Characteristics, treatment and outcomes of women with immature ovarian teratoma, 1998-2012

Management strategy for children with ovarian immature teratoma: results from a tertiary pediatric oncology center

OBJECTIVES

We present an Egyptian study on pediatric ovarian immature teratomas (ITs), aiming to clarify our treatment strategy selection.

METHODS

A retrospective review of all children with pure ovarian ITs who were treated at our institution between 2008 and 2023. The analysis included clinical characteristics, tumor staging according to Children's Oncology Group (COG), grading based on the Norris system, management, and outcomes.

RESULTS

Thirty-two patients were included, with a median age of 9 years. All patients underwent primary surgery. Unilateral salpingo-oophorectomy was performed in 31 patients. Surgical staging was completed in all patients. Based on COG staging, there were 28 patients (87.5%) stage I, 1 (3%) stage II, and 3 (9.5%) stage III. According to Norris classification, 16 patients (50%) were classified as grade I, 9 (28%) grade II, and 7 (22%) grade III. All patients in stage I were treated using surgery-alone approach, whereas the remaining four (12.5%) received adjuvant chemotherapy. Five patients in stage I had gliomatosis peritonei (GP), and none of them underwent extensive surgery. At a median follow-up of 86 months, two patients had events. The first patient (stage III/grade I) developed IT relapse on the operative bed, and the second (stage I/grade I) had a metachronous IT on the contralateral ovary. Both patients were successfully managed with surgery followed by second-line chemotherapy. Five-year overall survival and event-free survival for all patients were 100% and 93.4%, respectively.

CONCLUSIONS

Surgery-alone strategy with close follow-up achieves excellent outcomes for localized ovarian ITs in children, irrespective of the Norris grading or the presence of GP. However, adjuvant chemotherapy is questionable for patients with incompletely resected or locally advanced tumors, and its role requires further evaluation through prospective multicentric studies with a larger sample size.

Comparison of overall and patterns of care in patients with a malignant ovarian germ cell tumor by age in the United States: a National Cancer Database (2004-2016) analysis

BACKGROUND

Women aged ≥40 years diagnosed with a malignant ovarian germ cell tumor are more likely to have poor outcomes than their younger counterparts (aged 15-39 years).

OBJECTIVE

We used the National Cancer Database (NCDB) to evaluate patterns of care and overall survival for individuals diagnosed with one of the four most common histologic subtypes of malignant ovarian germ cell tumor by age group.

METHODS

We identified women aged 15-90 diagnosed with ovarian germ cell tumors in the NCDB (2004-2016). Logistic regression was used to compare patterns of care, demographic, and disease characteristics by age group. Cox proportional hazards regression was used to evaluate associations between a range of demographic, clinical, and treatment characteristics with overall survival.

RESULTS

A total of n=2998 patients who were diagnosed with one of the four most common histologic subtypes (immature teratoma, dysgerminoma, yolk sac tumor, and mixed germ cell) of ovarian germ cell tumor were included in the analysis. Patients aged ≥40 years diagnosed with ovarian germ cell tumors were more likely to have co-morbidities, a bilateral tumor, higher stage of disease, receive chemotherapy only, and have a residual tumor after resection as compared with patients aged <40 years. Moreover, women aged ≥40 years had the highest risk of death (reference: 15-24 year olds; HR=5.37, 95% CI 3.76 to 7.66) after adjustment for demographic characteristics, tumor histology, and treatment received. In stratified analyses, women aged ≥40 years had significantly worse overall survival at each disease stage and histologic subtype.

CONCLUSION

Findings suggest that women aged ≥40 years who are diagnosed with ovarian germ cell tumors have worse overall survival than those aged <40, independent of stage, disease characteristics, and treatment. Our study highlights the need for future research to better understand reasons for poorer outcomes in women aged ≥40 years.

Component Patterns and Survival Outcomes in Patients with Mixed Malignant Ovarian Germ Cell Tumors: A Retrospective Cohort Study

AIMS

To evaluate the component patterns and risk stratification in patients with mixed malignant ovarian germ cell tumors (mMOGCT).

