Successful treatment of good-risk disseminated testicular cancer with cisplatin, bleomycin, and reduced-dose vinblastine

A Serial Analysis of Gene Expression (SAGE) database analysis of chemosensitivity: comparing solid tumors with cell lines and comparing solid tumors from different tissue origins

Drug sensitivity and resistance has been most extensively studied in cell lines carried in tissue culture. Furthermore, cell lines have been widely used in testing new anticancer agents, despite the widely recognized observation that cell lines are more sensitive to cytotoxic drugs than are their corresponding solid tumors. We used the Serial Analysis of Gene Expression (SAGE) database to identify differences between solid tumors and cell lines, hoping to detect genes that could potentially explain differences in drug sensitivity. SAGE libraries were available for both solid tumors and cell lines from breast, colon, ovarian, pancreatic, and prostate carcinomas and from gliomas and medulloblastomas. Sixty-two genes were identified as overexpressed in tumors. The immune response and complement pathways were the significant common themes, with extracellular matrix (ECM) proteins third. For the 61 genes overexpressed in cell lines, protein synthesis was the dominant theme. We next used the SAGE database to identify genetic differences between tumor types that convey a broad range of survival to the patients that bear them as distant metastases. SAGE gene expression data were correlated with 5-year survivals documented in the SEER (Surveillance, Epidemiology and End-Results) database for patients diagnosed with "distant" or metastatic cancers. These are unlikely to be amenable to surgical resection; therefore, survival here reflects, to some extent, sensitivity to systemic therapy, i.e., chemotherapy. Using survival data as a surrogate of chemotherapy sensitivity, a spectrum can be generated, with testicular cancer at one end and pancreatic cancer at the other. Favorable 5-year survival, despite a distant presentation, correlates with expression of protein synthesis genes. Poor 5-year survival correlates with expression of cell adhesion, cytoskeletal, and ECM genes, a pattern similar to that found to distinguish solid tumors from the more cytotoxin-sensitive cancer cell lines. One interpretation is that resistance to chemotherapy may arise, in part, from the adherent, relatively inert condition (i.e., low in protein synthesis potential) of refractory cancers. Thus, attachment or ECM genes could be targets for anticancer therapy.

Teratomas in infancy and childhood

BACKGROUND AND PROCEDURE

Outcomes in children with teratomas collected between October 1982 and December 1995 in cooperative protocols of the German Society of Pediatric Oncology and Hematology (GPOH) were analyzed. Teratomas were diagnosed in 329 (42%) of 780 registered patients with germ cell tumors. The annual incidence was 0.24/100,000. Main primary sites were coccygeal (n = 132, 2.2:1 female predominance), ovary (n = 81), testis (n = 40) and brain (n = 15, 2.8:1 male predominance).

RESULTS

Two hundred seventy cases of extracranial non-testicular teratoma were evaluated: In mature teratomas (n = 154) the observed relapse rate was 10%. Incomplete resection was the main risk factor for relapse. After complete resection, the relapse-free survival (RFS, Kaplan-Meier-estimation) was 0.96 +/- 0.01 (n = 126, observation time 18-155 months) in comparison to an RFS of 0.56 +/- 0.09 in incompletely resected teratomas grade 0 (n = 28, observation time 28-94 months) (P < 0.01). Im-mature teratomas were treated by surgery alone in 76 cases and by surgery and adjuvant chemotherapy in 40 cases. The observed relapse risk was 18%. Main risk factors for relapse were incomplete tumor resection (n = 38) as well as immaturity in incompletely resected teratomas. Fifteen of 29 relapsing patients presented with malignant tissue in the recurrent tumor (mainly yolk sac tumor); in contrast, seven of 40 patients with immature teratoma relapsed despite adjuvant chemotherapy without showing malignant components (P = 0.014). Nine of 36 (25%) relapsing patients died of disease. Eleven of the 27 (41%) surviving children suffered from mutilation after repeated surgery.

COMMENTS

It is suggested that an international randomized trial for patients with incompletely resected high risk teratoma be initiated to evaluate the effect of adjuvant chemotherapy on specific end-points: 1) influence on relapse rate in general; 2) reduction of the proportion of malignant relapses; 3) avoidance of mutilating surgery.

