Ifosfamide in small cell lung cancer

Ifosfamide, an analogue of cyclophosphamide, has been proven to be of value in numerous malignancies, including testicular cancer, sarcoma, and lymphoma. Furthermore, ifosfamide is more suitable for combination chemotherapy than its parent compound because it causes less myelosuppression than cyclophosphamide. There have been only a few studies evaluating single-agent ifosfamide in small cell lung cancer (SCLC). In patients who have had little or no prior chemotherapy, ifosfamide appears as active as any single agent. Combination chemotherapy regimens employing cisplatin (or carboplatin) plus etoposide plus ifosfamide are currently under way on both sides of the Atlantic. A Hoosier Oncology Group (HOG) study will evaluate this three-drug regimen v cisplatin plus etoposide, and this protocol will establish or refute the value of ifosfamide as first-line therapy in extensive SCLC.

Ten-year follow-up of patients receiving cisplatin, doxorubicin, and cyclophosphamide chemotherapy for advanced epithelial ovarian carcinoma

Fifty-six patients were randomly assigned to receive either one-day cisplatin, doxorubicin, and cyclophosphamide (PAC) chemotherapy (PAC-I) or five-day PAC (PAC-V) for advanced epithelial ovarian carcinoma. Follow-up has been 120+ months or to death. Ninety-one percent had either suboptimal stage III or stage IV disease and 55% had grade 2 or 3 lesions. Two patients died of toxicity and were free of disease at autopsy. A third patient died of congestive heart failure with no disease at 103 months. Additionally, eight patients had a negative second-look laparotomy, and three (37.5%) are alive with no evidence of disease (NED) 133 to 144 months after diagnosis. Five patients (62.5%) died of disease 2 to 123 months after negative second-look. Patients with optimal stage III disease had a longer median progression-free interval (PFI) and survival (33.3 and 44.5 months, respectively) than those with suboptimal or stage IV disease (16.4 and 22.5 months, respectively), and the difference in median PFI is significant (P less than .02). Patients with ascites at diagnosis had a shorter median PFI and survival (14.7 and 18 months) than those without ascites (30.0 and 33.0 months). Both differences were significant (PFI, P less than .04; survival, P = .005). PAC produces response rates that are superior to those obtained historically with single-agent alkylating therapy. Late recurrences after negative second-look laparotomy suggest that 5-year survival data may be inadequate in ovarian carcinoma.

Ifosfamide in testicular cancer: the Indiana University experience

The systemic treatment of patients with metastatic germ cell tumors has improved dramatically during the past 15 years. Nonetheless, a cohort of patients are candidates for salvage chemotherapy. Having ruled out the possibility of pseudoprogression (eg, false elevated serum markers, teratoma, bleomycin lung disease), salvage therapy is indicated. Numerous trials in Europe and at Indiana University have confirmed single-agent activity of ifosfamide in patients with refractory germ cell tumors. As a consequence, a trial evaluating VeIP (vinblastine, ifosfamide, cisplatin) and VIP (etoposide, ifosfamide, cisplatin) was undertaken in 57 patients previously not cured with cisplatin, vinblastine, and etoposide regimens. Twenty patients achieved disease-free status with chemotherapy alone (n = 12) or chemotherapy plus surgical resection of residual carcinoma or teratoma (n = 8). Fifteen of these 20 patients remained free of recurrent disease from 18 to 53 months, including seven patients in continuous remission for over 2 years. Ifosfamide combination chemotherapy has curative potential in this heavily pretreated population. Further work to determine the role of ifosfamide in initial therapy is under way.

Cisplatin as first-line therapy for metastatic breast cancer

Cisplatin has had only minimal activity when used as second- and third-line chemotherapy for metastatic breast cancer (MBC). There have been no phase II studies in the United States evaluating cisplatin in patients with MBC with no prior chemotherapy. We therefore treated 20 consecutive patients with cisplatin 30 mg/m2/d for four days every 3 weeks for a maximum of six courses. We obtained partial responses in nine of 19 evaluable patients (47%), with responses in liver, lung, and soft tissue indicator lesions. Our data suggest that cisplatin has substantial single-agent activity as front-line therapy in MBC, and should be considered for inclusion in first-line combination chemotherapy regimens.

