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Oing C, Hentrich M. [Conventional versus high-dose salvage chemotherapy for relapsed testicular germ cell tumours]. Aktuelle Urol 2024. [PMID: 39106898 DOI: 10.1055/a-2364-4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024]
Abstract
Since the introduction of cisplatin-based combination chemotherapy, patients with metastatic germ cell tumours achieve very high cure rates of >80%. Nevertheless, about 30% of patients relapse despite guideline-endorsed first-line treatment. Of these, again about 50% of patients can still achieve cure with platinum-based salvage chemotherapy and eventually post-chemotherapy residual mass resection.Salvage chemotherapy generally involves platinum-based combination chemotherapy, either as conventional dose cisplatin-based combinations again or as high-dose chemotherapy with subsequent autologous stem cell transplantation.To date, high level evidence from randomised trials supporting the use of salvage high-dose chemotherapy for all patients relapsing after first-line treatment remains lacking, but a large international retrospective registry study had shown a 15% overall survival benefit for patients undergoing salvage high-dose chemotherapy.In this article, we summarise the available literature on the different salvage treatment approaches and discuss these in the light of current treatment guideline recommendations for the management of testicular cancer.
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Affiliation(s)
- Christoph Oing
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
- Northern Centre for Cancer Care, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom of Great Britain and Northern Ireland
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Marcus Hentrich
- Abteilung für Innere Medizin III, Rotkreuzklinikum München, München, Germany
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Hack J, Crabb SJ. Platinum-Based Chemotherapy 'Rechallenge' in Advanced Non-ovarian Solid Malignancies. Clin Oncol (R Coll Radiol) 2022; 34:e329-e344. [PMID: 35282934 DOI: 10.1016/j.clon.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 01/02/2023]
Abstract
Platinum-based chemotherapy forms the backbone of treatment for many solid cancers. However, resistance inevitably develops in those with advanced disease. Platinum rechallenge is a well-established concept in the management of ovarian cancer, small cell lung cancer and germ cell tumours. In other solid malignancies there is a lack of quality evidence to support platinum rechallenge, yet it is a widely adopted strategy. Often, patients are within the last year of life, making questions of efficacy, treatment-related toxicity and quality of life critical factors for treatment recommendations. In this overview we appraise the available evidence for platinum rechallenge and strategies being developed to attempt resensitisation of tumours to platinum-based chemotherapy.
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Affiliation(s)
- J Hack
- Southampton Clinical Trials Unit, University of Southampton, Southampton General Hospital, Southampton, UK.
| | - S J Crabb
- Southampton Clinical Trials Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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Adra N, Abonour R. High-Dose Chemotherapy and Autologous Stem Cell Transplant. Urol Clin North Am 2019; 46:439-448. [DOI: 10.1016/j.ucl.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Oing C, Lorch A. The Role of Salvage High-Dose Chemotherapy in Relapsed Male Germ Cell Tumors. Oncol Res Treat 2018; 41:365-369. [PMID: 29843143 DOI: 10.1159/000489135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/11/2018] [Indexed: 11/19/2022]
Abstract
Germ cell tumors (GCT) are a unique tumor entity with excellent cure rates if guideline-endorsed treatment is thoroughly applied. Even patients with widespread metastatic disease can often be cured with cisplatin-based combination chemotherapy as part of a multimodal treatment approach. However, about 30% of patients with metastatic disease at initial presentation, corresponding to about 5-10% of all GCT patients, relapse or progress despite first-line treatment and therefore require salvage chemotherapy. Salvage systemic treatment either consists of conventional-dose cisplatin-based combination chemotherapy or sequential high-dose treatment with carboplatin and etoposide plus subsequent autologous stem cell support. This review is based on a comprehensive literature search of MEDLINE and conference proceedings of ESMO, ASCO, and EAU meetings until 2018 and provides an overview of current treatment options for germ cell cancer patients relapsing after or progressing during first-line cisplatin-based combination chemotherapy.
