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Information from PDQ -- for Health Professionals
Ovarian germ cell tumor
208/03125
** GENERAL INFORMATION **
Germ cell tumors of the ovary, uncommon but aggressive tumors seen most often
in young women or adolescent girls, are frequently unilateral, and are
generally curable if found and treated early. Use of combination chemotherapy
after initial surgery has dramatically improved the prognosis for many women
with these tumors.[1-3] Although long-term survival is the rule for mature
teratoma, survival for immature teratoma following surgery only is related to
the grade of the tumor, especially its neural elements. In a series of 58
patients with immature teratoma treated before the modern chemotherapeutic era,
Norris et al. reported recurrence in 18% with grade 1 disease, in 37% with
grade 2 disease, and in 70% with grade 3 disease, and similar findings have
been reported by others.[4] Endodermal sinus tumors of the ovary are
particularly aggressive. A review of the literature in 1979 prior to the
widespread use of combination chemotherapy, found only 27% of 96 patients with
stage I endodermal sinus tumor alive at 2 years. Over 50% died within a year
of diagnosis.[5]
Other studies found that size and histology were the major factors determining
prognosis for patients with malignant mixed germ cell tumors of the ovary.[4,6]
Prognosis was poor for large tumors when more than one-third of the tumor was
composed of endodermal sinus elements, choriocarcinoma or grade 3 immature
teratoma. On the other hand, when the tumor was less than 10 centimeters in
diameter, the prognosis was good regardless of the composition of the tumor.[6]
For dysgerminoma confined to the ovary, less than 10 centimeters in size, with
an intact, smooth capsule unattached to other organs and without ascites, the
10-year survival following conservative surgery was 88.6% in a series, and a
number of patients had 1 or more successful pregnancies following unilateral
salpingo-oophorectomy.[7] Even patients with incompletely resected
dysgerminoma can be rendered disease free following BEP
(bleomycin/etoposide/cisplatin) or PVB (cisplatin/vinblastine/bleomycin)
chemotherapy.[8] A report of 35 cases of germ cell tumors, half of which were
advanced stage or recurrent or progressive disease, demonstrated a 97%
sustained remission at 10 to 54 months after the start of BEP chemotherapy.[1]
Also, reported results of 2 Gynecologic Oncology Group (GOG) trials show that
89 of 93 patients with stages I, II, and III disease who had completely
resected tumors were disease free after 3 cycles of BEP.[1,3] However, in a
similar nonseminomatous germ cell tumor of the testis, the combination of
bleomycin, etoposide, and carboplatin (CEB) was inferior to BEP in a randomized
multicenter trial comparing BEP to CEB in 598 patients with good-risk
nonseminomatous testicular germ cell tumors.[9]
References:
1. Gershenson DM: Update on malignant ovarian germ cell tumors. Cancer
71(4, Suppl): 1581-1590, 1993.
2. Segelov E, Campbell J, Ng M, et al.: Cisplatin-based chemotherapy for
ovarian germ cell malignancies: the Australian experience. Journal of
Clinical Oncology 12(2): 378-384, 1994.
3. Williams S, Blessing JA, Liao SY, et al.: Adjuvant therapy of ovarian
germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of
the Gynecologic Oncology Group. Journal of Clinical Oncology 12(4):
701-706, 1994.
4. Norris HJ, Zirken HJ, Benson WL: Immature (malignant) teratoma of the
ovary: a clinical and pathologic study of 58 cases. Cancer 37(5):
2359-2372, 1976.
5. Gallion H, Van Nagell JR, Powell DF, et al.: Therapy of endodermal sinus
tumor of the ovary. American Journal of Obstetrics and Gynecology
135(4): 447-451, 1979.
6. Kurman RJ, Norris HJ: Malignant germ cell tumors of the ovary. Human
Pathology 8(5): 551-564, 1977.
