¹Medical Oncology Department, Cellular Therapy Department, Surgery Department, Institut Paoli-Calmettes, Marseille, France

²Hôpital Ambroise Paré, Marseille, France

³University Méditerranée, IFR57, Marseille, France

Correspondence to: Dr F Viret, Medical Oncology Department, Institut Paoli-Calmettes, 232, Boulevard de Sainte-Marguerite, 13273 Marseille Cedex 9, France

From August 1995 to December 1997, 15 patients with stage III-IV ovarian cancer were treated with outpatient intensive chemotherapy with G-CSF and stem cell support. The first cycle consisted of cyclophophamide IV 6 g/m²; second, third, fourth and fifth paclitaxel 250 mg/m² and the sixth and seventh carboplatin AUC 18. CD34⁺ cells were collected after the first cycle and reinfused after completion of cycles 6 and 7. Fourteen patients had stage IIIc and one patient had stage IV disease with liver metastases. All patients underwent laparotomy to maximize tumor debulking. This was optimal in eight patients and suboptimal in seven patients. Second-look surgery was performed in 14 patients. All patients had macroscopic complete responses and 10 patients had complete histologic response. Median follow-up was 48 months (range, 20 to 62). Twelve patients had further progression at a median of 27 months (range, 9 to 42) and nine are alive, three without evidence of disease progression. This pilot study shows that dose-dense chemotherapy with paclitaxel and carboplatin is associated with low toxicity and may improve the outcome of patients with poor prognosis ovarian cancer.

Bone Marrow Transplantation (2002) 30, 879-884. doi:10.1038/sj.bmt.1703762

advanced ovarian carcinoma; sequential dose dense chemotherapy

Ovarian cancer is the second most frequent gynecological malignancy. Despite substantial therapeutic progress, most patients with advanced disease (stage III or IV) are still incurable. In fact, only 20-30% of stage III patients survive after 5 years.¹

The optimal first treatment approach in advanced ovarian cancer is to surgically remove most of the tumor bulk. There is a strong correlation between level of residual disease and survival in patients with stage III disease.² Patients with bulky residual tumors have the worst overall long-term survival.

The second treatment approach in advanced disease is chemotherapy. In women treated with cisplatin as first-line, clinical and radiological response rates are 60-80%, and include a high proportion of complete responses.^3,4 Cytotoxic agents most frequently combined with platinum have been alkylating agents in the past, and more recently, paclitaxel. A combination of a platinum agent and paclitaxel has become standard therapy,^5,6 with benefits in terms of response, progression-free and overall survival, leading in stage III and IV, to a median survival of more than 35 months.

Several laboratory models,⁷ as well as retrospective analyses of clinical studies,^8,9 have strongly suggested that chemotherapy dose could favorably influence ovarian cancer outcome. Such benefit has been shown both in terms of both tumor response and survival. Major chemotherapy dose intensification using alkylating agents with autologous stem cell transplantation has been investigated in this setting, with encouraging results in pilot studies.^10,11,12,13 However, in these strategies, high-dose chemotherapy and stem cell transplantation were only used after standard chemotherapy and furthermore, mainly in chemosensitive patients who have the best prognosis.¹⁴ If chemotherapy is important for rescue and survival, it could be hypothesized that high dose chemotherapy should be beneficial as part of the primary regimen: it should increase response (without excluding 'bad' patients) and optimally improve survival by increasing the number of responders. Intensive sequential chemotherapies, used as first-line regimen, have been developed for this purpose, in conjunction with hematopoietic growth factors and stem cell infusions acquired from peripheral blood.^15,16,17 Such sequential chemotherapies are based on the hypothesis that sequential administration of drugs with various mechanisms of action should limit the development of anti-tumor resistance.^18,19

The objectives of the present study were to evaluate tolerance and anti-tumor response of a combination of drugs active against ovarian carcinoma given in a dose-intense regimen with stem cell support, after initial surgery.

Patients and methods

Eligibility and evaluation

Between August 1995 and December 1997, 15 consecutive women were entered into this study. Eligible patients were aged between 18 and 60 years and had histologically confirmed advanced common epithelial ovarian cancer. Other patient eligibility requirements included WHO performance status less than grade 3, and hematologic, renal, hepatic and cardiorespiratory function within normal limits. Laparotomy was considered for all patients, with the objective of initial staging and maximum tumor debulking. Patients had not received prior chemotherapy or radiotherapy. Informed consent was obtained from all patients.

