Intensive chemotherapy and radical resections for primary nonseminomatous mediastinal germ cell tumors

Background. Primary nonseminomatous germ cell tumors of the mediastinum (PN SGM), unlike malignancies of gonadal origin, have a poor prognosis. We repo rt a single institutional experience over a 5-year period of PNSGM treated with intensive chemotherapy, followed by radical operation in those who res ponded to this neoadjuvant regimen. Methods. From 1993 to 1998, 20 patients were referred for the management of PNSGM. All were male, with a median age of 30.5 years (range 18 to 48). Ei ghteen of 20 (90%) presented with symptoms. Most tumors were large, with a median diameter of 10 cm (range 3 to 20 cm). Thirteen patients (65%) had me tastatic disease at the time of presentation. Eleven patients had received no prior treatment (initial group) and 9 were referred for salvage therapy after progression of their tumors, following treatment at other facilities (salvage group). All had elevated serum tumor markers (beta hCG and alpha-f etoprotein). Preoperative chemotherapy included alternating cycles of combi nations of 3 or more drugs, including cisplatin, bleomycin, etoposide, vinc ristine, methotrexate, actinomycin, cyclophosphamide, and doxorubicin. An a verage of 10 cycles of chemotherapy was given to each patient in the initia l group, and six to those in the salvage group. Five patients (25%) develop ed transient renal insufficiency, and 35% developed pulmonary infiltrates r elated to bleomycin. There were 3 chemotherapy related deaths. Results. After chemotherapy, 11 patients underwent operation, with 10 compl ete resections of the residual mediastinal tumors. There were no perioperat ive deaths. The 2-year survival in the initial group is 72%, and 42% for th e salvage group. Conclusions. An aggressive, multidisciplinary approach of alternating cycle s of chemotherapy, followed by complete surgical resection of all remaining disease in patients whose markers normalize, can be associated with prolon ged survival in patients with PNSGM. (C) 2000 by The Society of Thoracic Su rgeons.