What is the treatment for a germ cell tumor?

From the Guidelines

The treatment for germ cell tumors should involve a combination of surgery and chemotherapy, with the BEP regimen (bleomycin, etoposide, and cisplatin) being the most widely used and recommended chemotherapy regimen, particularly for 3-4 cycles, as supported by the most recent and highest quality study 1.

Treatment Overview

The treatment approach for germ cell tumors depends on the type, location, and stage of the tumor. Surgery is typically the first step, aiming to remove the entire tumor if possible. For ovarian germ cell tumors, this may involve removal of the affected ovary or more extensive surgery, while considering fertility preservation options.

Chemotherapy

Chemotherapy regimens containing platinum agents like cisplatin are commonly used. The BEP regimen, which includes bleomycin, etoposide, and cisplatin, is the most widely recommended chemotherapy regimen for germ cell tumors, as indicated by the 2018 study 1. This regimen has shown excellent cure rates, particularly for testicular germ cell tumors, with success rates exceeding 90% even in advanced cases.

Fertility Preservation and Monitoring

Fertility preservation options should be discussed before treatment begins, as both the disease and its treatments can affect reproductive function. Regular monitoring with tumor markers (AFP, beta-hCG, LDH) and imaging studies is essential throughout treatment. Long-term follow-up is crucial due to potential late effects of treatment, including secondary cancers and cardiovascular complications.

Specific Recommendations

• For patients with stage I dysgerminoma or stage I, grade 1 immature teratoma, observation with surveillance is recommended after surgery, as per the guidelines 1.
• For patients with stage II to IV malignant dysgerminomas or immature teratomas, postoperative chemotherapy with the BEP regimen is recommended 1.
• The use of bleomycin should be cautious, especially in patients over 40 years of age or those with pre-existing pulmonary disease, due to the risk of drug-related lung injury 1.

Key Considerations

• The optimal number of cycles of BEP has not been fully established but typically ranges from 3 to 4 cycles, depending on the disease stage and patient factors 1.
• Alternative chemotherapy regimens, such as POMB/ACE and CBOP/BEP, have been evaluated but lack direct comparison with BEP in randomized trials 1.
• For patients with platinum-sensitive relapse, ifosfamide/platinum with or without paclitaxel should be considered as second-line treatment 1.

From the FDA Drug Label

Ifosfamide for Injection, used in combination with certain other approved antineoplastic agents, is indicated for third line chemotherapy of germ cell testicular cancer.

A germ cell tumor is treated with chemotherapy, specifically with ifosfamide in combination with other approved antineoplastic agents, as a third-line treatment for germ cell testicular cancer 2.

• The treatment regimen may include a combination of ifosfamide with cisplatin and either vinblastine or etoposide 2.
• Surgical resection may also be used to render patients free of cancer after treatment with the ifosfamide regimen 2.

From the Research

Treatment Options for Germ Cell Tumors

• The treatment of germ cell tumors depends on the stage and type of tumor, with options including surgery, radiation therapy, and chemotherapy 3, 4, 5, 6, 7.
• For stage I testicular seminoma, management options include irradiation, surveillance, or chemotherapy, with adjuvant irradiation being the standard of care but associated with late complications such as cardiotoxicity and second malignancy 3.
• For non-seminoma tumors, options include active surveillance, retroperitoneal lymph node dissection (RPLND), or 1-2 cycles of bleomycin plus etoposide plus cisplatin (BEP) 5.

Chemotherapy Regimens

• The BEP regimen is the most recommended chemotherapy for metastatic disease, with a cure rate of approximately 90% for good-risk patients 4, 6, 7.
• Other chemotherapy regimens, such as EP or VIP, may be used to avoid bleomycin in some patients, and salvage treatment options include conventional-dose chemotherapy (TIP) and/or high-dose chemotherapy 4, 6, 7.

Surgical Management

• Orchiectomy is the main diagnostic procedure and is also curative for most localized tumors 4, 5.
• Retroperitoneal lymph node dissection (RPLND) is an option for non-seminoma tumors, and surgery after chemotherapy is essential for removing residual masses 4, 5, 6.

Follow-up and Risk Stratification

• Routine follow-up after irradiation and the role of risk stratification remain unclear, but efforts should be made to avoid unnecessary delays and dose reductions wherever possible 3, 4.
• Patients at high risk of relapse, those with refractory tumors, or those who relapse after chemotherapy should be managed by multidisciplinary teams in experienced centers 4.