Chemotherapy

Chemotherapy consisted of a sequential dose-intense regimen of three drugs (Figure 1): cyclophosphamide, paclitaxel and carboplatin. Seven cycles of chemotherapy were planned. Cycle 1 consisted of cyclophosphamide 6 g/m²; cycles 2, 3, 4 and 5 of Paclitaxel 250 mg/m² and cycles 6 and 7 of carboplatin AUC 18.²⁰ An inter-treatment interval of 3 weeks following cycles 1 and 6 and of 2 weeks following cycles 2, 3, 4 and 5, was planned. Cyclophosphamide was administered as a 1-h intravenous infusion and the dose was divided into 2 consecutive days in cycle 1. Paclitaxel was given as a 3-h intravenous infusion and carboplatin as a 1-h intravenous infusion. Mesna dose was given as an intravenous bolus starting 1 h before each dose of cyclophophamide and then 4 and 8 h after. All patients received a standard premedication regimen with oral dexamethasone 12 h before paclitaxel and for the 3 days after treatment. Anti-emetic prophylaxis was with anti-HT3 serotonin receptors and corticosteroids. Chemotherapy was administered if the absolute neutrophil count (ANC) was 1.5 ´ 10⁹/l and platelet count 100 ´ 10⁹/l. No dose reduction was planned. If patient neutrophil and platelet counts did not meet these criteria on the planned day, chemotherapy was delayed until adequate count recovery.

rhG-CSF, stem cell collection and reinfusion

rhG-CSF (Neupogen) was given at a daily dose of 5 g/kg (maximum 300 g/kg per day) by subcutaneous infusion after each cycle. Administration started on day 5 of each cycle and was stopped the day before the last apheresis or when the ANC reached 0.5 ´ 10⁹/l on 3 consecutive days for cycles 6 and 7.

Aphereses were performed after the first cycle of chemotherapy using an automated continuous-flow blood cell separator (Cobe Spectra, Lakewood, CO, USA). Approximately two blood volumes were processed during an average 3-h procedure as previously described.²¹ The procedure was started when the absolute number of CD34⁺ cells in peripheral blood rose to 20/l. A minimum of 5.5 ´ 10⁶ CD34⁺ cells/kg was required. Cells were divided into at least two bags and stored in liquid nitrogen, to allow reinfusion of a minimum of 2 ´ 10⁶ CD34⁺ cells/kg after cycles 6 and 7. No attempt was made to purge hematopoietic stem cells of possible tumor contamination before reinfusion on day 5 of cycles 6 and 7.

Supportive care

Patients were discharged from hospital after chemotherapy. Hematopoietic stem cell collection and reinfusion were performed in an outpatient clinic. Patients were re-admitted for intravenous antibiotics if they experienced febrile neutropenia, as defined by a temperature of 38°C or higher with an ANC of less than 1.0 ´ 10⁹/l or other treatment-related toxicity. Patients were discharged on neutrophil recovery. All patients received a single-donor platelet transfusion when the platelet count was less than 20 ´ 10⁹/l with an episode of grade 1-2 bleeding, and a red blood cell transfusion when the hemoglobin was less than 80 g/l. All blood products, except for hematopoietic stem cells, were irradiated at 25 Gy.

Toxicity

Toxicity was evaluated using WHO criteria. Once per course (D1) physical evaluation was carried out and Karnofsky index, vital signs, electrocardiogram, complete blood count (CBC) and differential, liver function and creatinine were assessed. During the treatment period, CBC and differential were obtained three times a week. At the end of chemotherapy, pre-treatment evaluation was repeated. Toxicities were assessed according to WHO criteria.

Response and survival

The evaluation response included physical examination, CA 125 level, imaging work-up including computed tomographic (CT) scan, and histological criteria after a second laparotomy. Second-look laparotomy was not considered for patients with no clinical response. Chemosensitivity of the disease suggested by complete clinical remission (physical examination, serum CA 125 level, imaging work-up) was confirmed by a second-look operation: Complete pathological response (PCR) was defined as complete disappearance of all macroscopic disease with negative peritoneal washings and negative multiple random biopsies. Microscopic disease (MiD) was defined as complete disappearance of all microscopic disease, but positive peritoneal washings or positive multiple random biopsies. A third situation is known as macroscopic disease (MaD) and included cases with persistent macroscopic disease.

The main aim of the present study was to demonstrate its feasibility. It preceded an actual phase III study associated with a patient inventory. Efficiency was evaluated by estimating response rate, progression-free survival (PFS) and overall survival (OS). PFS and OS were measured in months from the date of diagnosis until disease progression and death from any cause. Survival curves were estimated using Kaplan-Meier techniques.²²

Results

Patient characteristics

The characteristics of all 15 patients are listed in Table 1. Median age was 53 years (range, 35 to 60). All patients, except one (with FIGO IV disease and liver involvement), had FIGO IIIc disease. Initial laparotomy was performed in all patients and was optimal (residual disease 1 cm) in eight patients (53%) and suboptimal (residual tumor >1 cm) in seven patients (47%).

