251
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Horwich A, Daugaard G, Kollmannsberger C, Beyer J, Jewett MAS. Salvage therapy: SIU/ICUD Consensus Meeting on Germ Cell Tumors (GCT), Shanghai 2009. Urology 2011; 78:S469-74. [PMID: 21986226 DOI: 10.1016/j.urology.2011.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/08/2011] [Accepted: 03/08/2011] [Indexed: 11/19/2022]
Affiliation(s)
- Alan Horwich
- Department of Clinical Oncology, Royal Marsden Hospital and Institute of Cancer Research, Sutton, Surrey, United Kingdom.
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252
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Simonelli M, Rosti G, Banna GL, Pedrazzoli P. Intensified chemotherapy with stem-cell rescue in germ-cell tumors. Ann Oncol 2011; 23:815-22. [PMID: 21948814 DOI: 10.1093/annonc/mdr403] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Based on the high chemosensitivity of germ-cell tumors (GCTs), the concept of high-dose chemotherapy (HDCT) has been developed worldwide and investigated through many clinical trials. It has been carried out in different clinical settings, ranging from resistant or absolute refractory disease to chemosensitive relapse. HDCT with stem-cell support has been also explored as a part of first-line strategy for poor-prognosis patients. PATIENTS AND METHODS Our review summarized results from clinical trials evaluating the role of HDCT in patients with advanced GCTs. So far available data were obtained through a Medline search of English-language literature. RESULTS Several phase II trials and retrospective series have shown a possible benefit for GCT patients with recurrent disease as well as in first-line setting. Despite these results, data derived from randomized phase III studies failed to demonstrate any survival advantage for HDCT over conventional chemotherapy. CONCLUSIONS The role of HDCT in GCTs remains controversial. We need new prospective studies based on prognostic factors with multiple transplants of carboplatin and etoposide as the preferred high dose regimen. At present, based mainly on retrospective and phase II studies, HDCT may represent a therapeutic option for patients with primary refractory disease or for those with a second or further relapse.
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Affiliation(s)
- M Simonelli
- Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano.
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253
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Abstract
PURPOSE OF REVIEW This overview discusses several important developments in testicular germ cell tumors in the last year. RECENT FINDINGS Genomic studies are examining gene expression as possible markers for disease relapse and chemotherapy resistance. Optimal treatment strategies for early-stage nonseminomatous tumors continue to evolve, and advanced disease states continue to be challenging entities in terms of optimizing therapy and outcome. Long-term survivorship issues are also being evaluated in this patient population. SUMMARY Significant challenges remain for treatment of certain categories of testicular germ cell tumors. Treatment and surveillance paradigms continue to be defined and refined as research in these areas continues.
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254
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Voss MH, Feldman DR. Paclitaxel, ifosfamide and cisplatin (TIP) beyond its original indication for salvage treatment of germ cell tumors. Oncol Res Treat 2011; 34:410-1. [PMID: 21934338 DOI: 10.1159/000331699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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255
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Park S, Lee S, Lee J, Park SH, Park JO, Kang WK, Park YS, Lim HY. Salvage chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP) in relapsed or cisplatin-refractory germ cell tumors. ACTA ACUST UNITED AC 2011; 34:416-20. [PMID: 21934340 DOI: 10.1159/000331129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In relapsed germ cell tumors, salvage chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP) is a well-established regimen for patients with favorable features such as a primary testicular tumor and prior complete remission (CR) after the initial chemotherapy. We reviewed patients who had received salvage TIP chemotherapy, and evaluated the efficacy of TIP, linking it to patient characteristics. PATIENTS AND METHODS Between August 1998 and May 2009, a total of 14 patients were treated with salvage TIP chemotherapy. 10 of 14 had cisplatin-refractory disease, and none of the patients were expected to show a favorable outcome to conventional-dose salvage chemotherapy. RESULTS Of the 14 patients, 5 (37.5%) showed a favorable response (CR in 1 patient, partial response (PR) in 4 patients) to TIP alone, and 1 had CR with subsequent surgery after TIP. 2 patients with CR and another 2 patients who attained disease stabilization are still alive at 81.3, 25.4, 69.3, and 27.4 months, respectively. After a median follow-up of 41.0 months (range 11.1-137.6), the median overall survival time for all patients was 21.1 (range 5.0-112.6). CONCLUSIONS Even in the presence of poor prognostic features, salvage TIP chemotherapy can be an active regimen in patients with relapsed or refractory germ cell tumors.
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Affiliation(s)
- Silvia Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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256
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Lorch A, Albers P, Winter C, Beyer J. [High-dose chemotherapy and residual tumor resection in male germ cell tumors]. Urologe A 2011; 50:1047-54. [PMID: 21845425 DOI: 10.1007/s00120-011-2683-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As a consequence of the unsatisfactory results of conventional dose salvage regimens, in particular for patients with poor prognostic features at the time of relapse or in patients with refractory disease, high-dose chemotherapy (HDCT) was introduced into clinical practice in the late 1980s. The combination of carboplatin and etoposide (CE) still remains the backbone of most high-dose regimens. Multiple modifications with more dose escalations or addition of further drugs have been explored, most often with increased toxicity. With improved expertise in supportive care and the use of peripheral blood stem cells, hematopoetic recovery has been significantly shortened and the initial high treatment-related mortality reduced from more than 10% to about 3%. Since the incorporation of HDCT, even patients with unfavorable prognostic features or patients with second or subsequent relapses can achieve long-term remission. Following HDCT residual tumor resection plays a major role in achieving these long-term results. The proportion of vital residual tumor after HDCT is much higher than in patients after conventional chemotherapy. The role of HDCT remains controversial particularly as a first-line treatment and less so in the first salvage setting. As these patients are rare HDCT and residual tumor resection should only be be provided by high-volume centers with sufficient expertise in performing these complex procedures.
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Affiliation(s)
- A Lorch
- Klinik für Hämatologie, Onkologie und Immunologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstraße, 35033, Marburg, Deutschland.
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257
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[High dose chemotherapy and germ cell tumor]. Bull Cancer 2011; 98:945-9. [PMID: 21821481 DOI: 10.1684/bdc.2011.1406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Germ cell tumors are cured by cisplatin-based chemotherapy and secondary surgery. Patients with initial poor response to chemotherapy and relapsed disease patients have poor prognosis. Among different therapeutic approaches high dose chemotherapy with hematopoietic stem cell support has been studied. Despite the existence of a number of phase II trials and several well-conducted phase III trials, this approach is neither a standard nor an option in the setting of first line and first salvage treatment. A randomized phase III trial has recently been initiated and patients with relapsed disease should be offered to participate in the trial. Several selected indications could be discussed in further lines of treatment.
