Cisplatin-based chemotherapy for ovarian germ cell malignancies: the Australian experience

Fertility sparing surgery in malignant ovarian Germ cell tumor (MOGCT): 15 years experiences

Aim

We aim to evaluate the reproductive outcome of fertility-sparing surgery and chemotherapy among young women diagnosed with MOGCT of any stage.

Methods

In the current retrospective study we evaluated 79 patients with malignant ovarian germ cell tumors (MOGCT) who visited at Imam Center, Vali-e-asr Hospital, Gynecologic Oncology department during 2001–2016. Reproductive outcomes (menstruation status and childbearing) followed fertility-preserving surgery and adjuvant chemotherapy by filling questionnaires. Statistical analysis was done with SPSS software, Chi-Square Tests were done, and significance was determined at P ≤ 0.05. Results among 79 young women who underwent fertility-sparing treatment, 72 patients followed up for reproductive outcome, and 7 patients excluded because of death (3 cases), XY genotyping (3 cases), and bilateral ovarian involvement (1 case). The mean age at presentation was 23 years. (Range: 19–33 years). The 5 and 10-year disease-free survival rate was 87% and 94.4%, respectively. The overall survival rate (OSR) was 94.4% at 5 and 10 years. Regular menstruation recovered in 60 of 72 patients after treatment (83%). All patients without adjuvant chemotherapy experienced regular menstruation, while normal menstruation was retrieved in 78% in the adjuvant chemotherapy group at the end of treatment. This retrieval of regular menstruation was not dependent on the age or number of chemotherapy cycles. 19 of 26 patients who attempted pregnancy were led to delivery (73%). No one required infertility treatments. The mean of chemotherapy cycles is related to a successful pregnancy.

Conclusion

We showed patients with MOGCT could become pregnant and give birth if they desire. The advanced tumor stage wasn't the convincing factor for avoiding fertility preservation. Fertility sparing surgery with adjuvant chemotherapy is a safe treatment and results in a high fertility rate.

Reproductive outcomes following fertility-sparing surgery for malignant ovarian germ cell tumors: A systematic review of the literature

OBJECTIVE

Investigate the reproductive outcomes of patients diagnosed with malignant ovarian germ cell tumors (MOGCTs) following fertility-sparing surgery (FSS).

METHODS

A systematic review of the Pubmed/Medline, EMBASE and Web-of-Science databases between January 1st 1990 and February 28th 2020 was performed. Full articles reporting on at least 10 patients with MOGCT who underwent FSS and provided data on fertility or pregnancy outcomes were included.

RESULTS

A total of 47 studies that included 2189 patients with MOGCT who underwent FSS were included. Rate of chemotherapy use was 79.9% while cumulative relapse rate was 8.7%. Based on 1110 patient from 27 studies rate of premature ovarian failure was 3.7%. Fecundity rate was 24.6% (n = 1980, from 42 studies), while 80.6% of patients attempting pregnancy had at least one pregnancy (n = 474, from 27 studies). Based on 294 live births, the rate of preterm delivery was 3% while among 261 live infants, only 3 (1.2%) malformations were reported.

CONCLUSIONS

The majority of patients with MOGCTs have normal menstrual and reproductive function following FSS. Fecundity and pregnancy outcomes are comparable to the general population.

Outcomes and prognostic factors of patients with recurrent and persistent malignant ovarian germ cell tumors

OBJECTIVE

Due to the rarity of recurrent and persistent malignant ovarian germ cell tumors (MOGCTs), there is no standardized protocol for salvage therapy. This study aimed to investigate the outcomes and prognostic factors of patients with recurrent and persistent MOGCTs.

METHODS

Clinical data for 59 patients with recurrent and persistent MOGCTs admitted to Peking Union Medical College Hospital from January 1, 2000, to April 30, 2018, were retrospectively analyzed.

RESULTS

Twenty-one cases (35.6%) were recurrent, and 38 (64.4%) were persistent. Patient age ranged from 1 to 39 years, and disease stage was as follows: 33 stage I, 4 stage II, 21 stage III, and 1 stage IV. There were 19 immature teratomas, 26 yolk sac tumors, 1 dysgerminoma, and 13 mixed germ cell tumors. Regarding the primary surgery, fertility was preserved in 49 patients and not preserved in 10 patients. Among the patients who underwent fertility-preserving primary surgery, 40 had fertility preserved in the second operation, and 9 did not. In the mean follow-up of 52.6 months (range 2-279 months) after recurrence, 19 patients (32.2%) experienced a second relapse, and 16 (27.1%) died. The 5-year survival and progression-free survival rates after relapse were 70.0% and 67.0%, respectively. The optimal salvage surgery and chemotherapy regimen after relapse were independent prognostic factors (P < 0.05).

