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Nasioudis D, Pashankar FD. Management of recurrent and persistent malignant ovarian germ cell tumors: a narrative review. Int J Gynecol Cancer 2024:ijgc-2023-005052. [PMID: 38991656 DOI: 10.1136/ijgc-2023-005052] [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: 07/13/2024] Open
Abstract
Approximately 10% of patients with malignant ovarian germ cell tumors will experience a tumor relapse. Given the rarity of malignant ovarian germ cell tumors, management of these patients is challenging. Secondary cytoreductive surgery can be considered for carefully selected patients with a goal to achieve complete gross or optimal resection. For patients with platinum sensitive disease who have already received platinum-based chemotherapy, standard dose chemotherapy with paclitaxel/ifosfamide/cisplatin or vinblastine/ifosfamide/cisplatin can be considered. High-dose chemotherapy protocols at specialized centers should be explored even for patients with platinum-resistant disease; however, optimal timing is under investigation. A subset of patients with malignant ovarian germ cell tumors harbors potentially actionable genomic alterations. Further research is required to identify novel therapeutic approaches for these patients.
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Affiliation(s)
- Dimitrios Nasioudis
- Division of Gynecologic Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Richardson NH, Althouse SK, Ashkar R, Cary C, Masterson T, Foster RS, Einhorn LH, Adra N. Late Relapse of Germ Cell Tumors After Prior Chemotherapy or Surgery-only. Clin Genitourin Cancer 2023; 21:467-474. [PMID: 37088659 DOI: 10.1016/j.clgc.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Late relapse (LR) of germ cell tumor (GCT) is defined as relapsed disease >2 years from initial treatment. LR remains a challenge both for optimal screening methods and management. We report the method of detection, treatments received, and outcomes in patients with chemotherapy-exposed vs chemotherapy-naïve LR GCT. PATIENTS AND METHODS The Indiana University testicular cancer database was queried identifying 131 patients with LR GCT evaluated at Indiana University from January 2000 to January 2019. Method of detection of LR was recorded along with site, treatment received, and survival outcomes. The cohort was divided into 4 groups according to seminoma versus non-seminoma GCT (NSGCT) and chemotherapy-exposed vs chemotherapy-naïve LR. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method and compared using the log-rank test. Medians with 95% confidence intervals were also calculated along with the 2-year probabilities. RESULTS Median age at LR was 38.3 (range, 19.3-56.8). Chemotherapy-exposed accounted for 75 (57%) and chemotherapy-naïve for 56 (43%) of cases. The 2-year OS comparing chemotherapy-exposed versus chemotherapy-naïve was 78.2% versus 100% (P = .0003). For the 72 chemo-exposed NSGCT LR pts, 2-year PFS based on treatment: surgery vs chemotherapy versus surgery + chemotherapy was 67.1% versus 0% versus 47.1% (P < 0.0001). Fifty-nine percent of chemotherapy-exposed LR had elevation of alpha fetoprotein (AFP) at LR diagnosis. CONCLUSION GCT pts require lifetime follow-up with annual physical exam and tumor markers. Surgical resection, when feasible, remains the preferred treatment for chemotherapy-exposed LR. Chemotherapy-exposed LR has worse outcomes compared to chemotherapy-naïve LR patients.
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Affiliation(s)
- Noah H Richardson
- Division of Hematology & Medical Oncology - Melvin & Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sandra K Althouse
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan Ashkar
- Division of Hematology & Medical Oncology - Melvin & Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Clint Cary
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Timothy Masterson
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Foster
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Lawrence H Einhorn
- Division of Hematology & Medical Oncology - Melvin & Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Nabil Adra
- Division of Hematology & Medical Oncology - Melvin & Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN.
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Abstract
Testicular cancer is a curable cancer. The success of physicians in curing the disease is underpinned by multidisciplinary advances. Cisplatin-based combination chemotherapy and the refinement of post-chemotherapy surgical procedures and diagnostic strategies have greatly improved long term survival in most patients. Despite such excellent outcomes, several controversial dilemmas exist in the approaches to clinical stage I disease, salvage chemotherapy, post-chemotherapy surgical procedures, and implementing innovative imaging studies. Relapse after salvage chemotherapy has a poor prognosis and the optimal treatment is not apparent. Recent research has provided insight into the molecular mechanisms underlying cisplatin resistance. Phase 2 studies with targeted agents have failed to show adequate efficacy; however, our understanding of cisplatin resistant disease is rapidly expanding. This review summarizes recent advances and discusses relevant issues in the biology and management of testicular cancer.
