Pathology Report Question

[Eleven11]

I've been told that my 15 year old daughter has an immature teratoma - grade 2.
Though no surgical staging was done, there was no gross evidence of implants, peritoneal washings were clear... Post Surgery Diagnosis:  Beign right Mature Teratoma of the ovary.
Post-Op, there were some questions about some of the frozen sections of the cyst, so it was sent off to a separate pathology lab.

In looking at the pathology report, I have some questions about terminologies:

Final Microscopic Diagnosis:
Right Ovary, Cystectomy:
Teratoma with Mature and Immature components.
The Immature components are grade 2 (based on the extent of the immature foci).

In the comment section it states:
The immature neuroepithelial foci seen on several slides, total greater than a 40x microscopic field.  Oncologic consultation is recommended.

Based on my research, Grading is of extreme importance in determining a course of action.
My question is:  Does that comment jive with the final assessment of: Grade 2?
Another question:  Would the Oncologist review the pathology, and verify the grade himself, or would I have to request another pathology report be completed?
Another question (sorry):  How long can a "frozen section" be kept for a pathological review? (ie: when is it too late?)

We have been to a Gyn/Oncologist, and he said in older patients, he would recomend chemo treatment right away (3 rounds of BEP).... After consulting with a pediatric oncologist, they have determined that we will take a "wait and see" approach.  We have monthly appointments set up to do bloodwork, and there will be sonograms and CT scans at regular intervals as well.

[Annekathryn Goodman, M.D.]

thank you
that is a nice reference
take care

[Eleven11]

Thank you for taking the time to respond... I really appreciate it.
Though no Surgical staging was done, washings from surgery tested negative.
Gross examination occurred by a regular gyno, not an oncologys.
No biopsies were taken.

Our visit to the Gyn/Onc included:
Bloodwork - including 7 different marker checks.
Cat Scan of chest and abdomen
Followup call to the Gynocologyst that performed the surgery.

The things that I've been reading are a little more optimistic than the percentages that you quote (albeit from 1976)... especially for younger patients... I hope that's the case.

I'm currently "hanging my hat" on the following study performed in 1999...
http://jco.ascopubs.org/cgi/content/full/17/7/2137

I'm glad to hear that the Oncologysts probably reviewed the slides themselves before determining their "course of action".  I will specifically ask that questions on my return visit in a couple of days.

[Annekathryn Goodman, M.D.]

Hi There

Immature teratoma is a type of germ cell malignancy. That is - it is a cancer that comes from the egg cell in the ovary. While mature teratomas or dermoid cysts are the most common (benign) tumor of the ovary. Immature teratomas are among the rarest type . They make up about less than 1 % of ovarian teratomas.

These malignancies are graded 1 to 3.
grade 1 : mature teratoma with only rare immature cells
grade 2 : moderate quantities of immature cells
grade 3 large quantities of immature cells

As a general rule, staging surgery is important. Immature teratomas spread directly into the abdomen along the lining of the peritoneum.

Prognosis is correlated with grade and spread (and the grade of implants when there is spread)

Here is a table from an old paper that looks at deaths from immature teratoma by grade (Cancer 37:2356 1976)

Grade                               Tumor deaths (%)
1                                           4/22 (18%)
2                                          9/24 (37%)
3                                           7/10 (70%)

Based on this data, the recommendation has been to give BEP (bleomycin, etoposide, cisplatin) chemotherapy for 3 cycles to all people with grade 2 and 3 tumors

I know that looks pretty spooky.  Since the 1970s, we have tried to comprehensively surgically stage girls and women with germ cell tumors.  For  31 girls who had immature teratomas tumors completely confined to the ovary (stage 1) and completely resected, the 4 year survival was 97%. Based on this report, the recommendation has been to not give chemo to girls with completely resected tumors regardless of grade. (Am J Obstet Gynecol 181:353 1999)


So ultimately it is a question of whether there is any other sign of immature teratoma becomes important.

If she has seen a gyn oncologist, I fully defer to their judgment. There is nothing better than seeing the patient, reviewing the slides and surgery directly to give the best opinion.  I am sure that the gyn oncologist has personally looked at the slides with their pathologist.  One question to ask him is: is there a role for a laparoscopy to reevaluate the abdomen and take washings and biopsies?

best wishes