Abstract P5-09-14: Understanding and attitudes towards cancer clinical research among breast cancer patients compared to the general population: Prospective cross-sectional study

Background: In 2009 the Irish Platform for Patients' Organisations, Science and Industry (IPPOSI) commissioned research to ascertain the Irish public's understanding and opinion of clinical research (CR) and clinical trials (CT). The aim of this study was to compare attitudes and understanding regarding participation in cancer CT in breast cancer pts treated in a disadvantaged area to those of the general population surveyed by IPPOSI.

Methods: Eligibility criteria included: a cancer diagnosis (dx), attendance at the Mater Hospital, able to complete a questionnaire. We examined: a) demographics b) cancer dx, c) understanding and attitudes towards CR, 4) discussion regarding participation and 5) experience on a CT. Comparison was made between this study and the IPPOSI survey of 1000 members of the Irish public.

Results: 356 pts completed the questionnaire. The majority (58%, n=206) had a history of breast cancer and these results focus on this group. The median age was 56 yr (range: 28-81 yr), 19% were ≥ 65 yr. 87% had adjuvant disease, 13% had advanced cancer. 36% did not complete 2nd level education and 38% reported inaccurate cancer details. Most reported understanding the terms 'CR' (91%) and 'CT' (84%). Nearly half (46%) expressed ambivalence or would decline participation in a CT. Reasons offered for this attitude include: fear of side effects (46%), requiring more information (24%), and inappropriate candidate/age (10%). There was a significant association between the decision to participate in a CT and participant's level of education (p=0.02) and cancer stage (p=0.01). Participants with a low level of education were more likely to decline participation (57%). Participants with advanced cancer were more likely to agree to participate (79%). 47% of the study population used support to help in the decision making process. Family (40%), GP (7%) and members of the CT team (10%) were the forms of support most commonly accessed. 33% had the option to participate in a CT. 86% (n=59) accepted. 9% (n=6) were ineligible. The majority of pts who took part in a CT reported a positive experience (89%) and a positive impact on their quality of life (82.5%). Over 90% of pts would recommend or take part in another CT.

In comparison with the IPPOSI study, breast cancer pts displayed a greater understanding than the Irish public of the terms 'CR' (91% vs 52%) and 'CT' (84% vs 75%). They were more willing than the Irish public to participate in CR (73% vs 42%) and more specifically research involving the donation of blood (78% vs 71%) or supply of medical details (92% vs 67%). However, there was a similar level of reluctance to participate in a 'CT' amongst both groups.

Citation Format: Kelly CM, McCaffrey JA, Kelly CM. Understanding and attitudes towards cancer clinical research among breast cancer patients compared to the general population: Prospective cross-sectional study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-09-14.

Breast cancer detection among Irish BRCA1 & BRCA2 mutation carriers: a population-based study

BACKGROUND

High-risk breast cancer screening for BRCA1/2 mutation carriers with clinical breast exam, mammography and MRI has reported sensitivity of 100 %, but BRCA1/2 mutation carriers still present with interval cancers.

AIMS

We investigated the presentation and screening patterns of an Irish cohort of BRCA1/2 mutation carriers with breast cancer.

MATERIALS AND METHODS

BRCA1/2 mutation carriers with breast cancer were identified in this retrospective cohort study. Records were reviewed for BRCA1/2 mutation status, demographics, screening regimen, screening modality, stage and histology at diagnosis.

RESULTS

Fifty-three cases of breast cancer were diagnosed between 1968 and 2010 among 60 Irish hereditary breast ovarian cancer (HBOC) families. In 50 of 53 women, the diagnosis of breast cancer predated the identification of BRCA1/2 mutations. Breast cancer detection method was identified in 47 % of patients (n = 25): 80 % (n = 20) by clinical breast exam (CBE), 12 % by mammography (n = 3), 8 % by MRI (n = 2). Fourteen women (26 %) developed a second breast cancer. Ten of these patients (71 %) were involved in regular screening; 50 % were detected by screening mammography, 20 % by MRI and 30 % by CBE alone. Six patients (43 %) had a change in morphology from first to second breast cancers. There was no change in hormone receptor status between first and second breast cancers.

CONCLUSION

In this cohort of Irish BRCA1/2 mutation carriers, compliance with screening was inconsistent. There was a 30 % incidence of interval cancers occurring in women in high-risk screening. Preventive surgery may be a more effective risk reduction strategy for certain high-risk women.

Collecting Duct Carcinoma of the kidney: A case report with variable immunohistochemistry

BACKGROUND

Collecting duct carcinoma of the kidney is a rare tumour with distinctive clinical and histopathological features. Management of this malignancy remains a challenge because of advanced stage at presentation and aggressive clinical course.

AIMS

We describe a case of Collecting Duct Carcinoma with variable immunohistochemistry and review the pathology and management.

