Conservative management of testicular germ-cell tumors

Cure rates of germ-cell cancer have been greater than 95% for the last decade; therefore, over the past few years there has been a greater focus on 'conservative' approaches to treatment. The increased incidence of late non-germ-cell cancers in the era of radiotherapy and the incidence of subclinical testicular deficiency and metabolic syndrome in cured patients have accelerated this trend. Taking account of the increase in cure rates of primary chemotherapy failures from 5% to 60% with intensification of chemotherapy and surgery, this Review focuses on three areas: lessons from the initial failed trials of less-intensive treatment (i.e. bleomycin withdrawal and carboplatin substitution) that emphasised the need for improved salvage therapy; successes of reducing treatment of patients with metastases classed as good-risk from four cycles(20 days) to three cycles(9 days) and using 1 day carboplatin instead of 21 day radiotherapy as adjuvant for stage 1 seminoma; and the unexpected finding at 5 years of a 72% reduction of contralateral second germ-cell cancer. This finding provides the stimulus for the next generation of conservative trials using organ preservation, aiming to reduce occurrence of metabolic syndrome and using new radiological and minimal surgery techniques to accelerate the assessment of less toxic drugs and new approaches for combined medial and surgical treatment.