Effect of lymphadenectomy on fertility and prognostic outcome in adult patients with clinically early-stage malignant ovarian germ cell tumors during fertility-sparing surgery: A retrospective multicenter study (178)

Abstract

<b>Objectives:</b> Malignant ovarian germ cell tumors (MOGCTs), as a rare type of ovarian malignancies, are commonly present in children as well as young women and have an excellent prognosis when treated by surgery, followed by platinum-based chemotherapy. Based on the current National Comprehensive Cancer Network (NCCN) clinical practice guidelines, systematic lymphadenectomy (LND) can be omitted for child and adolescent patients with early-stage MOGCTs. However, the clinical role of LND for adult patients with early-stage MOGCTs remains ambiguous. The purpose of this retrospective multi-center study was to evaluate the effect of systematic LND on prognostic and fertility outcome in adult patients with clinically stage I MOGCTs who received fertility-sparing surgery (FSS) treatment and to investigate the clinical-pathologic factors associated with fertility outcomes. <b>Methods:</b> This study included adult MOGCTs patients who underwent fertility-sparing surgery (FSS) and were deemed to have disease clinically confined to the ovary at the time of the surgery (stage I) between January 2005 to June 2020 from four medical institutions. All patients were classified into two groups: the LND group (patients who underwent systematic pelvic and/or para-aortic lymphadenectomy) and the no-LND group (patients who did not undergo lymphadenectomy). Propensity score matching (PSM) algorithm was adopted to reduce the bias resulting from the differences in clinical characteristics between the two groups. The Chi-square test and the Kaplan-Meier analysis were used to compare the fertility outcome as well as the disease-free survival (DFS). The univariate logistic regression analysis was performed to evaluate the clinical-pathologic factors associated with fertility outcomes. <b>Results:</b> A total of 168 adult patients with clinically stage I MOGCTs who received FSS treatment were enrolled in the study. There were 92 (54.8%) patients in the LND group and 76 (45.2%) patients in the no-LND group, with a median age of 26 years (range:18-44 years). Only two (2.6%) patients had lymph nodal metastasis. Among a total of 60 patients who attempted pregnancy, 49 (81.7%) succeeded to conceive, and 40 (66.7%) delivered successfully. In the before PSM cohort, patients in the no-LND group showed a better pregnancy rate than the LND group (93.3% vs 70.0%, p=0.020). However, in the after PSM cohort, there was no significant difference in pregnancy rates between no-LND and LND groups (92.9% vs 76.9%, p=0.326). Univariate logistic regression analysis showed that age ≤25 years (OR: 3.50, 95% CI: 1.11-11.01, p=0.032) correlated with a better live birth rate. Regarding the prognostic outcome, only three (0.18%) patients had recurrence after a median follow-up of 65 months and no patient died after surgery. In the before and after PSM cohort, the 5-year DFS for patients in the LND and the no-LND groups were 97.6% versus 97.9% (p=0.707) and 89.3% versus 95.0% (p=0.335), respectively. There was no significant difference in DFS between the LND and no-LND groups in the before and after PSM cohorts. <b>Conclusions:</b> Lymphadenectomy provided no significant benefit in both prognostic and fertility outcomes for adult patients with clinically early-stage (stage I) MOGCTs who underwent FSS in our study. Moreover, age ≤25 years was associated with favorable fertility outcomes for early-stage MOGCTs patients after FSS treatment. Our study suggests that abandonment of LND seems to be a preferred choice for clinically stage I adult MOGCTs patients with FSS treatment.