Bleomycin, Etoposide And Cisplatin Research Articles

Juvenile granulosa cell tumor of the ovary associated with hypercalcemia

Juvenile granulosa cell tumors (JGCTs) are rare ovarian neoplasms that typically occur in children and young women. While most JGCTs are diagnosed in Stage IA and can be cured by unilateral oophorectomy alone, the remainders are diagnosed in more advanced stages and may exhibit aggressive behavior despite surgery and chemotherapy. Paraneoplastic hypercalcemia occurs in 5% of ovarian malignancies with small cell and clear cell carcinoma being the commonest ovarian tumors associated with hypercalcemia. Only one case of ovarian JGCT associated with hypercalcemia has previously been documented in the literature. A 25-year-old married childless woman presented with a unilateral ovarian mass associated with profound hypercalcemia and suppressed serum parathyroid hormone-intact (PTH-i) level. After rectifying the hypercalcemia with saline hydration, furosemide, and anti-hypercalcemic drugs, the patient underwent unilateral salpingo-oophorectomy that demonstrated Stage IC ovarian JGCT. The patient received adjuvant chemotherapy with three courses of BEP (bleomycin, etoposide and cisplatin) and to date, ten months after surgery, she is disease-free, eucalcemic, and menstruating normally. This is the second case reported in the literature of ovarian JGCT associated with hypercalcemia. Since serum PTH-i level was suppressed and the hypercalcemia did not recur after resection of the tumor, it is concluded that the hypercalcemia was caused by parathyroid hormone-related protein (PTH-rP) produced by the tumor. It seems that unilateral salpingo-oophorectomy followed by BEP chemotherapy is an appropriate treatment for unilateral Stage IC ovarian JGCT in women desiring to preserve ovarian function and childbearing capacity.

Mixed Germ Cell Tumor of the Testis with Post- Chemotherapy Perineal Tumor Recurrence

We present an 18-year-old man who was treated with four courses of BEP (bleomycin, etoposide and cisplatinum) chemotherapy after left orchiectomy for mixed seminomatous and non- seminomatous germ cell tumor of the testis. He presented four months post-chemotherapy with a left scrotal mass which was excised and histologically diagnosed as granulation tissue. A month later he presented with a perineal and left pararectal mass fungating through the skin, which was treated by excision of the mass. Histopathological examination showed mature teratoma with endodermal components but no malignant elements. At 24 months follow-up the patient was disease-free. It remains speculative whether the scrotal and perineal tumors represent local recurrence or true metastases of post-chemotherapy teratoma. Keywords : testicular tumor, perineal metastasis, surgical removal African Journal of Urology Vol. 13 (3) 2007: pp. 203-205

Long‐term results of first‐line sequential high‐dose carboplatin, etoposide and ifosfamide chemotherapy with peripheral blood stem cell support for patients with advanced testicular germ cell tumor

Standard chemotherapy shows relatively low long-term survival in patients with poor-risk testicular germ cell tumor (GCT). First-line high-dose chemotherapy (HD-CT) may improve the result. High-dose carboplatin, etoposide, ifosfamide chemotherapy followed by autologous peripheral blood stem cell transplantation (PBSCT) was investigated as first-line chemotherapy in patients with advanced testicular GCT. Fifty-five previously untreated testicular GCT patients with Indiana 'advanced disease' criteria received three cycles of bleomycin, etoposide and cisplatin (BEP) followed by one cycle of HD-CT plus PBSCT, if elevated serum tumor markers were observed after three cycles of the BEP regimen. Thirty patients were treated with BEP alone, because the tumor marker(s) declined to normal range. Twenty-five patients received BEP and HD-CT. One patient died of rhabdomyolysis due to HD-CT. Three and six (13% and 25%) out of 24 patients treated with BEP and HD-CT achieved marker-negative and marker-positive partial responses, respectively. The other patients achieved no change. Fifteen (63%) are alive and 14 (58%) are free of disease at a median follow-up time of 54 months. Severe toxicity included treatment-related death (4%). HD-CT with peripheral stem cell support can be successfully applied in a multicenter setting. HD-CT demonstrated modest anticancer activity for Japanese patients with advanced testicular GCT and was well tolerated. This regimen might be examined for further investigation in randomized trials in first-line chemotherapy for patients with poor-risk testicular GCT.

