Adjuvant hormonal treatment with radiotherapy for locally advanced prostate cancer

OBJECTIVES

Long-term results of radiotherapy in locally advanced prostate cancer are poor due to local and distant failures. Since prostate cancer is hormone dependent, tumor androgen deprivation may enhance tumor eradication.

METHODS

Three randomized phase III trials, RTOG and EORTC are reported: they assess androgen suppression by using a luteinizing hormone-releasing hormone analogue (LH-RHa) with or without androgen blockade before and during, or during and after external irradiation.

RESULTS

A gain in disease-free, local relapse-free and metastasis-free survival has been obtained (p < 0.001). Only the EORTC 22863 trial has reported a significant improvement in overall survival (p = 0.001) with an LH-RHa started the first day of radiotherapy and administered every 4 weeks over 3 years. In the RTOG 85-10 trial, and LH-RHa, initiated in the last week of radiation therapy and continued until relapse, increased overall survival only in patients with poorly differentiated tumor with a Gleason score of 8-10 (p = 0.03).

CONCLUSION

Androgen suppression prior to and during radiation improves disease-free survival; adjuvant hormonal therapy with an LH-RHa during and after radiation improves overall survival.

Prognostic of DNA-synthesizing enzyme activities (thymidine kinase and thymidylate synthase) in 908 T1-T2, N0-N1, M0 breast cancers: a retrospective multicenter study

Among the methodological approaches of tumor proliferation, thymidine kinase (TK) and thymidylate synthase (TS) assays take into account the specific pathways of pyrimidine synthesis. Studies pointing to a prognostic value of TK and TS in breast cancer involved small numbers of patients. We investigated the prognostic value of these enzymes and their combination in a large retrospective multicenter study. Nine hundred eight T1T2, N0N1, M0 primary breast cancer samples (median follow-up 68 months) were tested. TK and TS were measured in cytosols by using standardized radioenzymatic methods. Although a positive correlation was obtained between TK and TS (p<10(-5)), major discrepancies were observed in some tumors. High levels of both enzymes were associated with large tumor size, histological grade III and steroid receptor-negative tumors. Univariate analysis showed that TK, TS and their combination were predictive of poor metastasis-free (MFS) (p < 10(-4); p=0.004; p < 10(-4)) and disease-free survival (DFS) (p < 10(-4); p=0.007; p=0.0001). TK was selected as an independent factor for MFS in Cox analysis. It was the only variable selected in node-negative patients. Subgroups with specific outcomes, with possible therapeutic implications, were identified: a) in node-negative patients not receiving adjuvant treatment, TK values in the 4th quartile were associated with poor MFS (p=0.0002) and DFS (p=0.0005) as compared to the other quartiles; b) in node-positive patients receiving adjuvant chemotherapy, low levels of both TK and TS were associated with the highest survival rates (MFS: p=0.04; DFS: p=0. 03).

Post-radiation severe xerostomia relieved by pilocarpine: a prospective French cooperative study

BACKGROUND AND PURPOSE

The aim of the study was: (1) to confirm the action of pilocarpine hydrochloride (Salagen) against xerostomia: (2) to correlate the response to dose/volume radiotherapy parameters.

MATERIALS AND METHODS

From June 1995 to February 1996, 156 patients with severe radiation induced xerostomia received pilocarpine hydrochloride orally. IS mg per day with a 5 mg optional increase at S weeks up to a daily dose of 25 mg beyond 9 weeks.

RESULTS

One hundred and forty five patients are fully evaluable. Treatment compliance was 75%. Thirty eight patients (26%) stopped treatment before week 12 for acute intolerance (sweating, nausea, vomiting) or no response. No severe complication occurred. Ninety ses en patients (67%) reported a significant relief of symptoms of xerostomia at 12 weeks. Within 12 weeks, the size of the subgroup ith normal food intake almost doubled (13-24 patients) while the size of the subgroup with (nearly) impossible solid food ingestion decreased by 38% (47 vs. 29 patients). The impact on quality of life was considered important or very important by 77% of the responders.

CONCLUSIONS

No difference was found according to dose/volume radiotherapy parameters suggesting that oral pilocarpine hydrochloride: (1) acts primarily by stimulating minor salivary glands: (2) can be of benefit to patients suffering of severe xerostomia regardless of radiotherapy dose/volume parameters: (3) all responders are identified at 12 weeks.

[Breast, cervical and colo-rectal simultaneous mass screening program for women 50 to 69 years old in Isere]

A cervical screening campaign is implemented in the Isere department since 1990 for women aged 50 to 69, together with breast cancer and colo-rectal cancer screening. The attendance rate is about 30% but a survey performed among this population shows that 68.6% of these women did presented for screening during the year following their invitation. One and a half per cent of all smears were abnormal or ASCUS smears. Cancer detection rate for invasive cancer and CIN III was 1.3/1000. General practitioners and gynaecologists took the same part in the programme. During a postal survey conducted among them, they declared that they felt concerned with cancer screening, even if they met some difficulties. This results suggest that nominative invitations and a good cooperation of GPs may improve the coverage of eligible women. For the future success of the National Programme, which is to be implemented in France, organisational arrangements have to be set up. The review of positive points and difficulties met by Isere's local programme may help to discuss it.

Fast growing cervical carcinomas. A retrospective analysis of 20 IB-IIB FIGO

INTRODUCTION

Fast growing cervix carcinomas have a pejorative outcome: they may occur quickly after cervical smears qualified as normal - within an interval from 12 to 18 months in women less than 50 years old, and involveing the endocervix. This retrospective analysis is aimed at assessing 5-year outcomes.

