Prognostic factors and role of salvage surgery in chemorefractory ovarian germ cell malignancies: a study in Chinese patients.

BACKGROUND AND OBJECTIVES: The majority of the studies on ovarian germ cell malignancies (OGCMs) focused on combination chemotherapy and fertility sparing surgery in primary treatment. Prognostic factors and the salvage treatment, particularly the role of salvage surgery, for the chemorefractory disease are much less documented. The purpose of this study was to explore the prognostic factors and the role of salvage surgery in Chinese patients with chemorefractory OGCMs.

METHODS: A total of 34 patients with chemorefractory OGCMs who underwent salvage surgery at Fudan University Cancer Hospital from April 1992 to December 2005 were retrospectively identified and analyzed. Survival was analyzed using the Kaplan-Meier and the statistical significance of various prognostic factors was tested using both the log-rank and the Cox proportional hazards models.

RESULTS: The median age of the study patients was 22.76 years. The histological subtypes included 2 dysgerminomas (DSG), 7 immature teratomas (IMT), 22 endodermal sinus tumors (EST) (including 16 pure EST, 3 mixed type with DSG, 3 with EC), 2 embryonal carcinomas (EC) and 1 mixed form (with component of sex cord-stromal tumor). The median follow-up time was 44.09 months (range, 5-164 months). For the entire study population, 1-, 3-, and 5-year survival were 82.35%, 45.64%, and 33.17%, respectively. The 1-, 3-, and 5-year survival in patients who were rendered macroscopically disease-free or had residual disease < or = 1 cm after surgical salvage were 93.33%, 80.00%, and 60.95%, compared to 68.42%, 21.05%, and 14.04% in those who had postoperative residual disease >1 cm (P=0.0036). Histology (DSG/IMT vs. non-DSG/IMT) (P=0.0221), primary and salvage chemotherapy regimen (non-BEP/PVB regimen for primary chemotherapy and BEP/PVB regimen for salvage chemotherapy vs. all other regimens in primary and salvage chemotherapy) (P=0.0316), site of chemorefractory disease (retroperitoneal vs. intraperitoneal) (P=0.0221), and salvage surgery states (optimal cytoreduction vs. suboptimal cytoreduction) (P=0.0036) were significant prognostic factors for survival through univariate analysis. However, site of chemorefractory disease was excluded as an independent prognostic factor according to multivariate analysis.

CONCLUSIONS: Chemorefractory cases with dysgerminoma or immature teratoma appear to have better outcome than the other subtypes. When offered standard BEP/PVB regimen as salvage chemotherapy, patients with chemorefractory disease after non-BEP/PVB primary chemotherapy have better prognosis. Optimal cytoreduction during salvage surgery does benefit chemorefractory patients.