Fertility-preserving treatment for patients with malignant germ cell tumors of the ovary

AIM: The aim of this study was to investigate whether fertility preservation influences the clinical outcome in patients with malignant germ cell tumors of the ovary (MGCTO). METHODS: A case study analysis was performed on patients with MGCTO treated at Kurume University Hospital between 1986 and 2004. Thirty-five patients were included in the study, 14 with immature teratoma, 11 with dysgerminoma, eight with endodermal sinus tumor, and two with mixed germ cell tumor. Twenty-three patients had International Federation of Gynecology and Obstetrics stage I (Ia, 11; Ib, 2; Ic, 10), one had stage II, seven had stage III, and four had stage IV disease. RESULTS: Five patients with stage III or IV disease received radical surgery. Thirty patients underwent conservative surgery. As the adjuvant treatment, 30 patients received chemotherapy, while five patients did not receive any chemotherapy. The overall survival rate was 97.1%. One patient died of the disease. She was 13 years old with a stage IV endodermal sinus tumor. Twelve have attempted conception, and eight have achieved at least one pregnancy (66.7%). CONCLUSIONS: Irrespective of the stage of the disease, conservative surgery and adjuvant chemotherapy for MGCTO can achieve a favorable outcome in terms of survival and fertility.     

Germ cell tumors of the ovary: Is there a role for aggressive cytoreductive surgery for nondysgerminomatous tumors?

Abstract. Bafna UD, Umadevi K, Kumaran C, Nagarathna DS, Shashikala P, Tanseem R. Germ cell tumors of the ovary: Is there a role for aggressive cytoreductive surgery for nondysgerminomatous tumors?
Thirty-three patients with germ cell tumor of the ovary were seen at Kidwai Memorial Institute of Oncology (KMIO), Bangalore, between 1996 and 1999. Twelve patients had endodermal sinus tumor (EST), 11 dysgerminoma, seven mixed germ cell tumor, and three immature teratoma. Thirteen patients had bulky residual disease of>10 cm after the primary surgery. All but one patient received a combination of bleomycin, etoposide, and cisplatin (BEP) either as neoadjuvant (NACT, 3 cases) or as adjuvant therapy (28 cases). In the present study, all 11 patients with dysgerminoma achieved sustained complete remission (CR), irrespective of the size of residual disease at the time of chemotherapy. Four out of six cases (66.6%) with bulky nondysgerminomatous tumor achieved CR, which was sustained in three cases and one recurred. Fifteen of the remaining 16 (93.7%) nonbulky, nondysgerminomatous tumors achieved CR, which was sustained in 14 cases and recurred in one. This study indicates that there may be a role for aggressive cytoreductive surgery, either primary/interval or at the time of second-look laparotomy, in selected patients with nondysgerminomatous germ cell tumor of the ovary.     

Pregnancies following conservative treatment of malignant ovarian tumors

Summary Sixteen patients with malignant ovarian tumors were treated conservatively; 1 had a serous cystadenoma of low potential malignancy; 6 had a mucinous cystadenoma of low potential malignancy; 2 had a pure dysgerminoma; 2 had a mature solid teratoma; 3 had a mucinous cystadenocarcinoma; and 2 had an endodermal sinus tumor. Postoperative chemotherapy was given in 12 cases and 1 patient with a pure dysgerminoma had radiotherapy. Eighteen pregnancies occurred in 13 patients. One full-term and one 8 month premature infant died in utero, and 2 infants had malformations; the other 14 infants are all well. The patient with moderately differentiated mucinous cystadenocarcinoma who delivered a premature infant and 2 patients with endodermal sinus tumors died of recurrence.     

