Biweekly dose escalation in curative accelerated hyperfractionation for advanced head and neck cancer: a feasibility study

PURPOSE

To study the feasibility of a dose-escalated accelerated hyperfractionation schedule for patients with advanced head and neck cancer.

MATERIALS AND METHODS

Twenty-nine previously untreated patients with advanced squamous cell carcinoma were treated with the following biweekly dose-escalated accelerated hyperfraction schedule: during the first 2 weeks 1.2 Gy twice a daily (bid) up to 24 Gy, thereafter during the next following 2 weeks 1.4 Gy bid to 28 Gy in 20 fractions, and thereafter 22.4 Gy in 1.6 Gy bid fractions during 1 1/2 weeks. Thus, the the total dose was 74.4 Gy in 54 fractions given in 5 1/2 weeks.

RESULTS

The planned total dose was given within the planned time to 19 (66%) patients. For seven patients the treatment time was prolonged with 1 to 6 days because of department closure for holidays or machine-down days, and in three cases the treatment time was prolonged more than 8 weeks. When the tumor responses were evaluated at 3 months after given radiotherapy, 27 (93%) patients showed complete tumor clearance, 1 patient had a recidual focus, and 1 patient showed progressive disease. The ultimate 1-, 2-, and 3-year local control rates were: 87, 71, and 60%. Four patients had a salvage laryngectomy. The 1-, 2-, and 3-year survival rates for all patients were as follows: 96, 81, and 73%. All patients developed confluent mucositis, 15 patients were hospitalized for nutritional support, and 11 patients had moist desquamation. However, all acute reactions healed completely, and no serious late complications were observed.

CONCLUSIONS

This is a safe and effective treatment schedule for patients with advanced head and neck cancer.

Altered fractionation of hemithorax irradiation for pleural mesothelioma and failure patterns after treatment

Malignant pleural mesothelioma is a rare malignancy with a bleak prognosis. The role of radiotherapy has not yet been clarified. Our aim was to study the effect of altered fractionation on mesothelioma. We have treated 57 patients, 41 males and 16 females, with hemithorax irradiation with six different fractionation schedules. All the patients have been included in a combined modality program consisting of surgery followed by chemotherapy and finally by hemithorax irradiation. The radiotherapy schedules used were: I. Conventional fractionation of 20 Gy in 10 fractions over 12 days. II. Split-course radiotherapy 55 Gy in 25 fractions of 2.2 Gy over 7 weeks (a two weeks rest halfways) followed by a boost dose of 15 Gy over 8 days to the major tumour area. III. Hyperfractionation of 70 Gy over 7 weeks, 1.25 Gy BID with a 6-h interval and a 10-day rest halfways. IV. Combined hyperfractionation and hypofractionation, 35 Gy hyperfractionation in 28 fractions (1.25 Gy BID with a 6-h interval) over three weeks followed by 36 Gy hypofractionation 9 fractions of 4 Gy given every other day over 3 weeks to the major tumour areas only. V. Hypofractionation of 38.5 Gy over 15 days (9 x 3.5 Gy). VI. Combined conventional radiotherapy and hypofractionation with 20 Gy given conventionally in 10 fractions followed by 10 fractions of 3 Gy over two weeks, overall time 4 weeks. The 2-year survival rate of all patients was 21% and the 5-year survival rate 9%. Two patients are still alive more than 6 and 9 years after radiotherapy. Progression occurred after surgery in four patients, during and after chemotherapy in 22 patients and after completed radiotherapy in 29 patients. The pattern of progression was similar in each treatment group.

How radiation oncology emerged as a discipline in Finland

The news about the discovery of Röntgen's new rays spread over Finland quite early, and the first Finnish writing about the rays appeared in February 1896. The first x-ray machine was installed in 1897. Proper training of radiologists began, however, at a comparatively late date. For a long time the position of radiologists remained a subordinate one. Radiology had the nature of a spare time hobby, because in most hospitals surgeons treated x-ray machines as a sideline. Because of this, scientific research work was delayed. The specialty of x-ray diagnosis and therapy was, however, established in 1921, and the Finnish Society of Radiology was founded in 1924. The first radiotherapy department with its own beds was opened in 1936 in Helsinki. In 1950, the first professor of medical radiology was appointed at the University of Helsinki. The Finnish Cancer Society played an important role in developing the radiotherapy net in the country by supplying cobalt devises and auxiliary hospital activities in the 1960s. In the early 1960s roentgen diagnosis and radiotherapy were separated into two distinct disciplines. There are now five medical faculties with chairs in radiation oncology. The country is divided into five regions for cancer care. The managing groups in each region are headed by the professor of radiotherapy and oncology. The radiation oncologists in Finland are involved in diagnosis and staging of cancer and are responsible for radiation therapy, chemotherapy and hormones. They are responsible for follow-up of treated patients, their own wards, and the general care of their patients.

