Primary Treatment for Immature Teratoma
Surgery with complete resection is the primary treatment for immature teratoma, with the need for adjuvant chemotherapy determined by stage and grade. 1
Surgical Management
Initial Surgical Approach
Unilateral salpingo-oophorectomy with preservation of the contralateral ovary and uterus is the standard fertility-sparing surgery for patients with immature teratoma, even in advanced disease due to high chemosensitivity. 1
Comprehensive surgical staging includes infracolic omentectomy, biopsy of diaphragmatic peritoneum, paracolic gutters, pelvic peritoneum, and peritoneal washings. 1
Lymph node dissection should only be performed if there is evidence of nodal abnormality, as routine lymphadenectomy is not required. 1
In postmenopausal women or those with bilateral ovarian involvement, abdominal hysterectomy with bilateral salpingo-oophorectomy and careful surgical staging should be performed. 1
The surgical approach can be open or laparoscopic in selected cases, avoiding tumor rupture during surgery. 1
Adjuvant Chemotherapy Decision Algorithm
Stage IA Grade 1 Immature Teratoma
No adjuvant chemotherapy is required after adequate surgical staging. 1
Observation with surveillance is the recommended approach. 1
Stage IA Grade 2-3 and Stage IB-IC Immature Teratoma
Adjuvant chemotherapy is recommended, though active surveillance is an acceptable option. 1
The decision remains controversial, as some data indicate all grades can be managed with close surveillance after fertility-sparing surgery, reserving chemotherapy for documented recurrence. 1
This surveillance approach is not universally accepted, and the benefit of avoiding chemotherapy versus the risk of relapse must be discussed with the patient. 1
Stage II-IV Immature Teratoma
Postoperative chemotherapy is mandatory. 1
Debulking surgery should remove as much gross tumor as possible without major extensive procedures due to high chemosensitivity. 1
Chemotherapy Regimen
Standard Regimen
BEP (bleomycin, etoposide, cisplatin) 5-day regimen is the most widely used chemotherapy. 1
Three cycles of BEP for completely resected disease; four cycles for macroscopic residual disease (bleomycin should be omitted after the third cycle to reduce lung toxicity risk). 1
The 4-cycle BEP regimen is the standard (category 2A), though 3-week BEP for 3 cycles may be considered in low-risk or stage I disease (category 2B). 1
Pulmonary function tests are recommended if considering bleomycin use. 1
Pediatric Considerations
In children and adolescents with early-stage germ cell tumors, comprehensive staging may be omitted. 1
Surgical excision is safe and effective treatment for 80-100% of children with immature teratoma. 2
Complete surgical resection without adjuvant chemotherapy is effective for children with completely resected immature teratomas, regardless of grade, if there are no foci of yolk sac tumor. 3, 2
If foci of yolk sac tumor are present on pathology review, chemotherapy is required as this determines prognosis. 4, 2
Critical Pitfalls to Avoid
Expert pathology review should always be obtained to confirm diagnosis and exclude foci of yolk sac tumor or other malignant elements, as this fundamentally changes management. 1, 4, 2
Incomplete surgical staging can lead to understaging and inadequate treatment planning. 5
The completeness of primary tumor resection is the most powerful prognostic parameter, superior to tumor markers or primary site. 3
Any resectable residual disease should be removed, particularly in patients with normal serum markers, to avoid growing teratoma syndrome. 1
Surveillance After Treatment
Regular clinical review with physical examination, radiological imaging including abdomen-pelvic ultrasound, and monitoring of tumor markers (AFP, β-hCG if initially elevated) should be performed over 10 years with gradually increasing intervals. 1
For patients choosing surveillance over adjuvant chemotherapy, close monitoring every 2-4 months for the first 2 years is essential to detect early recurrence. 1