Serum alpha-fetoprotein surge after the initiation of chemotherapy for non-seminomatous testicular cancer has an adverse prognostic significance

It has been recognized that the tumour markers alpha-fetoprotein (AFP) and human chorionic gonadotrophin (HCG) may show a transient elevation after the initiation of chemotherapy in non-seminomatous testicular cancer. We investigated the prognostic importance of these so-called marker surges in a cohort of patients treated with cisplatin combination chemotherapy between 1983 and 1991. A total of 669 patients were studied. Of 352 patients who had an elevated AFP at the start of treatment and for whom we had data at both day 1 and day 8, 101 (29%) had a surge. Of 317 patients for whom we had data for HCG, 80 patients (25%) had a surge. It was found that an AFP surge was a strong adverse prognostic factor for progression [hazard ratio (HR) 2.28, P=0.005]. There was no statistically significant difference in survival (HR 1.65, P=0.13). There was no prognostic significance of a HCG surge, either for progression or for survival. To investigate whether a surge was an independent prognostic factor for progression and survival, multivariate Cox regression models were fitted using the independent prognostic factors for progression and survival and the surge/decline variable. An AFP surge was retained in the final model for progression. A HCG surge was of no prognostic importance for progression or survival. We conclude that an AFP surge has an adverse prognostic significance, independent of pretreatment characteristics.

Fatal bleomycin pulmonary toxicity in the west of Scotland 1991-95: a review of patients with germ cell tumours

We conducted a retrospective review of fatal bleomycin pulmonary toxicity in patients treated for germ cell tumours during 1991-95 at the Beatson Oncology Centre, Glasgow. Case notes of patients treated with bleomycin were reviewed with respect to cumulative bleomycin dose, renal impairment, exposure to supplemental oxygen, thoracic radiotherapy and age. A total of 194 patients underwent chemotherapy, of whom 180 received bleomycin-containing regimens. Five fatal cases of pulmonary toxicity were identified, an incidence of 2.8%. These cases were older than the remaining patients (P < 0.001), with a median age at diagnosis of 55 vs 33 years. The incidence of fatal pulmonary toxicity increased with each decade of life above age 30. Renal function also differed between the two groups, with the worst glomerular filtration rate recorded at the time of bleomycin administration for each patient, lower in the fatal group, median 69 vs 107 ml min(-1) (P < 0.001). There was no difference with respect to cumulative bleomycin dose or exposure to supplemental oxygen. For patients aged over 40 years, especially those with renal function in the lower range of normal, the risk of developing fatal toxicity may exceed 10%. The benefits of bleomycin could be questioned for this age group.

Central corneal endothelial guttae and age-related macular degeneration: is there an association?

The similarities between the corneal endothelium and retinal pigment epithelium in terms of their embryology, barrier function and predilection to age-related degeneration prompted this investigation into a possible association between central corneal guttae (CCG) and age-related macular degeneration (ARMD). 50 patients with clinically significant CCG were prospectively evaluated for the presence of ARMD. 51 age-matched patients attending for unrelated ailments who did not have CCG were also evaluated for the presence of drusen and other signs of ARMD. Of the 50 patients with CCG, 23 had bilateral ARMD and 4 had unilateral ARMD. In the control group, 9 patients had bilateral and 4 had unilateral ARMD. There was significant difference in the prevalence of ARMD between patients with CCG and those with no CCG (p = 0.017 and p < 0.001 for right and left eyes respectively). We found an association between CCG and ARMD. The presence of CCG in a patient may imply increased risk for the presence of ARMD. In a patient with CCG requiring cataract or corneal surgery, the successful outcome may be compromised by the presence of ARMD.

