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384 Chapter 7: Solid Tumors<br />

months off therapy. For this platinum-resistant group, a variety of agents may<br />

produce remissions, including paclitaxel, 713<br />

topotecan, 7,8<br />

liposomal doxorubicin, 15<br />

oral low-dose etoposide, 16<br />

<strong>and</strong> hexamethymelamine. 17<br />

Remissions occur in approximately<br />

20% <strong>and</strong> last 3-4 months, <strong>and</strong> survival from the onset of first relapse is<br />

5-12 months. In contrast, those whose remissions lasted more than 6 months can<br />

expect to respond to platinum in the range of 35^10%. Remissions for these<br />

patients usually last 6-9 months, <strong>and</strong> survival averages 20-24 months. No conventional<br />

single agent or combination chemotherapy is superior to the reintroduction<br />

of platinum for this patient group. 13<br />

Our results indicate that for patients with recurrent platinum-sensitive, lowtumor-burden<br />

disease, transplant offers a superior overall survival to conventional<br />

options, with approximately 20% having long-term PFS. However, for those with<br />

platinum-resistant <strong>and</strong>, especially, bulky disease, transplant appears to offer similar<br />

PFS <strong>and</strong> OS to conventional therapies <strong>and</strong>, given its toxicity <strong>and</strong> costs, should not<br />

be generally recommended. Patients meeting the criteria of platinum-sensitive,<br />

low-tumor-burden disease then should be offered the option of transplant at the<br />

time of first relapse.<br />

Regarding the comparisons reported here, the only significant difference<br />

between the transplant patients <strong>and</strong> those treated with conventional-dose<br />

chemotherapy is that the median age for the transplant patients was approximately<br />

10 years younger. While we found that age was an important prognostic factor for<br />

survival of the transplant patients, it was not so for PFS. In addition, Duska et al. 18<br />

recently reported that controlling for stage <strong>and</strong> tumor grade, the median survival for<br />

women in the reproductive age group with advanced ovarian cancer was not<br />

different from that for older patients. None of the patients described here were<br />

treated for low malignant potential tumors.<br />

With the suggestion that platinum sensitivity <strong>and</strong> low tumor burden are<br />

important prognostic factors for patients undergoing transplants for this disease, it is<br />

possible that transplanting patients at an earlier point in their disease will yield<br />

superior results. The results with 10 patients described here treated with taxenebased<br />

therapy suggest that transplants are of value in this setting, with the best PFS<br />

reported for suboptimal III/IV disease with conventional platinum/taxene therapy at<br />

18 months compared with the >26 months reported here. Several larger pilot studies<br />

have recently been reported that also describe transplants at the time of second-look<br />

surgery. The largest report to date is that by Legros et al. 19<br />

Patients received<br />

chemotherapy with a platinum-based combination after debulking surgery, <strong>and</strong> after<br />

demonstrating platinum sensitivity, all were treated with high-dose chemotherapy<br />

with either melphalan at 140 mg/m 2<br />

(23 patients) or carboplatin 1600 mg/m 2<br />

<strong>and</strong><br />

cyclophosphamide 6.4 g/m 2<br />

(30 patients). At a median follow-up of >6.5 years, 23%<br />

are in continuous CR, <strong>and</strong> 45% are alive. Of 31 patients with no or only microscopic<br />

disease at second look, the disease-free survival at 5 years was 26.9%. For the 19

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