[Salvage chemotherapy for advanced testicular cancer]

In general, 80% of advanced germ cell tumors (GCTs) with metastasis can be cured, since clinical treatment guidelines for testicular cancer has been established after the International Germ Cell Cancer Collaborative Group announcement in 1997. Of those with advanced GCTs, 20-30% of the cases are defined as 'difficult-to-treat' GCTs. In particular, inadequate induction chemotherapy might result in "refractory" or "resistant" GCTs. In such cases, salvage chemotherapy will be required. Long-term survival can be guaranteed in 30% of the cases treated by conventional VIP (etoposide, ifosfamide, cisplatin) or VeIP (vinblastine, ifosfamide, cisplatin) therapy. Previously, high-dose chemotherapy (HDCT) was attemped to gain better results as induction therapy, but has not been shown to be superior to conventional chemotherapy. Furthermore a randomized control trial failed to show the superiority of HDCT as an induction therapy. Therefore, new drugs such as paclitaxel, gemcitabine and irinotecan have been used as salvage chemotherapy. Especially, TIP (paclitaxel, ifosfamide, cisplatin) therapy has become a new treatment option as first salvage chemotherapy in patients with favorable features such as testis primary and first relapse after complete remission. Regarding gemcitabine or irinotecan, some regimens have been reported in combination with oxaliplatin or paclitaxel. These studies were performed using multi-regimen chemotherapy, so the efficacy was limited. According to the Japanese guidelines for testicular cancer TIP therapy is recommendation grade B and gemcitabone-containing therapy is grade C. Currently, it is very difficult to conduct a randomized control trial on a large scale in a salvage setting. It is necessary to accumulate a number of cases with advanced GCTsin high-volume centers.