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van der Schoot GGF, Ormel HL, Westerink NDL, Wempe JB, Lefrandt JD, May AM, Vrieling AH, Meijer C, Gietema JA, Walenkamp AME. Physical exercise in patients with testicular cancer treated with bleomycin, etoposide and cisplatin chemotherapy: pulmonary and vascular endothelial function-an exploratory analysis. J Cancer Res Clin Oncol 2023; 149:17467-17478. [PMID: 37889308 PMCID: PMC10657310 DOI: 10.1007/s00432-023-05469-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Bleomycin, etoposide, and cisplatin combination chemotherapy (BEP) improves the survival of patients with testicular cancer, but is associated with potentially life-threatening toxicities like pneumonitis and thromboembolic events. This study explored the effects of physical exercise in patients with testicular cancer during or after BEP-chemotherapy on pulmonary and vascular endothelial toxicity. METHODS In this post hoc analysis of a multicenter randomized clinical trial (NCT01642680), patients with metastatic testicular cancer scheduled to receive BEP-chemotherapy were randomized to a 24-week exercise intervention, initiated during (group A) or after BEP-chemotherapy (group B). Endpoints were pulmonary function (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), lung transfer-coefficient and transfer factor for carbon monoxide (KCO, DLCO) and markers of vascular endothelial dysfunction (von Willebrand factor (vWF) and factor VIII). RESULTS Thirty patients were included. Post-chemotherapy, patients declined less in FVC, FEV1 and DLCO in group A compared to group B. Post-chemotherapy, vWF and factor VIII were significantly lower in group A compared to group B. After completion of exercise, started either during BEP-chemotherapy or thereafter, no between-group differences were found. At 1-year post-intervention, significant between-group differences were found in favour of group A in DLCO and KCO. CONCLUSIONS Patients who exercised during BEP-chemotherapy better preserved FVC, FEV1 and DLCO, measured directly post-chemotherapy and 1-year post-intervention (DLCO, KCO). This coincided with less increase in vWF and factor VIII measured directly post-chemotherapy. These data support a beneficial role of a physical exercise intervention during BEP-chemotherapy on pulmonary and vascular damage in patients with testicular cancer. TRIAL REGISTRY Optimal Timing of Physical Activity in Cancer Treatment (ACT) Registry URL: https://clinicaltrials.gov/ct2/show/NCT01642680 . TRIAL REGISTRATION NUMBER NCT01642680.
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Affiliation(s)
- Gabriela G F van der Schoot
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Harm L Ormel
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Nico-Derk L Westerink
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Johan B Wempe
- Department of Pulmonary Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joop D Lefrandt
- Department of Vascular Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Aline H Vrieling
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Coby Meijer
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Jourik A Gietema
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Annemiek M E Walenkamp
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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Wood GE, Bunting CP, Veli M, Arora R, Berney DM, Alifrangis C, MacDonald ND, Miller RE, Shamash J, Stoneham S, Lockley M. Seminoma and dysgerminoma: evidence for alignment of clinical trials and de-escalation of systemic chemotherapy. Front Oncol 2023; 13:1271647. [PMID: 37954076 PMCID: PMC10634240 DOI: 10.3389/fonc.2023.1271647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/18/2023] [Indexed: 11/14/2023] Open
Abstract
Malignant germ cell tumours are a group of rare cancers whose incidence peaks in late adolescence and early adulthood. Dysgerminomas of the ovary and seminomas of the testis are analogous diseases, but seminomas have a 10-fold higher incidence. The two tumours are morphologically identical and are only differentiated by surrounding organ-specific tissue or testicular germ cell neoplasia in situ. They share genetic features including KIT and RAS mutations, amplification of chromosome 12p, and expression of pluripotency markers (NANOG (Nanog homeobox), OCT3/4 (Octamer-binding transcription factor 3/4), and SAL4 (Spalt-like trascription factor 4)). Both histologies are exquisitely sensitive to platinum chemotherapy, and the combination of bleomycin, etoposide, and cisplatin (BEP) yields survival rates greater than 90%. However, BEP causes significant, lifelong toxicity (cardiovascular, renal, respiratory, and neurological) in these young patients with an expectation of cure. Here, we comprehensively review the biological features of dysgerminoma and seminoma to demonstrate that they are biologically analogous diseases. We present available clinical trial data supporting de-escalation of chemotherapy treatment. Finally, we propose that future trials should enrol men, women, and children to benefit all patients regardless of age or sex.
