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Ovarian Germ Cell Tumour

What are Ovarian Germ Tell Tumours?

Ovarian germ cell tumours are of two types, benign and malignant (cancer). This information paper will cover malignant germ cell tumours of the ovary. Malignant germ cell tumours of the ovary are uncommon, accounting for no more than 5% of ovarian cancers. They arise from the germ cells or egg-making cells of the ovary and usually occur in young women under the age of 40 years; they are most common in teenagers or women in their twenties. This is different to the epithelial cancers of the ovary which arise from the surface tissue of the ovary, are more common and usually occur in women after the menopause.


What are the ovaries?

The ovaries are almond shaped organs that hold the eggs for reproduction and make the female hormones oestrogen and progesterone. There are two ovaries, one on each side of the uterus (womb) in the pelvis.


Diagnosis

Ovarian germ cell tumours of the ovary whether they are benign or malignant, are not easy to diagnose. Very often there are no symptoms in the early stages and many are found in an incidental (accidental) way during a routine gynaecological check-up.

  1. If a woman notices any of the following, she should see her family doctor for a check-up:

  2. Increasing swelling of her lower abdomen without weight gain elsewhere, or

  3. Increasing swelling of her lower abdomen which does not improve with diet and exercise, or

  4. A lump or mass in her abdomen especially her lower abdomen, or

  5. Lower abdominal/pelvic pain that does not settle quickly and simply, or

  6. Feelings of pressure on the bowel or bladder and a feeling that the bowel or bladder cannot be completely emptied, or

  7. Abnormal bleeding from the vagina especially bleeding after the menopause.

Your doctor may use several tests to see if there is a tumour present on the ovaries. He/she will probably begin by taking a history and doing an internal (pelvic) examination. During this examination the doctor will be feeling for the shape, size and position of the pelvic organs (cervix, uterus & ovaries) to see if they are normal.

Blood tests may be ordered as well as an ultrasound examination of the pelvis. The ultrasound examination uses sound waves to create a picture of the pelvic organs. While most ultrasound examinations are done through the abdomen the pelvic organs are better seen when the scan is done through the vagina; this is called a trans-vaginal ultrasound.  In some cases a CT scan may be performed, this is a special type of computerised x-ray.

The prognosis (chance of recovery) and treatment depends on the type of tumour and stage of disease, i.e., whether it involves one or both ovaries and whether it has spread beyond the ovaries. However, with modern day chemotherapy the results for the treatment of ovarian germ cell cancers is very good with some young women retaining their fertility and going on to later have babies.


Staging of ovarian germ cell tumours

Once an ovarian tumour has been investigated and been found to need removal a laparotomy should be performed. This is an operation where the abdomen is opened through a cut to remove and examine tissue from inside.

Depending on the circumstances either a biopsy or removal of the tumour will be undertaken. Biopsies (tissue samples) will be taken from any areas where tumour might be thus allowing the tumour extent to be assessed (staged).


The following stages are used for ovarian cancers:

  • Stage I - Cancer is found only in one or both ovaries

  • Stage II - Cancer is found in one or both ovaries and has spread to other organs in the pelvis such as the uterus and/or fallopian tubes and/or bladder and/or bowel.

  • Stage III - Cancer is found in one or both ovaries and has spread outside the pelvis to involve abdominal organs such as the intestines or has spread to the lymph nodes. The lymph nodes are small bean shaped structures that are found along blood vessels in all parts of the body. They are part of the immune system and are involved in fighting such things as infection.

  • Stage IV - Cancer is found in one or both ovaries and has spread outside the abdomen or has spread to involve the inside of the liver.

  • Recurrent cancer means that the cancer has come back after it has been treated.  If a patient's cancer has recurred it s NOT re-staged.  A patient who originally had Stage I cancer who develops a recurrence, say in the lungs some time later, does NOT then have Stage IV cancer; they have recurrent metastatic Stage I cancer.


Treatment of Germ Cell Cancers

Malignant germ cell tumours should be treated by a certified gynaecological oncologist. Their treatment varies depending on a number of factors, the most important are:

  • The age of the patient and her desire to have children

  • The type of tumour

  • The stage of the tumour

As most of these tumours arise in relatively young women or teenagers, maintenance of reproductive potential is a major issue. Fortunately, these tumours tend to be very sensitive to chemotherapy. This means that radical cancer operations which involve removal of both ovaries and the uterus are often not needed, even if there is stage II, III or IV disease.

However, in women who have finished child bearing removal of both ovaries and the uterus is generally recommended. The surgery in most cases involves the removal of the affected ovary and if there is metastatic disease, removal of that which is readily and easily removable. After surgery the patient should be treated with chemotherapy.

The choice of chemotherapy drugs is dependent on the type of tumour. Anywhere between 4 & 6 cycles of chemotherapy are generally given.


Follow-up

It is important after treatment is completed that proper follow-up is undertaken. Patients are seen for follow-up as follows: every 3 months for 2 years, then every 6 months for a further 3 years, then yearly there-after.

At each follow-up visit a short history is taken to see if there has been any changes since the last visit. A physical examination, including examination of the neck, abdomen and pelvis is then performed.

Some of the malignant germ cell tumours produce chemicals called tumour markers that can be measured in the blood called tumour markers. These results may give a guide to how effective treatment has been and can be used as part of the follow-up.

In follow-up, if the levels of the chemical being measured rises then it may indicate that the tumour has recurred and further investigations may be warranted to tell what is happening. Because of the sensitivity of these tumours to chemotherapy, successful treatment of recurrence is possible.


Having Further Children - is it safe?

For years people have worried about the possible risks associated with having children, after surgery and chemotherapy for malignant germ cell tumours.

However, some recent studies would indicate that neither the women nor the baby are at any increased risk. There seems to be no increased risk of the tumour recurring as a result of pregnancy. The baby does not seem to be at any increased risks because its' mother has had chemotherapy. The pregnancy does not seem to be at any increased risks of complications.


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