MATERIALS AND METHODS

Twenty cases of fast-growing cancer of the uterine cervix classified according to the FIGO clinical staging system as IB (n=14), IIA (3), and IIB (3), have been reviewed and compared to a cohort of 160 cases not having this feature. As regard to fast-growing carcinoma, the median age was 41 years (range 25-50), and the median follow-up 22 months (8-213) as compared to 54 years (27-79) and 80 months (5-199) for the reference cohort. The comparison of the two cohorts shows only a difference of breakdown which concerns the histological pelvic lymph nodes status (P<0.05), more often positive in fast-growing forms. The treatment policy was equally distributed between a radio-surgical approach, cesium 137 intracavitary irradiation followed by radical hysterectomy and lymphadenectomy, or a definitive irradiation with pelvic external irradiation followed by cesium 137 intracavitary irradiation.

RESULTS

Thirteen deaths are reported in the fast-growing series instead of 54 in the other series. The 5-year overall survival is, respectively, 34 (13-55) vs. 74% (68-82) (P<0.001), the loco-regional-free survival 58 (33-84) vs. 85% (79-81) (P<0.001), the 5-year metastasis-free survival 61 (38-84) vs. 84% (78-90) (P=0. 004).

CONCLUSION

These poor results emphasize the need to intensify loco-regional therapy with a concurrent cisplatin-based chemotherapy within the framework of a multidisciplinary approach.

Phase II trial of up-front accelerated thoracic radiotherapy combined with chemotherapy and optional up-front prophylactic cranial irradiation in limited small-cell lung cancer. Groupe d'Oncologie Thoracique des Régions Alpines

PURPOSE

To investigate the feasibility and outcome of bifractionated, up-front thoracic radiotherapy (TR) (45 Gy in 30 fractions of 1.5 Gy twice daily over 3 weeks) combined with chemotherapy (CT) (six cycles of cisplatin and etoposide) and optional low-dose, up-front prophylactic cranial irradiation (18 Gy in 10 fractions of 1.8 Gy twice daily over 5 days) in limited small-cell lung cancer.

PATIENTS AND METHODS

CT (etoposide 100 mg/m(2) for 3 days and cisplatin 25 mg/m(2) for 3 days) was started on day 8 or 15 after the first TR treatment. In the five subsequent cycles, cisplatin was given as a single 100-mg/m(2) dose on day 1 every 4 weeks. A total of 52 patients were entered (41 men and 11 women); the median age was 55 years (range, 33 to 67 years). World Health Organization performance status was 0 in 34 patients, 1 in 16 patients, and 2 in two patients. Thirty-six patients (69%) received the full planned six cycles of CT.

RESULTS

All treated patients were assessable for response. Thirty-one patients (60%) achieved a complete response, and 16 (30%) had a partial response. One-, 3-, and 4-year survival rates were 74% (95% confidence interval [CI], 60% to 84%), 34% (95% CI, 21% to 49%), and 32% (95 CI, 16% to 46%), respectively. The median survival time was 18 months. Event-free survival at 1 year was 45% (95% CI, 32% to 58%) and at 3 years, 30% (95% CI, 18% to 44%). The main radiation-related acute toxicity was esophageal: 38% of the patients experienced grade 3 or 4 acute toxicity. CT was well tolerated. Although grade 3/4 neutropenia was observed in 86% of the patients, only 4% presented with associated fever. Grade 3/4 nausea and vomiting was seen in 35% of patients.

CONCLUSION

This trial demonstrates that up-front accelerated TR associated with CT is feasible, has acceptable toxicity, and shows considerable long-term survival potential.

Clinical impact of dosimetry quality assurance programmes assessed by radiobiological modelling of data from the thermoluminescent dosimetry study of the European Organization for Research and Treatment of Cancer

The European Organization for Research and Treatment of Cancer (EORTC) Radiotherapy Group initiated its mailed thermoluminescence dosimetry (TLD) programme in 1986. The aim of the present study was to evaluate the clinical relevance of variations in beam output detected in the period 1993 to 1996. A total of 140 beam outputs were checked (26 for cobalt-60 units and 114 for linear accelerators) in 35 centres. Clinical dose-response data for tumour control and normal tissue morbidity were used to assess the variation in clinical outcome resulting from variability in beam output. For 75 checked beams with nominal accelerating potentials (n. a.p.) of 6 MV or less the mean ratio, +/- standard deviation (S.D.) of measured to stated output was 1.004+/-0.020. For 65 beams with n. a.p. of 8 MV or more, the ratio was 1.009+/-0.021. Even with this relatively high level of precision, broad distributions of estimated tumour control or normal tissue morbidity were found. In the 10% of the beams with the most pronounced underdosage, the loss in tumour control probability was estimated at 7-8 percentage points. Likewise, in the 10% of the beams with the most pronounced overdosage, the increase in mild/moderate morbidity was 19-22 percentage points. For severe morbidity the same beams raised the estimated incidence of severe complications from 5% to 9-10%. An estimation of the loss of uncomplicated cure probability was about 1% for both high and low energy beams. Sequential mailings considerably improved the uniformity of clinical outcome. We conclude that small deviations in beam output may lead to clinically important variations in outcome. Substantial reductions in the variation between measured and stated output can be achieved by sequential mailings. Mailed TLD checks should be an integral part of a continuously ongoing quality assurance activity in radiotherapy.

Pathological prognostic factors in a series of 137 stage I TNM/UICC endometrial carcinomas

PURPOSE

We report on the long-term results of combination surgery-radiotherapy in cT1 carcinoma of the endometrium according to prognostic factors.

PATIENTS AND METHODS

From 1974 to 1993, 130 women suffering from cT1Nx-O Mo endometrial carcinoma, underwent surgical resection. The median age was 62 years. Thirteen received pre-operative irradiation, two pre-operative brachytherapy followed by post-operative external irradiation and 115 patients (88.35%) underwent post-operative irradiation therapy by brachytherapy or external beam irradiation.

