their prognosis. seidman counted 43 cases of junctional plasmacytic tumors with lymph node metastases and had a survival rate of 98% at 6.5 years (median) follow-up. Therefore, the term “lymph node metastasis” is not used, but rather “lymph node involvement” is recommended to describe such lesions. (vi) Pseudomyxoma peritonei (PMP) is a mucinous tumor with a large amount of mucinous ascites and/or numerous mucinous nodules on the peritoneal surface, usually in association with the ovaries and appendix, found intraoperatively in the pelvic abdomen. Previously, PMP was thought to develop from the rupture of a primary mucinous tumor of the ovary, particularly an intestinal type MBOT that had disseminated to the peritoneum. However, recent morphologic, immunohistochemical, and molecular genetic studies have provided strong evidence that virtually all PMP originate from mucinous tumors of the gastrointestinal tract, particularly the appendix, while ovarian tumors coexisting with PMP are secondary.PMP was previously used as a diagnostic term. It is now considered that PMP is only a clinical description and not a pathological diagnosis. In patients with peritoneal pseudomucinous tumor, attention should be paid to the examination of the appendix and a thorough histological examination of the specimen of peritoneal pseudomucinous tumor should be performed to grade the epithelial component present in it: i.e. benign, junctional or malignant. Clinical features Patients usually have no special symptoms. With the increase of tumor, it may manifest as abdominal discomfort, gastrointestinal symptoms, and urinary tract pressure symptoms. If the tumor ruptures, acute abdominal symptoms may appear. Some patients are found by gynecological examination. The common serum tumor marker for plasmacytic junctional tumor is CA125, Gotlieb retrospectively analyzed 91 patients, 75% of patients with plasmacytic junctional tumor had elevated CA125 before surgery, with an average of 156 IU/ml, while only 30% of patients with mucinous had elevated CA125, with an average of 28 IU/ml. CA19-9 is a tumor-associated antigen that is usually found in gastrointestinal tumors. Engelen reported that 57% of mucinous junctional tumors have elevated CA19-9 preoperatively, so CA19-9 is recommended as a tumor marker for mucinous tumors. CA19-9 can also be used to monitor the disease, and CA19-9 is recommended for follow-up of mucinous tumors for early detection of recurrence. The positive rate of CEA in junctional tumor is only 7.7%~9%, which is not specific for diagnosis. IV. Imaging examination Color ultrasonography is an important auxiliary examination. For the sonographic diagnosis of ovarian junctional tumor: firstly, there should be intracapsular complex (i.e. papilla or atrial septum), PI<1.0, lack of confluent vessels in the tumor; combined with CA125<150U/L and age<60 years, its diagnostic accuracy can reach 91%. To date, the two most common characteristic sonograms of junctional tumors remain intracapsular papillary structures and multiple atrial septa, but are not sensitive indicators for diagnosis. Although their positive predictive value and sensitivity are poor, their specificity and negative predictive value are high. Recently, Exacoustos retrospectively analyzed the ultrasound data of 33 patients with junctional tumors and compared them with 82 malignant and 337 benign patients and found that 48% of junctional patients had small papillary structures, i.e. papillae with basal width <10 mm and height <15 mm, and 24% had atrial septal structures; whereas malignant patients more often presented with purely solid or cystic masses with intracapsular papillae with basal width Most of the malignant patients showed pure or cystic masses, with the basal width of intracapsular papillae >10mm and height >15mm; benign tumors were mostly single atrial, smooth-walled cysts with diameter <5cm. Only 9% of cross-sectional tumors are single-compartment cysts, and there are no single-compartment cysts in malignancy. The presence of blood flow signal inside the tumor, especially inside the papilla, was more common in junctional and malignant tumors, 56.3% and 66.7%, respectively, while none of the benign ones had blood flow signal. Also junctional and malignant tumors showed low resistance flow signals more often than benign tumors, but there was no difference between the two. If the characteristic sonogram is combined with blood flow, its specificity can be up to 100%, but the sensitivity decreases to 27%. Fruscella further noted that the sonographic features of junctional tumors still differ between pathological types. Plasmacytoma and endocervical type of mucinous tumors have more similar features: smaller tumor size, few cystic cavities (usually single chamber), more papillae or solid areas within the cyst, and more papillae with low obstruction to internal blood flow (RI <0.4). In contrast, the intestinal type of mucinous tumors is characterized by unilateral, large tumor volume, multiple atrial compartments (>10 cystic lumens more often), smooth cystic wall, and few intracapsular solid areas or papillae (Figure 57-13). Given that the preoperative diagnosis rate of junctional tumors is still not high, intraoperative frozen pathology is very important. The reliability of cryopathology has been reported by different authors, especially for mucinous junctional tumors. Wong reported that 22% of mucinous junctional tumors were misdiagnosed