Fertility-Sparing Surgery Should Be the Standard Treatment in Patients with Malignant Ovarian Germ Cell Tumors.

PURPOSE: To validate the oncological safety of fertility preservation in malignant ovarian germ cell tumors (MOGCTs) and to define the significance of maximal cytoreduction in early stage MOGCTs. MATERIALS AND METHODS: Sixty-nine patients with stage I and II MOGCTs who underwent surgical treatment were included in the study. Fertility-sparing surgery is defined as conservative surgery and hysterectomy and contralateral salpingo-oophorectomy were defined as definitive surgery. Both surgical approaches involved lymphadenectomy and omentectomy. Most patients received platinum-based combinations for adjuvant therapy. Survival outcomes of the conservative surgery group were compared with the definitive surgery group. RESULTS: Median age of the study group was 21 years (range: 12-40 years). Median tumor size measured 150 mm (range, 20-300 mm). Surgery type (conservative surgery vs. definitive surgery) and lymphadenectomy (performed vs. not performed) were insignificant for the recurrence (p = 0.758, p = 0.271). However, surgical outcome (maximal vs. optimal and suboptimal) and type of tumor (dysgerminoma vs. nondysgerminoma) determined the recurrence (p = 0.001, p = 0.021). CONCLUSION: Fertility-conserving approach is safe in early stage MOGCTs. However, maximal cytoreduction should be achieved in this group of patients, without conceding fertility-conserving approach. On the other hand, development of chemotherapy options with less gonadotoxic effects, but equal or stronger efficiency in comparison with platinum-based chemotherapy, will certainly facilitate management of this patient group.

Extrauterine Spread, Adjuvant Treatment, and Prognosis in Noninvasive Uterine Papillary Serous Carcinoma of the Endometrium: A Retrospective Multicenter Study.

OBJECTIVES: The aim of this retrospective multicenter study was to investigate the frequency of extrauterine metastasis and to evaluate the importance of surgical staging and adjuvant treatment among patients with noninvasive uterine papillary serous carcinoma (UPSC) of the endometrium. MATERIALS AND METHODS: A multicenter, retrospective department database review was performed to identify patients with UPSC of the endometrium who underwent surgical staging between 2000 and 2015 at 4 Gynecologic Oncology Centers in Turkey. Demographic, clinicopathological, and survival data were collected. RESULTS: A total of 182 patients with primary UPSC of the endometrium were identified. Of these, 33 (18.1%) had tumors limited to the endometrium with no myometrial invasion. Twenty (60.6%) of these 33 patients had no extrauterine involvement and International Federation of Gynecology and Obstetrics 2009 stage 1A disease was diagnosed after complete staging. The remaining 13 (39.4%) patients had disease beyond the uterine corpus including 5 with omental, 3 with adnexal, 1 with cervical stromal involvement, 1 with disease in the pelvic lymph nodes, and 1 with isolated para-aortic lymph node metastasis. Two patients had metastases in more than one location including omentum/adnexa/pelvic-para-aortic lymph nodes and omentum/pelvic-para-aortic lymph nodes, respectively. Of the 20 patients with disease confined to the endometrium, 6 (30%) patients received adjuvant treatment. CONCLUSIONS: Noninvasive UPSC has a high tendency for extrauterine spread and omentum is the most commonly involved location. Therefore, comprehensive surgical staging including omentectomy and pelvic-para-aortic lymph node dissection is mandatory in this group of patients. Risk of extrauterine spread is significantly associated with the presence of lymphovascular space invasion, elevated preoperative CA 125 levels, and positive peritoneal cytology. Adjuvant therapy for women with endometrium-confined disease improves neither progression-free survival nor overall survival.

Factors related to treatment outcomes in low-risk gestational neoplasia.

OBJECTIVE: To define the factors associated with methotrexate (MTX) resistance in patients with low-risk gestational trophoblastic neoplasia (GTN). METHODS: A total of 63 patients with low-risk GTN according to International Federation of Gynecology and Obstetrics (FIGO) criteria were included. A total of 37 (58.7%) patients were treated with successive doses of 1 mg/kg intramuscular (IM) MTX on days 1, 3, 5, and 7, and 0.1 mg/kg IM folinic acid (FA) on days 2, 4, 6, and 8, until ß-human chorionic gonadotropin (hCG) levels were normalized. After the ß-hCG value dropped to the normal level, an additional cycle of MTX/FA was administered. This protocol is defined as the standard protocol. In a watchful waiting protocol, the same 8-day IM MTX/FA regimen was given only once (n = 8) or twice (n = 18) to 26 (41.3%) patients and patients in whom ß-hCG values declined were subjected to follow-up and no additional cycles were administered as long as there was a decrease in ß-hCG value. Clinical response and factors affecting therapeutic outcomes were analyzed retrospectively. RESULTS: Of 63 patients, 47 (74.3%) were cured with primary MTX/FA treatment irrespective of any protocol. Of the 16 patients who were not able to be treated with primary MTX/FA, 3 were treated with single-agent actinomycin-D and 11 were treated with multi-agent chemotherapy. Univariate analysis showed that a pretreatment ß-hCG level of ≥5000 IU/L was related to reduced therapeutic response (p = 0.001). The FIGO score, antecedent gestational pathology, and treatment with standard or watchful waiting protocol were not related to treatment response. CONCLUSIONS: The level of ß-hCG prior to therapy is an important factor for predicting therapeutic outcomes. It should be noted that the success of the therapy decreases notably in case of high ß-hCG level.