Active surveillance after orchiectomy for nonseminomatous testicular germ cell tumors: late relapse may occur

OBJECTIVES

To review the outcome of men with Stage I nonseminomatous germ cell tumors managed with a policy of active surveillance following orchiectomy.

METHODS

The clinical records of all men with Stage I nonseminomatous germ cell tumors seen at Royal Prince Alfred Hospital, Australia between 1982 and 1995 were reviewed. Data were obtained concerning the histologic type of tumor, levels of serum tumor markers, relapse and subsequent treatment, and survival.

RESULTS

Seventy-seven patients were entered into the active surveillance protocol between 1982 and 1995. With a minimum follow-up of 2 years, 27 (35%) have relapsed, with a median time to relapse of 5 months. Two late relapses occurred at 37 and 57 months after diagnosis. Relapses occurred most commonly in the retroperitoneal lymph nodes, with the lungs the second most common site. Following treatment with chemotherapy and surgery, all patients achieved complete remission, with 1 patient subsequently relapsing and ultimately dying of progressive tumor. One other patient died of acute myeloid leukemia, thought to be secondary to chemotherapy. Overall, 75 patients (97%) remain alive and free of disease.

CONCLUSIONS

Active surveillance is a safe and effective approach to the management of Stage I nonseminomatous germ cell tumors. Although most relapses occur within the first 2 years, late relapses may occur.

Determination by high-performance liquid chromatography of hydroxyurea in human plasma

An assay using reversed-phase high-performance liquid chromatography with electrochemical detection was developed to measure hydroxyurea in plasma at concentrations suitable for pharmacokinetic studies. The sample preparation is simple, the analysis rapid and assays can be batched. The between-run precision is excellent (coefficient of variation = 2.8-4.5%) and the limit of detection is 0.02 mmol/l. Preliminary studies have shown that the method is suitable for pharmacokinetic studies.

Hypercholesterolemia after chemotherapy for testis cancer

PURPOSE

The study was designed to determine prospectively the prevalence of fasting serum lipid abnormalities in patients who were treated with cisplatin-based chemotherapy for germ cell tumors. We unexpectedly had demonstrated hypercholesterolemia in 20 of 30 nonfasting patients in a prior study of long-term toxicity of chemotherapy for germ cell tumors. The present study was designed to explore this phenomenon further.

PATIENTS AND METHODS

Seventeen unselected patients with biopsy-proven germ cell tumors, who underwent cisplatin-based chemotherapy and who had no prior history of cardiac disease nor known hypercholesterolemia, were studied. In addition to the standard staging tests, blood was drawn for a pretreatment fasting lipid screen, which included cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and apolipoproteins A1, B, and (a). Repeat samples were drawn 24 hours after the administration of cisplatin and at intervals of 6 to 24 months after the completion of treatment.

RESULTS

Seven of 17 patients (41%) had higher than desirable levels of total serum cholesterol and low-density lipoprotein cholesterol. Two of them had normal levels before treatment, four had preexisting hypercholesterolemia that increased further, and one patient had an elevated pretreatment level that did not alter. Absolute increases in serum cholesterol were noted in 14 of 17 patients. No consistent patterns of change beyond the reference ranges were found for other serum lipids.

CONCLUSIONS

We have confirmed our initial observation that serum cholesterol increases in patients who received cisplatin-containing chemotherapy regimens for germ cell tumors. Further studies will be necessary to define whether other lipid abnormalities occur and the biologic significance of these findings.

Combination chemotherapy with cisplatin, vindesine and mitomycin-C for advanced, inoperable non-small-cell lung cancer

OBJECTIVES

To assess the activity of chemotherapy with cisplatin, vindesine and mitomycin-C (PVM) in advanced non-small-cell lung cancer (NSCLC) and to test the feasibility of preemptive therapy with PVM.

DESIGN AND SETTING

A phase II clinical trial of PVM in patients with NSCLC treated at the Royal Prince Alfred Hospital between June 1987 and July 1990.

PATIENTS

Forty-one patients with advanced, inoperable or recurrent NSCLC--22 women, 19 men, with a median age of 51 years. Thirteen patients had been treated previously with radiotherapy and/or surgery; 18 had extrathoracic metastases. Four patients previously deemed inoperable were treated preemptively with PVM before proceeding to radical surgery.

INTERVENTIONS

Cisplatin 100 mg/m2, vindesine 5 mg and mitomycin-C 8 mg/m2, all given intravenously on Day 1, with vigorous hydration and antiemetic therapy. Cycles were repeated every four weeks.

MAIN OUTCOME MEASURES

Objective tumour response to treatment, patient survival time, time to treatment failure, and treatment toxicity.

RESULTS

There was one complete tumour response to PVM and 15 partial responses; 14 patients had stable disease and nine had progressive disease--yielding an objective response rate (complete plus partial responses) of 39% (16/41; 95% confidence interval [CI], 24%-56%). Responses were documented in all histological subgroups, in both locally advanced and disseminated disease, and in recurrent disease. Median survival of the group was six months (95% CI, 5-10 months; range, 0.5-19+ months), and is unchanged by exclusion of the four patients treated before surgery. Seven of the 41 patients (17%) survived 12 months or longer. Median time to treatment failure in patients who had an objective response was six months (95% CI, 5-10 months). Grade 3 or 4 nausea and vomiting occurred in 21 patients (51%). Haematological, renal and neurological toxicity were not major problems; there were no deaths from treatment toxicity.

CONCLUSION

PVM is an active regimen in advanced NSCLC and can produce durable remissions. The potential palliative effects of PVM in incurable disease must be weighed against the risk of subjective toxicity.

Phase I and pharmacokinetic study of tiazofurin (NSC 286193) administered by 5-day continuous infusion

A phase I and pharmacokinetic study of tiazofurin (NSC 286193), a C-nucleoside that inhibits IMP dehydrogenase, has been completed. The drug was administered by continuous infusion over 5 days. The maximum tolerated dose was 1650 mg/m2 per day, neurological toxicity being the dose-limiting factor. Gastrointestinal and hematological toxicity were mild. A definite relationship exists between dosage and steady-state levels. The plasma clearance was 29.13 (+/- SD 4.05) ml/min per m2. No complete or partial remissions were demonstrated among the 18 patients treated at five dose levels between 550 mg/m2 and 2200 mg/m2 per day.

Phase I and pharmacokinetic study of tiazofurin (TCAR, NSC 286193) administered by continuous infusion

Tiazofurin (2-beta-D-ribofuranosylthiazole-4-carboxamide, TCAR) is a synthetic C-nucleoside that demonstrated significant in vivo activity against a variety of animal tumors as well as in vitro activity against human tumor-derived cell lines. Thirteen patients were treated with TCAR administered as a 5-day continuous infusion in this Phase I trial. Seventeen complete cycles were administered in three dose levels ranging from 550 to 1450 mg/M2. Dose-limiting toxicities were myelosuppression and neurotoxicity including severe lethargy. Other toxicities including superficial skin peeling, myalgias, and tearing were seen at all doses. One patient had chest pain on day 4 resulting in stopping the drug, however, there was no evidence of cardiac or pericardial disease. Uric acid levels rose within one day in the absence of allopurinol treatment. There were no treatment related deaths. HPLC measurement of drug levels demonstrated steady-state plasma levels during the infusion, and a half-life following the infusion of 7.7 +/- 0.6 hours. Minor abnormalities in renal function were associated with dramatic changes in pharmacokinetics and toxicity. No clinical responses were observed in this trial.