Prolonged survival following salvage surgery for chemorefractory ovarian immature teratoma: a case report and review of the literature

BACKGROUND: Data regarding salvage surgery for ovarian immature teratoma (IT) are lacking despite its established role in the management of chemorefractory testicular germ cell tumors. In this report, a case of advanced IT that was salvaged by secondary cytoreduction following failure of both primary therapy and salvage chemotherapy is described, and the available literature is reviewed. CASE: A 28-year-old patient underwent primary cytoreductive surgery followed by platinum-based chemotherapy for stage IIIC, grade 3, ovarian IT. Second-line chemotherapy was administered after residual disease was identified at second-look surgery. Following failure of salvage chemotherapy, aggressive secondary debulking resulted in long-term disease-free survival of over 48 months. CONCLUSION: There appears to be a distinct role for salvage surgery in selected cases of chemorefractory IT. More studies are needed to further define the subset of patients who benefit most from this management approach.     

Reproductive function after conservative surgery and chemotherapy for malignant germ cell tumors of the ovary

OBJECTIVE: To analyze the long-term effects on reproductive function of fertility-preserving treatment for malignant germ cell tumors of the ovary. METHODS: A case series analysis was performed on patients with malignant germ cell tumors of the ovary seen or consulted on at our institution between 1975 and 1995. Follow-up information regarding reproductive function was obtained by a mailed or telephone questionnaire. RESULTS: A total of 106 patients with malignant germ cell tumors of the ovary were included in the study. Twenty patients were excluded because of loss of follow-up or death. For the remaining 86 patients, the median follow-up was 122 months (24-384 months). Fertility-preserving surgery was performed in 64 patients. Thirty-eight have attempted conception and 29 have achieved at least one pregnancy (76%). Among the patients who conceived, 20 were International Federation of Gynecology and Obstetrics (FIGO) stage I, one was stage II, and eight were stage III. Sixteen received vincristine, actinomycin D, and cyclophosphamide; three received cisplatin, vinblastine, and bleomycin; three received bleomycin, etoposide, and cisplatin; one received etoposide and cisplatin; four did not receive any chemotherapy; and two were treated with other combinations. Among the nine patients who could not conceive, seven were FIGO stage I and two were stage III. Four of these patients received vincristine, actinomycin D, and cyclophosphamide; three received etoposide and cisplatin; one received cisplatin, vinblastine, and bleomycin; and one patient received no chemotherapy. A total of 38 children were born to these women. Follow-up was available for 16 of these children, who have no evidence of congenital anomalies. CONCLUSION: Fertility-preserving surgery followed by chemotherapy, even in advanced-stage malignant germ cell tumors of the ovary, is effective in conserving the reproductive function of women with malignant germ cell tumors of the ovary.     

Stage IC adenocarcinoma of the endometrium: survival comparisons of surgically staged patients with and without adjuvant radiation therapy

OBJECTIVE: The goal of this study was to determine the outcomes of stage IC endometrial carcinoma patients who are managed with and without adjuvant radiation therapy after comprehensive surgical staging. METHODS: Patients with FIGO stage IC adenocarcinoma of the endometrium diagnosed from 1988 to 1999 were identified from tumor registry databases at four institutions. A retrospective chart review identified 220 women who underwent comprehensive surgical staging including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic/paraaortic lymphadenectomy, and peritoneal cytology. RESULTS: Of the 220 stage IC patients, 56 (25%) patients received adjuvant brachytherapy (BT), 19 (9%) received whole-pelvis radiation (WPRT), and 24 (11%) received both WPRT and BT. One hundred twenty-one patients (55%) did not receive adjuvant radiation. There were 6 recurrences (6%) in the radiated group and 14 (12%) in the observation group (P = 0.20). Seven of fourteen recurrences in the observation group were local, and all local recurrences were salvaged with radiation therapy. Two of seven distant recurrences in this group were also salvaged with surgery and chemotherapy. The overall salvage rate for the observation group was 64%. There was a statistical difference in 5-year disease-free survival between the radiated and observation groups (93% vs 75%, P = 0.013). However, the 5-year overall survival was similar in the two groups (92% vs 90%, P = 0.717). CONCLUSION: Adjuvant radiation therapy improves disease-free survival in surgical stage IC patients; however, overall survival is not improved with adjuvant radiation therapy since the majority of local recurrences in conservatively managed patients can be salvaged with radiation therapy.     