Modified cisplatin, etoposide (or vinblastine) and ifosfamide salvage therapy for male germ-cell tumors. Long-term results

Between 1985 and 1989, 36 consecutive male patients with advanced germ-cell tumors, who had failed to be cured with either the cisplatin, vinblastine, bleomycin (PVB) or the cisplatin, etoposide, bleomycin (PEB) combinations, entered either of two modified salvage therapy regimens consisting of cisplatin, etoposide, and ifosfamide (PEI) or cisplatin, vinblastine and ifosfamide (PVI). All patients had evidence of active disease. Ifosfamide was given at the dosage of 2.5 gr/m2 (with mesna protection) on days 1 and 2; etoposide and cisplatin were given at the dosage of 100 mg/m2 and 40 mg/m2, respectively, on days 3 to 5. In the PVI schedule, vinblastine 6 mg/m2 was given on day 3. Overall, 20 (56%, C.I. 39 to 72) patients entered complete response (CR) or achieved disease-free status (NED) with post-chemotherapy surgery. After a follow-up of 2 to 7 years, 15 patients (42%, C.I. 24 to 58) remain alive and free of disease. None of the 9 patients unresponsive to the first-line therapy and/or with extragonadal primaries entered CR or achieved the NED status, versus 20 (74%, C.I. 58 to 91) of the 27 patients with primary testicular tumors who were responsive to the first-line therapy (p less than 0.001). PEI was used in 20 of these 27 patients, with excellent results (90% CR and 70% continuously NED) independently of primary therapy, PVB or PEB. By contrast, only 2 of the 7 patients treated with PVI following PEB entered CR. Toxicity was not life-threatening. Nine (25%) patients suffered granulocytopenic fever and 3 (8%) required platelet transfusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in metastatic testicular cancer

The prognosis for metastatic testicular cancer has been analysed in seven reports using multivariate analysis. Serum hCG is the most important factor. Volume of metastases, serum LDH and serum AFP are also of prognostic value. Bone, liver, nodal or retroperitoneal metastases are not independent prognostic factors. The prognosis for extragonadal nonseminomas remains in dispute. Future studies should categorize poor prognosis patients using one of the several available prognostic formulas. No consensus yet exists on optimal treatment for such patients.

Retroperitoneal lymph node dissection in clinical stage IIA and IIB nonseminomatous germ cell tumours of the testis

From 1980 to 1984 inclusive, ninety-one consecutive evaluable patients underwent primary retroperitoneal lymphadenectomy for clinical stage IIA or IIB nonseminomatous germinal testicular cancer. Nodes were negative in twenty cases (22%), and forty-seven patients (52%) were treated with chemotherapy either postoperatively (thirty clinically understaged patients) or at relapse (seventeen cases). After a median follow-up period of nearly 5 years (range 18-78 months) the disease-free survival was 98%. None of thirty patients with radiographic abnormalities greater than or equal to 3 cm in the retroperitoneal nodes had negative histology, and twenty-two (73%) were treated with chemotherapy. Preoperative serum levels of AFP and hCG were not useful in selecting patients with positive nodes. Primary chemotherapy is now used in patients with radiographic evidence of retroperitoneal metastases greater than or equal to 3 cm.

Cisplatin combination chemotherapy in advanced seminoma

Thirty-one patients were treated with cisplatin combination chemotherapy for advanced seminoma (26 Stage III or bulky Stage II testicular, and five disseminated extragonadal). Seventeen (89%) of 19 patients not previously pretreated and four (80%) of five who had received only abdominal irradiation entered continuous complete remission (CR), versus only two (28%) of seven patients who had received extensive infra- and supradiaphragmatic radiotherapy. Results were not significantly influenced by stage, human chorionic gonadotropin (HCG) titers and histologic subgroups, whereas patients with lactic dehydrogenase (LDH) values exceeding 500 mIU/ml did worse (50% continuous CR rate in 12 cases) than those with normal or less elevated titers (89% continuous CR rate in 19 cases). After a median follow-up period of 34 months (range, 12+ to 77+ months), 23 patients (74.5%) remain alive in continuous CR, two (6%) died in CR and another one (3%) entered CR after deferred treatment of residual disease. Five patients (16%) died of cancer. Toxicity was severe in extensively irradiated patients, but it was acceptable in those not pretreated and in those who had received only subdiaphragmatic radiotherapy. Cisplatin combination chemotherapy can be successfully and safely used as the primary treatment of choice in patients with advanced seminoma. It is also an excellent salvage therapy for patients who had received subdiaphragmatic irradiation only. On the contrary, it is very difficult to treat with chemotherapy extensively irradiated patients.