BEP
Bleomycin, 30 units i.v. on days 1, 8, and 15 or on days 2, 9, and 16
Etoposide (VP-16), 100 mtg/m2 i.v. days 1–5
Cisplatin, 20 mg/m2 i.v. from days 1–5
EP
Etoposide (VP-16), 100 mg/m2 on days 1–5
Cisplatin, 20 mg/m2 i.v. on days 1–5
VeIP
Vinblastine 0.11 mg/kg i.v. on days 1–2
Ifosfamide 1,200 mg/m2 i.v. on days 1–5
Cisplatin 20 mg/m2 i.v. on days 1–5
Mesna 400 mg/m2 i.v. daily every 8 h on days 1–5
VIP
Etoposide 75 mg/m2 on days 1–5
Ifosfamide 1,200 mg/m2 on days 1–5
Cisplatin 20 mg/m2 on days 1–5
Mesna 400 mg/m2 i.v. daily every 8 h on days 1–5
TIP
Paclitaxel, 250 mg/m2 i.v. on day 1
Ifosfamide, 1,500 mg/m2 i.v. daily on days 2–5
Mesna, 500 mg/m2 i.v. before, and then 4 and 8 h after each dose of ifosfamide
Cisplatin, 25 mg/m2 i.v. daily on days 2–5
All regimens are given on 21-day cycles
B. Testicular nonseminoma
1. Stage I. For patients with disease confined to the testicle and whose serum tumor markers (if elevated pre-orchiectomy) normalize, 70% of these individuals are already cured of their disease with the orchiectomy and will never relapse. Therefore, any additional therapy (surgery, chemotherapy) will unnecessarily cause toxicity in these individuals. Additionally, in the 30% destined to relapse after orchiectomy, their close follow-up should have assured a relatively small tumor burden at relapse, which is associated with a >95% cure rate with subsequent chemotherapy. For that reason, active surveillance represents the best option for these patients. In a recent multicenter study evaluating 1,139 patients with nonseminoma undergoing surveillance after orchiectomy, there were 221 (19%) relapses, including 81 out of 183 (44%) patients with LVI, 132 out of 934 (14%) without LVI, and 8 out of 21 (38%) with unknown LVI status. The median time to relapse and percentage of relapses within 3 years were 4 months and 98% for patients with LVI and 8 months and 93% for those without LVI. The overall 5-year disease-specific survival was 99.7% (J Clin Oncol 2014, in press). With the patterns of relapse, the authors suggested that the surveillance include physical examination and tumor markers every 2 months on the first year, every 3 months on the second year, and every 6 months from the third to fifth year. Chest radiograph and CT scan of the abdomen was recommended at 4, 8, 12, 18, and 24 months after orchiectomy, with consideration for repeating CT scan at 36 and 60 months.
Traditionally these patients were treated surgically with a full, bilateral retroperitoneal lymph node dissection, developed at a time when systemic curative chemotherapy had not been yet developed. Despite modifications to this approach over the past several decades (modified template dissections, nerve-sparing approaches, etc.), this procedure is being offered much less frequently. As a result, with the exception of high volume testicular cancer centers, fewer urologists are being trained in this technique and its utilization will continue to fade in the clinical stage I patient.
2. Stage II. Patients with stage IIA and negative serum tumor markers should be treated with NS-RPLND, whereas four cycles of EP or three cycles of BEP remains an alternative option. For patients with stage IIB and negative serum tumor markers, the primary option is chemotherapy with four cycles of EP or three cycles of BEP. In case of complete response or residual tumor less than 1 cm after chemotherapy, there is no need for additional therapy. However, tumors measuring 1 cm or more after chemotherapy should be treated with NS-RPLND. Patient with persistently elevated serum tumor markers should be treated with chemotherapy.
3. Stages IIC and III. Patients with advanced nonseminoma, similar to those with seminoma, should be classified according to the IGCCCG criteria as having either good, intermediate, or poor-prognosis disease.
a. Good-risk patients. This category includes 56% of patients and is associated with a 5-year overall survival of 92%. The recommended treatment is four cycles of EP or three cycles of BEP, which have been shown to have similar efficacy. The substitution of carboplatin for cisplatin in either EP or BEP has been associated with inferior outcomes.
b. Intermediate- and poor-risk patients.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