RESULTS

Our patient died shortly after commencing systemic chemotherapy.

CONCLUSION

Advances in immunohistochemistry have aided in diagnosis of this tumour. Early detection and nephrectomy offer the best chance of cure. Newer chemotherapeutic regimens may improve survival in more advanced disease.

Breast cancer in Irish families with Lynch syndrome

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Background: Breast cancer is not a recognised malignant manifestation of Lynch Syndrome which includes colorectal, endometrial, gastric, ovarian and upper urinary tract tumours. In this study we report the prevalence of breast cancer in Irish Lynch Syndrome families and determine immunohistochemical expression of mismatch repair proteins (MMR) in available breast cancer tissue.

Methods: Breast cancer prevalence was determined among Lynch Syndrome kindreds from two institutions in Ireland, and a genotype phenotype correlation was investigated. One kindred was omitted due to the presence of a biallelic MMR and BRCA1 mutation. The clinicopathological data that was collected on breast cancer cases included age of onset, morphology, and hormone receptor status. Immunohistochemical staining was performed for MLH1, MSH2, MSH6, and PMS2 on all available breast cancer tissue from affected individuals.

Results: The distribution of MMR mutations seen in 16 pedigrees was as follows; MLH1 (n=5), MSH2 (7), MSH6 (3), PMS2 (1). Sixty cases of colorectal cancer and 14 cases of endometrial cancer were seen. Seven breast cancers (5 invasive ductal and 2 invasive lobular cancers) and 1 case of ductal carcinoma in situ were reported in 7 pedigrees. This compared with 4 cases of prostate cancer. Six MSH2 mutations and 1 MSH6 mutation were identified in the 7 Lynch syndrome kindreds. Median age of breast cancer diagnosis was 49 years (range 38-57). Hormone receptor status is available on 3 breast cancer cases at time of abstract submission; all were ER positive and HER 2 negative. All cases had grade 2 or 3 tumours. Final results of immunohistochemistry for mismatch repair protein expression on breast cancer samples are pending and will be reported at the meeting. One breast cancer has been tested to date and demonstrated loss of MSH2 protein expression in an individual carrying an MSH2 mutation.

Conclusions: Breast cancer occurred at an early age and was more common than prostate cancer in Irish Lynch Syndrome pedigrees. All reported breast cancer cases were in kindreds with MSH2 or MSH6 mutations. Enhanced breast cancer screening may be warranted in certain Lynch Syndrome kindreds.

Hypertensison is a significant adverse effect of bevacizumab treatment

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Introduction: Vascular endothelial growth factor (VEGF) is upregulated in many tumours. Bevacizumab (BV) is a recombinant, humanised monoclonal antibody against the VEGF receptor and has shown promising results in phase II / III trials in colorectal cancer, non-small cell lung cancer, renal cell carcinoma, and breast cancer. Hypertension (HT) has been reported in all studies involving BV and management of this is not well established. Methods: The records of patients treated with BV in our institution were analyzed from January to August 2006. Indications for BV therapy, incidence and management of HT, and resulting outcomes were assessed. Results: 71 patients (45 male, 28–84 years) were treated with BV, at a dose of 5mg/kg every two weeks. 87% (n=60) had colon cancer. Lung cancer, renal cell carcinoma, melanoma, and pancreatic cancer accounted for the rest. 20% (n=14) had pre-existing HT. In all of these cases HT was well controlled with medication. 10 patients developed new-onset HT, and 7 patients experienced exacerbation of existing HT. Using the CTCAE(v3.0) guidelines for grading of HT, 5 had grade II and 10 had grade III. HT developed after a median of 15 weeks of BV (range 6–36 weeks), and a median cumulative BV dose of 20mg/kg (range 10 - 85 mg/kg). In the new onset HT cases 8 patients were controlled (BP= 140/90) with a single anti-HT, and one patient needed two or more agents (BP<160/100). In the pre-existing HT cases who needed an adjustment of anti-hypertensives, 3 were controlled (BP=160/100) with two or more agents and 4 patients required dose escalation of a single agent. In 2 patients BV was permanently discontinued. Anti-HT agents used included beta-blockers, ACE-inhibitors and Ca++- channel blockers. Conclusions: HT may develop at any point during treatment with BV. BP should be measured regularly. In this study 14% of patients developed HT de novo, and 50% experienced exacerbation of pre-existing HT. Median time to BV-induced HT was 15 weeks. There is currently no data to define which anti-HT is the best to use. BV is now becoming widely used, and as with all new targeted therapies, it is important that oncologists recognise relatively unusual side effects, and develop appropriate practice guidelines.

No significant financial relationships to disclose.

High dose chemotherapy and stem cell support for poor risk and recurrent nonseminomatous germ cell cancer: initial experience with sequential therapy

BACKGROUND

Approximately 20% of patients with germ cell tumours do not respond fully to standard therapy, or relapse after treatment. The prognosis of these patients is poor with conventional chemotherapy. Preliminary data suggest that they may have a higher durable response rate with high dose chemotherapy and peripheral blood stem cell support.

