Long-term survivors after salvage high dose chemotherapy with bone marrow rescue in refractory germ cell cancer

Role of one, two and three doses of high-dose chemotherapy with autologous transplantation in the treatment of high-risk or relapsed testicular cancer: a systematic review

Approximately 20-30% of patients with metastatic germ cell cancers (GCCs) can develop relapsed or refractory (RR) disease, about 40-50% of patients who relapse after salvage chemotherapy may reach long-term remission. The goal of this review was to identify patients who appear to benefit from high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT). To access this, we performed a systematic medical literature review to evaluate the effectiveness of HDCT in the frontline setting, as well as in patients with RR testicular cancer. We searched databases for interventional clinical studies and identified 5883 studies. We selected 49 studies for inclusion, which included a total of 5985 patients. Seventeen studies reported results of newly diagnosed poor-risk GCC patients and 32 studies reported results of RR patients. For newly diagnosed patients with poor prognostic predictors, a risk adjusted strategy using unfavorable tumor marker decline with initial standard chemotherapy regimen and upfront HDCT demonstrated improved outcomes. Our data suggest a minimum of two HDCT cycles with ASCT should be standard of care for patients with RR GCC. Failure of HDCT results in a poor prognosis with only 10% of patients achieving lasting remission with salvage therapy.

[Treatment of testicular cancer]

Germ-cell tumours (GCTs) are the most common type of cancer in young men. Since the late 1970s, disseminated GCT have been a paradigm for curable metastatic cancer and metastatic GCTs are highly curable with cisplatin-based chemotherapy followed by surgical resection of residual masses. Patients' prognosis is currently assessed using the International Germ-Cell Consensus Classification (IGCCC) and used to adapt the burden of chemotherapy. Approximately 20% of patients still do not achieve cure after first-line cisplatin-based chemotherapy, and need salvage chemotherapy (high dose or standard dose chemotherapy). Clinical stage I testicular cancer is the most common presentation and different strategies are proposed: adjuvant therapies, surgery or surveillance. During the last three decades, clinical trials and strong international collaborations lead to the development of a consensus in the management of GCTs.

Failure of High-Dose Cyclophosphamide and Etoposide Combined with Double-Dose Cisplatin and Bone Marrow Support in Patients with High-Volume Metastatic Nonseminomatous Germ-Cell Tumours: Mature Results of a Randomised Trial

OBJECTIVES

To assess the impact on survival of high-dose chemotherapy with haematopoietic support in patients with high-volume, metastatic nonseminomatous germ cell tumours.

METHODS

One hundred fifteen patients were randomised to receive either four cycles every 21 d of vinblastine (0.2 mg/kg on day 1), etoposide (100 mg/m2/d on days 1 through 5), cisplatin (40 mg/m2/d on days 1 through 5), and bleomycin (30 mg on days 1, 8, and 15) (arm A), or a slightly modified regimen followed by a high-dose chemotherapy including etoposide (350 mg/m2/d on days 1 through 5), cisplatin (40 mg/m2/d on days 1 through 5), and cyclophosphamide (1600 mg/m2/d on days 2 through 5) (arm B).

RESULTS

In an intent-to-treat analysis, there were 32 (56%) and 24 (42%) complete responses in arms A and B, respectively (p=0.099). After a median follow-up of 9.7 yr, 31 and 27 patients have continuously shown no evidence of disease in arms A and B, respectively. There was no significant difference between the overall survival curves (p=0.167). According to the International Germ Cell Cancer Collaborative Group prognostic classification, the 5-yr survival rates were 88% and 82% in the intermediate group and 69% and 44% in the poor group (p=0.045) in arms A and B, respectively.

CONCLUSIONS

This trial failed to demonstrate an impact on response and survival of high-dose chemotherapy with haematopoietic support in first-line treatment of patients with high-volume, metastatic nonseminomatous germ cell tumours.

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.

