Prognosis

Prognostic indicators in ovarian germ cell tumors have yet to be formalized into a scoring system such as that used in testicular tumors.99 However, several studies have demonstrated that FIGO stage, elevated tumor markers, nondysgerminoma or immature teratoma histology, sarcomatous elements, and lymph node involvement all are associated with poor outcomes.100-103

In a review of 113 patients with ovarian germ cell tumors, Murugaesu and associates101 found that when both AFP and P-hCG are elevated, there is a dramatic decrease in overall survival: One-year survival for patients with normal tumor markers was 89.6% compared with 50.4% for those who had elevations of both. Despite accruing 113 patients, the authors noted that this study was not sufficiently powered to establish threshold values for either AFP or P-hCG. Lai and associates,103 in a review of 93 patients, demonstrated that patients with dysgerminoma or immature teratoma histology had a 100% 5-year survival rate compared with 83.3% for those with other histologies. This confirms prior observations that patients with endodermal sinus or choriocarcinomas have a worse prognosis. Malagon and associ-ates100 reviewed 46 cases of germ cell tumors in which sarcomatous elements were found (e.g., embryonal rhabdomyosarcoma, angiosarcoma, and leiomyosarcoma) and compared them with historical controls matched for age and stage of disease who lacked these elements. They found that patients who lack sarcomatous components were more likely to show no evidence of disease after therapy than those with these elements.

More recently, Kumar and colleagues,102 in a review of SEER data, found that lymph node metastasis was associated with an almost threefold risk of death (HR 2.87, 95% CI 1.44-5.73), regardless of age, stage, grade, and histology. In addition, the data demonstrate a possible survival benefit of lymphadenectomy, since patients who received a lymph node dissection had a 5-year survival rate of 94% compared with 89% in those who had no lymph nodes removed. Of note, increasing grade of the tumor was associated with lymph node metastasis, but this was not statistically significant. However, O'Connor and colleagues104 demonstrated that tumor grade is the most important prognostic indicator of overall survival in the setting of immature teratomas. Finally, whereas age has not been shown to be an independent predictor of outcome in ovarian germ cell tumors, a Pediatric Intergroup Study of 109 girls with primary extragonadal germ cell tumors demonstrated a significant decrease in overall survival for girls 12 years old or older at diagnosis.105

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