Carboplatin, Continuous Infusion Fluorouracil and Mid-cycle High-dose Methotrexate as Initial Treatment in Patients with Locally Advanced Head and Neck Cancer

Forty-nine patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with 3 cycles of induction chemotherapy prior to definitive local treatment (surgery and/or radiation therapy). Chemotherapy consisted of carboplatin 300 mg/m2 on day 1, fluorouracil 1000 mg/m2 daily as a continuous infusion on days 1 to 5 and high-dose methotrexate 1.2 g/m2 with leucovorin rescue on day 14. After completing the induction chemotherapy, 9 patients (18%) achieved a complete remission (CR), 26 (54%) a partial remission (PR), 7 had stable disease and 7 a progression. The response rates increased to 53% CR and 18% PR following locoregional treatment. Survival at 12 months was 61% and its actuarial probability at 24 months 31%. Median time to progression was 14 months. Toxicity from chemotherapy was generally mild. Nausea was observed in 35%, vomiting in 26%, stomatitis in 57%, anemia in 22%, leukopenia in 36%, thrombocytopenia in 26% and diarrhea in 6% of the patients. In conclusion, the combination of carboplatin, 5-day continuous-infusion fluorouracil and mid-cycle high-dose methotrexate is a moderately effective, well tolerated regimen in patients with SCCHN but does not seem superior to the combination of carboplatin and fluorouracil only.

Occupational dermatoses in beedi rollers

A total of 91 beedi workers were analyzed for the pattern of cutaneous lesions. Period of rolling beedi ranged from 2 months to 40 years. Dermatological findings included; callosities seen in 51 (56.04%) of workers on fingers and feet, nail changes in 22 (24.18%) like pigmentation, paronychia, dystrophy which were more prominent on the right index finger, fungal infections in 15 and eczemas in 29. Callosities and localised nail changes can be considered to be occupational marks in beedi rollers correlated to use of scissors for cutting leaves and use of gum and artificial metallic nails for rolling beedis.

NASA/American Cancer Society High-Resolution Flow Cytometry Project - III. Multiparametric analysis of DNA content and electronic nuclear volume in human solid tumors

BACKGROUND

The NASA/American Cancer Society (ACS) flow cytometer can simultaneously measure electronic nuclear volume (ENV) and DNA content of nuclei. The preceding articles in this volume ("NASA/American Cancer Society High-Resolution Flow Cytometer Project-I") described the schematics, performance, and procedures used for the preparation of nuclei for analysis on this unit. In the present article, we describe the analysis of selected human tumors using the ratio of ENV/DNA content (nuclear packing efficiency [NPE]).

METHODS

Tumor specimens (frozen) were minced with scalpels and stained with 1-10 microg/ml of 4',6-diamidino-2-phenylindole (DAPI) dihydrochloride at pH 6.0-7.2. Trout erythrocytes were used as internal standards. Data on ENV and DNA content were collected in list mode files. Propidium iodide-stained nuclei, analyzed on a Coulter XL cytometer, were used for comparison.

RESULTS

Simultaneous measurement of ENV and DNA makes it possible to discriminate between hypodiploid or hyperdiploid tumor cells, as well as to differentiate between near-diploid aneuploid and diploid cells on the basis of their increased ENV. The NPE ratio is a valuable parameter for the detection of small quantities of tumor cells, separating overlapping diploid and aneuploid populations for cell cycle analysis and characterizing the level of differentiation in some tumors.

CONCLUSION

NPE analysis provides unique measuring capabilities for the study of human solid tumors by flow cytometry.

Pattern of skin diseases in Bantwal Taluq, Dakshina Kannada

A survey was conducted to find out the pattern of skin diseases among patients who attended the fortnightly medical camp held in Bantwal Taluq, a rural area. Infective disorders were found in 42.68% and non infective in 41.58%. Among the infective disorders fungal infections were most common (24.08%). Among the non infective dermatoses eczemas were most common (33.93%). On comparing the proportional infectivity rate of infectious diseases among males and females it was found that in scabies males were more affected than females.

Synergistic effect of prochlorperazine and dipyridamole on the cellular retention and cytotoxicity of doxorubicin

Incubation of drug-resistant human tumor cells with a combination of prochlorperazine and dipyridamole has additive/synergistic effect on the cellular retention and cytotoxicity of doxorubicin. In patients administered a fixed dose of doxorubicin and prochlorperazine with escalating doses of dipyridamole, mean plasma levels of dipyridamole and prochlorperazine achieved were as high as 3.01 +/- 0.41 microm and 0.94 +/- 0.09 microm, respectively. Plasma samples from patients were analyzed in an in vitro assay to monitor the effect on the cellular retention of tritium-labeled daunorubicin in MDR1-transfected P388 cells. In 22 of 49 of the plasma samples analyzed, the daunorubicin in efflux blocking activity was one-half or greater than that of cells incubated with 12.5 microM verapamil, a well-known efflux blocker. These observations suggest that a combination of prochlorperazine and dipyridamole may enhance cellular doxorubicin retention by blocking efflux while reducing normal tissue toxicity and unwanted side effects in vivo.

Effects of cis-platinum chemotherapy on otoacoustic emissions: the development of an objective screening protocol. Third place--Resident Clinical Science Award 1998

To develop an objective, fast, and simply performed screening protocol for cis -platinum (CP) ototoxicity, we compared the efficacy of screening with distortion-product otoacoustic emissions (DPOAEs) with the outcome of both conventional and ultra-high-frequency (UHF) audiometry. Baseline audiometric and DPOAE testing was performed in 66 patients, 33 of whom met criteria for inclusion in the final database. Comparisons were made between baseline measurements and those recorded before subsequent CP infusions. Outcomes were analyzed clinically and with paired repeated-measures analysis of variance. Results indicated that DPOAEs and UHF were better measures than conventional audiometry. Further, DPOAEs may be better suited for screening older patients receiving CP chemotherapy because DPOAEs are as sensitive as UHF and are present in a greater number of these patients. Screening with DPOAEs may be enhanced by testing only in the 3- to 5.2-kHz range, thus decreasing testing time. Higher time averages to increase the signal-to-noise ratio and use of this narrower bandwidth might also allow for accurate bedside testing.

Digital clubbing and lung cancer

OBJECTIVES

To determine the relative frequency of clubbing in small cell lung carcinoma (SCLC) versus non-small cell lung carcinoma (NSCLC).

DESIGN

Examine patients with lung cancer for digital clubbing and relate the findings to the histopathologic subtype of lung cancer.

SETTING

Cancer center at a tertiary teaching hospital.

PATIENTS OR PARTICIPANTS

One hundred and eleven consecutive patients with a pathological diagnosis of lung cancer examined by one physician (KSS).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Clubbing was present in 32 (29%) of the 111 patients with lung cancer. Clubbing was more common in women (40%) than in men (19%; chi2 test p = 0.011), and was more common in patients with NSCLC (35%) than those with SCLC (4%; chi2 test p = 0.0036).

CONCLUSION

In a prospective study, digital clubbing was less frequently observed in men than women and in patients with SCLC than NSCLC. These clinical observations may assist in the initial evaluation of patients for planning workup and therapy.

A case of dermatomyositis responding to three weeks of treatment with methotrexate and steroid

A case of dermatomyositis in a young girl of 18 years is reported. Though it is generally held that it is a very recalcitrant condition, we found that the patient improved by all parameters to treatment with methotrexate and steroids in three weeks.

Somatostatin receptor expression in Hürthle cell cancer of the thyroid

Somatostatin receptor expression, which was not a previously described marker for Hürthle cell cancer of the thyroid, was demonstrated by in vivo imaging with (111)In-pentetreotide in three patients. This phenomenon not only adds another imaging technique to the nuclear medicine armamentarium for detecting recurrent and metastatic cancer in patients with Hürthle cell cancer but also opens up an alternative therapeutic avenue with somatostatin analogs or their radiolabeled compounds.

