Surgery

A small percentage of patients treated with chemotherapy may have normalization of tumor markers with a less-than-complete radiographic response. Occasionally, a mass continues to expand in size even though tumor markers may have normalized. This condition, designated as growing teratoma syndrome, represents an accelerated growth of the mature teratoma components during or after treatment.[2,12-14] In such circumstances, complete surgical resection is the treatment of choice, as it provides histological confirmation and exclusion of mixed germ cell tumor components.

A SIOP trial identified a significant OS advantage for patients without residual disease (5-year PFS rate, 85% ± 0.04% vs. 48% ± 0.07%), which underscores the important role of second-look surgery after chemotherapy and before irradiation.[3]

A second-look surgery can help determine whether the residual mass contains teratoma, fibrosis, or residual NGGCT.[7,15] If second-look surgery finds mature teratoma or fibrosis after chemotherapy, the general approach is to proceed with radiation therapy as if the patient had achieved a CR to chemotherapy. However, if an active tumor is observed, then alternative treatment approaches are generally considered.[2]