Longitudinal evaluation of plasma miR371 to detect minimal residual disease and early relapse of germ cell tumors

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Background: Active surveillance is routinely recommended to manage patients (pts) with clinical stage I (CSI) germ cell testicular tumors (GCT), the most common presentation of newly diagnosed GCT. Circulating plasma miR371a-3p (miR371) has shown high sensitivity and specificity in pts with metastatic non teratoma GCT or in pts with clinically detectable testicular GCT prior to orchiectomy. However, limited data are available about this biomarker accuracy to detect minimal residual disease post-orchiectomy in pts on active surveillance for early stage disease. Methods: CSI GCT pts with available plasma samples after radical orchiectomy enrolled in the British Columbia provincial biobank research program were selected for this study. RT-PCR was used for qualitative miR371 analysis. Sensitivity, specificity, negative and positive predictive values (NPV, PPV) and AUC in predicting tumor recurrence were evaluated for miR371 and compared to the same operating characteristics of current gold standard diagnostic tests. Relapse free survival (RFS) was correlated to post-orchiectomy miR371 (positive or negative) status. Fisher’s exact test was used to evaluate the sensitivity and specificity, unpaired t-test for comparison of miR371 expression. RFS was calculated using the Kaplan-Meier method, and differences between groups were estimated using the log rank test, 2-sided and with 5% significance threshold. Results: With a median follow-up of 41 months, 101 pts with CSI GTCwere included, of whom 35 (34.6%) experienced a disease relapse during the follow-up. miR371 was positive in 22/35 (62.8%) of the relapsed pts. miR371 positivity preceded clinical evident disease by a median of 3 months (range: 1-12 months).The specificity and PPV were 100% (95% CI: 94.5 - 100 for both), sensitivity 62.8% (95% CI: 44.9 - 78.5), NPV 83.5% (95% CI: 76.7 - 88.6) and AUC 0.81 (95% CI: 0.71 - 0.91). No false positive results were observed. The RFS of the pts with positive post-orchiectomy miR371 was significantly shorter (median: 3.5 months vs. not reached; p<0.0001) compared to the pts with a negative post-orchiectomy miR371 (HR: 16.9; 95% CI: 2.1 - 135.7; p<0.0001). miR371 sensitivity correlated with tumor burden, time between tumor relapse and miRNA testing and histology (nonseminoma > seminoma). Conclusions: miR371 has high specificity and PPV in detecting GCT at an early stage and could be used to guide treatment selection after orchiectomy. Further studies, including the SWOG S1823 clinical trial, are ongoing or have been planned in this setting for validation of clinical utility.

Longer follow-up data of circulating miR371a-3p expression across the spectrum of germ cell tumors (GCT)

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Background: miR371a-3p (miR371) is overexpressed in seminoma (S) and nonseminoma (NS) active germ cell malignancy (aGCM) and easily detectable in blood. We previously described1 a remarkably high accuracy of miR371 in detecting aGCM in early and advanced stages germ cell tumor (GCT) patients (pts). We here present the updated miR371 expression data with a longer follow-up, particularly relevant to assess miR371 clinical utility to predict GCT relapse in clinical stage I (CSI) and stage IIA pts. Methods:119 samples from 99 pts enrolled in the GU biobank program at the British Columbia Cancer – Vancouver were analyzed. The pts were divided according to their risk of aGCM in low (CSIA NS and CSI S), moderate (CSIB NS, stage IIA markers negative/low elevated S and NS), and high risk (definitively metastatic aGCM) groups. Blood of the low and moderate risk pts was collected post orchiectomy and at the time of the clinical relapse; prior to/post-chemotherapy in the high risk group. Plasma miR371 expression was evaluated by RT-PCR and quantified by ΔΔCT method. Sensitivity, specificity, negative and positive predictive values (NPV, PPV) and AUC of the ROC curve were analyzed. Results: Five (2 moderate - 3 low risks) pts were lost at follow-up and 1 high risk pt had deceased. Overall, 113 samples (50, 36, 27 in the low, moderate, and high risk groups, respectively) were analyzed. The median follow-up from study entry was 30 (6-51), 28 (20-52), and 29 (7-53) months for the low, moderate and high risk, respectively. Seven more relapses occurred: 4 in the low risk (3 S and 1 NS) and 3 in the moderate risk groups (2 NS and 1 S). miR371 was found falsely negative post-orchiectomy in 4 pts and truly negative in 3 relapsed pts (2 pure teratoma and 1 unconfirmed relapse). Serial analysis of the false negative relapsed pts showed that miR371 became detectable at the time of clinical relapse. The operating characteristics of miR371 are summarized in the table below. Conclusions: Our follow-up has exceeded the expected time of relapse even in the low risk pts. The high accuracy of miR371 in detecting aGCM was confirmed with a longer follow up. However, the few false negatives in relapsed pts and the serial analysis suggest a lack of sensitivity in the detection of microscopic disease post-orchiectomy with the current methodology while miR371 high sensitivity was confirmed in presence of radiologic measurable disease (≥ 1 cm). The definitive operating characteristics of miR371 post-orchiectomy and during the follow-up of stages I/ IIA pts will be prospectively validated by the S1823 study that is actively recruiting pts. [Table: see text]

SEMS trial: Result of a prospective, multi-institutional phase II clinical trial of surgery in early metastatic seminoma

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Background: Chemotherapy or radiotherapy are standard treatments for stage II seminoma, though they are associated with significant long-term treatment-related toxicities. Retroperitoneal lymph node dissection (RPLND) is an established treatment for testicular germ cell tumors but little data exists on its efficacy as a front-line treatment in early metastatic (stage II) seminoma. This is a single-arm, multi-institutional (NCT02537548), phase II study of retroperitoneal lymph node dissection (RLND) as first-line treatment for testicular seminoma with isolated retroperitoneal disease. Methods: Twelve sites in the United States and Canada prospectively enrolled patients (16 years of age) with testicular seminoma and isolated retroperitoneal lymphadenopathy between 1-3 cm in size. Patients were excluded if they received prior therapy (except orchiectomy) for testicular cancer. Open, modified-template RPLND was performed by qualified surgeons with a primary endpoint of 2-year recurrence-free survival. Data on complication rates (short and long-term), pathologic up/downstaging, recurrence patterns, adjuvant therapies, and treatment-free survival were assessed. Results: A total of 55 patients were enrolled and underwent RPLND. Fourteen patients had initial stage I disease who developed isolated retroperitoneal relapse while 41 patients had clinical stage IIA-B at presentation. With a median follow-up of 24 months (8-52 months), there were a total of 10 recurrences. The overall recurrence rate was 18% with a median time to recurrence of 8 months. Of the recurrences, 8 underwent chemotherapy (6 BEP X 3, 1 EP X 4, 1 carbo/etoposide) and 2 underwent additional surgery. The two-year recurrence free survival was 87% and the overall survival was 100%. There were 7 (13%) patients who experienced short-term complications within 1 year of RPLND. Of these, 5 (9%) were classified as Clavien Dindo I-II and 2 (3.6%) were classified as Clavien Dindo III. No patients have reported long-term complications. Conclusions: This trial establishes RPLND as a therapeutic option as a first-line treatment in early metastatic seminoma. The surgery offers cancer control rates similar to those seen in non-seminomatous germ cell tumors. Clinical trial information: NCT02537548.

