Ovarian Dysgerminomas Follow-up

Updated: Apr 15, 2015
  • Author: Chad M Michener, MD; Chief Editor: Warner K Huh, MD  more...
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Follow-up

Further Outpatient Care

No precise recommendations are known based on any randomized controlled trials. However, follow-up should maximize the ability to identify recurrences while minimizing risks (ie, from repetitive imaging). Follow-up care depends on the stage of disease, which is typically predictive of recurrence risk. Ovarian dysgerminomas tend to recur most often in the first 2-3 years after treatment. Therefore, most authors suggest follow-up observation and a physical examination every 3-4 months for the first 3 years, every 6 months during the fourth and fifth year, and annual surveillance thereafter.

CT imaging should be considered during months 6 and 12, especially if tumor markers were negative at the time of diagnosis. However, the risks of repetitive imaging in women with no symptoms and a normal examination should be considered in this young population of women.

Tumor markers should be drawn (see Lab Studies), especially if known to be elevated preoperatively. The authors recommend following lactate dehydrogenase, but if marker status is unknown, they add serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG). An increasing trend in tumor markers warrants repeat body imaging and possible surgical exploration. Tumor marker levels may begin to rise several months before a clinical recurrence can be identified. Moreover, pregnancy should be ruled out in patients who underwent fertility-sparing surgery and have elevations in AFP and beta-hCG.

Given the potential for late recurrences, patients should be observed for up to 10 years, although they are rare.

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Further Inpatient Care

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

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Inpatient & Outpatient Medications

See Medication.

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Transfer

The need for transfer to a tertiary facility is predominantly determined by the availability of specialists to assist with surgery if the index of suspicion for malignancy in women with a pelvic mass is high. Otherwise, transfer should be considered for complications of surgery or chemotherapy requiring more intensive treatment than what can be offered at smaller facilities.

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Deterrence/Prevention

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

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Complications

Standard surgical complications (eg, bleeding, infection, bowel or bladder injury) and anesthetic complications apply.

Adhesion formation following surgery or radiation therapy can lead to bowel obstruction and/or decreased fertility.

Medical complications from chemotherapy are common. The most common medical complications from chemotherapy for dysgerminomas are bone marrow abnormalities and renal toxicity. Care should be taken to monitor for signs of pulmonary toxicity in patients receiving bleomycin-containing regimens. Secondary malignancies are rare, but leukemias may occur in patients receiving etoposide, especially if doses exceed 2000 mg/m2 (ie, >4 cycles of standard BEP [bleomycin, etoposide, platinum] regimen).

Observe pregnant patients with presumed dysgerminoma until 16 weeks' gestation before performing surgery.

Dysgerminomas in patients with karyotypic abnormalities

Remove all gonads in patients with concomitant karyotypic abnormalities, owing to the 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 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.

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Prognosis

Prognosis depends on the staging of the 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. No correlation exists between tumor size and prognosis.

In a 2014 retrospective review (1978-2010) of data from the Surveillance, Epidemiology and End Results program that evaluated cause-specific survival (CSS) in patients with malignant ovarian germ cell tumors, investigators found a 97% 5-year CSS in those with ovarian dysgerminoma compared with a 92% 5-year CSS for those with non-dysgerminoma. [10] Significant prognostic factors for cause-specific mortality in ovarian dysgerminoma included age older than 40 years at diagnosis and metastatic disease. In addition, a second cancer occurred in 10% of all patients who survived to 10 years and had received radiotherapy compared to 2% of those who had not received radiation treatment (P = 0.002).

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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.

Prior to and following chemotherapy, discuss with patients the potential for lung toxicity with bleomycin and the rare occurrence of secondary leukemias.

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