METHODS

A retrospective study of 70 mMOGCT patients treated in our hospital between 2000 and 2022 was conducted. The recurrence-free survival (RFS), disease-specific survival (DSS), and risk stratification systems based on scoring the identified prognostic factors were assessed.

RESULTS

Yolk sac tumor component was the most common type (80%), followed by dysgerminoma (50%), immature teratoma (40%), embryonic carcinoma (27.1%), and chorionic carcinoma (15.7%). The 5-year RFS and DSS rates were 77.9% and 87.9%, respectively. International federation of gynecology and obstetrics (FIGO) stage III-IV (RR 3.253, P = 0.029) and normalization of tumor marker (TM) ≤ 3 cycles of chemotherapy (RR 6.249, P = 0.017) were risk factors for RFS and DSS, respectively. Significant DSS (RR 8.268, P = 0.006) was also noted between patients who had normalized TM ≤ 4 and ≥5 cycles of chemotherapy. FIGO stages I-II and stages III-IV were scored as 0 and 2, respectively. AFP normalization ≤3, 4, and ≥5 cycles of chemotherapy were scored as 0, 1, and 4, respectively. A total score of 0, 1-2, and ≥3 stratified patients into low-risk (43 patients), intermediate-risk (13 patients), and high-risk groups (14 patients), respectively. Patients in three risk stratifications manifested significant differences in DSS (P = 0.010) but not in RFS (P > 0.05).

CONCLUSION

Distinct different component patterns existed among mMOGCT patients, and predicting survival outcomes in a universal model was challenging.

Outcome of patients with stage I immature teratoma after surveillance or adjuvant chemotherapy

Objective

Immature teratomas are rare malignant ovarian germ cell tumours, typically diagnosed in young women, where fertility-sparing surgery is the treatment of choice. The role of adjuvant chemotherapy in stage I disease remains controversial. We evaluated the impact of surveillance versus chemotherapy on the recurrence rate in stage I immature teratomas.

Methods

We collected a single centre retrospective series of patients with stage I immature teratomas treated with fertility-sparing surgery at San Gerardo Hospital, Monza, Italy, between 1980 and 2019. Potential risk factors for recurrence were investigated by multivariate logistic regression.

Results

Of the 74 patients included, 12% (9/74) received chemotherapy, while 88% (65/74) underwent surveillance. Median follow-up was 188 months. No difference in recurrence was found in stage IA/IB and IC immature teratomas [10% (6/60) vs. 28.6% (4/14) (P=0.087)], grade 1, grade 2, and grade 3 [7.1% (2/28) vs. 14.3% (4/28) vs. 22.2% (4/18) (p=0.39)], and surveillance versus chemotherapy groups [13.9% (9/65) vs. 11.1% (1/9)) (p = 1.00)]. In univariate analysis, the postoperative approach had no impact on recurrence. The 5-year disease-free survival was 87% and 90% in the surveillance and chemotherapy groups, respectively; the overall survival was 100% in both cohorts.

Conclusions

Our results support the feasibility of surveillance in stage I immature teratomas. Adjuvant chemotherapy may be reserved for relapses. However, the potential benefit of chemotherapy should be discussed, especially for high-risk tumours. Prospective series are warranted to confirm our findings.

What is already known on this topic

To date, no consensus has been reached regarding the role of adjuvant chemotherapy in stage I immature teratomas of the ovary. Some studies suggest that only surveillance is an acceptable choice. However, guidelines are not conclusive on this topic.

What this study adds

No difference in terms of recurrence was observed between the surveillance and the adjuvant chemotherapy group. All patients who relapsed were successfully cured with no disease-related deaths.

How this study might affect research practice or policy

Adjuvant chemotherapy should be appropriately discussed with patients. However, it may be reserved for relapse according to our data.

