eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Ovarian Dysgerminomas: Follow-up

Author: Allan Y Wu, MD, Director, The Midwest Women's Specialty Group; Adjunct Clinical Professor, Department of Molecular Biology, The Terre Haute Center for Medical Education, Indiana University School of Medicine
Coauthor(s): Chad M Michener, MD, Assistant Professor, Obstetrics/ Gynecology and Women's Health Institute, Section of Gynecologic Oncology, The Cleveland Clinic
Contributor Information and Disclosures

Updated: Oct 7, 2008

Follow-up

Further Inpatient Care

Follow-up care and treatment is conducted in the outpatient setting (see Further Outpatient Care).

Further Outpatient Care

• Follow-up care depends on the status of metastatic disease. If no metastasis is observed at the time of laparotomy or laparoscopy, conduct observation and a physical examination every 2 months for the first 2 years, then every 6 months.
• A CT scan should be performed during months 6 and 12.
• Tumor markers should be drawn (see Lab Studies).
• An increasing trend warrants repeat body imaging and possible laparotomy.
• Follow-up care for patients with metastatic disease requires mandatory adjuvant chemotherapy followed by a second-look laparotomy at 2-5 years.

Inpatient & Outpatient Medications

See Medication.

Transfer

• The need for transfer to a tertiary facility is predominantly determined by complications of surgery or chemotherapy.
• Transfer patients requiring intubation or invasive hemodynamic monitoring to a facility with intensive care capabilities.

Deterrence/Prevention

• No methods of deterrence or prevention for this disease are known.

Complications

• Standard surgical complications (eg, bleeding, infection, bowel or bladder injury) and anesthetic complications apply.
• Medical complications from chemotherapy are common; stomatitis (methotrexate) and pulmonary complications (bleomycin) are reported most frequently.
• Adhesion formation following surgery or radiation therapy can lead to bowel obstruction and/or decreased fertility.

Prognosis

• Prognosis depends on staging of tumors.
• Five-year survival rates are as follows:
  • Stage Ia-Ic - 91%
  • Stage III - 74%
  • Stage III with retroperitoneal disease - 24%
• Ten-year survival rates, comparing conservative surgery alone versus surgery plus radiation, are 92% and 85%, respectively.
• As a rule, any peritoneal involvement carries a poor prognosis. Contrary to previous beliefs, no correlation exists between tumor size and prognosis.

Patient Education

Educate patients about the importance of follow-up care during the first 2 years after initial therapy because 90% of recurrences manifest during this time.

Miscellaneous

Medicolegal Pitfalls

• Failure to observe until 16 weeks' gestation before performing surgery on a pregnant patient with a presumed dysgerminoma
• Failure to remove all gonads in patients with concomitant karyotypic abnormalities due to risk of gonadoblastoma formation
  • Five percent of all dysgerminomas are associated with genetic disorders of the ovaries (ie, karyotypic abnormalities [46,XY testicular feminization], gonadal dysgenesis, 45,X/46,XY mixed gonadal dysgenesis). Typically, these individuals have streak gonads. Under these unusual circumstances, the surgeon must remove both the dysgerminoma and the contralateral streak gonad to prevent gonadoblastoma formation. Because these individuals already are sterile, fertility preservation is not an issue.
  • Individuals with a Y chromosome revealed through karyotyping require a delayed gonadectomy after puberty because secondary sexual characteristics should be allowed to develop before removal.
  • Medical abnormalities associated with each respective genetic disease also must be addressed.

Special Concerns

• Management in pregnancy
  • Fortunately, most adnexal masses found in pregnancy resolve spontaneously within the first trimester. For this reason, a more cautious observational approach is advocated up to 16 weeks' gestation. Moreover, risk of aborting a viable fetus with surgery in the first trimester approaches 30%.
  • Two percent of masses presenting in pregnancy are malignant (dysgerminomas included). Most (90%) dysgerminomas found in pregnancy are unilateral.
  • If surgery is indicated, the ideal intervention time is 16-18 weeks' gestation. General anesthesia should be used. Placement of a higher-than-usual vertical or paramedian incision is necessary because the ovary becomes an abdominal structure after 16 weeks' gestation.
  • Avoid biopsy of the contralateral ovary if the ovary appears normal. Also, avoid lymph node sampling if the uterus is obstructive.
  • Frozen sections should be taken at the time of surgery. If the pathology is hyperreactio luteinalis or luteoma, nonintervention is indicated and the abdomen should be closed.
  • Benign or low-grade tumors generally require unilateral salpingo-oophorectomy, whereas bilateral involvement and malignant or metastatic tumors require bilateral salpingo-oophorectomy with or without total abdominal hysterectomy. If patients are at or near term, delivery of the fetus is performed; otherwise, pregnant patients with flagrant bilateral malignancies should be treated as if they are not pregnant and should receive a total abdominal hysterectomy and bilateral salpingo-oophorectomy.
  • Postoperative progesterone has unproved efficacy. Use of tocolytics postoperatively has not been studied well.
  • The 5-year patient survival rate for dysgerminoma removal in pregnancy is encouraging, at 90%. The fetal mortality rate approaches 25%.
  • Adjuvant chemotherapy in patients who are pregnant reportedly is successful when used during the second and third trimesters with methotrexate and cisplatin. Chlorambucil has been used as early as the first trimester.

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