MKSAP: 45-year-old man with a mediastinal germ cell tumor

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

Seven years ago, a 45-year-old man was diagnosed with a biopsy-proven mediastinal germ cell tumor. The patient was treated with combination chemotherapy (bleomycin, etoposide, and cisplatin) and had a complete radiographic response. He has been disease-free since completing therapy, and follow-up serum tumor marker measurements, chest radiographs, and CT scans of the abdomen and pelvis have been normal.

Which of the following is the most appropriate management at this time?

A) Age- and sex-appropriate screening
B) Audiometry
C) Exercise stress test
D) Pulmonary function tests
E) Renal ultrasonography

MKSAP Answer and Critique

The correct answer is A) Age- and sex-appropriate screening. This item is available to MKSAP 15 subscribers as item 55 in the Hematology and Oncology section. More information about MKSAP 15 is available online.

Although bleomycin may be associated with pulmonary toxicity and cisplatin has known ototoxic effects, no delayed cardiovascular effects are associated with this patient’s chemotherapeutic regimen that would require surveillance beyond age- and sex-appropriate screening. Screening recommendations for survivors of germ cell cancer are no different than those for the general population, and, for this patient, include periodic lipid screening (every five years), annual blood pressure measurement (or at each office visit), and counseling regarding tobacco use.

Because his risk for cardiovascular risk is not increased, an exercise stress test is not indicated in this patient.

Cisplatin therapy is related to high-tone hearing loss, but in most patients, this long-term complication presents predominantly asymptomatically. Audiometry screening in asymptomatic individuals is not recommended because it has little impact on subsequent management.

Although this patient does remain at risk for late-onset bleomycin-induced lung injury, pulmonary function tests are not advised in the absence of symptoms. Whether the patient should wear a Medic-alert bracelet warning of the dangers of high Fio2 during subsequent surgery is debatable.

Although dose-related nephrotoxicity may occur during cisplatin therapy, there is no risk for late renal injury or renal neoplasia, and screening renal ultrasonography is not recommended.

Key Point

  • Nothing beyond age- and gender-based screening is recommended for long-term germ cell cancer survivors who received cisplatin or bleomycin chemotherapy.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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