Epirubicin, Methotrexate and Bleomycin (EMB) in the Treatment of Recurrent Epidermoid Cancer of the Head and Neck

During the period May 1989 to November 1990, at the « O. Alberti » Radium Institute of Brescia's General Hospital, 35 patients affected by epidermoid head and neck carcinoma were treated every 28 days with the salvage chemotherapy regimen EMB (epirubicin, 50 mg/m2 i.v. day 1; methotrexate, 40 mg/m2 i.v. days 1, 18; bleomycin, 10 mg/m2 i.v. days 4, 11, 18). Sixteen patients had been previously treated with surgery, 15 with radiotherapy and 4 with chemotherapy. Six patients (Group A) received only 1 cycle of chemotherapy because of disease progression and subsequent death. In another 15 patients (Group B) it was possible to administer 2 cycles of EMB, and 9 of them showed local disease progression and died. Among the remaining 6 patients, evaluated as PR, 1 refused further therapy and 5 were amenable to a previously impossible radiotherapy (4 of them are still alive). Fourteen patients received 3 or more cycles of EMB (Group C): 8 subjects showed progression and died; 1 reached CR and is alive without any evidence of tumor; 5 are in PR (3 of them underwent subsequent radiotherapy and 1 chemotherapy with CDDP). Out of 35 patients, 12 (34 %) reached a favorable response (CR or PR) and 8 (22 %) are still alive. As regards toxicity, the following adverse events were recorded (≥ 2 Miller's scale): leukopenia (8.5 %), thrombocytopenia (5.7 %), anemia (14.2 %), stomatitis (5.7 %), vomiting (5.7 %), alopecia (8.5 %), and fever (11.4 %). It can be concluded that the EMB regimen is very well tolerated and shows good effects in the treatment of patients with relapsed head and neck carcinoma.

High-Dose Interstitial Brachytherapy for Glioblastoma Multiforme

Aims and background

The long-term prognosis for survival of patients with inoperable glioblastoma multiforme (GBL) is very poor. Conventional external radiotherapy gives only transitory result. This severe prognosis led us to elaborate a high-dose rate (HDR), after-remote-loading brachytherapy treatment protocol: our aim was both therapeutic and psychologic

Methods

Five patients with GBL (T1 G4 UICC) were treated with stereotactic biopsy followed by HDR brachytherapy. A unique coaxial after-loading catheter was stereotactically inserted through the center of the target volume. The treatment schedule considered 5 fractions, 5 Gy/fraction at the dose specification surface, 2 fractions per day.

Results

The treatment was well tolerated. Tumor progression started again at the 8th to the 16th week from the end of the treatment. ECOG performance status at the 8th week was better than before the therapy in 2 of 5 patients and was stable in 2 of 5 patients. Order neuroperformance status was stable in 2 patients at 8 weeks. At the 16th week there was neurologic deterioration. The average survival was 21 weeks.

Conclusions

Our approach seems to be of some interest for the pal-lation of GBL, and it offers some advantages, in particular regarding the short treatment period. Our procedure can be improved: a multicatheter implant and a more fractionated schedule could be taken into account.

Are International Guidelines for the Prescription of Adjuvant Treatment for Early Breast Cancer Followed in Clinical Practice? Results of a Population-Based Study on 1547 Patients

Aims and background

The results of several randomized trials and meta-analyses have been reported on adjuvant treatment for early breast cancer and treatment guidelines have been defined accordingly, but detailed data are lacking on the appropriateness of treatment prescription in clinical practice.

Methods

We performed a prospective, observational, multicenter study to monitor the prescription, delivery and effectiveness of radiotherapy following conservative surgery for early breast cancer; 1610 patients treated with postoperative radiation to the breast in 1997 were entered by 12 centers in Lombardy, Italy. Here we report the results of a secondary analysis focused on the prescription of medical adjuvant treatment (1547 eligible patients).

Results

Chemotherapy only was prescribed to 526 patients (33%), hormonal therapy only to 539 (33%), and both treatments to 85 patients (5%); 460 women (29%) received no medical adjuvant treatment. We compared the collected data with guidelines defined in 1995 by the St Gallen Consensus Conference. Undertreatment was most frequent in node-negative patients at intermediate/high risk, no treatment (instead of tamoxifen or chemotherapy) being prescribed in 21–45% of cases. Node-negative patients at low risk, on the other hand, were overtreated with tamoxifen in 31% of cases. In node-positive, premenopausal women compliance with guidelines was far better, with a 91–96% rate of chemotherapy prescription. In node-positive, postmenopausal, estrogen receptor-positive patients chemotherapy was unduly prescribed in as many as 56% of cases. Comparison of clinical practice with the next version of the guidelines (1998) showed a somewhat better compliance.

Conclusions

Despite the availability of official and authoritative guidelines, adjuvant treatment prescription for early breast cancer in Lombardy in 1997 was suboptimal, especially in well-defined subgroups of patients.

