Viable malignant cells after primary chemotherapy for disseminated nonseminomatous germ cell tumors: Prognostic factors and role of postsurgery chemotherapy-results from an international study group

Purpose: To assess the value of postsurgery chemotherapy in patients with d isseminated nonseminomatous germ-cell tumors (NSGCTs) and viable residual d isease after first-line cisplatin-based chemotherapy. Patients and Methods: The outcome of 238 patients was reviewed. Tumor marke rs had normalized in all patients before resection. A multivariate analysis of survival was performed on 146 patients. Results: The 5-year progression-free survival (PFS) rate was 64% and the 5- year overall survival (OS) rate wets 73%. Three factors were independently associated with both PFS and OS: complete resection (P < .001), < 10% of vi able malignant cells (P = .001), and a good International Germ Cell Consens us Classification (IGCCC) group (P = .01). Patients were assigned to one of three risk groups: those with no risk factors (favorable group), those wit h one risk factor (intermediate group), and those with two or three risk fa ctors (poor-risk group). The 5-year OS rate was 100%, 83%, and 51%, respect ively (P < .001). The 5-year PFS rate was 69% (95% confidence interval [CI] , 62% to 76%) and 52% (95% CI, 40% to 64%) in postoperative chemotherapy re cipients and nonrecipients, respectively (P < .001). No significant differe nce was detected in 6-year OS rates. After adjustment on the three prognost ic factors, postoperative chemotherapy was associated with a significantly better PFS (P < .001) but not with better OS. Patients in the favorable ris k group had a 100% 5-year OS, with or without postoperative chemotherapy. P ostoperative chemotherapy appeared beneficial in both PFS (P < .001) and OS (P = .02) in the intermediate-risk group but was not statistically benefic ial in the poor-risk group. Conclusion: A complete resection may be more critical than recourse to post operative chemotherapy in the setting of postchemotherapy viable malignant NSGCT. Immediate postoperative chemotherapy or surveillance alone with chem otherapy at relapse may be reasonable options depending on the completeness of resection, IGCCC group, and percent of viable cells. Validation is nece ssary.