The effectiveness of local methods of treatment in patients with germ cell tumors who have exhausted all curative options of systemic therapy. Clinical case report and literature review

Vollständiger Abstract

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Introduction. With adequate initial therapy, germ cell tumors (GCTs) have a relatively favorable prognosis; however, approximately 20–25% of patients experience relapse or refractory disease. Currently, there are several potentially curative treatment options for this patient population but the optimal approach remains undetermined in both adult and pediatric practice. A particular challenge is the management of patients who have not responded to multiple lines of systemic therapy. Although most GCTs are considered as a primarily systemic disease, in this population with an extremely low chance of cure with systemic treatment alone, local control modalities may offer a chance of cure. Clinical experience demonstrates the effectiveness of not only surgical but also radiotherapeutic approaches, despite the fact that non-seminomatous/non-dysgerminomatous GCTs were previously considered radioresistant. Clinical case. Here, we report a clinical case of a 16-year-old female adolescent with secreting malignant ovarian germ cell tumor. The patient received 3 cycles of multi-agent chemotherapy according to the MAKEI-05 protocol, followed by surgical treatment (left-sided salpingo-oophorectomy). After surgery, a radiological complete response was achieved, however, alpha-fetoprotein (AFP) levels did not normalize. Later, the patient showed a rise in AFP levels and a metabolically active tumor on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT). Therefore, second-line therapy was administered according to the TIGER protocol, after which AFP levels normalized. One month after the completion of multi-modal treatment, an increase in AFP was observed, and PET/CT again revealed metabolically active lesions. To achieve systemic disease control, the girl received chemotherapy with the GOP regimen (gemcitabine, oxaliplatin, paclitaxel), followed by surgical exploration of the abdominal cavity, which revealed no pathological findings. Given the inability to rule out the presence of viable tumor cells, a multidisciplinary decision was made to administer radiation therapy to the metabolically active lesions visualized on PET/CT (in the region of the right uterine adnexa). The patient underwent radiation therapy to the right adnexal bed to a total dose of 50.4 Gy. The girl was discharged for follow up. At the time of this report, the patient remains in complete unmaintained remission for 30 months. Conclusion. This clinical case illustrates successful curative local treatment of the patient with recurrent disease after multiple surgeries in the same area, who had exhausted all available systemic curative options.