Bleomycin alone and in Combination with Methotrexate in the Treatment of Carcinoma of the Esophagus

Adriamycin plus Cyclophosphamide in Advanced Bronchial Carcinoma

Adriamycin (40 mg/m2 i.v., on day 1) plus cyclophosphamide (200 mg/m2 orally, day 1 to 5) were given to 23 patients with advanced lung cancer. Administration cycles were repeated every 3 weeks. No patient had been previously treated with chemotherapy, 5 received prior radiotherapy. Objective improvement was observed in 7 patients, partial remission was observed in 3. The median duration of response was 2 months.

Therapy of Advanced Esophageal Cancer with Bleomycin, Irradiation and Combination of Bleomycin with Irradiation

Results from treating 51 patients with advanced esophageal cancer are presented. Fifteen patients were treated with Bleomycin, 12 with radiotherapy, and 24 with a combination of Bleomycin and radiotherapy. The best results were achieved in the group of patients treated with combined therapy showing 62% objective remissions (15/24) which was statistically significant (P < 0.001) in comparison to the other groups. In the Bleomycin therapy group, there were 26% objective remissions (4/15), and in the group treated only with radiotherapy 33% (4/12). The median duration of remission was 9 months in the combined therapy group, 6.3 months in the group treated with radiotherapy, and 2.6 months in the Bleomycin treated group. The authors concluded that the combination of Bleomycin and radiotherapy seems to be a further step in palliative treatment of advanced esophageal cancer.

Bleomycin Infusions Combined with Radiotherapy in the Treatment of Inoperable Esophageal Cancer

A combination of bleomycin, in a 12 h infusion, and radiotherapy was applied in 25 patients with untreated inoperable esophageal cancer. Bleomycin was administered 15 mg/m2 twice weekly, concurrently with irradiation (total dose 3600–4000 rad). Such combined treatment produced 3 complete remissions of the esophageal tumor, 10 partial remissions (response rate 52 % - 13/25), 3 stable disease cases, while in 9 cases the disease progressed in spite of therapy. The median duration of remissions was 8.7 months in complete responders, 6.0 months in partial responders, and 3.0 months in stable disease cases. Similarly, median survival was the longest in complete remission cases (10.3 months). Patients who did not respond to therapy had a median survival of only 2.8 months. Adverse treatment reactions were of a milder character, except retrosternal pain and burning caused by irradiation mucositis, which occurred in 80 % of patients. The trial showed that the combination of bleomycin applied in the form of 12 h infusion and irradiation can produce remissions in 50 % of inoperable esophageal cancer cases, i.e., a rate of remission which is similar to that achieved by irradiation and bleomycin applied in the form of rapid (push) i.v. injections.

Cisplatin and intravenous continuous infusion of bleomycin in advanced and metastatic esophageal cancer

Thirty-four patients with locally advanced or metastatic esophageal cancer were treated with cisplatin 35 mg/m2/day x 3 days in bolus, plus bleomycin 15 mg/day x 3 days, as an 18 h infusion, every 21-28 days. Twenty-nine are evaluable for response. Objective response was seen in 15 (52%, 95% confidence limits 35-69%) patients. Toxicity was mild. Twelve patients with locoregional disease were treated with this combination followed by radiotherapy and three of them are alive without disease at 18, 22 and 36 months. This combination warrants further study in the setting of combined treatment.

Anterior chemotherapy in esophageal cancer

Front loading chemotherapy using methotrexate (200 mg/m2) alone or methotrexate (200 mg/m2) with cisplatin (20 mg/m2 daily for 5 days) was used in epidermoid carcinoma of esophagus. Evaluation after two courses showed objective response of 50% or greater in 48% of patients with methotrexate alone. Response rate was increased to 76.2% with addition of cisplatin to methotrexate. Small lesions (less than 10 cm) showed better response as compared to advanced cases. Therapy was generally well tolerated and good palliation was obtained even after the first course. Postchemotherpy treatment either with surgery or radiotherapy was tolerated without any major complications. The data confirm the short-term usefulness of initial chemotherapy with methotrexate and cisplatin in esophageal cancer. Results of prolonged follow-up will help to evaluate the role of front loading chemotherapy on long-term survival.

Cisplatin and bleomycin in the treatment of esophageal carcinoma. A final report

During the period from September, 1976 to June, 1979, 70 patients with locoregional or extensive epidermoid carcinoma of the esophagus were treated with the two-drug combination of cisplatin and bleomycin (DB). For the 43 patients with locoregional disease (LRD), DB was used prior to surgery and/or radiation therapy; it was the primary treatment for 27 patients with extensive disease (ED). The major objective response rates [complete remission (CR) and partial remission (PR)] to DB for the LRD and ED groups were 14% and 17%, respectively, for an overall response rate of 15%. For the LRD group, the minimum follow-up was 42 months; four patients (10%) remain alive and free of disease. The median survival of 34 patients treated with DB preoperatively was 10 months, which did not differ significantly from that of a historic control group receiving preoperative radiation therapy. The median duration of response for ED patients was 6 months, and the median survival for the entire ED group was 4 months. DB alone had only modest activity in epidermoid carcinoma of the esophagus.