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258
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Koychev D, Oechsle K, Bokemeyer C, Honecker F. Treatment of patients with relapsed and/or cisplatin-refractory metastatic germ cell tumours: an update. ACTA ACUST UNITED AC 2011; 34:e266-73. [DOI: 10.1111/j.1365-2605.2011.01145.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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259
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Alva AS, Hahn NM, Aparicio AM, Singal R, Yellapragada S, Sonpavde G. Hypomethylating agents for urologic cancers. Future Oncol 2011; 7:447-63. [PMID: 21417907 DOI: 10.2217/fon.11.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Silencing of tumor suppressor genes by promoter-region methylation as an epigenetic mechanism of gene regulation is increasingly recognized as beneficial in cancer. Initially developed as cytotoxic high-dose therapies, azacitidine and decitabine are now being reinvestigated in lower-dose cancer treatment regimens with a different paradigm - hypomethylation. Recent evidence for benefit in myelodysplastic syndromes and acute myeloid leukemias has renewed interest in hypomethylation as a therapeutic option in epithelial cancers. In this article, we describe the mechanistic aspects of DNA methylation, which alters gene expression, and review the evidence for hypomethylation as a therapeutic option in urologic cancers. Potential correlative studies that may assist in developing tailored therapy with hypomethylating agents are reviewed. Given that the population with urologic cancers is typically elderly with multiple comorbidities, the excellent tolerability of lower-dose hypomethylating agents provides a high therapeutic index and rational development is warranted, bearing in mind that the cytostatic and delayed activity present challenges in the choice of appropriate trial end points.
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Affiliation(s)
- Ajjai S Alva
- Baylor College of Medicine & Michael E DeBakey VA Medical Center, Houston, TX 77030, USA
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260
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Sneag DB, Ramaiya N, O'Regan KN, Jagannathan JP, Hornick JL, Ho VT, Hayes JH. Peritoneal relapse of testicular seminomatous germ cell tumor treated successfully with salvage chemotherapy and autologous stem cell transplantation. Clin Genitourin Cancer 2011; 9:124-9. [PMID: 21723796 DOI: 10.1016/j.clgc.2011.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/14/2011] [Accepted: 05/13/2011] [Indexed: 11/18/2022]
Affiliation(s)
- Darryl B Sneag
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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261
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Voss MH, Feldman DR, Motzer RJ. High-dose chemotherapy and stem cell transplantation for advanced testicular cancer. Expert Rev Anticancer Ther 2011; 11:1091-103. [PMID: 21806332 PMCID: PMC3253700 DOI: 10.1586/era.10.231] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
High-dose chemotherapy (HDCT) with autologous stem cell support has been studied in both the salvage and first-line setting in advanced germ cell tumor (GCT) patients with poor-risk features. While early studies reported significant treatment-related mortality, introduction of peripheral blood stem cell transplantation, recombinant growth factors and better supportive care have decreased toxicity; and in more recent reports treatment-related deaths are observed in <3% of patients. Two to three cycles of high-dose carboplatin and etoposide is the standard backbone for HDCT, given with or without additional agents including ifosfamide, cyclophosphamide and paclitaxel. Three large randomized Phase III trials have failed to show a benefit of HDCT over conventional-dose chemotherapy (CDCT) in the first-line treatment of patients with intermediate- or poor-risk advanced GCT, and to date the routine use of HDCT has been reserved for the salvage setting. Several prognostic models have been developed to help predict outcome of salvage HDCT, the most recent of which applies to both CDCT and HDCT in the initial salvage setting. Patients that relapse after HDCT are usually considered incurable, and additional therapy is provided with palliative intent.
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Affiliation(s)
- Martin H Voss
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan–Kettering Cancer Center, NY 10065, USA
| | - Darren R Feldman
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan–Kettering Cancer Center, NY 10065, USA
| | - Robert J Motzer
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan–Kettering Cancer Center, NY 10065, USA
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262
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Feldman DR, Huddart R, Hall E, Beyer J, Powles T. Is high dose therapy superior to conventional dose therapy as initial treatment for relapsed germ cell tumors? The TIGER Trial. J Cancer 2011; 2:374-7. [PMID: 21750688 PMCID: PMC3133961 DOI: 10.7150/jca.2.374] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 06/15/2011] [Indexed: 11/05/2022] Open
Abstract
Metastatic germ cell tumours (GCTs) are usually cured with cisplatin based chemotherapy and standard treatment algorithms are established. However when this treatment fails and the disease relapses, standard treatment is much more uncertain. Both conventional dose therapy (CDT) and high dose therapy (HDT) are widely used, due to the lack of conclusive data supporting one specific approach. A recent retrospective analysis focusing on this population suggested a significant benefit for HDT. Retrospective analyses are prone to bias, and therefore while this data is provocative it is by no mean conclusive. For this reason the international community is supporting a prospective randomised trial in this area comparing CDT(TIP) with sequential HDT (TICE). The planned open labelled randomised phase III study (TIGER) is due to open in 2011 and will recruit 390 patients to detect a 13% difference in 2 year progression free survival (primary endpoint). It is hoped that this large study will conclusively resolve the uncertainty which currently exists.
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Affiliation(s)
- Darren R Feldman
- Genitourinary Oncology Service, Memorial Sloan-Kettering Cancer Center, New York USA
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263
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Salvage Chemotherapy With High-Dose Carboplatin and Etoposide With Peripheral Blood Stem Cell Transplant in Patients With Relapsed Pure Seminoma. Am J Clin Oncol 2011; 34:286-8. [PMID: 20523207 DOI: 10.1097/coc.0b013e3181d6b518] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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264
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Kesler KA, Kruter LE, Perkins SM, Rieger KM, Sullivan KJ, Runyan ML, Brown JW, Einhorn LH. Survival after resection for metastatic testicular nonseminomatous germ cell cancer to the lung or mediastinum. Ann Thorac Surg 2011; 91:1085-93; discussion 1093. [PMID: 21440128 DOI: 10.1016/j.athoracsur.2010.12.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 12/14/2010] [Accepted: 12/17/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since the advent of cisplatin-based chemotherapy, nonseminomatous germ cell tumors (NSGCT) have been considered one of the most curable solid neoplasms and a model for multimodality cancer therapy. We undertook an institutional review of testicular NSGCT patients who underwent operations to remove lung or mediastinal metastases after chemotherapy in the cisplatin era to determine outcomes. METHODS From 1980 to 2006, 431 patients underwent 640 postchemotherapy surgical procedures to remove lung (n = 159, 36.8%), mediastinal (n = 136, 31.6%), or both lung and mediastinal (n = 136, 31.6%) metastases within 2 years of chemotherapy. Multiple variables potentially predictive of survival were analyzed. RESULTS The overall median survival was 23.4 years, with 295 (68%) patients alive and well after an average follow-up of 5.6 years. There was no survival difference in patients who underwent removal of lung or mediastinal metastases. Pathologic categories of resected residual disease were necrosis (21.5%), teratoma (52.7%), persistent NSGCT (15.0%), and degenerative non-germ cell cancer (10.1%). Multivariable analysis identified older age at time of diagnosis (p = 0.001), non-germ cell cancer in testes specimen (p = 0.004), and pathology of residual disease (p < 0.001) as significantly predictive of survival. CONCLUSIONS Patients who undergo resection of residual lung or mediastinal disease for metastatic testicular NSGCT as a planned approach after cisplatin-based chemotherapy have overall excellent long-term survival. Survival is equivalent comparing hematogenous and lymphatic routes of metastases but depends on the pathology of the resected disease. These results justify an aggressive surgical approach, particularly to remove residual teratoma in the lung or mediastinum after chemotherapy, including multiple surgical procedures if necessary.
