High-dose chemotherapy and autologous stem cell transplantation for breast cancer

Prospective, randomized comparison of high-dose chemotherapy with stem-cell support versus intermediate-dose chemotherapy after surgery and adjuvant chemotherapy in women with high-risk primary breast cancer: a report of CALGB 9082, SWOG 9114, and NCIC MA-13

PURPOSE

The prognosis for women with primary breast cancer involving multiple axillary nodes remains poor. High-dose chemotherapy with stem-cell support produced promising results in initial clinical trials conducted at single institutions.

PATIENTS AND METHODS

Seven hundred eighty-five women aged 22 to 66 years with stage IIA, IIB, or IIIA breast cancer involving 10 or more axillary lymph nodes were randomized after surgery and standard adjuvant chemotherapy to either high-dose cyclophosphamide, cisplatin, and carmustine (HD-CPB) with stem-cell support or intermediate-dose cyclophosphamide, cisplatin, and carmustine (ID-CPB) with G-CSF support but without stem cells. Planned treatment for all patients included locoregional radiation therapy. Hormone-receptor-positive patients were to receive 5 years of tamoxifen. Event-free survival (EFS) was the primary end point.

RESULTS

Median follow-up was 7.3 years. Event-free survival was not significantly different between the two treatment groups (P = .24). The probability of being free of an event at 5 years with HD-CPB was 61% (95% CI, 56% to 65%), and was 58% (95% CI, 53% to 63%) for ID-CPB. Thirty-three patients died of causes attributed to HD-CPB, compared with no therapy-related deaths among women treated with ID-CPB. Overall survival for the two arms was identical at 71% at 5 years (P = .75).

CONCLUSION

HD-CPB with stem-cell support was not superior to ID-CPB for event-free or overall survival among all randomized women with high-risk primary breast cancer.

Dose-dense vinorelbine and paclitaxel with granulocyte colony-stimulating factor in metastatic breast cancer patients: anti-tumor activity and peripheral blood progenitor cell mobilization capability

We studied the safety, activity and peripheral blood progenitor cell mobilizing capability of a dose-dense combination of vinorelbine (VNB) and paclitaxel (PTX) as first-line chemotherapy for patients with metastatic breast cancer (MBC). Forty-three MBC patients were submitted to four cycles of VNB 30 mg/m2 and PTX 175 mg/m2 intravenously, every 2 weeks, as the first induction step of a tandem high-dose chemotherapy program. Granulocyte colony-stimulating factor (G-CSF) 5 microg/kg was administered daily from day +5 to +10 in order to accelerate hematopoietic recovery, or 48h after the last VNB-PTX when a leukapheresis was planned (after the third or fourth cycle). A total of 172 cycles were administered. The mean delivered dose-intensity of VNB and PTX was 14.7 and 86 mg/m2/week, respectively (98% of the planned dose-intensity). The main per-patient toxicities were: peripheral neurotoxicity (G1/2 60%, G3 5%), constipation (G1/2 10%), oral mucositis (G1/2 20%), and asthenia (G1/2 35%). Hematological toxicity was unremarkable, except for anemia with hemoglobin (Hb) values < 10 g/dl (28%), and lymphopenia with lymphocyte counts < 1000/mm3 (28%). Two complete (5.1%) and 24 partial (61.5%) responses were observed in 39 assessable patients, for an overall response rate of 66.6% (95% CI 51.6-80.9). A median of one apheretic procedure (range 1-3) was required to achieve the target number of 6 x 10(6)/kg CD34+ cells. The median number of CD34+ harvested per patient was 15 x 10(6)/kg (range 6.4-36.5). Four cycles of dose dense VNB and PTX showed a favorable toxicity profile, a relevant anti-tumor activity and a high peripheral blood progenitor cell mobilizing activity.

A rat model of syngeneic bone marrow transplantation during breast cancer therapy

The purpose of this study was to develop a breast cancer model in rats, in which myeloablative chemotherapy and syngeneic bone marrow transplantation (SBMT) could be evaluated systematically for therapeutic effect. The Wistar-Furth (WF) DMBA-4 breast cancer cell line transplanted into naive WF rats produced rapidly growing tumors that were lethal within 2 months. SBMT was performed following preparation with a regimen (Bu-Cy), consisting of busulfan 16 mg/kg by gastric gavage on days -3 and -2 followed by 250 mg/kg of cyclophosphamide i.p. on day -1. Marrow was prepared from the femurs of donors and infused i.v. into the recipient on day 0. In all, 15 rats treated with Bu-Cy without marrow died, while 22 of 25 transplanted rats survived. In total, 16 rats with measurable tumors showed tumor responses following transplantation, but tumors recurred and survival was minimally prolonged. Of nine rats transplanted before clinical tumors were detected, five became long-term survivors that resisted further tumor challenge. It was concluded that the DMBA-4 breast cancer in WF rats could serve to evaluate SBMT following myeloablative doses of chemotherapy at various tumor loads. At large tumor loads therapy was not curative, but at low tumor burdens cures were possible and resistance to subsequent tumor challenge was demonstrated. The model may be useful for further studies of stem cell infusion in rodent tumor systems.

