IMMATURE TERATOMA: SURGICAL TREATMENT

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1 CARAVAGGIO MAGGIO 2010 IMMATURE TERATOMA: SURGICAL TREATMENT G. Mangili, E. Garavaglia, C. Sigismondi R VIGANO Dipartimento Materno Infantile, UF Ginecologia Oncologica IRCCS San Raffaele Milano

2 SURGERY in Immature teratoma 1. first surgery: - fertility-sparing surgery (cistectomy) - peritoneal washing - retroperitoneal study - controlateral ovarian biopsy - peritoneal biopsy 1. Surgical restaging 3. IIlook 4. Second debulking surgery (salvage surgery)

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4 IMMATURE TERATOMA: MITO EXPERIENCE 35 women years (median age 25.5) 28 pts in I stage Median follow up of 59 months» Mangili, Gynecol Oncol 2010 (in press)

5 IMMATURE TERATOMA: MITO EXPERIENCE Clinical presentation Abdominopelvic mass (53%), clinical relevant in (48%), with ascite (2 pts) abdominal pain (54%), menstrual irregularities (17%) Median diameter of the mass: 15 cm (range 4-28) 1 pt with emergent surgery 5 pts alfa FP, 9 ca125, 3 ca19.9

6 IMMATURE TERATOMA: Clinical presentation MOGCTs grow rapidly (2-4 wks) and present symptoms secondary to capsular distension, hemorrhage or necrosis: the majority are diagnosed with I stage disease (70%) Ascites or peritonitis is secondary to tortion, infection or ropture

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8 Stage Grade I Surgery O Biopsy P biopsy N CT IB IB IC IC IC IC IC IC IC CYT TAH+BSO CYT TAH+ TAH+ TAH+BSO PEB PEB PEB PEB PEB PEB PEB PEB PEB

9 Time to Stage relapse Outcome after relapse Treatment at relapse Histology treatment (months) G3 (CT) (CT) 47 Surgery Mature teratoma NED G3 (CT) 5 Surgery Mature teratoma NED G3 7 Surgery Mature teratoma NED IC G2 30 Surgery IC G2 7 IC G2 4 Mature teratoma NED Surgery + BEP x 3 Immature teratoma NED Surgery + BEP x 4 Immature teratoma NED

10 THE GROWING TERATOMA SYNDROME mature teratoma may grow in extragonadal locations along with the line of migration of the primitive germ cells from the wall of the yolk sac to the gonadal

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12 ADVANCED STAGES: first treatment (7 pts) 3 pts in II stage (2 pts G2, 1pt G3), 1 pts in IIIB G1, 2 pts in IIIC (G2, G3), 1 pt in IV (liver) I surgery: debulking surgery with ovarian conservation (TR in 2pts) (peritoneal implants grading ovarian grading) All PEB

13 ADVANCED STAGES: relapse (3/7 pts) 3 relapse (after median 5.6 months) All second citoreductive surgery (1 TR) 2 immature teratoma relapse II line CT 1 mature teratoma (retroconvertion, All NED Disaia, 1977)

14 SURGERY in Immature teratoma 1. first surgery: - fertility-sparing surgery (cistectomy) - washing - retroperitoneal study - controlateral and peritoneal biopsy 1. Surgical restaging 3. IIlook 4. Second debulking surgery (savage surgery)

15 FIRST SURGERY: I stage Abdominal hysterectomy and U/BSO for women who have completed chilbearing E. Garavaglia, HSR, Milan

16 FIRST SURGERY: I stage fertility-sparing surgery with frozen section unilateral oophorectomy (Carinelli,Tumori 1981) Unilateral salpingectomy (rich lymphovascular connections) Careful inspection of the abdominal cavity with peritoneal, omental biopsies

17 FIRST SURGERY: I stage Controlateral ovarian biopsy not recommended, in grossly normal, bilateral ovarian involvement is uncommon (dysgerminoma 15%). In our series no relapse on the controlateral ovary or uterus were documented (Bonazzi Obstet Gynecol, 1994; Peccatori, Obstet Gynecol 1995) washing peritoneal cytology

18 FIRST SURGERY: I stage Cistectomy? (bilateral ovarian involvement does not automatically herald a malignant process) 2 pts (Bonazzi 1994) (1 bilateral cystectomy G2, 1 unilateral C G1: no CT, no relapse) 2 pts (Mangili 2010) ( G1 e G2: no CT, no relapse) 3 pts (Beiner 2004) (2 pts G1, 1 pt G2: no CT, no relapse) Cushing, Am j Obstet Gynecol 1999: 1 controlateral mature cystic teratoma and 1 controlateral benign mass during follow up

