Editing Germ Cell Tumours (section)

===== Special scenarios =====

====== Residual masses after chemotherapy for NSGCT ======

* After receiving first-line cisplatin-based chemotherapy, 5-15% of patients will have partial remission with positive tumour markers or have disease progression.
* '''<span style="color:#ff0000">Management</span>'''
** '''<span style="color:#ff0000">If serum tumour markers elevated after induction chemotherapy, in general patients should receive salvage chemotherapy</span>'''
** ''''<span style="color:#ff0000">If serum tumour markers normal and</span>'''
*** ''''<span style="color:#ff0000">Residual mass >1 cm: resection of residual mass</span>'''
*** ''''<span style="color:#ff0000">Residual mass <1 cm: controversial management</span>'''
** If the mass was retroperitoneal, a full bilateral template RPLND should be performed.
** '''<span style="color:#ff0000">PC-RPLND in NSGCT</span>'''
*** '''<span style="color:#ff0000">Distribution of histology[https://pubmed.ncbi.nlm.nih.gov/2478726/]</span>:'''
***# '''<span style="color:#ff0000">Necrosis/fibrosis (≈40%)</span>'''
***# '''<span style="color:#ff0000">Teratoma (≈45%)</span>'''
***# '''<span style="color:#ff0000">Viable (≈15%) malignancy (with or without teratoma)</span>'''
***#* ≈6-8% of post-chemotherapy surgery specimens contain evidence of non-GCT malignancy arising from malignant transformation of teratoma
**** While those with necrosis could theoretically avoid post-chemotherapy surgery, '''necrosis only in the retroperitoneum cannot be predicted with sufficient accuracy to obviate safely the need for post-chemotherapy surgery in patients with residual masses.'''
***** '''Pure embryonal carcinoma in the primary tumour is the best predictor of fibrosis only in the retroperltoneum'''
**** 90% long-term survival with fibrosis and/or teratoma only at PC-RPLND vs. 50-70% for patients demonstrating viable GCT at PC-RPLND
*** '''<span style="color:#ff0000">If PC-RPLND pathology demonstrates</span>''' (2021 NCCN TEST-12)
**** '''<span style="color:#ff0000">Teratoma or necrosis/fibrosis: surveillance</span>'''
**** '''<span style="color:#ff0000">Viable disease (e.g. residual embryonal carcinoma, yolk sac, choriocarcinoma, seminoma) in PC-RPLND pathology: 2 cycles chemotherapy</span>''' (EP (etoposide/ciplatin), TIP (paclitaxel, ifosfamide, cisplatin), VIP (etoposide, ifosfamide, cisplatin), or VeIP (vinblastine, ifosfamide, cisplatin) [2021 NCCN Guidelines]
* '''<span style="color:#ff0000">FDG-PET has NO role in the assessment of patients with NSGCT and residual masses after chemotherapy</span>'''
* '''Patients with residual masses at multiple anatomic sites (retroperitoneum, chest, and left supraclavicular fossa are the most common) and normal tumour markers should undergo resection of all sites of measurable residual disease.'''
** '''RPLND should be performed before post-chemotherapy surgery at other sites because the probability of residual disease in the retroperitoneum is highest, and RPLND histology is a strong predictor of histology at other sites.''' Therefore, if no disease in retroperitoneum, unlikely to have any disease elsewhere.
*** If RPLND histology shows
**** Viable malignancy, then patient should undergo chemotherapy
**** Fibrosis, then patient should undergo surveillance or resection
**** Teratoma, then patient should undergo resection.

====== Relapsing NSGCT ======

* '''Treatment depends on what treatment the patient previously received and, in certain cases, the location of the relapse.'''
* '''Chemotherapy-naïve:'''
** '''First-line chemotherapy based on ICCCG risk classification'''
** Cure rates > 95%
** Select CS I patients on surveillance who relapse in the retroperitoneum with non-bulky (<3 cm) tumor and normal serum tumor markers may be treated by induction chemotherapy or RPLND (particularly if teratoma was present in the primary tumor)
* '''Relapse after chemotherapy:'''
** '''Salvage-line chemotherapy.'''
** Patients with serologic complete response to second-line chemotherapy with residual masses should undergo surgical resection after salvage chemotherapy.
*** Patients with viable malignancy in post–salvage chemotherapy surgical specimens have a particularly poor prognosis, and their survival is not improved with the use of postoperative chemotherapy.
** In general, late relapse is resistant to chemotherapy, and the outcome is related to the ability to render patients disease-free by complete surgical resection

====== Scrotal exploration ======

* Patients found to have NSGCT in orchiectomy pathology following scrotal exploration require further treatment
** Low-stage NSGCT: wide excision of scrotal scar and removal of spermatic cord.
** High-stage NSGCT: systemic therapy will be given and therefore hemiscrotectomy is not needed