Management of advanced germ-cell tumors of the testis.

Advanced tumors of the testis are curable. Standard treatment includes chemotherapy with a combination of bleomycin, etoposide and cisplatin, followed by surgical resection of residual tumor. The number of cycles of chemotherapy needed depends on prognostic factors such as the primary site, histology, presence of visceral metastases, and serum levels of tumor markers. Patients with a favorable risk profile receive three cycles of chemotherapy, and those with increased risk receive four cycles. After chemotherapy, resection of all residual local disease and systematic retroperitoneal dissection of bulky lymph-node disease are mandatory for patients with nonseminoma germ-cell tumors. In patients with seminoma, surgery is required when residual disease is either bulky or functional on (18)fluorodeoxyglucose-PET scan. When complete resection of necrosis, teratoma and/or active germ-cell cancer has been done, no further treatment is needed. The consequences of therapy are complex: treatment could affect fertility, sexuality, metabolic status and renal and neurological function. Secondary malignancies are reported, as well as contralateral germ-cell tumors. Owing to the complexity of treatment and the multidisciplinary approach required, patients with advanced germ-cell tumors should be managed in high-volume centers with experience of treating large numbers of patients.