Bleomycin 15 units/m2/week × 5; then on day 1 of course 4 Etoposide 100 mg/m2/day × 5 days every 3 weeks Cisplatin 20 mg/m2/day × 5 days, or 100 mg/m2/day × 1 day
Vinblastine 0.15 mg/kg days 1 and 2 every 3 weeks Bleomycin 15 units/m2/week × 5; then on day 1 of course 4 Cisplatin 100 mg/m2 on day 1 every 3 weeks
Vincristine 1–1.5 mg/m2 on day 1 every 4 weeks Actinomycin D 0.5 mg/day × 5 days every 4 weeks Cyclophosphamide 150 mg/m2/day × 5 days every 4 weeks a All doses given intravenously.
with six cycles of VAC (vincristine, actinomycin D, and cyclophosphamide). In the second trial, patients received three cycles of BEP initially, followed by consolidation with VAC, which was later discontinued in patients with dysgerminomas (358). The VAC consolidation after BEP is no longer used. A total of 20 evaluable patients with stages III and IV dysgerminoma were treated in these two protocols, and 19 were alive and free of disease after 6 to 68 months (median = 26 months). Fourteen of these patients had a second-look laparotomy, and all findings were negative. Another study at M. D. Anderson Cancer Center used BEP in 14 patients with residual disease, and all patients were free of disease during long-term follow-up (361). These results demonstrate that patients with advanced-stage, incompletely resected dysgerminoma have an excellent prognosis when treated with cisplatin-based combination chemotherapy. The standard regimen is three to four cycles of BEP, depending on assigned risk based on the data from testicular cancers (372,373).
About 75% of recurrences occur within the first year after initial treatment, the most common sites being the peritoneal cavity and the retroperitoneal lymph nodes (2,335,336). These patients should be treated with chemotherapy, although radiation may be appropriate in selected patients. Patients with recurrent disease who had no therapy other than surgery should be treated with chemotherapy. If prior chemotherapy with BEP was given, there are a number of second-line options including TIP (paclitaxel, iphosphamide, cisplatin) or VIP (vinblastine, iphosphamide, cisplatin) (Table 35.7), and consideration should be given to the use of high-dose chemotherapy in selected patients. Patients with recurrent disease should be managed in specialized centers. Radiation therapy is effective for this disease, with the major disadvantage being loss of fertility if pelvic and abdominal irradiation is required.
Because dysgerminomas tend to occur in young patients, they may coexist with pregnancy.
When a stage IA cancer is found, the tumor can be removed intact and the pregnancy continued. For patients with more advanced disease, continuation of the pregnancy depends on the gestational age of the fetus. Chemotherapy can be given in the second and third trimesters in the same dosages as given for the nonpregnant patient without apparent detriment to the fetus (368).
For patients whose initial disease is stage Ia (i.e., a unilateral encapsulated dysgerminoma), unilateral oophorectomy alone results in a 5-year disease-free survival rate of greater than 95% (355). The features associated with a higher tendency to recur, include lesions larger than
Table 37.7 POMB-ACE Chemotherapy for Germ Cell Tumors of the Ovary