Update on malignant ovarian germ cell tumors

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.

Growing teratoma syndrome after chemotherapy for a mixed germ cell tumor of the ovary

A retroperitoneal enlarging mass was detected and resected in a 24-year-old nulliparous woman after fertility-preserving surgery and adjuvant chemotherapy for a malignant germ cell tumor (MGCT) of the right ovary. This enlarging mass contained only a mature teratoma component. Alpha-fetoprotein, which was elevated to 21236.6 ng/mL before the initial surgery, persisted within normal after the completion of adjuvant platinum-based chemotherapy. The patient was diagnosed with growing teratoma syndrome. Growing teratoma syndrome originating from ovarian germ cell tumor is very rare. Only 15 cases have been reported. Surgical resection and histological confirmation of growing mass after MGCT treatment is essential before conducting salvage chemotherapy.

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

BACKGROUND

Malignant germ cell tumors of the ovary are often curative after conservative surgery and adjuvant chemotherapy. Persistent tumors despite normalization of serum tumor markers may represent retroconversion to benign masses, but this is rare in ovarian tumors without teratoma elements. The management in such cases has not been defined.

CASE

A young woman with a stage IIIC mixed germ cell ovarian tumor containing endodermal and dysgerminoma elements and elevated serum tumor markers underwent conservative surgery followed by chemotherapy. Residual tumor persisted on CT despite the normalization of serum tumor markers. The residual tissue was resected and contained benign tissue.

CONCLUSIONS

In cases where masses persist and serum tumor markers normalize, attaining a histological diagnosis, and not chemotherapy, should be considered.

Sustained complete remission in a patient with platinum-resistant ovarian yolk sac tumor

BACKGROUND

Yolk sac tumors of the ovary are generally very responsive to chemotherapy; however, they are difficult to manage in the setting of platinum resistance where treatment options are limited and outcomes are poorer.

CASE

We present a 39-year-old woman who had a platinum-resistant yolk sac ovarian tumor. She achieved complete remission on an innovative regimen of docetaxel, gemcitabine, and thalidomide.

CONCLUSION

The combination of docetaxel, gemcitabine, and thalidomide might be an active regimen for platinum-resistant ovarian nondysgerminomas and further investigation of this combination is warranted.

Dysgerminoma associated with hypercalcemia: A case report

Hypercalcemia is an extremely rare paraneoplastic manifestation of malignancy in children. The authors report a case of dysgerminoma in a 14-year-old girl associated with severe hypercalcemia that only resolved after excision of the tumor. There are only 6 previously reported cases of dysgerminoma associated with hypercalcemia. Serum calcium levels should be checked in all children with solid ovarian tumors. Hypercalcemia in such circumstances may be resistant to medical management, and surgical resection of the tumor results in the normalization of calcium levels.

Prognostic factors of patients with yolk sac tumors of the ovary

OBJECTIVE

Our purpose was to evaluate the prognostic factors in yolk sac tumors of the ovary.

STUDY DESIGN

We performed a retrospective review of 47 patients with yolk sac tumors of the ovary from 1979 to 1997.

RESULTS

Twenty-two patients had pure yolk sac tumors and 25 had germ cell tumors with yolk sac tissue as a component of the disease. The 5-year survival rate in stages I, II, III, and IV was 95%, 75%, 30%, and 25%, respectively. Patients with stage I disease had a more favorable prognosis than those with stage III and IV disease (P <.001). All patients who did not respond to chemotherapy died of this disease within 36 months of the first treatment. Chemotherapy regimens that included cisplatin gave better results than those without cisplatin (P <.05). The difference in prognosis was significant in cases in which the size of residual tumor was <2 cm in diameter (P <.01) and in cases in which ascites was either absent or <100 mL in volume (P <.05). Coexistence of other components of ovarian germ cell tumors in histologic specimens, preoperative serum alpha-fetoprotein level, fertility-sparing surgery, dissection of intrapelvic nodes, and p53 status had no significant correlation with the prognosis in this study.

