Dysgerminoma: the role of conservative surgery

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review

BACKGROUND

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review.

RESULTS

Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence.

CONCLUSIONS

Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly 3-4).

Cancer of the ovary, fallopian tube, and peritoneum

The Gynecologic Oncology Committee of FIGO in 2014 revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

Ovarian Germ Cell Cancer: Clinicopathologic Analysis and Outcome of 31 Cases

Aims

The aim of the study was to evaluate some clinicopathologic characteristics and the outcome of patients with ovarian germ cell cancer (OGCC) treated with cisplatin-based chemotherapy.

Methods

It was a clinical retrospective study. The clinical charts of 31 patients with OGCC assisted at the Department of Obstetrics and Gynecology of the State University of Campinas, Brazil, from January 1986 to June 1997 were reviewed.

Results

Ten patients had dysgerminoma and 21 patients nondysgerminomatous tumors. Women with dysgerminoma and nondysgerminomatous tumors did not present differences regarding surgical staging, age, ascites or residual tumor after the initial surgery. Frozen section, performed in 16 patients, showed some discrepancy with paraffin histology diagnosis in 8 patients. Platinum-based chemotherapy was used in 5/10 patients with dysgerminoma and in 17/21 patients with nondysgerminomatous tumors, with a 5-year survival of 100% for the dysgerminoma and 53% for the nondysgerminomatous group.

Conclusions

Women with dysgerminoma and nondysgerminomatous tumors did not present differences regarding clinicopathologic characteristics. The prognosis for patients with dysgerminoma was better than for those with nondysgerminomatous tumors. Frozen section had a high error rate in diagnosing OGCC intraoperatively.

Paediatric dysgerminoma: Results of three consecutive French germ cell tumours clinical studies (TGM-85/90/95) with late effects study

METHODS

French patients (≤18years) treated for dysgerminoma between 1985 and 2005 in TGM-85, 90, 95 protocols were included. Treatment was based on primary unilateral oophorectomy followed by prophylactic lymph node irradiation (1985-1998) or a wait-and-see strategy (1998-2005) for localised completely resected tumours (pS1) or by platinum-based chemotherapy for advanced diseases.

RESULTS

Forty-eight patients (median age 12.8 years) were included. Six patients had gonadal dysgenesis. Two had bilateral dysgerminoma. Twenty-eight patients had loco-regional dissemination, seven with para-aortic lymph nodes. None had distant metastases. Primary surgery was performed in 47/48 patients. Among the 15 patients with pS1 tumour: seven did not receive adjuvant treatment, six had lymph node irradiation and two received chemotherapy. Among the 32 patients with advanced tumour, 31 received cisplatinum-based (n = 25) or carboplatin-based (n = 8) regimen with lymph node irradiation for one of them and one did not receive adjuvant treatment. With a median follow-up of 14 years, all patients are alive in complete remission. Five events occurred: 2 contralateral dysgerminomas, 1 peritoneal relapse and 2 second neoplasms (teratoma and melanoma). Bilateral oophorectomy was necessary for 12 patients. Desire of pregnancy was expressed for 17/36 patients with unilateral oophorectomy, which succeeded in 13 cases (5 medically assisted). 2/17 had ovarian failure. The renal function was normal in 24/25 evaluated patients treated with platinum, ifosfamide or irradiation. The hearing function was evaluated on 17/36 patients treated with platinum: 12 Brock grade-0, 3 brock grade-1 and 2 grade-4.

CONCLUSION

Dysgerminoma has an excellent prognosis even in advanced cases with conservative surgery and platinum-based chemotherapy. However the disease and/or treatment resulted in a high rate of bilateral oophorectomies and a significant impact on future fertility.

Dual malignancy in adolescence: A rare case report of metachronous papillary carcinoma of thyroid following dysgerminoma of ovary

Dual malignancy is rare in adolescents. Dual malignancy with the second malignancy of thyroid is rare. No association has been reported between dysgerminoma of ovary and carcinoma thyroid in medical literature. Despite a thorough PubMed search (key words — Papillary carcinoma of thyroid, metachronous, dysgerminoma ovary), we were unable to find a previous reported case of metachronous papillary carcinoma of thyroid (PTC) following dysgerminoma of the ovary. After surgery, the patient is being regularly followed up for recurrence/development of new primary. We report this unusual and rare case in a 17-year-old female patient.

