552 © 2 0 0 4 B J U I N T E R N A T I O N A L | 9 4 , 5 5 2 – 5 5 8 | doi:10.1111/j.1464-410X.2004.04999.x Original Article LIVER METASTASES IN GERM CELL CANCER COPSON et al. Liver metastases in germ cell cancer: defining a role for surgery after chemotherapy ELLEN COPSON, JOE McKENDRICK*, NIKLAS HENNESSEY†, KEN TUNG† and GRAHAM Z. MEAD CRC Wessex Medical Oncology Unit and †Department of Radiology, Southampton General Hospital, Southampton, UK, and *Department of Haematology and Medical Oncology, Box Hill Hospital, Melbourne, Victoria, Australia Accepted for publication 4 May 2004 RESULTS Twenty-seven patients with germ cell cancer metastatic to the liver were identified. Complete biochemical and radiological responses were achieved in eight patients after initial chemotherapy and surgery for non-hepatic residual disease. Seven patients had only residual radiological hepatic abnormalities with normal tumour markers at the completion of initial treatment. There were no immediate hepatic resections and no further therapy was given. Serial computed tomography (CT) confirmed a progressive reduction in the size of hepatic lesions in six of seven patients. The persistence of residual hepatic abnormalities was not predictive of relapse, and overall survival of these patients (median survival 49 months, range 15–120) compared well with recent reports of such patients who have undergone hepatic resection. CONCLUSIONS Conservative management with regular assessment by CT is an acceptable alternative to immediate hepatic resection for patients with isolated residual radiological hepatic abnormalities on completing first-line therapy for metastatic germ cell cancer, and does not adversely affect their survival. KEYWORDS hepatic metastases, germ cell cancer, chemotherapy, surgery, outcome, survival OBJECTIVE To review the clinical course and outcome of patients with germ cell cancer and liver metastases treated at one centre, as the presence of hepatic metastases, although rare, is a poor prognostic feature in germ cell cancer. PATIENTS AND METHODS The case records of all patients with germ cell cancer and liver metastases at presentation, and treated with chemotherapy at a medical oncology unit between 1984 and 2001, were reviewed. The treatment regimens, tumour responses and patient outcome were recorded. INTRODUCTION Many prognostic indices have been devised for germ cell cancer (GCT) and all include the presence of nonpulmonary visceral metastases as an indicator of poor prognosis [1–6]. The current standard prognostic classification of the International Germ Cell Cancer Collaborative group (IGCCCG) [1] includes the presence of nonpulmonary visceral disease as an independent factor, placing such patients immediately into the poorest risk group for nonseminomatous (NS) metastatic GCT (NSGCT), and the intermediate-prognosis group for cases of metastatic seminoma, associated with 5-year progression-free survival rates of 41% (nonseminoma) and 67% (seminoma). Little has been published on the natural history and optimum treatment of metastatic disease to the liver. The IGCCCG series reported a 5-year progression-free survival and survival of 43% and 49%, respectively, in patients with NSGCT and liver metastases [1]. Despite extensive clinical research there is no clear evidence that any initial induction chemotherapy regimen is more effective than bleomycin, etoposide and cisplatin (BEP) in managing these patients [7]. However, a contentious management issue in patients specifically with liver metastases is the potential role of surgery. It is well recognized that residual masses after chemotherapy in patients with metastatic NSGCT can represent active cancer, mature teratoma (which carries a risk of malignant transformation), or necrotic tissue [8,9]. The use of surgery to remove any residual retroperitoneal or pulmonary/mediastinal masses is now well established, and patients undergoing complete excision of necrosis or mature teratoma have improved recurrence-free and overall survival rates [10,11]. Resection of residual hepatic metastases is a more controversial area, with limited published data available. Two recent referral series described the resection of all residual hepatic lesions in 57 and 37 patients with NSGCT [12,13]. Hahn et al. [12] concluded that hepatic resection of residual metastases is safe and effective for all patients with normal serum tumour markers, whilst Rivoire et al. [13] recommended the resection of residual hepatic masses of 10–29 mm (greatest diameter) in male patients. Herein we review patients with GCT and liver metastases, treated in one centre between 1979 and 2001. PATIENTS AND METHODS The medical records of all patients treated for metastatic germ cell cancer at the authors’ oncology unit between January 1978 and July 2001 were reviewed; patients with hepatic metastases at first presentation were identified and their case-notes reviewed retrospectively. The following data were retrieved: patient characteristics, primary tumour site and histology, disease distribution, serum a-fetoprotein, hCG and lactate dehydrogenase (LDH) at presentation, initial chemotherapy and surgical treatment, response, time to progression, salvage