Intensive induction chemotherapy for poor risk non-seminomatous germ cell tumours

Accelerated BEP: a phase I trial of dose-dense BEP for intermediate and poor prognosis metastatic germ cell tumour

Background:

We used bleomycin, etoposide, cisplatin (BEP), the most effective regimen in the treatment of germ cell tumours (GCTs) and increased dose-density by using pegfilgrastim to shorten cycle length. Our aim was to assess safety and tolerability.

Methods:

Sixteen male patients with intermediate or poor prognosis metastatic GCT were treated with four cycles of 3-day BEP with G-CSF on a 14-day cycle for a planned relative dose-density of 1.5 compared with standard BEP.

Results:

Eleven intermediate and five poor prognosis patients were treated. In all, 14 of 16 patients completed the study treatment. Toxicities were comparable to previous studies using standard BEP, except for mucositis and haematological toxicity that were more severe. The overall relative dose-density for all 16 patients was mean 1.38 (range 0.72–1.5; median 1.46). Complete response was achieved after chemotherapy alone in two patients (13%) and following chemotherapy plus surgery in nine additional patients (56%). Four patients (25%) had a partial response and normalised their marker levels. At a median follow-up of 4.4 years (range 2.1–6.8) the estimated 5-year progression-free survival probability is 81% (95% CI 64–100%).

Conclusion:

Accelerated BEP is tolerable without major additional toxicity. A randomised controlled trial will be required to obtain comparative efficacy data.

Emotional disorders in testicular cancer survivors in relation to hypogonadism, androgen receptor polymorphism and treatment modality

PURPOSE

It has been documented that testicular germ cell cancer (TGCC) patients may be at increased risk of developing emotional distress (EMD). Hence, the aim of the present study was to investigate whether EMD is related to the presence of hypogonadism, androgen receptor (AR) polymorphism and/or treatment intensity.

PATIENTS AND METHODS

Three to five years after treatment, testosterone and luteinizing hormone (LH) levels were measured in 165 TGCC patients. These patients also completed a questionnaire concerning mental health. EMD was measured by the Hospital Anxiety and Depression Scale (HADS). The androgen receptor (AR) gene has two polymorphic regions in exon I; glutamine encoding CAG and glycine encoding GGN repeats. Association between emotional disorders and AR polymorphisms as well as type of treatment was assessed.

RESULTS

Neither anxiety (OR 1.0; 95% CI 0.40-2.4) nor depression (OR 1.1; 95% CI 0.20-6.4) were overrepresented in biochemically hypogonadal TGCC patients and no association between AR polymorphisms and EMD was found. Patients treated with >or=5 cycles of cisplatinum based chemotherapy due to refractory or relapsed disease were more prone to experiencing symptoms of anxiety (p=0.006), but not depression (p=0.38).

CONCLUSIONS

Biochemical hypogonadism and AR polymorphism do not seem to be risk factors for EMD in TGCC patients. Patients with refractory or relapsed disease receiving >or=5 cycles of cisplatinum based chemotherapy may, to a higher degree than patients receiving less intense therapy, suffer from anxiety.

Sexual function in men treated for testicular cancer

INTRODUCTION

Testicular germ cell cancer (TGCC) patients may be at risk of developing sexual dysfunction after treatment.

AIM

The aim of this study was to assess the prevalence of sexual dysfunctions in TGCC patients 3 to 5 years after treatment, and relate findings to biochemical hypogonadism, treatment intensity, and the expected prevalence in the Swedish male population.

METHODS

A questionnaire study on 129 consecutive TGCC patients 3 to 5 years post-treatment was performed. Comparators were an age-matched nationally representative group of men (N = 916) included in a study on sexual life in Sweden.

MAIN OUTCOME MEASURES

Sexual functions (including erectile dysfunctional distress), time since last intercourse, sexual satisfaction, and experience of sexological treatment seeking were assessed using the same questions used in the epidemiological study on sexual life in Sweden. The findings in TGCC patients were correlated to biochemical signs of hypogonadism and type of oncological treatment: Surveillance, adjuvant chemotherapy, adjuvant radiotherapy, or standard doses of chemotherapy.

RESULTS

A higher proportion of TGCC patients than comparators were likely to report low sexual desire (odds ratio [OR] 6.7 [95% confidence interval {CI} 2.1-21]) as well as erectile dysfunction (OR 3.8 [95% CI 1.4-10]). No significant differences were observed regarding erectile dysfunctional distress, change of desire over time, interest in sex, premature or delayed ejaculation, time since last intercourse, need for or receiving sexual advice, or sexual satisfaction. Hypogonadism did not predict erectile dysfunction (OR 1.1 [95% CI 0.26-4.5]) or low sexual desire (OR 1.2 [95% CI 0.11-14]). Treatment modality had no obvious impact on sexual function.

CONCLUSION

Men treated for testicular cancer had higher risk of having low sexual desire and erectile dysfunction 3 to 5 years after completion of therapy than comparators. These sexual dysfunctions were not significantly associated with treatment intensity or hypogonadism.

Intensive induction chemotherapy with C-BOP/BEP for intermediate- and poor-risk metastatic germ cell tumours (EORTC trial 30948)

New chemotherapy regimens are continuously explored in patients with high-risk malignant germ cell tumours (MGCTs). This multicentre phase II trial assessed the efficacy and toxicity of C-BOP/BEP chemotherapy in intermediate and poor prognosis MGCT (IGCCCG criteria). C-BOP/BEP treatment consisted of cycles of cisplatin, vincristine, bleomycin and carboplatin, followed by one cycle of vincristine and bleomycin and three cycles of BEP (bleomycon, etoposide, cisplatin). The trial was designed to demonstrate a 1-year progression-free survival rate of 80%, that is, to exclude a 1-year rate of 70% or less, with a one-sided significance level of 5%. Secondary end points included toxicity, overall survival and the postchemotherapy complete response rate. In total, 16 European hospitals entered 66 eligible patients (intermediate prognosis group: 37; poor prognosis group: 29). A total of 45 patients (68.2%, 95% confidence interval (95% CI): 56.9–79.4%) achieved a complete response (intermediate prognosis: 30; poor prognosis: 15). After a median observation time of 40.4 months (range: 13.7–66.3), the 1-year progression-free survival rate was 81.8% 95% CI: 72.5–91.1%). The 2-year overall survival was 84.5% (95% CI: 75.6–93.3%). In all, 51 patients experienced at least one episode of WHO grade 3/4 leucopenia, and at least one event of grade 3/4 thrombocytopenia occurred in 30 patients. There was no toxic death. With an 82% 1-year progression-free survival and a lower limit of the 95% CI above 70%, the efficacy of C-BOP/BEP is comparable to that of published alternative chemotherapy schedules in high-risk MGCT patients. The treatment's toxicity is manageable in a multicentre setting. In poor prognosis patients, C-BOP/BEP should be compared to standard chemotherapy of four cycles of BEP.