Etoposide combination chemotherapy in refractory ovarian malignant germ cell tumor

Thirty-three patients with malignant germ cell tumor of the ovary received postoperative vincristine, dactinomycin, and cyclosphosphamide (VAC) treatment. Eight failed VAC treatment and received etoposide, bleomycin, and cisplatin (PEB) combination chemotherapy. Three were cured and remained disease free 24-79 months after completion of PEB therapy.     

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.     

Controversial Issues in the Management of Early Epithelial Ovarian Cancer: Conservative Surgery and Role of Adjuvant Therapy

The feasibility of conservative surgery and the role of postoperative adjuvant therapy are still controversial issues in the management of early ovarian cancer. Data on 99 patients below the age of 40 with stage I ovarian cancer are reported and conservative surgery was performed in 56 (56%) patients (36 stage Ia, 1 stage Ib, and 19 stage Ic). Relapse occurred in 3 stage Ia (grades 1, 2, and 3) patients, but only 1 occurrence was in the residual ovary and the patient was rescued by surgery. The other 2 patients who relapsed in distant sites died as a result of their tumors. Seventeen patients who desired to become pregnant did so for a total of 25 conceptions. These data support the possibility of some extension of the traditional conservative approach. Only two randomized studies so far have tested cisplatin as an adjuvant treatment of early disease. A Norwegian trial compared cisplatin to 32P in stage I-III ovarian cancer without residual tumor after primary surgery and found no difference in survival. An Italian study compared cisplatin to observation in stage Ia and Ib grade 2 and 3 tumors and cisplatin to 32P in stage Ic patients. While disease-free survival was statistically longer in cisplatin-treated patients of both groups, no difference in survival could be detected. These results supported the design of a currently ongoing multicenter trial testing platinum-based therapy soon after surgery or at time of relapse.     

Borderline ovarian tumors

Ninety-four patients with borderline ovarian tumors were retrospectively analyzed for clinical features, treatments, and survival characteristics. There were 46 patients with FIGO stage IA cancer, 7 with stage IB, 20 with stage IC, 4 with stage IIB, 5 with stage IIC, 5 with stage IIIA, 3 with stage IIIB, and 4 with stage IIIC tumors. Seventy patients had at least a total abdominal hysterectomy and bilateral salpingo-oophorectomy, 20 patients had conservative surgery including unilateral salpingo-oophorectomy or ovarian cystectomy, and 4 patients had bilateral salpingo-oophorectomy. Fifteen patients with stage I disease received adjuvant melphalan therapy and 2 received external beam radiation for concomitant gynecologic cancers; 7 with stage II tumors received adjuvant melphalan therapy and 1 received external beam radiation; and 5 with stage III tumors received melphalan therapy and 6 patients received cisplatin-based combination chemotherapy. Follow-up ranged from 1 to 117 months, with a median of 33.5 months. Eighty-seven patients were alive. Seven patients died, two of disease. The overall 5-year survival rate was 83.0%; those treated with adjuvant therapy had a 79.5% survival, whereas the others had 84.6% survival. Second-look surgery was performed in 10 patients; six results were negative after melphalan therapy, one was negative after cisplatin combination therapy, and one was negative after no adjuvant treatment. Two patients had positive second-look surgery, one with stage IIIC disease treated with a cisplatin combination and the other with stage IC disease treated with melphalan. This review did not demonstrate that patients with borderline ovarian tumors benefited from adjuvant therapy.     