Development of clinical radiotherapy since 1896

From the discovery of x-rays in November 1895 and the first publication in December 1985 it did not take long for the first x-ray therapy of cancer in January 1896. The first 25 years in the history of radiotherapy was not a very flattering period for the discipline. During the following 25 years, however, important developments in clinical radiotherapy occurred and in some countries the speciality of radiotherapy was established in the 1930s. In the last 50 years gradual changes have taken place and now modern radiotherapy is an established curative method in the treatment of cancer. The scientific background of radiotherapy is solid, and the understanding of cancer biology and radiobiology has improved drastically. The radiotherapists of today are cancer specialists, oncologists. The technical development has been enormous. The future of radiation oncology looks very promising, with local cancer treatment being shown to be most effective.

Effect of split-course radiotherapy on survival and local control in advanced localized prostatic carcinoma

PURPOSE

to analyze the effect of overall treatment time of radiotherapy on survival and local control in locally advanced prostatic cancer in a split-course treatment setting.

METHODS AND MATERIALS

168 patients with Stage C prostatic cancer treated during 1979-1989 by the split-course method where the overall treatment time is protracted. Treatment consisted of whole pelvis irradiation of 40 Gy in 4 weeks, followed by a planned 3-week interruption and an additional 26 Gy by the reduced field technique to a total dose of 66 Gy in 9 weeks and 30-33 fractions. The overall treatment time varied from 55 to 100 days. Thirty-eight percent (63) of the patients were treated primarily with radiotherapy, while the rest (105) had received androgen ablative therapy during 2 to 4.5 years before radiotherapy. To examine the effect of treatment time on local control, the patients were divided into three groups ( < or = 63 days, 64-70 days, and > 70 days) by treatment time.

RESULTS

the 5-year actuarial survival rates, calculated from the date of diagnosis, were 91% for the hormonally manipulated patients and 69% for the patients treated with radiotherapy alone. The 5-year actuarial local control rates, counted from the start of radiotherapy, were 84% for radiotherapy and 80% for the hormonally manipulated group. Overall, no significant effect of treatment time could be seen, either for radiotherapy alone or for the hormonally manipulated group. The results were similar when the material was further divided by T category and histologic grade.

CONCLUSIONS

no significant effect of overall treatment time (55 to 100 days) on survival or local control was found in either group. The survival time from diagnosis was longer in the hormonally pretreated group. Apparently, with adequate doses ( > or = 65 Gy) the overall treatment time becomes less important for local control of advanced prostatic cancer, even in a split-course treatment setting.

Radical surgery and postoperative split-course radiotherapy in squamous cell carcinoma of the head and neck--factors influencing local control and survival

During the period 1970-1989, 256 patients with squamous cell carcinoma of the head and neck were treated with radical surgery and postoperative split-course radiotherapy. The 3-week rest period was compensated by a 10% increase in the total radiation dose to 66 Gy. The 5-year actuarial local control rate was 66% in tonsillar, 60% in mobile tongue, 64% in floor of the mouth, 51% in lower gingiva, 63% in laryngeal, and 35% in hypopharyngeal cancer. Failures were observed in 102 patients (40%) and 51 (20%) died of intercurrent diseases. Except in mobile tongue cancer, the results in the logistic regression analyses showed that T- and N-category and pretreatment Karnofsky index had the strongest association with local control, whereas in Cox's proportional hazard's regression analyses T-category and pretreatment Karnofsky had the strongest association with survival. In mobile tongue cancer, the histologic grade and the time interval between surgery and radiotherapy had the strongest association with local control and survival respectively. However, the lengthening of the time interval was often caused by factors or events which could have influenced the prognosis. On the basis of both univariate and multivariate analyses, when the tumour resection margins were free, a time interval of less than 3 months, the overall treatment time and the duration of the split of radiotherapy, became less important for local control and survival when doses of 65 Gy were given by fraction of 2 Gy or greater.

N-acetylcysteine in combination with radiotherapy in the treatment of non-small cell lung cancer: a feasibility study

N-Acetylcysteine (NAC) is a free radical scavenger and could therefore act as a radioprotector. To test the feasibility of administering NAC in combination with radiotherapy, we studied 10 patients with inoperable non-small cell lung cancer who were receiving hyperfractionated radiotherapy (RT) of 1.25 Gy B.I.D. (6-h interval) up to a total dose of 60 Gy/48 fractions/32 days. They were given NAC concomitantly with RT: 100 mg/kg i.v. 30 min before the first RT session followed by 30 mg/kg as an i.v. infusion over 7 h; and 600 mg inhaled 30 min before and after each RT session. The patients were assessed by serial CT scans and lung function studies during a 1-year follow-up period. The treatment regime was feasible, but expensive in time and resources. Normal tissue reactions and tumour responses were similar to those in a control group.