RESULTS

The median follow-up is 67 months. Overall and specific survival rates for patients with cT1pT1 tumours were 71.1 and 85% at 10 years. For overall survival, lymph node invasion was the most powerful prognostic factor in the multivariate analysis (P = 0.02). If lymph node invasion is not taken into account, the WHO histological grade exerts a significant prognostic impact (P = 0.001).

CONCLUSION

For stage cT1 endometrial carcinoma, primary surgery allows radiotherapy to be adjusted according to the WHO histological grade, myometrial invasion and the pelvic lymph node status.

The use of a semi-customized phantom for verification of conformal plans

We have developed a technique for inverse treatment planning of prostate therapy designed to improve the degree of conformation between the dose distribution and the target volume. We compared the inverse plan with a "standard" four-field box technique as well as a four-field technique using oblique fields ("cross technique"). We validated the dosimetry of the inverse plan using Fricke gel solution in phantom specifically designed for this purpose. The phantom is a Plexiglas tank with a cross section, which approximates the dimensions of the pelvis. Anatomical data from computed tomography (CT) images of a patient were used to simulate organs in our phantom. This allows us to calculate dose distributions with the external geometry of the phantom and internal anatomy of the patient. Dose-volume histograms (DVHs) for the three different plans were calculated. The phantom containing the Fricke gel was irradiated according to the inverse plan. Magnetic resonance (MR) images was used to determine the dose distribution delivered to the phantom. We observe, on DVHs, that the inverse plan significantly reduces the dose to the rectum and the bladder but slightly increases the inhomogeneity inside the target volume. Correlation is good between isodoses on MR images and calculated isodoses. We conclude that inverse planning software can greatly improve the conformal degree of treatment to the prostate. This technique could be applied to other complex anatomic sites at which dose to organs at risk is a limiting factor and increased dose to the target volume is indicated. Our phantom and the Fricke gel solution are convenient to carry out validation of conformal treatments.

Accelerated radiotherapy, carbogen, and nicotinamide in glioblastoma multiforme: report of European Organization for Research and Treatment of Cancer trial 22933

PURPOSE

A three-step phase I/II trial associating accelerated radiotherapy with carbogen (step 1, ARCO), with nicotinamide (step 2, ARN), or with both (step 3, ARCON) was conducted, the aim of which was to overcome the effects of proliferation and hypoxia as potential causes of tumor radioresistance in glioblastoma multiforme.

PATIENTS AND METHODS

Radiotherapy consisted of 60 Gy delivered over 4 weeks in 1.5-Gy fractions twice daily, 5 days a week. Carbogen breathing was started 5 minutes before each fraction and continued until the end of each treatment session. Nicotinamide was given daily as a single oral dose of 85 mg/kg.

RESULTS

A total of 115 patients with a median age of 55 years were registered. Of 107 eligible patients, 23 were registered in step 1, 28 in step 2, and 56 in step 3. The planned treatment was administered without any interruption in 72% of patients (86% in ARCO but 68% in ARN and ARCON). The incidence and severity of acute skin and mucous membrane toxicity were higher in patients who received nicotinamide (ie, the ARN and ARCON groups). Grade 1 to 2 gastrointestinal toxicity was observed in 44% of patients in the ARN group and 32% of patients in the ARCON group, but only in 8% of patients in the ARCO group. Eight percent of evaluated patients presented with abnormal liver test results at treatment completion. The dose of corticosteroids had to be increased in 44% of patients. Late neurologic side effects were similar in all treatment steps and were observed mostly in patients with disease progression. Median survival times for patients treated with ARCO, ARN, and ARCON were 10.1, 9.7, and 11.1 months, respectively.

CONCLUSION

Feasibility of ARCO treatment was good but that of ARN and ARCON was only fair. This probably reflected the higher acute toxicity rate, particularly gastrointestinal, for patients receiving nicotinamide. The dose of corticosteroids had to be increased frequently during treatment, suggesting a higher than expected acute neurologic toxicity. Overall survival was similar in the three treatment steps and not different when compared with results of other series that used radiotherapy alone.

[Conformal radiotherapy of prostatic cancer: a general review]

Recent progress in radiotherapeutic management of localized prostate cancer is reviewed. Clinical aspects--including dose-effect beyond 70 Gy, relative role of conformal radiation therapy techniques and of early hormonal treatment--are discussed as well as technical components--including patient immobilization, organ motion, prostate contouring, beam arrangement, 3-D treatment planning and portal imaging. The local control and biological relapse-free survival rates appear to be improved by high dose conformal radiotherapy from 20 to 30% for patients with intermediate and high risk of relapse. A benefit of overall survival is expected but not yet demonstrated. Late reactions, especially the rectal toxicity, remain moderate despite the dose escalation. However, conformal radiotherapy demands a high precision at all steps of the procedure.

[Standardization and quality control in the evaluation of proliferation parameters in T1T2, N0N1, M0 breast cancer: multicentric retrospective study II. DNA-ploidy and S-phase fraction]

As part of a clinical research project, proliferative parameters were studied in primary breast cancer: standardization and technical validation of thymidine kinase (TK), thymidylate synthase (TS) and protein tyrosine kinase (PTK) are described. A total of 633 frozen tumor specimens, available in four institutions, was analyzed in three flow cytometry laboratories for DNA content and percentage of S-phase cells (%S) measurement. 1) The standardization step consisted in developing a common protocol for sample preparation; then, common cell suspensions were analyzed in order to perform an inter-laboratory control. Objective guidelines were elaborated to interpret DNA histograms in breast carcinoma. 2) DNA-aneuploidy was observed in 61% of cases of the retrospective series. Compared with DNA-aneuploid tumors, mean %S was significantly lower in case of DNA-diploidy (respectively: 6.4% and 2.2%, p < 0.001). When compared between the four institutions, %S distributions did not differ significantly. 3) %S is strongly correlated with TK, TS and PTK and high percentages were also observed in high grade tumors or tumor without hormone receptors. These results show that a standardization in using flow cytometers and DNA software allows multicenter studies.

