Prognostic Factors for Germ Cell Tumor Patients With Brain Metastases

Overall prognosis is poor in men with brain metastases (BM) from germ cell tumors (GCTs), according to a new study. High-dose chemotherapy and multimodal treatment could improve survival in men who present with BM at relapse.

“Because BM of GCT are rare, their optimal management remains controversial,” wrote study authors led by Jörg Beyer, MD, of University Hospital Zurich in Switzerland. Because prospective trials of this population are unlikely to be performed, the researchers retrospectively collected data on 228 men with BM present at initial diagnosis and 295 men with BM at relapse. The results were published online ahead of print in the Journal of Clinical Oncology.

The overall survival (OS) at 3 years was better in those who presented with BM at initial diagnosis than at relapse (48% vs 27%; P < .001). This was in spite of more of those patients presenting with multiple BM (67% vs 56%; P < .05) and concurrent systemic disease.

In the initial diagnosis patients, three factors were significantly associated with poor OS on multivariable analysis: mediastinal primary site for patients with nonseminoma; the presence of liver and/or bone metastases; and the presence of multiple BM. The latter two were also significant predictors in the relapse patients, as was having at least one elevated tumor marker (alpha-fetoprotein or HCG).

Almost all patients in the initial diagnosis group received chemotherapy either alone or in combination with other therapies (99%). Far fewer in the relapse group received chemotherapy, at 58% (P < .05). Significantly more patients in the relapse group underwent surgery alone, radiation therapy alone, or surgery combined with radiation therapy.

In those presenting with BM at relapse, the use of multimodality treatment was associated with a significantly improved OS, with a hazard ratio (HR) of 0.52 (95% confidence interval [CI], 0.37–0.73; P < .001) on multivariate analysis. High-dose chemotherapy was also associated with better OS, with an HR of 0.41 (95% CI, 0.24–0.69; P < .001).

The researchers noted that these results have “all the shortcomings” of retrospective analysis. “Nevertheless, this large series describes prognostic factors and supports decision-making in a clinical scenario that previously lacked robust data.” They recommended that chemotherapy remain the standard of care for those who present with BM at initial diagnosis of GCT, and that high-dose chemotherapy and multimodal treatment be considered in those presenting with BM at relapse.