Radiotherapy of Oral Tongue Cancer

The results in the treatment of oral tongue cancer are analysed to suggest a highly specified therapeutic program. Two hundred and thirty-two cases, radiologically treated at the Istituto del Radio Alberti, Brescia, Italy, from 1964 to 1978 are considered. Depending on the staging, exclusive interstitial curietherapy, exclusive external radiotherapy, or external plus interstitial radiotherapy were applied. The therapy of locoregional lymph nodes was surgical and/or radiological. The statistical analysis deals with actuarial survival, local remission, recurrences and radionecroses. Particular attention is paid to N0 cases that became N positive. The suggested therapeutic program depends strictl on the staging and defines also the optimal doses.

[Intracavitary brachytherapy in esophageal neoplasms. Experience at the Radiology Institute of Brescia]

We investigated the role of brachytherapy in the management of esophageal cancer. From March, 1990, to December 1994, seventy patients, with biopsy-proved esophageal carcinoma, were treated with brachytherapy +/- external beam radiotherapy. According to the TNM staging system, 24 patients were graded as T1, 24 as T2, 10 as T3, 9 as T4, and 3 as Tx. Median Karnofsky score was 80. Dysphagia was the major symptom in 68% of cases. Treatment consisted of low dose rate first, and then high dose rate brachytherapy, with progressive optimization of doses and fractions, up to total doses of 15-30 Gy in low dose rate and 7-21 Gy in high dose rate. When associated, external beam radiotherapy was delivered with conventional schedules. Tolerance to treatment was good with slight acute toxicity. Symptoms were markedly improved, with reduction of dysphagia in 100% of cases. Overall survival was 75%, 47%, 23% and 18% at 6, 12, 24, 36 months; no significant difference was found between low and high dose rate groups. Furthermore, no difference was shown in the overall survival of the group treated with brachytherapy alone and the one with associated external beam radiotherapy. Late toxicity occurred in 10% of patients and was managed by endoscopic procedures in all cases. In our opinion, brachytherapy appears to be an effective palliative treatment; its role as radical treatment remains to be defined.

[Exclusive radiotherapy in the treatment of carcinoma of the portio cervicis, stage IIB FIGO]

From January 1970 through December 1987, 135 patients with cervical cancer in stage IIB (FIGO criteria) were treated by means of exclusive radiotherapy in the Istituto del Radio of the Brescia University. Thirty cases were treated by exclusive external-beam radiotherapy (RTT), 39 by brachytherapy (CU) plus external-beam radiotherapy, 24 by combined RTT and CU, 41 by RTT + CU + RTT, and 1 case by CU alone. Crude survival at 5 years is 52.4%, and NED survival is 50%. The differences between the values of crude and NED survival by radiotherapy technique were statistically significant (p 0.05), ranging from 69.8% in the RTT + CU group to 35.5% in the RTT alone group. Twenty-four cases (18%) failed to obtain complete remission, and 24 more cases recurred in the pelvis. Sequelae were evaluated by the French-Italian glossary; they were present in 62 cases (46%), but in 12 cases only (9%) they were severe. The incidence of sequelae was highest in the groups of patients treated with the combined techniques (RTT and CU) which allowed best disease control.

[Rhinopharyngeal carcinoma. Clinical prognostic factors]

The authors report the results of the retrospective analysis of 306 patients with nasopharyngeal carcinoma. All patients had received high-dose radiation therapy. First, overall results were analyzed, and then the prognostic value of the patients' data (age and sex) and of tumor features (histology, local spread, lymph node involvement). Crude actuarial survival rate is 42.9% (+/- 2.9) at 5 years; loco-regional control at the end of treatment was obtained in 16.8% of cases; 53.6% of them (126 patients) had relapses, especially on T and M. Cumulative relapse rate was 51.1% (+/- 3.3) at 5 years. Mean relapse-free interval was 10 months. All the clinical factors we examined had prognostic value; especially local tumor spread, with a worse prognosis for tumors with extra-nasopharyngeal spread (5-year survival: 38.3% +/- 6.9 for T3 and 33.9% +/- 4.8 for T4), and especially for tumors with neurological deficits (5-year survival: 19.9% +/- 6.3). Regional lymph node metastases were an important factor too, with a special emphasis on size (5-year survival: 26.4% +/- 6.5 in the cases with adenopathies with phi greater than 6 cm), and fixed adenopathies (5-year survival: 23.9% +/- 4.6). These prognostic factors are considered only in part in the current TNM 1987 staging system, which calls for its partial revision.