CONCLUSIONS

Staging and tumor-reductive surgery strongly affected the prognosis of this disease. Tumor-reductive surgery is advisable when ascites is minimal. Cisplatin-based chemotherapy after surgery was superior to chemotherapy without cisplatin; however, p53 status seemed to have no impact on chemosensitivity in yolk sac tumors of the ovary.

Chien-Tien Hsu Memorial Lecture. Fertility and gynaecologic malignancies

Fertility and gynaecological malignancies have an important relationship. A clear inverse relationship exists between family size and the incidence of ovarian and endometrial cancer. Current methods of fertility control have an influence on subsequent development of various gynaecological malignancies. A slightly increased risk of breast cancer has been reported in current users and those who had used hormonal contraceptives (OCs) within 10 years; this risk declined with time and disappeared after 10 years. Women who started OC before age 20 had a higher relative risk; the disease did not spread beyond the breast in the majority. Most studies found OC to reduce the risk of ovarian and endometrial cancer. The relative risks of squamous cell carcinoma and adenomatous carcinoma of the cervix have been reported to be 1.3 and 1.5, respectively in ever-users of OCs; however, the aetiology of cervical cancer is multifactoral. Several reports suggest the beneficial effect of tubal ligation and breast feeding in reducing the risk of ovarian cancer. Therapy of gynaecological malignancies may have an influence on subsequent fertility. Amenorrhoea developing after treatment of hydatidiform mole may be due to choriocarcinoma, recurrent mole or a normal pregnancy. Choriocarcinoma can also develop after a partial mole. The risk of fetal teratogenicity from chemotherapy is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTD including cerebral metastases. In the young patient with gynaecological malignancy preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian epithelial cancers and even in advanced germ cell tumours. Recently, the fertility-sparing surgery of radical trachelectomy and pelvic lymphadenectomy has been carried out for early invasive cervical cancer in young women. Gynaecological cancer occurring in pregnancy is uncommon; it presents the clinician with a difficult situation to manage. In most instances the cancer is treated as though the patient is not pregnant; the timing and mode of delivery needs individualization. The overall prognosis for breast cancer complicating pregnancy is poor. Survival in cervical cancers diagnosed antepartum is similar to the non-pregnant patient. Ovarian cancer in pregnancy has a good prognosis because of the early stage at diagnosis.

Malignant ovarian tumors in children: 22 years of experience at a single institution

PURPOSE

Malignant ovarian tumors of childhood are relatively rare and thus, management is still unclear. We reviewed our experience with these tumors to evaluate their histopathologic characteristics, treatment, and outcome.

PATIENTS AND METHODS

From January 1975 to December 1997, 56 patients had their malignant ovarian tumors diagnosed, treated, and followed-up in our institution. All tumors were completely excised when possible; otherwise, biopsy was performed. Staging was made according to Federation Internationale de Gynecologie Oncologique classification. Chemotherapy was recommended for all patients. Twelve cases were treated with vincristine, actinomycin, cyclophosphamide (VAC) before 1986; 12 with cisplatin, vinblastine, and bleomycin (PVB) from 1986 to 1989; and 23 with the bleomycin, etoposide, and cisplatin (BEP) regimen from 1989 to present. The Kaplan-Meier survival method was used to calculate the survival. The log-rank test was used to compare groups with respect to survival.

RESULTS

Age range was 0 to 16 years (median 11 yrs; average 9.8 yrs). Only two patients were younger than 1 year. The most common presenting symptom was abdominal pain, occurring in 27 patients (48.2%). Thirty-three patients (60%) had total one-sided salpingo-oophorectomy and three patients had bilateral salpingo-oophorectomy. Nineteen patients had stage I, 15 had stage II, 19 had stage III, and 3 had stage IV disease. Dysgerminoma was the most common type. Overall survival (OAS) and event-free survival were 68% (median follow-up time: 71 mos) and 57%, respectively, after 22 years. Histopathology was not correlated with survival. Two important predictors for survival are age (P < 0.0001) and treatment protocol (P = 0.013). The BEP protocol was superior to the other regimens. The OAS was 74.6% in BEP, 55% in PVB, and 63.6% in VAC regimens.

