|Year : 2018 | Volume
| Issue : 1 | Page : 51-54
Outcome of fertility-preserving surgery for ovarian malignancy in young women
M Ali Ashraf, Paapa Dasari
Department of Obstetrics and Gynaecology, WCH, JIPMER, Puducherry, India
|Date of Web Publication||13-Feb-2018|
Department of Obstetrics and Gynaecology, WCH, JIPMER, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Ovarian cancer is considered to be one of the most lethal gynecological malignancies. It is estimated that 10% of ovarian cancer cases will be diagnosed in women of reproductive age and >80% would be in advanced stage. Conservative treatment can be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics) to preserve fertility. However, accurate staging prior to surgery is difficult and some of these women require chemotherapy after fertility-preserving surgery which affects ovarian reserve, and there are a lot of anxieties regarding the aftereffects of chemotherapy on conception. In this article, cases of three young women who underwent conservative surgery for ovarian cancer followed by chemotherapy and subsequent treatment for infertility are presented. These are immature teratoma, juvenile granulosa cell tumor, and dysgerminoma. There was tumor spill in case of immature teratoma and capsule rupture in case of juvenile granulosa cell tumor. All the three women received chemotherapy and could achieve pregnancy after infertility treatment and had normal children. Tumor spill or rupture did not result in adverse outcomes and hence it should not prompt the surgeon to undertake radical procedure in women desirous of pregnancy. Undergoing chemotherapy subsequently did not result in adverse fetal outcome and there was no recurrence of malignancy among these women.
Keywords: Chemotherapy, fertility-sparing surgery, germ cell tumor, infertility
|How to cite this article:|
Ashraf M A, Dasari P. Outcome of fertility-preserving surgery for ovarian malignancy in young women. Onco Fertil J 2018;1:51-4
Tumor spill and rupture while performing fertility-sparing surgery for ovarian cancer does not result in poor prognosis and such women can be subjected to chemotherapy safely. Adverse fetal outcome and recurrence are less with such approach.
| Introduction|| |
Ovarian cancer is considered to be one of the most lethal gynecological malignancies. It is estimated that 10% of women with ovarian carcinoma will be diagnosed in women of reproductive age  and >80% would be in advanced stage. The definitive surgery for Stage I ovarian carcinoma is removal of the uterus and both ovaries and tubes in addition to the rest of the staging procedure. The reason for this approach is the fear of leaving an undiagnosed carcinoma in the contralateral normal-looking ovary when only one ovary is macroscopically involved. Conservative treatment should be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics [FIGO]) when future fertility is desired. However, accurate staging prior to surgery is difficult and some of these women require chemotherapy after fertility-preserving surgery which affects ovarian reserve, and there are a lot of anxieties regarding the aftereffects of chemotherapy on conception. Controversy also exists regarding the outcome when tumor spill and tumor rupture occur.
| Case Reports|| |
Mrs. B, 25-year-old unmarried woman, presented with acute abdomen and was suspected clinically to have torsion of ovarian tumor. She underwent laparotomy and right ovariotomy in 2006. During laparotomy, there was capsule rupture and histopathology reported it as immature teratoma. The disease was upstaged by a multidisciplinary team who advised completion surgery and the patient went into depression subsequently as she wanted her fertility. She was counseled and given three cycles of chemotherapy involving bleomycin/etoposide/cisplatin (BEP) regimen. She got married in 2008 and was treated for infertility in 2009. She conceived during the 3rd cycle of clomiphene citrate (CC) + metformin.
Mrs. C, a 25-year-old married woman, presented with acute pain abdomen. Clinically there were ascites and ruptured ovarian cyst was diagnosed on ultrasound examination in 2009. She underwent laparotomy and left ovariotomy, and histopathology reported it as juvenile cystic granulosa cell tumor and she was upstaged. She received four cycles of BEP and did not conceive for 4 years. She was given three cycles of CC and later her husband was found to have oligospermia and was treated for the same with antioxidants and clomiphene. She conceived on the 2nd cycle of CC + antioxidants (Ovaa Shield) and underwent lower segment cesarean section for fetal distress. Her second pregnancy was a spontaneous conception after 2 years of thefirst pregnancy.