[Standardization and quality control in the evaluation of proliferation parameters in T1T2, N0N1, M0 breast cancer : multicentric retrospective study I. DNA synthesis enzyme activities]

As part of a clinical research project co-ordinated in Grenoble, six French institutions (CRLCC Angers, CHU Grenoble, Hospices civils Lyon, AP Marseille, CRLCC St-Cloud, CHU Tours) grouped together in order to study the following proliferative parameters in primary breast cancer: DNA synthesis enzymes [thymidine kinase (TK), thymidylate synthase (TS)], signal transduction enzyme [protein tyrosine kinase (PTK)] and S-phase fraction (%S). TK, TS and PTK were measured in cytosols using radio-enzymatic biochemical methods. S-phase was estimated using flow cytometry. The first step consisted in standardization and technical validation of the measurements. The second step consisted in the clinical validation by using a retrospective series of 1,003 breast cancers T1T2, N0N1, M0. We report the results of the first step, together with the distributions of the variables and their relationship with classical clinical variables: 1) Using standardized methods and a cytosolic control, a good reproducibility of measurements was obtained, whether assays were performed in one (TS, PTK) or in several laboratories (TK). 2) Significantly different distributions of TK and TS were observed between the different centres mainly due to different conditions of storage of tumours and cytosols. 3) A highly significant correlation was observed between TK, TS and PTK. Highest TK, TS and PTK levels were observed in tumours with high histological grade or receptor negative tumors. This study clearly illustrates the importance of quality assurance of multicentre studies.

Analysis and classification of interval cancers in a French breast cancer screening programme (département of Isère)

The objective of this study is to analyse detection rates and stage of diagnosis of interval cancers in the mass screening mammography programme of Isère (France), launched in 1990. Interval cancers are defined as breast cancers diagnosed within 30 months after a negative screening assessment, for women attending the programme between November 1990 and December 1994. Stages of diagnosis of these cancers are compared with those of screened cancers and to those of cancers diagnosed outside the programme. The rates of invasive interval cancers are 17.7% of the expected incidence rate during the first year, 60.0% during the second year and 58.8% after the second year. Sensitivity of the programme (one test every 30 months) is 74%; sensitivity at one year is 82%. Results are better for women aged 60-69 years than for younger women (50-59 years). Diagnosis is made at an early stage with 8% of in situ cases, and with 40% of very small tumours (sizes < or = 10 mm). Those stages are very close to the ones for screened cases. Interval cancer rates are low during the first year. Higher rates for the second year and early stages of diagnosis could be explained by self-referred screening practice in our area.

[Evaluation of a series of 137 carcinomas of the endometrium of stage I TNM/UICC]

PURPOSE

To assess retrospectively the long-term results of the combination of surgery and radiotherapy in carcinoma classified cT1.

PATIENTS AND METHODS

From 1974 to 1993, 137 women suffering from endometrial carcinoma cT1Nx-0 M0 were entered into the study. The median age was 62 years (range: 39-85 years) and the median follow up was 67 months (range: 0-224 months).

RESULTS

Surgery was performal in 132 women (96.35%). For cT1, the 5-year overall and specific survivals were 81.1% and 84.5%, respectively. The 10-year overall and specific survivals were 68.8% and 82.2%, respectively. Concerning cT1pT1, the 5-year overall and specific survivals, were 83.9% and 87.4%. The 10-year overall and specific survivals were 71.1% and 85%, respectively. Histological grade, pelvic lymph node involvement and myometrial infiltration influence significantly the overall and specific survivals of cT1pT1 tumors. According to multivariate analysis, pelvic lymph node involvement was a powerful prognostic factor for both the overall and specific survivals. If we rule out pelvic lymph node involvement, WHO histological grade was a significant prognostic factor.

CONCLUSION

Combination of surgery and radiotherapy is still a common procedure for cT1 tumors. When surgery is done before radiotherapy, tailored irradiation may further take place, according to WHO histological grade and pelvic lymph node status.

Comparative study of physical properties of three suture materials: silk, e-PTFE (Gore-Tex), and PLA/PGA (Vicryl)

The aim of this in-vitro study was to compare the physical properties of three suture materials used in periodontal surgery: silk, expanded polytetrafluoroethylene (e-PTFE), and polylactic acid/polyglycolic and (PLA/PGA). Five physical tests were carried out on each of the three suture materials: strain to failure, tensile strength, knot tensile strength, knot slippage, and capillarity. For each test, 30 samples of each suture material were used. In all cases, the statistical results showed that the e-PTFE and the PLA/PGA threads were superior.

[Current studies of combined radiotherapy-hormone therapy in localized and locally advanced prostatic cancers]

In locally advanced prostate cancer three clinical randomized trials have shown that external irradiation combined with LHRH analogue with or without antiandrogen improved survival: disease-free survival, local recurrence-free survival, metastasis-free survival (P < 0.001). EORTC trial 22863 alone has shown a significant improvement of overall survival (P = 0.001), with an LHRH analogue (goserilin acetate, zoladex) started the first day of irradiation and followed every 4 weeks for 3 years; for RTOG trial 85-31 the same LHRH analogue started during the last week of irradiation and given until relapse increases survival of patients with poor differentiated tumours with gleason score ranging from 8 to 10 (P = 0.03). In locally confined prostate carcinoma randomized trials are ongoing to assess the impact of conventional irradiation or three dimensional conformal radiotherapy with or without adjuvant hormonotherapy.

