BERKELEY, CA (UroToday Inc.) - Testis cancer remains the paradigm of success in the treatment of solid malignancies. Approximately 70% of patients with metastatic testicular cancer are cured with their initial cisplatin-based combination chemotherapy. However, 30% of patients fail and will require salvage therapy.

Dr. Daniel A. Vaena and colleagues at the University of Indiana, School of Medicine report their ?modern era? outcomes in a cohort of high risk patients with metastatic testicular cancer who failed initial chemotherapy. Their findings can be found in the November issue of the Journal of Clinical Oncology.

The cohort of 80 patients studied received high dose chemotherapy (HDCT) between 1988 and 2001. Patients included in this analysis fulfilled one of the following criteria: platinum refractory disease, absolute platinum refractory disease, HCG ³ 1,000mU/mL, alpha-fetoprotein (AFP) ³ 1,000ng/mL or primary mediastinal nonseminomatous germ cell tumor (PMNSGCT).

High dose chemotherapy in these patients required bone marrow transplant with stem cells collected either from bone marrow (65%) or peripheral-blood. High dose chemotherapy consisted of carboplatin with etoposide. A few patients also received ifosfamide as part of a different clinical trial. The primary end points of the study were two-year failure-free survival and two-year overall survival.

Twenty-five of 80 patients (31%) obtained a complete remission. Eleven additional patients (14%) had a partial remission with negative markers, and 4 of these 11 ultimately had resection of a residual mass. Twenty-two patients (27.5%) did not respond to high-dose chemotherapy. Prior to 1994 five patients died of bone marrow transplant-related complications.

Median survival for the group was 14.7 months with a 2-year predicted overall survival of 40% and a 2-year predicted failure-free survival of 32%.

No relapse occurred after 2 years of follow up of the continuously disease-free patients. Twenty had initial complete remission and 4 others had negative markers with radiographic disease that was stable or decreasing. All four of these latter patients had resection of their residual masses. Seven additional patients with negative markers and a stable residual mass but who did not have surgery eventually relapsed or died.

The Beyer Prognostic Score further evaluated patients? outcome, where one point was given to patients with platinum-refractory disease, primary mediastinal disease or progressive disease after high-dose chemotherapy. Two points would be assigned for absolute-platinum refractory disease or an HCG> greater than 1,000. Using this system patients with > 2 points in the Beyer Score, platinum-refractory patients, patients with HCG> than 1,000 mU/mL, AFP > 1,000 mg/mL and PMNSGCT had 2-year failure-free survival of 30%, 37%, 26%, 18% and 0% respectively.

This study demonstrates that despite the overall high initial success rates in treating testis cancer, a subset of patients continues to do poorly. Until we find improved modalities for treating this subset of patients, it is felt that they should continue to undergo aggressive, high dose salvage chemotherapy treatment. Study data helps to define parameters for these patients, especially those with PMNSGCT, all of whom failed aggressive therapy.

J Clin Oncol 2003;21:4100-4104