IMMATURE TERATOMA

LITERATURE REVIEW

BY

DR. KHANSA IQBAL SENIOR REGISTRAR GYNAE UNIT-II

Germ cell tumors - Immature teratoma

Clinical features

Management

Approach to young girl’s future fertility prospects

Need for adjuvant chemotherapy

CLASSIFICATION OF OVARIAN TUMORS

Epithelial ovarian cancer 65 – 70 %

Benign

Malignant

Germ cell tumors 15%

Benign

Malignant

Sex cord stromal cell origin 10 %

Benign

Malignant

Metastatic ovarian carcinomas 05 %

HISTOLOGICAL TYPING OF OVARIAN GERM CELL TUMORS

Primitive germ cell tumor includesDysgerminoma Yolk sac tumor

Biphasic or triphasic teratomaImmature teratoma Mature teratoma

Monodermal teratomaThyroid tumorCarcinoids

MATURE CYSTIC TERATOMA

0.2 to 02% malignant potential

Mainly Squamous cell carcinoma

IMMATURE TERATOMA WHO DEFINITION

Teratoma containing variable amount of immature

embryonal type neuroectodermal tissue

IMMATURE TERATOMA

Incidence

01% of all ovarian cancers

03% of all teratomas

20% of malignant ovarian germ cell tumors

IMPORTANCE OF GERM CELL TUMORS

Heterogeneous and complex group of diseases

Women of young age group

Modern treatment – highly curable

GRADES

Grade 0: Mature tissue only

Grade 1: Limited immature neuroepithelial tissue

Grade 2: Moderate immature neuroepithelial

tissue

Grade 3: Large immature neuroepithelial tissue

CLINICAL FEATURES

Age:

Essentially in first two decades of life

1/3 malignant

Ethnicity

Rapid progression

Sub acute pelvic pain

Haemorrhage

Necrosis

CLINICAL FEATURES (Cont….)

Pressure symptoms

Abdominal ascites

Menstrual irregularities

Pseudoprecocious puberty

Paraneoplastic syndrome

SIGNS

Palpable abdominopelvic mass

Ascites / pleural effusion

Organomegaly

MANAGEMENT

Diagnosis

Investigations

Blood CP

BSR

Urine R/E

HBsAg / Anti HCV

SPECIFIC INVESTIGATIONS

Tumor markers Serum beta HCG Serum AFP titre Serum CA-125 Serum LDH

USG abdomen and pelvis LFT’s Chest X ray Karyotyping Abdomino pelvic CT scan / MRI

SPECIFIC INVESTIGATIONS (Cont…)TUMOR MARKERS

Embryonal carcinoma: Serum AFP and

Serum Beta HCG

Endodermal sinus tumour : Serum AFP

Choriocarcinoma: Serum beta HCG

Dysgerminoma: PLAP and Serum LDH

FIGO STAGING OF OVARIAN CARCINOMA Stage 1

Growth limited to ovaries

Stage 2Growth on one or both ovaries with peritoneal implants

within the pelvis

Stage 3Tumor in one or both ovaries with peritoneal implants

outside the pelvis or retroperitoneal node metastasis

Stage 4Tumor involving one or both ovaries with distant metastasis

CRITERIA FOR POTENTIAL FERTILITY SPARING SURGERY IN OVARIAN CA

Patient desirous of preserving fertilityPatient and family consent and agreement for close

follow upNo evidence of dysgenetic gonads Specific situations

Any unilateral malignant germ cell tumorAny unilateral sex cord stromal tumorAny unilateral borderline tumorStage 1A epithelial tumor

DISCUSSION WITH FAMILY

Conservative surgery

Repeat surgery

Adjuvant chemotherapy

TREATMENT

Surgery

Staging laparotomy

Unilateral salpingo-oophorectomy and complete staging

? ? Debulking surgery

TREATMENT (Cont….)

Adjuvant chemotherapy (BEP Regimen)

Advanced Disease

Recurrent disease

TREATMENT (Cont….)

Second look Laparotomy

Radiotherapy: No role in primary treatment

PROGNOSIS

Depends on

Undifferentiated neural tissue

FIVE YEARS SURVIVAL RATE

Stage 1 grade 1 disease: 90 – 95 %

All stages of Immature teratoma: 70 – 80

%

CONCLUSION

Morphologic pattern is varied and complex

Combination of surgery and chemotherapy has

longer survival

TAKE HOME MESSAGE

Management of ovarian tumors at a younger age group

still poses a challenge for the clinician

Early recognition, timely diagnosis and thorough

surgical staging are hall marks for successful outcome

An expert gynaecologist is the right person to manage

these cases who knows the importance of conservative

surgery for maintenance of future reproductive function.