Abstract
Purpose
In general, 50 % up to 80 % of metastasized germ cell tumor patients can be cured by platinum-based chemotherapy. However, 3–5 % of patients will still die of platinum-refractory disease and new systemic treatment options are needed to improve treatment success in this difficult setting. This review aims to give an overview on treatment options and current developments in the field of platinum-refractory male germ cell tumors.
Methods
A comprehensive literature search was conducted searching PubMed, Medline, Cochrane and Embase to identify clinical trials regarding the treatment of platinum-refractory disease. ASCO, EAU and ESMO conference proceedings were searched to identify unpublished results of relevant trials. Comprehensive review papers were hand searched for additional references. Clinicaltrials.gov was checked for ongoing clinical trials in the field of platinum-refractory germ cell tumors.
Results
Outcome of platinum-refractory disease remains poor. Single-agents with reasonable activity are gemcitabine, oxaliplatin and paclitaxel, but complete remissions resulting in long-term survival could not be achieved. The triple-combination of gemcitabine, oxaliplatin and paclitaxel followed by resection of residual masses provides the best outcomes with objective responses in 51 % of patients and long-term survival in approximately 10–15 %. To date, no molecularly targeted agent has shown reasonable activity.
Conclusions
Treatment options for platinum-refractory disease are limited, but a small subset of patients may achieve long-term disease-free survival by multimodal treatment. The potential of novel targeted agents, i.e. by immune-checkpoint-inhibition remains to be defined.
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References
Huyghe E, Plante P, Thonneau PF (2007) Testicular cancer variations in time and space in Europe. Eur Urol 51(3):621–628
IGCCCG (1997) International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 15(2):594–603
van Dijk MR, Steyerberg EW, Habbema JD (2006) Survival of non-seminomatous germ cell cancer patients according to the IGCC classification: an update based on meta-analysis. Eur J Cancer 42(7):820–826
Horwich A, Shipley J, Huddart R (2006) Testicular germ-cell cancer. Lancet 367(9512):754–765
Beyer J, Kramar A, Mandanas R, Linkesch W, Greinix A, Droz JP, Pico JL, Diehl A, Bokemeyer C, Schmoll HJ, Nichols CR, Einhorn LH, Siegert W (1996) High-dose chemotherapy as salvage treatment in germ cell tumors: a multivariate analysis of prognostic variables. J Clin Oncol 14(10):2638–2645
Lorch A, Beyer J, Bascoul-Mollevi C, Kramar A, Einhorn LH, Necchi A, Massard C, De Giorgi U, Flechon A, Margolin KA, Lotz JP, Germa Lluch JR, Powles T, Kollmannsberger CK, International Prognostic Factors Study G (2010) Prognostic factors in patients with metastatic germ cell tumors who experienced treatment failure with cisplatin-based first-line chemotherapy. J Clin Oncol 28(33):4906–4911
Einhorn LH (1990) Treatment of testicular cancer: a new and improved model. J Clin Oncol 8(11):1777–1781
Gandaglia G, Becker A, Trinh QD, Abdollah F, Schiffmann J, Roghmann F, Tian Z, Montorsi F, Briganti A, Karakiewicz PI, Sun M (2014) Long-term survival in patients with germ cell testicular cancer: a population-based competing-risks regression analysis. Eur J Surg Oncol 40(1):103–112
O’Carrigan B, Grimison P (2015) Current chemotherapeutic approaches for recurrent or refractory germ cell tumors. Urol Oncol 33(8):343–354
Oechsle K, Kollmannsberger C, Honecker F, Mayer F, Waller CF, Hartmann JT, Boehlke I, Bokemeyer C, German Testicular Cancer Study G (2011) Long-term survival after treatment with gemcitabine and oxaliplatin with and without paclitaxel plus secondary surgery in patients with cisplatin-refractory and/or multiply relapsed germ cell tumors. Eur Urol 60(4):850–855
