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

The Role of High Dose Chemotherapy with Autologous Hematopoietic Cell Transplant in Relapsed/Refractory Ovarian Germ Cell Tumors: A Single Center Experience

OBJECTIVE

We aimed to investigate response rates, survival analyses and factors affecting survival in patients with relapsed or refractory ovarian germ cell tumours who had previously received multiple lines of treatment, including high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT).

METHODS

This study was designed as a cross-sectional, retrospective study.

RESULTS

Twenty-one patients were included. After HDC + ASCT, complete response (CR) was observed in 11 patients (52.3%), partial response (PR) in 3 patients (14.3%), stable disease (SD) in 3 patients (14.3%) and progressive disease (PD) in 4 patients (19.1%). TRM was observed in 1 patient. Median follow-up was 51.7 months. Median PFS and OS after HDC + ASCT were calculated to be 6.0 months and 14.8 months, respectively.

CONCLUSIONS

Salvage HDC + ASCT is an effective option in the treatment of relapsed/refractory ovarian germ cell tumours, offering the potential for prolonged survival and cure.

Clinical Challenges in the Management of Malignant Ovarian Germ Cell Tumours

Nonepithelial ovarian cancers (NEOC) are a group of rare malignancies, including germ cell tumours (GCT) and sex cord-stromal tumours (SCST), along with small-cell carcinomas and sarcomas. GCTs represent 2-5% of ovarian cancers, with a yearly incidence of 4:100,000, and they usually affect young women and adolescents. Precursory germ cells of the ovary form the basis of GCT. They are histologically classified into primitive GCT, teratomas, and monodermal and somatic-type tumours associated with dermoid cysts. A primitive GCT can be either a yolk sac tumour (YST), dysgerminoma, or mixed germ cell neoplasm. Teratomas are either mature (benign) or immature (malignant). Given that malignant GCTs occur rarely compared to epithelial ovarian tumours (EOC), greater focus is required in their diagnosis and treatment. In this article, we review the epidemiology, clinical manifestations, diagnosis, and molecular biology, along with the management and therapeutic challenges.

30-Year Experience With 22 Cases of Malignant Transformation Arising From Ovarian Mature Cystic Teratoma: A Rare Disease

Objective

To investigate the clinical characteristics and survival outcomes of patients with malignant transformation arising from ovarian mature cystic teratoma (MT-MCT).

Methods

This retrospective study included patients with ovarian MCTs at Peking Union Medical College Hospital (PUMCH) during 1990.01-2020.12. When the pathologic histology was MT-MCT, detailed information was collected.

Results

Overall, 7229 ovarian MCT patients and 22 patients with MT-MCT were enrolled. The rate of malignant transformation of all ovarian MCTs was 0.30%. Most patients with MT-MCT were 51 (21–75) years old, and the tumor mass size was 10 (3–30) cm. The typical clinical symptoms were mainly abdominal pain and distension. The levels of tumor markers were elevated on preoperative examination. Early diagnosis could be made by ultrasonic examination, pelvic enhanced MRI and CT. Most patients underwent debulking surgery and adjuvant chemotherapy. The most common histological type to exhibit malignant transformation was squamous cell carcinoma (59.1%), followed by adenocarcinoma (13.6%), carcinoid (9.1%), and borderline tumor (18.2%). The 5-year RFS and OS rates were 54.5% and 81.8%, respectively. Patients with FIGO stage I had the best RFS (P=0.047) and OS (P=0.018), followed by those with FIGO stage II-IV.

Conclusion

MT-MCTs mainly occur in elderly females, are rare and have a poor prognosis. Advanced FIGO stage is a risk factor for survival. Although there is no standard treatment, cytoreductive debulking surgery and adjuvant chemotherapy could be considered. Perimenopausal and menopausal women with MCT should receive surgical treatment.

Epidemiological profile and clinico-pathological features of pediatric gynecological cancers at Moi Teaching & Referral Hospital, Kenya

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Fertility-sparing surgery for pediatric gynecological cancers should be the primary management.

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Dysgerminomas are the commonest ovarian germ cell tumors.

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Neo-adjuvant chemotherapy is feasible in advanced germ cell tumors.

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Pediatric gynecological cancers can have excellent prognosis.

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Early diagnosis and treatment can improve prognosis for germ cell tumors in LMICs.

Background

The main pediatric (0–18 years) gynecologic cancers include stromal carcinomas (juvenile granulosa cell tumors and Sertoli-Leydig cell tumors), genital rhabdomyosarcomas and ovarian germ cell. Outcomes depend on time of diagnosis, stage, tumor type and treatment which can have long-term effects on the reproductive career of these patients. This study seeks to analyze the trends in clinical-pathologic presentation, treatment and outcomes in the cases seen at our facility. This is the first paper identifying these cancers published from sub-Saharan Africa.

Method

Retrospective review of clinico-pathologic profiles and treatment outcomes of pediatric gynecologic oncology patients managed at MTRH between 2010 and 2020. Data was abstracted from gynecologic oncology database and medical charts.