Malignant germ cell tumors of the ovary. Pregnancy considerations

OBJECTIVE: To study the pregnancy association and malignant germ cell tumors of the ovary with regard to its effects on tumor prognosis. STUDY DESIGN:: Seventy-five patients with malignant germ cell tumors of the ovary treated at the King Faisal Specialist Hospital-Research Center (KFSH-RC) Riyadh, Kingdom of Saudi Arabia between January 1976 and December 1992, were reviewed. Data was retrieved from the medical records and the database of ovarian tumor pathology. Patients with tumor/pregnancy association were identified and correlation with obstetrical outcome and tumor prognosis analyzed. Patients who conceived after treatment were identified and their reproductive outcome described. RESULTS: Malignant germ cell tumor was associated with pregnancy in a group of ten patients. Possible tumor effects upon pregnancy in this group included operative delivery by caesarean section (n=3), mid-trimester termination (n=2), spontaneous abortion (n=1). Four patients had normal vaginal birth with no apparent tumor effects upon pregnancy. Pregnancy did not seem to influence the tumor prognosis of pure dysgerminoma (n=6), however, two patients with non-dysgerminomatous germ cell tumor (one endodermal sinus tumor and one immature teratoma) died of rapidly progressive disease during the second trimester. Two patients with advanced (stage IIIC) disease concurrent with pregnancy (one pure dysgerminoma and one mixed germ cell tumor), had normal fetal outcomes and achieved long-term survival. Amongst the 22 patients who planned to conceive after conservative surgery, with or without post-operative adjuvant chemotherapy, 12 conceived (12/22) and achieved a total of 20 pregnancies. Their outcomes included normal births (n=18) including one set of twins and hydatidiform moles (n=2). CONCLUSIONS: Our findings suggest that, (1) The association of pure dysgerminoma and pregnancy did not adversely affect the tumor prognosis or fetal outcome. However, the question remains as to whether pregnancy worsened the prognosis of non-dysgerminomatous germ cell tumors. (2) Recent platinum-based regimens of multiagent chemotherapy for germ cell tumors did not seem to affect fertility potential.     

卵巢恶性生殖细胞肿瘤合并肺转移15例临床分析

目的 探讨卵巢恶性生殖细胞肿瘤(MOGCT)合并肺转移的临床特点、诊断、出现肺转移时间、治疗及预后.方法 对北京协和医院1982年1月至2010年12月收治的15例MOGCT合并有肺转移患者的临床资料进行回顾性分析.结果(1)临床特点:患者平均发病年龄为(23±11)岁(6 ～48岁).首发临床表现以腹部疼痛和不规则阴道流血为主,分别为8、4例.原发灶位于卵巢左、右侧者分别为8、6例,双侧者1例.转移灶仅为肺者12例,其他3例为多部位转移.(2)诊断:15例患者中,单纯性卵巢非妊娠性绒毛膜癌(绒癌;NGOC)9例,含有绒癌成分的卵巢混合性生殖细胞肿瘤3例(包括卵巢成熟性畸胎瘤合并绒癌1例、卵黄瘤为主伴绒癌及胚胎癌成分1例、绒癌伴无性细胞瘤1例),不含绒癌成分的卵巢恶性生殖细胞肿瘤3例(包括内胚窦瘤2例、未成熟性畸胎瘤1例).其中,仅1例于术前明确诊断.(3)出现肺转移时间:12例NGOC或含绒癌成分的混合性生殖细胞肿瘤患者中,11例在初始治疗的过程中即出现肺转移,1例为肿瘤复发后出现肺转移;3例不含绒癌成分的卵巢恶性生殖细胞肿瘤患者,均为肿瘤复发后在疾病晚期出现肺转移.(4)治疗:15例MOGCT合并有肺转移患者均采用手术联合化疗的综合治疗,平均化疗疗程数为16个(5 ～ 43个).(5)预后:10例(10/15)完全缓解,其病理类型均为NGOC或含绒癌成分的混合性生殖细胞肿瘤;3例患者在治疗过程中病情进展死亡(1例NGOC,1例内胚窦瘤,1例未成熟性畸胎瘤),2例肿瘤进展(1例NGOC,1例内胚窦瘤)放弃治疗后失访.结论 MOGCT发生肺转移以含绒癌成分者多见.MOGCT合并肺转移患者给予手术联合化疗的结合治疗,多数可获完全缓解,病理类型为NGOC或是含绒癌成分的混合生殖细胞肿瘤肺转移患者的预后远较其他类型的恶性生殖细胞肿瘤合并肺转移者为好.     

