Clinicopathologic characteristics of malignant germ cell tumors in the ovaries of Korean women: a Korean Gynecologic Oncology Group Study

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.

Fertility outcomes following surgery and multiagent chemotherapy in malignant ovarian germ cell tumor survivors: a survey study

OBJECTIVE

To assess fertility outcomes in long-term survivors of malignant ovarian germ cell tumors treated with fertility-sparing surgery with or without additional chemotherapy.

METHODS

Women diagnosed and treated for malignant ovarian germ cell tumors at Charing Cross Hospital or Mount Vernon Cancer Centre between 1977 and 2015 were included. Questionnaires assessing fertility issues were sent to patients treated with fertility-sparing surgery. Fertility outcomes were evaluated according to the treatment received. The effect of the mean total dose of cyclophosphamide and cisplatin was assessed.

RESULTS

A total of 146 patients were sent the questionnaire; 77 (56.5%) patients were included in the analysis. A total of 49 (64%) patients received platinum-based chemotherapy after surgery, 39 (79.6%) of these with cisplatin, vincristine, methotrexate, bleomycin, actinomycin D, cyclophosphamide, and etoposide, while 10 (20.4%) with bleomycin, etoposide, and cisplatin. After any treatment, 39/46 patients (85%) became pregnant: the conception rate was not different between those receiving surgery only and those receiving also chemotherapy (85.7% vs 84.4%, p=1.0). Live birth rate was 80.4% (37/46), with no statistically significant difference between the treatment groups (p=0.42). Median age of women achieving conception was 29 years (IQR 26-33). The probability of live birth at 5 years was 48% and 40% for patients in the surgery only and chemotherapy group, respectively (p=0.55). Infertility and miscarriage rates did not differ significantly between the two treatment groups (p=0.30 and p=0.32). The mean doses of cisplatin and cyclophosphamide received by patients failing and achieving conception were not different (p=0.10, p=0.47).

CONCLUSIONS

Our results suggest that fertility may not be hampered in patients with malignant ovarian germ cell tumor treated with fertility-sparing surgery or receiving additional chemotherapy.

Nomograms to predict the prognosis in malignant ovarian germ cell tumors: a large cohort study

Background

Malignant ovarian germ cell tumors (MOGCTs) are rare gynecologic neoplasms. The use of nomograms that are based on various clinical indicators to predict the prognosis of MOGCTs are currently lacking.

Methods

Clinical and demographic information of patients with MOGCT recorded between 2004 and 2015 were obtained from the Surveillance, Epidemiology, and End Results database, and Cox regression analysis was performed to screen for important independent prognostic factors. Prognostic factors were used to construct predictive calculational charts for 1-year, 3-year, and 5-year overall survival (OS). The externally validated case cohort included a total of 121 MOGCT patients whose data were recorded from 2008 to 2019 from the database of the Shengjing Hospital of China Medical University.

Results

A total of 1401 patients with MOGCT were recruited for the study. A nomogram was used to forecast the 1-year, 3-year, and 5-year OS using data pertaining to age, International Federation of Gynecology and Obstetrics (FIGO) staging, histological subtype and grade, and surgical type. Nomograms have a more accurate predictive ability and clinical utility than FIGO staging alone. Internal and external validation also demonstrated satisfactory consistency between projected and actual OS.

Conclusions

A nomogram constructed using multiple clinical indicators provided a more accurate prognosis than FIGO staging alone. This nomogram may assist clinicians in identifying patients who are at increased risk, thus implementing individualized treatment regimens.

Reproductive Outcomes and Fertility Preservation Strategies in Women with Malignant Ovarian Germ Cell Tumors after Fertility Sparing Surgery

Malignant ovarian germ cell tumors are rare tumors that mainly affect patients of reproductive age. The aim of this study was to investigate the reproductive outcomes and fertility preservation strategies in malignant ovarian germ cell tumors after fertility-sparing surgery. Data in literature support that fertility-sparing surgery is associated with an excellent oncological outcome not only in early stages malignant ovarian germ cell tumors but also in advanced stages. Moreover, the possibility of performing conservative treatment should be considered even in case of relapse or advanced disease, given the high chemosensitivity. Indeed, available data have shown that menstrual function is maintained after platinum-based regimens in over 85-95% of patients with malignant ovarian germ cell tumors and rate of premature menopause reported in literature ranges between 3% and 7.4%, while premature ovarian failure rates are between 3.4% and 5%. Moreover, reproductive outcomes are about 80% with no increase in the risk of teratogenicity compared to general population. Therefore, conservative surgery for malignant ovarian germ cell tumors currently may represent a therapeutic option in patients who wish to preserve fertility but must be available for extended follow-up and after subscribing to informed consent.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in the surgical management of malignant ovarian germcell tumors

OBJECTIVE

To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests.

RESULTS

A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p > 0.05).

CONCLUSIONS

Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.

Cytoreductive surgery in advanced stage malignant ovarian germ cell tumors

INTRODUCTION

To evaluate the survival effect of cytoreductive surgery in advanced stage malignant ovarian germ cell tumors (MOGCT).

