Disseminated seminoma: re-evaluation of treatment protocols

Radiotherapy provides a high cure rate for patients with stages I and II seminoma but the results for those with stage III disease have been disappointing. We report on 19 patients with high stage seminoma who have been treated with platinum, vinblastine and bleomycin (14 patients) or platinum, vinblastine, bleomycin and doxorubicin hydrochloride (5 patients). Of the 19 patients 12 (63 per cent) had complete remission of the disease and the remaining 7 had partial remission. To date, 11 patients (58 per cent) remain free of disease. Of the 6 patients with no prior irradiation 5 achieved complete remission, while the 1 failure had massive hepatic metastases. The median followup was 19 months (range 12 to 37 months). These results parallel that achieved with the same chemotherapy regimen in patients with stage III nonseminomatous testicular cancer.

The role of maintenance therapy in disseminated testicular cancer

We concluded a prospective study of the value of maintenance therapy in disseminated testicular cancer after chemotherapy-induced complete remission or chemotherapy cytoreduction followed by surgical resection of residual teratoma. A group of 171 patients were randomized to treatment consisting of cisplatin, vinblastine, and bleomycin, or these drugs plus doxorubicin. There was no apparent difference between these two induction regimens. Complete remission was achieved in 113 patients (66 per cent), and 19 (11 per cent) were free of disease by surgical resection of residual tumor. Of the 171 who started, 113 were eligible to receive either maintenance doses of vinblastine (58 patients) or no further therapy (55 patients) after remission-induction therapy. There was a 9 per cent relapse rate during maintenance with vinblastine and a 7 per cent relapse rate with no maintenance therapy; the overall relapse rate was 8 per cent (nine of 113). Our data indicate that maintenance therapy is unnecessary in disseminated testicular cancer.

Testicular cancer as a model for a curable neoplasm: The Richard and Hinda Rosenthal Foundation Award Lecture

The combination of platinum, vinblastine, and bleomycin was first used at Indiana University in 1974. Thirty of 47 patients (64%) survived for 5 years, and 27 (57%) are currently disease free (NED) and cured of their neoplasm. From 1976 to 1978, 78 consecutive patients were entered on a random prospective study that indicated that equal therapeutic results could be achieved with a lower dosage (0.3 mg/kg) of vinblastine. Fifty-two (67%) patients are continuously NED, and 57 (73%) are currently NED for 2 or more years. Our third-generation study, done in conjunction with the Southeastern Cancer Study Group, tested the hypothesis of whether maintenance vinblastine was necessary to ensure optimal cure rates in disseminated testicular cancer. One hundred thirteen patients entered this maintenance study, and the results demonstrated that cure in a far-advanced cancer could be achieved with only 12 weeks of therapy (remission induction) because the relapse rate in such patients was only 7%. The cure rate for patients presenting with locoregional disease (Stages A and B) should approach 100%. Platinum, vinblastine, and bleomycin will regularly produce a 70% complete remission rate, and a further 10% of patients will be rendered NED with surgical resection of residual disease. The relapse rate with four courses of remission induction therapy in a large cooperative group study (Southeastern Cancer Study Group) was only 7%. The high success rate in disseminated disease has allowed the option of high cure rate in Stage B disease (positive retroperitoneal nodes) with or without adjuvant chemotherapy. At Indiana University, 137 patients have been followed with Stage A and B nonseminomatous testicular cancer from 1973 to 1979 with a minimum follow-up of 2 years, and currently 135 are alive and well. Successful treatment strategies in testicular cancer have yielded a cure rate unparalleled in cancer treatment.

