Vol 7, No 3

July 2019 Characteristics, Management and Survival 233

Research Article

Characteristics, Management and Survival Rate of

Karakteristik, Manajmen, dan Tingkat Kesintasan

Laila Nuranna1 , Zakiah Tourik2

1
Division of Oncology Department of Obstetrics and Gynecology
2
Department of Obstetrics and Gynecology
Faculty of Medicine Universitas Indonesia,
Dr. Cipto Mangunkusumo National General Hospital
Jakarta

Abstract Abstrak
Objective : To determine the prevalence of malignant ovarian Tujuan : Mengetahui sebaran meliputi karateristik,
germ cell tumour in term of characteristics, management, penatalaksanaan dan kesintasan 3 tahun pasien tumor
and 3-year survival rate in Dr. Cipto Mangunkusumo Hospital ganas sel germinal ovarium di RSCM tahun 2011 – 2013.
Jakarta from 2011 to 2013.
Metode : Penelitian ini menggunakan studi potong lintang
Methods : This is a cross-sectional study. Secondary data dengan mengambil data sekunder dari rekam medis dan
were collected from medical record as well as interviewing mewawancarai pasien atau keluarga pasien via telepon atau
patients through phone call or home visit. kunjugan rumah.
Results : We collected data from 24 subjects. As many as Hasil : Pada penelitian ini, dari 24 subjek penelitian,
54.2% of subjects were between 20 to 40 year old, and 58.3% 54,2% ditemukan pada usia 20-40 tahun dan 58,3%
was single. Around 83.3% of the subjects came with chief subjek belum menikah. Sebanyak 83,3% datang dengan
complaint of abdominal enlargement. Histopathology finding keluhan perut membesar. Secara histopatologi didapatkan
confirmed dysgerminoma in 50% subjects, mixed ovarian jenis disgeminoma, tumor sel germinal campuran, sinus
germ cell tumour in 25%, endodermal sinus tumour or yolk endodermal (yolk sac) dan teratoma imatur dengan proporsi
sac tumour in 16.7%, and immature teratoma in 8.3%. Half masing-masing 50%, 25%, 16,7% dan 8,3%, sebagian besar
of the cases were found in stage I. The primary therapy was kasus (50%) ditemukan pada stadium I. Conservative
conservative surgical staging and adjuvant chemotherapy.In surgical staging dan kemoterapi adjuvan tatalaksana pilihan.
2 subjects with dysgerminoma, neoadjuvant chemotherapy Terdapat 2 subjek jenis disgerminoma yang diberikan dengan
(bleomycin, etoposide, cisplatin, and cyclophosphamide- kemoterapi neoadjuvan (regimenbleomycin, etoposide,
cisplatin regimen) resulted in a good response. The 3-year cisplatin dan cyclophosmide-cisplatin) memberikan respon
survival rate was 83.3% in dysgerminoma, 100% in mixed yang baik. Kesintasan ≥ 3 tahun pada jenis disgerminoma
ovarian germ cell tumour, and 50% in immature teratoma. mencapai 83,3%, pada tumor sel germinal campuran 100%
dan pada teratoma imatur mencapai 50%.
Conclusions : In malignant ovarian germ cell tumour,
conservative surgical staging followed by a complete course Kesimpulan : Pada tumor ganas sel germinal ovarium
of chemotherapy is the treatment of choice with 3-year conservative surgical staging diikuti kemoterapi lengkap
survival rate exceeding 70%. merupakan pilihan terapi dengan kesintasan ≥ 3 tahun
mencapai > 70%.
Keywords : dysgerminoma, non-epithelial ovarian
tumour,ovarian germ cell tumour, survival. Kata kunci : disgerminoma,kesintasan, tumor ovarium non
epithelial, tumor sel germinal ovarium.
Correspondence author: Laila Nuranna. [email protected]
 Indones J
234 Nuranna and Tourik Obstet Gynecol
INTRODUCTION all patients with malignant ovarian germ cell
tumour who received a complete course of
Around 70% of ovarian tumour that affects therapy in Dr. Cipto Mangunkusumo Hospital
teenager and young adult is ovarian germ Jakarta from 2011 to 2013.
cell tumour and one-third of the total cases is
malignant.1Malignant ovarian germ cell tumour We calculated the sample size based on prior
is a rare occurrence, accounts for 5% of total data on disease prevalence in Asia. The result
ovarian malignancy.2Unlike malignant neoplasm was 49 subjects. Subjects were recruited with
from epithelial ovary cells, this type of tumour total sampling from cancer registration in the
affects women in reproductive age, including oncology division of Obstetrics and Gynecology
teenager and young adult. Department. Collected data were analyzed with
the Statistical Program for Social Sciences (SPSS)
According to Surveillance, Epidemiology and 20. Ethical clearance was obtained from the Health
Results (SEER) in 1973 to 2003, identification in Research Ethics Committee, Faculty of Medicine,
1,262 patients with malignant ovarian germ cell Universitas Indonesia, in August 2017.
tumour showed dysgerminoma in 32.4% cases,
immature teratoma with malignant degeneration RESULTS
in 35.6% cases, and mixed germ cell tumour in
28.7% cases.3In Asian and African population, the There were 57 patients with malignant ovarian
most common type of malignant ovarian germ germ cell tumour in Cipto Mangunkusumo
cell tumour is dysgerminoma.4 Hospital Jakarta from 2011 to 2013. However,
only 24 subjects fulfilled the inclusion criteria
Management in malignant ovarian germ cell of having a complete medical record. Baseline
tumour has improved dramatically, giving rise characteristics of the subjects are presented in
to improvement in survival rate. Survival rate table 1.
reaches 100% in dysgerminoma type and 85% in Table 1.Subjects Baseline Characteristics and Histo-
non-dysgerminoma type.5 Treatment in ovarian pathology Finding
germ cell tumour used to result in impaired
fertility.6In the 1980s, reserving fertility could only Variables (n : 24) n %
be performed in stage 1 and 2 malignant ovarian Age (yo)
germ cell tumour with normal contralateral ovary 10-19 1 1
20-40 13 13
and uterus. Starting in 1989, fertility function ≥ 40 10 10
could be well maintained in all stage of the Marital status
tumour, even in patients with involvement of Single 14 14
both ovaries.7 Married 10 10
Parity
0 14 14
Compared to data on testicle germ cell tumour, ≤2 7 7
