Alternating dose-dense chemotherapy in patients with high volume disseminated non-seminomatous germ cell tumours

Outcomes of Local Radiation and Intensified Combined Intrathecal Methotrexate and High-dose Chemotherapy for Intracranial Germ Cell Tumors

Many attempts to reduce radiation fields for intracranial germ cell tumors (iGCTs) remain unsuccessful. To assess the possibility of reduction, we analyzed registry data of 57 patients who mostly underwent local irradiation for iGCTs between 1997 and 2006. The recommended treatment for pure germinomas (PGNs) included 3 courses of cisplatin and etoposide followed by 24 Gy local irradiation. Intensified chemotherapy using a combination of cyclophosphamide and intrathecal methotrexate was recommended for human chorionic gonadotropin-producing germinomas (hCG-GNs) and nongerminomatous germ cell tumors (NGGCTs); both received 50.4 Gy local irradiation. High-dose chemotherapy was only administered for residual NGGCTs after chemoradiotherapy. Craniospinal irradiation was recommended only in metastatic cases. During the median follow-up of 114.8 months, 8 of 9 relapses from 24 PGNs occurred outside irradiation fields, with a 5-year progression-free survival (5-year PFS) of 75%±8.8%. Conversely, no recurrences occurred from 11 hCG-GNs, with a 5-year PFS of 100%. Eleven of 22 patients with NGGCTs received high-dose chemotherapy; the 5-year PFS was 81.3%±8.4%; 2 of 3 relapses occurred in the spinal cord. Thus, local irradiation for PGNs was insufficient without treatment intensification. The introduction of intensified chemotherapy improved outcomes of both patients with hCG-GNs and NGGCTs. However, the contributions of either modality remained unclear.

Dose intense chemotherapy in the management of poor prognosis and relapsed testicular cancer: experiences and controversies

INTRODUCTION

The treatment of poor prognosis chemotherapy naïve or relapsed testicular cancer is challenging. In poor prognosis treatment naïve disease, the outlook for patients with standard approaches utilising three weekly cisplatin based regimens, most commonly bleomycin, etoposide and cisplatin (BEP) is suboptimal, and one can expect more than half of patients to relapse or progress and need salvage treatment. Recent randomised studies have lent weight to the use of dose intensified treatments in these selected patient groups. In relapsed testicular cancer, post platinum based chemotherapy controversy exists as to the optimum relapse regimen as significant cure rates can be expected by re-treating with both conventional dose and high dose or dose intense regimens. Areas covered: This review seeks to outline the evidence for alternative approaches beyond standard three weekly cisplatin based regimens in poor risk metastatic disease. It also explores the evidence available for selection between conventional dose and high dose strategies on relapse. Expert commentary: An overview of the data is presented to support personalising therapy selection in both poor risk and relapsed metastatic germ cell tumors.

Personalised chemotherapy based on tumour marker decline in poor prognosis germ-cell tumours (GETUG 13): a phase 3, multicentre, randomised trial

BACKGROUND

Poor prognosis germ-cell tumours are only cured in about half of patients. We aimed to assess whether treatment intensification based on an early tumour marker decline will improve progression-free survival for patients with germ-cell tumours.

