Combined treatment of soft tissue and osteosarcomas by radiation and ICRF 159

The radiation response of sarcomas by histologic subtypes: a review with special emphasis given to results achieved with razoxane

Purpose. Relatively few results are available in the literature about the radiation response of unresectable sarcomas in relation to their histology. Therefore, an attempt was made to summarize the present situation. Materials and methods. This report is based on a review of the literature and the author's own experience. Adult-type soft tissue sarcomas, chondrosarcomas, and chordomas were analyzed. Radioresponse was mainly associated with the degree of tumor shrinkage, that is, objective responses. Histopathologic responses, that is, the degree of necrosis, are only discussed in relation to radiation treatment reports of soft tissue sarcomas as a group. Results. Radiation therapy alone leads to major responses in about 50% of lipo-, fibro-, leiomyo-, or chondrosarcomas. The response rate is less than 50% in malignant fibrous histiocytomas, synovial, neurogenic, and other rare soft tissue sarcomas. The response rates may increase up to 75% through the addition of radiosensitizers such as halogenated pyrimidines or razoxane, or by the use of high-LET irradiation. Angiosarcomas become clearly more responsive if biologicals, angiomodulating, and/or tubulin affinic substances are given together with radiation therapy. Razoxane is able to increase the duration and quality of responses even in difficult-to-treat tumors like chondrosarcomas or chordomas. Conclusions. The available data demonstrate that the radioresponsiveness of sarcomas is very variable and dependent on histology, kind of radiation, and various concomitantly given drugs. The rate of complete sustained remissions by radiation therapy alone or in combination with drugs is still far from satisfactory although progress has been made through the use of sensitizing agents.

Treatment of vascular soft tissue sarcomas with razoxane, vindesine, and radiation

PURPOSE

In previous studies, razoxane and vindesine together with radiotherapy was proved to be effective in soft tissue sarcomas (STS). Because razoxane leads to a redifferentiation of pathological tumor blood vessels, it was of particular interest to study the influence of this drug combination in vascular soft tissue sarcomas.

METHODS AND MATERIALS

This open multicenter Phase II study was performed by the Austrian Society of Radiooncology. Among 13 evaluable patients (10 angiosarcomas and 3 hemangio-pericytomas), 9 had unresectable measurable disease, 3 showed microscopic residuals, and 1 had a resection with clear margins. They received a basic treatment with razoxane and vindesine supported by radiation therapy. Outcome measures were objective response rates, survival time, and the incidence of distant metastases.

RESULTS

In nine patients with measurable vascular soft tissue sarcomas (eight angiosarcomas and one hemangiopericytoma), 6 complete remissions, 2 partial remissions, and 1 minor remission were achieved, corresponding to a major response rate of 89%. A maintenance therapy with razoxane and vindesine of 1 year or longer led to a suppression of distant metastases. The median survival time from the start of the treatment is 23+ months (range, 3-120+) for 12 patients with macroscopic and microscopic residual disease. The progression-free survival at 6 months was 75%. The combined treatment was associated with a low general toxicity, but attention must be given to increased normal tissue reactions.

CONCLUSIONS

This trimodal treatment leads to excellent response rates, and it suppresses distant metastases when given as maintenance therapy.

Combined razoxane and radiotherapy for melanoma brain metastases. a retrospective analysis

We retrospectively compared the efficacy of razoxane and radiotherapy with radiotherapy alone or in combination with a non-razoxane based medication in patients with melanoma brain metastases. From 19 assessable patients receiving whole brain irradiation with or without a boost (mean total dose 40.5 Gy) for measurable brain metastases, 8 patients underwent an additional razoxane therapy with 125 mg per os twice daily started 5 days before radiotherapy and given throughout the whole radiation period. The median razoxane dose was 6.25 g (range 3.2-8.0 g). Endpoints included radiation response rates, median survival time and 1-year survival rates. To generate reliable prognostic parameters for this non-randomized study population, the Score Index for Stereotactic Radiosurgery and the Radiation Therapy Oncology Group Recursive Partitioning Analysis score were applied. Radiotherapy with razoxane led to higher response rates (62% vs. 27%) and a lower percentage of progressive disease (12.5% vs. 36%) if compared with radiotherapy alone or with a non-razoxane based medication. This combination was associated with a longer median survival (5 months vs. 2.2 months; P=0.052) and a 1-year survival rate of 37.5% vs. 0% (P=0.027). Both treatment groups belonged to similar prognosis subsets. The treatment was well tolerated. Taken together our data support the therapeutic concept of a combined razoxane radiation therapy in melanoma patients with brain metastases. The favorable treatment effects are probably due to the radiosensitizing and the cytorallentaric mode of action of razoxane. Since the patient numbers are low, confirmatory studies are certainly necessary.