Imaging Findings in Dysgerminoma in a Case of 46 XY, Complete Gonadal Dysgenesis (Swyer syndrome)

A 46 XY pure gonadal dysgenesis also known as Swyer syndrome. These patients are phenotypic females with normal female external genitalia and absent testicular tissue. The patients with swyer syndrome have streak gonads and increased risk of dysgerminoma and gonadoblastoma. We present a case of dysgerminoma in dysgenetic gonads of swyer syndrome. A 23-year-old female had come with complaints of primary amenorrhea, pelvic mass and abdominal pain. Clinical findings, pathology investigation and imaging findings revealed swyer syndrome. On MRI it showed a large lobulated mass in the pelvis. Mass was excised and dysgerminoma was given on the histopathology.

Menstrual function and childbearing potential after fertility-sparing surgery and platinum-based chemotherapy for malignant ovarian germ cell tumours

Malignant ovarian germ cell tumours (MOGCT) account for 5% of all ovarian malignancies. Their elevated chemosensitivity, the frequent unilaterality and the young age of patients have strongly supported the conservative surgery as the standard approach, often followed by adjuvant platinum-based chemotherapy. The risk for recurrence is not affected by the performance of conservative versus radical surgery. During chemotherapy 50% of patients become amenorrhoeic but more than 95% of them resume normal menses after treatment completion. Literature has reported several healthy babies born after fertility-sparing surgery with or without chemotherapy for MOGCT. The incidence of miscarriages is in the normal range, whereas malformation rate is slightly higher compared to general population, without any difference between chemotherapy-treated and -untreated patients. Therefore, young women with MOGCT must be reassured of their excellent chances of survival and fertility preservation following conservative surgery and adjuvant platinum-based chemotherapy.

Pure dysgerminoma of the ovary: a single institutional experience of 65 patients

Ovarian dysgerminomas are rare entity and account for only about 2% of all malignant ovarian neoplasm. The aim of this study was to evaluate the clinicopathologic characteristics, treatment, long-term survival, and fertility outcome of women diagnosed with ovarian dysgerminoma at our institution. Sixty-five women with histologically proven pure ovarian dysgerminoma were identified in this retrospective study. They were treated at King Faisal Specialist Hospital, Riyadh; Saudi Arabia between 1976 and 2010. The median age was 20 years. The most frequent symptoms at presentation were abdominal pain and abdominal/pelvic mass. Thirty-three patients (50.7%) presented with stage I, 2 (3.1%) had stage II, 22 (33.8%) had stage III, and 4 (6.2%) had stage IV (4 unknown stage). Unilateral oophorectomy was performed in 50 patients (76.9%) while bilateral oophorectomy±hysterectomy was done in 12 patients (18.4%). Three patients had biopsy only. Forty patients (61.5%) received only chemotherapy, and 4 patients (6.2%) received radiotherapy alone. Recurrence was observed in 6 patients (9.2%). With median follow-up of 54 months, the 5-year disease-free survival (DFS) and overall survival (OS) were 88 and 95%, respectively. On univariate analysis, adjuvant chemotherapy was independent better prognostic factor for DFS (HR, 0.09; 95% CI, 0.01-0.84; P=0.034). Of the 50 patients treated with fertility-sparing surgery, 16 patients (32%) achieved pregnancy with 14 live births. Patients with pure ovarian dysgerminoma have excellent long-term outcome. There is no difference at outcome between fertility-sparing and nonconservative surgeries. Adjuvant chemotherapy was associated with significant improvement in DFS. It is possible to maintain good reproductive function after conservative surgery followed by chemotherapy in our series.

Dysgerminoma in a case of 46, XY pure gonadal dysgenesis (Swyer syndrome): a case report

Simple 46, XY gonadal dysgenesis syndrome, also called Swyer syndrome, is known as pure gonadal dysgenesis. Individuals with the syndrome are characterized by 46, XY karyotype and phenotypically female with female genital appearance, normal Müllerian structures and absent testicular tissue. The condition usually first becomes apparent in adolescence with delayed puberty and primary amenorrhea due to the gonads have no hormonal or reproductive potential. Herein, we report a case of dysgerminoma diagnosed in a dysgenetic gonad of a 21-year-old patient with Swyer syndrome.