Testicular cancer management: Population-wide, rapid case ascertainment to drive early expert engagement and reduced practice variation

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Background: Research priorities in germ cell tumor (GCT) management have moved sharply from therapeutic improvements to cancer care delivery research and biomarker-based decision making. Early intervention with centralized decision support and oversight by expert teams result in best therapeutic outcomes and survivorship with decreased resource utilization. We describe Kaiser Permanente Northern California’s (KPNC) re-organization of care delivery through rapid case ascertainment and early expert input, as well as early results of reduction in practice variation and system-wide practice change. Methods: In 2016, KPNC reorganized oncology from a distributed generalist model to a model led by a centralized multidisciplinary expert team to share in initial and ongoing care delivery for all GCT patients in the system. Central to the re-organization was rapid ascertainment of the entire population of patients with GCT within the system and early expert engagement in treatment decision-making. Results: Between May 2016 and June 2018, 274 GCT patients were recorded in the tumor registry, of whom 69% were < 40 years of age, 16% were non-white, 56% had seminoma and 63% had stage 1 disease. Rapid case ascertainment identified 89% (95% CI, 86-93%) of the cases, increasing from 79% in 2016 to 97% in 2018 as false negatives were identified and used to improve the case finding algorithm. The overall positive predictive value was 57% (52-62%) and number needed to detect was 1.75 (1.62-1.91). Of the 274 cases, 92% (89-95%) were engaged by the expert team. In addition, the team reviewed 61 testicular cancer patients who had recurrences or metastatic cancers. Among 177 patients with stage I seminoma, the preferred use of active surveillance over adjuvant chemotherapy or radiation therapy rose from 48% (95% CI, 35-62%) in 2015 to 87% (75-99%) in 2018 (p = 0.0005). For patients with nonseminoma, the rate of the preferred option of retroperitoneal lymphadenectomies being performed by a high volume urologic surgeon increased markedly from 62% in 2015 to 95% in 2018. Conclusions: To our knowledge, the KPNC re-organization of GCT care delivery with comprehensive rapid case ascertainment is unique for integrated health care delivery systems in the USA. While early, KPNC has a working platform for early, expert multidisciplinary review and bidirectional communication with local care teams for population-based care. Early evidence points to system-wide reductions in practice variation and improvements in practice.

A Canadian approach to the regionalization of testis cancer: A review

At the Canadian Testis Cancer Workshop, the rationale and feasibility of regionalization of testis cancer care were discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents and fellows, and nurses, as well as patients and patient advocacy groups.This review summarizes the discussion and recommendations of one of the central topics of the workshop - the centralization of testis cancer in Canada. It was acknowledged that non-guideline-concordant care in testis cancer occurs frequently, in the range of 18-30%. The National Health Service in the U.K. stipulates various testis cancer care modalities be delivered through supra-regional network. All cases are reviewed at a multidisciplinary team meeting and aspects of care can be delivered locally through the network. In Germany, no such network exists, but an insurance-supported online second opinion network was developed that currently achieves expert case review in over 30% of cases. There are clear benefits to regionalization in terms of survival, treatment morbidity, and cost. There was agreement at the workshop that a structured pathway for diagnosis and treatment of testis cancer patients is required.Regionalization may be challenging in Canada because of geography; independent administration of healthcare by each province; physicians fearing loss of autonomy and revenue; patient unwillingness to travel long distances from home; and the inability of the larger centers to handle the ensuing increase in volume. We feel the first step is to identify the key performance indicators and quality metrics to track the quality of care received. After identifying these metrics, implementation of a "networks of excellence" model, similar to that seen in sarcoma care in Ontario, could be effective, coupled with increased use of health technology, such as virtual clinics and telemedicine.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Mantle cell lymphoma: initial report from the North American Mantle Cell Lymphoma Consortium

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Background: The goal of the North American Mantle Cell Lymphoma (MCL) Project is to evaluate the clinical, biological, and genomic markers that affect the outcome of patients with MCL. Methods: We have retrospectively studied the clinical and pathological features of 307/421 patients diagnosed with MCL between January 2000 to December 2012 from 23 institutions across North American. Results: The male to female ratio of MCL patients was 3.5:1, with a median age of 66 years (range: 24-106 years). Approximately 29% of patients (78/269) presented with B symptoms and 257 (257/307, 83.7%) patients had extranodal involvement at diagnosis. Median follow-up was 7.1 years (range, 0.03 to 16.6 years) with the five-year PFS and OS at 27.8%, and 54.4%, respectively. Univariate analysis revealed that the following factors were significantly associated with both inferior OS and PFS ( p< 0.05): older age (≥60 years), presence of B symptoms, advanced Ann Arbor stage, elevated LDH, low platelets (≤100K/ml), blastoid/pleomorphic cytology, Ki67 proliferation ≥30%, circulating tumor cells, no transplantation (vs. transplantation), and allogeneic (vs. autologous) stem cell transplantation. In addition, large tumor size (maximal diameter > 3cm), high WBC ( > 10×103/ml), CD5 or CD23 positivity, and a complex karyotype were associated with inferior OS ( p< 0.05). Multivariate Cox regression analysis showed age (≥ 60y; p= 0.0028, HR = 2.44, 95% CI: 1.36-4.38) and high LDH ( p= 0.0062, HR = 2.19, 95% CI: 1.25-3.84) were the two factors predicting the clinical outcome. MIPI-c, a commonly used prognostic scoring system which includes Ki67, stratified the 100 MCL cases into four group with distinct clinical outcomes ( p< 0.001). Using readily-available clinical and pathological variables, we developed a simple and robust scoring system, MIPI-P (pathology), which consisted of age (≥60 years), LDH (high), Ki67 index (≥30%), Ann Arbor stage (III/IV), and cytological type (blastoid/pleomorphic), each contributing one point. The MIPI-P system stratified 104 MCL cases into three distinct groups ( p< 0.001). Median survival for the different groups were: low grade (0-1 points): 11.8 years; intermediate grade (2-3 points): 4.9 years; and high grade (4-5 points): 1.6 years. We further validated this system in an independent cohort of 33 MCL cases and confirmed that the modified MIPI-P provided robust prognostic predication ( p= 0.014). Conclusions: The clinical and biologic characteristics of MCL can provide information assisting with the prognosis of patients with MCL.