CONCLUSIONS

The prognosis of recurrent and persistent MOGCTs was good after salvage therapy. The optimal salvage surgery and adjuvant standardized chemotherapy significantly impact patient prognosis. For young nulliparous patients, secondary fertility-sparing salvage therapy can be considered.

Therapeutic Challenges for Cisplatin-Resistant Ovarian Germ Cell Tumors

The majority of patients with advanced ovarian germ cell cancer are treated by cisplatin-based chemotherapy. Despite adequate first-line treatment, nearly one third of patients relapse and almost half develop cisplatin-resistant disease, which is often fatal. The treatment of cisplatin-resistant disease is challenging and prognosis remains poor. There are limited data on the efficacy of specific chemotherapeutic regimens, high-dose chemotherapy with autologous progenitor cell support and targeted therapies. The inclusion of patients in clinical trials is strongly recommended, especially in clinical trials on the most frequent male germ cell tumors, to offer wider therapeutic opportunities. Here, we provide an overview of current and potential new treatment options including combination chemotherapy, high-dose chemotherapy and molecular targeted therapies, for patients with cisplatin-resistant ovarian germ cell tumors.

Reproductive outcomes of 105 malignant ovarian germ cell tumor survivors: a multicenter study

BACKGROUND

Malignant ovarian germ cell tumors usually occur in young women. Until the 1970s, before establishment of systemic chemotherapy, malignant ovarian germ cell tumors had a very poor prognosis. Recently, prognosis has improved, and fertility-sparing treatment is being adopted in patients who desire to become pregnant. However, the number of malignant ovarian germ cell tumor survivors who actually became pregnant remains unknown.

OBJECTIVE

The present study aimed to clarify the reproductive outcomes in malignant ovarian germ cell tumor survivors by using data from a multicenter database and an additional survey on reproductive outcomes.

STUDY DESIGN

The study used the Tokai Ovarian Tumor Study Group database on ovarian cancer patients. We assessed the database from 1986 through 2016 and selected malignant ovarian germ cell tumor patients <40 years of age who received fertility-sparing treatment. Questionnaires on reproductive outcomes were sent to the registered facilities. The following data were collected and used in this study: age, date of onset, surgical procedure, chemotherapy regimen, tumor type, International Federation of Gynecology and Obstetrics stage, survival outcome and period, number of pregnancies and childbirths, marital status, childbearing desire, method of pregnancy, gestational weeks at delivery, birthweight of the baby, obstetric complications, and menstrual status after fertility-sparing treatment.

RESULTS

A total of 110 malignant ovarian germ cell tumor patients who received fertility-sparing treatment were identified. The median follow-up period was 10.4 years. Five patients were excluded because of death or loss of fertility after treatment for recurrence. Thus, 105 patients were finally included. The additional survey revealed that 42 of 45 patients who desired childbirth became pregnant. The total number of pregnancies was 65, and 56 babies were born to 40 malignant ovarian germ cell tumor survivors.

CONCLUSION

The reproductive outcomes of malignant ovarian germ cell tumor survivor are promising with fertility-sparing treatment. Malignant ovarian germ cell tumor survivors can become pregnant and give birth if they desire.

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.

Pure Immature Teratoma of the Ovary in Adults: Thirty-Year Experience of a Single Tertiary Care Center

The aim of this study was to evaluate clinicopathologic characteristics, treatment outcome, and reproductive function in women diagnosed with ovarian immature teratoma (IT). Our standard chemotherapy regime is currently etoposide/cisplatin (EP), creating a unique opportunity to evaluate this protocol in ovarian ITs.

Outcomes of ovarian germ cell tumors: ten years of experience at the Brazilian National Cancer Institute

OBJECTIVE

Ovarian germ cell malignancies are a rare group of chemosensitive malignances that predominantly occur in young women. Bleomycin, etoposide, cisplatin (BEP) regimen was consolidated, by previous studies, as the standard treatment. This Brazilian single institutional study was performed to evaluate our experience in treating patients with ovarian germ cell tumors (OGCTs).

METHODS/MATERIALS

A retrospective analysis of all patients as having OGCTs, from April 2003 to July 2013, was carried out at the Brazilian National Cancer Institute.

RESULTS

Data on 30 patients were obtained, and 19 patients were treated with BEP. Median overall survival and progression-free survival were not reached. Just 4 (13.3%) patients had progressed and 5 (16.7%) had died up to the date of analysis. The proportion of patients who had dysgerminoma was 53.3%. From the 18 patients considered to have had an incomplete resection, 84.6% achieved objective response (partial or complete response) with chemotherapy. Patients with stage IV and incomplete resection had markedly ominous prognosis. Alopecia was the most frequent adverse event; grade 2 was presented in 17 (89.4%) patients. Nausea and vomiting were related by more than one-half of the patients. Grade 3 and 4 neutropenia was presented in 5 (26.3%) patients. One patient died of pneumonitis related to bleomycin.