Surgical resection in disseminated testicular cancer following chemotherapeutic cytoreduction

Platinum combination chemotherapy will regularly produce a 70% complete response rate in testicular cancer. Many patients failing to achieve complete remission can still be rendered disease-free with surgical resection of residual localized disease. Twenty-one patients underwent resection for residual pulmonary lesions and 41 underwent lymphadenectomy for persistent retroperitoneal disease. There were no characteristic radiographic findings for fibrous tissue versus mature teratoma versus carcinoma. Although elevated HCG or AFP levels indicated the presence of carcinoma, negative HCG and AFP did not rule out such a diagnosis as 12 of 22 resected carcinoma patients were seronegative. Of 35 patients, 31 (89%) with fibrous tissue or mature teratomas and all four patients with immature teratomas have been continuously free of disease with a minimal postoperative follow-up time of six months. However, only two of 22 patients with resected carcinomas have been continuously disease-free. Post-operative chemotherapy for mature teratoma or fibrous tissue is probably not necessary. However, we feel that further aggressive chemotherapy is needed in the resected carcinoma patient with at least two courses of platinum combination chemotherapy. Surgical resection of residual disease following chemotherapy-induced cytoreduction with platinum combination chemotherapy may be therapeutic in some cases and helps to define the optimal subsequent treatment strategy.

Nabilone: an effective antiemetic in patients receiving cancer chemotherapy

Eighty evaluable patients receiving chemotherapy were entered on a random prospective double-blind study to evaluate the effectiveness of nabilone, a synthetic cannabinoid, compared to prochlorperazine. Most of these patients received cisplatin, a drug that universally produces severe nausea and vomiting, as part of a combination chemotherapy regimen. The patients served as their own controls, receiving either nabilone or prochlorperazine during two consecutive treatment courses with the identical chemotherapy. Side effects consisting of hypotension and lethargy were more pronounced with nabilone. Toxicity, in general, did not preclude antiemetic treatment and in no way interfered with chemotherapy. Sixty patients (75 per cent) reported nabilone to be more effective than prochlorperazine for relief of nausea and vomiting. Of these 60 patients, 46 required further chemotherapy and continued taking nabilone as the antiemetic of choice.

Phase II study of vindesine in patients with metastatic breast cancer

Twenty-six patients with far-advanced, refractory breast cancer were treated iv with vindesine (DVA) at a dose of 3 mg/m2/week. In 21 evaluable patients there were six partial remissions. Four patients who did not respond after at least four doses of intermittent DVA received continuous-infusion DVA at a dose of 1.5 mg/m2/day X 2 every other week; none responded. Five of the six responders had had disease progression on other vinca alkaloids. Leukopenia and neuromuscular toxicity were dose-limiting.

Relationship between steroid receptors and response to endocrine therapy and cytotoxic chemotherapy in metastatic breast cancer

The relationship between steroid receptor content and response of metastatic breast cancers to endocrine therapy and cytotoxic chemotherapy has been examined. In 54 advanced breast cancers treated with hormonal therapy, 20 of 29 (69%) ER+, PR+ and 3 of 14 (21%) ER+, PR- tumors responded. Of the nine tumors that lacked both ER and PR, 2 (22%) were hormonally responsive. Based on either the ER or PR content alone, 68% of the PR+ and 54% of the ER+ tumors responded to endocrine therapy. Thus, the addition of PR assay could improve the accuracy of ER assay in selecting a hormonally responsive breast cancer. In 29 advanced breast cancers treated with cytotoxic drugs, the presence of ER and/or PR in the tumors seemed to favor an objective response to cytotoxic chemotherapy. The response rate was about 67% regardless of whether the cancers were ER+ or PR+.

VP-16-213 salvage therapy for refractory germinal neoplasms

Thirty-three patients with advanced refractory germinal neoplasms were treated with VP-16-213 alone or in combination with cis-platinum, bleomycin, and frequently Adriamycin. All had prior chemotherapy, which in most was extensive. There were 14 complete and 15 partial remissions. Five of the patients with partial remission were rendered disease free by resection of residual tumor. Eleven remain disease free from 6+--23+ months. Toxicity was considerable. One-third were hospitalized for fever and granulocytopenia and four had life-threatening thrombocytopenia. There was one drug-related death. VP-16 is an active drug in germinal neoplasms. It appears to be an important component of "salvage" regimens for refractory patients, but severe toxicity may ensue.