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Affiliation(s)
- Kenneth A Kesler
- Department of Surgery, Cardiothoracic Division, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana 46202, USA.
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265
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Abstract
Testicular germ cell tumors and, in particular, seminomas are exquisitely radiation and chemotherapy-sensitive and most presentations are highly curable. In recent years the management focus has been on reducing late sequelae of treatment. For Stage I disease surveillance and adjuvant carboplatin, chemotherapy has become an option. The efficacy of combination chemotherapy has been established for advanced metastatic disease. Through a review of the available literature this article outlines the recent changes in the management of seminoma.
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Affiliation(s)
- Emma J Alexander
- Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 5PT, United Kingdom
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266
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Khurana K, Gilligan TD, Stephenson AJ. Management of poor-prognosis testicular germ cell tumors. Indian J Urol 2011; 26:108-14. [PMID: 20535296 PMCID: PMC2878420 DOI: 10.4103/0970-1591.61228] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Currently, the outcome of patients with intermediate-and poor-risk germ cell tumors at diagnosis is optimized by the use of risk-appropriate chemotherapy and post-chemotherapy surgical resection of residual masses. Currently, there is no role for high-dose chemotherapy in the first-line setting. Patients who progress on first-line chemotherapy or who relapse after an initial complete response also have a poor prognosis. In the setting of early relapse, the standard approach at most centers is conventional-dose, ifosfamide-based regimens and post-chemotherapy resection of residual masses. The treatment of patients with late relapse is complete surgical resection whenever feasible. Salvage chemotherapy for late relapse may be used prior to surgery in patients where a complete resection is not feasible. A complete surgical resection of all residual sites of disease after chemotherapy is critical for the prevention of relapse and the long-term survival of patients with advanced germ cell tumors.
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Affiliation(s)
- Kiranpreet Khurana
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Department of Solid Tumor Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
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267
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De Giorgi U, Rosti G, Salvioni R, Papiani G, Ballardini M, Pizzocaro G, Marangolo M. Long-term outcome of salvage high-dose chemotherapy in patients with germ cell tumor with poor prognostic features. Urol Oncol 2011; 29:284-90. [DOI: 10.1016/j.urolonc.2009.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 03/16/2009] [Accepted: 03/31/2009] [Indexed: 12/01/2022]
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268
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Voss MH, Feldman DR, Bosl GJ, Motzer RJ. A review of second-line chemotherapy and prognostic models for disseminated germ cell tumors. Hematol Oncol Clin North Am 2011; 25:557-76, viii -ix. [PMID: 21570609 DOI: 10.1016/j.hoc.2011.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite an excellent prognosis even for patients with disseminated disease, about 20% to 30% of men with advanced germ cell tumors are refractory to first-line chemotherapy or experience disease recurrence after an initial remission with such treatment. Many of these are cured with conventional dose cisplatin/ifosfamide-based regimen or high-dose chemotherapy with stem cell rescue. Controversy exists regarding the optimal choice between these 2 second-line approaches, and available data for each is reviewed here. Clinical factors can help prognosticate patients, and recently an international effort developed a prognostic model for the second-line setting that can be universally applied in future studies.
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Affiliation(s)
- Martin H Voss
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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269
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Lorch A, Bascoul-Mollevi C, Kramar A, Einhorn L, Necchi A, Massard C, De Giorgi U, Fléchon A, Margolin K, Lotz JP, Germà-Lluch JR, Powles T, Kollmannsberger C, Beyer J. Conventional-dose versus high-dose chemotherapy as first salvage treatment in male patients with metastatic germ cell tumors: evidence from a large international database. J Clin Oncol 2011; 29:2178-84. [PMID: 21444870 DOI: 10.1200/jco.2010.32.6678] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Conventional-dose chemotherapy (CDCT) and high-dose chemotherapy (HDCT) may both be successfully used as salvage treatment for patients with metastatic germ cell tumors (GCTs) who experience progression with first-line treatment. PATIENTS AND METHODS Data on 1,984 patients with GCTs who experienced progression after at least three cisplatin-based cycles and were treated with either cisplatin-based CDCT or carboplatin-based HDCT chemotherapy were collected from 38 centers or groups worldwide. Of 1,984 patients, 1,594 (80%) were eligible, and among the eligible patients, 1,435 (90%) could reliably be classified into one of the following five prognostic categories based on prior prognostic classification: very low (n = 76), low (n = 257), intermediate (n = 646), high (n = 351), and very high risk (n = 105). Within each of the five categories, the progression-free survival (PFS) and overall survival (OS) after CDCT and HDCT were compared using the Cox model adjusted for significant distributional differences between important variables. RESULTS Overall, 773 patients received CDCT, and 821 patients received HDCT. Both treatment modalities were used with similar frequencies within each prognostic category. The hazard ratio for PFS was 0.44 (95% CI, 0.39 to 0.51) stratified on prognostic category, and the hazard ratio for OS was 0.65 (95% CI, 0.56 to 0.75), favoring HDCT. These results were consistent within each prognostic category except among low-risk patients, for whom similar OS was observed between the two treatment groups. CONCLUSION This retrospective analysis suggests a benefit from HDCT given as intensification of first salvage treatment in male patients with GCTs and emphasizes the need for another prospective randomized trial comparing CDCT to HDCT in this patient population.
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Affiliation(s)
- Anja Lorch
- University of Giessen and Marburg, Marburg, Germany
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270
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Kramer MW, Krege S, Peters I, Merseburger AS, Kuczyk MA. [Targeted therapy of urological tumours. Experimental field or established therapeutic approach?]. Urologe A 2011; 49:1260-5. [PMID: 20848076 DOI: 10.1007/s00120-010-2397-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Unlike conventional systemic chemotherapies, the aim of targeted therapeutic approaches is not to address general mechanisms involved in cellular replication. In contrast, they aim at such regulatory pathways that have been identified to be involved in the progression of human malignant disease. Whereas the application of targeted therapeutic modalities is well established for the treatment of metastatic renal cell cancer, only very few data on their clinical efficacy during the treatment of other urological tumours such as prostate and bladder cancer are currently available. The aim of this paper is to reflect on the current status regarding the relevance of targeted therapeutic approaches during the treatment of urological cancers of different origin.
