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

Oncological outcomes among young women with non-epithelial ovarian cancer: the YOC-Care study (Young Ovarian Cancer - Care)

OBJECTIVE

To determine oncological outcomes and associated prognostic factors in women younger than 45 years diagnosed with non-epithelial ovarian cancer.

METHODS

A retrospective, multicenter Spanish study was performed including women with non-epithelial ovarian cancer younger than 45 years between January 2010 and December 2019. All types of treatments and stages at diagnosis with at least 12 months of follow-up were collected. Women with missing data, epithelial cancers, borderline or Krukenberg tumors, and benign histology, as well as patients with previous or concomitant cancer, were excluded.

RESULTS

A total of 150 patients were included in this study. The mean±SD age was 31.45±7.45 years. Histology subtypes were divided into germ cell (n=104, 69.3%), sex-cord (n=41, 27.3%), and other stromal tumors (n=5, 3.3%). Median follow-up time was 58.6 (range: 31.10-81.91) months. Nineteen (12.6%) patients presented with recurrent disease with a median time to recurrence of 19 (range: 6-76) months. Progression-free survival and overall survival did not significantly differ among histology subtypes (p=0.09 and 0.26, respectively) and International Federation of Gynecology and Obstetrics (FIGO) stage (I-II vs III-IV) with p=0.08 and p=0.67, respectively. Univariate analysis identified sex-cord histology with the lowest progression-free survival. Multivariate analysis showed that body mass index (BMI) (HR=1.01; 95% CI 1.00 to 1.01) and sex-cord histology (HR=3.6; 95% CI 1.17 to 10.9) remained important independent prognostic factors for progression-free survival. Independent prognostic factors for overall survival were BMI (HR=1.01; 95% CI 1.00 to 1.01) and residual disease (HR=7.16; 95% CI 1.39 to 36.97).

CONCLUSIONS

Our study showed that BMI, residual disease, and sex-cord histology were prognostic factors associated with worse oncological outcomes in women younger than 45 years diagnosed with non-epithelial ovarian cancers. Even though the identification of prognostic factors is relevant to identify high-risk patients and guide adjuvant treatment, larger studies with international collaboration are essential to clarify oncological risk factors in this rare disease.

Impact of Optimal Therapy and Prognostic Factors in Malignant Germ Cell Tumors of Ovary: 20 Years' Institutional Experience

The objective of this study is to analyze the impact of clinicopathological and treatment-related factors on survival in patients with malignant ovarian germ cell tumor. A total of 253 patients of ovarian germ cell malignancy were retrospectively reviewed during 2000-2019. Out of these, 111 had primary treatment at our institute, which is a dedicated regional cancer center. The remaining 142 were operated elsewhere and were referred to us for adjuvant chemotherapy or with recurrent disease. The clinicopathological and treatment-related characteristics were analyzed for association with tumor persistence/recurrence or death. Among them, 107 were dysgerminomas; 60 had endodermal sinus tumor, 53 mixed germ cell tumors, and 31 immature teratoma; and one each had embryoma and primitive germ cell tumor. The median follow-up period was 19 months (range 0-214). Median time to recurrence or progression was 5 months. Forty-nine patients (19.4%) had a recurrence and there were 16 (6.3%) deaths. Five-year disease-free-survival was 71.3% and 5-year overall survival rate was 88.1%, for the entire cohort. Disease-free-survival was 90.4% and overall survival was 92.1% for patients entirely treated at the reporting institute. Sub-group analysis based on treatment adequacy showed that survival rate was 91.0% in patients who had timely and complete initial treatment versus 78.3% in patients where treatment was incomplete or delayed (p = 0.032). Factors affecting relapse were tumor histology, absence of surgical staging, presence of residual disease, inadequate response to chemotherapy, treatment outside reporting institute, and incomplete/delayed chemotherapy. Significant factors adversely affecting survival were presence of post-operative residual disease, tumor histology, incomplete response to chemotherapy, and inadequate/delayed treatment at primary setting. There was no statistically significant difference based on disease stage and whether fertility-sparing surgery or non-fertility-sparing surgery was performed. Prognosis of ovarian germ cell malignancies is excellent with timely, optimal treatment. The outcome improves significantly if managed adequately in the primary setting, involving dedicated gynecologic oncologists.

