Intermediate-Prognosis Metastatic NSGCT: Protocol After Retroperitoneal Lymph Node Dissection Fails to Achieve Complete Resection
This protocol addresses patients with non-seminomatous germ cell tumour (NSGCT), metastatic disease in the IGCCCG intermediate prognosis group, in whom prior retroperitoneal surgery has not achieved complete resection of residual masses.
Clinical Scenario
The IGCCCG intermediate prognosis classification applies when the primary site is testis or retroperitoneal and there are no nonpulmonary visceral metastases, combined with at least one of the following serum tumour marker elevations:
- Alpha-fetoprotein (AFP) 1,000–10,000 ng/mL
- hCG 5,000–50,000 IU/L
- LDH 1.5–10 × upper limit of normal
Previous Treatment and Failure Condition
The preceding step — surgical resection of residual retroperitoneal masses greater than 1 cm (bilateral nerve-sparing retroperitoneal lymph node dissection) — did not reach its primary goal of complete resection of residual masses. Failure to achieve that endpoint is the indication for this protocol.
Next Treatment Approach
Salvage chemotherapy with a platinum- and ifosfamide-based multi-agent regimen is indicated. The clinical goals are normalization of serum tumour markers and complete or partial radiological response. The full regimen — including agent selection and cycle structure — is set out in the complete protocol.
References
Any of the following criteria: Testis/retro-peritoneal primary, No nonpulmonary visceral metastases. And any of the following criteria: AFP 1,000 - 10,000ng/mL or hCG 5,000 - 50,000 IU/L or LDH 1.5-10 x ULN.
The regimens of choice are four cycles of a three-agent regimen including cisplatin and ifosfamide plus a third drug: etoposide (VIP), paclitaxel (TIP), or potentially gemcitabine (GIP).