Management after resection of residual masses

The histology of the resected residual masses guides further treatment. Patients who have necrosis require no more immediate treatment and should be followed with careful surveillance. Completely resected teratoma also does not warrant further systemic therapy. Patients who have residual viable cancer, however, may be treated with additional cisplatin-based chemotherapy. Fox and colleagues [37] reviewed 580 postchemo-therapy RPLNDs at a single institution and found 133 patients who had viable nonteratomatous GCT. Seventy percent (19 of 27) of those who received primary chemotherapy followed by two additional courses of postoperative chemotherapy after complete resection remained disease-free, whereas 100% (7 of 7) who did not undergo additional chemotherapy relapsed. Thirty-six percent (9 of 25) of patients who had a complete resection after salvage chemotherapy and subsequently received postoperative chemotherapy remained disease-free compared with 43% (12 of 28) of those who received no additional chemotherapy. Only 9% (4 of 43) of patients who had an incomplete resection were disease-free at the time of publication. The authors concluded that two additional courses of cisplatin-based chemotherapy after complete resection of viable GCT was safe and reduced the risk for relapse in patients who initially underwent primary chemotherapy. Additional standard chemotherapy was not beneficial in those who received preoperative salvage chemotherapy. An international, multicenter, retrospective review assessed the value of postchemotherapy surgery in patients who had viable GCT who initially received cisplatin-based chemotherapy [10]. An analysis of 238 patients, 53.5% of whom demonstrated residual masses outside the retroperito-neum, revealed that complete resection, 10% or fewer viable malignant cells, and good International Germ Cell Consensus Classification (IGCCC) were independent predictors of improved progression-free and overall survival. Recipients of postoperative chemotherapy demonstrated a significantly improved progression-free survival compared with nonrecipients. There was no significant difference in overall survival between the postoperative chemotherapy recipients and nonrecipients, however. On multivariate analysis, postoperative chemotherapy was associated with an improved progression-free survival (P<.001) but no improvement in overall survival (P — .26). Patients were assigned to one of three risk groups based on the above-mentioned prognostic indicators (complete resection, <10% viable malignant cells, and good IGCCC): those who had no risk factors (favorable group), those who had one risk factor (intermediate group), and those who had two or three risk factors (poor-risk group). Recipients ofpostoperative chemotherapy in the intermediate-risk group revealed an improved progression-free and overall survival compared with nonrecipients. Patients in the favorable-risk group faired well with or without additional chemotherapy and those in the poor-risk group did poorly regardless of additional systemic therapy. The above results highlight the importance of a complete resection of viable GCT and suggest that patients who have favorable characteristics (complete resection, <10% viable malignant cells, and good IGCCC) may not require postoperative chemotherapy.

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