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Darren R. Feldman, MD; George J. Bosl, MD; Joel Sheinfeld, MD; Robert J. Motzer, MD

JAMA. 2008;299(6):672-684.

Context  The medical treatment of advanced testicular germ cell tumors has changed over the past 30 years, with long-term survival now achieved in the majority of patients. Clinicians need to be familiar with the available treatment regimens for testicular cancer and their associated toxic effects.

Objective  To review the treatments used for advanced testicular germ cell tumors and their associated short-term and long-term complications.

Evidence Acquisition  A search was performed of all English-language literature (1966 to October 2007) within the MEDLINE database using the terms neoplasms, germ cell, or embryonal or testicular neoplasms restricted to humans, drug therapy, complications, and mortality. The Cochrane Register of Controlled Trials Databases (through October 2007) was also searched using the terms testicular cancer or germ cell tumors. Bibliographies were reviewed to extract other relevant articles. One hundred eighty-six articles were selected based on pertinence to advanced testicular cancer treatment, associated complications, and late relapses with an emphasis on randomized controlled trials.

Data Synthesis  The treatment of advanced testicular germ cell tumors with cisplatin combination chemotherapy is based on risk stratification (good, intermediate, or poor prognosis) according to pretreatment clinical features of prognostic value. Clinical trials have demonstrated that approximately 90% of patients classified as having a good prognosis achieve a durable complete remission to either 4 cycles of etoposide and cisplatin or 3 cycles of cisplatin, etoposide, and bleomycin. Complete responses are achieved less frequently for patients with intermediate- and poor-risk germ cell tumors, in whom 4 cycles of bleomycin, etoposide, and cisplatin remains the standard of care. Second- and third-line programs, including high-dose chemotherapy, also have curative potential. Chronic toxicities associated with therapy include cardiovascular disease, infertility, and secondary malignancies. Late relapses may also occur.

Conclusions  Clinical trials have led to evidence-based treatment recommendations for advanced testicular cancer based on risk stratification. Clinicians should be familiar with the potential complications of these therapies.

Author Affiliations: Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine (Drs Feldman, Bosl, and Motzer) and Urology Service, Department of Surgery (Dr Sheinfeld), Memorial Sloan-Kettering Cancer Center, and Department of Medicine (Drs Bosl and Motzer) and Department of Surgery (Dr Sheinfeld) Weill Medical College of Cornell University, New York, New York.

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