The long term results of radiotherapy with or without surgery in management of advanced vulvar cancer: report of 76 patients

BACKGROUND: The combination of conservative surgery plus radiotherapy for vulvar cancer has been well established as a therapeutic alternative to extensive radical surgery. This study was undertaken to evaluate the long-term results of radiotherapy with or without surgery in the management of advanced vulvar cancer. PATIENTS AND METHODS: The cases of 76 patients who had advanced carcinoma of the vulva treated with different modalities at the University of Texas M.D. Anderson Cancer Center were retrospectively reviewed. Three patients had unstaged disease as a result of previous surgery, 19 had stage II, 40 had stage III, and 14 had stage IV disease. Follow-up ranged from 4 to 17 years (median, 11 years). RESULTS: Five-year disease-free survivals were 75, 67, 68 and 52% for treatment groups I, II, III, and IV, respectively. Disease was controlled locally in 83, 80, 73 and 56% of patients in groups I through IV, respectively; the overall rate of local control was 79%. There was no significant difference in primary tumor control, 5-year disease-free survival, or overall survival among the different treatment groups (p=0.1300). However, these rates did differ significantly (p<0.006) based on FIGO stage of disease. CONCLUSION: In this report, the cure of vulvar cancers with radiotherapy alone (5-year disease-free survival 52% and local control 56%), the radiotherapeutic salvage of patients with surgical failure and/or large tumors, the improved survival with low morbidity by pre- and postoperative radiotherapy were provocative observations suggesting the value of this therapy for advanced vulvar cancer.     

Endodermal sinus tumor of the ovary: the Hacettepe University experience

OBJECTIVE: The purpose of this study was to evaluate the treatment regimens used for patients with endodermal sinus tumors (EST), and also to examine the prognostic value of surgicopathological variables. STUDY DESIGN: Twenty-two patients treated for pure EST, and seven patients who had mixed germ cell tumors with EST components were included. Initial surgery consisting of surgical staging to achieve optimal debulking was the principal mode of therapy. Data were obtained from patients' files, a special gynecologic oncology database, and pathology records. RESULTS: The median age at the time of diagnosis was 18 (range 8-45). Sixteen patients had stage I (55%), and 13 (45%) had stage II-IV disease. As an adjuvant therapy 18 patients (62%) received platin-based chemotherapy, three patients (10%) had non-platin-based chemotherapy, four patients (14%) had radiotherapy, and four patients (14%) had combined radiotherapy plus non-platin-based chemotherapy. The 5-year disease-free and overall survival rates were 47 and 48%, respectively. Survival rates were dismal in patients with stage II-IV disease (P < 0.001). Platin-based chemotherapy achieved significant survival benefit (P = 0.03 and P < 0.001, respectively). Fertility-saving surgery had an overall survival no worse than those who underwent more extensive surgery. There was no significant survival difference with respect to age, histology, and tumor size. CONCLUSION: Fertility-sparing surgery with a postoperative platin-based combination chemotherapy should be the selected mode of treatment.     

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.     

Childhood malignant ovarian germ cell tumors: a monoinstitutional experience

OBJECTIVES: We reviewed our 23-year monoinstitutional exprience with childhood malignant ovarian germ cell tumors (MOGCT), with respect to survival and iatrogenic sequelae. METHODS: Twenty-nine patients (median age 12 years) with newly diagnosed MOGCT were treated: all girls but 2 underwent surgery as initial treatment. There were 9 pure dysgerminomas and 20 nondysgerminoma tumors (5 immature teratomas, 4 yolk sac tumors, and 11 mixed histology tumors). According to the FIGO classification, 9 girls were classified as stage I, 4 as II, 11 as III, and 3 as IV, and 2 were not evaluable because they were submitted to primary chemotherapy. Twenty-four received chemotherapy with VAC, PVB, or PEB regimens, according to the ongoing protocols through the years. Three stage I girls did not receive adjuvant chemotherapy because of their histology (2 dysgerminomas, 1 immature teratoma) and stage. In the early years, postoperative radiotherapy was given alone in advanced dysgerminoma stages. RESULTS: Five patients died of their disease: 2 dysgerminomas (stage IIIc and IV) and 3 nondysgerminomas (2 stage II and 1 stage IIIc). OS and EFS rates at a median of 112 months were 81.8%. Among 24 survivors, 4 experienced iatrogenic amenorrhea because of radiotherapy and/or bilateral oophorectomy. CONCLUSIONS: MOGCT are highly chemosensitive and curable, with preservation of reproductive function. The management of recurrent disease remains an open issue.     

