Elsevier

Gynecologic Oncology

Volume 147, Issue 3, December 2017, Pages 493-496
Gynecologic Oncology

Fertility-preserving surgery for advanced stage ovarian germ cell tumors

https://doi.org/10.1016/j.ygyno.2017.10.010Get rights and content

Highlights

  • Rate of uterine preservation among women with advanced stage MOGCTs was 79.8%.

  • Uterine preservation was not associated with a decreased survival.

  • FSS should be considered in women with advanced stage MOGCTs interested in future fertility.

Abstract

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 < 40 years, 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 20 years, 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.

Introduction

Malignant ovarian germ-cell tumors (MOGCTs) represent approximately 2–3% of all ovarian tumors [1]. Contrary to the more prevalent epithelial carcinomas, their incidence peaks during childbeaging age [1], [2]. As such the majority of women diagnosed with MOGCTs may wish to retain their reproductive potential. Standard management of MOGCT includes surgical removal of the affected ovary and administration of adjuvant chemotherapy [1], [3]. Due to the sensitivity of these tumors to platinum-based chemotherapy, overall survival rates are excellent even for women with advanced disease [4], [5]. The oncologic safety of fertility-preserving surgery (unilateral salpingo-oophorectomy and uterine preservation) for women with early-stage disease has been extensively evaluated and is currently the gold standard [1], [3], [4]. Given the chemosensitivity of MOGCTs, the practice of fertility-preserving cytoreductive surgery has also been extrapolated and applied to women with advanced stage disease [6]. However, evidence on its safety is sparse and derives from single-institutional retrospective studies. In the present study we investigated the prevalence and safety of uterine preservation among young premenopausal women (age < 40 years) diagnosed with advanced stage (II-IV) MOGCTs, using a multi-institutional, hospital-based database.

Section snippets

Materials and methods

A cohort of women diagnosed between 2004 and 2014 with a malignant ovarian germ-cell tumor (MOGCT) (ICD-O-3 histology codes 9060/3-9102/3) was drawn from the National Cancer Data Base (NCDB). The NCDB, established jointly by the American Cancer Society and Commission on Cancer of the American College of Surgeons, is a hospital-based database capturing approximately 70% of all malignancies diagnosed in the United States. Patient data are prospectively collected from participating

Results

A total of 526 eligible patients, managed in 288 institutions were identified. The median number of cases reported by a facility was 2; 33.7% of patients were treated in institutions that had reported only a single case while 37.7% and 28.6% were managed in facilities that reported 2–3 and > 3 cases respectively. Median patient age was 21 years (range 2–39); the majority was of White race (75.7%) while 15.4% and 5.5% were Black and Asian respectively. Most women had stage III disease (65%); 24.3%

Discussion

The results of the present study demonstrate that during the past decade across the United States, uterine preserving surgery is commonly offered to premenopausal women diagnosed with advanced stage MOGCTs. A non-statistically significant trend toward an increased use of uterine preservation was noted with no adverse effect on survival. Patient age was the only significant factor associated with the use of uterine-sparing surgery. A decrease in the rate of uterine preservation was observed

Conflicts of interest

No conflicts of interest to report.

References (19)

There are more references available in the full text version of this article.

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    Before the introduction of platinum-based chemotherapy in 1980s, radical resection was commonly performed given the dismal prognosis [5]. Currently, fertility-sparing surgery with preservation of the uterus and contralateral ovary is the golden standard for all patients with apparent early stage MOGCTs who wish to maintain their reproductive potential while it also offered even in the presence of residual tumor or advanced stage disease [1–8]. Several series have confirmed the excellent oncologic and reproductive outcomes following FSS for MOGCTs [7,8].

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    When treated early (Stage I and II), prognosis is good with stage-specific long term survival rates of 94.8% and 97.1% respectively (Nasioudis et al., 2017a). There is thus an urgent need to develop fertility-sparing surgical and treatment strategies for this patient group to minimize damage to their potential fertility (Aviki and Abu-Rustum, 2017; Nasioudis et al., 2017b). A report by de La Motte Rouge et al published in 2008 recorded that 21% of women presenting with yolk-sac cancers underwent radical surgery (bilateral salpingo oophorectomy with or without total abdominal hysterectomy) and 79% underwent conservative surgery (unilateral salpingo oophorectomy, unilateral oophorectomy or unilateral cystectomy) (de La Motte Rouge et al., 2008).

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