Etoposide and split-dose cisplatin in bronchogenic carcinoma

The Hoosier Oncology Group (HOG) treated 13 patients with bronchogenic carcinoma with an innovative schedule of cisplatin and VP-16. Unexpected toxicity was noted, with five deaths secondary to granulocytopenia and septic shock and three episodes of renal failure. Despite early closure of this study, we conclude that this schedule of cisplatin and VP-16 results in greater toxicity than comparable dosages in a more routine schedule.

Testicular cancer: the quest continues

Treatment for testicular cancer has dramatically improved during the last 15 years. Much of this success has come about because of improved staging and operative techniques but, most importantly, through the introduction of successful systemic chemotherapy. Nonetheless, relevant issues still remain to be addressed in regard to the optimal therapy for patients with germ cell neoplasms. Included in these issues is delineating the most effective but minimally morbid treatment for patients with early-stage and low-volume metastatic disease while continuing to create innovative treatment approaches for poor-risk patients with metastatic disease. The unique association of primary mediastinal germ cell neoplasms with the development of non-germ cell cancers and Klinefelter's syndrome may provide some early clues for the determination of factors controlling differentiation. These observations issue a challenge to both clinical and preclinical researchers involved in the study of this neoplasm.

Salvage therapy in recurrent germ cell cancer: ifosfamide and cisplatin plus either vinblastine or etoposide

STUDY OBJECTIVE

To determine the efficacy of the addition of ifosfamide to cisplatin plus etoposide (VIP), or vinblastine (VeIP), in patients with recurrent germ cell tumors.

DESIGN

Nonrandomized, prospective phase II trial.

SETTING

Tertiary referral university hospital.

PATIENTS

Fifty-six of fifty-eight entered patients with measurable and progressive recurrent germ cell tumors of testicular (46 patients), ovarian (1 patient), and extragonadal (9 patients) origin were evaluable for response after not being cured with cisplatin, vinblastine, and etoposide regimens.

INTERVENTIONS

Patients were administered cisplatin (20 mg/m2 body surface area daily for 5 days), ifosfamide (1.2 g daily for 5 days), plus either etoposide (75 mg daily for 5 days) or vinblastine (0.11 mg/kg body weight on days 1 and 2). In addition, vigorous intravenous hydration therapy with normal saline (100 to 125 mL/h) was administered during the treatment course. Uroepithelial protective agents, N-acetylcysteine (orally) or mesna (intravenously), were administered. Four courses were administered to responding patients every 3 weeks. When complete excision was feasible, surgical resection of residual tumor was done approximately 6 to 8 weeks after chemotherapy.

MEASUREMENTS AND MAIN RESULTS

Twelve of fifty-six evaluable patients had a complete remission with chemotherapy alone, whereas 8 additional patients were free of disease after resection of teratoma (3 patients) or carcinoma (5 patients) for a total disease-free rate of 36% (95% CI, 23.4 to 49.6). The 95% CI median duration of remission for these patients is 34 months (range, 3 to more than 42; 95% CI, 9 months to infinity), and the median survival for all eligible patients is 12.7 months (95% CI, 10 months to 26 months), with 15 of the 20 patients who achieved disease-free status alive 18 to 53 months or more. Nine of fifty-eight patients remain free of disease, including 7 patients for 2 years or longer. Hematologic and nephrotoxicity were the predominant drug-related toxicities, with one drug-related death secondary to pneumonia.

CONCLUSIONS

Ifosfamide combination chemotherapy as third-line or greater therapy can produce durable complete remissions in heavily pretreated patients with recurrent germ cell tumors.

Neoadjuvant therapy of stage III non-small cell lung cancer

During the past several years, there has been a resurgence of interest in preoperative or postoperative chemotherapy in patients with Stage III lung cancer. The staging system for lung cancer has recently been modified, and at the present time Stage III disease is now subdivided into Stage III-A (potentially surgically resectable for cure) and Stage III-B (unresectable). This article will review five recently completed studies utilizing neoadjuvant therapy in various types of Stage III lung cancer. The thoracic surgeon is faced with the dilemma of reviewing this literature and trying to make a conclusion as to what is appropriate therapy for Stage III disease. Unquestionably, neoadjuvant therapy appears to increase the resectability rate in Stage III-A disease and can make some Stage III-B patients anatomically resectable. It is hoped that future well-designed phase III studies can be accomplished in Stages III-A and III-B disease so that we can determine whether neoadjuvant chemotherapy is or is not beneficial for these patients.