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Affiliation(s)
- M W Kramer
- Klinik für Urologie und Urologische Onkologie, Medizinische Hochschule Hannover, Hannover
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271
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Pelus LM, Farag SS. Increased mobilization and yield of stem cells using plerixafor in combination with granulocyte-colony stimulating factor for the treatment of non-Hodgkin's lymphoma and multiple myeloma. STEM CELLS AND CLONING-ADVANCES AND APPLICATIONS 2011; 4:11-22. [PMID: 24198526 PMCID: PMC3781755 DOI: 10.2147/sccaa.s6713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple myeloma and non-Hodgkin’s lymphoma remain the most common indications for high-dose chemotherapy and autologous peripheral blood stem cell rescue. While a CD34+ cell dose of 1 × 106/kg is considered the minimum required for engraftment, higher CD34+ doses correlate with improved outcome. Numerous studies, however, support targeting a minimum CD34+ cell dose of 2.0 × 106/kg, and an “optimal” dose of 4 to 6 × 106/kg for a single transplant. Unfortunately, up to 40% of patients fail to mobilize an optimal CD34+ cell dose using myeloid growth factors alone. Plerixafor is a novel reversible inhibitor of CXCR4 that significantly increases the mobilization and collection of higher numbers of hematopoietic progenitor cells. Two randomized multi-center clinical trials in patients with non-Hodgkin’s lymphoma and multiple myeloma have demonstrated that the addition of plerixafor to granulocyte-colony stimulating factor increases the mobilization and yield of CD34+ cells in fewer apheresis days, which results in durable engraftment. This review summarizes the pharmacology and evidence for the clinical efficacy of plerixafor in mobilizing hematopoietic stem and progenitor cells, and discusses potential ways to utilize plerixafor in a cost-effective manner in patients with these diseases.
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Affiliation(s)
- Louis M Pelus
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana
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272
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Parkinson CA, Hatcher HM, Earl HM, Ajithkumar TV. Multidisciplinary management of malignant ovarian germ cell tumours. Gynecol Oncol 2011; 121:625-36. [PMID: 21353692 DOI: 10.1016/j.ygyno.2010.12.351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/17/2010] [Accepted: 12/19/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Malignant ovarian germ cell tumours (MOGCT) are rare cancers of young women. Limited prospective trials exist from which evidence-based management can be developed. This review summarizes the available literature concerning MOGT in order to provide the clinician with information relevant to their multidisciplinary management. METHODS MEDLINE was searched between 1966 and 2010 for all publications in English where the studied population included women diagnosed with malignant ovarian germ cell tumours. RESULTS The majority of patients can be cured with fertility-preserving surgery with or without combination chemotherapy. Long term survival approaches 100% in early stage disease and is approximately 75% in advanced stage disease. Most studies suggest that the treatment has little, if any, effect on future fertility and limited data suggest that there is no adverse effect on the future quality of life. CONCLUSION MOGCTs are rare tumours of young women the majority of which can be successfully treated with fertility-preserving surgery with or without chemotherapy with preservation of reproductive function. Minimisation of chemotherapy in good prognostic groups and improved treatment in resistant and relapsed MOGCT are important goals for the future. Further studies are needed to quantify the late adverse effects of treatment in long term survivors.
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Affiliation(s)
- C A Parkinson
- Medical Oncology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK.
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273
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Einhorn LH, Abonour R, Kesler KA. Paclitaxel Plus Ifosfamide Followed by High-Dose Carboplatin Plus Etoposide for Patients With Relapsed Primary Mediastinal Nonseminomatous Germ Cell Tumors: Benefit From Chemotherapy, Surgery, or Both? J Clin Oncol 2010; 28:e739; author reply e740. [DOI: 10.1200/jco.2010.30.4626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lawrence H. Einhorn
- Melvin and Bren Simon Cancer Center; and Lance Armstrong Foundation Chair in Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Rafat Abonour
- Melvin and Bren Simon Cancer Center, Indianapolis, IN
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Daugaard G, Skoneczna I, Aass N, De Wit R, De Santis M, Dumez H, Marreaud S, Collette L, Lluch JRG, Bokemeyer C, Schmoll HJ. A randomized phase III study comparing standard dose BEP with sequential high-dose cisplatin, etoposide, and ifosfamide (VIP) plus stem-cell support in males with poor-prognosis germ-cell cancer. An intergroup study of EORTC, GTCSG, and Grupo Germinal (EORTC 30974). Ann Oncol 2010; 22:1054-1061. [PMID: 21059637 DOI: 10.1093/annonc/mdq575] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To compare the efficacy of one cycle of standard dose cisplatin, etoposide, and ifosfamide (VIP) plus three cycles of high-dose VIP followed by stem-cell infusion [high-dose chemotherapy (HD-CT arm)] to four cycles of standard cisplatin, etoposide, and bleomycin (BEP) in patients with poor-prognosis germ-cell cancer (GCC). PATIENT AND METHODS Patients with poor-prognosis GCC were assigned to receive either BEP or VIP followed by HD-CT. To show a 15% improvement in a 1-year failure-free survival (FFS), the study aimed to recruit 222 patients but closed with 137, due to slow accrual. RESULTS One hundred thirty-one patients were included in this analysis. The complete response rates in the HD-CT and in the BEP arm did not differ: (intention to treat) 44.6% versus 33.3% (P = 0.18). There was no difference in FFS between the two treatment arms (P = 0.057, 66 events). At 2 years, the FFS rate was 44.8% [95% confidence interval (CI) 32.5-56.4] and 58.2%, respectively (95% CI 48.0-71.9); but this 16.3% (standard deviation 7.5%) difference was not statistically significant (P = 0.060). Overall survival did not differ between the two groups (log-rank P > 0.1, 47 deaths). CONCLUSION This study could not demonstrate that high-dose chemotherapy given as part of first-line therapy improves outcome in patients with poor-prognosis GCC.
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Affiliation(s)
- G Daugaard
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark.
