Cancer. Patients who present with widely metastatic germ cell tumors (GCTs) are characteristically treated with cisplatin-based chemotherapy. Depending on the patient population selected, approximately 70% of these patients will obtain a complete clinical response, with normalization of serum tumor markers and the complete resolution of all metastatic disease. The policy at Indiana University has been to observe these patients because only 3% to 5% will develop disease recurrence. 2 Those patients not achieving a complete clinical response, with residual radiographic tumor and serum tumor marker normalization, routinely undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). Pathology of the residual tumor mass at postchemotherapy surgery consists of necrosis in 45% of cases, teratoma in 45% of cases, and cancer in 10% of cases.
The surgical resection of necrotic tissue after chemotherapy offers no therapeutic benefit to the patient. Therefore, postchemotherapy surgery with the finding of necrosis is a staging procedure only. The rate of disease recurrence in this population is <5% and we would not typically reimage the retroperitoneum and follow the patient only with physical examination, chest imaging, and serum tumor markers. Donohue and Foster reported a 93% progression-free survival rate for patients harboring fibrosis only at the time of PC%RPLND. 3 Researchers at the Memorial Sloan-Kettering Cancer Center recently reported recurrence rates for resected fibrosis in 150 patients treated between 1989 and 1997 and 113 patients treated between 1998 and 2003. 4 The 5-year disease-free survival rate was 83% and 95%, respectively, for men treated between these 2 time periods. Ideally, patients with known residual fibrosis would be excluded from surgery although currently we are unable to accurately predict necrosis with the use of clinical parameters. The European Organization for Research and Treatment of Cancer/Medical Research Council (EORTC/MRC) recently assessed the external validity of a prediction rule developed to predict the probability of retroperitoneal metastases being necrosis only after chemotherapy. 5 Patients with a high probability of necrosis might be offered surveillance as opposed to surgery. Criteria used to calculate the probability of benign histology included: the absence/presence of teratoma in the primary tumor, See referenced original article on pages 2700-8, this issue.