Chemotherapy for advanced germ cell tumors.
OBJECTIVE
Germ cell tumors constitute the most curable of all cancers. Standard treatment of previously untreated and treated patients has evolved on the basis of prospective clinical trials and prognostic factors. This review summarizes the prognostic criteria on which treatment decisions may be based, and outlines the current treatment approaches.


METHODS
Randomized and nonrandomized trials of first-line, salvage, and palliative therapy and the role of surgery after chemotherapy were reviewed. In the treatment of previously untreated patients, emphasis was placed on interpretation of data of trials according to the International Germ Cell Cancer Collaborative Group model, which has evolved into a universally accepted classification algorithm for determining appropriate risk-directed chemotherapy. This system permits treatment choices based on the balance between benefit and toxicity and allows comparison of results across multiple clinical trials.


RESULTS
Standard therapy for good-risk patients is four cycles of etoposide plus cisplatin or three cycles of cisplatin, etoposide plus bleomycin (BEP x 3); both approaches cure approximately 90% of patients. After chemotherapy and normalization of markers, patients should generally undergo resection of residual masses. Approximately 75% of intermediate-risk and 45% of poor-risk patients group achieve a durable complete response with BEP x 4. Potentially curative options in the salvage setting include ifosfamide plus cisplatin-containing standard dose therapy and high-dose carboplatin plus stem-cell rescue. Surgery remains an essential component of care.


CONCLUSIONS
Curative therapy exists even in patients with resistant disease, and treatment choices can be based on established clinical criteria. Serum tumor markers and surgery after chemotherapy have essential roles in patient management
Kondagunta
G Varuni
GV
Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center,New York, NY 10021, USA. kondaguv@mskcc.org
Motzer
Robert J
RJ
D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000627:therapeutic use*; D001761:Bleomycin / Q000008:administration & dosage; D002945:Cisplatin / Q000008:administration & dosage; D005047:Etoposide / Q000008:administration & dosage; D006801:Humans; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy* / Q000601:surgery; D010166:Palliative Care; D016032:Randomized Controlled Trials as Topic; D016879:Salvage Therapy
D001761:Bleomycin; D005047:Etoposide; D002945:Cisplatin