| | - I Skoneczna
- Department of Urology, Chemotherapy Unit, Maria Sklodowska-Curie Memorial Center, Warsaw, Poland
| | - N Aass
- Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - R De Wit
- Department Medical Oncology, Erasmus University Hospital, Rotterdam, The Netherlands
| | - M De Santis
- LBI-ACR VIEnna and ACR-ITR VIEnna/CEADDP-Kaiser Franz Josef-Spital, Vienna, Austria
| | - H Dumez
- Department of Oncology, University Hospitals, Leuven, Belgium
| | - S Marreaud
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - L Collette
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - J R G Lluch
- Institut Català d'Oncologia, Htal. Duran i Reynals, Hòspitalet Barcelona, Barcelona, Spain
| | - C Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Cancer Center (UCCH), University Medical Center Hamburg Eppendorf, Hamburg
| | - H J Schmoll
- Department of Oncology and Hematology, Martin Luther University, Halle, Germany
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275
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Zynger DL, McCallum JC, Luan C, Chou PM, Yang XJ. Glypican 3 has a higher sensitivity than alpha-fetoprotein for testicular and ovarian yolk sac tumour: immunohistochemical investigation with analysis of histological growth patterns. Histopathology 2010; 56:750-7. [PMID: 20546340 DOI: 10.1111/j.1365-2559.2010.03553.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIMS Glypican 3 (GPC3) has been reported to be overexpressed in yolk sac tumour (YST), but the sensitivity has not been compared with alpha-fetoprotein (AFP). YST can form numerous growth patterns and the expression of GPC3 in these patterns has not been studied. The aim was to address these aspects. METHODS AND RESULTS Sections from testicular or ovarian YST were subjected to immunohistochemistry using GPC3 (n = 39) and AFP (n = 24). Overall immunoreactivity for each case and specific histological patterns were semiquantitatively evaluated (0-3+) and intensity of reactivity was scored (0-3). All cases expressed GPC3 (1+, 5%; 2+, 8%; 3+, 87%) with strong intensity (2.9). The majority expressed AFP (58%) but immunoreactivity was often focal (0, 42%; 1+, 33%; 2+, 25%) and intensity was low (1.0). Using GPC3, >75% of the microcystic (n = 38), macrocystic (n = 26), solid (n = 21), glandular-alveolar (n = 8), endodermal sinus (n = 7), polyvesicular vitelline (n = 5), enteric (n = 4) and micropapillary (n = 2) growth patterns displayed 2+ or 3+ positivity. CONCLUSIONS YST can display a variety of growth patterns that can be confused with other germ cell tumour components. GPC3 detects all growth patterns tested and has a higher sensitivity for detecting YST than AFP.
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Affiliation(s)
- Debra L Zynger
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH, USA
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276
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Seftel MD, Paulson K, Doocey R, Song K, Czaykowski P, Coppin C, Forrest D, Hogge D, Kollmansberger C, Smith CA, Shepherd JD, Toze CL, Murray N, Sutherland H, Nantel S, Nevill TJ, Barnett MJ. Long-term follow-up of patients undergoing auto-SCT for advanced germ cell tumour: a multicentre cohort study. Bone Marrow Transplant 2010; 46:852-7. [PMID: 21042312 DOI: 10.1038/bmt.2010.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Failure of cisplatin-based chemotherapy in advanced germ cell tumour (GCT) is associated with a poor outcome. High-dose chemotherapy and auto-SCT is one therapeutic option, although the long-term outcome after this procedure is unclear. We conducted a multicentre cohort study of consecutive patients undergoing a single auto-SCT for GCT between January 1986 and December 2004. Of 71 subjects, median follow-up is 10.1 years. OS at 5 years is 44.7% (95% confidence interval (CI) 32.9-56.5%) and EFS is 43.5% (95% CI 31.4-55.1%). There were seven (10%) treatment-related deaths within 100 days of auto-SCT. Three (4.2%) patients developed secondary malignancies. Of 33 relapses, 31 occurred within 2 years of auto-SCT. Two very late relapses were noted 13 and 11 years after auto-SCT. In multivariate analysis, favourable outcome was associated with IGCCC (International Germ Cell Consensus Classification) good prognosis disease at diagnosis, primary gonadal disease and response to salvage chemotherapy. We conclude that auto-SCT results in successful outcome for a relatively large subgroup of patients with high-risk GCT. Late relapses may occur, a finding not previously reported.
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Affiliation(s)
- M D Seftel
- Section of Medical Oncology/Hematology, University of Manitoba, Canada.
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Lorch A, Beyer J, Bascoul-Mollevi C, Kramar A, Einhorn LH, Necchi A, Massard C, De Giorgi U, Fléchon A, Margolin KA, Lotz JP, Germa Lluch JR, Powles T, Kollmannsberger CK. Prognostic factors in patients with metastatic germ cell tumors who experienced treatment failure with cisplatin-based first-line chemotherapy. J Clin Oncol 2010; 28:4906-11. [PMID: 20956623 DOI: 10.1200/jco.2009.26.8128] [Citation(s) in RCA: 197] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To develop a prognostic model in patients with germ cell tumors (GCT) who experience treatment failure with cisplatin-based first-line chemotherapy. PATIENTS AND METHODS Data from 1,984 patients with GCT who progressed after at least three cisplatin-based cycles and were treated with cisplatin-based conventional-dose or carboplatin-based high-dose salvage chemotherapy was retrospectively collected from 38 centers/groups worldwide. One thousand five hundred ninety-four (80%) of 1,984 eligible patients were randomly divided into a training set of 1,067 patients (67%) and a validation set of 527 patients (33%). Seminomas were set aside for posthoc analyses. Primary end point was the 2-year progression-free survival after salvage treatment. RESULTS Overall, 990 patients (62%) relapsed and 604 patients (38%) remained relapse free. Histology, primary tumor location, response, and progression-free interval after first-line treatment, as well as levels of alpha fetoprotein, human chorionic gonadotrophin, and the presence of liver, bone, or brain metastases at salvage were identified as independent prognostic variables and used to build a prognostic model in the training set. Survival rates in the training and validation set were very similar. The estimated 2-year progression-free survival rates in patients not included in the training set was 75% in very low risk, 51% in low risk, 40% in intermediate risk, 26% in high risk, and only 6% in very high-risk patients. Due to missing values in individual variables, 69 patients could not reliably be classified into one of these categories. CONCLUSION Prognostic variables are important in patients with GCT who experienced treatment failure with cisplatin-based first-line chemotherapy and can be used to construct a prognostic model to guide salvage strategies.
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Affiliation(s)
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- Philipps-University Marburg, Marburg, Germany
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279
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Ehrlich Y, Beck SDW, Foster RS, Bihrle R, Einhorn LH. Serum tumor markers in testicular cancer. Urol Oncol 2010; 31:17-23. [PMID: 20822927 DOI: 10.1016/j.urolonc.2010.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 10/19/2022]
Abstract
Testicular cancer has become a model for a curable neoplasm, where biochemical markers play a critical role. Serum tumor markers are integral in patient management and contributes to the diagnosis, staging, and risk assessment, as well as evaluation of response to therapy and detection of relapse. We review their biochemistry, biology, and clinical use in the setting of localized and metastatic disease. The integration of tumor markers in prognostic models as well as the significance of marker kinetics during chemotherapy is discussed.
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Affiliation(s)
- Yaron Ehrlich
- Department of Urology, School of Medicine, Melvin and Bren Simon Cancer Center, Indianapolis, IN 46292, USA.