Simultaneous quantitation of plasma doxorubicin and prochlorperazine content by high-performance liquid chromatography

A high-performance liquid chromatographic method has been developed and tested for simultaneous extraction, elution and determination of doxorubicin and prochlorperazine content in human plasma samples. The procedure consists of extraction through a conditioned C18 solid-phase extraction cartridge, elution from a Spherisorb C8 reversed-phase column by an isocratic mobile phase (60% acetonitrile, 15% methanol and 25% buffer) followed by detection with electrochemical and fluorescence detectors. Recovery of doxorubicin and prochlorperazine from pooled human plasma samples (n=3) containing 100 ng/ml of the two drugs was 77.8+/-3.5% and 89.1+/-6.0%, respectively. The lower limits of quantitation for doxorubicin and prochlorperazine in plasma samples were 6.25 ng/ml and 10 ng/ml, respectively. A linear calibration curve was obtained for up to 2 microg/ml of doxorubicin and prochlorperazine. This combination method may be of particular value in clinical studies where phenothiazines such as prochlorperazine are used to enhance retention of doxorubicin in drug resistant tumor cells.

Hyperfractionated radiation therapy and 5-fluorouracil, cisplatin, and mitomycin-C (+/- granulocyte-colony stimulating factor) in the treatment of patients with locally advanced head and neck carcinoma

BACKGROUND

The authors had previously reported preliminary results of a treatment regimen of concurrent hyperfractionated radiation therapy and chemotherapy in patients with locally advanced head and neck carcinoma that demonstrated both feasibility and high local control. In an attempt to reduce acute mucosal and hematologic toxicity, granulocyte-colony stimulating factor (G-CSF) was added during the second phase of this study.

METHODS

Seventy patients (53 with Stage IV and 17 with Stage III disease) were entered between May 1988 and June 1995 into a Phase I/II trial of concurrent radiation therapy (74.4 gray (Gy) total dose; 1.20 Gy twice daily), 5-fluorouracil (1000 mg/m2/24 hours for 72 hours), and cisplatin (50 mg/m2) for 3 cycles with the addition of mitomycin C (8 mg/m2) in Cycle 2. G-CSF was added after the initial entry of 34 patients.

RESULTS

At a median follow-up of 41 months (range, 12-80 months), 44 patients were alive with a projected median overall survival of 54 months. Grade 3/4 mucositis, observed in 65% of patients, was equally prevalent and prolonged in both G-CSF-treated (+) and G-CSF-naive (-) patients. Grade 3/4 leukopenia was present in 45% and 36% of G-CSF- and G-CSF+ patients, respectively. The 3-year locoregional control and cause specific survival rates were 68% and 75%, respectively.

CONCLUSIONS

This regimen was feasible and effective but caused severe mucositis. No benefit was derived from the addition of G-CSF. This regimen deserves further modification to reduce acute mucositis toxicity yet maintain the high locoregional control rate.

K A P study on HIV / AIDS among first year MBBS students

This Kap (Knowledge, Attitude, Practical) study was to assess the current level of knowledge among first year M.B.B.S. students about AIDS at the point of entry to medical course. One hundred and seventy-one students were given a pre-tested close ended questionnaire. Overall level of knowledge about AIDS was found to be 64.91%. Male students were found to have better knowledge regarding transmission and prevention of AIDS than female students. Misconceptions were found to exist regarding mode of transmission, prognosis and prevention. Awareness programmes should be initiated among M.B.B.S. students in the first year itself, so that, lacunae can be rectified.

Review of tests for monitoring doxorubicin-induced cardiomyopathy

The objective of this review is to make physicians aware of new radionuclide methods to detect cardiac effects of chemotherapeutic drugs. This knowledge is important because of the limitations of the physical examination and the electrocardiogram for detecting early reversible cardiac damage. Presently left ventricular ejection fraction (LVEF) is routinely used to screen for cardiotoxicity. Since LVEF obtained by radionuclide angiocardiography is more accurate than the LVEF estimated by echocardiography, serial radionuclide LVEF monitoring is most commonly used to monitor cardiotoxicity. Diastolic measurements of left ventricular function (such as peak filling rate) are now being added to routine LVEF measurements to enhance standard radionuclide evaluation. This screening test should be done prior to beginning therapy and at appropriate points based on the baseline study, therapy scheme and the patient's clinical status. At some centers, exercise LVEF methods are being used to determine if cardiac reserve is adequate for the patient to tolerate additional chemotherapy when cardiac injury may be present. Previously, endomyocardial biopsy was needed to detect and confirm early anthracycline cardiotoxicity. This invasive test may be replaced by a new noninvasive in vivo method using radioactive monoclonal antibodies against cardiac muscle (indium-111-antimyosin). Because cardiac failure has been associated with adrenergic neuron injury, it has been proposed that radioactive methyliodobenzylguanine may detect the adrenergic abnormality which may predict future development of congestive heart failure or sudden death months after therapy is discontinued. Advantages and disadvantages of these methods in evaluating cardiotoxicity, and an algorithm to optimally monitor antitumor therapy-induced cardiomyopathy are discussed.

Cisplatin and continuous infusion of fluorouracil followed by radiation and weekly carboplatin in the treatment of locally advanced head and neck cancer: a Hellenic Cooperative Oncology Group study

Induction chemotherapy followed by radiation has been extensively studied in an effort to improve local control and possibly overall survival of patients with locally advanced head and neck cancer. From June 1989 until May 1991, 39 patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with 3 cycles of induction chemotherapy, consisting of cisplatin (100 mg/m2 d 1) and fluorouracil (1000 mg/m2 d 2-6) followed by radiation potentiated by weekly administration of carboplatin (60 mg/m2). Surgery was performed in selected patients with residual disease after the combined modality approach. Four cycles of adjuvant chemotherapy with carboplatin (325 mg/m2) and bleomycin (15 u) were administered in those patients who demonstrated a partial response after locoregional treatment. There were 36 men and 3 women with a median age of 56 (range 39-74) years and Karnofsky performance status of 70 (range 60-100). The primary site of the tumor was nasopharynx (8), oropharynx (8), hypopharynx (3), oral cavity (4), larynx (13), paranasal sinus (2), and salivary glands (1). Thirty-two (82%) patients presented with stage IV disease. After the completion of induction chemotherapy, 14 (36%, 95% CI 21-53%) patients achieved a complete response (CR). This CR rate was increased to 56% (95% CI, 42-74%) after locoregional treatment. Main toxicities included nausea/vomiting (56%), leukopenia (40%), anemia (30%), thrombocytopenia (10%), stomatitis (28%), diarrhea (17%), and alopecia (12%). Median relapse-free survival was 18 (1-50) months, median time to progression was 13 (0.3-58.5) months, and median survival 19 (0.3-59) months. Induction chemotherapy with cisplatin and fluorouracil followed by radiation potentiated with carboplatin is feasible. However, this combined modality approach, as applied in the present study, does not appear to yield superior results than those reported with chemotherapy followed by radiation alone.

