The management of nonseminomatous testicular cancer.

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Despite the fact that testis cancer accounts for only 1% of all male malignancies, it is the most common solid malignancy affecting males between the ages of 15 to 35 years. The management of germ cell tumors (GCT) of the testis has proved to be a model of success among solid tumors. This is due to tremendous advances during the past 2 decades, which have changed the once dismal prognosis for patients with advanced disease. Testicular cancer has, in fact, become one of the most curable of all solid neoplasms. Thirty years ago testicular cancer accounted for 11.4% of all cancer deaths in the 25 to 34 year age group, with an overall 5 year survival rate of 64%. The most recent five-year survival rate for GCT of the testis in the United States was recently reported as being in excess of 90%. Improved prospects for cure and long-term disease free survival rate, are related to a better understanding of the natural history of testicular tumors, improved staging methods and surgical techniques, as well as to the introduction of effective platinum based combination chemotherapy. Modifications to the surgical management of testis cancer have significantly reduced morbidity associated with the classical full bilateral retroperitoneal lymph node dissection. Template and nerve sparing retroperitoneal node dissections are now routinely employed in low stage nonseminomatous germ cell tumors (NSGCT), providing the patient with the benefit of accurate pathological staging combined with reduced morbidity. In addition, nerve sparing techniques have also been used in dissections for residual disease following chemotherapy. Chemotherapy for advanced GCT has undergone a number of important breakthroughs during the past three decades. In the 1960's the first major chemotherapeutic advance in metastatic NSGCT was described; a combination of chlorambucil, methotrexate and dactinomycin produced a response rate of 30%. By the 1970's combination therapies such as vinblastine and bleomycin had been shown to produce objective responses; 57% complete response rates and 45% long-term disease-free survival rates were reported. The discovery of cisplatin as a highly effective anti-neoplastic agent in 1965, and its later use in germ cell tumors of the testis (GCT), was another important breakthrough. In 1974 the combination of cisplatin, vinblastine and bleomycin was investigated by the Indiana group. Of the 47 patients in the initial phase II study, 100% achieved a response rate. Thirty five (74%) patients achieved complete remission, the remaining patients achieved a partial remission.