Cisplatin-based combination chemotherapy for disseminated germ cell tumors: long-term follow-up

A retrospective analysis of the initial 229 cases of disseminated germ cell tumors treated at Indiana University with cisplatin, vinblastine, and bleomycin (PVB), with or without doxorubicin revealed 146 patients who are alive and disease-free with a minimum follow-up of 6 years and a median follow-up of 8.5 years. At 12 years, the estimated probability of survival is 65.0%, and the estimated probability of relapse-free survival for complete responders is 83.5%. Long-term complications, such as clinically significant organ toxicity or therapy-related second malignancies, have not been observed. The functional status of survivors is maintained, with 95% returning to their pretherapy status, of which 88% are fully employed. Of patients receiving chemotherapy without abdominal surgery, 35% have fathered healthy children posttherapy. Achievement of complete remission (CR) in disseminated germ cell tumors with cisplatin-based combination chemotherapy translates to long-term disease-free survival and cure for the majority of patients, with preservation of functional status.

Relation of proliferative activity to survival in patients with advanced germ cell cancer

Patients with advanced disseminated germ cell tumors of the testis, retroperitoneum, and mediastinum have impaired survival compared to other patients with disseminated germ cell tumors having less bulky metastatic disease. Among patients with advanced disseminated germ cell tumors, we currently lack adequate predictors of long-term survival. Flow cytometric analysis of the paraffin-embedded, formalin-fixed tumor blocks of 50 of these patients suggests that proliferative activity is significantly correlated with survival (p less than 0.001) in multivariate analysis. Log (beta-human chorionic gonadotropin) is the only other useful predictor of long-term survival in multivariate analysis of prognostic factors in this group of patients. Flow cytometric DNA analysis may be useful in predicting survival in patients with advanced disseminated germ cell tumors.

Toxicity comparisons between two chemotherapy regimens as adjuvant or salvage treatment in nonseminomatous testicular cancer

The Testicular Cancer Intergroup Study was initiated to evaluate the efficacy of adjuvant chemotherapy in Stage II and salvage therapy in Stage I nonseminomatous testicular carcinoma. Chemotherapy regimens of cisplatin, vinblastine, and bleomycin (PVB) or the same drugs plus cyclophosphamide and dactinomycin (VAB) were used at institution or cooperative group preference. A comparison of the toxicities of these two regimens shows that VAB caused significantly more mucosal, dermatologic, and otologic toxicity than PVB, and PVB caused more leucopenia. Both regimens were equally effective in controlling cancer. Either regimen could be used as chemotherapy in testicular cancer, and the decision about which one to use could be based on their differences in toxicity and degree of patient convenience.

Complicated problems in testicular cancer

Although testicular cancer is a relatively rare disease, it nevertheless is extremely important, as it has become a model for a curable neoplasm. Cisplatin combination chemotherapy has revolutionized the cure rate in this once highly lethal disease: Today over 90% of all patients are cured of their disease, including an 80% cure rate in disseminated testicular cancer. However, these dramatic advances have created a new set of questions relating to the proper management of clinical stage I disease, challenging the role of retroperitoneal lymph node dissection (RPLND) in such patients. Despite the potential value of a surveillance policy, we continue to advocate routine RPLND for clinical stage I nonseminomatous germ cell tumors. Salvage chemotherapy has been refined and improved with the availability of new active agents such as ifosfamide. Dosage intensity is very important in oncology, and this concept is also being tested in refractory testicular cancer with very high-dose carboplatin plus etoposide with autologous bone marrow transplantation. We are currently in the enviable position in testicular cancer where we can now concentrate on small subsets of patients with advanced disseminated disease and evaluate innovative aggressive regimens. We expect future fine-tuning to provide continued improved therapeutic index in testicular cancer patients.