Lung cancer in patients with human immunodeficiency virus infection

This retrospective study determined the clinical course of lung cancer in patients with human immunodeficiency virus (HIV) infection. A total of 23 patients with HIV infection archived as lung cancer were studied: 16 were identified from about 1,000 lung cancer patients entered in the tumor registry and medical records of Jackson Memorial Hospital, 7 were identified from about 1,000 HIV-positive patients entered in the Special Immunology registry of Veterans Administration Medical Center, 4 patients did not have pathologic confirmation of lung cancer, and 19 patients, all men, met the criteria for analysis (histopathologic diagnosis of lung cancer and HIV+ by serology). The median age was 47 (range: 36-66). Risk factors for HIV were homosexuality (6 patients), blood transfusion (3), promiscuity (5), intravenous drug abuse (4), and none (3). Six patients had a history of coexistent pulmonary tuberculosis and 5 had Pneumocystis carinii pneumonia. Median survival from diagnosis of lung cancer was 3 months. Advanced stages of both HIV infection and lung cancer may account for the poor survival. All patients were men and noted to be younger than other patients with lung cancer.

Bronchogenic carcinoma in HIV-positive patients: findings on chest radiographs and CT scans

OBJECTIVE

The radiographic manifestations of bronchogenic carcinoma in HIV-positive individuals may resemble or accompany changes of inflammatory disease. To provide information that is useful in the differential diagnosis, we studied the findings on plain radiographs and chest CT scans in 30 HIV-positive patients with proven bronchogenic carcinoma and correlated the radiographic features with the presence or absence of thoracic opportunistic infection.

SUBJECTS AND METHODS

Thirty HIV-positive individuals had bronchogenic carcinoma diagnosed at our institution between 1986 and 1993. Fourteen (47%) of the 30 had AIDS at the time of cancer diagnosis. All but one of the patients were men, and the median age at diagnosis was 48 years (range, 32-66 years). Most (90%) had a history of smoking. Eighteen (60%) of the 30 had a history of pulmonary tuberculosis, Pneumocystis carinii pneumonia, or both. We retrospectively reviewed all available chest radiographs (n = 27) and chest CT scans (n = 25) for tumor size and location, adenopathy, pleural disease, and pulmonary infiltrates.

RESULTS

Eighteen tumors (60%) were peripheral, 11 (37%) were central (hilar or mediastinal), and one manifested as a metastatic pleural mass. Of the peripheral tumors, 17 (94%) were in the upper lobes. All the central tumors showed obstructive consolidation of lung in the distribution of the affected airway. Adenopathy was present in 63% of the patients, and pleural effusions or masses were seen in 33%. A history of tuberculosis or Pneumocystis carinii pneumonia was present in 83% of the patients with peripheral tumors but only 27% of the patients with central lesions (p = .005). Superimposed infiltrates were present in six patients (20%). Three (17%) of 18 peripheral tumors were obscured by or mistaken for inflammatory disease, delaying the diagnosis of cancer.

CONCLUSION

Bronchogenic carcinoma usually manifests as a peripheral upper lobe mass in HIV-positive patients with a history of tuberculosis or Pneumocystis carinii pneumonia, whereas central masses are more common in patients without a history of thoracic opportunistic infection. Carcinoma should be suspected in patients with peripheral lesions that persist despite appropriate antibiotic therapy.

Prognostic significance of DNA aneuploidy in diffuse malignant mesothelioma

DNA ploidy of pepsin digested preparations of 48 paraffin-embedded specimens from 19 patients with histologically confirmed malignant mesothelioma was determined by laser flow cytometry. Eight of the 19 tumors (42%) were diploid and 11 (58%) were aneuploid. Of the aneuploid tumors, only one showed multiploidy. The median survival time of the patients with diploid tumors was 19, 16, and 14 months from the onset of symptoms, diagnosis, and treatment, respectively. The median survival in patients with aneuploid tumors was 8, 7, and 7 months from the onset of first symptoms, diagnosis, and treatment. Thus, patients with diploid tumors lived longer than patients with aneuploid tumors. These results suggest that DNA ploidy analysis may be of prognostic value in malignant mesothelioma.

A randomized clinical trial in bronchogenic small-cell carcinoma evaluating alternating maintenance therapy of vincristine, adriamycin, procarbazine, and etoposide (VAPE) with cyclophosphamide, CCNU, and methotrexate (CCM) versus CCM maintenance alone in complete responders following VAPE induction and late intensification

Initially, 109 evaluable patients with locally advanced or metastatic small cell lung cancer (SCLC) were treated with vincristine, Adriamycin, procarbazine, and etoposide (VAPE). Partial (PR) or nonresponders (NR) were crossed to CCM (cyclophosphamide, CCNU, and methotrexate) and then to HMiVe (hexamethylmelamine, mitomycin C, vinblastine) sequentially at maximum response. Complete responders (CR) were intensified by 50% with VAPE primarily and randomized to VAPE, alternating with CCM or CCM alone during maintenance. CR patients with limited disease received local thoracic irradiation and prophylactic cranial irradiation (PCI), whereas those with extensive disease received PCI alone. There were 45 patients (41%) who achieved a CR to chemotherapy, and 27 patients were eligible for randomization. Of 12 CR patients randomized to alternating therapy (VAPE/CCM), the median survival was 25.9 months compared to 12.9 months for 15 CR patients randomized to continuous CCM (P = .049). In addition, 35 patients achieved a PR (32%) and 29 were NR (27%). Overall median survivals were significantly different for the CR patients (13.0 months) as compared to PR (7.6 months) and NR patients (6.4 months). Late intensification did not appear to add substantially to survival while contributing to toxicity. In summary, VAPE is a new outpatient regimen for SCLC, which is highly effective as an induction regimen with moderate hematologic toxicity and predominantly gastrointestinal nonhematologic toxicity.

The role of steroids in the management of metastatic carcinoma to the brain. A pilot prospective trial

This prospective study attempted to evaluate the indications for glucocorticoids which are commonly given to patients with brain metastases. Twelve patients with histologically confirmed malignancies and radiographically documented brain metastases were enrolled. Patients were scored for general performance status and neurologic function class. All subjects were given high-dose dexamethasone (HDD) for 48 hours and then randomized to receive either intermediate-dose dexamethasone (IDD) or no steroids with cranial radiotherapy. Of these 12 study patients, 3 achieved a complete response, 1 partial response, and 8 nonresponses to HDD. Seven patients had IDD, while five received no IDD. Although a small sample size prevented any statistical analysis, this study does suggest that the place for using glucocorticoids in treating patients with metastatic carcinoma to the brain remains uncertain and should be evaluated in a cooperative prospective trial.

Doxorubicin retention and chemoresistance in human mesothelioma cell lines

Eight cell lines were established from the pleural effusion of 4 patients with malignant mesothelioma. The most sensitive (FCCMES-4) and the most resistant (FCCMES-2) mesothelioma cell lines had IC50 of 0.66 and 1.85 microM for doxorubicin in clonogenic assays, respectively. In comparison with murine leukemic P388 cells, mesothelioma cell lines were 7.5- to 21-fold more resistant to doxorubicin. Co-incubation with verapamil significantly increased doxorubicin retention in one of the cell lines (FCCMES-2) expressing P-glycoprotein in 16.8% of the cells. These results indicate that doxorubicin resistance may be intrinsic in refractory mesothelioma patients and P-glycoprotein-mediated drug efflux may be involved in resistance of some of the mesotheliomas.

