Should high dose chemotherapy with, or without, autologous bone marrow transplant be included in the primary treatment of testicular cancer? Round table discussion.
Most patients with metastatic testicular cancer can be cured by standard chemotherapeutic regimes but the group of high risk patients fail to respond adequately. The results of salvage chemotherapy trials including high dose chemotherapy (HDCT) plus autologous bone marrow transplantation (ABMT) or peripheral stem cell reinfusion (PSCR) suggest a dose response relationship indicating that the inclusion of HDCT + ABMT/PSCR could also have the potential of increasing survival of high risk patients in first line treatment. Therefore, in a coordinated international clinical trial HDCT + ABMT should be compared with the standard chemotherapy. The standard drug treatment worldwide for testicular cancer is PEB (cisplatin, etoposide, bleomycin) x3 for good risk and x4 for high risk patients, but there is cumulating evidence that VIP (cisplatin, ifosfamide, etoposide) is more effective for poor risk patients. Therefore in the randomized trial standard dose VIP would be compared with high dose carboplatin, etoposide and ifosfamide or cyclophosphamide (CEI or CEC). Because of the toxicity and expense of HDCT + ABMT it must be discussed whether this treatment could be given upfront to all patients with high risk criteria, or only to patients with poor response under standard dose induction chemotherapy (intensification or consolidation). If HDCT is considered for first line chemotherapie the group of patients with very poor prognostic criteria have to be selected very carefully to avoid overtreatment.