Results

Records of 40 patients were analyzed. Most, (92.5%, 37/40) of the patients were between 10 and 18 years. Ovarian germ cell tumors were the leading histological diagnosis in 72.5% (29/40) of the patients; with dysgerminomas being the commonest subtype seen in 12 of the 37 patients (32.4%). The patients received platinum-based chemotherapy in 70% of cases (28/40). There were 14 deaths among the 40 patients (35%)

Conclusion

Surgery remains the main stay of treatment and fertility-sparing surgery with or without adjuvant platinum-based chemotherapy are the standard of care with excellent prognosis following early detection and treatment initiation. LMICs face several challenges in access to quality care and that affects survival of these patients. Due to its commonality, ovarian germ cell cancers warrant a high index of suspicion amongst primary care providers attending to adnexal masses in this age group.

The effect of fertility-sparing surgery on sexuality and global quality of life in women with malignant ovarian germ cell and sex cord stromal tumors: an analysis of the CORSETT database of the AGO study group

Purpose

Malignant ovarian germ cell (MOGCT) and sex cord stromal tumors (SCST) are ovarian neoplasms that affect disproportionally young women. Little is known about the impact of surgical and adjuvant management of these patient’s sexual life. This study investigated the effect of fertility-sparing surgery on sexual activity and global quality of life (gQoL) in women with MOGCT and SCST.

Methods

CORSETT was an observational, multicenter, mixed retrospective/prospective cohort study of the AGO study group. Women of any age who had been diagnosed with MOGCTs and SCSTs between 2001 and 2011 were asked to complete the Sexual Activity Questionnaire (SAQ) and the EORTC QLQ-C30.

Results

In total, 355 patients were included. Of these, 152 patients with confirmed histological diagnosis had completed the questionnaires. A total of 106 patients were diagnosed with SCST and 46 with MOGCT.

Totally, 83 women (55%) were sexually active. After fertility-sparing surgery, patients had a 2.6 fold higher probability for being sexually active than after non-fertility-conserving treatment (unadjusted odds ratio (OR) 2.6, p = 0.01). After adjustment for age, time since diagnosis, FIGO stage, histology and phase of disease, the OR dropped to 1.8 (p = 0.22).

Of the sexually active patients, 35 (42%) reported high levels of discomfort during intercourse; 38% after fertility-sparing; and 58% after non-fertility-sparing surgery (adjusted OR 2.8, p = 0.18).

Women with fertility-conserving treatment reported a significantly better global QoL (F_adj 2.1, 6.2 points difference, p = 0.03) but not more pleasure during intercourse than women without fertility-sparing surgery (F_adj 0.4, p = 0.52).

Conclusion

Fertility preserving approaches should be offered to every patient, when oncologically acceptable.

Histopathology and prognosis of germ cell tumors metastatic to brain: cohort study

INTRODUCTION

Germ cell tumors (GCTs) are uncommon neoplasms predominantly arising in midline tissues. The prognostic significance of histopathology in predicting metastatic GCT behavior is poorly understood.

METHODS

Multicenter international cohort study including 29 patients with GCTs metastatic to brain were retrospectively investigated (18 patients from Mayo Clinic and 11 patients from the intracranial germ cell tumor genome analysis consortium in Japan). Clinical characteristics were analyzed using the Chi-square test (two-tailed) for categorical variables and using the log-rank test for survival data.

RESULTS

Median age at treatment was 31 years (range 14-58). Primary disease sites were testis (71%), mediastinum (18%), and female reproductive organs (11%). Median metastatic interval was 223 days (range, 6-6124). Median follow-up was 346 days (range, 1-5356), with 16 deaths (57%) occurring after the median overall survival of 455 days. Actuarial one-year survival was 51%; 12-of-16 deaths (75%) were attributed to intracranial disease. Appearance of the same GCT subtype at the metastatic site as the primary was high for non-seminomatous GCT (NSGCT, 64-100%), but low for seminoma/dysgerminoma and mature teratoma (MT, 14, 17%, respectively). Gain of a new component was seen in 4 (20%)-3 of which included embryonal carcinoma (EC) at the primary site (75%). Incidence of cases without seminoma/dysgerminoma increased significantly after metastasis (p = 0.02). Metastatic interval was shorter in cases with histological change (199 vs 454 days, p = 0.009). Overall survival was associated with MT primary histopathology (p = 0.02).

CONCLUSION

Histological differentiation at the primary GCT site influences metastatic prognosis. Aggressive behavior is associated with NSGCT, while EC frequently demonstrates multi-directional histological differentiation after brain metastasis, and such histological dynamism is associated with shorter metastatic interval. Most metastases occurred within one year of diagnosis, emphasizing the need for close surveillance in newly diagnosed extra-cranial GCT.