Treatment options for malignant hemangioendotheliomas of the thyroid

BACKGROUND

Malignant hemangioendotheliomas of the thyroid are rare tumors predominantly seen in areas with endemic goiter such as the Alpine regions. The estimated incidence of the disease is between 0.15 and 0.25 per 100.000 inhabitants annually for Western Austria. The tumor is regarded as radio-resistant, and its prognosis is reported to be dismal.

PATIENTS AND METHODS

Between 1982 and 1999, 12 cases with immunohistochemically confirmed malignant hemangioendotheliomas of the thyroid were referred for postoperative or palliative treatment. There were 8 men and 4 women with a median age of 67 years (range, 55-81 years). With surgery, clear margins were achieved in 5, microscopic residues were left in 3, and gross residual disease in 3 patients. One patient had an inoperable primary tumor. Postoperative radiotherapy was given to 8 cases, 6 of them received the radiosensitizer razoxane on radiation days. Total tumor doses ranged between 54 and 65 Gy. Two patients with clear margins at surgery received no adjuvant radiotherapy and were observed only.

RESULTS

Local tumor control was achieved in 11 of 12 patients; 5 lived longer than 5 years. The median survival time of all cases is presently 14 months (range, 0.5-196 months). If 3 cases with metastasis at diagnosis were left out of the analysis, the median survival is 70 months. Noteworthy is a complete regression of 2 lung metastases in a 72-year-old man treated with the combination of vindesine, razoxane, and radiotherapy; the patient is still in complete remission more than 94 months after 3-year maintenance therapy with vindesine and razoxane. Fibrinogen, factor VIII, and factor VIII-related antigen in the serum could serve as surrogate markers during the follow-up. The tolerance to the combined modality treatment was good to fair, local chemoradiation reactions of normal tissues have to be considered as the principal toxicity. It may also be of interest that 5 of 12 patients were exposed to vinyl chloride and other polymeric materials during their working life.

CONCLUSIONS

This small series indicates that the course of the disease is not uniformly bleak and that the resistance to radiotherapy reported in the literature has to be questioned. It appears that adequate surgery together with rapid radiation therapy in combination with razoxane, a radiosensitizer and agent that can normalize tumor blood vessels, is able to improve the local control rate and thus perhaps to alter the natural history of this disease. In addition, the data offer new evidence of the occurrence of vinyl-chloride-induced angiosarcomas outside the liver, and support similar observations that have already been published in case reports.

[Angiosarcoma of the right atrium: local control via low radiation doses and razoxane. A case report]

BACKGROUND

Angiosarcomas of the heart are rare neoplasms bearing an unfavorable prognosis. In recent series, the median survival is about 5 months. The response to radiation therapy is uncertain.

CASE REPORT

A 65-year-old copper smith with an angiosarcoma of the right atrium and metastases of the liver received a partial resection of the primary tumor in January 1992. This was followed by a polychemotherapy including ifosfamide, epirubicin and dacarbacin (DTIC). In April 1992, after 5 cycles of this treatment a large regrowth of the primary and multiple pulmonary metastases were observed. After a 4-day pretreatment with the radiosensitizer razoxane, the large tumor of the right heart was irradiated with 25 MV photons of a linear accelerator. Single doses of 200 cGy were given via parallel opposed fields. The total radiation dose at the tumor was 30 Gy. Concomitantly, razoxane was given at a dose of 125 mg twice daily during the radiation days until the end of the radiotherapy. The treatment was well tolerated and the patient went into a subtotal remission. Chest X-rays from September 1992 revealed a progression of the metastases in the lung and the liver, the recurrent tumor of the right atrium remained in a subtotal remission. The patient was retreated with ifosfamide, epirubicin and DTIC. No substantial remission of the metastases occurred and the patient died at the end of January 1993. At autopsy, the recurrent primary and the lung metastases within the region of the former radiation field remained locally controlled.

CONCLUSION

Reviewing the literature and considering this case, irradiation seems to be a valid treatment option for the local control of cardiac angiosarcomas. The combination of radiotherapy with razoxane eventually allows a considerable reduction of the radiation dose.

Radiotherapy vs. radiotherapy and razoxane in the treatment of soft tissue sarcomas: final results of a randomized study

PURPOSE

The effect of the sensitizer razoxane on soft tissue sarcomas (STS) was prospectively evaluated in a randomized, controlled trial. The main purpose of the study was to determine the response rates and local control under the combined treatment compared to irradiation alone.