Cisplatin plus etoposide in small cell lung cancer

Bronchogenic carcinoma is the leading cause of cancer related death in the United States. Approximately 20% to 25% of patients will present with small cell lung cancer (SCLC). The median survival time of patients treated with supportive care alone is about 2 to 4 months. Despite this grim prognosis, chemotherapy, with or without radiotherapy, has impacted upon the survival of patients with SCLC. Combination chemotherapy with agents such as cyclophosphamide, vincristine, and doxorubicin has routinely produced response rates of 60% to 80%. Subsequently, the median survival of treated patients has been lengthened to 10 to 14 months, with apparent cures in approximately 10% of patients with limited-stage disease. To improve these results, investigators have tried various treatment strategies, including evaluation of preclinical models of synergy, clinical trials with newer agents, and theoretic and practical considerations of dosing and scheduling. Recently, two groups of compounds, the epipodophyllotoxins and the platinum compounds have demonstrated single-agent activity in SCLC. This paper highlights the developmental role of two of these agents, cisplatin and etoposide, in this disease.

Cisplatin plus etoposide consolidation following cyclophosphamide, doxorubicin, and vincristine in limited small-cell lung cancer

From June 1982 through October 1985, the Southeastern Cancer Study Group randomized patients with limited small-cell lung cancer (SCLC) to cyclophosphamide plus doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH) plus vincristine (CAV) for six cycles v CAV plus concomitant thoracic irradiation as induction therapy. Patients achieving either a complete or partial response and remaining in remission after completion of induction therapy were subsequently randomized to consolidation chemotherapy consisting of cisplatin 20 mg/m2 X 4 plus etoposide (VP-16) 100 mg/m2 X 4 every 4 weeks for two courses v no further therapy. There were 160 patients entered on the consolidation phase and 148 were fully evaluable. The median survival for patients randomized to cisplatin plus VP-16 (PVP16) from start of CAV chemotherapy was 97.7 weeks, compared with 68 weeks for the no-consolidation arm (P = .0094). PVP16 consolidation also significantly increased the duration of remission, with median durations of 49 weeks v 28 weeks (P = .0008). The median durations for partial remission were 41 weeks v 23 weeks (P = .013), and for complete remission, 52 weeks v 30.5 weeks (P = .0091). Furthermore, 18 patients on PVP16 consolidation remain in a continuous complete remission for 12+ months and 13 of these are continuously disease free 2+ years. Eight patients randomized to no consolidation remain in a continuous complete remission, with only four patients disease free 2+ years. PVP16 consolidation has significantly improved the duration of remission and overall survival and appears capable of improving the cure rate in limited SCLC.

Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer

Between 1979 and 1984, 195 evaluable patients were entered in an international multicenter study comparing two regimens for patients with completely resected pathological Stage II testicular cancer (that is, with positive retroperitoneal lymph nodes). All patients had undergone orchiectomy and dissection of the retroperitoneal lymph nodes. They were randomly assigned to be treated with two cycles of immediate adjuvant cisplatin-based chemotherapy or to be observed monthly with treatment at relapse. The median follow-up period was four years. Of the 97 patients assigned to adjuvant chemotherapy, 6 (6 percent) had a recurrence; however, only 1 had received adjuvant chemotherapy before the recurrence. Three died (one of testicular cancer), and 94 of the 97 survived. Of the 98 patients who were observed, 48 (49 percent) had a relapse. However, almost all patients with relapses were effectively treated, and 93 of the 98 are alive and disease-free; 3 have died of testicular cancer. No identifiable factors were strongly associated with the risk of relapse. We conclude that two courses of cisplatin-based adjuvant chemotherapy will almost always prevent relapse in pathological Stage II testicular cancer treated with orchiectomy and retroperitoneal-lymph-node dissection. However, when surgery, follow-up, and chemotherapy are optimal, observation with chemotherapy only for relapse will lead to equivalent cure rates.

Status of chemotherapy for testis cancer

Significant advances have been made in the treatment of advanced testicular cancer. These advances have been centered on better staging techniques with procedures such as computed tomography as well as the development of reliable serum markers. Based on these techniques, patients can be directed toward primary surgical therapy or systemic therapy. Cisplatin combination chemotherapy can be expected to cure approximately 80 per cent of all patients with advanced disease. Currently, cisplatin plus etoposide plus bleomycin is the standard treatment for patients with advanced disease. Newer trials are currently addressing the role of more aggressive therapy in patients with a poor prognosis while parallel trials examine the possibility of minimizing toxicity for those patients with good-risk disease.