7. Thomas GM, Dembo AJ, Hacker NF, et al.: Current therapy for dysgerminoma
of the ovary. Obstetrics and Gynecology 70(2): 268-275, 1987.
8. Williams SD, Blessing JA, Hatch KD, et al.: Chemotherapy of advanced
dysgerminoma: trials of the Gynecologic Oncology Group. Journal of
Clinical Oncology 9(11): 1950-1955, 1991.
9. Horwich A, Sleijfer DT, Fossa SD, et al.: Randomized trial of bleomycin,
etoposide, and cisplatin compared with bleomycin, etoposide, and
carboplatin in good-prognosis metastatic nonseminomatous germ cell
cancer: a Multiinstitutional Medical Research Council/European
Organization for Research and Treatment of Cancer Trial. Journal of
Clinical Oncology 15(5): 1844-1852, 1997.
** CELLULAR CLASSIFICATION **
The following histologic subtypes have been described.[1,2]
- dysgerminoma
- other germ cell tumors
- endodermal sinus tumor (rare subtypes are hepatoid and intestinal)[1]
- embryonal carcinoma
- polyembryoma
- choriocarcinoma
- teratoma:
- immature
- mature:
- solid
- cystic:
- dermoid cyst (mature cystic teratoma)
- dermoid cyst with malignant transformation
- monodermal and highly specialized:
- struma ovarii
- carcinoid
- struma ovarii and carcinoid
- others (e.g., malignant neuroectodermal and ependymoma)
- mixed forms
References:
1. Gershenson DM: Update on malignant ovarian germ cell tumors. Cancer
71(4, Suppl): 1581-1590, 1993.
2. Serov SF, Scully RE, Robin IH: International Histologic Classification
of Tumours: No. 9. Histological Typing of Ovarian Tumours. Geneva: World
Health Organization, 1973.
** STAGE INFORMATION **
In the absence of obvious metastatic disease, accurate staging of germ cell
tumors of the ovary requires laparotomy with careful examination of the entire
diaphragm, both paracolic gutters, pelvic nodes on the side of the ovarian
tumor, the para-aortic lymph nodes, and the omentum. The contralateral ovary
should be carefully examined and biopsied if necessary. Ascitic fluid should
be examined cytologically. If ascites is not present, it is important to
obtain peritoneal washings before the tumor is manipulated. In patients with
dysgerminoma, lymphangiography or computed tomography is indicated if the
pelvic and para-aortic lymph nodes were not carefully examined at surgery.
Although not required for formal staging, it is desirable to obtain serum
levels of alpha fetoprotein (AFP) and human chorionic gonadotropin (HCG) as
soon as the diagnosis is established since persistence of these markers in the
serum after surgery indicates unresected tumor.
Stages are similar to those defined by the International Federation of
Gynecology and Obstetrics (FIGO) for malignant epithelial ovarian tumors.[1]
-- Stage I --
Stage I ovarian germ cell tumor is growth limited to the ovaries.
Stage IA: growth limited to 1 ovary; no ascites. No tumor on the external
surface; capsule intact.
Stage IB: growth limited to both ovaries; no ascites. No tumor on the
external surfaces; capsules intact.
Stage IC: tumor either stage IA or IB, but with tumor on the surface of one
or both ovaries; or with capsule ruptured; or with ascites present
containing malignant cells or with positive peritoneal washings.
In order to evaluate the impact on prognosis of the different criteria for
allotting cases to stage IC, it would be of value to know if rupture of the
capsule was spontaneous or caused by the surgeon and if the source of
malignant cells detected was peritoneal washings or ascites.
-- Stage II --
Stage II ovarian germ cell tumor is growth involving 1 or both ovaries with
pelvic extension.
Stage IIA: extension and/or metastases to the uterus and/or tubes.
Stage IIB: extension to other pelvic tissues.
