High-dose chemotherapy with autologous peripheral stem cell support in advanced ovarian cancer

High dose chemotherapy with autologous hematopoietic stem cell support for solid tumors other than breast cancer in adults

Since the early 1980s high dose chemotherapy with autologous hematopoietic stem cell support was adopted by many oncologists as a potentially curative option for solid tumors, supported by a strong rationale from laboratory studies and apparently convincing results of early phase II studies. As a result, the number and size of randomized trials comparing this approach with conventional chemotherapy initiated (and often abandoned before completion) to prove or disprove its value was largely insufficient. In fact, with the possible exception of breast carcinoma, the benefit of a greater escalation of dose of chemotherapy with stem cell support in solid tumors is still unsettled and many oncologists believe that this approach should cease. In this article, we critically review and comment on the data from studies of high dose chemotherapy so far reported in adult patients with small cell lung cancer, ovarian cancer, germ cell tumors and sarcomas.

Long-term haematological recovery following high-dose chemotherapy with autologous bone marrow transplantation or peripheral stem cell transplantation in patients with solid tumours

long-term peripheral blood counts and factors influencing long-term trilineage haematological recovery of consecutive patients in a single institution treated with high-dose chemotherapy (hdc) and abmt or psct for solid tumours were examined. patients with a relapse-free survival of >1 year were included in the analysis (n = 131). Peripheral blood counts were examined 6 months and yearly following transplantation. Median follow-up was 4.1 years (range 1-10+ years). Three years after transplantation 91% of patients had normal white blood counts (WBC), 94% normal haemoglobin (Hb) and 75% normal platelets. Trilineage recovery was complete in 70% (n = 83) at 3 years and 85% (n = 50) at 5 years. Recovery of Hb occurred before WBC and platelet recovery. Approximately 25% of patients displayed an elevated MCV throughout the follow-up period. These long-term results were independent of age, high-dose regimen, number of reinfused stem cells and stem cell source. Double (n = 12) vs single (n = 119) transplantations showed significantly slower trilineage recovery and higher MCV. No secondary graft failure, myelodysplasia or leukaemia was encountered. In conclusion, complete trilineage recovery after HDC followed by ABMT or PSCT occurs slowly. PSCT and ABMT are capable of maintaining long-term haematopoiesis. Slower recovery is seen after double transplantations. The results suggest lasting implications for bone marrow function after autologous transplantation.

High-dose chemotherapy for ovarian carcinoma: long-term results from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT)

PURPOSE

to determine the outcome of epithelial ovarian cancer in patients registered with the European Group for Blood and Marrow Transplantation (EBMT).

PATIENTS AND METHODS

A retrospective analysis was performed on 254 patients with advanced or recurrent disease, median age 46 years (14-63) from 39 centres treated between 1982 and 1996. Only 25% of patients were known to have no or microscopic disease after initial surgery; in approximately 20% the disease status was unknown, the remainder had macroscopic disease.

RESULTS

One hundred five patients received high-dose chemotherapy in complete or very good partial remission, twenty-seven in second remission and the remainder in the presence of residual disease. Most received melphalan or carboplatin, or a combination (86%) supported by autologous bone marrow or peripheral blood stem cells. The survival of patients treated in remission was significantly better than in other groups (median 33 vs. 14 months; P = 0.0001). The durability of remission was longer after transplantation in first remission than in second remission (median disease-free survival 18 vs. 9 months; P = 0.005). With a median follow-up of 76 months from diagnosis the median disease-free and overall survival in stage III disease transplanted in remission is 42 and 59 months and for stage IV disease 26 and 40 months.

CONCLUSIONS

High-dose chemotherapy has a potential benefit for patients in remission. The results support the conduct of randomised studies to determine whether there is a real value from this treatment.

High-dose melphalan-based chemotherapy and autologous stem cell transplantation after second look laparotomy in patients with chemosensitive advanced ovarian carcinoma: long-term results

The importance of dose intensity has been suggested in ovarian carcinoma. We retrospectively evaluated the long-term results of melphalan-based high-dose chemotherapy (HDC) with hematopoietic rescue in a unicentric series of 33 patients with advanced ovarian cancer sensitive to first-line chemotherapy. Before HDC, treatment with debulking surgery and platinum-based chemotherapy was followed by second-look operation (SLO). HDC consisted of melphalan (n = 8), melphalan and cyclophosphamide (n = 9), or melphalan, etoposide and carboplatinum (n = 16). Toxicity was mainly hematological. One death occurred from infection during aplasia. With a median follow-up of 60 months after intensification, the 5-year progression-free survival (PFS) rate was 29% and the 5-year overall survival (OS) rate was 45%. Survival differed significantly according to tumor status at SLO. Women with microscopic or macroscopic disease at SLO, ie with a pathological partial response to first-line therapy (PPR), had survivals of 7% at 5 years, similar to other salvage therapies. Better results were obtained in the 20 women with a complete pathological response (PCR) at SLO with 43% 5-year PFS (median, 51 months) and 75% 5-year OS (median not reached). In conclusion, melphalan-based HDC with hematopoietic rescue had an acceptable toxicity in patients with chemosensitive advanced ovarian cancer. In situations of salvage therapy for patients in PPR, this treatment was not effective in long-term analysis. On the contrary, long-term results were favorable in patients with PCR, suggesting further prospective randomized studies comparing HDC and other consolidation treatments should be undertaken in this particular situation.

