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ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 4  |  Page : 612-614
 

A review of squamous cell carcinoma arising in mature cystic teratoma of the ovary


Department of Gynaecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India

Date of Web Publication21-Apr-2017

Correspondence Address:
N Abhilasha
Department of Gynaecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.204763

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 » Abstract 

INTRODUCTION: Germ cell tumors account for 20-25% of ovarian neoplasms. Mature cystic teratoma (MCT) is the most common ovarian germ cell tumor. Malignancy in MCT is seen in 1-2% of the cases. Squamous cell carcinoma (SCC) accounts for 80% of the cases and carries a poor prognosis. AIM: To study the clinicopathological factors, management protocols and its outcome. MATERIALS AND METHODS: Case records reviewed from August 2006 to August 2011 at our institute identified 10 women with SCC in ovarian MCT. Staging was done according to FIGO 2009 guidelines. Primary surgery followed by adjuvant treatment with platinum based chemotherapy was given. RESULTS: Median age was 53.5 years. Six out of 10 patients were postmenopausal and aged above 50 years. Abdominal pain and abdominal mass were the most common presenting symptoms. According to FIGO: Two in stage 1, five in stage 2, two in stage 3 and one in stage 4. Among six optimally cytoreduced patients, five (83%) had no evidence of disease with a median follow up of 10 months. Whereas all four (100%) suboptimally cytoreduced patients had progressive disease within 3 to 4 months of primary surgery despite chemotherapy. CONCLUSION: Squamous cell carcinoma in MCT of ovary is a rarity. It carries a poor prognosis, especially in advanced stages and suboptimally cytoreduced patients. Platinum with or without taxane based chemotherapy may be useful as adjuvant treatment. However, further studies and standardization of treatment protocols are required for any recommendations.


Keywords: Mature cystic teratoma, ovary, squamous cell carcinoma


How to cite this article:
Abhilasha N, Bafna U D, Pallavi V R, Rathod P S, Krishnappa S. A review of squamous cell carcinoma arising in mature cystic teratoma of the ovary. Indian J Cancer 2016;53:612-4

How to cite this URL:
Abhilasha N, Bafna U D, Pallavi V R, Rathod P S, Krishnappa S. A review of squamous cell carcinoma arising in mature cystic teratoma of the ovary. Indian J Cancer [serial online] 2016 [cited 2019 Dec 12];53:612-4. Available from: http://www.indianjcancer.com/text.asp?2016/53/4/612/204763



 » Introduction Top


Germ cell tumors account for 20-25% of all ovarian neoplasms and mature cystic teratoma (MCT) is the most common ovarian germ cell tumor. MCT has a wide age distribution (2-80 yrs), but most commonly seen in reproductive years and only 5% in postmenopausal women.[1] Malignancy in a MCT is uncommon, reported to occur in 1-2% of cases and mostly in postmenopausal women (mean age 51-62 yrs).[1],[2],[3],[4] Any component of a mature teratoma can undergo malignant transformation. Squamous cell carcinoma (SCC) is the most common malignancy accounting for 80% of the cases carrying a poor prognosis.[2],[5] Diagnosis is rarely made preoperatively, though certain imaging features [6],[7] and elevation of SCC Antigen tumor marker [4],[8],[9] have been suggested to be useful for diagnosis. Because of its rare occurrence, there is no consensus regarding the standard line of management. We report our experience with 10 cases of SCC in ovarian MCT, their clinicopathological factors, management protocols and outcome.


 » Materials and Methods Top


The case records from August 2006 to August 2011 were reviewed at our institute and 10 women with malignancy in ovarian mature cystic teratoma were identified and all 10 of them were squamous cell carcinoma. Out of the 10 patients, primary surgery was done at our institute in 4 cases. Six patients were referred after primary surgery to our institute, out of which 2 were again reoperated at our institute. Diagnosis in these referred patients was based on postoperative histopathological reports and the slides were reviewed at our institute. Primary surgery at our institute included total hysterectomy, bilateral salpingo oophorectomy, omentectomy with or without pelvic and para aortic lymph node dissection, with aggressive cytoreduction in advanced cases. In all the four cases operated at our institute, diagnosis was made by intraoperative frozen section analysis. Staging was done according to FIGO 2009 guidelines. Post operative adjuvant treatment with platinum based chemotherapy (CT) was given. Follow up was done with clinical examination and imaging with either ultrasound or CT scan.

Prognostic factors and outcome were analysed using the following non parametric statistical tests, Mann-Whitney test and Kruskal-Wallis test.


