Malignant ovarian germ cell tumours -- a survival and prognostic analysis

Need for risk-adapted therapy for malignant ovarian germ cell tumors: A large multicenter analysis of germ cell tumors' patients from French TMRG network

BACKGROUND

Malignant ovarian germ cell tumors are rare tumors, affecting young women with a generally favorable prognosis. The French reference network for Rare Malignant Gynecological Tumors (TMRG) aims to improve their management. The purpose of this study is to report clinicopathological features and long-term outcomes, to explore prognostic parameters and to help in considering adjuvant strategy for stage I patients.

PATIENTS AND METHODS

Data from patients with MOGCT registered among 13 of the largest centers of the TMRG network were analyzed. We report clinicopathological features, estimated 5-year event-free survival (5y-EFS) and 5-year overall survival (5y-OS) of MOGCT patients.

RESULTS

We collected data from 147 patients including 101 (68.7%) FIGO stage I patients. Histology identifies 40 dysgerminomas, 52 immature teratomas, 32 yolk sac tumors, 2 choriocarcinomas and 21 mixed tumors. Surgery was performed in 140 (95.2%) patients and 106 (72.1%) received first line chemotherapy. Twenty-two stage I patients did not receive chemotherapy. Relapse occurred in 24 patients: 13 were exclusively treated with upfront surgery and 11 received surgery and chemotherapy. 5y-EFS was 82% and 5y-OS was 92.4%. Stage I patients who underwent surgery alone had an estimated 5y-EFS of 54.6% and patients receiving adjuvant chemotherapy 94.4% (P < .001). However, no impact on estimated 5y-OS was observed: 96.3% versus 97.8% respectively (P = .62). FIGO stage, complete primary surgery and post-operative alpha fetoprotein level significantly correlated with survival.

CONCLUSION

Adjuvant chemotherapy does not seem to improve survival in stage I patients. Active surveillance can be proposed for selected patients with a complete surgical staging.

Germ Cell Tumor Ovary: an Institutional Experience of Treatment and Survival Outcomes

Malignant germ cell tumors (GCT) of the ovary account for 2-3% of all ovarian neoplasms and occur mostly in the second and third decade of life. Over the past three decades, survival rates for germ cell tumors have dramatically improved, coincident with more aggressive surgical staging and combination chemotherapy. Although there are several studies describing ovarian GCT and fertility-preserving surgery in the western population, there is very little Indian data. We present our experience of germ cell tumor ovary in the Department of Surgical Oncology, King George's Medical University over the last 5 years with special emphasis on treatment outcome and role of fertility preservation surgery. A retrospective review of medical records of patients with ovarian germ cell tumors, treated at our center from January 2012 to December 2016, was performed. Epidemiological and clinical profile of patients was reviewed. Clinical stage of presentation, neoadjuvant treatment, surgical treatment, and adjuvant treatment data were analyzed, and treatment outcome data was recorded. Patient follow-up was done to ascertain disease-free interval, treatment outcome, ability to conceive following fertility-preserving surgery, and quality of life. A total of 39 patients with ovarian germ cell tumor were treated during this period. Their median age at diagnosis was 22 years (range 11-65 years) and most common mode of presentation was abdominal lump without ascites. Around 36.8% (n = 14) patients had conservative surgery with preservation of opposite ovary and uterus. Most patients (71.1% n = 27) received neoadjuvant chemotherapy due to advanced disease in form of ascites or large mass, and five of these patients were amenable to fertility-preserving surgery after chemotherapy. Nine out of the fourteen patients have had return of menstrual function after a mean period of 3.5 + 0.5 months. One patient who underwent fertility-preserving surgery has delivered healthy children after treatment. Stage distribution for stage I to IV was as follows: 15.4% (n = 6), 35.9% (n = 14), 46.2% (n = 18), and 2.6% (n = 1), respectively. Dysgerminoma was the commonest histology (37.1% n = 13) followed by teratoma (22.9% n = 8). 17.1% (n = 6) patients had recurrence, with a median time to recurrence 16 months (range 5.5 to 37 months) and they were treated with second-line chemotherapy. Germ cell tumor of the ovary is an eminently treatable disease and selected patients can be managed with fertility-preserving surgery. BEP is the most effective chemotherapy regimen. Disease-free survival rates in these patients are quite high and recurrences can be managed with second-line chemotherapy.

Socioeconomic disparities affect survival in malignant ovarian germ cell tumors in AYA population

BACKGROUND

Malignant ovarian germ cell tumors (MOGCTs) are a rare form of ovarian malignancy. Socioeconomic status (SES) has been shown to affect survival in several gynecologic cancers. We examined whether SES impacted survival in adolescent and young adults (AYAs) with MOGCT.