Stage IIC: tumor either stage IIA or stage IIB, but with tumor on the
surface of 1 or both ovaries; or with capsule(s) ruptured; or with
ascites present containing malignant cells or with positive peritoneal
washings.
In order to evaluate the impact on prognosis of the different criteria for
allotting cases to stage IIC, it would be of value to know if rupture of the
capsule was spontaneous or caused by the surgeon and if the source of
malignant cells detected was peritoneal washings or ascites.
-- Stage III --
Stage III ovarian germ cell tumor is growth involving 1 or both ovaries with
peritoneal implants outside the pelvis and/or positive retroperitoneal or
inguinal nodes. Superficial liver metastasis equals stage III. Tumor is
limited to the true pelvis but with histologically verified malignant extension
to small bowel or omentum.
Stage IIIA: tumor grossly limited to the true pelvis with negative nodes but
with histologically confirmed microscopic seeding of abdominal peritoneal
surfaces.
Stage IIIB: tumor of 1 or both ovaries with histologically confirmed
implants of abdominal peritoneal surfaces, none exceeding 2 cm in
diameter; negative nodes.
Stage IIIC: abdominal implants greater than 2 cm in diameter and/or positive
retroperitoneal or inguinal nodes.
-- Stage IV --
Stage IV ovarian germ cell tumor is growth involving 1 or both ovaries with
distant metastasis. If pleural effusion is present, there must be positive
cytologic test results to allot a case to stage IV. Parenchymal liver
metastasis equals stage IV.
In any stage, ascites is peritoneal effusion that is cytologically positive or,
in the opinion of the surgeon, clearly exceeds normal amounts, or both.
References:
1. Shepherd JH: Revised FIGO staging for gynaecological cancer. British
Journal of Obstetrics and Gynaecology 96(8): 889-892, 1989.
** TREATMENT OPTION OVERVIEW **
All patients except those with stage I, grade I immature teratoma and stage IA
dysgerminoma require postoperative chemotherapy. With platinum-based
combination chemotherapy, the prognosis for patients with endodermal sinus
tumors, immature teratomas, embryonal carcinomas, choriocarcinomas, and mixed
tumors containing 1 or more of these elements has improved dramatically.[1] As
new and more effective drugs are developed, many of these patients will be
candidates for newer clinical trials.
The designations in PDQ that treatments are "standard" or "under clinical
evaluation" are not to be used as a basis for reimbursement determinations.
References:
1. Gershenson DM, Morris M, Cangir A, et al.: Treatment of malignant germ
cell tumors of the ovary with bleomycin, etoposide, and cisplatin.
Journal of Clinical Oncology 8(4): 715-720, 1990.
** STAGE I OVARIAN GERM CELL TUMOR **
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
-- Dysgerminoma --
Standard treatment options:
For patients with stage I dysgerminoma, unilateral salpingo-oophorectomy
conserving the uterus and opposite ovary is accepted treatment of the younger
patient anxious to preserve fertility or to preserve a pregnancy.
Postoperative lymphangiography or computed tomography is indicated before
treatment decisions are made for patients who have not had careful surgical and
pathological examination of pelvic and para-aortic lymph nodes during surgery.