AIMS

To treat a group of testicular cancer patients, either with relapsed disease or with poor prognostic features initially, with high dose chemotherapy and stem cell support, and evaluate their outcome.

METHODS

Five patients with testicular cancer were treated with high dose chemotherapy and stem cell support. Of these, four underwent this treatment as salvage therapy and one patient with poor prognostic features was treated as primary treatment.

RESULTS

At an average follow-up of 18 months, four patients remain free of disease while one patient has developed relapse.

CONCLUSION

This report provides further support for high dose chemotherapy in this setting although randomised, controlled trials are essential to clarify its use.

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse

PURPOSE

To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting.

PATIENTS AND METHODS

Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months).

RESULTS

Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers.

CONCLUSION

Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

Evaluation of drug delivery and survival impact of dose-intense relative to conventional-dose methotrexate, vinblastine, doxorubicin, and cisplatin chemotherapy in urothelial cancer

The efficacy of dose-intense methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy relative to conventional-dose M-VAC in patients with advanced transitional cell carcinoma is unknown. The outcomes of 33 patients on two successive protocols using dose-intense M-VAC with granulocyte colony-stimulating factor (G-CSF) support were compared with those of 129 patients treated with conventional-dose M-VAC to assess for an impact of dose-intense therapy on long-term survival. The mean relative dose intensity of chemotherapy delivered to the dose-intense cohort was 55% higher than that delivered to the conventional-dose cohort (p = 0.0001). However, no significant differences were observed with regard to response proportion (72% vs. 76%), median survival (13.3 vs. 16.7 months, p = 0.31), or 5-year survival (16% vs. 15%). Growth factor support enabled a statistically significant increase in the delivered dose intensity of M-VAC chemotherapy, but no survival advantage relative to conventional-dose M-VAC was observed.

Phase II trial of pyrazoloacridine as second-line therapy for patients with unresectable or metastatic transitional cell carcinoma

PURPOSE

A phase II trial of pyrazoloacridine (PZA) was conducted to assess its activity and toxicity in patients with advanced transitional cell carcinoma (TCC) refractory to or progressing after one prior cisplatin-, carboplatin- or paclitaxel- based regimen.

PATIENTS AND METHODS

PZA at a dose of 750 mg/m2 was administered to 14 patients as a three-hour intravenous infusion on day 1 every 21 days. Premedication consisted of lorazepam 0.5-1.0 mg prior to each cycle to alleviate central nervous system toxicity. Reduction of subsequent doses was made for hematologic or central nervous system toxicity.

RESULTS

Among fourteen patients evaluable for response, no responses were observed (0% response rate; 95% confidence interval 0% to 23%). The median duration of survival for all patients was 9 months with a median follow-up of 8.5 months. Toxicity to PZA included grade 3 or 4 neutropenia in 8/14 (57%) and grade 3 or 4 thrombocytopenia in 2/14 (14%). Non-hematologic toxicity was mild.

CONCLUSIONS

PZA at this dose and schedule does not have significant single-agent activity in patients with TCC who have failed one prior regimen.

Ifosfamide, paclitaxel, and cisplatin for patients with advanced transitional cell carcinoma of the urothelial tract: final report of a phase II trial evaluating two dosing schedules

BACKGROUND

A combination regimen of ifosfamide, paclitaxel, and cisplatin (ITP), recycled every 4 weeks, was reported in the treatment of previously untreated patients with advanced transitional cell carcinoma (TCC). This study sought to examine ITP at 3-week intervals to assess its feasibility and toxicity, compare the results for different schedules, and assess the impact of prognostic factors and postchemotherapy surgery on outcome.

METHODS

ITP (ifosfamide 1.5 g/m(2) daily for 3 days, paclitaxel 200 mg/m(2) over 3 hours, and cisplatin 70 mg/m(2) on Day 1) was administered to patients with metastatic or unresectable TCC and was recycled every 4 weeks (for 30 patients) or 3 weeks (for 15 patients). Granulocyte-colony stimulating factor was given during each cycle.

RESULTS

Thirty of 44 assessable patients (68%; 95% confidence interval, 52-81%) demonstrated a major response (10 complete responses [23%], 20 partial [45%]), with durations of response ranging from 4 to 36 months. At a median follow-up of 28 months, the median survival was 20 months. Eleven patients (25%) were disease free at last follow-up. Overall toxicity for the 15 patients whose treatment was recycled at 3 weeks was similar to that for patients treated every 4 weeks. Hematologic toxicity included anemia, thrombocytopenia, and febrile neutropenia. Febrile neutropenia was observed in 7 patients (16%) and in 3.3% of cycles of therapy. No Grade 4 nonhematologic toxicity was observed. Grade 3 nonhematologic toxicity included alopecia, renal insufficiency (11%), and neuropathy (9%).