METHODS

In this phase 3, multicentre, randomised trial, patients were enrolled from France (20 centres), USA (one centre), and Slovakia (one centre). Patients were eligible if they were older than 16 years, had evidence of testicular, retroperitoneal, or mediastinal non-seminomatous germ cell tumours based on histological findings or clinical evidence and highly elevated serum human chorionic gonadotropin or alfa-fetoprotein concentrations that matched International Germ Cell Cancer Consensus Group poor prognosis criteria. After one cycle of BEP (intravenous cisplatin [20 mg/m(2) per day for 5 days], etoposide [100 mg/m(2) per day for 5 days], and intramuscular or intravenous bleomycin [30 mg per day on days 1, 8, and 15]), patients' human chorionic gonadotropin and alfa-fetoprotein concentrations were measured at day 18-21. Patients with a favourable decline in human chorionic gonadotropin and alfa-fetoprotein continued BEP (Fav-BEP group) for 3 additonal cycles, whereas patients with an unfavourable decline were randomly assigned (1:1) to receive either BEP (Unfav-BEP group) or a dose-dense regimen (Unfav-dose-dense group), consisting of intravenous paclitaxel (175 mg/m(2) over 3 h on day 1) before BEP plus intravenous oxaliplatin (130 mg/m(2) over 3 h on day 10; two cycles), followed by intravenous cisplatin (100 mg/m(2) over 2 h on day 1), intravenous ifosfamide (2 g/m(2) over 3 h on days 10, 12, and 14), plus mesna (500 mg/m(2) at 0, 3, 7 and 11 h), and bleomycin (25 units per day, by continuous infusion for 5 days on days 10-14; two cycles), with granulocyte-colony stimulating factor (lenograstim) support. Centrally blocked computer-generated randomisation stratified by centre was used. The primary endpoint was progression-free survival and the efficacy analysis was done in the intention-to-treat population. The planned trial accrual was completed in May, 2012, and follow-up is ongoing. This study is registered with ClinicalTrials.gov, number NCT00104676.

FINDINGS

Between Nov 28, 2003, and May 16, 2012, 263 patients were enrolled and 254 were available for tumour marker assessment. Of these 51 (20%) had a favourable marker assessment, and 203 (80%) had an unfavourable tumour marker decline; 105 were randomly assigned to the Unfav-dose-dense group and 98 to the Unfav-BEP group. 3-year progression-free survival was 59% (95% CI 49-68) in the Unfav-dose-dense group versus 48% (38-59) in the Unfav-BEP group (HR 0·66, 95% CI 0·44-1·00, p=0·05). 3-year progression-free survival was 70% (95% CI 57-81) in the Fav-BEP group (HR 0·66, 95% CI 0·49-0·88, p=0·01 for progression-free survival compared with the Unfav-BEP group). More grade 3-4 neurotoxic events (seven [7%] vs one [1%]) and haematotoxic events occurred in the Unfav-dose-dense group compared with in the Unfav-BEP group; there was no difference in grade 1-2 febrile neutropenia (18 [17%] vs 18 [18%]) or toxic deaths (one [1%] in both groups). Salvage high-dose chemotherapy plus a stem-cell transplant was required in six (6%) patients in the Unfav-dose-dense group and 16 (16%) in the Unfav-BEP group.

INTERPRETATION

Personalised treatment with chemotherapy intensification reduces the risk of progression or death in patients with poor prognosis germ-cell tumours and an unfavourable tumour marker decline.

FUNDING

Institut National du Cancer (Programme Hospitalier de Recherche Clinique).

Current chemotherapeutic approaches for recurrent or refractory germ cell tumors

INTRODUCTION

Up to 25% of patients with metastatic testicular germ cell tumour (GCT) are not cured by first line therapy and require treatment for refractory or relapsed disease.

METHODS

A literature search was conducted through PubMed, Medline, Cochrane and EMBASE from January 1950 to April 2014 for articles relating to trials of chemotherapy for patients with relapsed or refractory germ cell tumours. Relevant review papers and conference proceedings were hand searched for additional references.

RESULTS

A range of conventional dose chemotherapy (CDCT) regimens can provide durable remissions in 20-30% of patients at first or subsequent salvage.

CONCLUSIONS

This article reviews the evidence underlying commonly used salvage CDCT based on ifosfamide and cisplatin such as TIP, VIP and VeIP; other active combinations; and single agent salvage regimens. The treatment of growing teratoma syndrome and malignant transformation of teratoma will also be discussed. Companion articles will explore the role of high dose chemotherapy (HDCT) and novel targeted agents.

Metastatic germ cell tumour following renal transplantation

BACKGROUND

Treatment of germ cell tumours with cisplatin-based chemotherapy results in cure for the majority of patients. There is, however, a small but significant mortality rate, reported to be higher in patients with multiple co-morbidities.