Immature ovarian teratoma in a 20-year-old woman: A case report

Immature ovarian teratomas are a rare subtype of germ cell tumours characterized by the presence of embryonic elements, particularly primitive neuroepithelium, and they typically affect young women. We report the case of a 20-year-old woman who presented with a growing abdominal mass that turned out to be a grade II immature teratoma after adnexectomy. This article reviews the clinical presentation, imaging features, and some of the main problems that arise in the management of immature ovarian teratomas.

Prognostic factors for pure ovarian immature teratoma and the role of adjuvant chemotherapy in stage I diseases

BACKGROUND

The prognostic factors for patients with pure ovarian immature teratoma (POIT) and the role of adjuvant chemotherapy in stage IA G2-G3 and IB-IC POIT remains controversial.

METHODS

We conducted a retrospective study of 155 POIT patients treated in our hospital between 2000 and 2022. The recurrence-free survival (RFS), disease-specific survival (DSS), and potential prognostic factors of POIT patients were evaluated. Subgroup analysis was conducted in stage I other than stage IA G1 POIT.

RESULTS

The median age at diagnosis was 23.0 years (range: 4.0 - 39.0), and 126 (81.3%), 2 (1.3%), 26 (16.8%), and 1 (0.6%) patients had FIGO stage I, stage II, stage III, and stage IV disease, respectively. Twenty-three patients relapsed and five died of the diseases after a median follow-up of 7.6 years, with a 5-year RFS and DSS rate of 86.0% and 97.0%, respectively. Multivariate analysis showed that positive postoperative tumour markers (TM) were the risk factor for recurrence in the overall cohort (hazard ratio [HR] 4.058, 95% CI 1.175 - 14.019, p = 0.027) and subgroup (HR 10.237, 95% CI 2.175 - 48.179, p = 0.003), and FIGO stage II-IV was the only factor for DSS in overall cohort (HR 7.751, 95% CI 1.281 - 46.895, p = 0.026). In 110 patients subjected to subgroup analysis, 29 patients received surveillance without chemotherapy and 81 patients were administered adjuvant chemotherapy. Multivariate analysis revealed active surveillance significantly increased the recurrence rate (5-year RFS of 75.7% vs. 93.6%, HR 7.562, 95% CI 2.441 - 23.424, p < 0.001) but not the death related to POIT (p = 0.338).

CONCLUSION

Positive postoperative TM and FIGO stage II-IV were the prognostic factors for POIT. Active surveillance in stage I POIT of any grade may be practical for those with negative postoperative TM.

Seminoma and dysgerminoma: evidence for alignment of clinical trials and de-escalation of systemic chemotherapy

Malignant germ cell tumours are a group of rare cancers whose incidence peaks in late adolescence and early adulthood. Dysgerminomas of the ovary and seminomas of the testis are analogous diseases, but seminomas have a 10-fold higher incidence. The two tumours are morphologically identical and are only differentiated by surrounding organ-specific tissue or testicular germ cell neoplasia in situ. They share genetic features including KIT and RAS mutations, amplification of chromosome 12p, and expression of pluripotency markers (NANOG (Nanog homeobox), OCT3/4 (Octamer-binding transcription factor 3/4), and SAL4 (Spalt-like trascription factor 4)). Both histologies are exquisitely sensitive to platinum chemotherapy, and the combination of bleomycin, etoposide, and cisplatin (BEP) yields survival rates greater than 90%. However, BEP causes significant, lifelong toxicity (cardiovascular, renal, respiratory, and neurological) in these young patients with an expectation of cure. Here, we comprehensively review the biological features of dysgerminoma and seminoma to demonstrate that they are biologically analogous diseases. We present available clinical trial data supporting de-escalation of chemotherapy treatment. Finally, we propose that future trials should enrol men, women, and children to benefit all patients regardless of age or sex.