MATERIAL AND METHODS

Clinicopathological data of patients with MOGCT that were treated between 1991 and 2014. Maximal debulking was defined as no gross residual tumor after primary or recurrence surgery; optimal and suboptimal debulking were used for patients with residual tumors of ≤1cm and >1cm, respectively.

RESULTS

In total, 31 patients with advanced stage MOGCT were analyzed. The median age at diagnosis was 21 (14-57) years. The median follow-up duration was 64.1 months. Of these 31 patients; 7 patients underwent sub-optimal debulking, 5 patients had optimal surgery and 18 had maximal debulking. Five-year DFS according to surgical resection rates were 29% in suboptimal debulking group, 75% in optimal debulking group and 93% in maximal cytoreduction group (p<0.001). Three of seven patients who underwent sub-optimal debulking were died of disease, however no deaths were seen in patients with optimal and maximal debulking. Five-year OS was 32% in suboptimal debulking group, and 100% in optimal and maximal debulking groups (p=0.001).

DISCUSSION

The benefit of cytoreductive surgery is less well-established in MOGCT of ovary compared to ovarian tumors of epithelial origin due to rareness of this histological subtype. Patients with MOGCT are usually younger and preservation of fertility is an important issue which may lead to suboptimal procedures, sometimes in exchange for diminished survival. Our data demonstrated that maximal cytoreduction should be aimed in patients with advanced stage MOGCT, as it is significantly associated with improved overall survival.

Current Strategy for the Treatment of Ovarian Germ Cell Tumors: Role of Extensive Surgery

OPINION STATEMENT

The necessity and extent of comprehensive surgical staging (CSS) and lymphadenectomy in the treatment of malignant ovarian germ cell tumors (MOGCTs) is still controversial. However, it is uniformly agreed that CSS with lymphadenectomy is crucial to follow up patients without adjuvant chemotherapy in stage I MOGCTs. Considering the chemotherapy-sensitive nature of MOGCTs, fertility-sparing cytoreductive surgery (FSCS) seems a reasonable approach in initial treatment for patients with advanced stage. When encountered with bilateral MOGCTs, debulking is surely granted if there is no desire for fertility. Both ovaries completely replaced by neoplastic tissue composed the most challenging situation especially when patients require childbearing potential. In dysgerminoma histology, which usually has good prognosis, residual disease could be left to spare fertility. USO of the largest and more heterogeneous ovarian mass and a biopsy of the contralateral lesion may be considered if the patients are compliant to regular follow-up. NACT followed by interval FSCS may be a reasonable option in patients with extensive disease, when initial debulking is not an option or where the poor general condition or clinical findings suggest an increased risk of surgical morbidity or preclude fertility-sparing surgery. This is currently not the standard of care but deserves future study. In some rare situation, when any remaining ovarian tissue means high risk, BSO may be performed with the uterus preserved for possible assisted reproduction with donor egg. Treatment failure occurs in a small group of MOGCTs after primary treatment. A good number of recurrences can be salvaged with selected salvage surgery, especially when optimal secondary cytoreduction can be achieved. Immature teratoma is a subtype of MOGCTs where secondary cytoreduction may have a strong role to play.

An Analysis of Prognostic Factors in Patients with Ovarian Malignant Germ Cell Tumors Who Are Treated with Fertility-Preserving Surgery

BACKGROUND/AIMS

To analyze the clinicopathological factors that affect the prognosis and fertility of patients with malignant ovarian germ cell tumors (MOGCTs).

METHODS

The medical records and follow-up data of 106 patients with MOGCTs who were treated at The Affiliated Tumor Hospital of Guangxi Medical University between January 1986 and December 2010 were enrolled in this study. A Kaplan-Meier analysis was used to analyze the survival curves. The different prognoses among the various clinicopathological factors were evaluated using a univariate analysis and a log-rank test. The multivariate analysis was performed using the Cox proportional hazard regression method. A logistic regression analysis was used to evaluate the influence of different factors on the prognoses and fertility.

RESULTS

The median age at primary treatment was 22 years (range: 9-61years). A total of 59 patients received fertility-preserving surgery, 45 received radical surgery and 94 received postoperative adjuvant chemotherapy. The median follow-up time was 56.5 months (range: 2-309 months). A total of 11 patients experienced a recurrence, and 23 patients died from their cancer. Of the 47 patients who are alive without tumor, 45 have normal menstruation. Of the 39 patients who wished to become pregnant, 31 patients had 33 successful pregnancies that resulted in 33 live births. No statistically significant difference (p > 0.05) was observed with respect to the progression-free survival (PFS; 67.6 vs. 63.3%), the overall survival (OS; 70 vs. 64.1%) and the mortality rate (15.3 vs. 31.3%) between patients who received fertility-preserving surgery and those who received radical surgery. The univariate analysis showed that the pathological types, postoperative residual tumor size, lymph node resection, and omental resection were associated with OS (p < 0.1), whereas postoperative residual tumor size, number of chemotherapy cycles, lymph node resection, and omental resection were associated with PFS (p < 0.1). The multivariate analysis showed that only the postoperative residual tumor size was an independent prognostic factor of OS, whereas the postoperative residual tumor size, number of chemotherapy cycles and lymph node resection were independent prognostic factors of PFS. No statistically significant difference (p > 0.05) was observed with respect to the OS, PFS and fertility between patients who received fertility-preserving surgery and those who were treated with or without comprehensive surgical staging.