CASE REPORT

We report our management of a renal transplant patient with spina bifida, who was diagnosed with stage IIIC, poor-risk, non-seminomatous germ cell carcinoma. A marker-negative partial response, which has been maintained more than 2 years following completion of treatment, was seen following chemotherapy with cisplatin and etoposide. Performance status has been preserved at pre-treatment levels.

CONCLUSION

Administration of cisplatin-based chemotherapy is feasible for treatment of renal transplant patients with advanced non-seminomatous germ cell tumours. Treatment strategies require careful planning and monitoring. Dose modifications may be required. This case highlights a favourable outcome in spite of multiple obstacles to ideal management.

Revisiting bleomycin from pathophysiology to safe clinical use

Bleomycin is a key component of curative chemotherapy regimens employed in the treatment of curable cancers, such as Hodgkin lymphoma (HL) and testicular germ-cell tumours (GCT), yet its use may cause bleomycin-induced lung injury (BILI), which is associated with significant morbidity and a mortality rate of 1-3%. Diagnosis of BILI is one of exclusion and physicians involved in the care of HL and GCT patients should be alerted. Pharmacogenomic studies could contribute towards the identification of molecular predictors of bleomycin toxicity on the aim to optimize individual use of bleomycin. We review all existing data on bleomycin's most recent integrated chemical biology, molecular pharmacology and mature clinical data and provide guidelines for its safe clinical use.

Thoracic metastasectomy for nonseminomatous germ cell tumors

Pulmonary metastases are common in patients after resection for nonseminomatous germ cell tumor of the testis. There is solid evidence that resection for residual pulmonary disease, after adjuvant chemotherapy, can provide patients with a long-term survival. This article addresses the issues of patient selection and prognostic factors with the current review of pulmonary metastasectomy in metastatic nonseminomatous germ cell tumors retrieved from retrospective studies. In summary, there is a substantial body of evidence demonstrating that resection of residual lesions after chemotherapy can be performed safely with a low mortality rate. For a subset of patients with viable malignant tumor cells after chemotherapy, the overall results of a 5-year actuarial survival rate ranged between 42 and 61%. However, no presurgical algorithm had proven effective at predicting histologic outcome and, similar to that in pulmonary metastasectomy in general, no prospective randomized trials have been conducted to define the role of surgery versus a nonsurgical treatment regimen.

The challenge of poor-prognosis germ cell tumors

Patients who have a poor prognosis can be identified at presentation by well-defined prognostic factors. Prognostic groups as defined by the International Germ Cell Consensus Classification should be used in the clinic, in clinical trials, and when reporting results. No systemic treatment has been shown to improve outcome compared with four cycles of chemotherapy composed of bleomycin, etoposide, and cisplatin, which remains the standard of care. Surgery to resect residual masses after chemotherapy and in the salvage setting is a vital component of optimal care. The best outcomes occur with treatment at a center with experience and expertise in their management. Further major improvements are likely to require novel systemic therapies rather than modifications of existing approaches.

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.

Survival of non-seminomatous germ cell cancer patients according to the IGCC classification: An update based on meta-analysis

The International Germ Cell Consensus (IGCC) Classification distinguishes patients with non-seminomatous germ cell tumours (NSGCT) with a good, intermediate or poor prognosis, with a reported 5-year overall survival of 92%, 80% and 48%, respectively. Since the IGCC classification was based on patients treated between 1975 and 1990, we aimed to investigate whether survival has improved for more recently treated patients. We did a systematic search of the literature and included studies on survival of patients with NSGCT, treated after 1989 and classified according to the IGCC classification. Survival estimates of selected studies were pooled using meta-analytic techniques. We included 10 papers, describing 1775 patients with NSGCT with good (n = 1087), intermediate (n = 232), or poor (n = 456) prognosis. Pooled 5-year survival estimates were 94%, 83% and 71%, respectively. Since the publication of the IGCC classification, there was a small increase in survival for good and intermediate prognosis patients, and a large increase in survival for patients with a poor prognosis. This increase is most likely due to both more effective treatment strategies and more experience in treating NSGCT patients.

