1. BY DR. KHANSA IQBAL SENIOR REGISTRAR GYNAE UNIT-II

2. Germ cell tumors - Immature teratoma Clinical features Management Approach to young girl’s future fertility prospects Need for adjuvant chemotherapy

3. CLASSIFICATION OF OVARIAN TUMORS Epithelial ovarian cancer 65 – 70 % Benign Malignant Germ cell tumors15% Benign Malignant Sex cord stromal cell origin 10 % Benign Malignant Metastatic ovarian carcinomas 05 %

4. HISTOLOGICAL TYPING OF OVARIAN GERM CELL TUMORS Primitive germ cell tumor includes Dysgerminoma Yolk sac tumor Biphasic or triphasic teratoma Immature teratoma Mature teratoma Monodermal teratoma Thyroid tumor Carcinoids

5. MATURE CYSTIC TERATOMA 0.2 to 02% malignant potential Mainly Squamous cell carcinoma

6. IMMATURE TERATOMA WHO DEFINITION Teratoma containing variable amount of immature embryonal type neuroectodermal tissue

7. IMMATURE TERATOMA Incidence 01% of all ovarian cancers 03% of all teratomas 20% of malignant ovarian germ cell tumors

8. IMPORTANCE OF GERM CELL TUMORS Heterogeneous and complex group of diseases Women of young age group Modern treatment – highly curable

9. GRADES Grade 0:Mature tissue only Grade 1:Limited immature neuroepithelial tissue Grade 2:Moderate immature neuroepithelial tissue Grade 3:Large immature neuroepithelial tissue

10. CLINICAL FEATURES Age: Essentially in first two decades of life 1/3 malignant Ethnicity Rapid progression Sub acute pelvic pain Haemorrhage Necrosis

11. CLINICAL FEATURES (Cont….) Pressure symptoms Abdominal ascites Menstrual irregularities Pseudoprecocious puberty Paraneoplastic syndrome

12. SIGNS Palpable abdominopelvic mass Ascites / pleural effusion Organomegaly

13. MANAGEMENT Diagnosis Investigations Blood CP BSR Urine R/E HBsAg / Anti HCV

14. 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

15. 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

16. FIGO STAGING OF OVARIAN CARCINOMA Stage 1 Growth limited to ovaries Stage 2 Growth on one or both ovaries with peritoneal implants within the pelvis Stage 3 Tumor in one or both ovaries with peritoneal implants outside the pelvis or retroperitoneal node metastasis Stage 4 Tumor involving one or both ovaries with distant metastasis

17. CRITERIA FOR POTENTIAL FERTILITY SPARING SURGERY IN OVARIAN CA Patient desirous of preserving fertility Patient and family consent and agreement for close follow up No evidence of dysgenetic gonads Specific situations Any unilateral malignant germ cell tumor Any unilateral sex cord stromal tumor Any unilateral borderline tumor Stage 1A epithelial tumor

18. DISCUSSION WITH FAMILY Conservative surgery Repeat surgery Adjuvant chemotherapy

19. TREATMENT Surgery Staging laparotomy Unilateral salpingo-oophorectomy and complete staging ? ? Debulking surgery

20. TREATMENT (Cont….) Adjuvant chemotherapy (BEP Regimen) Advanced Disease Recurrent disease

21. TREATMENT (Cont….) Second look Laparotomy Radiotherapy: No role in primary treatment

22. PROGNOSIS Depends on Undifferentiated neural tissue

23. FIVE YEARS SURVIVAL RATE Stage 1 grade 1 disease:90 – 95 % All stages of Immature teratoma:70 – 80 %

24. CONCLUSION Morphologic pattern is varied and complex Combination of surgery and chemotherapy has longer survival

25. 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.