Phase I study of high-dose ifosfamide, carboplatin and etoposide with autologous hematopoietic stem cell support.

More effective high-dose combination regimens are needed which have broad cytotoxic activity, steep doseresponse relations and non-overlapping non-hematologic toxicities (to allow administration of full doses of each agent). This study was designed to define the doselimiting toxicities and maximum tolerated doses of ifosfamide, carboplatin and etoposide (ICE) with hematopoietic stem cell support. Ifosfamide and carboplatin were initially fixed at 75% and 80% of the single agent maximum tolerated doses, respectively, and etoposide added to the combination. After the dose-limiting toxicity of etoposide was reached, its dose was fixed and ifosfamide and carboplatin were individually dose escalated as tolerated. All agents were given by 96h continuous infusion (days -7 to -3). Autologous marrow, with or without peripheral blood progenitor cells, was reinfused on day 0. Forty eight adults with advanced malignancies were enrolled in cohorts of three to five patients. At the maximum tolerated doses of ifosfamide 16 g/m 2 , carboplatin 1.8 g/m 2 and etoposide 1.2 g/m 2 , renal toxicity precluded further dose escalation. Two patients died of organ (renal, CNS) toxicity (4%). Renal toxicity was particularly prominent in patients with prior cisplatin exposure. An early chemotherapy-stopping rule was developed, supported by pharmacologic analysis, which resulted in immediate discontinuation of ifosfamide and carboplatin if the serum creatinine, monitored twice daily during chemotherapy, exceeded 1.5 mg/dl and was >0.5 mg/dl above baseline. High-dose ICE is well tolerated if serum creatinines are carefully monitored during chemotherapy administration. The early chemotherapy-stopping rule may enhance safety of the regimen but requires validation by additional correlation with pharmacokinetic data for each of the chemotherapeutic agents. The ICE regimen is active and should be evaluated in phase II trials of patients with small-cell lung, ovarian and germ cell carcinomas, and lymphomas