The Role of Surgery in the Management of Recurrent or Persistent Non-seminomatous Germ Cell Tumors

ObjectiveTo review the management of patients with non-seminomatous germ cell tumors (NSGCTs) with persistent or recurrent disease following primary or secondary therapy, with particular attention devoted to the role of surgery.MethodsA non-structured review of the literature until January 2007 was performed using the PubMed database.ResultsThe management of persistent or recurrent disease among patients with NSGCT depends on stage at presentation and relapse, serum tumor marker levels at relapse, prior therapy, and timing of relapse. Clinical stage I patients who relapse following active surveillance are usually treated with induction chemotherapy. Likewise, patients who relapse following primary retroperitoneal lymph node dissection (RPLND) are treated with induction chemotherapy based on the systemic pattern of recurrence. Advanced cases with residual radiographic disease >1 cm and normal tumor markers following induction chemotherapy are generally recommended for postchemotherapy surgical resection, whereas those with persistently elevated markers undergo salvage chemotherapy. Select patients with resectable disease and elevated serum tumor markers may be appropriate candidates for surgery. Based on intrinsic chemoresistance, the treatment of patients with advanced disease who relapse >2 yr (late relapse) following successful chemotherapy is primarily surgery.ConclusionPatients with NSGCTs with persistent disease or recurrence within 2 yr of initial therapy remain highly curable. The prognosis of patients with late relapse is compromised based on tumor chemoresistance. The role of surgery in the management of recurrent disease is primarily limited to the postchemotherapy setting; however, in the context of late relapse it often represents the primary treatment.