High-dose chemotherapy in adult patients with germ cell tumors

BACKGROUND

Approximately 80% of patients with advanced germ cell tumors (GCTs) can be cured with cisplatin-based chemotherapy. Patients with poor-prognosis disease have a cure rate of only 50%, whereas patients with first relapse have only a 25% chance of prolonged survival and potential cure following standard therapy. High-dose chemotherapy (HDC) is being investigated in patients with GCTs to improve the results of salvage treatment and in first-line setting for poor prognosis disease.

METHODS

The authors review the results of the clinical trials that have evaluated the role of HDC in GCT patients. Data were obtained using a computer-assisted MEDLINE search, and meeting abstracts with clinical relevance in this field were hand-searched. Open randomized phase III studies are described and examined.

RESULTS

Several phase II studies have shown a possible benefit for patients with recurrent disease, but the preliminary results of a phase III randomized trial did not demonstrate a survival advantage for HDC after three courses of standard-dose chemotherapy in the salvage therapy of patients in whom first-line treatment has failed. Three prospective, randomized trials are evaluating the role of HDC in a first-line setting.

CONCLUSIONS

New HDC strategies are emerging, involving new drugs (eg, paclitaxel), intensive induction regimens, and upfront and/or multiple courses of HDC. The evaluation of mature data of randomized trials will better define the role of HDC in this disease.

High-dose chemotherapy with peripheral blood stem cell transplantation for advanced testicular cancer

BACKGROUND

The aim of this study was to investigate the efficacy and safety of high-dose chemotherapy (HDCT) for the treatment of patients with advanced testicular cancer.

METHODS

Fourteen patients were treated with high-dose carboplatin, etoposide and cyclophosphamide (with or without THP-adriamycin) followed by peripheral blood stem cell transplantation. The treatment was used for two refractory cases, a second relapse, and for consolidation after the first relapse in one case each. It was also used for nine cases as part of the first-line treatment following primary conventional-dose chemotherapy, and for one case as the first salvage for a late recurrent tumor of teratoma with malignant transformation.

RESULTS

The first two patients who received intensive pretreatment with cisplatin-based chemotherapy did not respond to HDCT. The two patients who were treated with HDCT as the first or second salvage therapy achieved successful outcomes. The results for the subsequent nine patients (consisting of two with stage IIIC, five with IIIB2, one with IIB, and one extragonadal seminoma) were two progressive disease, three no change and four partial remission. Only three are alive with NED following salvage surgery. Finally, a case of teratoma with malignant transformation did not respond well to two cycles of HDCT. There were no marked adverse reactions except one episode of severe neutropenic colitis.

CONCLUSIONS

The results demonstrated the limited efficacy of HDCT even in cases with a good to intermediate risk rating according to classification by the International Germ Cell Cancer Collaborative Group. Because treatment for relapse after HDCT is extremely difficult, new HDCT regimens consisting of drugs that are not used in induction chemotherapy need to be established.

Double dose-intensive chemotherapy with autologous stem cell support for relapsed and refractory testicular cancer: the University of Michigan experience and literature review

Testicular cancer patients refractory or in relapse after primary chemotherapy have < or =25% 5-year progression-free survival with salvage. To improve prognosis, patients entered a phase I/II tandem dose-escalation trial of carboplatin (1500-2100 mg/m(2)) and etoposide (1200-2250 mg/m(2)) with ABMT. Patients were eligible for a second cycle if disease progression was absent and performance status allowed. From August 1990 to June 1998, 29 males (25 NSGCT) were treated. At the time of ABMT, 10 were chemosensitive, four were chemoresistant, and 10 were absolutely refractory to platinum. Disease status (no. patients) at transplant: primary refractory disease (six), first relapse (10), second relapse (eight), third relapse (five). Fifteen (52%) received both transplants. Treatment-related mortality was 10%. Best response after ABMT included: two CR, one CR surgically NED, five PR, three PR surgically NED, seven SD, and eight PD. Eight (28%) patients are continuously progression-free a median 60 months (range, 31-93) from first ABMT. Three seminoma patients remain progression-free. Of five long-term NSGCT survivors, four were treated in first relapse with platinum-sensitive disease. Eighteen relapses occurred a median of 4 months after ABMT I (two late relapses at 28 and 44 months). The median PFS and OS for the whole group are 4 and 14 months, respectively. Patients with relapsed/ refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse. Patients who do poorly despite ABMT have a mediastinal primary site, true cisplatin-refractory disease, disease progression prior to ABMT, and/or markedly elevated betaHCG at ABMT. New treatment modalities are needed for the latter group.

