1
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Şahin U, Demirer T. Graft-versus-cancereffect and innovative approaches in thetreatment of refractory solid tumors. Turk J Med Sci 2020; 50:1697-1706. [PMID: 32178508 PMCID: PMC7672351 DOI: 10.3906/sag-1911-112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/14/2020] [Indexed: 12/23/2022] Open
Abstract
Background/aim Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been used for the treatment of various refractory solid tumors during the last two decades. After the demonstration of graft-versus-leukemia (GvL) effect in a leukemic murine model following allo-HSCT from other strains of mice, graft-versus-tumor (GvT) effect in a solid tumor after allo-HSCT has also been reported in a murine model in 1984. Several trials have reported the presence of a GvT effect in patients with various refractory solid tumors, including renal, ovarian and colon cancers, as well as soft tissue sarcomas [1]. The growing data on haploidentical transplants also indicate GvT effect in some pediatric refractory solid tumors. Novel immunotherapy-based treatment modalities aim at inducing an allo-reactivity against the metastatic solid tumor via a GvT effect. Recipient derived immune effector cells (RDICs) in the antitumor reactivity following allo-HSCT have also been considered as an emerging therapy for advanced refractory solid tumors. Conclusion This review summarizes the background, rationale, and clinical results of immune-based strategies using GvT effect for the treatment of various metastatic and refractory solid tumors, as well as innovative approaches such as haploidentical HSCT, CAR-T cell therapies and tumor infiltrating lymphocytes (TIL).
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Affiliation(s)
- Uğur Şahin
- Hematology Unit, Yenimahalle Education and Research Hospital, Yıldırım Beyazıt University, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, School of Medicine, Ankara University, Ankara, Turkey
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2
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Cengiz Seval G, Topçuoğlu P, Demirer T. Current Approach to Non-Infectious Pulmonary Complications of Hematopoietic Stem Cell Transplantation. Balkan Med J 2018; 35:131-140. [PMID: 29553463 PMCID: PMC5863250 DOI: 10.4274/balkanmedj.2017.1635] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Hematopoietic stem cell transplantation is an established treatment for patients with a wide range of malignant and nonmalignant conditions. Noninfectious pulmonary complications still remain a leading cause of morbidity and mortality in these patients. Treating hematopoietic stem cell transplantation recipients with noninfectious pulmonary complications is still challenging, and the current treatment armamentarium and strategies are not adequate for patients receiving hematopoietic stem cell transplantation. Further trials are needed for a better description of the pathogenesis and the complete diagnostic criteria as well as for the development of effective therapeutic approaches for the management of noninfectious pulmonary complications of the hematopoietic stem cell transplantation. This review outlines the incidence, risk factors, pathogenesis, and clinical spectrum and discusses the current approaches to the management of noninfectious pulmonary complications of Hematopoietic stem cell transplantation.
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Affiliation(s)
- Güldane Cengiz Seval
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Pervin Topçuoğlu
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
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3
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Bozdağ SC, Yüksel MK, Demirer T. Adult Stem Cells and Medicine. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1079:17-36. [DOI: 10.1007/5584_2018_184] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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4
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Sahin U, Demirer T. Current strategies for the management of autologous peripheral blood stem cell mobilization failures in patients with multiple myeloma. J Clin Apher 2017; 33:357-370. [DOI: 10.1002/jca.21591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Ugur Sahin
- Department of Hematology; Ankara University Medical School; Ankara Turkey
| | - Taner Demirer
- Department of Hematology; Ankara University Medical School; Ankara Turkey
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5
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Atilla E, Atilla PA, Toprak SK, Demirer T. A review of late complications of allogeneic hematopoietic stem cell transplantations. Clin Transplant 2017; 31. [PMID: 28753218 DOI: 10.1111/ctr.13062] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 12/13/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective and curative treatment of different malignant and non-malignant diseases. Early transplant-related mortality after allo-HSCT has decreased with reduced-intensity conditioning regimens and effective anti-infectious treatments, but late transplant-related mortality is still a problem. Physicians are now paying more attention to late complications that may worsen the quality of life of many transplant recipients. Chronic graft versus host disease (cGVHD) is one of the major causes of late transplant-related mortality after allo-HSCT. This review discusses recent advances that have been made in clinical evaluation and treatment of late transplant-related complications including cGVHD. The different sites of involvement are organs, especially the skin and eye, and the gastrointestinal, endocrinologic, metabolic, renal, cardiologic, pulmonary, connective tissue, and neurological systems. In addition, this review includes infections and secondary malignancies in post-transplant settings that worsen quality of life in long-term follow-ups.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | - Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | | | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
