Accelerated radiotherapy followed by chemotherapy for locally recurrent small-cell carcinoma of the lung. A phase II study of Cancer and Leukemia Group B

The cancer and leukemia group B respiratory committee

The Cancer and Leukemia Group B Respiratory Committee has a 30-year track record of clinical investigation in patients with small-cell lung cancer and non-small-cell lung cancer (NSCLC) and mesothelioma. The most widely recognized contributions of the Committee include the early confirmation of the role of concurrent chemoradiotherapy in LD-SCLC, the effect of combination chemotherapy followed by radiation in stage III NSCLC, the introduction of third-generation agents into concurrent chemoradiation for stage III disease, the prospective demonstration of the benefit of treating older (70 years old) and poorer performance status (performance status = 2) patients with first-line combinations for stage IV disease, and the development of the "Herndon prognostic index" to normalize patient characteristics and outcomes in sequential phase II trials of new agents in patients with mesothelioma. Many other contributions have also emerged from the Committee's clinical trials and correlative science programs. We look forward to making additional critical contributions during future decades of Cancer and Leukemia Group B Respiratory Committee research.

Radiation therapy for chest recurrences following induction chemotherapy in small cell lung cancer

Once small cell lung cancer fails induction chemotherapy, second line drugs are usually ineffective, accounting for mostly partial responses in the order of 0-20% and a median survival of 6-10 weeks. A review of patients with relapsed small cell lung cancer was carried out at the University of Maryland. Of 51 such patients, 44 received thoracic irradiation at the time of relapse. Excluding 8 patients who received insufficient treatment, the series consists of 36 patients (27 with limited and 9 with extensive disease) and represents the largest experience with relapsed small cell lung cancer subjected to radiation alone. Total radiation doses were 60 Gy in 11, 45-55 Gy in 14, and 38-42 Gy in the remaining 11 patients. No second line chemotherapy was given simultaneously with radiation at time of relapse and it was only given subsequently during the course of the disease to four patients. Responses to radiation were seen in 28 (77%) with 9 (25%) complete and 19 (52%) partial. The median survival was 16-40 weeks varying with disease extent, response, and total dose. Subsequent failures occurred in chest (34%) and distant sites (66%). A dose-response curve was attempted; the higher doses achieved as much as 75% local control. A poor response to induction chemotherapy did not predict a poor radiation response at time of relapse. Nearly 2/3 of patients who had not responded to induction chemotherapy responded to radiation at the time of relapse. The post-recurrence survival after radiation therapy was as long as or longer than the recurrence-free interval after induction chemotherapy, and this clearly demonstrates the value of radiation in achieving excellent palliation and good quality of life in these patients. Thoracic irradiation is recommended as a therapeutic alternative for locally recurrent small cell lung cancer after induction chemotherapy.

Importance of radiation dose in achieving improved loco-regional tumor control in limited stage small-cell lung carcinoma: an update

Between 1974 and 1986, 576 patients (284 limited and 292 extensive stages) were treated at this institution. To keep multiagent chemotherapy (CT) at a uniform intensity, patients who received (a) combined modality approach of both multiagent chemotherapy and thoracic radiotherapy (RT) and (b) greater than or equal to 3 cycles of multiagent chemotherapy (greater than or equal to 3 drugs), were chosen for this analysis. Out of 284 patients with limited Stage small-cell lung carcinoma, there were 154 such patients who met these strict criteria, and the treatment methods for the remaining 130 patients were as follows: (a) chemotherapy alone with radiotherapy reserved for local failure (47 pts); (b) radiotherapy alone (20 pts); (c) surgery +/- adjuvant chemotherapy or radiotherapy (37 pts); (d) modified chemotherapy plus radiotherapy (26 pts). During the 12-year period, the therapeutic factors have evolved. Radiation-dose was increased from 30-40 Gy (time dose fractionation 49-66) in 1974-1977 to 44-52 Gy (time dose fractionation 73-86) in 1978-1986. The target volume for radiotherapy included the primary lesion with a 2-cm margin of normal lung and the mediastinum. Chemotherapy program also evolved from COP, CAV (1974-1977) to MACC, VCE-VCA, PCE-ACE (1978-1986). Fifty of 154 patients (32%) developed loco-regional recurrence (infield failure) and 98% (49/50) of these patients exhibited this by 2.5 years. Survival data of 154 patients were as follows: (a) Median survival time (MST) was 12 M; (b) actuarial survival rates at 2 and 5 years were 21% and 8%, respectively. Fifty percent of these patients died within 12 months (MST 12 M) and were not exposed to the full length of the risk period for loco-regional failure. To take into account the duration of exposure to the risk period, actuarial method was employed to measure the probability of loco-regional failure. Loco-regional failure rates at 2.5 years were 37%, 39%, 49%, 79%, and 84% for 50 Gy, 45 Gy, 40 Gy, 35 Gy, and 30 Gy, respectively. The difference between the recurrence rates of 37% and 79% by 50 Gy and 35 Gy was statistically significant, p less than 0.05. Although the recurrence rates of 37% and 49% by 50 Gy and 40 Gy were not statistically different, there was a strong trend of a better control rate of loco-regional carcinoma by higher radiation doses. The time to recurrence seems also shorter with lower radiation-dose than that of higher radiation doses.(ABSTRACT TRUNCATED AT 400 WORDS)

Experimental and clinical studies alternating chemotherapy and radiotherapy

Clinical and experimental results with radiotherapy and chemotherapy for the treatment of cancer emphasize the necessity of giving treatment with both modalities with the greatest intensity possible in the initial phase of induction therapy. This can best be accomplished by utilizing new approaches, such as alternating the chemotherapy with newer methods of delivery of radiotherapy, which has the potential for greater destruction of tumor within acceptable limits of host toxicity. The clinical data from Institut Gustave Roussy, Villejuif, shows that alternating chemotherapy and radiotherapy produced an excellent complete response rate of 79% and a 4 year relapse-free survival rate of 22% in 109 patients with limited small cell lung cancer. Based on 5 year survival criteria, approximately one-fourth of the patients can be considered cured in 1 more year if no further change occurs. The results of the University of Virginia experimental studies have also demonstrated the superiority of alternating cyclophosphamide and radiotherapy in three courses of induction therapy over conventional methods of delivery of the two modalities. Using the experimental solid tumor 3924A, a cure rate of 50% or greater was obtained with this protocol with acceptable toxicity to the host, as opposed to no cures from three or more courses of either modality alone. One of the major deterrents to tumor cure with concomitant chemotherapy and radiotherapy has been excessive toxicity, which can be avoided by temporal separation (+/- 7 days) of the delivery of the two modalities without a significant loss of therapeutic effectiveness. Well-defined clinical protocols to determine how to more effectively interact chemotherapy with radiotherapy offer some of the greatest potential for a more rapid improvement in treatment.

The combination of radiotherapy and chemotherapy: a review

The association of radiotherapy (RT) and chemotherapy (CT) is clearly beneficial in tumours which are both chemosensitive and radiosensitive (Tubiana et al. 1987). However, contrary to the expectations, in most solid tumours this association did not lead to significant progress in long-term survival. In head and neck cancers, for example, despite a large number of controlled clinical trials, there is not yet a clear-cut demonstration of any increase in survival (DeVita et al. 1986, Tannock and Browman 1986, Taylor 1987, Tubiana et al. 1985). These disappointing results are probably due to two factors: (1) the insufficient effectiveness of the available drugs on most solid tumours; (2) the cumulative toxic effects of radiation and drugs on the normal tissues, which limits the dose of both modalities in combined treatments.