Patients who have been completely staged and have stage IA tumors may be
observed carefully after surgery without adjuvant treatment. About 15% to 25%
will recur, but can be treated successfully at the time of recurrence with a
high likelihood of cure. Incompletely staged patients or those with higher
stage tumors probably should receive adjuvant treatment. Options include
radiation therapy or chemotherapy. A disadvantage of the former is loss of
fertility due to ovarian failure. Experience with adjuvant chemotherapy is
limited, but considering the effectiveness of chemotherapy in tumors other than
dysgerminoma and in advanced stage dysgerminoma, it is likely to be very
effective and to allow recovery of reproductive potential in patients with an
intact ovary, tube, and uterus.[1]
-- Other germ cell tumors --
Standard treatment options:
For patients with stage I germ cell tumors, unilateral salpingo-oophorectomy
should be performed when fertility is to be preserved. For all tumors other
than pure dysgerminoma and low-grade (grade I) immature teratoma, chemotherapy
is usually given postoperatively, although a series demonstrated excellent
survival for all types of stage I tumors managed by surveillance, reserving
chemotherapy for cases in which post-surgery recurrence is documented.[2][Level
of evidence: 3iiiA] There is considerable experience with VAC, a combination
of vincristine, dactinomycin, and cyclophosphamide given in an adjuvant
setting, however, combinations containing cisplatin, etoposide, and bleomycin
(BEP) are now preferred because of a lower relapse rate and shorter treatment
time.[3] While a prospective comparison of VAC versus BEP has not been
performed, it should be noted that in well-staged patients with completely
resected tumors, relapse is essentially unheard of following platinum-based
chemotherapy.[3] However, the disease will recur in about 25% of well-staged
patients treated with 6 months of VAC.[4]
Evidence suggests that second-look laparotomy is not beneficial in patients
with initially completely resected tumors who receive cisplatin-based
adjuvant treatment.[5,6]
References:
1. Thomas GM, Dembo AJ, Hacker NF, et al.: Current therapy for dysgerminoma
of the ovary. Obstetrics and Gynecology 70(2): 268-275, 1987.
2. Dark GG, Bower M, Newlands ES, et al.: Surveillance policy for stage I
ovarian germ cell tumors. Journal of Clinical Oncology 15(2): 620-624,
1997.
3. Williams S, Blessing JA, Liao SY, et al.: Adjuvant therapy of ovarian
germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of
the Gynecologic Oncology Group. Journal of Clinical Oncology 12(4):
701-706, 1994.
4. Slayton RE, Park RC, Silverberg SG, et al.: Vincristine, dactinomycin,
and cyclophosphamide in the treatment of malignant germ cell tumors of
the ovary. Cancer 56(2): 243-248, 1985.
5. Williams SD, Blessing JA, DiSaia PJ, et al.: Second-look laparotomy in
ovarian germ cell tumors: the Gynecologic Oncology Group experience.
Gynecologic Oncology 52(3): 287-291, 1994.
6. Gershenson DM: The obsolescence of second-look laparotomy in the
management of malignant ovarian germ cell tumors. Gynecologic Oncology
52(3): 283-285, 1994.
** STAGE II OVARIAN GERM CELL TUMOR **
-- Dysgerminoma --
Standard treatment options:
For patients with stage II dysgerminoma, total abdominal hysterectomy and
bilateral salpingo-oophorectomy are usually performed. However, for the
younger patient anxious to preserve fertility, a unilateral
salpingo-oophorectomy can be considered standard therapy at this time; adjuvant
chemotherapy should be given.
These patients should receive adjuvant treatment. Options include radiation
therapy or chemotherapy. A disadvantage of the former is loss of fertility due
to ovarian failure. Experience with adjuvant chemotherapy is limited, but
considering the effectiveness of chemotherapy in tumors other than dysgerminoma
and in advanced stage dysgerminoma, it is likely to be effective and to allow
recovery of reproductive potential in patients with an intact ovary, tube, and
uterus. Thus, adjuvant cisplatin, etoposide, and bleomycin have replaced
radiation therapy except in the rare patient in whom chemotherapy is not
considered appropriate.
