autologous blood and marrow transplantation - Blog Science ...

High-Dose Chemotherapy in the Management
of Germ Cell Tumors
Rafat Abonour, Kenneth Cornetta, Craig R. Nichols,
Lawrence Einhorn
Indiana University Cancer Center, Section of Hematology/Oncology,
Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
ABSTRACT
Although the majority of patients with disseminated germ cell tumors (GCT)
are cured with first-line therapy containing cisplatin, etoposide, and bleomycin
(BEP), 20-30% of patients are not cured with this treatment. The use of
vinblastine, ifosfamide, and cisplatin (VelP) as a second-line therapy cures about
30% of patients. High-dose chemotherapy (HDCT) is used early in the
management of germ cell tumors in two settings: first, as initial salvage therapy,
and second, as first-line therapy in patients with newly diagnosed poor-prognosis
disease. The latter is given in an intergroup trial that compares the efficacy of two
cycles of BEP followed by two cycles of high-dose carboplatin, etoposide and
cyclophosphamide with autologous bone marrow (BM) or peripheral blood
progenitor cells (PBPC) to four cycles of BEP. This trial is accruing well, with >90
patients enrolled to date. Earlier observations from a single institution
demonstrated the feasibility of this approach. When the outcome of HDCT was
compared with that of a historical group treated with conventional therapy, there
was a significant advantage to using HDCT. With regard to rescue of HDCT as
initial salvage therapy, we recently reported our results on 49 patients. After
patients received zero to two cycles of cytoreductive therapy consisting of VelP or
a similar regimen, autologous BM (n=10) or PBPC were collected. All patients
were treated with two cycles of etoposide (750 mg/m 2
) and carboplatin (700
mg/m 2
) a day for 3 consecutive days. There was no treatment-related mortality. At
a minimum follow-up of 12 months, 51% of patients are continuously disease-free.
Eleven of the 17 patients (65%) who achieved complete remission with initial
chemotherapy are continuously disease-free, compared with nine of 20 patients
(45%) with partial remission (PR) and negative markers and four of 11 patients
(36%) with PR and positive markers. In contrast to the 69% of patients with good
prognostic factors, only 18% of those with intermediate prognostic factors are
continuously disease-free. These data indicate that high-dose chemotherapy is
effective as initial salvage chemotherapy and has acceptable toxicity.
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