Stem cell collection and infusion

All patients except one had successful collection of CD34⁺ cells after cycle 1. A median of one (range, 1 to 3) apheresis yielded 8.2 ´ 10⁶ CD34⁺ cells/kg (range, 3.8 to 34.1). One patient had sufficient collected after cycle 2 (one apheresis yielded 5.1 ´ 10⁶ CD34⁺ cells/kg). A median of 3.3 ´ 10⁶/kg (range, 2 to 11.3) and 5.2 ´ 10⁶/kg (range, 3.5 to 22.7) CD34⁺ cells were, respectively, reinfused after cycles 6 and 7.

Chemotherapy delivery

A total of 102 cycles of chemotherapy were administered to 15 patients. Thirteen received the seven-planned cycles; one patient stopped before cycle 6 and one before 7 for, respectively, patient request and hematological toxicity. Delay in administration of chemotherapy affected one patient after cycle 2 (1 day, patient request), one patient after cycle 4 (1 day, fever grade 2), two patients after cycle 5 (2 days, neurologic toxicity grade 3 and obstructive syndrome caused by small bowel adhesions), one patient after cycle 6 (1 day, neutropenia grade 3) and three patients after cycle 7 (3 days, neutropenia grade 2, thrombopenia grade 4 and patient request). Chemotherapy was delivered with no dose reduction.

Toxicity

All patients included in the study were evaluated for toxicity (Table 2). There were no treatment-related deaths.

Cycle 1: Eleven (74%) patients were hospitalized; seven for febrile neutropenia. Other reasons for hospitalization were fever, neutropenia without fever, red blood cell (RBC) transfusions and abdominal pain. Median days of hospitalization per patient were 5 (range, 1 to 10). Median days to ANC <0.5 ´ 10⁹/l was 1 (range, 0 to 4).

Cycles 2, 3, 4 and 5: Peripheral neurologic toxicity concerned all patients. Of the 15 patients, three had episodes of grade III neuropathy and 12 of grade I-II neuropathy. No grade IV neuropathy occurred. The neuropathy was generally reversible after 3 to 6 months. The patient who developed grade III neuropathy after the fifth cycle of treatment, asked to be withdrawn from the study. Complete recovery of neuropathy was observed in the 3 months following the end of the last cycle of chemotherapy. Other non-hematological toxicities were grade I-II mucositis, fever and grade II cytolytic liver injury. Hematologic toxicity was mild. Only one patient, after cycle 2, developed grade IV neutropenia. No grade III or IV thrombopenia was observed. RBC transfusions were required in 7, 7 and 13% of patients after cycle 3, 4 and 5, respectively. Respectively one, two, two and zero patients were hospitalized after cycles 2, 3, 4 and 5.

Cycles 6 and 7: Seven (46%) and two (15%) patients were hospitalized after cycles 6 and 7. Median days of hospitalization per patient were, respectively, 5 (range, 2 to 13) and 7 (range, 1 to 13). Hematologic toxicity was the main reason for hospitalization, with grade IV neutropenia affecting 64% and 46% of these patients, respectively. Median days to ANC <0.5 ´ 10⁹/l was 1 (range, 0 to 5) and 0 (range, 0 to 4), respectively. Grade IV thrombopenia affected 64% and 38% of patients, respectively. Median days to platelets <20 ´ 10⁹/l were 1 (range, 0 to 6) and 0 (range, 0 to 7), respectively. RBC and platelet transfusions were given to 40% and 29% of patients, respectively. Grade I-II peripheral neurologic toxicity occurred in 11 patients. Nausea and vomiting occurred frequently, but reached grade 3 in only three patients.

Response and survival

No patient progressed during chemotherapy. Second-look surgery was performed in 14 patients (one patient refusal). Thirteen patients had a pathological complete response (PCR) and one microscopic disease (MiD). However, response to chemotherapy was clearly achieved in only eight patients, since five patients had no residual disease after debulking surgery. Median follow-up is 48 months (range, 20 to 62). At the present time, 12 patients have had further progression at a median of 27 months (range, 9 to 42). Two patients, having withdrawn from the study early (one before cycle 6 and one before cycle 7), developed the following profile: one relapsed and died 6 months later and the other is still alive in complete remission. Nine patients are alive, three without evidence of disease progression (Figure 2).

