In total, 93 patients diagnosed with malignant ovarian germ cell tumor were enrolled between January 1997 and December 2016. Two patients were excluded because they had diagnosis of mature teratoma with squamous cell carcinoma transformation. Two patients were excluded due to incomplete data in medical records and the other two were excluded because they had loss of follow-up. Complete data from 87 patients with MOGTCs were proceeded for final analysis. Of these patients, 67 were managed by Gynecologist and 20 cases by Pediatrician (Fig. 1). The median age at diagnosis was 21 years (range 2–47 years). Most of the patients were diagnosed to have stage I disease (n = 68, 78.2%). The most common histological types of these patients were immature teratoma (n = 41, 47.1%), followed by yolk sac tumor (25.3%) and dysgerminoma (14.9%). The most patients received fertility-sparing staging operation (n = 44, 50.6%) and most of these patients were in the Gynecologic groups (gynecology vs pediatric: 59.7% vs 20%, p = 0.002). There were 25 patients (28.7%) received unilateral salpingo-oophorectomy, which was the majority surgical methods in the patients in pediatric group (gynecology vs pediatric: 14.9% vs 75%, p < 0.05). All patients were re-staged with 2014 FIGO stage system; 78.2% had stage I disease while 4% and 15% had stage II and stage III disease. 10-year progression-free survival rate was 88.5%. Data of clinical characteristic, surgical methods, histological type, FIGO stage and recurrence in gynecologic group and pediatric group are presented in Table 1.
Table 1
The characteristics of our all cases, in pediatric group and gynecologic group separately.
Characteristics | Gynecology (n = 67) | Pediatric (n = 20) | P Value | Total (n = 87) |
Age | 23 (10–47) | 10.5 (2–17) | < 0.05 | 21 (2–47) |
| n (%) | n (%) | | n (%) |
Tumor type | | | | |
Immature teratoma | 32 (47.8) | 9 (45) | 0.828 | 41 (47.1) |
Yolk sac tumor | 17 (25.4) | 5 (25) | 0.973 | 22 (25.3) |
Embryonal carcinoma | 0 (0) | 1 (5) | 0.230 | 1 (1.1) |
Choriocarcinoma | 1 (1.5) | 0 (0) | 0.770 | 1 (1.1) |
Dysgerminoma | 11 (16.4) | 2 (10) | 0.381 | 13 (14.9) |
Mixed germ cell tumor | 6 (9) | 3 (15) | 0.341 | 9 (10.3) |
Surgical methods | | | | |
USO | 10 (14.9) | 15 (75) | < 0.05 | 25 (28.7) |
BSO | 1 (1.5) | 0 (0) | 0.770 | 1 (1.1) |
Ovarian cystectomy | 9 (13.4) | 0 (0) | 0.083 | 9 (10.3) |
Fertility sparing staging operation | 40 (59.7) | 4 (20) | 0.002 | 44 (50.6) |
Complete staging operation | 7 (10.4) | 0 (0) | 0.149 | 7 (8.0) |
FIGO stage | | | | |
1 (include 1B and 1C) | 53 (79.4) | 15 (73.7) | 0.697 | 68 (78.2) |
2 (include 2B) | 3 (4.4) | 1 (5.3) | 0.656 | 4 (4.6) |
3 (include 3B and 3C) | 11 (16.2) | 4 (21.1) | 0.470 | 15 (17.2) |
Chemotherapy | 44 (66.2) | 11 (52.6) | 0.386 | 55 (63.2) |
Recurrence or progression | | | 0.027 | |
Negative | 63 (92.6) | 14 (73.7) | | 77 (88.5) |
Recurrence | 4 (7.4) | 3 (21.1) | | 7 (10.3) |
Progression | 0 (0) | 2 (5.3) | | 2 (1.1) |
Follow-up time (months) | 73 (0-153) | 144 (1-229) | < 0.05 | 73 (0-247) |
Survival analysis:
Median follow-up time was 73 months (range, 0-247). Recurrence developed in seven (10.3%) patients and progression noted in two (1.1%) during follow up. The progression- free survival and overall survival curve (Kaplan-Meier) of all patients is plotted in Fig. 2. Eight patients had recurrence or progression within 10 years and one patient had recurrence 141 months after initial treatment.
In the seven patients with recurrence (Table 2); four (57.1%) had fertility-sparing staging operation, six (85.7%) were stage I disease and five of the six patients did not received chemotherapy. Two patients had progression (#69 and #51). One of them had fertility-sparing staging operation and the histological type was mixed germ cell tumor with grade 3 immature teratoma component. The other one had received USO and histological type was Yolk sac tumor. Both were stage III disease and had received adjuvant chemotherapy with four courses JEB regimen. Progression was noted within one month and three months respectively after initial treatment. Besides, there was one patient who had recurrence of pelvic tumor received debulking operation. However, the pathology showed mature teratoma; therefore, the case was not included in recurrence group.
