Table 1 -IGCCCG classification:
There have been several attempts to improve the outcomes of poor-risk patients, but all randomized trials have been negative so far as shown in table 3. However, there is no doubt that widespread use of cisplatin chemotherapy has improved outcome. The utilization of postchemotherapy surgery has significantly helped in achieving this. Other important and beneficial factors include improved supportive care and increased use of guidelines and expert centers.
Table 2 –Improved outcomes over the years:
Table 3 - Negative randomized trials demonstrating attempts to improve outcomes:
Standard chemotherapy in these poor-risk patients includes BEP (cisplatin, etoposide, bleomycin) given for 4 cycles every 3 weeks irrespective of blood counts on the day of treatment. This should be given to patients with high HCG levels and extensive metastases. Full dose chemotherapy should start as soon as the patient recovers from the “mini” cycle (usually around day 10-14 days). The “mini” cycle is not standardized, and most commonly entails cisplatin 20 mg/m2 and etoposide 100 mg/m2 for 3-4 days. Most importantly, patients need to be treated at an expert center.
Next, Dr. Kollmannsberger discussed the management of brain metastases in poor-risk patients. There are currently no general guidelines for the treatment of these metastases. The treatment is based on the treating physician’s experience and preferences. Chemotherapy within a multimodality strategy remains the standard of care. The role of surgery and/or radiation in patients with synchronous brain metastases and complete remission to chemotherapy remains unclear. Patients with metachronous brain metastases and systemic relapse carry a very unfavorable prognosis and should be treated with multimodality therapy including high-dose chemotherapy.
When encountering residual lesions, they should be resected if bigger than 1 cm. If they are extra retroperitoneal and RPLND is planned – the RPLND should be done first, followed by their resection. If the resected RPLND specimen shows mature teratoma, further surgery of all residual lesions if technically feasible should be attempted. In contrast, if the RPLND shows necrotic tissue/fibrosis – the need for further resection of other residual sites is still controversial.
Concluding his talk, Dr. Kollmannsberger stated that there has been no significant breakthrough in testis cancer management in the last 20 years, but the prognosis has improved. This has been brought by reduction of treatment toxicity, better integration of various treatment modalities, and better prognostic models.
Most importantly, optimal treatment of poor-risk patients requires an expert center with expertise in various disciplines with the full cooperation and support of a multidisciplinary team.
Presented by: Christian K. Kollmannsberger, MD, BC Cancer–Vancouver Cancer Centre, British Columbia, Canada
Written By: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA @GoldbergHanan at the 2020 Genitourinary Cancers Symposium, ASCO GU #GU20, February 13-15, 2020, San Francisco, California