1 Oncologia Medica, 2 Chirurgia Toracica, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Azienda Ospedaliera San Luigi, Orbassano, Italy
*E-mail: luigi.dogliotti@unito.it
The prognosis for patients with relapsed mediastinal germ-cell tumor (MNGCT) is uniformly poor. The condition of platinum refractoriness is an additional negative prognostic factor [1].
We describe the case of a 33-year-old man with MNGCT refractory to salvage chemotherapy, who entered complete remission after single agent docetaxel administration.
The patient had the following cancer history. In October 1999, a mediastinal mass of 8 cm diameter was diagnosed by chest X-ray and computed tomography (CT) scan. Histology after mediastinal resection biopsy revealed a yolk sac tumor. Baseline -fetoprotein (AFP) was >100 000 ng/ml, while human chorionic gonadotropin was within the normal range. The patient underwent four cycles of PEB (cisplatin, etoposide and bleomycin) attaining a partial response at CT staging. However, the AFP values at the end of treatment failed to attain normality (98 ng/ml). He therefore received two chemotherapy cycles with a PVI scheme (cisplatin, vinblastine and ifosfamide), but during the second cycle of salvage chemotherapy AFP increased to 154 ng/ml after an initial decrease. The CT scan showed disease stabilization. The patient was therefore immediately admitted to surgery, which was performed in March 2000. The residual mass was radically resected, AFP decreased to within the normal range (3 ng/ml) and post-chemotherapy histology revealed viable neoplastic germ cells (<10% of total residual mass) scattered within necrotic tissue. The patient underwent two further chemotherapy cycles with cisplatin and etoposide. From April to August 2000, the marker values remained within normality, but unfortunately in September 2000 two subsequent measurements of AFP were 196 ng/ml and 406 ng/ml, respectively. A CT scan of the chest and abdomen, PET (positron emission tomography) scan and brain MRI (magnetic resonance imaging) scan did not reveal disease recurrence. On October 2000, AFP rose to 1600 ng/ml. We decided on a third-line chemotherapy consisting of docetaxel 40 mg/m2 administered intravenously on days 1, 8, 15 and 21 of each 28-day cycle. The AFP serum levels monitored every week showed a progressive decrease, attaining normality (11 ng/ml) after 2 months. The CT scan performed after four cycles still documented no evidence of disease. In February 2003, the patient was disease free and the AFP value was 3.8 ng/ml.
The treatment of patients with primary MNSGCT, refractory to cisplatin-based chemotherapy, who relapse after salvage surgery, is challenging. No known treatment appears to cure or substantially prolong survival [1]. High-dose therapy with carboplatin and etoposide was excluded in this patient since it would have subjected him to severe toxicity with at best a very brief response. Single agent paclitaxel [2, 3] or the combination of paclitaxel and gemcitabine [4] have been found to be active as a third-line approach in patients with germ-cell tumors, but long lasting complete response were rarely observed. To our knowledge, the activity of docetaxel has never been tested in this clinical setting. The >26 months disease free survival obtained with docetaxel in a weekly schedule is therefore noteworthy and makes this case unique. This man has a chance of a cure, since relapse is rare in germ-cell tumor patients who achieve a complete response for >2 years [5].
A. Berruti1, A. Saini1, G. Gorzegno1, M. Tampellini1, P. Borasio2 & L. Dogliotti1*
1Oncologia Medica, 2Chirurgia Toracica, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Azienda Ospedaliera San Luigi, Orbassano, Italy (*E-mail: luigi.dogliotti@unito.it)
References
1. Hartman JT, Einhorn L, Nichols CR et al. Second line chemotherapy in patients with relapsed extragonadal germ cell tumors: results of an international multicenter analysis. J Clin Oncol 2001; 19: 16411648.
2. Bokemeyer C, Beyer J, Meztner B et al. Phase II study of paclitaxel in patients with relapsed or cisplatin-refractory testicular cancer. Ann Oncol 1996; 7: 3134.[Abstract]
3. Amato RJ, Prow DM. Paclitaxel-based chemotherapy for patients with refractory or relapsed nonseminomatous germ cell tumors. Urol Oncol 2000; 5: 134138.[CrossRef][ISI][Medline]
4. Hilton S, Catalano P, Einhorn LH et al. Phase II study of paclitaxel plus gemcitabine in refractory germ cell tumors (E9897): a trial of the Eastern Cooperative Oncology Group. J Clin Oncol 2002; 20: 18591863.
5. Baniel J, Foster R, Gonin R et al. Late relapse of testicular cancer. J Clin Oncol 1995; 13: 11701176.[Abstract]