Rational approach to genetic testing of cystic fibrosis (CF) in infertile men

Male infertility as a result of isolated congenital bilateral absence of the vas deferens (CBAVD) is one primary genital form of cystic fibrosis (CF) and occurs in 1-2% of infertile men. Assisted fertilization in patients with CBAVD increases the risk of transmitting mutations in the CF gene. We developed a rational approach to genetic CF testing in infertile men. A total of 282 infertile male patients were screened for the most common CF mutations (DeltaF508, R117H, IVS8-5T). Clinical data including medical history, examination, semen analysis, sweat tests, karyotypes and hormonal values were analysed. We identified 23 patients carrying mutations in the CF gene (DeltaF508: 10 patients; R117H: six patients; IVS8-5T: 11 patients). Two patients were compound heterozygote for DeltaF508/R117H, two others for DeltaF508/IVS8-5T. Correlating these molecular analyses with the clinical data pertaining to serum follicle-stimulating hormone concentration, semen pH, sperm count and total testicular volume, we were able to develop a score with a high specificity (98.4) for the presence of a cystic fibrosis transmembrane conductance regulator (CFTR) mutation, but only with a low sensitivity (positive post-test likelihood: 62.5%; negative post-test likelihood: 6.3%). With regard to the low sensitivity and the high number of CFTR mutations found in this heterogeneous group of infertile men, we still recommend genetic CF testing before assisted fertilization.

Salvage, dose intense and high-dose chemotherapy for the treatment of poor prognosis or recurrent germ cell tumours

Most patients with metastatic testicular cancer are cured with cisplatin-based chemotherapy regimens. However, about 20-30% of patients with poor-risk germ cell tumours either fail to respond adequately or relapse after initial complete response. In an attempt to improve the treatment results, several phase II studies of high-dose chemotherapy (HDCT) and haematopoeitic stem cell support were performed initially in refractory or heavily pre-treated patients with germ cell tumours (GCT). Long-term disease-free survival (DFS) has been reported in nearly 13% (range 0-35%) of the patients in this group. Subsequently, HDCT trials have been conducted in first relapse; long-term DFS has been seen in 45% of the patients in these trials (range 21-67%). HDCT has also been evaluated in the first-line treatment of poor-risk GCTs; long-term DFS was achieved in 52% of the patients in this group (range 36-84%). Despite these encouraging results, a French randomised trial has failed to demonstrate any advantage of HDCT in the first-line treatment of poor-risk GCTs and thus the place of HDCT in routine practice remains uncertain. A number of randomised trials of HDCT are currently ongoing in the United States and Europe to better define the role of HDCT in this disease.

Bleomycin, vincristine, cisplatin/bleomycin, etoposide, cisplatin chemotherapy: an alternating, dose intense regimen producing promising results in untreated patients with intermediate or poor prognosis malignant germ-cell tumours

Patients with poor and intermediate prognosis metastatic germ-cell tumours (MGCTs) are at a significant risk of relapse after standard platinum-based chemotherapy. Novel treatment regimens are required to improve survival. Dose intense, alternating combinations of drugs with known activity in germ-cell tumours represents one approach. In all, 43 patients with IGCCCG intermediate/poor prognosis MGCT were treated with a dose intense regimen alternating bleomycin, vincristine, cisplatin (BOP) with bleomycin, etoposide, cisplatin (BEP) to a maximum of three cycles. Data were collected on the maintenance of dose intensity, toxicity, response, progression-free (PFS) and overall survival (OS). The complete response rate was 58%; a further 7% of patients being rendered disease free by resection of viable residual tumour. With a median follow-up of more than 4 years in surviving patients, 3-year OS and PFS rates of 81% (95% CI: 66–91%) and 72% (95% CI: 56–83%) are seen, respectively. Bleomycin, vincristine, cisplatin (BOP)/bleomycin, etoposide, cisplatin (BEP) was well tolerated, with 86% of patients completing all planned courses. Toxicity was predominantly haematological with common toxicity criteria grade III neutropenia in 90% of patients. Cisplatin neuropathy and bleomycin-induced pulmonary toxicity represented the most significant nonhaematological toxicity. Bleomycin, vincristine, cisplatin (BOP)/bleomycin, etoposide, cisplatin (BEP) represents a practicable, well-tolerated, dose intense chemotherapy regimen with significant activity in intermediate and poor prognosis MGCT.

Neuron-specific enolase in testicular cancer--clinical experiences with serum neuron-specific enolase in patients with testicular cancer at diagnosis and during follow-up

The clinical significance of serum neuron-specific enolase (NSE) was evaluated at diagnosis (before orchiectomy) in 132 patients, and in the follow-up of 236 men with germ cell tumours of the testis. The purpose of the study was to determine whether serum NSE was a more clinically useful tumour marker than the existing tumour markers beta-hCG, AFP and LDH. The mean observation time was 4.3 years. At orchiectomy, serum NSE levels were raised in 38 (29%) of all the patients, and in 8/53 (15%) of the patients with clinical stage 1 seminoma. NSE had the same sensitivity as beta-hCG in seminoma. There were very few false-positive values for the classic markers beta-hCG and AFP, but 117 out of 219 patients (53.5%) did experience false-positive serum NSE levels at least once during follow-up. The false-positive values were wide ranging [13-70 microg/L]. None of the four evaluable patients with seminoma who experienced relapse had increased levels of serum NSE at relapse. Two out of 14 non-seminoma patients who experienced relapse had elevated serum NSE levels at the time of relapse, but increased NSE was not the first sign of relapse in any of them. It is concluded that serum NSE is of no clinical value in monitoring patientswith testicular cancer.

Intensive induction chemotherapy with CBOP/BEP in patients with poor prognosis germ cell tumors

PURPOSE

Despite a high cure rate in patients with testicular cancer, there remain patients in the poor prognosis group who have a less favorable outcome. Intensive induction chemotherapy using a regimen consisting of carboplatin, bleomycin, vincristine, and cisplatin, followed by bleomycin, etoposide, and cisplatin (CBOP/BEP), developed at the Royal Marsden Hospital, is designed to overcome the rapid proliferation seen in germ cell tumors. This study assesses the outcome of patients with poor-prognosis nonseminomatous germ cell tumors (NSGCT) treated with CBOP/BEP.

PATIENTS AND METHODS

Patients with NSGCT from three centers, classified as poor prognosis according to International Germ Cell Classification Consensus Group criteria, were treated with CBOP/BEP regimen during the period from 1989 to 2000. Data on treatment toxicity, relapse-free survival (RFS), and overall survival (OS) were collected prospectively on a hospital database.

RESULTS

Fifty-four male patients with poor prognosis NSGCT were treated with CBOP/BEP. The RFS at 3 and 5 years for all patients was 83.2% (95% confidence interval [CI], 68.8% to 91.3%). After a median follow-up of 4 years, the OS of the 54 patients was 91.5% (95% CI, 78.6% to 96.8%) at 3 years and 87.6% (95% CI, 71.3% to 94.9%) at 5 years. Three-year OS in patients with a primary mediastinal germ cell tumor was 77.1% (95% CI, 34.5% to 93.9%) compared with 95.4% (95% CI, 82.8% to 98.8%) in patients with a testicular primary tumor (P =.24).

CONCLUSION

The results reported here compare favorably with the historical results of alternative regimens used in the management of poor-prognosis NSGCT. We suggest a phase III trial to confirm our findings.

Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours

BACKGROUND

Bleomycin pulmonary toxicity (BPT) has been known since the early clinical trials of bleomycin in the 1960s. Postulated risk factors include cumulative bleomycin dose, reduced glomerular filtration rate (GFR), raised creatinine, older age and supplemental oxygen exposure.

PATIENTS AND METHODS

From our prospectively collected testicular cancer research database, we reviewed 835 patients treated at the Royal Marsden NHS Trust (Sutton, UK) with bleomycin-containing regimens for germ-cell tumours between January 1982 and December 1999, to identify those with BPT.

RESULTS

Fifty-seven (6.8%) patients had BPT, ranging from X-ray/CT (computed tomography) changes to dyspnoea. There were eight deaths (1% of patients treated) directly attributed to BPT. The median time from the start of bleomycin administration to documented lung toxicity was 4.2 months (range 1.2-8.2). On multivariate analysis, the factors independently predicting for increased risk of BPT were GFR <80 ml/min [hazard ratio (HR) 3.3], age >40 years (HR 2.3), stage IV disease at presentation (HR 2.6) and cumulative dose of bleomycin >300,000 IU (HR 3.5).

CONCLUSIONS

Patients with poor renal function are at high risk of BPT, especially if they are aged >40 years, have stage IV disease at presentation or receive >300,000 IU of bleomycin. In such cases alternative drug regimens or dose restriction should be considered.

Management of spinal cord and cauda equina compression secondary to epidural metastatic disease in adults with malignant germ cell tumours

AIM

To review the management and clinical outcome of 10 patients, presenting to a single centre with symptoms and signs of spinal cord or cauda equina compression secondary to epidural metastatic disease from a testicular germ cell cancer.

METHODS

Clinical data regarding presenting history, physical examination, staging investigations, treatment and clinical outcome were retrospectively obtained from patient records.

RESULTS

Eight patients exhibited neurological deficits at the time of initial presentation of germ cell cancer or as a first manifestation of relapse following dog leg irradiation. Four of these cases were managed with chemotherapy alone, with excellent neurological recovery, whilst four underwent decompressive laminectomy--in three cases prior to referral and in one case after commencing chemotherapy. Five of the eight patients relapsed. Four required further chemotherapy (high dose in two cases). The remaining patient underwent thoracic surgery, with resection of teratoma differentiated. Six of the eight patients are currently alive and disease free. Two patients had chemorefractory disease and died, though one was treated in the pre-cisplatin era. Two patients presented with cord compression as a feature of disease relapse following chemotherapy, and were managed with radiotherapy alone in an attempt to achieve local disease control and limit neurological dysfunction. However, both subsequently died with progressive disease.

CONCLUSION

Epidural spinal cord or cauda equina compression is a rare complication of metastatic germ cell cancer, which can be successfully managed in chemo-naive patients with good neurological outcome.

Combination carboplatin and radiotherapy in the management of stage II testicular seminoma: comparison with radiotherapy treatment alone

PURPOSE

To assess the results of treatment in 33 patients with stage IIA/B seminoma who were treated with carboplatin and radiotherapy (RT) between January 1989 and December 1996.

PATIENTS AND METHODS

Thirty patients received single course single agent carboplatin (400 mg/m2 or area under curve (AUC 7), two patients received two courses carboplatin, and one patient received single course carboplatin and etoposide, all 4-6 weeks prior to infra-diaphragmatic RT. Results were retrospectively compared with those obtained for 80 patients treated from 1970 to 1998 with radiotherapy alone.

RESULTS

There was minimal toxicity associated with the use of carboplatin prior to RT. With a median follow-up of 4 years (range 2-70 months) 2/33 patients treated with chemotherapy and RT have relapsed, 5-year relapse free survival (RFS) = 96.9% (95% confidence interval (CI) 72.9-99.4%), and one patient has died of progressive disease, 5-year overall survival (OS) = 96.7%. With a median follow-up of 11.2 years (range 6 months to 25.8 years) 15/80 patients treated with RT alone have relapsed, 5-year RFS = 80.7% (95% CI 70.1-87.9%), including 13/61 patients treated with infra-diaphragmatic RT, 5-year RFS = 77.9%, and 2/19 treated with additional supra-diaphragmatic RT, 5-year RFS = 89.5% (P = 0.277). Eleven out of 80 patients have died, 5-year OS = 94.7%. For stage IIA, 1/14 patients treated with chemotherapy and RT have relapsed, 5-year RFS = 92.3%, compared with 5/34 treated with infra-diaphragmatic RT alone 5-year, RFS = 84.9% (P = 0.527). For stage IIB, 1/19 patients relapsed (at 69 months) following chemotherapy and RT (5-year RFS = 100%), whereas 8/27 relapsed following infra-diaphragmatic RT alone, 5-year RFS = 69.4% (P = 0.0595).

CONCLUSION

Infradiaphragmatic RT alone cures the majority of patients with stage II seminoma, but the relapse rate remains high particularly for patients with stage IIB disease. As compared with historical controls, carboplatin with RT appears to reduce the relapse rate in stage II seminoma with minimal additional toxicity and the results approach statistical significance for stage IIB patients. Confirmation would require a phase III randomized comparison.

Bone scintigraphy in testicular tumors

PURPOSE

Testicular tumors do not occur frequently. Primary treatment is surgical, and radiotherapy and chemotherapy can play important roles in cases of metastatic disease. Bone scintigraphy is used largely for early detection of skeletal metastases from several tumors, and conventional radiographic studies are less sensitive than the nuclear technique for such a purpose. The aim of this study was to identify the role of bone scintigraphy in cases of testicular tumors, regardless of the grade.

MATERIALS AND METHODS

The authors examined 28 patients (8 to 52 years old) with proved testicular tumors using Tc-99m MDP (750 MBq; 20 mCi) injected intravenously. Whole-body images were obtained 2 hours later, at 500,000 counts per image. Radiographic studies were obtained to investigate abnormal areas noted on scintigraphy.

RESULTS

The results of bone scintigraphy were abnormal in seven cases, consisting of variable but diffuse uptake in the iliac bone on the same side as the affected testicle. MDP uptake was substantial in five of these patients (four seminomas, one nonseminoma; only two radiographic studies were abnormal), and the two other patients had moderate uptake of the radiopharmaceutical (two seminomas; radiographic studies were normal). Metastases were confirmed by biopsy in three cases.

DISCUSSION

Early metastases from seminomas can occur through the lymphatic drainage toward the iliac lymph node chain. This could explain these findings. The scintigraphic aspects of the affected iliac bones seem characteristic.

CONCLUSIONS

Early detection of metastases is very important to ensure the efficacy of radiotherapy and chemotherapy. Bone scintigraphy may play an important role in such cases and seems to be more sensitive than conventional radiography. Testicular tumor metastases should be considered when iliac involvement is observed. Paget's disease should be included in a differential diagnosis.

