Survival and Reproductive Function After Treatment of Malignant Ovarian Germ Cell Tumor
abstract & commentary
Synopsis: Fertility-sparing surgery should become the standard for patients with malignant ovarian germ cell tumors, and fertility seems to be only marginally affected by treatments.
Source: Zanetta G, et al. J Clin Oncol. 2001;19: 1015-1020.
Zanetta and colleagues report their experience with 169 women with malignant ovarian germ cell tumors seen between 1982 and 1996. The purpose of their study was to evaluate the outcome and reproductive function in this population. Fertility-sparing surgery was performed in 138 (81%) women, 81 of whom received postoperative chemotherapy. With a median follow-up of 67 months, the survival rate was 94% for dysgerminomas, 89% for endodermal sinus tumors, 100% for mixed types, and 98% for immature teratoma. For women who were treated conservatively, the survival rate was 98%, 90%, 100%, and 100%, respectively. Two women had adnexal recurrences, and both received salvage treatment. After treatment, all but 1 postpubertal woman had recovery of menses within 9 months. During follow-up, 12 untreated and 20 treated patients had 55 conceptions. Zanetta et al recorded 40 pregnancies at term, 6 terminations, and 9 miscarriages. Four malformations were observed: 1 in 14 conceptions of patients who had not received chemotherapy and 3 in 41 conceptions of treated patients. Zanetta et al concluded that, irrespective of subtype and stage, conservative surgery should become the standard approach to treating most patients with malignant germ cell tumors. They further observed that fertility seems to be only marginally affected by treatments and noted that miscarriages were in the expected range for the general population and the malformation rate was slightly higher than in the general population. No difference, however, was observed between patients who did and did not receive chemotherapy.
Comment by David M. Gershenson, MD
Malignant ovarian germ cell tumors are among the most curable of all cancers. This report of a large Italian series confirms the findings of other investigators that cure rates for patients with stage I disease should approximate 100%, and cure rates for those with metastatic tumor are in the range of 75-90%, depending on cell type and completeness of cytoreduction. For those patients who require postoperative chemotherapy (the majority), the standard regimen is the combination of cisplatin, bleomycin, and etoposide. The major strengths of this paper are the confirmation of the safety of fertility-sparing surgery and the report of the high rate of maintenance of menstrual function in those patients who received platinum-based chemotherapy. In 2 previous questionnaire studies from our group at M.D. Anderson Cancer Center, we reported a rate of retention of menstrual function after combination chemotherapy of at least 75%. Several full-term pregnancies were also documented, as also reported in this study. Although Zanetta et al report a slightly higher malformation rate than in the general population, this observation requires confirmation from other large studies. In collaboration with researchers at Indiana University, we are currently completing an extensive questionnaire study of approximately 130 women who received platinum-based chemotherapy for malignant ovarian germ cell tumors in the past. An acquaintance control group is the comparison group. This study is focusing on the late effects of chemotherapy on the physical, psychosocial, sexual, and reproductive health of these women and will provide important insights that will lead to better interventions in the future.
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