This month we will be focusing on data from the recent 2009 Genitourinary Cancers Symposium. This meeting was held on February 26-28, 2009 in Orlando, FL and co-sponsored by the American Society of Clinical Oncology (ASCO), the American Society for Therapeutic Radiology and Oncology (ASTRO), and the Society of Urologic Oncology (SUO). The following topics were presented as part of educational sessions along with oral abstract presentations.

Penile Cancer

A 90-minute session was held reviewing current concepts and controversies in penile cancer. Dr Dean Bajorin from Memorial-Sloan Kettering Cancer Center and Christine Haie-Meder from the Institut Gustave-Roussy created and moderated the session. In 2008, it was estimated that there were 1250 cases and 290 deaths from penile cancer in the United States. This is essentially 1 case per 100,000 men. However, in other parts of the world, penile cancer can account for 12% to 22% of all male breast cancers, including China, Uganda, and Puerto Rico. Because of the small number of cases of penile cancer in North America, there are limited data regarding standards of care locally and systemically.

Several presentations were made regarding the brachytherapy of penile cancer post-operatively in order to prevent total penectomy. Juanita Crook, MD from the Princess Margaret Hospital described their experience with multiple methods for brachytherapy with excellent long-term cosmetic effects and minimal morbidity.¹ Dr Crook presented the results of brachytherapy on 74 men between September 1989 and September 2008. They chose men with T1, T2, and selected T3 tumors. Of the 74 men, a penectomy was required in 10, 8 for local failures, and 2 for therapy-related necrosis. There were 12 regional failures, of which 6 were salvaged by lymph node dissection, and 6 died from systemic disease. Grade of the tumor was a significant predictor of regional or distant metastases.

During the educational session, Lance Pagliaro, MD from M. D. Anderson Cancer Center presented the concept and data regarding neoadjuvant systemic therapy. A phase II study from his institution recently finished accrual with 30 patients. Of the first 20 patients, there were 11 objective responses using cisplatin, paclitaxel, and ifosfamide. Because of the histologic similarity between squamous cell cancer of the anus, and vulvar cancer and the use of chemoradiation, some have used this procedure to treat locally advanced penile cancer as well. However, with the limited numbers of patients available to participate in clinical trials with locally advanced penile cancer, there are no prospective studies comparing the use of neoadjuvant chemoradiation versus chemotherapy. The group at M. D. Anderson has developed the following algorithm for patients with bulky regional lymph node metastases.²

Pagliaro LC. Advanced primary and concurrent bulky nodes in penile cancer that may or may not be resectable. 2009 Genitourinary Cancers Symposium: Penile Cancer Educational Session. Reprinted with permission.

Testes Cancer

An eloquent educational session on the challenges in advanced testes cancer was held and was moderated by Dr Michael Jewett from the Princess Margaret Hospital and Dr Robert Motzer from Memorial-Sloan Kettering Cancer Center.

Dr Craig Nichols from the Earle Chiles Research Institute in Portland Oregon presented an overview of the treatment of standards of care for patients with advanced germ cell tumors. He stressed the importance that treating physicians understand the International Germ Cell Consensus Classification. Understanding whether a patient is good risk or poor risk is critical in the decision-making for duration of therapy, but not in the selection of drugs. It was also stressed that physicians should give the drugs on schedule without delays or dose reductions. At this time, there is no clinical trial evidence to support the use of additional drugs, altered dose schedules, targeted agents, or high-dose chemotherapy in the front-line.

The secondary challenge is the approach to the post-chemotherapy resection of residual radiographic abnormalities. Dr Nichols emphasized that a multidisciplinary team perform such surgery with expertise in what can be very challenging surgeries.³

Second-line therapy

Dr Christian Kollmannsberger from the British Columbia Cancer Agency and Dr Carsten Bokemeyer from the University of Hamburg Medical Center presented an overview of relapsing disease and second-line therapy.⁴ Depending upon the clinical trial, patients with a first relapse with germ cell tumor are “cured” 25% to 60% of the time. Although there is no risk classification system to understand the risk factors associated with the benefit to second-line therapy, there is agreement that those with the best prognosis meet 1 of the following criteria: favorable response to front-line therapy, testicular primary, and cisplatin-sensitive disease. The options for treatment with favorable prognostic criteria include either conventional or high-dose chemotherapy. The most commonly used conventional regimens are paclitaxel, ifosfamide, and cisplatin (TIP) or etoposide, ifosfamide, and cisplatin (VIP). The timing of when high-dose chemotherapy is offered or considered is still controversial in the setting of relapsed favorable prognostic patients. In addition, there is controversy over delivering single high-dose therapy versus 2-3 consecutive high-dose cycles.

Poor prognostic features include incomplete response to the first-line treatment, cisplatin-refractory disease, advanced disease at initial diagnosis, or progressive disease during or after salvage therapy. The presenters stated that a sequential high-dose regimen with 1 or 2 conventional chemotherapy cycles followed by 2 or 3 high-dose cycles of carboplatin and etoposide should be the strategy of choice. Newer agents that have salvaged a small, but clinically significant number of patients after standard or high-dose chemotherapy include oxaliplatin, irinotecan, and gemcitabine. These authors also stated that because of the complexity of advanced and relapsed germ cell tumors, and the possibility that long-term cancer control or cure can be obtained in some of these patients, that they be referred to a specialized center with expertise in the medical and surgical management of these patients.

Incidence of testes cancer in the US, 1999-2004

Dr Townsend from the Centers for Disease Control (CDC) in Atlanta presented a paper on the incidence of testes cancer in the US, focusing on not only incidence, but also demographics, and tumor characteristics.⁵ The authors reviewed the testicular cancer cases diagnosed between 1999-2004 that were reported to the CDC, the National Program of Cancer Registries, or to the Surveillance, Epidemiology and End Results Program (SEER). Results: During this period of time, 40,682 new cases of malignant germ cell tumors were diagnosed. Incidence rates were higher for seminomas (3.1 per 100,000) compared to NSGCT (2.0/100,000). NSGCT increased from 1.9 cases in 1999 to 2.1/100,000 in 2004. Seminomas peaked at 8.4/100,000 in men aged 35-39 years and non-seminomas peaked at 6.1/100,000 in men aged 25-29. Incidence rates in black, American Indian/Alaska Native (AI/AN), Asian/Pacific Islander (API), and Hispanic men were lower than non-Hispanic white men. With regards to ethnic and racial differences, there are differences in the presentation of advanced disease. In non-Hispanic white men, 9.5% presented with advanced disease. The findings were 16%, 13.6%, 16.8%, and 14.9% in Hispanics, black, AI/AN, and API men with advanced disease. The authors concluded that while testes cancer is highly curable, there are racial and ethnic disparities in incidence and extent of cancer. The continued slow increase in incidence among Hispanic white and non-Hispanic white men will continue to be monitored and may give further insights into the etiology of this disease.

OncoFacts™ Editor:

Christy Russell, MD

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