Treatment of Patients with Stage II A/B and Advanced Nonseminomatous Germ Cell Tumors

Abstract

Since the introduction of cisplatin in the 1970s, the treatment of patients with advanced germ cell tumors has been constantly refined and improved within prospective studies. Patients with advanced disease are classified according to the International Germ Cell Cancer Consensus Group (IGCCCG) classification in which patients with advanced disease are classified on the basis of their prognostic features, such as location of the primary tumor, presence of nonpulmonary visceral metastases, and serum tumor marker level. Approximately 60% of all patients with advanced nonseminoma present with favorable prognostic criteria (“good prognosis”), which achieve a survival rates of approximately 90% following 3 cycles of cisplatin, Etoposide, bleomycin (BEP) combination chemotherapy. The intermediate prognosis group encompasses approximately 20–25% of patients with a long term survival rate of 80% after four cycles of BEP chemotherapy. The poor-prognosis group exhibits a much lower and very unsatisfactory long-term survival rate of only 40–50%. The prognosis of metastatic germ cell cancer patients has not been further improved over the past decade. In good prognosis patients efforts concentrated on reducing toxicity while at the same time maintaining efficacy. Trials of replacing cisplatin with carboplatin in order to further decrease toxicity have failed. A number of different approaches have been tested to improve the prognosis of intermediate and poor prognosis patients. Increased doses of cisplatin, dose dense regimens and high dose chemotherapy have not shown a benefit over standard BEP and 3 and 4 cycles of BEP remain the standard of care for good and intermediate/poor prognosis patients, respectively. In nonseminomatous germ cell cancer, residual lesions should be resected whenever possible.