New antimetabolites in cancer chemotherapy and their clinical impact

It is almost 50 years since antimetabolites were first found to have clinical antitumour activity, with Farber's discovery that aminopterin could cause remission in acute leukaemia. In the following 10 years, methotrexate, 6-mercaptopurine and 5-fluorouracil (5-FU) found their way into clinical practice. Subsequently, cytosine arabinoside was found to have activity in acute leukaemia, but, until recently, other significant developments have involved optimizing the efficacy of existing antimetabolites, including the use of leucovorin with methotrexate or 5-FU. Recently, new antimetabolites have become a fertile area for anti-cancer drug research. Gemcitabine (GEMZAR) has emerged as an important new agent in several tumour types, including pancreatic, non-small-cell lung, bladder, breast and ovarian cancers. Capecitabine is an intriguing new prodrug, offering tumour selectivity and prolonged tumour exposure to 5-FU. More potent thymidylate synthase inhibitors have also emerged; raltitrexed is now commercially available for the treatment of colorectal cancer. Others under development include LY231514, which has other sites of action, hence the acronym MTA (multi-targeted antifolate). A novel target is glycinamide ribonucleotide formyltransferase (GARFT) and LY309887 and AG2034 are undergoing clinical investigation as GARFT inhibitors. A critical element with LY309887 appears to be co-administration of folate. It seems entirely possible that several novel antimetabolites will establish themselves in clinical practice in future for the treatment of solid tumours.

Multidrug resistance: clinical relevance in solid tumours and strategies for circumvention

Strictly speaking, multidrug resistance (MDR) describes the experimental observation of cross resistance to various structurally unrelated cytotoxic agents in laboratory models of cancer. These drugs have in common their origin as natural products, and in 1985 the basis of this MDR was established as the over-expression of a membrane glycoprotein, called P-glycoprotein (Pgp), which acts as a drug efflux pump actively depleting intracellular drug concentrations in resistant tumour cells. Since then, MDR has arguably taken on a second meaning, i.e. 'misunderstood drug resistance', through the understandable, but mistaken assumption by many scientists and some clinicians that the clinical observation in cancer patients treated with chemotherapy of resistance to a wide range of cytotoxic drugs (either as a primary or acquired property) inevitably involves the same mechanism. At present, the evidence from clinical studies to support such a notion is clearly lacking, particularly in solid tumours. However, increased Pgp expression has been observed in a number of clinical situations, and its relevance requires further elucidation. Current data indicate that increased Pgp expression represents an adverse prognostic factor, for reasons which may be quite unrelated to developing drug resistance. Experimentally, MDR can be reversed by simultaneous treatment with a number of non-cytotoxic agents which competitively inhibit Pgp function. Despite the reservations outlined, numerous clinical trials of this approach have been conducted. The results have generally been negative in solid tumours, although some have been more promising in haematological cancers. The most recent studies have used more potent modulating agents, such as the cyclosporin analogue, PSC833. Interpretation of data from these trials is complicated by pharmacokinetic interactions between the target cytotoxic drug and the modulating agent. Randomized trials are now underway in a number of tumour types; thus a clearer picture of the clinical relevance of MDR should emerge over the next few years.

The effect of cimetidine on the pharmacokinetics of epirubicin in patients with advanced breast cancer: preliminary evidence of a potentially common drug interaction

Epirubicin is known to be metabolized in the liver. Therefore, drugs such as cimetidine, which inhibit the cytochrome P-450 enzyme system or reduce liver blood flow, may reduce the plasma clearance of epirubicin. In a small study, epirubicin 100 mg/m2 every 3 weeks was administered intravenously to eight patients, who also received oral cimetidine (400 mg b.d. for 7 days starting 5 days before chemotherapy) with either the first or second cycles. Epirubicin pharmacokinetics and liver blood flow (idocyanine green clearance) were assessed at each course. The areas under the plasma concentration time curves (AUCs) were used to compare the systemic exposure to epirubicin and its metabolites with each course. The estimated median percentage increase (95% confidence interval CI) in the AUC with cimetidine were: epirubicin 50% (95% CI -18 to 193, epirubicinol 41% (95% CI 1 to 92). Despite the small numbers studied, the increase in the active metabolite epirubicinol was significant (P < 0.05). These changes in exposure were not explained by reduced cytochrome P-450 activity as the 7-deoxy-doxorubicinol aglycone AUC was not reduced (357% increase: 95% CI 17 to 719) or by a decrease in liver blood flow (17% increase: 95% CI -39 to 104). Cimetidine is likely to be coprescribed or self-administered with epirubicin and therefore clinicians should be aware of this potential interaction.