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Role of one, two and three doses of high-dose chemotherapy with autologous transplantation in the treatment of high-risk or relapsed testicular cancer: a systematic review. Bone Marrow Transplant 2018; 53:1242-1254. [PMID: 29703969 DOI: 10.1038/s41409-018-0188-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 11/09/2022]
Abstract
Approximately 20-30% of patients with metastatic germ cell cancers (GCCs) can develop relapsed or refractory (RR) disease, about 40-50% of patients who relapse after salvage chemotherapy may reach long-term remission. The goal of this review was to identify patients who appear to benefit from high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT). To access this, we performed a systematic medical literature review to evaluate the effectiveness of HDCT in the frontline setting, as well as in patients with RR testicular cancer. We searched databases for interventional clinical studies and identified 5883 studies. We selected 49 studies for inclusion, which included a total of 5985 patients. Seventeen studies reported results of newly diagnosed poor-risk GCC patients and 32 studies reported results of RR patients. For newly diagnosed patients with poor prognostic predictors, a risk adjusted strategy using unfavorable tumor marker decline with initial standard chemotherapy regimen and upfront HDCT demonstrated improved outcomes. Our data suggest a minimum of two HDCT cycles with ASCT should be standard of care for patients with RR GCC. Failure of HDCT results in a poor prognosis with only 10% of patients achieving lasting remission with salvage therapy.
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Petrelli F, Coinu A, Rosti G, Pedrazzoli P, Barni S. Salvage treatment for testicular cancer with standard- or high-dose chemotherapy: a systematic review of 59 studies. Med Oncol 2017; 34:133. [DOI: 10.1007/s12032-017-0990-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/23/2017] [Indexed: 11/24/2022]
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Nieto Y, Tu SM, Bassett R, Jones RB, Gulbis AM, Tannir N, Kingham A, Ledesma C, Margolin K, Holmberg L, Champlin R, Pagliaro L. Bevacizumab/high-dose chemotherapy with autologous stem-cell transplant for poor-risk relapsed or refractory germ-cell tumors. Ann Oncol 2015. [PMID: 26199392 DOI: 10.1093/annonc/mdv310] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND High-dose chemotherapy (HDC) using sequential cycles of carboplatin/etoposide is curative for relapsed germ-cell tumors (GCT). However, outcomes of high-risk patients in advanced relapse remain poor. We previously developed a new HDC regimen combining infusional gemcitabine with docetaxel/melphalan/carboplatin (GemDMC), with preliminary high activity in refractory GCT. Given the high vascular endothelial growth factor expression in metastatic GCT and the synergy between bevacizumab and chemotherapy, we studied concurrent bevacizumab and sequential HDC using GemDMC and ifosfamide/carboplatin/etoposide (ICE) in patients with poor-risk relapsed or refractory disease. PATIENTS AND METHODS Eligibility criteria included intermediate/high-risk relapse (Beyer Model), serum creatinine ≤ 1.8 mg/dl and adequate pulmonary/cardiac/hepatic function. Patients received sequential HDC cycles with bevacizumab preceding GemDMC (cycle 1) and ICE (cycle 2). The trial was powered to distinguish a target 50% 2-year relapse-free survival (RFS) from an expected 25% 2-year RFS in this population. RESULTS We enrolled 43 male patients, median age 30 (20-49) years, with absolute refractory (N = 20), refractory (N = 17) or cisplatin-sensitive (N = 6) disease, after a median 3 (1-5) prior relapses. Disease status right before HDC was unresponsive (N = 24, progressive disease 22, stable disease 2), partial response with positive markers (PRm(+)) (N = 8), PRm(-) (N = 7) or complete response (N = 4). Main toxicities were mucositis and renal. Four patients (three with baseline marginal renal function) died from HDC-related complications. Tumor markers normalized in 85% patients. Resection of residual lesions (N = 13) showed necrosis (N = 4), mature teratoma (N = 2), necrosis/teratoma (N = 3) and viable tumor (N = 4). At median follow-up of 46 (9-84) months, the RFS and overall survival rates are 55.8% and 58.1%, respectively. CONCLUSIONS Sequential bevacizumab/GemDMC-bevacizumab/ICE shows encouraging outcomes in heavily pretreated and refractory GCT, exceeding the results expected in this difficult to treat population. CLINICALTRIALSGOV NCT00936936.