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.

Overview of autologous stem cell transplantation

There has been a dramatic increase in the number of autologous peripheral blood stem cell transplants over the last decade. Faster recovery of cell counts, lesser transplant morbidity, shorter hospital stay and reduced cost compared with marrow autografts have been the main advantages of autologous peripheral blood cell over marrow transplants. In this paper we attempt to review the advances in the biology and mobilization of stem cells, and focus on clinical results of autologous peripheral stem cell and marrow transplants for disease specific sites such as breast cancer, myeloma, autoimmune diseases, germ cell tumors, the acute and chronic leukemias, the non-Hodgkin's lymphomas and Hodgkin's disease. We also discuss transplant related complications, gene therapy and the different methods of purging. This review was intended for autologous peripheral stem cell transplants, however, unavoidably, it also discusses autologous marrow transplantation and aspects common to both procedures.

High-dose chemotherapy with hematopoietic stem-cell support in germ-cell tumor patient treatment: the French experience

Germ-cell tumors (GCTs) are very chemosensitive and highly curable cancers. For the small proportion of patients who fail conventional chemotherapy (CT), high-dose CT (HDCT) was introduced in France and elsewhere in 1982-1984. We report here on the French experience with HDCT in GCTs. At the Centre Léon Bérard, 75 patients were treated with HDCT between 1982 and 1996. Patients received HDCT in 2 different settings: 46 in consolidation of first-line treatment or in incomplete response, 29 in salvage of relapse or refractory disease. The most common regimens of HDCT were the combination of etoposide, double-dose cisplatin and either ifosfamide (VIC regimen, n = 46) or cyclophosphamide (PEC regimen, n = 9) and the combination of carboplatin, etoposide and cyclophosphamide (Carbo-PEC regimen, n = 17). Seven patients died of toxicity. The median follow-up was 42 months. Forty-five of 75 patients are alive and free of disease at long term, 2 of whom had refractory disease. The median time to recovery of a granulocyte count > or = 0.5 x 10(9)/l and a platelet count > or = 25 x 10(9)/l was 14 and 11 days, respectively. The French development was based on double-dose cisplatin until the results of the French randomized trial, which showed no advantage of HDCT in the first-line treatment of poor-risk group patients. Then carboplatin was associated with etoposide and cyclophosphamide in a phase I trial. A European randomized trial, which studies the role of HDCT in the first-line salvage treatment of non-refractory disease, is ongoing. So far, HDCT is not a standard treatment of GCT.

Standard-dose recombinant human granulocyte colony-stimulating factor (rhG-CSF) allows safe and repeated administration of high-dose cyclophosphamide, etoposide, and cisplatin (CEP)

High-dose chemotherapy often requires hematopoietic progenitor cell reinfusion, but drugs with extramedullary dose-limiting toxicity may be administered in the high-dose range by simple growth factor support. In this study, we evaluated the feasibility and toxicity of a three-drug high-dose regimen supported by recombinant human granulocyte colony-stimulating factor (rhG-CSF). Ten patients with histologically proven malignancy were enrolled. Eight had breast cancer, one non-Hodgkin's lymphoma, and one a mediastinal tumor of unknown origin. The regimen included cyclophosphamide (C) 5 g/m2, etoposide (E) 1.5 g/m2, and cisplatin (P) 150 mg/m2 (CEP), administered in a 3-day schedule followed by rhG-CSF, 300 micrograms once a day, beginning from day +5 (36 h after the end of chemotherapy). The cycle was repeated as clinically needed up to three times. After the first course, hematologic recovery was rapid and complete without documented infections, and no relevant extramyeloid toxicities were observed. Eight of 10 patients received a second course with comparably low toxicity, and three of them received a third course. We concluded that CEP therapy can be administered safely and even repeatedly, by simple growth factor support, in good performance status cancer patients.