Oncological and Reproductive Outcomes in Patients With Advanced-Stage Ovarian Immature Teratoma: Experience From a Tertiary Center

Objective

To evaluate the oncological and reproductive outcomes in patients with advanced-stage ovarian immature teratoma (IMT).

Methods

We retrospectively reviewed the medical records of patients with advanced-stage IMT who were treated with surgery between January 1985 and December 2020. Fertility-sparing surgery (FSS) was defined as preservation of the uterus and at least one adnexa. Oncological outcomes were compared between patients who underwent FSS and radical surgery. Patients who underwent FSS were also contacted to gather information about their menstrual history and reproductive outcomes.

Results

Forty-six patients fulfilled the inclusion criteria, of whom 38 underwent FSS and eight were treated with radical surgery. Fifteen patients suffered recurrence after a median follow-up time of 74.2 months (range: 4.1–434.1 months). The 5-year disease-free survival (DFS) and overall survival (OS) rates were 69.1% and 89.9%, respectively. Multivariate analysis identified suboptimal cytoreductive surgery as the only independent risk factor for recurrence. There was no significant difference in DFS or OS between patients with different surgical procedures. Ten of the 15 relapsed patients had optimal salvage surgery and all remained alive with no evidence disease. Among the 32 patients who underwent FSS, 29 resumed menstruation after surgery, and five of seven patients who designed pregnancy achieved a total of five successful pregnancies.

Conclusions

Ovarian IMT has a favorable prognosis, even when diagnosed at an advanced stage. FSS is feasible in patients with advanced-stage IMT who wish to preserve their fertility. Patients may benefit from optimal cytoreductive surgery during initial and salvage surgery.

Machine learning methods to predict presence of residual cancer following hysterectomy

Surgical management for gynecologic malignancies often involves hysterectomy, often constituting the most common gynecologic surgery worldwide. Despite maximal surgical and medical care, gynecologic malignancies have a high rate of recurrence following surgery. Current machine learning models use advanced pathology data that is often inaccessible within low-resource settings and are specific to singular cancer types. There is currently a need for machine learning models to predict non-clinically evident residual disease using only clinically available health data. Here we developed and tested multiple machine learning models to assess the risk of residual disease post-hysterectomy based on clinical and operative parameters. Data from 3656 hysterectomy patients from the NSQIP dataset over 14 years were used to develop models with a training set of 2925 patients and a validation set of 731 patients. Our models revealed the top postoperative predictors of residual disease were the initial presence of gross abdominal disease on the diaphragm, disease located on the bowel mesentery, located on the bowel serosa, and disease located within the adjacent pelvis prior to resection. There were no statistically significant differences in performances of the top three models. Extreme gradient Boosting, Random Forest, and Logistic Regression models had comparable AUC ROC (0.90) and accuracy metrics (87–88%). Using these models, physicians can identify gynecologic cancer patients post-hysterectomy that may benefit from additional treatment. For patients at high risk for disease recurrence despite adequate surgical intervention, machine learning models may lay the basis for potential prospective trials with prophylactic/adjuvant therapy for non-clinically evident residual disease, particularly in under-resourced settings.

Recurrent High-grade Ovarian Immature Teratoma with Peritoneal Dissemination

BACKGROUND

Peritoneal dissemination of ovarian immature teratoma in children is a rare entity and is associated with a poor prognosis. There are no guidelines on the optimal management of these patients with regard to surgery and systemic treatments.

CASE

This is the case of a 16-year-old patient who experienced an early recurrence of immature teratoma with peritoneal dissemination after surgery and systemic chemotherapy failure, and was treated with an aggressive salvage cytoreductive surgery. She was still disease-free 6 months after her second surgery.

SUMMARY AND CONCLUSION

Upfront aggressive surgical management with complete cytoreductive surgery is recommended when patients present with disease recurrence and peritoneal dissemination of ovarian immature teratoma. Such cases should be managed in centers with local expertise in the treatment of peritoneal surface malignancies.

