Adult ovarian granulosa cell tumour is a slowly progressive rare ovarian tumour, with a better prognosis when compared to epithelial tumours, though 20–30% of them may recur late.(1,5,22)
Ovarian granulosa cell tumour has different clinical behavior and biology compared to epithelial ovarian tumors, with the sustained ability for Estrogen production, which Explains the prevalence of hormone dysfunction related symptoms. In our study Approximately half of the patients presented with either; vaginal bleeding (43%), or Amenorrhea (7%), which may explain the early diagnosis of the disease as 74% were diagnosed in stage I. This is of utmost importance, as it may lead to endometrial abnormalities with an incidence of 30–85% endometrial hyperplasia and 3–20% endometrial carcinoma.(9,23,24) In our study hyperplasia was documented in 26% of all group with no endometrial carcinoma found, which matches the international results.
The mean tumour size in our report was 11.8 cm, which is matched with the average value documented in most studies, Miller and his colleagues, (25) found that 33% of patients with recurrence had tumour larger than 15 cm, which was encountered in eight patients in our study. Other studies were unable to validate the prognostic significance of tumour size.(22,26,27) Impact of size on survival was not analysed in this report due to low number of tumour size above 15 cm.
The rarity of the disease and the small number of publications are the main reasons of absence of prognostic model for AOGCT. However, certain common factors published in the literature had an impact on local failure rate and overall survival, among them; Stage which was shown to be a prognostic factor for survival in many reports. (1,5,27) Five-year overall survival was reported to range between 75–95% in patients with stage I disease and 22–50% in higher stages.(28–30) Similarly, in the present study, stage was important factor predicting survival with 5-year OS was 100% in stage I disease, whereas it was 64% in stage II -III. Although there was a numerical difference in favoring better DFS for stage I but was not statistically significant in our report.
The prognostic value of age in AOGCT is controversial in the literature. Although Chan et al (31) reported that age younger than 50 years was a favorable prognostic factor, Zhang et al(22).
It has been demonstrated that women under the age of 50 years had a 10% survival advantage in a series of 376 women. but Lee and his colleagues (32) showed that the recurrence rate was higher at the age younger than 40 years. In this study age of 55 years chose as a cut of value for analysis; with survival reached 77% for the older group in contrary to 100% for the younger group, which may in light the impact of menopausal status as a co-prognostic factor in this study group at this age level. Which was found to be statistically significant, and 5-year OS of 84% for postmenopausal patients.
Presence of Ascites, and high Tumour marker CA125 found to be the most important 2 independent factors for recurrence with an impact on survival as well. They are common presentation in epithelial ovarian tumors, and rarely reported among AOGCT.(33–36) Studies on Ascites and tumour marker CA125 among AOGCT are scarce, on the other hand, presence of ascites is a sign of higher stage, which was validated in literature as a strong prognostic factor for survival as mentioned above. While high CA125 reported in one study to be poor predictor of AOGCT.(37) To our knowledge this could be the first study to test ,the prognostic value of tumour marker CA125 in AOGCT, in contrary to serum inhibin ,which was extensively investigated.(38) This should be validated in larger studies.
performing of conservative surgical approach (Fertility-sparing surgery is appropriate for patients with stage I and stage II disease, because high survival and late disease recurrences.(39,40)In the present study, the performance of conservative surgery was not associated with recurrence failure and mortality, which confirm its role in fertility sparing age group without compromisation on survival.
There is no prospective, randomized, controlled study evaluating the effectiveness and necessity for adjuvant radiotherapy or chemotherapy in AOGCT.(41) Therefore, the role of adjuvant therapy is controversial. In our study, chemotherapy was applied as the adjuvant therapy in 8%, hormonal treatment in 2%, no one received adjuvant radiotherapy. This is due to the low numbers of patients presented with stage II-III (12%), low mean tumour size, and no presurgical tumour rupture documented. In addition to that optimal debulking achieved in 98% of the cases. Although high rate of late failure, indicate other poor risk features for investigation, Nevertheless, 90% of the patients with recurrence underwent resurgery.
The Prognostic effect of tumor cyst rupture time, spontaneously before the operation or iatrogenic rupture during the operation is also controversial. Tumour Cyst rupture was found to be associated with poor prognosis in some literature.(32,42)In the present study, presence of tumour cyst rupture was noted only intraoperatively in 3 patients. However, it was not tested against survival, due to low number of patients.
The retrospective nature of this study is one of its limitations. Nevertheless, the achievement of maximal debulking in all patients in this study is one of its advantages. In addition, relatively higher number of patients in comparison to international reports, long follow-up time (median, 97 months), involvement of patients from a single center, performance of staging surgery including lymphadenectomy in 76.6% of the patients, and performance of surgery in 90% of the patients who had recurrence are considered points of strengths in this study.
In summary, AGCT is diagnosed at earlier stages, Surgery is the standard treatment with a potential role for fertility preservation, and longer survival was achieved with maximal surgical resection. Stage of the disease was identified as the most important prognostic factor predicting local recurrence and overall survival.