Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers

Purpose: We evaluated the prognostic criteria for salvage surgery in patients with persistent marker elevation after chemotherapy for metastatic germ cell tumors. Materials and Methods: Of 125 men who underwent post-chemotherapeutic resection of residual tumors 30 had persistent marker elevation at surgery. This group was subdivided into 17 patients with no evidence of disease, 7 dead of disease and 6 others. Outcome analysis was performed in the subgroups with regard to preoperative and postoperative parameters. Mean followup was 120.3 months (range 1 to 228) after surgery. Results: Of the 30 patients 17 (57%) with persistently elevated tumor markers after chemotherapy were long-term survivors after salvage surgery. Overall persistent viable cancer and teratomatous elements were identified in 64% and 11% of cases, respectively. Significantly more patients died of disease who had a poor prognosis according to International Germ Cell Cancer Collaborative Group guidelines. Embryonal carcinoma was the predominant initial histology in this group and residual disease was more often located at various sites, for example the viscera, with a lower chance of complete surgical resection. Marker status before surgery, and chemotherapeutic pretreatment and postoperative histological findings did not differ significantly in patients with no evidence of disease and those dead of disease. Conclusions: Salvage surgery results in long-term success in greater than 50% of patients. Complete resection is the most important single parameter for a favorable outcome. Even patients with visceral metastasis benefit from surgery. Our data do not justify omitting surgery in certain subgroups.