Fertility in women after surgical treatment of nonepithelial ovarian tumors

Conservative treatment is an acceptable option for women with nonepithelial ovarian tumors who wish to preserve fertility.

Atypical presentation and management dilemma of mixed gonadal dysgenesis

OBJECTIVE

To describe a case of 45,X/46,XY mixed gonadal dysgenesis complicated by malignancy with possible metastasis.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 15-year-old female with primary amenorrhea, short stature, and a vaginal septum.

INTERVENTION(S)

Resection of transverse vaginal septum and laparoscopic bilateral gonadectomy.

RESULT(S)

The patient had dysgerminoma arising from gonadoblastoma in the left gonad and gonadoblastoma in the right gonad. No normal gonadal tissue could be identified. Postoperative computed tomography scan results were suspicious for lung metastases, but the patient opted for conservative management without chemotherapy.

CONCLUSION(S)

Mixed gonadal dysgenesis involves inherent malignancy risk and complex psychosocial issues, which necessitate a multidisciplinary approach to diagnosis and treatment.

A practical approach to ambiguous genitalia in the newborn period

The evaluation and management of neonates with ambiguous genitalia requires sensitivity, efficiency, and accuracy. The approach to these neonates is facilitated by a multidisciplinary team including urology, endocrinology, genetics, and psychiatry or psychology. Disorders of sex development (DSD) encompass chromosomal DSD, 46,XX DSD, and 46,XY DSD. The 46,XX DSD is the most common DSD and in the majority of these children congenital adrenal hyperplasia is the underlying etiology. The 46,XY DSD is a heterogeneous disorder that often results from a disruption in the production or response to testosterone, dihydrotestosterone, or Mullerian inhibitory substance. Chromosomal DSD includes conditions resulting from abnormal meiosis, including Klinefelter syndrome (47, XXY) and Turner syndrome. The evaluation of children with DSD demands a thorough physical examination, medical history, karyotype, metabolic panel, 17-OH progesterone, testosterone, luteinizing hormone, follicle stimulation hormone, and urinalysis. A radiographic evaluation should begin with an abdominal and pelvic ultrasound but may include magnetic resonance imaging, endoscopy, or laparoscopy.

Pure dysgerminoma of the ovary 35 years on: a single institutional experience

OBJECTIVE

The aim of this study was to evaluate clinicopathologic characteristics, long-term outcome and reproductive function in women diagnosed with pure dysgerminoma of the ovary.

METHODS

Sixty-five women with stage IA to IIIC pure ovarian dysgerminoma were identified and included in this retrospective study. Patients were treated at one institution between 1970 and 2005.

RESULTS

Median age at diagnosis was 22.2 years (range 8.2-64.1 years). 72.3% of patients presented with stage I, 4.6% stage II and 21.5% stage III disease (1.5% stage unknown). Initial management was surgical for all patients: unilateral oophorectomy in 47 patients (72.2%), bilateral oophorectomy +/- hysterectomy in 14 (21.5%) and cystectomy alone in 3 (4.6%). Seventeen patients received chemotherapy (15 adjuvant, 2 for residual disease), 20 received adjuvant radiotherapy and one patient received both. Recurrence occurred in 6 (9.2%) patients (5 stage IA, 1 stage IIA). All recurrences occurred within 19 months of primary diagnosis. All patients were successfully salvaged with radiotherapy (2 patients), chemotherapy (1 patient) or a combination of surgery and chemotherapy (3 patients). Overall, median follow up from time of recurrence was 22.5 years (range 9.3-31.4 years). Median follow-up of all patients was 10.5 years (range 1.1-31.9 years). Fifteen patients reported an attempt to conceive posttreatment resulting in 12 pregnancies and 12 live births in 8 women.

CONCLUSION

The long-term outcome of patients with pure ovarian dysgerminoma is excellent. Recurrences occur within 2 years of diagnosis and are treatable. Patients can be treated with fertility-sparing surgery and can expect good reproductive outcomes.