CONCLUSIONS

ITP is an active, well-tolerated regimen for previously untreated patients with TCC of the urothelial tract, resulting in a median survival of 20 months. Treatment can be recycled at 3-week intervals without enhanced toxicity.

Phase I evaluation of sequential doxorubicin gemcitabine then ifosfamide paclitaxel cisplatin for patients with unresectable or metastatic transitional-cell carcinoma of the urothelial tract

PURPOSE

This phase I trial sought to evaluate the toxicity of and determine the maximum-tolerated dose (MTD) for the two-drug regimen doxorubicin and gemcitabine (AG) followed by the three-drug regimen of ifosfamide, paclitaxel, and cisplatin (ITP) in patients with unresectable or metastatic transitional-cell carcinoma.

PATIENTS AND METHODS

Patients received AG every other week for six cycles followed by ITP every 3 weeks for four cycles. Five AG dose levels were investigated, up to doxorubicin 50 mg/m(2) and gemcitabine 2, 000 mg/m(2), to determine the MTD of the regimen. The dose and schedule of ITP were constant: ifosfamide 1,500 mg/m(2) (days 1 to 3); paclitaxel 200 mg/m(2) (day 1); and cisplatin 70 mg/m(2) (day 1). Granulocyte colony-stimulating factor was given between all cycles of therapy.

RESULTS

Fifteen patients enrolled onto this phase I trial. AG was well tolerated at all dose levels, with no grade 3 or 4 myelosuppression. Toxicity experienced with ITP included grade 3 and 4 granulocytopenia in four patients and grade 3 nausea/vomiting in three patients. No grade 3 and 4 neurotoxicity was observed. Eight of 14 assessable patients experienced a major response to AG, including five of six patients treated at the two highest AG dose levels. After completion of AG-ITP, nine of 14 assessable patients had a major response (three complete responses and six partial responses).

CONCLUSION

AG is a well-tolerated and active regimen. Sequential chemotherapy with AG-ITP is also well tolerated, and phase II investigation at the highest dose level is ongoing.

Long-term survival in metastatic transitional-cell carcinoma and prognostic factors predicting outcome of therapy

PURPOSE

The variation in reported survival of patients with metastatic transitional-cell carcinoma (TCC) treated with systemic chemotherapy may be a consequence of pretreatment patient characteristics. We hypothesized that a prognostic factor-based model of survival among patients treated with methotrexate, vinblastine, doxorubicin, and cisplatin chemotherapy could account for such differences and help guide clinical trial design and interpretation.

PATIENTS AND METHODS

A database of 203 patients with unresectable or metastatic TCC was retrospectively subjected to a multivariate regression analysis to determine which patient characteristics had independent prognostic significance for survival. Patients were assigned to three risk categories depending on the number of unfavorable characteristics. Patient selection in phase II studies was addressed by developing a table of expected median survival for patient cohorts that had varying proportions of patients from the three risk categories.

RESULTS

Two factors had independent prognosis: Karnofsky performance status (KPS) less than 80% and visceral (lung, liver, or bone) metastasis. Median survival times for patients who had zero, one, or two risk factors were 33, 13.4, and 9.3 months, respectively (P =.0001). The median survival time of patient cohorts could vary from 9 to 26 months simply by altering the proportion of patients from different risk categories.

CONCLUSION

The presence of baseline KPS less than 80% or visceral metastasis has an impact on survival. Reporting the proportion of patients with zero, one, and two risk factors will facilitate understanding of the relevance of the median survival in phase II trials. Phase III trials should stratify patients according to the number of risk factors to avoid imbalance in treatment arms.

Outcome of postchemotherapy surgery after treatment with methotrexate, vinblastine, doxorubicin, and cisplatin in patients with unresectable or metastatic transitional cell carcinoma

PURPOSE

The role of postchemotherapy surgery for patients with metastatic transitional cell carcinoma (TCC) is controversial. We retrospectively analyzed our experience with patients who underwent postchemotherapy surgery after methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy to assess an impact on long-term survival.

PATIENTS AND METHODS

This report is based on the retrospective analysis of 203 patients with unresectable primary tumors or metastatic TCC, previously reported in five trials of M-VAC chemotherapy. Fifty patients underwent postchemotherapy surgery for suspected or known residual disease. Characteristics of patients selected for surgery, results of surgery, and the impact of surgery on survival were assessed.

RESULTS

In 17 patients, no viable tumor was found at postchemotherapy surgery, pathologically confirming a complete response to chemotherapy. Three patients had unresectable residual TCC. In 30 patients, residual, viable TCC was completely resected, which resulted in a complete response to chemotherapy plus surgery. Ten (33%) of these 30 patients remained alive at 5 years, similar to results observed for patients who attained a complete response to chemotherapy alone (41%). Analysis by baseline extent of disease suggested that patients with unresectable primary tumors or with metastases restricted to lymph node sites were most likely to survive for 5 years.