Prognostic factors and role of salvage surgery in chemorefractory ovarian germ cell malignancies: a study in Chinese patients

BACKGROUND AND OBJECTIVES: The majority of the studies on ovarian germ cell malignancies (OGCMs) focused on combination chemotherapy and fertility sparing surgery in primary treatment. Prognostic factors and the salvage treatment, particularly the role of salvage surgery, for the chemorefractory disease are much less documented. The purpose of this study was to explore the prognostic factors and the role of salvage surgery in Chinese patients with chemorefractory OGCMs. METHODS: A total of 34 patients with chemorefractory OGCMs who underwent salvage surgery at Fudan University Cancer Hospital from April 1992 to December 2005 were retrospectively identified and analyzed. Survival was analyzed using the Kaplan-Meier and the statistical significance of various prognostic factors was tested using both the log-rank and the Cox proportional hazards models. RESULTS: The median age of the study patients was 22.76 years. The histological subtypes included 2 dysgerminomas (DSG), 7 immature teratomas (IMT), 22 endodermal sinus tumors (EST) (including 16 pure EST, 3 mixed type with DSG, 3 with EC), 2 embryonal carcinomas (EC) and 1 mixed form (with component of sex cord-stromal tumor). The median follow-up time was 44.09 months (range, 5-164 months). For the entire study population, 1-, 3-, and 5-year survival were 82.35%, 45.64%, and 33.17%, respectively. The 1-, 3-, and 5-year survival in patients who were rendered macroscopically disease-free or had residual disease < or = 1 cm after surgical salvage were 93.33%, 80.00%, and 60.95%, compared to 68.42%, 21.05%, and 14.04% in those who had postoperative residual disease >1 cm (P=0.0036). Histology (DSG/IMT vs. non-DSG/IMT) (P=0.0221), primary and salvage chemotherapy regimen (non-BEP/PVB regimen for primary chemotherapy and BEP/PVB regimen for salvage chemotherapy vs. all other regimens in primary and salvage chemotherapy) (P=0.0316), site of chemorefractory disease (retroperitoneal vs. intraperitoneal) (P=0.0221), and salvage surgery states (optimal cytoreduction vs. suboptimal cytoreduction) (P=0.0036) were significant prognostic factors for survival through univariate analysis. However, site of chemorefractory disease was excluded as an independent prognostic factor according to multivariate analysis. CONCLUSIONS: Chemorefractory cases with dysgerminoma or immature teratoma appear to have better outcome than the other subtypes. When offered standard BEP/PVB regimen as salvage chemotherapy, patients with chemorefractory disease after non-BEP/PVB primary chemotherapy have better prognosis. Optimal cytoreduction during salvage surgery does benefit chemorefractory patients.     