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Affiliation(s)
- Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University, National Cancer Institute, Bratislava, Slovakia
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Lifespan Academic Medical Center, Providence, RI, USA
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Országhová Z, Kalavska K, Mego M, Chovanec M. Overcoming Chemotherapy Resistance in Germ Cell Tumors. Biomedicines 2022; 10:biomedicines10050972. [PMID: 35625709 PMCID: PMC9139090 DOI: 10.3390/biomedicines10050972] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 12/03/2022] Open
Abstract
Testicular germ cell tumors (GCTs) are highly curable malignancies. Excellent survival rates in patients with metastatic disease can be attributed to the exceptional sensitivity of GCTs to cisplatin-based chemotherapy. This hypersensitivity is probably related to alterations in the DNA repair of cisplatin-induced DNA damage, and an excessive apoptotic response. However, chemotherapy fails due to the development of cisplatin resistance in a proportion of patients. The molecular basis of this resistance appears to be multifactorial. Tracking the mechanisms of cisplatin resistance in GCTs, multiple molecules have been identified as potential therapeutic targets. A variety of therapeutic agents have been evaluated in preclinical and clinical studies. These include different chemotherapeutics, targeted therapies, such as tyrosine kinase inhibitors, mTOR inhibitors, PARP inhibitors, CDK inhibitors, and anti-CD30 therapy, as well as immune-checkpoint inhibitors, epigenetic therapy, and others. These therapeutics have been used as single agents or in combination with cisplatin. Some of them have shown promising in vitro activity in overcoming cisplatin resistance, but have not been effective in clinical trials in refractory GCT patients. This review provides a summary of current knowledge about the molecular mechanisms of cisplatin sensitivity and resistance in GCTs and outlines possible therapeutic approaches that seek to overcome this chemoresistance.
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Affiliation(s)
- Zuzana Országhová
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
| | - Katarina Kalavska
- Translational Research Unit, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia;
- Department of Molecular Oncology, Cancer Research Institute, Biomedical Research Center, Slovak Academy Sciences, 845 05 Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
- Translational Research Unit, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia;
| | - Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, 833 10 Bratislava, Slovakia; (Z.O.); (M.M.)
- Correspondence:
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Delaye M, Benderra MA, Deforceville L, Larghero J, Parquet N, Culine S, Grazziotin-Soares D, Lotz JP. High-dose Chemotherapy in Germ Cell Cancer Patients With Brain Metastases: Experience of an Expert Center. Am J Clin Oncol 2021; 44:423-428. [PMID: 34081032 DOI: 10.1097/coc.0000000000000836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Germ cell tumor (GCT) patients with brain metastases (BM) have a poor prognosis and high risk of treatment failure. Optimal therapies for these patients remain controversial. The aim of this study was to report the outcomes of all GCT patients with BM treated with high-dose chemotherapy (HDCT) in our French expert center for GCT. METHODS We carried out a retrospective study of 35 GCT patients with BM who were treated from 2003 to 2019 with HDCT, followed by infusions of autologous peripheral blood hematopoietic stem cells. RESULTS The overall survival at 2 years was 36.9% (95% confidence interval, 19.7-54). The median overall survival was 12 months and the median progression-free survival was 8 months. No variables were associated with better survival in the univariable analysis. Among the 35 patients included in our study, 31 completed HDCT and 4 stopped treatments after mobilization. Eleven patients (11) showed favorable responses (complete, partial, or stable disease) to HDCT and 20 patients died of disease progression (17) or toxicities (3). Among the 11 patients with favorable responses to HDCT, 8 (72.7%) had metachronous BM, mostly isolated. The majority of these patients did not receive local treatment at diagnosis or at relapse. CONCLUSIONS Together, our study reveals that GCT patients can experience long-term survival even in the presence of BM. Metachronous BM can also be cured with HDCT even in the absence of local treatment. Biological and radiologic responses to mobilization could be a predictor of favorable responses to HDCT.