Expression of circulating miR375 and miR371 to differentiate teratoma and viable germ cell tumor in patients with post-chemotherapy residual disease

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Background: Viable germ cell tumors (vGCT) express high levels of certain circulating microRNAs, including miR-371a-3p (miR371) that has shown high specificity and sensitivity. However, neither tissue nor serum/plasma from patients with only teratoma are miR371 positive. miR375 is overexpressed in teratoma tissue, but detectability in blood is unknown. Methods: miR371 and miR375 expression was analyzed in 100 patients with various stages and histology of GCT. miR375 expression in teratoma was validated in patients with post-chemotherapy pathologically confirmed teratoma (PCPCT). The miRNAs expression was assessed by RT-PCR and quantified by ΔΔCT method. The optimal cut-off for miR375 expression was estimated by Youden index ( > 20). Spike-in cel-miR-39-3p, miR-451 and miR-30b-5p were used as internal controls. Sensitivity, specificity, AUC of the ROC of miR375 in detecting teratoma was analyzed. Results: In the discovery cohort miR371 and miR375 were measured in 62 pts: 27 CSI NED, 15 chemo-naïve metastatic seminoma and 20 with PCPCT. miR375 was over-expressed in pts with teratoma compared to CSI and seminoma pts (p = 0.002), while miR371 was expressed in the seminoma pts and undetectable in the PCPCT and CSI pts (p < 0.001). In the post-chemotherapy setting, 38 pts were analyzed: 21 PCPCT, 6 vGCT and 11 complete remission (CR). Also in this cohort, miR375 was over-expressed in pts with teratoma compared to the pts presenting vGCT and post-chemotherapy CR (p = 0.01), while miR371 was detectable only in the pts with vGCT (p < 0.001). Overall, sensitivity and specificity of miR375 in identifying teratoma were 78% and 80%, respectively; the AUC was 0.7 (95% CI: 0.5490-0.8186; p < 0.01). Conclusions: Pts with residual post-chemotherapy teratoma present higher plasma levels of miR375 compared to pts with vGCT in whom miR375 is low but miR371 is expressed at high levels. The simultaneous evaluation of miR371 and miR375 may be clinically useful to predict the histology of the GCT components in pts with post-chemotherapy residual disease to inform the best therapeutic options (surgery or chemotherapy). Further validation within larger studies is warranted.

Validation of plasma miR-371a-3p expression in patients with metastatic and early stage germ cell tumor

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Background: Identification of relapsing/residual viable germ cell malignancy (GCM) is often challenging in patients with CSI on surveillance or with residual post-chemotherapy disease. The presence of a biomarker for GCM would overcome the uncertainty of the current methods and improve the quality of care of those patients. Methods: A 2-cohorts pilot study involving patients with clearcut evidence of GCM (clinical stage IS, metastatic and GCM prior orchiectomy) for the development cohort and patients with CSI with or without signs of tumor relapse and patients with metastatic GCM post-chemotherapy for the validation cohort. Blood samples collected in Streck tubes were obtained prior to chemotherapy for the development cohort and post-orchiectomy, at the time of suspicious relapse or post-chemotherapy in the validation cohort. Plasma miR-371a-3p (miR371) was analyzed by RT-PCR. Positive predictive value (PPV), sensitivity, specificity, negative predictive values (NPV) and AUC of the ROC for miR371 and standard diagnostic tools (CT scan, AFP, BHCG and LDH) were calculated correlating qualitative miR371 expression to the presence of viable GCM. Results: 132 patients were enrolled into the development (33 pts) and validation (99 pts) cohorts. Within the development cohort 31/33 pts were miR371 positive, 2/33 pts were negative. 31 true positives were found among the 31 miR371 positive patients for a PPV of 100% (31/31). Two true negatives were found among the 2 patients who had no miR371 expression identified (teratoma, lymphoma). The validation cohort was chosen to evaluate the methodology among patients with predicted lower volumes or no clinically apparent disease. 13/99 patients within the validation cohort were miR371 positive and all 13 had subsequent confirmation of viable GCM. For the overall study of 132 pts, PPV was 100% (46/46), NPV 98%, sensitivity 96% and specificity 100%, the AUC of the ROC was 0.96. Conclusions: Detectable circulating miR-371a-3p levels predict viable GCM and may represent a strategy for biological rather than radiographic assessment for surveillance of early stage and for post-treatment patients. Larger studies to validate these and like results have been planned.

Plasma miR371 for the detection of viable germ cell tumor in testicular cancer patients with enlarging or post chemotherapy residual nodes

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Background: The pathological constitution of post-chemotherapy residual disease (PCRD) or enlarged nodes in clinical stage I (CSI) patients (pts) with germ cell tumor (GCT) is guesswork, especially when tumor markers (β-HCG, AFP, LDH) are negative. Currently, accurate assessment requires clinical follow-up with imaging to establish patterns of growth or pathological confirmation with RPLND. A blood-based approach reliably to identify patients with non teratoma viable GCT (NTVGCT) would be valuable. Methods: miR371 extracted from plasma of 44 pts with GCT was analyzed by RT-PCR and relative expression calculated by the 2-ΔΔCt method. Plasma from healthy male volunteers was used as negative control while miR-93-5p as internal positive control. The sensitivity and specificity of miR371 were calculated correlating miR371 overexpression to the presence of relapsed/residual NTVGCT. Results: Fifty eight samples (20 CSI, 20 metastatic, 18 PCRD) were analyzed. Ten CSI pts presented with suspicious enlarging nodes (≥ IIA) and miR371 was overexpressed in 5/6 pts with confirmed tumor relapse. Neither CSI pts with unconfirmed enlarging nodes (n = 4) or with no signs of relapse (n = 10) presented high miR371 levels. miR371 was overexpressed in all the pre-chemotherapy metastatic pts (n = 10) and negative after chemotherapy (n = 10), with 4 pts presenting PCRD. miR371 was negative in all the pts with PCRD and no residual NTVGCT was detected in those pts by either pathology (n = 10) or clinical follow-up (n = 8). Sensitivity and specificity were 93.3% and 100%, respectively. Conclusions: Elevated plasma levels of miR371 correlate with the presence of NTVGCT and may lead to biological rather than radiographic assessment of active GCT. Since chemotherapy is first line option for NTVGCT while is inactive in teratoma, miR371 status may be used to select pts for chemotherapy or surgery. These encouraging findings inform upcoming North American trials for further definition of miR371 operating characteristics in all stages, sites of origin, gender and age specific GCTs. [Table: see text]