Mrs. T, a 24-year-old unmarried woman, presented with pain abdomen in 2007 and diagnosed to have ovarian tumor clinically. She underwent staging laparotomy, and frozen section showed dysgerminoma and was categorized into Stage IA. She required counseling as she went into depression because of fear of malignancy and also fears of whether she can get married and have children. She required nine cycles of chemotherapy as her tumor markers showed initial decrease and later an increasing trend. She got married in 2010 and treated for infertility after 1 year of married life. She did not achieve pregnancy with three cycles of ovulation induction with CC and timed intercourse, three cycles of intrauterine insemination with gonadotropins, and one cycle of in vitro fertilization (IVF). She ultimately conceived spontaneously after 2 months of the IVF cycle.
In all the three cases, the neonates were normal and healthy and there was no recurrence observed till date. The details are represented in [Table 1].
| Discussion|| |
Germ cell ovarian tumors more commonly occur at younger age, the reported median age being 24 years, which is similar the cases reported in this series. A 5-year survival rate of 62%–85% is reported for Stage I ovarian cancer and it is better (90%) for those suffering from a germ cell tumor. Mrs. B though was advised re-laparotomy by the multidisciplinary team, she could be managed by three cycles of chemotherapy. Tumor spill should not upstage the disease as per the current recommendations of FIGO (2014). Mrs. C had rupture of ovarian tumor and was also upstaged.
ICON-1 study concluded that adjuvant chemotherapy improves survival and delays recurrence in early-stage ovarian cancer. Platinum-based chemotherapy regimens have been the treatment of choice and the BEP regimen is the most widely used one for germ cell tumors. BEP is usually administered for three cycles in patients with completely resected disease and for four cycles in patients with macroscopic residual disease. However, there is no consensus as to the optimal duration of therapy., The three women in this series received BEP regimen which they tolerated well and achieved remission.
Immature teratoma represents 1% of all ovarian cancers, 3% of all teratomas, and 20% of malignant ovarian germ cell tumors. It presents either in pure form or as a mixed germ cell tumor in thefirst two decades of life. The median age at presentation was reported to be 19 years.
Granulosa cell tumors of the ovary account for 1%–2% of all the ovarian malignancies, and the overall incidence varies from 0.4 to 1.7 cases/100,000 women. The juvenile form of granulosa cell tumor is even rarer as compared to its adult counterpart and usually presents as predominantly solid mass lesions.
Dysgerminoma is the most common malignant germ cell tumor of the ovary, accounting for approximately 2% of all ovarian malignancies. It occurs commonly in girls and young women and bilateral in 10%.
Effects of chemotherapy on ovary include decline in the number of primordial and larger maturing follicles and end results can be premature ovarian failure, leading to permanent infertility. Premature ovarian failure is reported only in 20%–30% of women who underwent chemotherapy. Alkylating agents confer the greatest risk of infertility. Methotrexate, vincristine, bleomycin, 5-fluorouracil, and dactinomycin are associated with low or no risk of infertility. After chemotherapy, at least 6-month waiting period is essential before pregnancy to eliminate the effect of the chemotherapy on the oocytes, as folliculogenesis takes about 6 months.
A pregnancy rate of 50% is reported in women who undergo fertility-sparing surgery in Stage I, and for germ cell tumors, the fertility-sparing surgery can be advised even in advanced stages as the prognosis is good. So far, no negative effects from the disease or due to chemotherapy on fetus have been observed. Pregnancy was not reported to be a risk factor for recurrence. Women who undergo fertility-sparing surgery for an early cancer of the ovary have a 10.3% chance of recurrence and only 5.5% chance of death from disease. A close surveillance with imaging and tumor markers is essential as relapse rate in Stage IA nondysgerminomas was 36% and for dysgerminomas it was 22%. Recurrence is reported as late as 12 years in Stage IC dysgerminoma who did not receive adjuvant therapy. They must, therefore, be informed about the pros and cons of fertility-preserving surgery, the need for a close surveillance, and about the availability of other fertility preservation methods such as ovarian tissue cryopreservation and oocyte cryopreservation.