45,X/46,XY Mosaicism in an 18-year-old Girl with Primary Amenorrhea : A Case Report

45,X/46,XY mosaicism is a rare disorder with a wide heterogeneity in its manifestations. An 18-year-old girl was referred to the endocrine clinic for investigation of her primary amenorrhea. Clinical examination was unremarkable. Hormonal profile was consistent with primary ovarian insufficiency and human chorionic gonadotropin (hCG) stimulation did not show evidence of active testicular tissue. Karyotyping studies by G-banding revealed a 45,X/46,XY karyotype. She was diagnosed with mosaic Turner syndrome with Y chromosomal material and investigation was performed to identify the presence of male gonads due to the risk of gonadal malignancy. Magnetic resonance imaging (MRI) of the pelvis did not show evidence of gonads. Laparoscopic exploration was proposed but the patient and parents refused opting for conservative management. This case highlights the challenges in the management of this rare condition.

Gender issues of antibody-mediated diseases in neurology: (NMOSD/autoimmune encephalitis/MG)

Neuromyelitis optica spectrum disorder (NMOSD), autoimmune encephalitis (AE), myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) are antibody-mediated neurological diseases. They have mostly female predominance, affecting many women during childbearing age. Interactions between the underlying disease (or necessary treatment) and pregnancy can occur in every of these illnesses. Herein, we present the characteristics of NMOSD, AE, MG and LEMS in general, and review published data regarding the influence of the different diseases on fertility, pregnancy, puerperium, treatment strategy during pregnancy and post-partum period, and menopause but also male factors. We summarise key elements that should be borne in mind when confronted with such cases.

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.

Late Relapse of Ovarian Germ Cell Tumour

BACKGROUND

Malignant ovarian germ cell tumours typically require multimodal therapy including surgery and systemic platinum-based chemotherapy. Most patients are cured, with survival rates exceeding 95%.

CASE

This report describes an unusual case of ovarian germ cell tumour (GCT) recurring 15 years after surgery and manifesting as metastatic disease to the liver, lung, and retroperitoneal lymph nodes.

CONCLUSION

Thymic hyperplasia was a confounding finding in this case, and it should be considered in the differential diagnosis of a mediastinal mass in heavily treated patients with GCT.

Sex differences in autoimmune disorders of the central nervous system

Stronger adaptive immune responses in females can be observed in different mammals, resulting in better control of infections compared to males. However, this presumably evolutionary difference likely also drives higher incidence of autoimmune diseases observed in humans. Here, we summarize sex differences in the most common autoimmune diseases of the central nervous system (CNS) and discuss recent advances in the understanding of possible underlying immunological and CNS intrinsic mechanisms. In multiple sclerosis (MS), the most common inflammatory disease of the CNS, but also in rarer conditions, such as neuromyelitis optica spectrum disorders (NMOSD) or neuronal autoantibody-mediated autoimmune encephalitis (AE), sex is one of the top risk factors, with women being more often affected than men. Immunological mechanisms driving the sex bias in autoimmune CNS diseases are complex and include hormonal as well as genetic and epigenetic effects, which could also be exerted indirectly via modulation of the microbiome. Furthermore, CNS intrinsic differences could underlie the sex bias in autoimmunity by differential responses to injury. The strong effects of sex on incidence and possibly also activity and progression of autoimmune CNS disorders suggest that treatments need to be tailored to each sex to optimize efficacy. To date, however, due to a lack of systematic studies on treatment responses in males versus females, evidence in this area is still sparse. We argue that studies taking sex differences into account could pave the way for sex-specific and therefore personalized treatment.

Malignant ovarian germ cell tumours in the post-menopausal population

BACKGROUND

Malignant ovarian germ cell tumours (MOGCT) are uncommon in the general population and very rare in post-menopausal women.

AIMS

To evaluate the demographics, treatment and survival of post-menopausal women with MOGCT treated at the Queensland Centre for Gynaecological Cancer (QCGC) and compare these with pre-menopausal women.

MATERIALS AND METHODS

Retrospective analysis was performed of the QCGC database from January 1981 to February 2017. The disease course of post-menopausal women was compared with pre-menopausal women affected by MOGCT over the same period and compared with the world literature.

RESULTS

There were six post-menopausal women with MOGCT treated at the QCGC compared with 166 pre-menopausal women. In the post-menopausal group of women, there was no mortality directly attributed to germ cell ovarian disease compared with 10 (6.0%) women in the pre-menopausal group.

CONCLUSIONS

Malignant ovarian germ cell tumours are a very rare condition in post-menopausal women. Despite some suggestion in the world literature that survival outcomes are worse in this population, this was not found in our study.

Extradural Spinal Metastasis in Ovarian Mixed Germ Cell Tumor

Ovarian germ cell tumors (GCTs) are rare and affect mainly young girls and women. Two histological groups are distinguished: dysgerminomas and nondysgerminomatous tumors. These tumors have initial good responses to surgery and chemotherapy in 80% cases, but >75% of patients die due to complications of disease progression. There are very few case reports of mixed GCT with extradural spine metastases. We report a rare case of a 17-year-old girl who had undergone left salpingo-oophorectomy with omental and peritoneal biopsy for ovarian GCT with extradural spinal metastasis.

