Management of good-risk metastatic nonseminomatous germ cell tumors of the testis: current concepts and controversies.
METHODS
Approximately 30% of nonseminomatous germ-cell tumors (NSGCT) of the testis present with metastatic disease. In 1997, the International Germ Cell Cancer Collaborative Group (IGCCCG) stratified all patients with metastatic NSGCT into various risk groups based on serum tumor markers and presence of visceral disease. We review the literature and present optimal stage-dependent management strategies in patients with favorable-risk metastatic NSGCT.


RESULTS
Primary chemotherapy (3 cycles BEP or 4 cycles EP) has been shown to be the preferred modality in patients with Clinical Stage IS (cIS) and in patients with bulky metastatic disease (>/=CS IIb) due to their high risk of systemic disease and recurrence. Primary retroperitoneal lymph node dissection appears to be the most efficient primary therapy for retroperitoneal disease <2 cm (CS IIa), with adjuvant chemotherapy reserved for patients who are pathologically advanced (>5 nodes involved, single node > 2 cm) and for those who are non-compliant with surveillance regimens. Following primary chemotherapy, STM and radiographic evaluation are used to assess treatment response. For patients with normalization of STM and retroperitoneal masses < 1 cm, retroperitoneal lymph node dissection or observation with treatment at disease progression are considered options. Due to risk of teratoma or chemoresistant GCT, masses >1 cm and extra-retroperitoneal masses should be treated with surgical resection, which should be performed with nerve-sparing, if possible.


CONCLUSIONS
In patients with favorable disease based on IGCCCG criteria, clinical stage, STM, and radiographic evaluation are used to guide appropriate therapy to provide excellent long-term cure rates (>92%) in patients with metastatic NSGCT.
Section of Urology, Department of Surgery, University of Chicago Medical Center, USA.
Gautam
G
Jayram
Russell Z
RZ
Szmulewitz
Scott E
SE
Eggener