MATERIALS AND METHODS

The National Cancer Data Base was used to identify AYAs (aged 15-39 years) with MOGCT from 1998 to 2012. Three SES surrogate variables identified were as follows: insurance type, income quartile, and education quartile. Pooled variance t-tests and chi-square tests were used to compare tumor characteristics, the time from diagnosis to staging/treatment, and clinical outcome variables for each SES surrogate variable, while controlling for age and race/ethnicity in a multivariate model. Kaplan-Meier survival estimates were calculated using the log-rank test.

RESULTS

A total of 3125 AYAs with MOGCT were identified. Subjects with lower SES measures had higher overall stage and T-stage MOGCTs at presentation. There was no significant difference in the time to staging/treatment, extent of surgery, or use of chemotherapy by SES. Subjects from a lower education background, from a lower income quartile, and without insurance had decreased survival (P ≤ 0.02 for all). Controlling for overall stage and T-stage, the difference in survival was no longer significant.

CONCLUSIONS

AYAs with MOGCT from lower SES backgrounds presented with more advanced stage disease. Further studies that focus on the underlying reasons for this difference are needed to address these disparities.

Special issues in fertility preservation for gynecologic malignancies

Gynecologic malignancies account for 1,09 million new cancer cases worldwide consisting of about 12% of tumors affecting female population. About 10% of all female cancer survivors are younger than 40 years of age. Since cancers affecting female genital organs are usually treated by radical surgery, chemotherapy or chemoradiation approaches that induce permanent damage of reproductive functions, the development of strategies for fertility preservation represent one of the most important goals for gynecologic oncology. In this scenario, the newly defined oncofertility discipline acquires increasing interest, offering patients maximal chances to make an adequate decision about future fertility, based on their oncologic diagnosis and prognosis. However, the majority of physicians do not pay particular attention to these issues, even if impressive progresses have been made in this field in the last decades. Possibly, it is due to the lack of strong evidences from clinical trials without an adequate number of cases to establish safety and efficacy of these procedures. In this review we will discuss the most recently debated options for fertility preservation in gynecologic oncology, highlighting issues and controversies related to oncofertility.

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.

Multidisciplinary management of malignant ovarian germ cell tumours

OBJECTIVES

Malignant ovarian germ cell tumours (MOGCT) are rare cancers of young women. Limited prospective trials exist from which evidence-based management can be developed. This review summarizes the available literature concerning MOGT in order to provide the clinician with information relevant to their multidisciplinary management.

METHODS

MEDLINE was searched between 1966 and 2010 for all publications in English where the studied population included women diagnosed with malignant ovarian germ cell tumours.

RESULTS

The majority of patients can be cured with fertility-preserving surgery with or without combination chemotherapy. Long term survival approaches 100% in early stage disease and is approximately 75% in advanced stage disease. Most studies suggest that the treatment has little, if any, effect on future fertility and limited data suggest that there is no adverse effect on the future quality of life.

CONCLUSION

MOGCTs are rare tumours of young women the majority of which can be successfully treated with fertility-preserving surgery with or without chemotherapy with preservation of reproductive function. Minimisation of chemotherapy in good prognostic groups and improved treatment in resistant and relapsed MOGCT are important goals for the future. Further studies are needed to quantify the late adverse effects of treatment in long term survivors.

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.

A review of the close surveillance policy for stage I female germ cell tumors of the ovary and other sites

Ovarian germ cell tumors are rare but very curable at all stages of disease. There is good evidence that surveillance for stage I dysgerminomas is a safe option although many centers worldwide still advocate adjuvant chemotherapy for stage IA nondysgerminomatous tumors, despite the significant risk of developing long-term treatment side effects. Here, we review the safety of our ongoing surveillance program of all stage IA female germ cell tumors. Thirty-seven patients (median age 26, range 14-48 years) with stage I disease were referred to Mount Vernon and Charing Cross Hospitals between 1981 and 2003. Patients underwent surgery and staging followed by intense surveillance, which included regular tumor markers and imaging. The median period of follow-up was 6 years. Relapse rates for stage IA nondysgerminomatous tumors and dysgerminomas were 8 of 22 (36%) and 2 of 9 (22%), respectively, plus one patient with mature teratoma and glial implants also relapsed; 10 of these 11 patients (91%) were successfully cured with platinum-based chemotherapy. Only one patient died from chemoresistant disease. All relapses occurred within 13 months of initial surgery. The overall disease-specific survival of malignant ovarian germ cell tumors was 94%. Over 50% of patients who underwent fertility-sparing surgery went on to have successful pregnancies. We have confirmed again that surveillance of all stage IA ovarian germ cell tumors is very safe and that the outcome is comparable with testicular tumors. We question the need for potentially toxic adjuvant chemotherapy in nondysgerminoma patients who have greater than 90% chance of being salvaged with chemotherapy if they relapse later.