Treatment of malignant ovarian germ cell tumors with preservation of fertility

Preservation of fertility was practiced in 28 young patients with malignant germ cell tumors from 1962 through 1987. The pathologic diagnosis was immature teratoma in 16, endodermal sinus tumor in 7, dysgerminoma in 2 and germ cell tumor of mixed type in 3. At laparotomy, 16 patients proved to have stage I disease, one stage II, 9 stage III and 2 stage IV disease. The tumor was confined to one ovary in all the 22 cases operated on for the first time and the preserved ovary and uterus were normal in all 6 referred cases for recurrent diseases. Postoperative chemotherapy was given to all patients except two with stage I immature teratoma. A persistent remission was achieved in 22 patients, while 5 patients died and one was out of contact. The duration of survival was more than one year for all patients, more than 3 years in 16 cases (72.7%) and more than 5 years in 13 cases (59.1%). The menstrual periods were normal in all cases except 3, of which 2 were below the age of 12 and one failed to menstruate at the age of 19 with a hypoplastic uterus and underdeveloped secondary sex characteristics. Among 12 married patients, 7 of 10 desirous of childbirth became pregnant during follow-ups. Of these, 6 had normal term-deliveries and one is currently pregnant. The preliminary conclusion is that preservation of fertility for young patients with malignant ovarian germ cell tumor is a safe and practicable procedure in the absence of involvement of the contralateral ovary and uterus.     

Tumor chemoconversion following surgery, chemotherapy, and normalization of serum tumor markers in a woman with a mixed type germ cell ovarian tumor

BACKGROUND: Malignant germ cell tumors of the ovary are often curative after conservative surgery and adjuvant chemotherapy. Persistent tumors despite normalization of serum tumor markers may represent retroconversion to benign masses, but this is rare in ovarian tumors without teratoma elements. The management in such cases has not been defined. CASE: A young woman with a stage IIIC mixed germ cell ovarian tumor containing endodermal and dysgerminoma elements and elevated serum tumor markers underwent conservative surgery followed by chemotherapy. Residual tumor persisted on CT despite the normalization of serum tumor markers. The residual tissue was resected and contained benign tissue. CONCLUSIONS: In cases where masses persist and serum tumor markers normalize, attaining a histological diagnosis, and not chemotherapy, should be considered.     

Malignant ovarian germ cell tumor — Role of surgical staging and gonadal dysgenesis

Objective

To evaluate the effect of comprehensive surgical staging and gonadal dysgenesis on the outcomes of patients with malignant ovarian germ cell tumor.

Methods

We performed a retrospective review of patients with ovarian germ cell tumors who were treated at our institution between 1976 and 2012.

Results

Malignant ovarian germ cell tumors (MOGCTs) were identified in 50 females. The median age was 24 years (range 13 to 49). Of all MOGCT patients, 42% had dysgerminoma, 20% immature teratoma, 16% endodermal sinus tumor, and 22% mixed germ cell tumor. Univariate analyses revealed that the lack of surgical staging (p = 0.048) and endodermal sinus tumor (p = 0.0085) were associated with disease recurrence, while age at diagnosis, ethnicity, and stage of the disease were not. Multivariate analyses revealed that the lack of surgical staging (p = 0.029) and endodermal sinus tumor (p = 0.016) were independently associated with disease recurrence. In addition, 7 patients (14%) had 46 XY karyotype, including 6 with pure dysgerminoma and 1 with mixed germ cell tumor. Five had Swyer syndrome and 2 had complete androgen insensitivity syndrome. Concurrent gonadoblastoma was found in 5 of the patients. No difference was found in the mean age at presentation, stage distribution, or recurrence rate for MOGCT patients with or without XY phenotype.

Conclusions

Comprehensive surgical staging was associated with a lower rate of recurrence. Fourteen percent of phenotypic females with MOGCT and 29% of those with dysgerminoma had XY karyotype. The clinical outcome of these patients is similar to that of MOGCT patients with XX karyotype.     