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280
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Wood L, Kollmannsberger C, Jewett M, Chung P, Hotte S, O'Malley M, Sweet J, Anson-Cartwright L, Winquist E, North S, Tyldesley S, Sturgeon J, Gospodarowicz M, Segal R, Cheng T, Venner P, Moore M, Albers P, Huddart R, Nichols C, Warde P. Canadian consensus guidelines for the management of testicular germ cell cancer. Can Urol Assoc J 2010; 4:e19-38. [PMID: 20368885 PMCID: PMC2845668 DOI: 10.5489/cuaj.815] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lori Wood
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS
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Gallagher DJ, Riches J, Bajorin DF. False elevation of human chorionic gonadotropin in a patient with testicular cancer. Nat Rev Urol 2010; 7:230-3. [DOI: 10.1038/nrurol.2010.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Feldman DR, Sheinfeld J, Bajorin DF, Fischer P, Turkula S, Ishill N, Patil S, Bains M, Reich LM, Bosl GJ, Motzer RJ. TI-CE high-dose chemotherapy for patients with previously treated germ cell tumors: results and prognostic factor analysis. J Clin Oncol 2010. [PMID: 20194867 DOI: 10.1200/jco.2009.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We previously reported a dose-finding and phase II trial of the TI-CE regimen (paclitaxel [T] plus ifosfamide [I] followed by high-dose carboplatin [C] plus etoposide [E] with stem-cell support) in germ cell tumor (GCT) patients predicted to have a poor prognosis with conventional-dose salvage therapy. We now report the efficacy of TI-CE with prognostic factors for disease-free survival (DFS) and overall survival (OS) in our full data set of 107 patients. PATIENTS AND METHODS Eligible patients had advanced GCTs with progressive disease following chemotherapy and unfavorable prognostic features (extragonadal primary site, incomplete response [IR] to first-line therapy, or relapse/IR to ifosfamide-cisplatin-based conventional-dose salvage). Univariate and multivariate analyses (MVAs) of prognostic factors were performed. The predictive ability of the Einhorn and Beyer prognostic models was assessed. RESULTS Most patients were platinum refractory and had an IR to first-line chemotherapy. There were 54 (5%) complete and eight (8%) partial responses with negative markers; 5-year DFS was 47% and OS was 52% (median follow-up, 61 months). No relapses occurred after 2 years. Five (24%) of 21 primary mediastinal nonseminomatous GCTs are continuously disease free. On MVA, primary mediastinal site (P < .001), two or more lines of prior therapy (P < .001), baseline human chorionic gonadotropin > or = 1,000 U/L (P = .01), and lung metastases (P = .02) significantly predicted adverse DFS. Poor-risk patients did worse than good- or intermediate-risk patients according to both Beyer (P < .002) and Einhorn (P < .05) models. CONCLUSION TI-CE is effective salvage therapy for GCT patients with poor prognostic features. Mediastinal primary site and two or more lines of prior therapy were most predictive of adverse DFS. Beyer and Einhorn models can assist in predicting outcome.
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Affiliation(s)
- Darren R Feldman
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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283
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Feldman DR, Sheinfeld J, Bajorin DF, Fischer P, Turkula S, Ishill N, Patil S, Bains M, Reich LM, Bosl GJ, Motzer RJ. TI-CE high-dose chemotherapy for patients with previously treated germ cell tumors: results and prognostic factor analysis. J Clin Oncol 2010; 28:1706-13. [PMID: 20194867 DOI: 10.1200/jco.2009.25.1561] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We previously reported a dose-finding and phase II trial of the TI-CE regimen (paclitaxel [T] plus ifosfamide [I] followed by high-dose carboplatin [C] plus etoposide [E] with stem-cell support) in germ cell tumor (GCT) patients predicted to have a poor prognosis with conventional-dose salvage therapy. We now report the efficacy of TI-CE with prognostic factors for disease-free survival (DFS) and overall survival (OS) in our full data set of 107 patients. PATIENTS AND METHODS Eligible patients had advanced GCTs with progressive disease following chemotherapy and unfavorable prognostic features (extragonadal primary site, incomplete response [IR] to first-line therapy, or relapse/IR to ifosfamide-cisplatin-based conventional-dose salvage). Univariate and multivariate analyses (MVAs) of prognostic factors were performed. The predictive ability of the Einhorn and Beyer prognostic models was assessed. RESULTS Most patients were platinum refractory and had an IR to first-line chemotherapy. There were 54 (5%) complete and eight (8%) partial responses with negative markers; 5-year DFS was 47% and OS was 52% (median follow-up, 61 months). No relapses occurred after 2 years. Five (24%) of 21 primary mediastinal nonseminomatous GCTs are continuously disease free. On MVA, primary mediastinal site (P < .001), two or more lines of prior therapy (P < .001), baseline human chorionic gonadotropin > or = 1,000 U/L (P = .01), and lung metastases (P = .02) significantly predicted adverse DFS. Poor-risk patients did worse than good- or intermediate-risk patients according to both Beyer (P < .002) and Einhorn (P < .05) models. CONCLUSION TI-CE is effective salvage therapy for GCT patients with poor prognostic features. Mediastinal primary site and two or more lines of prior therapy were most predictive of adverse DFS. Beyer and Einhorn models can assist in predicting outcome.
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Affiliation(s)
- Darren R Feldman
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Karadimou A, Dimopoulos MA, Bamias A. The role of high-dose chemotherapy in the treatment of testicular cancer. Open Access J Urol 2010; 2:25-30. [PMID: 24198610 PMCID: PMC3818874 DOI: 10.2147/rru.s6571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Testicular cancer is a highly curable neoplasm, even in the case of extragonadal disease. Nevertheless, patients with adverse prognostic features or relapsing after first-line cisplatin-based chemotherapy have a worse prognosis with a death rate greater than 50%. High-dose chemotherapy (HDC) has long been used in this group of patients. The introduction of stem cells, instead of bone marrow, as the source of hemopoietic cells and the use of leukocyte growth factors have substantially reduced the mortality and morbidity of this procedure although the role of HDC is not well defined. This review summarizes the available data, focusing on published randomized studies. The problems associated with the design of these studies and the interpretation of data are discussed. Currently this HDC approach is mainly used in patients who relapse after first-line chemotherapy. Nevertheless, selection of patients likely to benefit from this treatment remains an issue of intense clinical research.
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Affiliation(s)
- Alexandra Karadimou
- Dept of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
| | | | - Aristotle Bamias
- Dept of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
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285
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Kawai K, Akaza H. Current status of chemotherapy in risk-adapted management for metastatic testicular germ cell cancer. Cancer Sci 2010; 101:22-8. [PMID: 19922501 PMCID: PMC11159163 DOI: 10.1111/j.1349-7006.2009.01373.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Today, approximately 80% of men with metastatic testicular cancer can be cured with chemotherapy combined with the appropriate surgery. The improved treatment outcome has led to the stratification of patients with metastatic disease by the consensus prognostic index; the International Germ Cell Cancer Consensus Group classification. Currently, the first-line chemotherapy with bleomycin, etoposide, and cisplatin (BEP) remains the standard management of metastatic testicular cancer. Three cycles of BEP for good-prognosis patients and four cycles of BEP for intermediate- and poor-prognosis patients are the standard first-line chemotherapy. To achieve the optimal outcome, BEP should be given with appropriate supportive care and risk assessment for toxicity. Although no universal prognostic criteria have been defined for the recurrent or refractory disease, the risk-adapted approach may clarify the role of ifosfamide- and paclitaxel-containing conventional-dose chemotherapy or high-dose chemotherapy in the second-line setting. Several investigators reported recent improvement of treatment outcome of testicular cancer patients, especially those with poor prognosis. Along with the progress in chemotherapy, the risk-adapted management at experienced hospitals seems to be responsible for the recent progress in treatment outcome.
