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Management of advanced germ-cell tumors of the testis

Abstract

Advanced tumors of the testis are curable. Standard treatment includes chemotherapy with a combination of bleomycin, etoposide and cisplatin, followed by surgical resection of residual tumor. The number of cycles of chemotherapy needed depends on prognostic factors such as the primary site, histology, presence of visceral metastases, and serum levels of tumor markers. Patients with a favorable risk profile receive three cycles of chemotherapy, and those with increased risk receive four cycles. After chemotherapy, resection of all residual local disease and systematic retroperitoneal dissection of bulky lymph-node disease are mandatory for patients with nonseminoma germ-cell tumors. In patients with seminoma, surgery is required when residual disease is either bulky or functional on 18fluorodeoxyglucose-PET scan. When complete resection of necrosis, teratoma and/or active germ-cell cancer has been done, no further treatment is needed. The consequences of therapy are complex: treatment could affect fertility, sexuality, metabolic status and renal and neurological function. Secondary malignancies are reported, as well as contralateral germ-cell tumors. Owing to the complexity of treatment and the multidisciplinary approach required, patients with advanced germ-cell tumors should be managed in high-volume centers with experience of treating large numbers of patients.

Key Points

  • Patients with advanced germ-cell tumors (GCTs) should be assigned to a prognostic group to guide treatment decision-making: the International Germ Cell Consensus Classification is currently used for this purpose

  • The standard treatment strategy for GCTs is chemotherapy followed by surgical resection of all residual disease

  • The standard chemotherapy regimen for first-line treatment of GCTs is a combination of bleomycin, etoposide and cisplatin (BEP)

  • Patients in the good-risk category receive three cycles of BEP, patients in the poor-risk and intermediate-risk categories receive four cycles of BEP

  • Overall cure rates for patients in the good-risk, intermediate-risk and poor-risk categories are 95%, 85% and 45%, respectively

  • The rate of relapse after first-line treatment of GCTs is 5–10%; patients who relapse after first-line treatment have only a 30% chance of cure

  • Complications associated with treatment of GCTs can include retrograde ejaculation, decreased fertility, long-term impairment of metabolic, renal and neurological functions, contralateral GCTs, second primary cancers, and blood disorders

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Figure 1: Decision tree for use of chemotherapy in the management of patients with germ-cell tumors.
Figure 2: Decision tree for surgical management of patients with germ-cell tumors.

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The authors thank Marie-Dominique Reynaud for editing the manuscript.

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Fléchon, A., Rivoire, M. & Droz, JP. Management of advanced germ-cell tumors of the testis. Nat Rev Urol 5, 262–276 (2008). https://doi.org/10.1038/ncpuro1101

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