| Conclusion|| |
Fertility preservation is very important in young women with ovarian cancer. The patient's wishes must be weighed against the risks and the risk–benefit ratio should be assessed carefully. Counseling regarding the methods of fertility preservation have to be undertaken before adjuvant chemotherapy. Tumor spill and/or rupture should not prompt the surgeon to undertake radical procedure of losing the reproductive potential.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ditto A, Bogani G, Martinelli F, Raspagliesi F. Fertility-sparing surgery in high-risk ovarian cancer. J Gynecol Oncol 2015;26:350-1.
Fakhr I, Abd-Allah M, Ramzy S, Mohamed AM, Saber A. Outcome of fertility preserving surgery in early stage ovarian cancer. J Egypt Natl Canc Inst 2013;25:219-22.
Prat J, FIGO Committee on Gynecologic Oncology. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2014;124:1-5.
Mangili G, Sigismondi C, Gadducci A, Cormio G, Scollo P, Tateo S, et al.
Outcome and risk factors for recurrence in malignant ovarian germ cell tumors: A MITO-9 retrospective study. Int J Gynecol Cancer 2011;21:1414-21.
Henes M, Neis F, Krämer B, Walter C, Brucker S, Von Wolff M, et al.
Possibilities of fertility preservation in young patients with ovarian cancer. Anticancer Res 2014;34:3851-4.
Colombo N, Guthrie D, Chiari S, Parmar M, Qian W, Swart AM, et al.
International collaborative ovarian neoplasm trial 1: A randomized trial of adjuvant chemotherapy in women with early-stage ovarian cancer. J Natl Cancer Inst 2003;95:125-32.
Saber MM, Zeeneldin AA, El Gammal MM, Salem SE, Darweesh AD, Abdelaziz AA, et al.
Treatment outcomes of female germ cell tumors: The Egyptian National Cancer Institute experience. J Egypt Natl Canc Inst 2014;26:103-8.
Colombo N, Peiretti M, Garbi A, Carinelli S, Marini C, Sessa C, et al.
Non-epithelial ovarian cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23 Suppl 7:vii20-6.
Deodhar KK, Suryawanshi P, Shah M, Rekhi B, Chinoy RF. Immature teratoma of the ovary: A clinicopathological study of 28 cases. Indian J Pathol Microbiol 2011;54:730-5.
] [Full text]
Anandpara KM, Aswani Y, Thakkar H, Hira P, Sathe PA. Juvenile granulosa cell tumour of the ovary with unilocular pure cystic presentation: A Case report and review of literature. Pol J Radiol 2016;81:120-4.
Brewer M, Gershenson DM, Herzog CE, Mitchell MF, Silva EG, Wharton JT, et al.
Outcome and reproductive function after chemotherapy for ovarian dysgerminoma. J Clin Oncol 1999;17:2670-75.
Gershenson DM. Management of ovarian germ cell tumors. J Clin Oncol 2007;25:2938-43.
Patterson DM, Murugaesu N, Holden L, Seckl MJ, Rustin GJ. A review of the close surveillance policy for stage I female germ cell tumors of the ovary and other sites. Int J Gynecol Cancer 2008;18:43-50.
Arend R, Holland A, St. Clair C, Herzog TJ. Fertility preservation in ovarian cancer. Therapy 2010;7:257-67.
Park JY, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, et al.
Outcomes of fertility-sparing surgery for invasive epithelial ovarian cancer: Oncologic safety and reproductive outcomes. Gynecol Oncol 2008;110:345-53.
Jeyakumar A, Cabeza R, Hindenburg A. Late recurrence in ovarian dysgerminoma with successful response to standard adjuvant chemotherapy: A case report and review of the literature. Gynecol Oncol 2001;81:314-7.