The value off high-dose chemotherapy for malignant germ cell tumors

The role of high-dose chemotherapy in the treatment of patients with advanced germ cell tumors has been and remains an area of considerable clinical interest. Recently, the results of the first randomized trial showing no superiority of high-dose chemotherapy over conventional dose chemotherapy in the first line setting have been made public. Another earlier trial had shown similar results regarding the role of high-dose chemotherapy in patients with relapsed germ cell tumors. However, important clinical questions remain open, as in the first line setting patients seem to exist with a certain risk profile (slow marker decline) who seem to profit from such an approach. There are also single institution results on high-dose chemotherapy in selected patients after relapse which suggest that the same might be true for subgroups in the relapsed setting. Patients with primary mediastinal non-seminomatous germ cell tumors or cerebral metastases might also be candidates for up-front high-dose chemotherapy, as suggested by historical subgroup analyses. In patients with refractory or relapsed disease, risk factors are already defined and allow a risk adapted treatment strategy. Sequential high-dose chemotherapy is feasible in patients with intermediate or poor prognosis with a tolerable toxicity profile, and can lead to long-term survival in a number of patients after the secondary resection of residual tumor masses. Furthermore, in untreated patients with a poor prognosis, the results of a second randomized trial on primary high-dose chemotherapy, currently performed by the European Organization for Research and Treatment of Cancer (EORTC) have to be awaited.