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Affiliation(s)
- Y Nieto
- Department of Stem Cell Transplantation and Cellular Therapy
| | - S-M Tu
- Department of Genitourinary Medical Oncology
| | | | - R B Jones
- Department of Stem Cell Transplantation and Cellular Therapy
| | - A M Gulbis
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - N Tannir
- Department of Genitourinary Medical Oncology
| | - A Kingham
- Department of Stem Cell Transplantation and Cellular Therapy
| | - C Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy
| | - K Margolin
- Department of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - L Holmberg
- Department of Medical Oncology, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - R Champlin
- Department of Stem Cell Transplantation and Cellular Therapy
| | - L Pagliaro
- Department of Genitourinary Medical Oncology
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Salvage high-dose chemotherapy for germ cell tumors. Urol Oncol 2015; 33:355-62. [PMID: 25837842 DOI: 10.1016/j.urolonc.2015.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 01/11/2015] [Accepted: 01/28/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Salvage high-dose chemotherapy (HDCT) along with autologous stem cell transplant (ASCT) plays an important role in the management of patients with germ cell tumors (GCT) and progression after first-line cisplatin-based chemotherapy. In this review, the authors will discuss the history of HDCT as salvage management of patients with GCT, improvement in efficacy and safety over the past 25 years, prognostic factors for outcome, and the conflicting data on the optimal initial salvage approach. METHODS The authors performed a PubMed search of HDCT and GCT to identify articles relevant to this review. After discussion, the articles felt to have contributed most notably to the field were selected for inclusion and summarized. RESULTS Depending on patient selection and timing of HDCT, durable remission rates with salvage HDCT range between 30% and 63%. The combination of carboplatin and etoposide is the standard regimen for the high-dose cycles with more variability in the regimens used for stem cell mobilization. Adding a third agent, particularly an oxazophosphorine (cyclophosphamide and ifosfamide), may add toxicity without increasing efficacy. In addition, sequential (2 or 3 cycle) HDCT regimens appear more effective and safer than single-cycle HDCT regimens. The optimal initial salvage approach (HDCT or conventional-dose chemotherapy) remains an unanswered question and highly controversial. CONCLUSIONS Salvage HDCT with ASCT can cure a significant proportion of patients with GCT and progression after one or more lines of cisplatin-based chemotherapy and thus plays an important role in the contemporary management of high-risk patients.
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Kosmas C, Papachrysanthou T, Daladimos T, Athanasopoulos A, Tsavaris N, Vlachoyiannopoulos PG. Control of relapsed germ cell tumor and SLE nephritis by high-dose chemotherapy and autologous hematopoietic cell transplantation. Future Oncol 2013; 9:1401-6. [PMID: 23980687 DOI: 10.2217/fon.13.70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
High-dose chemotherapy and hematopoietic stem cell support remains a curative treatment option for relapsed or nonresponsive germ cell tumors, and has been applied experimentally to control severe autoimmune diseases. In the present study, we report on a patient with systemic lupus erythematosus nephritis who developed a nonseminomatous germ cell tumor that relapsed after standard chemotherapy and surgery. The patient received high-dose chemotherapy supported by autologous hematopoietic cell transplantation based on its indication for relapsed germ cell tumors. Prolonged control of his relapsed germ cell tumor and systemic lupus erythematosus was attained with high-dose chemotherapy and hematopoietic stem cell support. An extensive literature review is provided alongside a detailed discussion of the aforementioned case.
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Affiliation(s)
- Christos Kosmas
- Department of Medicine, 2nd Division of Medical Oncology & Hematopoietic Cell Transplantation Program, Metaxa Cancer Hospital, 51 Botassi Street, Piraeus, Greece.
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Nieto Y. Transplantation for refractory germ cell tumors: does it really make a difference? Curr Oncol Rep 2013; 15:232-8. [PMID: 23494829 DOI: 10.1007/s11912-013-0309-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
High-dose chemotherapy (HDC) has been used over the past 25 years for germ-cell tumors in a variety of clinical scenarios. There is consensus at this point that its use as part of first-line treatment does not benefit patients with high-risk tumors. Long-term results of prospective trials in patients with relapsed or with refractory disease indicate that a fraction of them achieve long-term remissions consistent with cures. While HDC constitutes for many oncologists in the US an accepted treatment modality for relapsed or refractory GCT, controversy surrounds its use in those settings. Prognostic models have been developed that allow to prospectively identify poor prognosis patients that might benefit from novel HDC-based approaches.
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Affiliation(s)
- Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 423, Houston, TX, 77030, USA.