Phase I and pharmacokinetics studies of prochlorperazine 2-h i.v. infusion as a doxorubicin-efflux blocker

In an earlier phase I study, we reported that the maximal tolerated dose (MTD) of prochlorperazine (PCZ) given as a 15-min i.v. infusion was 75 mg/m2. The highest peak plasma PCZ concentration achieved was 1100 ng/ml. The present study was conducted to determine if PCZ levels high enough to block doxorubicin (DOX) efflux in vitro could be achieved and sustained in vivo by increasing the duration of i.v. infusion from 15 min to 2 h. The treatment schedule consisted of i.v. prehydration with at least 500 ml normal saline (NS) and administration of a fixed standard dose of 60 mg/m2 DOX as an i.v. bolus over 15 min followed by i.v. doses of 75, 105, 135, or 180 mg/m2 PCZ in 250 ml NS over 2 h. The hematologic toxicities attributable to DOX were as expected and independent of the PCZ dose. Toxicities attributable to PCZ were sedation, dryness of mouth, anxiety, akathisia, hypotension, cramps, and confusion. The MTD of PCZ was 180 mg/m2. Large interpatient variation in peak PCZ plasma levels (91-3215 ng/ml) was seen, with the plasma half-life (t1/2 alpha) being approximately 57 min in patients given 135-180 mg/m2 PCZ. The volume of distribution (Vd), total clearance (ClT), and area under the curve (AUC) were 350.1 +/- 183.8 1/m2, 260.7 +/- 142.7 l m2 h-1 and 1539 +/- 922 ng ml h-1, respectively, in patients given 180 mg/m2 PCZ and the respective values for patients receiving 135 mg/m2 were 48.9 +/- 23.76 l/m2, 33.2 +/- 2.62 l m2 h-1, and 4117 +/- 302 ng ml h-1. High PCZ plasma levels (> 600 ng/ml) were sustained in all patients treated with 135 mg/m2 PCZ for up to 24 h. DOX plasma elimination was biphasic at 135 and 180 mg/m2 PCZ, and a > 10-ng/ml DOX plasma level was maintained for 24 h. Partial responses were seen in three of six patients with malignant mesothelioma, in two of ten patients with non-small-cell lung carcinoma, and in the single patient with hepatoma. Our data show that PCZ can be safely given as a 2-h infusion at 135 mg/m2 with clinically manageable toxicities. The antitumor activity of the combination of DOX and PCZ needs to be confirmed in phase II trials.

Radiation therapy and concurrent cisplatin administration in locally advanced head and neck cancer. A Hellenic Co-operative Oncology Group study

In an attempt to improve local control of locally advanced head and neck cancer, radiation therapy was combined with cisplatin. Forty-eight patients entered into this study. All patients were irradiated with a 60Co unit and according to the protocol they should receive 70 Gy in the tumor area and 45 Gy in the rest of neck. Cisplatin was administered at a dose of 100 mg/m2 on days 2, 22 and 42. Thirty-seven (80%) patients received the total radiation dose as initially planned. Thirty-four (72%) patients achieved complete and 5 (10%) partial response. Grade 3-4 toxicities included vomiting (14%), stomatitis (4%), diarrhea (2%), myelotoxicity (14%), hoarseness (4%), dysphagia (30%), weight loss (32%), nephrotoxicity (4%) and dermatitis (2%). After a median follow-up of 26 (range, 18-33) months, 16 patients have died. Among the 35 complete responders 6 later on relapsed. Median relapse-free survival has not yet been reached. Combined radiation therapy and cisplatin appears to be a highly active treatment in patients with advanced head and neck cancer as far as primary locoregional response is concerned.

Prognostic factors in lung cancer based on multivariate analysis

Multivariate analysis was performed on 1,336 patients with lung cancer to determine the prognostic significance of stage, race, gender, age, and treatment in each histologic subtype. The study was designed to establish a subgroup of patients whose survival outcome might be better, based on these factors. On univariate analysis, stage and surgery were significant factors in each histologic subtype. The presence of liver metastases, was an important prognostic factor in all subtypes except large cell carcinoma. However, 131 of 140 patients with large cell carcinoma had liver metastases, and this factor may account for the observation that liver metastases was not a significant prognostic factor. In the multivariate analysis, good prognosis was associated with early stage disease and surgical treatment in all cell types. For a given stage, the improvements in relative risk due to surgery represent both the effect of treatment and the effects of other unmeasured patient characteristics, such as performance status and physiological status, that make the patient a suitable candidate for surgery.

Detection of early anthracycline cardiotoxicity by monitoring the peak filling rate

Three patients developed clinical congestive heart failure after cumulative doxorubicin doses of 264, 440, and 450 mg/m2, respectively, despite serial monitoring of systolic cardiac function by resting gated radionuclide scanning. All three patients had depressed diastolic function, as shown by a decreased peak filling rate preceding a change in systolic function, which was assessed by left ventricular ejection fraction prior to the development of clinical congestive heart failure. We recommend serial monitoring of the peak filling rate, in addition to left ventricular ejection fraction. If broader experience confirms our impression that the peak filling rate is more sensitive than the current standard assessment of left ventricular ejection fraction, new guidelines may need to be drawn to monitor cardiotoxicity of anthracyclines and anthraquinones.

Multidisciplinary approach to the treatment of locally and regionally advanced non-small cell lung cancer: University of Miami experience

An intensive multimodality therapy protocol incorporating neoadjuvant chemotherapy was initiated in July 1985 for patients with either borderline resectable or unresectable non-small cell carcinoma of the lung. Thirty-five patients, 21 men and 14 women were entered till March 1991. The median age was 58 years (27-74). Histology was squamous in 15, adenocarcinoma in 11, large cell in 6, and adenosquamous carcinoma in 3. Initial stages were IIIA in 19 patients, IIIB in 14 and II in 2. All patients tolerated preoperative chemotherapy with 5-FU, etoposide and cisplatin (FED). The response to chemotherapy was complete response in 2 (6%), and partial response in 22 (63%). Thirty-two patients underwent surgery. 26 patients were rendered disease free including two found disease free at surgery. Fifteen underwent pneumonectomy, 14 lobectomy and 3 biopsy only. Interstitial radiation therapy was used in 7 patients. The median survival of all patients was 19 months, those who underwent incomplete surgical resection was 12 months and patients rendered disease free at operation 21 months. Thirteen patients are alive and free of disease, including 6 patients alive longer than 5 years. Only patients who responded to chemotherapy and also had complete resection survived more than 2 years. Aggressive neoadjuvant therapy with FED, followed by resection, brachytherapy, postoperative radiation therapy, and adjuvant chemotherapy can be safely accomplished with encouraging survival in stage III patients.

MDR-1 gene expression, anthracycline retention and cytotoxicity in human lung-tumor cells from refractory patients

Lung-tumor cells from pleural effusion of four refractory patients and in cell lines established from them were analyzed for anthracycline retention, cytotoxicity, and MDR-1 gene and P-glycoprotein expression. Murine leukemic P388 and doxorubicin-resistant P388/R84 lines were used as controls. The 50% growth-inhibitory concentration (IC50) for doxorubicin among lung-tumor lines varied from 0.16 to 0.31 microM in soft agar. Heterogeneity in doxorubicin or daunorubicin retention and response to the efflux-blocking action of 25 microM prochlorperazine was noted in pleural effusion of FCCL-1, -4, and -8. Among the cell lines established, an efflux-blocking effect in a subpopulation was noticed only in FCCL-1 and -4. Although the MDR-1 gene was present in all cell lines, including P388, its expression was pronounced only in P388/R84 and FCCL-1. In situ hybridization of antisense RNA probe to tumor cells showed high heterogeneity for MDR-1 message in the human lung-tumor cells as compared with the murine cells. Northern and slot blot hybridization confirmed in situ hybridization in lines with high levels of MDR-1 expression. The synthesis of MDR-1 mRNA and P-glycoprotein in tumor lines was correlated. The results suggest that because of extensive tumor-cell heterogeneity in human tumors, monitoring of MDR expression by in situ hybridization, quantitation of P-glycoprotein content by laser flow cytometry (and/or immunohistochemical methods), and drug efflux (by laser flow cytometry) may be the best ways to monitor multidrug resistance in human tumors.

