Significant factors in the optimal management of advanced stage germ cell carcinoma.

Twenty-two patients with advanced stage germ cell carcinomas received a combination chemotherapy regimen of cis-platinum, vinblastine, bleomycin and actinomycin D. There were 16 (73%) complete remissions, (five documented at surgery), one patient (5%) whose residual disease was completely resected and five (22%) partial remissions. The only adverse significant pretreatment factors were extent or bulk of initial disease and poor performance status. Prior radiotherapy or chemotherapy did not influence the potential to achieve complete remission, but was associated with increased haematological toxicity. Toxicities were common and there were three treatment related deaths, one from septicaemia and two from pulmonary fibrosis, emphasising the need for expertise and optimal supportive care when administering this complicated regimen. There was a significant survival advantage for the patients achieving disease-free status compared to partial responders (p = 0.02). Only one relapse has occurred among the former group with 82% alive and disease-free with follow-up of 27-50 months, indicating the majority of these patients may be cured. Management of advanced stage germ cell carcinoma can now be considered highly successful although further studies are needed to determine optimal treatment for patients with bulky disease and the role, if any, of maintenance therapy.