title: Beyond stage I germ cell tumors: current status regarding treatment and long-term toxicities.
abstract: Approximately 20% to 40% of patients with germ-cell tumors (GCT) will need advanced medical treatment because of relapse or initial metastatic disease. The survival and recommended treatment for men with metastatic disease varies according to histology, primary and metastatic sites, and the level of prechemotherapy tumor markers. For patients with a good prognosis, three cycles of bleomycin, etoposide, and cisplatin (BEP) or four cycles of etoposide, and cisplatin are recommended. For patients with intermediate- and poor prognosis, four cycles of bleomycin, etoposide, and cisplatin remains the preferred treatment option, although a switch to a more intensive regimen can be considered a new alternative. A major advance in salvage therapy for GCT in the last 5 years was the development of a new risk classification system. Initial salvage treatment includes both high-dose chemotherapy and standard-dose chemotherapy. There is clear consensus that patients with residual masses larger than 1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND); however, the role of PC-RPLND in patients with serologic and radiographic complete response to first-line chemotherapy is controversial. The rationale for PC-RPLND in patients with small residual masses is discussed, and only a small minority of advanced nonseminoma GCT (NSGCT) patients are suitable candidates for observation after first-line chemotherapy. Post-treatment long-term toxicity has emerged as an important issue for GCT survivors. Examples of late effects are secondary nongerm-cell cancers and cardiovascular disease, which represent the most severe and potentially life-threatening effects of cancer treatment. Follow-up of cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of serious long-term and late effects of treatment.
authors.affiliation: From the Department of Oncology, University Hospital of North Norway, Tromsø, Norway; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Hege Sagstuen
authors.initials: HS
authors.lastname: Haugnes
authors.affiliation: From the Department of Oncology, University Hospital of North Norway, Tromsø, Norway; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Stephenson
authors.affiliation: From the Department of Oncology, University Hospital of North Norway, Tromsø, Norway; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Darren Richard
authors.initials: DR
authors.lastname: Feldman
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000628:therapy*; D009373:Neoplasms, Germ Cell and Embryonal / Q000473:pathology* / Q000628:therapy*; D012186:Retroperitoneal Neoplasms / Q000473:pathology / Q000556:secondary / Q000628:therapy*; D016896:Treatment Outcome; D055815:Young Adult