Long-term outcome of patients with relapsed and refractory germ cell tumors treated with high-dose chemotherapy and autologous bone marrow rescue

Testicular cancer

Although testicular cancer accounts for approximately 1% of all male malignancies, it has a significant impact on the social, economic, and emotional status of the young population in which it occurs. TSE is the best available tool for early detection of testicular cancer. Only 15 to 20 years ago, testicular cancer was often fatal because of the rapidity of metastasis to the lungs and other vital organs. Because of progress in surgical technique and chemotherapy, it is today one of the most curable cancers. The use of serum markers and early diagnosis and treatment are of great importance in the management of testicular cancer.

High-dose chemotherapy and autologous bone marrow transplantation for patients with poor prognosis nonseminomatous germ cell tumours

Twenty-one patients with poor prognosis nonseminomatous germ cell tumours (six with extreme burden disease at presentation in whom partial remission had been achieved with initial induction therapy, and 15 with recurrent disease after induction therapy) were treated with high-dose chemotherapy and autologous bone marrow transplantation (BMT). The first six received etoposide 3.0 g m-2, ifosfamide 6.0 g m-2 and carboplatin 1.2 g m-2 (Regimen 1), and the subsequent 15 received etoposide 2.4 g m2 (continuous infusion), cyclophosphamide 7.2 g m-2 and carboplatin 0.8 g m-2 (Regimen 2) followed by infusion of previously stored autologous marrow. Regimen 1 was associated with considerable renal toxicity and mucositis, whereas Regimen 2 was relatively well tolerated. Two patients died as a consequence of the treatment: one of candidemia and one of interstitial pulmonary fibrosis. Only one of 17 patients who were autografted in or approaching marker remission subsequently developed disease progression (event-free survival 82%, 95% confidence interval [CI] 55% to 94%), whereas all four patients who had progressive disease at autografting subsequently developed further disease progression and died. Fourteen patients remain well and free of disease 0.5 to 6.5 years (median 3.3) post-BMT (event-free survival 67%, 95% CI 43% to 83%). A strategy of prompt reinduction followed by high-dose chemotherapy and autologous BMT at the first sign of failure of standard therapy may allow cure to be a realistic expectation.

Reduction of infection rates in cancer patients associated with the use of haematopoietic growth factors

As the risk of infection associated with chemotherapy is related to the depth of the fall in neutrophil counts, protection from neutropenia has been used as an endpoint for growth factors in this setting. However, the functional status of these and other myeloid cells are also important. Therefore, more direct measurements of clinical improvement will also be useful. Several studies have suggested that the use of granulocyte-macrophage colony-stimulating factor (GM-CSF) can result in improvements in hospital stay, days of fever, antibiotic use and thrombocytopenia. Similar findings have been confirmed by our own work which indicates that GM-CSF not only shortens the period of leukopenia, but also reduces the complications of infection. More sensitive and appropriate endpoints should be included in future trials, including rate of and survival from infection as well as overall and disease-free survival.

Prediction of long-term response after high-dose chemotherapy with autologous bone marrow transplantation in the salvage treatment of non-seminomatous germ cell tumours

High-dose chemotherapy (HDCT) and autologous bone-marrow transplantation (ABMT) are widely used in the salvage treatment of non-seminomatous germ cell tumours (NSGCT). We compiled 10 published series with NSGCT patients treated by HDCT and ABMT. Several prognostic factors for long-term non-evolutive disease (NED) were studied: dose of etoposide (ETO), oxazaphosphorine derivative (OXA) (expressed in cyclophosphamide equivalents using a cyclophosphamide/ifosfamide ratio of 1:3), platin-derivate (PLAT) (expressed in cisplatin equivalents using a cisplatin/carboplatin ratio of 1:4), disease status (refractory or responder), OXA and PLAT compounds. Strong interactions were shown between disease status and PLAT and ETO. In refractory patients, logistic regression analysis showed that the doses of OXA and PLAT increase the probability of NED. Conversely, in responder patients only ETO and OXA dosages increase the probability of NED. It is concluded that the status of the disease is the most important prognostic factor for long-term NED after HDCT + ABMT in NSGCT.

Granulocyte-macrophage colony-stimulating factor (GM-CSF): what role in bone marrow transplantation?

Infection during the period of bone marrow aplasia remains one of the major risks associated with high-dose chemotherapy and transplantation. Over the past several years, a number of investigators in Europe and North America have evaluated the use of GM-CSF in the setting of autologous bone marrow transplantation. These studies have almost all shown a hastening of myeloid engraftment. This, for the most part, has led to fewer serious infections and a decreased hospital stay for the GM-CSF treated patients. An overall survival advantage has not been noted. There has also not been any consistent multi-lineage effect. Future trials with combinations of sequentially used cytokines may lead to more rapid recovery of red blood cells and platelets in addition to granulocytes.