Postoperative Therapy for Malignant Teratoma?
Postoperative Therapy for Malignant Teratoma?
An 8-cm pelvic mass was found in a 45-year-old woman who presented with a 2-month history of lower abdominal pain. She underwent oophorectomy and salpingectomy. Pathology revealed a malignant teratoma, with high-grade sarcoma and osteosarcoma. What would you recommend for postoperative therapy?
Paulo Mora, MD
This is a case of a patient with a malignant teratoma of the ovary with high-grade sarcomatous and osteosarcomatous elements. The initial surgery was unilateral salpingo-oophorectomy only. We have no information regarding the opposite ovary, the omentum, or the lymph nodes. In other words, there is no surgical stage and the extent of residual and/or metastatic disease is not known.
The tumor marker status is also not known -- it would be useful to check the levels of alpha fetoprotein, CA125, CA19.9, CEA, LDH, and beta-hCG now, and if possible, to get preoperative levels if any samples are still available for testing.
Conservative surgery is not a problem, but you'd need to know if there is any residual or metastatic disease. I would suggest a baseline CT scan or PET/CT to evaluate disease status; endovaginal sonography would be helpful in evaluating the opposite ovary and the endometrial lining. In addition, the pathology should be reviewed by an expert gynecologic pathologist to confirm the diagnosis of immature teratoma vs a malignant mixed mesodermal tumor of the ovary.
The type of follow-up chemotherapy that the patient should receive will depend upon the final review of the pathology slides. If the review confirms an immature teratoma, the patient should receive platinum-based combination chemotherapy. My choice would be a regimen consisting of bleomycin, etoposide, and cisplatin. Unlike with a seminoma, I have not seen convincing data to suggest that bleomycin can be omitted in these patients, nor that carboplatin can be substituted for cisplatin.
An 8-cm pelvic mass was found in a 45-year-old woman who presented with a 2-month history of lower abdominal pain. She underwent oophorectomy and salpingectomy. Pathology revealed a malignant teratoma, with high-grade sarcoma and osteosarcoma. What would you recommend for postoperative therapy?
Paulo Mora, MD
This is a case of a patient with a malignant teratoma of the ovary with high-grade sarcomatous and osteosarcomatous elements. The initial surgery was unilateral salpingo-oophorectomy only. We have no information regarding the opposite ovary, the omentum, or the lymph nodes. In other words, there is no surgical stage and the extent of residual and/or metastatic disease is not known.
The tumor marker status is also not known -- it would be useful to check the levels of alpha fetoprotein, CA125, CA19.9, CEA, LDH, and beta-hCG now, and if possible, to get preoperative levels if any samples are still available for testing.
Conservative surgery is not a problem, but you'd need to know if there is any residual or metastatic disease. I would suggest a baseline CT scan or PET/CT to evaluate disease status; endovaginal sonography would be helpful in evaluating the opposite ovary and the endometrial lining. In addition, the pathology should be reviewed by an expert gynecologic pathologist to confirm the diagnosis of immature teratoma vs a malignant mixed mesodermal tumor of the ovary.
The type of follow-up chemotherapy that the patient should receive will depend upon the final review of the pathology slides. If the review confirms an immature teratoma, the patient should receive platinum-based combination chemotherapy. My choice would be a regimen consisting of bleomycin, etoposide, and cisplatin. Unlike with a seminoma, I have not seen convincing data to suggest that bleomycin can be omitted in these patients, nor that carboplatin can be substituted for cisplatin.