Immature Teratoma in Pregnancy: A Case Report

Immature teratoma is one of the rare malignant germ cell tumours presented in pregnancy. Here, we present 26-year-old pregnant women who had an incidental finding of left adnexal mass in an anomaly scan at 19 weeks of pregnancy. Laparotomy with peritoneal fluid cytology, left salpingo-oophorectomy and omental biopsy at 20 weeks of pregnancy revealed immature teratoma stage 1A, grade 2 in the histopathology report. However, she followed up with the metastatic mass in the pouch of Douglas at 30 weeks of pregnancy in magnetic resonance imaging despite being counselled for possible chemotherapy and surveillance. A baby with a good Apgar score and grade 3 immature teratoma in the metastatic mass was revealed following the exploratory laparotomy and cesarean section at 36 weeks of pregnancy. Fertility-sparing surgery with chemotherapy during pregnancy for high-grade tumours may result in a good prognosis.

Keywords

case reports; chemotherapy; immature teratoma; pregnancy; surgery.

Immature Teratoma: Diagnosis and Management-A Review of the Literature

An immature teratoma is a germinal malignant tumor composed of three germ cell layers, occurring more frequently in young women. It is the second most frequent among the malignant germinal tumors after dysgerminoma, and it is the only neoplasm with germ cells that are histologically graded. Even if we do not have a consensus regarding its therapeutical management, it has a good prognosis, with an excellent overall survival rate and good fertility preservation. More studies are needed regarding the necessity of adjuvant chemotherapy in pediatric oncology, and because of chemotherapy's long-term adverse effects, surveillance or a targeted treatment is preferred, but the main therapy is fertility-sparing surgery. Special attention should be given to the genetic mapping of the histological pieces for patient risk stratification due to its value in prognosis and future treatment.

Role of Adjuvant Chemotherapy in Stage I Pure Ovarian Immature Teratoma: A Systematic Review and Meta-Analysis

To determine the role of adjuvant chemotherapy in stage IA G2-3 and stage IB-IC pure ovarian immature teratoma (POIT), we performed a systematic review and meta-analysis by searching PubMed, Embase, Cochrane library, Web of Science, and ClinicalTrials.gov. Randomized controlled trials or cohort studies on stage IA G2-G3 or stage IB-IC POIT between 1 January 1970 and 15 December 2022 were enrolled. The recurrence rate and mortality rate were the primary outcomes, and subgroup analysis based on the tumor stage and grade was also conducted. In total, 15 studies with 707 patients were included. Compared with surveillance, adjuvant chemotherapy significantly decreased the mortality rate (RR 0.31, 95% CI 0.11–0.88, p = 0.03), but not recurrence (RR 0.74, 95% CI 0.39–1.42, p = 0.37), in the overall population. Subgroup analysis showed no statistical difference in the recurrence rate and mortality rate between patients who received adjuvant chemotherapy and surveillance in pediatric POIT, stage IA G2-3 POIT, stage IB-IC POIT, and stage IA-IC G3 POIT (all with p > 0.05). However, patients who underwent adjuvant chemotherapy appeared to have a lower risk of both recurrence (RR 0.17, 95% CI 0.03–0.83, p = 0.03) and death (RR 0.04, 95% CI 0.00–1.00, p = 0.05) in adult POIT. Adjuvant chemotherapy significantly decreased the mortality rate in patients with stage I POIT and lowered the risk of recurrence in the adult subgroup. Surveillance administered in stage I POIT over IA G1 should be cautious, especially in adult patients.

UNDIFFERENTIATED SARCOMA ARISING IN AN IMMATURE TERATOMA OF THE OVARY: A case report

INTRODUCTION

The immature teratomas present less than 1 % of ovarian cancers and affect preferentially young women (1). We report a rare case of an ovarian teratoma harboring undifferentiated sarcoma highlighting the clinical and pathological characteristics.

CASE PRESENTATION

The patient was a 24-year-old female who consulted for an abdominal mass. Pelvic ultrasound and magnetic resonance imaging (MRI) revealed an ovarian teratoma measuring 22 cm with no evidence of malignancy. She underwent an exploratory laparotomy. She had a unilateral adnexectomy as the ovarian parenchyma was damaged and the fallopian tube was involved in the mass. The final anatomopathological examination revealed the presence of a teratoma with a predominant component of undifferentiated sarcomatous. This component made the prognosis worse and led to a rapid unfavorable evolution with numerous metastases (lung, liver, and peritoneum). She refused all treatment and died within a week of diagnosis.