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Affiliation(s)
- Koji Kawai
- Department of Urology, Institute of Clinical Medicine, University of Tsukuba Graduate School of Comprehensive Human Sciences, Tsukuba, Ibaraki, Japan.
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286
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Nguyen CT, Fu AZ, Gilligan TD, Wells BJ, Klein EA, Kattan MW, Stephenson AJ. Defining the Optimal Treatment for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer Using Decision Analysis. J Clin Oncol 2010; 28:119-25. [DOI: 10.1200/jco.2009.22.0400] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeThere is equipoise regarding the optimal treatment of clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT). Formal mechanisms that enable patients to consider cancer outcomes, treatment-related morbidity, and personal preferences are needed to facilitate decision making between retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and surveillance.MethodsDecision analysis was performed using a Markov model that incorporated likelihoods of survival, treatment-related morbidity, and utilities for seven undesired post-treatment health states to estimate the quality-adjusted survival (QAS) for each treatment option. Utilities were obtained from 24 hypothetical NSGCT patients using a visual analog (rating) scale and standard gamble.ResultsOverall, QAS associated with each treatment was high and differences in QAS were small. Surveillance was the preferred intervention for patients with a risk of relapse less than 33% and 37% using the rating scale and standard-gamble method of utility assessment, respectively. Active treatment was favored over surveillance for patients with relapse risk on surveillance greater than 33% and 37% by the rating scale (RPLND preferred) and standard-gamble methods (primary chemotherapy preferred), respectively. Substantial differences in average utilities were seen depending on the method used. By the rating scale, patients substantially devalued life in six of seven undesired health states but they were surprisingly tolerant of treatment-related morbidity using standard gamble.ConclusionA decision model has been developed for CS I NSGCT that estimates QAS for RPLND, primary chemotherapy, and surveillance by considering cancer outcomes, morbidity, and patient preferences. Surveillance was the preferred intervention for all except those patients at high risk for relapse.
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Affiliation(s)
- Carvell T. Nguyen
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Alex Z. Fu
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Timothy D. Gilligan
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Brian J. Wells
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Eric A. Klein
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Michael W. Kattan
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Andrew J. Stephenson
- From the Glickman Urological and Kidney Institute, Department of Quantitative Health Sciences, and Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
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287
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Incidental CNS involvement of testicular germ cell cancer: a growing trend? Radiother Oncol 2009; 93:654-6. [DOI: 10.1016/j.radonc.2009.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 04/26/2009] [Indexed: 11/21/2022]
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288
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289
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Kollmannsberger C, Beyer J, Bokemeyer C. High-dose chemotherapy in nonseminomatous germ cell cancer. BJU Int 2009; 104:1398-403. [DOI: 10.1111/j.1464-410x.2009.08866.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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290
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Lorch A, Neubauer A, Hackenthal M, Dieing A, Hartmann JT, Rick O, Bokemeyer C, Beyer J. High-dose chemotherapy (HDCT) as second-salvage treatment in patients with multiple relapsed or refractory germ-cell tumors. Ann Oncol 2009; 21:820-825. [PMID: 19822531 DOI: 10.1093/annonc/mdp366] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Survival after high-dose chemotherapy (HDCT) as second-salvage treatment (SST) in multiple relapsed germ-cell tumors (GCTs). PATIENTS AND METHODS Existing databases in Berlin and Marburg of HDCT trials from 1989 to 2008 were retrospectively screened. Among 534 patients, 71 of 534 (13%) patients were scheduled for HDCT having failed previous conventional-dose first-line and first-salvage chemotherapy regimens; those 49 patients who had received at least cisplatin plus etoposide first-line as well as conventional-dose cisplatin-based first-salvage regimens and were diagnosed after 1 January 1990 were further analyzed. RESULTS Median age at SST was 32 years (range 19-52 years). Median follow-up for surviving patients was 4 years (range 1.7-8.5 years). Three of 49 (6%) patients either progressed or died before scheduled HDCT; the remaining 46 of 49 (94%) received either single or sequential HDCT. The rate of favorable responses to HDCT was 27 of 49 (55%). Nine patients remain alive and free of progression. One additional patient was lost to follow without progression at 4 years. The projected overall survival rate at 5 years was 17% (95% confidence intervals 7% to 30%). CONCLUSION HDCT can induce remissions in patients with multiple relapsed GCTs with a long-term survival rate of approximately 17%.
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Affiliation(s)
- A Lorch
- Departments of Hematology and Oncology, Universitätsklinikum Giessen und Marburg GmbH, Marburg
| | - A Neubauer
- Departments of Hematology and Oncology, Universitätsklinikum Giessen und Marburg GmbH, Marburg
| | - M Hackenthal
- Departments of Hematology and Oncology, Vivantes Klinikum Am Urban, Berlin
| | - A Dieing
- Departments of Hematology and Oncology, Charite Campus Mitte, Berlin
| | - J T Hartmann
- Departments of Hematology and Oncology, South West German Comprehensive Cancer Center, Tübingen
| | - O Rick
- Departments of Hematology and Oncology, Klinik Reinhardshöhe, Bad Wildungen
| | - C Bokemeyer
- Departments of Oncology, Hematology and BMT with section Pneumology, Hubertus Wald Tumorzentrum - UCCH University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - J Beyer
- Departments of Hematology and Oncology, Vivantes Klinikum Am Urban, Berlin.
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291
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Salvioni R, Nicolai N, Necchi A, Torelli T, Piva L, Stagni S, Catanzaro MA, Biasoni D, Milani A. State of the Art and Controversies in the Treatment of Testis Germ-Cell Tumors (TGT). Urologia 2009. [DOI: 10.1177/039156030907600401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many different, intersecting strategies are available for managing germ-cell cancers, particularly in early-stage disease. Which is ‘right’ remains a matter of debate, and requires balancing efficacy against late effects, bearing in mind the complexity of treatment strategies and the available expertise.
