P31: Salvage surgery for PMGCT: beneficial for persistent positive-marker patients?

Background: Primary mediastinal germ cell tumors (PMGCT) are rare and high-grade malignant tumors. Mainstay treatment for PMGCT is systemic chemotherapy, and salvage surgery for residual tumor is considered in patients with normalized tumor makers. However, survival benefit of salvage surgery for persistent positive-marker patients remains unclear. The purpose is to clarify the outcome of salvage surgery for PMGCT.

Methods: A total of eight patients undergoing salvage surgery for PMGCT in our institution from July 2000 to February 2013 were enrolled. Surgical outcomes of these patients were retrospectively analyzed.

Results: All patients were men and the median age was 25 years (range, 18–37 years). Histological type was seminoma in one and non-seminomatous germ cell tumor in seven. Serum alpha-fetoprotein (AFP) level was initially elevated in seven patients. All patients received primary chemotherapy consisting of bleomycin, etoposide, and cisplatin with a median cycle of 3 (range, 3–4). Four patients additionally received 2^nd (n=2), 3^rd (n=1), or 4^th (n=1) line chemotherapy. AFP level normalized in five patients. Complete R0 resection was achieved and serum AFP level normalized in all patients. Median duration of postoperative hospital stay was 7 days (range, 5–11 days), and there was no morbidity or mortality. Pathological complete response was observed in four patients. The median recurrence-free and overall survival (RFS and OS) periods for all eight patients were 31 (range, 6–74) and 31 (range, 15–74) months, respectively. All of the five patients with preoperatively normalized AFP levels were alive without recurrence, with a median follow-up period of 56 (range, 26–74) months. Of the three persistent AFP-positive patients, two were alive without recurrence at 24 and 33 months after surgery.

Conclusions: We confirmed that complete resection of residual PMGCT achieved favorable prognosis in patients with preoperatively normalized AFP levels. This study suggests that salvage surgery might be beneficial even in persistent positive-marker patients if complete resection is deemed possible.

Keywords: Primary mediastinal germ cell tumors (PMGCT); salvage surgery; alpha-fetoprotein (AFP); complete resection