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6
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Atilla E, Atilla PA, Bozdağ SC, Demirer T. A review of infectious complications after haploidentical hematopoietic stem cell transplantations. Infection 2017; 45:403-411. [PMID: 28417421 DOI: 10.1007/s15010-017-1016-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/05/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation from haploidentical donor is a feasible option for patients with hematological diseases who lack a suitable HLA-matched donor, but viral and fungal infections are still the most common causes of morbidity and mortality in haploidentical transplantation setting because of delayed immune reconstitution, increased risk of graft vs host disease (GvHD) or systemic steroid use. Therefore, this review will focus on the infectious complications after haploidentical hematopoietic stem cell transplantation (HSCT). MATERIALS AND METHODS Electronic publications were searched until February 2017 throughout databases, including Pubmed, Cochrane, and Embase. The following keywords were used 'haploidentical transplantation', 'infection', 'T cell replete', and 'T cell deplete'. RESULTS An increased incidence of bacterial, fungal, or viral infections is detected in haplo-HSCT compared to related, unrelated, or cord blood transplantations. Neutropenia and use of systemic steroid for GvHD and delayed immune reconstitution are important risk factors for infection after haplo-HSCT. CONCLUSION A shift towards T cell repletes haplo-HSCT with post-transplant cyclophosphamide (CY) for GvHD has been emerged in recent years, in which the incidence of viral and fungal infections is detected to be lower. Prophylaxis and pre-emptive treatment strategies should be applied according to patient status.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Sinem Civriz Bozdağ
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey.
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7
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Ataca Atilla P, Bakanay Ozturk SM, Demirer T. How to manage poor mobilizers for high dose chemotherapy and autologous stem cell transplantation? Transfus Apher Sci 2016; 56:190-198. [PMID: 28034547 DOI: 10.1016/j.transci.2016.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/16/2016] [Accepted: 11/26/2016] [Indexed: 12/15/2022]
Abstract
Today, peripheral blood stem cells are the preferred source of stem cells over bone marrow. Therefore, mobilization plays a crutial role in successful autologous stem cell transplantation. Poor mobilization is generally defined as failure to achieve the target level of at least 2×106 CD34+ cells/kg body weight. There are several strategies to overcome poor mobilization: 1) Larger volume Leukapheresis (LVL) 2) Re-mobilization 3) Plerixafor 4) CM+Plerixafor (P)+G-CSF and 5) Bone Marrow Harvest. In this review, the definitions of successful and poor mobilization are discussed. Management strategies for poor mobilization are defined. The recent research on new agents are included.
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Affiliation(s)
- Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Cebeci, 06590 Ankara, Turkey.
| | | | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Cebeci, 06590 Ankara, Turkey.
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8
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Karadurmus N, Sahin U, Basgoz BB, Arpaci F, Demirer T. Review of allogeneic hematopoietic stem cell transplantation with reduced intensity conditioning in solid tumors excluding breast cancer. World J Transplant 2016; 6:675-681. [PMID: 28058217 PMCID: PMC5175225 DOI: 10.5500/wjt.v6.i4.675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/01/2016] [Accepted: 11/22/2016] [Indexed: 02/05/2023] Open
Abstract
Solid tumors in adults constitute a heterogeneous group of malignancy originating from various organ systems. Solid tumors are not completely curable by chemotherapy, even though some subgroups are very chemo-sensitive. Recently, oncologists have focused on the use of allogeneic hematopoietic stem cell transplantation (allo-HSCT) with reduced intensity conditioning (RIC) for the treatment of some refractory solid tumors. After the demonstration of allogeneic graft-versus-leukemia effect in patients with hematological malignancies who received allo-HSCT, investigators evaluated this effect in patients with refractory metastatic solid tumors. According to data from experimental animal models and preliminary clinical trials, a graft-versus-tumor (GvT) effect may also be observed in the treatment of some solid tumors (e.g., renal cell cancer, colorectal cancer, etc.) after allo-HSCT with RIC. The use of RIC regimens offers an opportunity of achieving full-donor engraftment with GvT effect, as well as, a reduced transplant-related mortality. Current literature suggests that allo-HSCT with RIC might become a choice for elderly and medically fragile patients with refractory metastatic solid tumors.