New treatments for stage I testicular cancer

Clinical stage I represents the most frequent presentation of both seminoma and nonseminoma testicular cancer. Despite a survival rate of close to 100%, the management of patients with this disease stage is controversial. The recurrence rate is 10% to 20% for patients with stage I seminoma and 15% to 50% for those with stage I nonseminoma. A highly sensitive and specific biomarker of relapse that is applicable to both seminoma and nonseminoma, and able to drive a definitive risk-adapted management of the patients, still is not available. Lymphovascular invasion (LVI) in the orchiectomy specimen has been used as a risk factor in patients with stage I nonseminoma. However, with a risk of recurrence of 50% for LVI-positive patients and 15% for LVI-negative patients, the discriminative power of LVI is modest at best. Various management options exist. In the absence of a predictive biomarker for recurrence, active surveillance avoids overtreatment in 50% to 85% of patients, with no risk of long-term side effects in nonrelapsing patients and a preserved overall survival of almost 100% after specific treatment for recurrent disease. However, although active surveillance has been accepted as the preferred option for stage I seminoma and low-risk stage I nonseminoma, its role in high-risk stage I nonseminoma remains controversial.

Enhancing Adolescent and Young Adult Oncology Research Within the National Clinical Trials Network: Rationale, Progress, and Emerging Strategies

Adolescent and Young Adult Oncology (AYAO, including patients 15-39 years of age) is an emerging discipline in the field of cancer treatment and research. Poorer survival outcomes for this population and characteristic age-related challenges in care have called attention to the need for increased AYAO research. This chapter outlines pressing questions and reviews recent progress in AYAO research within the current organizational structure of the federal clinical trials enterprise, emphasizing how the United States National Cancer Institute's National Clinical Trials Network (NCTN) has created novel opportunities for collaborative AYAO research among the pediatric and adult NCTN groups. Potential strategies for expanding AYAO research, both within the NCTN and with other partners in the federal and advocacy domains are identified.

Is the International Germ Cell Consensus Classification (IGCCC) sufficiently predictive in 2015?

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Background: The IGCCC has been an invaluable tool to guide clinical trial development in disseminated germ cell tumors. This classification was developed in the early 1990s. The data were abstracted from records of pts treated between 1975 and 1990 and > 100 institutions submitted data. This analysis resulted in the development and validation of a simple system based on clinically derived parameters. Three risk groups were identified for disseminated nonseminoma.; “good risk” group with a predicted 5 year overall survival (OS) > 90%, ‘intermediate risk” with a 5 yr OS of 75% and “poor risk” with a predicted 48% 5 yr OS. Recently, a number of clinical trials and large institutions have reported outcomes in intermediate and poor risk disseminated germ cell tumors. Outcomes reported exceed IGCCC predictions. We hypothesize that the IGCCC substantially underestimates outcomes in the modern era. Further we speculate that a re-analysis of existing clinical trial data would be fruitful in predicting outcomes for disseminated germ cell tumors in the 21st century. Methods: Reports from large randomized clinical trials reporting outcomes in intermediate and poor risk disseminated germ cell tumors were reviewed and estimates of Progression Free and Overall survival made. Results: See Table. Conclusions: Compared to the IGCCC predictions based on data from 25-40 years ago, there appears to be improved overall survival in disseminated germ cell tumors in the modern era. Intermediate risk and poor risk disease appears to have OS exceeding 80-85% and 75% respectively. A more accurate prediction of outcomes with standard treatments should inform clinical trial design going forward. [Table: see text]

Quality Oncology Practice Initiative (QOPI) participation as a means to physician engagement, performance improvement, and delivery of safe and high-quality cancer care

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Background: High quality and safe medical care has been a consistent goal of the medical community at Virginia Mason Medical Center (VMMC). The Am Soc of Clinical Oncology (ASCO) has set out a list of criteria as part of Its Quality Oncology Practice Initiative (QOPI), which are increasingly being adopted as standards for quality measurement in the Oncology community. Our practice at VMMC participated in the QOPI quality metric survey, with the intent of measuring and enhancing cancer care delivery. Methods: We participated in the web-based QOPI quality metric during the September, 2013 and April, 2014 sessions. Chart abstraction was shared by the providers. Following the Sept session, our performance was analyzed, and targeted areas of improvement were collectively identified by all providers. Following the April session, the clinical note format was changed to incorporate a standard template, addressing areas of underperformance. Results: In the September 2013 session, the primary areas of underperformance were assessment of: a) pain, b) emotional distress, c) performance status (PFS), and d) documentation of staging. Following the April 2014 session, we noted improved performance in all these assessments. Thus, pain reporting rates improved from 40.6 to 61.2%; emotional distress screening from 37.3% to 42.8%; PFS documentation from 42.6 to 53.7%; and staging at initial diagnosis from 74.6% to 80.9%. However our areas of underperformance continued to lag 10 to 30% behind QOPI aggregate reporting rates. With the introduction of a structured note in the electronic medical record (EMR), further improvements are expected the results of which will be reported at the time of the meeting. On the positive side, chemotherapy education and discussion of risk/benefit were consistently areas of superior performance in our practice with our reporting rates being 10 to 40% higher than the QOPI aggregate. Conclusions: QOPI participation is a useful tool for improving and sustaining a high level of practice performance in oncology. Structured notes in the EMR maybe indispensable for maintaining a high level of compliance with performance measures.

Modeling Management Strategies for Clinical Stage I Seminoma: Direct and Indirect Costs for the First 5 Years

INTRODUCTION

Clinical stage I seminoma can be managed with surveillance, chemotherapy or radiotherapy with similar survival rates. However, costs and side effects vary among these treatment modalities. We created a model to estimate the direct and indirect costs during the first 5 years of treatment for the 3 treatment strategies.