CONCLUSIONS

Our study confirms the effectiveness of BEP regimen and the great prognosis for patients with OGCTs. Advanced-stage and persistent disease configured as an important risk factor for survival. The chemotherapy regimen was associated with significant but manageable toxicity.

Outcome of 3-day bleomycin, etoposide and cisplatin chemotherapeutic regimen for patients with malignant ovarian germ cell tumours: a Taiwanese Gynecologic Oncology Group study

BACKGROUND

The combination of bleomycin, etoposide and cisplatin (BEP) is currently the most widely used treatment for malignant ovarian germ cell tumours (MOGCTs). The aim of this study was to evaluate the efficacy and adverse effects of the 3-day BEP regimen in Taiwan. The prognostic factors of the MOGCT patients were also analysed.

PATIENTS AND METHODS

Two hundred and thirty-nine cases of MOGCTs were identified from the Taiwanese Gynecologic Oncology Group database, and 204 of those who received postoperative BEP chemotherapy were then analysed.

RESULTS

The estimated rate of no evidence of disease was 94.0% for 204 patients with adjuvant BEP regimen. Seven grade 3/4 haematological adverse effects including four subjects with neutropenia, one with pancytopenia and two with neutropenic fever were recorded in the 853 total courses of chemotherapeutic cycles. The rates of haematological and non-haematological adverse effects were 0.82% and 2.3%, respectively. No treatment-related mortality was noted. In the analysis of prognostic factors, only tumour stage had a significant impact on disease recurrence (95% confidence interval (CI), 4.2–94.4, p < 0.001) and disease-related mortality (95% CI, 2.2–163.9, p = 0.007).

CONCLUSIONS

The current 3-day adjuvant BEP regimen was effective and safe for patients with MOGCTs.

Presentation of a Patient who Underwent Fertility-Sparing Surgeries for Contralateral Recurrence of Ovarian Immature Teratoma with Gliomatosis Peritonei

We report a patient who has maintained a regular menstrual cycle despite undergoing cystectomy and chemotherapy for contralateral recurrence of ovarian immature teratoma with gliomatosis peritonei. We initially performed a fertility-sparing right salpingo-oophorectomy, omentectomy and peritoneal biopsy for immature teratoma with gliomatosis peritonei, with adjuvant chemotherapy; we performed a left ovarian cystectomy and peritoneal biopsy for mature cystic teratoma with gliomatosis peritonei 16 months after the first surgery, a fertility-sparing left ovarian cystectomy and peritoneal biopsy for contralateral recurrence of ovarian immature teratoma with gliomatosis peritonei 60 months after the first surgery, and a left ovarian cystectomy and peritoneal and external iliac lymph node biopsy for endometrial cyst with gliomatosis peritonei 71 months after first surgery. The peritoneal gliomatosis lesions gradually decreased through the 4 surgeries over 8 years. The patient has maintained a regular menstrual cycle and currently shows no evidence of disease.

Updates in the management of ovarian germ cell tumors

Ovarian germ cell tumors are rare events at all ages-in pediatrics, adolescence, and during young adulthood. Combining the knowledge and experience of pediatric and gynecologic oncologists can lead to better outcomes for all. In this review, we intend to present the latest consensus on management of women and children with this disease and highlight the opportunities for collaboration and clinical research going forward.

Chemotherapy for malignant germ cell ovarian cancer in adult patients with early stage, advanced and recurrent disease

BACKGROUND

Malignant germ cell tumour of the ovary occurs in up to 0.07% of woman globally. Due to its rarity, evidence for treatment is lacking and often extrapolates clinical trial results of testicular germ cell cancers. The investigation on this rare tumour is further compounded by the fact that its occurrence in the adult population is even less compared to their paediatric counterpart. At present, the effectiveness of chemotherapy, regardless of stage in malignant germ cell tumour of the ovary is not entirely clear.

OBJECTIVES

To evaluate the effectiveness and safety of chemotherapy in adult women with early stage, advanced and recurrent malignant germ cell ovarian cancers.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2010, Cochrane Gynaecological Cancer Group Trials Register, MEDLINE and EMBASE up to April 2010. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs), quasi-RCTs and non-randomised studies that compared systemic therapy in adult women diagnosed with germ cell ovarian cancer who have confirmed pathological diagnoses.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed risk of bias.

MAIN RESULTS

We found one RCT and one retrospective study that met our inclusion criteria. The data from these studies were too sparse to adequately assess the effectiveness and safety of adjuvant chemotherapy in the treatment of malignant germ cell ovarian cancer. All comparisons were restricted to single study analyses and this review was only based on 32 women, so it was not adequately powered to detect differences in survival. Adverse effects of treatment and recurrence-free survival were incompletely documented and QoL was not reported in any of the studies. We did not find any studies that reported specifically on adults so there were problems in separating data on adults and children in many of the potentially relevant studies.