Serum alpha-fetoprotein and human chorionic gonadotropin in patients with seminoma

We analyzed the case histories of 31 patients who initially had a diagnosis of seminoma and elevated serum levels of alpha-fetoprotein or human chorionic gonadotropin. We concluded that an elevated alpha-fetoprotein level is firm evidence of the presence of non-seminomatous germ cell tumor and that the patient should be treated accordingly. However, if the level of human chorionic gonadotropin alone is elevated the diagnosis may be either non-seminomatous tumor or seminoma. Patients with seminoma and an elevated level of human chorionic gonadotropin do respond well to radiation therapy if they have low stage disease but if metastatic seminoma is present an elevated human chorionic gonadotropin level appears to be a poor prognostic sign if conventional treatment is given. A plan of treatment is proposed for these patients.

Chemotherapy of disseminated testicular cancer. A random prospective study

Seventy-eight patients with disseminated testicular cancer were entered on a random prospective study evaluating three separate remission induction arms. Therapy with cis-diamminedichloroplatinum (20 mg/M2 for five consecutive days every three weeks for 3-4 courses) and bleomycin (30 units intravenous push weekly for 12 consecutive weeks) was constant. Patients were allocated at random to one of the following induction regimens (in combination with platinum plus bleomycin): (1) vinblastine 0.4 mg/kg every three weeks for four courses; (2) vinblastine 0.3 mg/kg every three weeks for four courses; or (3) vinblastine 0.2 mg/kg plus Adriamycin 50 mg/M2 every three weeks for four courses. All patients received maintenance therapy with vinblastine 0.3 mg/kg once a month for 20 months (total therapy two years) unless progressive disease intervened. The incidence of granulocytopenic fever and sepsis was highest with regimen 1, as 9 patients (35%) developed granulocytopenic fever requiring hospitalization and antibiotics; only 4 (15%) patients on regimen 2 developed granulocytopenic fever. No patients on regimen 2 had documented sepsis. Fifty-three patients (68%) achieved complete remission and an additional 11 patients were rendered free of disease with surgical resection of residual localized disease. Fifty-three patients (68%) remain alive and continuously free of disease from 15+ to 39+ months. There was no difference in the complete remission rate or disease-free status with the higher dosage of vinblastine (regimen 1) during remission induction therapy compared to the less toxic lower dosage of vinblastine (regimen 2). This suggests that dosage reduction of vinblastine to 0.3 mg/kg can produce equivalent therapeutic results with diminished toxicity, and we no longer recommend the 0.4 mg/kg vinblastine dosage.

Aggressive surgical management of testicular carcinoma metastatic to lungs and mediastinum

During the past six years, more than 200 patients were treated with chemotherapy for disseminated testicular cancer with a 70% complete remission rate. In 22 patients who were 17 to 46 years old, there was persistent thoracic disease, which was treated surgically. Six required a median sternotomy for bilateral pulmonary involvement or mediastinal metastasis. In 8 patients, chemotherapy had altered the histological appearance of the metastases from that of an undifferentiated primary tumor to a mature cystic teratoma. Five patients had nodules in the lungs, which were necrotic and fibrosed with no evidence of tumor. Nine showed embryonal cell carcinoma metastases in the lungs. All who had cystic teratoma are alive and free from disease. Three of the 5 with nodules and 1 of the 9 with metastases are currently free from disease. Agressive surgical intervention is important in this unique group of patients in order to determine the precise pathological category of the lesions, to remove intrathoracic malignancy, and to assess the need for additional chemotherapy. An operative mortality of zero and a low morbidity justify this approach.

Binding of medroxyprogesterone acetate in human breast cancer

Human mammary tumor cytosol containing macromolecules which bound 3H-MPA (3H-medroxyprogesterone acetate or 1,2-3H-6 Alpha-methyl-17 alpha-acetoxy-pregn-4-ene-3,20-dione) and 3H-R5020 (6,7-3H-17,21-dimethyl-19-nor-pregna-4,9-diene-3,20-dione) similarly with high affinity (Ka approximately equal to 2 nM-1) and specificity. The progestin-binding components had sedimentation coefficients of about 4S and 7S in sucrose gradients and had approximately the same number of binding sites for Ma and R5020 as revealed by gradient centrifugation and saturation analysis. Among the steroids tested, these components had the highest affinities for progestins and were probably progesterone receptors of human breast cancer. A 4S component of human serum bound 3H-R5020 but not 3H-MPA. With 3H-MPA and 3H-estradiol used as the tracers, the concentrations of progesterone and estrogen receptors have been determined in 236 human breast cancers by saturation analysis. Our results on the receptor content and response of 31 of these tumors to endocrine therapy suggest that progesterone receptor may be a better marker of a hormonally responsive breast cancer.