CONCLUSION

Postchemotherapy surgical resection of residual cancer may result in 5-year disease-free survival in some patients who would otherwise succumb to disease. Optimal candidates include patients whose prechemotherapy sites of disease are restricted to the primary or lymph node sites and who have a major response to chemotherapy.

Phase II trial of intermediate dose methotrexate in combination with vinblastine, doxorubicin, and cisplatin in patients with unresectable or metastatic transitional cell carcinoma

BACKGROUND

This study was undertaken to determine whether the use of intermediate dose methotrexate in combination with vinblastine, doxorubicin, and cisplatin as first-line therapy increases the proportion of major responders and overall survival in patients with unresectable or metastatic transitional cell carcinoma (TCC) of the urothelial tract.

METHODS

Twenty-nine patients with histologically confirmed TCC received methotrexate at a dose of 1000 mg/m2 on Day 1 followed by leucovorin calcium rescue on Day 2 and vinblastine (3 mg/m2), doxorubicin (30 mg/m2), and cisplatin (70 mg/m2) (VAC) on Day 2. Therapy was recycled at 28-day intervals.

RESULTS

Fourteen of 28 patients (50%; 95% confidence interval [CI], 31-69%) achieved a major response, including 6 pathologic or clinical complete responses (CR) and 8 partial responses (PR). Nine patients were rendered disease free after postchemotherapy surgical resection of residual disease (surgical CR), including five patients who had PR and four nonresponders to chemotherapy alone. Five of 18 patients with disease limited to lymph nodes attained CR, in contrast to only 1 of 10 patients with visceral metastatic disease. The median survival for the entire population was 13.6 months.

CONCLUSIONS

The escalation of methotrexate to 1000 mg/m2 in combination with vinblastine, doxorubicin, and cisplatin did not result in a response proportion or median survival superior to that observed with standard dose M-VAC. As previously observed in a Phase II trial of M-VAC, only the attainment of CR was associated with prolongation of survival.

Treatment of patients with transitional-cell carcinoma of the urothelial tract with ifosfamide, paclitaxel, and cisplatin: a phase II trial

PURPOSE

A phase II trial of ifosfamide, paclitaxel, and cisplatin (ITP) was conducted in previously untreated patients with advanced transitional-cell carcinoma (TCC) to assess its efficacy and toxicity.

PATIENTS AND METHODS

Thirty patients with metastatic or unresectable TCC were treated with ifosfamide 1.5 g/m2/d for 3 days with paclitaxel 200 mg/m2 over 3 hours and cisplatin 70 mg/m2 on day 1 of each 28-day treatment cycle. Therapy was continued for a maximum of six cycles. Prophylactic hematopoietic growth factor (recombinant human granulocyte colony-stimulating factor [rhG-CSF]) was given on days 6 to 17 of each cycle.

RESULTS

Twenty-three of 29 assessable patients (79%; 95% confidence interval [CI], 60% to 92%) demonstrated a major response (six complete [CR] and 17 partial [PR]) with response durations that ranged from 5 to 24+ months. Five patients with T4 bladder primary tumors had a major response, two with pathologic CR. At a median follow-up duration of 17.9 months, nine (31%) patients remain disease-free (range, 10+ to 24+). Hematologic toxicity included anemia, thrombocytopenia, and neutropenia; febrile neutropenia was observed in 17% of patients and 4% of cycles. No grade 4 nonhematologic toxicity was observed. Grade 3 nonhematologic toxicity included alopecia, allergy (3%), renal insufficiency (13%), and neuropathy (10%). Dose reductions or drug omissions were necessary for adverse events in seven (23%) patients.

CONCLUSION

ITP is an active, well-tolerated regimen in previously untreated patients with TCC of the urothelial tract. Further study of this regimen in patients with both TCC and non-transitional-cell urothelial tumors is ongoing.

Risk assessment for metastatic testis cancer

Metastatic germ cell tumors represent a model for curable malignancy, with 70% to 80% of patients cured of their disease. Patients with a good prognosis are likely to be cured, and the aim of investigation is to maintain the high cure rate while minimizing toxicity. For patients who fail to achieve a complete response (CR) to therapy, or who relapse after achieving CR, the prognosis is poor--these patients have become the focus of more intensive treatment to increase the cure rate. Distinguishing which patients will require more aggressive therapy ab initio has been the goal of successive attempts to stratify patients into either good- or poor-risk groups to tailor treatment accordingly. A number of analyses have yielded variable factors and differing schemas to classify patients, culminating in the International Germ Cell Consensus Group whose findings have been utilized to develop the new testicular cancer staging system for the American Joint Committee on Cancer (AJCC) and the Union International contre le Cancre (UICC). This article traces the developments in risk assessment that have lead to this consensus, which would prospectively allow comparison among future clinical trials.

