Metastatic NSGCT (IGCCCG Poor Prognosis) After Dose-Dense Chemotherapy Failure
This protocol addresses the clinical scenario of metastatic non-seminomatous germ cell tumour (NSGCT) classified as IGCCCG poor prognosis, where the preceding intensified chemotherapy line did not achieve its required endpoints. The step described here follows that failure.
The IGCCCG poor prognosis classification applies when any of the following criteria are present: mediastinal primary site, non-pulmonary visceral metastases, AFP > 10,000 ng/mL, hCG > 50,000 IU/L, or LDH > 10 × the upper limit of normal.
The preceding treatment — a dose-dense (intensified) chemotherapy regimen replacing the remaining cycles of standard BEP — did not achieve normalisation of serum tumour markers (AFP, hCG, LDH) or the required radiological response on cross-sectional imaging. This unmet outcome is what triggers escalation to the present protocol.
Complete resection of residual masses.
References
- Any of the following criteria: Mediastinal primary, Non-pulmonary visceral metastases, AFP > 10,000ng/mL, hCG > 50,000 IU/L (10,000ng/mL), LDH > 10 x ULN.
- Treat metastatic NSGCT with a poor prognosis and favourable marker decline with four cycles of BEP.
- Perform surgical resection of visible (> 1cm in longest diameter) residual masses after chemotherapy for NSGCT when serum levels of tumour markers are normal or normalising.
- Residual masses after salvage chemotherapy or HDCT in first or subsequent salvage settings have a greater risk of harbouring active disease. Surgery is therefore indicated even for residual masses < 1cm.