Alison Amsterdam

High-dose carboplatin, etoposide, and cyclophosphamide for patients with refractory germ cell tumors: treatment results and prognostic factors for survival and toxicity.

PURPOSE The efficacy and toxicity of high-dose carboplatin, etoposide, and cyclophosphamide with autologous bone marrow transplantation (AuBMT) was investigated in a prospective trial for patients with cisplatin-refractory germ cell tumor (GCT). Prognostic factors for survival and treatment-related toxicity were identified. PATIENTS AND METHODS Fifty-eight patients with refractory GCT were treated with high-dose carboplatin, etoposide, and cyclophosphamide plus AuBMT. Prognostic factors for toxicity and survival were examined in multivariate analyses. RESULTS Twenty-three patients (40%) achieved a complete response and 12 (21%) are alive and free of disease at a median follow-up time of 28 months. Myelosuppression was severe and there were seven (12%) treatment-related deaths. Independently predictive factors that resulted in faster blood count recovery were the use of granulocyte colony-stimulating factor (G-CSF) for the number of days to neutrophil count recovery (P = .013) and prior treatment with cisplatin limited to six cycles or less for the number of days to platelet count recovery (P = .0012). Both were predictive for the number of days of hospitalization (P = .04 and .03, respectively). The two independently predictive variables for survival were pretreatment level of HCG; human chorionic gonadotrophin (HCG; < or = 100 times the upper limit of normal [xnl] v > 100 xnl, P = .02) and the presence of retroperitoneal metastases (yes or no, P = .04). Patients grouped by HCG < or = 100 xnl with retroperitoneal metastases, HCG < or = 100 xnl without retroperitoneal metastases, and all patients with HCG more than 100 xnl had median survival times of 14, 11, and 3 months, respectively (P = .04). CONCLUSION High-dose carboplatin, etoposide, and cyclophosphamide is an effective therapy for patients with refractory GCT, and results in a complete response proportion of 40% and a 2-year survival rate of 31% at a median follow-up time of 28 months. This was accomplished in a group of patients with a dismal prognosis to conventional-dose therapy.

Sexual Oncology: Sexual Health Issues in Women with Cancer

Sexual problems are widespread among female cancer patients and survivors. Dysfunction may result from various oncologic therapies such as surgery, radiation therapy, chemotherapy, hormonal manipulation, and cytostatic medication. Additionally, psychologic distress that the patient or her partner experiences during diagnosis and treatment of malignancy can impair a healthy female sexual response cycle. A sexual rehabilitation program in an oncology setting is necessary to provide comprehensive care to the cancer patient and her partner. A multidisciplinary treatment approach to sexual dysfunction includes psychological and psychiatric intervention, medical intervention, cognitive behavioral therapy, and recommended lifestyle adjustments. A holistic approach to assessing and treating sexual concerns should be individually tailored to the female patient in light of her disease stage and prognosis, age, marital status, fertility concerns, and social and professional environment.

Salvage chemotherapy for patients with advanced pure seminoma

PURPOSE We describe the response to conventional or high-dose salvage chemotherapy in patients with advanced seminoma who experience disease progression after receiving first-line platinum-based treatment. PATIENTS AND METHODS Twenty-seven patients with progressive, advanced, pure seminoma were treated with salvage chemotherapy. Fifteen patients were treated with conventional-dose cisplatin-and-ifosfamide combination chemotherapy. Twelve patients were treated with high-dose chemotherapy followed by autologous stem-cell rescue. RESULTS Fifteen patients (56%) achieved a complete response (CR), nine achieved CR with a conventional-dose cisplatin and ifosfamide program, and six experienced CR after high-dose chemotherapy. Fourteen patients (52%) are alive and disease-free, with 13 (48%) continuously disease-free at a median follow-up of 72 months. Twelve (57%) of 21 patients whose pretreatment tumors were studied morphologically were found to have seminoma with atypia. Eight patients underwent resection after salvage chemotherapy; six with histologic findings of necrotic debris/fibrosis alone are alive and disease-free at last follow-up. Both patients with viable seminoma found at surgery died of disease. CONCLUSION Most patients with advanced seminoma are cured with standard first-line programs of cisplatin and etoposide with or without bleomycin. A small minority of patients with pure seminoma have resistant tumors and require salvage chemotherapy. In this setting, approximately 50% of patients with recurrent pure seminoma achieve durable CR with conventional or high-dose salvage chemotherapy. Identification of biologic markers to predict clinical outcome and an enhanced understanding of the basic biologic features of seminoma may lead to improvements in the management of this disease.

