February 23, 2011 (Orlando, Florida) — Computed tomography (CT) scans could prove to be a valuable tool in helping identify late relapses in patients treated for nonseminoma germ cell tumors (NSGCT), according to a study presented here at the 2011 Genitourinary Cancers Symposium (GUCS).
Testicular cancer is the most common solid malignancy that occurs in men 18 to 35 years old. Principal author Robert Huddart, MD, a reader in urological oncology at the Royal Marsden Hospital in London, United Kingdom, pointed out that since cisplatin became available, most patients with metastatic disease are successfully cured. Even so, in recent years, investigators have noted a risk for late relapse (more than 2 years after first-line therapy) in up to 6% of patients treated for NSGCT; some relapses have been seen as much as 30 years after initial treatment.
"Follow-up for these patients is problematic," Dr. Huddart told Medscape Medical News in an interview. "We watch these patients for, say, 5 years, and then think, 'Well, what kind of follow-up should we do now? Do we need to continue?' We simply don't have appropriate strategies."
Another potentially complicating factor, Dr. Huddart said, is that late relapses tend to be governed by different biology than earlier relapses. "With good chemo, we can usually cure early relapsers. But with men who relapse later, it's not as likely that we can cure them with chemotherapy alone; we have to resort to surgery," he said.
The problem is, however, that once late relapses manifest themselves clinically, they can be larger masses that are more difficult to resect surgically. "If we can detect the relapse at an earlier stage, then we could find patients, treat them earlier, and cure them by more straightforward surgery," he explained.
To that end, Dr. Huddart and colleagues have begun investigating the utility of long-term CT surveillance. Since they began the study in 2006, they have recruited 108 patients, about a third of the eventual total they hope to enroll. Eligible patients have been treated for NSGCT, stage IM to stage IV, diagnosed 5 years prior to entry. Median age at diagnosis is 31 years.
Patients undergo CT scans at entry, then 5 years later, and are checked annually using tumor markers and clinical exams.
Results From 88 Patients
Here at the GUCS meeting, interim results were reported from the first patients in the cohort who have reached the 5-year posttreatment threshold and who have undergone repeat CTs.
Dr. Huddart explained that full clinical data are available on 88 patients. Of these, 52 patients initially presented with evidence of teratoma differentiated (TD). At initial treatment, 1 patient had stage IM disease, 45 had stage II disease, 6 had stage III disease, and 36 had stage IV disease.
These patients were initially treated with regimens of bleomycin, cisplatin, and etoposide; carboplatin, bleomycin, vincristine, and cisplatin, followed by bleomycin, etoposide, and cisplatin; or another type of platinum-based regimen.
Twenty-seven of the patients experienced relapse.
In all, 38 of the patients had retroperitoneal lymph node; TD was noted in 28. Ten had metastasectomy, including brain masses (n = 2), a pelvic mass (n = 1, who had TD), pulmonary masses (n = 6, 2 of whom had TD), neck masses (n = 2), and iliac node (n = 1, who had TD).
Scans were normal in 71 patients, Dr. Huddart said, and so far none of those patients have relapsed, although 1 patient died of interval lung cancer.
Abnormalities on radiography were noted in 14 patients, 4 of whom had surgery (3 for retroperitoneal lymph node dissection and 1 for excision of a node in his lung). Two of the masses were benign and 2 had TD. One of the patients had hepatic lesions that, on ultrasound, proved to be cysts. Eight of the patients had small-volume nodal abnormalities that appeared stable on repeat imaging. One of the patients is undergoing annual CT scanning for evaluation of indeterminate lung nodules. Four patients in the cohort are awaiting their initial scans.
Dr. Huddart emphasized that a sizable portion of late relapses appear to originate in areas of TD, which are often found after initial treatment. "Although our results are very preliminary, we're hoping that if we can identify those kinds of areas earlier, we can take action before they cause problems."
He emphasized, however, that it's unclear at the moment whether late CT surveillance will turn out to be worthwhile. "It may be that we're doing a lot of scans but only finding very small numbers of problems," he said, adding that "then there is a downside, since repeat scans are a major stress factor for patients."
