Chemotherapy and evaluation
Preoperative courses of chemotherapy were administered to patients with bulky disease or metastasis. Initial chemotherapy comprised cisplatin, etoposide, and bleomycin (PEB regimen): bleomycin 15 mg/m2 on day 1, etoposide 100 mg/m2on days 1 through 5 and cisplatin 20mg/m2 on days 1 through 5. Every cycle was repeated at three-week interval. Chemotherapy doses were adjusted for infants < 12 months of age: cisplatin 0.7 mg/kg/dose, etoposide 3 mg/kg/dose, and bleomycin 0.5 mg/kg/dose.
AFP was monitored prior to every cycle of chemotherapy. Patients underwent a thorough evaluation every two cycles of chemotherapy by imaging work-up and tumor marker determinations. We proposed 4-6 preoperative chemotherapy courses before a radical complete resection without major morbidity was achieved. Postsurgical chemotherapy was determined based on histologic findings. If the resected specimen showed no viable tumor cells and AFP declined within reasonable range of half-life, pathologic response was considered complete. Additional two courses of chemotherapy were administered to patients. Patients with malignant residual disease in pathological specimen continued to receive chemotherapy. Patients with progressive disease or no response to the initial chemotherapy were considered treatment failures and received second-line chemotherapy. Total cycles of chemotherapy varied between 6-8 courses.