A phase I and pharmacokinetic study of LY231514, the multitargeted antifolate

LY231514 is a novel antifolate that principally inhibits thymidylate synthase, but with additional folate-dependent enzyme targets. A Phase I study of single-agent LY231514 administered as a daily i.v. infusion over 10 minutes for 5 days, repeated every 3 weeks, was conducted to evaluate the maximum tolerated dose, pharmacokinetic profile, and antitumor activity of the drug using this schedule. Thirty-eight patients with advanced malignancies that were refractory or not amenable to standard therapy were treated with a total of 116 courses of LY231514, escalating treatment doses through 10 dose levels, from 0.2-5.2 mg/m2/day. No objective clinical responses were observed, although minor antitumor activity not fulfilling the response criteria was seen in three patients. A maximum tolerated dose of 4.0 mg/m2/day was determined, with neutropenia as the predominant dose-limiting toxicity. Reversible disturbances of liver biochemistry, fulfilling the protocol definitions of dose-limiting toxicity, were also observed. Other toxicities included diarrhea, mucositis, skin rash, and fatigue. Pharmacokinetic studies were performed at all treatment levels. Analysis showed a linear relation between administered dose and both maximum plasma concentration (Cmax) and area under the plasma concentration/time curve. The drug was cleared with a day 1 total body clearance of 108.9 +/- 38.8 ml/min/m2, with plasma concentrations declining with a mean harmonic terminal half-life of 1.4 +/- 0.98 h. When given by this schedule, LY231514 is tolerable, and Phase II studies are in progress.

Validation of a handheld automated keratometer in adults

PURPOSE

To evaluate the Nidek handheld automated keratometer and compare it with the manual Zeiss keratometer.

SETTING

St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.

METHODS

Forty-five normal adult volunteers were included in the study. Three sets of randomized keratometry measurements were taken from both eyes of each adult, with both instruments by two independent observers. Readings included powers of the steep and flat meridians and axis of the flat meridian. The mean difference between the two instruments was calculated. The variance of each instrument was calculated for the axis, the steep and flat meridians, and the mean of the two meridians.

RESULTS

There was no significant difference between the mean Nidek and Zeiss keratometry readings for the steep (0.015 mm; P = .167) or flat (0.054 mm; P = .069) meridian or axis measurements (P = .172). On repeated measurements, the within-subject and within-group variabilities, calculated separately for each instrument, were significantly less for the Nidek automated keratometer than the Zeiss keratometer (P < .01) when measuring the steep and flat meridians. There was however, a significant increase in axis variability using the Nidek keratometer (range 20 degrees; P < .01).

CONCLUSION

The Nidek automated keratometer was accurate, reliable, and easy to use and compared favorably with the manual Zeiss keratometer when measuring corneal curvature. In the handheld mode, the Nidek is not suitable for axis measurements. It has the additional advantage of portability.

Tumour specific regulation of telomerase RNA gene expression visualized by in situ hybridization

Maintenance of telomere structure by the ribonucleoprotein enzyme telomerase is considered central to the development of most human cancers. However, regulatory mechanisms governing telomerase expression during oncogenesis are largely unknown. We address potential tumour-specific regulation of telomerase RNA gene expression by RNA in situ hybridization to over 300 tumour samples of germ cell and epithelial origin. Twenty-six per cent of non-small cell lung cancers (NSCLC), expressed detectable levels of the telomerase RNA gene (hTR), and interestingly expression was almost confined to squamous carcinomas (41%), being rare in pulmonary adenocarcinomas and large-cell anaplastic carcinomas (P=0.006). Low frequency hTR expression was also associated with adenocarcinoma of the breast (13%), and ovary (17%). In comparison, hTR expression was detected in 43% of cervical cancers with no significant differences in frequency between squamous-cell carcinoma and adenocarcinoma or in transitions between intraepithelial neoplasia and invasive carcinoma. In contrast to the common epithelial cancers, the malignant cells in 73% of testicular germ-cell tumours (seminomas and teratomas), expressed hTR consistent with hTR expression in normal testicular germ cells. Differentiated tissues within ovarian germ cell tumours and in testicular teratomas lacked detectable hTR expression. These studies show that different tumour types have distinct patterns of hTR expression, which has implications for our understanding of mechanisms regulating telomerase activity and for targeting the telomerase RNA component as an anti-cancer therapy.