Hematopoietic stem cell transplantation for hematological malignancies in Europe

Hematopoietic stem cell transplants (HSCTs) are considered the best treatment option for many hematological malignancies, and transplant numbers have increased five-fold during the last decade. Only a few controlled prospective studies are available, and different opinions prevail. Data from 118 167 HSCT (36% allogeneic, 64% autologous) collected within the EBMT activity survey from 1990 to 2001 were used to assess trends over time, transplant rates and coefficient of variation (CV) of transplant rates among European countries for acute myeloid leukemia (AML; 18.5%), acute lymphocytic leukemia (ALL; 12%), chronic myeloid leukemia (CML; 11.5%), myelodysplastic syndromes (MDS; 3%), lymphoproliferative disorders (LPS; 36.3%) and multiple myeloma (MM; 18.7%). Transplant rates increased in all countries and for all indications from 1990 to 2001 from 1.7-fold (CML) to 24.8-fold (MM). Transplant rates have declined for CML since 1999. Autologous HSCT are the preferred choice for LPS and MM, allogeneic HSCT for ALL and myeloid malignancies. CVs of less than 50% suggest consensus for allogeneic HSCT in AML, ALL, CML, MDS and NHL, for autologous HSCT in LPS and MM. These data give an overview of the current status of HSCT for hematological malignancies in Europe and provide objective information for health-care providers and patient counselling.

Increasing use of reduced intensity conditioning transplants: report of the 2001 EBMT activity survey

Since 1990, the EBMT has annually collected numbers of HSCT by disease indication, donor type and stem cell source. The 2001 survey concentrates on the use of reduced intensity conditioning (RIC) transplants and its dissemination in Europe. In 2001, there were 19576 HSCT for new patients, 6413 with allogeneic HSCT (33%), 13163 with autologous HSCT (67%) and 3256 additional re- or multiple transplants, 868 (667/201) allogeneic and 2658 (537/2121) autologous, collected from 596 centers in 35 European countries. The main indications in 2001 were leukemias (32%; 73% of them allogeneic); lymphomas (53%; 92% of them autologous); solid tumors (11%; 93% of them autologous) and non-malignant disorders (4%; 90% of them allogeneic). Compared to 2000, there was a drop in allogeneic HSCT of over 20% for chronic myeloid leukemia and an increase of 2% in autologous HSCT. A total of 1759 or 27% of allogeneic transplants were reported as RIC HSCT. These have risen in number in 3 years from <1% in 1998. There are wide variations from 0 to 71% RIC HSCT in European countries with no obvious explanation. These data document the current status of blood and marrow transplantation in Europe and indicate a marked change towards RIC HSCT in allogeneic transplantation.

Current trends in hematopoietic stem cell transplantation in Europe

Major changes have occurred in the transplantation of hematopoietic stem cells (HSCs) during the last decade. This report reveals the changes, reflects current status, and provides medium-term projections of HSC transplantation (HSCT) development in Europe. Data on 132 963 patients, 44 165 with allogeneic HSC transplant (33%) and 88 798 with an autologous HSC transplant (67%), collected prospectively from 619 centers by the European Group for Blood and Marrow Transplantation (EBMT) in 35 European countries between 1990 (4234 HSCTs) and 2000 (19 136 HSCTs) illustrate utilization of HSCT. HSCT increased in all European countries and for all indications. There were major differences depending on disease indication and donor type. Transplantation rates (numbers of HSCTs per 10 million inhabitants) varied from less than 1 for some rare indications to 37.7 +/- 4.1 for acute myeloid leukemia in allogeneic HSCT or 95.5 +/- 13.5 for non-Hodgkin lymphoma in autologous HSCT. There were indications with a steady, continuing increase and others with initial increase but subsequent decrease. Projections on medium-term development for each disease based on a weighted sensitivity analysis predict an ongoing increase in allogeneic HSCT except for chronic myeloid leukemia. In autologous HSCT they predict an increase for lymphoproliferative disorders, acute myeloid leukemia, myelodysplastic syndromes, and some solid tumors but a decrease for most solid tumors, acute lymphoid leukemia, and chronic myeloid leukemia. Transplantation rates can be predicted with reasonable sensitivity for most disease indications. Despite marked changes in the rapidly developing field of HSCT, this information on current use, trends, and midterm predictions forms a rational basis for patient counseling and health care planning.

