Should high-dose chemotherapy be used to consolidate second or third line treatment in relapsing germ cell tumours?

Thirty consecutive patients with relapsing germ cell tumours (GCT) were treated with induction chemotherapy and high-dose chemotherapy consolidation (HDCT). Overall, 47% were progressionfree and 53% were alive with a median follow up of 40 months. Initially, HDCT was given as consolidation of third line VIP (etoposide/ifosfamide and cisplatin), following failure of a weekly cisplatin regimen. During 1995, paclitaxel was introduced into second line therapy with cisplatin and ifosfamide (TIP), with immediate consolidation using HDCT. At the same time the carboplatin dosing calculation was changed and an area under the curve (AUC) formula rather than by mg/m2 was used to calculate this. The main determinant of post-treatment renal dysfunction was pretreatment renal function rather than the AUC dose of carboplatin. Only a raised LDH prior to induction or absolute refractory disease in response to induction chemotherapy predicted poor survival following HDCT. In patients relapsing following HDCT, the outcome was poor with many patients relapsing in the central nervous system and other new sites of disease. Further responses were seen to chemotherapy or radiotherapy but these were not sustained. The failure to improve results when HDCT was used as second line rather than third line chemotherapy consolidation was disappointing and adds to further uncertainty of the role of this approach as far as timing and the ideal preparative regimen are concerned.