title: The importance of the dose of etoposide in the initial treatment of metastatic germ cell tumors and advances in management of patients that relapse.
abstract: OBJECTIVE
  The primary objective was to evaluate the effect of etoposide dose in a 3-day cisplatin/etoposide/bleomycin (PEB) regimen on progression free survival (PFS) and overall survival (OS). Secondary objectives were to determine the impact of a paclitaxel-based salvage regimen on OS and to compare the risk distribution of germ cell patients seen at a tertiary care center to that quoted in the International Germ Cell Consensus Classification (IGCCC).
  
  
  METHODS
  A retrospective chart review of all 302 metastatic germ cell patients requiring cisplatin-based chemotherapy between January 1980 and December 2004 was conducted. Data collected on initial treatment included the dose of etoposide: 500 mg/m2/cycle (E500) or 360 mg/m2/cycle (E360) and whether the salvage treatment contained paclitaxel or not. PFS and OS were calculated. Patients were risk stratified as per IGCCC variables.
  
  
  RESULTS
  The relapse rate and overall survival for E500 was 3% and 97% respectively compared to a relapse rate and OS rate of 29% and 80% respectively for E360. The addition of paclitaxel to salvage chemotherapy regimens for patients that relapsed results were 1/5 (20%) of patients dying compared to 26/39 (67%) for those who received a non-paclitaxel based salvage regimen. Ninety percent of seminoma patients were good risk and 10% were intermediate risk. Non-seminoma (NSGCT) patients were skewed to the good-risk category: 71% good risk, 10% intermediate risk and 18% poor risk as compared to 56%, 28% and 16% respectively as reported by the IGCCC. Five-year PFS and OS were comparable to those documented by the IGCCC with the exception of the intermediate risk NSGCT patients.
  
  
  CONCLUSIONS
  This review demonstrated that PEB treatment containing higher dose etoposide was superior in terms of PFS and OS. Although the sample size was small, it appeared that paclitaxel containing salvage regimens resulted in superior outcomes compared to previously used salvage regimens. Our center had a similar risk distribution of patients as that quoted by the IGCCC.
authors.affiliation: University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Edmonton, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Marwaha
authors.forename: P M
authors.initials: PM
authors.lastname: Venner
authors.forename: S A
authors.initials: SA
authors.lastname: North
mesh_terms: D000903:Antibiotics, Antineoplastic / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000627:therapeutic use; D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage*; D001761:Bleomycin / Q000627:therapeutic use; D002945:Cisplatin / Q000627:therapeutic use; D018572:Disease-Free Survival; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D005047:Etoposide / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy*; D017239:Paclitaxel / Q000627:therapeutic use; D012189:Retrospective Studies; D016879:Salvage Therapy; D055502:Secondary Prevention; D013736:Testicular Neoplasms / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D000903:Antibiotics, Antineoplastic; D000970:Antineoplastic Agents; D000972:Antineoplastic Agents, Phytogenic; D001761:Bleomycin; D005047:Etoposide; D017239:Paclitaxel; D002945:Cisplatin