-- Other germ cell tumors --
Standard treatment options:
For patients with stage II germ cell tumors other than pure dysgerminoma,
unilateral salpingo-oophorectomy should be performed when fertility is to be
preserved. Although there is considerable experience with VAC
(vincristine/dactinomycin/cyclophosphamide), especially when given in an
adjuvant setting, combinations containing bleomycin, etoposide, and cisplatin
(BEP) are more effective.[1-3] Patients who do not respond to a
cisplatin-based combination may still attain a durable remission with VAC as
salvage therapy.[4] Recurrence after 3 courses of BEP as adjuvant therapy is
rare.[4] All patients who do not respond to standard therapy are candidates
for clinical trials. When there is residual disease or elevated levels of AFP
or HCG after maximal surgical debulking, 3 or 4 courses of BEP combination
chemotherapy are indicated.[5]
Evidence suggests that second-look laparotomy is not beneficial in patients
with initially completely resected tumors who receive cisplatin-based adjuvant
treatment.[6] Second-look surgery may be of benefit for a minority of patients
whose tumor was not completely resected at the initial surgical procedure and
who had teratomatous elements in their primary tumor.[6,7] Surgical resection
of residual masses detected by clinical examination, by radiographic
procedures, or at re-exploration should be undertaken since reversion to germ
cell tumor has been described.
Treatment options under clinical evaluation:
Patients with stage II germ cell tumors of the ovary are candidates for
clinical trials.[4] Information about ongoing clinical trials is available
from the NCI (http://cancer.gov/clinical_trials).
References:
1. Williams S, Blessing JA, Liao SY, et al.: Adjuvant therapy of ovarian
germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of
the Gynecologic Oncology Group. Journal of Clinical Oncology 12(4):
701-706, 1994.
2. Pinkerton CR, Pritchard J, Spitz L: High complete response rate in
children with advanced germ cell tumors using cisplatin-containing
combination chemotherapy. Journal of Clinical Oncology 4(2): 194-199,
1986.
3. Gershenson DM, Morris M, Cangir A, et al.: Treatment of malignant germ
cell tumors of the ovary with bleomycin, etoposide, and cisplatin.
Journal of Clinical Oncology 8(4): 715-720, 1990.
4. Williams SD, Blessing JA, Moore DH, et al.: Cisplatin, vinblastine, and
bleomycin in advanced and recurrent ovarian germ-cell tumors: a trial of
the Gynecologic Oncology Group. Annals of Internal Medicine 111(1):
22-27, 1989.
5. Williams SD, Birch R, Einhorn LH, et al.: Treatment of disseminated
germ-cell tumors with cisplatin, bleomycin, and either vinblastine or
etoposide. New England Journal of Medicine 316(23): 1435-1440, 1987.
6. Williams SD, Blessing JA, DiSaia PJ, et al.: Second-look laparotomy in
ovarian germ cell tumors: the Gynecologic Oncology Group experience.
Gynecologic Oncology 52(3): 287-291, 1994.
7. Gershenson DM: The obsolescence of second-look laparotomy in the
management of malignant ovarian germ cell tumors. Gynecologic Oncology
52(3): 283-285, 1994.
** STAGE III OVARIAN GERM CELL TUMOR **
-- Dysgerminoma --
Standard treatment options:
For patients with stage III dysgerminoma, total abdominal hysterectomy and
bilateral salpingo-oophorectomy are recommended with removal of as much gross
tumor as can be done safely without resection of portions of the urinary tract
or large segments of small or large bowel. Patients who wish to preserve
fertility may be treated with unilateral salpingo-oophorectomy if chemotherapy
is to be employed.[1-5]
Chemotherapy with bleomycin/etoposide/cisplatin (BEP) can cure the majority of
such patients. In a report of results from 2 Gynecologic Oncology Group (GOG)
trials, 19 of 20 patients with incompletely resected tumor who were treated
with BEP or PVB were disease free at a median follow-up of 26 months.[1] When
there is bulky residual disease, it is common to give 3 to 4 courses of a
cisplatin-containing combination such as PVB or BEP.[6-8] A randomized study