Survival and fertility of patients with malignant ovarian germ cell tumours

Disease-free survival (DFS), overall survival (OS) and fertility of patients treated for malignant ovarian germ cell tumours at the Institute of Oncology Ljubljana from 1990-2000 were assessed. Twenty-three patients with a median age of 25 (15-67) years were treated. Five had pure dysgerminoma, three endodermal sinus tumour, ten immature teratoma and five had mixed germ cell tumours. Eleven patients had FIGO Stage I and the others advanced stage disease. All patients underwent initial surgery; in 13 of 15 patients under 35 years unilateral salpingo-oophorectomy was performed. Twenty-one patients received adjuvant cisplatin-based chemotherapy. At the median follow-up of 68 (11-140) months DFS was 74% and OS 87%. Six patients (two did not receive adjuvant chemotherapy) relapsed at a median of 16 (3-63) months after surgery. At relapse four were treated with surgery and chemotherapy, one with chemotherapy only and one with palliative radiotherapy only: two are still in complete remission, one has residual disease and three died of disease. Ten of 13 patients with fertility-preserving surgery regained menstrual cycles and one gave birth to a normal child. DFS and OS in our group of patients (over 15 years of age) are comparable to other institution's experience. Fertility in young patients can be preserved without compromising outcome.     

Retrospective review of 41 patients with endodermal sinus tumor of the ovary

Forty-one patients with endodermal sinus tumors of the ovary (EST) (23: pure EST, nine: EST with dysgerminoma; and nine: EST with immature teratoma) were treated with cytoreductive surgery, with or without subsequent adjuvant chemotherapy including VAC or PVB. Clinical staging of these patients showed 23 in stage I, six in stage II and 12 in stage III and IV. The outcome was good in the patients with stage I or II disease, with 5- and 10-year survival rates of around 80%. In contrast, all except two patients with stage III or IV disease died within 2 years. Aggressive surgery did not change the outcome of patients with stage I disease. In addition, postoperative chemotherapy was necessary, but the choice of vincristine, actinomycin-D and cyclophosphamide (VAC) or cis-platin, vinblastine and bleomycin (PVB) did not make any difference. Based on the results of the present study, VAC or PVB chemotherapy, after cytoreductive surgery, is essential for cure and conservative surgery followed by VAC or PVB regimen should be recommended for young patients.     

Conservative surgical management of malignant ovarian germ cell tumors: the experience of the Gynecologic Oncology Unit at Ain Shams University

PURPOSE: To evaluate the role of extended surgical staging in patients with malignant ovarian germ cell tumors in the presence of cisplatinum-based combination chemotherapy. MATERIALS & METHODS: 16 patients aged between 13 and 40 years (mean 20.5) diagnosed and treated for malignant ovarian germ cell tumors at the Gynecologic Oncology Unit. Ain Shams University, during the period from May 1994 to October 1999. RESULTS: Six patients were diagnosed with dysgerminoma, six with immature teratoma and four with endodermal sinus tumor. Only seven cases were primarily managed at the unit and were subjected to proper surgical staging as required by FIGO (two in each of the stages IC, IIC and IIIA and one in stage IV). However, the remaining nine cases were referred to the unit, six after having unilateral salpingo-oophorectomy and no surgical staging, one patient after total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO), and one with recurrent dysgerminoma in the retroperitoneum and mediastinum following suboptimal treatment. None of these cases were surgically re-explored and all including the first six cases were given the standard BEP chemotherapy for 4-6 courses (mean 5.8). Follow-up ranged from 7-72 months (mean 30.5). All patients are alive without any evidence of disease recurrence except for one patient with a stage IIIA immature teratoma who had a local and distant recurrence and is undergoing second-line chemotherapy. All patients have their menstrual function preserved except for three patients; one having 46,XX pure gonadal dysgenesis with a preoperative FSH level of 120 U/l and the eldest two patients having a TAH+BSO as they had completed their families. Three patients are currently pregnant. CONCLUSION: In view of the high chemosensitivity and curability of ovarian germ cell tumors and their occurrence in young patients, every effort should be made to preserve one ovary and the uterus for future reproduction even in advanced cases. The role of revisional surgical staging, in particular retroperitoneal lymphadenectomy in light of these data and those of others should be redefined in the future.     

Malignant germ cell tumors of the ovary

OBJECTIVE: To evaluate the efficacy of adjuvant therapy for ovarian germ cell tumors. METHODS: We reviewed records of women who had malignant germ cell tumors of the ovary from 1977-1997. RESULTS: Seventy-two women had surgical resections of malignant ovarian germ cell tumors and most received adjuvant therapy. Fifty-six women (78%) presented with stage I disease, and 16 (22%) had more advanced disease. Tumor subtypes included dysgerminoma (n = 20), yolk sac tumor (n = 8), immature teratoma (n = 29) and mixed germ cell tumor (n = 15). Surgical management of the 56 with stage I disease consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and extensive surgical staging in ten women, whereas a conservative surgical approach, consisting of unilateral adnexectomy with or without comprehensive surgical staging, was adopted in later years (n = 46). Fifty-six women were treated with postoperative chemotherapy, predominantly platinum-based regimens. The 5-year actuarial survival rate was 93%. None of the 36 women who presented after 1984 have died of disease. CONCLUSION: These data confirmed that platinum-based adjuvant treatments allow most women with ovarian germ cell malignancies to have conservative surgery without compromising survival.     