Intensive and timely chemotherapy, the key of success in testicular cancer

More than 90% of patients with advanced germ cell tumors (GCT) are curable since the introduction of cisplatin-based chemotherapy, but only half of them with poor-risk characteristics and less than a quarter after the first relapse are cured by conventional chemotherapy. In this review, we have studied the results of dose-intensity in conventional chemotherapy and high-dose chemotherapy (HDCT) in the treatment of GCT patients. In first line, only one randomized trial of HDCT was performed and no benefit was demonstrated. One US randomized trial is ongoing. In first salvage treatment, no randomized trial was performed, and a European trial (IT94) is ongoing. In the refractory situation, there is no indication of high-dose chemotherapy. In conclusion, high-dose chemotherapy is not a standard treatment for different situations. New strategies are needed to improve the survival rate of poor prognosis germ cell tumor patients.

Sixty percent salvage rate for germ-cell tumours using sequential m-BOP, surgery and ifosfamide-based chemotherapy

BACKGROUND

In germ-cell tumours (GCT), there is continuing controversy over the relative merits of dose dense therapy (increased frequency over a given time) versus vertical intensification (increased dose per fraction). The value of using a cisplatin-based dose dense approach in the salvage setting has not been documented and in addition the role of methotrexate remains uncertain. This paper reviews results from our investigations of these issues.

PATIENTS AND METHODS

Between 1987 and 1996, 65 patients with relapsing or refractory germ-cell tumour received weekly m-BOP (methotrexate, bleomycin, vincristine and cisplatin) as salvage therapy. Residual masses were excised if possible and patients progressing after this received cisplatin and ifosfamide based chemotheraphy with or without high dose chemotherapy (HDCT) consolidation.

RESULTS

With a median follow-up of 33 months, 34% are progression free following m-BOP, 11% who had surgery for residual masses which showed viable cancers are progression free. A further 15% who progressed following m-BOP with or without surgery were rendered progression free by third-line therapy.

CONCLUSIONS

The use of m-BOP as second line therapy with deferment of cisplatin and ifosfamide based treatment to third line therapy with consolidation of third line responses with HDCT, leads to an overall progression-free survival of 60%. It does not appear that M-BOP prejudiced the response to third line therapy suggesting a lack of cross resistance. The potentially lower risk of leukaemia and infertility from m-BOP requires further evaluation.

Treatment of nondysgerminomatous ovarian germ cell tumors: an analysis of 69 cases

BACKGROUND

Combination chemotherapy has dramatically improved the prognosis of patients with nondysgerminomatous ovarian germ cell tumors (NDOGCT). However, guidelines are needed for the identification of patients at risk of relapse.

METHODS

The authors performed a retrospective analysis of women with NDOGCT managed during the period 1970-1994 at the Royal Marsden Hospital and other hospitals of the London Gynaecological Oncology Group.

RESULTS

Sixty-nine women were included; their median follow-up was 5.7 years (minimum, 12 months). The median age was 21 years (range, 4-44 years), with a histology of immature teratoma (IT) for 17 patients, endodermal sinus tumor (EST) for 20 patients, and mixed tumors for 32 patients. Thirty-five patients (51%) had Stage I disease. Nine patients with Stage I tumors were observed without further therapy (six with IT and three with mixed tumors), and one relapsed. Seven patients received non-platinum-based chemotherapy, and four relapsed. A total of 52 patients were treated with platinum-based chemotherapy, with relapse free and overall survival rates of 87% (95% confidence interval [CI], 73-93%) and 84% (95% CI, 70-91%), respectively. Of these patients, relapse was seen in 0 of 9 IT patients, 1 of 25 patients with mixed tumors, and 6 of 18 EST patients. With alpha-fetoprotein (AFP) > 1000 kU/L, relapse was seen in 6 of 18 patients compared with 1 of 33 relapses with lower AFP levels. In multivariate analysis, including all patients who received chemotherapy, AFP >1000 kU/L (P = 0.001) and non-platinum-based chemotherapy (P = 0.005) were associated with relapse. When only patients given platinum-based treatment were considered, EST histology (P = 0.003) and AFP >1000 kU/L (P = 0.003) were associated with relapse in univariate analysis; however, these factors were linked. No malignant tumor was found at second-look surgery performed on 24 patients. Of 26 women assessable for fertility, 24 subsequently recommenced regular menstrual function, and 11 patients had pregnancies.

CONCLUSIONS

Platinum-based chemotherapy has been confirmed to be effective in the management of patients with NDOGCT. Relapses were principally seen among patients with AFP >1000 kU/L or pure EST histology. Efforts to improve outcome need to focus on patients with EST, whereas less intensive management strategies may be appropriate for some patients with IT.

Haematological toxicity of cranio-spinal irradiation

BACKGROUND

To assess the frequency and severity of myelosuppression due to cranio-spinal irradiation either alone or in combination with chemotherapy and to identify patients at high risk of haematological toxicity who may require supportive therapy.

MATERIALS AND METHODS

Between 1965 and 1994, 210 patients received cranio-spinal axis (CSA) radiotherapy as a component of treatment for primary CNS tumours at the Royal Marsden Hospital. Full blood counts (FBC) were obtained before, during and after radiotherapy in 200 patients. Haematological toxicity was graded according to the WHO criteria and duration was measured from the onset of grades 3 and 4 toxicity until recovery to grade 2.

RESULTS

Sixty-six (33%) patients developed grades 3 and 4 haematological toxicity. Nadir occurred during radiotherapy and was most frequent during the second week of spinal radiotherapy. Low haemoglobin and white cell counts prior to radiotherapy increased the likelihood of myelosuppression. Nine patients had febrile episodes requiring antibiotic therapy. Treatment was interrupted in 49 patients but treatment time was extended beyond 12 weeks in only 17 (8%) patients of which nine were due to haematological toxicity. Chemotherapy (vincristine) during radiotherapy did not impact on haematological toxicity. Age and prior chemotherapy were independent predictive factors for haematological toxicity. The relative risk of leukopaenia in children compared to adults was 7.9 (95% CI 3.4-18.6%). Patients who received prior chemotherapy had a relative risk of toxicity of 6.1 (95% CI 2.9-12.8%).

CONCLUSION

One-third of patients undergoing CSA radiotherapy develop grades 3 and 4 haematological toxicity. The risk is higher in children and in patients who receive chemotherapy prior to radiation. There was no treatment-related mortality and only nine of 200 patients (9/60 of those with toxicity) required supportive treatment for neutropaenic sepsis. The low incidence severe haematological toxicity does not warrant routine use of haemopoietic growth factors during CSA irradiation and future studies should target high risk subgroups.

Treatment of men with metastatic non-seminomatous germ cell tumours with cyclical POMB/ACE chemotherapy

BACKGROUND

An alternating combination chemotherapy schedule for advanced nonseminomatous germ cell tumours (NSGCT) has been in use since 1977.

PATIENTS AND METHODS

Three hundred thirty-nine men with metastatic NSGCT were treated with POMB/ACE (cisplatin, vincristine, methotrexate, bleomycin, actinomycin D, cyclophosphamide and etoposide), including 42 who had received previous chemotherapy or radiotherapy. Previously untreated patients were classified according to the International Germ Cell Cancer Collaborative Group (IGCCCG) model, and 31% were in the worst prognostic group.