in testicular cancer has shown that bleomycin is an essential component of the
BEP regime when only 3 courses are administered.[9] Since chemotherapy with
BEP appears to be less sterilizing than wide-field radiation, combination
chemotherapy is the preferred treatment in the patient who still desires to
have children.[1]
-- Other germ cell tumors --
Standard treatment options:
For patients with stage III germ cell tumors other than pure dysgerminoma,
total abdominal hysterectomy and bilateral salpingo-oophorectomy is recommended
with removal of as much tumor in the abdomen and pelvis as can be done safely
without resection of portions of the urinary tract or large segments of small
or large bowel. Patients who wish to preserve fertility can be treated with
unilateral salpingo-oophorectomy.[1,3,4] For patients with extensive
intra-abdominal disease whose clinical condition precludes debulking surgery,
chemotherapy can be considered prior to surgery. Following maximal surgical
debulking, 3 to 4 courses of cisplatin-containing combination chemotherapy are
indicated.[2,6,10]
Evidence suggests that second-look laparotomy is not beneficial in patients
with initially completely resected tumors who receive cisplatin-based adjuvant
treatment.[11] Patients who do not respond to a cisplatin/etoposide-based
combination may still attain a durable remission with VAC or
cisplatin/vinblastine/ifosfamide as salvage therapy.[6] Second-look surgery
may be of benefit for a minority of patients whose tumor was not completely
resected at the initial surgical procedure and who had teratomatous elements in
their primary tumor.[11] Surgical resection of residual masses detected by
clinical examination, by radiographic procedures, or at re-exploration should
be undertaken since reversion to germ cell tumor or progressive teratoma has
been described.
Treatment options under clinical evaluation:
Patients with stage III germ cell tumors of the ovary, including pure
dysgerminoma, are candidates for clinical trials. Information about ongoing
clinical trials is available from the NCI (http://cancer.gov/clinical_trials).
References:
1. Williams SD, Blessing JA, Hatch KD, et al.: Chemotherapy of advanced
dysgerminoma: trials of the Gynecologic Oncology Group. Journal of
Clinical Oncology 9(11): 1950-1955, 1991.
2. Gershenson DM, Morris M, Cangir A, et al.: Treatment of malignant germ
cell tumors of the ovary with bleomycin, etoposide, and cisplatin.
Journal of Clinical Oncology 8(4): 715-720, 1990.
3. Wu PC, Huang RL, Lang JH, et al.: Treatment of malignant ovarian germ
cell tumors with preservation of fertility: a report of 28 cases.
Gynecologic Oncology 40(1): 2-6, 1991.
4. Schwartz PE, Chambers SK, Chambers JT, et al.: Ovarian germ cell
malignancies: the Yale University experience. Gynecologic Oncology
45(1): 26-31, 1992.
5. Low JJ, Perrin LC, Crandon AJ, et al.: Conservation surgery to preserve
ovarian function in patients with malignant ovarian germ cell tumors: a
review of 74 cases. Cancer 89(2): 391-398, 2000.
6. Williams SD, Blessing JA, Moore DH, et al.: Cisplatin, vinblastine, and
bleomycin in advanced and recurrent ovarian germ-cell tumors: a trial of
the Gynecologic Oncology Group. Annals of Internal Medicine 111(1):
22-27, 1989.
7. Williams SD, Birch R, Einhorn LH, et al.: Treatment of disseminated
germ-cell tumors with cisplatin, bleomycin, and either vinblastine or
etoposide. New England Journal of Medicine 316(23): 1435-1440, 1987.
8. Taylor MH, Depetrillo AD, Turner AR: Vinblastine, bleomycin, and
cisplatin in malignant germ cell tumors of the ovary. Cancer 56(6):
1341-1349, 1985.
9. Williams S, Blessing JA, Liao SY, et al.: Adjuvant therapy of ovarian
germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of
the Gynecologic Oncology Group. Journal of Clinical Oncology 12(4):
701-706, 1994.
10. Williams SD, Blessing JA, DiSaia PJ, et al.: Second-look laparotomy in
ovarian germ cell tumors: the Gynecologic Oncology Group experience.
Gynecologic Oncology 52(3): 287-291, 1994.
