Nonseminoma
Mediastinal Nonseminoma
Retroperitoneal Nonseminoma
Current Clinical Trials
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
Patients with nonseminomas should receive chemotherapy at diagnosis. These
patients tend to have a very 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 would generally be considered to be 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 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: 1iiA] Of the 304 patients on this study, 66 patients had extragonadal primary tumors, and in this subset
of patients, responses were similar on the two regimens. Hematologic toxic effects in the
overall study 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: 3iiiDii] 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 transplantation, that have had success for recurrent testicular
cancer.[6-8] Such patients, therefore, are candidates for studies of new
approaches.
Mediastinal Nonseminoma
Mediastinal nonseminomas have certain unique aspects. The tumors are more frequent in
individuals with Klinefelter syndrome and are associated with a risk of
subsequent development of hematologic neoplasia that is not treatment related.[9,10] Approximately 50% of patients with mediastinal nonseminomas will survive with appropriate
management.[11] High risk is partially related to tumor bulk, to chemotherapy
resistance, and to a predisposition to develop hematologic neoplasia and other
nongerm cell malignancies.
In an uncontrolled study, some patients with a postchemotherapy residual mediastinal mass achieved long-term disease-free survival after complete resection, even when serum tumor markers were elevated.[5][Level of evidence: 3iiiDii] Patient selection factors may play a role in these favorable outcomes.
Retroperitoneal Nonseminoma
The prognosis of retroperitoneal nonseminoma is reasonably good and, similar to
the situation with nodal metastasis from a testicular primary, is related to
tumor volume.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with malignant extragonadal non-seminomatous germ cell tumor. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References
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Williams SD, Birch R, Einhorn LH, et al.: Treatment of disseminated germ-cell tumors with cisplatin, bleomycin, and either vinblastine or etoposide. N Engl J Med 316 (23): 1435-40, 1987.
[PUBMED Abstract]
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Bosl GJ, Gluckman R, Geller NL, et al.: VAB-6: an effective chemotherapy regimen for patients with germ-cell tumors. J Clin Oncol 4 (10): 1493-9, 1986.
[PUBMED Abstract]
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Nichols CR, Catalano PJ, Crawford ED, et al.: Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: an Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group B Study. J Clin Oncol 16 (4): 1287-93, 1998.
[PUBMED Abstract]
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Hinton S, Catalano PJ, Einhorn LH, et al.: Cisplatin, etoposide and either bleomycin or ifosfamide in the treatment of disseminated germ cell tumors: final analysis of an intergroup trial. Cancer 97 (8): 1869-75, 2003.
[PUBMED Abstract]
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Schneider BP, Kesler KA, Brooks JA, et al.: Outcome of patients with residual germ cell or non-germ cell malignancy after resection of primary mediastinal nonseminomatous germ cell cancer. J Clin Oncol 22 (7): 1195-200, 2004.
[PUBMED Abstract]
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Saxman SB, Nichols CR, Einhorn LH: Salvage chemotherapy in patients with extragonadal nonseminomatous germ cell tumors: the Indiana University experience. J Clin Oncol 12 (7): 1390-3, 1994.
[PUBMED Abstract]
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Beyer J, Kramar A, Mandanas R, et al.: High-dose chemotherapy as salvage treatment in germ cell tumors: a multivariate analysis of prognostic variables. J Clin Oncol 14 (10): 2638-45, 1996.
[PUBMED Abstract]
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Loehrer PJ Sr, Gonin R, Nichols CR, et al.: Vinblastine plus ifosfamide plus cisplatin as initial salvage therapy in recurrent germ cell tumor. J Clin Oncol 16 (7): 2500-4, 1998.
[PUBMED Abstract]
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Nichols CR, Heerema NA, Palmer C, et al.: Klinefelter's syndrome associated with mediastinal germ cell neoplasms. J Clin Oncol 5 (8): 1290-4, 1987.
[PUBMED Abstract]
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Nichols CR, Roth BJ, Heerema N, et al.: Hematologic neoplasia associated with primary mediastinal germ-cell tumors. N Engl J Med 322 (20): 1425-9, 1990.
[PUBMED Abstract]
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Nichols CR, Saxman S, Williams SD, et al.: Primary mediastinal nonseminomatous germ cell tumors. A modern single institution experience. Cancer 65 (7): 1641-6, 1990.
[PUBMED Abstract]
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