data in Indonesia regarding ovarian germ cell >2 3 3
tumour is scarce. Therefore, we collected and Chief complaint
analyzed the data to determine the prevalence Abdominal enlargement 20 20
Abdominal pain 4 4
and management of malignant ovarian germ cell Ultrasound/chest X-ray
in Indonesia, especially in Jakarta. No ascites and effusion 12 12
Ascites or effusion 9 9
METHODS Ascites and effusion 3 3
Histopathology
Dysgerminoma 12 12
This is a cross-sectional study. Secondary Mixed germ cell tumour 6 6
data were collected from the medical record Endodermal sinus 4 4
and from interviewing patients. The interview tumour (yolk sac)
was performed via phone call or home visit to Immature teratoma 2 2
determine the 3-year survival rate. We recruited
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July 2019 Characteristics, Management and Survival 235
We also collected data on tumour marker Options for chemotherapy were grouped
examination. Most of the subjects with based on histopathology type of the tumour. Half
dysgerminoma had raised the level of lactate of the subjects with dysgerminoma underwent
dehydrogenase (LDH). We found two (16.7%) complete series of cisplatin, vinblastine, and
subjects with cancer antigen 125 (CA125) bleomycin (PVB); bleomycin, etoposide, and
elevation, which is uncommon as Ca125 elevation cisplatin (BEP); and cyclophosphamide-cisplatin
is usually associated with the ovarian epithelial (CP) with the proportion of 8.3%, 25%, and 16.7%
tumour. In three (25%) subjects, elevation in LDH consecutively. The rest of the subjects did not
was accompanied with other tumour marker undergo chemotherapy.
elevation such as alpha-fetoprotein (AFP), human
Chorionic Gonadotrophin (bHCG) and CA125. In term of 3-year survival rate, most of the
Another significant elevation of a tumour marker patients (70.8%) were alive, and 83.3% were
is presented in Table 2. asymptomatic.
Table 2. Tumor Marker Findings
We analyzed survival functions with Kaplan
Variables n % Meier curve and found that all patients with stage
Dysgerminoma (n : 12) 3 and 4 tumour despite their histopathology
Elevated LDH 6 50 type had a 3-year survival rate of 100% with
Elevated Ca125 2 16.7 treatment. Similarly, the 3-year survival rate
Elevated bHCG 1 8.3
Elevated LDH, Ca125 2 16.7 for patients with neoadjuvant chemotherapy is
Elevated LDH, AFP, bHCG 1 8.3 100%. We also found that 3-year survival rate
Mixed germ cell tumor in dysgerminoma with complete treatment is
Elevated LDH 3 50 higher than endodermal sinus tumour, immature
Elevated Ca125 3 50
teratoma, and mixed germ cell tumour.
Endodermal sinus tumor
Elevated AFP 2 50
Elevated AFP, Ca125 1 25 DISCUSSION
Elevated AFP, LDH, Ca125 1 25
Immature teratoma (n : 2) The highest prevalence of malignant ovarian germ
Elevated LDH 2 100
cell tumour was found in age 20 to 40 year old,
Table 3. Clinical Staging Grouped by Histopathology Type. followed by those older than 40, and younger than
20. This finding agrees with prior epidemiological
Variables n % data in which the highest incidence of malignant
Dysgeminoma (n : 12) ovarian germ cell tumour occurs in young females
Stage 1 8 66.7 aged 15 to 30-year-old.8However, one study
Stage 3 2 16.7
stated that the highest incidence is within 15 to
Stage 4 2 16.7
Mixed germ cell tumor (n : 6) 19 year old.3 Up until 20 years old, almost 70% of
Stage 1 4 66.7 ovarian tumour originates from germ cells, and
Stage 3 2 33.3 one-third of this number proves to be malignant.6
Endodermal sinus tumor (n : 4) The tendency of malignancy in younger age may
Stage 1 2 50
Stage 2 2 50
be caused by a hormonal factor as in the high
Immature teratoma (n : 2) level of exogenous and endogenous estrogen
Stage 1 1 50 that disturbs the development of germ cell
Stage 3 1 50 from primitive to mature cells. These abnormal
germ cells are retained until puberty in which
Furthermore, we noted clinical staging from gonadotropin further initiates proliferation and
each subject grouped by type of histopathology results in tumour with various histopathology.9
findings, as shown in Table 3.
In this study, most of the patients came with a
In term of case management, unilateral chief complaint of abdominal enlargement. This
salphingo-oophorectomy (USO) was is inconsistent with several other studies that
performed in half of the total subjects with or presented abdominal pain and distention as their
without omentectomy, appendectomy, and chief complaints.10,11
lymphadenectomy.
 Indones J
236 Nuranna and Tourik Obstet Gynecol
We found that most of our subjects epidemiology data which stated that 60-70%
had dysgerminoma. This is consistent cases were FIGO stage I or II.11
with epidemiology data from that stated
dysgerminoma as the most frequent type of Malignant ovarian germ cell tumour is
malignant ovarian germ cell tumour.10Another sensitive to chemotherapy. The standard regimen
important finding we need to highlight is tumour for non-dysgerminoma cases is BEP.14 In a study,
marker test. Carcinoembryonic antigen (CEA) is 75% of patients with adjuvant chemotherapy
associated with gastrointestinal tract tumour. postoperatively, 77% received BEP regimen. One
However, 4 of our subjects underwent this patient with immature teratoma stage IIIc grade
test that we think is unnecessary. Elevation in 2-3 was given additional VAC regimen when the
CA125 may be caused by various factors since tumour recurred.5 In our study, only 10 subjects
this tumour marker is usually associated with completed 6 series of chemotherapy, 8 of them
ovary epithelial cell tumour. Each of our subjects had adjuvant chemotherapy (6 with PEB regimen,
underwent a test for multiple types of tumour 1 with PVB regimen, and 1 with CP regimen) while
markers, and therefore, we found overlapping the remaining 2 had neoadjuvant chemotherapy
results. However, we only presented results with with BEP and CP regimen. Both groups presented
significant elevation. a satisfying result.