RESULTS

The median follow-up is eight years. The overall survival at five years is 82% (95% confidence interval (CI); 78%-85%). The survival of untreated patients exceeded that for previously treated patients (log-rank P = 0.04) and of testicular tumours exceeded that for primary extragonadal tumours (log-rank P < 0.0001). The survival of men with IGCCCG poor prognosis disease at three years is 75% (95% CI: 65%-84%) compared to 50% in the large cohort which was used to derive the model. There were five early treatment related deaths. In addition, five patients developed acute leukaemia, one developed a second primary lung adenocarcinoma, one man died of pulmonary fibrosis and three men died of cerebrovascular or cardiovascular disease.

CONCLUSIONS

The POMB/ACE schedule has been employed in a large series of men with metastatic NSGCT over two decades. The fatal toxicity is equivalent to that described for simpler regimens. It yields equivalent response rates and survival in men with good prognosis disease and appears to achieve better survival in patients with poor prognosis disease.

Future trials in germ cell malignancy (GCM) of the testis

With overall cure in excess of 95%, there is a debate about how to conduct further trials. Three areas are reviewed: (1) Relapse and high risk patients. With a plethora of new drugs and high dose salvaging one in three second-line failures, there is plenty of choice. Substituting taxol for etoposide in etoposide, ifosfamide and cisplatin (VIP), followed by high dose, is one possibility. (2) For low-risk metastatic disease the current priority is to recruit large numbers to the EORTC/MRC three vs four courses bleomycin, etoposide and cisplatin (BEP) and 3 vs 5 day etoposide trial to evaluate the safety of risking less toxic treatment. (3) For stage 1 disease, non-seminoma, quality of life assessments and evaluating patient participation in decisions about adjuvant therapy are the principal priorities. For seminoma one course carboplatin, the first realistic alternative to radiotherapy, is currently being tested in a MRC trial. During the next decade there will be two areas of interest in addition to those above. Firstly, trials of testis conservation to reduce the use of orchidectomy on diagnosis. For advanced drug-resistant disease, gene therapy using candidate genes found to be responsible for a chemotherapy response, and exploration of their role within non-germ cell cancer.

Residual mass following chemotherapy of seminoma

BACKGROUND

The residual mass so frequently found after chemotherapy of advanced seminoma may consist entirely of benign tissue or may contain residual disease amenable to adjuvant therapy.

PATIENTS AND METHODS

A detailed retrospective analysis was performed on 45 patients treated with cisplatin based chemotherapy for advanced seminoma between 1978 and 1994.

RESULTS

The probability of a residual mass after chemotherapy was higher if the pre-treatment mass diameter was > 5 cm (78% versus 15%, P = 0.0009). Of 33 patients with residual masses following cisplatin chemotherapy, 4 were explored surgically showing fibrosis only, 15 were treated by adjuvant radiotherapy and 14 were managed by observation alone. Recurrence occurred in 2 of 14 patients managed by observation and in 2 of 15 managed by radiotherapy. There was no evidence that risk of recurrence was related to diameter of residual mass.

CONCLUSION

Residual masses persisted following cisplatin based combination chemotherapy for seminoma in 73% of cases. In our study, recurrence was rare and there was no evidence that this was influenced by either the size of the residual mass or the use of adjuvant therapy.

Accuracy of clinical staging in non-seminomatous testicular cancer--a single centre experience of retroperitoneal lymph node dissection

The management of low stage non-seminomatous testicular cancer remains a controversial issue. Programs of surveillance or primary retroperitoneal lymph node dissection (RPLND) after orchiectomy show equally good survival rates. Current focus is therefore on reduction of toxicity or side effects of the treatment while maintaining maximal prognostic safety. The clinician's decision of therapy is based on clinical staging methods including computerized tomography, pulmonary x-rays and serum tumour marker levels. In this study, the accuracy of clinical staging was compared with histopathology in 64 patients with clinical stages (CS) I and IIa, operated upon with RPLND between 1980 and 1992. Lymph node metastases were histopathologically verified in 37% of CS I and in 47% of CS IIa tumours. Thus, the clinical staging was inaccurate in 37% in CS I and in 53% in CS IIa patients. No clear relationship was shown between the risk factors: vascular invasion and/or tumour marker levels and metastatic spread. The specificity of clinical staging in non seminomatous testicular cancer was low. RPLND, on the other hand, is a reliable method for assessment of metastatic spread and will minimise unnecessary use of chemotherapy. Modern techniques for lymphadenectomy have a very low rate of post-operative morbidity. Development of better non-invasive imaging techniques for detection of lymph node metastases is hoped for, in order to improve the information on tumour spread and make it possible to individualize therapy. Thus, unnecessary therapy and following side-effects can be avoided, improving the patient's quality of life during and after treatment.

Four cycles of BEP versus an alternating regime of PVB and BEP in patients with poor-prognosis metastatic testicular non-seminoma; a randomised study of the EORTC Genitourinary Tract Cancer Cooperative Group

We have investigated whether an alternating induction chemotherapy regimen of PVB/BEP is superior to BEP in patients with poor-prognosis testicular non-seminoma. A total of 234 eligible patients were randomised to receive an alternating schedule of PVB/BEP for a total of four cycles or four cycles of BEP. Poor prognosis was defined as any of the following: lymph node metastases larger than 5 cm, lung metastases more than four in number or larger than 2 cm, haematogenic spread outside the lungs, such as in liver and bone, human chorionic gonadotrophin > 10,000 IU l-1 or alphafetoprotein > 1000 IU l-1. The complete response (CR) rates to PVB/BEP and BEP were similar, 76% and 72% respectively (P = 0.58). In addition, there was no significant difference in relapse rate, disease-free and overall survival at an average follow-up of 6 years. The 5-year progression-free and survival rates in both treatment groups were approximately 80%. The PVB/BEP regime was more toxic with regard to bone marrow function; the frequencies of leucocytes below 1000 microliters-1, leucocytopenic fever and platelets below 25,000 microliters-1, throughout four cycles were 28% vs 5% (P < 0.001), 16% vs 5% (P = 0.006), and 10% vs 1% (P = 0.001) respectively. Neuropathy also occurred more often in the PVB/BEP arm: 47% vs 25% (P = 0.001). This study shows that an alternating regimen of PVB/BEP is not superior to BEP and that it is more myelo- and neurotoxic.

A complicated case of metastatic teratoma. Growing teratoma syndrome and cerebral metastasis

All patients presenting with metastatic teratoma should be regarded as potentially curable and this case demonstrates the multiple treatment modalities which are often needed in the management of such patients. Increasing experience with cisplatin based combination chemotherapy has led to the development of prognostic factors which are used to determine the intensity of treatment given to individual patients. Surgical intervention plays a very important role in the management of residual disease at the completion of chemotherapy. Recognition of the growing teratoma syndrome and the importance of early surgical excision is illustrated by this case. Isolated CNS relapse may occur because the CNS may act as a sanctuary site in patients receiving systemic chemotherapy, but does not preclude long term disease free survival.