METHODS

Markov model based analyses were conducted to compare the costs of the 3 management strategies during the first 5 years. In this model clinicians and patients were assumed to be 100% compliant with the 2012 NCCN Guidelines® for testicular cancer. Model parameters were collected from the Washington State CHARS (Comprehensive Hospital Abstract Reporting System), published literature and Medicare reimbursement amounts. A 5% annual health inflation rate was assumed.

RESULTS

The model predicts an initial cost premium for carboplatin (1 cycle-$9,199.49; 2 cycles-$10,613.85) and radiotherapy ($9,532.80) compared with surveillance ($9,065.31). Radiotherapy (145.8 hours) and surveillance (123.0 hours) require more patient time than carboplatin (1 cycle-93.2 hours, 2 cycles-106.3 hours). When the direct and indirect costs are considered, the least expensive management strategy is surveillance.

CONCLUSIONS

Surveillance is the most cost-effective management strategy for clinical stage I seminoma during the first 5 years of treatment. Although not evaluated in this analysis, costs of late side effects associated with radiotherapy and chemotherapy should be considered. Due to potentially minimal late side effects and superior cost-effectiveness, surveillance represents a safe, cost-effective and time effective option for the management of stage I seminoma.

Patterns of relapse in patients with clinical stage I testicular cancer managed with active surveillance

PURPOSE

To evaluate the performance of active surveillance as a management strategy in broad populations and to inform the development of surveillance schedules by individual patient data regarding timing and type of relapse.

METHODS

Retrospective study including data from 2,483 clinical stage I (CSI) patients, 1,139 CSI nonseminoma and 1,344 CSI seminoma managed with active surveillance, with the majority treated between 1998 and 2010. Clinical outcomes including relapse and death, time distribution, extent of relapse and method of relapse detection observed on active surveillance were recorded.

RESULTS

Relapse occurred in 221 (19%) CSI-nonseminoma and 173 (13%) CSI-seminoma patients. Median time to relapse was 4 months (range, 2-61 months), 8 months (range, 2-77 months) and 14 months (range, 2-84 months) for lymphovascular invasion-positive CSI nonseminoma, lymphovascular invasion-negative CSI nonseminoma and CSI seminoma. Most relapses were observed within the first 2 years/3 years after orchiectomy for CSI nonseminoma (90%)/CSI seminoma (92%). Relapses were detected by computed tomography scan/tumor-markers in 87%/3% of seminoma recurrences, in 48%/38% of lymphovascular invasion-negative and 41%/61% of lymphovascular invasion-positive patients, respectively. 90% of CSI-nonseminoma and 99% of CSI-seminoma relapses exhibited International Germ Cell Collaborative Group good-risk features. Three patients with CSI nonseminoma died of disease (0.3%). One patient with CSI seminoma and two patients with CSI nonseminoma died because of treatment-related events. Overall, advanced disease was seen in both early- and late-relapse patients. All late recurrences were cured with standard therapy. Five-year disease-specific survival was 99.7% (95% CI, 99.24% to 99.93%).

CONCLUSION

Active surveillance for CSI testis cancer leads to excellent outcomes. The vast majority of relapses occur within 2 years of orchiectomy for CSI nonseminoma and within 3 years for CSI seminoma. Late and advanced stage relapse are rarely seen. These data may inform further refinement of rationally designed surveillance schedules.

United States trends in patterns of care in clinical stage I testicular cancer: Results from the National Cancer Database (1998-2011)

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Background: There has been significant evolution in worldwide guidelines for management of clinical stage I (CS1) testicular cancer where active surveillance (AS) strategies are now considered a first choice, especially for patients with lower recurrence risk after orchiectomy. Conversely, local therapies for CS1 such as primary retroperitoneal lymphadenectomy (RPLND) in non-seminoma and regional radiation in seminoma are phasing out of recommendations. In the US, there have been no comprehensive efforts to measure uptake of guideline recommendations and modern patterns of care for early-stage testicular cancer. Methods: Access to the testicular cancer data set within the National Cancer Data Base (NCDB) was granted to Virginia Mason Medical Center (A SWOG affiliated cancer research program) for this retrospective cohort study. We identified all patients with CS1 testicular cancer between 1998 and 2011. Management options after orchiectomy such as adjuvant radiotherapy, adjuvant chemotherapy, RPLND, or AS were analyzed using cross tabulation and trend analysis. Results: Within the NCDB, of 75,902 patients with testicular cancer, 31,208 and 13,301 were diagnosed with CS1 seminoma and non-seminoma, respectively. For CS1 seminoma, AS use increased from 25.2% in 1998 to 55.8% in 2011. Similarly adjuvant chemotherapy use also increased (1.9 % to 16.7%). Conversely, use of adjuvant radiation decreased from 72.9% to 27.5%. For CS1 non-seminoma, AS remained the main treatment modality ranging between 58.8% and 66.2%. The use of adjuvant chemotherapy increased (28.3% in 2011) and the rate of primary RPLND constantly decreased down to 12.9% that same year. Interestingly, 50.3% of patients with CS1 non-seminoma and negative lympho-vascular invasion status had chemotherapy rather than AS. Trends analyses were statistically significant for all treatment modalities (p<0.05). Conclusions: Active surveillance as a management strategy has increased and is currently the most common treatment modality used for both CS1 seminoma and non-seminoma in the US. Regional therapies in CSI seminoma and non-seminoma are decreasing but persist even in patients with a low risk of recurrence.

Influence of social demographics and African-American race on outcomes in testicular cancer: Analysis of 75,902 patients in the National Cancer database

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Background: While there have been substantial advances in treatment and outcomes in testicular cancer, most of the data are derived from large institutionals or clinical trials. Testicular germ cell tumors are uncommon (8,000 new patients annually in US). The incidence among patients (pts) of African origins is extremely low. Most of the conclusions regarding outcomes are based on Caucasian pts from research institutions. Information about modern outcomes in non-Caucasian races is scant and little is known about the influence of various social demographic parameters on presentation patterns and survival. Using this population-based database available through the NCDB, we sought to better understand social and racial variations in outcomes. Methods: Within the NCDB, 75,902 testicular cancer pts were available for review. Tools available through the NCDB were utilized for analysis. Herein, we evaluated social demographics (insurance type, educational achievement, annual income, type of treating institution) and racial/ethnic characteristics as they pertained to stage at presentation and survival. Results: 75,902 pts were available from the timeframe of 1998 through 2011 for aggregation of social demographic features as well as racial/ethnic characteristics. Overall survival was available on 48573 pts through 2006. Racial-ethnic breakdown at presentation was 84.1% (n=63,867) Caucasian and African-American 2.7% (n=2,083). Overall, insurance type, education (% without high school degree), income (< $ 30000 to >$46,000) and type of treating hospital were analyzed using univariate and multivariate models. Full details will be presented. Conclusions: Unfavorable presentations and outcomes in testicular cancer are seen by race and social demographics. In depth analytics are being performed to characterize the variations as related to biological/genetic differences and/or differences in social demographics. In this very large cohort, the National Cancer database demonstrates a 2-fold risk increase in death in African American pts relative to Caucasian pts with similar stage at presentation.