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Affiliation(s)
- Georgina E. Wood
- Medical Oncology, University College London Hospital, London, United Kingdom
| | - Christopher P. Bunting
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mesel Veli
- Medical Oncology, University College London Hospital, London, United Kingdom
| | - Rupali Arora
- Histopathology, University College London Hospital, London, United Kingdom
| | | | | | - Nicola D. MacDonald
- Department of Gynaecology, University College London Hospital, London, United Kingdom
| | - Rowan E. Miller
- Medical Oncology, University College London Hospital, London, United Kingdom
- Medical Oncology, Barts Health NHS Trust, London, United Kingdom
| | - Jonathan Shamash
- Medical Oncology, Barts Health NHS Trust, London, United Kingdom
| | - Sara Stoneham
- Paediatric Oncology, University College London Hospital, London, United Kingdom
| | - Michelle Lockley
- Medical Oncology, University College London Hospital, London, United Kingdom
- Centre for Cancer Genomics and Computational Biology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
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Alifrangis C, Sharma A, Chowdhury S, Duncan S, Milic M, Gogbashian A, Agarwal S, Sahdev A, Wilson P, Harland S, Stoneham S, Lockley M, Rustin G, Oliver T, Berney D, Shamash J. Single-agent carboplatin AUC10 in metastatic seminoma: A multi-centre UK study of 216 patients. Eur J Cancer 2022; 164:105-113. [PMID: 33041185 DOI: 10.1016/j.ejca.2020.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/10/2020] [Accepted: 08/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiotherapy and cisplatin-based combination chemotherapy are accepted standard-of-care treatments for metastatic seminoma with excellent survival outcomes but with established short- and long-term morbidity. Carboplatin monotherapy may be a less toxic alternative; however early historic studies at AUC7 showed inferior outcomes. OBJECTIVES To evaluate multi-institutional data on and toxicity and longer-term survival for metastatic seminoma patients treated with the single-agent carboplatin AUC10. METHODS We undertook a multi-institutional analysis incorporating all men with the International Germ Cell Cancer Collaborative Group good-prognosis metastatic seminoma treated until 2018. Carboplatin AUC10 was given every 21 days. Toxicity, progression-free survival (PFS), disease-specific survival (DSS) and overall survival were noted. Variables predictive of progression were identified. RESULTS AND LIMITATIONS 216 patients were treated. The three-year PFS rate was 96.5%, and five-year DSS was 98.3%. There were seven relapses, of which 5 were successfully salvaged with further chemotherapy ± surgery, and three non-seminoma-related deaths. There were no treatment-related deaths. Of 148/216 evaluable patients for toxicity, 37% and 27% suffered >/ = grade III neutropenia and thrombocytopenia, respectively. Twelve percent of patients needed a platelet or blood transfusion (or both). The incidence of febrile neutropenia was 5%. CONCLUSION For metastatic seminoma, carboplatin AUC10 harbours a similar oncological efficacy to established therapies, with a low failure risk. The major acute toxicity was myelosuppression. Our study establishes carboplatin AUC10 as another standard-of-care treatment option for good-prognosis metastatic seminoma, with a potentially lower toxicity profile than other therapies.
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Affiliation(s)
- Constantine Alifrangis
- University College London Hospitals NHS Trust, NW1 2BU, UK; Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Anand Sharma
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, HA6 2RN, UK
| | - Shafi Chowdhury
- Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Sarah Duncan
- Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Marina Milic
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, HA6 2RN, UK
| | - Andrew Gogbashian
- Department of Radiology, Mount Vernon Cancer Centre, Paul Strickland Scanner Centre, Northwood, HA6 2RN, UK
| | - Samita Agarwal
- Department of Histopathology, East and North Herts NHS Trust, Lister Hospital Stevenage, SG1 4AB, UK
| | - Anju Sahdev
- Department of Radiology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Peter Wilson
- Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | | | - Sara Stoneham
- University College London Hospitals NHS Trust, NW1 2BU, UK
| | - Michelle Lockley
- University College London Hospitals NHS Trust, NW1 2BU, UK; Centre for Molecular Oncology, Barts Cancer Institute, Queen Mary University of London, UK
| | - Gordon Rustin
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, HA6 2RN, UK
| | - Timothy Oliver
- Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Daniel Berney
- Department of Histopathology, St Bartholomew's Hospital, London, EC1A 7BE, UK
| | - Jonathan Shamash
- Department of Medical Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK.