AUTHORS' CONCLUSIONS

We found only low quality evidence on the use of chemotherapy in malignant germ cell tumours of the ovaries. Therefore we are unable to reach definite conclusions about the relative benefits and harms of chemotherapy use in this disease regardless of disease stage. Due to the benefit of chemotherapy in germ cell cancer of the testis, a trial of chemotherapy versus best supportive care is unlikely to be feasible. Despite this, good quality randomised studies are warranted in this disease to define the role of chemotherapy (type of chemotherapy, duration of treatment, benefit, short and long term toxicities). Given the rarity of this disease, we feel a trans-global approach would be essential in order to perform such trials.

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.

Nondysgerminomatous ovarian tumors: clinical characteristics, treatment, and outcome. A case-controlled study

OBJECTIVE

The aim of this study is to assess the response of patients with nondysgerminomatous ovarian germ-cell tumors (NDOGCT) to platinum-based chemotherapy and to determine association of prognostic factors to relapse of disease.

METHODS

We retrospectively reviewed 21 patients who had surgical resection of nondysgerminomatous ovarian germ-cell tumors (NDOGCT) and received adjuvant chemotherapy in Vali-e-Asr Hospital, Tehran, Iran during 1997-2004. The median age at presentation was 18 years and the median follow-up was 20 months. Histological type of tumors included the following: immature teratoma (n=7), mixed germ-cell tumor (n=7), yolk sac tumors (n=4), and embryonal carcinoma (n=3). Distribution by stage at the time of surgery was as follows; stage I (n=10), stage III (n=6), and stage IV (n=5).

RESULTS

Sixteen patients underwent unilateral salpingo-oophorectomy and 5 patients underwent cystectomy. After the initial surgery, 13 patients immediately received chemotherapy and the other 8 patients received chemotherapy at a median time of 5.5 months (range, 1-40 months). Postoperative chemotherapy included the following: bleomycin, etoposide, and cisplatin (n=17); vincristine, actinomycin-D, and cyclophosphamide (n=2); methotrexate, etoposide, and cisplatin (n=l); and cisplatin (n=l). Thirty-one percent of the patients suffered a relapse after platinum-based combination chemotherapy. The median disease-free survival was 40 months and the median overall survival was 50 months. The 5-year survival rate was 39%.

CONCLUSIONS

This study showed that stage at the initial surgery, residual disease and the interval from initial diagnosis to the start of chemotherapy were possible prognostic factors for relapse. Also, our study indicates that there may be a role for aggressive cytoreductive surgery in advance NDOGCT, and a need for second-line combination chemotherapy.

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.

Good pregnancy outcome after prenatal exposure to bleomycin, etoposide and cisplatin for ovarian immature teratoma: a case report and literature review

AIM

The administration of bleomycin plus etoposide and cisplatin during pregnancy is rare.

MATERIALS AND METHODS

We describe a case with good pregnancy outcome after exposure to these chemotherapeutic agents at the third trimester of pregnancy.

RESULTS AND DISCUSSION

A pregnant woman with stage IIIc immature teratoma underwent surgical staging, and received two cycles of bleomycin, etoposide and cisplatin from the 29th week of pregnancy until delivery. The patient did not have any evidence of recurrence of ovarian cancer for 1.5 years. Her infant did not have any evidence of minor or major malformations, and showed normal neurological development during 1.5 years of follow-up.

Reproductive and sexual function after platinum-based chemotherapy in long-term ovarian germ cell tumor survivors: a Gynecologic Oncology Group Study

PURPOSE

To compare malignant ovarian germ cell tumor survivors with a matched control group of females on menstrual and reproductive outcomes, sexual functioning, and dyadic adjustment.

PATIENTS AND METHODS

Eligible patients met the following criteria: (1) history of malignant ovarian germ cell tumor; (2) treatment with surgery plus platinum-based chemotherapy; (3) age at least 18 years and continuously disease-free with minimum follow-up of 2 years; (4) capability of completing questionnaire and telephone interview; and (5) completion of written informed consent. The control group was drawn from acquaintances recommended by survivors and matched for age, race, and education. Scales with established reliability and validity were used to measure quality-of-life concepts of sexual functioning and social networks.

RESULTS

One hundred thirty-two survivors and 137 controls completed the study. Of 132 survivors, 71 (53.8%) had fertility-sparing surgery. Of fertile survivors, 62 (87.3%) reported still having menstrual periods. Twenty-four survivors reported 37 offspring after cancer treatment. Compared with controls, survivors had significantly greater reproductive concerns (P < .0001), less sexual pleasure (P = .003), and lower scores on the total Sexual Activity Scale Score (P = .001). However, survivors had better dyadic consensus (P = .004), dyadic satisfaction (P = .005), and dyadic cohesion (P = .014).

CONCLUSION

Women who had fertility-sparing surgery were very likely to retain menstrual function and fertility after chemotherapy. Although there is some increase in gynecologic symptoms and diminution in sexual pleasure, survivors tended to have stronger, more positive relationships with significant others.

