Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with Stage 1 nonseminoma treated with adjuvant chemotherapy.

OBJECTIVES: To study survival and late events after adjuvant chemotherapy in Stage 1 nonseminoma. METHODS: From 1978 to 1986, all patients had surveillance. From 1986, adjuvant chemotherapy (initially a 3-day regimen of etoposide, bleomycin, and cisplatin, but, more recently, bleomycin, Oncovin, and cisplatin) was offered to patients at a high risk of relapse (greater than 30%). RESULTS: A total of 382 patients with Stage 1 nonseminoma treated between 1978 and 2000 were reviewed. Of the 234 patients treated by surveillance, 71 (30%) had relapses (5 after 2 years), 6 died (2.6%) of germ cell cancer, and 3 developed second primary testicular cancer. Of the 148 men treated with adjuvant chemotherapy, 6 (4%) had relapses and 2 (1.4%) died of chemoresistant cancer. After one course of etoposide, bleomycin, and cisplatin, 3 (6.5%) of 46 developed a relapse; after two courses, 1 (3.6%) of 28 did so; and after bleomycin, Oncovin, and cisplatin every 10 days x2, 2 (2.7%) of 74 patients did so. Of the high-risk patients who were offered adjuvant treatment, 24% declined. As a consequence, the relapse rate of the surveillance patients only fell from 36% to 27% after the introduction of adjuvant therapy, although for the total cohort treated in the adjuvant era, the relapse rate was 16%. CONCLUSIONS: Adjuvant chemotherapy is more effective than retroperitoneal lymph node dissection for reducing the relapse risk in high-risk Stage 1 nonseminoma. However, given the uncertainty about the incidence of postchemotherapy late events, surveillance and retroperitoneal lymph node dissection remain justified alternatives. With positron emission tomography and laparoscopy showing increasing promise in these cases, quality-of-life studies and greater patient involvement in treatment selection are needed.

Carboplatin AUC8 in combination with etoposide and bleomycin in the treatment of intermediate and poor-risk metastatic germ cell tumours: a phase II study.

PURPOSE: Carboplatin has demonstrated significantly poorer response rates in non-seminomatous germ cell tumours. A phase II study of higher than standard doses of carboplatin was conducted because of suspicion that the poorer response might have been due to suboptimal dosing. PATIENTS AND METHODS: A group of 19 patients with advanced germ cell tumours (International Germ Cell Cancer Collaborative Group intermediate and poor prognosis) were treated with carboplatin at an AUC of 8 mg/ml.min (using Calvert's formula) on day 1, etoposide 120 mg/m2 days 1-3 and bleomycin 60,000 U over 2 days (EBCa). Treatment was repeated every 3 weeks and a maximum of four courses was given. RESULTS: Of the 19 patients, 7 (37%) achieved complete remission, of whom 6 (32%) remained long-term progression-free. Post-chemotherapy surgery and further chemotherapy salvaged an additional 26%, leading to an overall disease-free survival rate of 58%. No relationship between outcome and degree of myelosuppression could be established. CONCLUSION: Dose-escalated carboplatin in combination, although feasible, did not improve the results and led to poorer results than those expected with cisplatin-based therapy. There is no evidence that the patients relapsing following this were easier to salvage. Further investigation of this regimen cannot be recommended.

Sixty percent salvage rate for germ-cell tumours using sequential m-BOP, surgery and ifosfamide-based chemotherapy.

