Management of the postchemotherapy residual mass

The role of surgery in patients with advanced germ-cell tumors after chemotherapy has evolved substantially in the era of combined modality therapy. In evaluating patients for surgery after chemotherapy, the clinician must consider carefully the histologic type (seminoma versus nonseminomatous germ-cell tumors) of the primary tumor as well as the extent of the residual disease. Criteria designed to select patients with non-seminomatous tumors in whom the surgical histologic findings are negative are associated with substantial error. A normal radiographic evaluation in patients with nonseminomatous germ-cell tumors is not entirely predictive of negative pathology findings, and the treating physician must consider the risk of residual tumor despite a radiographic complete remission. In contrast, patients with seminoma have less potential for residual tumor, and the size of the residual disease permits more accurate selection of patients who still have malignancy. Continued research is needed to improve the sensitivity and specificity of patient selection for surgery after chemotherapy in order to limit the toxicity of curative therapy.