Mesenteric lymphadenopathy in testicular germ cell tumor

In approximately 25% of patients with testicular germ cell tumor (GCT), the cancer metastasizes to lymph nodes and distant organs. The initial lymphatic drainage site of GCTs is the retroperitoneum. GCTs rarely involve mesenteric lymph nodes. In this study, we report a case of a 32-year-old male patient with GCT and associated mesenteric lymphadenopathy.

Building clinical volumes, research capacity, and quality care in testicular cancer

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Background: Developing consistent, evidence-based, personalized and cost appropriate management of germ cell tumors is challenging for two reasons: these are uncommon diseases and successful management requires nuanced input from many disciplines with specialized interest in germ cell tumors. We speculated model combining a working tumor board and a true multidisciplinary clinic would improve volumes, research contributions, consistency and personalized care for patients with germ cell tumors. Methods: Beginning in March 2011, we developed a multidisciplinary clinic model, flow and communications with the following principles in mind. 1.) embed electronic capacity to capture clinical and biological datasets to serve as a template for research collaborations with national and international colleagues, 2.) coordinate clinical operations around a mandate for expert pathological and radiographic review, 3.) develop and apply evidence-based clinical guidelines, 4.) build an “open-source” operation and accept cases for electronic review and deliberation from patients and providers who desired expert oversight from an experienced team. Results: Our current clinical volumes have grown to an average of two new cases/week along with 1-2 outside reviews. Ongoing follow-up patients average 10/week. RPLND volumes have increased markedly to more than 20/year. All cases undergo pathology and radiology review. Adherence to published guidelines is superb with few deviations. Imaging schedules have been scaled down to approximately one third of previous radiation exposure. Research contributions have increased with the development of international collaborations, publications and new investigator-initiated studies. Conclusions: Our results demonstrate that purposeful coordination and consolidation of expertise and interests can result in the development of regional and national resources for management of rare malignancies such as testicular cancer. These high functioning clinics result in cost-effective, evidence-based management and high patient satisfaction.

Wisconsin Ginseng (Panax quinquefolius) to improve cancer-related fatigue: a randomized, double-blind trial, N07C2

BACKGROUND

Safe, effective interventions to improve cancer-related fatigue (CRF) are needed because it remains a prevalent, distressing, and activity-limiting symptom. Based on pilot data, a phase III trial was developed to evaluate the efficacy of American ginseng on CRF.

METHODS

A multisite, double-blind trial randomized fatigued cancer survivors to 2000mg of American ginseng vs a placebo for 8 weeks. The primary endpoint was the general subscale of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) at 4 weeks. Changes from baseline at 4 and 8 weeks were evaluated between arms by a two-sided, two-sample t test. Toxicities were evaluated by self-report and the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) provider grading.

RESULTS

Three hundred sixty-four participants were enrolled from 40 institutions. Changes from baseline in the general subscale of the MFSI-SF were 14.4 (standard deviation [SD] = 27.1) in the ginseng arm vs 8.2 (SD = 24.8) in the placebo arm at 4 weeks (P = .07). A statistically significant difference was seen at 8 weeks with a change score of 20 (SD = 27) for the ginseng group and 10.3 (SD = 26.1) for the placebo group (P = .003). Greater benefit was reported in patients receiving active cancer treatment vs those who had completed treatment. Toxicities per self-report and CTCAE grading did not differ statistically significantly between arms.

CONCLUSIONS

Data support the benefit of American ginseng, 2000mg daily, on CRF over an 8-week period. There were no discernible toxicities associated with the treatment. Studies to increase knowledge to guide the role of ginseng to improve CRF are needed.

Characterization of relapse in patients with clinical stage I (CSI) nonseminoma (NS-TC) managed with active surveillance (AS): A large multicenter study

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Background: Large single institution trials have demonstrated that AS for patients with CSI NS-TC is safe and effective. Information on timing and extent of relapse following AS has the potential to guide intensity and duration of imaging on AS. Methods: Retrospective clinical data on CSI patients were obtained from existing large databases, including institutions/regions which have a standardized policy of centralized management of testicular cancer including AS for patients with CSI NS-TC. In all, 1,034 patients with CSI NS-TC managed with AS were reviewed of whom 886 had no lymphovascular invasion (LVI-), 220 had lymphovascular invasion (LVI+) and 28 had unknown lymphovascular status (LVI unknown). Results: A total of 221 relapses occurred with 150/886 (17%) of LVI– pts , 60/120 (50%) LVI+ pts and 11/28 (39%) of LVI unknown pts (Table). Median follow-up was 63 months (1-163 months). At last follow up 1,013/1,034 (98%) were alive without disease, 16/1,034 (1.5%) were dead of other causes and 7/1,035 (0.05%) were alive with disease or dead of disease. Relapse was identified by marker elevation and/or abdominal imaging in almost all patients. Few patients relapsed with IGCCCC intermediate (18/221, 8%) or poor risk disease (3/221, 1.4%). Conclusions: AS for CSI NS-TC is safe and effective, using a policy of centralized management with loco-regional delivery of care. Our multinational outcomes compare well to single institutional reports. Relapse other than with IGCCC good risk disease was uncommon and death from disease was rare. Compared to patients with LVI-, relapses in LVI + CSI patients occur earlier and few relapses are detected past the first year of follow-up. This data may help in the design of follow up schedules tailored towards the relapse risk in CSI NS-TC AS. [Table: see text]

Building platforms for collaborative care and clinical research in testicular cancer (TC): New approaches for care delivery for a model neoplasm