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Bhanvadia RR, Baky FJ, Lafin JT, Bagrodia A. How can we mitigate treatment-associated morbidity in patients with germ cell tumors? Expert Rev Anticancer Ther 2021; 21:805-807. [PMID: 34006160 DOI: 10.1080/14737140.2021.1932473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Raj R Bhanvadia
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Fady J Baky
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - John T Lafin
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Bui A, Han S, Alexander M, Toner G, Irving L, Manser R. Pulmonary function testing for the early detection of drug-induced lung disease: a systematic review in adults treated with drugs associated with pulmonary toxicity. Intern Med J 2021; 50:1311-1325. [PMID: 31588628 DOI: 10.1111/imj.14647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 11/30/2022]
Abstract
Pulmonary function tests (PFT) are sometimes monitored during treatment with known pulmonary toxic drugs to detect asymptomatic drug-induced interstitial lung disease (DILD). We conducted a systematic review to assess the accuracy of PFT, including the diffusing capacity for carbon monoxide (DLCO), for early detection of DILD in a range of drugs. Using a pre-specified, registered review protocol, OvidMEDLINE and EMBASE were searched from 1946 to February 2018. Two reviewers independently screened abstracts and reviewed full-text articles for inclusion. Included studies were assessed for risk of bias using adapted QUADAS-2 domains and primary outcome data were extracted and entered into RevMan5 to estimate sensitivity and specificity with 95% confidence intervals (CI). The search identified 4065 citations and included 42 studies. The most commonly studied drugs were bleomycin and amiodarone. Due to clinical heterogeneity between studies, a pooled analysis was not performed. Sensitivity of monitoring with DLCO varied between 0 and 100%, with the majority of studies finding a sensitivity of <80%. CI were wide for the majority of studies. Specificity was less than 90% in all studies. Risk of bias was high for the majority of studies for the quality domain of reference standard. The findings of this review do not support routine PFT for early detection of DILD. Due to methodological limitations, the relatively small number of participants and the low prevalence of DILD in the included studies, there remains significant uncertainty about the sensitivity of PFT to screen for DILD.
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Affiliation(s)
- Allan Bui
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sangjin Han
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Guy Toner
- Department of Medical Oncology, Sir Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Lou Irving
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medical Oncology, Sir Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Renee Manser
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medical Oncology, Sir Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Thakkar DN, Prapath I, Adithan S, Ramasamy K, Selvarajan S, Dubashi B. Variants in XPC, Noxa and TLR4 genes are not associated with bleomycin-induced lung injury in Hodgkin lymphoma patients. Per Med 2020; 17:203-212. [PMID: 32320335 DOI: 10.2217/pme-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: Pulmonary toxicity is a well-known adverse reaction of bleomycin. In this study, we investigated the influence of XPC, PMAIP1/Noxa and TLR4 genetic variants on the development of bleomycin-induced lung injury (BILI) in south Indian patients with Hodgkin lymphoma. Materials & methods: Hodgkin lymphoma patients receiving adriamycin, bleomycin, vinblastine and dacarbazine regimen were recruited for the study and BILI was diagnosed based on symptoms and/or radiological signs. DNA samples were genotyped using real-time PCR. Results: A total of 78 patients were recruited in the study and BILI was observed in 17 (21.8%) patients. Polymorphisms in XPC, PMAIP1/Noxa and TLR4 genes were not associated with the development of BILI. Conclusion: The selected genetic polymorphisms do not predict the risk of BILI in south Indian population.
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Affiliation(s)
- Dimpal N Thakkar
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
| | - Indumathi Prapath
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
| | - Subathra Adithan
- Department of Radio Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
| | - Kesavan Ramasamy
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
| | - Sandhiya Selvarajan
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Gorimedu, Puducherry 605006, India
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Modified-BEP Chemotherapy in Patients With Germ-Cell Tumors Treated at a Comprehensive Cancer Center. Am J Clin Oncol 2020; 43:381-387. [PMID: 32079853 DOI: 10.1097/coc.0000000000000679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Bleomycin, etoposide, and cisplatin (BEP) is the most common and successful chemotherapy regimen for germ-cell tumor (GCT) patients, accompanied by a bleomycin-induced dose-dependent lung toxicity in certain patients. In an attempt to reduce bleomycin-toxicity, we developed a modified-BEP (mBEP) regimen. MATERIALS AND METHODS Between August 2008 and February 2018, 182 unselected mainly testicular GCT patients (39 with adjuvant purpose and 143 with curative purpose) received a tri-weekly 5-day hospitalization schedule with bleomycin 15 U intravenous (IV) push on day 1 and 10 U IV continuous infusion over 12 hours on days 1 to 3, cisplatin 20 mg/m IV, and etoposide 100 mg/m IV on days 1 to 5. Pulmonary toxicity was assessed through chest computed tomography scan and clinical monitoring. RESULTS Median number of mBEP cycles was 3 (range: 1 to 4). In the curative setting, according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic system, 112, 21, and 9 patients had good-risk, intermediate-risk, and poor-risk class, respectively; 66 (46%) patients had complete response (CR), 67 (47%) had partial response (52 of whom became CR afterwards), 6 (4%) had stable disease (that in 3 became CR afterwards), 3 (2%) progressed, and 1 (1%) died of brain stroke. At a median follow-up of 2.67 years (interquartile range: 1.23-5.00 y), 1 and 5-year overall survival and progression-free survival were 99% and 95%, and 90% and 88%, respectively. In the entire patient population, there was grade 3/4 neutropenia in 92 patients (51%), febrile neutropenia in 11 patients (6%), grade 1/2 nausea in 74 patients (41%), and no death due to pulmonary toxicity. CONCLUSION In GCT patients, our mBEP-schedule would suggest an effective treatment modality without suffering meaningful pulmonary toxicity.