CONCLUSION

MOGCTs can achieve a good prognosis after surgery and chemotherapy. Postoperative residual tumor size was an independent prognostic factor of PFS and OS. Moreover, comprehensive surgical staging cannot improve the prognosis. Fertility-preserving surgery plus adjuvant chemotherapy appeared to have little or no effect on prognosis and fertility.

Outcome and risk factors for recurrence in malignant ovarian germ cell tumors: a MITO-9 retrospective study

AIMS

This study aimed to investigate the outcome of patients with malignant ovarian germ cell tumors (MOGCTs) and to define the risk factors for recurrence.

METHODS

A total of 123 patients with MOGCTs were retrospectively reviewed among MITO centers. Eighty-one patients had primary treatment in a MITO center, whereas the other 42 were referred for adjuvant chemotherapy or recurrence. The clinicopathologic characteristics were evaluated for association with relapse or death.

RESULTS

Median age was 24 years (range, 11-76 years). Forty-nine (39.8%) had dysgerminomas, 35 (28.5%) had immature teratomas, 12 (9.8%) had mixed germ cell tumors, 26 (21.1%) had yolk sac tumors, and 1 (0.8%) had embryonal carcinoma. International Federation of Gynecology and Obstetrics stage distribution was as follows: stage I, 87 (70.7%); stage II, 3 (2.4%); stage III, 29 (23.6%); and stage IV, 4 (3.3%). Fertility-sparing surgery was performed in 92 patients, whereas the remaining 31 received radical surgery; 65.8% of patients received adjuvant chemotherapy. Recurrence rate was 17.8% and the median time to recurrence was 9 months. Univariate and multivariate analyses showed that patient age (>45 years) and treatment outside a referral (MITO) center were the most important predictors of recurrence. The 5-year overall survival rate was 88.8%, with a median follow-up of 61 months. Univariate and multivariate analyses demonstrated that stage greater than I and yolk sac tumors were independent poor prognostic indicators.

CONCLUSIONS

This study confirms that MOGCTs have excellent prognosis, with 5-year overall survival rates of 95.6% and 73.2% in stage I and advanced stages, respectively. Age older than 45 years and treatment not in a referral center are independent risk factors for recurrence, whereas stage greater than I and yolk sac histology are independent poor prognostic indicators.

[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.

Residual tumor after the salvage surgery is the major risk factors for primary treatment failure in malignant ovarian germ cell tumors: a retrospective study of single institution

BACKGROUND

Malignant ovarian germ cell tumors are rare, and knowledge of their prognostic factors is limited, with little available randomized data. This study was conducted to evaluate the clinicopathologic characteristics of malignant ovarian germ cell tumors and to determine the association of their prognostic factors to primary treatment failure.

METHODS

The medical records of 57 patients with stages I to IV malignant ovarian germ cell tumor were retrospectively reviewed, and their clinicopathologic and treatment-related data were collected and analyzed.

RESULTS

The median age at the diagnosis was 23.3 years (range: 8-65 years), and the median follow-up period was 108 months (range: 48-205 months). The histological types of the tumors were immature teratoma (n = 24), dysgerminoma (n = 20), endodermal sinus tumor (n = 8), mixed germ cell tumor (n = 4), and choriocarcinoma (n = 1). 66.7% of the patients had stage I disease; 5.2%, stage II; 26.3%, stage III; and 1.8%, stage IV. After the initial surgery, 49 patients (86%) received cisplatin-based chemotherapy. The five-year survival rate was 96.5%. There were six primary treatment failures, with two of the patients dying of the disease, and the median time to the recurrence was 8 months. The histological diagnosis (P < 0.0001), tumor stage (P = 0.0052), elevation of beta-hCG (P = 0.0134), operation methods (P = 0.0006), and residual tumor after the salvage surgery (P < 0.0001) were significantly associated with the risk of primary treatment failure in the univariate analysis. In the multivariate analysis, the residual tumor after the salvage surgery was the only significant variable associated with primary treatment failure (P = 0.0011, Hazard ratio = 29.046, 95% Confidence interval 3.832-220.181).

CONCLUSION

Most malignant ovarian germ cell tumors have excellent prognoses with primary treatment, and good reproductive outcomes can be expected. Because primary treatment failure is associated with the residual disease after the salvage surgery, knowledge of the presence or absence of this risk factor may be helpful in risk stratification and individualization of adjuvant therapy in malignant ovarian germ cell tumors. Further large-scale prospective studies to confirm these results should be performed.