Ovarian Cancer in Young Women

It is not clear how often epithelial tumours affect young women. This study aimed to evaluate the clinico-pathological pattern and survival outcome of women, 40 years and younger, with cancer ovary. Women 40 years and younger, operated between 2008 and 2012 for ovarian cancer, were retrospectively recruited and followed up. The study design was descriptive as well as a survival analysis. A hybrid of retrospective and prospective cohort design was used for risk factor analysis. Of the 115 women less than 40 years being operated for probable ovarian cancer, 22 were excluded for various reasons. Demographic details, clinical presentations, histopathological features, treatments and survival outcomes were studied. The primary outcomes looked for were death and recurrence. Secondary outcomes were complications of treatment and fertility. The predominant histology in the study population was epithelial tumour (70%), and serous adenocarcinoma was the commonest tumour type. The overall survival rate was 87%, and progression free survival was 63%. Time to death and recurrence were dependent on stage of disease, histology of tumour, primary treatment and residual disease at surgery. In multivariate analysis, the hazard ratio for recurrence in advanced stages was 12.6 (95% CI 3.5 to 45.5; p < 0.001) as compared to early stage disease. Epithelial ovarian cancers are common in young women. Death and recurrence are more likely in women with epithelial cancers, advanced stage disease and in those with residual tumour at cytoreductive surgery.

Management of menopausal symptoms in women with gynecologic cancers

OBJECTIVE

Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients.

METHODS

MEDLINE was searched for studies on menopause management published in English through December of 2016.

RESULTS

Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking.

CONCLUSIONS

Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.

Insights into dovetailing GTD and Cancers

Gestational trophoblastic diseases (GTD) encompass a group of placental tumors which mostly arise due to certain fertilization defects, resulting in the over-proliferation of trophoblasts. The major characteristic of this diseased state is that β-hCG rises up manifold than that is observed during pregnancy. The incidence of GTD when analyzed on a global scale, figures out that there is a greater risk in South-East Asia, the reason of which remains unclear. An insight into any possible correlation of GTD incidence with cancers, other than choriocarcinoma, is being attempted here. Also, we review the recent developments in research on the molecular etiopathology of GTD. This review would render a wider eye towards a new paradigm of thoughts to connect GTD and breast cancer, which has not been into the picture till date.

Menopausal hormone therapy in cancer survivors: A narrative review of the literature

Decision making regarding the use of menopausal hormone therapy (MHT) for the treatment of bothersome menopausal symptoms in a cancer survivor can be complex, and includes assessment of its impact on disease-free or overall survival. Estrogen receptors are present in several cancer types, but this does not always result in estrogen-mediated tumor proliferation and adverse cancer-related outcomes. Estrogen may even be protective against certain cancers. Menopausal hormone therapy is associated with an increased risk of recurrence and mortality after diagnosis of some cancer types, but not others. We provide a narrative review of the medical literature regarding the risk of cancer recurrence and associated mortality with initiation of MHT after the diagnosis of breast, gynecologic, lung, colorectal, hematologic cancers, and melanoma. Menopausal hormone therapy may be considered for management of bothersome menopausal symptoms in women with some cancer types (e.g., colorectal and hematologic cancer, localized melanoma, and most cervical, vulvar and vaginal cancers), while nonhormonal treatment options may be preferred for others (e.g., breast cancer). In women with other cancer types, recommendations are less straightforward, and the use of MHT must be individualized.

Chemotherapy in ovarian germ cell tumors: A systematic review

OBJECTIVE

Ovarian germ cell tumors (OGCTs) are rare tumors that comprise a diverse group of histologic subtypes that can either be benign or malignant. Malignant ovarian germ cell tumors (OGCTs) historically carried a poor prognosis, especially among those diagnosed with advanced disease. With the advent of combination chemotherapy, risk of relapse has markedly decreased. There is limited prospective data on the efficacy of specific chemotherapy regimens in the treatment of malignant OGCTs. This article critically reviews the literature pertinent to the treatment of OGCTs with chemotherapy.

METHODS

MEDLINE was searched for English language literature on prospective studies on the treatment of malignant OGCTs, focusing on publications since 1995.

RESULTS

As modern chemotherapy regimens have evolved, risk of relapse has decreased with implementation of platinum based regimens in the adjuvant setting. However, the role of neoadjuvant platinum based regimens and treatment of metastatic or recurrent malignant OGCTs remains poorly understood due to lack of randomized control trials.

CONCLUSIONS

Malignant OGCTs represent a rare subset of ovarian neoplasms for which focused, prospective clinical trials are needed to determine the most effective therapies.

Development of a risk stratification system to guide treatment for female germ cell tumors

OBJECTIVE

Due to their rarity, little is known about prognostic factors in female germ cell tumors (GCTs) or outcomes following systemic therapy. Management is largely based on studies of male GCT and epithelial ovarian cancer.

METHODS

Chart review was performed for all females with GCT seen at Memorial Sloan Kettering Cancer Center (MSKCC) from 1990 to 2012. Patients receiving chemotherapy were stratified using a modification of the male IGCCCG risk system, and the classifier was correlated with outcome.