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Background: TC is a “model of a curable neoplasm.” In expert centers, more than 95% of patients are cured and enjoy long, high quality survivorship. Unfortunately, emerging data demonstrate variations in quality outcomes seen in high volume centers. Result are not fully replicated in U.S. community settings, low resources countries or in settings of uneven access. We hypothesize that real time, electronic information exchange in TC can influence favorably clinical decision making, patient-centered outcomes, value and quality of survivorship across business and geographic boundaries. Further, we speculate that aggregated, de-identified clinical/ biological information will serve as a template for a rapid learning system to refine clinical management and advance biological understanding. Methods: Our primary objectives were to (1) Build organizational/administrative capacity. (2) Engage patients/local providers. (3) Develop the information infrastructure to accomplish real time exchange of live patient-permitted clinical data (patient reported inputs, laboratory, imaging) and timely transmission of clinical decision support and ongoing oversight of care delivery in the community. (4) Establish a proof-of-principle demonstration in a community-based, electronically organized care delivery system. Results: Organizational: TC Commons, a nonprofit organization, was founded to house this effort. Leading academic institutions form the knowledge base, initial data sharing network and administrative structure for this electronic cooperative group. Early implementation has utilized cloud-based resources and telepresence. Community Engagement: We are utilizing organized social media efforts and partnering with patient advocacy groups. IT Infrastructure: We are creating public/private collaboratives to house the electronic capacity with appropriate privacy concerns. Proof of Principle: We are selecting community partner organizations and planning grant submissions. Conclusions: Expert platforms to enhance care delivery, patient value and experience, and clinical research can be built using a “bootstapping,” cost-sensitive approach.

Phase III evaluation of American ginseng (panax quinquefolius) to improve cancer-related fatigue: NCCTG trial N07C2

9001

Background: Ginseng is popularly used as a treatment for fatigue, one of the most common and disabling symptoms in people diagnosed with cancer. It is termed an “adaptogen”, thought to help the body combat negative effects of stress. This trial was to evaluate 2,000 mg American Ginseng versus placebo for cancer-related fatigue (CRF). Methods: Patients with cancer undergoing or having completed curative intent treatment and experiencing fatigue, rated at least 4 on a numeric analogue fatigue scale (1-10) for ≥1 month, were eligible. Exclusion criteria included CNS lymphoma, brain malignancies, or prior use of ginseng or chronic systemic steroids. Other etiologies for fatigue, such as pain and sleep, were also excluded. Patients were randomized to receive, in a double blind manner, 2,000 mg/d of American Ginseng or placebo in BID dosing for 8 weeks. The primary endpoint was change from baseline in the general subscale of the Multidimensional Fatigue Symptom Inventory (MFSI) at 4 weeks. Other MFSI subscales and the fatigue-inertia subscale of the Profile of Mood States (POMS) were also analyzed. Data were transformed to a 0-100 scale. Results: 364 patients were enrolled from 10/2008 to 07/2011. Data at 4 and 8 weeks are provided for several fatigue endpoints in the table below; higher numbers are better. Mental, emotional and vigor subscales of the MFSI were not significantly different between arms. There were no statistically significant differences in any grade of toxicity or self reported side effects between ginseng and placebo. Conclusions: This trial provides data to support that American Ginseng reduces general and physical CRF over 8 weeks without side effects. The treatment did not provide significant reductions in fatigue at 4 weeks and did not impact mental, emotional, and vigor dimensions of fatigue. [Table: see text]

Adjuvant surgery in patients with testicular cancer undergoing post-chemotherapy retroperitoneal lymph node dissection

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Background: Up to 50% of patients who undergo induction chemotherapy for metastatic germ cell cancer have significant residual retroperitoneal disease in whom post chemotherapy RPLND is indicated with intent to cure. Since complete resection is a critical component in PC-RPLND, meticulous dissection of the retroperitoneum with resection of involved organs or structures (adjuvant surgery) should be considered whenever feasible to ensure optimal outcome.

Methods: From 2004 to 2010, 85 testicular cancer patients underwent PC-RPLND by a single surgeon (SD). A bilateral template approach was utilized with nerve sparing technique whenever feasible. The clinico-pathologic and outcome of patients who underwent adjuvant surgery during PC-RPLND were reviewed.

Results: Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/ caval resection in six, aortic resection in eight, common iliac vessels resection in four and renal vessels resection/reimplant in two. Twelve patients (14%) required adjuvant nephrectomy (10/12 left sided). There was 1 ureteral resection with appendiceal substitution, 1 partial duodenectomy, 2 cholecystectomy, 2 thoracotomies, 4 liver resection/ biopsy, and 1 neck dissection. There were 8 early complications (28%) including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, UGI bleeding, retroperitoneal hematoma and alcohol withdrawal. No peri-operative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 (39%), fibrosis in 8 (28%) and viable germ cell tumor (GCT) in 9 (32%) patients. 75%, 82% and 66% of patients with fibrosis, teratoma and viable GCT had no evidence of recurrence in mean follow up of 18 months.

Conclusions: A significant number of patients undergoing PC-RPLND require adjuvant surgery including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity/mortality validate such aggressive surgical approaches performed by experienced surgeons.

Mesenteric lymphadenopathy in patients with germ cell tumor

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Background: Mesenteric lymphadenopathy may be secondary to inflammatory, infectious or tumoral pathologies. The most common malignancies causing mesenteric adenopathy are gastrointestinal and lymphoma. To the best of our knowledge, there are no reports of germ cell tumor (GCT) presenting with mesenteric adenopathy.

Methods: Four patients with GCTs presenting with mesenteric adenopathies were treated in two academic centers (OHSU and USC) by a single surgeon since 2004. All pathologies were non-seminomatous GCT. Their presentation, clinico-pathologic findings and outcome are reviewed.

Results: Two cases (19 and 51 yo) were IGCCC poor risk, stage II, testicular GCTs presenting with bulky retroperitoneal, periportal and mesenteric adenopathy. They both underwent post-chemo RPLND with mesenteric lymph node biopsy/resection. The intraoperative mesenteric lymph node frozen section study in one case revealed embryonal cell carcinoma and teratoma; he had early postoperative recurrence and is awaiting high dose chemotherapy and autologous stem cell transplant (HDC/ASCT). The other was teratoma and underwent resection, however he developed lung metastases with elevated AFP 6 months later and was treated with HDC/ASCT, being disease free for 2.5 years. The third case was a 29 yo IGCCC good risk testicular GCT who presented with retroperitoneal (II B) and mesenteric lymphadenopathy. He underwent post-chemo exploration and intraoperative frozen section of the mesenteric lymph nodes showed fibrosis and histiocytic infiltration; therefore classic RPLND was completed. The fourth case was a 24 yo HIV (-) patient with extragonadal GCT originating from the rectosigmoid. At presentation, he had a widespread mesenteric adenopathy, partially responded to primary (BEP) and salvage chemotherapy (VIP); he underwent recto/sigmoid resection, RPLND and PLND and had 52/104 lymph nodes positive for yolk sac tumor. He was referred for HDC/ASCT. Three cases were done recently with limited follow-up.