METHODS AND MATERIALS

Between 1978 and 1988, 144 patients entered the study; 130 were evaluable for response, toxicity, or survival. The patients were randomized to receive radiotherapy alone or radiotherapy with razoxane. They were divided into postoperative cases and patients with gross disease (unresectable primaries, recurrent disease, or metastatic disease). The median radiation dose was 60 Gy postoperatively, and 56-58 Gy in patients with gross disease. The dose difference has palliative reasons. Razoxane was given orally at a daily dose of 150 mg/m2 during the time of the radiotherapy, starting 5 days before the first irradiation. In general, the groups were comparable as to their prognostic factors. There was some imbalance, however, in favor of the postoperative group reveiving radiotherapy alone.

RESULTS

Between the patient groups treated postoperatively in an adjuvant form, there were no substantial differences in local control and survival. Among 82 patients with gross disease, the treatment with radiotherapy and razoxane led to an increased response rate compared to photon irradiation alone (74 vs. 49%). The local control rate was likewise improved (64 vs. 30%;p < 0.05). The acute toxicity was somewhat higher in the sensitizer arm, but there was no difference in the occurrence of late complications.

CONCLUSIONS

Radiotherapy combined with razoxane seems to improve the local control in inoperable, residual, or recurrent STS compared to radiotherapy alone. The combined treatment is a fairly well tolerated procedure at low costs. It can be recommended for inoperable primary STS or gross disease after incomplete resection, conditions which are still associated with limited local control and a grave prognosis.

Phase I clinical trial and pharmacokinetics of weekly ICRF-187 (NSC 169780) infusion in patients with solid tumors

ICRF-187 was given to 62 evaluable patients with advanced solid tumors in a Phase I clinical trial. Weekly infusions were given in dosages ranging from 0.85 g/m2 to 7.42 g/m2 for a total of four weeks with a two week rest period between courses. Dose-limiting hematological toxicity was seen in heavily pretreated patients at a dose of 3.8 g/m2/week. All patients also developed reversible SGOT elevations. In patients with less prior therapy hematologic toxicity was not dose-limiting but hepatotoxicity, manifest by transient SGOT levels greater than 5 times baseline was seen at 7.42 g/m2/week even though only 3/6 patients could receive 4 consecutive weekly doses. At virtually all dose levels tested some patients developed anemia. Other toxicities, including alopecia, nausea, vomiting and reversible serum amylase elevations, were mild. Cumulative monthly doses achieved on this weekly schedule are significantly higher than a 48-hour infusion or daily times 3 or 5 schedule in adults and a daily times 3 schedule in children. Pharmacokinetic studies in eight patients indicate that the drug disappears from the plasma biphasically with a terminal t1/2 of 3.2 +/- 0.9 hr. The total clearance was 288.7 +/- 85.0 ml/hr/kg and the volume of distribution (Vda) was 1.3 +/- 0.4 l/kg. Pharmacokinetics were not dose-dependent from 3.8-7.4 g/m2 and no difference in pharmacokinetics was found in patients studied during the first and second treatments of a course. If Phase II trials of ICRF-187 are to be pursued on this schedule, appropriate doses would be 3.8 g/m2/week X 4 for heavily pretreated and 7.42 g/m2/week for "good risk" patients. Because of erratic hematologic toxicity in heavily pretreated patients, some might only tolerate three weekly doses. In good risk patients transaminitis was significant but reversible, thus, Phase II protocols should include dose escalation schemata.

Radiotherapy plus razoxane for advanced limited extent carcinoma of the lung

Forty-four patients with limited extent American Joint Committee on Cancer Stage II-III non-small cell carcinoma of the lung were randomly assigned to potentially curative radiation therapy plus one of two schedules of razoxane. The weekly schedule was 1 gram per square meter body surface area (BSA) every 8 hours for two doses per week, and the daily schedule was a fixed dose of 250 mg per day. The 50% Kaplan-Meier survival estimate for both groups combined was 9 months. There was no survival difference between the two dose-schedules. Toxicity was formidable with an 82% incidence of esophagitis, and a 20% incidence of grade III-IV esophagitis. Fifty-nine percent of patients developed hematologic toxicity. This was greater with the weekly dose-schedule (P = 0.01). Forty-one percent of patients developed radiographic or symptomatic pneumonitis. One patient developed a fatal myelitis. This program is no more effective than irradiation alone, and has substantial morbidity.

Neurogenic sarcomas of the neck in neurofibromatosis

Based on two observations and a review of the literature, the pathological and clinical findings in sarcomas of the neck in patients with neurofibromatosis are described. Histologically these neurogenic tumours show a manifold picture; in addition to spindle-cell sarcomas pleomorphic structures are to be found, which can be similar to rhabdomyo-, lipo-, chondro-, angio-, or osteogenic sarcomas so that a histological diagnosis of a neurogenic sarcoma cannot always be made without clinical details. Up to the present surgical treatment is preferred; the value of cytostatic therapy and irradiation is controversial. The results of treating these tumours are unsatisfactory. Of 29 cases reported in the literature, only two could be found in which the patient survived without a recurrence for more than five years.