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BrintzenhofeSzoc K, Krok-Schoen JL, Canin B, Parker I, MacKenzie AR, Koll T, Vankina R, Hsu CD, Jang B, Pan K, Lund JL, Starbuck E, Shahrokni A. The underreporting of phase III chemo-therapeutic clinical trial data of older patients with cancer: A systematic review. J Geriatr Oncol 2020; 11:369-379. [PMID: 31932259 DOI: 10.1016/j.jgo.2019.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Inspired by the American Society of Clinical Oncology's recommendations to strengthen the evidence base for older adults with cancer, the purpose of this systematic review is to identify the reporting of treatment efficacy and adverse events specific to older adults with cancer in Phase III chemo-therapeutic clinical trials. This review also investigates the frequency with which these data points were reported in the literature to identify gaps in reporting and opportunities to expand the knowledge base on clinical outcomes for older adults with cancer. METHODS Chemo-therapeutic clinical trial data published from July 1, 2016 to June 30, 2017 was reviewed. Manuscripts (n = 929) were identified based on keyword searches of EMBASE and PubMed. After removal of duplicates (n = 116) and articles that did not meet this study's inclusion criteria (n = 654), 159 articles were identified for review. RESULTS Reviewed papers were published in 36 different scientific journals and included twenty-five different cancer types. Of the 159 articles, 117 (73.6%) reported age-specific medians and 75 (47.2%) included stratifications of data by age. Treatment efficacy was reported in 96.2% of the articles with 39.9% reporting effectiveness of treatment by age. Reporting of adverse events was included in 84.9% of the articles with only 8.9% reporting these events stratified by age. CONCLUSION Results suggest inadequate reporting of treatment efficacy and adverse events as well as basic descriptive statistics about the age distribution of study subjects. Conscious efforts are needed to address these deficiencies at every level of planning and conducting clinical trials as wells as reporting outcomes stratified by age. Ultimately, standardized reporting could lead to improved treatment decisions and outcomes for older adults with cancer.
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Affiliation(s)
| | | | | | | | | | - Thuy Koll
- Department of Internal Medicine, University of Nebraska Medical Center, USA
| | | | | | - Brian Jang
- Tulane University School of Medicine, USA
| | | | | | - Edith Starbuck
- University of Cincinnati Libraries, University of Cincinnati, USA
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Stephens M, Murphy T, Hendry D. Anaesthesia for retroperitoneal lymph node dissection in the treatment of testicular cancer. BJA Educ 2019; 19:283-289. [DOI: 10.1016/j.bjae.2019.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 11/24/2022] Open
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10
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Batra A, Ernst S, Potvin K, Fernandes R, Power N, Vanhie J, Winquist E. Early experience with chemotherapy intensification for poor-prognosis metastatic germ cell cancer and unfavorable tumor marker decline. Can Urol Assoc J 2019; 14:43-47. [PMID: 31348750 DOI: 10.5489/cuaj.5802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intensified chemotherapy improved outcomes for men with poor-prognosis metastatic germ cell cancer (GCC) and unfavorable tumor marker decline after one cycle of bleomycin, etoposide, and cisplatin (BEP) chemotherapy in the GETUG-13 trial. Herein, we report our experience to date using a similar approach. METHODS Patients were identified from our electronic GCC database. Men with poor-prognosis GCC and unfavorable tumor marker decline were offered intensified chemotherapy consisting of T-BEP (three cycles) plus paclitaxel, ifosfamide, and cisplatin (TIP) (one cycle), along with prophylactic granulocyte-colony stimulating factor (G-CSF) and resection of residual masses. Cisplatin, etoposide, and ifosfamide (PEI) replaced the last cycle of T-BEP for bleomycin pulmonary concerns. Serious toxicities, progression-free survival, and overall survival were evaluated retrospectively. RESULTS Ten patients with poor-prognosis GCC were identified from May 2012 to April 2016. Eight patients had unfavorable tumor marker decline. Six were offered and received intensified chemotherapy (two T-BEPx3 + TIP and four T-BEPx2 + PEI + TIP). Serious toxicities included neutropenic sepsis, deep venous thrombosis, and C. difficile colitis, but there were no toxic deaths. One patient died of synchronous metastatic adenocarcinoma ex teratoma. The remaining five patients achieved marker-negative partial response, two had residual mature teratoma excised, and four have no evidence of disease after surgery. All are alive at a median of 63.5 months (range 46.3-65.6); one patient has grade 2 peripheral sensory neuropathy, and one patient has grade 2 cognitive disturbance. Of four patients treated with standard BEP, two have died of disease and two are alive at 51.4 and 53.6 months. CONCLUSIONS Our experience with intensified chemotherapy for men with poor-prognosis GCC and unfavorable tumor marker decline confirms that it is feasible, reasonably safe, and appears to provide results similar to those reported in GETUG-13.