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Pal SK, Yamzon J, Sun V, Carmichael C, Saikia J, Ferrell B, Frankel P, Hsu J, Twardowski P, Stein CA, Margolin K. Paclitaxel-based high-dose chemotherapy with autologous stem cell rescue for relapsed germ cell tumor: clinical outcome and quality of life in long-term survivors. Clin Genitourin Cancer 2012; 11:121-7. [PMID: 23062817 DOI: 10.1016/j.clgc.2012.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/30/2012] [Accepted: 09/13/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-dose chemotherapy (HDCT) is a viable and potentially curative approach for patients with relapsed or refractory germ cell tumors (GCTs). However, no comparative data exist to define the optimal chemotherapeutic strategy, and little is known about the quality of life (QOL) of long-term survivors. Herein we attempt to characterize the QOL in long-term survivors who received high-dose paclitaxel, etoposide, carboplatin, and ifosfamide (TECTIC). PATIENTS AND METHODS Details of the TECTIC regimen and clinical outcomes for the initial 33 patients have been reported. In the present study, we report the clinical data for 15 additional patients. Using the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) and the Functional Assessment of Cancer Therapy-Taxane (FACT-T) questionnaires, we surveyed all patients who survived at least 4 years after HDCT. RESULTS Forty-eight patients were enrolled and 46 patients received protocol therapy. For all 48 patients, the median progression-free survival (PFS) and overall survival (OS) were 11.8 months (range, 5.8-not reached) and 21.7 months (range, 12.7-not reached), respectively. Seventeen patients were progression free at a median of 123.2 months (51.6-170.2 months), and 6 patients remain alive after progression with a median OS of 68.8 months (47.6-147.1 months). Of the 23 surviving patients, 18 were accessible and consented to telephone interviews. Compared with historical cohorts, survivors had a higher global health scale score (87.04 vs. 75.62; P = .02) but a lower physical functioning score (68.89 vs. 92.66; P = .0001) by the QLQ-C30 scale. CONCLUSIONS HDCT with the TECTIC regimen produces durable remissions in patients with relapsed or refractory GCTs with acceptable QOL in long-term survivors.
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Affiliation(s)
- Sumanta K Pal
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
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Haugnes HS, Laurell A, Stierner U, Bremnes RM, Dahl O, Cavallin-Ståhl E, Cohn-Cedermark G. High-dose chemotherapy with autologous stem cell support in patients with metastatic non-seminomatous testicular cancer - a report from the Swedish Norwegian Testicular Cancer Group (SWENOTECA). Acta Oncol 2012; 51:168-76. [PMID: 22175254 DOI: 10.3109/0284186x.2011.641507] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The SWENOTECA IV protocol from 1995 is a prospective population-based study in metastatic non-seminomatous germ cell testicular cancer (NSGCT), designed for early identification of patients with poor response to standard cisplatin-based chemotherapy. A slow tumor marker decline (HCG T(½) > 3 days, AFP T(½) > 7 days) after BEP or BEP plus ifosfamide was regarded as poor response. The aim of this study was to present survival and toxicity data for patients treated with high-dose chemotherapy (HDCT) within the SWENOTECA IV cancer care program. MATERIAL AND METHODS In total 882 adult men diagnosed with metastatic NSGCT between July 1995 and June 2007 in Sweden and Norway (except one center) were included in SWENOTECA IV and treated accordingly. Among these, 55 men (6.2%) were treated with HDCT according to three different indications in the protocol: A) poor response to standard-dose intensified chemotherapy (BEP plus ifosfamide); B) vital cancer at surgery after intensified chemotherapy; and C) selected relapses after previous chemotherapy. In situation A and C two HDCT cycles and in situation B one HDCT cycle was recommended. Situation A was the reason for HDCT in 36 patients, B in seven and C in 12 patients. The first HDCT cycle consisted of carboplatin 28 × (GFR + 25) mg, cyclofosfamide 6000 mg/m(2) and etoposide 1750 mg/m(2), administered over four days. In cycle two, etoposide was replaced by tiotepa 480 mg/m(2). RESULTS After a median follow-up of 7.5 years, overall survival was 72%, 100% and 58%, while failure-free survival was 64%, 71% and 42% in situation A, B and C, respectively. Three patients (5.5%) died during HDCT (renal failure or intracerebral hemorrhage). Nephrotoxicity was the most common non-hematological grade 4 toxicity (n = 5, 9%). CONCLUSION The population-based SWENOTECA strategy, selecting patients who do not respond adequately to primary standard-dose chemotherapy for immediate treatment intensification with HDCT, is feasible and might be advantageous.
