Management of Disseminated Nonseminomatous Germ Cell Tumors With Risk-Based Chemotherapy Followed by Response-Guided Postchemotherapy Surgery

Purpose The management of patients with a radiographic complete response after chemotherapy remains controversial. The current study assesses the outcome for a modern, unselected patient population with disseminated testicular cancer with particular emphasis on those achieving a radiographic complete remission to combination chemotherapy. Patients and Methods All patients with disseminated nonseminoma seen between 1999 and 2007 at the British Columbia Cancer Agency (BCCA) as well as through the Oregon Testis Cancer Program were retrospectively reviewed. A total of 276 patients treated with combination chemotherapy were identified. A radiographic complete remission (CR) was defined as disappearance of all metastatic lesions or minimal residual tissue <= 1 cm. Results One hundred sixty-one patients achieved a CR. Results for the total population and CR subset were as follows: International Germ Cell Cancer Consensus Group stage good/intermediate/poor 84%/5%/11% (CR subset, 94%/3%/3%), presence of teratoma in the primary tumor 40% (CR subset, 55%), relapses 13%, death from disease 3% (CR subset, 6% and 0%, respectively). Two of the total 10 relapses in the CR group occurred beyond 2 years. Eight of the 10 relapses in the CR group were treated surgically for teratoma alone, whereas two required salvage chemotherapy. Disease-specific survival for the CR group was 100% after a median follow-up of 52 months (range, 3 to 135 months). Conclusion Modern risk-adapted systemic chemotherapy with or without surgery for current populations of patients with disseminated testicular nonseminoma results in superb outcomes. Patients with disseminated germ cell tumors who obtain a complete serologic remission and no or minimal radiographic residual can be safely observed without adjunctive regional surgery.