Surgical Management

The initial management of ovarian germ cell tumors is surgical, with fertility-sparing surgery being preferred, given the young age of the majority who present with these tumors. One contraindication to a fertility-sparing procedure would be the case of dysgenetic gonads, further emphasizing the importance of a comprehensive preoperative evaluation. In the absence of dysgenetic gonads, the outcomes of patients who received fertility-sparing surgery are comparable to those who received complete removal of both ovaries, regardless of stage or disease burden.97,106

The principles of cytoreductive surgery in epithelial ovarian cancer have been applied to the initial treatment of ovarian germ cell tumors. This is based on the findings of GOG protocols that have demonstrated at least some benefit to surgical debulking.107,108 Thus, the current management schema includes peritoneal washings, removal of the affected ovary, bilateral pelvic and para-aortic lymphadenectomy, omentectomy, and careful inspection of all peritoneal surfaces with excision of any suspicious lesions or systematic peritoneal biopsies in the absence of visible lesions94 (Fig. 11-11). Even so, given the high sensitivity of ovarian germ cell tumors to chemotherapy, significant tumor debulking is advised only if it can be accomplished without increasing morbidity or delaying the initiation of chemotherapy.91 These recommendations hold regardless of histology, although some authors have suggested that lymphadenectomy is not necessary in the setting of immature teratomas, given their propensity for peritoneal spread (rather than nodal spread), or in the setting of

Malignant ovarian germ cell tumor

Surgical management

• Peritoneal washings

• Omentectomy

• Debulking of gross disease or peritoneal biopsies

• Pelvic and para-aortic lymph node dissection

• Fertility sparing surgery or hysterectomy with bilateral salpingo-oophorectomy

* Dysgenetic gonads should be excised if present

Adjuvant management

• Observation in selected cases

* Stage IA dysgerminoma, IA grade 1 immature teratomas

• BEP chemotherapy x 3-4 cycles

• Close follow-up including applicable tumor markers

* Second-look laparotomy not proven beneficial

Recurrent disease

• Individualize therapy

* Surgery

* Chemotherapy: BEP, EP, POMB-ACE, paclitaxel + gemcitibine

* Radiation

Figure 11-11. Proposed management schema for malignant ovarian germ cell tumors.

endodermal sinus tumors for which chemotherapy is recommended regardless of nodal status.92

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