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De Giorgi U, Rosti G, Salvioni R, Papiani G, Ballardini M, Pizzocaro G, Marangolo M. Long-term outcome of salvage high-dose chemotherapy in patients with germ cell tumor with poor prognostic features. Urol Oncol 2011; 29:284-90. [DOI: 10.1016/j.urolonc.2009.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 03/16/2009] [Accepted: 03/31/2009] [Indexed: 12/01/2022]
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Feldman DR, Sheinfeld J, Bajorin DF, Fischer P, Turkula S, Ishill N, Patil S, Bains M, Reich LM, Bosl GJ, Motzer RJ. TI-CE high-dose chemotherapy for patients with previously treated germ cell tumors: results and prognostic factor analysis. J Clin Oncol 2010. [PMID: 20194867 DOI: 10.1200/jco.2009.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We previously reported a dose-finding and phase II trial of the TI-CE regimen (paclitaxel [T] plus ifosfamide [I] followed by high-dose carboplatin [C] plus etoposide [E] with stem-cell support) in germ cell tumor (GCT) patients predicted to have a poor prognosis with conventional-dose salvage therapy. We now report the efficacy of TI-CE with prognostic factors for disease-free survival (DFS) and overall survival (OS) in our full data set of 107 patients. PATIENTS AND METHODS Eligible patients had advanced GCTs with progressive disease following chemotherapy and unfavorable prognostic features (extragonadal primary site, incomplete response [IR] to first-line therapy, or relapse/IR to ifosfamide-cisplatin-based conventional-dose salvage). Univariate and multivariate analyses (MVAs) of prognostic factors were performed. The predictive ability of the Einhorn and Beyer prognostic models was assessed. RESULTS Most patients were platinum refractory and had an IR to first-line chemotherapy. There were 54 (5%) complete and eight (8%) partial responses with negative markers; 5-year DFS was 47% and OS was 52% (median follow-up, 61 months). No relapses occurred after 2 years. Five (24%) of 21 primary mediastinal nonseminomatous GCTs are continuously disease free. On MVA, primary mediastinal site (P < .001), two or more lines of prior therapy (P < .001), baseline human chorionic gonadotropin > or = 1,000 U/L (P = .01), and lung metastases (P = .02) significantly predicted adverse DFS. Poor-risk patients did worse than good- or intermediate-risk patients according to both Beyer (P < .002) and Einhorn (P < .05) models. CONCLUSION TI-CE is effective salvage therapy for GCT patients with poor prognostic features. Mediastinal primary site and two or more lines of prior therapy were most predictive of adverse DFS. Beyer and Einhorn models can assist in predicting outcome.
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Affiliation(s)
- Darren R Feldman
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Feldman DR, Sheinfeld J, Bajorin DF, Fischer P, Turkula S, Ishill N, Patil S, Bains M, Reich LM, Bosl GJ, Motzer RJ. TI-CE high-dose chemotherapy for patients with previously treated germ cell tumors: results and prognostic factor analysis. J Clin Oncol 2010; 28:1706-13. [PMID: 20194867 DOI: 10.1200/jco.2009.25.1561] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We previously reported a dose-finding and phase II trial of the TI-CE regimen (paclitaxel [T] plus ifosfamide [I] followed by high-dose carboplatin [C] plus etoposide [E] with stem-cell support) in germ cell tumor (GCT) patients predicted to have a poor prognosis with conventional-dose salvage therapy. We now report the efficacy of TI-CE with prognostic factors for disease-free survival (DFS) and overall survival (OS) in our full data set of 107 patients. PATIENTS AND METHODS Eligible patients had advanced GCTs with progressive disease following chemotherapy and unfavorable prognostic features (extragonadal primary site, incomplete response [IR] to first-line therapy, or relapse/IR to ifosfamide-cisplatin-based conventional-dose salvage). Univariate and multivariate analyses (MVAs) of prognostic factors were performed. The predictive ability of the Einhorn and Beyer prognostic models was assessed. RESULTS Most patients were platinum refractory and had an IR to first-line chemotherapy. There were 54 (5%) complete and eight (8%) partial responses with negative markers; 5-year DFS was 47% and OS was 52% (median follow-up, 61 months). No relapses occurred after 2 years. Five (24%) of 21 primary mediastinal nonseminomatous GCTs are continuously disease free. On MVA, primary mediastinal site (P < .001), two or more lines of prior therapy (P < .001), baseline human chorionic gonadotropin > or = 1,000 U/L (P = .01), and lung metastases (P = .02) significantly predicted adverse DFS. Poor-risk patients did worse than good- or intermediate-risk patients according to both Beyer (P < .002) and Einhorn (P < .05) models. CONCLUSION TI-CE is effective salvage therapy for GCT patients with poor prognostic features. Mediastinal primary site and two or more lines of prior therapy were most predictive of adverse DFS. Beyer and Einhorn models can assist in predicting outcome.