Successful pregnancy after conservative surgery and chemotherapy for dysgerminoma of the ovary: case report]

OBJECTIVES: Considering the important improvement of surgical techniques and chemotherapy in the last few years, it is possible today, in selected cases of patients previously treated for ovarian cancer, to support their desire for motherhood, thus improving the quality of life for them. The major problem for the Gynecologic Oncologist in treating young women for ovarian tumor is the lack of statistically significant experience world-wide, because of the very few cases in which the reproductive function is preserved, and pregnancy is subsequently possible. STUDY DESIGN: The aim of this study was presentation the successful pregnancy after conservative surgery and chemotherapy for dysgerminoma of the ovary stage Ia. RESULTS: The patient age 23 was admitted to Department of Gynecology & Obstetric in Hospital of S?upsk in 1995 year with diagnosis right ovarian tumor. Right-side adnexectomy was performed initially. Histopathological examination of surgical specimen revelated dysgerminoma ovary stage Ia. Due to the clearly elevated tumor marker levels, indicating an involvement of other germ cell elements, and necrobiosis of tumor, we opted for postoperative chemotherapy instead of radiotherapy. Six cycles of BEP protocol chemotherapy was given. The follow-up included regular monitoring of the tumor markers. In the year 1998 the patient conceived and had a delivery of a normal infant at term. To date, there has been no indication towards tumor recurrence. CONCLUSION: After adequate staging and accurate information is given to the patient, conservative treatment may be safe in some women with early ovarian cancer. In early stage pure ovarian dysgerminoma conservative surgery combined with radiotherapy or chemotherapy showed high complete remission rates and excellent survival rates. For younger patients and those with gestation desires as well as patients with advanced diseases, adjuvant chemotherapy following surgery might be a better choice.     

Malignant ovarian germ cell tumors: the experience at the Hospital de la Santa Creu i Sant Pau.

From 1979 to 1990, 33 patients with pathologically confirmed malignant ovarian germ cell tumors (MOGCT) were referred after initial surgical procedure at the Department of Oncology, Hospital de la Santa Creu i Sant Pau. The median age was 22 years (range, 10 to 39). Stage distribution was as follows: stage I, 12 patients; stage II, 6 patients; stage III, 11 patients; stage IV, 3 patients; and unstaged, 1 patient. The histologic diagnoses were 10 dysgerminomas, 4 endodermal sinus tumors, 11 immature teratomas, and 8 mixed germ cell tumors. Twenty-eight out of the thirty-three patients received postoperative chemotherapy with POMB-ACE-PAV or other platinum-containing regimens. One patient with stage IV disease failed to respond to chemotherapy and she died. Sixteen out of the twenty-eight treated patients had second-look laparotomy, which showed mature teratoma in six and persistent malignant teratoma in one patient. This last patient had complete remission with second regimen. No patient has developed recurrence. With a median follow-up of 66 months (range, 10 to 133), 32 patients (97%) are alive without evidence of disease. These data confirm that platinum-containing regimens have dramatically improved the prognosis for patients with MOGCT. This paper discusses primary chemotherapy and the role of the second-look in these patients.     