as benign, while the misdiagnosis rate of plasmacytotic junctional tumors was 5% in 200 cases of frozen pathology. The high rate of misdiagnosis of mucinous tumors is mainly due to the heterogeneity of mucinous tumors. Given the limitations of cryopathology, intraoperative decisions on the scope of surgery based on cryopathology findings are still quite risky. Preoperative communication with the patient and timely intraoperative communication with the family is very wise. Procedure Patients with suspected junctional ovarian tumors are first examined with serum CA125 and CA19-9, as well as vaginal ultrasound. Intraoperative cryopathology is sent for examination. For patients with fertility requirements, conservative surgery is performed. The standard procedure for patients without fertility requirements is total hysterectomy, bilateral adnexal, greater omentum, appendectomy and multi-point biopsy of the peritoneum after retention of abdominal irrigation fluid. Routine removal of pelvic and abdominal lymph nodes is not necessary. Patients without postoperative tumor residuals and without peritoneal infiltration do not need to receive adjuvant therapy. The treatment of ovarian junctional tumor is mainly surgical. Except for special cases, adjuvant treatment is not recommended. Conservative surgery for ovarian junctional tumors About 1/3 of patients with ovarian junctional tumors are less than 40 years old, and many of them have the requirement to preserve their reproductive function. The results of numerous clinical studies suggest that the disease-free survival and overall survival rates of patients with conservative surgery are no different from those of patients who have undergone satisfactory staging surgery, which are close to 100%. Also, fertility and pregnancy outcomes of patients after conservative surgery are good, but close postoperative follow-up is required. Conservative surgery usually refers to resection of the affected adnexa and is indicated for young patients with fertility requirements. The following conditions should be met: (1) the patient is young and desires fertility; (2) the patient is determined to be stage I with normal contralateral ovaries and fallopian tubes; and (3) the patient is eligible for long-term postoperative follow-up. In young patients with tumor on one ovary, generally, after opening the abdomen, ascites or abdominal flushing tuck is left and then one adnexal resection is performed first, and if there is suspicion on autopsy, frozen section is sent. If the pathology report is junctional ovarian tumor, the opposite ovary should be dissected and sent for pathological examination, and the pelvis and upper abdomen should be carefully explored. Since the recurrence rates after adnexal resection and cyst debridement are 2-3% and 20%, respectively, cyst debridement is limited to patients with bilateral junctional ovarian tumors or those who have had one ovary removed. The resected specimen should be sectioned every 1 to 2 cm to determine whether it is invasive or not. If the postoperative paraffin section is cancerous, re-staging of ovarian cancer and/or chemotherapy can be performed depending on the situation. Kennedy et al. investigated the possibility of conservative surgery in patients with extra-ovarian lesions or advanced stages. 76 patients with junctional plasmacytoma, 39/76 had extra-ovarian lesions and 28/74 were stage II or III patients, 66 of whom were followed up for 8 to 264 months (mean 99 months). Only 1/66 cases (1.5%) progressed and died of widely disseminated plasma cancer; 2/18 (11.1%) recurred in those with routine conservative surgery. Long-term follow-up showed that extra-ovarian lesions do not imply peritoneal implantation and that conservative surgery is feasible in young patients. Some authors have reported recurrence rates of 5.7%, 15.1% and 36.3% in patients with junctional tumors after hysterectomy + bilateral adnexal resection, adnexal resection and simple cystectomy, respectively. Recurrence can be followed by conservative surgery, and pregnancy and long-term survival can still be achieved. Yinon compared the results of 40 adnexal resections and 22 ovarian cyst debulking procedures with a mean follow-up of 88 months. There was no difference in tumor recurrence rates between the two groups, 27.5% and 22.7%, respectively; however, the tumor-free interval was significantly shorter in the cyst debulking group than in the adnexal resection group, 23.6 and 41 months, respectively (not statistically significant). A total of 25 patients obtained 38 pregnancies and 35 deliveries. In conclusion it is concluded that the risk of recurrence with conservative surgery, although significantly higher, does not affect the ultimate survival. Fertility issues are a concern after conservative surgery, and Morice reviewed that approximately 10-35% of patients have preoperative infertility problems, with a 32-65% spontaneous pregnancy rate after conservative surgery, with IVF as an option for cases of persistent infertility. Age is strongly correlated with pregnancy rates, with 42% for those <35 years old, decreasing to 22% for those 35-40 years old, and no pregnancy for those >40 years old. It is controversial whether ovulation-promoting drugs increase cancer. Ovulation promotion therapy after conservative surgery for early stage junctional tumors is currently considered safe. In patients with advanced or micropapillary type it is better not to