A randomized comparison of high-dose versus conventional-dose cyclophosphamide, doxorubicin, and vincristine for extensive-stage small-cell lung cancer: a phase III trial of the Southeastern Cancer Study Group

To assess the effect of dose escalation in the treatment of small-cell lung cancer (SCLC), 298 patients with extensive-stage disease were treated with either conventional-dose cyclophosphamide (1,000 mg/m2), doxorubicin (40 mg/m2), and vincristine (1 mg/m2), (CDCAV); or high-dose cyclophosphamide (1,200 mg/m2), doxorubicin (70 mg/m2), and vincristine (1 mg/m2) (HDCAV). No dose attenuation was allowed during the initial three cycles of therapy in either treatment arm. All patients received CDCAV in cycles 4 through 6, during which time dosages were adjusted according to granulocyte and platelet nadirs. No additional chemotherapy was administered until disease progression or relapse was documented. Complete responses were more frequent with HDCAV (22% v 12%; P = .045). However, overall response rate (63% v 53%) and median survival (29.3 v 34.7 weeks) were not significantly different (P greater than .05). HDCAV was substantially more toxic than CDCAV, causing more episodes of life-threatening leukopenia (ie, granulocytes less than 500/microL; 79% v 40%; P less than .05) and infections (15% v 4%; P less than .05). Dose intensification of cyclophosphamide and doxorubicin during induction chemotherapy did not produce any survival benefit compared with conventional dosages of these agents in SCLC patients with extensive-stage disease.

Postchemotherapy resection of residual tumor in limited stage small cell lung cancer

To determine the feasibility of post-chemotherapy resection of residual tumor in small cell lung cancer, 24 selected patients with limited-stage disease were evaluated for exploratory thoracotomy. All 24 patients achieved partial or complete clinical response to chemotherapy and were considered adequate medical candidates for surgical resection. Fifteen patients underwent a lobectomy or pneumonectomy, 13 of whom had residual tumor in the resected specimen. Of the nine remaining patients, seven had no tumor found on biopsy at thoracotomy and two had unresectable mediastinal node involvement. No chemotherapy was administered postoperatively in any patient until disease progression or relapse was documented. Median survival for the entire group was 19 months and did not differ according to the surgical procedure performed. Nineteen patients had relapse. Patients undergoing biopsy only recurred locally in six of seven cases a median of five months post-thoracotomy (range one to six months). Two "biopsy only" patients were tumor free at 34+ and 56+ months. Local recurrence was observed in six of 12 resected patients, while six patients experienced only extrathoracic metastases. Median time to recurrence for resected patients was also five months. Four resected patients experienced late recurrence 16 to 36 months postoperatively and were alive with tumor at 29+ to 42+ months. Two resected patients were tumor-free at 13+ and 37+ months. Post-chemotherapy surgical resection was feasible in limited-stage patients and improved local control of disease.

Chemotherapy of metastatic seminoma: the Southeastern Cancer Study Group experience

From 1978 to 1984, 62 patients with advanced seminoma of testicular or extragonadal origin were entered on two consecutive Southeastern Cancer Study Group (SECSG) protocols. All patients had progressive disease and were stratified according to tumor burden. Randomization on SEG 78-GU240 was cisplatin, vinblastine, and bleomycin (PVB), with or without doxorubicin; on SEG 81-GU332, randomization was to PVB or cisplatin, etoposide (VP-16), and bleomycin (PVP16B). Dosages of etoposide, vinblastine, and doxorubicin were decreased by 25% in patients who had received prior radiotherapy. Thirty patients (55%) had received prior chest and/or abdominal radiotherapy. Overall, 41 of 60 evaluable patients (68%) achieved a complete remission (CR) and 37 patients are alive and free of disease. CR was obtained in 13 of 15 patients (87%) with minimal disease, 13 of 16 (81%) with moderate disease, and 15 of 29 (52%) with advanced disease. Patients with no prior radiotherapy or limited-field (chest or abdomen) radiotherapy were more likely to achieve CR than those with prior chest and abdominal radiotherapy (75% v. 42%). Using univariate analysis, the extent of disease is the only significant prognostic factor, whereas both extent of disease and extent of prior radiotherapy are significant in a multivariate analysis. This study confirms the chemosensitivity of metastatic seminoma in a cooperative group setting and defines prognostic factors useful for comparison of other chemotherapeutic trials in seminoma.