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Affiliation(s)
- Matthieu Delaye
- Department of Medical Oncology and Cellular Therapy, Hospital Tenon
| | | | | | | | | | - Stéphane Culine
- Department of Medical Oncology, Hospital Saint-Louis (Public Assistance - Paris Hospitals, AP-HP)
| | - Daniele Grazziotin-Soares
- Department of Medical Oncology and Cellular Therapy, Hospital Tenon
- Alliance for Cancer Research, Tenon Hospital
| | - Jean-Pierre Lotz
- Department of Medical Oncology and Cellular Therapy, Hospital Tenon
- University Cancer Institute (IUC), Sorbonne University, Paris, France
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Gemcitabine, carboplatin and veliparib in multiple relapsed/refractory germ cell tumours: The GCT-SK-004 phase II trial. Invest New Drugs 2021; 39:1664-1670. [PMID: 34052929 DOI: 10.1007/s10637-021-01130-5] [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: 04/21/2021] [Accepted: 05/16/2021] [Indexed: 10/21/2022]
Abstract
Background Patients with multiple relapsed/refractory germ cell tumours (GCTs) have an extremely poor prognosis. PARP (poly-ADP-ribose polymerase) is overexpressed in GCTs compared to normal testes, and PARP overexpression is an early event in GCT development. This study aimed to determine the efficacy and toxicity of gemcitabine, carboplatin and the PARP inhibitor veliparib in patients with multiple relapsed/refractory GCTs. Methods Fifteen patients with multiple relapsed/refractory GCTs were enrolled in this phase II study from October 2016 to October 2020. Gemcitabine was administered at a dose of 800 mg/m2 on days 1 and 8 every 3 weeks; carboplatin at a target AUC of 4 on day 1 every 3 weeks; and veliparib at a dose of 250 mg b.i.d. throughout. The primary end point was 12-month progression-free survival (PFS). Results The median number of treatment cycles was 4 (range 2-8). Twelve-month PFS was achieved in 1 (6.7 %) patient. The median PFS was 3.1 months (95 % CI 2.2-3.9), and the median overall survival was 10.5 months (95 % CI 8.9-11.1). Partial remission was achieved in 4 (26.7 %) patients, and disease stabilization was observed in 5 (33.3 %) patients. A favourable response was achieved in 3 (20.0 %) patients. Treatment was well tolerated; however, 11 (73.3 %) patients experienced grade 3/4 neutropenia, 10 (66.7 %) experienced thrombocytopenia, 5 (33.3 %) anaemia and 2 (13.3 %) febrile neutropenia. Conclusions This study failed to achieve its primary endpoint, and our data suggest limited efficacy of gemcitabine, carboplatin and veliparib for multiple relapsed/refractory GCTs. ClinicalTrials.gov Identifier: NCT02860819, registered August 9, 2016.
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Kozakova K, Mego M, Cheng L, Chovanec M. Promising novel therapies for relapsed and refractory testicular germ cell tumors. Expert Rev Anticancer Ther 2020; 21:53-69. [PMID: 33138660 DOI: 10.1080/14737140.2021.1838279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Germ cell tumors (GCTs) are the most common solid malignancies in young men. The overall cure rate of GCT patients in metastatic stage is excellent, however; patients with relapsed or refractory disease have poor prognosis. Attempts to treat refractory disease with novel effective treatment to improve prognosis have been historically dismal and the ability to predict prognosis and treatment response in GCTs did not sufficiently improve in the last three decades. AREAS COVERED We performed a comprehensive literature search of PubMed/MEDLINE to identify original and review articles (years 1964-2020) reporting on current improvement salvage treatment in GCTs and novel treatment options including molecularly targeted therapy and epigenetic approach. Review articles were further searched for additional original articles. EXPERT OPINION Despite multimodal treatment approaches the treatment of relapsed or platinum-refractory GCTs remains a challenge. High-dose chemotherapy (HDCT) regimens with autologous stem-cell transplant (ASCT) from peripheral blood showed promising results in larger retrospective studies. Promising results from in vitro studies raised high expectations in molecular targets. So far, the lacking efficacy in small and unselected trials do not shed a light on targeted therapy. Currently, wide inclusion of patients into clinical trials is highly advised.