A Case of Metastatic Testicular Cancer Complicated by Tumour Lysis Syndrome and Choriocarcinoma Syndrome

A 26-year-old man was referred to our hospital for treatment of metastatic testicular cancer. The pathological diagnosis was choriocarcinoma with seminoma. Sequential computerized tomography examinations revealed rapidly progressing bulky liver metastases and a lung metastasis. Chemotherapy with bleomycin, etoposide and cisplatin (BEP) was started on the day of admission. Subsequently, the patient suffered from tumour lysis syndrome (TLS) and massive haemorrhage at metastatic sites. The latter complication is also called choriocarcinoma syndrome. To our knowledge, this is the first case report of testicular cancer complicated with both critical conditions. Intensive care and radiological intervention barely prevented a fatal outcome. The urological oncologist should be aware of the potential complications TLS and choriocarcinoma syndrome in cases of rapidly progressive and high-volume choriocarcinoma.

Magnesium Depletion in Patients Receiving Cisplatin-based Chemotherapy

Aims To assess the incidence of hypomagnesaemia, the influence of different cisplatin dosages on the degree of hypomagnesaemia and the effect of routine magnesium supplementation on magnesium levels. Materials and methods Magnesium levels for 214 consecutive patients receiving cisplatin-based chemotherapy were studied. Twenty different chemotherapy regimens were prescribed. Doses ranged from 7 to 51 mg/m 2/week. The interval between cycles ranged from 1 to 4 weeks. The number of evaluable cycles ranged from one to eight. Patients receiving bleomycin, etoposide and cisplatin (BEP) chemotherapy routinely received 60 mmol magnesium per cycle; patients receiving cisplatin, vincristine, methotrexate, bleomycin — dactinomycin, cyclophosphamide, etoposide (POMB–ACE) chemotherapy routinely received 20 mmol magnesium per cycle. For all other chemotherapy regimens, magnesium was not routinely prescribed. Results Baseline magnesium levels were available for 195 patients, 92% were within the normal range. The average level was 0.82 mmol/l. There was a statistically significant decrease in magnesium levels from baseline to the lowest magnesium level (mean = 0.68 mmol/l, standard deviation = 0.13) ( P < 0.0005). The incidence of hypomagnesaemia (serum magnesium < 0.7 mmol/l) at any point during chemotherapy was 43%. Multiple regression analysis showed a significant association between dose, frequency, and number of cycles given, and the degree of hypomagnesaemia ( P = 0.001, P = 0.03 and P < 0.0005, respectively). Routine magnesium supplementation significantly reduced the degree of hypomagnesaemia if sufficient amounts of magnesium are given: 60 mmol magnesium per cycle for a regimen containing 33 mg/m 2/week cisplatin is sufficient; 20 mmol magnesium per cycle for a regimen containing 40 mg/m 2/week cisplatin is insufficient. Conclusions It is recommended that magnesium levels should be measured routinely in all patients receiving cisplatin and that all cisplatin-based chemotherapy regimens should be supplemented routinely with sufficient doses of magnesium (40–80 mmol magnesium per cycle depending on the regimen).

