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Origi na l A r tic le
Outcome of Germ Cell Tumors of Ovary Treated with
Adjuvant Chemotherapy
M S Sowmya1, Datta Siddartha2
Junior Resident, Department of Nilratan Sircar Medical College, Kolkata, West Bengal, India, 2Professor, Department of Obstetrics and
Gynecology, Nilratan Sircar Medical College, Kolkata, West Bengal, India
1
Abstract
Background: Effective combination chemotherapy has improved the previously dismal prognosis for malignant ovarian germ
cell tumors dramatically. In young patients, conservative surgery with adjuvant chemotherapy has made the preservation of
fertility possible, even in patients with advanced disease.
Aim: The aim was to evaluate the outcome of treatment with adjuvant chemotherapy.
Materials and Methods: Retrospective analysis of 41,030 patients attending Gynecology OPD, between January 2012 and
December 2012 in NRS Medical College, Kolkata. Six cases of germ cell tumor of ovary diagnosed (1 mixed germ cell tumor,
2 dysgerminoma, 1 immature teratoma, 1 endodermal sinus tumor, 1 yolk sac tumor) 3 underwent fertility-sparing surgery. All
6 received post-operative chemotherapy with bleomycin, etoposide, platinum regimen.
Results: Incidence of germ cell tumor of the ovary was 1 in 6838 general population, mean age of presentation 21 years,
adjuvant chemotherapy given to all 6 patients, overall mean follow-up period was 8 months.
Conclusion: Effective combination chemotherapy has dramatically improved poor prognosis of malignant germ cell tumor of
the ovary. These patients may expect almost normal lives. Serial assay of tumor markers is useful for monitoring response to
chemotherapy and subsequent follow-up.
Keywords: Bleomycin, Etoposide, Platinum, Fertility preservation, Malignant germ cell tumors of the ovary
INTRODUCTION
becoming an important, although controversial, issue in
gynecologic oncology.2
Malignant germ cell tumors of ovaries are often diagnosed
in young females. Incidence of malignant germ cell tumors
of the ovary is 15% of ovarian cancers in Asian and African
societies. In first two decades of life comprises 70% of
ovarian tumors.1 These tumors are now curable, mainly
as a result of great advances in chemotherapy in the past
two decades. The possible sequelae of chemotherapy on
long-term survivors are still largely unknown, but based on
the available evidence, these patients may expect normal
lives. Preservation of their ovarian function and fertility is
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Prompt initiation of appropriate chemotherapy is a critical
factor for young patients with advanced malignant ovarian
germ cell tumor (MOGCT). Contemporary principles
of surgery for MOGCT dictate conservative surgery is
appropriate even in the face of extensive metastasis. Hence,
focus of the new study shifted to long-term sequelae such
as ovarian and reproductive function.3
MATERIALS AND METHODS
Retrospective analysis of 41,030 patients between January
2012 and December 2012 in NRS Medical College Kolkata,
a total of 6 women with germ cell ovarian malignancies
either underwent primary surgery in our department
or were referred for post-operative treatment. In all
instances, the microscopic slides were reviewed by our most
experienced pathologist to confirm the diagnosis 1 mixed
Corresponding Author:
Dr. M S Sowmya, Nilratan Sircar Medical College, AJC Bose Road, Kolkata - 14, West Bengal, India. E-mail : [email protected]
International Journal of Scientific Study | November 2014 | Vol 2 | Issue 8
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Sowmya and Siddartha: Germ Cell Tumors of Ovary Treated with Adjuvant Chemotherapy
germ cell tumor, 2 dysgerminoma, 1 immature teratoma,
1 endodermal sinus tumor, 1 yolk sac tumor.
Three women were referred at the time of recurrence
after primary treatment was performed elsewhere. Women
who underwent primary surgery in our department had
unilateral salpingo-oophorectomy, omentectomy, aimed for
random intraperitoneal sampling, and debulking. A biopsy
of the contralateral ovary usually was not performed, and
only suspicious lesions on the surface of the preserved
ovary were excised and sent for pathologic evaluation.
Such a policy was chosen as germ cell tumors are highly
chemosensitive, and wedge biopsy of the ovary is a
recognized cause of the mechanical infertility. Systemic
pelvic and para-aortic lymphadenectomy performed
part of the standard procedure thereafter. All 6 received
chemotherapy with bleomycin, etoposide, platinum (BEP)
bleomycin 15 U/m2 every week for 8 week and 1st day
of 4th cycle, etoposide 100 mg/m2 day 1-5, cisplatin
20 mg/m2 day every 3 weeks.
