CHEMOTHERAPY IN DISSEMINATED TESTICULAR CANCER

The chemotherapy of disseminated testicular cancer is subject to continuous change and further improvement. Because of the high efficacy, with a curability over 90 % for patients with good prognostic criteria, ongoing trials investigate how far the toxicity can be reduced without a negative impact on the cure rate. Besides the standard protocols for good risk (PEB x 3, PE x 4) the substitution of cisplatinum by carboplatinum (CEB) or bleomycin by vinblastine (VPV; CEV) is currently being tested in prospective randomized trials. In patients with poor prognostic criteria, e. g. advanced disease according to the Indiana classification, the cure rate is only 50-60 % with standard PEB x 4. The substitution of bleomycin by ifosfamide (PEI) seems to improve this result significantly, whereas dose escalation of platinum to double dose alone is not effective. A major advance can be expected from the early introduction of very high dose chemotherapy, within the first weeks of induction chemotherapy either by administration of megadose chemotherapy as a single cycle or by administration of sequential intermediate-dose cycles, using haematopoietic growth factors and peripheral blood progenitor cells. These types of dose-intensive regimens will be compared with standard PEB or PEI in prospective randomized trials in poor risk nonseminomatous germ cell tumours in first-line treatment as well as for salvage chemotherapy. For seminoma, however, due to the high platinum sensitivity the possibility of a carboplatinum single-agent chemotherapy for good risk seminoma patients is currently being investigated in prospective trials. The development of these new treatment strategies needs even more intense cooperation and joint effort from specialists in urology, surgery, radiotherapy, haematology, and medical oncology.