Completion and Toxicity of Induction Chemotherapy for Metastatic Testicular Cancer: An Updated Evaluation of Japanese Patients

Combination of bleomycin, etoposide and cisplatin (BEP) remains the standard chemotherapy for testicular cancer. Since the development of BEP in the 1980s, there has been a considerable advance in supportive therapies, such as granulocyte colony-stimulating-factor and 5-HT3 antagonists. Therefore, we re-evaluated the completion and toxicity of BEP combined with modern supportive care. The medical records of all 42 testicular cancer patients who received induction chemotherapy at Tsukuba University Hospital were reviewed. Toxicities during the induction chemotherapy were graded according to the Japanese CTCAE v3.0. Dose reduction was needed in only three patients. The subsequent chemotherapy was started at the planned 3 week interval or within 3 days of postponement in 89% of the treatment cycles. The average relative dose intensity (RDI) of bleomycin was 0.95, while that for etoposide and cisplatin was 0.97. There was no death due to toxicity. The most frequent toxicity was leukopenia (grade 3 in 44% and grade 4 in 55%). Post-chemotherapy diffusion capacity was significantly decreased in 30% of patients. Two patients developed bleomycin-induced pneumonitis, but recovered successfully. Sixteen patients received second line or salvage chemotherapy after BEP, subsequently. The overall 5 year cause-specific survival rate was 85%. BEP with high RDIs is acceptable if combined with modern supportive care, with acceptable toxicity profile in most patients.

A Phase II Trial of TIP (Paclitaxel, Ifosfamide and Cisplatin) Given as Second-Line (Post-BEP) Salvage Chemotherapy for Patients With Metastatic Germ Cell Cancer: A Medical Research Council Trial

This phase II trial describes the use of TIP chemotherapy (paclitaxel, ifosfamide and cisplatin) as salvage for patients with metastatic germ cell cancer (GCC) who have failed initial BEP (bleomycin, etoposide and cisplatin) chemotherapy. Patients with first relapse following BEP for metastatic GCC, confirmed by biopsy or sequentially rising markers, received four courses of TIP (paclitaxel 175 mg m(-2) day 1, followed on days 1-5 by ifosfamide 1 g m(-2) intravenously (i.v.) and cisplatin 20 mg2 i.v.) at 3-weekly intervals. The primary outcome measure was response to TIP. In all, 51 patients were registered, of whom 43 were eligible for response assessment. Eight achieved complete remission (CR) and 18 a partial remission with negative markers (PR(-ve)); favourable response rate (FRR = CR + PR(-ve)) 60%, 95% CI (44-75%); survival at 1 year was 70% (56-84%) and failure-free survival 36% (22-50%). In the group of 26 patients meeting the 'good-risk' criteria described by the Memorial Hospital, the FRR was 73% (52-88%) compared with 41% (18-67%) for the 17 'poor-risk' patients. These results are inferior to those previously reported for TIP in a single-centre study when it was given more intensively, at higher dose and with growth factor support. Nonetheless, TIP as described here can cure a substantial proportion of patients.

A phase II trial of TIP (paclitaxel, ifosfamide and cisplatin) given as second-line (post-BEP) salvage chemotherapy for patients with metastatic germ cell cancer: a medical research council trial: Mead GM, Cullen MH, Huddart R, Harper P, Rustin GJ, Cook PA, Stenning SP, Mason M, MRC Testicular Tumour Working Party, Medical Oncology Unit, Southampton General Hospital, Southampton, United Kingdom

This phase II trial describes the use of TIP chemotherapy (paclitaxel, ifosfamide and cisplatin) as salvage for patients with metastatic germ cell cancer (GCC) who have failed initial BEP (bleomycin, etoposide and cisplatin) chemotherapy. Patients with first relapse following BEP for metastatic GCC, confirmed by biopsy or sequentially rising markers, received four courses of TIP (paclitaxel 175 mg m−2 day 1, followed on days 1–5 by ifosfamide 1 g m−2 intravenously (i.v.) and cisplatin 20 mg2 i.v.) at 3-weekly intervals. The primary outcome measure was response to TIP. In all, 51 patients were registered, of whom 43 were eligible for response assessment. Eight achieved complete remission (CR) and 18 a partial remission with negative markers (PR−ve); favourable response rate (FRR = CR + PR−ve) 60%, 95% CI (44–75%); survival at 1 year was 70% (56–84%) and failure-free survival 36% (22–50%). In the group of 26 patients meeting the ‘good-risk’ criteria described by the Memorial Hospital, the FRR was 73% (52–88%) compared with 41% (18–67%) for the 17 ‘poor-risk’ patients. These results are inferior to those previously reported for TIP in a single-centre study when it was given more intensively, at higher dose and with growth factor support. Nonetheless, TIP as described here can cure a substantial proportion of patients.

