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Journal of Postgraduate Medicine, Vol. 52, No. 4, October-December, 2006, pp. 245-246 Expert's Comments The value of post-chemotherapy surgery for residual disease in ovarian germ cell tumors Naik R Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, NE9 6SX Code Number: jp06086 This edition of Journal of Postgraduate Medicine contains a publication by Mathew et al .,[1] describing their experience of laparotomy for post chemotherapy residue in ovarian germ cell tumors. They review 83 cases who were managed in their institution over a ten year period. Of 68 patients who completed cisplatin based combination chemotherapy, 35 had radiological evidence of residual masses of which 29 underwent exploratory laparotomy. They show that cases containing teratoma elements in the initial specimens and those cases where the tumor markers respond sluggishly to chemotherapy have a high likelihood of containing viable tumor. In addition, no cases of dysgerminoma, embryonal carcinoma, absence of teratoma element in the primary tumor and radiological residue of 5 cm or less had viable tumor on post-chemotherapy laparotomy. Despite being a small retrospective study of a mixed group of patients with various histological sub-types, the information provided is valuable to the management of such cases. These tumors are rare and usually affect young women. The published literature is best described as sparse with the absence of any controlled trials. The overall prognosis of the patients in this study was excellent. This is largely due to the use of aggressive salvage chemotherapy in cases with confirmed residual disease; the advantage of the laparotomy procedure being to allow debulking of residual tumor masses prior to salvage chemotherapy and to allow avoidance of salvage chemotherapy in those cases shown to have absence of viable disease. The study highlights a number of other important surgical issues relating to management of such cases. Firstly, the need for complete/optimal cytoreduction in high stage disease and an optimal staging procedure in early stage disease, with further assessments by CT scans and tumor markers during chemotherapy treatment. As many of these women are young, the performance of fertility sparing surgery with conservation of the uterus and contralateral tube and ovary does not appear to adversely affect survival. The added advantage of removal of residual masses following primary chemotherapy in those cases showing teratoma elements in the initial specimens being to prevent the "growing teratoma syndrome" where mature teratoma elements can grow to significant proportions causing pressure effects to surrounding structures as well as causing concerns of immature de-differentiation. The results of the study by Mathew et al . are in keeping with the previous experience of the Gynecologic Oncology Group,[2] which presented 117 cases and whose main conclusions were to support the role of second-look laparotomy in cases containing teratoma elements that were incompletely cytoreduced at initial laparotomy. References
Copyright 2006 - Journal of Postgraduate Medicine |
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