Molecular Pathways and Targeted Therapies for Malignant Ovarian Germ Cell Tumors and Sex Cord-Stromal Tumors: A Contemporary Review

Non-epithelial ovarian tumors are heterogeneous and account for approximately 10% of ovarian malignancies. The most common subtypes of non-epithelial ovarian tumors arise from germ cells or sex cord and stromal cells of the gonads. These tumors are usually detected at an early stage, and management includes surgical staging and debulking. When indicated for advanced disease, most respond to chemotherapy; however, options for patients with refractory disease are limited, and regimens can be associated with significant toxicities, including permanent organ dysfunction, secondary malignancies, and death. Targeted therapies that potentially decrease chemotherapy-related adverse effects and improve outcomes for patients with chemotherapy-refractory disease are needed. Here, we review the molecular landscape of non-epithelial ovarian tumors for the purpose of informing rational clinical trial design. Recent genomic discoveries have uncovered recurring somatic alterations and germline mutations in subtypes of non-epithelial ovarian tumors. Though there is a paucity of efficacy data on targeted therapies, such as kinase inhibitors, antibody–drug conjugates, immunotherapy, and hormonal therapy, exceptional responses to some compounds have been reported. The rarity and complexity of non-epithelial ovarian tumors warrant collaboration and efficient clinical trial design, including high-quality molecular characterization, to guide future efforts.

Fertility-sparing surgery for patients with malignant ovarian germ cell tumors: 10 years of clinical experience from a tertiary referral center

PURPOSE

To describe a case series of patients with malignant ovarian germ cell tumors (MOGCT) treated exclusively with fertility-sparing surgery (FSS) with or without adjuvant chemotherapy.

METHODS

We retrospectively reviewed the records of 27 patients with MOGCT treated in the Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Croatia, between January 2009 and July 2019.

RESULTS

The median age at diagnosis was 22 years, and the main symptom was abdominal distension (57.0%). The most prevalent histological subtype was immature teratoma (n = 13, 48.1%). Twenty-three patients (85.2%) had laparotomy and 4 (14.8%) had laparoscopy, without conversions. Lymphadenectomy was performed in 16 (59.3%) patients, with 184 removed lymph nodes, and omentectomy was performed in 19 (70.4%) patients. The rate of chemotherapy administration was 81.5%. The follow-up length ranged between 6.30 and 115.1 months (median: 49.60 months). No patient experienced tumor recurrence. The rate of complete gross resection was 100%. At the time of analysis, all patients were alive and disease free. Fifty percent of patients who actively tried to conceive after FSS became pregnant, with 12 deliveries.

CONCLUSION

This study suggests that FSS is a safe treatment option for MOGCT, regardless of tumor stage and histological type.

Clinicopathological factors and prognosis analysis of 39 cases of non-gestational ovarian choriocarcinoma

PURPOSE

Non-gestational ovarian choriocarcinoma (NGOC) is a rare malignant germ cell tumor. Through literature review and cases collection, we aim to analyze prognostic factors for NGOC and summarize its clinicopathological characteristics to guide the individualized treatment.

METHODS

We searched PubMed database, Cochrane library, and Google Scholar for cases published between January 1, 1967 and July 31, 2018 using various search terms. We retrieved patients' clinicopathological characteristics, treatment, and prognosis information from included studies. These patients were divided into two groups: died (case group) or alive (control group) group. We summarized and compared their clinical (age, symptoms, R0 resection, serum HCG levels, chemotherapy regimen) and pathological (pure vs non-pure type, tumor size, tumor location, metastasis sites, stage) features by statistical analysis.

RESULTS

Only 39 patients were retrieved from 36 studies in total. The median age was 30 years (range 12- to 65-years old). The peak incidence was in the adolescent age 12-25 years. Median follow-up was 20.3 months (range 1-84 months). 9 (23%) patients died; 24 (62%) patients were alive; 6 (15%) were lost to follow-up. Upon univariate analysis, we found age had a poor impact on overall survival (OS) in NGOC, HR - 0.057, 95% CI - 0.111 to - 0.004. Pure type NGOC has a better OS than mixed type, HR - 2.621, 95% CI - 4.577 to - 0.666. R0 resection is a good prognostic factor for OS, HR 2.967, 95% CI 0.709-5.224.

