Adjuvant Therapy for Stromal Cell Tumor of the Ovary?
A 54-year-old woman with ovarian cancer underwent TAH/BSO. Pathology showed stromal cell carcinoma, stage I. Her CA125 after surgery is 85; before surgery, it was 200. Is adjuvant chemotherapy warranted?
The majority of stromal cell tumors of the ovary are either granulosa cell or theca cell, and account for less than 3% of ovarian neoplasms. Given that theca cell tumors are benign, we will focus on adult granulosa cell tumors. (There is a juvenile variant associated with precocious puberty, which will not be discussed in this context).
Stromal tumors often produce estrogen and progesterone, and symptoms associated with excess female hormone secretion lead to the majority (60%) of patients presenting with stage I disease. Inhibin, which is secreted by granulosa cells and inhibits FSH, is a much more reliable marker than is estradiol or CA125, although the required assay is still not widely available.
The natural history of these tumors is one of indolent regrowth and late recurrences, but it is likely that the survival of patients with true stage IA disease approaches 100%. Even for more advanced stages of disease, 10-year survival is greater than 50%. When disease relapses, it is usually in the form of an intraabdominal lesion, and is generally able to be surgically resected. It is not uncommon for patients to relapse many times in their lifetimes and to undergo multiple operations over many years, with long periods of good health in between.
Because of this, chemotherapy is generally reserved for unresectable, symptomatic recurrences. Many regimens have been tried, virtually all of which are platinum-based, such as cisplatin/doxorubicin/cyclophosphamide. Overall, they have demonstrated high response rates and effective palliation of symptoms, but rarely long duration of responses. Standard treatment today consists of the same regimens used in the treatment of germ cell tumors, such as combinations of cisplatin, bleomycin, and etoposide.
These and similar regimens have been used in early-stage granulosa cell tumors, but there is no evidence to support their use as adjuvant treatment in this stage of disease. The excellent prognosis for these patients, even with relapsed disease, does not argue strongly for the use of potentially toxic chemotherapy in the adjuvant situation for early-stage tumors. Unfortunately, due to the rarity of this disease, all treatment guidelines are based on descriptive data.
To conclude, surgery almost always cures true stage I disease and provides effective palliation and long symptom-free survival in more advanced stages. Chemotherapy is best reserved for palliation of unresectable tumors.
A 54-year-old woman with ovarian cancer underwent TAH/BSO. Pathology showed stromal cell carcinoma, stage I. Her CA125 after surgery is 85; before surgery, it was 200. Is adjuvant chemotherapy warranted?
The majority of stromal cell tumors of the ovary are either granulosa cell or theca cell, and account for less than 3% of ovarian neoplasms. Given that theca cell tumors are benign, we will focus on adult granulosa cell tumors. (There is a juvenile variant associated with precocious puberty, which will not be discussed in this context).
Stromal tumors often produce estrogen and progesterone, and symptoms associated with excess female hormone secretion lead to the majority (60%) of patients presenting with stage I disease. Inhibin, which is secreted by granulosa cells and inhibits FSH, is a much more reliable marker than is estradiol or CA125, although the required assay is still not widely available.
The natural history of these tumors is one of indolent regrowth and late recurrences, but it is likely that the survival of patients with true stage IA disease approaches 100%. Even for more advanced stages of disease, 10-year survival is greater than 50%. When disease relapses, it is usually in the form of an intraabdominal lesion, and is generally able to be surgically resected. It is not uncommon for patients to relapse many times in their lifetimes and to undergo multiple operations over many years, with long periods of good health in between.
Because of this, chemotherapy is generally reserved for unresectable, symptomatic recurrences. Many regimens have been tried, virtually all of which are platinum-based, such as cisplatin/doxorubicin/cyclophosphamide. Overall, they have demonstrated high response rates and effective palliation of symptoms, but rarely long duration of responses. Standard treatment today consists of the same regimens used in the treatment of germ cell tumors, such as combinations of cisplatin, bleomycin, and etoposide.
These and similar regimens have been used in early-stage granulosa cell tumors, but there is no evidence to support their use as adjuvant treatment in this stage of disease. The excellent prognosis for these patients, even with relapsed disease, does not argue strongly for the use of potentially toxic chemotherapy in the adjuvant situation for early-stage tumors. Unfortunately, due to the rarity of this disease, all treatment guidelines are based on descriptive data.
To conclude, surgery almost always cures true stage I disease and provides effective palliation and long symptom-free survival in more advanced stages. Chemotherapy is best reserved for palliation of unresectable tumors.