Testicular cancer usually responds well to front line chemohthrapy. Salvage therapy has been shown to induce long-term complete responses in about 25% of patients with disease that has persisted or recurred following other cisplatin-based regimens. Patients who have had an initial complete response to first-line chemotherapy and those without extensive disease have the most favorable outcome. However, the literature states that few, if any, patients with recurrent non-seminomatous germ cell tumors of extragonadal origin achieve long-term disease-free survival using vinblastine, ifosfamide, and cisplatin if their disease recurred after they received an initial regimen containing etoposide and cisplatin. High-dose chemotherapy with autologous bone marrow transplantation (ABMT) has been used with some success in the setting of refractory disease. Durable complete remissions may be attainable in 10 to 20% of patients with disease resistant to standard cisplatin-based regimens who are treated with high-dose carboplatin and etoposide with ABMT.
Patients with relapsed/refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse. Patients who do poorly despite ABMT have a mediastinal primary site, true cisplatin-refractory disease, disease progression before ABMT, and/or markedly elevated beta-HCG at ABMT. New treatment modalities are needed for the latter group. This observation is in accordance with the view of Flechon and associates (2001) that new strategies are needed to improve the survival rate of poor prognosis germ cell tumor patients. Tandem transplants is an attempt to improve respnse in these situations. However, NCCN does not list tandem transplants and they remain investigational at this time.
Patients with relapsed/refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse, as this patient does. High-dose chemotherapy has been shown in phase II trials to be an effective salvage strategy in poor-risk patients with a suggestion of an improvement in survival as compared to standard dose salvage chemotherapy, albeit through matched-pair analysis rather than randomized trials. High-dose chemotherapy has also been shown to be a potentially curative option for patients with second or subsequent relapses. NCCN lists autologous transplantation for this group.
Adra N, Abonour R, Althouse SK, Albany C, Hanna NH, Einhorn LH. High-Dose Chemotherapy and Autologous Peripheral-Blood Stem-Cell Transplantation for Relapsed Metastatic Germ Cell Tumors: The Indiana University Experience. J Clin Oncol. 2016;35(10):1096-1102.
Lori Wood et al, Canadian consensus guidelines for the management of testicular germ cell cancer. Can Urol Assoc J. 2010 Apr; 4(2): e19–e38