BACKGROUND: In germ-cell tumours (GCT), there is continuing controversy over the relative merits of dose dense therapy (increased frequency over a given time) versus vertical intensification (increased dose per fraction). The value of using a cisplatin-based dose dense approach in the salvage setting has not been documented and in addition the role of methotrexate remains uncertain. This paper reviews results from our investigations of these issues. PATIENTS AND METHODS: Between 1987 and 1996, 65 patients with relapsing or refractory germ-cell tumour received weekly m-BOP (methotrexate, bleomycin, vincristine and cisplatin) as salvage therapy. Residual masses were excised if possible and patients progressing after this received cisplatin and ifosfamide based chemotheraphy with or without high dose chemotherapy (HDCT) consolidation. RESULTS: With a median follow-up of 33 months, 34% are progression free following m-BOP, 11% who had surgery for residual masses which showed viable cancers are progression free. A further 15% who progressed following m-BOP with or without surgery were rendered progression free by third-line therapy. CONCLUSIONS: The use of m-BOP as second line therapy with deferment of cisplatin and ifosfamide based treatment to third line therapy with consolidation of third line responses with HDCT, leads to an overall progression-free survival of 60%. It does not appear that M-BOP prejudiced the response to third line therapy suggesting a lack of cross resistance. The potentially lower risk of leukaemia and infertility from m-BOP requires further evaluation.

Primary rectal non-Hodgkin's lymphoma treated with radical radiotherapy.

A male patient with localized low grade stage IEA rectal non-Hodgkin's lymphoma is presented. The treatment of choice suggested by the literature is surgical excision, which, in this patient, would have resulted in abdominoperineal resection. He was successfully treated with radical radiotherapy and is well with no evidence of disease 4 years after treatment. A brief review of the literature on the clinical features, pathology and treatment of this condition is presented.

Outcome and prognostic factors in soft tissue sarcoma in the adult.

PURPOSE: To evaluate the outcome, patterns of failure and prognostic factors in this rare disease in adult patients treated at a single institution in the modern era. METHODS AND MATERIALS: The records of all patients (389 cases) with soft tissue sarcoma in the extremities, torso (excluding retroperitoneum), and head and neck managed between 1980 and 1988 were reviewed. A curative (radical) approach was used in 321 patients of whom 10% were recurrent lesions. The local management consisted of surgery alone in 54 cases, surgery and radiotherapy in 250 and radiotherapy alone in 17. Adjuvant chemotherapy was used as a policy for high grade lesions in the initial five years of the study (98 cases), but was omitted subsequently. RESULTS: Extremity lesions fared more favourably compared to head and neck and torso lesions (p = 0.02) with respect to survival. Extremity and torso lesions had significantly better local control (p < 0.0001) than in the head and neck where local failure was a common cause of death. A multiple Cox regression analysis revealed that resection margins, local extension of tumor, age at diagnosis, and grade correlated with local relapse and distant relapse was also associated with local extension, high grade and in addition, large lesions. Size appeared especially predictive for distant failure, the most common cause of death. Distant failure was not influenced by the use of adjuvant chemotherapy. Patients treated for recurrence in this series had significantly worse survival due to increased distant failure despite similar local control to primary cases. CONCLUSION: This series highlights the overall problem of distant failure in this disease. It also reaffirms the importance of obtaining local control both in the head and neck, where uncontrolled local disease is the major cause of death, and in general since local relapse appears to increase the risk of distant failure. It appears that the current staging systems should be reviewed in the light of the apparent effect of different prognostic factors.

A patient with regressing atypical histiocytosis running a far from benign course.

We describe a case of regressing atypical histiocytosis (RAH) which showed evidence of aggressive local disease and systemic involvement. Both the local response of this patient to low dose radiotherapy and the systemic response to combination chemotherapy were clinically complete and rapidly achieved.

Influence of microscopic residual disease on survival for stage IB and IIA carcinoma of the cervix following intracavitary irradiation.

From 1977 to 1982, 102 patients with Stage IB and IIA carcinoma of the cervix underwent preoperative intracavitary caesium irradiation followed by radical hysterectomy and pelvic lymphadenectomy at the Wessex Radiotherapy Centre. The actuarial 5-year survival rate for Stage IB is 80% and for Stage IIA is 62%. Patients who had microscopic residual disease in the hysterectomy specimen and negative nodes showed an actuarial 10-year survival rate of 62% as opposed to 82% in patients with no residual disease and negative nodes (P less than 0.05).