High‐dose chemotherapy plus peripheral blood stem cell transplantation for patients with relapsed germ cell tumors and active brain metastases

Abstract

Background The optimal management of progressive brain metastases in patients with germ cell tumors (GCTs) remains unsettled. This study reports the management of 25 consecutive patients with relapsed GCTs and progressive brain metastases undergoing high‐dose chemotherapy (HDCT) with peripheral blood stem cell transplantation (PBSCT) at Indiana University from 2006 to 2016. Methods All patients were planned to undergo HDCT, which consisted of carboplatin at 700 mg/m2 on days 1 to 3 plus etoposide at 750 mg/m2 on days 1 to 3, followed by PBSCT on day 5 for 2 cycles. Patients were treated with brain metastectomy, stereotactic radiotherapy or whole‐brain radiotherapy, HDCT alone, or a combination thereof. All 25 patients had progressive brain metastases at the time of initiating HDCT. Patient and disease characteristics, management of brain metastases, and outcomes were measured. Platelet transfusions were given to maintain platelet counts > 30,000/µL; the goal was >50,000/µL when there were signs of prior or active hemorrhaging. Results Twenty‐two of 25 patients completed both courses of HDCT. The median α‐fetoprotein level was 7.5 ng/mL (range, 1.6‐1130 ng/mL), and the human chorionic gonadotropin level was 31.3 IU/mL (range, 0.5‐25,601 IU/mL). At a median follow‐up of 24.5 months (range, 0.4‐117 months), 11 patients (44%) were alive with no evidence of disease, 2 patients were alive with relapsed disease, and 12 patients had died of disease progression or complications from HDCT. Fifteen patients developed progressive brain metastases despite radiation and/or craniotomy before HDCT, and 8 of these patients were alive without evidence of disease. There were no intracranial hemorrhagic events leading to death. Conclusions Patients with relapsed GCTs and progressive brain metastases are curable with multimodality therapy that includes HDCT and peripheral blood stem cell transplantation.

High-dose Chemotherapy in Germ Cell Cancer Patients With Brain Metastases

“…It is well known that survival rates in GCT patients with BM are poor. Published data that are based on retrospective studies and with small sample sizes have reported a 2-year OS of 20.7%,9 a 3-year OS of 34.6%,22 and a median OS of 21.8 months 12. These published rates, however, consider all types of treatment including local, conventional, or HDCT.…”

“…On the contrary, an improvement in OS was not observed in the population with BM at diagnosis. More recently, Kalra et al 12 reported data from 25 patients with relapsed GCT and progressive central nervous system metastases who underwent HDCT. With a median follow-up of 24.5 months (0.4 to 117 mo), 11 patients (44%) were alive, with no evidence of disease.…”

The benefits of etoposide capsules as maintenance therapy for patients with extensive-stage small cell lung cancer: a prospective two-stage, two-center study

“…Studies have shown that SCLC patients with progression after intravenous treatment with an EP regimen still show benefit from oral therapy with etoposide capsules (18). Furthermore, a promising stage II clinical trial reported promising results for patients with germ cell tumors after the oral administration of etoposide capsules, with a lower-than-expected tumor recurrence rate (19).…”

To Transplant or Not to Transplant During the SARS-CoV-2 Pandemic? That Is the Question

“…This patient was treated taking the same aforementioned prophylactic measures; he did not develop major complications during the aplasia phase. The two patients are now well and without evidence of disease [5, 6].…”