Laparoscopic management of ovarian dysgerminoma presenting with acute abdomen caused by adnexal torsion in a 17-year-old girl

BACKGROUND

Ovarian dysgerminoma cases very rarely present with acute abdomen due to adnexal torsion and the successful laparoscopic management of such a case has not been reported previously.

CASE

A 17-year-old sexually inactive high school girl presenting with acute abdomen was referred to our emergency department. Transabdominal ultrasonography showed the presence of homogeneous tumor in the lower abdomen. Emergency laparoscopic surgery was performed and left ovarian tumor with adnexal torsion was identified. Left salpingo-oophorectomy was performed carefully to avoid damaging the tumor capsule and the excised tissue was removed after retrieval in an endobag. The histopathological diagnosis was pure ovarian dysgerminoma. The postoperative course was uneventful.

CONCLUSION

Laparoscopic management with careful postoperative follow-up to monitor recurrence could be a treatment option in a young girl with dysgerminoma, if the disease condition is detected in the early stage.

Disorders of sexual development

In human sexual development, the female phenotype represents the default pathway. Therefore, a failure of testis determination results in the development of the female phenotype, while genetic alterations resulting in partial testicular development can give rise to a wide spectrum of masculinization. In addition to defects in peptide hormones and their receptors, timing of hormonal exposure is also critical to appropriate development. Although much work remains to be done, recent advances in our knowledge have begun to unravel the molecular basis of disorders of sexual development. Consensus statements from investigators have recommended changes in the nomenclature, and further investigations have examined the role of the female and male psyche in patients with these disorders. This review focuses on the diagnosis and management of conditions related to disorders of sexual development.

Germ cell tumors of the ovary

PURPOSE

Malignant ovarian germ cell tumors (MOGCTS) are rare but curable at all stages of disease. This review gives an outline of the management of this disease.

METHODS

We performed a literature search in the PubMed of almost all relevant articles concerning MOGCTs on pathology, prognostic factors, surgery, post-operative therapy and late effects of therapy. The available literature is mainly composed of retrospective reviews and articles.

RESULTS

Prognostic factors include stage, amount of residual tumor, histologic type and raised tumor markers. For patients with early stage disease, cure rates approach 100%, while for those with advanced-stage disease are at least 75%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy (USO) and resection of all visible disease. For patients with advanced-stage disease, the role and the extent of debulking surgery remain controversial despite its routine use. However, it is suggested a benefit from minimal residual disease at completion of primary surgical cytoreduction with both non-platinum and platinum-based chemotherapy regimens. Second-look surgery clearly is not indicated in patients with early stage non-dysgerminoma or in all patients with dysgerminoma. However, teratoma patients may benefit from secondary cytoreduction. Three courses of bleomycin, etoposide and cisplatin (BEP) is the current standard adjuvant chemotherapy and four courses of BEP are recommended in case of bulky residual tumor after surgery. More evidence is required to show that surveillance is a safe option. There is a hint that high-dose chemotherapy may play a role in relapsed patients. The majority of MOGCTs patients who undergo fertility-sparing surgery and chemotherapy retain their gonadal and reproductive function. There is an increasing concern about life-threatening long-term effects of treatment.

CONCLUSION

MOGCTs are rare neoplasms that affect girls and young women and have excellent prognosis at all stages of disease with optimal therapy. The majority of MOGCTs patients retain their reproductive function.

[Malignant ovarian germ cell tumours: a trial of 36 cases]

OBJECTIVE

With personal results and a review of the literature, we report the eventual interest of surgical staging in malignant ovarian germ cell tumours.

PATIENTS AND METHODS

This was a retrospective study of 36 patients (21.5-[8-61]) with malignant ovarian germ cell tumours between January 1984 and December 2004. There were 4 groups: no 1--dysgerminoma only, no 2--immature teratoma, no 3--malignant ovarian germ cell tumours with secretion. All the patients had a minimal follow up of 18 months after treatment. We reported conservative or non-conservative surgery, if surgical staging was made and description of eventual neoadjuvant or adjuvant chemotherapies and finally the recurrences and deaths.