The accuracy of the histological classification of lung carcinoma and its reproducibility: a study of 75 archival cases of adenosquamous carcinoma

The classification of lung carcinoma into a small cell lung carcinoma (SCLC) and non-small cell lung carcinoma (NSCLC), is highly reproducible. There are few studies on the reproducibility of subtyping NSCLC, with anecdotal reports on the subtype of adenosquamous carcinoma. We undertook a study of 75 cases archived as adenosquamous carcinoma. All cases were accepted as NSCLC on independent review by three pathologists utilizing the 1982 World Health Organization (WHO) classification criteria. The acceptance rate of adenosquamous carcinoma by the three pathologists was 65%, 28%, and 65%. Cases not accepted as adenosquamous fell into the different subtypes of NSCLC, with a concordance rate between each pair of pathologists of 49%, 61% and 43%, indicating poor agreement between pathologists. The study confirms the high reproducibility of the classification into SCLC and NSCLC; it shows poor concordance for all subtypes of NSCLC with poor reproducibility of diagnosis of adenosquamous carcinoma as specified by the 1982 WHO classification. Physicians dealing with lung carcinoma should be aware of this limitation of classification.

Prochlorperazine as a doxorubicin-efflux blocker: phase I clinical and pharmacokinetics studies

Doxorubicin (DOX) efflux in drug-resistant cells is blocked by phenothiazines such as trifluoperazine (TFP) and prochlorperazine (PCZ) in vitro. The present phase I study was conducted in 13 patients with advanced, incurable, nonhematologic tumors to determine whether PCZ plasma levels high enough to block DOX efflux could be achieved in vivo. The treatment schedule consisted of prehydration and i.v. administration of 15, 30, 50, and 75 mg/m2 PCZ followed by a standard dose of 60 mg/m2 DOX. The hematologic toxicities attributable to DOX were as expected and independent of the PCZ dose used. Toxicities attributable to PCZ were sedation, dryness of the mouth, cramps, chills, and restlessness. The maximal tolerated dose (MTD) of PCZ in this schedule was 75 mg/m2. Pharmacokinetic analysis indicated a large interpatient variation in peak plasma PCZ levels that ranged from 95 to 1100 ng/ml. The three plasma half-lives of PCZ were: t1/2 alpha (+/- SE), 20.9 +/- 5.3 min; t1/2 beta, 1.8 +/- 0.3 h; and t1/2 gamma, 21.9 +/- 5.3 h. The volume of distribution (Vd), total clearance (ClT), and area under the curve (AUC) for PCZ were 2254 +/- 886 l/m2, 60.2 +/- 13.5 l m-2 h-1, and 1624 +/- 686 ng ml-1 h, respectively. DOX retention in tumor cells retrieved from patients during the course of therapy indicated the appearance of cells with enhanced DOX retention. The combination of DOX and high-dose i.v. PCZ appeared to be safe, well tolerated, and active in non-small-cell lung carcinoma.

Randomized double-blind comparison of three dose levels of intravenous ondansetron in the prevention of cisplatin-induced emesis

The selective 5-hydroxytryptamine3 (5HT3) antagonist ondansetron has been shown to be an effective antiemetic in patients receiving cisplatin chemotherapy. This double-blind study compared the efficacy and safety of three doses of intravenous ondansetron in the prevention of nausea and vomiting associated with high-dose (> or = 100 mg/m2) cisplatin chemotherapy. A total of 125 patients were randomized (1:1:1) to receive 0.015, 0.15, or 0.30 mg/kg every 4 h for a total of 3 doses. All patients were monitored for emetic episodes, adverse events, and laboratory safety parameters for 24 h following cisplatin administration. The 0.15-mg/kg dose was superior to the 0.015-mg/kg dose with respect to the median number of emetic episodes (P = 0.033) and complete response (no emetic episodes, P = 0.005). No statistically significant difference was found between the 0.15 and the 0.30-mg/kg groups. The most common adverse event was headache. Three 0.15-mg/kg doses of intravenous ondansetron are safe, effective, and adequate for the control of cisplatin-induced emesis.

New strategies are needed in diffuse malignant mesothelioma

BACKGROUND

Medical records of 50 patients with malignant mesothelioma were reviewed to determine the clinical features and factors influencing survival.

METHODS

Charts of all patients whose conditions were diagnosed as malignant mesothelioma were abstracted and analyzed by statistical software.

RESULTS

The male-to-female ratio was 4:1. The age distribution was younger than 45 years of age, 10%; 45-54 years of age, 12%; 55-64 years of age, 37%; 65-74 years of age, 33%; and 75 years of age or older, 8%. Both mean and median ages were 58 years. Among the 32 patients in whom asbestos exposure was recorded, 24 had documented exposure. The sites were pleura, 73%; peritoneum, 20%; and both, 6%. The histologic types were epithelial, 51%; sarcomatous, 10%; mixed, 15%; and not specified, 24%. The stage at presentation was Stage I, 37%; II, 39%; III, 12%; IV, 6%; and unknown, 6%. The common symptoms in pleural disease were dyspnea and pain; in peritoneal disease, abdominal distension and pain were common. The median time from first symptom to diagnosis was 3 months (range, 0-23 months). The median survival after the appearance of symptoms, the diagnosis, and the treatment were 13, 10, and 8 months, respectively.

CONCLUSIONS

The survival was independent of age, sex, and smoking behavior. It was longer in patients with earlier-stage disease, a good performance status, a longer duration of symptoms, an absence of pain, and who were treated with combined surgery and chemotherapy. Chemotherapy using anthracyclines yielded more remissions (9 of 21) than that using nonanthracyclines (0 of 13). The remission rate after primary chemotherapy with anthracyclines (7 of 16) may be higher than in recurrent tumor (2 of 14). In future trials, stratification into primary chemotherapy and chemotherapy of recurrent cancer is suggested. There is a need for multitechnique trials incorporating primary chemotherapy.

A phase II clinical trial evaluating the use of two sequential, four-drug combination chemotherapy regimens in ambulatory bronchogenic adenocarcinoma patients

Forty-three ambulatory patients with locally advanced or metastatic bronchogenic adenocarcinoma were sequentially treated with two potentially mutually non-cross-resistant chemotherapy regimens. A new regimen, MVPF (mitomycin-c, vinblastine, procarbazine, and 5-fluorouracil), was given until progressive disease occurred. Then, a second regimen--MOCC (methotrexate, vincristine [Oncovin], cyclophosphamide, and CCNU)--was initiated. At further progression, regional disease patients received radiotherapy, whereas extensive disease patients received Phase II agents. Of the 43 patients entered on the study, 40 were evaluable. Three patients withdrew early due to poor tolerance of the regimen. The response rate for MVPF was 33% (12 of 40 PR, 1 of 40 CR) compared to a 4% (1 of 23 PR) response for MOCC (difference: p < or = .03), for a total response rate of 35%. Although there was an initial improvement in survival for responders (31.7 weeks) versus nonresponders (15.7 weeks) at the 75th percentile (p < or = .05), there was no significant difference in median survival. The hematologic toxicity was equivalent for both groups, whereas nonhematologic toxicity revealed a high incidence of nausea and vomiting in the MVPF group. It is concluded that this approach lent itself well to ambulatory care, and MVPF could be considered an alternative to cyclophosphamide-based regimens. However, the absence of a meaningful CR rate and lack of influence of response on median survival were factors limiting its effectiveness.