19 FIRST SURGERY PURE IMMATURE TERATOMA SPREAD INTRAPERITONEALLY (Robboy Human Pathol 1970): LYMPHOADENECTOMY NOT INDICATED MULTIPLE PERITONEAL BIOPSIES OMENTECTOMY I C :- capsule ruptured - tumor on ovarian surface - malignant cells in ascite or in peritoneal washing

20 FIRST SURGERY: advanced stages THE ADVENT OF CISPLATIN BASED CHEMOTHERAPY HAS TRANSFORMED THE MANAGEMENT OF ADVANCED GERM CELL TUMORS: THE EXTENT OF THE SURGICAL PROCEDURE REQUIRED HAS PROGRESSIVELY BEEN REDUCED AND BECOME MORE RESTRICTIVE, ALLOWING, WHENEVER POSSIBLE PRESERVATION OF FERTILITY. FERTILITY-SPARING SURGERY WITH HAS BECOME THE STANDARD PROCEDURE OVER THE PAST TWO DECADES. (Lee, Obstet Gynecol 1989; Gershenson, gynecol oncol 1994)

21 FIRST SURGERY: advanced stages DEMOLITIVE CYTOREDUCTIVE SURGERY IN EOC MOGCT DEMOLITIVE CYTOREDUCTIVE SURGERY EOC VAC 70s MOGCT VBP 80s BEP

22 FIRST SURGERY: advanced stage fertility-sparing surgery Frozen section unilateral salpingo-oophorectomy Optimal cytoreductive surgery (highly chemotherapysensitive tumors) (tumor stage and the amount of residual disease significantly affect prognosis) remove all visible peritoneal tumor (Slayton Cancer 1985, Williams Ann Intern Med 1989, Bafna Int J Gynecol Cancer 2001)

23 CONSERVATIVE SURGERY: 3/24 pts had pregnancies (1 after chemotherapy) (Mangili 2010) 5/30 pts had pregnancies (1 pts after CT) (Bonazzi 1994)

24 SURGICAL RESTAGING in early stage if peritoneal biopsies were not performed at first surgery in order to avoid chemotherapy (Bonazzi Obstet Gynecol 1994: 32 pts, conservative surgery, no ct : I stage G1,2, II stage G1,2) (Gadducci Anticancer Res 2003: I stage G1,G2) (Nissa, J Clin Oncol 1999: 44 children, I stage G1,2,3 : no relapse) (Cushing, Am J Obstet Gynecol, 1999: 31 chidren-adolescents, I stage G1,2,3) (Mangili, Gynecol oncol in press 2010: 28 pts, I stage G1,2,3) Better an intensive surveillance policy as described for testicular germ-cell tumors (Peccatori, Obstet Gynecol 1995)

25 SECOND-LOOK SURGERY after CT All residual masses post-chemotherapy should be excised for 3 reasons: 1. To exclude active residual tumor 2. To prevent a mature growing teratoma syndrome. An immature teratoma can become a mature teratoma (spontanously or after CT retroconvertion). Unresected mature teratoma may grow and become surgically unresectable potentially compromising vital organ function with obstructive features 3. To prevent subsequent (above 40 yrs) dedifferentation: a mature teratoma may rarely (2%) degenerate into a squamous cell carcinoma (85%) or adenocarcinoma (7%) (malignant transformation) with a very poor prognosis (Bal, Arch gynecol Obstet 2007)

26 SECOND-LOOK SURGERY These masses may be only necrosis or fibrosis, mature teratoma (4/6 pts), immature teratoma (2/6) and their status is crucial in planning further management. (Pectasides, Cancer Treatment Reviews 2008) II-look surgery is not indicated in women with initially completed resected disease (Culine J Surg oncol 1996) also in I stage G2, G3 not treated with chemotherapy (Mangili 2010)

27 SALVAGE SURGERY during follow up FOR PATIENTS WITH RECURRENCE (Munkarah, Gynecol Oncol 1994, Rezk Gynecol Oncol 2005) FOR CHEMOREFRACTORY OVARN IMMATURE TERATOMA after failed primary therapy (surgery + chemotherapy) and failed II-line CT Aggressive secondary debulking as in the germ cell tumors of the testis (Munkarah, Gynecol Oncol 1994; Rezk, Gynecol Oncol 2004, Wu, Gynecol Oncol 2004) FOR GROWING TERATOMA SYNDROME (Tejura J obstet gynaecol 2005, Umekawa gynecol oncol 2005, benoit Obstet Gynecol 2005)

28 STAGE I IMMATURE TERATOMA After a median follow-up of 59 months all patients are NED Conservative surgery is the gold standard Surveillance policy could be safe for stage I all grades immature teratoma Salvage chemotherapy should be reserved to relapse

29 Grazie!