DISCUSSION

Immature teratoma is a malignant tumor composed of tissues derived from the three embryonic cell lineages at different stages of maturation. This fact makes the determination of its histologic grade by radiologic examination very difficult (1) and consequently raises a challenge in the workup as the prognosis of immature teratomas is closely related to their histologic grade (16). Improved chemotherapy after surgery has increased the 5-year survival rate for these malignancies from 90 % to 100 % (18).

CONCLUSION

Young women are most commonly affected by immature teratomas. The prognosis and histologic grade are interrelated. To protect fertility, the trend now is treat them more frequently with conservative surgery.

Human chorionic gonadotropin elevation in gliomatosis peritonei complicated with immature teratoma: A case report and review of the literature

RATIONALE

Gliomatosis peritonei (GP) refers to the implantation of glial tissue on the visceral and parietal peritoneal surface, often associated with immature teratoma. It is a rare condition and the pathogenesis is not fully understood. In addition, the indistinguishable radiological appearance of immature and mature teratomas, and limited pathology samples make an accurate diagnosis difficult in most cases. More importantly, patients are also at risk of recurrence after surgery. This report aims to describe the process of diagnosis and treatment of GP with immature teratoma.

PATIENT CONCERNS

The patient, a 38-year-old woman presented with GP complicated with immature teratoma after laparoscopic ovarian cyst excision.

DIAGNOSES

On physical examination, a 15 cm-pelvic mass, with poor mobility, was palpated. And tumor marker demonstrated a moderate increase in α-fetoprotein and carbohydrate antigen 125. We suspected malignancy according to the comprehensive preoperative evaluation, the postoperative pathology revealed an immature teratoma of the left ovary and complicated with gliomatosis peritonei. Three months after the second surgery, possible recurrence of immature teratoma was considered and the patient underwent the third laparotomy. But the postoperative pathology indicated mature teratoma and mature glial components in the pelvic lesions.

INTERVENTIONS AND OUTCOME

The patient underwent 2 more surgical resections after the initial resection and 3 cycles of bleomycin, etoposide, and cisplatin regimen chemotherapy. She was regularly followed up in the outpatient after surgery, and no recurrence has been reported in the pelvic cavity till date.

LESSON

The case illuminated that the primary diagnosis of GP complicated with immature teratoma is critical but highly challenging for both gynecologists and pathologists and more attention should be paid to "GP complicated with immature cystic teratoma" patients to avoid inappropriate treatment.

Potential histological discordance revealed by second review in the national rare gynecological cancer network (TMRG)

INTRODUCTION

Since 2010, the network of rare malignant tumors of the ovary (TMRG) was developed to optimize the management of patients, also allowing a histological second opinion of rare ovarian tumors. The aim of this work was to study the contribution of second opinion to improve histological diagnostic accuracy on ovarian rare malignant tumors included in the TMRG database.

MATERIAL AND METHODS

Histological data of patients diagnosed with a rare ovarian tumor included in TMRG network over a one-year period (2018) were collected. Initial diagnoses were compared with second opinion from national gynecological pathologist experts. The modalities of histological second opinion requests were studied, as well as the histological characteristics of the tumors. The discordances were classified as minor (if the modification of histological diagnosis did not change patient management) and major (if the patient management can be modified).

RESULTS

Of 1185 included patients, 937 matched the inclusion criteria. Full concordance between primary diagnosis and expert second opinion was reached in 611 cases (65,3%), minor discordance was seen in 114 (12,2%) and major discordance in 209 (22,3%) of cases. In systematic review requested by the network, 26% (n = 137) of cases were reported with a change in histological diagnosis, while the change concerned 44% (n = 186) of cases for a second opinion spontaneously requested by the initial pathologist. The discrepancies concerned all categories of ovarian tumors, with a majority of mucinous tumors (43% of major discordances), followed by stromal and sex-cord tumors (13.8% of major discordances) and clear cell tumors (12,4% of major discordances).

