title: Decision analysis for avoiding postchemotherapy surgery in patients with disseminated nonseminomatous germ cell tumors.
abstract: OBJECTIVE
  This retrospective study was undertaken to assess the outcome of patients with disseminated nonseminomatous germ cell tumor (NSGCT) managed under a postchemotherapy strategy developed at Indiana University.
  
  
  METHODS
  This is a retrospective analysis of 295 consecutive patients with disseminated NSGCT treated with primary chemotherapy at Indiana University from 1987 to 1994. The patients were placed into five groups based on response to primary chemotherapy and the presence or absence of teratoma in the primary tumor. The 295 patients were divided as follows: group A (complete remission [CR]) n = 78; group B (unresectable), n = 50; group C (serologic CR, teratoma-positive primary tumor, resectable partial remission [PR]), n = 90; group D [serologic CR, teratoma-negative primary tumor, < 90% radiographic PR], n = 50; and group E (serologic CR, teratoma-negative primary tumor, > or = 90% radiographic PR), n = 27. Groups A, B, and E patients were routinely observed after chemotherapy, whereas groups C and D patients were routinely taken to postchemotherapy surgery.
  
  
  RESULTS
  The percent of patients who continuously had no evidence of disease (NED) were as follows: group A, 92%; group B, 40%; group C, 87%; group D, 86%; and group E, 74%. In assessing group A patients, the bulk of retroperitoneal disease at presentation had no influence on ultimate outcome.
  
  
  CONCLUSIONS
  Patients with NSGCT who achieve a serologic and radiographic CR with primary chemotherapy (group A) can be safely observed without surgical intervention, regardless of initial tumor bulk. Patients with a teratoma-negative primary tumor who achieve a serologic CR and a > or = 90% radiographic remission and are followed-up without surgical resection (group E) are at an increased risk of relapsed NSGCT. Decisions about postchemotherapy resection in this group remain complicated and controversial. Options include observation with serial radiologic evaluation or surgical resection of persistent mass or masses.
authors.affiliation: Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Debono
authors.forename: D K
authors.initials: DK
authors.lastname: Heilman
authors.forename: L H
authors.initials: LH
authors.lastname: Einhorn
authors.forename: J P
authors.initials: JP
authors.lastname: Donohue
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D003661:Decision Support Techniques; D006801:Humans; D008297:Male; D009367:Neoplasm Staging; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy / Q000556:secondary* / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome