Bone Marrow Transplantation (2003) 31, 487–491 & 2003 Nature Publishing Group All rights reserved 0268-3369/03 $25.00 www.nature.com/bmt Post-Transplant Complications Femoral head necrosis in three patients with relapsed ovarian cancer receiving high-dose chemotherapy followed by autologous peripheral blood stem cell transplantation

P Bojko1, RA Hilger1, SG Ruehm2, O Dirsch3, S Seeber1 and MEScheulen 1

1Department of Internal Medicine (Cancer Research), West German Cancer Center, University of Essen Medical School, Essen, Germany; 2Department of Radiology, University of Essen Medical School, Essen, Germany; and 3Department of Pathology, University of Essen Medical School, Essen, Germany

Summary: no influence.1 Ebeling et al2 reported a loss of 11.7% femoral neck BMD post-allo-bone marrow transplantation We report three patients with relapsed ovarian cancer who (BMT) as compared with a nonsignificant decrease of 1.1% developed femoral head necrosis requiring endoprosthetic post-auto BMT. In addition, the same group observed hip surgery 16–35 months after high-dose chemotherapy an avascular necrosis of the femoral head in four, and (HDC) with treosulfan (47 and 56g/m 2 body-surface area vertebral and rib fractures in another one of 116 patients (BSA)) given as 3–25 h infusions and followed by surviving longer than 6 months post-allo-BMT. All skeletal autologous peripheral blood stem cell (PBSC) transplan- events occurred a median of 19 months post-HDC and tation. One woman received two courses of single agent were observed only in patients receiving allo-BMT, while treosulfan while the other two patients received one course no such complications were reported after autologous of high-dose treosulfan either preceded or followed by transplantation. In addition, low testosterone and estrogen high-dose carboplatin, etoposide and cyclophosphamide. serum levels and secondary hyperparathyroidism because A total of 30 women with ovarian cancer were treated of low serum calcium3 and cytoreductive chemotherapy with HDC at our unit and 21 of them received treosulfan- prior to transplantation4 are further risk factors. containing regimens. Femoral head necrosis was not Patients undergoing bilateral oophorectomy may suffer observed in patients either receiving conditioning regimens a loss of trabecular bone as great as 20% during the first without treosulfan (n ¼ 9) or when the total treosulfan 18 months after surgery.5 While loss of BMD is not dose was given over 3 consecutive days (n ¼ 3) or in uncommon, the occurrence of avascular bone necrosis in patients with a diagnosis other than ovarian cancer and patients with ovarian cancer has been reported only treated with high-dose treosulfan (n ¼ 10). We conclude sporadically.6 that women with relapsed ovarian cancer receiving HDC HDC with treosulfan, a prodrug of a bifunctional with excessive single-dose treosulfan might be at an alkylating cytotoxic agent has been used in a clinical phase increased risk of developing bone necrosis. I dose escalation and pharmacokinetic study with auto- Bone Marrow Transplantation (2002) 31, 487–491. logous peripheral blood stem cell (PBSC) transplantation doi:10.1038/sj.bmt.1703886 in patients with ovarian cancer (n ¼ 20), lymphoma (n ¼ 4), Keywords: high-dose treosulfan; bone necrosis myeloma, yolk sac tumor, breast cancer and sarcoma (n ¼ 1 each). Ten other patients diagnosed with ovarian cancer received treosulfan-containing regimens outside of this phase I study. Pharmacokinetic data of 16 of these HDC Loss of bone mineral density (BMD) is a known side effect courses with treosulfan have been published recently.7 Three of high dose chemotherapy (HDC) and stem cell trans- of the patients with ovarian cancer treated at our clinic plantation and has increasing importance in long-term developed femoral head necrosis, suggesting that high-dose survivors of such intensive treatment regimens. It is mainly treosulfan or one of its metabolites including methane observed after allogeneic stem cell transplantation and sulfonic acid that is released during the formation of the there is a correlation between the cumulative dose and monoepoxy intermediate and its further metabolism to number of days of glucocorticoid therapy and the number l-(+)-diepoxybutane, respectively, could have contributed of days of cyclosporine or tacrolimus and the loss of BMD, to this complication. The clinical course of these patients while total body irradiation, diagnosis or donor type have is described and compared with pharmacokinetic data.

Patients Correspondence: Dr P Bojko, University of Essen Medical School, Department of Internal Medicine (Cancer Research), West German Cancer Center, Hufelandstr. 55, D-45122 Essen, Germany Patient 1, M.D., was diagnosed with adeno carcinoma of Received 10 December 2002 the left ovary in April 1996 at the age of 49 years. She Treosulfan and osteonecrosis P Bojko et al 488 Table 1 Patient characteristics

M.D. V.B. I.P Age at diagnosis (years) 49 40 39 Primary stage (FIGO) II III IIIB Histology Adeno carcinoma, G2 adenocarcinoma, G2-3 Cystodenocarcinoma, G1 Adjuvant therapy DDP/Cyclo DDP/Cyclo, Taxol DDP/Cyclo 1. HDC CEC Treosulfan Treosulfan 2. HDC Treosulfan Treosulfan CEC Time from (months) Diagnosis – relapse 19 66(#1)/81(#2) 44 Diagnosis – 1. HDC 23 85 48 Diagnosis – 2. HDC 24 87 49 1. HDC – relapse 12 16 7 HD treosulfan – hip surgery 28 (right)/39 (left) 35 16 OAS from diagnosis (months) 68+ 128+ 78+ OAS from HDC (months) 45+ 43+ 29+ Treatment for relapse after HDC (number of regimens incl. RTx) 10 4 5

HDC=high-dose chemotherapy; OAS=overall survival; RTx=radiotherapy; DDP=cisplatin; cyclo=cyclophosphamide; CEC=carboplatin (1500 mg/ m2)/etoposide (1200 mg/m2)/cyclo (5000 mg/m2).

underwent bilateral oophorectomy, hysterectomy, sigmoid colon resection and removal of two small-bowel metastases. From April to September 1996 she received six courses of cyclophosphamide and cisplatin, but residual disease was found on second-look surgery and three additional courses of chemotherapy with cyclophosphamide and cisplatin were added. Third-look surgery in May 1997 showed no evidence of disease. In November 1997 raising Ca 12-5 serum levels and splenic, lymphonodular and mesenterial recurrences were found, and two courses of cisplatin and paclitaxel were started. Cyclophosphamide (3 g/m2) for PBSC mobilization was given in January 1998 followed by two further courses of cisplatin and paclitaxel. In March 1998 the first HDC with the CEC regimen (Table 1) was given and 3.2Â106 CD34+ cells/kg body weight (bw) were transfused, resulting in complete remission. The second HDC with 56 g/m2 treosulfan given as a 4-h-infusion 6 followed in April 1998, and 6.4Â10 CD34+ cells/kg bw Figure 1 Patient 1, M.D. Aseptic necrosis of the femoral head showing were infused. In March 1999 splenic recurrence was necrosis of trabeculae and bone marrow, H&E, Â200. diagnosed and subsequent sequential chemotherapeutic regimens were applied including 5-fluorouracil and folinic acid (FU/FA) with or without mitomycin C, gemcitabine (GEM), epirubicin and tamoxifen and oral etoposide with grade 2–3 ovarian cancer stage FIGO III. She received five or without carboplatin. In October 1999 the course was courses of cisplatin and cyclophosphamide followed by complicated by a local recurrence in the left side of the paclitaxel which was complicated by allergic shock after pelvis, small-bowel obstruction and ischemic colitis neces- the second infusion. In October 1996 she underwent sitating surgery further complicated by renal failure, surgery for perirectal recurrence and in January 1998 a respiratory insufficiency and bioccipital insults. However, small-bowel resection was carried out after a pelvic relapse. she recovered fully but suffered from increasing bilateral In April 1998 she received cyclophosphamide (3 g/m2) for hip pain. In September 2000 she underwent endoprosthetic PBSC mobilization, and two courses of high-dose treosul- hip replacement surgery of the right (Figure 1), and in July fan (56 g/m2 given as a 3- and 4-h infusion) with PBSC 2001 of the left hip. In between and after the second surgery support (1.7 and 2.7Â106 CD34+ cells/kg bw, respectively) she was treated again for persistent ovarian cancer with were given in May and July 1998. Another pelvic relapse additional courses of etoposide and carboplatin, oral with vaginal invasion occurred in August 1999 for which cyclophosphamide, CPT-11, GEM, FU/FA and weekly she was irradiated. The total dose was 50.4 Gy and included paclitaxel. At the present time she is in good clinical the medial part of the right femoral head (local dose condition (WHO I) and no further skeletal complications o50 Gy). Increasing serological tumor markers and lym- have occurred to date. phonodular disease were found 5 months later and Patient 2, V.B., underwent bilateral oophorectomy, treatment with FU/FA and cisplatin was initiated. In hysterectomy and omental resection in April 1994 for March 2001 she received back-up PBSC (2.7Â106 CD34+

Bone Marrow Transplantation Treosulfan and osteonecrosis P Bojko et al 489 cells/kg bw) for persisting thrombocytopenia. Upon com- performed to date. Chemotherapy with FU/FA and pletion of HDC she was complaining of pain in her vinorelbine was resumed in June 2000 and was switched shoulders, hips and knees and conventional radiology to GEM in July because of increasing Ca 12-5 serum levels. showed irregularity of the right femoral head consistent Topotecan was started in January 2001 when pleural with avascular necrosis (Figure 2). Endoprosthetic hip effusions occurred, and finally carboplatin and paclitaxel replacement surgery was carried out in April 2001 and were given upon disease progression in April 2001. The last necrosis of the right femoral head was confirmed histori- treatment was given by a community oncologist and the cally. Further treatment with GEM was given for patient was lost to follow-up in July 2001. peritoneal progress and elevated serological tumor markers. Patient 3, I.P., had a highly differentiated cystadenocar- cinoma FIGO III of the left ovary treated with bilateral Discussion adnexectomy, hysterectomy and lymphonodular resection in January 1995 followed by six courses of adjuvant Bone necrosis is a rare complication after HDC and chemotherapy with cisplatin and cyclophosphamide. From autologous stem cell transplantation.2 The beginning of the October to December 1998 she received paclitaxel and symptoms relating to bone necrosis in our patients was cisplatin (Â3) followed by two courses of cyclophospha- between 5 (patient 3, I.P.) and 10 months (patient 2, V.B.) mide for PBSC mobilization because of peritoneal dis- upon completion of HDC with treosulfan. For patient 1 semination accompanied by serological tumor marker (M.D.) the exact beginning could not be recalled. Hip elevation. HDC with treosulfan (47 g/m2 over 25 h) was surgery was carried out between 16 and 35 months (mean started in January 1999. A second course of HDC with the 26 months) after HDC with treosulfan (Table 1). We have CEC regimen (Table 1) was added in February 1999. 2.9 recently conducted a phase I dose escalation and pharma- and 6.8Â106 CD34+ cells/kg bw were transfused after the cokinetic study of HDC treosulfan with autologous PBSC first and second HDC, respectively. In August 1999 her support. Treosulfan doses ranged from 16 to 56 g/m2 BSA serum Ca 12-5 was rapidly increasing and she was treated applied either as 2–4 h (29 courses in 24 patients) or with FU/FA plus vinorelbine until December 1999. From 24–25 h-infusion (seven courses in six patients), and the this time she complained of pain in both hipjoints and MRI results of patients receiving a 2-h infusion have been showed changes consistent with bilateral femoral head published recently.7 The three patients reported here necrosis (Figure 3). Endoprosthetic hip surgery of the right received 56 g/m2 treosulfan as a 4 (patient 1 M.D.: HDC side was performed in April 2000. Surgery of the left hip #2; patient 2 V.B.: HDC #2) or 3-h infusion (V.B.: HDC has been recommended after recovery but has not been #1) and 47 g/m2 as 24 h-infusion (patient 3 I.P.: HDC #1).