青少年卵巢肿瘤的临床病理分析

目的:探讨青少年卵巢肿瘤的临床病理特点。方法:回顾性分析67例20岁以下的青少年卵巢肿瘤患者的临床表现、诊断、病理和治疗。结果:临床症状以腹痛、腹部包块为主,肿瘤扭转率高。良性肿瘤41例,交界性3例,恶性23例;组织学类型以生殖细胞肿瘤最多。恶性肿瘤中65.2%为FIGOI期。除8例恶性患者进行了肿瘤细胞减灭术外,其余59例均进行了保留生育功能的手术。15例恶性肿瘤患者术后化疗。单因素分析显示仅化疗方案影响生存期,BEP优于VAC。结论:青少年卵巢肿瘤的临床病理特点与成人不同,首选保留生育功能的手术,BEP是恶性患者的一线化疗方案。     

Conservative management of stage I endometrial carcinoma after surgical staging.

OBJECTIVE: The aim of this study was to determine the outcomes of Stage I endometrial carcinoma patients who are managed without adjuvant radiation after comprehensive surgical staging. METHODS: A computerized hospital database identified women diagnosed with adenocarcinoma of the endometrium from 1993 to 1998. A chart review identified 864 women as having primary surgery for adenocarcinoma of the endometrium. A total of 670 of 864 patients (78%) underwent comprehensive surgical staging with total hysterectomy, bilateral salpingo-oophorectomy, pelvic/para-aortic lymphadenectomy, and peritoneal cytology. After 57 patients with high-risk histologic subtypes were excluded, 613 patients remained for analysis. RESULTS: A total of 321 of 325 Stage IB patients (99%) did not receive adjuvant radiation. Fifteen of 321 patients (5%) recurred; 9 recurred in the pelvis or vagina. All 9 local recurrences were salvaged with whole pelvic radiation (XRT) and brachytherapy (BT). Seventy-seven patients were diagnosed with Stage IC disease; 53 (69%) received no adjuvant therapy. Four patients (8%) recurred, of which 2 recurred in the vagina. Three of 4 patients (75%) were salvaged, 2 with XRT/BT and 1 with surgery and chemotherapy. For all Stage I patients, the 5-year disease-free survival was 93% and the 5-year overall survival was 98%. CONCLUSIONS: Surgically staged patients with endometrial carcinoma confined to the uterine corpus have a small risk of recurrence and the majority of these recurrences can be salvaged with radiation therapy. Conservative management of Stage I endometrial carcinoma patients is an effective treatment strategy.     

全面分期手术对卵巢恶性生殖细胞肿瘤初治患者预后的影响

目的探讨全面分期手术对卵巢恶性生殖细胞肿瘤（MOGCT）初治患者预后的影响。方法收集北京协和医院1980年6月-2003年6月收治的127例MOGCT患者的临床病理资料,分析其初治时的手术方式与预后的相关性。结果127例患者中,行全面分期手术者45例（35．4％）,未行全面分期手术者82例（64．6％）;术后残余瘤直径〈2cm（即手术彻底）者71例（55．9％）,直径≥2cm（即手术不彻底）者11例（8．7％）,不详者45例（35．4％）;采用顺铂＋长春新碱＋博莱霉素（PVB）或博莱霉素＋足叶乙甙＋顺铂（BEP）方案化疗者75例（59．1％）,长春新碱＋阿霉素＋环磷酰胺（VAC）方案化疗者18例（14．2％）,未化疗或行其他方案化疗者34例（26．8％）。随访期（2-254个月）内,行全面分期手术者复发率为16％（7／45）,未行全面分期手术者复发率为61％（50／82）,两者比较,差异有统计学意义（P〈0．05）。多因素分析结果显示,全面分期手术不影响无瘤生存时间（P=0．061）,化疗方案、手术彻底性是明显影响无瘤生存时问的因素（P〈0．05）。行全面分期手术者随访2—158个月,死亡率为7％（3／45）,未行全面分期手术者随访4～254个月,死亡率为15％（12／82）,两者比较,差异无统计学意义（P〉0．05）。全面分期手术不影响长期生存时间（P〉0．05）,化疗方案、手术彻底性明显影响长期生存时间（P〈0．05）。结论手术彻底和规范化疗明显影响MOGCT初治患者的预后,而是否实施全面分期手术对初治患者预后无明显影响。     

Clinical outcome of primary gastric lymphoma treated with chemotherapy alone or surgery followed by chemotherapy.

