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germ cell ovarian cancer

Germ cells are embryonic cells that develop into sperm in males and eggs in females. Tumours that arise from germ cells may be benign (non-cancerous) or malignant (cancer). Most types of germ cell tumours are not cancerous.

Germ cell tumours that are cancerous are referred to as Malignant Ovarian Germ Cell Tumours (MOGCT).

Approximately 1.5% to 5% of all ovarian cancers are MOGCT, and they are more common in younger people. MOGCT accounts for 70% of all ovarian cancer diagnoses in people aged 10 to 30 years old.

MOGCT grow very rapidly. Despite this, early diagnosis is common because the tumour can grow very large before it spreads. Some types of MOGCT also secrete hormones, which can cause additional symptoms. Most people are diagnosed at stage 1A when the tumour is contained within one ovary.
Even when the cancer has spread, in contrast to many other types of ovarian cancer, MOGCT treatment is often curative.

Types of germ cell tumours

The different types of ovarian germ cell tumours are called subtypes. Subtypes of ovarian germ cell tumours are (most common to rarest) teratoma, dysgerminoma, yolk sac tumour, mixed germ cell tumour, embryonal carcinoma, non-gestational choriocarcinoma and polyembryoma. The last three subtypes are rare.

Symptoms

The vast majority of people visit their doctor with abdominal pain and an abdominal mass. The pain can be due to the size and/or rupture and/or torsion (twisting) of the mass and/or ascites (fluid) in the abdomen.

Tumours which secrete human chorionic gonadotropin (HCG) may cause early puberty or atypical vaginal bleeding and can be the cause of a false positive pregnancy test result.

Other symptoms such as eating less and feeling fuller, needing to pee more often or urgently, a change in bowel habits, painful intercourse, indigestion, unexplained weight change and fatigue are also possible.

Diagnosis of malignant germ cell ovarian tumours

If a doctor suspects ovarian cancer is a possibility, they may order a CA-125 blood test and an ultrasound. In less common instances, other imaging, such as a computerised tomography (CT) or magnetic resonance imaging (MRI) scan may be used. CA-125 is not a specific marker for MOGCT, so the results may be normal. CA-125 is not typically used in children and adolescents.

Additional blood tests may be ordered because many germ cell tumours can produce abnormal levels of other proteins (tumour markers) that can be measured in the bloodstream.

Tumour markers that can rise with each germ cell tumour.

Subtype LDH HCG AFP E2 A
dysgerminomas
+
±
-
±
-
yolk sac tumours
+
-
+
-
-
embryonal carcinomas
±
+
±
±
-
polyembryoma
-
+
±
-
-
non-gestational choriocarcinoma
±
+
-
-
-
immature teratoma
±
-
±
-
±
mixed OGCT
±
±
±
±
±
gonadoblastoma*
-
-
-
±
±

mature teratoma dermoid cysts are non-cancerous but in rare cases (1%) portions of the tumour can develop into cancer

*gonadoblastomas are a non-invasive tumour with malignant potential (i.e. sometimes develop into cancer)

LDH = lactate dehydrogenase

HCG = human chorionic gonadotropin

AFP = alpha-fetoprotein

estrogens (i.e. estradiol, E2); A = androgens]

Reference: Society of Gynecologic Oncology – Malignant Germ Cell Tumours – What Should You Know

Like all ovarian cancers, a conclusive diagnosis can only be made by histology. Histology is when a specialised doctor, called a pathologist, examines tumour cells under a microscope. The cells can be taken during a biopsy or, more commonly, taken from tissue obtained when the ovary is removed by surgery.

Treatment of germ cell ovarian cancer

Surgery

The goal of surgery is to confirm the diagnosis, determine the spread (staging), and help treat the cancer by removing all visible cancer growth. Fertility-preserving surgery where one, rather than both ovaries, are removed, may be possible.

The extent of surgery will be individualised to the type of tumour, extent of disease and age of the patient. Generally speaking, adults will have more extensive surgery than children.

Surgery usually occurs before chemotherapy, but if the cancer is extremely advanced (stage III-IV), doctors may consider starting chemotherapy before surgery – this is called neoadjuvant treatment and can help preserve fertility and reduce the complexity of surgery.

Chemotherapy

Ovarian germ cell cancers are highly-sensitive to platinum-based chemotherapy, and treatment is often curative.

Chemotherapy is routinely offered to most people as the outcome is better than with surgery alone (except for stage IA, grade 1 immature teratoma, and stage IA and IB dysgerminoma where the outcome is excellent with just surgery). For children, chemotherapy may be recommended less frequently for certain stages and subtypes but this remains controversial.

The most commonly prescribed chemotherapy is bleomycin, etoposide and cisplatin (BEP). It is also used in testicular cancer. Sometimes carboplatin is used instead of cisplatin in younger people -this is being evaluated in AGCT1531. Usually, three-four cycles are prescribed.

