Surgery and chemotherapy (stages I–IV)

Surgery and chemotherapy with four cycles of standard cisplatin, etoposide, and bleomycin (PEb) is one treatment option. Patients with stage I and stage II disease treated with this regimen had an overall survival (OS) rate of 90%, suggesting that a reduction in therapy may be considered.[1,4] Patients with stage III and stage IV disease had OS rates of higher than 80%.[1]

An alternative treatment option is surgery and chemotherapy with carboplatin, etoposide, and bleomycin (JEb).[5] Stage III and stage IV patients treated with JEb had an OS rate similar to that with the PEb regimen.[5]

Two pediatric intergroup trials for patients with high-risk disease investigated the use of high-dose cisplatin (200 mg/m2) in a randomized study and a subsequent study that added amifostine to high-dose cisplatin.[1] No benefit in OS was observed, and 75% of patients required hearing aids. A Children's Oncology Group (COG) trial of patients with high-risk disease investigated the addition of cyclophosphamide to standard-dose PEb. The addition of cyclophosphamide was feasible and well tolerated at all dose levels, but there was no evidence that adding cyclophosphamide improved efficacy.[6]