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ABSTRACT & COMMENTARY
Surveillance for stage i male germ cell tumors is well-established as a standard practice; however, such a policy has not been evaluated for women with equivalent tumors. Dark et al designed a study to evaluate the management of grade 2 or higher stage Ia tumors by close surveillance to minimize treatment while reserving chemotherapy for patients with residual or recurrent disease. Between 1973 and 1995, 24 patients with malignant stage Ia ovarian germ cell tumors were enrolled onto a surveillance program. The group consisted of nine patients with dysgerminoma, nine with pure immature teratoma, and six with yolk sac tumor (with or without immature teratoma). Treatment consisted of surgical resection without adjuvant chemotherapy, followed by a surveillance program of clinical, serologic, and radiologic review, and included a second-look procedure for patients enrolled after 1982. At the time of the report, all but one patient are alive and in remission after a median follow-up of 6.8 years. The five-year survival is 95%, and the five-year disease-free survival is 68%. Eight patients required chemotherapy for recurrent disease or second primary ovarian germ cell tumor, including three patients with dysgerminoma, three with grade 2 immature teratoma, and a further two women with dysgerminoma who developed contralateral (presumed second primary) dysgerminoma 4.5 and 5.2 years after their first tumor. All but one, who died of a pulmonary embolus, have been successfully salvaged with chemotherapy. The authors conclude that patients with true stage Ia ovarian germ cell tumors do not require adjuvant chemotherapy or radiotherapy, thus avoiding the potential complications of secondary leukemia and infertility.
Except for patients with stage Ia pure dysgerminoma and stage Ia, grade 1 pure immature teratoma, the standard treatment for all patients with malignant ovarian germ cell tumors has been surgery followed by postoperative platinum-based chemotherapy: the combination of bleomycin, etoposide, and cisplatin. The evolution of this standard in the United States arose based on reports of very poor survival of such patients in the era prior to the development of combination chemotherapy. With the introduction of combination chemotherapy in the mid-1960s, the outcome for young patients with malignant ovarian germ cell tumors began to change dramatically. And the cure rates are approaching 100%. The problem with this whole evolutionary process is that the older literature on which the principles of clinical management are based included many patients who did not undergo comprehensive surgical staging. Therefore, treatment failure in a patient with apparent stage Ia disease treated with surgery alone may have been related principally to the fact that more extensive tumor went undetected. This group from the United Kingdom and the Pediatric Intergroup in the United States have been challenging our standard management by employing surveillance rather than chemotherapy for patients with stage Ia disease documented by comprehensive surgical staging. The real question is, "What is our threshold for failure in using this new strategy?" How many deaths from relapse is too many? If one excludes the two patients with dysgerminoma who had a new primary tumor in the contralateral ovary, the relapse rate was still 25%. For the six patients with yolk sac tumor, the relapse rate was two-sixths, or 30%; one of these patients died. Based on this information, I do not believe that I can yet embrace an approach using surveillance rather than postoperative chemotherapy until more experience is gained and its safety is demonstrated.