Dose-intense salvage therapy after neoadjuvant chemotherapy: feasibility and preliminary results

Breast cancer patients who, following treatment with primary chemotherapy ( FAC 50) present an axillary node involvement of more than 4 nodes together with clinically palpable residual disease (minor response to chemotherapy) and the presence of tumour cell emboli in lymphatics have a very poor outco me. DFS rates of 50 patients treated between 1990 and 1994 were 31% at 5 ye ars. Our aim was therefore to evaluate an entirely different therapeutic re gime in these very high risk patients. 32 patients selected for these crite ria entered a pilot study consisting in treatment with 3 four weekly cycles of vinorelbine, ifosfamide, cisplatinum followed by a high dose chemothera py (HDCT) course and rescue by peripheral hematopoietic stem cells which ha d been collected by cytapheresis after the second course of chemotherapy. H DCT consisted of thiotepa, L-Pam, CBDCA (800 mg/m(2) dl), ifosfamide and me sna. Following primary chemotherapy, 14 patients had breast conservation an d 18 had a modified mastectomy. Median number of involved lymph nodes was 1 1 (range 4-26). 29 patients received the complete HDCT course. Median age w as 40 (range 24-59). Engraftment was prompt with a median of 10 days to leu cocyte recovery to 1000/mu l and 9 days to platelet recovery. One patient d eveloped reversible renal failure, and subsequently died of Gram-septicemia . To date, with a median follow up of 20 months (range 14-36), 6 patients h ave relapsed and 2 patients have died. It is too early to make any firm con clusions, but we feel that this alternative regime is feasible and may prov e superior to the classical optimal dose anthracycline-containing regimes i n patients who have a tendency to rapidly develop resistance to anthracycli nes.