RESULTS

Of 93 patients, 92 (99%) underwent primary surgery and 85 (92%) received chemotherapy. Modified IGCCCG classification was significantly associated with progression-free survival (PFS) and overall survival (OS), both when applied preoperatively and pre-chemotherapy (p<0.001 for all four analyses). Progression after initial chemotherapy (n=29) was detected by imaging in 14 (48%) patients, by serum tumor markers in 6 (21%) patients, and by multiple methods in the rest. Seven (29%) of 24 patients treated with salvage chemotherapy achieved long-term PFS, including 4/6 who received high-dose chemotherapy (HDCT) as initial salvage versus 3/16 treated with other initial salvage regimens. The estimated 3-year OS rate was 84% (95% CI, 76-92%), with a trend favoring dysgerminoma over non-dysgerminoma histologies (p=0.12).

CONCLUSIONS

Modified IGCCCG classification was prognostic for female GCT patients in this cohort and identified a poor-risk group who may benefit from more intensive first-line chemotherapy. Both imaging and tumor marker evaluation were important in identifying relapses after first-line chemotherapy. The majority of long-term remissions with salvage therapy were achieved with initial salvage HDCT.

Cutaneous Fistulization of an Ovarian Mature Cystic Teratoma: An Unusual Occurrence

A bilobulated mature cystic teratoma (MCT) at the left ovary measuring 6 cm in diameter fistulized to the left lower quadrant of the anterior abdominal wall, contralateral to McBurney's point. This is the first reported case of a MCT fistulized to the skin. Symptoms, if present, usually depend on the size of the teratoma. However, most patients with a MCT are asymptomatic. Complications such as rupture of the cyst capsule are quite rare. Moreover, complication of fistulization is highly infrequent.

The Role of Human Chorionic Gonadotropin as Tumor Marker: Biochemical and Clinical Aspects

Tumor markers are biological substances that are produced/released mainly by malignant tumor cells, enter the circulation in detectable amounts and are potential indicators of the presence of a tumor. The most useful biochemical markers are the tumor-specific molecules, i.e., receptors, enzymes, hormones, growth factors or biological response modifiers that are specifically produced by tumor cells and not, or minimally, by the normal counterpart (Richard et al. Principles and practice of gynecologic oncology. Wolters Kluwer Health, Philadelphia, 2009). Based on their specificity and sensitivity in each malignancy, biomarkers are used for screening, diagnosis, disease monitoring and therapeutic response assessment in clinical management of cancer patients.This chapter is focused on human chorionic gonadotropin (hCG), a hormone with a variety of functions and widely used as a tumor biomarker in selected tumors. Indeed, hCG is expressed by both trophoblastic and non-trophoblastic human malignancies and plays a role in cell transformation, angiogenesis, metastatization, and immune escape, all process central to cancer progression. Of note, hCG testing is crucial for the clinical management of placental trophoblastic malignancies and germ cell tumors of the testis and the ovary. Furthermore, the production of hCG by tumor cells is accompanied by varying degrees of release of the free subunits into the circulation, and this is relevant for the management of cancer patients (Triozzi PL, Stevens VC, Oncol Rep 6(1):7-17, 1999).The name chorionic gonadotropin was conceived: chorion derives from the latin chordate meaning afterbirth, gonadotropin indicates that the hormone is a gonadotropic molecule, acting on the ovaries and promoting steroid production (Cole LA, Int J Endocrinol Metab 9(2):335-352, 2011). The function, the mechanism of action and the interaction between hCG and its receptor continue to be the subject of intensive investigation, even though many issues about hCG have been well documented (Tegoni M et al., J Mol Biol 289(5):1375-1385, 1999).

State of the art review in gonadal dysgenesis: challenges in diagnosis and management

Gonadal dysgenesis, a condition in which gonadal development is interrupted leading to gonadal dysfunction, is a unique subset of disorders of sexual development (DSD) that encompasses a wide spectrum of phenotypes ranging from normally virilized males to slightly undervirilized males, ambiguous phenotype, and normal phenotypic females. It presents specific challenges in diagnostic work-up and management. In XY gonadal dysgenesis, the presence of a Y chromosome or Y-chromosome material renders the patient at increased risk for developing gonadal malignancy. No universally accepted guidelines exist for identifying the risk of developing a malignancy or for determining either the timing or necessity of performing a gonadectomy in patients with XY gonadal dysgenesis. Our goal was to evaluate the literature and develop evidence-based medicine guidelines with respect to the diagnostic work-up and management of patients with XY gonadal dysgenesis. We reviewed the published literature and used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) system when appropriate to grade the evidence and to provide recommendations for the diagnostic work-up, malignancy risk stratification, timing or necessity of gonadectomy, role of gonadal biopsy, and ethical considerations for performing a gonadectomy. Individualized health care is needed for patients with XY gonadal dysgenesis, and the decisions regarding gonadectomy should be tailored to each patient based on the underlying diagnosis and risk of malignancy. Our recommendations, based on the evidence available, add an important component to the diagnostic and management armament of physicians who treat patients with these conditions.

