Salvage Treatment Regimens Regimen: Paclitaxel + Ifosfamide + Cisplatin (TIP × 4)
Kondagunta GV et al. J Clin Oncol 2005;23:6549–6555
Indications:
First-line salvage chemotherapy for patients who relapsed after a complete response or partial response with negative markers lasting >6 months
Other patients who are not candidates for high-dose chemotherapy or have progressed after high-dose therapy and have not received paclitaxel
Premedication for paclitaxel: Dexamethasone 20 mg/dose; administer orally or intravenously for 2 doses at 14 and 7 hours prior to paclitaxel, plus diphenhydramine 50 mg and cimetidine 300 mg; administer both intravenously 1 hour prior to paclitaxel
Paclitaxel 250 mg/m2; administer intravenously in 0.9% sodium chloride injection (0.9% NS) or 5% dextrose injection (D5W) to yield a final concentration within the range of 0.3 and 1.2 mg/mL over 24 hours on day 1, every 21 days for 4 cycles (total dosage/cycle = 250 mg/m2)
Hydration: 1000 mL 0.9% NS; administer intravenously over 2 hours on days 2–5 before or during ifosfamide administration. Consider additional intravenous fluid if medically appropriate until the patient has completed chemotherapy and is able to take adequate oral liquids to prevent dehydration. Monitor and replace electrolytes/magnesium as needed
Ifosfamide 1500 mg/m2 per day; administer intravenously in 0.9% NS or D5W to produce a concentration within the range of 0.6 and 20 mg/mL, over 2–3 hours for 4 consecutive days on days 2–5, every 21 days for 4 cycles (total dosage/cycle = 6000 mg/m2)
Mesna 500 mg/m2 per dose; administer intravenously in D5W to yield a concentration of 20 mg/mL, for 3 doses/day starting just before or coincident with the start of ifosfamide, with repeated doses at 4 and 8 hours after ifosfamide for 4 consecutive days on days 2–5, every 21 days for 4 cycles (total daily dosage = 1500 mg/m2; total dosage/cycle = 6000 mg/m2) (See Expert Opinion for alternative administration schemes)
Cisplatin 25 mg/m2 per day; administer intravenously in 25–250 mL 0.9% NS, over 30–60 minutes for 4 consecutive days on days 2–5, every 21 days for 4 cycles (total dosage/cycle = 100 mg/m2)
Supportive Care
Antiemetic prophylaxis
Emetogenic potential on day 1: LOW
Emetogenic potential on days 2–5: HIGH. Potential for delayed symptoms
See Chapter 39 for antiemetic recommendations
Hematopoietic growth factor (CSF) prophylaxis
Primary prophylaxis is indicated with one of the following:
Filgrastim (G-CSF) 5 mcg/kg per day by subcutaneous injection, or
Pegfilgrastim (pegylated filgrastim) 6 mg/0.6 mL by subcutaneous injection for 1 dose
Begin use from 24–72 hours after myelosuppressive chemotherapy is completed
Discontinue daily filgrastim use if WBC ≤10,000/mm3 on 2 consecutive daily measurements
See Chapter 43 for more information
Antimicrobial prophylaxis
Risk of fever and neutropenia is INTERMEDIATE
Antimicrobial primary prophylaxis to be considered:
Antibacterial—consider a fluoroquinolone or no prophylaxis; P. jirovecii prophylaxis is recommended (eg, cotrimoxazole)
Antifungal—consider use during neutropenia
Antiviral—antiherpes antivirals (eg, acyclovir)
See Chapter 47 for more information
Patient Population Studied (N = 46)
GCT patients fulfilling all of the following 3 criteria:
Gonadal primary tumor
Prior therapy with cisplatin-based treatment totaling 6 or fewer cycles
Prior CR or PR with negative markers lasting >6 months from completion of first-line chemotherapy
Kondagunta GV et al. J Clin Oncol 2005;23: 6549–6555