Feasibility of four consecutive high-dose chemotherapy cycles with stem-cell rescue for patients with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor after craniospinal radiotherapy: results of a collaborative study

PURPOSE

This study was designed to determine the feasibility and safety of delivering four consecutive cycles of high-dose cyclophosphamide, cisplatin, and vincristine, each followed by stem-cell rescue, every 4 weeks, after completion of risk-adapted craniospinal irradiation to children with newly diagnosed medulloblastoma or supratentorial primitive neuroectodermal tumor (PNET).

PATIENTS AND METHODS

Fifty-three patients, 19 with high-risk disease and 34 with average-risk disease, were enrolled onto this study. After surgical resection, high-risk patients were treated with topotecan in a 6-week phase II window followed by craniospinal radiation therapy and four cycles of high-dose cyclophosphamide (4,000 mg/m2 per cycle), with cisplatin (75 mg/m2 per cycle), and vincristine (two 1.5-mg/m2 doses per cycle). Support with peripheral blood stem cells or bone marrow and with granulocyte colony-stimulating factor was administered after each cycle of high-dose chemotherapy. Treatment of average-risk patients consisted of surgical resection and craniospinal irradiation, followed by the same chemotherapy given to patients with high-risk disease. The expected duration of the chemotherapy was 16 weeks, with a cumulative cyclophosphamide dose of 16,000 mg/m2 and a planned dose-intensity of 1,000 mg/m2/wk.

RESULTS

Fifty of the 53 patients commenced high-dose chemotherapy, and 49 patients completed all four cycles. The median length of chemotherapy cycles one through four was 28, 27, 29, and 28 days, respectively. Engraftment occurred at a median of 14 to 15 days after infusion of stem cells or autologous bone marrow. The intended dose-intensity of cyclophosphamide was 1,000 mg/m2/wk; the median delivered dose-intensity was 1,014, 1,023, 974, and 991 mg/m2/wk for cycles 1 through 4, respectively; associated median relative dose-intensity was 101%, 102%, 97%, and 99%. No deaths were attributable to the toxic effects of high-dose chemotherapy. Early outcome analysis indicates a 2-year progression-free survival of 93.6% +/- 4.7% for the average-risk patients. For the high-risk patients, the 2-year progression-free survival is 73.7% +/- 10.5% from the start of therapy and 84.2% +/- 8.6% from the start of radiation therapy.

CONCLUSION

Administering four consecutive cycles of high-dose chemotherapy with stem-cell support after surgical resection and craniospinal irradiation is feasible in newly diagnosed patients with medulloblastoma/supratentorial PNET with aggressive supportive care. The early outcome results of this approach are very encouraging.

Hematopoietic stem cell transplantation activity in Europe 1999

This survey on transplantation of hematopoietic stem cells from blood or bone marrow in Europe, the 10th in a series, reports the numbers of transplants performed in 1999 and concentrates on changes in indications and donor types. Members of the European Group for Blood and Marrow Transplantation and associated teams are invited every year to report their transplant numbers by indication, donor type and stem cell source. In 1999, a total 21 430 transplants were performed by 580 teams in 35 European countries. Of these transplants 18 720 were first transplants, 5879 (31%) allogeneic, 12 841 (69%) autologous; an additional 562 allogeneic and 2148 autologous transplants were re- or multiple transplants. Ninety-five percent of the autologous transplants and 45% of the allogeneic transplants were peripheral blood stem cell transplants. A total of 103, respectively 1.8% of the allogeneic transplants, were cord blood cell transplants. Main indications in 1999 were leukemias with 6289 transplants (34%), 70% thereof allogeneic transplants; lymphomas with 8219 transplants (44%), 92% thereof autologous transplants; solid tumors with 3302 transplants (18%), 99% thereof autologous transplants; nonmalignant disorders with 715 transplants (4%), 85% thereof allogeneic transplants. Absolute numbers of allogeneic transplants continued to increase as in previous years by 10%, in contrast, there was for the first time in 10 years a decrease in autologous transplants, mainly for solid tumors. Reasons therefore are discussed. These data reflect the most recent changes in utilisation and document current status of blood and marrow transplantation in Europe.