Treatment of advanced seminoma with cyclophosphamide, vincristine and carboplatin on an outpatient basis

An alternative treatment regimen of advanced seminoma with carboplatin, etoposide, and bleomycin instead of cisplatin-based therapy

BACKGROUND

Cisplatin-based therapy is associated with acute and late toxicities. Therefore, a potentially less toxic carboplatin-based regimen was evaluated in patients with advanced seminoma.

PATIENTS AND METHODS

Eighteen patients with advanced seminoma were treated on outpatient basis with carboplatin (AUC5) at day 1, etoposide (100 mgm(-2)) at days 1-5, and bleomycin (30 IU) at day 2 (CEB). Treatment was 3-weekly for a total of 4 cycles. Outcome and toxicities were analyzed.

RESULTS

Median follow-up was 4 years and 7.5 months. Five-year progression-free survival was 86.6% (95% confidence interval (CI), 70.6%-100%), 5-year overall survival 100%, and 10-year overall survival 85% (95% CI, 63.3%-100%); 39% of all patients reached complete remission. Two patients underwent adjuvant treatment. Two patients relapsed; 1 is in ongoing remission 4 years after salvage therapy, the other died almost 6 years after CEB-therapy, despite multiple lines of salvage therapy. The main acute toxicity observed was hematologic. No late cardiovascular events or secondary malignancies were noted.

CONCLUSION

CEB treatment is effective in advanced seminoma, showing minor toxicity. Progression-free and overall survival rates at 5 and 10 years are comparable to those achieved with cisplatin-based therapy. This indicates that carboplatin-combination therapy might be a good alternative to cisplatin-based therapy in the treatment of advanced seminomas.

Advances in the treatment of testicular cancer

Testicular cancer is the most common solid tumour in young men, and the treatment of testicular germ cell tumours (TGCT) has been called a success story of medical oncology, germ cell cancer being regarded as the "model of a curable neoplasm". Even with metastatic disease, high cure rates can be achieved: the overall 5-year survival for all stages of TGCT is approximately 80%. Today, elaborate systems for prognostic evaluation for gonadal and extragonadal germ cell tumours facilitate the choice of the most appropriate therapy for individual patients. In doing so, the ultimate goal of treatment is tumour-free survival for any patient with TGCT. This goal has already been reached for >99% of the patients with early-stage tumours, as well as for the majority of patients with advanced disease (56% of patients with metastases are considered to have a good prognosis at the time of diagnosis; the 5-year survival rate for this group is 90%). However, patients with 'intermediate' or 'poor' prognosis at the time of diagnosis, as well as patients with relapsed disease after cisplatin-containing therapy, still have an unsatisfactorily low 5-year survival rate after standard therapy with PEB (cisplatin, etoposide, bleomycin) of only 80%, 45-55% and 20-25%, respectively.Therefore, our goals must be (i) to limit acute and chronic toxicity by avoiding overtreatment for patients with localised disease and/or good prognosis with advanced disease; and (ii) to identify patients with poor prognosis and treat them in specialised centres, where not only is optimal interdisciplinary care available but new treatment strategies are being applied. For example, tandem high-dose chemotherapy regimens might be effective in achieving higher cure rates in these patients.

Diagnosis and treatment of patients with testicular germ cell cancer

Testicular germ cell tumours are a highly curable malignancy even in the presence of metastases, with an overall survival rate of approximately 90 to 95% when all stages are considered. Current therapeutic strategies aim at risk-adapted therapy, trying to maintain favourable overall results while reducing treatment-related toxicity, particularly in non-advanced disease. In stage I disease, unilateral inguinal orchiectomy represents the standard diagnostic and therapeutic approach. For patients with clinical stage I seminoma, prophylactic para-aortic radiotherapy with 26Gy is commonly employed. In patients with nonseminomatous germ cell tumours (NSGCT) at clinical stage I, the 3 options are: (i) retroperitoneal lymphadenectomy; (ii) a wait-and-see strategy; or (iii) 2 cycles of adjuvant chemotherapy. The individual risk profile for tumour recurrence, mainly based on histopathological criteria such as vascular tumour invasion, should guide treatment decisions in this group of patients. Radiotherapy is still the standard approach in clinical stage IIA/B seminoma, whereas in patients with a low tumour burden of NSGCT, retroperitoneal lymphadenectomy is frequently used followed by surveillance or adjuvant chemotherapy. Primary chemotherapy in these stages of disease may be at least equally successful. Major progress has also been achieved in the treatment of NSGCT patients with metastatic disease greater than clinical stage IIB, for whom primary chemotherapy represents the standard approach. After cisplatin-based combination chemotherapy, between 70 and 90% of patients will achieve a durable remission. In patients with 'good risk' metastatic disease, 3 cycles of cisplatin, etoposide and bleomycin (PEB) remain the standard treatment, despite several randomised trials trying to avoid the lung-toxic bleomycin or substituting cisplatin by carboplatin. In patients with 'intermediate' and 'poor prognosis' disease, 4 cycles of PEB given at 3-week intervals are considered routine treatment. The role of high dose chemotherapy with peripheral autologous blood stem cell transplantation is currently being investigated for patients presenting initially with advanced (poor prognosis) metastatic disease and for patients with relapse after previous chemotherapy, in whom conventional-dose salvage regimens will only result in 20% long-term survival. Because of the large group of patients with metastatic disease being cured, the possible long-term adverse effects of treatment have become important. Only a slightly elevated risk for therapy-related secondary malignancies has been identified. Long-term adverse effects associated with cisplatin may affect a larger proportion of patients. Further research should focus on reducing the risk of chemotherapy-related chronic toxicity.