 » Results Top


Patient characteristics are summarized in [Table 1]. Median age of the patients was 53.5 years (Range 40-70 years). Six out of 10 patients (60%) were postmenopausal and aged above 50 years. Abdominal pain (60%) and abdominal mass (30%) were the most common presenting symptoms.
Table 1: Clinicopathologic characteristics, treatment and outcome of 10 cases

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The FIGO staging was: Two in stage 1, five in stage 2, two in stage 3 and one in stage 4. To achieve optimal cytoreduction, four patients underwent extensive surgery with small bowel resection, partial bladder cystectomy and bladder peritonectomy [Table 2].
Table 2: Outcome of the disease in relation to stage of the disease and optimality of surgery

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Among six optimally cytoreduced patients, five (83%) had no evidence of disease with a median follow up of 10 months and one of these patients is lost to follow up. Whereas all four (100%) suboptimally cytoreduced patients had progressive disease within 3 to 4 months of primary surgery despite chemotherapy and these patients were lost to follow up after being considered for palliation only and hence period of survival could not be derived and only outcome analysis has been done.

One stage 1A patient did not receive any adjuvant treatment and rest all nine patients received platinum based chemotherapy, single agent, or combined with paclitaxel or cyclophosphamide. Two patients were given neoadjuvant chemotherapy, one with stage 3C before taking up for secondary debulking surgery but, without response and one with stage 4 with partial response. None of the patients with suboptimal surgery responded well to chemotherapy.


 » Discussion Top


Age had no relation with stage or grade or outcome of the disease in our study. However, Kikkawa et al.[2] and Sakuma et al.[10] showed a survival benefit in younger patients in contrast to Tseng et al.,[3] who showed that age did not correlate with survival. Grade showed variable relations to outcome of the disease in previous studies, whereas our study did not show any relation with outcome of the disease. The stage and optimal cytoreduction correlated with outcome in our study as in many of the previous studies.[2], 3, [10],[11],[12] Tseng et al.[3] showed a 2 year disease free survival of 100%-stage I and II, 30% in stage III and 0% in stage IV. Kashimura et al.[13] showed a 2 year survival after a review of 95 cases in past literature as 67% in stage I, 45% in stage II, 12% in stage II and 0% in stage IV with a overall 5 year survival of 28%. Second surgery is recommended in cases of incomplete staging and suboptimal surgery for proper management,[14] as evidenced in two of our patients with improved survival. Role of conservative surgery in stage 1A has been demonstrated,[2],[3] but none of our patients wished to conserve fertility, hence was not adopted. Past literature has shown variable results in relation to usefulness of adjuvant radiotherapy (RT) and CT.[3],[13],[15],[16]

Hackenthal et al.[17] showed no benefit of RT. Platinum and taxane based chemotherapy is used as first line therapy as it is generally accepted for epithelial ovarian cancers, ovarian SCC and SCC in cervix [18] and seems to be beneficial in SCC in teratomas also.[3],[10],[19] After complete surgical staging, stage 1A patients may be followed up without adjuvant treatment.[3] In our study, one of the patient in stage 1A has a disease free survival since 26 months after complete staging and without any adjuvant treatment. Neoadjuvant chemotherapy probably has no role as seen in two of our patients who had partial to no response. Complete surgical staging and optimal cytoreduction with adjuvant chemotherapy seems to have a good outcome with longer survival in early stage disease. Suboptimal surgery with residual disease and advanced stage have a worse prognosis even with adjuvant chemotherapy in contrast to epithelial ovarian tumors However, further studies and standardization of treatment protocols are required for any recommendations. In our setup, the number of referred cases who had suboptimal surgery was high and outcome in those patients was poor. Probably these patients would have fared better if primary surgery was optimal and completely staged or if these patients were referred earlier. In conclusion, squamous cell carcinoma is the most common malignancy in mature cystic teratoma of ovary, though malignancy is rare in occurrence. It carries a very poor prognosis especially in advanced stages and in suboptimally cytoreduced patients. Platinum with or without taxane based chemotherapy may be useful as adjuvant treatment.

 
 » References Top

1.
Nogales F, Talerman A, Kubik-Huch RA, Tavassoli FA, Devouassoux-Shisheboran M. Germ cell tumours. In: Tavassoli FA, Devilee P, editors. World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Breast and Female Genital Organs. Lyon: IARC Press; 2003.p. 163-70.  Back to cited text no. 1
    
2.
Kikkawa F, Ishikawa H, Tamakoshi K, Nawa A, Suganuma N, Tomada Y. Squamous cell carcinoma arising from mature cystic teratoma of the ovary: A clinicopathological analysis. Obstet Gynecol 1997;89:1017-22.  Back to cited text no. 2
    
