Survival of patients with viable malignant non-seminomatous germ cell tumour persistent after cisplatin-based induction chemotherapy.

OBJECTIVES

Review of the outcome in patients with viable residual postchemotherapy malignant germ cell tumour treated at the Norwegian Radium Hospital from 1980 to 1993 and to establish prognostic factors.

METHODS

During the years 1980-1993, about 270 patients with malignant non-seminomatous germ cell tumours underwent postchemotherapy surgery at the Norwegian Radium Hospital. In 27 of these patients, residual viable malignant germ cell tumour was found in the operation specimen. These patients were scheduled to receive 3 adjuvant cisplatin-based chemotherapy cycles after surgery, if possible, containing cytostatic agents not given during induction chemotherapy. All patients were followed up until death or January 1st, 1995 (median observation time in surviving patients: 51 months; range: 9-166 months).

RESULTS

Sixteen patients developed a relapse after surgery after a median time of 4 weeks (range 1-19 weeks), 12 of them before any adjuvant chemotherapy could be started. Only 2 of these relapsing patients could be salvaged. At the last follow-up, 13 patients were alive, and a 43% 5-year survival was obtained. All deaths occurred within 3 years after surgery. The 9 patients with elevated alpha-fetoprotein and/or human chorionic gonadotropin before surgery have a particularly low survival rate (11%), as compared to the 18 patients with normal markers (62%). The most important prognostic parameter for the postoperative survival was, however, the initial tumour burden: the 14 patients with initially large or very large tumour volume (MRC criteria) had a 9% 5-year survival, whereas the percentage was 84% for the 13 patients with small volume disease.

CONCLUSION

Prognosis is poor in patients in whom residual malignant germ cell tumour persists in spite of conventional cisplatin-based induction chemotherapy, especially in patients who initially present with large or very large volume disease and/or pre-operatively elevated tumour markers. More effective treatment modalities have to be developed for these patients. The role of high-dose chemotherapy with stem cell support should be investigated in future trials, especially in the subgroup of patients with poor prognosis.