Table 2
The clinical, surgical and pathological characteristics of patients with recurrence and progression
| Recurrence | Progression |
| #11 | #26 | #29 | #57 | #60 | #80 | #83 | #69 | #51 |
Age at diagnosis | 12 | 10 | 20 | 27 | 23 | 2 | 23 | 17 | 15 |
FIGO stage | 1C | 1A | 3C | 1C | 1A | 1A | 1A | 3 | 3B |
Surgical methods | USO | USO | Fertility-sparing staging operation | Fertility-sparing staging operation | Fertility-sparing staging operation | USO | Fertility-sparing staging operation | USO | Fertility-sparing staging operation |
Histological type | Immature teratoma grade3 | Mixed germ cell tumor | Dysgerminoma | Yolk sac tumor | Dysgerminoma | Immature teratoma grade1 | Dysgerminoma | Yolk sac tumor | Mixed germ cell tumor grade 3 |
Grossly residual | - | - | - | - | - | - | - | + | + |
initial Adjuvant chemotherapy | - | JEB*4 | BEP*4 | - | - | - | - | JEB*4 | JEB*4 |
Surgery after recurrence | + | + | - | - | + | + | + | + | + |
Chemotherapy after recurrence | JEB*6 | - | BEP*7 | - | BEP*3 | - | BEP*3 | PVB*2 | + |
time to recurrence (months) | 3 | 141 | 7 | 8 | 9 | 5 | 23 | 2 | Within 1 month |
The 10-year progression-free survival rate in USO group, BSO, ovarian cystectomy, fertility sparing staging operation and complete staging operation were 88%, 100%, 100%, 88.6% and 100% respectively (p = 0.747, compare USO and fertility sparing staging operation). Kaplan-Meier survival curves is presented in Fig. 3.
There were 55 patients received chemotherapy after operation. 10-year PFS rate in different chemotherapy regimen was analyzed as well. In BEP (bleomycin + etoposide + cisplatin) was 97.8% and in JEB (bleomycin + etoposide + carboplatin) was 77.8% (p = 0.0076) (Kaplan-Meier curve is shown in Fig. 4). In the JEB group, one patient had recurrence 141 months after initial treatment.
We also analyzed the PFS with different stage in pediatric groups (Table 3). In COG stage, the patients with elevated tumor markers after operation were defined as stage II but tumor markers were not one of the criteria for 2014 FIGO stage. Besides, the patients with tumor rupture during operation were defined as COG stage III but stage I in FIGO stage. Therefore, we re-stage the patients in pediatric groups by 2014 FIGO stage and analyzed if there was different recurrent rate. There were six patients with stage I disease, six patients with stage II disease and eight patients with stage III disease by COG stage system, recurrence in 10 years occurred in one(16.7%), zero(0%), three(37.5%) patients respectively in each stage. We converted the stage to FIGO stage system. Under FIGO stage system, 15 patients with stage I disease, one patient with stage II disease and four patients with stage III disease, patients with recurrence in 10 years were two(13.3%), zero(0%), two(50%) respectively. Kaplan Meier curves of different stage system in stage I and III are plotted in Fig. 5.
Table 3
The numbers and recurrence rate in 10 years for pediatric group by different staging system.
| Gynecologic Staging System (FIGO) | Pediatric Staging System (COG) |
| No. | No. of recur (%) | No. | No. of recur (%) |
Stage 1 | 15 | 2 (13.3) | 6 | 1 (16.7) |
Stage 2 | 1 | 0 (0) | 6 | 0 (0) |
Stage3 | 4 | 2 (50) | 8 | 3 (37.5) |
Besides, progression free survival was calculated in FIGO stage I, grade 2, 3 immature teratoma, between pediatric and gynecological group, with or without adjuvant chemotherapy (Table 4). In Gyneacological group, 14 (82.4%) of 17 patients with Stage I, grade 2, 3 immature teratoma received adjuvant chemotherapy and three (17.6%) did not. Neither of them had recurrence. In Pediatric group, 1(16.7%) of six patients had adjuvant chemotherapy, five (83.3%) patients did not and one of which had recurrence. Recurrence rate were 0% and 16.7% (gynecologic vs pediatric, p = 0.261).
Table 4
In stage 1, grade2, 3 immature teratoma, the proportion of received chemotherapy or not in gynecologic and pediatric groups. The recurrent rate in 10 years in different groups were presented as well
| Gynecologic group | Pediatric group |
| No. | No. of recur (%) | No. | No. of recur (%) |
Chemotherapy | 14 | 0 (0) | 1 | 0 (0) |
No chemotherapy | 3 | 0 (0) | 5 | 1 (16.7) |