Cisplatin, bleomycin and methotrexate in the treatment of advanced oesophageal cancer

From February 1981 to September 1982, 34 patients with metastatic or locally advanced (inoperable) epidermoid carcinoma of the oesophagus were treated with a combination of cisplatin, bleomycin and methotrexate. Thirty-one patients are now evaluable for response: 16 of 31 (52%) experienced some improvement, but only eight (26%) obtained major responses (one complete and seven partial). Responses were obtained rapidly within the first two courses. The median duration of responses was 5 months. The median survival from start of therapy was 8 months for responsive and 5 months for non-responsive patients. Gastrointestinal toxicity (cisplatin-related) and mild myelosuppression were the most prominent side-effects. This combination chemotherapy proved to be only of small efficacy in the long-term control of advanced oesophageal cancer. However, because the responses were obtained rapidly, it is conceivable that a similar regimen (with increased dosage of cisplatin) applied before surgery to patients with limited disease could obtain a reduction of the bulky tumour, with a possible increase of the resectability rate and destruction of micrometastases.

Cisplatin, vindesine, and bleomycin chemotherapy of local-regional and advanced esophageal carcinoma

Seventy-one patients with epidermoid carcinoma of the esophagus were treated with a three-drug combination of cisplatin, vindesine, and bleomycin. Forty-five patients had local-regional tumor and received chemotherapy prior to surgery or radiation therapy. Twenty-six patients with extensive disease were treated primarily with chemotherapy alone. The overall major objective response rate to cisplatin-vindesine-bleomycin was 53 percent (36 of 68 evaluable patients). Patients with local-regional disease had a higher response rate than those with extensive disease (63 and 33 percent, respectively). Following preoperative chemotherapy, 34 patients with local-regional disease underwent exploration. Resectable disease was present in 82 percent. There was no increase in operative morbidity or mortality (5.6 percent), when compared with historical control groups. The median survival for the preoperative chemotherapy group was 16.2 months, which is superior to that of a historical control group (p = 0.023). For patients with extensive disease, treated primarily with chemotherapy alone, the median duration of response was seven months. Toxicities of cisplatin-vindesine-bleomycin were in general well-tolerated, and included nausea and vomiting (seen less frequently because of extensive use of metoclopramide), alopecia, nephrotoxicity, and peripheral neuropathy. The dose-limiting toxicity was myelosuppression. Although conventional chemotherapeutic agents have little activity, these results indicate that the investigational combination of cisplatin, vindesine, and bleomycin can induce major regressions in a substantial proportion of patients with esophageal cancer. When this drug combination is used preoperatively, high resection rates and possibly improved survival are seen.

[Chemotherapy of esophageal and cardial carcinomas]

In esophageal carcinoma chemotherapeutic agents such as bleomycin, methotrexate, cisplatin, VP-16, and vindesine produce remission rates up to 30%. Combination chemotherapy resulting in remission rates of about 50% has so far been insufficiently tested. Selection of patients with favorable prognostic criteria is mandatory for optimal treatment results. A combined modality approach is promising but needs further evaluation. The FAM regimen is recommended for the routine treatment of inoperable stomach carcinoma. The specific problems of upper gastrointestinal tract cancer chemotherapy are discussed.

Combined modality therapy of esophageal carcinoma

One hundred ten patients with epidermoid carcinoma of the esophagus were treated at the Memorial Sloan-Kettering Cancer Center (MSKCC) with combined modality techniques involving preoperative irradiation (RT) and surgery, and with preoperative chemotherapy (CT), surgery, and irradiation. For the 76 patients receiving preoperative RT during the period 1965-1976, the overall resectability rate was 54% with an operative mortality of 12%; long-term survivors (greater than 3 years) were few (7%). For 34 patients receiving preoperative CT with cisplatin and bleomycin, major objective tumor regression (greater than 50%) was seen by day 18 in 20%, with an additional 44% having smaller but definite improvement in the barium esophagram and in swallowing function. Of those receiving preoperative CT, 76% had resectable lesions, with an operative mortality of 11%. The median follow-up for this group is 24 months; of the 30 patients followed for at least 12 months, 20% are alive without evidence of disease. Although the resection rate following preoperative chemotherapy seems to be higher, thus allowing better palliation, neither preoperative radiation nor chemotherapy with cisplatin and bleomycin have had a major impact on long-term survival.

Combination of bleomycin and adriamycin with and without radiation on the treatment of inoperable esophageal cancer. A randomized study

In a prospective randomized study, 31 patients with inoperable esophageal cancer were treated with a combination of bleomycin and adriamycin, and with a combination of these cytostatics and radiation. Evaluation of treatment results showed 3 partial remissions and 2 stable-disease cases in the group of 16 patients treated by cytostatic drugs alone; in all other cases, the disease progressed. The response rate achieved in this group was 19%. In the group including 15 patients who were irradiated with a dose of 3600--4000 rad and received simultaneously the same cytostatics with a somewhat lower dose of adriamycin, there were 3 complete remissions, 6 partial remissions, and 4 stable-disease cases, while in 2 cases the disease progressed. The response rate was 60%, which was statistically significant (P less than 0.025) when compared with the results achieved by the group receiving the bleomycin adriamycin combination. The average duration of remissions in the complete-response cases was 11 months, and in the partial-response cases, 5.2 months with combined treatment, and 4.2 months with combination chemotherapy. The toxic side-effects were tolerable for the patients, albeit more intensive with the combined-treatment modality. Four esophagobronchial fistulas (four disease progressions) and one rupture of the aorta were noted during treatment. This study has shown the advantages of chemoradiotherapeutic treatment of inoperable esophageal cancer.