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9
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Lee SC, Kim SJ, Lee DH, Kim WS, Suh C, Won JH. Excessive toxicity of once daily i.v. BU, melphalan and thiotepa followed by auto SCT on patients with non-Hodgkin's lymphoma. Bone Marrow Transplant 2009; 45:801-2. [PMID: 19767780 DOI: 10.1038/bmt.2009.240] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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10
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Holmberg L, Kikuchi K, Gooley TA, Adams KM, Hockenbery DM, Flowers MED, Schoch HG, Bensinger W, McDonald GB. Gastrointestinal graft-versus-host disease in recipients of autologous hematopoietic stem cells: incidence, risk factors, and outcome. Biol Blood Marrow Transplant 2006; 12:226-34. [PMID: 16443520 DOI: 10.1016/j.bbmt.2005.10.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 10/07/2005] [Indexed: 12/30/2022]
Abstract
Graft-versus-host disease (GVHD) is seen in skin, intestinal mucosa, and liver after autologous stem cell transplantation. We reviewed 681 consecutive patients to estimate the probability of gastrointestinal (GI) GVHD, response to treatment, risk factors for development, and effect on survival. GI GVHD was defined by persistent symptoms, mucosal abnormalities at endoscopy, and histology showing apoptotic crypt cells with or without lymphoid infiltrates. The proportion of patients with GI GVHD was 90/681 (13%). Nausea and vomiting occurred in 90% and diarrhea in 40%. The mean time to developing symptoms was day +15, that to histologically proven diagnosis was day +42, and that to starting prednisone treatment was day +45 after stem cell infusion. Treatment with a short course of prednisone effected durable responses in 79% of patients, and an additional 18% responded to a second course of prednisone. A multivariable logistic regression model demonstrated that the combined factor of a diagnosis of breast cancer or hematologic malignancy and female sex was statistically significantly associated with the probability of GI GVHD (P = .003). Survival in patients with GI GVHD was not statistically different than that in those without GVHD. We conclude that women with breast cancer or hematologic malignancy are more likely to develop GI GVHD after autologous transplantation, and that treatment with prednisone was effective.
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Affiliation(s)
- Leona Holmberg
- Medical Oncology, Clinical Research Division, Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, Seattle, Washington 98109, USA
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11
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Muramatsu T, Shinozuka T, Hirasawa T, Tsukada H, Maeda H, Miyamoto T, Murakami M, Kajiwara H, Yasuda M, Osamura RY, Mikami M. Treatment strategy for recurrent and refractory epithelial ovarian cancer: efficacy of high-dose chemotherapy with hematopoietic stem cell transplantation. Acta Histochem Cytochem 2006; 39:61-7. [PMID: 17327925 PMCID: PMC1790973 DOI: 10.1267/ahc.05030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 04/03/2006] [Indexed: 11/22/2022] Open
Abstract
According to population statistics in Japan, approximately 3,800 women die of ovarian -cancer annually, and approximately 6,000 are affected by this disease. Ovarian cancer is -referred to as a "silent tumor", since patients have few subjective symptoms and by the time symptoms are observed, the cancer has progressed to Stage III or IV in about half of the patients. The basic treatment for advanced epithelial ovarian cancer is to remove as much of the tumor as possible, and subsequently to perform anticancer therapy using drugs such as cisplatin, carboplatin and paclitaxel, all of which have been shown to be effective for epithelial ovarian cancer. However, the 5-year survival rate in advanced ovarian cancer patients is still only about 20%, and a treatment that leads to long-term survival has yet to be developed. Here, we review the available treatments for ovarian cancer, and present the results of high-dose chemotherapy (HDC) performed in our hospital for recurrent and refractory -ovarian cancer.
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Affiliation(s)
- Toshinari Muramatsu
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Takao Shinozuka
- Department of Gynecology, Ayase Kosei Hospital, Fukaya 3815, Ayase, Kanagawa, Japan
| | - Takeshi Hirasawa
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Hitomi Tsukada
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Hironobu Maeda
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Tsuyoshi Miyamoto
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Masaru Murakami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Hiroshi Kajiwara
- Department of Pathology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Masanori Yasuda
- Department of Pathology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - R. Yoshiyuki Osamura
- Department of Pathology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Shimokasuya 143, Isehara, Kanagawa 259–1143, Japan
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12
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Alajez NM, Schmielau J, Alter MD, Cascio M, Finn OJ. Therapeutic potential of a tumor-specific, MHC-unrestricted T-cell receptor expressed on effector cells of the innate and the adaptive immune system through bone marrow transduction and immune reconstitution. Blood 2005; 105:4583-9. [PMID: 15746083 PMCID: PMC1894994 DOI: 10.1182/blood-2004-10-3848] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
T-cell receptor (TCR) with unique major histocompatibility complex (MHC)-unrestricted antigen-binding properties was isolated from a human T-cell clone specific for the tumor antigen MUC1. This TCR binds its epitope on the MUC1 protein without the requirement of processing and presentation. A single-chain Valpha/Vbeta/Cbeta (scTCR) was fused to a CD3 zeta (zeta) chain to allow expression on the surface of cells of the innate (granulocytes, macrophages, natural killer [NK] cells) as well as the adaptive (T and B cells) immune system. To test the ability of the cells of the innate immune system to reject a tumor when provided with a tumor antigen-specific TCR, we reconstituted severe combined immunodeficiency (SCID) mice with bone marrow cells transduced with a retroviral vector encoding this receptor and challenged them with a MUC1-positive human tumor. These mice controlled the growth of the tumor significantly better than the control mice. We performed a similar experiment in immunocompetent mice transgenic for human MUC1. Expression of the TCR on large percentages of cells did not result in infiltration or destruction of tissues expressing MUC1. Reconstituted mice controlled the outgrowth of a MUC1-transfected but not the parental control tumor. scTCR expression appears lifelong, suggesting a successful transduction of the self-renewing stem cells.
