Germ cell tumors are among the most chemotherapy-sensitive solid tumors. The expectation for cure exceeds 95% for those patients presenting with testicular cancer.1 In the subset of patients with disseminated disease, cure with chemotherapy is slightly less reliable, despite dramatic advances since the introduction of cisplatin-based combination chemotherapy.12 Depending on presenting prognostic features, 40 to 90% of patients are cured with primary chemotherapy with or without postchemotherapy surgery.1-4 For those patients who do not achieve disease-free status after first-line treatment or for those who relapse after primary chemotherapy, the outlook is considerably less hopeful. Conventional-dose salvage chemotherapy in combination with resection of residual masses produces second complete remissions in 30 to 60% of patients, but less than half of these remissions are durable.5 Overall, approximately 25% of patients are cured with second-line standard therapy, and 15% are cured with third-line therapy using high-dose chemotherapy and stem cell transplantation. Certain prognostic factors predict exceedingly poor outcomes with salvage therapies; these factors include cisplatin-refractory disease, extragonadal primary, and failure of two or more lines of chemotherapy.6-8 Patients with these prognostic features, who have little hope of durable response to the currently available salvage therapies, are candidates for trials of novel agents.
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