Safety of hormone replacement therapy in gynaecological cancer survivors

Therapy for endometrial, ovarian and cervical cancer in young women can cause sudden onset of intense menopausal symptoms, such as hot flushes, emotional disorders and sexual dysfunction. In order to overcome these unpleasant and sometimes severe symptoms, hormone replacement therapy (HRT) has proven to be very effective. However, its safety remains controversial. We reviewed English literature and examined whether administration of HRT in this specific population is related with more recurrences and worse prognosis. Current scientific data, comprising mainly retrospective studies, suggest that recurrence rates and survival are comparable between HRT users and non-users. However, large randomised trials are missing and definitive conclusions cannot be drawn. Gynaecological cancer survivors using HRT, although they seem to have little if any risk for recurrence, should be correctly informed about the lack of strong evidence.

Ovarian tumor-derived ectopic hyperprolactinemia

To describe extreme hyperprolactinemia originating from a pituitary adenoma in the wall of an ovarian dermoid. This is a description of an unusual case and a review of ectopic prolactin production. Ectopic production of prolactin is a rare condition that has been reported in isolated organ system pathology including ovaries. An ovarian dermoid is a benign neoplasm that has the potential for active unregulated endocrine function. Hyperprolactinemia can result from functioning lactotrophs found in ovarian dermoids and can lead to clinical sequelae. Definitive treatment of the condition requires surgical removal of the functioning endocrine tissue. Extreme hyperprolactinemia caused by a pituitary tumor located within a dermoid has not been reported before. We present a case of profound hyperprolactinemia originating from a pituitary adenoma found in the wall of an ovarian dermoid and give a broad overview of the condition and literature. Ectopic prolactin production should always be considered in symptomatic patients found to have elevated serum levels and no findings on brain imaging.

[Ovarian yolk sac tumour: general review]

Ovarian yolk sac tumour (OYST) is a very rare malignancy arising most often in young women. Preoperative clinical, biological (alpha-foetoprotein) and radiological findings should help to establish the diagnosis of OYST, in order to propose adequate surgical treatment. The aim of surgery is to remove the primary tumour, to obtain an accurate histological diagnosis and to assess the disease extent. In young women, fertility-sparing surgery should be performed, in order to preserve the possibility of pregnancy later on. Chemotherapy has substantially modified the prognosis of these tumours, and practically all patients will be cured. The overall 5-year survival rate is 94% when patients are treated with BEP chemotherapy. Depending on the clinical situation, two to four cycles of the BEP regimen should be administered after surgery. Identification of prognostic factors may help to propose risk-adapted treatment in order to increase the cure rate in patients with a poor prognosis and to decrease toxicity in patients with a low risk of relapse. Fertility preservation represents a major objective in women treated for OYSTs.

Dysgerminoma and gonadal dysgenesis: the need for a new diagnosis tree for suspected ovarian tumours

PURPOSE

Diagnosis of dysgerminoma in the paediatric age group is uncommon, and most cases arise from dysgenetic gonads of 46, XY pure gonadal dysgenesis (PGD) patients. Bilateral gonadectomy is mandatory in these patients. So, the preoperative diagnosis of PGD is important in order to avoid multiple surgical procedures and delayed patient information in the case of a suspected 'ovarian' tumour. Our aim was to discuss preoperative clues that can lead to suspicion of dysgerminoma in the context of PGD.

MATERIALS AND METHODS

We reviewed the charts of six patients treated for dysgerminoma associated with 46, XY PGD. We focused on particularities of clinical and biological evaluations.

RESULTS

Median age at diagnosis was 11 years. Pubertal development was absent or incomplete even at late ages. Dysgerminoma was associated with gonadoblastoma foci in all cases. Tumoral marker profile was a normal alfafetoprotein level, a high lactate dehydrogenase level and normal or moderate human chorionic gonadotropin (βHCG) secretion, except for one patient who had a mixed tumour with notably a choriocarcinoma share (high βHCG). Follicle-stimulating hormone (FSH) level was very high in all patients tested and, interestingly, also in one prepubertal patient.

CONCLUSIONS

In the case of a suspected ovarian tumour, delayed pubertal development, moderate βHCG level and elevated FSH level are clinical and biological clues to a diagnosis of dysgerminoma in the context of PGD and should prompt karyotype analysis before surgery. Because FSH is an efficient indirect marker of this condition, we suggest including this analysis in the management of gonadal tumours.

Pediatric malignant ovarian tumors: 15 years of experience at a single institution

BACKGROUND

Malignant ovarian tumors in children are relatively rare. We reviewed our 15-year experience to understand their clinical presentations, managements, and prognoses.

METHODS

There were 15 children who were diagnosed to have malignant ovarian tumors from January 1994 to June 2009 in our hospital. The presenting symptoms, treatments, and outcomes were obtained retrospectively from the medical records.

RESULTS

The median age at presentation was 13 years. The most common presenting symptom was abdominal pain, occurring in 10 patients (66.7%). The tumors were in the left side in 10 patients (66.7%). The pathologic diagnoses were yolk sac tumors in four patients, immature teratomas in four, dysgerminomas in three, malignant mixed germ cell tumors in three, and carcinosarcoma in one patient. According to the Federation Internationale de Gynecologie Oncologique classification, seven girls had Stage I, one had Stage II, and seven had Stage III disease. Thirteen patients received chemotherapy with platinum-based regimens. Three patients died of their disease: one of yolk sac tumor, one of malignant mixed germ cell tumor, and one of carcinosarcoma. They all had Stage III disease at diagnosis. The 10-year overall survival and disease-free survival rates were 77% and 69%, respectively.