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Affiliation(s)
- Anupam Batra
- Division of Medical Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Scott Ernst
- Division of Medical Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kylea Potvin
- Division of Medical Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Ricardo Fernandes
- Division of Medical Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Nicholas Power
- Division of Urology, Department of Surgery, Western University and London Health Sciences Centre, London, ON, Canada
| | - James Vanhie
- London Health Sciences Centre, London, ON, Canada
| | - Eric Winquist
- Division of Medical Oncology, Department of Oncology, Western University and London Health Sciences Centre, London, ON, Canada
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Development of a best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours in the UK. Br J Cancer 2018; 119:1044-1051. [PMID: 30356125 PMCID: PMC6219480 DOI: 10.1038/s41416-018-0300-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/06/2018] [Accepted: 09/20/2018] [Indexed: 11/08/2022] Open
Abstract
Bleomycin, a cytotoxic chemotherapy agent, forms a key component of curative regimens for lymphoma and germ cell tumours. It can be associated with severe toxicity, long-term complications and even death in extreme cases. There is a lack of evidence or consensus on how to prevent and monitor bleomycin toxicity. We surveyed 63 germ cell cancer physicians from 32 cancer centres across the UK to understand their approach to using bleomycin. Subsequent guideline development was based upon current practice, best available published evidence and expert consensus. We observed heterogeneity in practice in the following areas: monitoring; route of administration; contraindications to use; baseline and follow-up investigations performed, and advice given to patients. A best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours has been developed and includes recommendations regarding baseline investigations, the use of pulmonary function tests, route of administration, monitoring and patient advice. It is likely that existing heterogeneity in clinical practice of bleomycin prescribing has significant economic, safety and patient experience implications. The development of an evidence-based consensus guideline was supported by 93% of survey participants and aims to address these issues and homogenise practice across the UK.
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Abstract
PURPOSE OF REVIEW The aim of this article is to examine significant advances in our understanding of the late respiratory effects of cancer treatment, including surgery, radiotherapy, chemotherapy, biological therapies and haematopoietic stem cell transplant, and to provide a framework for assessing such patients. RECENT FINDINGS Oncology therapies have advanced considerably over recent years but pulmonary toxicity remains a concern. Advances have been made in our understanding of the risk factors, including genetic ones that lead to toxicity from radiotherapy and chemotherapy and risk stratification models are being developed to aid treatment planning. Targeted biological treatments are continuously being developed and consequently the Pneumotox database of pulmonary toxicity continues to be an essential resource. Early detection of bronchiolitis obliterans in haematopoietic stem cell transplant patients has been found to be critical, with some positive results from intervention trials. SUMMARY Pulmonary toxicity is a common unwanted consequence of life enhancing or saving cancer treatments which remain difficult to treat. Developments in these fields are mainly in the areas of prevention, early detection and monitoring of unwanted side effects. We discuss some of these developments within this review.
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Maruyama Y, Sadahira T, Mitsui Y, Araki M, Wada K, Tanimoto R, Kobayashi Y, Watanabe M, Watanabe T, Nasu Y. Prognostic impact of bleomycin pulmonary toxicity on the outcomes of patients with germ cell tumors. Med Oncol 2018; 35:80. [DOI: 10.1007/s12032-018-1140-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/18/2018] [Indexed: 01/29/2023]
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