Current perspectives on the role of adjunctive surgery in combined modality treatment for patients with germ cell tumors.

The role of surgery in patients with advanced GCT after chemotherapy has evolved substantially in the era of combined modality therapy. In evaluating patients for surgery after chemotherapy, the clinician must consider carefully the histology (seminoma v NSGCT) of the primary as well as the extent of the residual disease. In patients with seminoma, the size of residual disease (greater than or equal to 3 cm) permits selection of patients with a high incidence of residual malignancy. In contrast, criteria designed to select NSGCT patients in whom surgical intervention after chemotherapy can be avoided are associated with substantial error. A normal radiographic evaluation in patients with NSGCT does not indicate a negative pathology and the treating physician must consider the approximately 20% risk of residual teratoma or carcinoma despite evidence of a radiographic CR. Continued research is needed to improve the sensitivity and specificity of case selection for patients requiring surgery after chemotherapy in order to limit the toxicity of curative therapy in this patient population.