The case for relevant staging of germ cell tumors

Successful treatment of germ cell tumors arising in the testes or extragonadal sites has become routine. The therapeutic approaches available for patients with germ cell tumor are determined by stage, histology, and site of tumor origin. Staging systems have played an important role in the development of therapy for patients with germ cell tumors. Staging systems must address not only the prognostic variables that determine survival but also the correct therapeutic approach available for such patients (surgery, chemotherapy, surgery plus chemotherapy). Trials are under way in many centers with the intention of reducing the intensity of therapy for patients with a good prognosis and increasing the intensity for those with a poor prognosis. The ability to compare data and, more importantly, to select safely and appropriately those patients to be placed at risk by reduced or increased intensity of therapy will require clinically relevant staging systems. Histologic type and the site of tumor origin markedly determine the clinical dilemmas existing for each group of patients. The subgroup with pure seminoma has tumors with a unique spectrum of sensitivity and toxicity to chemotherapy. A staging system for such patients must be necessity be designed specifically to meet their needs. Patients with nonseminomatous germ cell tumors have benefitted most from the introduction of chemotherapy. Tumor volume, histologic types, and site of origin greatly influence the results of treatment. Staging systems must be developed that meticulously evaluate tumor volume, secretion of serum biomarkers, and site of origin of tumor. The results of the M.D. Anderson Cancer Center experience treating germ cell tumors support the use of such clinically relevant staging systems. The therapeutic dilemmas outlined for each of the histologic subtypes will serve as the basis of future studies.