Purpose of review
To discuss the current role and future perspectives of high-dose chemotherapy (HDCT) in the management of advanced germ cell tumors (GCTs).
Multiple studies have demonstrated the safety and efficacy of HDCT, consisting of carboplatin and etoposide followed by stem cell reinfusion, for the salvage treatment of GCTs. However, three randomized trials showed no benefit for HDCT over conventional dose chemotherapy in the first-line setting. Similarly, adding a third drug to etoposide with carboplatin does not seem to substantially improve treatment efficacy and may increase toxicity and mortality. Recent retrospective data from single centers and a large international collaboration demonstrated better outcomes with use of HDCT in the initial (rather than later) salvage setting as well as with sequential rather than single cycle regimens. However, randomized data are lacking. Prognostic factors for outcome to salvage HDCT were recently established and enhanced supportive measures such as growth factors and antibiotic prophylaxis have resulted in a dramatic decrease in morbidity and mortality.
HDCT plays an integral role in the salvage treatment of patients with advanced GCTs. However, optimal timing (initial vs. later salvage), dosing, number of high-dose cycles, and patient selection remain to be defined.