Echovirus keratoconjunctivitis

PURPOSE

To investigate an outbreak of echovirus-related keratoconjunctivitis.

METHODS

We undertook a retrospective study of recent cases of echovirus infection with recall and further evaluation of conjunctivitis patients. All patients from whom an echovirus was isolated in Liverpool during 1995 were included. The natural course of ocular echovirus disease was studied, including the likelihood of echovirus keratoconjunctivitis being linked with meningitis and the risk of long-term carriage of the virus in the conjunctiva.

RESULTS

Of 10 unrelated patients with echovirus conjunctivitis, six also had a mild keratitis. None of these patients developed meningitis, and no cases of long-term carriage in the conjunctiva were encountered. There was no link between cases of echovirus meningitis and conjunctivitis. There was no corresponding increase in other ocular viral isolates.

CONCLUSIONS

Echovirus is a relatively unrecognized cause of keratoconjunctivitis. Echoviral keratoconjunctivitis appears to be an independent ocular event unassociated with systemic sequelae. Long-term carriage in the conjunctiva does not appear to occur.

Filgrastim during combination chemotherapy of patients with poor-prognosis metastatic germ cell malignancy. European Organization for Research and Treatment of Cancer, Genito-Urinary Group, and the Medical Research Council Testicular Cancer Working Party, Cambridge, United Kingdom

PURPOSE

To determine the effect of r-metHu granulocyte colony-stimulating factor (G-CSF) on the proportion of patients with metastatic poor-prognosis malignant germ cell tumors who receive full dose-intensity combination chemotherapy.

PATIENTS AND METHODS

In a phase III study patients received six cycles of BEP/EP (etoposide, and cisplatin, plus or minus bleomycin) or six cycles of BOP/VIP-B (bleomycin, vincristine, cisplatin/etoposide, ifosfamide, cisplatin, bleomycin). A subset were secondarily randomized to receive or not receive filgrastim. Filgrastim 5 microg/kg/day was administered subcutaneously on days 3 through 9 after each BOP and on days 6 through 19 after each VIP, BEP, or EP cycle.

RESULTS

Eighty-five percent of 120 eligible patients randomized to filgrastim received at least six chemotherapy cycles compared with 70% of 130 patients randomized to not receive filgrastim (VCP = .003). Patients in the filgrastim-arm achieved significantly higher dose-intensities. Neutropenic fever occurred in 25 of 128 filgrastim-patients and in 38 of 129 non-filgrastim-patients (P = .052). Twelve and three toxic deaths occurred in the non-filgrastim- and filgrastim-arms, respectively. Nine of the 12 toxic deaths and all of the three toxic deaths were associated with febrile grade 4 neutropenia. Failure-free and overall survival were similar in both arms.

CONCLUSION

During combination chemotherapy in patients with malignant germ cell tumors, the routine use of filgrastim significantly improved the delivery of the planned treatment schedule without effect on failure-free or overall survival. The use of filgrastim was associated with a clinically important reduction in the number of toxic deaths, confined to the experimental intensified-chemotherapy schedule. This study does not support the routine use of filgrastim during standard chemotherapy with BEP.

Intensive induction-sequential chemotherapy with BOP/VIP-B compared with treatment with BEP/EP for poor-prognosis metastatic nonseminomatous germ cell tumor: a Randomized Medical Research Council/European Organization for Research and Treatment of Cancer study

PURPOSE

The aim of this randomized trial was to assess the potential therapeutic advantage of an intensive induction-sequential chemotherapy schedule (bleomycin, vincristine, cisplatin [BOP])/etoposide, ifosfamide, cisplatin, and bleomycin [VIP-B]), compared with a regimen based on bleomycin, etoposide, and cisplatin (BEP) (BEP/etoposide and cisplatin [EP]) for the treatment of patients with poor-prognosis metastatic nonseminomatous germ cell tumors (NSGCTs).