RESULTS

Stages of FIGO were: group 1--IA n=2, IC n=2, IIB n=1, IIIA n=2, IIIC n=3; group 2--IA n=3 (G1, G2, G2), IC n=1 (G3); group 3--IA n=8, IC n=4, IIA n=1, IIIA n=1, IIIB n=3, IIIC n=5. Three patients had neoadjuvant chemotherapy. All the patients had cytoreductive surgery (conservative surgery n=31) with staging in 15 cases. Twenty-six patients had adjuvant chemotherapy. Five years global survival was 92%.

DISCUSSION AND CONCLUSION

Surgery in a young patient with malignant ovarian germ cells tumours must be conservative (adnexectomy) (preserving fertility and because of good prognostic). In case of stage IA with part of dysgerminoma and/or immature teratoma and/or embryonal carcinoma certified by surgical staging, strict follow up could be organized (clinic, radiology, AFP, HCG). In case of more than stage IA, chemotherapy is indicated after conservative surgery and surgical staging.

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.

A practical approach to intersex in the newborn period

Sexual determination is a complex process that occurs in an organized sequential manner. When chromosomal, gonadal, or phenotypic sex determination goes awry,intersexuality develops. Advances in molecular biology have made it easier to understand the various phenotypes that are encountered. It is easy to be overwhelmed when reviewing the testosterone synthesis pathway and the intersex differential diagnosis. This article presents a useful approach to the evaluation of the newborn with ambiguous genitalia.

Pregnancy outcomes and menstrual function after fertility sparing surgery for pure ovarian dysgerminomas

MATERIALS AND METHODS

The medical records of 23 patients with pure ovarian dysgerminoma treated by conservative surgery at SSK Ankara Maternity Hospital between 1991 and 2001 were reviewed retrospectively. Pregnancy outcomes and menstrual function after conservative surgery were analyzed.

RESULTS

Seven patients (30%) were incompletely staged and were assumed to be stage IA due to intraoperative findings. Fifteen patients (70%) were surgically staged. As a result 15 patients (65.2%) were diagnosed to be stage I while 2 patients (8.6%) were staged II and 6 patients (26%) were staged III. Wedge biopsy of contralateral ovary was performed in 17 patients (74%) and tumor was diagnosed in 2 (11.7%). Adjuvant chemotherapy was applied in 16 (70%) of the cases. BEP (bleomycin, etoposide, and cisplatin) was the most frequently used regimen (39%). Recurrences were seen in 3 (13%) patients. The sites of recurrences were contralateral ovary in all cases. Recurrences were treated with surgery and radiotherapy. None of the patients died of disease. Nine patients were sexually active. Five of these patients had prior live births. Three of the primiparous patients delivered after treatment. Five pregnancies occurred in 3 nulliparous patients at the time of primary surgery. Three of these reached term and healthy babies were delivered. One pregnancy was terminated at 18 weeks of gestation due to anencephaly and a dilatation and curettage was performed at 6th week in another patient. Menstrual problems occurred in 4 (17.3%) of the 23 patients.

CONCLUSION

Fertility sparing treatments are safe in patients with pure ovarian dysgerminoma.

Reproductive function after treatment of malignant germ cell ovarian tumors

The outcome and reproductive function were examined among patients with malignant ovarian germ cell tumors treated since 1980. Between 1980 and 2001, fertility-sparing surgery was performed in 26 women, 23 of whom received adjuvant chemotherapy. With a median follow-up of 66.6 months, all patients have been alive, with histological types of 6 immature teratomas, 8 dysgerminomas, 6 yolk sac tumors, and 6 mixed types. Clinical stages were involved of 17 early stage and 9 advanced stage patients. After treatment, 20 women out of 26 recovered menstruation within 6 months. During follow-up, two chemotherapy-untreated and one treated patients experienced 4 conceptions in total. A treated patient conceived but selected artificial termination by affection of chemotherapy. Conservative surgery with adjuvant chemotherapy is the standard approach to treat patients with malignant ovarian germ cell tumors. In these 20 years, we experienced no delivery, so that fertility seems to be seriously affected by treatments.

Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy

OBJECTIVES

The purpose of this study was to determine the recurrence rate, survival, and pregnancy outcome in patients with Stage IA and Stage IC invasive epithelial ovarian cancer treated with unilateral adnexectomy.