CONCLUSION

Clinicians should try to achieve R0 resection to improve the prognosis for NGOC patients even among advanced patients.

Role of optimal cytoreduction in patients with dysgerminoma

BACKGROUND

Dysgerminomas are malignant ovarian germ-cell tumors that typically affect young women. Although these tumors have an excellent response to chemotherapy, surgery is an integral part of primary treatment.

OBJECTIVE

To evaluate outcomes of initial cytoreduction in patients diagnosed with dysgerminomas.

METHODS

Patients who underwent primary cytoreductive surgery for ovarian dysgerminoma between January 1985 and December 2013 were identified and included in the study. A comparison was made between patients who underwent optimal versus sub-optimal cytoreduction. Descriptive, comparative statistics and odds ratios were used to establish an association. Survival curves were performed with the Kaplan-Meier method and compared using a log-rank test. A value of p<0.05 was used to establish a statistical difference.

RESULTS

A total of 180 patients with a histologically confirmed dysgerminoma were included in the analysis. A subsection of 37 patients in stages III/IV were analyzed. The median age at diagnosis was 21 years (IQR 18-26). Histologically, 166 (92.2%) patients had pure dysgerminomas, whereas the rest had mixed histologies. The median tumor size was 18 (IQR 12-22) cm. In all stages, factors associated with optimal cytoreduction, were higher lactate dehydrogenase levels (OR=1.01; p=0.03), higher CA125 levels (OR=1.01; p=0.04), receiving adjuvant chemotherapy (OR=0.22; p<0.01), or undergoing treatment in a specialized institution (OR=12.68; p<0.01). Patients in stages III/IV, initially managed outside our institution were less likely to be taken for cytoreduction (OR=16.88; p=0.013). Other factors, including age (OR=1.02; p=0.39), pelvic lymph-node positivity (OR=2.24; p=0.36), pregnancy during follow-up (OR=0.91: p=0.80), or recurrence of disease (OR=1.93; p=0.23) were found to be similar in both groups. Overall survival was higher in optimally cytoreducted patients (100% vs 95.7%; p=0.032) including all stages, but not if considering only stages III/IV (100% vs 90%, p=0.186); disease-free survival was the same for both groups regardless of stage (94.3% vs 91.1%; p=0.36).

CONCLUSION

Patients with optimal surgeries were most likely to be treated in referral centers. Initial residual disease did not significantly alter recurrence, progression, disease-free survival, or overall 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.

A case of metastatic dysgerminoma treated with two cycles neoadjuvant chemotherapy followed by fertility-sparing minimally invasive surgery

•

Neoadjuvant chemotherapy (NACT) followed by fertility-sparing surgery is a feasible treatment of metastatic dysgerminoma

•

As few as two cycles of NACT may result in enough of a tumor response for fertility-sparing surgery to be possible.

•

Tumor lysis syndrome is a possibility when administering chemotherapy to patients with metastatic dysgerminoma

Prognostic significance of residual disease in advanced stage malignant ovarian germ cell tumors

Objective

To investigate the prognostic significance of complete gross resection following cytoreductive surgery for patients with advanced stage malignant ovarian germ cell tumors.

Methods

The National Cancer Data Base was accessed and patients diagnosed with an advanced stage (II-IV) malignant ovarian germ cell tumor who underwent primary cytoreductive surgery between 2011 and 2014 were selected for further analysis. For analysis purposes two groups were formed: patients with complete gross resection and those with macroscopic residual disease. Demographic and clinico-pathological characteristics were compared with the chi-square and Mann–Whitney U test. Univariate survival analysis was performed with the log-rank test after generation of Kaplan–Meier curves, while a Cox proportional hazard model was constructed to evaluate mortality after controlling for confounders.

Results

A total of 343 patients who met the inclusion criteria were identified. Residual disease status was available for 276 patients: the rate of complete gross resection was 69.2 %. By univariate analysis there was no difference in overall survival between patients in the complete gross resection and macroscopic residual disease groups, P= 0.26; 3-year overall survival rates: 86.4 % and 82.8 %, respectively. No difference in overall survival was noted following stratification by histology; P = 0.64 and P = 0.24 for dysgerminoma and non-dysgerminoma tumor groups. After controlling for stage IV disease, histology and the administration of chemotherapy, macroscopic residual disease was not associated with a worse mortality (HR: 1.22, 95% CI: 0.61 to 2.46).