CONCLUSION

Although age at diagnosis and treatment with BEP regimen have major roles in determining prognosis of the ovarian tumors in childhood, for patients with advanced ovarian germ cell tumors, intensification of chemotherapy or the development of new approaches is necessary.

Surgery for germ cell tumors

We performed a review of the current modalities of surgical treatment of malignant ovarian germ cell tumors by clinical stages and histological types. Stage IA dysgerminoma is performed with a unilateral salpingo-oophorectomy (USO) without chemotherapy. However, for Stage IB or IC patients with dysgerminoma, USO plus chemotherapy as a primary treatment may or may not be followed with a second-look operation (SLO). For non-dysgerminomas, USO is indicated only for Stage IA immature teratoma grade 1. The treatment for Stage IA immature teratoma grade 2 or 3 and other histological types is USO plus chemotherapy. Patients with Stage IB, IC or higher with non-dysgerminoma are treated with USO plus chemotherapy or USO with contralateral partial ovariectomy plus chemotherapy. For patients who require non-conservative surgery, a total abdominal hysterectomy (TAH) and a bilateral salpingo-oophorectomy (BSO) plus chemotherapy are performed. For patients with Stage II of all histological types, conservative surgery consists of USO and a cytoreductive operation plus chemotherapy, followed by SLO or a second cytoreductive operation. For non-conservative surgery, TAH+BSO with or without a cytoreductive operation plus chemotherapy is followed by SLO. Conservative surgery for patients with Stage III and IV is USO and a cytoreductive operation plus chemotherapy followed by a second cytoreductive operation. Non-conservative surgery is TAH+BSO with a cytoreductive operation plus chemotherapy, followed by SLO or a second cytoreductive operation. However, primary or secondary cytoreductive surgery with or without lymphadenectomy and SLO are still controversial in terms of improving patient survival.

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.

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.

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

The medical records and histopathology of all ovarian germ cell tumours (OGCT) in a tertiary centre between 1980 and 1996 were reviewed. Response, overall survival (OS), relapse-free survival (RFS) and prognostic factors were analysed. Sixty-seven patients with OGCT were identified and treated, including 33 dysgerminomas, 18 immature teratomas, 10 endodermal sinus tumours, and 6 mixed tumours. Fifty-three patients (79%) received conservative surgery, 24 (36%) had residual disease post-primary surgery, and 43 (64%) had chemotherapy. Complete response was achieved in 62 patients (93%), 4 out of 5 patients who relapsed were successfully salvaged; OS and RFS at 5 years were 89% and 76%, respectively. Advancing stage of disease was the only significant adverse prognostic factor (p = 0.0001 for OS, and 0.0003 for RFS at 5 years). Out of 44 women with the potential to conceive following treatment, there were 16 successful pregnancies. None of the children born subsequent to the chemotherapy were reported to have any congenital abnormalities. The review indicates a high cure rate in OGCT with combined surgery and chemotherapy and that conservative surgery and preservation of fertility are feasible.

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.

Ovarian endometrioid-like yolk sac tumor treated by surgery alone, with recurrence at 12 years

We describe the case of a stage Ia endometrioid-like yolk sac tumor (YST) of the ovary, which was originally misdiagnosed as a malignant struma ovarii and not treated with adjuvant chemotherapy. After 12 years, a contralateral dermoid cyst was excised along with a small omental nodule of partially necrotic and calcified endometrioid-like YST. No tumor was detected in several other biopsy specimens, and a peritoneal lavage was negative for tumor cells. Since there was no evidence of remaining tumor and the serum alpha-fetoprotein (AFP) level was normal after the second operation, the patient was followed. Serial serum AFP levels remained normal for 4 months. At a second-look laparotomy after 4 months, a small tumor nodule was removed from the cul-de-sac. Postoperatively, the patient received three cycles of BEP chemotherapy. The long disease-free interval after the first operation in spite of the presence of occult spread to the omentum and to the pouch of Douglas in this case indicates that some endometrioid-like YSTs may have an indolent course. The present case underscores the importance of careful surgical staging and of long-term follow-up in cases of primitive germ cell tumors of the ovary.

