Stage migration and pilot studies of reduced chemotherapy supported by positron-emission tomography findings suggest new combined strategies for stage 2 nonseminoma germ cell tumour

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OBJECTIVETo examine the nodal (N+) vs extranodal (M+) staging in each of the International Germ Cell Consensus Classification Group (IGCCCG) subgroups in an audit of 437 patients treated in The Anglian Germ Cell Cancer Group, where chemotherapy was the primary management, as there is an increasingly earlier presentation of patients with less advanced disease who thus face potentially unnecessary treatment.PATIENTS AND METHODSClinicians from seven centres prospectively registered patients in a central database, and the follow-up was coordinated by one of the authors.RESULTSBetween 1982 and 2002, 436 patients (median follow-up 60 months) were registered; 63% of IGCCCG good risk (298), 42% of intermediate (62) and 8% poor risk (77) were stage II; 79% of N+M0 intermediate and poor risk cases (29) were alive, vs only 60% of M+ stage IV cases (92, P < 0.05). The trend was similar in IGCCCG good risk patients, with 92% of N+ stage II (156) alive vs only 85% (94) of stage IV M+ (not significant). The frequency of retroperitoneal lymph node dissection after chemotherapy increased from 26% (1983–1993) to 34% (1994–2002), and survival from 89% to 94%. There were no relapses in eight patients who elected to stop treatment after two courses. Four of six patients with positive findings on positron emission tomography had a durable complete response, assessed by standard uptake values, when tested at 72–96 h.CONCLUSIONExtra-lymphatic spread, although prognostically important within the IGCCCG subgroups, is only statistically significant for intermediate and poor risk combined. The observation that there might be N+ patients cured by two chemotherapy courses alone suggests that there might be opportunities to reduce the morbidity of treatment.

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