Fertility preservation with treatment of immature teratoma of the ovary

Fertility preservation for a patient with advanced immature teratoma of the ovary is reported. The patient, a 29-year-old woman, delivered a healthy baby after having had ovarian immature teratoma, grade 3, uncertain stage, at 13 years of age. She was initially treated with unilateral salpingo-oophorectomy and a contralateral wedge resection for tumor invasion, followed by a 6-course cisplatin+vinblastine+bleomycin regimen, a second operation, and an additional 6-course etoposide and cisplatin regimen with complete remission. The patient delivered a healthy baby 16 years after the initial treatment. Based on this successful case, intensive fertility-preserving surgery followed by chemotherapy, even in advanced-stage immature teratomas of the ovary, may be effective in preserving the reproductive function of women with malignant immature teratomas of the ovary.

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.

[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.

Controversies in the management of germ cell tumours of the ovary

PURPOSE OF REVIEW

Ovarian germ cell tumours are rare, but curable at all stages of disease. This review gives an outline of the main controversies regarding the management of this disease.

RECENT FINDINGS

Pelvic malignancies are very rare during pregnancy, which should avoid the need for radical surgery or termination in these patients. Also during pregnancy, AFP-L2 looks to be a promising tumour marker in detecting relapse. Malignant transformation of mature teratomas may be predicted by preoperative squamous cell antigen and tumour size. OCT4 immunohistochemistry has been shown to be a very useful adjunct in the diagnosis of dysgerminomas. The traditional method for grading immature teratomas is challenged by a new classification. Patients receiving cisplatin-based chemotherapy are at a higher risk of developing cardiovascular risk factors. There is a hint that high-dose chemotherapy may play a role in relapsed patients.

SUMMARY

Rarity of the disease means many controversies are difficult to resolve, with much reliance on using data from testicular cancer studies. Many clinicians still advocate adjuvant chemotherapy for stage I nondysgerminomatous tumours of grade 2 and above despite good evidence that surveillance is a safe option, and increasing concerns about life-threatening long-term effects of treatment.

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.

Treatment of ovarian germ cell tumors with a 3-day bleomycin, etoposide, and cisplatin regimen: a prospective multicenter study

BACKGROUND

Ovarian germ cell tumors (OGCT) are highly curable when treated with cytoreductive surgery and platinum-based chemotherapy. We evaluated the safety and activity of a 3-day modified bleomycin, etoposide, and cisplatinum (mBEP) regimen in patients with OGCT.

PATIENTS AND METHODS

Patients with FIGO stages I-IV OGCT were treated with three (stages I-III complete resection) or four cycles (incomplete resection or stage IV) of bleomycin 15 mg iv, etoposide 120 mg/m(2) iv, and cisplatin 40 mg/m(2) iv for 3 days every 3 weeks.

RESULTS

Forty-eight patients (14 with dysgerminoma and 34 with non-dysgerminomatous tumors) were included in our study. Most patients had stage I disease (65%) and complete resection of their tumor (67%). Twenty percent of patients developed grade 3 or 4 neutropenia with 4 episodes of neutropenic fever. During follow-up (median: 5 years), two patients developed progressive disease including one patient who died. All patients with stage I or II disease and all patients with dysgerminoma remain free of disease. However, 20% of patients with non-dysgerminomatous tumors stage III or IV experienced progressive disease.

CONCLUSION

The modified 3-day BEP regimen was safe and effective in patients with OGCT. Further improvements are needed for patients with advanced, suboptimally debulked non-dysgerminomatous tumors.

Adjuvant therapy of completely resected dysgerminoma with carboplatin and etoposide: a trial of the Gynecologic Oncology Group

OBJECTIVE

This study was designed to evaluate the effect of adjuvant chemotherapy with carboplatin and etoposide in patients with completely resected stage IB-III dysgerminoma.

METHODS

Eligible patients were treated with three courses of carboplatin 400 mg/m(2) on day 1 plus etoposide 120 mg/m(2) on days 1, 2, and 3 every 4 weeks for three courses.

RESULTS

Forty-two patients were entered on this trial, of whom 39 were eligible. No patient suffered a recurrence of dysgerminoma, but one patient ultimately died of lung adenocarcinoma. One patient was excluded on pathology review (elements of endodermal sinus tumor were present) developed recurrent tumor and died despite further therapy. As expected, the regimen was well tolerated. Median follow-up of surviving patients is 7.8 years (range: 2.86 months to 10.92 years).

CONCLUSION

The regimen used in this study is an alternative to cisplatin, etoposide, and bleomycin (BEP) for selected patients for whom minimizing toxicity (particularly neuropathy) is critical or for whom reduction in the number of treatment days is important.

