Management of advanced and extragonadal germ-cell tumors.

The management of patients with advanced and extragonadal germ-cell tumors is similar in many respects to that of the group with minimal or moderate disease. Initial chemotherapy consisting of a cisplatin-based regimen followed by surgical removal of residual disease or teratoma is utilized. The principal reason for failure of therapy is the presence of bulky disease not responding completely to chemotherapy. Unresectable residual teratoma after chemotherapy may also be responsible for therapeutic failure in this patient group. Additionally, the presence of non-germ-cell elements that are chemoresistant may be a third reason for failure. Despite previous reports and these recognized problems, recent studies indicate that this group of patients can be rendered disease free in more than 65% to 70% of instances. Therefore, these patients should be considered potentially curable, and aggressive multimodality therapy employed. Clinical trials of newer agents such as ifosfamide and procedures such as autologous bone marrow transplantation after intensive chemotherapy are under way to define their roles in patients with advanced disease.