Therapy for good risk germ cell tumors

Patients with good-prognosis germ cell tumors are those with the highest likelihood of cure. By identifying pre-treatment risk assignment, these patients may be treated with the most efficacious and least toxic regimens, while poor-risk patients may be selected to receive potentially more toxic combinations to optimize cure rates. The lack of uniform criteria of good-risk disease has been addressed by an international consortium, the International Germ Cell Cancer Collaborative Group. Recommendations for three risk strata, defined by serum tumor markers and specific sites of disease provide reproducible subsets of good-, intermediate-, and poor-risk populations that allow international trial collaborations and direct comparison of good-risk therapies and outcomes. Despite different criteria defining good-risk disease, trials in these patients have successfully eliminated bleomycin from combination regimens, have reduced the number of cycles of therapy, and have proven that carboplatin cannot replace cisplatin. As a consequence of controlled studies, three cycles of bleomycin, etoposide, and cisplatin (BEP) or four cycles of etoposide and cisplatin, using a 5-day etoposide schedule have been established as American standards. In Europe, four cycles of BEP using the 3-day etoposide schedule is considered the standard schedule. Because the schedule of etoposide is not uniform, prospective evaluation is necessary to determine whether the 3-day European standard is the equivalent of the 5-day American standard.

Adjuvant and neoadjuvant chemotherapy for urothelial carcinoma

Transitional cell carcinoma of the bladder is associated with a high relapse rate, locally and systemically, particularly in patients with nodal or soft-tissue involvement, despite radical cystectomy. The responsiveness of the disease to chemotherapy in the metastatic setting has stimulated the use of systemic therapy in earlier stage disease, either before (neoadjuvant) or after (adjuvant) definitive local therapy. Interpretation of the data is hampered by low patient accrual to randomized trials, lack of standardization of local treatment modalities, and the use of a variety of chemotherapy agents and regimens pointing to the difficulty in reaching a consensus as to what constitutes standard therapy. In this article, we review the use of adjuvant and neoadjuvant chemotherapy, the advantages and disadvantages of both approaches, and the recommendations that can be made based on available data. New approaches to improving survival, potentially with organ preservation, include the development of more effective chemotherapy, and the identification of prognostic features-clinical or biologic-that might be a better guide to patient selection.

Combined-modality therapy for bladder cancer

Radical cystectomy remains standard management for patients with locally advanced T2 through T4, N0, M0 transitional cell carcinoma of the urinary bladder. Although radical cystectomy results in excellent local control, 50% or more of patients relapse. Studies have shown that multidrug cisplatin (Platinol)-based chemotherapy prolongs disease-free survival in 10% to 15% of cases and is superior to single-agent cisplatin. These studies led to the application of these regimens in conjunction with surgery and/or radiation therapy in an attempt to preserve bladder function. With this approach, the decision to leave the bladder in place, remove a portion (partial cystectomy), or perform a radical cystectomy is made after assessing the initial response to therapy. Results from neoadjuvant studies have shown that: major responses are observed in at least 50% of patients; bladder preservation can be achieved in 25% to 50%; a pathologic complete response predicts long survival; and patients with deeply invasive lesions (T3b to T4) usually are not candidates for bladder preservation. Whether overall survival is improved has been difficult to ascertain due to such issues as small sample size and case selection. Concurrently, newer surgical approaches with continent diversions have reduced, to some extent, the need for ileal conduits, a factor influencing the bladder preservation approach. Adjuvant chemotherapy, although less well studied, suggests a possible survival benefit for selected patients with a high likelihood of relapse. To optimize patients selection, new prognostic factors are necessary. Many biologic variables based on expression of tumor-related proteins are under study. Combined-modality therapy is not standard management for the majority of bladder-cancer patients. However, it is a viable alternative for those who are committed to preserving bladder function. Additional research is required to determine whether these approaches improve survival and to identify better markers of treatment outcome.

Ifosfamide- and cisplatin-containing chemotherapy as first-line salvage therapy in germ cell tumors: response and survival

PURPOSE

To evaluate the efficacy and toxicity of ifosfamide- and cisplatin-containing chemotherapy as first-line salvage treatment for patients with germ cell tumors (GCT).

PATIENTS AND METHODS

Fifty-six patients with advanced GCT resistant to one prior cisplatin-containing regimen were treated with a salvage chemotherapy regimen of ifosfamide, cisplatin, and either vinblastine or etoposide (VeIP/VIP).

RESULTS

Twenty of 56 (36%) assessable patients achieved a complete response (CR). Thirteen (23%) are alive and continuously free of disease at a median follow-up time of 52 months; the median survival duration was 18 months. Among patients with a testis primary tumor site and a prior CR to first-line therapy, 65% are alive and 41% continuously disease-free, and the median survival time has not been reached. In contrast, for patients with an extragonadal primary tumor or with a testis primary tumor site and an incomplete response (IR) to first-line therapy, 31% are alive and 15% continuously free of disease, with a median survival time of 12 months (P < .03).