Bokemeyer C, Oechsle K, Honecker F, Mayer F, Hartmann JT, Waller CF, Bohlke I, Kollmannsberger C, German Testicular Cancer Study G (2008) Combination chemotherapy with gemcitabine, oxaliplatin, and paclitaxel in patients with cisplatin-refractory or multiply relapsed germ-cell tumors: a study of the German Testicular Cancer Study Group. Ann Oncol 19(3):448–453
Garraway LA, Verweij J, Ballman KV (2013) Precision oncology: an overview. J Clin Oncol 31(15):1803–1805
Squillante CM, Vaughn DJ (2015) Targeted therapies in germ cell tumors. Urol Oncol 33(8):363–369
Porcu P, Bhatia S, Sharma M, Einhorn LH (2000) Results of treatment after relapse from high-dose chemotherapy in germ cell tumors. J Clin Oncol 18(6):1181–1186
Kollmannsberger C, Honecker F, Bokemeyer C (2008) Pharmacotherapy of relapsed metastatic testicular cancer. Expert Opin Pharmacother 9(13):2259–2272
Sadeghi S, Quinn D, Tsao-Wei D, Hamid O, Hu J, Schuckman A, Daneshmand S, Groshen S, Raghavan D, Dorff T (2013) Phase II study of gemcitabine, oxaliplatin, and paclitaxel (GOT) on a 2-weekly schedule in patients (pts) with refractory germ cell tumor (rGCT): final results. J Clin Oncol 31(Suppl); abstr 4531
Necchi A, Nicolai N, Mariani L, Lo Vullo S, Giannatempo P, Raggi D, Fare E, Piva L, Biasoni D, Catanzaro M, Torelli T, Stagni S, Milani A, Gianni AM, Salvioni R (2014) Combination of paclitaxel, cisplatin, and gemcitabine (TPG) for multiple relapses or platinum-resistant germ cell tumors: long-term outcomes. Clin Genitourin Cancer 12(1):63–69
Zaffaroni N, Fiorentini G, De Giorgi U (2001) Hyperthermia and hypoxia: new developments in anticancer chemotherapy. Eur J Surg Oncol 27(4):340–342
Wessalowski R, Schneider DT, Mils O, Friemann V, Kyrillopoulou O, Schaper J, Matuschek C, Rothe K, Leuschner I, Willers R, Schonberger S, Gobel U, Calaminus G, group Ms (2013) Regional deep hyperthermia for salvage treatment of children and adolescents with refractory or recurrent non-testicular malignant germ-cell tumours: an open-label, non-randomised, single-institution, phase 2 study. Lancet Oncol 14(9):843–852
Lorch A, Bascoul-Mollevi C, Kramar A, Einhorn L, Necchi A, Massard C, De Giorgi U, Flechon A, Margolin K, Lotz JP, Germa-Lluch JR, Powles T, Kollmannsberger C, Beyer J (2011) Conventional-dose versus high-dose chemotherapy as first salvage treatment in male patients with metastatic germ cell tumors: evidence from a large international database. J Clin Oncol 29(16):2178–2184
Feldman DR, Sheinfeld J, Bajorin DF, Fischer P, Turkula S, Ishill N, Patil S, Bains M, Reich LM, Bosl GJ, Motzer RJ (2010) TI-CE high-dose chemotherapy for patients with previously treated germ cell tumors: results and prognostic factor analysis. J Clin Oncol 28(10):1706–1713
Lorch A, Neubauer A, Hackenthal M, Dieing A, Hartmann JT, Rick O, Bokemeyer C, Beyer J (2010) High-dose chemotherapy (HDCT) as second-salvage treatment in patients with multiple relapsed or refractory germ-cell tumors. Ann Oncol 21(4):820–825
Koster R, van Vugt MA, Timmer-Bosscha H, Gietema JA, de Jong S (2013) Unravelling mechanisms of cisplatin sensitivity and resistance in testicular cancer. Expert Rev Mol Med 15:e12
Feldman DR, Bagrodia A, Lee B, Lee W, Al-Ahmadie H, Cha EK, Sfakianos J, Iyer G, Zabor EG, Ostrovnaya I, Eng J, Arcila ME, Chaganti RSK, Schultz N, Reuter VE, Bains M, Sheinfeld J, Carver BS, Bosl GJ, Solit DB (2015) Association of genomic alterations with cisplatin resistance (cisR) in advanced germ cell tumors (aGCT). J Clin Oncol 33(Suppl):abstr 4510
Jacobsen C, Honecker F (2015) Cisplatin resistance in germ cell tumours: models and mechanisms. Andrology 3(1):111–121
