%0 Journal Article
%T Management of Refractory Germ Cell Cancer
%A Anja Lorch
%A MD
%J About the Ed Book | ASCO Educational Book
%D 2018
%R https://doi.org/10.1200/EDBK_201189
%X Over the past 5 decades, the use of well-validated, guideline-based strategies has resulted in high cure rates in newly diagnosed patients with germ cell cancer (GCC). However, about 30% of those with metastatic disease at initial presentation, corresponding to about 5% to 10% of all patients with GCC, will experience refractory disease with progression or recurrence at some time point and need for further therapy. Salvage treatment is far more complex and less validated than first-line treatment because it is rare, patient cohorts are more heterogeneous, and prognostic factors seem to have greater impact. Prior to the initiation of any salvage treatment, several considerations must be made: verification that first-line treatment has failed, search for metastatic sites and extent of disease, assessment of known prognostic factors, and finally choice of the optimal salvage strategy. Careful patient selection will be required to avoid overtreatment and unnecessary long-term toxicity. SPECIAL CONSIDERATIONS Section: ChooseTop of pageAbstractSPECIAL CONSIDERATIONS <<EVALUATION OF PATIENTS PR...PROGNOSTIC FACTORS FOR FI...CONVENTIONAL-DOSE CHEMOTH...HDCT AND THE SEARCH FOR A...SEQUENTIAL HDCT VERSUS SI...CDCT OR HDCT AS FIRST SAL...SECOND OR SUBSEQUENT SALV...FUTURE DIRECTIONSCONCLUSIONSReferences Patients who progress or relapse during active surveillance or after adjuvant chemotherapy for stage I disease are no candidates for any salvage treatment. Such patients should be managed according to the algorithms for primary metastatic disease depending on their initial histology and their stage at the time of progression.1 Salvage treatment should also not be given in patients who respond well but remain positive for the serum tumor markers alpha-fetoprotein or human chorionic gonadotrophin after completion of first-line treatment. Although some will eventually progress, others will develop a plateau or even normalize their markers later on and should be scheduled for resection of residual tumors.2 However, if the markers start to increase, salvage chemotherapy is mandatory.3 A dilemma exists for patients with evidence of high percentage of vital tumor after residual tumor resection. On the basis of retrospective analyses and the higher risk for relapse, two additional adjuvant cycles have been recommended by some authors.4 However, the benefit of this approach has never been prospectively validated. Alternatively, close follow-up of such patients can be done, and further treatment can be given only to those patients who progress during follow up. There are two
%U http://ascopubs.org/doi/full/10.1200/EDBK_201189