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Affiliation(s)
- Kristyna Kozakova
- Department of Anesthesiology and Intensive Care Medicine, National Cancer Institute , Bratislava, Slovakia.,2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine , Indianapolis, IN, USA.,Department of Urology, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
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Han C, Zhou Y, Ma JA, Liu J, Jiang YN, Zhang HX. A promising treatment option for refractory male primary choriocarcinoma: report of two cases. Transl Cancer Res 2020; 9:3054-3060. [PMID: 35117666 PMCID: PMC8799262 DOI: 10.21037/tcr.2020.02.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/18/2020] [Indexed: 12/26/2022]
Abstract
Male primary choriocarcinoma is a rare and invasive malignant neoplasm for which traditional chemotherapy has limited efficacy. Pembrolizumab is a humanized monoclonal anti-programmed death-1 antibody that has antitumor activity in numerous malignancies. The diagnosis and treatment of two cases of advanced male primary choriocarcinoma were retrospectively analyzed and relevant literature was reviewed to discuss the prognosis and the efficacy of different treatments, including pembrolizumab. The first patient, who presented with cough and hemoptysis, was diagnosed with primary mediastinal choriocarcinoma. He initially responded to the first-line chemotherapy of etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine, but eventually developed brain metastases. The patient did not respond to the second-line chemotherapy comprising paclitaxel and cisplatin, and he died 6.5 months after diagnosis. The second patient experienced repeated episodes of abdominal pain and was diagnosed with primary neck choriocarcinoma. He received chemotherapy regimens similar to those of the first patient. However, imaging showed no significant changes and his clinical symptoms were not improved. Immunohistochemistry showed that the expression of programmed death ligand 1 on the tumor cells was 40%, and he was administered pembrolizumab combined with chemotherapy. He achieved complete response and was subsequently switched to pembrolizumab maintenance monotherapy. He is still alive without evidence of disease 36 months after diagnosis. To our knowledge, this is the first case of advanced male primary choriocarcinoma successfully treated with pembrolizumab combined with chemotherapy. Advanced male primary choriocarcinoma is highly aggressive and insensitive to chemotherapy. Pembrolizumab may provide a promising treatment option to improve patient outcomes.
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Affiliation(s)
- Chen Han
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Ying Zhou
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Jin-An Ma
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Jia Liu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Yu-Na Jiang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Hai-Xia Zhang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
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Oing C, Giannatempo P, Honecker F, Oechsle K, Bokemeyer C, Beyer J. Palliative treatment of germ cell cancer. Cancer Treat Rev 2018; 71:102-107. [DOI: 10.1016/j.ctrv.2018.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
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Abstract
The introduction of cisplatin combination chemotherapy, 40 years ago, transformed metastatic testicular germ cell tumors from an almost uniformly fatal disease into a model for a curable neoplasm. Before the era of platinum combination chemotherapy, the 5-year survival rate among men with metastatic testicular germ cell tumors was 5% to 10%. Currently, the 5-year survival rate is 80% for patients with metastatic disease and 95% overall. Despite the substantial advances in the treatment of germ cell tumors, 20% to 30% of patients will relapse after first-line chemotherapy and will require additional salvage therapies. Standard-dose or high-dose chemotherapy can cure ≤ 50% of these patients. Relapses after high-dose chemotherapy generally carry a poor prognosis; however, cure is still possible in a small percentage of patients by using further salvage chemotherapy or salvage surgery.
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Abstract
PURPOSE OF REVIEW We review current management strategies for patients with relapsed and refractory germ cell tumors (GCTs), defined as relapsed or persistent disease following at least one line of cisplatin-based chemotherapy. Additionally, we discuss future directions in the management of these patients. RECENT FINDINGS Recent studies involving targeted therapies have been disappointing. Nevertheless, studies of the management of refractory germ cell cancer are ongoing, with a focus on optimal utilization of high-dose chemotherapy and autologous stem cell transplant, as well as the role of immune checkpoint inhibitors in refractory germ cell tumors. Studies aiming to identify those patients who may benefit from more intensive treatment up front to prevent the development of refractory disease are also in progress. Testicular germ cell tumors are among the most curable of all solid tumor malignancies, with cure being possible even in the refractory, metastatic setting. Treatment of refractory disease remains a challenging clinical scenario, but potentially practice changing studies are ongoing.