PATIENTS AND METHODS

Patients had one or more of the following: a retroperitoneal mass > or = 10 cm in diameter; mediastinal or supraclavicular mass > or = 5 cm in diameter; at least 20 lung metastases (any size); liver, bone, or brain metastases; and serum beta human chorionic gonadotropin (betaHCG) > or = 10,000 IU/L or alfa fetoprotein (AFP) > or = 1,000 IU/L. A total of 380 patients were accrued between May 1990 and June 1994 into this joint Medical Research Council (MRC)/European Organization for Research and Treatment of Cancer (EORTC) trial; of these, nine patients were deemed ineligible.

RESULTS

There was no significant difference between the two arms in the proportion of patients who achieved a complete response (CR) with chemotherapy alone, ie, 79 of 185 assessable patients (57%) with BEP/EP and 72 of 186 (54%) with BOP/VIP-B (P = 0.687). With a median follow-up of 3.1 years (maximum, 5.8), a total of 107 patients (28%) had progressive disease. There was no significant difference in time to first disease progression, or failure-free or overall survival between the two arms (P = 0.21, 0.101, and 0.190, respectively). The 1-year failure-free survival rates for BEP/EP and BOP/VIP-B were 60% (95% confidence interval [CI], 53% to 67%) and 53% (95% CI, 47% to 61%). Grade 3 or 4 myelosuppression, febrile neutropenia, and weight loss were more pronounced with BOP/VIP-B than with BEP/EP, and there were more toxic deaths with BOP/VIP-B than BEP/EP (18 [9%] v nine [5%]).

CONCLUSION

The intensive BOP/VIP-B therapy was associated with more toxicity, but there was no evidence of an improvement in response rate or survival compared with treatment with BEP/EP.

Clinical trials of nimodipine as a potential neuroprotector in ovarian cancer patients treated with cisplatin

Our previous randomised trial in patients with advanced ovarian cancer indicated a significant response and survival advantage for those receiving high-dose (100 mg/m2) as compared with low-dose (50 mg/m2) cisplatin in combination with cyclophosphamide (750 mg/m2). However, this was accompanied by more toxicity; peripheral neuropathy was troublesome, with 32% of patients experiencing > or = WHO grade 2 at the cisplatin dose of 100 mg/m2. Nimodipine is a calcium-channel antagonist that has provided protection from cisplatin-induced neurotoxicity in a rat model system. We performed a pilot study in 50 patients that demonstrated the feasibility of co-administration of nimodipine in a chronic oral dosing schedule with cisplatin-based chemotherapy in an open-label non-randomised trial. This led us to initiate a double-blind, placebo-controlled, randomised trial in patients with ovarian cancer, which was prematurely discontinued because of problems with nausea and vomiting, leading to poor patient compliance, that were not predicted by the pilot study. These studies did not demonstrate a neuroprotective effect for nimodipine. The primary efficacy variable, i.e, the neurotoxicity score at the end of treatment, gave a significantly lower mean for placebo patients than for nimodipine patients. This report details our experience and discusses the reasons for premature termination of the randomised trial.

Population pharmacokinetics/pharmacodynamics of docetaxel in phase II studies in patients with cancer

PURPOSE

The population pharmacokinetic/pharmacodynamic (PK/PD) approach was prospectively integrated in the clinical development of docetaxel to assess the PK profile in a large population of patients and investigate systemic exposure as a prognostic factor for clinical outcome.

PATIENTS AND METHODS

PK analysis was performed at first course in 24 phase II studies of docetaxel monotherapy using four randomized limited-sampling schedules. Bayesian estimates of clearance (CL), area under the concentration-time curve (AUC), and peak and duration of plasma levels greater than threshold levels were used as measures of exposure. PD data included for efficacy, response rate, time to first response, and time to progression (TTP) in breast cancer and non-small-cell lung cancer (NSCLC), and for toxicity, grade 4 neutropenia, and febrile neutropenia at first course and time to onset of fluid retention. PK/PD analysis was conducted using logistic and Cox multivariate regression models.