Study on tumour marker found that there We did not find any VAC regimen in our data.
were 7 significant tumour markers associated with There are no recurrent cases, and therefore we
various type of germ cell tumour in ovary. CA125 never used VAC regimen. Three patients with
was found in more than 50% of the subjects. AFP dysgerminoma had total abdominal radiotherapy,
was found positive mostly in endodermal sinus and 10 patients (5 with dysgerminoma and 5 with
tumour (100%), immature teratoma (61.9%), and immature teratoma) did not receive postoperative
dysgerminoma (11.8%). Significant elevation of adjuvant therapy unless 1 patient with stage Ia
LDH was found in 95% of dysgerminoma cases dysgerminoma with recurrence.5 In our study, we
and 83.3% of endodermal sinus tumour. CEA is did not examine radiotherapy treatment, and we
considered not associated with germ cell ovary did adjuvant chemotherapy for dysgerminoma,
tumor.12 mixed germ cell tumour, endodermal sinus
tumour, and immature teratoma patients
Half of our subjects did not present with ascites although chemotherapy was only performed in
or effusion. This condition may be caused by the 42% subjects.
fact that ascites or peritonitis due to effusion is a
secondary manifestation from torsion, infection, Overall survival rate was 100%. Based on
or ovarian tumour rupture.13 epidemiology data, the majority of patients with
ovarian germ cell malignancy has high cured rate
Unilateral Salphingo-Oophorectomy (USO) with a small proportion experiencing recurrence
was performed in 50% subjects in which 5 of them within 24 months after primary diagnosis.14As
underwent additional procedures (omentectomy, many as 71% of our subjects survived for at least
appendectomy, and / or lymphadenectomy) 3 years after surgery. Based on histopathology
due to the younger age and marital status of type, dysgerminoma, mixed germ cell tumour,
most subjects. One subject underwent bilateral and immature teratoma had a 3-year survival
salphingo-oophorectomy (BSO), and 11 subjects rate of 83.3%, 100%, and 50% consecutively.
underwent total hysterectomy with BSO. In a study Endodermal sinus tumour cases had a less-than-
by Weinberg et al in 2011, USO was performed 3-year survival rate of 100%.
in 67.5% patients while total hysterectomy with
BSO in 25% of patients. This study only examined We had 7 subjects who had survival duration
subjects with surgery and preserved fertility.5 of less than 3 years. This event may be caused by
a certain tendency to refuse chemotherapy. We
In term of histopathology, dysgerminoma, did not examine the recurrence or progression of
mixed germ cell tumour, endodermal sinus the disease.
tumour, and immature teratoma, more than 50%
were found in stage I. This finding agrees with This study examined rarely evaluated
epidemiology data. There is no recent data on
Vol 7, No 3
July 2019 Characteristics, Management and Survival 237
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