Special considerations

Breastfeeding is not recommended during chemotherapy and pregnancy must be avoided during, and for up to, two years after treatment. Sexually active people should ask their doctor or nurse about effective contraception before starting treatment.

Immunotherapy

Tumours with microsatellite instability and a high mutational burden may also respond to immunotherapy such as pembrolizumab. This is not funded in New Zealand.

Radiotherapy

In extremely rare circumstances, radiotherapy may be considered for a patient with dysgerminoma who cannot have chemotherapy. Other MOGCTs are not sensitive to radiotherapy.

Monitoring and side effects while on treatment

During treatment, frequent blood tests and imaging will take place. In addition, side effects will be closely monitored and side effects from treatment vary from person to person. It is important to discuss any side effects you are experiencing with your cancer care team.

Special considerations

Lung problems can develop after BEP chemotherapy with high doses of oxygen (such as during a general anaesthetic, oxygen therapy and scuba diving). Some people choose to wear a medical alert. If you need surgery in the future tell the doctor you have had bleomycin. If you want to go scuba diving, you’ll need additional tests after a year to check whether it is safe for you.

For further information on side effects visit:

Macmillan – BEP
Cancer Research UK – BEP 

Follow-up after chemotherapy

Recurrence is uncommon – most recurrences happen within two years (75% in the first year). Because of this, people will be monitored very closely for the first two years with a combination of specialist visits, blood tests (for tumour markers) and imaging (chest x-ray and ultrasound, or CT or MRI or PET).

Effect of treatment on fertility

When fertility-sparing surgery is used, most people will regain their periods and fertility within a year of completing chemotherapy. Three percent of people experience premature menopause.

If someone experiences menopause from surgery or chemotherapy and wants to have children, other pathways may be possible. These include egg donation, surrogacy and adoption. In New Zealand, government funding may be available for fertility treatment if IVF or an egg donor and/or surrogate is needed due to cancer-related infertility.

Survival rates

Survival rates correlated with the stage (spread) at diagnosis and levels of tumour markers hCG and AFP.

Five-year survival rates for ovarian germ cell cancers are:

  •  Stage 1A – 1C: 100%
  •  Stage 2: 85%
  •  Stage 3: 79%
  •  Stage 4: 71%

Approximately 5 in 6 people with MOGCT will experience a cure.

Navigating a new normal

Side effects from treatment and the mental challenge of cancer and its effects can impact life during and after treatment. The end of treatment doesn’t mean that life is back to normal.

Everyone’s coping mechanism is different. It is really helpful to have a supportive team around you at home and to keep a check on your physical and emotional care needs. Be open with your GP and cancer care team about any struggles you may be having.

Online support groups such as Facebook groups can also be useful to learn what has helped other people living with germ cell cancer. Many people find a psychologist helpful for processing and mental resilience. Mindfulness and yoga can also be helpful for mental health.

Recurrence

Even if MOGCT recurs, treatment can sometimes be curative. Treatment for recurrence usually consists of further surgery and/or chemotherapy.

Clinical trials

A clinical trial is research involving human participants. Clinical trials can offer new or different treatment options for people with ovarian cancer and help doctors make better decisions for people in the future. Medications in a clinical trial are provided at no cost to participants.

There may be unknown benefits and unique risks to participating in a clinical trial. An oncologist or gynae-oncologist can advise if there are any clinical trials for which people may be eligible.

As of January 2022, there are two clinical trials specifically for malignant ovarian germ cell tumours currently recruiting in New Zealand.

The first is an international study called Active Surveillance, Bleomycin, Carboplatin, Etoposide, or Cisplatin in Treating Pediatric and Adult Patients With Germ Cell Tumours (NCT03067181/AGCT1531). It is a Phase III clinical trial comparing outcomes with different dosing regimens and combinations of chemotherapy; and surveillance (in specific low-risk patients); in newly diagnosed Germ Cell Tumours. It is available in Auckland and Christchurch.

The second is an international trial called A Randomised Phase 3 Trial of Accelerated Versus Standard BEP Chemotherapy for Patients With Intermediate and Poor-risk Metastatic Germ Cell Tumours (ANZUP P3BEP). It is investigating outcomes with different dosing regimens. This study is for people 11 to 45 years old with newly diagnosed germ cell tumours that are considered intermediate or poor risk. Prior chemotherapy is accepted in limited circumstances. It is available in Auckland, Palmerston North, Christchurch and Dunedin.

Content has been reviewed by gynaecological, medical and paediatric oncologists in New Zealand. Information is provided for general use and not a substitute for professional medical advice.

Find out more information about ovarian cancer.

Note: this content has been reviewed by a gynaecological cancer specialist in New Zealand. Information is provided for general use and should not be a substitute for professional medical advice.

Last reviewed: 16 January 2024