High-dose carboplatin and etoposide for salvage chemotherapy of germ cell tumours

We evaluated high-dose carboplatin and etoposide with autologous bone marrow stem cell support in the salvage treatment of patients with metastatic germ cell tumours who had failed previous chemotherapy. The treatment programme comprised initial conventional dose chemotherapy. 23 patients received a first cycle of high-dose treatment, and 12 who showed no evidence of progression had a second cycle 2-3 months later. 8 of the 23 patients treated with high-dose chemotherapy are alive in remission 4-29 months from the start of high-dose treatment. 3 of these 8 required further treatment for recurrence. In the initial part of the study, the dose of carboplatin was escalated in successive patients. Grade 3/4 treatment-related toxicity occurred in 4 of 18 patients (1 fatal) who received carboplatin doses to give a AUC (area under the serum concentration/time curve) of 30 mg.min/ml or less and 3 of 5 patients (2 fatal) who received higher doses. We, therefore, recommend 30 mg.min/ml for further evaluation in chemotherapy sensitive patients.

Survival and prognostic factors associated with metastatic nonseminomatous testicular and extragonadal germ cell tumors

To assess prognostic factors in patients with metastatic nonseminomatous germ cell tumors, 50 patients with testicular germ cell tumors (TGCT) and 10 patients with extragonadal germ cell tumors (EGGCT) were studied. The clinical staging system for testicular tumors proposed by The Japanese Urological Association and The Japanese Pathological Society was applied. All patients with EGGCT had primary sites in the retroperitoneum. The 3-year survival rates of TGCT and EGGCT were 71.9% and 60.0%, respectively, and there were no differences in patient characteristics. Patients had significantly worse survival rates if the following applied: choriocarcinoma in the primary tumors, serum lactate dehydrogenase level greater than twice the upper limit of normal, liver, brain, or mediastinal metastases, or retroperitoneal tumors greater than 10 cm. It was concluded that the poor-risk group could be defined as those patients having lymph nodal disease only (stage II or III A) with retroperitoneal tumors greater than 10 cm, having pulmonary disease (stage III B) with retroperitoneal tumors greater than 5 cm, or liver, bone or brain metastases (stage III C), and these criteria will predict the prognosis for patients with advanced disease because the good-risk patients (53% of all patients) and poor-risk patients (47%) in this study had 3-year survival rates of 88.7% and 49.7% (p < 0.0001), and complete response rates of 96.9% and 60.7% (p < 0.005), respectively.

Primary chemotherapy for stage II nonseminomatous germ cell tumors of the testis

Between 1979 and 1989, 122 patients with clinical stage II testicular nonseminoma were treated with primary platinum-based combination chemotherapy following orchiectomy. Of the patients 58 had Royal Marsden Hospital stage IIA (nodes less than 2 cm. in diameter) and the other 64 had stage IIB (nodes 2 to 5 cm. diameter) disease. With a median followup after chemotherapy of 5.5 years, 118 patients (97%) were disease-free. Two patients died of progressive germ cell tumors, 1 of bleomycin toxicity and 1 of coincidental disease. The 5-year actuarial survival probability was 95% (95% confidence intervals 91 to 99%) and the 5-year failure-free survival probability was 92% (95% confidence intervals 88 to 97%). Tumor substage was not predictive of relapse but did indicate the probability of lymphadenectomy for a post-chemotherapy residual mass since this was performed in 17% of the patients with stage IIA disease and 39% with stage IIB disease (p < 0.05). Resected specimens contained mature teratoma (29), necrosis alone (5) or embryonal carcinoma (1). We conclude that for these clinical stages primary chemotherapy was as effective as primary lymph node dissection and a major operation was avoided in 68% of the cases.

Accelerated chemotherapy for poor prognosis germ cell tumours

A pilot study has been completed of an innovative dose intensive chemotherapy schedule for poor prognosis patients with metastatic germ cell tumours referred to the Royal Marsden Hospital between August 1989 and January 1992. The rationale underlying the regimen was the use of an extremely short intercycle interval in order to counteract the potential of these tumours for rapid proliferation. The drug combination in the first phase incorporated a combination of cisplatin and carboplatin, infusional bleomycin and vincristine and this was followed by three cycles of bleomycin, etoposide and cisplatin (C-BOP/BEP). 21 patients with adverse presentations were treated with C-BOP/BEP. The median follow-up of surviving patients is 36 months (range 18-52 months). 1 patient died of disease, 1 died of a treatment complication while in remission and 1 further patient relapsed, and is in remission after radiotherapy and surgery. The 2-year overall survival rate was 90% [95% confidence interval (CI) = 77-100%]. We conclude that this approach may represent an improvement over standard chemotherapy and should be assessed in a multicentre setting.

Phase I/II study of a short course of weekly cisplatin in patients with advanced solid tumours

Twenty-five patients with advanced solid tumours were entered in a phase I/II study of six, weekly cycles of cisplatin. Nineteen patients were chemonaive and six were previously treated. The starting dose was 50 mg m-2 week-1. This dose could be escalated without major toxicity to 70 mg m-2 week-1. At a dose of 80 mg m-2 myelosuppression grade 3 occurred as well as grade 1 nephro- and neurotoxicity. The maximum tolerated dose was 85 mg m-2 with dose limiting thrombocytopenia. Hypertonic saline was effective in preventing nephrotoxicity. Ondansetron was a very effective antiemetic in the first weeks of treatment but its efficacy waned later on. Responses were observed in head and neck cancer, melanoma and mesothelioma. At the dose level of 80 mg m-2 the optimal dose intensity was reached. This schedule will be tested further in phase II studies.

Pre- and post-treatment sexual life in testicular cancer patients: a descriptive investigation

Aspects of sexuality were assessed by questionnaires in 76 testicular cancer patients after orchiectomy before further treatment and, respectively, 6, 12 and 36 months after therapy. Before treatment 11% of the patients reported dissatisfaction with sexual life. About 20% of the patients sometimes experienced reduced libido and erectile difficulties. Six months after therapy significantly more patients (27%) recorded an unsatisfactory sexual life as compared to the pretreatment situation. At the 36 months' evaluation 22 of 76 evaluable patients (18%) still stated that their sexual life was inferior to the pretreatment experience. Libido and erectile function decreased transiently during the first year after treatment in most patients. Twelve patients reported permanent 'dry ejaculation' after bilateral retroperitoneal lymph node dissection. Other sexual disturbances could not be related to specified treatment modalities. Increased age at the time of diagnosis and psychological distress tended to correlate with the incidence of sexual problems. For about 60% of the patients the discussion of expected and experienced sexual life problems was an important issue to be discussed before their treatment for testicular cancer and during follow-up. The high frequency of any kind of long-lasting sexual problems (30%), though often of minor degree, warrants an adequate counselling of these patients before and after treatment.

Primary malignant mediastinal germ cell tumours: improved prognosis with platinum-based chemotherapy and surgery

A retrospective analysis was performed of 18 patients with primary malignant germ cell tumours of the mediastinum treated with platinum-based chemotherapy between 1977 and 1990. All seven patients with pure seminoma were treated initially with chemotherapy and four of these patients received additional mediastinal radiotherapy. Only one patient relapsed; his initial therapy had included radiotherapy and single-agent carboplatin and he was successfully salvaged with combination chemotherapy. With a follow-up of 11 to 117 months (median 41 months) all seven patients with seminoma remain alive and disease free giving an overall survival of 100%. Eleven patients had malignant non seminoma; following chemotherapy eight of these had elective surgical resection of residual mediastinal masses. Complete remission was achieved in nine (82%) patients, however, one of these patients died from bleomycin pneumonitis. With a follow-up of 12 to 113 months (median 55 months) eight of 11 (73%) patients with malignant mediastinal teratoma remain alive and disease free.