Influence of the 'directions for use' on positivity rates of the Hemoccult II test

OBJECTIVE

A concise, detailed, and complete instruction sheet is indispensable for adequate completion by the users of a product. This sheet should be enclosed in the envelope which contains Hemoccult II slides. The authors found that the instructions provided by the French manufacturer were unsatisfactory. They designed a short and simple notice, adequately detailed to be understandable by all volunteers and to obtain satisfactory stool smears. Positivity rates of Hemoccult II performed with the manufacturer's notice were compared to those obtained with Hemoccult II performed with the authors' instructions.

METHODS

This study was made during the third screening campaign carried out by the Office Departemental de Lutte contre le Cancer (ODLC). This screening programme only concerned women 59 to 69 years of age. Six thousand three hundred and ninety-two Hemoccult II containing the manufacturer's instructions were received at the laboratory during March, April, May, June and July 1996, and 2633 Hemoccult II containing the ODLC instructions during March, April, May, June and July 1997. All Hemoccult II were developed and read by one trained technician in the Biochemistry Laboratory (Grenoble University Hospital).

RESULTS

The two populations, studied in 1996 and 1997, were strictly comparable in terms of age and number of previous screenings. Out of 6392 Hemoccult II containing the manufacturer's instructions, 157 (2.5%) were found positive, as compared to 36 (1.4%) Hemoccult II out of 2633 which contained the authors' instructions. This difference is highly significant (P = 0.001).

CONCLUSION

The directions for use provided with Hemoccult II had a crucial influence on positivity rates, and therefore on the cost of screening. The instruction sheet provided by the French manufacturer is not satisfactory as it contains too much needless information, while several important pieces of advice are missing.

Quality of life after radiation therapy of cerebral low-grade gliomas of the adult: results of a randomised phase III trial on dose response (EORTC trial 22844). EORTC Radiotherapy Co-operative Group

In 1985, the EORTC Radiotherapy Co-operative Group launched a randomised phase III study comparing high-dose (59.4 Gy in 6.5 weeks) versus low-dose (45 Gy in 5 weeks) radiotherapy with conventional techniques in patients diagnosed with low-grade cerebral glioma. The primary endpoint of the study was survival. No difference in survival was observed between the two treatment strategies. A quality of life (QoL) questionnaire consisting of 47 items assessing a range of physical, psychological, social, and symptom domains was included in the trial to measure the impact of treatment over time. Patients who received high-dose radiotherapy tended to report lower levels of functioning and more symptom burden following completion of radiotherapy. These group differences were statistically significant for fatigue/malaise and insomnia immediately after radiotherapy and in leisure time and emotional functioning at 7-15 months after randomisation. These findings suggest that for conventional radiotherapy for low-grade cerebral glioma, a schedule of 45 Gy in 5 weeks not only saves valuable resources, but also spares patients a prolonged treatment at no loss of clinical efficacy.

Alternating radiotherapy and chemotherapy for inoperable Stage III non-small-cell lung cancer: long-term results of two Phase II GOTHA trials. Groupe d'Oncologie Thoracique Alpine

PURPOSE/OBJECTIVE

To report on two consecutive Phase II cooperative trials in which we evaluated the combination of alternating hyperfractionated accelerated radiotherapy and cisplatin-based chemotherapy in inoperable Stage III non-small cell lung cancer (NSCLC).

PATIENTS & METHODS

Between February 1986 and September 1989, 65 patients were entered in the first trial (GOTHA I), and between December 1989 and October 1992 67 were enrolled in the second trial (GOTHA II). In both protocols, radiotherapy (RT) was administered twice daily, at 6 h intervals, 5 days a week, to a total dose of 63 Gy in 42 fractions of 1.5 Gy. RT was given during weeks 2, 3, 6, and 7, over an elapsed time of 6 weeks. In GOTHA I, three cycles of cisplatin, 60 mg/m2 day 1, mitomycin, 8 mg/m2 day 1, and vindesin 3 mg/m2 day 1 and the first day of the following week, were given during weeks 1, 5, and 9; in GOTHA II, cisplatin 70 mg/m2 day 1 and vinblastin 5 mg/m2 day 1 and the first day of the following week were given during weeks 1, 5, 9, 13, 17, and 21.

RESULTS

With a minimum follow-up of 3 years, the 1-, 2-, 5-, and 8-year overall survival probability was 56% (95% CI 47-64%), 27% (20-35%), 12% (7-18%) and 9% (3-16%), respectively, with a median survival of 13.6 months (11.4-16.8). Median follow-up for survivors was 6 years (3.3-9.9). There were no survival differences between Stages IIIA and IIIB (p = 0.84), performance status 0, 1, 2 (p = 0.87), sex (p = 0.45) or between the two treatment protocols. At this time, 14 patients are alive, and 118 have died: 102 from NSCLC, 4 from acute toxicity, 2 from secondary surgery, 4 from other medical causes, and 6 from unknown causes. Correlation between response and long-term survival was poor, since of the 24 patients who survived 3 years or more, only 6 (25%) were classified as having a complete response; the remainder having either a partial response (11, 46%), no change (6, 25 %), or "progressive disease" (1, 4 %). First site of relapse was local in 31% of these cases, distant in 43%, local and distant in 15 %, and unknown in 11%. Main grade 3-4 acute toxicities were nausea-vomiting (17%), mucositis (15%), leukopenia (41%), and thrombocytopenia (11%). Eight patients presented with grade 3-4 symptomatic lung radiation pneumopathy.