CONCLUSION

Ifosfamide- and cisplatin-containing therapy achieves a durable CR in a minority of patients with resistant GCT as first-line therapy. Patients with a primary testis site who relapsed from a CR to first-line cisplatin therapy have a better prognosis than patients with an extragonadal primary tumor site or an IR to first-line therapy. Risk-directed clinical trials to improve response and survival in both subsets are warranted.

Phase II randomized trial of gallium nitrate plus fluorouracil versus methotrexate, vinblastine, doxorubicin, and cisplatin in patients with advanced transitional-cell carcinoma

PURPOSE

A phase II randomized trial of gallium nitrate/fluorouracil (5-FU) versus dose-intense methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) was performed in poor-risk patients with advanced urothelial tract tumors. The efficacy and toxicity of these regimens were compared. Assessment of dose-intense M-VAC as salvage treatment in patients who failed to respond to the gallium nitrate/5-FU regimen was also performed.

PATIENTS AND METHODS

Thirty-four patients who had not received prior systemic chemotherapy were randomized to either arm of the study. All patients had one or more clinical features predicting a low likelihood of durable complete response to standard chemotherapy, ie, weight loss, visceral metastases, and low performance status. Gallium nitrate and 5-FU were each administered by continuous 5-day infusions every 28 days. M-VAC was recycled every 21 days, with prophylactic recombinant human granulocyte colony-stimulating factor (rh-G-CSF).

RESULTS

Two of 17 patients (12%; 95% confidence interval [CI], 1.4% to 36.4%) had a major response to gallium nitrate/5-FU. Sixteen of 17 patients treated with M-VAC (94%; 95% CI, 71.3% to 99.8%) demonstrated a major response. Five of 12 patients who failed to respond to the gallium nitrate/5-FU combination responded to M-VAC as second-line therapy (42%; 95% CI, 15.2% to 72.3%). Median survival for the gallium nitrate and 5-FU arm was 19 versus 17 months for the M-VAC arm, with a median follow-up duration of 35 months (range, 2 to 51) for all patients. Dose-intense M-VAC was associated with a greater incidence of neutropenia and thrombocytopenia.

CONCLUSION

Dose-intense M-VAC is superior to gallium nitrate/5-FU in poor-risk patients (P < .0001). Despite the overall high response rate, the median survival for patients with M-VAC remained unsatisfactory. Similar survival distributions were observed for patients who received investigational therapy followed by cisplatin-based therapy and patients treated with initial cisplatin-based therapy.

Phase II trial of docetaxel in patients with advanced or metastatic transitional-cell carcinoma

PURPOSE

A phase II trial of docetaxel was conducted to assess its efficacy and toxicity in patients with advanced transitional-cell carcinoma (TCC) who had failed to respond to prior cisplatin-based therapy.

PATIENTS AND METHODS

Thirty assessable patients who had failed to respond to or relapsed after one prior cisplatin-containing regimen were treated with docetaxel 100 mg/m2 over 1 hour, every 21 days. All patients were premedicated with dexamethasone and diphenhydramine to reduce allergic reactions. Reductions of subsequent doses were made for severe hematologic toxicity. Prophylactic hematopoietic growth factors were not used.

RESULTS

Four of 30 patients (13.3%; 95% confidence interval [CI], 3.8% to 30.7%) demonstrated a partial response (PR), with durations of response ranging from 3 to 8 months. The estimated median survival duration for all patients is 9 months (95% CI, 6 to 12 months) with a median follow-up time of 14 months (range, 1 to 27). Hematologic toxicity included anemia, thrombocytopenia, neutropenia, and febrile neutropenia. Nonhematologic toxicity included alopecia and mucositis. Fluid retention was not observed and cutaneous toxicity was mild and infrequent. Dose reductions were necessary for adverse events in 18 patients (60%).

CONCLUSION

Docetaxel is an active single agent in previously treated patients with TCC of the urothelial tract. Therapy was well tolerated in this patient population but myelosuppression was frequent. Further study in previously untreated patients, both alone and in combination, is warranted.