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MESH Headings
- Amino Acid Sequence
- Animals
- Antigens, Neoplasm/chemistry
- B-Lymphocytes/immunology
- Bone Marrow Cells/cytology
- CD3 Complex/chemistry
- Cell Line, Tumor
- Cell Lineage
- Enzyme-Linked Immunosorbent Assay
- Epitopes/chemistry
- Flow Cytometry
- Granulocytes/cytology
- Green Fluorescent Proteins/metabolism
- Hematopoietic Stem Cells/cytology
- Humans
- Immune System
- Immunohistochemistry
- Immunotherapy/methods
- Interleukin-2/metabolism
- Killer Cells, Natural/cytology
- Macrophages/cytology
- Major Histocompatibility Complex
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, SCID
- Mice, Transgenic
- Microscopy, Fluorescence
- Molecular Sequence Data
- Mucin-1/chemistry
- Neoplasm Transplantation
- Neoplasms/therapy
- Rats
- Receptors, Antigen, T-Cell/chemistry
- Receptors, Antigen, T-Cell/therapeutic use
- Retroviridae/genetics
- Sequence Homology, Amino Acid
- Software
- Stem Cells/cytology
- T-Lymphocytes/immunology
- Time Factors
- Transfection
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Affiliation(s)
- Nehad M Alajez
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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13
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Stiff PJ, Shpall EJ, Liu PY, Wilczynski SP, Callander NS, Scudder SA, Jazieh AR, Samlowski W, McCoy J, Alberts DS. Randomized Phase II trial of two high-dose chemotherapy regimens with stem cell transplantation for the treatment of advanced ovarian cancer in first remission or chemosensitive relapse: a Southwest Oncology Group study. Gynecol Oncol 2004; 94:98-106. [PMID: 15262126 DOI: 10.1016/j.ygyno.2004.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate response rates, progression-free survival (PFS), overall survival (OS), and toxicity of two high-dose chemotherapy regimens with stem cell rescue used to treat patients with recurrent or persistent stage III/IV ovarian cancer, with the goal of taking one forward into a Phase III comparison with conventional therapy. METHODS Patients under 65 with clinically or pathologically persistent disease after initial chemotherapy or those relapsing >6 months after a complete remission (CR) were randomized to CMC carboplatin (1500 mg/m(2)), mitoxantrone (75 mg/m(2)), and cyclophosphamide (120 mg/kg)], or CTC: [cisplatin (165 mg/m(2)), thiotepa (600 mg/m(2)), and cyclophosphamide (5625 mg/m(2))] with stem cell rescue. RESULTS Of 67 randomized, the 32 and 26 eligible in the CMC and CTC arms were matched including age (median 49), maximum tumor diameter, and disease status at transplant. Low-risk disease (maximum diameter disease <or= 0.5 cm and platinum sensitivity) was demonstrated in only approximately one-half of the patients. There were two treatment-related deaths in each arm. The median PFS was 13 and 8 months, respectively, for the CMC and CTC arms. The median OS was 29 and 22 months for the CMC and CTC arms. In a multivariate analysis of PFS, normal CA125 at transplant and CR to primary therapy were significant; for OS, normal CA125 and platinum sensitivity were significant. CONCLUSIONS The CMC regimen was the superior regimen. However, few patients were long-term progression-free survivors. A clinical CR to primary therapy and a normal CA125, seen in a minority of patients, were requirements for a favorable outcome.