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Petrelli F, Coinu A, Rosti G, Pedrazzoli P, Barni S. Salvage treatment for testicular cancer with standard- or high-dose chemotherapy: a systematic review of 59 studies. Med Oncol 2017; 34:133. [DOI: 10.1007/s12032-017-0990-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/23/2017] [Indexed: 11/24/2022]
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Etoposide, Methotrexate, and Dactinomycin Alternating With Cyclophosphamide and Vincristine (EMACO) for Male Patients With HCG-expressing, Chemoresistant Germ Cell Tumors. Am J Clin Oncol 2017; 40:60-65. [DOI: 10.1097/coc.0000000000000113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term Survival With Paclitaxel and Gemcitabine for Germ Cell Tumors After Progression Following High-Dose Chemotherapy With Tandem Transplant. Am J Clin Oncol 2015. [DOI: 10.1097/coc.0b013e31829e19e0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current chemotherapeutic approaches for recurrent or refractory germ cell tumors. Urol Oncol 2014; 33:343-54. [PMID: 25308563 DOI: 10.1016/j.urolonc.2014.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/18/2014] [Accepted: 09/07/2014] [Indexed: 11/23/2022]
Abstract
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.
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Selle F, Wittnebel S, Biron P, Gravis G, Roubaud G, Bui BN, Delva R, Bay JO, Fléchon A, Geoffrois L, Caty A, Soares DG, de Revel T, Fizazi K, Gligorov J, Micléa JM, Dubot C, Provent S, Temby I, Gaulet M, Horn E, Brindel I, Lotz JP. A phase II trial of high-dose chemotherapy (HDCT) supported by hematopoietic stem-cell transplantation (HSCT) in germ-cell tumors (GCTs) patients failing cisplatin-based chemotherapy: the Multicentric TAXIF II study. Ann Oncol 2014; 25:1775-1782. [PMID: 24894084 DOI: 10.1093/annonc/mdu198] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND High-dose chemotherapy (HDCT) is an effective salvage treatment of germ-cell tumors (GCTs) patients. In the first salvage setting, 30%-70% of patients may achieve durable remissions. Even when HDCT is administered as subsequent salvage treatment, up to 20% of patients may still be definitively cured. However, patients with refractory/relapsed disease still have a very poor long-term prognosis, requiring earlier intervention of HDCT. PATIENTS AND METHODS This phase II trial was addressed to nonrefractory patients failing Cisplatin-based chemotherapy. Inclusion criteria included seminomatous GCT in relapse after two lines of chemotherapy, nonseminomatous GCT in relapse after first or second lines, partial remission after first line, primary mediastinal GCT in first relapse. Patients received two cycles combining Epirubicin and Paclitaxel (Epi-Tax), followed by three consecutive HDCT, one using a Paclitaxel/Thiotepa (Thio-Tax) association and two using the 5-day Ifosfamide-Carboplatin-Etoposide regimen. The main objective was to determine the complete response rate. RESULTS Forty-five patients were included between September 2004 and December 2007: 44 received the first HDCT cycle, 39 two HDCT cycles, 29 could receive the whole protocol. Sixteen patients did not receive the entire protocol, including eight (17.7%) for toxic side-effects. Two patients (4.4%) died of toxicities, and 17 (37.7%) of disease progression. With a median follow-up time of 26 months (range, 4-51), the final overall response rate was 48.8% (including a complete response rate of 15.5% and a partial response/negative serum markers rate of 26.6%) in an intent-to-treat analysis. The median progression-free survival (PFS) and overall survival (OS) times were 22 months [95% confidence interval (CI) 2-not reached] and 32 months (95% CI 4-49), respectively. The 2-year PFS was a plateau setup at 50% (95% CI 32-67) and the 2-year OS was 66% (95% CI 44-81). CONCLUSION The TAXIF II protocol was effective in nonrefractory GCT patients failing Cisplatin-based chemotherapy. The toxic death rate remained acceptable in the field of HDCT regimens. TRIAL REGISTRATION NUMBER NCT00231582.
