How would you treat an older patient with stage IIC nonseminoma who is unfit for platinum chemotherapy due to comorbidities?

These are difficult questions to answer. The definition of a patient unsuitable for cisplatin in an elderly patient varies from oncologist to oncologist. Cisplatin + etoposide for 4 courses is the “standard“ therapy for patients over the age of 50. For elderly patients with poor performance status for reasons presumably unrelated to cancer, it's possible to treat every 4 weeks rather than every 3 weeks with Neulasta. Substituting carboplatin for cisplatin, in 2 large co-operative studies, lowered the cure rate by 10-15%, but certainly is less toxic, and if utilized, could also be every 4 weeks with Neulasta. A non-platinum regimen would be moving back to an era in which a few patients were cured but the majority succumbed to their disease. Etoposide is well tolerated with Neulasta and arguably is the second-best drug. Finally, since the disease is limited to the abdominal nodes, 1-2 courses of any of the regimens listed above followed by RPLND by a skilled and experienced urologist would also be an option.

I agree with Dr. @Dr. First Last. I think his first point is really important. Perhaps you could clarify what constitutes "unfit for chemotherapy" in this patient. For example, if he has renal dysfunction due to urinary obstruction, that can be addressed and would make him "fit" for cisplatin; if he has a cardiac disease, is it diffuse or can it be addressed by stents, pacemakers, etc. Patients who are deemed "unfit" in the outpatient setting can sometimes be managed by an expert in an inpatient setting with meticulous hydration, attention to detail, tumor lysis prophylaxis, etc. So a full story might help us all to figure out the next steps. A reasonable option might be a referral to Dr. Einhorn or another center of excellence to allow clinical assessment and a recommendation.

P.S. I just noticed the date of submission of the question (so the answer is no longer helpful), but the point is useful for future questions.

I have a similar patient in his 50s with stage III seminoma (good risk) presented with hydronephrosis on the left, stent decompressed collecting system, and creatinine still 1.7 mg/dl, eGFR 47 ml/min. It seems like I'll have to do carboplatin for the first cycle and see where things flesh out as the tumor burden decreases and perhaps the kidneys improve (if possible). I'll have him see a nephrologist as well.

Any other thoughts?