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Affiliation(s)
- Darren R Feldman
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Karadimou A, Dimopoulos MA, Bamias A. The role of high-dose chemotherapy in the treatment of testicular cancer. Open Access J Urol 2010; 2:25-30. [PMID: 24198610 PMCID: PMC3818874 DOI: 10.2147/rru.s6571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Testicular cancer is a highly curable neoplasm, even in the case of extragonadal disease. Nevertheless, patients with adverse prognostic features or relapsing after first-line cisplatin-based chemotherapy have a worse prognosis with a death rate greater than 50%. High-dose chemotherapy (HDC) has long been used in this group of patients. The introduction of stem cells, instead of bone marrow, as the source of hemopoietic cells and the use of leukocyte growth factors have substantially reduced the mortality and morbidity of this procedure although the role of HDC is not well defined. This review summarizes the available data, focusing on published randomized studies. The problems associated with the design of these studies and the interpretation of data are discussed. Currently this HDC approach is mainly used in patients who relapse after first-line chemotherapy. Nevertheless, selection of patients likely to benefit from this treatment remains an issue of intense clinical research.
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Affiliation(s)
- Alexandra Karadimou
- Dept of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
| | | | - Aristotle Bamias
- Dept of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
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Banna GL, De Giorgi U, Ferrari B, Castagna L, Alloisio M, Marangolo M, Rosti G, Santoro A. Is high-dose chemotherapy after primary chemotherapy a therapeutic option for patients with primary mediastinal nonseminomatous germ cell tumor? Biol Blood Marrow Transplant 2007; 12:1085-91. [PMID: 17084372 DOI: 10.1016/j.bbmt.2006.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 06/08/2006] [Indexed: 02/07/2023]
Abstract
Patients with primary mediastinal nonseminomatous germ cell tumors have a poor prognosis, with a 5-year overall survival of nearly 50%. We investigated the feasibility and activity of early high-dose chemotherapy (HDCT) in these patients. After conventional induction chemotherapy, patients underwent a single shot of HDCT consisting of carboplatin, etoposide, and cyclophosphamide, followed by peripheral blood progenitor cell support. Twenty-one patients were considered for treatment with HDCT. Median age was 29 years (range, 19-55 years). Eight (38%) patients had lung metastases. After primary chemotherapy, 7 patients achieved complete remission, 4 achieved partial remission with negative marker, 1 achieved partial remission with positive marker, 2 had stable disease, and 7 progressive disease. Twelve patients were not treated with HDCT due to progressive disease and poor physical conditions. No HDCT-related deaths or irreversible organ toxicities were observed. Residual surgery after HDCT was performed in 4 patients and resulted in 3 pathologic complete remissions. With a median follow-up of 52 months (range, 15-71 months) in 9 patients treated with HDCT, 8 have been continuously free of disease. Of 12 patients who did not receive HDCT, 0 was alive at 2 years from diagnosis. A single course of HDCT after induction chemotherapy appeared to be inapplicable in most of our patients, mainly due to early progressive disease. These data should be considered in the analysis of retrospective series and in the design of new prospective trials with HDCT in these patients. Earlier HDCT administration followed by residual surgery should be considered for further investigation.
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Affiliation(s)
- Giuseppe Luigi Banna
- Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Rozzano, Milan, Italy.
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Abstract
Although front-line chemotherapy cures most men with testicular germ cell tumors, salvage therapy is still important in a small but significant minority. Second-line conventional-dose or high-dose chemotherapy with stem cell rescue may cure 25%-50% of patients. New chemotherapeutic agents, including the taxanes gemcitabine and oxaliplatin, have added to the therapeutic armamentarium. Salvage surgical resection has an important role in selected patients. Cisplatin-refractory patients have a poor prognosis with current therapy, and novel chemotherapeutic and biologic agents need to be discovered for such patients.
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