Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
Maitri Kalra , Nabil Adra , John Mckay , Rafat Abonour , Nasser H. Hanna , Lawrence H. Einhorn
Background: The optimal management of progressive brain mets in pts with GCT remains unsettled. Treatment options include chemotherapy, stereotactic or whole brain radiation (XRT), surgery, or a combination thereof. Global germ cell cancer group analysis suggested multimodality therapy improves survival probabilities in pts with brain mets at relapse (JCO.2016;1;34(4):345-51). We report our experience on managing 25 consecutive pts with relapsed GCT and progressive brain mets undergoing HDCT with PBSCT at Indiana University from 2006-2016. Methods: All pts received HDCT consisting of carboplatin 700 mg/m2 days 1-3 and etoposide 750 mg/m2 i.v. days 1-3 followed by PBSCT on day 5 for upto 2 cycles. Pts were treated with craniotomy, XRT, chemotherapy alone, or a combination of modalities. Patient and disease characteristics, management of brain mets, and outcomes were measured. Platelet transfusions were given to maintain platelet counts > 30,000 and goal of > 50,000 in those with signs of hemorrhage. Results: Patient characteristics and outcomes are summarized in Table 1. Median age was 27.7 years (range, 16-48). All pts had progressive brain mets at time of starting HDCT. AFP ranged 1.6 to 1130, hCG 0.5 to 25601. At median follow-up of 24.8 months (range 2.5 to 118.5 months), 11 pts (44%) were alive with NED, 2 pts were alive with relapsed disease, and 12 pts died of disease progression. 17/18 patients developed progressive CNS mets despite radiation and/or craniotomy and of those, 8 are alive with NED. Toxicity was as previously published with this regimen (N Engl J Med 2007;357:340-8). Conclusions: Patients with relapsed GCT with progressing brain mets, including those with prior locoregional therapy, are curable with HDCT.
Characteristic (N) | Alive with NED (11) | Dead of disease (12) | Alive with relapsed disease (2) |
---|---|---|---|
CNS as primary presentation (7) | 4 (36.37%) | 3 (25%) | - |
Predominant histology of craniotomy specimen (13) | |||
Embryonal carcinoma (5) | 4 | 1 | - |
Yolk Sac (6) | 3 | 3 | - |
Teratoma (1) | 1 | 0 | - |
Negative for malignancy (1) | 1 | - | - |
Craniotomy and XRT before HDCT (10) | 6 | 4 | - |
Craniotomy alone before HDCT (2) | 2 | - | - |
XRT alone before HDCT (6) | 1 | 4 | 1 |
HDCT alone (7) | 2 | 4 | 1 |
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