apply ovulation promotion + IVF to avoid accelerating disease progression.Fortin reported 30 postoperative ovulation promotion therapy in infertility patients with junctional tumors with a mean of 2.6 cycles and a median follow-up time of 93 months, with 4 recurrences at 42 months of follow-up (3 cases of simple ovarian cystectomy). All recurrence cases remained as junctional tumors and were treated by reoperation. All patients are currently tumor-free and there are 13 pregnancies. Follow-up after conservative surgery is very important and should be done every 3 months for 2 years after conservative surgery and every 6 months thereafter. recurrence rate can be up to 20% at 5 years, even after pregnancy and delivery. Whether to remove the ovaries after delivery is controversial and requires consideration of several factors: tumor tissue type, stage, conservative surgical procedure, and the patient’s wishes. Currently, it is not recommended to remove the ovaries in patients who can be followed routinely, but only in case of recurrence. Some patients request removal of the ovaries after delivery because of psychological factors or because they want to simplify the follow-up procedure. The issue of wedge biopsy of the contralateral ovary during surgery for junctional tumors deserves attention. Both plasmacytotic and mucinous junctional tumors can occur bilaterally, and many authors recommend wedge biopsy of the healthy ovary; however, others oppose it because of the risk of postoperative periovarian adhesions that can lead to infertility. Although the current minimally invasive techniques and the use of anti-adhesive agents can reduce the occurrence of adhesions, there are reports of ovaries with normal naked eye appearance and no lesions on microscopic analysis, thus questioning the value of contralateral ovarian biopsy. There is no unanimous opinion. Previously, resection of preserved ovaries after completion of reproductive function was advocated, but now it is considered that they can continue to be preserved. In adults with stage I clinical disease who no longer need to have children, the standard procedure is total hysterectomy, bilateral adnexa, greater omentum, appendicectomy, and multi-point biopsy of the peritoneum after retention of abdominal irrigation fluid. Since benign, junctional and malignant components are often present in the same tumor, lymph node dissection should be performed if junctional or malignant cannot be determined by intraoperative frozen section pathology; tumor cytoreduction is feasible in stage II, III and IV patients. Tumor cytoreduction should be performed in more advanced patients, but lymph node dissection is questionable as it is not associated with survival. Patients who have achieved complete remission with clinical treatment are now mostly advocated not to undergo secondary exploratory surgery. Laparoscopic surgery It was previously believed that laparoscopic treatment of junctional tumors was still immature, and laparoscopic surgery was not advocated for those who considered junctional tumors preoperatively to avoid implantation. Vaisbuch reviewed the history of laparoscopic management of junctional tumors and reported 30, 24, and 34 cases of laparoscopic surgery successfully completed in several medical centers after 2003, and concluded that laparoscopic surgery for junctional tumors is safe and effective. Desfeux reported 48 cases of laparoscopic surgery with no difference in survival rates from patients undergoing open surgery despite an increased chance of intraoperative tumor rupture. An Italian multicenter study included 113 patients with junctional tumors, 52 of whom were operated laparoscopically and the remainder openly. The tumors were 2-30 cm in diameter. rupture and leakage rates were as high as 34% during laparoscopy compared with only 7% during open surgery (a significant difference). The recurrence rate was 11.5%, but was not related to the surgical route and did not affect the prognosis.Maneo analysis of lesion persistence after laparoscopy was associated with tumors larger than 5 cm, and pathology of plasmacytosis, staging of Ic, and performing ovarian cyst debulking seemed to be associated with lesions. Therefore laparoscopic surgery seems to be more suitable for young patients with tumors less than 5 cm and early stage patients with fertility requirements who undergo conservative surgery, which can reduce postoperative adhesions and facilitate postoperative pregnancy. To reduce recurrence, conservative surgery is preferable to remove the affected adnexa. Cyst debridement is only considered if the lesion is bilateral to the ovary. The rate of perforator metastasis in laparoscopic management of gynecologic malignancies is generally at about 1%, which is not different from that of open surgery; there are only case reports of postoperative perforator metastasis in junctional tumors, so the issue of perforator implantation should not be a reason to oppose laparoscopy, and surgical resection is needed after metastasis diagnosis. Matters to note in laparoscopic surgery: a skilled physician is needed. At the beginning of surgery, abdominal irrigation fluid should be retained first, bilateral ovaries and the whole abdominal cavity should be carefully explored, and suspicious areas should be sent for frozen pathology. If the mass ruptures intraoperatively, it is important to flush it thoroughly. The use of a retrieval bag is recommended. Intraoperative