Management of Difficult Germ-Cell Tumors: Review 2
Although testicular cancer is a rare disease accounting for only 1% of all male neoplasms, it represents a paradigm for cancer curability. Overall, more than 95% of patients can expect to be cured of their disease with minimal long-term toxicity. Given these expectations, it is critical that cancer care providers are familiar with the diagnostic and therapeutic challenges encountered in these rare patients. In particular, clinicians managing these patients should be aware of some of the pitfalls encountered when determining relapse. In a series of case presentations, we review the evaluation and management of patients with persistent elevation of serum tumor markers and postchemotherapy residual radiographic abnormalities.
These three case reports illustrate some nuances in the care of testis cancer patients. Although the treatment paradigm for standard good-risk metastatic disease is fairly well delineated, some patients unfortunately do not conform to these standard treatment schemes and, therefore, require more individualized recommendations for therapy.
The first case illustrates the fact that some patients can be cured surgically even after failing all available chemotherapy. This has been recognized by several groups of physicians treating testis cancer patients in the United States, the United Kingdom, Europe, and elsewhere. Though expertise in testis cancer surgery is important in the therapy of these patients with elevated tumor markers, even more important is appropriate patient selection for these procedures. It is imperative that these patients be seen by medical oncologists familiar with complicated testis cancer patients in order to achieve the outcomes mentioned in the discussion following the first case report.
Other Take-Home Points
The surgical resection of teratoma after chemotherapy is the focus of case 2. These procedures can be challenging, but the treatment outcome can be very gratifying if all tumor can be resected. Surgeons attempting such resections of moderate- and high-volume teratoma should be comfortable with surgery of the retroperitoneum and great vessels, and must have the stamina and determination to conclude procedures that sometimes last several hours. Intraoperative judgement and decisions are very important in these complicated procedures, and the surgeon must be flexible enough to alter his "game plan" if intraoperative findings do not conform to what he expected based on the preoperative computed tomography (CT) scan.
The third case also illustrates the importance of making sound judgments in these sometimes complicated patients. At Indiana University Cancer Center, we, too, have seen patients with minimally elevated tumor markers who did not actually have recurrent cancer. Indeed, we have seen patients with falsely elevated tumor markers who have received unnecessary chemotherapy.
Conclusions
The authors are to be congratulated on these case presentations. Each illustrates the necessity for the treating physician to have an open mind and to consider all possibilities in complicated testis cancer patients. Although I have had the privilege of providing care to many testis cancer patients, I continue to be amazed at how often I am wrong if I jump to conclusions instead of taking a step back, slowing down, and considering all the possibilities.
Richard Foster, MD
Disclosures:
The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