Testicular germ-cell cancer

Testicular germ-cell tumours (TGCTs) represent the model of a curable malignancy; sensitive tumour markers, accurate prognostic classification, logical series of management trials, and high cure rates in both seminomas and non-seminomas have enabled a framework of effective cancer therapy. Understanding the molecular biology of TGCT could help improve treatment of other cancers. The typical presentation in young adults means that issues of long-term toxicity become especially important in judging appropriate management. A focus of recent developments has been to tailor aggressiveness of treatment to the severity of the prognosis. Recent changes affect the most common subtypes and include the reduction of chemotherapy for patients who have metastastic non-seminomas and a good prognosis, and alternatives to adjuvant radiotherapy in stage I seminomas. We summarise advances in the understanding and management of TGCT during the past decade.

Intensive Chemotherapy with Autologous Peripheral Blood Stem Cell Transplantation During a 10-Year Period in 64 Patients with Germ Cell Tumor

Despite gratifying cure rates in germ cell tumors, conventional-dose chemotherapy achieves long-term remissions in less than 50% of patients at high risk. High-dose chemotherapy followed by autologous (auto) peripheral blood stem cell transplantation (PBSCT) has shown impressive remission rates in high-risk and relapsed germ cell tumors. We report on 64 consecutive patients with high- (n=39), intermediate- (n=18), and refractory or relapsed low- (n=7) risk germ cell tumors who underwent auto-PBSCT between January 1993 and February 2003. PBSCTs were performed as a single (n=40) or repeated (n=24) transplantation using either etoposide, ifosfamide, and carboplatin (n=80) or related protocols (paclitaxel, ifosfamide, carboplatin, etoposide [n=7]; carboplatin, etoposide, thiotepa [n=4]). With a median follow-up of 6 years, estimated 2- and 5-year overall survivals were 77.2% (95% confidence interval [CI] 66.7-87.7) and 73.1% (95% CI 61.7-84.5), respectively. We observed unfavorable results in those patients showing refractoriness to cisplatin (hazard ratio 20.36; 95% CI 6.64-62.47) or no response to induction chemotherapy (hazard ratio 10.67; 95% CI 1.37-83.37). Auto-PBSCT was well tolerated, showed objective antitumor activity, and achieved long-term survival in patients at high risk and with relapse. Our data suggest that auto-PBSCT can increase response rates and may improve the outcome in these patients.

Recent advances in the treatment of testicular cancer

Testicular cancer is remarkable because it is curable by combination cytotoxic chemotherapy even when widely disseminated. Treatment is defined by widely accepted staging and prognostic factors. Three cycles of bleomycin, etoposide and cisplatin has been defined as the current optimum treatment in good prognosis metastatic disease, curing 90-95% of patients. Outcomes are less impressive for patients in intermediate and poor prognostic categories. A number of different approaches, including introduction of new agents and dose intensification, are being investigated to improve outcomes in these patients. Data developed over the last few years have identified increased risks of second malignancy and cardiovascular disease in long-term survivors. This has led to re-evaluation of strategies to manage Stage I patients. In particular, the use of radiotherapy in Stage I seminoma and the need for adjuvant therapy in Stage I nonseminoma are being re-examined. It is anticipated that advances in imaging and prognostic factors will facilitate this process.

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.

Viable malignant germ cell tumor in the postchemotherapy retroperitoneal lymph node dissection specimen

BACKGROUND

The presence of viable tumor in the surgical specimen after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is associated with an increased risk of disease progression. The objective of this study was to determine whether the presence of viable tumor in the surgical specimen could be predicted.

METHODS

Between 1980 and 2003, 236 patients underwent PC-RPLND for clinical Stage IIA or III nonseminomatous germ cell tumors (NSGCT). The authors retrospectively reviewed the medical records of those patients for pertinent clinical and treatment-related outcomes. A multivariate logistic regression analysis was used to evaluate whether clinical parameters were capable of predicting the presence of viable tumor in the surgical specimen.