puncture, biopsy or mincing of the ovaries is to be avoided. However, when the tumor is placed into the retrieval bag, puncture aspiration can be performed. Whether re-staging surgery is needed for ovarian junctional tumors Whether re-staging open surgery is needed after pathologic confirmation in patients who did not undergo staging surgery for initial treatment is a concern for clinicians. winter analyzed 48 patients who underwent conventional staging surgery versus 45 patients who did not and found that there was no difference in 5-year overall survival and recurrence rates despite 17% postoperative staging upgrade. rao analysis of data from 183 patients also concluded that routine pelvic and para-aortic lymph node dissection is not necessary in patients with junctional tumors. Therefore, it is currently considered that for patients without major residual lesions from initial unstaged surgery, it is questionable whether there is any therapeutic benefit from re-staging, although it may be “upgraded”. V. Adjuvant therapy Whether adjuvant chemotherapy is needed for patients with more than stage I disease is not yet agreed upon. It has been reported in the literature that adjuvant therapy not only cannot change the prognosis of patients with junctional tumors, but excessive chemotherapy can cause complications and increase the mortality of patients. There are no prospective randomized studies to support the benefit of chemotherapy. However, it has also been reported that junctional tumors are not completely insensitive to chemotherapy and that postoperative adjuvant therapy still has some near-term efficacy. Especially for those with residual lesions after surgery, chemotherapy can loosen the tumor and reduce the size of the lesion, and when conditions permit, reoperation can achieve complete resection of the tumor. Therefore, regarding the postoperative adjuvant therapy for junctional tumors, the following points are proposed: ①The purpose of adjuvant therapy for junctional tumors should be clearly defined as shrinking the lesions, and chemotherapy can be given to those with residual tumors to create conditions for successful surgery for tumor reduction again, but adjuvant therapy cannot be expected to improve the prognosis; ②Patients without residual tumors after FIGO stage I and other stages do not need to receive adjuvant therapy, but they should be followed up closely; ③Patients without (3) Patients without peritoneal infiltration do not need adjuvant therapy, and only those with infiltrative implantation in plasmacytotic junctional tumors need chemotherapy; (4) Tumor cells in junctional tumors proliferate more slowly than epithelial carcinoma, so chemotherapy should be different from ovarian epithelial carcinoma, and a milder regimen, such as PC regimen, is preferable, and the course of treatment should not be too concentrated; (5) It is recommended to carry out the detection of DNA content, ploidy level and relevant oncogenes of tumor cells It is recommended to carry out tests for DNA content of tumor cells, ploidy level and relevant oncogenes to clarify the pathological type of metastases so that the treatment can be targeted. Follow-up and factors affecting prognosis Ovarian junctional tumors should be followed up like ovarian cancer. Vaginal ultrasound, gynecologic examination and serum markers are routine items for postoperative follow-up of patients, among which vaginal ultrasound is currently the most effective means to detect recurrence. CA125 is used for plasmacytotic junctional tumors and CA19-9 for mucinous tumor follow-up. The most important prognostic factor is the nature of the extra-ovarian lesion. The morphology of peritoneal implants is the main prognostic factor in stage II and III patients, and those with poor prognosis show one of the following 3 features: micropapillary type, parenchymal epithelial nests surrounded by fissures, infiltrating the tissue beneath them. Plasmacytotic junctional tumors with micropapillary type have a poor prognosis, with a 10-year survival rate of only 60%. For example, Ayhan analyzed 100 cases of junctional tumors and found that disease-free survival was significantly lower in those younger than 30 years who underwent conservative surgery, had micropapillary structures, or had peritoneal implants. The type of peritoneal implant determines the patient’s prognosis, and patients with infiltrative peritoneal implants have a poor prognosis. The size of postoperative residual lesions also has prognostic significance, and the presence of residual lesions after initial surgery is an indicator of poor prognosis. Independent factors affecting prognosis in patients without residual lesions are: DNA ploidy, morphometry, FIGO staging, histological type and grading, and age. In particular, DNA ploidy and morphometry can be used as indicators to guide prognosis. The survival rate for aneuploidy in cross-sectional tumors is only 15%. And surgical modality and chemotherapy were not independent influencing factors. A cohort study of 399 patients from Sweden showed that 63 of them had aneuploid tumor DNA, most of them were adjuvanted with chemotherapy. After up to 11 years of follow-up, the cumulative relative 5- and 10-year survival rates were 99.9% and 103.5%, respectively. Aneuploidy was more common in patients older than 60 years; and it appeared that mucinous tumors were more common than plasmacytic tumors (not statistically significant).