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Affiliation(s)
- F Selle
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris; Sorbonne Universités, Université Pierre et Marie Curie (UPMC Univ Paris 06), Paris.
| | - S Wittnebel
- Department of Medicine, Institut Gustave Roussy, Villejuif
| | - P Biron
- Department of Medical Oncology, Centre Léon Bérard, Lyon
| | - G Gravis
- Department of Medical Oncology, Institut Paoli Calmette, Marseille
| | - G Roubaud
- Department of Medicine, Institut Bergonié, Bordeaux
| | - B N Bui
- Department of Medicine, Institut Bergonié, Bordeaux
| | - R Delva
- Department of Chemotherapy, Centre Paul Papin, Angers
| | - J O Bay
- Department of Medicine, Centre Hospitalier Universitaire, Clermont-Ferrand
| | - A Fléchon
- Department of Medical Oncology, Centre Léon Bérard, Lyon
| | - L Geoffrois
- Department of Medicine, Centre Alexis Vautrin, Nancy
| | - A Caty
- Department of Medicine, Centre Oscar Lambret, Lille
| | - D G Soares
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris
| | - T de Revel
- Department of Hematology, Hôpital D'Instruction des Armées Percy, Clamart
| | - K Fizazi
- Department of Medicine, Institut Gustave Roussy, Villejuif
| | - J Gligorov
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris; Sorbonne Universités, Université Pierre et Marie Curie (UPMC Univ Paris 06), Paris
| | - J M Micléa
- Cytapheresis and Cell Therapy Unit, Hôpital St Louis (AP-HP), Paris
| | - C Dubot
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris
| | - S Provent
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris
| | - I Temby
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris
| | - M Gaulet
- Statistic, 3ES-Cegedim Strategic Data, Boulogne, France
| | - E Horn
- Department of Internal Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - I Brindel
- Department of Clinical Research, Hôpital St Louis (AP-HP), Paris, France
| | - J P Lotz
- Department of Medical Oncology and Cellular Therapy, APREC (Alliance Pour la Recherche En Cancérologie), Hôpital Tenon (Hôpitaux Universitaires de l'Est-Parisien, AP-HP), Paris; Sorbonne Universités, Université Pierre et Marie Curie (UPMC Univ Paris 06), Paris
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Combination of Paclitaxel, Cisplatin, and Gemcitabine (TPG) for Multiple Relapses or Platinum-Resistant Germ Cell Tumors: Long-Term Outcomes. Clin Genitourin Cancer 2014; 12:63-69.e1. [DOI: 10.1016/j.clgc.2013.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 07/25/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
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19
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Einhorn LH. Salvage Chemotherapy for Patients With Germ Cell Tumors: Is There a Best Regimen? J Clin Oncol 2012; 30:771-2. [DOI: 10.1200/jco.2011.40.4160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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20
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Abstract
Cardiotoxicity of anticancer treatments has become an increasingly important clinical problem faced by cardiologists. Left ventricular systolic dysfunction and heart failure generate the most concern, but clinical features and prognosis vary considerably depending on the causative agent. Anthracycline-related cardiomyopathy differs fundamentally from effects associated with newer targeted agents, such as trastuzumab. Other forms of cardiovascular disease that occur as a result of cancer treatment include hypertension, thromboembolic disease, pericardial disease, arrhythmia, and myocardial ischemia. The approach to cardiovascular disease in patients with cancer is often different from that in the general population, not only because of distinct underlying mechanisms and clinical features of their heart disease, but also because of the potential ongoing need for additional cancer treatment as well as the altered duration of anticipated survival. In an effort to maximize both quality of life and survival, cardiologists and oncologists should collaborate with the aim of balancing the risks of cardiotoxicity with the benefits of oncologic therapy.
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21
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Third-Line Chemotherapy and Novel Agents for Metastatic Germ Cell Tumors. Hematol Oncol Clin North Am 2011; 25:577-91, ix. [DOI: 10.1016/j.hoc.2011.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Voss MH, Feldman DR, Bosl GJ, Motzer RJ. A review of second-line chemotherapy and prognostic models for disseminated germ cell tumors. Hematol Oncol Clin North Am 2011; 25:557-76, viii -ix. [PMID: 21570609 DOI: 10.1016/j.hoc.2011.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite an excellent prognosis even for patients with disseminated disease, about 20% to 30% of men with advanced germ cell tumors are refractory to first-line chemotherapy or experience disease recurrence after an initial remission with such treatment. Many of these are cured with conventional dose cisplatin/ifosfamide-based regimen or high-dose chemotherapy with stem cell rescue. Controversy exists regarding the optimal choice between these 2 second-line approaches, and available data for each is reviewed here. Clinical factors can help prognosticate patients, and recently an international effort developed a prognostic model for the second-line setting that can be universally applied in future studies.