Yolk sac tumours of the ovary: an update

AIMS

Yolk sac tumours of the ovary (YST), also called endodermal sinus tumours (EST) are rare and highly malignant tumours of utmost importance occurring in children and young adults. In the past, outcome was very poor and the disease was almost always fatal. With the refinement of chemotherapeutic regimens in the last several decades, survival rates have improved dramatically and fertility preserving surgery has become possible. The aim of this review is to provide the reader with an analysis of the available literature and a rational approach to patient management.

METHODS

We performed a literature search in the PubMed database and the reference lists of relevant articles concerning yolk sac tumours of the ovary.

FINDINGS AND CONCLUSION

There are no randomised studies relating to the management of YST of the ovary. The available literature is composed of retrospective reviews and case reports that span several decades. Prognosis nowadays is good in stage I and II but still comparable to that of ovarian epithelial cancer in stage III and IV. The overall good prognosis is due to the fact that most of ovarian YST are diagnosed at an early stage where 5years survival reaches 95%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy, peritoneal cytologic studies, omentectomy, multiple peritoneal and abdominal biopsies and resection of all visible disease. Three courses of BEP (bleomycin, etoposide, cisplatin) is the current standard therapy and four courses is recommended in case of bulky residual disease after surgery. Serum alpha-feto-protein (AFP) is a useful marker for the diagnosis and management of YST.

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.

Effects of cancer treatment on reproduction and fertility

OBJECTIVE

(1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment.

DATA SOURCES

Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article.

METHODS OF STUDY SELECTION

This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available.

TABULATION, INTEGRATION, AND RESULTS

The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility.

CONCLUSIONS

Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.

BRCA1/2 testing: complex themes in result interpretation

Since the cloning of BRCA1 and BRCA2, genetic testing for breast and ovarian cancer susceptibility has become more widespread. However, interpretation of test results is not always straightforward. To illustrate this point, five vignettes adapted from actual cases are presented. As these cases demonstrate, in many high-risk families, a deleterious mutation in BRCA1 or BRCA2 is not identified in an affected proband. There are several potential explanations for such a finding, namely that an undetected mutation in BRCA1 or BRCA2 may exist, or there could be a mutation in a rare or undiscovered gene. In addition, the possibility that women with breast cancer represent sporadic cases within hereditary cancer families must also be considered. Finally, the occurrence of BRCA1/2 variants of uncertain significance, often missense mutations, further complicates the risk assessment. In some of these instances, extending testing to relatives can be helpful to clarify results. When hereditary breast cancer cannot be ruled out, individuals may still be at increased risk for cancer and therefore need to obtain appropriate surveillance. The process of genetic counseling is critical both before and after testing to ensure that patients understand the potential medical and psychosocial implications of testing and are aware of available options and resources. A multidisciplinary approach to service delivery, which includes clinicians in genetics and oncology, can facilitate patients' decision making and provide continued access to information and support.

Survival and reproductive function after treatment of malignant germ cell ovarian tumors

PURPOSE

Germ cell ovarian tumors are curable. The possible sequelae of chemotherapy on long-term survivors are still unknown, but these patients may expect normal lives. The aim of this study was to evaluate the outcome and reproductive function in a population of women treated since 1982.

MATERIALS AND METHODS

Between 1982 and 1996, 169 women with malignant germ cell ovarian tumors were seen (70 dysgerminomas, 28 endodermal sinus tumors, 24 mixed tumors, and 47 immature teratomas). Seventy-one had advanced or recurrent disease. Fertility-sparing surgery was performed in 138 (81%) women, 81 of whom received postoperative chemotherapy.

RESULTS

With a median follow-up of 67 months, the survival rate was 94% for dysgerminoma, 89% for endodermal sinus tumors, 100% for mixed types, and 98% for immature teratoma. For women who were treated conservatively, the survival rate was 98%, 90%, 100%, and 100%, respectively. Two women had adnexal recurrences, and both received salvage treatment. After treatment, all but one postpubertal woman had recovery of menses within 9 months. During follow-up, 12 untreated and 20 treated patients had 55 conceptions. We recorded 40 pregnancies at term, six terminations, and nine miscarriages. Four malformations were observed: one in 14 conceptions of patients who had not received chemotherapy and three in 41 conceptions of treated patients.

CONCLUSION

Irrespective of subtype and stage, conservative surgery should become the standard approach to treating most patients with malignant ovarian germ cell tumors. Fertility seems to be only marginally affected by treatments. Miscarriages are in the expected range for the general population. The malformation rate is slightly higher than in the general population, but no significant difference was seen between patients who did and did not receive chemotherapy.