METHODS

A multi-institutional retrospective investigation was undertaken to identify patients with Stage IA and IC epithelial ovarian cancer who were treated with fertility-sparing surgery. All patients with ovarian tumors of borderline malignancy were excluded. Long-term follow-up was obtained through tumor registries and telephone interviews. The time and sites of tumor recurrence, patient survival, and pregnancy outcomes were recorded for every patient.

RESULTS

Fifty two patients with Stage I epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified. Forty-two patients had Stage IA disease, and 10 had Stage IC cancers. Cell type was distributed as follows: mucinous, 25; serous, 10; endometrioid, 10; clear cell, 5; and mixed, 2. Histologic differentiation was as follows: grade 1, 38; grade 2, 9; and grade 3, 5. Twenty patients received adjuvant chemotherapy (mean 6 courses, range 3-12 courses). Patients received the following chemotherapeutic agents: cisplatin/taxol or carboplatin/taxol, 11; melphalan, 5; cisplatin and cyclophosphamide, 3; and single-agent cisplatin, 1. Eight patients had second-look laparotomies and all were negative. Duration of follow-up ranged from 6 to 426 months (median 68 months). Five patients developed tumor recurrence 8-78 months after initial surgery. Sites of recurrence were as follows: contralateral ovary, 3; peritoneum, 1; and lung, 1. Nine patients underwent subsequent hysterectomy and contralateral oophorectomy for benign disease. At present, 50 patients are alive without evidence of disease and 2 have died of disease 13 and 97 months after initial treatment. The estimated survival was 98% at 5 years and 93% at 10 years.Twenty-four patients attempted pregnancy and 17 (71%) conceived. These 17 patients had 26 term deliveries (no congenital anomalies noted) and 5 spontaneous abortions.

CONCLUSION

The long-term survival of patients with Stage IA and IC epithelial ovarian cancer treated with unilateral adnexectomy is excellent. Fertility-sparing surgery should be considered as a treatment option in women with Stage I epithelial ovarian cancer who desire further childbearing.

Results of conservative treatment in epithelial ovarian carcinoma

BACKGROUND

The objective of this study was to assess and evaluate the clinical outcome and fertility in patients treated conservatively for epithelial ovarian carcinoma (EOC).

METHODS

Thirty-one patients treated with conservative management EOC were followed up. Optimal surgical staging was performed in 2 cases during the initial surgery and in 27 patients during a reassessment surgery. Six patients underwent hysterectomy during this restaging surgery.

RESULTS

Among 25 patients treated conservatively after the restaging surgery, the International Federation of Gynecology and Obstetrics (FIGO) staging distribution was 19 Stage IA (Grade 1, n = 9; Grade 2, n = 10), 1 Stage IC, 2 Stage II, and 3 patients with initial stage unknown. Seven patients had recurrence (five on the remaining ovary). The disease free survival rate at 5 years for patients with Stage IA Grade 1 and 2 tumors were 89% and 71%, respectively. All patients with Stage IA or higher disease experienced recurrence. Only four pregnancies (three spontaneous and one after in vitro fertilization procedure) were obtained.

CONCLUSIONS

Conservative surgery for patients with EOC could be considered in young patients with Stage IA Grade 1 disease adequately staged and desiring to preserve fertility potential. This procedure should not performed in patients with disease staged higher than FIGO Stage IA.

Late recurrence in ovarian dysgerminoma with successful response to standard adjuvant chemotherapy: a case report and review of the literature

BACKGROUND

Ovarian dysgerminomas are quite amenable to treatment and very good cure rates are achieved even with advanced disease. However, recent literature suggests that late recurrence may be associated with a poorer prognosis and bleomycin/etoposide/cisplatin (BEP) chemotherapy may play only a limited role in its management. We present a patient who had a late recurrence of ovarian dysgerminoma with successful treatment outcome.

CASE

A 25-year-old woman was diagnosed with a stage IC ovarian dysgerminoma in 1983 and did not undergo adjuvant treatment. She had late recurrence 12 years later with good treatment response to BEP chemotherapy given in a semiadjuvant fashion.

