Testicular Cancer. Conclusion
Two studies looking at carboplatin. One done at Memorial Sloan-Kettering. Higher failure rate with carboplatin although no difference in overall survival as a result of salvage. A European study, 598 men. Good risk. Difference in complete response was seen and there is ultimately differences in treatment failure and in survival, although this was not statistically significant. Carboplatin is considered an inferior drug to platinum in the context of testicular cancer. So this is the standard. It’s BEP, platinum 20 mg per meter squared given for five successive days, VP-16 100 mg per meter squared given for five successive days, bleomycin 30 units given weekly, three cycles on time, no dose reductions and no dose delays.
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For poor risk patients there have been attempts at improving the cure rates. As I mentioned before, the cure rate for these patients is about 50%. However, there has been no improvement over the past 10 or 15 years of research. The standard remains four cycles of BEP. Randomized study comparing BEP to double dose cisplatin BP, no better, greater toxicity with double dose cisplatin. There have been attempts at using high dose chemotherapy here but that remains unproven. Two recently published randomized studies looking at the substitution of ifosfamide for bleomycin, VIP versus BEP. Both of which showed equivalents of VIP to BEP with a higher hematologic toxicity associated with VIP. So for the majority of patients with poor risk germ cell tumors off of a clinical trial the standard remains four cycles of platinum, VP-16 and bleomycin.
Now here is a patient, a fairly typical patient, who has multiple pulmonary metastases and high tumor markers, treated with chemotherapy. Tumor markers normalize. The masses clear up completely. Complete response, no further therapy is necessary, the patient is observed. Female viagra enhances libido in women with lack of desire. This is a patient who received chemotherapy, markers normalized and was left with this large, irregular retroperitoneal mass. This started out as a non-seminoma in the testes. So the standard of care in the United States for residual masses, after tumor marker normalization, is resection of the residual mass. In 2006 what one finds in these residual masses 10% of the time is residual cancer. If residual cancer is seen, further chemotherapy is necessary. The standard has been two further cycles of the same chemotherapy, although salvage chemotherapy is appropriate here as well. Forty-five percent of the time one sees scar tissue. If scar tissue is seen, the patient obviously has a great prognosis. So further therapy is necessary. Forty-five percent of the time a mature teratoma will be seen. If it is seen, no further chemotherapy is necessary but there needs to be close surveillance in these patients for the possibility of other teratomas arising in other locations. For patients who were treated with primary chemotherapy and ultimately relapse with marker elevation and/or progression of tumor masses, some of those patients can still be cured with subsequent chemotherapy. For a patient who has received standard chemotherapy, about 20% of patients will be cured with a substitution of ifosfamide and Velban, plus platinum; so-called VEIP. So 20% of these patients will be cured with substitute standard chemotherapy and when high dose chemotherapy is used in combination with this, in non-randomized studies, about 50% of patients will be cured. These are obviously more selected patients, responding patients, so whether or not high dose chemotherapy as first salvage is better than chemotherapy alone, remains to be determined. For patients who failed primary chemotherapy and salvage chemotherapy, one can still cure some of these patients with high dose chemotherapy and bone marrow transplant. About 25% of patients in these studies that have been published will be cured.
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Finally, last but not least, there are some patients who become chemotherapy-resistant who ultimately can be cured with third line surgery. These are chemotherapy refractory patients who generally have resectable disease, hopefully single site disease, generally late relapsers. There tends to be teratoma in the original pathology and there tends to be alpha-fetoprotein marker elevation only. Patients with HCG elevations, very poor. I’ll stop here.