CONCLUSIONS

Pediatric malignant ovarian tumors were highly curable disease if they were not in the advanced stage at presentation. Earlier consideration of malignant ovarian tumor in the differential diagnosis of young girls with abdominal pain is important.

46,XY pure gonadal dysgenesis: clinical presentations and management of the tumor risk

PATIENTS

Eleven patients with 46,XY PGD were divided into two groups. Six symptomatic girls (group 1) were referred for amenorrhea (n = 3), gonadal tumor (n = 2) or campomelic dysplasia (n = 1). Five asymptomatic screened patients (group 2) were diagnosed as 46,XY PGD after familial investigation of the two probands with gonadal tumor. Bilateral gonadectomy was performed in all patients.

RESULTS

In group 1, pathologic examination revealed an association of dysgerminoma with gonadoblastoma (n = 2), bilateral gonadoblastoma (n = 2) and streak gonads (n = 2). Prophylactic gonadectomy in asymptomatic patients (group 2) also showed asymptomatic dysgerminoma with gonadoblastoma (n = 1), bilateral gonadoblastoma (n = 2) and streak gonads (n = 2).

CONCLUSIONS

A gonadal tumor arising in a girl with pubertal delay may be related to dysgenesis of the gonad. Primary amenorrhea or diagnosis of dysgerminoma should warrant karyotype, and familial study if 46,XY PGD is found. Considering the high incidence of gonadoblastoma and the early occurrence of dysgerminoma, early bilateral gonadectomy is recommended.

Hormone replacement after gynaecological cancer

Treatment of gynaecological cancer frequently results in the loss of ovarian function and menopausal symptoms. Symptoms of iatrogenic menopause are usually significantly more intense than those of natural menopause due to sudden onset of symptoms, younger age and its effects on common physical and psychological problems of cancer therapy like body image concerns and sexual dysfunction. The most effective treatment for menopausal symptoms is hormone replacement therapy (HRT). However, it is very controversial if HRT is safe in patients after a gynaecological malignancy. The main concerns are the potential stimulation of residual cancer and the induction of new hormone-dependent disease. However, the majority of the most common gynaecological malignancies like squamous cell carcinomas of the cervix, serous papillary epithelial ovarian carcinomas and squamous cell carcinomas of the vulva are not oestrogen dependent. Furthermore, current scientific evidence does not show HRT to adversely affect the outcome in patients after treatment for hormone sensitive cancers like early stage endometrioid adenocarcinomas of the endometrium. There are only a small number of gynaecological malignancies like low grade endometrial stromal sarcomas in which HRT is an absolute contraindication. Therefore, as maintaining quality of life and minimising the physical and psychological impact of treatment side effects is one of the most important factors in cancer care, it is imperative to give patients unbiased information about their individual cancer which in most cases will allow them to use HRT without any detrimental effect on their survival.

Anti-NMDA receptor encephalitis: report of ten cases and comparison with viral encephalitis

The California Encephalitis Project (CEP), established in 1998 to explore encephalitic etiologies, has identified patients with N-methyl-D-aspartate receptor (NMDAR) antibodies, the likely etiology of their encephalitis. This study compares the presentation of such patients to those with viral encephalitis, so that infectious disease clinicians may identify individuals with this treatable disorder. Patients were physician-referred, and standardized forms were used to gather demographic, clinical, and laboratory data. Features of anti-NMDAR+ patients were compared with the viral encephalitides of enteroviral (EV), rabies, and herpes simplex-1 (HSV-1) origins. Sixteen cases with confirmed viral etiologies were all negative on NMDAR antibody testing. Ten anti-NMDAR+ patients were profiled with a median age of 18.5 years (range 11-31 years). None were Caucasian. They had a characteristic progression with prominent psychiatric symptoms, autonomic instability, significant neurologic abnormalities, and seizures. Two had a teratoma, and, of the remaining eight, four had serologic evidence of acute Mycoplasma infection. The clinical and imaging features of anti-NMDAR+ patients served to differentiate this autoimmune disorder from HSV-1, EV, and rabies. Unlike classic paraneoplastic encephalitis, anti-NMDAR encephalitis affects younger patients and is often treatable. The association of NMDAR antibodies in patients with possible Mycoplasma pneumoniae infection warrants further study.

Improvement in the outcome of children with germ cell tumors

PURPOSE

To describe the clinical characteristics and estimate the survival of children and adolescents with germ cell tumors treated with cisplatin-based combination chemotherapy according to three different protocols in Brazil.

METHODS

From 1983 to 1997, 106 patients were treated at the Hospital do Cancer, Sao Paulo for a diagnosis of germ cell tumor. We performed a retrospective review of the clinical and histopathological data to identify prognostic factors and evaluate their outcome.

