Many patients with a dysgerminoma will have a tumor that is apparently confined to one ovary and will be referred after unilateral salpingo-oophorectomy without surgical staging. The options for such patients are (i) repeat laparotomy for surgical staging, (ii) regular pelvic and abdominal CT scans, or (iii) adjuvant chemotherapy. Because these are rapidly growing tumors, the preference is to perform regular surveillance. Tumor markers (LDH, AFP, and β-hCG) should be monitored in case occult mixed germ cell elements are present.
Radiation Therapy Dysgerminomas are very sensitive to radiation therapy, and doses of 2,500 to 3,500 cGy may be curative, even for gross metastatic disease. Loss of fertility is a problem with radiation therapy, and radiation is rarely used as first-line treatment ().
Chemotherapy There is very good evidence to demonstrate the effectiveness of platinum-based chemotherapy, which is regarded as the treatment of choice (356–367). The obvious advantage is the preservation of fertility (368).
The most frequently used chemotherapeutic regimen for germ cell tumors is BEP (bleomycin, etoposide, and cisplatin), EP or EC (etoposide and carboplatin) (356–373) (Table 37.6).
The GOG studied three cycles of the EC regimen, consisting of etoposide (120 mg/m2 intravenously on days 1, 2, and 3 every 4 weeks) and carboplatin (400 mg/m2 intravenously on day 1 every 4 weeks) for patients with completely resected ovarian dysgerminoma, stage IB, IC, II, or III (364). The results showed a sustained disease-free remission rate of 100%.
For patients with advanced, incompletely resected germ cell tumors, the GOG studied cisplatinbased chemotherapy in two consecutive protocols (357,358). In the first study, patients received four cycles of vinblastine (12 mg/m2 every 3 weeks), bleomycin (20 units/m2 intravenously every week for 12 weeks), and cisplatin (20 mg/m2 per day intravenously for 5 days every 3 weeks). Patients with persistent or progressive disease at second-look laparotomy were treated
CT scan or ultrasound of pelvis and abdomen q 2 mos × first 6 mos q 3 mos × next 6 mos q 6 mos × second yr Dysgerminoma Apparently confined to ovary(s)  Unilateral   oophorectomy  Inspect contralateral   ovary Surgical staging performed No metastatic disease Documented occult metastatic disease Small focus in contralateral ovary ?Second-look Metastatic disease  Unilateral salpingo  oophorectomy  Remove readily   resectable metastases BEP × 4–6 cycles BEP × 4 cycles BEP × 4 cycles BEP × 4 cycles Surgical staging not performed Resect focus with ovarian preservation If cytologic or histologic evidence of relapse ?Second-look  Observation  Physical examination   every 2 months for first 12 months  CT scan at 6 and 12 months Figure 37.20 Management of dysgerminoma of the ovary. BEP = bleomycin, etoposide, and cisplatin; CT = computed tomo-gram. (From Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:515, with permission. 1398
Table 37.6 Combination Chemotherapy for Germ Cell Tumors of the Ovary