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Connolly EA, Weickhardt A, Grimison P, Asher R, Heller GZ, Lewin J, Liow E, Toner G, Tung ILY, Tran B, Hill S, Walpole E, McKenzie J, Kuchel A, Goh J, Forgeson G, Tan A, Joshi A, Wickham A, Tan H, Wang Y, Winstanley MA, Hamad N, Wong V. High-dose chemotherapy for relapsed germ cell tumours: outcomes in low-volume specialized centres. BJU Int 2022; 130 Suppl 1:5-16. [PMID: 35355402 DOI: 10.1111/bju.15648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report treatment patterns and survival outcomes of patients with relapsed and refractory metastatic germ cell tumours (GCTs) treated with high-dose chemotherapy (HDCT) and autologous stem-cell transplantation in low-volume specialized centres within the widely dispersed populations of Australia and New Zealand between 1999 and 2019. PATIENTS AND METHODS We conducted a retrospective analysis of 111 patients across 13 institutions. Patients were identified from the Australasian Bone Marrow Transplant Recipient Registry. We reviewed treatment regimens, survival outcomes, deliverability and toxicities. Primary endpoints included overall (OS) and progression-free survival (PFS). Cox proportional hazards models were used to test the association of survival outcomes with patient and treatment factors. RESULTS The median (range) age was 30 (14-68) years and GCT histology was non-seminomatous in 84% of patients. International Prognostic Factors Study Group (IPFSG) prognostic risk category was very low/low, intermediate, high and very high in 18%, 36%, 25% and 21% of patients, respectively. Salvage conventional-dose chemotherapy (CDCT) was administered prior to HDCT in 59% of patients. Regimens included paclitaxel, ifosfamide, carboplatin and etoposide (50%), carboplatin and etoposide (CE; 28%), carboplatin, etoposide and ifosfamide (CEI; 6%), carboplatin, etoposide and cyclophosphamide (CEC; 5%), CEC-paclitaxel (6%) and other (5%). With a median follow-up of 4.4 years, the 1-, 2- and 5-year PFS rates were 62%, 57% and 52%, respectively, and OS rates were 73%, 65% and 61%, respectively. There were five treatment-related deaths. Progression on treatment occurred in 17%. In a univariable analysis, worse International Germ Cell Cancer Collaborative Group (IGCCCG) and IPFSG prognostic groups were associated with inferior survival outcomes. An association of inferior survival was not found with the number of high-dose cycles received nor when HDCT was delivered after salvage CDCT. CONCLUSION This large dual-national registry-based study reinforces the efficacy and deliverability of HDCT for relapsed and refractory metastatic GCT in low-volume specialized centres in Australia and New Zealand, with survival outcomes comparable to those found in international practice.
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Affiliation(s)
- Elizabeth A Connolly
- Chris O Brien Lifehouse, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Andrew Weickhardt
- Olivia Newton-John Cancer and Wellness Centre Austin Health, Melbourne, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)
| | - Peter Grimison
- Chris O Brien Lifehouse, Sydney, Australia.,University of Sydney, Sydney, Australia.,Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)
| | - Rebecca Asher
- NHMRC Clinical Trials Centre, Sydney, Sydney, Australia
| | - Gillian Z Heller
- University of Sydney, Sydney, Australia.,NHMRC Clinical Trials Centre, Sydney, Sydney, Australia
| | - Jeremy Lewin
- Peter MacCallum Cancer Centre, Melbourne, Australia.,Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)
| | - Elizabeth Liow
- Peter MacCallum Cancer Centre, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Guy Toner
- Peter MacCallum Cancer Centre, Melbourne, Australia.,Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)
| | | | - Ben Tran
- Peter MacCallum Cancer Centre, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)
| | - Sean Hill
- Princess Alexandra Hospital, Brisbane, Australia
| | - Euan Walpole
- Princess Alexandra Hospital, Brisbane, Australia
| | - Jane McKenzie
- Olivia Newton-John Cancer and Wellness Centre Austin Health, Melbourne, Australia
| | - Anna Kuchel
- Royal Brisbane and Women's Hospital and School of Medicine, University of Queensland, Brisbane, Australia
| | - Jeffrey Goh
- Royal Brisbane and Women's Hospital and School of Medicine, University of Queensland, Brisbane, Australia
| | - Garry Forgeson
- Palmerston North Hospital, Palmerston North, New Zealand
| | - Alvin Tan
- Waikato Hospital, Hamilton, New Zealand
| | - Abhishek Joshi
- Townsville University Hospital, James Cook University, Townsville, Australia
| | | | - Hsiang Tan
- Royal Adelaide Hospital, Adelaide, Australia
| | - Yang Wang
- St Vincent's Hospital, Melbourne, Australia
| | | | - Nada Hamad
- Australasian Bone Marrow Transplant Recipient Registry (ABMTRR), Sydney, Australia.,St Vincent's Hospital Sydney, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Vanessa Wong
- Olivia Newton-John Cancer and Wellness Centre Austin Health, Melbourne, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
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Role of High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation for Children and Young Adults with Relapsed Ewing's Sarcoma: A Systematic Review. Sarcoma 2018; 2018:2640674. [PMID: 29973774 PMCID: PMC6008812 DOI: 10.1155/2018/2640674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/24/2018] [Accepted: 05/13/2018] [Indexed: 12/27/2022] Open
Abstract
Background Relapsed Ewing's sarcoma (RES) is an aggressive malignancy with poor survival. Although high-dose chemotherapy (HDCT) with autologous stem cell transplantation (ASCT) given after conventional chemotherapy (CC) has shown survival benefits, it is not generally used in the United States for RES. We performed a systemic review to evaluate the benefits of HDCT for RES. Methods Literature search involved Medline, Embase, and Cochrane database. We included studies with RES patients treated with HDCT/ASCT. Results Twenty-four studies with total of 345 reported RES patients that got HDCT were included in final analysis. Seventeen studies had patients with multiple malignancies including RES, while seven had only RES patients. At 2 and 3–5 years, event-free survival (EFS) in studies with only RES patients ranged 42–47% and 20–61% and overall survival (OS) ranged 50–66% and 33–77%, respectively. In studies with combined patients that reported outcomes of RES separately, the EFS at 1–3 and 4 years was 36–66% and 17–50%, respectively. The OS at 1-2 and 3-4 years was 40–60% and 50–70%. Conclusions Most studies using HDCT/ASCT as consolidation regimen showed improved survival benefits compared to CC. Randomized controlled studies are needed to determine true clinical benefits of HDCT followed by ASCT in patients with RES.