Klinefelter's syndrome associated with mediastinal germ cell neoplasms

Several case reports have suggested an association of primary mediastinal germ cell tumor (PMGCT) and Klinefelter's syndrome (KS). In an effort to confirm this association, 22 patients with mediastinal germ cell tumors had chromosome studies performed in a prospective fashion. Five patients (22%) had karyotypic or pathologic evidence of KS. All of the patients with KS had germ cell tumors of the nonseminomatous subtype and were relatively young (median age, 15 years). The literature confirms the findings of a young median age (18 years), nonseminomatous subtype, and mediastinal location of the germ cell neoplasm. We conclude that patients with KS are predisposed to the development of mediastinal nonseminomatous germ cell cancers.

Chemotherapy of disseminated germ cell tumors

The treatment of patients with germ cell neoplasms has improved dramatically during the last 10 years. Combination chemotherapy with cisplatin + vinblastine + bleomycin (PVB) was initiated at Indiana University in 1974. In this original study 28 of 47 patients (60%) with disseminated testicular tumors are currently alive, with a minimal follow-up of 10 years. Our next PVB study demonstrated that the vinblastine dosage could be reduced 25% (0.4 mg/kg to 0.3 mg/kg), thereby significantly reducing toxicity, without compromising the cure rate. Our third generation study confirmed the fact that maintenance therapy was not necessary, and that optimal cure rates could be achieved with merely 12 weeks of PVB induction. Overall, with follow-up of 5 to 10 years, 202 of 272 patients (74%) with disseminated testicular cancer currently are alive on these three PVB protocols. Because of the success of salvage chemotherapy, demonstrating that approximately 25% of patients not curable by PVB achieved durable complete remissions (CRs) with cisplatin + VP-16 combination chemotherapy, our next study compared PVB to cisplatin + VP-16 + bleomycin (PVP16B) as initial chemotherapy for disseminated testicular cancer. This study demonstrated that the two induction regimens produced equivalent CR rates, but that PVP16B was the preferable induction regimen because of a statistically significant reduction in neuromuscular toxicity. Our current studies will evaluate whether three courses (9 weeks) of PVP16B compared to the standard four courses of PVP16B (12 weeks) will achieve similar cure rates in minimal moderate disseminated disease. In advanced disease presentations, we are comparing standard PVP16B to double-dose cisplatin (40 mg/M2 X 5) + VP-16 + bleomycin.

Treatment of disseminated germ-cell tumors with cisplatin, bleomycin, and either vinblastine or etoposide

Standard chemotherapy for disseminated germ-cell tumors includes a combination of cisplatin, vinblastine, and bleomycin, but this regimen produces substantial neuromuscular toxicity. In a randomized clinical trial in 261 men with disseminated germ-cell tumors, we substituted etoposide for the vinblastine in this regimen in half the patients to compare the efficacy and toxicity of the two treatments. Among 244 patients who could be evaluated for a response, 74 percent of those receiving the regimen including vinblastine and 83 percent of those receiving the regimen including etoposide became disease-free with or without subsequent surgery (P not significant). Among the 157 patients with high tumor volume, 61 percent became disease-free on the regimen that included vinblastine, as compared with 77 percent on the regimen that included etoposide (P less than 0.05). Survival among the patients who received etoposide was higher (P = 0.048). The regimens were similar in terms of myelosuppressive effects and pulmonary toxicity. However, the etoposide regimen caused substantially fewer paresthesias (P = 0.02), abdominal cramps (P = 0.0008), and myalgias (P = 0.00002). We conclude that etoposide with cisplatin and bleomycin is superior to vinblastine with cisplatin and bleomycin in the treatment of disseminated germ-cell tumors because of diminished neuromuscular toxicity and, among patients with advanced disease, better efficacy.