Combination of radiotherapy and razoxane (ICRF 159) for chondrosarcoma

Eight patients with 12 chondrosarcomas were treated with radiation and razoxane (ICRF 159). Two tumors in 1 patient progressed unequivocally, 3 tumors in 3 patients showed no change, and 7 tumors in 5 patients had complete or partial (more than 50%) regressions. At least 2 complete regressions have responded for more than 2 1/2 years at the present time.

The relative roles of surgery and radiotherapy in the management of soft tissue sarcomas of adults. A personal appraisal

The literature of the last 25 years pertaining to the treatment of sarcomas of the soft somatic tissues by surgery and radiotherapy, both separately and in combination, has been reviewed. Surgery alone, if it is to be successful in an appreciable proportion of cases, must be radical. There is a growing body of evidence which suggests that less-than-radical surgery in combination with postoperative radiotherapy may give results equal or superior to those of radical surgery alone. There is need for a multicentre controlled clinical trial to compare the results of the two modes of treatment.

Liposarcoma of the neck: a clinicopathologic study of 4 cases

A clinicopathological study of 4 patients with liposarcoma in the neck treated surgically is presented. Three of the liposarcomas were located in the supraclavicular region, two to the right one to the left, and one appeared to the left in the back of the neck. Liposarcoma rarely involves the head and neck region. A survey is given of the few reported liposarcomas in this region. Two of the tumors in the present series were well differentiated, one of which recurred repeatedly. The other two tumors were round-cell and pleomorphic in type, both of which recurred. At the end of follow-up 11 and 9 years, the two patients with well-differentiated liposarcomas were alive. The other two patients had died after 5 and 4 years from intercurrent disease and metastatic spread, respectively. The histopathological basis for the diagnosis, distinguishing features of intramuscular (infiltrating) lipoma, hibernoma and spindle cell lipoma, as well as the treatment, are discussed.

Comparison of radiotherapy with and without razoxane (ICRF 159) in the treatment of soft tissue sarcomas

Comparison of the recurrence rates of soft tissue sarcomas treated by radiotherapy (14 patients) or radiotherapy and synchronous administration of razoxane (19 patients) has shown a statistically significant benefit for those patients treated by the combination. No increase in tissue reactions or adverse side-effects (apart from a readily reversible leukopenia) was observed. The implication is that razoxane acts as a well tolerated adjuvant for radiotherapy.

Changes in sensitivity to radiation and ICRF 159 during the life of monolayer cultures of EMT6 tumour line

The response of EMT6 mouse tumour cells to ICRF 159, both with and without X-radiation, has been measured during the life of monolayer cultures. The cytotoxic effect of ICRF 159 was found to be proliferation-dependent. Flow cytofluorimetry studies of cell cycle distribution showed that ICRF 159 prevented cell division while allowing DNA synthesis to continue. This anti-mitotic action and the cytotoxic effect of the drug were found to be closely related. Increased sensitivity to X-radiation was observed in cultures pretreated for 24 h with 200 microgram/ml ICRF 159 In exponential and early plateau cultures this was seen as a reduced shoulder of the survival curve. In late plateau cultures there was no apparent reduction of the shoulder, but an increase in slope.

Modification of the radiocurability of a syngeneic murine squamous carcinoma by its site of growth, by electron-affinic drugs, and by ICRF 159

A series of TCD50 experiments using a spontaneously arising, syngeneically transplated, murine squamous carcinoma is reported. Tumours implanted intradermally and irradiated while they remained superficial had a small but nonetheless cure-limiting hypoxic fraction of cells (TCD50 3,324-4,257 rad). The hypoxic fraction increased dramatically when these tumours invaded the subcutaneous tissues, or when tumours were implanted subcutaneously (TCD50 greater than 5,544 rad). Pre-treatment of mice with the electron-affinic drug Ro-07-0582 at a dose of 1 mg/g i.p. 20-30 minutes before irradiation effectively eliminated the hypoxic element from superficaial tumours (TCD50 1.862 rad). The same drug at a dose of 0-25 mg/g reduced the TCD50 for superficial tumours by a factor of 1-87 (3,986-2,134 rad), while another electron affinic drug, metronidazole, given at a dose of 0-25 mg/g reduced the TCD50 by a factor of 1-28 (4,257-3,337 rad). Treatment of mice with the drug ICRF 159, 30 mug/g daily from the time of tumour cell injection until the day of irradiation, reduced the TCD50 in unclamped tumours by less than 1-19. However, a commensurate reduction of TCD50 in clamped tumours suggested that improved tumour vascularization could not explain fully the drug's "radiosensitizing" action. The unique single radiation dose curability of most human skin cancers is discussed in the light of the experimental results, and the possible clinical implication of an increase in hypoxic fraction with tumour invasion is raised.