Complicated problems in testicular cancer.

Although testicular cancer is a relatively rare disease, it nevertheless is extremely important, as it has become a model for a curable neoplasm. Cisplatin combination chemotherapy has revolutionized the cure rate in this once highly lethal disease: Today over 90% of all patients are cured of their disease, including an 80% cure rate in disseminated testicular cancer. However, these dramatic advances have created a new set of questions relating to the proper management of clinical stage I disease, challenging the role of retroperitoneal lymph node dissection (RPLND) in such patients. Despite the potential value of a surveillance policy, we continue to advocate routine RPLND for clinical stage I nonseminomatous germ cell tumors. Salvage chemotherapy has been refined and improved with the availability of new active agents such as ifosfamide. Dosage intensity is very important in oncology, and this concept is also being tested in refractory testicular cancer with very high-dose carboplatin plus etoposide with autologous bone marrow transplantation. We are currently in the enviable position in testicular cancer where we can now concentrate on small subsets of patients with advanced disseminated disease and evaluate innovative aggressive regimens. We expect future fine-tuning to provide continued improved therapeutic index in testicular cancer patients.