Analysis of serum CA125, CEA, AFP, LDH levels and LDH isoenzymes in patients with ovarian tumors--correlation between tumor markers and histological types of ovarian tumors

Serum CA125, CEA, AFP, LDH levels and LDH isoenzymes were analyzed in ovarian tumor patients, who were treated at Kyoto University Hospital. CA125 was positive in 10/16 (62.5%) cases of common epithelial carcinoma, especially 100% positive in serous carcinoma, but was negative in mucinous tumors. CA125 was also negative in patients with germ cell and sex cord stromal tumors. CEA was positive in 13/32 (40.6%) cases of epithelial carcinoma, most frequently elevated in patients with mucinous carcinoma, pseudomyxoma peritonei, and Krukenberg tumor. AFP was positive only in those with endodermal sinus tumors. LDH was elevated in 16/39 (41%) cases of epithelial carcinoma, but was not specific for histological types. In contrast, all 8 cases of dysgerminoma, 1 of immature teratoma and 2 of endodermal sinus tumor showed extremely elevated LDH levels. Moreover, the normal pattern or deviation to H subunit of LDH isoenzymes was seen in such cases of germ cell tumor, while deviation to M subunit was noted in epithelial and metastatic tumor patients. These data indicate that each parameter is useful as a tumor marker for the specific histological type of ovarian tumor; CA125 for non-mucinous epithelial carcinoma, CEA for mucinous tumor and Krukenberg tumor, AFP for yolk sac tumor, LDH and LDH isoenzymes for dysgerminoma and other solid germ cell tumors. In addition, preoperative diagnosis of histological types of ovarian tumors may be possible by combining these tumor markers.     

Growing teratoma syndrome vs chemotherapeutic retroconversion: case report and review of the literature

BACKGROUND: Immature ovarian teratoma is the third most common germ cell tumor (GCT) following dysgerminoma and endodermal sinus tumor. The treatment of choice during childbearing age for immature teratoma composes of unilateral oophorectomy and in case of metastatic disease postoperative chemotherapy (BEP). Finding a solid mass in the peritoneal or chest cavity during routine follow up raises the suspicion of distance recurrence. DiSaia was the first to describe the appearance of benign distant metastasis during routine follow up. He termed this phenomenon "chemotherapeutic retroconversion". Latter, Logothetis described what seems to be a similar phenomenon in testicular non-seminomatous germ cell tumor (NSGCT) that he called the "growing teratoma syndrome". CASE: We present a case of a 12-year-old girl treated for growing teratoma syndrome after primary ovarian GCT. CONCLUSION: Review of the literature shows that this syndrome and the "chemotherapeutic retroconversion" are probably the same phenomenon.     

Combination chemotherapy in the management of ovarian germ cell malignancies

Twenty-four patients with ovarian germ cell malignancies received combination chemotherapy in the present series. Fifteen patients received intensive vincristine, actinomycin-D, and cyclophosphamide therapy for 12 to 18 courses, and 13 are alive and free of disease 34 to 86 months later. One patient with a stage III pure endodermal sinus tumor and one patient with a stage III mixed germ cell tumor composed predominantly of endodermal sinus tumor elements failed vincristine, actinomycin-D, and cyclophosphamide therapy, but each transiently responded to cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy. Nine patients subsequently were treated on a new protocol that used the intensive vincristine, actinomycin-D, and cyclophosphamide regimen for five to six courses for all stage I ovarian germ cell malignancies and cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy for advanced stage tumors containing endodermal sinus tumor. Each patient on the new protocol is alive and free of disease 14 to 26 months later. Short-term intensive vincristine, actinomycin-D, and cyclophosphamide therapy is recommended for all stage I ovarian germ cell malignancies requiring adjuvant chemotherapy. Preservation of ovarian and reproductive function is appropriate in the present group of patients. Vincristine, actinomycin-D, and cyclophosphamide therapy is also recommended for biomarker negative advanced stage ovarian germ cell malignancies. Cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy is recommended for advanced stage biomarker positive ovarian germ cell malignancies. Serial alpha-fetoprotein (AFP) titers accurately reflect the status of endodermal sinus tumor elements and may be used as a guide to discontinue treatment for patients with pure endodermal sinus tumor malignancies, obviating the need for second-look surgery.     