BACKGROUND: The role of surgical resection in the treatment of primary gastric lymphoma (PGL) remains unclear. This retrospective study evaluated the clinical outcome of PGL treated with chemotherapy alone or surgery followed by chemotherapy. METHODS: During 1986-2003, 59 patients with PGL (other than mucosa-associated lymphoid tissue type lymphoma) were identified from hospital files. The medical records, pathologic sections, radiographic images and treatment modalities of these patients were reviewed. Patients were categorized into localized (stage IE and IIE-1) and advanced (stage IIE-2 or beyond) stage groups. Survival was estimated by the Kaplan-Meier method. RESULTS: The study included 55 patients who received treatment at the same institute. Among them, 32 had localized PGL (15 stage IE, 17 stage IIE-1) and 23 had advanced disease. The median survival of the localized stage group was not reached during a mean follow-up of 168.1 +/- 16.7 months (95% confidence interval [CI], 135.4-200.8 months), while that of the advanced stage group was 33.0 +/- 6.8 months (95% CI, 19.7-46.5; p < 0.001, log-rank test). Among patients with localized PGL, the 5-year overall survival rate of those receiving chemotherapy alone (n = 19) or combination therapy (surgery followed by chemotherapy, n = 13) was 73.4% and 87.5%, respectively (p = 0.229). The 5-year disease-free survival was 68.4% and 84.6%, respectively (p = 0.540). However, post-chemotherapy life-threatening hemorrhage occurred in five of the 32 patients (15.6%) in the localized stage group: four in the chemotherapy-alone group, and one in the combination therapy group, all of whom had failed to achieve complete response. CONCLUSION: The clinical outcome of localized PGL treated by chemotherapy alone is similar to that treated by surgery followed by chemotherapy in terms of tumor response, disease-free survival and overall survival, suggesting that surgery be reserved for those with residual tumors after chemotherapy.     

Neoadjuvant chemotherapy in vulvar cancer: avoiding primary exenteration

OBJECTIVE: To determine whether neoadjuvant cisplatin and 5-fluorouracil chemotherapy can be used to preserve the anal sphincter and/or urethra in patients with advanced vulvar cancer involving these sites. METHODS: Fourteen patients with advanced vulvar cancer (1997-2003) involving the anal sphincter and/or urethra were given 3-4 cycles of neoadjuvant chemotherapy to attempt preservation of these pelvic structures rather than undergoing a primary pelvic exenteration. Following 3 cycles, a radical vulvectomy and groin lymph node dissection were planned. All patients had lesion size documented by measurement and photograph prior to and following chemotherapy. RESULTS: The median age was 63 years (range 39-88). Thirteen patients received a median of 3 cycles (range 2-4) of neoadjuvant chemotherapy. Ten patients received cisplatin and 5-fluorouracil, while three received cisplatin alone. The median time from diagnosis to surgery was 77 days (range 54-143). All patients with cisplatin and 5-fluorouracil chemotherapy underwent surgery except one patient who had a synchronous renal cell carcinoma and died prior to surgery. Patients receiving cisplatin alone showed no measurable response, while all patients receiving cisplatin and 5-fluorouracil demonstrated at least a partial response. Two patients had no residual invasive carcinoma on final pathology. All patients receiving cisplatin and 5-fluorouracil followed by surgery are disease-free, while two of three receiving cisplatin have progressive disease. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil. CONCLUSION: Neoadjuvant cisplatin and 5-fluorouracil in advanced vulvar cancer demonstrated a response rate of 100%. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil. Responders are disease-free at this time. This response rate demonstrates superior activity of 5-fluorouracil in vulvar cancer and spares these patients the morbidity of exenteration or radiation.     

Nondysgerminomatous tumors of the ovary treated with cisplatin, vinblastine, and bleomycin: long-term results.