RESULTS

Patients were treated with only surgery (n = 32), surgery and radiotherapy (n = 1) and chemotherapy (n = 73). From 1983 to 1986 (period I), there were 30 patients and 21 received chemotherapy according to the modified VAB-6 protocol. Twenty-two of 35 patients registered between 1987 and 1991 (period II) were treated with EPO/VAC combination chemotherapy. From 1991 to 1997 (period III), there were 41 patients and 31 received chemotherapy according to the Brazilian TCG-91 protocol. Important prognostic factors included stage (P < 0.001), metastatic status (P < 0.001) and surgical procedure at diagnosis (P < 0.001). An incremental improvement in outcomes was noted across the periods of treatment (P = 0.070). Five-year OS was respectively 42.9 +/- 10.8%, 53.9 +/- 11.4% and 80.6 +/- 7.1% for periods I, II, and III for the patients who received chemotherapy.

CONCLUSION

An improvement in the survival of children with germ cell tumors was achieved in the most recent trial (TCG-91) with a risk adapted approach incorporating only cisplatin and etoposide. These results indicate that in selected patients complex three-agent regimens may not be necessary to achieve long term survival.

A large struma ovarii tumor removed via laparoscopy in a 16-year-old adolescent

Struma ovarii is rare ovarian tumor that is characterized by the presence of at least 50% thyroid tissue on histologic examination. This usually benign neoplasm is predominantly found in women between the ages of 40 and 60 years and infrequently in the pediatric age group. In the foregoing report, we present an unusual case of a large struma ovarii in a 16-year-old adolescent girl with abdominal pain and increasing abdominal girth. Removal of the mass was achieved via a laparoscopic approach. We conclude that the diagnosis of struma ovarii should be considered in adolescent girls presenting with large cystic ovarian masses and that a laparoscopic approach to management is the treatment of choice.

Malignant Adnexal Masses in Pregnancy

Ovarian tumors during pregnancy are very rare; however, a cancer diagnosis causes distress to the couple. Reassurance is paramount, and the first consideration should be given to the safety of the mother. If both mother and fetus can be preserved, treatment to minimize the risks to both should be planned accordingly. It is imperative to care for the patient with a multidisciplinary team that includes a high-risk obstetrician, a gynecologic oncologist, and a medical oncologist specialized in gynecologic cancers.

Endodermal sinus tumor of the vulva: successfully treated with high-dose chemotherapy

Endodermal sinus tumors (EST) of the lower female genital tract are uncommon malignancies. Most of these tumors are found in the vagina or in the cervix. Only seven cases of EST involving the vulva are reported. We report an eighth case of vulvar EST. The patient recurred and was successfully treated with high-dose chemotherapy and peripheral blood cell transplantation. Because of their location, an early diagnosis of vulvar EST should be possible. Resection of the lesion by using a modified radical vulvectomy followed by cisplatin-based chemotherapy seems the best treatment for these tumors today. Our patient was initially treated with the help of local surgery and adjuvant chemotherapy consisting of three courses of etoposide and cisplatin. Sixteen months after the first diagnosis, pleural and lung metastases were diagnosed. Second-line chemotherapy followed by high-dose chemotherapy with autologous peripheral blood stem cell support was administered after resection of the lung metastases and biopsy of the pleural metastases. There is no evidence of disease 40 months after the diagnosis of the lung and pleural metastases, and 56 months after the primary diagnosis.

Human chorionic gonadotropin in cancer

Human chorionic gonadotropin (hCG) is mainly used for detection and monitoring of pregnancy and pregnancy-related disorders but it is also an extremely sensitive and specific marker for trophoblastic tumors of placental and germ cell origin. Thus treatment of relapsing choriocarcinomas and testicular germ cell tumors is often initiated on the basis of rising hCG levels even in the absence of clinical or histological evidence of a relapse. While these tumors mostly produce the intact heterodimeric hormone consisting of an alpha (hCGalpha), and a beta subunit (hCGbeta), many nontrophoblastic tumors produce only hCGbeta This is usually a sign of aggressive disease and elevated serum levels of hCGbeta are strongly associated with poor prognosis. Elevated serum levels are observed in 45-60% of patients with biliary and pancreatic cancer and in 10-30% of most other cancers. Methods that detect hCG and hCGbeta together are mainly used for measurement of hCG-like immunoreactivity in serum. However, the reference range for hCG is 5-8 fold higher than that for hCGbeta and thus moderately elevated levels can be identified only with a specific and sensitive hCGbeta assay.

Oct-3/4 is a dose-dependent oncogenic fate determinant

The Oct-3/4 transcription factor sustains embryonic stem (ES) cell self-renewal and is a dose-dependent cell fate determinant. In the adult male, its expression is restricted to type A spermatogonia. We show that Oct-3/4 is expressed in all human testicular germ cell tumors (GCTs) tested, even in the early premalignant component. We demonstrate that Oct-3/4 dictates ES cells' oncogenic potential in a dose-dependent manner; high levels increase the malignant potential of ES cell-derived tumors while Oct-3/4 inactivation induces regression of the malignant component. Oct-3/4 expression in a heterologous cell system transforms nontumorigenic cells and endows tumorigenicity in nude mice. Our findings suggest that Oct-3/4 is not only a distinctive immunohistochemical marker for GCTs, but also plays a critical role in the genesis of these tumors.