A Phase II study of 13-cis-retinoic acid in patients with advanced renal cell carcinoma

The aim of this study was to determine the antitumor activity of 13-cis-retinoic acid as a single agent in patients with advanced renal cell carcinoma. Eligible patients had advanced renal cell carcinoma with bi-dimensionally measurable disease, a Karnofsky performance status of at least 70, life expectancy of greater than three months, no evidence of brain metastases, and treatment with no more than one chemotherapy regimen. Patients were treated with one mg/kg/day of 13-cis-retinoic acid orally. Twenty-six patients were enrolled in this study and 25 were evaluable for response and toxicity. Of the twenty-five evaluable patients, no major responses were achieved. Toxicity was mild, with no patient requiring a dose reduction. At the dose administered in this trial, 13-cis-retinoic acid is inactive as a single agent in renal cell carcinoma.

Phase II trial of topotecan in patients with cisplatin-refractory germ cell tumors

SummaryFifteen patients with advanced, cisplatin-refractory germ cell tumors (GCT) were treated on a phase II trial with topotecan. None of the 14 evaluable patients achieved a complete or partial response. Myelosuppression was the major toxicity. The median nadir leukocyte count was 1.75 cells/mm3, neutrophil count was 1.55 cells/mm3, hemoglobin was 8.75 gm/dl, and platelet count was 20,500 cells/mm3. Topotecan is not efficacious in the treatment of cisplatin-refractory GCT.

Brain cancer and sexual health: A case report

OBJECTIVE Cancer patients often encounter sexual concerns during the diagnosing, treatment, and recovery phase of their illness. However, the sexual concerns of these patients are often overlooked. Brain cancer patients are no exception to this oversight. METHODS A case report of a 39-year-old patient with a history of high-grade anaplastic astrocytoma presented to the Sexual Health Program at the Memorial Sloan-Kettering Cancer Center complaining of vaginal discharge and several months of amenorrhea. Although the patient was administered extensive aggressive antineoplastic treatments, her disease rapidly progressed. RESULTS Despite the patients terminal illness she continued to have normal sexual thoughts, feelings, and desires; however, she had difficulty discussing these issues with her partner and caregiver, who was her mother. An examination by the sexual medicine gynecologist noted no clinical signs of genital infections; however, there was minimal vaginal atrophy. Her sexual health laboratory evaluation was extensively abnormal. Her treatment consisted of intravaginal non-hormonal moisturizers and vaginal lubricants, counseling, and sexual education. The patient successfully engaged in sexual contact with her partner by the third counseling session. SIGNIFICANCE OF RESULTS Almost all oncology patients have sexual concerns during or following cancer treatment. These patients should be referred to comprehensive sexual health programs for treatment, if available.

CASE REPORTS: Clitoral Atrophy: A Case Series

INTRODUCTION Clitoral atrophy is often a neglected cause of female arousal complaints and warrants treatment with localized treatments. AIM This is a case series of patients with clitoral atrophy in which localized estrogens were used to treat separate, distinct sexual complaints. METHODS We report on three patients who were treated with localized estrogen tablets and cream for symptomatic clitoral atrophy despite a lack of data for use of these agents for the treatment of this diagnosis. The patients described here expressed understanding of the risks of vaginal hormonal therapy prior to treatment and at follow-up visits while on therapy. MAIN OUTCOME MEASURES Patient reports, physical examination, and vaginal pH. RESULTS All patients reported improvement or resolution of symptoms after the treatment with localized estrogen tablets and/or cream. CONCLUSIONS Low-dose minimally absorbed local estrogen products can be used in combination with excellent tolerance and low side-effect profile to treat female sexual complaints.

Evaluation of the Female with Sexual Dysfunction

The evaluation of a patient with sexual issues begins with a detailed medical history. Speaking generally allows the provider to initiate a discussion on sexual function using screening questions aimed at encouraging honest discussion about potentially revealing and perhaps embarrassing information. Using open-ended questions (e.g., “Is there anything else you want to talk about?”) can often be the key to broach sensitive issues. In the event the patient does not introduce the topic, more detailed questioning to assess sexual health may be required (e.g., “Are you having any problems with sexual arousal, desire, or orgasm?”).