Treatment of Nonseminoma

Patients with nonseminomas should receive chemotherapy at diagnosis. These patients tend to have a large tumor volume at diagnosis and are usually symptomatic. Initial debulking surgery is rarely useful. Many high-risk patients qualify for clinical trials. Standard therapy is generally four courses of BEP (bleomycin, etoposide, and cisplatin).[1,2]

A randomized study comparing four courses of BEP with four courses of VIP (etoposide, ifosfamide, and cisplatin) showed similar overall survival (OS) and time-to-treatment failure for the two regimens in patients with advanced disseminated germ cell tumors who had not received previous chemotherapy.[3,4][Level of evidence A1] Of the 304 patients in this study, 66 had extragonadal primary tumors. In this subset of patients, responses to the two regimens were similar. Hematologic toxic effects in OS were substantially worse with the VIP regimen than with the BEP regimen.

Patients with a residual mass after chemotherapy may achieve long-term disease-free survival after postchemotherapy surgery with resection of all residual disease.[5][Level of evidence C2] Patients with nonseminomatous extragonadal germ cell tumors who relapse after front-line chemotherapy generally have poor prognoses with poor responses to salvage chemotherapy regimens, including autologous bone marrow transplant, that have had success for recurrent testicular cancer.[6-8] Such patients are candidates for studies of new approaches.