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Ovarian germ cell tumor


Table of Contents

GENERAL INFORMATION
CELLULAR CLASSIFICATION
STAGE INFORMATION
Stage I
Stage II
Stage III
Stage IV
TREATMENT OPTION OVERVIEW
STAGE I OVARIAN GERM CELL TUMOR
Dysgerminoma
Other germ cell tumors
STAGE II OVARIAN GERM CELL TUMOR
Dysgerminoma
Other germ cell tumors
STAGE III OVARIAN GERM CELL TUMOR
Dysgerminoma
Other germ cell tumors
STAGE IV OVARIAN GERM CELL TUMOR
Dysgerminoma
Other germ cell tumors
RECURRENT OVARIAN GERM CELL TUMOR
Dysgerminoma
Other germ cell tumors

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 of 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. In a review of the literature in 1979 prior to the widespread use of combination chemotherapy, Gallion et al. 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]

Kurman and Norris found that size and histology were the major factors determining prognosis for patients with malignant mixed germ cell tumors of the ovary. 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 reviewed by Asadourian and Taylor, 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]

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

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 levels of evidence summary for more information.


Dysgerminoma

Treatment options:

Standard:

For 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

Treatment options:

Standard:

For 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

Treatment options:

Standard:

For 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

Treatment options:

Standard:

For 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.

Under clinical evaluation:
Patients with stage II germ cell tumors of the ovary are candidates for
clinical trials.[4] Refer to PDQ or to CancerNet
(http://cancernet.nci.nih.gov) for information on clinical trials for
patients with ovarian germ cell tumor.

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

Treatment options:

Standard:

For 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. Based on the efficacy of
chemotherapy in 20 patients with advanced or recurrent disease and on
anecdotal cases, patients who wish to preserve fertility may be treated with
unilateral salpingo-oophorectomy if chemotherapy is to be employed.[1-4]
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.[5-7] A
randomized study in testicular cancer has shown that bleomycin is an
essential component of the BEP regime when only 3 courses are
administered.[8] Since chemotherapy with BEP appears to be less sterilizing
that wide-field radiation, combination chemotherapy is the preferred
treatment in the patient who still desires to have children.[1]


Other germ cell tumors

Treatment options:

Standard:

For 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.[2,5,9]

Evidence suggests that second-look laparotomy is not beneficial in patients
with initially completely resected tumors who receive cisplatin-based
adjuvant treatment.[10] 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.[5] 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.[10] 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.

Under clinical evaluation:
Patients with stage III germ cell tumors of the ovary, including pure
dysgerminoma, are candidates for clinical trials. Refer to PDQ or to
CancerNet (http://cancernet.nci.nih.gov) for information on clinical trials
for patients with ovarian germ cell tumor.

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. 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.

  6. 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.

  7. Taylor MH, Depetrillo AD, Turner AR: Vinblastine, bleomycin, and cisplatin in malignant germ cell tumors of the ovary. Cancer 56(6): 1341-1349, 1985.

  8. 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.

  9. 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.

  10. 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

Treatment options:

Standard:

For 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] 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

Treatment options:

Standard:

For 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.[2,3] 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.[3] 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.[4,5]
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.

Under clinical evaluation:

Patients with stage IV germ cell tumors of the ovary (including pure
dysgerminoma) are candidates for clinical trials. Refer to PDQ or to
CancerNet (http://cancernet.nci.nih.gov) for information on clinical trials
for patients with ovarian germ cell tumor.

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. 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.

  4. 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.

  5. 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

Treatment options:

Standard:

Cisplatin-based chemotherapy has been used effectively for recurrent
dysgerminoma with and without adjuvant radiation therapy.[1]


Other germ cell tumors

Treatment options:

Standard:

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.

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: 08/1999



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