High dose chemotherapy with autologous stem cell support in the treatment of patients with ovarian carcinoma: long term results for 105 patients

BACKGROUND

In this study, the authors reviewed long term results and prognostic factors of high dose chemotherapy (HDC) with autologous stem cell support administered to 105 patients with epithelial ovarian carcinoma.

METHODS

Prior to HDC, platinum-based chemotherapy was given to optimize (n = 94) and/or to mobilize peripheral blood stem cells (n = 33). After maximum debulking surgery, HDC with stem cell support was given; it consisted of cyclophosphamide, doxoribicin, and cisplatin (Regimen A, administered to 58 patients) or cyclophosphamide and carboplatin (Regimen B, administered to 47 patients).

RESULTS

Five-year overall and disease free survival (OS, DFS) rates (%) according to stage were IC: 92.3, 92.3; II: 73.3, 73.3; III: 58.1, 35.7; IV: 33.7, 22.6; relapsed: 37.5, 31.0; OS, DFS at 8 years were IC: 92.3, 92.3; II: 73.3, 73.3; III: 48.8, 31.7; IV: 33.7, 22.6; relapsed: 37.5, 31.0. There was no difference in survival between patients who received Regimens A and B despite an increase in the total dose of platinum and an increase of more than 1.5- to 3.5-fold in the platinum course of HDC in Regimen B from the equivalence ratio of 4:1 between carboplatin and cisplatin. Among 65 Stage III and IV patients, the best results were obtained for 35 patients with small volume disease: 5-year OS, DFS rates were 74.3, 51.6, and 8-year OS, DFS rates were 66.4, 46.3.

CONCLUSIONS

Good long term results were obtained with HDC. Small volume residual disease, platinum sensitivity, and histology excluding mucinous and clear cell adenocarcinoma were important factors for better survival. However, because the results were obtained for selected patients, a prospective, randomized study comparing HDC and standard chemotherapy is necessary if any definitive conclusions are to be drawn.

High-dose chemotherapy with autologous stem cell support for the treatment of advanced ovarian cancer--initial experience in Uppsala and Turku

BACKGROUND

With current standard-dose chemotherapy ovarian cancer is a chemosensitive but not chemocurable disease in the majority of cases. The widely used first-line chemotherapy including a platinum analogue combined with cyclophosphamide results in response rates of 60-80%. However, only 10-20% of patients with advanced disease are alive 5 years after the diagnosis. The efficacy of high-dose chemotherapy supported by autologous stem cell transplantation (ASCT) is currently under intensive investigation.

METHODS

We report here our initial experiences of the use of high-dose chemotherapy supported by ASCT for patients with high-risk ovarian cancer. Two patients were treated at Uppsala University Hospital in 1992 and four patients at Turku University Central Hospital in 1994.

RESULTS

The first four patients treated either after heavy previous chemotherapy or recurrent disease relapsed within 5-10 months. Two patients received high-dose therapy as part of first-line treatment. One of them had a relapse 18 months after therapy, the other one has been disease free for 28 months. No toxic deaths occurred, but the patients had neutropenic febrile episodes and moderate to severe gastrointestinal toxicity.

CONCLUSIONS

Coordinated efforts in Nordic countries are indicated to evaluate the usefulness of high-dose therapy supported by ASCT in the treatment of advanced ovarian cancer.

High-dose chemotherapy with autologous stem cell support in advanced ovarian cancer

Since 1981, over 300 patients reported with advanced or refractory ovarian cancer have been treated with high-dose chemotherapy supported by autologous bone marrow or peripheral blood stem cell transplantation. Partial or complete clinical response has been reported in 54-100% of the cases, but the median duration of the response in the majority of patients has been only a few months. It is obvious from the available data that high-dose regimens supported by autologous stem cell transplantation (ASCT) are not capable of inducing long-term survival in patients with heavy tumour burden or chemoresistant ovarian cancer. Recent reports on nearly 100 patients have described results of the use of high-dose chemotherapy as first-line treatment for patients with optimally debulked disease or negative second-look laparotomy. Response rates and survival have been better when compared to historical controls, but the efficacy of this treatment modality in inducing durable remission has not been tested in randomized trials. Most of the ongoing trials presented briefly in this review have been designed to evaluate the potential of high-dose therapy as first-line treatment in preventing the development of resistant tumour clones and recurrence. The role of sequential high-dose chemotherapy with ASCT as a part of primary treatment or as salvage therapy for chemosensitive recurrent disease is also under investigation.