RESULTS

International Germ Cell Consensus Classification (IGCCC) risk categories could be assigned to 218 patients, with 101 patients in the good-risk category, 32 patients in the intermediate-risk category, and 85 patients in the poor-risk category. The incidence of viable tumor in the good-risk, intermediate-risk, and poor-risk categories was similar (17.8%, 15.6%, and 15.3%, respectively); however, the risk categories predicted disease-specific and recurrence-free survival (P = .022 and P < .0001, respectively). On multivariate analysis, an elevated serum alpha-fetoprotein (AFP) level prior to PC-RPLND (P = .05) and the size of the retroperitoneal mass on pathology review (P = .02) were predictive of viable tumor in the surgical specimen.

CONCLUSIONS

Although IGCCC risk categories were correlated with disease-related outcomes, the risk groups had similar incidences of viable tumor. Elevated serum AFP levels prior to surgery and the size of the retroperitoneal mass in the resected specimen may help to predict viable tumor in the PC-RPLND specimen.

The management of poor-prognosis, non-seminomatous germ-cell tumours

Despite a high cure rate in men with testicular cancer, some men in the poor-prognosis group have a less favourable outcome. Poor-prognosis non-seminomatous germ-cell tumours (NSGCT) are defined as those with high tumour markers, non-pulmonary visceral metastases or a mediastinal primary site at presentation. When treated with standard chemotherapy regimens, such as bleomycin, etoposide and cisplatin (BEP), cure rates of less than 50% have been achieved in an international pooled analysis. Some strategies aimed at improving results include the use of multi-agent regimens (e.g. POMB/ACE), intensive-induction chemotherapy (e.g. CBOP/BEP), new chemotherapy drugs, such as ifosfamide, gemcitabine, oxaliplatin, paclitaxel, high-dose chemotherapy, including autotransplantation. To date, no schedule has been proven to be better than standard BEP in randomised trials. We will review the published data relating to first-line and salvage treatment of poor-prognosis NSGCT. To advance the management of this disease, physicians treating poor-prognosis disease are urged to support multi-centre trials, such as the recently launched MRC TE23 study comparing BEP and CBOP/BEP.

Early predicted time to normalization of tumor markers predicts outcome in poor-prognosis nonseminomatous germ cell tumors

PURPOSE

The prognostic relevance of the rate of decline of serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) during the first 3 weeks of chemotherapy for nonseminomatous germ cell tumors (NSGCT) was studied in the context of the International Germ Cell Cancer Collaborative Group (IGCCCG) classification.

PATIENTS AND METHODS

Data from 653 patients prospectively recruited in clinical trials were studied. Tumor markers were obtained before chemotherapy and 3 weeks later. Decline rates were calculated using a logarithmic formula and expressed as a predicted time to normalization (TTN). A favorable TTN was defined when both AFP and HCG had a favorable decline rate, including cases with normal values.

RESULTS

The median follow-up was 50 months (range, 2 to 151 months). Tumor decline rate expressed as a predicted TTN was associated with both progression-free survival (PFS; P <.0001) and overall survival (OS; P <.0001). The 4-year PFS rates were 64% and 38% in patients from the poor-prognosis group who had a favorable and an unfavorable TTN, respectively. The 4-year OS rates were 83% and 58%, respectively. This effect was independent from the initial tumor marker values, the primary tumor site, and the presence of nonpulmonary visceral metastases: tumor marker decline rate remained a strong predictor for both PFS (hazard ratio = 2.5; P =.01) and OS (hazard ratio = 4.6; P =.002) in patients from the IGCCCG poor-prognosis group in multivariate analysis.

CONCLUSION

Early predicted time to tumor marker normalization is an independent prognostic factor in patients with poor-prognosis NSGCT and may be a useful tool in the therapeutic management of these patients.