Successful treatment of disseminated extragonadal germ cell cancer with intensive conventional chemotherapy after first-line high-dose chemotherapy

High-dose chemotherapy (HDCT) with peripheral blood stem cell (PBSC) support has been investigated as a first-line treatment in patients with poor risk germ cell cancer. However, effective management of patients with residual cancer after HDCT has not been well addressed, and the outcome in such patients is poor. Here, we report a case of disseminated germ cell cancer successfully treated with intensive conventional chemotherapy after HDCT. A 31-year-old man presented with a bulky mass at the retroperitoneum, which had invaded the lumbar and sacral vertebra, and multiple lung and liver metastases. The patient's serum beta subunit of human chorionic gonadotrophin (beta-hCG) was elevated to 2600 IU (cut-off value <0.1 IU). At the time of diagnosis of poor risk germ cell cancer of extragonadal origin, he underwent two cycles of BEP (bleomycin, etoposide, and cisplatin) chemotherapy and PBSC harvest followed by three cycles of HDCT with PBSC transplantation. The liver metastases disappeared. The retroperitoneal bulky mass and multiple lung metastases shrank but were still present, and the serum beta-hCG level was not completely normalized. An additional three courses of BEP and five courses of VIP (cisplatin, ifosfamide, etoposide) normalized the beta-hCG level. Pathological evaluation of the residual masses revealed no viable cancer cells at either site. The patient is alive without disease recurrence 5 years after completion of chemotherapy.

One Cycle of Bleomycin, Etoposide and Cisplatin plus Two Cycles of Etopeside and Cisplatin Chemotherapy in Selected Patients with Low-Volume Stage II Nonseminomatous Germ Cell Tumor of the Testis

Objective: To assess the feasibility of bleomycin omission from second and third cycles of bleomycin, etoposide and cisplatin (BEP) chemotherapy in low-volume stage II nonseminomatous germ cell tumor patients who achieve a normal tumor marker level after the first cycle of treatment. Materials and Methods: Out of 59 nonseminomatous testicular cancer patients with low-volume retroperitoneal disease, serum markers normalized after the first cycle of treatment in 30 cases. 12 patients completed 3BEP (group 1; years 1994–1998) and other 18 patients received etoposide and cisplatin (EP) as second and third cycles of chemotherapy (group 2; years 1998–2004). Results: All patients from each group achieved complete response with chemotherapy alone or by subsequent resection of teratoma or necrosis. There was no relapse with active cancer after the treatment. All patients remained disease-free during the median follow-up period of 97 and 48 months for groups 1 and 2 respectively. Conclusions: One cycle of BEP plus two cycles of EP chemotherapy was as effective as three standard cycles of BEP. The regimen can be suggested as a less toxic therapeutic alternative in these selected patients. More cases, however, in a prospective randomized setting are required to further verify these data.