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Affiliation(s)
- Patrick J Stiff
- Loyola University Stritch School of Medicine, Maywood, IL 60153, USA.
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14
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Kim HJ, Min WS, Eom KS, Park SJ, Park YH, Kim DW, Lee JW, Park CW, Kim CC. Autologous stem cell transplantation using modified TAM or combination of triple-alkylating agents conditioning regimens as one of the post-remission treatments in patients with adult acute myeloid leukemia in first complete remission. Bone Marrow Transplant 2004; 34:215-20. [PMID: 15170169 DOI: 10.1038/sj.bmt.1704556] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A total of 174 newly diagnosed adult acute myeloid leukaemia (AML) patients were treated in first complete remission (CR1) using modified TAM or a combination of triple-alkylating agents followed by autologous transplantation (AT). Cytogenetic risk groups were classified and most patients received mobilized peripheral blood stem/progenitor cells (PBSCs). The infused cell dose consisted of a median of 4.1+/-2 (range, 1.2-17.1)x 10(6)/kg CD34+ cells. With a median follow-up of 51 months (range, 5-131 months) after CR1, the estimated 5-year disease-free survival (DFS) rate was 68 (95% confidence interval (CI), 63-73%) and the event-free survival rate at 5 years was 59 (95% CI, 54-64%). AML patients other than M3 subtype, the long-term DFS rate was 76, 33% for favourable and unfavourable risk groups, respectively. In all, 40 patients had relapses (40/174, 23%) at the median 15 months after CR1 (range, 8-66 months). Overall, seven patients (4%) died in connection with AT. The infused CD34+ cell dose (P=0.0389) was associated with survival by multivariate analysis. In conclusion, two novel conditioning regimens in AT are feasible for adults with variable risk AML followed for over a 10-year period.
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Affiliation(s)
- H-J Kim
- Division of Hematology, Department of Internal Medicine, Catholic Hemopoietic Stem Cell Transplantation Center, The Catholic University of Korea College of Medicine, Seoul, Korea
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15
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Magagnoli M, Masci G, Castagna L, Rimassa L, Bramanti S, Santoro A. Intermediate-dose melphalan with stem-cell support in platinum-refractory ovarian cancer. Bone Marrow Transplant 2004; 33:1261-2. [PMID: 15107813 DOI: 10.1038/sj.bmt.1704527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Holmberg LA, Oparin DV, Gooley T, Sandmaier BM. The role of cancer vaccines following autologous stem cell rescue in breast and ovarian cancer patients: experience with the STn-KLH vaccine (Theratope). Clin Breast Cancer 2003; 3 Suppl 4:S144-51. [PMID: 12620152 DOI: 10.3816/cbc.2003.s.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The success of high-dose chemotherapy followed by autologous stem-cell rescue as treatment for breast and ovarian cancer is limited by a high incidence of relapse. After autologous transplantation, patients are likely to have a low tumor burden and thus would be more likely to respond immunologically to a cancer vaccine. Sialyl-Tn (STn) is a carbohydrate associated with the MUC1 mucin on breast and ovarian cancer and is an ideal candidate for vaccine immunotherapy. Sialyl-Tn-keyhole limpet hemocyanin (STn-KLH) vaccine (Theratope) incorporates a synthetic STn antigen that mimics the unique tumor-associated STn carbohydrate and is designed to stimulate tumor antigen-specific immune responses in patients with mucin-expressing tumors. Between 1995 and 2000, 70 patients (16 with stage II/III breast cancer, 17 with stage III/IV ovarian cancer, and 37 with stage IV breast cancer) were treated with 2 different formulations of STn-KLH. Toxicity, outcome, and immune response data are reported. STn-KLH was well-tolerated with minimal toxicity. The most common side effects were indurations and erythema at the sites of injections. Humoral and cellular responses were elicited in the majority of patients. Overall, these data indicate that post-autologous transplant patients are able to mount an effective immune response to vaccine immunotherapy with minimal side effects, and that vaccine immunotherapy may be a useful addition to high-dose chemotherapy regimens.
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Affiliation(s)
- Leona A Holmberg
- Department of Medicine, University of Washington School of Medicine, and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle 98109-1024, USA.
