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High-Dose Melphalan With Autologous Stem-Cell Rescue in Metastatic Rhabdomyosarcoma

From the Department of Pediatrics, Oncology/Hematology Division, University of Padova, Padova, Italy; Institut Gustave Roussy, Villejuif, France; The Birmingham Children's Hospital, Birmingham, and The Royal Marsden Hospital, Children's Department, London, United Kingdom; and the Department of Oncology/Hematology, Pediatric Center Olgahospital, Stuttgart, Germany.

Address reprint requests to Modesto Carli, MD, Department of Pediatrics. Oncology/Hematology Division, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; email carli{at}child.pedi.unipd.it

PURPOSE: The European Collaborative MMT4-91 trial was conducted as a prospective nonrandomized study to evaluate the potential benefit of high-dose melphalan as consolidation of first complete remission in children with stage IV rhabdomyosarcoma.

PATIENTS AND METHODS: Fifty-two patients in complete remission after six courses of chemotherapy received "megatherapy": 42 received melphalan alone, whereas 10 received melphalan in combination with etoposide, carboplatin/etoposide, or thiotepa/busulfan and etoposide. The outcome of this group of patients was compared with that observed in 44 patients who were also in complete remission after six courses of identical chemotherapy (plus surgery or radiotherapy) but went on to receive a total of up to 12 courses of conventional chemotherapy (four cycles). No differences were found between the two groups regarding clinical characteristics, chemotherapy received before complete remission, or response to chemotherapy. In particular, there was no significant difference between the groups for site of primary tumor, histologic subtype, age at presentation, presence of bone or bone marrow metastases, or number of metastases.

RESULTS: The 3-year event-free survival (EFS) and overall survival (OS) rates were 29.7% and 40%, respectively, for those receiving high-dose melphalan or other multiagent high-dose regimens and 19.2% and 27.7%, respectively, for those receiving standard chemotherapy. The difference was not statistically significant (P = .3 and P = .2 for EFS and OS, respectively). There was a significant prolongation in the time from the last day of high-dose chemotherapy or the end of chemotherapy cycle 4 to the time of relapse in those receiving megatherapy (168 days for patients receiving megatherapy v 104 days for those receiving standard therapy; P = .05).

CONCLUSION: The addition of a high-dose alkylating agent to consolidation therapy may have prolonged progression-free survival in this poor-risk patient group, but it did not significantly improve the ultimate outcome.

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