Discussion

This pilot study aimed to test the feasibility of dose-intensive chemotherapy with stem cell support as first-line treatment of ovarian carcinoma immediately following a debulking laparotomy.

Doses and times of administration of the various drugs used produced acceptable and reversible toxicity with good compliance (13/15 patients received all seven cycles of chemotherapy). Hematologic toxicity remained low and occurred essentially after high doses of cyclophosphamide and carboplatin. Hematologic toxicity observed was generally identical to other studies using a similar chemotherapy plan with peripheral blood progenitor support.¹⁷ Of the three cell lineages, however, the leukocytes were the most commonly reduced. Frequent rehospitalization was required mainly to treat febrile neutropenia (12/25). Various methods of limiting further hematologic toxicity are under investigation including use of cocktails of hematological growth factors (combinations of G-CSF, EPO and/or TPO),²³ expansion of PBSC, or more simply reinfusion of a greater numbers of CD34⁺ cells.²⁴ As two patients could not receive the high-dose carboplatin, this raises the question of the order in which drugs are administered. The anticipated hematologic toxicity was the main reason for giving high-dose carboplatin therapy at the end of the regimen.

The increased incidence of neuropathy is the most unpleasant toxicity and is a direct result of the use of big doses of paclitaxel and carboplatin. However, toxicity rarely exceeded grade II and was completely reversible.

Complete remission is, as for most cancers, correlated with survival and possible cure is the major objective. The most critical prognostic factor for survival in ovarian cancer remains the level of residual disease after cytoreductive surgery and chemotherapy.^25,26 With the aim of obtaining a high rate of pathological complete response, we designed a high-dose sequential program including drugs active against ovarian carcinomas. We observed a high pathological complete response, but this result has to be tempered by the small number of patients and by the fact that 53% (eight out of 15) had initial optimal debulking surgery. The three long-term survivors had optimal stage III disease. Similar results were observed in a study recently published where high doses of carboplatin were used.²⁷ Two previous studies^17,28 using a similar approach, but with different results suggest that patients with suboptimal disease did not seem to receive any benefit from dose-intensive chemotherapy. The relapse rate observed in our study is higher than in the two aforementioned studies, as well as other studies using platinum agents and taxane at conventional doses. Single agent chemotherapy may promote the emergence of drug resistant tumor cells and may contribute the high rates of relapse. Differences from the other studies can also be explained by the relatively small number of patients.

Despite the fact that the role of high-dose chemotherapy with stem cell support in adult solid tumors is currently highly controversial, some recently published data²⁹ have suggested that high-dose chemotherapy could have a place in chemosensitive ovarian cancer. However, this selected population represents only about 50 to 60% of all ovarian cancers. The efficiency of dose-intensive chemotherapy with stem cell support must be investigated in a large cohort of patients to determine which patients with optimal or suboptimal disease may benefit from it. In our study, we tested the feasibility of first-line out-patient intensive sequential therapy with the concomitant use of hematologic growth factors and stem cells in ovarian carcinomas. We have confirmed that this treatment can be given to most patients, without any selection after first debulking surgery. The pathological complete response rate was high, but the number of patients low, and relatively young (53 years, median). For these reasons, such an observation must be treated with caution and needs further confirmation in a larger cohort of patients.

The persistent problem in advanced ovarian carcinoma remains the high relapse rate despite achieving complete response. This paradoxical situation should encourage the use of combined strategies after debulking surgery and chemotherapy.

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23 Pierelli L, Perillo A, Greggi S et al. Erythropoietin addition to granulocyte colony-stimulating factor abrogates life-threatening neutropenia and increases peripheral-blood progenitor-cell mobilization after epirubicin, paclitaxel, and cisplatin combination chemotherapy: results of a randomized comparison. J Clin Oncol 1999; 17: 1288-1295. MEDLINE

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29 Cure H, Battista C, Guastalla J et al. Phase III randomized trial of high-dose chemotherapy and peripheral blood stem cell support as consolidation in patients with responsive low-burden advanced ovarian cancer: preliminary results of a GINECO/FNCLCC/ SFGM-TC study. Proc Am Soc Clin Oncol 2001; 20: 204a, (Abstr. 815).

Figure 1 Treatment plan. G, rhG-CSF started at day 5 of each cycle and was stopped the day before last apheresis or when ANC reached 0.5 ´ 10⁹/l on 3 consecutive days for cycles 6 and 7.

Figure 2 Disease-free survival and overall survival for all patients.

Table 1 Patient characteristics and response (n = 15)

Table 2 Number of patients with toxicity