Risk stratification and initial chemotherapy for men with metastatic germ cell tumors

AFP: alpha-fetoprotein; beta-hCG: beta-human chorionic gonadotropin; LDH: lactate dehydrogenase; ULN: upper limit of normal; BEP: bleomycin, etoposide, cisplatin; EP: etoposide, cisplatin; VIP: ifosfamide, etoposide, cisplatin.
* Patients with elevated tumor markers are considered to have non-seminomatous germ cell tumors, even if histology is consistent with seminoma.
¶ For patients with good-risk seminoma and LDH greater than 2.5 times ULN, we treat using an approach similar to those with intermediate-risk seminoma.
Δ For intermediate- and poor-risk disease, 4 cycles of BEP is generally preferred. 4 cycles of VIP is preferred if the patient has a primary, mediastinal non-seminomatous germ cell tumor or any contraindication to bleomycin.