Diagnosis and treatment of patients with testicular germ cell cancer

Testicular germ cell tumours are a highly curable malignancy even in the pr esence of metastases, with an overall survival rate of approximately 90 to 95% when all stages are considered. Current therapeutic strategies aim at r isk-adapted therapy, trying to maintain favourable overall results while re ducing treatment-related toxicity, particularly in non-advanced disease. In stage I disease, unilateral inguinal orchiectomy represents the standard diagnostic and therapeutic approach. For patients with clinical stage I se minoma, prophylactic para-aortic radiotherapy with 26Gy is commonly employe d. In patients with nonseminomatous germ cell tumours (NSGCT) at clinical s tage I, the 3 options are: (i) retroperitoneal lymphadenectomy; (ii) a wait -and-see strategy; or (iii) 2 cycles of adjuvant chemotherapy. The individu al risk profile for tumour recurrence, mainly based on histopathological cr iteria such as vascular tumour invasion, should guide treatment decisions i n this group of patients. Radiotherapy is still the standard approach in clinical stage IIA/B seminom a, whereas in patients with a low tumour burden of NSGCT, retroperitoneal l ymph adenectomy is frequently used followed by surveillance or adjuvant che motherapy. Primary chemotherapy in these stages of disease may be at least equally successful. Major progress has also been achieved in the treatment of NSGCT patients wi th metastatic disease greater than clinical stage IIB, for whom primary che motherapy represents the standard approach. After cisplatin-based combinati on chemotherapy, between 70 and 90% of patients will achieve a durable remi ssion. In patients with 'good risk' metastatic disease, 3 cycles of cisplat in, etoposide and bleomycin (PEB) remain the standard treatment, despite se veral randomised trials trying to avoid the lung-toxic bleomycin or substit uting cisplatin by carboplatin. In patients with 'intermediate' and 'poor p rognosis' disease, 4 cycles of FEB given at 3-week intervals are considered routine treatment. The role of high dose chemotherapy with peripheral autologous blood stem ce ll transplantation is currently being investigated for patients presenting initially with advanced (poor prognosis) metastatic disease and for patient s with relapse after previous chemotherapy, in whom conventional-dose salva ge regimens will only result in 20% long-term survival. Because of the large group of patients with metastatic disease being cured, the possible long-term adverse effects of treatment have become important. Only a slightly elevated risk for therapy-related secondary malignancies h as been identified. Long-term adverse effects associated with cisplatin may affect a larger proportion of patients. Further research should focus on r educing the risk of chemotherapy-related chronic toxicity.