Multimodality treatment of patients with liver metastases from germ cell tumors

Abstract

BACKGROUND The presence of liver metastases represents an independent poor risk prognostic factor for survival in patients with germ cell tumors. METHODS The clinical files of 37 patients who had undergone liver resection for the treatment of disseminated germ cell tumors were reviewed to define the indications for resection of residual liver metastases after chemotherapy in patients with germ cell tumors. The histologic patterns of primary tumor and residual disease were compared. The prognostic factors for survival were studied by univariate analysis. RESULTS All but 2 of 37 patients underwent complete resection. One patient died of postoperative complications. Thirteen complications occurred in 10 patients. Twelve patients had active residual tumor, 7 patients had mature teratoma, and 18 patients had only necrosis on histologic examination. Twenty‐three of 37 patients (62%) were alive with no evidence of disease after a median follow‐up of 66 months (range, 31–134 months). Three prognostic factors were found to be significant in the univariate analysis for unfavorable outcome: the presence of pure embryonal carcinoma in the primary tumor, liver metastases measuring > 30 mm in greatest dimension at the time of surgery, and the presence of viable, active residual disease. CONCLUSIONS Because it is impossible to determine the histologic pattern of residual liver masses after chemotherapy with current imaging tools and percutaneous biopsy, patient selection for liver surgery may be undertaken according to the size of residual liver masses. Patients with masses that measure ≤ 10 mm in greatest dimension should be considered for close follow‐up, because they have a high probability of necrosis and are at low risk for malignant disease. Male patients with masses that measure ≥ 30 mm in greatest dimension represent a high‐risk group of patients who are not likely to benefit from liver surgery. Only male patients with masses that measure 10–29 mm in greatest dimension and all female patients with masses that measure > 10 mm in greatest dimension should be considered for liver resection. Cancer 2001;92:578–87. © 2001 American Cancer Society.

Hepatic Metastasectomy for Testicular Germ Cell Tumors: Is it worth it?

“…Previous studies have found necrosis in 16-67%, teratoma in 12-51%, and viable cancer in 21-55%. 8,9,14 In our study, the distribution of these histologies was 33%, 13%, and 27%, respectively, with another 27% being benign hepatic lesions. While no study has specifically examined the role of preoperative hepatic biopsy and the concordance rate between hepatic histology found at preoperative biopsy versus at surgical resection, preoperative hepatic biopsy is only pursued if its findings would alter patient's overall treatment plan.…”

“…6, 10-12 Experiences with resection of metastatic disease in the liver, however, have only been reported in four previous studies. 8,9,13,14 The current study demonstrated that (1) resection of hepatic metastases from GCT can be performed safely, (2) hepatic pathology may be discordant with extrahepatic disease and remain difficult to predict, and (3) long-term overall survival can be achieved. Thus, the experiences reported herein support the integration of hepatic metastasectomy into the multidisciplinary care of patients with metastatic GCT.…”

“…The presence of pure embryonal carcinoma, liver metastases measuring >30 mm, the presence of viable residual disease, and refractoriness to chemotherapy had been suggested by previous investigators. 8,9 It is thus noteworthy that, of the three patients who died of disease or of unknown cause in our study, one had embryonal carcinoma (patient 5), another had viable tumor at the time of hepatic resection (patient 15), and the last had persistent tumor marker elevation despite systemic therapy (patient 11). Unfortunately, the small and heterogeneous cohort in our study did not allow formal validation of prognostic factors.…”

“…14 Similarly, another report of 37 patients revealed that 62% were alive without evidence of disease after 5.5 years of follow-up. 9 Finally, the calculated 5-year survival for the small subset of patients with active tumor at hepatic resection was 33%, with a median survival of 4.6 years. These figures from the subset of patients with worse disease refractory to preoperative treatments compare favorably to the 5-year overall survival rates of 25-40% typically reported after hepatic metastasectomy for patients with colorectal, neuroendocrine, and other malignancies.…”

“…3 While aggressive surgery to resect residual radiographic disease after systemic chemotherapy has become well integrated into the multidisciplinary care of patients with advanced GCT 4,5 , the role of surgical resection in patients with hepatic metastases from GCT remains poorly defined. 6,7 Recent literature reported calculated 5-year survivals of 62-70% 8,9 , suggesting oncologic benefit in comparison with historical controls. However, reported experiences are limited and patient selection criteria, resection extent, and long-term outcomes have not been established.…”