Management of metastatic germ cell tumors

Germ cell tumors are the most common solid malignancies to affect young adult men and incidence is increasing worldwide. The introduction of cisplatin-based combination chemotherapy in the late 1970s resulted in a dramatic improvement in the prognosis of patients with metastatic germ cell tumors, and overall cure rates in this group now exceed 80%. Randomized clinical trials and prognostic factors have guided treatment strategies over the last two decades. Clinical research for most advanced adult malignant diseases is driven by the need to improve response rates and prolong survival. The remarkable chemotherapy sensitivity of testicular germ cell cancers has revolutionized treatment results in the last 20 years, substantially altering the landscape in these tumors with greater than 80% cure rates routinely achievable. Furthermore, it seems unlikely that modifications in dose or scheduling of currently available drugs will improve the outlook for the small minority of poor-prognosis metastatic disease cases. Failing this there are real changes in our approach to these tumors that could enhance outcomes, including better supportive care, better service delivery and better public education. The choice of different platinum, and total dose of etoposide and bleomycin and their impact on the clinical outcome in context of various trials is discussed in detail in this review.