Conclusions: The most common etiologies for mesenteric adenopathy are inflammatory, infection and neoplastic diseases. In the presence of germ cell tumor however, mesenteric adenopathy is most likely secondary to metastasis rather than secondary pathology.

Testicular cancer survivorship: research strategies and recommendations

Testicular cancer represents the most curable solid tumor, with a 10-year survival rate of more than 95%. Given the young average age at diagnosis, it is estimated that effective treatment approaches, in particular, platinum-based chemotherapy, have resulted in an average gain of several decades of life. This success, however, is offset by the emergence of considerable long-term morbidity, including second malignant neoplasms, cardiovascular disease, neurotoxicity, nephrotoxicity, pulmonary toxicity, hypogonadism, decreased fertility, and psychosocial problems. Data on underlying genetic or molecular factors that might identify those patients at highest risk for late sequelae are sparse. Genome-wide association studies and other translational molecular approaches now provide opportunities to identify testicular cancer survivors at greatest risk for therapy-related complications to develop evidence-based long-term follow-up guidelines and interventional strategies. We review research priorities identified during an international workshop devoted to testicular cancer survivors. Recommendations include 1) institution of lifelong follow-up of testicular cancer survivors within a large cohort setting to ascertain risks of emerging toxicities and the evolution of known late sequelae, 2) development of comprehensive risk prediction models that include treatment factors and genetic modifiers of late sequelae, 3) elucidation of the effect(s) of decades-long exposure to low serum levels of platinum, 4) assessment of the overall burden of medical and psychosocial morbidity, and 5) the eventual formulation of evidence-based long-term follow-up guidelines and interventions. Just as testicular cancer once served as the paradigm of a curable malignancy, comprehensive follow-up studies of testicular cancer survivors can pioneer new methodologies in survivorship research for all adult-onset cancer.

Testicular cancer: a prototypic tumor of young adults

Testicular cancer is the most common solid tumor among males in the 20- to 39-year age range. Moreover, testicular cancer has unique biological associations, clinical features, and psychosocial impacts that establish this tumor as a prototypic malignancy of young adults. The biology of testicular germ cell tumors after puberty is distinctive. Epidemiologic patterns of testicular cancer suggest etiologic factors that may be congenital, racial, and geographic. The clinical management of a cancer common among young adults, but rare among adults in general, requires expertise so as not to jeopardize the high rates of survivorship associated with modern therapy. The concurrent but separate development of staging, prognostic systems, and treatment recommendations between the fields of pediatric and adult oncology highlights the need for increased integration and cooperation across these subspecialties. The high rate of survival, combined with the need for long-term monitoring for relapse or late effects, demonstrates the challenge of delivering longitudinal care in this mobile and active young adult population.

Evaluation of the Combination of Docetaxel/Carboplatin in Patients with Metastatic or Recurrent Squamous Cell Carcinoma of the Head and Neck (SCCHN): A Southwest Oncology Group Phase II Study

Carboplatin/docetaxel chemotherapy was evaluated in advanced squamous cell carcinoma of the head and neck (SCCHN). Eligibility included patients with recurrent, persistent, or metastatic SCCHN with Zubrod performance status 0-2. Docetaxel 65 mg/m(2) and carboplatin (AUC of 6) were given IV in a 21-day cycle to 68 patients. Response probability was 25 percent (95%CI: 15-38). The major toxicity observed was neutropenia, with 36 patients (61 percent) experiencing Grade 3 or worse. Median progression-free survival was 3.8 months (95%CI, 3.1-4.8) Median overall survival was 7.4 months (95%CI, 6.2-8.9). The results of this study suggest this regimen is active for outpatient treatment of recurrent SCCHN patients with good performance status.

Palonosetron plus dexamethasone for prevention of chemotherapy-induced nausea and vomiting in patients receiving multiple-day cisplatin chemotherapy for germ cell cancer

GOALS OF WORK

The aims of this study were to assess the safety and antiemetic efficacy of multiple-day dosing of palonosetron plus dexamethasone in patients receiving highly emetogenic multiple-day cisplatin-based chemotherapy for germ cell tumors.

MATERIALS AND METHODS

Forty-one men undergoing 5-day cisplatin-based chemotherapy for testicular cancer received palonosetron 0.25 mg IV once daily 30 min before chemotherapy on days 1, 3, and 5 plus IV dexamethasone 20 mg before chemotherapy on days 1 and 2, and 8 mg PO bid on days 6 and 7 and 4 mg bid on day 8. Safety and efficacy were assessed in 24-h intervals for 9 days. Efficacy endpoints included emesis, intensity of nausea and its interference with patient functioning, and rescue antiemetic use. A subset of patients (n = 11) was studied for electrocardiograph effects and pharmacokinetic evaluation.

MAIN RESULTS

This multiple-day antiemetic regimen was safe, with headache and constipation the most common treatment-related adverse events, mostly mild. Neither adverse events nor electrocardiographic changes appeared to increase in frequency, duration, or intensity over time despite a 1.42-fold systemic accumulation of palonosetron with repeated doses. The majority of patients had no emesis at any time throughout days 1-5 (51%) or days 6-9 (83%), had no moderate-to-severe nausea, and did not require rescue medication. Most patients reported that nausea had no significant effect on daily functioning on days 1-4 (72%) and days 5-9 (85%).

CONCLUSIONS

Palonosetron on days 1, 3, and 5, along with a regimen of dexamethasone, was safe and well tolerated and effectively controlled both nausea and emesis in patients undergoing 5-day cisplatin-based chemotherapy for testicular cancer.

Management of difficult germ-cell tumors

Although testicular cancer is a rare disease accounting for only 1% of all male neoplasms, it represents a paradigm for cancer curability. Overall, more than 95% of patients can expect to be cured of their disease with minimal long-term toxicity. Given these expectations, it is critical that cancer care providers are familiar with the diagnostic and therapeutic challenges encountered in these rare patients. In particular, clinicians managing these patients should be aware of some of the pitfalls encountered when determining relapse. In a series of case presentations, we review the evaluation and management of patients with persistent elevation of serum tumor markers and postchemotherapy residual radiographic abnormalities.