Para-aortic lymphadenectomy after chemotherapy for metastatic non-seminomatous germ cell tumours: prognostic value and therapeutic benefit

Between 1976 and 1990, 231 patients had excision of para-aortic lymph node masses remaining after chemotherapy for metastatic non-seminomatous germ cell tumours. The overall 5-year survival rate was 80%. Multivariate analysis of survival after surgery was performed and the following were found to be independent prognostic variables: completeness of surgical excision, pathology of excised mass, timing of surgery after chemotherapy (elective versus salvage) and year of treatment (before or after 1984). Para-aortic lymphadenectomy provided both therapeutic benefit and histological information of prognostic value in planning future treatment and follow-up. Size of mass and serum markers at the time of surgery were of no additional prognostic value once completeness of excision and pathology were taken into account. We therefore recommend that all residual masses should be removed soon after completion of chemotherapy.

Etoposide, cisplatin, bleomycin, and cyclophosphamide (ECBC) as first-line chemotherapy for poor-risk non-seminomatous germ cell tumors

Sixty-one patients with advanced metastatic non-seminomatous germ cell tumors were treated with etoposide 120 mg/m2, cisplatin 30 mg/m2, bleomycin 12 mg/m2, and cyclophosphamide 300 mg/m2 daily for four days; and additional bleomycin bolus injection of 15 mg was given on day 1. Fifty patients (82%) were treated with four to six courses at 3-week intervals. Forty patients (66%) attained complete remission, and further 7 patients (11%) achieved a marker-negative partial remission accounting for a favorable response rate of 77%. Hematologic toxicity was considerable and there were two treatment-related deaths. After a median observation time of 47 months (range 12 to 108 months), 43 patients were alive, of which 38 had continuous complete remission, one a second complete remission, two marker-negative stable disease and two progressive disease. Our results are similar to those reported by other investigators for poor-risk metastatic non-seminomatous germ cell tumors treated with dose-intensified regimens.

New approaches to the management of poor prognosis non-seminomatous germ cell tumours

While most patients with disseminated non-seminomatous germ cell tumours (NSGCT) are cured by treatment with cisplatinum-based chemotherapy, a subset die from refractory or relapsing disease. Poor prognostic factors at diagnosis include bulky disease, visceral involvement, high serum marker levels and an inadequate rate of fall in these markers in response to treatment. There are a number of approaches to poorer risk patients. One is to use conventional induction chemotherapy followed by second-line salvage regimens in those who fail induction. Results with this approach have been disappointing. A second approach is to use more intensive induction regimens, in some cases with growth factor support; whether these are superior to standard treatment has yet to be established by randomised studies. A third approach, based on the chemotherapy-dose responsiveness of NSGCT, consists of the administration of very high dose chemotherapy followed by haematological rescue with autologous marrow to patients failing initial therapy. Review of autograft studies suggest that durable remissions can be obtained in most patients with responsive disease, but not if the disease is chemotherapy-refractory. A new approach may be elective early autografting in patients identified at diagnosis to have very poor prognosis disease.

Does extragonadal presentation impart a worse prognosis to abdominal germ-cell tumours?

The prognostic significance of extragonadal rather than gonadal presentation of germ-cell tumour in 51 patients presenting between 1979 and 1988 with abdominal tumours was compared with that of 51 control patients with testicular primary tumours matched for bulk fo disease, serum tumour marker concentration, age and year of treatment. Very large volume tumour was found at initial staging in 24 extra-gonadal cases (47%) and high tumour markers in 29 (57%). Actuarial survival at 2 and 5 years was 82% and 70% for cases and 78% and 63%, respectively, for controls. These outcomes were not significantly different and the relative hazard of death for cases compared with controls was 0.7 (95% confidence intervals 0.3-1.5). Thus the presentation of germ-cell tumours with a retroperitoneal mass does not itself adversely influence prognosis compared with testicular presentation with equivalent disease extent. However it is rare for extragonadal presentation to be associated with small volume disease.

Treatment of poor-risk germ-cell tumors with high-dose cisplatin and etoposide combined with bleomycin

Seventy-two patients with far advanced ('high-risk') germ-cell tumors were treated with cisplatin 40 mg/m2 i.v. and etoposide 200 mg/m2 i.v. daily for 5 days and bleomycin 15 mg/m2 i.v. once a week. At least 3 cycles of this treatment were given at three-week intervals to all patients. Seventy-five percent of the patients obtained CR and 67% are without evidence of disease after a median observation time of 47 months (range 5 to 80 months). Hematologic toxicity was severe and 10% of the patients died due to treatment-related toxicity. Neurotoxicity was a clinical problem in 58% of the patients. Glomerular filtration rate decreased significantly after 3 cycles (29% +/- 16%). No clinically significant pulmonary toxicity was observed. The specific role of high-dose cisplatin in such intensive treatment has until now been the subject of only one randomized study in which no superiority of high-dose cisplatin was found. Significant improvement of therapeutic outcome over that of today's standard treatment conceivably necessitates an even greater increase in dose intensity of the active drugs--or inclusion of new drugs.

The activity of single-agent carboplatin in advanced seminoma

Between 1982 and 1990, 70 patients with advanced metastatic seminoma were treated with 4-6 courses of single-agent carboplatin (SAC) administered at 400 mg/m2 every 3-4 weeks. Treatment was of low toxicity and no patients suffered neurotoxicity, ototoxicity or significant renal damage. There was only one episode of neutropenic sepsis and no thrombocytopenic bleeding. The median follow-up of surviving patients was 3 years. 16 patients have relapsed and 4 of these 16 have died, thus the actuarial 3-year relapse-free survival was 77% (95% CI 65-86%), cause-specific survival was 94% (95% CI 82-99%) and overall survival was 91% (95% CI 80-96%). The risk of relapse was reduced by post-chemotherapy irradiation (PCRT) to involved nodes, occurring in 1/20 patients treated with PCRT compared with 11/31 who could have been treated but were not (P = 0.04). Of the 16 patients who relapsed, 12(75%) have been salvaged with combination chemotherapy and remain free from further relapse with a median follow-up of 18 months. Though this level of survival is equivalent to that obtained with initial cisplatin-based combination chemotherapy, the recurrence rate indicates that SAC remains an investigative treatment, except for unfit patients.