Best Center in Europe
Commenting on the study, Nicholas Vogelzang, MD, a clinician at the Comprehensive Cancer Centers of Las Vegas in Nevada, and a member of the 2011 GUCS news planning group, told Medscape Medical News that "this study comes from one of the best testicular cancer research groups in England. It's a really interesting study, finding that a significant portion of these patients have abnormalities that are worrisome and require removal."
Dr. Vogelzang noted, however, that since the study was carried out in Europe, and there might be important epidemiologic differences in that population, compared with the American population, the results, if they hold up in further studies, might not necessarily translate to therapy in patients in the United States. "In some cases, they don't do scans as much as we do here in the United States because of financial restraints in their healthcare programs. So when they do resume scans, it may be that they see a lot of disease, particularly in the lymph nodes and abdomen."
He added, however, that "what the study does say is that 5 years is not enough to conclude that you're cured of testicular cancer. There are still men, even though their markers are negative, who remain at risk beyond that time, and it's important that they be monitored closely."One other physician, Torgrim Tandstad, MD, a medical oncologist at St. Olavs University Hospital in Trondheim, Norway, offered comments on the paper. "It's a very significant study, I'd say, especially since no one else has tried this approach systematically."
He said that in Norway clinicians don't generally use CT, favoring magnetic resonance imaging instead, out of concern about the risk of causing secondary cancer induced by CTs. "Perhaps you could say we're a little more conservative about imaging, because we choose not to routinely expose patients to radiation."
He conceded, however, that if on further study interval CT scanning turns out to be superior to other modalities for monitoring patients with NSGCT, "you'd have a good case for advocating later imaging than what's generally used today."
Dr. Huddart and Dr. Tandstad have disclosed no relevant financial relationships. Dr. Vogelzang reports a leadership position at US Oncology; serving as a consultant for Amgen, Aveo, Bayer, Celgene, Dendreon, Eisai, GE Healthcare, Genentech, GlaxoSmithKline, Medscape, Novartis, Pfizer, Sanofi-Aventis, and Wilex; receiving honoraria from Amgen, ArQule, Bayer, Clinical Care Options, Cougar Biotechnology, Genentech, Imedex, Lilly Lippincott, Williams and Wilkins, Medscape, Novartis, Onyx, Pfizer, and Veridex; and receiving research funding from Algeta, Pfizer, and Tokai Pharmaceuticals.
2011 Genitourinary Cancers Symposium (GUCS): Abstract 223. Presented February 18, 2011.
Testicular cancer is the most common solid malignancy that occurs in men 18 to 35 years old. Principal author Robert Huddart, MD, a reader in urological oncology at the Royal Marsden Hospital in London, United Kingdom, pointed out that since cisplatin became available, most patients with metastatic disease are successfully cured. Even so, in recent years, investigators have noted a risk for late relapse (more than 2 years after first-line therapy) in up to 6% of patients treated for NSGCT; some relapses have been seen as much as 30 years after initial treatment.
"Follow-up for these patients is problematic," Dr. Huddart told Medscape Medical News in an interview. "We watch these patients for, say, 5 years, and then think, 'Well, what kind of follow-up should we do now? Do we need to continue?' We simply don't have appropriate strategies."
Another potentially complicating factor, Dr. Huddart said, is that late relapses tend to be governed by different biology than earlier relapses. "With good chemo, we can usually cure early relapsers. But with men who relapse later, it's not as likely that we can cure them with chemotherapy alone; we have to resort to surgery," he said.
The problem is, however, that once late relapses manifest themselves clinically, they can be larger masses that are more difficult to resect surgically. "If we can detect the relapse at an earlier stage, then we could find patients, treat them earlier, and cure them by more straightforward surgery," he explained.
To that end, Dr. Huddart and colleagues have begun investigating the utility of long-term CT surveillance. Since they began the study in 2006, they have recruited 108 patients, about a third of the eventual total they hope to enroll. Eligible patients have been treated for NSGCT, stage IM to stage IV, diagnosed 5 years prior to entry. Median age at diagnosis is 31 years.
Patients undergo CT scans at entry, then 5 years later, and are checked annually using tumor markers and clinical exams.
Results From 88 Patients
Here at the GUCS meeting, interim results were reported from the first patients in the cohort who have reached the 5-year posttreatment threshold and who have undergone repeat CTs.
Dr. Huddart explained that full clinical data are available on 88 patients. Of these, 52 patients initially presented with evidence of teratoma differentiated (TD). At initial treatment, 1 patient had stage IM disease, 45 had stage II disease, 6 had stage III disease, and 36 had stage IV disease.