CONCLUSION

This analysis confirms the diagnostic difficulty of ovarian tumors, due to their rarity and morphological heterogeneity. French pathologists are aware of these difficulties and spontaneously refer ovarian tumors with unusual histology for a second opinion and collaborate with rare tumor networks for systematic review.

Retrospective Analysis of Pure Ovarian Immature Teratoma in Patients Aged 15-39 Years: A Turkish Multicenter Study

Purpose: To evaluate the clinicopathological characteristics and surgical outcomes in patients with pure ovarian immature teratomas (POITs). Materials and Methods: In this multicenter study, a retrospective review was made of the databases of six Gynecology Oncology Departments in Turkey to identify patients with POITs who had undergone surgery between 1993 and 2019. Results: Evaluation was made of 48 patients with a median age at diagnosis of 22.5 years (range, 15-37 years). In 40 (83%) patients, stage I was determined and in eight patients, an advanced stage (IIIB, IIIC, and IVB) was determined. Tumors were found to be grade I in 17 (35.4%) cases, grade II in 12 (25%), and grade III in 19 (39.6%). Fertility-sparing surgery was applied to 42 (87.5%) patients and radical surgery to 6 (12.5%). The median follow-up was 60 months (range, 3-246 months). Recurrence was seen in seven patients, all with grade III tumors. In the final pathological examination of recurrent tumors, mature teratoma was reported in five patients, and immature teratoma in one patient. Salvage surgery was not performed in one patient as the tumor was unresectable and so a regimen of bleomycin, etoposide, and cisplatin (BEP) was administered. Conclusion: POITs are rare tumors seen at a young age, and benign or malignant relapse can be seen in these tumors. In this cohort, the malignant recurrence rate was 4.1%, and the benign recurrence rate was 10.4%. All the recurrences were in grade III tumors. Benign recurrences can be treated with surgery alone and the malignant group should be treated with surgery followed by chemotherapy.

Single-cell transcriptional profiling identifies a cluster of potential metastasis-associated UBE2C+ cells in immature ovarian teratoma

To dissect the disease heterogeneity and identify the underlying cellular and molecular events related to metastasis of immature ovarian teratoma in children, single-cell RNA sequencing was performed for a 2-year-old patient with liver metastases from immature ovarian teratoma. A total of 5976 cells were obtained for further analysis, with a median unique molecular identifier count of 6011 per cell and a median number of 1741 genes detected per cell. Fourteen clusters were recognized, with the main lineages comprising epithelial cells, macrophages, fibroblasts, glial cells, and dendritic cells. Ten subclusters of epithelial cells were further defined, originating from the urinary tract, esophagus, bronchus, lung, skin, and gastrointestinal tract. An undefined UBE2C + population in an active state of proliferation was also identified and its biological processes were related to meiosis and maturation of oocytes. Pseudotime analysis revealed different distributions of epithelial cells in the development trajectory. In conclusion, a cluster of UBE2C + epithelial cells in an active state of proliferation was identified in an immature ovarian teratoma in a child, and may contribute to metastasis by regulating epithelial-mesenchymal transition. These findings help toward understanding the origin of the malignant behaviors, offer a potential biomarker for early determination of the tumor nature, and provide new ideas for the therapy of immature ovarian teratoma in children.

Multiregion exome sequencing of ovarian immature teratomas reveals 2N near-diploid genomes, paucity of somatic mutations, and extensive allelic imbalances shared across mature, immature, and disseminated components