[Exclusive radiotherapy of stage Ib cervix carcinoma]

From January 1st 1970 to December 31 1987, 178 consecutive cervical cancer Ib patients were treated at the Istituto del Radio, University of Brescia, by means of radiotherapy alone. In spite of the negative selection of the patients (advanced age, poor general conditions, associated pathologies) the results were good: 5-year cumulative survival was 86.5%, with a total failure rate of 13.5% (24 failures: 18 in the pelvis, 3 metastases and 3 both). The incidence of major complications (G2-G3-G4 of the Italian-French glossary) was 20% (36 patients): 19 G2, 15 G3 and 2 G4. The results in terms of survival and complications were related to the prognostic factors of the tumor (histology, grading, tumor size), of the patient (age, Karnofsky scale, associated pathologies, number of erythrocytes and hemoglobin rate) and treatment modalities (total dose, fractionation, combination of intracavitary brachytherapy and external beam).

[Radiotherapy of locally advanced tumors of the mouth floor and the tongue]

At Istituto Radio "O. Alberti" in Brescia 312 patients with locally advanced cancers (T3-4N0 and T1-4N1-3) of the tongue or floor of the mouth were treated between 1970 and 1985. All underwent high energy radiotherapy associated, in 93 cases, with surgery on the T and/or on the N. The cases were divided by T and N in order to evaluate the prognostic importance of these parameters. Total remission (TR) at the end of treatment was achieved in 52% of the cases (163 patients). A relationship was found between tumor size, degree of lymph node involvement and the likelihood of response. Of the 163 cases in TR, 89 (55%) showed recurrence; 80% taking place within the first two years. After correction for natural death, the actuarial 5 year survival rate for the entire case study proved to be 27% while NED was 22%. The group undergoing radiotherapy in association with surgery showed a better survival rate than the group which only underwent radiotherapy (45% vs. 20% at 5 years). In the cases of advanced T (T3-4) lymph node involvement did not appear to affect prognosis.

[Significance of preventive radiotherapy of the neck in clinically N0 tumors of the larynx]

The role of precautionary radiotherapy of the neck in laryngeal cancers (except T1-T2 glottic and some T1 supraglottic cancers) N0 at the clinical staging was investigated. Two-hundred and fifty-three patients were examined: 143 were irradiated only on T, and 110 also on the neck. Radiotherapy of the neck in the latter group was performed either by means of two large opposed fields of photon beams including T and N, or by means of fields of photon beams on T and electron beams (8 x 12 cm2 average) on the neck, to quite exclude any risks for the spinal cord. The dose was 45-50 Gy (2 Gy/fraction/day; 5 fraction/week) in 4-5 weeks. A comparison of the results obtained in the two groups, in terms of survival-rate and relapse-free time, indicates that radiotherapy reduces the change of relapses on N (6.1% vs. 14.62% at 3 years; p = 0.04) and improves the patient's survival chances (82.5% vs. 68.4% at 3 years; and 80.8% vs 63.4% at 5 years). Our data were then compared with literature data on the importance of N field size in radiation treatment. As a rule, some authors enlarge the field to be treated to a total nodal neck irradiation, but their results are not significantly different from those we obtained with 8 x 12 cm2 field size.

Statistical evaluation of a total dose-dose rate relationship in oral tongue cancer 192 Ir implants

A statistical tool has been made by us on 55 patients treated for oral tongue cancer with unique 192 Ir interstitial curietherapy in Brescia from 1973 to 1981. Our aim was to verify a simple analytical relationship proposed and adopted by us for oral tongue cancer implants in order to reduce the total dose with increasing dose rates and to calculate the equivalent total dose when referred to 0.357 Gy/hr. Recurrences and radionecroses are studied in a variance analysis, distinguishing according to stage and total dose; within the dose rate range used, a highly significant difference in radionecrosis rate (P less than 0.005) confirms our isoeffect relationship.

[Tangential pendular cobalt-therapy in the management of malignant testis tumors: a clinical evaluation after 14 years' experience]

129 cases of malignant testis tumors (88 seminoma and 41 carcinomas) treated at Istituto del Radio "O. Alberti" from 1966 to 1979 were statistically reviewed. All patients had inguinal orchiectomy followed by irradiation to iliac and lumbar para-aortic lymph nodes, with an original technique, tangential pendular cobalt therapy, worked out at our Institute in 1966. Results are very good: there is calculated with actuarial method, a 92% of patients with seminoma alive at 5 years and 84% of patients with carcinoma. Earlier or later iatrogenic sequences did not happened. The worth and actuality of tangential pendular cobalt therapy to post-operative irradiation in patients with stage I or II malignant testis tumors is confirmed.

[Clinical dosimetry in radium 226 and iridium 192 interstitial therapy of oral tongue cancer (author's transl)]

On 96 patients with carcinoma of the floating part of the tongue in the early stage treated by interstitial curietherapy alone have been effect both a comparison between the obtainable results with the 192Ir and with the 226Ra and a total valuation of some able factors (dose-rate, total dose, tumor volume) to influence the curietherapy after loading with 192Ir.