These patients were initially treated with regimens of bleomycin, cisplatin, and etoposide; carboplatin, bleomycin, vincristine, and cisplatin, followed by bleomycin, etoposide, and cisplatin; or another type of platinum-based regimen.
Twenty-seven of the patients experienced relapse.
In all, 38 of the patients had retroperitoneal lymph node; TD was noted in 28. Ten had metastasectomy, including brain masses (n = 2), a pelvic mass (n = 1, who had TD), pulmonary masses (n = 6, 2 of whom had TD), neck masses (n = 2), and iliac node (n = 1, who had TD).
Scans were normal in 71 patients, Dr. Huddart said, and so far none of those patients have relapsed, although 1 patient died of interval lung cancer.
Abnormalities on radiography were noted in 14 patients, 4 of whom had surgery (3 for retroperitoneal lymph node dissection and 1 for excision of a node in his lung). Two of the masses were benign and 2 had TD. One of the patients had hepatic lesions that, on ultrasound, proved to be cysts. Eight of the patients had small-volume nodal abnormalities that appeared stable on repeat imaging. One of the patients is undergoing annual CT scanning for evaluation of indeterminate lung nodules. Four patients in the cohort are awaiting their initial scans.
Dr. Huddart emphasized that a sizable portion of late relapses appear to originate in areas of TD, which are often found after initial treatment. "Although our results are very preliminary, we're hoping that if we can identify those kinds of areas earlier, we can take action before they cause problems."
He emphasized, however, that it's unclear at the moment whether late CT surveillance will turn out to be worthwhile. "It may be that we're doing a lot of scans but only finding very small numbers of problems," he said, adding that "then there is a downside, since repeat scans are a major stress factor for patients."
Best Center in Europe
Commenting on the study, Nicholas Vogelzang, MD, a clinician at the Comprehensive Cancer Centers of Las Vegas in Nevada, and a member of the 2011 GUCS news planning group, told Medscape Medical News that "this study comes from one of the best testicular cancer research groups in England. It's a really interesting study, finding that a significant portion of these patients have abnormalities that are worrisome and require removal."
Dr. Vogelzang noted, however, that since the study was carried out in Europe, and there might be important epidemiologic differences in that population, compared with the American population, the results, if they hold up in further studies, might not necessarily translate to therapy in patients in the United States. "In some cases, they don't do scans as much as we do here in the United States because of financial restraints in their healthcare programs. So when they do resume scans, it may be that they see a lot of disease, particularly in the lymph nodes and abdomen."
He added, however, that "what the study does say is that 5 years is not enough to conclude that you're cured of testicular cancer. There are still men, even though their markers are negative, who remain at risk beyond that time, and it's important that they be monitored closely."One other physician, Torgrim Tandstad, MD, a medical oncologist at St. Olavs University Hospital in Trondheim, Norway, offered comments on the paper. "It's a very significant study, I'd say, especially since no one else has tried this approach systematically."
He said that in Norway clinicians don't generally use CT, favoring magnetic resonance imaging instead, out of concern about the risk of causing secondary cancer induced by CTs. "Perhaps you could say we're a little more conservative about imaging, because we choose not to routinely expose patients to radiation."
He conceded, however, that if on further study interval CT scanning turns out to be superior to other modalities for monitoring patients with NSGCT, "you'd have a good case for advocating later imaging than what's generally used today."
Dr. Huddart and Dr. Tandstad have disclosed no relevant financial relationships. Dr. Vogelzang reports a leadership position at US Oncology; serving as a consultant for Amgen, Aveo, Bayer, Celgene, Dendreon, Eisai, GE Healthcare, Genentech, GlaxoSmithKline, Medscape, Novartis, Pfizer, Sanofi-Aventis, and Wilex; receiving honoraria from Amgen, ArQule, Bayer, Clinical Care Options, Cougar Biotechnology, Genentech, Imedex, Lilly Lippincott, Williams and Wilkins, Medscape, Novartis, Onyx, Pfizer, and Veridex; and receiving research funding from Algeta, Pfizer, and Tokai Pharmaceuticals.
2011 Genitourinary Cancers Symposium (GUCS): Abstract 223. Presented February 18, 2011.
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