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17
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Hänel M, Bornhäuser M, Müller J, Thiede C, Ehninger G, Kroschinsky F. Evidence for a graft-versus-tumor effect in refractory ovarian cancer. J Cancer Res Clin Oncol 2003; 129:12-6. [PMID: 12618895 DOI: 10.1007/s00432-002-0399-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2002] [Accepted: 11/05/2002] [Indexed: 12/30/2022]
Abstract
PURPOSE A 31-year-old woman suffered a 4th relapse of epithelial ovarian cancer refractory to several cytotoxic drugs including platinum, paclitaxel, and topotecan. METHODS Sequential high-dose chemotherapy with autografting (three courses) led to a minor response of short duration. In order to induce a graft-versus-tumor effect, allogeneic hematopoietic stem cell transplantation (HSCT) from an HLA-identical sibling donor, after dose-reduced conditioning, was performed in January 2001. RESULTS On day +51 the patient developed acute grade II graft-versus-host disease of the skin and gastrointestinal tract, which was successfully treated by prednisolone. Six months after allogeneic HSCT a complete disappearance of the tumor could be seen. Unfortunately, 14 months later a 5th relapse was diagnosed. CONCLUSIONS This case demonstrates, on the one hand, that allogeneic HSCT is able to induce complete remissions (CR) in chemoresistant ovarian cancer. On the other hand, despite achievement of CR after allografting, the chance of cure remains limited for these patients.
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Affiliation(s)
- M Hänel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Margolin K, Synold T, Longmate J, Doroshow JH. Methodologic guidelines for the design of high-dose chemotherapy regimens. Biol Blood Marrow Transplant 2002; 7:414-32. [PMID: 11569887 DOI: 10.1016/s1083-8791(01)80009-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The objective of this report is to review the research methods that have been used in the design, analysis, and reporting of Phase I dose-escalation studies of high-dose chemotherapy (HDCT) with bone marrow or stem cell support and to propose new guidelines for such studies that incorporate emerging principles of pharmacology, toxicity assessment, statistical design, and long-term follow-up. METHODS We performed a search of original, English-language, peer-reviewed full-length reports of HDCT (with or without radiotherapy) and unmanipulated hematopoietic precursor support (autologous bone marrow or stem cells or allogeneic bone marrow) in which one or more drug doses were escalated to identify dose-limiting toxicities needed for the design of subsequent Phase II trials. We reviewed the design, execution, analysis, and reporting of these trials to develop a coherent set of guidelines for the initiation of new HDCT regimens. The primary elements included in our analysis were the technique of dose escalation, the choice and application of toxicity grading scale, and the pharmacologic correlates of dose escalation. We also evaluated the methods employed to define dose-limiting toxicities and to select the maximum tolerated dose and the dose recommended for further study. We then examined whether subsequent Phase II trials based on these definitions corroborated the findings from the prior Phase I studies and summarized the findings from pharmacologic analyses that were reported from a subset of these investigations. RESULTS Thirty-five reports met the criteria for our literature review. Two standard methods of dose escalation (fixed increments or modified Fibonacci increments) were described in detail and were employed in the majority (30/35) of the studies. In 5 studies, the details of dose escalation were either not provided or not adequately referenced. There was marked heterogeneity among toxicity grading methods; scales used included the National Cancer Institute Common Toxicity Criteria (or similar scales such as the United States cooperative group or World Health Organization scales) as well as substantially modified versions of those instruments. Wide variations in the methods used to identify dose-limiting toxicities were observed. Statistical considerations, applied to the identification of the maximum tolerated or Phase II recommended dose, were similarly heterogeneous. Phase II trial designs varied from a simple expansion of the Phase I trial to separate, formally conducted studies. Nine Phase I trials featured pharmacologic analyses, and these ranged from simple pharmacokinetic evaluations to more complex analyses of the relationship between drug dose and the molecular targets of drug action. CONCLUSIONS Phase I clinical trials in the HDCT setting have been designed, analyzed, and reported using heterogeneous methods that limited their application to Phase II and II investigations. Moreover, correlative pharmacologic analyses have not been routinely undertaken during this critical Phase I stage. We propose guidelines for the design of new Phase I studies of HDCT based on 4 essential elements: (1) rational preclinical and clinical pharmacologic foundation for the regimen and for the agent selected for dose escalation; (2) incorporation of analytical pharmacology in the design and analysis of the regimen under investigation; (3) clear, prospective definitions of the dose- or exposure-limiting toxicities that can be distinguished from modality-dependent toxicities; selection of an appropriate toxicity grading scale, including an assessment of cumulative, delayed, and long-term effects of HDCT, particularly when designing tandem or repetitive cycle regimens; and (4) statistical input into the design, execution, analysis, interpretation, and reporting of these studies.
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Affiliation(s)
- K Margolin
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California USA.