CONCLUSION

Based on this experience with 132 patients, this combination of alternated RT and chemotherapy (CT) for inoperable Stage III NSCLC is feasible with acceptable toxicity, and long-term results suggest a gain in survival when compared to those obtained with conventional RT alone. However, the still high local and distant failure rates indicate that both local and systemic therapies need to be improved.

Pharmacokinetics of nicotinamide in cancer patients treated with accelerated radiotherapy: the experience of the Co-operative Group of Radiotherapy of the European Organization for Research and Treatment of Cancer

BACKGROUND

The EORTC has initiated studies to combine nicotinamide with carbogen in accelerated fractionation schedules (ARCON), since for some tumour types, acute and chronic hypoxia as well as treatment protraction may prejudice the outcome of radiotherapy. The tolerable dose of nicotinamide and the optimal interval for administration need to be ascertained.

AIM

Full pharmacokinetic profiles of nicotinamide concentrations in plasma were analyzed repeatedly in 15 patients to determine the inter- and intra-patient variability in peak plasma concentrations and the optimum times for administering nicotinamide as a radiosensitizer.

METHODS

Nicotinamide (Nicobion) was administered in tablet form to patients with advanced head and neck and non-small cell lung carcinomas. A standard 6 g dose was given regardless of body weight after an overnight fast and at least 30 min before breakfast. In 15 patients, blood samples were taken prior to and 1, 2, 4, 6, 8, 12 and 24 h after administration of the drug. This full profile was determined on two to four occasions for the head and neck cancer patients and on two occasions for the lung cancer patients. For each profile, the maximum concentration of nicotinamide (Cmax), time to peak plasma concentration (Tmax), elimination half-lives (t1/2) and area under the curve (AUC) were determined. Compliance was recorded and nausea and vomiting were graded on a 0-3 scale. Complete profiles of the five major metabolites were also obtained.

RESULTS

In the 48 complete sets of blood samples, peak plasma concentrations ranged from 787 to 2312 nmol/ml with a median value of 1166 nmol/ml. The peak plasma concentration was achieved at 1 h in only 54% of the pharmacokinetic profiles, but at this time 92% of the profiles had already exceeded the target concentration of 700 nmol/ml, the level required in the mouse for tumour radiosensitization. The median t1/2 for all 15 cases was 9.3 h, with minimum and maximum values of 4.2 and 26.8 h. The highest concentrations of nicotinamide metabolites were found to be the N-oxide, 2-pyridone and 1-methylnicotinamide. The toxicity (nausea and vomiting) was scored and found not to be correlated with any of the pharmacokinetic parameters.

CONCLUSIONS

The plasma concentrations considered necessary to radiosensitize can easily be exceeded with a dose of 6 g taken as 12 x 500 mg in tablet form; 700 nmol/ml was achieved in all patients and apparently would have been achieved in most even with a considerable reduction in dose. An adequate time between administration and radiotherapy appeared to be 1 h with this drug formulation for 92% of the profiles.

[Radiotherapy of stage T1-T2 M0 prostatic adenocarcinoma. Analysis of the carcinologic results of a multicenter study of 610 patients. Groupe Radiothérapie de la Commission de Coopération Médicale Intercentres (CCMI)]

PURPOSE

Retrospective analysis of the results of radiotherapy in localized prostatic adenocarcinoma. Complications were excluded.

PATIENTS AND METHODS

Six-hundred-and-ten T1-T2 adenocarcinomas of the prostate were treated with continuous courses of external beam radiation therapy in 19 participating Institutes between January 1983 and January 1988. The mean follow-up was 10.4 years; the mean age of patients at the beginning of radiotherapy was 68.5 years.

RESULTS

A 10-year, local control had been achieved in 86% of T1-T2 (81.4% for T2). The 5- and 10-year metastatic relapse rates were 25.3% and 30% (29% and 38.1% for T2), respectively. At 10 years, 62.4% of T1-T2 were recurrence-free; overall survival rate was 45.8% and cause-specific survival rate was 70.5%; 29.9% of T1-T2 patients were alive and disease-free. T category (TNM), pathologic grade, pelvic lymph node status, local tumor control, and obstructive ureteral symptoms were correlated with survival. The influence of pelvic nodes radiation, dose, overall treatment time, previous endocrine treatment, and transuretral resection was not significant for disease-free survival (alive and disease-free) and other endpoints.

CONCLUSION

There was no difference between the French series (1975-1982 and 1983-1988). The results of the literature are comparable to ours. As far as prognostic factors are concerned, this report provides evidence that the explainable variables which influence survival depend on the tumor and patient status.

[Scoring system of late effects of radiations on normal tissues: the SOMA-LENT scale]

Radiation tolerance of normal tissues remains the limiting factor for delivering tumoricidal dose. The late toxicity of normal tissues is the most critical element of an irradiation: somatic, functional and structural alterations occur during the actual treatment itself, but late effects manifest months to years after acute effects heal, and may progress with time. The optimal therapeutic ratio ultimately requires not only complete tumor clearance, but also minimal residual injury to surrounding vital normal tissues. The disparity between the intensity of acute and late effects and the inability to predict the eventual manifestations of late normal tissue injury has made radiation oncologists recognize the importance of careful patient follow-up. There is so far no uniform toxicity scoring system to compare several clinical studies in the absence of a "common toxicity language". This justifies the need to establish a precise evaluation system for the analysis of late effects of radiation on normal tissues. The SOMA/LENT scoring system results from an international collaboration. European Organization Treatment of Cancer (EORTC) and Radiation Therapy Oncology Group (RTOG) have created subcommittees with the aim of addressing the question of standardized toxic effects criteria. This effort appeared as a necessity to standardize and improve the data recording, to then describe and evaluate uniform toxicity at regular time intervals. The current proposed scale is not yet validated, and should be used cautiously.