High-dose chemotherapy in germ-cell tumors

The majority of patients with advanced-stage germ-cell tumor are curable by cisplatin-based chemotherapy, but about 10% of those in the good-risk and 30%-50% in the poor-risk groups will experience relapse. Patients in first relapse have a 60% chance of entering a second complete remission and a 15%-25% probability that it will be durable. Regimens of high-dose chemotherapy with hematopoietic stem-cell support have been developed specifically for this patient population; they are usually based on combinations of etoposide, cyclophosphamide, ifosfamide and, originally, double-dose cisplatin or, nowadays, high-dose carboplatin. The role of high-dose chemotherapy was studied initially in salvage and later in first-line treatment. Four hundred thirty-six patients who received high-dose salvage chemotherapy have been reported, 96 (22%) of whom have obtained long-term complete remissions. Prognostic factors for outcome were disease status (absolute refractory, refractory or sensitive diseases), primary tumor site, response to prior chemotherapy and serum hCG levels prior to high-dose treatment. Patients with no adverse prognostic factors have a greater than 50% chance of cure after high-dose treatment. Patients with refractory disease did not benefit from high-dose chemotherapy. A randomized European trial is ongoing to evaluate prospectively the role of high-dose chemotherapy in comparison to standard ifosfamide-based salvage treatment. In first-line consolidation treatment of poor-risk non-seminomatous germ-cell tumors, the results of phase II trials with carboplatin-based high-dose therapy are in favor of a survival impact when compared to historical controls. A prospective randomized trial is ongoing in the US to study the role of carboplatin-based high-dose consolidation treatment. The only prospective trial comparing a cisplatin-based high-dose treatment to standard chemotherapy failed to demonstrate any survival advantage for the high-dose procedure in this setting. New developments include the use of repeated cycles of high-dose chemotherapy with peripheral blood stem-cell support and the introduction of paclitaxel, a new active drug in this disease, and other non-cross-resistant cytotoxic agents in high-dose combination regimes.

High dose chemotherapy with ifosfamide, carboplatin, and etoposide combined with autologous bone marrow transplantation for the treatment of poor-prognosis germ cell tumors and metastatic trophoblastic disease in adults

BACKGROUND

A Phase I-II trial to assess the toxicity and efficacy of a tandem high dose chemotherapy combining ifosfamide, carboplatin, and etoposide in germ cell tumors and metastatic trophoblastic disease was performed.

METHODS

Thirty-nine patients, with a total of 22 testicular tumors, 9 extragonadal germ cell tumors, 3 ovarian germ cell tumors, and 5 cases of metastatic trophoblastic disease, received tandem high dose therapy combining ifosfamide (7500-12,500 mg/m2), carboplatin (875-1225 mg/m2), and etoposide (1000-1250 mg/m2), followed by bone marrow reinfusion. Among the 39 patients, 33 were refractory to cisplatin- or carboplatin-based regimen and the response of 37 could be evaluated; 69 cycles of this tandem high dose therapy were administered.

RESULTS

The overall response rate was 46%, including a complete response (CR) rate of 35%. Of 21 patients with testicular tumors who could be evaluated, 10 (47%) achieved a CR. No CRs were obtained in patients with refractory extragonadal germ cell tumors. Nine partial responders after the first cycle became complete responders after the second. Nine (23%) of the patients were long term survivors (> 18 months), 7 of them in continuous CR. Side effects primarily were renal toxicity and enterocolitis. Seven patients (18%) died of therapy-related be explored and the maximum tolerated doses of this three-drug regimen remain to be determined.