Conclusions

Macroscopic residual disease following primary cancer-directed surgery was not associated with a worse prognosis in a cohort of patients with advanced stage malignant ovarian germ cell tumors.

Fertility-preserving surgery for advanced stage ovarian germ cell tumors

OBJECTIVE

To evaluate the prevalence and safety of uterine preservation among premenopausal women diagnosed with a malignant ovarian germ-cell tumor (MOGCT) of advanced stage (stage II-IV).

MATERIALS AND METHODS

The National Cancer Database was accessed and a cohort of women aged <40years, diagnosed with a MOGCT were identified. Those with stage II-IV disease who underwent cancer-directed surgery and received chemotherapy were selected for further analysis. Performance of hysterectomy was assessed from site-specific surgery codes. Overall survival (OS) was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox multivariate model was constructed to control for possible confounders.

RESULTS

A total of 526 eligible patients were identified; rate of hysterectomy was 20.2%. Women who had a hysterectomy were older (median age 30.5 vs 20years, p<0.001) and more likely to present with bilateral tumors (12.6% vs 3.8%, p<0.001). No differences were noted based on tumor histology (p=0.67). Rate of uterine preservation was 82.8%, 79.5% and 75% for those with stage II, III and IV disease respectively (p=0.46). There was no difference in OS between women who had hysterectomy and those who did not (p=0.051); five-year OS rates were 87.1% and 94.4% respectively. After controlling for disease stage, tumor histology and patient race, uterine preservation was not associated with a decreased survival (HR: 0.59, 95% CI: 0.28, 1.24, p=0.19).

CONCLUSIONS

Uterine preservation was not associated with decreased survival and should be considered in women with advanced stage GCTs interested in future fertility.

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.

Immature teratoma of ovary--outcome following primary and secondary surgery: study of a single institution cohort

OBJECTIVE

To analyse the clinical presentation, treatment - primary and secondary debulking and outcomes with focus on recurrences in ovarian immature teratoma.

STUDY DESIGN

This is a single institution, retrospective analysis of 24 women who presented to a gynecologic oncology unit from 1999 to 2011 with ovarian immature teratoma. Patient's clinical presentation, operative and chemotherapy details were included in a database. Follow up details regarding recurrence and management and future outcomes were also noted. Overall survival was calculated from the date of registration to last follow up or date of death. Survival curve was constructed by Kaplan-Meier method.

RESULTS

Immature teratoma accounted for 11% of 218 malignant germ cell tumors. Of the 24 patients, pain was the predominant symptom and abdominal mass was the commonest clinical presentation. Sixteen out of 24 patients presented in Stage I and grade 3 tumors were found in 43% of patients. Six patients had only unilateral salpingo oophorectomy and no staging procedure. Twelve patients underwent staging, with omentectomy being the commonest procedure. All but one, had cisplatin based combination chemotherapy. Six patients underwent secondary debulking of recurrence. Most recurrences were recorded in Stage III, higher grade tumors. With secondary cytoreduction and platinum based chemotherapy, it was possible to salvage most recurrences as well. Overall survival after a mean follow-up of 39 months was 91.6%.

CONCLUSION

Majority of the patients did well with conservative surgery in terms of survival, menstrual and reproductive function. Platinum based chemotherapy was indicated in higher grade and higher stage tumors as recurrences commonly occurred in this subgroup of patients. Recurrences could be salvaged with selected secondary cytoreduction and platinum based chemotherapy.

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.

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.

