Current chemotherapeutic approaches for recurrent or refractory germ cell tumors

INTRODUCTION

Up to 25% of patients with metastatic testicular germ cell tumour (GCT) are not cured by first line therapy and require treatment for refractory or relapsed disease.

METHODS

A literature search was conducted through PubMed, Medline, Cochrane and EMBASE from January 1950 to April 2014 for articles relating to trials of chemotherapy for patients with relapsed or refractory germ cell tumours. Relevant review papers and conference proceedings were hand searched for additional references.

RESULTS

A range of conventional dose chemotherapy (CDCT) regimens can provide durable remissions in 20-30% of patients at first or subsequent salvage.

CONCLUSIONS

This article reviews the evidence underlying commonly used salvage CDCT based on ifosfamide and cisplatin such as TIP, VIP and VeIP; other active combinations; and single agent salvage regimens. The treatment of growing teratoma syndrome and malignant transformation of teratoma will also be discussed. Companion articles will explore the role of high dose chemotherapy (HDCT) and novel targeted agents.

[Medical treatment of metastatic germ cell cancers]

The treatment options in metastatic testicular germ cell cancer are based on prognostic the factor-based staging system from IGCCCG. Since 1987 (!), the optimal chemotherapy regimen has been BEP with a weekly administration of 30 mg of bleomycine, and a 3 or 5-day schedule of 500 mg/m(2) etoposide and 100 mg/m(2) cisplatin. Dose reduction of this regimen or use of carboplatin provide lower efficacy and should be abandoned. As a first line treatment, 3 cycles of BEP should be used in good-risk metastatic nonseminomatous germ cell tumours whereas 4 cycles of BEP are mandatory in poor-risk nonseminomatous cancers. No other chemotherapy regimen has proven superior efficacy. In the lack of specific controlled studies, metastatic seminoma should be treated as nonseminomatous tumours. As second line treatment, VeIP, high-dose chemotherapy with autologous stem cell transplantation and paclitaxel are the main options. Precise predictive factors of recurrence are needed to better define indications of first and other lines of treatment in specific situations such as non-resected residual seminoma.