Effect Of Lymphadenectomy On Prognostic And Fertility Outcomes In Patients With Clinically Early-stage Malignant Ovarian Germ Cell Tumors

Objective:Malignant ovarian germ cell tumors(MOGCT),as a rare type of the ovarian malignancies,commonly present in children as well as young women and have an excellent prognosis when treated by surgery followed by platinum-based chemotherapy.Based on the current National Comprehensive Cancer Network(NCCN)clinical practice guidelines,systematic lymphadenectomy(LND)can be omitted for child and adolescent patients with early-stage MOGCT.However the clinical role of LND for adult patients with early-stage MOGCT remains ambiguous.The purpose of this retrospective multicenter study was to determine the effect of systematic LND on prognostic and fertility outcomes in adult patients with clinically stage I MOGCT who received fertility-sparing surgery treatment and to investigate the clinicopathologic factors associated with fertility outcome.Methods:This study included adult MOGCT patients who underwent fertility-sparing surgery and were deemed to have disease clinically confined to the ovary at time of the surgery(stage I)between January 2005 to June 2020 from four major medical institutions in China.All patients were classified into two groups:LND group(patients who underwent systematic pelvic and/or para-aortic lymphadenectomy)and no-LND group(patients who did not undergo lymphadenectomy).Propensity score matching(PSM)algorithm was adopted to reduce the bias resulting from the differences of clinical characteristics between the two groups.The Chi-square test and the Kaplan-Meier analysis was used to compare the fertility outcome and the disease-free survival(DFS),respectively.The univariate logistic regression analysis was performed to evaluate the clinicopathologic factors associated with fertility outcome.Results:In the study,a total of 168 adult patients with clinically stage I MOGCT who received FSS treatment were enrolled.The median age of 26 years(range,18-44 years).There were 92(54.8%)patients in the LND group and 76(45.2%)patients in the no-LND group.Only 2(2.6%)patients had lymph nodal metastasis in the LND group upstaged to stage IIIA.Regarding the prognostic outcome,only 3(0.18%)patients had recurrence after a median follow-up of 65 months and no patient died after surgery.In the before and after PSM cohort,the 5-year DFS for patients in the LND group and no-LND group were 97.6%versus 97.9%and 92.8%versus 95.0%,respectively.There was no significant difference in DFS between the LND and no-LND groups in the before and after PSM cohorts(P>0.05).As for the fertility outcome,a total of 60 patients attempted pregnancy,among whom 49(81.7%)patients succeeded to conceive and 40(66.7%)patients delivered successfully.In the before PSM cohort,patients in the no-LND group showed a better pregnancy rate than the LND group(93.3%versus 70.0%,P<0.05).However,in the after PSM cohort,there was no significant difference of pregnancy rates between no-LND and LND groups(92.9%versus 76.9%,P>0.05).Univariate logistic regression analysis showed that age ≤25 years(OR 3.50,95%CI 1.11-11.01,P<0.05)was an independent factors for better live birth rate.Conclusions:Lymphadenectomy showed no significant effect on both prognostic and fertility outcomes for adult patients with clinically early-stage(stage I)MOGCT who underwent FSS in our study.Meanwhile,age≤25 years were associated with favorable fertility outcome for early-stage MOGCT patients after FSS treatment.Our study suggests that abandonment of LND seems to be a preferred choice for clinically stage I adult MOGCT patients with FSS treatment.