title: Factors that influence the results of salvage surgery in patients with chemorefractory germ cell carcinomas with elevated tumor markers.
abstract: BACKGROUND
  A standard concept for the integration of surgery into the chemotherapy-based treatment of patients with advanced germ cell carcinoma has been that surgery should be avoided in patients with serum tumor markers (alpha-fetoprotein [AFP] and human chorionic gonadotropin [HCG]) that remain elevated. However, some patients may benefit from resection under such chemorefractory conditions. The objective of this retrospective study was to clarify the outcome and clinical prognostic variables of salvage surgery in patients with disseminated (AJCC Stage II or III) testicular germ cell carcinoma or extragonadal germ cell carcinoma who had elevated serum markers.
  
  
  METHODS
  The authors reviewed the clinical records of 24 patients who underwent salvage surgery with elevated serum AFP and/or HCG levels after at least 3 courses of cisplatin-based, systemic chemotherapy between January, 1985 and December, 2000. The survival rates were compared between the subgroups with regard to preoperative and postoperative clinical parameters using the Kaplan-Meier method and a Cox proportional hazards model.
  
  
  RESULTS
  Ten of 24 patients (41.7%) were rendered free of disease and alive without disease after the surgery with or without adjuvant therapy at a median follow-up of 74 months (range, 24-207 months). Among the preoperative parameters, high HCG levels were associated with significantly poorer survival (hazard ratio [HR], 8.321; 95% confidence interval [95% CI], 1.0753-64.553; P = 0.043 and P = 0.016, respectively; log-rank test). In addition, patients who had visceral lesions at resection had a significantly poorer prognosis compared with patients who had retroperitoneal and/or mediastinal lymph node lesions (P = 0.038; log-rank test). Among postoperative parameters, incomplete resection and persistently high HCG levels were associated significantly with poor survival, with a risk of death from disease of 12.516-fold (95% CI, 1.786-87.781) and 9.311-fold (95% CI, 1.796-48.256), respectively.
  
  
  CONCLUSIONS
  Salvage surgery in patients with high serum tumors markers resulted in long-term disease free status in approximately 40% of patients in a small subset with advanced germ cell carcinoma. Patients with elevated AFP levels alone (i.e., normal HCG levels) or with lymph node lesions alone seem to be good candidates for such surgery. Complete resection of target lesions and normalization of HCG levels after surgery are mandatory to achieve long-term disease free status.
authors.affiliation: Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Tomonori
authors.initials: T
authors.lastname: Habuchi
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Kamoto
authors.forename: Isao
authors.initials: I
authors.lastname: Hara
authors.forename: Koji
authors.initials: K
authors.lastname: Kawai
authors.forename: Masahiro
authors.initials: M
authors.lastname: Nakao
authors.forename: Norio
authors.initials: N
authors.lastname: Nonomura
authors.forename: Takashi
authors.initials: T
authors.lastname: Kobayashi
authors.forename: Osamu
authors.initials: O
authors.lastname: Ogawa
authors.forename: Sadao
authors.initials: S
authors.lastname: Kamidono
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Akaza
authors.forename: Akihiko
authors.initials: A
authors.lastname: Okuyama
authors.forename: Tetsuro
authors.initials: T
authors.lastname: Kato
authors.forename: Tsuneharu
authors.initials: T
authors.lastname: Miki
mesh_terms: D000293:Adolescent; D000328:Adult; D014408:Biomarkers, Tumor / Q000032:analysis; D006063:Chorionic Gonadotropin / Q000097:blood; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009373:Neoplasms, Germ Cell and Embryonal / Q000097:blood / Q000401:mortality / Q000601:surgery*; D011379:Prognosis; D012189:Retrospective Studies; D016879:Salvage Therapy; D015996:Survival Rate; D013736:Testicular Neoplasms / Q000097:blood / Q000401:mortality / Q000601:surgery*; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: D014408:Biomarkers, Tumor; D006063:Chorionic Gonadotropin; D000509:alpha-Fetoproteins