3.
Tseng CJ, Chou HH, Huang KG, Chang TC, Liang CC, Lai CH, et al. Squamous cell carcinoma arising in mature cystic teratoma of the ovary. Gynecol Oncol 1996;63:364-70.  Back to cited text no. 3
    
4.
Suzuki M, Kobayashi H, Sekiguchi I, Konnai K, Terao T, Sato I. Clinical evaluation of squamous cell carcinoma antigen in squamous cell carcinoma arising in mature cystic teratoma of the ovary. Oncology 1995;52:287-90.  Back to cited text no. 4
    
5.
Amerigo J, Nogales FF, Fernandez-Sanz J, Olivia H, Velasco A. Squamous cell neoplasms arising from ovarian benign cystic teratoma. Gynecol Oncol 1979;8:277-83.  Back to cited text no. 5
    
6.
Emoto M, Obama H, Horiuchi S, Miyakawa T, Kawarabayashi T. Transvaginal color Doppler ultrasonic characterization of benign and malignant ovarian cystic teratomas and comparison with serum squamous cell carcinoma antigen. Cancer 2000;88:2298-304.  Back to cited text no. 6
    
7.
Kido A, Togashi K, Konishi I, Kataoka ML, Koyama T, Ueda H, et al. Dermoid cysts of the ovary with malignant transformation: MR appearance. AJR Am J Roentgenol 1999;172:445-9.  Back to cited text no. 7
    
8.
Miyazaki K, Tokuaga T, Katabuchi H, Ohba T, Tashiro H, Okamura H. Clinical usefulness of serum squamous cell carcinoma antigen for early detection of squamous cell carcinoma arising in mature cystic teratoma of the ovary. Obstet Gynecol 1991;78:562-5.  Back to cited text no. 8
    
9.
Kimura T, Inoue M, Miyake A, Tanizawa O, Oka Y, Amemiya K, et al. The use of serum TA-4 in monitoring patients with malignant transformation of ovarian mature cystic teratoma. Cancer 1989;64:480-3.  Back to cited text no. 9
    
10.
Sakuma M, Otsuki T, Yoshinaga K, Utsunomiya H, Nagase S, Takano T, et al. Malignant transformation arising from mature cystic teratoma of the ovary: A retrospective study of 20 cases. Int J Gynecol Cancer 2010;20:766-71.  Back to cited text no. 10
    
11.
Rose PG, Tak WK, Reale FR. Squamous cell carcinoma arising in a mature cystic teratoma with metastasis to the paraaortic nodes. Gynecol Oncol 1993;50:131-3.  Back to cited text no. 11
    
12.
Kurtz JE, Jaeck D, Maloisel F, Jung GM, Chenard MP, Dufour P. Combined modality treatment for malignant transformation of a benign ovarian teratoma. Gynecol Oncol 1999;73:319-21.  Back to cited text no. 12
    
13.
Kashimura M, Shinohara M, Hirakawa T, Kamura T, Matsukuma K. Clinicopathologic study of squamous cell carcinoma of the ovary. Gynecol Oncol 1989;34:75-9.  Back to cited text no. 13
    
14.
Tangjitgamol S, Manusirivithaya S, Sheanakul C, Leelahakorn S, Thawaramara T, Jesadapatarakul S. Squamous cell carcinoma arising from dermoid cyst: Case reports and review of literature. Int J Gynecol Cancer 2003;13:558-63.  Back to cited text no. 14
    
15.
Krumerman MS, Chung A. Squamous carcinoma arising in benign cystic teratoma of the ovary: A report of four cases and review of literature. Cancer 1977;39:1237-42.  Back to cited text no. 15
    
16.
Ribeiro G, Hughesdon P, Wiltshaw E. Squamous carcinoma arising in dermoid cysts and associated with hypercalcemia: A clinicopathologic study of six cases. Gynecol Oncol 1988;29:222-30.  Back to cited text no. 16
    
17.
Hackethal A, Brueggmann D, Bohlmann MK, Frank FE, Tinneberg HR, Munstedt K. Squamous cell carcinoma in mature cystic teratoma of the ovary: Systematic review and analysis of published data. Lancet Oncol 2008;9:1173-80.  Back to cited text no. 17
    
18.
McGuire WP, Blessing JA, Moore D, Lentz SS, Photopulos G. Paclitaxel has moderate activity in squamous cervix cancer: A Gynecologic Oncology Group study. J Clin Oncol 1996;14:792-5.  Back to cited text no. 18
    
19.
Ohtani K, Sakamoto H, Masaoka N, Shimada K, Kanaeda T, Kurihara M, et al. A case of rapidly growing ovarian squamous cell carcinoma successfully controlled by weekly paclitaxel-carboplatin administration. Gynecol Oncol 2000;79:515-8.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2]

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