Lung cancer in patients with human immunodeficiency virus infection compared with historic control subjects

Lung cancer infrequently may be associated with human immunodeficiency virus (HIV) infection. This retrospective case-control study was undertaken to determine if there were differences in age, sex, and stage distribution and in survival between HIV-positive and HIV-indeterminate lung cancer patients. We compared 19 patients with both pathologically verified lung cancer and HIV infection proved by serologic study with lung cancer patients with an indeterminate HIV status. All 19 HIV-positive lung cancer patients were men. This was significantly (p = 0.004) different from the 69 percent male preponderance in 1,335 HIV-indeterminate lung cancer patients. Median ages of HIV-positive and HIV-indeterminate patients were 48 and 61 years, respectively. HIV-positive patients were significantly (p = 0.0139) younger. Stage distribution was similar in both groups. Histologic features and smoking were not significantly different between the two groups. Survival data that were available in 16 HIV-positive patients were compared with 32 HIV-indeterminate control subjects matched for stage, age, sex, and race. The median survival was three months in the HIV-positive group and ten months in the HIV-indeterminate cohort. The survival was significantly different (p = 0.002). There were no one-year survivors in HIV-positive lung cancer patients.

Phase II trial of 4'-0-tetrahydropyranyladriamycin (pirarubicin) in head and neck carcinoma

BACKGROUND

4'-0-tetrahydropyranyladriamycin (Pirarubicin, Meiji Seika (USA) Inc., New York, NY) may be less toxic than doxorubicin.

METHODS

A Phase II trial of Pirarubicin was done in 26 patients who had not previously had chemotherapy and who had measurable and incurable head and neck carcinoma. All patients received an intravenous bolus dose of 60 mg/m2 Pirarubicin in the first cycle without any prophylactic antiemetic. The cycles were repeated every 3 weeks. Based on tumor response, nadir counts, or complications of myelosuppression, the doses were escalated or de-escalated by 10 mg/m2, if necessary, in the second cycle to achieve mild leukopenia (3000-4000 leukocytes/microliters).

RESULTS

Leukopenia was mild, moderate (2000-2999 leukocytes/microliters), severe (1000-1999 leukocytes/microliters), and life threatening (less than 1000 leukocytes/microliters) in 13%, 31%, 27%, and 9% of the first two courses, respectively. The median interval to nadir leukopenia was 13 days (range, 7-21 days), with a median of 8 days (range, 5-13 days) to recover to normal. One patient with a leukocyte count of 800/microliters and an absolute granulocyte count (AGC) of 488/microliters died of sepsis 15 days after the first course. All patients had at least one course that resulted in leukopenia. One episode each of mild (100,000-150,000 platelets/microliters) and severe (25,000-49,999 platelets/microliters) thrombocytopenia occurred in the first two courses. Leukocyte, granulocyte, and platelet counts were not done routinely after the second cycle. Six patients who received four or more courses with cumulative doses of 310, 610, 340, 260, 660, and 550 mg/m2 had decrements of 0%, 1%, 7%, 10%, 12%, and 13%, respectively, in radionuclide left ventricular ejection fraction (LVEF). All other toxic effects were mild.

CONCLUSIONS

In the 24 patients with disease evaluable for response to Pirarubicin therapy, 1 had a complete response that lasted 5 months and 4 had a partial response of 2, 3, 6, and 8 months. The median survival time in patients with disease that responded to Pirarubicin therapy was 27 months; in patients with disease that did not respond to Pirarubicin therapy, the median survival time was 4 months, and in the total cohort, it was 5 months. Pirarubicin was well tolerated and was an active agent in head and neck squamous cell carcinoma.

The increasing recognition of adenosquamous lung carcinoma (1977-1986)

A retrospective analysis of the data in the tumor registry on all 103 patients with adenosquamous lung carcinoma diagnosed and treated at our center between 1977 and 1986 was performed. The history of tobacco use was available for 100 patients (72 men and 28 women). Ninety-four percent of the patients (100% of men and 79% of women) were smokers, suggesting that adenosquamous carcinoma may be a Kreyberg I type of lung carcinoma. The gender, race, and age distributions in adenosquamous carcinoma were similar to other histologic subtypes of lung carcinoma. Patients less than 45 years old constituted 10%; 45-54 years old, 24%; 55-64 years old, 34%; 65-74 years old, 25%; and greater than 75 years, 7%. In the 95 patients whose stage at the time of diagnosis was known, 11% had local stage; 28%, regional; and 61%, distant stage. The 1-, 2- and 5-year survival of the 103 patients were 27%, 18%, and 8%, respectively. Survival was related to stage. Local stage had the best survival, and greater than 50% of patients were alive at 4 years. Regional stage had an intermediate median survival of 10 months but no survivors at 5 years. Distant stage had the worst median survival (5 months), and one patient (2%) was alive at 3 years. There was a significant increase (two- to three-fold) in the frequency of adenosquamous carcinoma over the 10-year study period, 1977-1986.

Superior vena cava obstruction in a patient with chronic lymphocytic leukemia and lung cancer

A patient with cervical lymphadenopathy secondary to chronic lymphocytic leukemia (CLL) developed acute superior vena cava (SVC) obstruction. Poor response to chemotherapy, a history of smoking, and lobar atelectasis suggested a different diagnosis. Bronchoscopy established the presence of a bronchogenic adenocarcinoma of the right lung as the etiology of the obstruction. Based on our experience and a review of the literature, we recommend that if a patient with CLL or a diffuse well-differentiated lymphocytic lymphoma presents with or develops SVC obstruction, additional invasive diagnostic tests must be initiated to exclude the possibility of a coexistent second malignancy or a transformation to a higher grade lymphoma. Other features warranting a search for another diagnosis are lack of the expected response to glucocorticoids, chemotherapy, or radiation therapy.

Factors influencing complete response and survival in patients with head and neck cancer treated with platinum-based induction chemotherapy. A Hellenic Co-operative Oncology Group Study

One hundred fifteen consecutive patients with locally advanced carcinoma of the head and neck were treated between August 1984 and August 1989 with three cycles of either of two platinum-based induction chemotherapies, followed by local treatment. After the completion of chemotherapy 26 (23%) patients had complete responses (CR). Several pre-treatment characteristics were analyzed for a possible correlation to CR to induction chemotherapy and to survival. The following variables were closely interrelated: sex, history of smoking, alcohol abuse, histologic type, tumor site and grade. Tumor stage and negative history of smoking were correlated with CR. The variables which were individually correlated with survival were keratinization, CR to chemotherapy, alcohol abuse, histologic type, site and grade of the primary tumor, serum albumin level and tumor stage. A regression analysis after Cox's model to identify a limited set of predictors selected CR, serum albumin, tumor grade, performance status and nodal status as the most significant; when analyzing the data without the time-dependent variable CR, the factors selected by the model were serum albumin, tumor grade, performance status and tumor stage. In conclusion, serum albumin level, tumor grade, performance status and tumor stage prior to treatment can be used to define risk classes in our patient population.

A phase III randomized study comparing cisplatin and fluorouracil as single agents and in combination for advanced squamous cell carcinoma of the head and neck

PURPOSE

To determine whether combination chemotherapy is superior to single agents for recurrent/metastatic head and neck cancer, we compared the efficacy and toxicity of cisplatin (CP) and fluorouracil (5-FU), alone and in combination in a phase III trial.

PATIENTS AND METHODS

Two hundred forty-nine patients with recurrent head and neck cancer were randomized to one of three treatments: CP (100 mg/m2) and 5-FU (1 g/m2 x 4), CP, or 5-FU every 3 weeks.

RESULTS

The overall response rate to the combination (32%) was superior to that of CP (17%) or 5-FU (13%) (P = .035). Response was associated with good performance status (PS) but not with primary site, site of recurrence, histology, prior irradiation, or relative dose intensity. Median time to progression was less than 2.5 months, and there was no significant difference in median survival (5.7 months) among the groups. By multivariate analysis, patients with better PS and poorly differentiated tumors had superior survival. Hematologic toxicity and alopecia were worse in the combination arm.