869 POSTER Prognostic significance of early predicted time to normalization (TTN) of tumor markers in advanced nonseminomatous germ cell tumors (NSGCT): validation study

Despite a high cure rate in men with testicular cancer, some men in the poor-prognosis group have a less favourable outcome. Poor-prognosis non-seminomatous germ-cell tumours (NSGCT) are defined as those with high tumour markers, non-pulmonary visceral metastases or a mediastinal primary site at presentation. When treated with standard chemotherapy regimens, such as bleomycin, etoposide and cisplatin (BEP), cure rates of less than 50% have been achieved in an international pooled analysis. Some strategies aimed at improving results include the use of multi-agent regimens (e.g. POMB/ACE), intensive-induction chemotherapy (e.g. CBOP/BEP), new chemotherapy drugs, such as ifosfamide, gemcitabine, oxaliplatin, paclitaxel, high-dose chemotherapy, including autotransplantation. To date, no schedule has been proven to be better than standard BEP in randomised trials. We will review the published data relating to first-line and salvage treatment of poor-prognosis NSGCT. To advance the management of this disease, physicians treating poor-prognosis disease are urged to support multi-centre trials, such as the recently launched MRC TE23 study comparing BEP and CBOP/BEP.

The Management of Poor-prognosis, Non-seminomatous Germ-cell Tumours

Despite a high cure rate in men with testicular cancer, some men in the poor-prognosis group have a less favourable outcome. Poor-prognosis non-seminomatous germ-cell tumours (NSGCT) are defined as those with high tumour markers, non-pulmonary visceral metastases or a mediastinal primary site at presentation. When treated with standard chemotherapy regimens, such as bleomycin, etoposide and cisplatin (BEP), cure rates of less than 50% have been achieved in an international pooled analysis. Some strategies aimed at improving results include the use of multi-agent regimens (e.g. POMB/ACE), intensive-induction chemotherapy (e.g. CBOP/BEP), new chemotherapy drugs, such as ifosfamide, gemcitabine, oxaliplatin, paclitaxel, high-dose chemotherapy, including autotransplantation. To date, no schedule has been proven to be better than standard BEP in randomised trials. We will review the published data relating to first-line and salvage treatment of poor-prognosis NSGCT. To advance the management of this disease, physicians treating poor-prognosis disease are urged to support multi-centre trials, such as the recently launched MRC TE23 study comparing BEP and CBOP/BEP.

Retroperitoneal extragonadal germ cell tumor in a patient with Klinefelter's syndrome

A 22-year-old man was diagnosed with retroperitoneal seminoma associated with Klinefelter's syndrome. The tumor was 14 x 12 cm in size and surrounded the superior mesenteric artery. He received induction chemotherapy with bleomycin, etoposide and cisplatin (BEP) followed by salvage chemotherapy with paclitaxel, ifosfamide and cisplatin (TIP). The tumor considerably decreased in size and remains as a poorly defined plaque. At the time of writing, he is being followed closely and is free from progression.

Images in neuro-oncology: brain metastases and leptomeningeal dissemination of nonseminomatous germ cell tumor

A 39-year-old man with a right testicular mass and a 3month history of asthenia was admitted to hospital on June 6. Physical examination evidenced a large, hard right testicle and bilateral cervical nodes. Computerized tomography scanning revealed, in addition, retroperitoneal and lung metastases. Head CT scan was normal on admission. The patient’s a-fetoprotein level was 2414.7 lg/l b-human chorionic gonadotropin level was 2149.3 lg/l and LDH level was 1095 IU/l. On June 16, the right testicle was excised. Histological analysis revealed nonseminomatous germ cell tumor (NSGCT) with elements of embryonal cell carcinoma and endodermal sinus tumor (Figure 1). The patient underwent four courses of chemotherapy consisting of bleomycin, etoposide and cisplatin (BEP). By the end of this treatment, LDH, b-HCG and a-FP were normal, but residual retroperitoneal mass was still observed on CT scan. While waiting for surgery of this retroperitoneal mass, the patient developed partial motor seizures on the left arm. CT scan and cranial MRI were obtained showing bilateral parietal and left cerebellar metastases (Figure 2). Whole brain radiation therapy (10 · 300 cGy) was administered over 2 weeks, reducing the size of the lesions. We then decided to operate the largest metastases (>3 cm large in diameter) and treat with radiosurgery the other two lesions and the bed of the resected one. While waiting for radiosurgery, the patient complained of neck pain, gait difficulty and urinary incontinence. Cranial and spinal MRI were performed (Figure 3), showing massive regrowth of the right parietal metastases and cervical and thoracic leptomeningeal dissemination. Symptoms progressed very rapidly driving the patient lethargic, incontinent and bedridden. By that time, surgery was considered not indicated, and

Pregnancy outcomes and menstrual function after fertility sparing surgery for pure ovarian dysgerminomas.

