Late relapse of germ cell tumors

Salvage management of patients with relapsing testicular germ cell tumors

PURPOSE OF REVIEW

This review aims to summarize the latest evidence of medical and surgical treatment options for patients with relapsing testicular germ cell tumors.

RECENT FINDINGS

Depending on International Germ Cell Cancer Classification Group risk classification 10-50% of patients with metastatic TGCT develop relapse which needs further multimodality treatment. With regard to therapy, early relapses are stratified according to their prognostic risk profile which results in a 3-year overall survival between 6% in the very high to 77% in the very low risk group. Prognostic risk score dictates systemic therapy which might be second line chemotherapy (TIP, PEI) or high dose chemotherapy. Any residual masses following salvage chemotherapy need to be completely resected due the presence of viable cancer and/or teratoma in more than 50% of cases. Targeted therapy in men with druggable mutations is for individualized cases only. Patients with late relapses developing more than 2 years after first-line chemotherapy are best managed by surgery. Desperation surgery is reserved for those patients with rising markers during or immediately after chemotherapy and good risk factors such as rising alpha-fetoprotein, <3 metastatic sites and complete resectability. Multimodality treatment will result in long-term cure of 25% to 60%. Due to the complexity of treatment, chemotherapy as well as surgery should be performed in highly experienced centres only.

SUMMARY

Multimodality treatment to salvage relapsing patients with metastatic testis cancer requires extensive experience for both systemic therapy and surgery. If done properly, it will result in moderate to high cure rates. Personalized therapeutic options are currently evaluated in clinical trials.

Imaging of Metastatic Germ Cell Tumors in Male Patients From Initial Diagnosis to Treatment-Related Toxicities: A Primer for Radiologists

OBJECTIVE. This review describes the influence of histology and metastatic sites on prognosis in male patients with metastatic germ cell tumors (GCTs) and explains the role imaging in assessing therapeutic response, residual disease, recurrence, sand treatment-related toxicities. CONCLUSION. Seminomatous and nonseminomatous GCTs differ in imaging appearance, pattern of spread, and prognosis, and an organ-based approach is helpful in prognostication. Multimodality imaging aids in accurate staging, prognostication, characterization of treatment response, and identification of therapy-related toxicity.

[Update on first-line and relapse chemotherapy for testicular cancer]

Germ-cell cancer (GCC) is still the most common cancer diagnosis in men between the ages of 20 and 45 years with an increasing incidence. Due to effective and standardized algorithms that have been developed to stratify patients into different risk groups, remarkable progress has been made in the medical treatment of testicular cancer with an overall cure rate of 88%. The application of surgery, radiotherapy and chemotherapy, the choice of chemotherapy agents as well as treatment duration is defined in international consensus guidelines. The guidelines are based on histology, tumor stages and presence or absence of already known and well-established risk factors. These stringent parameters guarantee the optimal curative treatment options for each GCC patient and can avoid overtreatment as well as undertreatment. For patients with early stage disease, careful consideration between possible side effects due to an adjuvant therapy and the expected relapse rate must be made, whereas in advanced tumor stages the optimal sequence of chemotherapy, surgery and radiotherapy is the focus. In patients who progress or relapse after first-line therapy, the issue of optimal treatment represents a particular challenge and is far more complex. It needs to take into account the analysis of special prognostic variables for a further risk-tailored therapy. A careful weighting between the chosen regimen and the often higher rate of treatment failure in contrast to increased toxic side-effects is mandatory.The disregard of accurate risk stratification and application of accepted treatment standards for patients with GCC at the time of initial diagnosis or at relapse is associated with developing more extensive disease and more intensive treatment. It also results in lower cure rates with the need for further therapy or leads to death of the patient without ever having had a chance for cure.