CONCLUSION

This tandem therapeutic regimen is able to overcome resistance to a platinum-based regimen in highly refractory germ cell tumors and gestational trophoblastic disease and to cure a number of patients.

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.

High-dose therapy with stem cell support in solid tumors

We describe some issues of ongoing studies and results in metastatic and high-risk breast cancer. Caution should be used to not over interpret the outcomes of these data given the patient selection. In other tumors with lesser developed studies, such as with ovarian cancer, non seminomatous germ cell tumors (NSGC), childhood sarcoma, melanoma and limited small cell carcinoma, promising outcomes in small phase II studies are identified and proposed or potential studies comparing high-dose therapy to conventional are outlined. High-dose therapy with either peripheral blood stem cell support (PBSC) or autologous bone marrow transplantation (ABMT) in Phase II studies on a diverse array of solid tumors shows exciting promise of long-term, disease-free survival. Comparative studies in early-stage patients are urgently needed to confirm these outcomes.

Long-term disease-free survival in a child with refractory metastatic malignant germ cell tumor treated by high-dose chemotherapy with autologous bone marrow rescues

We report the case of a 8-month-old girl who presented with a metastatic malignant germ cell tumor (MGCT) that proved to be resistant to chemotherapy, including salvage platinum-based combination therapy, surgery, and metastatectomy. The child was then treated with high-dose carboplatin, etoposide, and cyclophosphamide with autologous bone marrow rescue (ABMR) for two courses, since the first course was well tolerated and resulted in serum alpha-f etoprotein normalisation. The child remains in complete remission 3 years post-ABMR and 4 years post-diagnosis, with no detectable treatment-related sequelae. Thus, as already reported in adults, dose-intensive chemotherapy with ABMR may have curative potential in children with refractory MGCT.

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

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

Salvage treatment in male patients with germ cell tumours

The outcome of salvage treatment was reviewed in 55 patients relapsing during or after their primary chemotherapy for advanced malignant germ cell tumours. Fifty-two patients had been given cisplatin-based chemotherapy as their primary treatment, whereas three patients had received carboplatin-based chemotherapy. The median time to relapse was 2 months (range: 0-96 months) from discontinuation of the primary treatment. Two patients underwent radical surgery only, and one patient had radiotherapy to a brain metastasis as his only curatively intended salvage treatment. Six patients did not receive any treatment for their recurrent malignancy (refusal, terminal condition) except for purely palliative measures. The disease-free survival for the total group was 27% at 5 years. Complete response to primary treatment lasting for > or = 6 months was the only parameter which significantly predicted a favourable outcome (45% 5 year disease-free survival in 12 eligible patients).

High-dose chemotherapy with etoposide, cyclophosphamide and escalating dose of carboplatin followed by autologous bone marrow transplantation in cancer patients. A pilot study

25 patients with poor-prognosis malignancies were treated with a combination of fixed-dose etoposide (1750 mg/m2), cyclophosphamide (6400 mg/m2) and escalating doses of carboplatin (from 800 to 1600 mg/m2) followed by autologous bone marrow transplantation (ABMT). The median duration of granulocytopenia (< 500/mm3) and thrombocytopenia (< 20,000/mm3) was 23 days and 20.5 days, respectively. The main non-haematological toxicity was gastro-intestinal, with moderate to severe diarrhoea in 15 patients. No significant renal toxicity was observed. 2 patients died early due to toxicity. The overall response rate was 58% including 42% having complete responses. 4 of the 25 patients are alive with no evidence of disease at 22, 27, 40 and 43 months after ABMT. The encouraging antitumoral activity of this regimen makes it a good candidate for intensified chemotherapy in patients with various malignancies. Toxicity is acceptable and may be reduced in the near future with the widespread use of haematopoietic growth factors.

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

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