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Prince HM, Rischin D, Quinn M, Allen D, Planner R, Neesham D, Gates P, Davison J. Repetitive high-dose topotecan, carboplatin, and paclitaxel with peripheral blood progenitor cell support in previously untreated ovarian cancer: results of a Phase I study. Gynecol Oncol 2001; 81:216-24. [PMID: 11330952 DOI: 10.1006/gyno.2001.6121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In view of the significant activity of topotecan in ovarian cancer with dose-limiting toxicity (DLT) of myelosuppression, we evaluated the addition of topotecan to carboplatin and paclitaxel with peripheral blood progenitor cell (PBPC) support. METHODS Patients with previously untreated stage IIIC or IV ovarian cancer with macroscopic residual disease following primary debulking surgery were eligible. Patients received two cycles of carboplatin AUC = 5 and 175 mg/m(2) of paclitaxel with collection of PBPCs after the second cycle. Patients subsequently received three cycles of high-dose therapy (HDT) with topotecan on a daily x5 schedule, paclitaxel (250 mg/m(2) over 24 h), and carboplatin (AUC = 12-16). RESULTS Nineteen patients with a median age of 49 years (range 21-63) were enrolled and topotecan was escalated in 6 patient cohorts up to a dose of 4.5 mg/m(2)/day. Fifty-two of the planned 57 treatment cycles were delivered with no treatment-related deaths. Neutrophil and platelet recovery was rapid and the interval between HDT was 28 days. Febrile neutropenia occurred following 57% of all HDT cycles. DLTs of mucositis and diarrhea were observed at topotecan (4.5 mg/m(2)/day), paclitaxel (250 mg/m(2)) and carboplatin (AUC = 12). The protocol was subsequently modified to administer topotecan (2.5 mg/m(2)/day) with carboplatin (AUC = 16); however, 2 patients developed grade 4 diarrhea (1 with grade 3 mucositis and 1 with grade 4 mucositis). The clinical CR rate was 73% (14/19) with an overall clinical response rate of 95% (18/19). Of the 14 patients with a CCR, 13 of these underwent a second-look laparotomy with 8 (61%) achieving a pathological CR. With a median follow-up of 28 months (range 11-40 months), the median PFS is 36 months and OS has not been reached. CONCLUSION When combined with carboplatin (AUC = 12) and paclitaxel (250 mg/m(2)), the recommended topotecan dose is 3.5 mg/m(2)/day for 5 days. This outpatient HDT regimen combines three of the most active drugs in ovarian cancer with acceptable toxicity and promising activity.
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Affiliation(s)
- H M Prince
- Blood and Marrow Transplant Service, Division of Haematology and Medical Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria 3000, Australia
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Gutierrez-Delgado F, Holmberg LA, Hooper H, Appelbaum FR, Livingston RB, Maziarz RT, Weiden P, Rivkin S, Montgomery P, Kawahara K, Bensinger W. High-dose busulfan, melphalan and thiotepa as consolidation for non-inflammatory high-risk breast cancer. Bone Marrow Transplant 2000; 26:51-9. [PMID: 10918405 DOI: 10.1038/sj.bmt.1702461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this study was to evaluate the toxicity and efficacy of high-dose busulfan, melphalan and thiotepa (Bu/Mel/TT) in patients with high-risk non-inflammatory breast cancer defined as stage II disease > or =10 lymph nodes (n = 52) or stage III (n = 69), and prognostic factors for treatment outcome. One hundred and twenty-one patients (median age, 46 years) were treated with high-dose Bu (12 mg/kg), Mel (100 mg/m2) and TT (500 mg/m2) (HDC) followed by autologous stem cell infusion (ASCI). One hundred patients were initially treated with surgery followed by standard adjuvant chemotherapy prior to HDC/ASCI. Twenty-one patients with stage III disease had inoperable tumors at diagnosis and were treated with neoadjuvant chemotherapy and surgery before HDC/ASCI. Transplant-related mortality was 6%. The probabilities of event-free survival (EFS) at 3 and 5 years (median follow-up of 36 months) from transplant were, for all patients: 0.62-0.60; stage II: 0.71-0.67: stage III: 0.55-0.55 (for stage III adjuvant and neoadjuvant groups: 0.60-0.60 and 0.42-0.42, respectively). Multivariate analysis did not identify variables associated with poor outcome. The efficacy of Bu/Mel/TT is similar to other HDC regimens reported for patients with high-risk non-inflammatory breast cancer. Bu/Mel/TT has high activity in stage II disease and a moderate benefit in stage III operable tumors.