Feldman DR, Iyer G, Van Alstine L, Patil S, Al-Ahmadie H, Reuter VE, Bosl GJ, Chaganti RS, Solit DB (2014) Presence of somatic mutations within PIK3CA, AKT, RAS, and FGFR3 but not BRAF in cisplatin-resistant germ cell tumors. Clin Cancer Res 20(14):3712–3720
Oing C, Bokemeyer C, Russell K, Millis SZ, Bender R, Gatalica Z, Voss A (2015) Molecular profiling of cisplatin-resistant testicular germ cell tumors. Oncol Res Treat 38(Suppl. 5):168–169 (abstr V556)
Juliachs M, Munoz C, Moutinho CA, Vidal A, Condom E, Esteller M, Graupera M, Casanovas O, Germa JR, Villanueva A, Vinals F (2014) The PDGFRbeta–AKT pathway contributes to CDDP-acquired resistance in testicular germ cell tumors. Clin Cancer Res 20(3):658–667
Fukuda S, Shirahama T, Imazono Y, Tsushima T, Ohmori H, Kayajima T, Take S, Nishiyama K, Yonezawa S, Akiba S, Akiyama S, Ohi Y (1999) Expression of vascular endothelial growth factor in patients with testicular germ cell tumors as an indicator of metastatic disease. Cancer 85(6):1323–1330
Laplante M, Sabatini DM (2012) mTOR signaling in growth control and disease. Cell 149(2):274–293
Cutcutache I, Suzuki Y, Tan IB, Ramgopal S, Zhang S, Ramnarayanan K, Gan A, Lee HH, Tay ST, Ooi A, Ong CK, Bolthouse JT, Lane BR, Anema JG, Kahnoski RJ, Tan P, Teh BT, Rozen SG (2015) Exome-wide sequencing shows low mutation rates and identifies novel mutated genes in seminomas. Eur Urol 68(1):77–83
Honecker F, Wermann H, Mayer F, Gillis AJ, Stoop H, van Gurp RJ, Oechsle K, Steyerberg E, Hartmann JT, Dinjens WN, Oosterhuis JW, Bokemeyer C, Looijenga LH (2009) Microsatellite instability, mismatch repair deficiency, and BRAF mutation in treatment-resistant germ cell tumors. J Clin Oncol 27(13):2129–2136
Ohaegbulam KC, Assal A, Lazar-Molnar E, Yao Y, Zang X (2015) Human cancer immunotherapy with antibodies to the PD-1 and PD-L1 pathway. Trends Mol Med 21(1):24–33
Frankhauser CD, Fontecedro AC, Beyer J, Tischler V, Sulser T, Moch H, Bode PK (2015) Frequent expression of PD-L1 in testicular germ cell tumors. J Clin Oncol 33
Gold EJ, Bosl GJ, Itri LM (1984) Phase II trial of 13-cis-retinoic acid in patients with advanced nonseminomatous germ cell tumors. Cancer Treat Rep 68(10):1287–1288
Moasser MM, Motzer RJ, Khoo KS, Lyn P, Murphy BA, Bosl GJ, Dmitrovsky E (1995) All-trans retinoic acid for treating germ cell tumors. In vitro activity and results of a phase II trial. Cancer 76(4):680–686
Beer TM, Tangen CM, Nichols CR, Margolin KA, Dreicer R, Stephenson WT, Quinn DI, Raghavan D, Crawford ED (2006) Southwest Oncology Group phase II study of arsenic trioxide in patients with refractory germ cell malignancies. Cancer 106(12):2624–2629
Schmidt BA, Rose A, Steinhoff C, Strohmeyer T, Hartmann M, Ackermann R (2001) Up-regulation of cyclin-dependent kinase 4/cyclin D2 expression but down-regulation of cyclin-dependent kinase 2/cyclin E in testicular germ cell tumors. Cancer Res 61(10):4214–4221
Strohmeyer T, Reissmann P, Cordon-Cardo C, Hartmann M, Ackermann R, Slamon D (1991) Correlation between retinoblastoma gene expression and differentiation in human testicular tumors. Proc Natl Acad Sci USA 88(15):6662–6666
Vaughn DJ, Flaherty K, Lal P, Gallagher M, O’Dwyer P, Wilner K, Chen I, Schwartz G (2009) Treatment of growing teratoma syndrome. N Engl J Med 360(4):423–424
Vaughn DJ, Hwang WT, Lal P, Rosen MA, Gallagher M, O’Dwyer PJ (2015) Phase 2 trial of the cyclin-dependent kinase 4/6 inhibitor palbociclib in patients with retinoblastoma protein-expressing germ cell tumors. Cancer 121(9):1463–1468
Narayan V, Hwang WT, Lal P, Rosen MA, Gallagher M, O’Dwyer PJ, Vaughn DJ (2016) Cyclin-dependent Kinase 4/6 Inhibition for the treatment of unresectable mature teratoma: long-term follow-up of a phase II study. Clin Genitourin Cancer