CONCLUSION

Although the response rate to the combination of CP plus 5-FU was superior to that achieved with single agents, survival did not improve.

Five-drug antiemetic combination for cisplatin chemotherapy

A combination of metoclopramide, dexamethasone, droperidol, lorazepam, and diphenhydramine was used in prophylaxis of high-dose (greater than or equal to 100 mg/m2) or moderate dose (greater than or equal to 50 mg/m2) cisplatin. Sixty minutes prior to starting cisplatin, 16 mg dexamethasone, 50 mg diphenhydramine, and 0.5 mg lorazepam were given orally (PO). Droperidol 1 mg was given intramuscularly (IM) 15 minutes prior to beginning cisplatin. Repetitive doses of intravenous (IV) metoclopramide, 2 mg/kg in 75 ml 5% dextrose in water over 15 minutes was given 30 minutes prior to, and at 1 1/2, 4 1/2, and 7 1/2 hours after beginning cisplatin chemotherapy. Only patients with nausea and/or vomiting received subsequent doses of 2 mg/kg metoclopramide IV every 3 hours as needed. Patients refractory to metoclopramide were given 1 mg droperidol IM and 50 mg of diphenhydramine PO every 6 hours. There were 19 men and 9 women with a median age of 58 (range 31-75) years. Complete protection from nausea and vomiting in all courses of treatment occurred in 17 (61%) patients. In 63% and 70% of the 57 evaluable courses, there was neither nausea nor vomiting, during the first 24 hours after cisplatin. When present, nausea was mild and the median number of vomiting episodes was 2 (range 1-3). This antiemetic regimen was well tolerated. Toxicities were mild and occurred in 3 patients (angioneurotic edema, transient episode of facial twitching, and heaviness of tongue, respectively). The 5-drug antiemetic combination can prevent cisplatin-induced nausea and vomiting in a majority of patients.

Present and past smoking history and other predisposing factors in 100 lung cancer patients

This study assessed the accuracy of obtaining smoking history, relationships between smoking and the histologic subtypes of lung cancer, past and present smoking history, and co-carcinogen history in 100 patients seen between 1982 and 1989. A standard questionnaire filled out by the patients, a data base filled out by the physician, and medical records were abstracted, and detailed information on smoking and co-carcinogen history was obtained. Eleven percent of the patients were nonsmokers and another 41 percent were former smokers who had quit smoking more than one year prior to the diagnosis of lung cancer. Mean ages at onset and cessation of smoking and diagnosis were 17, 59, and 62 years, respectively. The histologic subtypes were as follows: adenocarcinoma, 34; squamous, 18; small cell, 24; adenosquamous, nine; large cell, nine; and bronchioloalveolar carcinoma, six. Mean pack-years of cigarette smoking for the subtypes were as follows: squamous, 82; small cell, 78; large cell, 72; adenocarcinoma, 65; adenosquamous, 48; and bronchioloalveolar carcinoma, 41. The patient and physician questionnaires had comparable data on smoking status in continued smokers and never smokers. Many former smokers filled out the patient questionnaire as a nonsmoker, but on query by the physician admitted to smoking in the past. The physician data set was more accurate in former smokers than questionnaires completed by the patients. Patients with squamous and small cell carcinomas were heavier smokers than patients with adenosquamous and bronchioloalveolar carcinomas. About 50 percent were active smokers until the diagnosis of lung cancer, but only 18 percent of patients continued to smoke after the diagnosis. About 10 percent were never smokers and about 40 percent were former smokers. Most former smokers quit smoking less than five years antecedent to the diagnosis of lung cancer.

Lung carcinoma in 1,336 patients

Characteristics of 1336 successive lung cancer patients diagnosed between 1977 and 1986 according to the Tumor Registry of the University of Miami and Jackson Memorial Hospitals were 92% smokers, 69% men, and 68% white. The histologic subtypes were 32% squamous cell carcinoma, 26% adenocarcinoma, 19% small-cell carcinoma, 12% large-cell carcinoma, 8% adenosquamous carcinoma, and 3% bronchioalveolar carcinoma. Age distribution was as follows: younger than 45, 8%; 45-54, 21%; 55-64, 36%; 65-74, 25%; and 75 years or older, 10%. Local stage constituted 15%; regional, 26%; and distant 60%. Women had a higher number of nonsmokers and adenocarcinoma. Black patients presented with lung carcinoma at a younger age than white patients. Younger patients and black patients presented with more advanced stages than older patients and white patients. The significant factors predictive of better survival were local stage and white race. Patients with bronchioloalveolar carcinoma had a better survival rate (p less than 0.02) than the other histologic subtypes, probably because of a higher incidence of local stage. There were no differences in survival between the other histologic subtypes. There were significant increases in adenocarcinoma (p less than 0.01) and adenosquamous histologies (p less than 0.025) and in distant stage (p less than 0.0001); but there were no significant changes in the age and sex distribution, smoking history, and survival rate at our center over the 10-year study period.

Sensorimotor myeloradiculoneuropathy in thymoma

This is the first report describing the clinical, electrophysiological, and neuropathological findings in a patient with thymoma and sensorimotor myeloradiculoneuropathy. Degeneration of the Clarke's nucleus and posterior horns were noted in addition to segmental demyelination and variable axonal loss of the anterior and posterior roots. The segmental demyelination was more severe in the anterior roots of the lower thoracic and lumbosacral regions. A possible rare association between paraneoplastic myeloradiculoneuropathy and thymoma is suggested.

A phase I, II study of high-dose 5-fluorouracil and high-dose leucovorin with low-dose phosphonacetyl-L-aspartic acid in patients with advanced malignancies

Twenty-eight patients with refractory advanced malignancies were treated with a 24-hour infusion of 5-fluorouracil (5-FU), leucovorin (LV), and N-(phosphonacetyl)-L-aspartic acid (PALA) weekly. Twenty-seven patients were evaluable to assess toxicity and antitumor activity. The PALA was administered as an intravenous bolus over 15 minutes at a fixed dose (250 mg/m2) 24 hours before the start of the 5-FU and leucovorin infusions. Initially the dose of 5-FU was 750 mg/m2; this was increased incrementally to 2600 mg/m2. The LV was administered in a fixed dose of 500 mg/m2 concurrently with the 5-FU over a 24-hour period. This regimen was repeated weekly. Diarrhea, stomatitis, nausea, and vomiting were among the dose-limiting toxicities. Others were hand-foot syndrome, hair loss of the scalp and eyelashes, overall weakness, rhinitis, and chemical conjunctivitis. The maximum tolerated dose of 5-FU in this combination and schedule was 2600 mg/m2. Seven of 14 patients treated with 2600 mg/m2 were able to tolerate the chemotherapy on a weekly basis without interruption. The other seven patients required dose reductions, but most received 5-FU at a dose of 2100 mg/m2. Twenty-three of 27 patients were treated previously. Eight patients had a partial response; five of these were treated previously. A complete response was observed in one patient with pancreatic carcinoma, previously untreated. The overall response rate for patients treated with 2100 or 2600 mg/m2 of 5-FU was nine of 18 patients (50%). Three of four previously untreated patients with pancreatic cancer responded to this treatment (two responded partially, and one had a complete response). One of three heavily pretreated patients with non-small cell lung cancer had a partial response as did a patient with breast cancer. Four of ten patients with colorectal cancer responded to the treatment (four partial responses), of whom three had been treated previously.