Evaluation of genomic changes in a large series of malignant ovarian germ cell tumors—relation to clinicopathologic variables

Malignant ovarian germ cell tumors (mOGCT) affect women in their reproductive years, making fertility-saving treatment important. A reliable prediction of the clinical behavior is essential for an optimal therapeutic approach. The genetic changes and molecular mechanisms underlying these rare tumors remain poorly understood. To address these issues, we performed DNA ploidy analysis by high-resolution image cytometry in a series of 47 mOGCT and correlated the findings with the DNA copy number changes detected by comparative genomic hybridization (CGH) and clinical outcome. Of 47 tumors, 15 were diploid, 14 were tetraploid, 2 were polyploid, and 13 were aneuploid. All the immature teratomas were diploid, in contrast to the dysgerminomas and endodermal sinus tumors. The International Federation of Gynecology and Obstetrics (FIGO) staging, residual tumors after surgery, and DNA ploidy distribution were significant, independent prognostic factors in survival analysis. The study revealed that the number of DNA copy number aberrations was increased in tetraploid and aneuploid tumors as compared to diploid tumors. Furthermore, a high percentage of aneuploid nuclei in a sample were associated with a complex CGH profile of the tumor in question. The present study confirms that DNA aneuploidy assessment by image analysis may be linked to genetic instability, which is detected as genetic aberrations by CGH. DNA ploidy gives significant prognostic information in addition to the clinical stage in mOGCT with FIGO stage II-IV.

Long-term survivors of ovarian malignancies after cisplatin-based chemotherapy

Male germ cell tumour patients treated with cisplatin-based chemotherapy frequently develop cardiovascular risk factors and disease, but sparse information is available about long-term complications of this type of chemotherapy in women. We investigated the prevalence of cardiovascular risk factors and vascular damage in 21 women (median age 39 years; range 26-57 years) with an epithelial or germ cell tumour of the ovary cured by cisplatin-based chemotherapy after a median follow-up of 14 years (range 3-21 years). Hypercholesterolaemia was present in 62%, obesity in 24%, hypertension in 14%, insulin resistance in 14%, and microalbuminuria in 24% of patients. Microalbuminuria was more frequent in long-term cancer survivors than in a female background population with a similar age (23.8 versus 3.2%; P<0.05). A substantial portion of young female patients cured by cisplatin-based chemotherapy are likely to develop cardiovascular risk factors and signs of endothelial damage at an early stage.

Experience of a 2-day BEP regimen in postsurgical adjuvant chemotherapy of ovarian germ cell tumors

The outcome of 31 patients with malignant ovarian germ cell tumors treated by surgery and a medium dose etoposide containing short chemotherapy regimen between 1988 and 1997 is reported. Of the 31 patients, 16 (51.6%) had malignant teratomas, 8 (25.8%) had dysgerminomas, 6 (19%) endodermal sinus tumors and one (3.2%) mixed germ cell tumor. Twenty-four (77.4%) patients were at FIGO stage I (of which 18 were stage IA), 2 (6.5%) at stage II, 4 (12.9%) at stage III and 1 (3.2%) at stage IV. Twenty-five (80.6%) patients underwent conservative surgery, 1 (3.2%) underwent bilateral salpingo-oophorectomy and 4 (12.9%) had total hysterectomy with bilateral salpingo-oophorectomy and omentectomy. One (3.2%) patient refused definitive treatment. Three patients with stage IA grade 1 immature teratomas were not treated with adjuvant chemotherapy and one patient with a stage IA dysgerminoma refused chemotherapy. Two patients with endodermal sinus tumor returned to their countries of origin after surgery. Twenty-five patients received bleomycin, etoposide, and cisplatin (BEP) regimen with etoposide dosage fixed at 120 mg/m2 on day 1 and day 2, bleomycin 15 mg intravenous bolus on days 1 and 2 and cisplatin 100 mg/m2 on day 1. Chemotherapy was administered at four weekly intervals for 4 cycles or until complete response was achieved. The median number of cycles of chemotherapy was four (range 3-6) for stage I, 6 (range 4-7) for stage II and 5 (range 5-6) for stage III tumors. Of the entire cohort of 29 patients analyzed, the median follow up period was 5 years. One patient died from stage IIIC endodermal sinus tumor and one patient had persistent teratoma in the lungs. The overall disease free survival control rate was 93.1%. There were three cases of the growing teratoma syndrome involving the liver, abdominal peritoneum, and the pelvis, respectively. No mortality resulted from the growing teratomas. No pulmonary complications, secondary primary tumor or leukemia was detected. Menstrual function returned in all patients with fertility-preserving surgery and one pregnancy occurred. This interesting data suggest that a medium dose 2-day BEP postsurgical adjuvant chemotherapy regimen is effective and superior to expectant treatment of malignant ovarian germ cell tumors. This report, however, should be viewed as a pilot study. The result indicates that a prospective randomised controlled trial to demonstrate equivalence of this regimen with the standard BEP regimen is warranted.

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.