Ovarian yolk sac tumor with endometrioid carcinoma arising from endometriosis in a postmenopausal woman, with special reference to expression of alpha-fetoprotein, sex steroid receptors, and p53

A case of a yolk sac tumor (YST) with an ovarian endometrioid adenocarcinoma arising from endometriosis in a postmenopausal woman is described. Clinically, the case showed an aggressive course and did not respond to chemotherapy; the patient died of her disease 6 months after the operation. Histologically, the tumor consisted predominantly of an endometrioid adenocarcinoma, but it also showed microscopic features characteristic of YST. The tumor also contained benign endometriotic lesions with direct transition to the endometrioid adenocarcinoma. Immunohistochemical study revealed that not only the YST, but also the endometrioid adenocarcinoma was partly positive for alpha-fetoprotein. There was an inverse relationship between the endometriosis and the endometrioid adenocarcinoma in terms of the expression of sex steroid receptors and p53: adenocarcinoma cells were positive for p53 but negative for sex steroid receptors, whereas endometriotic epithelial cells were positive for sex steroid receptors but negative for p53.

Ovarian mixed germ cell tumor composed of dysgerminoma, endodermal sinus tumor, choriocarcinoma and mature teratoma in a 44-year-old woman: case report and literature review

A case of ovarian mixed germ cell tumor in a 44-year-old woman was examined. The tumor was well circumscribed, measured 15 x 11 x 10 cm and appeared solid and partly cystic on the cut surface. Light microscopic examinations revealed that the tumor was composed of four different neoplastic germ cell elements, intermingled with each other. They are: (i) choriocarcinoma, immunohistochemically positive for human placental lactogen (hPL) and human chorionic gonadotropin (hCG); (ii) dysgerminoma, positive for placental alkaline phosphatase; (iii) endodermal sinus tumor positive for alpha-fetoprotein (AFP); and (iv) mature teratoma. Among these histological types, dysgerminoma occupied more than 50% of the neoplasm. The patient was diagnosed as a stage la ovarian mixed germ cell tumor and was subsequently treated with chemotherapy. A second-look laparotomy after completion of chemotherapy revealed no residual tumors in the abdomen and the patient is alive and well 15 months after operation. This is the fourth reported case of ovarian mixed germ cell tumor arising in patients over 40 years old.

Ovarian mixed germ cell tumor composed of polyembryoma and immature teratoma

We report the case of a 41-year-old woman with ovarian mixed germ cell tumor which was composed of polyembryoma and immature teratoma and who had high serum levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). By immunohistochemical methods, AFP was found in yolk sac cells of the embryoid bodies and immature hepatoid tissues, and hCG was found in giant syncytiotrophoblastic cells. She was treated with surgery followed by cisplatin-based combination chemotherapy. She is well, and her serum levels of AFP and hCG have not been elevated for more than 4 years after the treatment.

Conservative surgery for ovarian cancer and effect on fertility

OBJECTIVE

A survey that compared two alternatives (conservative and radical surgery) is presented on ovarian cancer treatment evaluating its effect on progression-free survival and fertility, in a 10-year time period, in Mexican women.

METHODS

72 women between 11 and 58 years old with unilateral ovarian cancer in different stages were studied. Several methods were analyzed: (1) progression-free survival, using Mantel and Haenzsel test to compare in terms of life curves and the Kaplan-Meier method. The exposure variable was surgery type, using the Mantel-Cox test to evaluate the difference in life curves by clinical stages and by surgery type; (2) fertility was evaluated in women who received conservative surgery, considering the cumulative pregnancy rate in women successfully pregnant after surgical and/or adjuvant treatment.