The cmax for all patients analyzed receiving treosulfan over 2–4 h was between 431 and 1720 mg/ml, and 88 and 229 mg/ ml during continuous infusion. The values for the three patients with femoral head necrosis who were treated at the two highest dose-levels of 47 and 56 g/m2 BSA were 1530 (M.D.), 1380 and 1180 (V.B.) and 186 mg/ml (I.P.),

Figure 2 Patient 2, V.B. Conventional X-ray film of right hip shows Figure 3 Patient 3, I.P. Coronal, T2-weighted MRI of the hips shows a irregularity of femoral head with increased density and flattening of the bilateral low-intensity signal intensity band in combination with a slight articular surface consistent with an avascular necrosis of the femoral head contour irregularity in the superior portion of the femoral head indicating with concomitant joint space narrowing and degenerative changes. the presence of an avascular necrosis.

Bone Marrow Transplantation Treosulfan and osteonecrosis P Bojko et al 490 respectively, excluding the possible explanation that ex- results published by Wagner et al 8 or Baynes et al.9 Reichle cessive peak serum levels of treosulfan may be responsible and co-workers have now conducted a total of 109 for the occurrence of bone necrosis. Figure 4 shows typical autologous transplants after high-dose therapy with treo- plasma concentration curves for treosulfan after different sulfan, carboplatin and etoposide in patients with lympho- applications (2-h infusion, 24-h infusion, split dose- ma and ovarian cancer. Femoral head necrosis was infusion over 2-h for 3 days). The highest AUC, however, observed in one patient only, who received a combination was measured in patient 1 (M.D., 8360 mg/mlÂh, range for of autologous and allogeneic transplantation and required all other patients 1390 to 7710 mg/mlÂh after 2–4 h-infusion steroid treatment for severe graft-versus-host disease, while and 2450 to 4930 mg/mlÂh during 24 h-infusion), while the no such complication was seen after autologous transplan- corresponding values for patient 2 (V.B.) and 3 (I.P.) were tation with cumulative absolute treosulfan doses of up to 5600 (HDC #1) and 5610 (HDC #2) and 4720 mg/mlÂh, 84 g/m2 (Reichle et al, personal communication). Together, respectively. Figure 5a shows the AUC vs. dose-level of 35 these data indicate that the time schedule of infusion of high-dose chemotherapies with treosulfan. The values for excessive doses of treosulfan might be an important factor. the three patients reported here fall into the right upper end For comparison, Figure 5b shows the plot of the applied

of the plot, suggesting at least some correlation between dose-level and cmax. AUC and the observed side effects. Four therapies Another possible explanation for the occurrence of conducted with split-dose treosulfan (ie daily infusion for osteonecrosis could be the release of methane sulfonic acid 3 consecutive days with total doses of up to 45 g/m2) (MSA) during the formation of a monoepoxide and l-(+)- resulted in similar cumulative AUC-values after three diepoxybutane. A total of 2 mol MSA are released for each consecutive days. However, no osteonecrosis occurred in mole of treosulfan during transformation into the active the corresponding patients. This is in accordance with metabolites. To our knowledge, the importance of in- creased MSA serum levels has not been studied before and we found no literature about osteonecrosis and MSA. However, this hypothesis would need confirmation in 1000 g/ml] animal models, for example. µ split dose 24 h-infusion The fact that no skeletal events were observed in patients 2 h-infusion with diagnoses other than ovarian cancer is indicative that prior oophorectomy with subsequent endocrine deprivation 100 might be an additional trigger for the induction of bone necrosis. The application of steroids as a further risk factor must be considered, but it is part of most high-dose or cisplatin-containing chemotherapy regimens and given to 10 many patients without subsequent bone necrosis. Patient 2 received pelvic irradiation including the medial part of the right femoral head. However, according to the treating radiotherapist, radiation field and local dose should not be 1 plasma concentration treosulfan [ 0 12 24 36 48 60 72 causative for femoral head necrosis, but additional trigger- time [h] ing cannot be ruled out completely. Patients who are scheduled for HDC and stem cell Figure 4 HD treosulfan. Comparison 2 h vs 24 h vs split dose. transplantation usually present with advanced disease and

