Failure of salvage treatment in metastatic testicular teratoma

Abstract

From January 1978 to March 1989, 92 consecutive patients with metastatic testicular teratoma have been treated with cisplatin-based chemotherapy. Thirty seven failed to achieve a complete response, and another four subsequently relapsed. These 41 have required further treatment, consisting of surgery (16 patients), radiotherapy ( n =13) and chemotherapy ( n =12). Surgery was generally used for residual masses where tumour markers were normal, radiotherapy for masses where surgery was not possible or for palliation, and second line chemotherapy was used in patients with raised serum tumour markers or in the presence of multiple inoperable pulmonary metastases. Nine of 16 (56%) patients treated surgically are disease-free, including two who had malignant teratoma in the resection specimen. Three of 13 patients irradiated are disease-free, although two of these three had subsequent excision of residual masses. All 12 patients treated with second-line chemotherapy have died. Surgical excision of residual masses appears to be the most effective way of rendering patients disease-free, providing serum tumour markers are normal. Most of these residual masses will consist of differentiated teratoma or necrosis, but it may be possible to salvage patients with residual malignant disease, providing complete clearance can be achieved. Incompletely resected malignant disease carries a poor prognosis, and incompletely resected disease that is histologically benign will run the risk of subsequent relapse. Radiotherapy provides good palliation but is much less effective than surgery as treatment for residual masses, and should only be used if complete excision cannot be accomplished. Second line chemotherapy based on BEP (bleomycin, etoposide and cisplatin) or POMBACE (cisplatin, vincristine, methotrexate, bleomycin, actinomycin-D, cyclophosphamide and etoposide) has been ineffective in our hands. New approaches are needed for patients in high-risk subgroups, and include using intensive regimens as induction chemotherapy, or in patients with cisplatin-refractory tumours, high dose chemotherapy or novel scheduling of cytotoxic drugs.