Immature teratoma is a subtype of malignant germ cell tumor of the ovary that occurs most commonly in the first three decades of life, frequently with bilateral ovarian disease. Despite being the second most common malignant germ cell tumor of the ovary, little is known about its genetic underpinnings. Here we performed multiregion whole-exome sequencing to interrogate the genetic zygosity, clonal relationship, DNA copy number, and mutational status of 52 pathologically distinct tumor components from ten females with ovarian immature teratomas, with bilateral tumors present in five cases and peritoneal dissemination in seven cases. We found that ovarian immature teratomas are genetically characterized by 2N near-diploid genomes with extensive loss of heterozygosity and an absence of genes harboring recurrent somatic mutations or known oncogenic variants. All components within a single ovarian tumor (immature teratoma, mature teratoma with different histologic patterns of differentiation, and yolk sac tumor) were found to harbor an identical pattern of loss of heterozygosity across the genome, indicating a shared clonal origin. In contrast, the four analyzed bilateral teratomas showed distinct patterns of zygosity changes in the right versus left sided tumors, indicating independent clonal origins. All disseminated teratoma components within the peritoneum (including gliomatosis peritonei) shared a clonal pattern of loss of heterozygosity with either the right or left primary ovarian tumor. The observed genomic loss of heterozygosity patterns indicate that diverse meiotic errors contribute to the formation of ovarian immature teratomas, with 11 out of the 15 genetically distinct clones determined to result from nondisjunction errors during meiosis I or II. Overall, these findings suggest that copy-neutral loss of heterozygosity resulting from meiotic abnormalities may be sufficient to generate ovarian immature teratomas from germ cells.

Ultrasound features of immature ovarian teratomas: Case series and review of literature

INTRODUCTION

Immature ovarian teratomas are rare but account for 10-20% of ovarian cancers in women under the age of 20 years. This study aimed to characterise immature ovarian teratomas using grey-scale and Doppler ultrasonography and review the literature to refine the diagnosis of immature ovarian teratomas.

METHODS

Patients with a confirmed histological diagnosis of immature ovarian teratoma from years 2006-2018, who had undergone a transvaginal ultrasound at two large teaching hospitals, were identified. The imaging was retrieved from the centres clinical databases. Ultrasound scans were performed by experienced ultrasound examiners and described according to International Ovarian Tumour Analysis criteria.

RESULTS

Eight patients were identified in total with a mean age of 26 years (range 13-35). Half of the patients had a past history of a mature ovarian teratoma (3 ipsilateral, 1 contralateral). The cysts were generally large (median 115 mm), fast growing unilateral lesions with a single, peripheral predominantly solid component arising from the cyst wall. The solid component was hyperechoic with multiple foci of fibrosis and numerous small cysts. The cystic component typically formed less than 75% of the lesion and the cyst fluid was of low-level echogenicity. Subjective assessment of vascularity of the solid part of the tumours varied between scores of 1 and 2. Tumour markers showed a raised serum a-fetoprotein level in 42% of these patients.

CONCLUSION

Although there were no ultrasound features that were pathognomonic of immature teratoma, the diagnosis should be suspected in a young woman with a large ovarian cyst with a fibrotic, microcystic solid component, particularly if she has a past history of a dermoid cyst.

Immature teratoma diagnosed and treated during pregnancy and later complicated by growing teratoma syndrome: A case review with clinical considerations

•Immature teratomas are rare in pregnancies.•Surgical and chemotherapeutic considerations during pregnancy.•Growing teratoma syndrome treated with surgical management.

Detailed overview on rare malignant ovarian tumors

The group of rare malignant ovarian tumors includes the group of germ cell tumors, sex cords stromal ovarian tumors, small cell carcinoma, malignant Brenner tumors, rare epithelial tumors such as mucinous carcinoma, clear cell carcinoma, or low-grade serous carcinoma, as well as ovarian carcinosarcoma. Together they comprise about 10% of all ovarian tumors. Due to their low prevalence and their heterogeneity, data and treatment recommendations are limited. Even though all ovarian tumors are staged according to the FIGO staging of epithelial ovarian tumors, treatment differs especially in germ cell tumors and sex cords stromal ovarian tumors. Non-epithelial ovarian tumors can arise from a variety of ovarian precursor cells such as germ cells, granulosa cells, theca cells, or stromal fibroblasts. As can be expected already due to their divergent precursor lesions, these malignancies are substantially different but united by their rarity. This overview article gives a comprehensive summary on the pathology and clinical presentation, as well as therapy recommendations of a selection of those rare ovarian tumors, based on the latest national guidelines and related important publications.