Human germ cell tumours: expression of gamma-glutamyl transpeptidase and sensitivity to cisplatin

Previous studies have shown that the enzyme-glutamyl transpeptidase (GGT) is essential for the nephrotoxicity of cisplatin. This study was designed to determine whether GGT activity is necessary for the therapeutic effect of the drug. The relationship between GGT expression and clinical response to platinum-based chemotherapy was examined in 41 human germ cell tumours. Sections of formalin-fixed, paraffin-embedded tumours were immunohistochemically stained with an antibody directed against human GGT. There was no expression of GGT in any of the 17 seminomas or four dysgerminomas; whereas, 12/12 ovarian yolk sac tumours and 4/4 embryonal carcinomas of the testis were GGT-positive. In stage I tumours fewer tumour cells expressed GGT than in later stage tumours. In four germ cell tumours of mixed histology, the seminomatous and dysgerminoma areas were GGT-negative while the areas of the tumour with yolk sac or embryonal histology contained GGT-positive tumour cells. The patients with seminomas or dysgerminomas who were treated with cisplatin-based chemotherapy, all had a complete response despite the absence of GGT expression in these tumours. Fifteen of the 16 patients with yolk sac or embryonal carcinomas received cisplatin-based chemotherapy following surgery. Twelve had a complete response, while three failed to respond to platinum-based therapy. There was no correlation between the level of GGT-expression and response to therapy in this group. Three of the four patients with tumours of mixed histology were treated with cisplatin-based therapy, and had a complete response. Therefore, expression of GGT is not necessary for the therapeutic effect of cisplatin in germ cell tumours. The results from this study suggest that systemic inhibition of GGT would inhibit the nephrotoxic side-effect of cisplatin without interfering with its activity towards germ cell tumours.

Treatment of nondysgerminomatous ovarian germ cell tumors: an analysis of 69 cases

BACKGROUND

Combination chemotherapy has dramatically improved the prognosis of patients with nondysgerminomatous ovarian germ cell tumors (NDOGCT). However, guidelines are needed for the identification of patients at risk of relapse.

METHODS

The authors performed a retrospective analysis of women with NDOGCT managed during the period 1970-1994 at the Royal Marsden Hospital and other hospitals of the London Gynaecological Oncology Group.

RESULTS

Sixty-nine women were included; their median follow-up was 5.7 years (minimum, 12 months). The median age was 21 years (range, 4-44 years), with a histology of immature teratoma (IT) for 17 patients, endodermal sinus tumor (EST) for 20 patients, and mixed tumors for 32 patients. Thirty-five patients (51%) had Stage I disease. Nine patients with Stage I tumors were observed without further therapy (six with IT and three with mixed tumors), and one relapsed. Seven patients received non-platinum-based chemotherapy, and four relapsed. A total of 52 patients were treated with platinum-based chemotherapy, with relapse free and overall survival rates of 87% (95% confidence interval [CI], 73-93%) and 84% (95% CI, 70-91%), respectively. Of these patients, relapse was seen in 0 of 9 IT patients, 1 of 25 patients with mixed tumors, and 6 of 18 EST patients. With alpha-fetoprotein (AFP) > 1000 kU/L, relapse was seen in 6 of 18 patients compared with 1 of 33 relapses with lower AFP levels. In multivariate analysis, including all patients who received chemotherapy, AFP >1000 kU/L (P = 0.001) and non-platinum-based chemotherapy (P = 0.005) were associated with relapse. When only patients given platinum-based treatment were considered, EST histology (P = 0.003) and AFP >1000 kU/L (P = 0.003) were associated with relapse in univariate analysis; however, these factors were linked. No malignant tumor was found at second-look surgery performed on 24 patients. Of 26 women assessable for fertility, 24 subsequently recommenced regular menstrual function, and 11 patients had pregnancies.

CONCLUSIONS

Platinum-based chemotherapy has been confirmed to be effective in the management of patients with NDOGCT. Relapses were principally seen among patients with AFP >1000 kU/L or pure EST histology. Efforts to improve outcome need to focus on patients with EST, whereas less intensive management strategies may be appropriate for some patients with IT.

Fertility and ovarian function after conservative surgery for germ cell tumours of the ovary

Malignant ovarian germ cell tumours (MOGCT) principally occur in girls and young women and are generally unilateral. Effective combination chemotherapy with conservative surgery has seen a dramatic improvement in survival rates. This increase has shifted the focus to long-term fertility and reproductive outcome. The present study describes 45 patients with MOGCT treated with conservative surgery to preserve fertility, with or without the addition of chemotherapy. The age range was 10 to 32 years with a mean of 20 years. The majority of the subjects had Stage 1 tumours; 44 underwent unilateral salpingo-oophorectomy and 1 patient ovarian cystectomy. Adjuvant chemotherapy was administered in 29 patients. Overall mean follow-up was 58.7 months. There were 4 recurrences and 2 deaths. Survival of those with Stage 1 disease was 97% and for advanced stages 87%. During chemotherapy 50% became amenorrhoeic but 96% resumed normal menstrual function on completion. Seven healthy babies were recorded in the chemotherapy group and no documented birth defects occurred in any of these. There was no case of persistent infertility; 3 patients experienced temporary problems. It is concluded that conservative fertility-sparing surgery is the treatment of choice in these young women and advanced disease is not necessarily a contraindication. The majority can anticipate normal menstrual function and fertility.

