Laparotomy for post chemotherapy residue in ovarian germ cell tumors

Background: Primary conservative surgery and cisplatin-based chemotherapy have resulted in high cure rates in malignant ovarian germ cell tumors. A significant proportion of advanced tumors may have post-chemotherapy residue and it is important to distinguish necrosis or fibrosis without viable tumor from persistent viable tumor and teratoma. Aims: To evaluate the role of laparotomy in assessing the nature of post-chemotherapy residue in ovarian germ cell tumors. Materials and Methods: Eighty-three patients with malignant ovarian germ cell tumors seen at Cancer Institute, Chennai between 1992 and 2002 were studied. Sixty-eight patients completed combination chemotherapy with cisplatin regimes, of whom 35 had radiological residual masses. Twenty-nine out of these 35 patients underwent laparotomy to assess the nature of the residue. Results: On laparotomy, three patients had viable tumor, seven immature teratoma, three mature teratoma and 16 only necrosis or fibrosis. None of our patients with dysgerminoma, embryonal carcinoma, absence of teratoma element in the primary tumor and radiological residue of < 5 cm had viable tumor whereas all patients with tumors containing teratoma component initially had residual tumor. Absence of viable disease was higher in patients who had normalization of serum markers by two cycles of chemotherapy. Conclusion: Our study suggests that patients with absence of teratoma element initially, radiological residue of <5 cm and normalization of serum markers after two cycles of chemotherapy do not require surgery to assess the nature of post-chemotherapy residue. However, laparotomy should be performed in patients with tumors that initially contain teratoma element and in those with sluggish tumor marker response after two cycles of chemotherapy since they have a high chance of having viable postchemotherapy residue.