Yolk sac tumor of the ovary: a retrospective multicenter study of 33 Japanese women by Tohoku Gynecologic Cancer Unit (TGCU)

Yolk sac tumor (YST) of the ovary is a rare germ cell tumor comprising about 1% of all ovarian malignancies. YST usually occurs as a rapidly growing unilateral tumor in young women. With the introduction of cisplatin, YST has been changed from a fatal tumor to a curable tumor. The standard treatment of YST consists of fertility-preserving surgery and 3 or 4 courses of adjuvant combination chemotherapy with bleomycin, etoposide, and cisplatin (BEP). However, the long-term prognosis of BEP-treated YST patients has not been well studied. We therefore conducted a retrospective multicenter study to investigate the prognostic factors of 33 YST patients, including 25 patients treated with BEP. The median age at initial treatment was 20 years (range 10-53). There were 15 patients (at stage I), one (stage II), 16 (stage III), and one (stage IV). Nominal and grouped numerical values were analyzed by the Kaplan-Meier method. All patients had unilateral tumor, with right-side predominance (23 patients; P = 0.02). Eighteen patients had pure YST, 13 had mixed germ cell tumor with YST component, and other 2 patients were not specified. Twenty-eight patients received fertility-preserving surgery. Twenty-seven patients had optimal surgery with less than 1 cm residual tumor diameter. Median number of chemotherapy courses was 5. Median follow-up period was 49 months. The cumulative 5-year survival rate was 87%. Univariate analysis revealed the following significant prognostic factors (P < 0.05): stage, tumor diameter, and residual tumor. Extensive debulking surgery to minimize residual tumor would improve the prognosis.

Role of neoadjuvant chemotherapy in the management of advanced ovarian yolk sac tumor

OBJECTIVE

The aim of the study was to identify the role of neoadjuvant chemotherapy (NACT) in the treatment of the patients with advanced stage ovarian yolk sac tumor (OYST).

METHODS

The comparative study was based on 53 cases with advanced stage OYST registered at Peking Union Medical College Hospital from 1995 to 2010. Twenty one cases were treated with NACT followed by interval debulking surgery (IDS). Thirty two cases were treated with primary debulking surgery (PDS). Data on patient characteristics, treatment and survival were analyzed and compared between two groups to assess the outcome of NACT.

RESULTS

After NACT, the overall status of the patients was improved significantly. Patients in NACT had better optimal cytoreduction rate and less peri-operative morbidities. Seven patients (13.2%) suffered from relapse. There was a significantly better PFS for patients with ovarian tumor size >20cm in the NACT than those underwent PDS. Residual disease >2cm was the independent risk factor of relapse.

CONCLUSIONS

NACT is the better treatment option for some patients with advanced stage OYST, especially for those with unresectable tumors and poor general condition.

Long-term oncological and reproductive outcomes of fertility-sparing cytoreductive surgery in females aged 25 years and younger with malignant ovarian germ cell tumors

AIM

To evaluate the long-term oncological and reproductive outcomes of patients aged 25 years and younger who were treated by fertility-sparing cytoreductive surgery (FSCS) plus adjuvant chemotherapy (ACT) or observation alone for malignant ovarian germ cell tumors (MOGCT).

METHODS

Records of 42 eligible female patients treated for MOGCT between 1 May 1995 and 31 December 2010 at two centers were analyzed retrospectively. A telephone questionnaire was performed to gather reproductive and menstrual history.

RESULTS

One patient was treated without FSCS and two patients were lost to follow-up. The mean age of the remaining 39 patients was 18.4 ± 3.2 years. Eighteen of the tumors were histologically pure dysgerminomas (PD) and 21 were non-dysgerminomatous tumors (non-DT). Thirteen patients (33%) presented with stage II-III disease. Optimal cytoreduction was achieved in 34 of the 39 patients (87%). Systematic pelvic and para-aortic lymphadenectomy was performed in 31 of the 39 patients (79.5%). The frequency of lymph node metastasis was 29% (9/31). Twenty-seven patients (69.2%) received ACT. Disease recurred in six (15.3%) patients, all in the non-DT group. Four of six underwent secondary optimal FSCS followed by chemotherapy. Retroperitoneal nodal recurrence was detected in two of these four patients (50%). Four deaths occurred, three due to chemoresistant aggressive disease and one due to secondary acute myelocytic leukemia. The overall survival rates for patients with PD and non-DT were 100% and 81.4%, respectively. Twenty-three of 27 patients who received ACT continued their regular menses. Sixteen spontaneous pregnancies and one pregnancy by intrauterine insemination were achieved by 21 patients who attempted conception.

CONCLUSION

Either primary or secondary FSCS followed by ACT seems to be a feasible and safe approach to preserving future fertility and hormonal function in young patients with MOGCT.