What is the administration protocol for BEP (Bleomycin, Etoposide, Cisplatin) regimen in testicular cancer?

BEP Administration Protocol for Testicular Cancer

The BEP (Bleomycin, Etoposide, Cisplatin) regimen for testicular cancer is administered as a 3-week cycle with cisplatin 20 mg/m² IV on days 1-5, etoposide 100 mg/m² IV on days 1-5, and bleomycin 30 mg IV on days 1,8, and 15.

Standard Dosing Regimen

The BEP regimen consists of:

• Cisplatin: 20 mg/m² IV daily on days 1-5
• Etoposide: 100 mg/m² IV daily on days 1-5
• Bleomycin: 30 mg IV on days 1,8, and 15

Cycles are repeated every 21 days 1.

Number of Cycles Based on Risk Classification

The number of cycles administered depends on the International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification:

• Good prognosis: 3 cycles of BEP 1
• Intermediate or poor prognosis: 4 cycles of BEP 1

Alternative Regimens When Bleomycin is Contraindicated

If bleomycin is contraindicated:

• Good prognosis: 4 cycles of EP (Etoposide, Cisplatin) 1
• Intermediate or poor prognosis: 4 cycles of VIP/PEI (Etoposide, Ifosfamide, Cisplatin) 1

Administration Guidelines

Cisplatin Administration

• Dilute in 2 liters of 5% Dextrose in 1/2 or 1/3 normal saline containing 37.5 g of mannitol
• Infuse over 6-8 hours
• Ensure adequate hydration before and after administration to minimize nephrotoxicity 2

Etoposide Administration

• Must be diluted to a concentration of 0.2 to 0.4 mg/mL with either 5% Dextrose or 0.9% Sodium Chloride
• Administer over 30-60 minutes
• Do not give by rapid IV injection to avoid hypotension
• Caution: Plastic devices made of acrylic or ABS may crack when used with undiluted etoposide 3

Bleomycin Administration

• For testicular cancer: 30 mg IV on days 1,8, and 15
• For lymphoma patients: Start with 2 units or less for the first 2 doses to minimize risk of anaphylactoid reactions
• Monitor pulmonary function as toxicity increases significantly when total dose exceeds 400 units 4

Monitoring and Supportive Care

• Complete blood counts should be monitored at the start of therapy and prior to each cycle
• Consider dose modifications if:
  • Platelet count falls below 50,000/mm³
  • Absolute neutrophil count falls below 500/mm³ 5
• Consider G-CSF prophylaxis in patients with risk factors for febrile neutropenia 5
• Monitor renal function: Do not administer subsequent cycles until serum creatinine is below 1.5 mg/100 mL 2
• Perform audiometric analysis before subsequent cycles to ensure auditory acuity is within normal limits 2

Post-Chemotherapy Management

• Evaluate response 4-8 weeks after the last cycle with tumor markers and imaging
• For complete response (normal markers, no residual lesions, no retroperitoneal lymph nodes ≥10 mm): no further treatment needed
• For residual lymph nodes >10 mm: consider nerve-sparing retroperitoneal lymph node dissection (RPLND) 1
• For seminoma with residual tumor >3 cm: consider PET scan at least 6 weeks after chemotherapy 1

Common Toxicities and Management

• Myelosuppression: Risk of grade 3/4 neutropenia as high as 85.2% with BEP regimen 5
• Pulmonary toxicity: Monitor respiratory symptoms; bleomycin-induced toxicity is dose-dependent 4
• Nephrotoxicity: Maintain adequate hydration; monitor renal function 2
• Neurotoxicity: Monitor for peripheral neuropathy 2
• Ototoxicity: Perform audiometric testing before subsequent cycles 2

This standardized BEP regimen has demonstrated excellent efficacy in testicular cancer, with high cure rates even in patients with advanced disease.