PVB chemotherapy in patients with recurrent or advanced dysgerminoma: a Phase II study of the EORTC Gynaecological Cancer Cooperative Group

Dysgerminoma accounts for 1% of all ovarian cancers and for 50% of all ovarian germ cell malignancies. Low stage patients (50%) can be cured with local treatment. The aim of this trial was to study the objective tumour response rate and toxicity of PVB (cisplatin, vinblastine, bleomycin) chemotherapy in patients with pure advanced or recurrent dysgerminoma. Eighteen eligible patients with advanced dysgerminoma were entered into this study. Three patients had local bulky recurrence only; all the others also had metastatic disease. The median age at entry was 27 years (range 1348). Seventeen patients had had prior surgery and one had undergone prior radiotherapy. The WHO performance status was 0 in 12 patients, 1 in three patients, and 2 in three patients. The treatment consisted of: intravenous or intramuscular bleomycin 30 mg on days 2, 9 and 16, intravenous vinblastine 0.15 mg/kg on days 1 and 2, and intravenous cisplatin 20 mg/m2 on days 1-5. This regimen was given at 3-week intervals for a total of four cycles. Twelve patients obtained a complete response (66%), five a partial response (28%), and one could not be evaluated because radiotherapy was administered immediately after chemotherapy. After a median follow-up of 76 months (range 4-132), 14 (78%) patients were alive and well. Two died of disease progression, one of neutropenic septicaemia and one of lung fibrosis. No unusual toxicity was reported. Alopecia, as well as nausea and vomiting, were common. Leucopenia (78%), thrombocytopenia (17%) and infection (11%) were the other severe (grade 3-4) side effects. The PVB chemotherapy regimen is highly effective in patients with advanced ovarian dysgerminoma. However, the BEP (bleomycin, etoposide, cisplatin) regimen, which is equally as potent and less toxic, is preferred.

Favorable outcome of ovarian germ cell malignancies treated with cisplatin or carboplatin-based chemotherapy: a Hellenic Cooperative Oncology Group study

PURPOSE

To evaluate the outcome and the prognosis of patients with ovarian germ cell malignancies who were treated with platinum-based chemotherapy immediately after initial surgery.

METHODS

We conducted a retrospective review of patients with ovarian germ cell tumors who were referred for consideration of treatment to the Departments of Medical Oncology participating in the Hellenic Cooperative Oncology Group.

RESULTS

Over a 14-year period 53 patients were included in our study. There were 13 patients with dysgerminoma and 40 patients with nondysgerminomatous tumors. Forty percent of patients underwent complete resection of their tumors. Platinum-based chemotherapy consisted primarily of cisplatin, vinblastine, and bleomycin (PVB) in 9 patients; bleomycin, etoposide, and cisplatin (BEP) in 15 patients; and bleomycin, etoposide, and carboplatin (BEC) in 25 patients. With a median follow-up of 39 months, 5 patients developed progressive disease and died of their tumor and 1 patient died of bleomycin-induced lung toxicity with no evidence of active tumor. The 5-year overall survival was 100% for patients with dysgerminoma and 85% for patients with nondysgerminomatous tumors. Eighty percent of patients with advanced nondysgerminomatous tumors and residual disease after surgery remain disease free.

CONCLUSION

With this study we confirm that patients with ovarian germ cell malignancies have a favorable outcome when treated with platinum-based chemotherapy.

Chemotherapy for ovarian germ cell tumours

59 patients were treated for newly diagnosed metastatic ovarian germ cell tumours with POMB/ACE chemotherapy (which contains cisplatinum, vincristine, methotrexate, bleomycin, actinomycin D, cyclophosphamide and etoposide). The median follow-up was 7.7 years. The 3 year survival is 87.8% (95% confidence interval 76.9-93.9%) and no relapses occurred more than 3 years after treatment. 4 (7%) patients had primary drug resistance to POMB/ACE and 4 (7%) have relapsed. One patient in complete remission developed secondary acute myeloid leukaemia after receiving a total of 1.3 g/m2 etoposide. 6 of 12 (50%) patients referred at relapse were salvaged by POMB/ACE. 14 of 33 (42%) women (> 18 years old) have had successful pregnancies after fertility conserving surgery and chemotherapy with no congenital abnormalities reported. The POMB/ACE regimen is as efficacious as other published regimens for ovarian germ cell tumours (OGCT) and balances a low incidence of life-threatening toxicity with a high success rate.