Surgical approach, relapse risk and overall survival in borderline ovarian tumors: age-stratified analysis based on real-world data

Background: The need for complete staging surgery including hysterectomy for all age patients with borderline ovarian tumors (BOT) is debatable, considering fertility in younger patients and potential higher morbidity in older patients. We aimed to investigate the relapse risk and overall survival in a cohort including patients who underwent conservative surgery (organ-preserving procedures) to minimize complications, independent of fertility considerations. Methods: We conducted a retrospective, population-based review of 217 surgically treated BOT patients in Southern Sweden (2017-2022). Patients were stratified by age (≤40, 41-50, 51-65, >65 years) and surgical approach (conservative vs complete staging). Outcomes included recurrence, 5-year overall survival (OS), progression-free survival (PFS) and OS at end-of-follow-up. Kaplan-Meier analyses with log-rank tests evaluated survival differences; univariate and multivariate Cox proportional hazards models identified independent predictors. Results: Of 217 patients, 9 had a synchronous malignancy and were excluded from the survival analyses. 36 underwent conservative surgery, 167 complete staging surgery and 5 bilateral salpingo-oophorectomy with uterus preservation. Recurrence was more frequent after conservative surgery (12.1%) than complete surgery (3.2%) but did not reach statistical significance. Five-year OS was 100% for patients ≤40 and 41-50 years, 95.3% for those 51-65 years and 92.5% for >65 years (log-rank p=0.02). PFS differed by age in the overall cohort (p=0.002) and among complete surgery patients (p=0.001), but not in conservative surgery patients (p=0.721). OS did not differ significantly among complete surgery patients across age categories (p=0.287). In multivariate Cox regression, age at first operation was the only independent predictor of survival (HR = 1.068, 95% CI 1.018-1.119, p=0.007). Conclusion: Age at first operation independently predicts survival in BOT. Young age at first surgery was associated with a higher risk of relapse, regardless the type of surgery, whereas older age was associated with an increased risk of death. Conservative surgery does not compromise long-term outcomes and can be considered across age categories to balance oncologic safety with the goal of reducing surgical morbidity, supporting individualized treatment planning.