The medical records of 23 patients with pure ovarian dysgerminoma treated by conservative surgery at SSK Ankara Maternity Hospital between 1991 and 2001 were reviewed retrospectively. Pregnancy outcomes and menstrual function after conservative surgery were analyzed. Seven patients (30%) were incompletely staged and were assumed to be stage IA due to intraoperative findings. Fifteen patients (70%) were surgically staged. As a result 15 patients (65.2%) were diagnosed to be stage I while 2 patients (8.6%) were staged II and 6 patients (26%) were staged III. Wedge biopsy of contralateral ovary was performed in 17 patients (74%) and tumor was diagnosed in 2 (11.7%). Adjuvant chemotherapy was applied in 16 (70%) of the cases. BEP (bleomycin, etoposide, and cisplatin) was the most frequently used regimen (39%). Recurrences were seen in 3 (13%) patients. The sites of recurrences were contralateral ovary in all cases. Recurrences were treated with surgery and radiotherapy. None of the patients died of disease. Nine patients were sexually active. Five of these patients had prior live births. Three of the primiparous patients delivered after treatment. Five pregnancies occurred in 3 nulliparous patients at the time of primary surgery. Three of these reached term and healthy babies were delivered. One pregnancy was terminated at 18 weeks of gestation due to anencephaly and a dilatation and curettage was performed at 6th week in another patient. Menstrual problems occurred in 4 (17.3%) of the 23 patients. Fertility sparing treatments are safe in patients with pure ovarian dysgerminoma.

The management and survival of patients with advanced germ-cell tumours: improving outcome in intermediate and poor prognosis patients.

The survival of germ-cell tumours (GCT) was transformed after the introduction of cisplatin-based therapy. Previous trials have indicated BEP (bleomycin, etoposide and cisplatin) as the optimum treatment, although some centres including our own advocate the use of the alternating regimen POMB-ACE (cisplatin, vincristine, methotrexate, bleomycin and dactinomycin, cyclophosphamide and etoposide) for men with intermediate or poor prognosis disease. We analysed the survival and management of GCT patients treated at a specialist cancer centre in relation to internationally recognised prognostic groupings. We retrieved patient information using the Trent Testicular Tumour Registry and supplemented it with information from patient notes. This included all patients with Royal Marsden Hospital Stage II, III and IV disease and patients with stage I disease at diagnosis with raised markers or subsequent relapse. We compared the efficacy and toxicity of the BEP and POMB-ACE chemotherapy regimens, and assessed relapse-free and overall survival. We identified 178 non-seminomatous germ cell tumours (NSGCT) and 71 seminoma patients. Overall survival was similar to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification for the good (95% vs 92%) and intermediate groups (82% vs 80%). The outcome for the poor prognosis group was better than expected in our series (57% vs 48%). There was a higher proportion of both immediate and late side-effects with POMB-ACE. Survival and disease progression rates at this single institution were at least as good as reported by the IGCCCG and somewhat better for the poor-prognosis group. This may reflect use of the POMB-ACE chemotherapy regimen as opposed to standard BEP regimen. However, a randomised comparison of BEP and POMB-ACE would be required to validate this.

Changes in cellular immunity during chemotherapy for testicular cancer.

