title: Double dose-intensive chemotherapy with autologous stem-cell support for metastatic breast cancer: no improvement in progression-free survival by the sequence of high-dose melphalan followed by cyclophosphamide, thiotepa, and carboplatin.
abstract: OBJECTIVE
  Twenty-one percent of responding metastatic breast cancer patients remain progression-free a median 50 months following one intensification cycle of cyclophosphamide (6,000 mg/m2), thiotepa (500 mg/ m2), and carboplatin (800 mg/m2) (CTCb) with autologous bone marrow transplantation (ABMT). This trial studied whether the sequence of high-dose melphalan followed by CTCb resulted in improved disease response and duration.
  
  
  METHODS
  Women with at least partial responses (PRS) to induction received melphalan (140 or 180 mg/ m2) with peripheral-blood progenitor cell (PBPC) and granulocyte colony-stimulating factor (G-CSF) support. They were monitored as outpatients. After recovery, patients were hospitalized for CTCb with marrow, PBPC, and G-CSF support.
  
  
  RESULTS
  Data on 67 women, at a median of 25 months from CTCb, were examined. After melphalan, 49 (73%) required admission for fever (89%), mucositis (35%), or infection (15%) (median stay, 8 days). All received CTCb. For the first 33 patients, the median days from start of melphalan to CTCb was 24. After liver toxicity (one death from venoocclusive disease [VOD]) developed in 11 patients during CTCb, the interval between intensifications was increased to 35 days without incident. Twenty-three patients (34%) are progression-free a median of 16 months post-CTCb. The median progression-free survival (PFS) and survival times for the whole group are estimated at 11 and 20 months, respectively.
  
  
  CONCLUSIONS
  Treatment with this sequence of high-dose melphalan followed by CTCb has not resulted in superior PFS to date, when compared with single-intensification CTCb. This report discusses factors related to patient selection, the role of induced drug resistance, and the schedule of administration of alkylating agenting that may adversely influence outcome.
authors.affiliation: Department of Cancer Pharmacology, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
authors.forename: L J
authors.initials: LJ
authors.lastname: Ayash
authors.forename: A
authors.initials: A
authors.lastname: Elias
authors.forename: G
authors.initials: G
authors.lastname: Schwartz
authors.forename: C
authors.initials: C
authors.lastname: Wheeler
authors.forename: J
authors.initials: J
authors.lastname: Ibrahim
authors.forename: B A
authors.initials: BA
authors.lastname: Teicher
authors.forename: E
authors.initials: E
authors.lastname: Reich
authors.forename: D
authors.initials: D
authors.lastname: Warren
authors.forename: C
authors.initials: C
authors.lastname: Lynch
authors.forename: P
authors.initials: P
authors.lastname: Richardson
authors.forename: L
authors.initials: L
authors.lastname: Schnipper
authors.forename: E
authors.initials: E
authors.lastname: Frei
authors.forename: K
authors.initials: K
authors.lastname: Antman
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use*; D016026:Bone Marrow Transplantation / Q000009:adverse effects; D001943:Breast Neoplasms / Q000188:drug therapy / Q000473:pathology*; D016190:Carboplatin / Q000008:administration & dosage / Q000009:adverse effects; D003131:Combined Modality Therapy; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000009:adverse effects; D005260:Female; D006801:Humans; D008558:Melphalan / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local; D013852:Thiotepa / Q000008:administration & dosage / Q000009:adverse effects; D014182:Transplantation, Autologous
chemical_list: D003520:Cyclophosphamide; D013852:Thiotepa; D016190:Carboplatin; D008558:Melphalan