Surgical Resection Alone Is Effective Treatment for Ovarian Immature Teratoma in Children and Adolescents: A Report of the Pediatric Oncology Group and the Children’s Cancer Group

Abstract

This study was conducted to evaluate the routine use of chemotherapy, with its attendant long-term effects, in children and adolescents after the surgical removal of ovarian immature teratoma. Forty-four girls who underwent laparotomy for complete removal of an ovarian tumor containing pure immature teratoma between 1995 and 1996 served as subjects. Patients were classified as having stage I cancer when disease was found in the ovary only with negative peritoneal washings. Among the patients who had adequate staging, no stage II disease was observed. Follow-up for the first 2 years included frequent measurements of serum levels of α-fetoprotein (AFP) and diagnostic imaging studies of the chest and pelvis. Thereafter, patients returned annually for regular physical examinations. At diagnosis, the age range of the subjects was 1.5 to 20 years. Four girls were lost to follow-up, two shortly after surgery and two within 2 years. Nineteen patients were followed for more than 5 years, and four had undergone surgery less than 2 years earlier. Histologic examination found no embryonal carcinoma, choriocarcinoma, or germinoma. Fifteen patients were classified as having grade 1 tumors, 12 had grade 2 tumors, and 2 had grade 3 tumors. On central pathology review, 13 patients were found to have tumors containing microscopic foci of a yolk sac tumor that was previously undetected. Unilateral salpingo-oophorectomy was the treatment selected in 28 patients (64 percent). Only one hysterectomy was necessary. Lymph node samples, obtained from 16 patients, showed mature gliomatosis in three patients. Three subjects had positive peritoneal washings, all of which contained only mature teratomatous or immature glial cells. The 13 patients with ovarian immature teratoma plus yolk sac tumor were slightly older (median, 12 years) than those with pure teratoma (median, 10 years) and were more likely to have larger tumors. Fifty-five percent of the girls with immature teratoma had grade 1 disease, compared with only 8 percent of those whose teratoma contained a yolk sac tumor. Conversely, 46 percent of the children with immature teratoma plus yolk sac tumor were classified as having grade 3 disease, compared with 6 percent of those without yolk sac tumor. Ten of the 13 girls (80 percent) with yolk sac components had measurable levels of AFP, compared with only 10 of 31 of the girls (34 percent) with no yolk sac tumor elements. Furthermore, the median level of AFP was 252 among children with yolk sac tumor, compared with 25 among those without yolk sac tumor. Ovarian immature teratoma containing yolk sac tumor was less likely to rupture during removal than immature teratoma (8 vs. 32 percent). No patients died. There was one malignant recurrence in a 12-year-old girl who had a large ovarian immature teratoma with yolk sac tumor, an initial serum AFP level of 1045 ng/ml, and peritoneal washings and lymph nodes positive for gliomatosis. A sharp rise in her serum AFP level at 18 weeks signaled a recurrence. Two nodules containing grade 2 immature teratoma with yolk sac tumor were found in her liver. She was disease free 57 months after four courses of cisplatin, etoposide, and bleomycin therapy. Two other patients required additional surgical procedures. Both girls underwent exploratory laparotomy for a pelvic mass. One contained ovarian mature cystic teratoma and mature glial implants. The other was composed of multiple mature glial implants on the peritoneal surfaces and on the surface of the remaining ovary, which was removed. Both patients had normal serum AFP levels that did rise, and both continue to be well without additional symptoms. Normal adolescent follicular cysts were frequently observed among the entire study group. Am J Obstet Gynecol 1999;181:353–358