autologous blood and marrow transplantation - Blog Science ...

Abonour et al. 391
A more recent extension of this trial at Memorial Sloan Kettering enrolled a
similar population of poor-risk patients with sluggish declines in serum markers. 14
Patients with poor-risk features were begun on VIP; if markers failed to decline by
the predicted half-life, conventional dose therapy was discontinued and the patient
proceeded to two high-dose cycles of carboplatin (1800 mg/m 2
), etoposide (1800
mg/m 2
), and cyclophosphamide (150 mg/kg). Thirty untreated patients were
enrolled, and 16 received VIP alone. Fourteen had conventional therapy truncated
and moved to HDCT due to poor marker decline. Overall, 15 of the 30 (50%)
remain progression-free, a significantly better response rate than that of a historical
group of poor-prognosis patients from the same institution. Again, whether this
represents a therapeutic advance is being assessed in a randomized clinical trial in
poor-risk patients. A large intergroup trial has been started in the United States,
enrolling patients with poor-prognosis disease defined by the new International
Prognostic System and randomizing them to receive either standard therapy (BEP
X four) or high-dose therapy (BEP X two followed by carboplatin, etoposide, and
cyclophosphamide X two). This trial is ongoing; whether it supports or refutes the
role of HDCT in patients presenting with poor-risk disease remains to be seen.
INITIAL SALVAGE THERAPY
Since the overall cure rate for recurrent germ cell tumor with ifosfamidecisplatin
based therapy is 20-25%, the proper next investigative step is incorporation
of HDCT as a component of initial salvage therapy. 15
A recent pilot study at
Indiana University enrolled 25 patients with cisplatin-sensitive disease who were
treated with conventional salvage therapy (usually vinblastine, ifosfamide, and
cisplatin [VelP]) for two courses followed by a single course of high-dose
carboplatin and etoposide. Several preliminary results of this trial merit emphasis.
Only six of the 25 patients enrolled did not enter the transplantation portion of the
protocol. Overall, eight patients obtained a CR, 14 PR, two stable disease, and one
progressive disease. There was only one therapy-related death. With a median
follow-up of 18 months, 14 of the 25 (56%) remain progression-free. Three
additional patients who progressed after protocol treatment are disease-free after
subsequent surgeries or additional chemotherapy. Although it was unclear whether
these results were superior to conventional salvage approaches since these patients
were highly selected, the excellent tolerance of therapy and the high response rate
were encouraging and set the stage for subsequent trials.
A recent study from our institution yielded more insight into the role of HDCT
as an initial salvage therapy. 16
Forty-nine patients with relapsed or refractory
testicular cancer were treated with salvage therapy that included HDCT between
August 1992 and November 1996. Patients with extragonadal primaries were
excluded because of our prior work showing no benefit with this therapy for this