Macroscopic and microscopic aspects of incinerated teeth

Fifty-eight premolars, extracted for orthodontic reasons, were incinerated for one hour in a furnace at temperatures varying from 150 degrees C to 1150 degrees C, increasing at 100 degrees C intervals. Between 150 degrees C and 700 degrees C the teeth changed from light yellow to bluish-white passing through brown. The scanning electron microscope showed that at 150 degrees C cracks appeared in the enamel, increasing in number as the temperature rose. At 450 degrees C the internal surface detached from the dentine and showed the same cracked surface as the exterior. Above 1100 degrees C the enamel fragments had a prismatic structure difficult to identify due to their melted structure. Dentine retained its tubular structure up to 1150 degrees C even when the tubules' diameter decreased at 700 degrees C. The cementum cracked as the temperature increased. Certain cracked areas actually detached at 600 degrees C giving a corroded aspect to the cementum and the residual zones became irregular when the temperature rose and eventually at 1150 degrees C the cementum was no longer identifiable.

[Combination of radiotherapy and hormonotherapy in locally advanced cancers of the prostate]

The long-term results of external irradiation in locally advanced prostate cancer are poor: relapses are local or distant from infra-clinical disease present at diagnosis. Three clinical randomized trials have shown that hormonotherapy with LH-RH analogue with or without antiandrogen has improved: disease-free survival, local recurrence-free survival and metastasis-free survival (P < 0.001). The EORTC trial 22863 has shown a significant improvement of the overall survival (P = 0.001), with an LH-RH analogue (goserilin acetate, Zoladex) was administered the first day of irradiation and then every 4 weeks for 3 years; for the RTOG trial 85-31 the same LH-RH analogue was administered during the last week of irradiation and given until relapse increases survival of patients with poor differentiated tumours with a Gleason score ranging from 8 to 10 (P = 0.03). Adjuvant hormonal treatment with an LH-RH analogue is recommended, but the optimal duration of the treatment remains unclear.

[Localized prostatic adenocarcinoma: role of pelvic radiotherapy following radical prostatectomy]

Radical prostatectomy after pelvic lymphadenectomy is an effective treatment for patients with T1-2 pN0 adenocarcinoma of the prostate. However, pathologic analysis of resected tissue reveals that in 20 to 40% of clinical stage B lesions, the tumour has extended locally beyond the prostate. This infra-clinical disease may be the origin of local relapse. Radiation oncologists are often asked to deliver post-operative irradiation. There is sufficient evidence in the literature that postoperative radiation therapy can improve local control rate for patients with pT3 pN0 adenocarcinoma of the prostate; however, the effect of this radiotherapy on survival in this category of patients remains unclear. It is the reason why randomised clinical trials have been implemented for investigating the role of pelvic external irradiation with respect to the effects on local control, acute and late morbidity, overall survival and cancer-related survival, and for better defining the selective indications of radiotherapy, regarding pathological data.

Delapril slows the progression of atherosclerosis and maintains endothelial function in cholesterol-fed rabbits

The renin-angiotensin system is an important modulator of arterial blood pressure and inhibitors of the angiotensin-converting enzyme (ACE-Is) and are currently used in the treatment of hypertension. The pleiotropic actions exerted by angiotensin II (AngII) on the functionality of the vessel wall may have pro-atherosclerotic outcomes; evidence for an anti-atherosclerotic effect of ACE-Is has been presented and an antioxidant effect has been attributed to thiol-containing ACE-Is, like Captopril. The present study has been undertaken to investigate the effect of Delapril, a lipophilic ACE-I, on the development of atherosclerosis in cholesterol-fed rabbits. While it did not correct hyperlipidemia, Delapril dose dependently inhibited the development of atherosclerosis, expressed as aortic area covered by lesions (23.3+/-4.1, 21.3+/-2.4 and 18.5+/-3.3% with Delapril at the daily dose of 5, 10 and 20 mg/kg, respectively, versus 38.2%+/-6.4 for control animals) and its effect was similar to that of Captopril (14.5+/-5.1% at the daily dose of 25 mg/kg). Furthermore, Delapril partially and dose dependently restored endothelium-dependent relaxation, which is impaired in vessels from hypercholesterolemic animals (51.80+/-12.18, 59.74+/-5.16, 69.13+/-8.70 maximal percent relaxation versus 48.26+/-3.05% for the untreated control and 67.67+/-6.72% for Captopril-treated animals). An antioxidant mechanism is unlikely to explain this data, since Delapril does not contain thiol groups. These observations suggest that Delapril may represent an effective pharmacological approach for the treatment of atherosclerosis during its early phases.

Experimental single controlled study of burned bones: contribution of scanning electron microscopy

Burned bones were studied using Scanning Electron Microscopy. The samples were cut from a maxillary-mandibular block taken during an autopsy. These fragments were heated in a furnace under controlled temperature conditions for 60 minutes. The temperatures ranged from 150 to 1150 degrees Celsius. The results are as following: (i) there are significant alterations of the bone, more and more obvious as the temperature increases, (ii) it appears to be difficult to establish a precise correlation between the temperature and the scanning electron microscopy patterns.

