Role of postchemotherapy adjunctive surgery in the management of patients with nonseminoma arising from the mediastinum

Purpose: To evaluate the role of postchemotherapy surgery in patients with nonseminomatous germ cell tumors arising from the anterior mediastinum. Patients and Methods: Thirty-two patients with nonseminoma arising from a m ediastinal primary site were treated on a clinical trial at our center, and they underwent postchemotherapy surgery. The results of postchemotherapy s urgical resection, frequency of viable tumor found during postchemotherapy surgery, and prognostic factors for survival were assessed. Results: Complete resection of all gross residual dis ease was achieved in 27 patients (84%). Histologic analysis of resected residua postchemotherapy revealed viable tumor in 66%, teratoma in 22%, and necrosis in 12% of the specimens. Viable tumor included embryonal carcinoma, choriocarcinoma, yolk sac carcinoma, seminoma, and teratoma with malignant transformation to non germ cell histology (eg, sarcoma). Clinical characteristics associated with a shorter survival after surgery included the presence of viable tumor in a resected specimen (P = .003) and more than one site resected during surge ry (P = .06). There were no statistically significant differences in surviv al for patients who underwent surgical resection with normal markers compar ed with patients with elevated serum tumor markers (P = .33). A trend towar d shorter survival was found in patients with increasing tumor markers befo re surgery compared with patients with normal and declining serum tumor mar kers (P = .09). Conclusion: Surgical resection of residual mass after chemotherapy plays an integral role in the management of patients with primary mediastinal nonse minoma. Teratoma and viable tumor were found in the majority of resected re sidua after chemotherapy. Because patients who undergo conventional salvage che motherapy programs rarely achieve long-term disease-free status, selec ted patients with elevated markers after chemotherapy are considered candid ates for surgical resection. (C) 2001 by American Society of Clinical Oncol ogy.