Prognostication After Chemotherapy

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Much experience has been gained in predicting outcomes of patients who complete chemotherapy and in regard to adjunctive therapies following chemotherapy. In particular, post-chemotherapy surgical findings have been analyzed in efforts to identify those who are at high risk for additional events.

Foster and colleagues recently reported the role of retroperitoneal lymph node dissection (RPLND) in patients with persistently elevated markers after the completion of standard chemotherapy for disseminated disease. Of those patients with persistently elevated markers and residual radiographic abnormalities, all were able to undergo complete resection. Approximately one-third of the patients were disease free with either surgery alone or surgery plus post-surgery chemotherapy, with a minimum follow-up of 24 months.18

Patients who have an incomplete radiographic response to chemotherapy but a normalization of elevated serum biomarkers frequently undergo post-chemotherapy resection of residual disease. A number of attempts to characterize the nature of postchemotherapy radiographic abnormalities have been undertaken. The histologic characteristics of the primary, the percentage of radiographic response, and the IGCCC designation can provide rough guidelines as to the chances of finding residual cancer or teratoma, but the performance characteristics of these predictive parameters are insufficiently precise to be useful in the day-to-day management of patients. However, it is well known that histologic findings at postchemotherapy surgery are predictive of risk of relapse. Patients who undergo resection of large-volume teratoma have a significant chance (up to 30%) of developing recurrent teratoma and require additional surgery. Patients who have residual viable germ cell elements have up to a one-in-three chance of developing recurrent germ cell tumor. Therefore, the current recommendation at Indiana University is that additional chemotherapy (usually two additional cycles of EP) should be administered to those patients with residual germ cell cancer in the resected specimen after primary chemotherapy. The absolute contribution of additional chemotherapy in this setting is somewhat speculative, but this represents the standard of care at Indiana University.

New functional imaging modalities such as positron emission tomography (PET) have been investigated in attempts to characterize postchemotherapy residual masses. To date, PET has been insufficiently discriminatory, especially in being able to distinguish teratoma from residual cancer in order to guide decisions regarding surgery after chemother-apy.19(See also Chapters 6 and 11.)

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