Treatment of nonretroperitoneal residual germ cell tumor masses.

The appropriate treatment of residual disease outside the retroperitoneum after chemotherapy is a crucial component of the comprehensive approach to treating advanced testicular germ cell tumors (GCT). Residual nonretroperitoneal disease is most commonly found in the thorax but can also be identified in other sites, including the neck, liver, and brain. Although some data suggest that certain variables such as retroperitoneal lymph node dissection histology can accurately predict nonretroperitoneal histology, a multitude of studies show significant histologic discordance among different sites. Therefore, in patients with normalized serum tumor markers, we recommend resection of all sites of residual disease outside the retroperitoneum. Surgical approaches to the various lesions must minimize morbidity, and synchronous resections under the same anesthetic should be performed if technically feasible. After excision of residual viable GCT, evidence suggests that at least intermediate-risk patients who have received only induction chemotherapy will benefit from further systemic treatment. Patients with residual nonretroperitoneal viable GCT after salvage chemotherapy receive no benefit from additional systemic chemotherapy.