Prolonged and continuous percutaneous intra-arterial hepatic infusion chemotherapy in advanced metastatic liver adenocarcinoma from colorectal primary

Sixty patients with advanced metastatic adenocarcinoma of the liver from a colorectal primary were treated by prolonged and continuous intra-arterial hepatic arterial infusion chemotherapy over a period of time from December 1969 through July 1976. A 10-day course of 5-FU was administered in the hospital, and patients were discharged receiving 5-FUDR by continuous arterial infusion through a chronometric infusion pump. Objective responses of 100% were obtained in 15% of patients, 50% response in 39% of patients, and 25% response in 21% of patients. The median survival from onset of treatment was 8.5 months, 6.9 months, and 7 months, respectively, for 100%, 50%, and 25% responders versus 3.6 months for nonresponders. Survivals from onset of treatment were generally less in those with no disease-free interval. No relationship of response to sex and age was found. Patients previously treated with 5-FU intravenously responded to intra-arterial chemotherapy; 13% had a 100% response, and 54% had a 50% response. No relationship of drug dose to response was observed. Drug toxicity was frequently systemic and mild to moderate. Numerous complications occurred due to the catheter, complete or partial thrombosis occurring in 18.6% and 20.8%, respectively, and 30% of patients had displacement of the catheter. The role of partial arterial occlusion in terms of response and survival may be significant. Future studies should involve comparison of direct surgical placement versus percutaneous placement of catheters.

Prolonged and continuous percutaneous intra-arterial hepatic infusion chemotherapy in advanced metastatic liver adenocarcinoma from colorectal primary

Sixty patients with advanced metastatic adenocarcinoma of the liver from a colorectal primary were treated by prolonged and continuous intra-arterial hepatic arterial infusion chemotherapy over a period of time from December 1969 through July 1976. A 10-day course of 5-FU was administered in the hospital, and patients were discharged receiving 5-FUDR by continuous arterial infusion through a chronometric infusion pump. Objective responses of 100% were obtained in 15% of patients, 50% response in 39% of patients, and 25% response in 21% of patients. The median survival from onset of treatment was 8.5 months, 6.9 months, and 7 months, respectively, for 100%, 50%, and 25% responders versus 3.6 months for nonresponders. Survivals from onset of treatment were generally less in those with no disease-free interval. No relationship of response to sex and age was found. Patients previously treated with 5-FU intravenously responded to intra-arterial chemotherapy; 13% had a 100% response, and 54% had a 50% response. No relationship of drug dose to response was observed. Drug toxicity was frequently systemic and mild to moderate. Numerous complications occurred due to the catheter, complete or partial thrombosis occurring in 18.6% and 20.8%, respectively, and 30% of patients had displacement of the catheter. The role of partial arterial occlusion in terms of response and survival may be significant. Future studies should involve comparison of direct surgical placement versus percutaneous placement of catheters.

Complications of long term transbrachial hepatic arterial infusion chemotherapy

A total of 127 transbrachial hepatic artery catheters were placed in 75 patients for prolonged infusion of chemotherapeutic agents for primary and secondary tumors of the liver. Hepatic or celiac artery catheterization was possible in 97.4% of patients. The most frequent major complication was partial or complete arterial thrombosis (30 patients). bleeding at the arteriotomy site and pseudoaneurysm also occurred. Minor complications included displacement of catheter from the hepatic artery in 46, cracks or leaks in the catheter at the arteriotomy site in 21, and clotted catheter in 10 instances. Infection occurred in four patients and loss of radial pulse in seven. In view of a significant increase in survival, the complications did not contraindicate long term intraarterial infusion of chemotherapeutic agents. The no. 5 French blue thin wall 1.24-1.70 mm tubing proved to be easiest to use and least prone to complications. Proper management of these patients by a team approach (nurse, oncologist, and radiologist) helps to minimize the frequency and severity of complications.

The relative roles of gallium-67-citrate scanning and lymphangiography in the current management of malignant lymphoma

The usefulness of gallium-67-citrate scanning and lymphangiography in the detection of iliac and paraaortic lymph node involvement was evaluated in 53 patients with Hodgkin's disease and non-Hodgkin's lymphomas who subsequently underwent laparotomy. Our data suggest that the overall accuracies of the two procedures in this regard are comparable. Although in this anatomic area the gallium scan tends to underestimate the presence of disease (higher false-negative rate), the false-negative rate is quite low. The false-negative rate with lymphangiography is lower than with scanning but it tends to overestimate the presence of disease (higher false-positive rate). It was concluded that gallium scanning should be an integral part of the staging of lymphomas and a schema for their clinical staging based on the use of gallium scanning early in the diagnostic sequence is proposed.

Clinical usefulness of 67gallium scanning in the malignant lymphomas

To determine the clinical usefulness of 67 gallium (Ga) scanning in the evaluation of patients with lymphomas, we reviewed 142 total body Ga scans performed on 44 patients with Hodgkin's disease and 53 patients with non-Hodgkin's lymphoma. Fifty-two per cent (123 of 236) of known disease sites were detected on scan. The false-positive rate was less than 5 per cent. The accuracy of detecting lymphoma varied in individual anatomic areas from 33 per cent in the axilla to 73 per cent in the thorax. In eight patients with bone involvement, all bone lesions were detected on scan. The size of the lesion appeared to influence accuracy, since tumors greater than 3 cm in diameter were more often positive.