Primary mediastinal nonseminomatous germ cell tumors: The influence of postchemotherapy pathology on long-term survival after surgery

Objectives: The treatment of nonseminomatous germ tell tumors with cisplati n-based chemotherapy followed by aggressive surgical resection of residual disease is one of the most successful models for multimodality cancer thera py. We reviewed the case histories of 91 patients treated at our institutio n from 1981 to 1998 with primary mediastinal nonseminomatous germ cell tumo rs to evaluate variables that may influence survival after surgery Methods: Twelve of the 91 patients did not undergo postchemotherapy resection becau se of progressive disease. Seventy-nine of them underwent 82 thoracic surgi cal procedures and are the basis of this review The majority (71/75) had el evated serum tumor markers, 75% (n = 50) of which returned to normal levels after first- or second-line chemotherapy. Results: There were 3 operative deaths and I late death, attributed to pulmonary complications. Twenty-four patients died of recurrent disease and 3 of leukemia, for an overall survi val of 61% after an average follow-up of 48 months. The pathologic findings of complete tumor necrosis (n = 19) and benign teratoma (n = 28) in the su rgical specimen predicted excellent and good long-term survival, respective ly, which was statistically better than that of patients having persistent nonseminomatous germ cell turners (n = 24) or carcinomatous/sarcomatous deg eneration (n = 8), Conclusions: primary nonseminomatous germ cell tumors of the mediastinum can be cured with a multimodality therapy, particularly in the subset of patients with postchemotherapy pathologic findings of tumor necrosis and teratoma, Survival is poor but possible in patients with unfav orable pathologic findings after chemotherapy, currently justifying an aggr essive surgical approach in patients with otherwise operable disease.