Second-look laparotomy in the management of malignant germ cell tumors of the ovary

From 1970 to 1985, 53 patients with malignant nondysgerminomatous germ cell tumors of the ovary underwent second-look laparotomy after initial surgery and combination chemotherapy. Twenty-two patients had immature teratoma, 15 had endodermal sinus tumor, 15 had mixed germ cell tumor, and one patient had embryonal carcinoma. Thirty-one of the neoplasms were stage I, four were stage II, 17 were stage III, and one was stage IV. Two patients received a combination of actinomycin-D, 5-fluorouracil, and cyclophosphamide; four patients received vinblastine, bleomycin, and cisplatin; 44 patients received vincristine, actinomycin-D, and cyclophosphamide; and three patients received a combination of the last two regimens. Second-look findings were negative in 52 patients and positive in one patient who was subsequently salvaged with further chemotherapy. One patient with stage I endodermal sinus tumor relapsed nine months after a negative second-look laparotomy and died. Two patients with negative findings subsequently died of leukemia. Of 53 patients undergoing second-look laparotomy, three are dead (one of cancer and two of leukemia), and 50 patients are surviving without disease. Although the precise role of second-look laparotomy in patients with malignant germ cell tumors is yet to be established, possible indications are discussed.     

Outcome and prognostic factors in ovarian germ cell malignancies

OBJECTIVES: This study was undertaken to investigate the outcome and prognostic factors in patients with ovarian germ cell malignancies (OGCMs). METHODS: A total of 93 patients with OGCMs were retrospectively reviewed, among whom 84 patients had primary treatment at Chang Gung Memorial Hospital (CGMH) between 1984 and 2003. The other nine patients were primarily treated outside and referred for follow-up (n = 1), adjuvant chemotherapy (n = 4), or salvage therapy after recurrence (n = 4). The clinicopathological and treatment-related characteristics were analyzed for association with the occurrence of tumor persistence/recurrence or death. RESULTS: Of the study patients, 32 had dysgerminoma (DSG), 29 immature teratoma (IMT), 23 endodermal sinus tumor, 7 mixed germ cell tumors, and 1 each had choriocarcinoma and embryonal carcinoma. The median follow-up of survivors was 66 months (range, 12-236 months). The median time to recurrence or progression was 8 months. There were 11 treatment failures with 6 died of cancer. The 5-year survival rate was 97.4% for those primarily treated at CGMH. Histology (DSG/IMT versus non-DSG/IMT) (P < 0.0001) and International Federation of Gynecology and Obstetrics stage (P = 0.001) were significantly associated with treatment failure, while histology (P = 0.0004), salvage high-dose chemotherapy (HD-CT) after primary chemotherapy failed (P = 0.0405), and residual tumor after salvage surgery (P = 0.0014) were significant prognostic factors for overall survival. CONCLUSIONS: Prognosis of OGCMs is excellent if managed with standard treatment initially. Aggressive HD-CT with salvage surgery needs to be applied for recurrent/persistent disease after primary chemotherapy.     

Management of Early Ovarian Cancer: Germ Cell and Sex Cord-Stromal Tumors

Malignant ovarian germ cell tumors (OGCT) and sex cordstromal tumors (OSCST), each of which account for less than 5% of all ovarian malignancies, are much less common than epithelial ovarian cancer. In young patients suspected of having an OGCT, laparotomy is initially indicated for both diagnosis and treatment. For most patients, unilateral salpingo-oophorectomy with preservation of the contralateral ovary and the uterus is appropriate. The basis for this surgical approach is retrospective studies that show an equivalent cure rate for patients who undergo unilateral or bilateral adnexectomy. No prospective studies have compared unilateral with bilateral adnexectomy. Surgical staging is also important to determine the extent of disease, to determine prognosis, and to guide postoperative management. If metastatic disease is encountered during initial surgery for OGCT, the same principles of cytoreductive surgery that have been applied to surgically manage advanced epithelial ovarian cancer are recommended, with resection of as much tumor as is technically feasible and safe. For all OGCT patients except those with well-documented stage IA grade 1 pure immature teratoma or stage IA pure dysgerminoma, postoperative chemotherapy is indicated. The current recommended regimen for OGCT is bleomycin, etoposide, and cisplatin—a combination that appears to result in at least a 95% cure rate for stage I disease and at least a 75% cure rate for advanced-stage disease. For patients with metastatic dysgerminoma, chemotherapy, which has the advantage of preserving fertility in the majority of patients, has supplanted radiotherapy as standard treatment. For patients with OSCST, no standard therapy exists. Surgery alone is currently acceptable treatment for all patients with OSCST except those who have metastatic disease or Sertoli-Leydig cell tumors with poor differentiation or heterologous elements. Currently, platinum-based combination chemotherapy is favored for these latter patients, but the activity of such regimens appears only modest.