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Affiliation(s)
- Martin H Voss
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Durand X, Avances C, Flechon A, Mottet N. Récidives tardives des tumeurs germinales du testicule. Prog Urol 2010; 20:416-24. [DOI: 10.1016/j.purol.2010.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 10/02/2009] [Accepted: 02/09/2010] [Indexed: 12/01/2022]
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24
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Nicolai N, Necchi A, Gianni L, Piva L, Biasoni D, Torelli T, Stagni S, Milani A, Pizzocaro G, Salvioni R. Long-term results of a combination of paclitaxel, cisplatin and gemcitabine for salvage therapy in male germ-cell tumours. BJU Int 2009; 104:340-6. [DOI: 10.1111/j.1464-410x.2009.08453.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Necchi A, Nicolai N, Salvioni R. Does oxaliplatin and paclitaxel combination show an activity of some extent in pretreated patients with germ-cell tumors? Ann Oncol 2008; 19:1509. [DOI: 10.1093/annonc/mdn371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Wheater MJ, Mead GM, Bhandari S, Fennell J. Recombinant Factor VIIa in the Management of Pulmonary Hemorrhage Associated With Metastatic Choriocarcinoma. J Clin Oncol 2008; 26:1008-10. [DOI: 10.1200/jco.2007.14.8486] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Matthew J. Wheater
- Department of Medical Oncology, Southampton General Hospital, Southampton, United Kingdom
| | - Graham M. Mead
- Department of Medical Oncology, Southampton General Hospital, Southampton, United Kingdom
| | - Sandeep Bhandari
- Department of Haematology, Southampton General Hospital, Southampton, United Kingdom
| | - Jonathan Fennell
- Department of Critical Care, Southampton General Hospital, Southampton, United Kingdom
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28
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De Giorgi U, Rosti G, Ciucci G, Kopf B, Minzi C, Argnani M, Marangolo M. Multiple cycles of PBPC-supported high-dose carboplatin and paclitaxel following mobilization with epirubicin and cisplatin are feasible but ineffective in treating patients with advanced non-small cell lung cancer. Bone Marrow Transplant 2007; 40:735-9. [PMID: 17700603 DOI: 10.1038/sj.bmt.1705793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We verified the feasibility of a multi-cycle peripheral blood progenitor cell (PBPC)-supported high-dose chemotherapy (HDC) regimen in patients with non-small cell lung cancer (NSCLC). The HDC regimen consisted of a single course of high-dose epirubicin given in combination with cisplatin plus filgrastim, followed by three courses of high doses of carboplatin and paclitaxel with PBPC reinfusion and filgrastim. Of the 16 enrolled patients, 13 provided an adequate number of PBPCs by a single leukapheresis, while in the three needed two procedures, with a median number of CD34+, CD34+/CD33- and CD34+/CD38- cells collected per patient was 13.5 x 10(6), 10.9 x 10(6) and 0.9 x 10(6)/kg, respectively. No toxic death occurred, and the collected PBPCs supported a rapid hematopoietic reconstitution after HDC; however, seven patients early interrupted the treatment early due to early progressive disease (n=4) or prolonged grade 3 peripheral neurotoxicity (n=3). Despite an overall response rate of 42%, the median survival for stage IV patients has been 5 months (range: 1-25+). Of two patients with stage IIIB NSCLC, one is continuously disease-free at 71+ months, while of 14 with stage IV disease, one is currently alive with disease at 25+ months. In conclusion, the combination of high-dose epirubicin with cisplatin plus filgrastim is an effective regimen in releasing large amounts of PBPCs, which can then be safely employed to support multiple courses of HDC. Multiple cycles of PBPC-supported high-dose carboplatin and paclitaxel are ineffective in treating patients with advanced NSCLC.
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Affiliation(s)
- U De Giorgi
- Istituto Oncologico Romagnolo-Department of Oncology and Hematology, Santa Maria delle Croci Hospital, Ravenna, Italy.
