Role of adjuvant chemotherapy

Postoperative chemotherapy appears to improve disease-free recurrence in patients with germ-cell cancer after first-line chemotherapy but not when given after second-line chemotherapy [2]. This lack of benefit in the salvage setting is thought to be secondary to the development of tumor che-moresistance. Persistently elevated serum tumor markers after systemic therapy implies a degree of chemoresistance and in the current series adjuvant chemotherapy did not improve patient survival. In the Albers series of 30 patients with elevated serum tumor markers undergoing surgery, only 6 of the 18 patients with viable cancer in the residual tumor specimen received postoperative chemotherapy, of whom 4 have remained free of disease, 1 died of disease, and 1 has progressive disease [4]. The Royal London Hospital, in their series of 30 patients, cautioned that in ''. managing these patients do not continue indefinitely with chemotherapy in the face of persistently elevated markers and remember that surgery has a cure rate in its own right'' [11]. In the Indiana cohort, the 5-year overall survival for patients with germ-cell cancer receiving (18 patients) and not receiving (42 patients) adjuvant chemotherapy was 44.4% and 25.7%, respectively (P = .067). Administration of adjuvant chemotherapy to patients in the first-line subset must be individualized. Patients with declining markers (resembling patients undergoing standard PCRPLND) are not platinum refractory and we would recommend two courses of adjuvant etopo-side and cisplatin. Patients with rising serum tumor markers during or after chemotherapy should be considered platinum refractory and we would not recommend postoperative chemotherapy.

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