Late recurrences in long-term survivors of germ cell neoplasms

Patients with germ cell neoplasms who are in complete remission 2 years after treatment have a very high probability of cure, and reports of recurrences occurring after 2 years are rare. Of 81 testicular cancer patients treated for advanced disease at Vanderbilt University between 1970 and 1985, five developed a recurrent or metachronous germinal tumor 58 to 195 months after the initial treatment. Only two of these patients had received prior cisplatin-based combination chemotherapy. Four patients had unfavorable prognostic features when tumor recurrence was diagnosed. All five patients responded to salvage chemotherapy, although there were only two complete responses. The extent of disease was a significant factor in predicting response to salvage therapy. The possible mechanisms of development of a late recurrence of germinal neoplasms include the following: (1) malignant degeneration of mature teratoma to germinal malignancy; (2) growth of an occult testicular tumor not eliminated by chemotherapy due to the presence of a blood-testicular barrier; (3) development of a second primary germ cell neoplasm; or (4) late relapse due to persistent microscopic viable tumor with an atypical less aggressive biologic behavior. "Cured" germ cell tumor patients need careful follow-up beyond 2 years. At a minimum, these patients should be seen annually. Patients found to have teratomas following cisplatin-based chemotherapy should probably undergo more frequent evaluations.