RESULTS

There were no difference in survival curves when evaluating progression-free survival, in either group (Z = 1.09 and Pr > (z) = 0.27). During the study period, we found that 87.5% of patients were alive with no evidence of disease. There were no differences in survival curves when evaluating progression-free survival according to surgery type and clinical stage (chi 2 = 0.66, P = 0.88). Restart of menstruation in patients with conservative surgery occurred before 6 months in 89% of the sample, 22 women with possible parity had a 59.1% cumulative pregnancy rate.

CONCLUSION

The outcomes from this survey carried out in Mexico show that conservative treatment of ovarian cancer in early clinical stages is an efficient alternative to preserve reproductive function in young women, and does not show differences in progression-free survival compared to radical surgery.

Diagnosis and management of malignant germ cell ovarian tumors in young females

Germ cell tumors (GCT) compose most of the preadolescent malignant ovarian tumors; dysgerminoma being the most common (48%), followed by endodermal sinus tumor, immature teratoma, mixed GCT and embryonal carcinoma. The percentage of malignant epithelial ovarian tumors rises with increasing age, while that of the GCT tumors declines. Of all tumor markers discussed, only AFP and hCG are being routinely monitored. Their most effective use is in monitoring response to therapy and detecting recurrences early. The current therapeutic regimens are presented, among them bleomycin, etoposide and platinol (BEP) and other new regimens; their influence on the patients' fertility is discussed. Further improvement in the prognosis of these young patients will hopefully follow development of new surgical and chemotherapeutic approaches.

Recurrent ovarian endodermal sinus tumor: demonstration by computed tomography, magnetic resonance imaging, and positron emission tomography

We report a case of recurrent endodermal sinus tumor of the ovary that was identified and/or clearly depicted by computed tomography, magnetic resonance imaging, and positron emission tomography. The potential roles of various imaging modalities in the detection of recurrent endodermal sinus tumor are discussed.

Immunoelectrophoretic differentiation of alpha-fetoprotein in disorders with elevated serum alpha-fetoprotein levels or during pregnancy

Our study aims to make differential diagnosis by immunoelectrophoresis for some common conditions with elevated levels of serum alpha-fetoprotein (AFP). One hundred and nine cases with elevated AFP levels were included in this study: yolk sac tumor (n = 8), hepatocellular carcinoma (n = 26), gastric cancer (n = 12), chronic hepatitis (n = 27) and normal pregnancy (n = 36). Lectin agarose gel electrophoresis, antibody-affinity blotting, and immunoreaction were used to identify the specific patterns of AFP in the respective conditions. The results showed that there were three possible bands: L1, L2 and L3. Yolk sac tumor produced a prominent L2 band and a light L3 band. Hepatocellular carcinoma produced a prominent L1 band and a light L3 band. Gastric cancer produced only an L1 band. Chronic hepatitis had a light L1 band and a pronounced L3 band. In pregnancy, the AFP pattern is similar to that of hepatocellular carcinoma. Immunoelectrophoresis is a useful method facilitating the differentiation of AFP origins.

Long-term results of two VAB-like regimens (vinblastine + actinomycin-D + bleomycin + cyclophosphamide + cisplatin) in malignant germ cell tumours of the ovary

21 patients with malignant germ cell tumours of the ovary were treated with two chemotherapy regimens including vinblastine, actinomycin-D, bleomycin, cyclophosphamide and cisplatin. Chemotherapy was delivered as primary postoperative therapy in 15 patients and for recurrent disease in 6 patients. 3 of 4 patients with pure dysgerminomas and 10 of 17 patients with non-dysgerminomatous tumours are alive without evidence of disease. The overall progression-free survival is 62% (95% confidence interval 45-77) with a median follow-up of 7 years. Two toxic deaths were observed. Less toxicity and better efficacy favour etoposide- and cisplatin-based regimens as standard chemotherapy for germ cell tumours of the ovary.