Beyrouthy MJ, Garner KM, Hever MP, Freemantle SJ, Eastman A, Dmitrovsky E, Spinella MJ (2009) High DNA methyltransferase 3B expression mediates 5-aza-deoxycytidine hypersensitivity in testicular germ cell tumors. Cancer Res 69(24):9360–9366
Roth BJ, Elson P, Sledge GW Jr, Einhorn LH, Trump DL (1993) 5-Azacytidine (NSC 102816) in refractory germ cell tumors. A phase II trial of the Eastern Cooperative Oncology Group. Investig New Drugs 11(2–3):201–202
Clavel M, Monfardini S, Fossa S, Smyth J, Renard J, Kaye SB (1992) 5-Aza-2′-deoxycytidine (NSC 127716) in non-seminomatous testicular cancer. Phase II from the EORTC Early Clinical Trials Cooperative Group and Genito-Urinary Group. Ann Oncol 3(5):399–400
Rick O, Braun T, Siegert W, Beyer J (2006) Activity of thalidomide in patients with platinum-refractory germ-cell tumours. Eur J Cancer 42(12):1775–1779
Oechsle K, Bokemeyer C, Honecker F (2010) Lenalidomide in patients with cisplatin-refractory and multiply relapsed germ cell tumors. J Cancer Res Clin Oncol 136(1):165–167
Jain A, Brames MJ, Vaughn D, Einhorn L (2011) Phase II clinical trial of oxaliplatin and bevacizumab in refractory metastatic germ cell tumors (GCT). J Clin Oncol 29(Suppl):abstr 4579
Nieto Y, Tu SM, Bassett R, Jones RB, Gulbis AM, Tannir N, Kingham A, Ledesma C, Margolin K, Holmberg L, Champlin R, Pagliaro L (2015) Bevacizumab/high-dose chemotherapy with autologous stem-cell transplant for poor-risk relapsed or refractory germ-cell tumors. Ann Oncol 26(10):2125–2132
Einhorn LH, Brames MJ, Heinrich MC, Corless CL, Madani A (2006) Phase II study of imatinib mesylate in chemotherapy refractory germ cell tumors expressing KIT. Am J Clin Oncol 29(1):12–13
Oechsle K, Honecker F, Cheng T, Mayer F, Czaykowski P, Winquist E, Wood L, Fenner M, Glaesener S, Hartmann JT, Chi K, Bokemeyer C, Kollmannsberger C (2011) Preclinical and clinical activity of sunitinib in patients with cisplatin-refractory or multiply relapsed germ cell tumors: a Canadian Urologic Oncology Group/German Testicular Cancer Study Group cooperative study. Ann Oncol 22(12):2654–2660
Feldman DR, Turkula S, Ginsberg MS, Ishill N, Patil S, Carousso M, Bosl GJ, Motzer RJ (2010) Phase II trial of sunitinib in patients with relapsed or refractory germ cell tumors. Investig New Drugs 28(4):523–528
Giannatempo P, Nicolai N, Farè E, Raggi D, Piva L, Biasoni D, Catanzaro M, Torelli T, Stagni S, Maffezzini M, Crestani A, Togliardi E, Salvioni R, Gianni AM, Necchi A (2014) Activity of pazopanib in chemo-resistant patients with germ cell tumors (GCT): first results of the open-label, single-group, phase II PAZOTEST-01 trial. J Clin Oncol 32(Suppl 4):abstr 376
Skoneczna IA, Natorska U, Tacikowska M, Kraszewska E, Kotowicz B, Fuksiewicz M, Rogowski WW, Federowicz I, Poniatowska G, Chaladaj-Kujawska A, Michalski W (2014) Sorafenib monotherapy in patients with inoperable/recurrent germ cell tumors (GCT) refractory to chemotherapy: Phase II study. J Clin Oncol 32(Suppl 4):abstr 367
Steinemann G, Jacobsen C, Gerwing M, Hauschild J, von Amsberg G, Hopfner M, Nitzsche B, Honecker F (2015) Activity of nintedanib in germ cell tumors. Anticancer Drugs
Motzer RJ, Dmitrovsky E, Miller WH Jr, Tong WP, Bajorin DF, Scher HI, Bost GJ (1993) Suramin for germ cell tumors. In vitro growth inhibition and results of a phase II trial. Cancer 72(11):3313–3317
Mego M, Svetlovska D, Miskovska V, Obertova J, Palacka P, Rajec J, Sycova-Mila Z, Chovanec M, Rejlekova K, Zuzak P, Ondrus D, Spanik S, Reckova M, Mardiak J (2016) Phase II study of everolimus in refractory testicular germ cell tumors. Urol Oncol 34(3):122