Acute and subacute side effects due to infra-diaphragmatic radiotherapy for testicular cancer: a prospective study

Acute/subacute side effects were evaluated in 39 testicular cancer patients before infra-diaphragmatic radiotherapy, twice during therapy and 3, 6, and 12 months after treatment discontinuation. The evaluation was primarily based on questionnaires filled in by the patients. At the end of radiotherapy nausea was reported by all responding patients, and 29 patients complained of diarrhea. Two-thirds of the patients reported abdominal pain and/or meteorism, and one-half complained of retching and/or vomiting. During therapy the median weight was significantly reduced by three kilos and the median value of the performance status decreased by 20%. The hematological and biochemical toxicity was low. At the 3-month evaluation more patients complained of nausea, abdominal pain, and meteorism than before irradiation. Compared to the pretreatment situation the patients evaluated their physical condition to be reduced during treatment and at the first follow-up visit. One year posttreatment the patients had regained their physical fitness. All patients in income-producing activity were on sick leave during the period of radiotherapy and for 5 weeks (median) thereafter. In conclusion, infra-diaphragmatic radiotherapy leads to significant but reversible acute/subacute side effects lasting for a median of 9 weeks. It is hoped that better symptomatic therapy and modifications of the radiotherapy technique will reduce the side effects.

Psychosocial well-being in testicular cancer patients

149 testicular cancer patients with no evidence of disease for 3 or more years filled in a questionnaire which covered the following subjects: psychosocial well-being, working ability and use of analgesics/tranquilisers. The questions were chosen to compare cancer patients' morbidity with that of age-matched controls. The patients had been treated with surgery (32 patients), radiotherapy (39 patients), cisplatin-based chemotherapy plus surgery (46 patients) or chemotherapy plus radiotherapy with or without surgery (32 patients). Since no systematic differences between the treatment groups were found, the analyses were undertaken with all patients combined. The patients felt significantly less exhausted after a working day, were more satisfied with life and felt stronger and more fit than the controls. On the other hand, the patients reported a significantly higher incidence of anxiety and depression than the normal population. The results indicate that patients treated for a malignant disease may have greater fluctuations in mood and affect than the general population.

Rapid VAC high dose melphalan regimen, a novel chemotherapy approach in childhood soft tissue sarcomas

Forty-three children with malignant soft tissue sarcomas (IRS Groups II-IV) were treated with rapid dose delivery chemotherapy protocol comprising six courses of vincristine, adriamycin and cyclophosphamide, given in most cases within 8 weeks (Rapid VAC). This was followed in 36 patients by high dose melphalan with autologous bone marrow rescue. Twenty-six patients also received irradiation to the site of primary tumour. The Rapid VAC regimen was well tolerated and largely administered as an out-patient. There was one toxic death which occurred 2 months after high dose melphalan due to a combination of infection and possible anthracycline cardiomyopathy. Stages were, (Intergroup Rhabdomyosarcoma Study (IRS) system) Group, Group II--four patients. Group III--27 patients and Group IV--12 patients; International Society of Paediatric Oncology (SIOP) staging, Stage I--11, Stage II--13, Stage III--7, Stage IV--12. Actuarial survival at 5 years for all stages is 57% and event free survival 44%. For patients with non-metastatic diseases, 62% and 53% respectively. This treatment strategy utilises the philosophy of rapid drug delivery with high dose consolidation and enables all chemotherapy to be finished within a 4 month period. In general, a conservative approach was applied to both radiation and surgery to minimise late sequelae related to these treatment modalities. Although the small number of high risk patients in this study limits conclusions regarding efficacy in these subgroups the overall results with this regimen appear to be comparable to that with other approaches.

Cisplatin/etoposide/ifosfamide stepwise dose escalation with concomitant granulocyte/macrophage-colony-stimulating factor for patients with far-advanced testicular carcinoma

In order to develop a more dose-intensive induction regimen for the treatment of far-advanced testicular tumours, the German Cooperative Group for Testicular Tumours started a dose-escalation trial of cisplatin, etoposide and ifosfamide. At the first dose level 18 patients with advanced testicular cancer (Indiana University classification) received cisplatin 25 mg/m2, etoposide 120-150 mg/m2 and ifosfamide 1.2 g/m2 for 5 days every 3 weeks. Of these, 13 patients (72%) became tumour-free, 2 achieved a stable, marker-negative partial remission, 2 had progressive disease and 1 patient died of Clostridium sepsis. The main toxicity was myelosuppression with a white blood cell nadir of 900/microliters and a thrombocyte nadir of 47,000/microliters. Granulocytopenic fever occurred in 43% of all cycles. At the second dose level 15 patients received cisplatin 30 mg/m2, etoposide 150 mg/m2 and ifosfamide 1.6 g/m2 five times every 3 weeks together with s.c. recombinant granulocyte/macrophage-colony-stimulating factor (GM-CSF) 10 micrograms/kg on days 6-15. Acute toxicity was severe with a white blood cell nadir of 300/microliters and thrombocyte nadir of 11,000/microliters. The duration of the thrombocytopenia increased with cycle number; 63% of all cycles were associated with granulocytopenic fever and in 83% platelet transfusions were required. One patient died from acute renal failure and Aspergillus sepsis; 3 patients experienced adverse reactions to GM-CSF, requiring omission of this drugs in 2; 33% had grade 3 or 4 mucositis. At this dose level 8 patients (53%) became tumour-free, 4 patients (26%) had marker normalization with irresectable residual disease and 2 patients were treatment failures. Though acute toxicity was severe at this dose level, there was no unexpected or unmanageable organ toxicity and thus patients are now entered at dose level 3, which consists of cisplatin 30 mg/m2, etoposide 200 mg/m2 and ifosfamide 1.6 g/m2 for 5 days and GM-CSF 10 micrograms kg-1 day-1 on days 6-15 s.c.

Combination chemotherapy with bleomycin, etoposide and cisplatin (BEP) for metastatic testicular teratoma: long-term follow-up

127 men with previously untreated non-seminomatous germ cell tumours (NSGCT) of the testis were given BEP chemotherapy (bleomycin, etoposide and cisplatin) between 1979-1986. Long-term follow-up (median 65 months) has shown an overall 5 year survival of 87.2% (95% confidence limits 81.1%-93.3%). Outcome was related to both tumour volume and serum marker levels of alpha-fetoprotein (alpha FP) and beta human chorionic gonadotropin (HCG), with 5 year actuarial survivals of 97.8%, 72.2% and 26.7% respectively for small, large and very large volume disease defined by Medical Research Council criteria, and 91.2% and 60.8%, respectively, for men with low (alpha FP less than or equal to 500 kU/l and HCG less than or equal to 1000 iU/l) or high serum marker levels. 79 men (62%) had a complete radiological and serum marker response to chemotherapy alone; residual masses postchemotheraphy were resected in 39 patients (31%), showing undifferentiated tumour in only 6 (15%). 23 of the 127 patients (18%) failed to respond or developed recurrent disease after BEP; only 5 were successfully salvaged. Myelotoxicity of treatment was mild with grade 4 toxicity in 2% of chemotherapy courses and 3 episodes of neutropenic sepsis. Mean glomerular filtration rates fell by 15.6% between courses 1 and 4 of BEP. Bleomycin pneumonitis developed in 13% of cases with 1 fatality. So far 21 men have had children following chemotherapy, but semen analysis 12 months or more (median 36 months) after treatment showed azoospermia in 11 out of 54 (20%) men tested. BEP chemotherapy can be regarded as standard treatment for patients with metastatic NSGCT in low-risk categories, but more intensive therapy is required for advanced presentations. Strategies to develop "risk related" treatment are under investigation.