SURVIVAL OF PATIENTS WITH VIABLE MALIGNANT NONSEMINOMATOUS GERM-CELL TUMOR PERSISTENT AFTER CISPLATIN-BASED INDUCTION CHEMOTHERAPY

Objectives: Review of the outcome in patients with viable residual pos tchemotherapy malignant germ cell tumour treated at the Norwegian Radi um Hospital from 1980 to 1993 and to establish prognostic factors. Met hods: During the years 1980-1993, about 270 patients with malignant no n-seminomatous germ cell tumours underwent postchemotherapy surgery at the Norwegian Radium Hospital. In 27 of these patients, residual viab le malignant germ cell tumour was found in the operation specimen. The se patients were scheduled to receive 3 adjuvant cisplatin-based chemo therapy cycles after surgery, if possible, containing cytostatic agent s not given during induction chemotherapy. All patients were followed up until death or January Ist, 1995 (median observation time in surviv ing patients: 51 months; range: 9-166 months). Results: Sixteen patien ts developed a relapse after surgery after a median time of 4 weeks (r ange 1-19 weeks), 12 of them before any adjuvant chemotherapy could be started. Only 2 of these relapsing patients could be salvaged. At the last follow-up, 13 patients were alive, and a 43% 5-year survival was obtained. All deaths occurred within 3 years after surgery. The 9 pat ients with elevated alpha-fetoprotein and/or human chorionic gonadotro pin before surgery have a particularly low survival rate(11%), as comp ared to the 18 patients with normal markers (62%). The most important prognostic parameter for the postoperative survival was, however, the initial tumour burden: the 14 patients with initially large or very la rge tumour volume (MRC criteria) had a 9% 5-year survival, whereas the percentage was 84% for the 13 patients with small volume disease. Con clusion: Prognosis is poor in patients in whom residual malignant germ cell tumour persists in spite of conventional cisplatin-based inducti on chemotherapy, especially in patients who initially present with lar ge or very large volume disease and/or pre-operatively elevated tumour markers. More effective treatment modalities have to be developed for these patients. The role of high-dose chemotherapy with stem cell sup port should be investigated in future trials, especially in the subgro up of patients with poor prognosis.