Necchi A, Magazzu D, Anichini A, Raggi D, Giannatempo P, Nicolai N, Colecchia M, Paolini B, Coradeshi E, Tassi E, Grazia G, Mortarini R, Calareso G, Togliardi E, Crippa F, Salvioni R, Gianni AM, Valagussa P (2016) An open-label, single-group, phase 2 study of brentuximab vedotin as salvage therapy for males with relapsed germ-cell tumors (GCT): Results at the end of first stage (FM12GCT01). J Clin Oncol 34(Suppl 2S):abstr 480
Rick O, Bokemeyer C, Weinknecht S, Schirren J, Pottek T, Hartmann JT, Braun T, Rachud B, Weissbach L, Hartmann M, Siegert W, Beyer J (2004) Residual tumor resection after high-dose chemotherapy in patients with relapsed or refractory germ cell cancer. J Clin Oncol 22(18):3713–3719
Beck SD, Foster RS, Bihrle R, Einhorn LH, Donohue JP (2005) Pathologic findings and therapeutic outcome of desperation post-chemotherapy retroperitoneal lymph node dissection in advanced germ cell cancer. Urol Oncol 23(6):423–430
Masterson TA, Shayegan B, Carver BS, Bajorin DF, Feldman DR, Motzer RJ, Bosl GJ, Sheinfeld J (2012) Clinical impact of residual extraretroperitoneal masses in patients with advanced nonseminomatous germ cell testicular cancer. Urology 79(1):156–159
Daneshmand S, Albers P, Fossa SD, Heidenreich A, Kollmannsberger C, Krege S, Nichols C, Oldenburg J, Wood L (2012) Contemporary management of postchemotherapy testis cancer. Eur Urol 62(5):867–876
Coogan CL, Foster RS, Rowland RG, Bihrle R, Smith ER Jr, Einhorn LH, Roth BJ, Donohue JP (1997) Postchemotherapy retroperitoneal lymph node dissection is effective therapy in selected patients with elevated tumor markers after primary chemotherapy alone. Urology 50(6):957–962
Albers P, Ganz A, Hannig E, Miersch WD, Muller SC (2000) Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers. J Urol 164(2):381–384
Heidenreich A, Thuer D, Polyakov S (2008) Postchemotherapy retroperitoneal lymph node dissection in advanced germ cell tumours of the testis. Eur Urol 53(2):260–272
Beck SD, Foster RS, Bihrle R, Einhorn LH, Donohue JP (2005) Outcome analysis for patients with elevated serum tumor markers at postchemotherapy retroperitoneal lymph node dissection. J Clin Oncol 23(25):6149–6156. doi:10.1200/JCO.2005.11.684
Miller JC, Einhorn LH (1990) Phase II study of daily oral etoposide in refractory germ cell tumors. Semin Oncol 17(1 Suppl 2):36–39
Authors’ contribution
C Oing was involved in project development, data collection, data analysis and manuscript writing/editing. WH Alsdorf collected data, analyzed data, and wrote and edited the manuscript. G von Amsberg was involved in project development and manuscript writing/editing. K Oechsle was involved in data analysis and manuscript writing/editing. C Bokemeyer developed the project, and wrote and edited the manuscript.
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All authors herewith declare that there is no financial or non-financial conflict of interest to bias the development of this manuscript.
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As this project is solely a review of the literature, no primary research involving human participants has been conducted, and accordance of the literature included in the manuscript with accepted ethical guidelines has been assumed.
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Christoph Oing and Winfried H. Alsdorf have contributed equally to the manuscript.
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Oing, C., Alsdorf, W.H., von Amsberg, G. et al. Platinum-refractory germ cell tumors: an update on current treatment options and developments. World J Urol 35, 1167–1175 (2017). https://doi.org/10.1007/s00345-016-1898-z
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DOI: https://doi.org/10.1007/s00345-016-1898-z