RESULTS

PK protocol implementation was successful. Most of the patients registered (721 of 936, 77%) were sampled and 68% were assessable for PK (640 patients). First-course docetaxel AUC was a significant predictor (P = .0232) of TTP in NSCLC (n = 151). Docetaxel CL was a strong independent predictor (P < .0001) of both grade 4 neutropenia and febrile neutropenia (n = 582). Cumulative dose was the strongest predictor (P < .0001) of the time to onset of fluid retention (n = 631). However, the duration of exposure over 0.20 micromol/L (0.16 microg/mL) at first course was an independent predictor (P = .0029). Few patients (n = 25, 4%) received the recommended dexamethasone premedication.

CONCLUSION

First-course docetaxel PK is a predictor of first-course hematologic toxicity, but also of fluid retention, which is cumulative in nature. Patients with elevated hepatic enzymes have a 27% reduction in docetaxel CL and are at a higher risk of toxicity. A starting dose of 75 mg/m2 is currently being evaluated in this population. Prospective implementation of large-scale population PK/PD evaluation is feasible in early drug development and this approach generates clinically relevant findings.

Association between total astigmatism and myopia

PURPOSE

To determine whether there is an association between degree of myopia and total astigmatism.

SETTING

St. Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, United Kingdom.

METHODS

Refractive and keratometric data for 105 eyes of 105 patients with myopia and astigmatism who attended a photorefractive keratectomy (PRK) assessment clinic were analyzed. The refractive data of the patients having PRK were also analyzed before and after treatment.

RESULTS

There was a strong correlation between total astigmatism (A) and degree of myopia. This could be represented by a linear regression line in the form A = -0.13 x myopia + 0.86 (at the corneal plane). Although there were trends, there was no significant correlation between the degree of corneal (keratometric) astigmatism and myopia. Data of 35 patients who had PRK were analyzed to determine whether the observed effect on astigmatism could have been predicted from the relationship between myopia and astigmatism. Forty-nine percent of patients with myopia and astigmatism were overcorrected by 0.6 diopter (D) (0.2 to 2.0 D), resulting in a preoperative to postoperative axis shift of 73 degrees; 40% were undercorrected by 1.2 D (0.5 to 3.1 D). Both over- and undercorrections could have been predicted from the relationship between myopia and astigmatism.

CONCLUSIONS

The total amount of astigmatism in the myopic eye is proportional to the degree of myopia. The amount that one intends to treat should, therefore, be modified according to the amount of myopia to be treated, as determined by the relationship between the degree of astigmatism and myopia.

Phase II trials of docetaxel (Taxotere) in advanced ovarian cancer--an updated overview

Docetaxel (Taxotere) has been studied at a dose of 100 mg/m2 i.v. as a one hour infusion every 3 weeks, in four phase II trials in patients with extensively pretreated ovarian cancer. A total of 340 patients were treated, including 256 patients in two separate EORTC (European Organization for Research and Treatment of Cancer) trials and 84 patients in two trials in the U.S.A. All patients had received prior cisplatin or carboplatin therapy and the treatment-free interval was less than 4 months in 155 patients. The overall response rate using conventional UICC criteria was 30% among 315 evaluable cases (95% confidence interval: 24-36%). Among 155 patients whose disease was most refractory (i.e. treatment-free interval was less than 4 months), the overall response rate was 28% (95% confidence interval: 19-36%). Response duration ranged from 4 to 17 months. Grade IV neutropenia was a common finding and fluid retention was observed. The incidence of febrile neutropenia ranged from 8 to 44% of patients with two deaths (i.e. 0.6% of the total treated) related to neutropenic sepsis. Docetaxel and paclitaxel (Taxol) have comparable activities in ovarian cancer. Ongoing studies with docetaxel include its use in patients as part of first-line therapy, as well as in patients refractory to paclitaxel. To prevent the development of fluid retention, these now involve the routine use of steroid prophylaxis. It is expected that docetaxel will prove to be an important addition to the drugs available for the treatment of ovarian cancer.