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29
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Abstract
PURPOSE OF REVIEW Preclinical and clinical developments in germ cell tumors over the past year are summarized. RECENT FINDINGS Attenuations in the rising incidence of testicular germ cell tumors are beginning to be observed in certain European populations. Additional data on predisposing factors related to race, estrogenic exposure, cryptorchidism, and infertility are becoming available. Significant work on the genetic and molecular alterations in tissue specimens and cell culture models of germ cell tumors continues. Additional treatment strategies for advanced stages of the disease are being evaluated. Cardiovascular and metabolic consequences of therapies in long-term testicular germ cell tumor survivors are being further clarified. Late relapses of successfully treated patients are also being increasingly recognized. SUMMARY More effective treatments for intermediate risk, poor risk, and recurrent germ cell tumors need to be developed, while long-term toxicities of therapies need to be further modified. Given these challenges, active research on these fronts continues and remains a priority.
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Affiliation(s)
- Benjamin Bridges
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Shamash J, Powles T, Ansell W, Berney D, Stebbing J, Mutsvangwa K, Wilson P, Asterling S, Liu S, Wyatt P, Joel SP, Oliver RTD. GAMEC--a new intensive protocol for untreated poor prognosis and relapsed or refractory germ cell tumours. Br J Cancer 2007; 97:308-14. [PMID: 17609665 PMCID: PMC2360316 DOI: 10.1038/sj.bjc.6603865] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
There is no consensus as to the management of untreated poor prognosis or relapsed/refractory germ cell tumours. We have studied an intensive cisplatin-based regimen that incorporates high-dose methotrexate (HD MTX) and actinomycin-D and etoposide every 14 days (GAMEC). Sixty-two patients were enrolled in a phase 2 study including 27 who were untreated (IGCCCG, poor prognosis) and 35 with progression despite conventional platinum based chemotherapy. The pharmacokinetics of the drugs were correlated with standard outcome measures. Twenty of the untreated patients were progression free following GAMEC and appropriate surgery, as were 18 individuals in the pretreated group. None of the established prognostic factors for therapy for pretreated patients could identify a poor-prognosis group. Five out of nine late relapses to prior chemotherapy were progression free following GAMEC and appropriate surgery. All patients had at least one episode of febrile neutropenia and there were five (8%) treatment-related deaths. PK values were not predictive of efficacy or toxicity, although the dose intensity in the pretreated group of patients, especially of HD MTX, was significantly correlated with progression-free survival (PFS). GAMEC is a novel intensive regimen for this group of patients producing encouraging responses, although with significant toxicity. For those in whom it fails, further therapy is still possible with durable responses being seen.
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Affiliation(s)
- J Shamash
- Department of Medical Oncology, St Bartholomew's Hospital, London, UK.
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Shamash J, Powles T, Mutsvangwa K, Wilson P, Ansell W, Walsh E, Berney D, Stebbing J, Oliver T. A phase II study using a topoisomerase I-based approach in patients with multiply relapsed germ-cell tumours. Ann Oncol 2007; 18:925-30. [PMID: 17355956 DOI: 10.1093/annonc/mdm002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The outcome of patients with germ-cell tumours (GCTs), who relapse more than once or relapse with a mediastinal primary is poor. We have shown that topoisomerase 1 may be an attractive target in relapsed GCT. We investigated the role of irinotecan, paclitaxel and oxaliplatin (IPO) followed by topotecan-based high-dose therapy in responding patients, in this patient population. PATIENTS AND METHODS Twenty-eight patients with multiply relapsed gonadal and mediastinal GCT were recruited to this phase 2 study. All patients received IPO chemotherapy and 12 (43%) went on to receive high-dose therapy. The outcome of these patients was assessed using the Kaplan-Meier method with a median progression-free follow-up of 1 year. RESULTS Twenty patients (71%) responded to the therapy including five complete remissions (18%), 13 (46%) marker-negative partial responses and two (7%) marker-positive partial responses. Nine (32%) patients continue to be progression free, and the median survival for the whole group currently measures 17 months. Out of 12 individuals who received subsequent high-dose therapy consolidation, seven (58%) remain progression free. The commonest grade III/IV toxicity was infection (68%) and there were no IPO-related toxic deaths; there was one death from high-dose therapy. CONCLUSION Topoisomerase I-based IPO chemotherapy that lacks etoposide is very active in multiply relapsed GCT. This data merit further investigation.
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Affiliation(s)
- J Shamash
- The Department of Medical Oncology, St Bartholomew's Hospital, London, UK.
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