Pharmacological characterization of the cysteinyl-leukotriene antagonists CGP 45715A (iralukast) and CGP 57698 in human airways in vitro

1. Cysteinyl-leukotrienes (cysteinyl-LTs) are important mediators in the pathogenesis of asthma. They cause bronchoconstriction, mucus hypersecretion, increase in microvascular permeability, plasma extravasation and eosinophil recruitment. 2. We investigated the pharmacological profile of the cysteinyl-LT antagonists CGP 45715A (iralukast), a structural analogue of LTD4 and CGP 57698, a quinoline type antagonist, in human airways in vitro, by performing binding studies on human lung parenchyma membranes and functional studies on human isolated bronchial strips. 3. Competition curves vs [3H]-LTD4 on human lung parenchyma membranes demonstrated that: (a) both antagonists were able to compete for the two sites labelled by [3H]-LTD4; (b) as in all the G-protein coupled receptors, iralukast and CGP 57698 did not discriminate between the high and the low affinity states of the CysLT receptor labelled by LTD4 (Ki1=Ki2= 16.6 nM+/-36% CV and Ki1= Ki2 = 5.7 nM+/-19% CV, respectively); (c) iralukast, but not CGP 57698, displayed a slow binding kinetic, because preincubation (15 min) increased its antagonist potency. 4. In functional studies: (a) iralukast and CGP 57698 antagonized LTD4-induced contraction of human bronchi, with pA2 values of 7.77+/-4.3% CV and 8.51+/-1.6% CV, respectively, and slopes not significantly different from unity; (b) the maximal LTD4 response in the presence of CGP 57698 was actually increased, thus clearly deviating from apparent simple competition. 5. Both antagonists significantly inhibited antigen-induced contraction of human isolated bronchial strips in a concentration-dependent manner, lowering the upper plateau of the anti-IgE curves. 6. In conclusion, the results of the present in vitro investigation indicate that iralukast and CGP 57698 are potent antagonists of LTD4 in human airways, with affinities in the nanomolar range, similar to those obtained for ICI 204,219 and ONO 1078, two of the most clinically advanced CysLT receptor antagonists. Thus, these compounds might be useful drugs for the therapy of asthma and other allergic diseases.

Leukotrienes: lipid bioeffectors of inflammatory reactions

The leukotrienes arise from oxidative metabolism of arachidonic acid through the action of the 5-lipoxygenase enzyme, leading to the unstable allylic epoxide leukotriene A4. This intermediate represents the substrate for two different specific enzymes, namely leukotriene A4-hydrolase and leukotriene C4-synthase, generating LTB4 and cysteinyl leukotrienes, respectively. The name "leukotriene" is referring to the cellular source (leukocytes are one of the major sources) as well as the conjugated triene that characterizes their structure. LTC4 and LTD4 are potent contracting agents of smooth muscle in airways and blood vessels; in addition, they induce mucus secretion and promote plasmatic exudation with direct action on endothelial cells. On the other side, LTB4 is known as a potent chemokinetic and chemotactic agent. A number of evidences reported in the literature underline the potential role of leukotrienes in the inflammatory responses that characterize asthma and other pathological conditions. These potent lipid bioeffectors are synthesized during the course of inflammatory reactions and their pharmacological modulation is able to significantly attenuate the clinical manifestations associated with different inflammatory pathologies.

The polymorphonuclear leukocyte: a cell tuned for transcellular biosynthesis of cys-leukotrienes

Sulfidopeptide leukotrienes (cysLT) are potent vasoactive mediators that can constrict coronary vessels and alter caliber of the microcirculation. They can be formed "in situ" via a peculiar type of cell communication termed "transcellular biosynthesis" whereby donor cells (polymorphonuclear leukocytes, PMNL) feed acceptor cells (endothelial cells, EC) the unstable epoxide intermediate leukotriene A4 for further metabolism to cysLT. We have investigated the relative amount of leukotriene A4 that is synthesized by PMNL and made available for transcellular biosynthesis. This has been accomplished by measuring the relative amounts of enzymatic vs non-enzymatic leukotriene A4-derived metabolites after challenge with the Ca(2+)-ionophore A23187, using PMNL suspensions at different concentrations. Non-enzymatic leukotriene A4-derived metabolites were used as a quantitative index of the amount of leukotriene A4 released into the extracellular milieu. In human, as well as in bovine PMNL, the relative amounts of non-enzymatic vs enzymatic leukotriene A4-derived metabolites increased with decreasing cell concentrations. By diminishing possible cell-cell interactions via increased dilution, it is calculated that approx. 60% of leukotriene A4 synthesized is released from the PMNL. These data provide evidence that, in PMNL, transfer of leukotriene A4 to neighbouring acceptor cells is taking place as a predominant mechanisms of cell communication.

[Evaluation of the diagnostic usefulness of CA125 immunoscintigraphy for ovarian carcinoma follow-up after treatment: contribution of this technique in Grenoble University Medical Center]

Immunoscintigraphy using indium-111-labeled OC125 monoclonal antibody F(ab')2 fragments is a technic complementary of morphological imaging (i.e. ultrasonography and computed tomography). It allows early detection of recurrences of ovarian carcinomas. We performed immunoscintigraphy 30 times in 26 patients who previously underwent radical treatment for ovarian carcinoma, and were suspected to have a recurrence. Our purposes were appreciation of diagnostic accuracy of the method, and above all its impact on clinical decisions and evolution of the patients. There were, after reevaluation of the results, 18 true positives, 7 true negatives, 3 false negatives and 2 false positive cases (sensitivity 85.7%, specificity 77.8%). Bayesian analysis showed positive and negative predictive values of 86% and 87% when probability of recurrence a priori was 50%, and 80% and 58% when probability of recurrence a priori was 70%. The result of immunoscintigraphy contributed to clinical decisions in 24 cases out of 30, and led to a correct decision for the patient in 21 cases. Conversely, for the 6 cases in which the result has not been considered, to take this result into account would have been beneficial in 4 cases, but harmful in 2. Finally, survival tended to be longer when immunoscintigraphy was negative, which could be associated with a better prognosis. We conclude that OC125-immunoscintigraphy may be useful for ovarian carcinoma follow-up and may contribute to a better therapeutic strategy.