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Zschäbitz S, Distler FA, Krieger B, Wuchter P, Schäfer-Eckart K, Jenzer M, Hohenfellner M, Dreger P, Haag GM, Jäger D, Pahernik S, Grüllich C. Survival outcomes of patients with germ cell tumors treated with high-dose chemotherapy for refractory or relapsing disease. Oncotarget 2018; 9:22537-22545. [PMID: 29854297 PMCID: PMC5976483 DOI: 10.18632/oncotarget.25162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/04/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Male patients with metastatic germ cell tumors can be cured in up to 96% of cases depending on stage and IGCCCG prognosis group. Treatment in relapse consists of conventional or high-dose chemotherapy (HDCT) with autologous stem cell transplantation (ASCT) combined with local treatment modalities. Results Most patients were classified as poor risk according to IGCCCG (n = 24; 52%) and as intermediate (n = 12), high (n = 16), or very high risk (n = 9) at time of first relapse according to IPFSG criteria. In 67% of patients (n = 31) HDCT/ASCT was performed as first salvage treatment in relapse or for primary refractory disease following first line chemotherapy. In 46% of patients (n = 21) progressive disease was documented after mobilization and prior to HDCT/ASCT. Median progression free survival (mPFS) was 7.4 months (95% confidence interval (CI): 1.3-13.6) while median overall survival (mOS) was 22.2 months (95% CI: 8.9-35.5). When stratified for IPFSG risk group, mPFS (p < 0.001) and mOS (p = 0.009) differed significantly between risk groups (very low vs. low vs. intermediate vs. high vs. very high). Metastases to liver/bone/brain and platinum refractory disease were independent risk factors for inferior PFS (p = 0.024; p = 0.008) but not OS. Materials and Methods Forty-six patients treated with HDCT/ASCT at the university clinics in Heidelberg and Nuremberg between 2000-2016 were identified and analyzed. Data was collected retrospectively. Conclusions HDCT/ASCT offers a potential curative strategy for patients with relapsed GCT. Improvement is still needed in patients with intermediate, high, and very high IPFSG risk group.
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Affiliation(s)
- Stefanie Zschäbitz
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Florian A Distler
- Department of Urology, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Benjamin Krieger
- Department of Oncology and Hematology, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Patrick Wuchter
- Department of Hematology, Oncology, and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany.,Present address: Institute for Transfusion Medicine and Immunology Mannheim, Medical Faculty Mannheim, University of Heidelberg, DRK-Blutspendedienst Baden-Württemberg-Hessen gGmbH, 68167 Mannheim, Germany
| | - Kerstin Schäfer-Eckart
- Department of Oncology and Hematology, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Maximilian Jenzer
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Markus Hohenfellner
- Department of Urology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Peter Dreger
- Department of Hematology, Oncology, and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Georg Martin Haag
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Dirk Jäger
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sascha Pahernik
- Department of Urology, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Carsten Grüllich
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, 69120 Heidelberg, Germany
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Ng K, Duncan S, Shamash J, Alifrangis C. Dose intense chemotherapy in the management of poor prognosis and relapsed testicular cancer: experiences and controversies. Expert Rev Anticancer Ther 2018; 18:431-436. [PMID: 29557197 DOI: 10.1080/14737140.2018.1454313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The treatment of poor prognosis chemotherapy naïve or relapsed testicular cancer is challenging. In poor prognosis treatment naïve disease, the outlook for patients with standard approaches utilising three weekly cisplatin based regimens, most commonly bleomycin, etoposide and cisplatin (BEP) is suboptimal, and one can expect more than half of patients to relapse or progress and need salvage treatment. Recent randomised studies have lent weight to the use of dose intensified treatments in these selected patient groups. In relapsed testicular cancer, post platinum based chemotherapy controversy exists as to the optimum relapse regimen as significant cure rates can be expected by re-treating with both conventional dose and high dose or dose intense regimens. Areas covered: This review seeks to outline the evidence for alternative approaches beyond standard three weekly cisplatin based regimens in poor risk metastatic disease. It also explores the evidence available for selection between conventional dose and high dose strategies on relapse. Expert commentary: An overview of the data is presented to support personalising therapy selection in both poor risk and relapsed metastatic germ cell tumors.
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Affiliation(s)
- Kenrick Ng
- a Department of Medical Oncology , St Bartholomew's Hospital , London , UK
| | - Sarah Duncan
- a Department of Medical Oncology , St Bartholomew's Hospital , London , UK
| | - Jonathan Shamash
- a Department of Medical Oncology , St Bartholomew's Hospital , London , UK
| | - Constantine Alifrangis
- a Department of Medical Oncology , St Bartholomew's Hospital , London , UK.,b Division of Cancer , University College London Hospital , London , UK
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