CONCLUSION

Our case demonstrates that BEP chemotherapy still plays an important role in treatment of late recurrence in ovarian dysgerminomas provided there is small volume disease at time of detection. Also important is long-term surveillance in an effort to detect recurrence while still small in volume and potentially curable.

Treatment of malignant ovarian germ cell tumors with preservation of fertility: reproductive performance after persistent remission

To describe our experience with malignant ovarian germ cell tumors with special reference to reproductive performance after remission, medical records of 31 patients were reviewed. The mean age at diagnosis was 18.6 years. Tumor by stage was I in 16 cases, II in 5, III in 5, IV in 3, and recurrence in 2. Histology was dysgerminoma in 7 cases, yolk sac tumor in 10, immature teratoma in 7, choriocarcinoma in 1, and mixed-type tumor in 6. Conservative surgery for fertility preservation was performed in 21 cases. Postoperative chemotherapy was given to all cases except two with stage Ia dysgerminoma. Of 31 cases, 4 including one fertility-preserved case died of disease. The other 27 cases including 20 fertility-preserved cases were successfully treated. Twenty-five cases (92.6%) have been followed longer than 60 months and 13 cases (48.1%) longer than 120 months. By the last follow-up, 8 of the 20 fertility-preserved cases delivered a total of 9 normal babies. Of the remaining 12 nonpregnant cases, 3 married, 9 have had regular menses, and 3 have had menstrual problems. Two of the latter three cases have been in hypergonadotropic anovulatory cycles. One patient has been diagnosed with tubal infertility caused by peritubal adhesion. Thus, management of the disease with fertility preservation is safe and the majority of patients can attain or retain normal ovarian function and reproductive potential.

Recent management of malignant ovarian germ cell tumors: a study of 34 cases

OBJECTIVE

To review the outcome of the treatment in patients with malignant ovarian Germ cell tumors with respect to survival and surgical management at a single institution during 1990-1996.

METHODS

Thirty-four patients with malignant ovarian Germ cell tumors were studied retrospectively for their surgical management. Fourteen patients had pure dysgerminoma, 11 endodermal sinus tumor, 6 immature teratoma, and 3 mixed Germ cell tumors. Nine patients had stage IA, 8 stage IC, 2 stage IIC, 8 stage III, 3 stage IV, and 4 referred patients with recurrent diseases.

RESULTS

Nineteen patients underwent primary conservative surgery, 11 had primary nonconservative surgery. Twenty-two patients were treated with chemotherapy (BEP or EP or PVB regimen). Five patients with pure dysgerminoma received adjuvant radiotherapy. Persistent remission was achieved in 26 patients. Two patients (7.4%) had recurrence after remission. Seven patients had died of the diseases. Patients with complete clinical remission did not undergo second-look surgery. The overall survival was 78.8%, 100% for immature teratoma, 84.6% for pure dysgerminoma, 72.8% for endodermal sinus tumor, and 33.3% for mixed Germ cell tumors, with median follow-up time 31 (3-93) months.

CONCLUSION

Patients with limited diseases regardless of histologic types can be safely managed by unilateral salpingo-oophorectomy followed by, if indicated, 3-4 courses of cisplatin-based chemotherapy. For advanced diseases, conservative surgery is advisable in patients with endodermal sinus tumor.

Late relapse of ovarian dysgerminoma: case report and literature review

Dysgerminoma of the ovary is a rare tumor. Ovarian dysgerminoma is chemosensitive and potentially curable even when in advanced stage. We report a case of intra-abdominal relapse of stage Ia ovarian dysgerminoma 20 years following initial surgery. The patient was treated with surgical resection followed by a full course of platinum-based chemotherapy. However, she had rapidly progressive disease and eventually died. To date, this is the latest reported case of relapse of ovarian dysgerminoma. This rare situation has been reported in patients with germ cell tumors of the testis, the male counterpart of ovarian germ cell tumors. Testis cancer patients with late relapse are rarely, if ever, curable by chemotherapy. A diagnosis of recurrent dysgerminoma should be considered in patients who have the appropriate findings with a history of dysgerminoma, even if remote. Patients with late recurrences of ovarian germ cell tumors may be less responsive to chemotherapy.