11. Gershenson DM: The obsolescence of second-look laparotomy in the
management of malignant ovarian germ cell tumors. Gynecologic Oncology
52(3): 283-285, 1994.
** STAGE IV OVARIAN GERM CELL TUMOR **
-- Dysgerminoma --
Standard treatment options:
For patients with stage IV dysgerminoma, total abdominal hysterectomy and
bilateral salpingo-oophorectomy is recommended with removal of as much gross
tumor in the abdomen and pelvis as can be done safely without resection of
portions of the urinary tract or large segments of small or large bowel,
although unilateral salpingo-oophorectomy should be considered in patients who
wish to preserve fertility.[1,2] Chemotherapy with
bleomycin/etoposide/cisplatin (BEP) can cure the majority of such patients.
Stage IV dysgerminoma is not treated with radiation therapy, but rather with
chemotherapy, preferably with 3 to 4 courses of cisplatin-containing
combination chemotherapy such as BEP.[1] A second-look operation following
treatment is rarely beneficial.
-- Other germ cell tumors --
Standard treatment options:
For patients with stage IV germ cell tumors other than pure dysgerminoma, total
abdominal hysterectomy and bilateral salpingo-oophorectomy is recommended with
removal of as much tumor from the abdomen and pelvis as can be done safely
without resection of kidney or large segments of small or large bowel.
Patients who wish to preserve fertility can be treated with unilateral
salpingo-oophorectomy. Following maximal surgical debulking, 3 to 4 courses of
cisplatin-containing combination chemotherapy are indicated.[3,4] For patients
with extensive intra-abdominal disease whose clinical condition precludes
debulking surgery, chemotherapy can be considered prior to surgery. Patients
who do not respond to a cisplatin/etoposide-based combination may still attain
a durable remission with VAC or cisplatin/vinblastine/ifosfamide as salvage
therapy.[4] Second-look surgery may be of benefit for a minority of patients
whose tumor was not completely resected at the initial surgical procedure and
who had teratomatous elements in their primary tumor.[5,6] Surgical resection
of residual masses detected by clinical examination, by radiographic
procedures, or at re-exploration should be undertaken since reversion to germ
cell tumor or progressive teratoma has been described.
Treatment options under clinical evaluation:
Patients with stage IV germ cell tumors of the ovary (including pure
dysgerminoma) are candidates for clinical trials. Information about ongoing
clinical trials is available from the NCI (http://cancer.gov/clinical_trials).
References:
1. Williams SD, Blessing JA, Hatch KD, et al.: Chemotherapy of advanced
dysgerminoma: trials of the Gynecologic Oncology Group. Journal of
Clinical Oncology 9(11): 1950-1955, 1991.
2. Low JJ, Perrin LC, Crandon AJ, et al.: Conservation surgery to preserve
ovarian function in patients with malignant ovarian germ cell tumors: a
review of 74 cases. Cancer 89(2): 391-398, 2000.
3. Gershenson DM, Morris M, Cangir A, et al.: Treatment of malignant germ
cell tumors of the ovary with bleomycin, etoposide, and cisplatin.
Journal of Clinical Oncology 8(4): 715-720, 1990.
4. Williams SD, Blessing JA, Moore DH, et al.: Cisplatin, vinblastine, and
bleomycin in advanced and recurrent ovarian germ-cell tumors: a trial of
the Gynecologic Oncology Group. Annals of Internal Medicine 111(1):
22-27, 1989.
5. Williams SD, Blessing JA, DiSaia PJ, et al.: Second-look laparotomy in
ovarian germ cell tumors: the Gynecologic Oncology Group experience.
Gynecologic Oncology 52(3): 287-291, 1994.
6. Gershenson DM: The obsolescence of second-look laparotomy in the
management of malignant ovarian germ cell tumors. Gynecologic Oncology
52(3): 283-285, 1994.
