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Case History

Image not available. A previously healthy 29-year-old man was admitted through the accident and emergency department with a history of a swollen left testis, weight loss and more recently breathing difficulties. A chest radiograph reveals multiple pulmonary metastases with an α-fetoprotein (AFP) of 65 000 ng/ml and β human chorionic gonadotrophin (hCG) 205 000 IU/l.

What further investigations should he have?

What is the prognosis and treatment?

If he relapses what chemotherapy options are there?

Background

What further investigations should he have?

Image not available. The immediate concern is to stabilize the patient. A computed tomography (CT) scan (head, chest, abdomen and pelvis) should be done to determine the extent of the disease. Tissue diagnosis is not mandatory in this case as it would delay the time to treatment, and the diagnosis of a non-seminomatous germ cell tumour is clear from the raised tumour markers (both AFP and β-hCG). However, if possible, tissue diagnosis is valuable, particularly if the patient is stable.

What is the prognosis and treatment?

The prognosis of patients with germ cell cancer is derived from the International Germ Cell Consensus Classification (IGCCC) published in 19971 (Table 13.1). It relies on the extent of disease and tumour markers and the primary site. The IGCCC was developed because of the variations in the classifications and staging systems used worldwide, making it difficult to compare trial data. Approximately 60% of all patients with metastatic non-seminomas come under the good prognosis category, 25% in the intermediate and 15% in the poor category; 90% of patients with metastatic seminoma come under the good prognosis category and 10% in the intermediate. Treatment is based on the IGCCC prognostic classification. BEP (bleomycin, etoposide and cisplatin) is the universal chemotherapy regimen and no other regimen to date has been shown to be superior. Scheduling of treatment and number of cycles depend on the prognosis. In 2001, the European Organisation for Research and Treatment of Cancer (EORTC) published data confirming that for good prognostic disease three cycles of 3-day BEP (500 mg/m2 etoposide) was sufficient with a progression-free survival (PFS) at 2 years of 90.4%.2 For patients with intermediate and poor prognosis four cycles of 5-day BEP is the standard. Bleomycin is an important component of the regimen, but in disease with good prognosis four cycles of EP (500 mg/m2 etoposide + cisplatin) have been shown to be equivalent to three cycles of BEP.

Table 13.1International Germ Cell Consensus Classification (IGCCC)

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