a 9000 b 2000 2 - 4hour-infusion 8000 1800 2 - 4hour-infusion continuous infusion continuous infusion split dose 1600 7000 split dose VB 1400 VB

h] MD × 6000 1200 MD IP

g/ml] IP µ

g/ml 5000 1000 µ 4000 800 Cmax [ AUC [ 600 3000 400 2000 200 1000 0 10 20 30 40 50 60 10 20 30 40 50 60 dose-level [g/m2] dose-level [g/m2]

Figure 5 HD treosulfan: (a) dose-level vs. AUC; (b) dose-level vs. cmax.

Bone Marrow Transplantation Treosulfan and osteonecrosis P Bojko et al 491 the main focus is induction of remission of their underlying 3 Weilbacher KN. Mechanisms of osteoporosis after hemato- malignancy and to keeping them alive. Although the risk of poietic cell transplantation. Biol Blood Marrow Transplant bone necrosis is low, this complication should be kept in 2000; 6: 165–174. mind especially in patients treated with high-dose treosul- 4 Schulte C, Beelen DW, Schaefer UW et al. Bone loss in long- fan and allogeneic stem cell transplantation followed by term survivors after transplantation of hematopoietic stem Osteoporosis Int steroids and other immunosuppressants. Modified sche- cells: a prospective study. 2000; 11: 344–353. 5 Lappe JM, Tinley ST. Prevention of osteoporosis in women dules such as splitting the treosulfan dose seem to be an treated for hereditary breast and ovarian cancer. Cancer 1998; easy way for safe use of this otherwise well-tolerated and 83: 830–834. effective drug. 6 Gogas H, Fennelly D. Avascular necrosis following extensive chemotherapy and dexamethasone treatment in a patient with advanced ovarian cancer: case report and review of the Acknowledgements literature. Gynecol Oncol 1996; 63: 379–381. 7 Scheulen ME, Hilger RA, Oberhoff C et al. Clinical phase I dose escalation and pharmacokinetic study of high-dose We thank Dr C Poettgen, University of Essen Medical School, chemotherapy with treosulfan and autologous peripheral West German Cancer Center, Department of Radiotherapy for blood stem cell transplantation in patients with advanced critical review of the radiation chart of patient 2, V.B. malignancies. Clin Cancer Res 2000; 6: 4209–4216. 8 Wagner HM, Baumgart J, Andreesen R et al. Dose-escalation of treosulfan in a high-dose-protocol: a classical alkylating References agent new in high-dose combination chemotherapy. Proc ASCO 2000; 19: 54a (Abstr. 208). 1 Stern JM, Sullivan KM, Ott SM et al. Bone density loss after 9 Baynes RD, Dansey RD, Klein JL et al. A phase I trial of allogeneic hematopoietic stem cell transplantation. Biol Blood escalating treosulfan in combination with high-dose melphalan Marrow Transplant 2001; 7: 257–264. and dacarbazine (TMD) with peripheral blood progenitor 2 Ebeling PR, Thomas DM, Erbas B et al. Mechanism of bone cell transplant (PBPCT) in recurrent metastatic ovarian and loss following allogeneic and autologous hematopoietic stem breast cancer. Bone Marrow Transplant 2000; 26 (Suppl. 1) 33 cell transplantation. J Bone Miner Res 1999; 14: 342–350. (Abstr. P36).

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