A 25-year single institution experience with surgery for primary mediastinal nonseminomatous germ cell tumors.

Background: The treatment of primary mediastinal nonseminomatous germ cell tumors (PMNSGCT) with cisplatin-based chemotherapy, followed by surgical resection of residual disease, has been established. We reviewed our institution's 25-year experience in the cisplatin era to determine surgical risks and predictors of survival after surgery for PMNSGCT.

Methods: A total of 158 patients (mean age, 29 +/- 8 years) who underwent postchemotherapy operations for PMNSGCT were reviewed and multiple variables analyzed.

Results: Ten (6%) operative deaths occurred, nine of which were attributed to respiratory failure, and 26 (18%) patients experienced postoperative complications, including 9 with respiratory failure. None of 17 recent patients who received chemotherapy regimens that did not contain bleomycin experienced pulmonary complications (p = 0.12 vs patients who received bleomycin). Operative survivors were followed up a median of 34 months (range, 1 to 194 months). Multivariable analysis demonstrated that the postchemotherapy pathologic category of complete necrosis vs teratoma), persistent germ cell or nongerm cell cancer, and elevated serum tumor markers after operation were independently predictive of survival.

Conclusions: Operative risks for PMNSGCT appear to be improved with the use of chemotherapy regimens that do not contain bleomycin. Patients pathologically demonstrating complete tumor necrosis in the residual mass after chemotherapy have excellent long-term survival, with decreasing survival after resection of teratoma and persistent germ cell or nongerm cell cancer. Patients pathologically demonstrating persistent germ cell or nongerm cell cancer have poor but possible long-term survival, which justifies an aggressive surgical approach in patients who are deemed operable.