** RECURRENT OVARIAN GERM CELL TUMOR **
-- Dysgerminoma --
Standard treatment options:
Cisplatin-based chemotherapy has been used effectively for patients with
recurrent dysgerminoma with and without adjuvant radiation therapy.[1]
-- Other germ cell tumors --
Standard treatment options:
Patients with recurrent germ cell tumors of the ovary other than pure
dysgerminoma should be treated with chemotherapy, the type of which is
determined by previous treatment.[2] Radiation therapy is not effective in
this setting. Cisplatin-based combination chemotherapy is effective.[1,3,4]
Patients who do not respond to a cisplatin-based combination may still attain a
durable remission with VAC or ifosfamide/cisplatin as salvage therapy.[1]
Newer potential treatments include an ifosfamide combination [5] or high-dose
chemotherapy and autologous marrow rescue.[6-8] Although the role of secondary
cytoreductive surgery for patients with recurrent or progressive ovarian germ
cell tumors remains controversial, it may have some benefit for a select group
of patients, particularly those with immature teratoma.[9] After maximal
effort for surgical cytoreduction, chemotherapy should be considered.
Treatment options under clinical evaluation:
Patients with recurrent germ cell tumors of the ovary (including pure
dysgerminoma) are candidates for clinical trials. Some consideration should be
given to the use of high-dose regimens with rescue.[10]
References:
1. Williams SD, Blessing JA, Moore DH, et al.: Cisplatin, vinblastine, and
bleomycin in advanced and recurrent ovarian germ-cell tumors: a trial of
the Gynecologic Oncology Group. Annals of Internal Medicine 111(1):
22-27, 1989.
2. Williams SD, Blessing JA, Hatch KD, et al.: Chemotherapy of advanced
dysgerminoma: trials of the Gynecologic Oncology Group. Journal of
Clinical Oncology 9(11): 1950-1955, 1991.
3. Williams SD, Birch R, Einhorn LH, et al.: Treatment of disseminated
germ-cell tumors with cisplatin, bleomycin, and either vinblastine or
etoposide. New England Journal of Medicine 316(23): 1435-1440, 1987.
4. Taylor MH, Depetrillo AD, Turner AR: Vinblastine, bleomycin, and
cisplatin in malignant germ cell tumors of the ovary. Cancer 56(6):
1341-1349, 1985.
5. Munshi NC, Loehrer PJ, Roth BJ, et al.: Vinblastine, ifosfamide and
cisplatin (VeIP) as second line chemotherapy in metastatic germ cell
tumors (GCT). Proceedings of the American Society of Clinical Oncology
9: A-520, 134, 1990.
6. Broun ER, Nichols CR, Kneebone P, et al.: Long-term outcome of patients
with relapsed and refractory germ cell tumors treated with high-dose
chemotherapy and autologous bone marrow rescue. Annals of Internal
Medicine 117(2): 124-128, 1992.
7. Motzer RJ, Bosl GJ: High-dose chemotherapy for resistant germ cell
tumors: recent advances and future directions. Journal of the National
Cancer Institute 84(22): 1703-1709, 1992.
8. Mandanas RA, Saez RA, Epstein RB, et al.: Long-term results of autologous
marrow transplantation for relapsed or refractory male or female germ
cell tumors. Bone Marrow Transplantation 21(6): 569-576, 1998.
9. Munkarah A, Gershenson DM, Levenback C, et al.: Salvage surgery for
chemorefractory ovarian germ cell tumors. Gynecologic Oncology 55(2):
217-223, 1994.
10. Williams SD, Gynecologic Oncology Group: Phase II Combination
Chemotherapy with BEP (CDDP/VP-16/BLEO) as Induction Followed by VAC
(VCR/DACT/CTX) as Consolidation in Patients with Incompletely Resected
Malignant Ovarian Germ Cell Tumors (Summary Last Modified 09/98),
GOG-90, clinical trial, closed, 07/27/1998.
Date Last Modified: 07/2002
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