Phase II trial of mitoxantrone in head and neck carcinoma

Nineteen patients with measurable and incurable head and neck carcinoma (17 squamous cell and two adenoid cystic) received intravenous bolus doses of 14 mg/m2 mitoxantrone in the first course. The doses were escalated or de-escalated by 2 mg/m2 in subsequent courses, based on leukocyte nadir, to achieve mild (3,000-3,999/mm3) or moderate (2,000-2,999/mm3) toxicity and response. The courses were repeated every 3 weeks. All 60 courses were evaluated for toxicity. Leukopenia was mild, moderate, severe (1,000-1,999/mm3), and life-threatening (less than 1,000/mm3) in 17%, 23%, 42%, and 2% of courses, respectively. Mild thrombocytopenia (100,000-129,999/mm3) occurred in two courses. The median interval to nadir leukopenia was 14 days (range 7-36) with a median of 13 days (range 3-50) to recover to normal. After the first course, leukopenia was mild in 16%, moderate in 32%, severe in 26%, and life-threatening in 5%. One patient died of pulmonary embolism 8 days after the first course and had concomitant leukocyte count of 700/mm3. Eighteen patients had at least one course resulting in leukopenia. Three of six patients receiving greater than or equal to 4 courses (cumulative dose 56-102 mg/m2) had an asymptomatic decrement of 14%, 17%, and 29%, respectively, in radionuclide left ventricular ejection fraction. The other toxicities were mild. In the 16 patients with squamous cell carcinoma that could be evaluated for response, one had a partial response lasting 8 months, and six had stable disease. One of the two patients with parotid adenoid cystic carcinoma had a minor response lasting 16 months. Mitoxantrone on a bolus schedule has minimal activity and is not indicated in head and neck squamous cell carcinoma.

Platinum-based induction chemotherapy followed by radiation as definitive treatment for patients with locally advanced cancer of the oral cavity, oropharynx and hypopharynx. A retrospective analysis of 32 cases

Thirty-two patients with locally advanced cancer of oral cavity, oropharynx and hypopharynx were treated with three cycles of platinum-based induction chemotherapy followed by radiation therapy. After completion of the combined treatment 50% of the patients were in complete response (CR) and 28% in partial response (PR). So far, 24 patients have died. Local progression occurred in 20 patients. Survival is 29% at 24 months. Seven (22%) patients remain alive and have been disease-free for 22-59 months. In conclusion, induction chemotherapy followed by radiation therapy may omit radical surgery, without compromising survival, in some patients with locally advanced cancer of the oral cavity, oropharynx and hypopharynx.

Phase I trial of piritrexim capsules using prolonged, low-dose oral administration for the treatment of advanced malignancies

A phase I trial of piritrexim was conducted by use of a prolonged, low-dose oral schedule. A number of different regimens were tested, including daily dosing for 21 days followed by 7 days of no drug therapy; continuous dosing; and daily dosing for 5 of 7 days for 3 consecutive weeks followed by a week of rest. Dose escalation was accomplished by increasing the dosing frequency from once a day to twice a day and then to three times a day and by increasing the number of days of administration. Fifty-one patients with advanced cancer were entered in the study. One hundred twenty-four (96%) of 129 courses were considered assessable. Myelosuppression proved to be the dose-limiting toxic effect. Other toxic effects included stomatitis, nausea and vomiting, anorexia, diarrhea, skin rash, fatigue, and elevation of liver transaminase levels. Antitumor activity was observed in patients with melanoma and bladder cancer, and disease stabilization occurred in those with sarcoma and pheochromocytoma. The recommended dosing schedule for phase II clinical trials is 25 mg three times a day for 5 days for 3 consecutive weeks followed by 1 week of no drug therapy.

Platinum-based chemotherapy followed by radiation therapy of locally advanced nasopharyngeal cancer. A retrospective analysis of 39 cases

A retrospective analysis was performed of 39 patients with locally advanced nasopharyngeal cancer treated with combined chemotherapy and radiation therapy during the last five years at our departments. There were 26 men and 13 women with median age 55 (24-75) years. Histology was squamous cell carcinoma in 6 patients and undifferentiated carcinoma in the remaining 33 patients. Induction chemotherapy consisted of either regimen A (cisplatin 100 mg/m2 day 1, 5-FU 1,000 mg/m2 days 2-6 as continuous infusion, bleomycin 15 mg days 15 and 29 i.m., mitomycin 4 mg/m2 day 22 and hydroxyurea 1,000 mg/m2 daily days 23-27) or regimen B (carboplatin 300 mg/m2 day 1, 5-FU 1,000 mg/m2 days 1-5 as continuous infusion and methotrexate 1.2 g/m2 day 14 with leucovorin rescue). After completion of induction chemotherapy 13 patients (33%) had complete remission (CR) and 19 (49%) partial remission (PR). The CR rate was increased after radiation therapy to 72%. Survival rates were 88% at 12 and 78% at 24 months. Median time to progression was 29.5 months. In conclusion, induction chemotherapy with a platinum-based regimen followed by radiation therapy achieved a high rate of local control. If the treatment also prolongs survival must, however, be studied by randomized trials.

Spontaneous pneumomediastinum in esophageal carcinoma

Although fistulae and hypercalcemia are rare at the time of diagnosis of esophageal carcinoma, they are not uncommon terminal events. Most fistulae communicate with the respiratory tract. Uncommon sites of fistulae due to esophageal carcinoma include extension to the aorta, pleura, pericardium, and mediastinum. We report a patient with a spontaneous pneumomediastinum discovered during radiologic staging of esophageal carcinoma. The symptoms were dysphagia, weight loss, and pneumonia. The patient had hypercalcemia refractory to conventional measures, another adverse prognostic factor. Cisplatin 100 mg/m2 was tolerated without acute toxicity and lowered the serum calcium to normal. However, the patient died due to respiratory failure 2 days after cisplatin therapy. To our knowledge, this is the first report of a spontaneous pneumomediastinum at presentation of an esophageal carcinoma. The course of our patient and a review of the literature suggest that fistulae and/or hypercalcemia are medical emergencies and are often fatal in esophageal carcinoma.

A phase I study of 4'-0-tetrahydropyranyladriamycin. Clinical pharmacology and pharmacokinetics

A Phase I study of intravenous (IV) bolus 4'-0-tetrahydropyranyladriamycin (Pirarubicin) was done in 55 patients in good performance status with refractory tumors. Twenty-six had minimal prior therapy (good risk), 23 had extensive prior therapy (poor risk), and six had renal and/or hepatic dysfunction. A total of 167 courses at doses of 15 to 70 mg/m2 were evaluable. Maximum tolerated dose in good-risk patients was 70 mg/m2, and in poor-risk patients, 60 mg/m2. The dose-limiting toxic effect was transient noncumulative granulocytopenia. Granulocyte nadir was on day 14 (range, 4-22). Less frequent toxic effects included thrombocytopenia, anemia, nausea, mild alopecia, phlebitis, and mucositis. Myelosuppression was more in patients with hepatic dysfunction. Pharmacokinetic analyses in 21 patients revealed Pirarubicin plasma T 1/2 alpha (+/- SE) of 2.5 +/- 0.85 minutes, T beta 1/2 of 25.6 +/- 6.5 minutes, and T 1/2 gamma of 23.6 +/- 7.6 hours. The area under the curve was 537 +/- 149 ng/ml x hours, volume of distribution (Vd) 3504 +/- 644 l/m2, and total clearance (ClT) was 204 + 39.3 l/hour/m2. Adriamycinol, doxorubicin, adriamycinone, and tetrahydropyranyladriamycinol were the metabolites detected in plasma and the amount of doxorubicin was less than or equal to 10% of the total metabolites. Urinary excretion of Pirarubicin in the first 24 hours was less than or equal to 10%. Activity was noted in mesothelioma, leiomyosarcoma, and basal cell carcinoma. The recommended starting dose for Phase II trials is 60 mg/m2 IV bolus every 3 weeks.