Follow-up examinations were conducted every 3 months
for the 1st year after surgery, consisted of physical and
gynecologic examination, diagnostic imaging of the
abdomen and the pelvis, and measurement of serum tumor
markers (alfa feto protein, lactate dehydrogenase, serum
βhCG) and computed tomography scan.
RESULTS
Total number of retrospectively studied patients was 6.
Mean age of presentation 21 years. Incidence of germ cell
tumor of the ovary in our institution is 1 in 6838 of the
general population. Patients who underwent incomplete
surgery elsewhere were called unstaged. 3 patients were
unstaged, 2 unstaged patients had fertility-sparing surgery.
2 patients who were surgically staged in Stage IIIA and
1 in Stage IIIC. Fertility preserving surgery was done on
4 patients, 2 in our institute.
Adjuvant chemotherapy with BEP given to all 6 patients, 4
of them completed 6 cycles, 1 patient completed 4 cycles,
1 died after single cycle of chemotherapy (Tables 1 and 2).
Follow-up
Median follow-up period is 14 months. 1 patient with
endodermal sinus tumor had recurrence at 18 month of
follow-up in left ovary. Total abdominal hysterectomy
with left salpingo opherctomy done with histopathology
showing metastatic deposit. Rest 3 patients are in diseasefree survival. Mean period of overall survival till date is
14 months. In this study, remission rate with BEP is 67%.
Median time to recovery of menstruation was 3 months
after completion of chemotherapy observed side effects
were febrile neutropenia, alopecia and intestinal obstruction.
DISCUSSION
Principles for surgical management of MOGCT include
fertility-sparing surgery with preservation of contralateral
ovary, fallopian tube and uterus. Even in dysgerminomas, in
which bilaterality is more common, bilateral oopherectomy
is not necessary, post-operative chemotherapy is often
capable of eradicating disease. 4 The treatment of
MOGCTs, with BEP regimen is becoming the most widely
used chemotherapeutic regimen.5-7 The overall survival
of patients treated with platinum-based chemotherapy
currently ranges from 878 to 98%.7
MD Anderson group used BEP in patients with metastatic
dysgerminomas in 1984 with all 14 BEP treated patients
disease free at a median follow-up of 22.4 months.5 Brewer
et al. reported 26 patients with dysgerminomas who received
BEP with 14 of them with fertility sparing surgery, 93% had
normal menstrual function with five pregnancies reported.6
There is no role of second look operation in GCT who are
clinically free of disease after chemotherapy. In patients, whose
tumor contains teratomatous element second look procedure
may be beneficial.4 In our study even unstaged patients, with
chemotherapy had remission of the disease without the need
for second look laparotomy, monitored with tumor markers
measurement and thus reducing morbidity to patients.8
CONCLUSION
Fertility-sparing surgery for all patients with MOGCT is
recommended irrespective of the stage of the disease. Young
Table 1: Characteristics of cases
Name Age Parity
A
B
14
20
Surgery
Nulliparous RSO+Optimal cytoreduction
P1+0
RSO+Left ovariotomy (elsewhere)
Stage at diagnosis Histopathology
IIIC
Mixed germ cell tumor
Dysgerminoma
C
35
P2+0
Right ovariotomy elsewhere followed by RSO+Left ovariotomy+TAH IIIA
Immature teratoma
D
E
F
22
13
15
Nullipara
Nullipara
Nullipara
RSO+Optimal cytoreduction
TAH+BSO (elsewhere)
LSO (elsewhere)
Endodermal sinus tumor
Dysgerminoma
Yolksac tumor
IIIA
RSO: Right salpingo opherectomy, TAH: Total abdominal hysterectomy, LSO: Left salpingo opherctomy, BSO: Bilateral salpingo-oophorectomy
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Sowmya and Siddartha: Germ Cell Tumors of Ovary Treated with Adjuvant Chemotherapy
Table 2: Survival and follow-up
A
B
C
Number of BEP cycles 6 6
6
Follow-up (months)
16 13 14
Site of recurrence
- - Pelvis
Overall survival
Death
23 21
22
D
2.
E
F
6
4
1
14
1
Left Paraaortic Pelvis and
ovary
nodes
abdominal
wall
18
s
+
+
BEP: Bleomycin, etoposide, platinum
women who are treated with multidrug chemotherapy for
ovarian germ cell tumors may expect a recovery of ovarian
function within a few months after treatment.
3.
4.
5.
6.
7.
8.
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How to cite this article: Sowmya MS, Siddartha D. Outcome of germ cell tumors of ovary treated with adjuvant chemotherapy. Int J Sci
Stud 2014;2(8):136-138.
Source of Support: Nil, Conflict of Interest: None declared.
International Journal of Scientific Study | November 2014 | Vol 2 | Issue 8
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