Twenty-four consecutive patients with nondysgerminomatous germ cell tumor of the ovary were treated after surgery with cisplatin, vinblastine, and bleomycin (PVB regimen). The cycle was repeated every 3 weeks for three to five courses. Fourteen patients had endodermal sinus tumor, and 10 had mixed germ cell tumors. Stage of disease (FIGO, 1986) was as follows: stage I, 6; stage IIc-IV, 17; and recurrence, 1 patient. All patients were monitored by alpha-fetoprotein and human chorionic gonadotropin. Only 1 patient had received previous chemotherapy. All 5 patients without residual disease and with negative marker levels in which PVB was used as adjuvant treatment were free of disease for a median duration of 59 months from the start of PVB. Of the 19 patients with measurable disease (evident disease or positive marker levels), complete remission was obtained in 16 (84%), but 5 of these relapsed. Therefore, treatment with PVB failed in 8 out of 19 patients (42%) with measurable disease. Toxicity was evident, but no patient died of it. Menses were regular in 11 patients whose initial surgery was conservative. PVB regimen is an effective but not a satisfactory treatment. The considerable failure rate of PVB treatment suggests the investigation of other regimens.     

Immature teratoma of the ovary

Twenty-five cases of patients with pure immature teratoma of the ovary, accrued from the Connecticut Tumor Registry from 1969 to 1984, were reviewed. Two patients had grade 1 tumors, twelve had grade 2 tumors, and eleven had grade 3 tumors. The majority of patients (23) were stage I at the time of initial surgery. Twenty-one of the twenty-three patients were treated with some form of unilateral adnexal surgery with or without adjuvant combination chemotherapy (VAC). Two of the twenty-three patients were treated with total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) with the addition of either VAC chemotherapy or radiation therapy. Recurrence occurred in two patients, both of whom had grade 3 tumors and were subsequently treated with surgical resection plus VAC chemotherapy. One patient, who recurred after initial therapy with unilateral salpingo-oophorectomy (USO) plus VAC chemotherapy, was successfully treated with surgical resection and further chemotherapy. Two patients were stage III at the time of initial surgery, one of whom was treated with USO plus adjuvant combination chemotherapy and radio-therapy. The other patient was treated with TAH/BSO plus VAC chemotherapy. In our series, no patient died from immature teratoma (one patient died from advanced breast carcinoma). It is reasonable to withhold chemotherapy from patients with stage I, grade 1 and 2, immature teratoma which may be treated initially with conservative surgery. The risk of recurrence in patients with grade 3 tumors warrants the addition of further chemotherapy.     

Primary chemotherapy and the role of second-look laparotomy in non-dysgerminomatous germ cell malignancies of the ovary

In view of the rarity of germ cell tumors of the ovary, it is not surprising that little information exists about the indications for and significance of findings at second-look laparotomy in patients with these tumors. For this reason, we have reviewed 16 patients who received primary chemotherapy for malignant germ cell tumors of the ovary at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1976 and 1983. Eleven of them underwent a second-look laparotomy after completion of their therapy. Primary therapy consisted of surgery, usually unilateral oophorectomy, and cis-platinum-based VAB chemotherapy. The histologic diagnoses were six immature teratomas, five endodermal sinus tumors, four mixed germ cell tumors, and one nongestational choriocarcinoma. Stage distribution was as follows: Stage IA, eight patients; Stage IC, one patient; Stage IIA, one patient; Stage III, four patients, and unstaged, two patients. The ages ranged from 15 to 56 years, with the mean of 29 years. All of the 11 patients undergoing second-look laparotomy were found to be free of disease. They are alive and have been continuously free of disease from 9 to 77 months (mean 39 months). This paper discusses primary chemotherapy and the role of the second-look laparotomy and suggests its value in modifying treatment, predicting cure, and safely stopping therapy in patients with germ cell malignancies of the ovary.