Prognostic impact of the number of lymph nodes examined in different stages of colorectal mucinous adenocarcinoma

BACKGROUND

Mucinous adenocarcinoma (MC) is a special kind of colorectal adenocarcinoma that occurs more frequently in young patients and females, but the prognostic effect of lymph nodes in MC patients is unclear. This population-based study was conducted to analyze the prognostic value of the number of lymph nodes examined in different stages of colorectal MC.

METHODS

We included 17,001 MC patients from the Surveillance, Epidemiology, and End Results program database between 2003 and 2013, of which 12,812 (75%) had >12 lymph nodes examined.

RESULTS

Compared to the group with insufficient lymph nodes examined, patients with more lymph nodes (>12) examined tended to come from east and central America, were more frequently female and young, were diagnosed after 2008, had larger-sized tumors of less differentiated grade and in later stages, had not received radiation therapy and had more positive nodal status. Patients with more lymph nodes (>12) examined demonstrated significantly better survival than those with insufficient lymph nodes examined only in stages II and III (stage II: overall, P<0.001; cancer-specific, P<0.001; stage III: overall, P=0.093; cancer-specific, P=0.032), even though the overall (P<0.001) and cancer-specific survival (P<0.001) showed significant differences between the two groups. Both univariate (overall, HR=0.739, 95% CI=0.703-0.777, P<0.001; cancer-specific, HR=0.742, 95% CI=0.698-0.788, P<0.001) and multivariate (overall, HR=0.601, 95% CI=0.537-0.673, P<0.001; cancer-specific, HR=0.582, 95% CI=0.511-0.664, P<0.001) Cox proportional hazards models verified the association between >12 lymph nodes examined and better survival.

CONCLUSION

More number of lymph nodes (.12) examined significantly increased the survival probability of MC patients in stages II and III, but had no significant influence on patients in stages I and IV, indicating the effect of number of lymph nodes examined was a stage-dependent prognostic factor in clinical utility.

Taking stock: A systematic review of archaeological evidence of cancers in human and early hominin remains

This study summarizes data from 154 paleopathological studies documenting 272 archaeologically recovered individuals exhibiting skeletal or soft tissue evidence of cancer (malignant neoplastic disease) between 1.8 million years ago and 1900 CE. The paper reviews and summarizes the temporal, spatial and demographic distribution of the evidence and the methods used to provide the cancer diagnoses. Metastasis to bone is the most widely reported evidence (n = 161), followed by multiple myeloma (n = 55). In the dataset, males were represented more than females (M = 127, F = 94), and middle-adults (35-49) and old-adults (50+) were represented most among age groups (MA = 77, OA = 66). The majority of the evidence comes from Northern Europe (n = 51) and Northern Africa (n = 46). The data are summarized in the Cancer Research in Ancient Bodies (CRAB) Database, a growing online resource for future paleo-oncological research. This systematic review contributes to broader studies of malignant neoplastic disease in antiquity; it provides an overview of paleo-oncological data, discusses the many practical and methodological challenges of paleo-oncological research, and dispels presumptions about cancer's rarity in the past.

Fertility sparing approach as the standard of care in young patients with immature teratomas

Immature teratomas are quite rare tumors arising in young women. They are usually diagnosed in early stage and grade and have a good prognosis. In these young patients, fertility-sparing management is suggested as the standard of care. Bilateral immature teratoma is a rare condition with an incidence of 10%, with a five-year survival rate of 80%. The majority of patients received fertility-sparing treatment followed by adjuvant chemotherapy in 78%. Older age, advanced stage, and high grade are negative prognostic factors. The surgery-only, watch-and-wait approach was evaluated; however, after a median follow-up time of 42 months, 50% of patients experienced recurrence, but they were successfully salvaged with chemotherapy. In a retrospective study, 12 out of 27 patients tried to conceive, resulting in 10 pregnancies (8 after chemotherapy). We present a narrative review of the current literature regarding the essential multidisciplinary approach of such patients in order to achieve the best oncologic and fertility-sparing outcome.

Fertility preservation in women with cervical, endometrial or ovarian cancers

Background

Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance.

Outcomes

Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery.

Conclusions

Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.