Increasing the dose intensity of chemotherapy in poor-prognosis metastatic non-seminoma.
The overall cure rate of patients with metastatic non-seminoma of the testis is high and a recent survey of 795 patients by the Medical Research Council indicated that 85% were alive 3 years after the start of chemotherapy. Two major categories of patients can be identified with a poorer prognosis. First are those with adverse prognostic factors at presentation defined by presence of one of the following factors: high tumour markers, more than 20 lung metastases, liver bone or brain metastases, mediastinal mass more than 5 cm. In these patients, the RMH is investigating accelerated chemotherapy employing a 7 day cycle, combined carboplatin and cisplatin and infusional bleomycin (C-BOP regimen). Of 21 patients followed for a median of 18 months, 18 (85%) have remained continuously disease free. The second adverse group are patients who have already failed first line chemotherapy. A multivariate prognostic factor analysis on 105 patients treated at the Royal Marsden Hospital indicates that adverse factors for salvage chemotherapy are the disease-free interval and the extent of disease at relapse. Our approach to patients with disseminated relapse includes high dose carboplatin and etoposide with autologous bone marrow support. With follow-up from 3-24 months, 7 of 11 patients treated with high dose chemotherapy remain continuously free from progressive disease. The need for an alkylating agent in the high dose combination is questionable.