Fertility Preservation Possible in Rare Ovarian Tumors

Women with bilateral malignant ovarian germ cells tumors may still have a good prognosis and may be able to maintain fertility with conservative treatment.

Women diagnosed with bilateral malignant ovarian germ cells tumors (MOGT) may still have a good prognosis and may be able to maintain fertility when a conservative treatment approach is taken by physicians, according to the results of the MITO-9 study.

This small analysis of patients with MOGT found that a majority of patients with bilateral disease were able to remain disease free at a median follow-up of 54 months, and, if managed correctly, women could maintain fertility.

“Treatment should consist of USO and enucleation of contralateral lesion,” wrote researcher Cristina Sigismondi, MD, of the department of gynecology at IRCCS Ospedale San Raffaele, Milan, and colleagues in the International Journal of Gynecological Cancer. “If cystectomy is not possible, the confirmation of dysgerminoma histology should be taken into great consideration in the decision-making process leading not to proceed to complete eradication of the residual ovarian mass, with the aim to preserve young patient fertility.”

In the study, Sigismondi and colleagues reviewed all patients with MOGT treated at MITO group centers. Of the 145 patients identified with MOGT, 8 patients (5.5%) had bilateral disease, a rate consistent with data from the Surveillance, Epidemiology, and End Results Program.

The median age of these patients was 23.5 years. Only one of the patients had a term pregnancy. Of these eight women, three patients were affected by dysgerminoma, two by immature teratoma, two by mixed germ cell tumors, and one by embryonal carcinoma. Stage of disease ranged from Ib–IV.

Four patients underwent radical surgery defined as bilateral salpingo-oophorectomy or hysterectomy. In contrast, four patients underwent fertility-sparing surgery. Specifically, two of the patients classified as having immature teratoma underwent unilateral salpingo-oophorectomy and contralateral cystectomy plus peritoneal staging. The other two patients had ovaries completely transformed by neoplastic tissue and they underwent unilateral salpingo-oophorectomy with biopsy of the contralateral mass.

“The two patients with both ovaries completely replaced by neoplastic tissue underwent unilateral salpingo-oophorectomy of the largest and more heterogeneous ovarian mass, and only a biopsy of the contralateral lesion, based on macroscopic appearance of dysgerminoma, thus postponing radical surgery in case of a different histology at definitive histological evaluation or in case of no response to chemotherapy, given the well known high chemosensitivity of MOGTs and, in particular, of dysgerminoma,” the researchers wrote.

Six patients were assigned to receive neoadjuvant chemotherapy with cisplatin, etoposide, and bleomycin. With a median follow-up of 54 months, seven of the eight patients remained alive. The patient with stage IIIc embryonal carcinoma had recurring disease and died after 7 months, “suggesting that a possible conservative approach to this very rare MOGT tumor characterized by an extremely aggressive clinical outcome and a reported survival rate of 39% should be considered with great caution,” according to the researchers.

Looking at those four women treated conservatively, two patients went on to resumes normal menstruation and one patient conceived and carried a full-term pregnancy.

“Patients who had received fertility-sparing treatment should [undergo] regular and careful follow-up evaluation of their reproductive function; indeed, although patients treated for MOGT may retain fertility and spontaneously conceive, their window of fertility may be shortened,” the researchers wrote. “Therefore, the evaluation of ovarian reserve through anti-Mullerian hormone testing should be performed.”