Metastatic Disease The primary goal of treatment for metastatic disease is to achieve complete remission with chemotherapy alone or with a combined-modality approach of chemotherapy followed by surgical resection of residual disease, as is done routinely for the treatment of germ cell tumors. One can define a goal in terms of cure or palliation on the basis of the probability of achieving a complete response to chemotherapy using prognostic factors, such as Karnofsky Performance Status (KPS) (. | Chapter 090. Bladder and Renal Cell Carcinomas Part 4 Metastatic Disease The primary goal of treatment for metastatic disease is to achieve complete remission with chemotherapy alone or with a combined-modality approach of chemotherapy followed by surgical resection of residual disease as is done routinely for the treatment of germ cell tumors. One can define a goal in terms of cure or palliation on the basis of the probability of achieving a complete response to chemotherapy using prognostic factors such as Karnofsky Performance Status KPS 80 and whether the pattern of spread is nodal or visceral liver lung or bone . For those with zero one or two risk factors the probability of complete remission is 38 25 and 5 respectively and median survival is 33 and months respectively. Patients who are functionally compromised or who have visceral disease or bone metastases rarely achieve long-term survival. The toxicities also vary as a function of risk and treatment-related mortality rates are as high as 3-4 using some combinations in these poor-risk patient groups. Chemotherapy A number of chemotherapeutic drugs have shown activity as single agents cisplatin paclitaxel and gemcitabine are considered most active. Standard therapy consists of two- three- or four-drug combinations. Overall response rates of 50 have been reported using combinations such as methotrexate vinblastine doxorubicin and cisplatin M-VAC cisplatin and paclitaxel PT gemcitabine and cisplatin GC or gemcitabine paclitaxel and cisplatin GTC . M-VAC was considered standard but the toxicities of neutropenia and fever mucositis diminished renal and auditory function and peripheral neuropathy led to the development of alternative regimens. At present GC is used more commonly than M-VAC based on the results of a comparative trial of M-VAC versus GC that showed less neutropenia and fever and less mucositis for the GC regimen. Anemia and thrombocytopenia were more common with GC. GTC is not more .