Prognostic factors for patients with advanced seminoma treated with platinum-based chemotherapy

Prognostic factors for 3-year progression-free survival (PFS) were defined in 286 patients with advanced seminoma treated with cisplatin-based chemotherapy at 10 European oncology units (no prior treatment: 236; prior radiotherapy: 50). Previously irradiated patients displayed a 69% PFS as compared to 87% in those presenting with advanced seminoma at the time of diagnosis (P = 0.009). In the univariate analysis, the extent and site of disease before chemotherapy and the level of serum LDH (< 2.0 versus > or = 2.0 x upper limit of normal) correlated with PFS in previously non-irradiated patients, but not in patients with prior radiotherapy. The multivariate analysis was, therefore, restricted to previously non-irradiated patients. The presence of non-pulmonary visceral metastases and a serum LDH level of > or = 2 x normal (N) proved to be independent prognostic factors. Based on these variables, two prognostic models were constructed and validated in an external data set of 166 comparable patients. For clinical use, Model 2 is recommended. The good-prognosis group comprises non-irradiated patients with stage II seminoma and any LDH level at presentation, or stage III and IV patients (with lung metastases only) whose serum LDH level is < 2 x N. These patients display a 94% 3-year PFS. The poor prognosis group includes all other patients with a 56% PFS. With this prognostic model, individualisation of the therapeutic approach may be considered in patients with advanced seminoma and a high risk of chemotherapy-related toxicity.

Importance of bleomycin in combination chemotherapy for good-prognosis testicular nonseminoma: a randomized study of the European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group

PURPOSE

This prospective randomized trial was designed to compare the efficacy of etoposide plus cisplatin (EP) versus bleomycin, etoposide, and cisplatin (BEP) chemotherapy in patients with good-prognosis metastatic nonseminomatous testicular cancer.

PATIENTS AND METHODS

Four hundred nineteen patients with good-prognosis nonseminomatous testicular cancer were randomized to receive four cycles of cisplatin 20 mg/m2 on days 1 to 5 plus etoposide 120 mg/m2 on days 1, 3, and 5 with or without bleomycin 30 mg weekly.

RESULTS

Of 395 eligible patients, 169 of 195 patients allocated to EP (87%) and 189 of 200 patients allocated to BEP (95%) achieved a complete response with chemotherapy alone or after postchemotherapy surgery. These results are significantly different (P = .0075). After a median follow-up duration of 7.3 years, eight patients (4%) on each treatment arm relapsed. In view of the low number of unfavorable treatment outcomes (11%), no significant differences were detected in time to progression (P = .136) and survival (P = .262). Both the acute and late pulmonary toxicity and neurotoxicity were significantly greater in patients who received BEP, whereas Raynaud's phenomenon occurred exclusively in patients who received BEP (P < .001). Two patients treated with BEP died of bleomycin pulmonary toxicity.

CONCLUSION

BEP is the most effective combination regimen in the treatment of disseminated nonseminomatous germ cell cancer. In this particular BEP regimen with etoposide at a dose of 360 mg/m2 per cycle, even in good-prognosis patients, bleomycin cannot be deleted without compromising treatment efficacy, but its use is associated with more toxicity (particularly pulmonary) and efforts to reduce this merit further exploration.

Randomized trial of bleomycin, etoposide, and cisplatin compared with bleomycin, etoposide, and carboplatin in good-prognosis metastatic nonseminomatous germ cell cancer: a Multiinstitutional Medical Research Council/European Organization for Research and Treatment of Cancer Trial

PURPOSE

This prospective randomized multicenter trial was designed to evaluate the efficacy of carboplatin plus etoposide and bleomycin (CEB) versus cisplatin plus etoposide and bleomycin (BEP) in first-line chemotherapy of patients with good-risk nonseminomatous germ cell tumors.