Cytoreductive surgery for metastatic testis cancer: considerations of timing and extent

We report on 26 patients who presented with widespread, massive metastatic disease from nonseminomatous germinal cell tumors of the testis. Of these 26 patients 22 (85 per cent) are well and 21 (80 per cent) are presumed to be cured after initial chemotherapy with platinum, vinblastine and bleomycin cytoreduction followed by secondary retroperitoneal lymph node dissection. The most critical prognostic determination was the nature of the tissue resected. Patients with only fibrous or cystic elements and those with mature teratoma fared well. All 22 patients are well from 1 to 5 years postoperatively. However, of 9 patients with persistent cancer in the resected tissue 4 are dead and 2 others were salvaged only after extensive further chemotherapy. Of the several options available pre-treatment with 4 courses of platinum, vinblastine and bleomycin before any surgical treatment in those with massive bulk metastatic disease seems to provide the most effective cytoreduction and best survival.

Brain metastases in disseminated germinal neoplasms: incidence and clinical course

From July 1973, to March 1978, 139 patients with disseminated germinal neoplasms were treated with a variety of combination chemotherapy regimens. Twenty-one patients (15.1%) exhibited evidence of brain metastases at some time during their course. Central nervous system spread occurred somewhat more frequently in patients with choriocarcinoma and yolk sac histologies, although all types were at risk. This was a major cause of morbidity and mortality. However, central nervous system spread almost always occurred in patients with systemic relapse and thus did not affect overall survival. We have yet to identify a subgroup who potentially could benefit from prophylactic central nervous system therapy.

Advanced bladder cancer: therapy with cis-dichlorodiammineplatinum(II), adriamycin, and 5-fluorouracil

Nineteen patients with unresectable or metastatic urothelial cancer were treated with the combination of cis-dichlorodiammineplatinum(II), Adriamycin, and 5-fluorouracil. One patient died within 2 weeks of therapy and one patient had no measurable disease, leaving 18 patients evaluable for survival and toxicity and 17 patients evaluable for response. Eleven patients (65%) achieved a partial remission with attendant clinical improvement, with a median duration of 25 weeks. All nonresponders have died, with a median survival of 17 weeks. The median survival of responding patients was 40 weeks, with two patients alive at 33+ and 63+ weeks. Of particular interest are three patients who had resections of residual pelvic disease after significant regression with chemotherapy. One of these patients remains disease-free at 63+ weeks. Toxicity was significant but generally manageable.

Chemotherapy of disseminated testicular cancer

Dramatic improvements have been made in recent years in treatment of disseminated testicular cancer. Germ-cell neoplasms, even when advanced, are potentially curable by modern chemotherapy. Although disseminated testicular cancer is a rare disease, it is highly treatable, and primary physicians, internists and urologists should have some knowledge of its management.

Superiority of nabilone over prochlorperazine as an antiemetic in patients receiving cancer chemotherapy

Two double-blind, crossover trials comparing the antiemetic effectiveness of nabilone, a new synthetic cannabinoid, with that of prochlorperazine were conducted in patients with severe nausea and vomiting associated with anticancer chemotherapy. Of 113 patients evaluated, 90 (80 per cent) responded to nabilone therapy, whereas only 36 (32 per cent) responded to prochlorperazine (P less than 0.001). Complete relief of symptoms was infrequent, occurring only in nine patients (8 per cent) given nabilone. When both drugs were compared, both nausea (P less than 0.01) and vomiting episodes (P less than 0.001) were significantly lower in patients given nabilone. Moreover, patients clearly favored nabilone for continued use (P less than 0.001). Predominant side effects noted by patients were similar for both agents and included somnolence, dry mouth and dizziness but were about twice as frequent and more often severe in patients receiving nabilone. In addition, four patients (3 per cent) taking nabilone had side effects (hallucinations in three, hypotension in one) that required medical attention. Euphoria associated with nabilone was infrequent (16 per cent) and mild.