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Affiliation(s)
- F Gutierrez-Delgado
- Fred Hutchinson Cancer Research, University of Washington and Puget Sound Oncology Consortium, Seattle, WA 98109-1024, USA
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Holmberg LA, Oparin DV, Gooley T, Lilleby K, Bensinger W, Reddish MA, MacLean GD, Longenecker BM, Sandmaier BM. Clinical outcome of breast and ovarian cancer patients treated with high-dose chemotherapy, autologous stem cell rescue and THERATOPE STn-KLH cancer vaccine. Bone Marrow Transplant 2000; 25:1233-41. [PMID: 10871727 DOI: 10.1038/sj.bmt.1702430] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purpose of this study was to evaluate the toxicity and potential efficacy of administering the THERATOPE STn-KLH cancer vaccine to ovarian and breast cancer patients after an autologous stem cell transplant. Forty patients (11 high-risk stage II/III breast cancer, 22 stage IV breast cancer, and seven stage III/IV ovarian cancer patients) were treated with high-dose chemotherapy followed by autologous/syngeneic stem cell rescue and vaccination with THERATOPE STn-KLH (Sialyl-Tn-KLH with Detox-B Stable Emulsion). Each patient was scheduled to receive a total of five vaccinations beginning on days 30-151 after stem cell infusion. The vaccine was well tolerated. Induration and erythema at the site of injection were the most common side-effects. When one compares the outcome of patients vaccinated with 66 breast and ovarian cancer patients who were not, following risk-adjustment analysis, vaccinated patients appeared more likely to survive (P = 0.07) and less likely to relapse (P = 0. 10). Vaccinated patients with the greatest specific lytic activity against STn+OVCAR tumor cells relative to nonspecific killing of Daudi cells tended to remain in remission longer than patients who displayed less specific immune activity (P = 0.057). We conclude that the THERATOPE STn-KLH cancer vaccine is well tolerated in breast and ovarian cancer patients after autologous transplant and, while not statistically significant, the trends in data support the concept that THERATOPE vaccine may decrease the risk for relapse and death and thus warrants further study. Bone Marrow Transplantation (2000) 25, 1233-1241.
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Affiliation(s)
- L A Holmberg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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Demirer T, Ilhan O, Mandel NM, Arat M, Günel N, Celebi H, Ustün C, Akan H, Demirer S, Aydintuğ S, Uysal A, Koç H. A phase I dose escalation study of high-dose thiotepa, melphalan and carboplatin (TMCb) followed by autologous peripheral blood stem cell transplantation (PBSCT) in patients with solid tumors and hematologic malignancies. Bone Marrow Transplant 2000; 25:697-703. [PMID: 10745253 DOI: 10.1038/sj.bmt.1702239] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purpose of this study was to determine the maximum tolerated dose of carboplatin administered with 500 mg/m2 thiotepa and 100 mg/m2 melphalan followed by autologous peripheral blood stem cell (PBSC) infusion in patients with refractory malignancies. Twenty-eight patients with refractory malignancies received high-dose thiotepa (500 mg/m2, melphalan (100 mg/m2) and escalating doses of carboplatin 900-1500 mg/m2) followed by infusion of cryopreserved autologous PBSCs. The maximum tolerated doses were determined to be 500 mg/m2 thiotepa, 100 mg/m2 melphalan and 1350 mg/m2 carboplatin. Two consecutive patients receiving 1500 mg/m2 carboplatin experienced grade 3 mucositis and colitis. Ten patients were enrolled at the maximum tolerated dose and none had grade 3-4 regimen-related toxicity and mortality. All patients at this level experienced grade 1-2 mucositis, 90% grade 1-2 gastrointestinal toxicity, 30% grade 1-2 cardiac and renal toxicity, and 10% experienced grade 1 hepatic toxicity. The median time to achieve a granulocyte count of 0.5x10(9)/l was 9 days (range 7-12 days) and platelet count of 20x10(9)/l was 10 days (range 7-15 days). Of eight patients with stage IV refractory breast cancer, even were evaluable for response, one patient on day 75 will be evaluated soon. Five of seven (71.5%) evaluable patients achieved a complete remission (CR) and two had no response. Of seven patients with non-Hodgkin's lymphoma (n = 4) or Hodgkin's disease (n = 3), five achieved a CR (71.5%). Thiotepa, melphalan and carboplatin can be administered in high doses with tolerable mucositis as the major side-effect. This combination has significant activity in patients with breast cancer, and phase II studies in patients with breast cancer and other chemotherapy-sensitive malignancies are warranted.
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Affiliation(s)
- T Demirer
- Ankara University Medical School, Ibni Sina Hospital, Department of Hematology/Oncology and Bone Marrow Transplant Unit, Ankara, Turkey
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