1Department of Medicine, Institut Gustave Roussy, Villejuif Cedex, France.
Background: Approximately 30% of patients with metastatic germ cell tumors require salvage chemotherapy for recurrent or refractory disease after first-line treatment. The optimal salvage chemotherapy regimen remains to be determined.
Methods: Fifty-four patients with metastatic germ cell tumors who failed to be cured with first-line therapy, were treated with a salvage VIP/VeIP regimen including cisplatin (20 mg/m2/d dl to d5), ifosfamide (1.2 gm/m2/d dl to d5), and either etoposide (75 mg/m2/d dl to d5) or vinblastine (0.11 mg/kg/d dl and d2) for 5 consecutive days every 3 weeks.
Results: A complete remission was observed in 24 patients (44%) at completion of VIP/VeIP chemotherapy. In 17 patients (31%), complete remission was reached with chemotherapy alone, whereas four (7%) were rendered tumor-free by resection of the residual inactive tumor. Three patients (6%) became tumor-free by resection of the residual carcinoma. Ten other patients (19%) achieved a partial response, with normalization of serum tumor markers. Eleven of those thirty-four patients additionally received high-dose chemotherapy with hematopoietic stem cell support as consolidation treatment. Twenty patients (37%) were judged to be treatment failures because of either incomplete response (3 patients) or progression of disease (17). Myelotoxicity was severe, but no toxicity deaths were noted. After a median follow-up of 30 months, 23 patients (43%) are alive, 16 of whom (30%) are without evidence of progression of disease. Among patients who received high-dose chemotherapy, the relapse-free survival was 63% compared with 35% for patients who did not receive this consolidation treatment.
Conclusions: Currently available salvage chemotherapy with ifosfamide and cisplatin is predicted to cure approximately 30% of the patients who have failed first-line treatment. Whether high-dose chemotherapy with hematopoietic stem cell support after salvage VIP/VeIP could improve these modest results remains to be confirmed in a randomized study.