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Affiliation(s)
- R. Salvioni
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - N. Nicolai
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - A. Necchi
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - T. Torelli
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - L. Piva
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - S. Stagni
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - M. A. Catanzaro
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - D. Biasoni
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
| | - A. Milani
- SC di Chirurgia Urologica, Fondazione IRCCS Istituto Tumori, Milano
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292
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Affiliation(s)
- H-J Schmoll
- Department of Oncology/Haematology/Haemostaseology, University Hospital Halle, Halle, Germany
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293
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Hentrich M, Schiel X, Niedermeier A, Lutz L, Rupec R, Stief C, Bogner J, Karthaus M, Gerl A. Successful salvage high-dose chemotherapy and autologous stem-cell transplantation in HIV-related germ-cell tumor. Ann Oncol 2009; 20:1900-1. [PMID: 19748902 DOI: 10.1093/annonc/mdp448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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294
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Ljungman P, Bregni M, Brune M, Cornelissen J, Witte TD, Dini G, Einsele H, Gaspar HB, Gratwohl A, Passweg J, Peters C, Rocha V, Saccardi R, Schouten H, Sureda A, Tichelli A, Velardi A, Niederwieser D. Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe 2009. Bone Marrow Transplant 2009; 45:219-34. [PMID: 19584824 DOI: 10.1038/bmt.2009.141] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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295
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Gemcitabine Plus Vinorelbine as an Effective Salvage Chemotherapeutic Regimen in Cisplatin-Refractory Germ Cell Tumor. South Med J 2009; 102:546-8. [DOI: 10.1097/smj.0b013e3181a0ae6a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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296
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Connolly RM, McCaffrey JA. High-dose chemotherapy plus stem cell transplantation in advanced germ cell cancer: a review. Eur Urol 2009; 56:57-64. [PMID: 19303697 DOI: 10.1016/j.eururo.2009.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Accepted: 03/03/2009] [Indexed: 11/30/2022]
Abstract
CONTEXT High-dose chemotherapy (HDCT) with stem cell transplantation (SCT) has been investigated as a treatment strategy for advanced germ cell cancer (GCC) for >2 decades. In an effort to improve on the overall cure rates of 80% achievable with conventional chemotherapy, researchers have investigated this therapeutic option as a first-line therapy for those with poor-prognosis disease and as a salvage therapy for those with relapsed or refractory disease. OBJECTIVE The primary objective of this review is to define the role of HDCT plus SCT in advanced GCC. Prognostic indicators for this group of patients are also presented. EVIDENCE ACQUISITION A Medline search of English-language literature was performed to identify studies published in the last 20 yr relating to the use of HDCT plus SCT in advanced GCC. Phase 1, phase 2, and phase 3 trials were included, as were retrospective reviews and meta-analyses. EVIDENCE SYNTHESIS Phase 2 trials investigating HDCT plus SCT as a therapeutic option for advanced germ cell cancer have indicated a survival advantage over conventional chemotherapy. This has not been confirmed in the phase 3 setting. Alternative chemotherapeutic strategies and options following failure of HDCT plus SCT are discussed. CONCLUSIONS Studies to date have not indicated a survival advantage for the use of HDCT plus SCT in advanced germ cell cancer. Many questions, however, remain unanswered, and further research is required to identify whether optimising the strategy of HDCT plus SCT will improve outcome in this predominantly young group of patients.
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Affiliation(s)
- Roisin M Connolly
- Sidney Kimmel Comprehensive Cancer Centre, Johns Hopkins School of Medicine, 1650 Orleans Street, CRB 1, Room 186, Baltimore, MD 21231-1000, USA.
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297
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[Salvage treatment in germ cell tumors : high-dose chemotherapy and the impact of prognostic factors]. Urologe A 2009; 48:364-71. [PMID: 19255738 DOI: 10.1007/s00120-009-1947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The majority of patients with germ cell tumors who fail first-line treatment will still be cured. Patients without first-line chemotherapy who fail surveillance, radiotherapy, or surgery will be managed according to the treatment algorithms of their primary metastatic disease. These patients usually receive three to four cycles of cisplatin, etoposide, and bleomycin.Salvage treatment of patients who relapse after first-line chemotherapy is more complex and requires an experienced and highly specialized team. Two distinct treatment strategies can be pursued: four cycles of conventional-dose chemotherapy with cisplatin, ifosfamide, and either etoposide, paclitaxel, or vinblastine; or early intensification of first-salvage treatment using sequential high-dose chemotherapy. Salvage surgery is frequently required after completion of salvage chemotherapy to completely resect all radiologic residual manifestations. Patients with brain metastases should receive upfront whole brain radiation concurrent with salvage chemotherapy. Patients with late relapses more than 2 years after first-line treatment should receive immediate salvage surgery whenever this is technically feasible.
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298
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Telekes A. Off-label therapies in oncology. Orv Hetil 2009; 150:363-72. [DOI: 10.1556/oh.2009.28522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Az indikáción kívüli (off-label) kezelések speciális problémát jelentenek az onkológiában, mivel a jogi szabályozás és a szabad orvosi gyakorlat határterületén állnak. Bár Magyarországon az off-label kezelés a 2008. október végén életbe léptetett rendelet megjelenéséig engedély nélküli klinikai vizsgálatnak minősült, egyes szakemberek mégis azzal érveltek alkalmazása mellett, hogy a klinikai gyakorlat gyorsabban változik, mint az alkalmazási előirat. Mi több, a gyártók még megfelelő evidencia esetén sem kötelesek az indikáció bővítésére. Az off-label kezelések szabályozása egyaránt meg kell hogy feleljen a szabad orvosi gyakorlatnak, az evidencián alapuló medicinának, a betegek új esélyekhez való igényének és a hatóságok elvárásainak. A közleményben a hazai helyzet és a törvény bírálata, illetve a nemzetközi gyakorlat áttekintése után egy, a fenti szempontoknak megfelelő lehetséges szabályozás kereteit vázolja a szerző, külön-külön kifejtve a kezelőorvos és a hatóságok szerepét.
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Affiliation(s)
- András Telekes
- 1 Országos Onkológiai Intézet (2009. január 1-jétől: Bajcsy-Zsilinszky Kórház és Rendelőintézet) III. Belgyógyászati Ambulancia (2009. január 1-jétől: Onkológiai Osztály) 1106 Budapest Maglódi u. 89–91
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299
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Vaughan W, Seshadri T, Bridges M, Keating A. The principles and overview of autologous hematopoietic stem cell transplantation. Cancer Treat Res 2009; 144:23-45. [PMID: 19779877 DOI: 10.1007/978-0-387-78580-6_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- William Vaughan
- University of Alabama Bone Marrow Transplantation Program, University of Alabama Comprehensive Cancer Center, Birmingham, AL, USA.
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300
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Abstract
Use of a drug outside the terms of its official labelling is referred to as off-label prescription. Many categories of use exist because labelling of anticancer agents is very precise in terms of type or subtype of tumour, association, line, and duration of treatment. Off-label prescription of anticancer drugs is thought to be frequent but, in fact, very few surveys have been done to ascertain its real extent. Findings of prospective studies undertaken between 1990 and 2002 showed proportions of off-label drug use in children and adults of 6.7-33.2%. Most off-label prescription was reported in patients treated with palliative intent, some was associated with clinical benefits, and in specific cancers it formed the standard of care. Off-label use can lead to reimbursement restrictions. Regulatory agencies have created incentives to extend indications for approved drugs to remove them from the off-label area. Proposals have also been made to gather and disseminate accurate and unbiased information on off-label use and to record unapproved indications.
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Affiliation(s)
- Dominique Levêque
- Department of Pharmacy-Pharmacology, Hôpitaux Universitaires de Strasbourg, Hôpital Hautepierre, 67000 Strasbourg, France
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