PATIENTS AND METHODS

Between September 1989 and May 1993, a total of 598 patients with good-risk nonseminomatous germ cell tumors were randomized to receive four cycles of either BEP or CEB. In each cycle, the etoposide dose was 120 mg/m2 on days 1, 2, and 3, and the bleomycin dose was 30 U on day 2. BEP patients received cisplatin at 20 mg/m2/d on days 1 to 5 or 50 mg/m2 on days 1 and 2. For CEB patients, the carboplatin dose was calculated from the glomerular filtration rate to achieve a serum concentration x time of 5 mg/mL x minutes. Chemotherapy was recycled at 21-day intervals to a total of four cycles.

RESULTS

Of patients assessable for response, 253 of 268 (94.4%) of those allocated to receive BEP achieved a complete response, compared with 227 of 260 (87.3%) allocated to receive CEB (P = .009). There were 30 treatment failures in the 300 patients allocated to BEP and 79 in the 298 allocated to CEB (log-rank chi 2 = 26.9; P < .001), which led to failure-free rates at 1 year of 91% (95% confidence interval [CI], 88% to 94%) and 77% (95% CI, 72% to 82%), respectively. There were 10 deaths in patients allocated to BEP and 27 in patients allocated to CEB (log-rank chi 2 = 8.77; P = .003), which led to 3-year survival rates of 97% (95% CI, 95% to 99%) and 90% (95% CI, 86% to 94%), respectively.

CONCLUSION

With these drug doses and schedules, combination chemotherapy based on carboplatin was inferior to that based on cisplatin. This BEP regimen that contains moderate doses of etoposide and bleomycin is effective in the treatment of patients with good-prognosis metastatic nonseminoma.

Radiotherapy after chemotherapy for metastatic seminoma--a diminishing role. MRC Testicular Tumour Working Party

In a retrospective study, data from 302 patients with metastatic testicular seminoma treated with chemotherapy between 1978 and 1990 in 10 European centres were analysed to evaluate the role, if any, of postchemotherapy treatment with irradiation. The primary endpoint of this study was the progression-free survival rate after chemotherapy with or without additional radiotherapy. This was related to the type of primary chemotherapy, sites and sizes of pre- and postchemotherapy masses, the extent of surgical resection after chemotherapy and the use of radiotherapy. 174 patients had residual disease at the end of chemotherapy. The most important prognostic factors for progression were the presence of any visceral metastases or raised LDH prechemotherapy, and the presence of residual disease at visceral sites after chemotherapy. Approximately half the patients with residual masses underwent postchemotherapy radiotherapy, with selection based predominantly on institutional practice. In patients receiving platinum-based chemotherapy, no significant difference was detected in progression-free survival whether or not radiotherapy was employed. Patients receiving BEP (bleomycin, etoposide and cisplatin) had a progression-free survival rate of 88% (95% CI, 80-96%) uninfluenced by postchemotherapy radiotherapy. In patients with residual masses confined to the abdomen after platinum-based chemotherapy, the absolute benefit to radiotherapy was estimated to be 2.3%. The potential benefit of postchemotherapy radiotherapy is minimal, and so it is concluded that the use of adjuvant radiotherapy to residual masses after platinum-based chemotherapy for metastatic seminoma is unnecessary.

The establishment of a xerostomia clinic: a prospective study

The study investigated the aetiological factors and management of patients who have xerostomia. The subjects were 100 consecutive patients referred to the Oral Medicine Unit for investigation of oral dryness. A detailed case history was recorded and patients underwent a systematic examination together with sialometry, haematological, biochemical and immunological investigations. Suspected cases of Sjögren's syndrome (SS) were referred for assessment by a rheumatologist and ophthalmologist. Objective evidence of salivary gland hypofunction was found in 39 patients. A definite diagnosis of primary and secondary SS was made in 24 and 15 patients respectively, a further five cases had possible primary SS. Other causes of xerostomia were: undiagnosed diabetes (3); drug-induced (11); therapeutic radiation (3); alcohol-related (3); psychogenic (15) and idiopathic (21). Patients complaining of a dry mouth should be questioned about non-oral symptoms. In total, 40% of patients attending the dry mouth clinic had a diagnosis of SS.