Importance of surgery as salvage treatment after high dose chemotherapy failure in germ cell tumors

Purpose: The survival of patients with germ cell cancer after failed high dose chemotherapy is poor. We retrospectively reviewed the various treatment choices in this situation. Materials and Methods: From March 1986 to July 1996, 32 patients had disease progression after high dose cisplatin based chemotherapy plus hematopoietic stem cell support. Patients received high dose chemotherapy in the first line (11) or salvage (21) setting. Results: There was relapse after a complete or partial marker negative response after high dose chemotherapy in 19 cases at a median time to disease progression of 7 months (range 1.5 to 72). Salvage treatment involved chemotherapy alone in 5 cases, chemotherapy plus surgery in 6, surgery plus radiotherapy in 3, surgery alone in 2, combined radiotherapy, chemotherapy and surgery in 1, and no treatment in 1 due to a rapid disease course. The most common chemotherapy regimen was combined vinorelbine, ifosfamide and epirubicin. Eight patients achieved a complete response with the resection of all residual disease. At long-term followup 2 patients have been continuously disease-free for 84 and 109 months, respectively. After high dose chemotherapy 13 patients had evidence of disease, including 4 with a partial marker positive response and 9 with progressive disease. Salvage treatment involved chemotherapy plus surgery in 6 cases, chemotherapy alone in 2, no treatment in 2, and radiotherapy plus chemotherapy, radiotherapy alone and surgery alone in 1 each. One patient with progressive disease and 3 with a partial marker positive response achieved a complete response after salvage surgery, and combined surgery and high dose chemotherapy, respectively. These 4 patients have been continuously free of disease for 105, 95, 92 and 72 months, respectively. Conclusions: Six of the 32 patients with relapse or progressive disease after high dose chemotherapy have been free of disease in the long term. The most effective treatment was the resection of all residual masses. Chemotherapy had only marginal activity and the efficacy of radiotherapy seems to have been nil.