The changes in vivo in immunocyte functions during chemotherapy that is administered in combination with granulocyte colony-stimulating factor (G-CSF) in humans have not been fully investigated. This study was designed to examine neutrophil functions and the activities of natural killer (NK) cells, during the administration of chemotherapy and G-CSF for the treatment of testicular cancer. Seven patients with germ cell tumors at stage IIA, IIB or IIIB, who were treated with bleomycin, etoposide and cisplatin (BEP), were enrolled in the study. Numbers and activities of neutrophils and NK cells were measured at various times during and after the first course of chemotherapy. Neutrophil phagocytosis was quantitated by flow cytometry with fluorescent latex beads. Bactericidal activity was measured in terms of colony-forming units. The activity of NK cells was measured by monitoring the release of 51Cr. After BEP chemotherapy, CD16+ and CD56+ cell counts, and neutrophil granulocyte counts decreased while there were no significant changes in the number of lymphocytes. Phagocytosis by neutrophils was enhanced after administration of G-CSF. The activity of NK cells was severely impaired after chemotherapy and did not change after administration of G-CSF. After BEP chemotherapy for testicular cancer with G-CSF, neutrophil function was not at all inferior to those before treatment. Natural killer cell activity was suppressed by the BEP chemotherapy and did not change after administration of G-CSF.

Advanced testis cancer

Advanced testis tumors are highly curable. The treatment strategy is chemotherapy followed by the surgical exeresis of residual disease. The standard chemotherapy regimen is BEP (bleomycin, etoposide, and cisplatin); the number of cycles of chemotherapy depends upon prognostic factors, based on the primary site, histology, presence of visceral metastases, and serum tumor marker levels. Patients in the good-risk group receive three cycles of chemotherapy, whereas those in the intermediate- and high-risk groups receive four cycles. Exeresis of all residual disease and systematic postchemotherapy retroperitoneal dissection in bulky disease are mandatory. When complete exeresis of necrotic tissue, teratoma, or active germ-cell cancer has been performed, no further postsurgical treatment is warranted. A multidisciplinary approach, rigorous administration of chemotherapy, and skill in surgery of germ-cell tumors are favored in the treatment of these patients in trained centers.

Chemotherapy of disseminated germ cell tumors

The fact that germ cell tumors can be successfully managed puts an extraordinary burden on the physician and health care system to ensure that the promise of cure is achieved in all patients except the small proportion that present with advanced refractory disease. Good risk disseminated disease should be treated with three cycles of bleomycin, etoposide and cisplatin (BEP) whereas those with more advanced disease should receive four cycles. Postchemotherapy resection of residual disease is commonly required. In patients in whom disease recurs after primary chemotherapy, salvage treatments can result in cure in 30-40% of patients. Physicians managing these patients should be aware of some of the pitfalls encountered when determining relapse and should be versed in the indications for salvage conventional dose chemotherapy, high dose chemotherapy, and the role of aggressive desperation surgery.

Chemotherapy of Testis Cancer.

BACKGROUND: Prior to the use of cisplatin, durable complete remissions of metastatic testis cancer were rare. In 1977, a treatment program including a chemotherapy program of cisplatin, vinblastine, and bleomycin (PVB) led to high response rates and acceptable toxicities in patients with disseminated testis cancer. Since then, the BEP (bleomycin, etoposide, and cisplatin) regimen has been established as standard therapy for good- and poor-risk disease and ifosfamide-based regimens or high-dose chemotherapy with stem cell rescue as salvage therapy. METHODS: The results of those prospective, randomized clinical trials that have markedly improved the outlook of patients with this type of cancer have been reviewed. RESULTS: Categories of risk have been defined. Standard therapy for both good-risk and poor-risk disease remains BEP therapy. High-dose chemotherapy with autologous bone marrow or peripheral stem cell rescue transplantation is being investigated to overcome chemotherapy resistance. CONCLUSIONS: While the present state of the art for treating metastatic testicular cancer is promising, approximately one third of patients with "poor-risk" disease will not achieve a remission. Trials of new agents and approaches are needed to increase patient survival.