Diagnosis and prognostic factors in malignant pleural mesothelioma: a retrospective analysis of sixty-five patients

This report is an analysis of the medical records of 83 patients registered between 1960 and 1980 at Helsinki University Central Hospital as having malignant pleural mesothelioma. 65 of 83 patients had histologically confirmed malignant mesothelioma, and are the focus of this analysis. The remaining 18 (22%) patients were excluded because malignant mesothelioma was only confirmed cytologically, or because the primary tumor was not a mesothelioma. The ratio of men to women was 2:1.30 of 65 (46%) patients were not known or not likely to have been exposed to asbestos. The main symptoms at presentation were dyspnea, cough, chest pain, fatigue and weight loss. The median survival from diagnosis was 12 months, and from the onset of symptoms 18 months. Clinical stage and performance status were significant prognostic factors. Hematogenous metastases were present at autopsy in most cases. Disease and performance status therefore need to be well established and documented in clinical trials involving mesothelioma.

Multimodality treatment programs for malignant pleural mesothelioma using high-dose hemithorax irradiation

The characteristic of malignant pleural mesothelioma is a tumor that grows by plate-like extension over the pleura, and invades adjacent tissues and organs. Radical surgical removal of the tumor is generally not possible, and most treatment regimens involve combined chemotherapy and radiotherapy, as well as debulking surgery. We have prospectively evaluated five locally-aggressive multi-modality treatment programs, using different hemithorax irradiation schedules and chemotherapy regimens. One hundred patients with confirmed malignant pleural mesothelioma entered the study between 1977 and 1989. The treatment programs, which can consecutively, were: I, 20 Gy (10 x 2 Gy) to the hemithorax + CYVADIC (cyclophosphamide 500 mg/m2 d 1, vincristine 1 mg/m2 d 1 and 5, adriamycin 40 mg/m2 d 1 and dacarbazine 200 mg/m2 d 1 and 5, several cycles before and after irradiation); II, 55 Gy (25 x 2.2 Gy) to the hemithorax + 15 Gy (6 x 2.5 Gy) to the tumor + CYVADIC (2 cycles before, 1 cycle during, and 2 cycles after irradiation); III, Mitoxantrone (14 mg/m2 q 28 d, < or = 6 cycles) followed by 70 Gy (56 x 1.25 Gy, twice a day); IV, 4-Epirubicin (110-130 mg/m2 q 28 d, < or = 6 cycles) followed by 35 Gy (28 x 1.25 Gy twice a day) to the hemithorax + 36 Gy (9 x 4 Gy every 2 days) to the tumor; V, Etoposide (150 mg/m2 1, 3, 5 q 28 d) followed by 38.5 Gy (11 x 3.5 Gy) to the hemithorax. A new system for evaluating tumor response in pleural mesothelioma was applied. None of the combined treatment programs prevented local invasive growth or the spread of mesothelioma outside the hemithorax. The median survival time was slightly increased from 8 to 12 months for those patients who completed the protocol treatments, but progressive disease was the invariable outcome. Radiation pneumonitis and fibrosis were severe and compatible with results of total loss of lung function on the irradiated side. We conclude that data relating to therapeutic responses and treatment programs in malignant mesothelioma should be better correlated internationally, if the problems associated with the evaluation of treatment and the management of patients with mesothelioma are to be improved.

Natural alpha-interferon in combination with hyperfractionated radiotherapy in the treatment of non-small cell lung cancer

Our previous study in patients with small-cell lung cancer indicated that natural alpha interferon might be a radiosensitiser. In this study we considered 20 patients with inoperable non-small cell lung cancer, who were randomly assigned to receive either hyperfractionation radiotherapy alone, 1.25 Gy twice a day (6 hr interval), 60 Gy/48F/32d; or the same radiotherapy concurrently with alpha interferon. Patients in the radiotherapy+alpha interferon arm received 3 x 10(6) IU natural alpha interferon intramuscularly and 1.5 x 10(6) IU inhaled via a dosimeter-equipped jet nebulizer 30 min before each radiotherapy session. Tumor response and radiation-induced lung injury were assessed by serial chest radiographs, computerized tomography scans and lung function studies, during a 1 year follow-up period. No patient in either arm achieved complete response. On the other hand, five patients in the radiotherapy arm and six in the radiotherapy+interferon arm experienced partial response, and the corresponding figures for stable disease were three and one. Combined treatment with radiotherapy and inhaled and intramuscular interferon proved feasible but laborious, for both patients and staff. Pneumonitis and/or oesophagitis in the radiotherapy+interferon arm were moderate to severe, and only two patients tolerated the treatment without any modifications. No treatment modifications were necessary in the radiotherapy arm. The early deaths in the radiotherapy+interferon arm may have been treatment-related. The optimal way to combine interferon and radiotherapy to further evaluate its role as a radiosensitiser needs further studies in larger series.

Natural interferon alfa as maintenance therapy for small cell lung cancer

We performed a 3-armed phase III study between 1982 and 1990 to evaluate low dose natural interferon alfa (nIFN-alpha) as a maintenance therapy in small cell lung cancer (SCLC) following induction chemotherapy (CT) and consolidation radiotherapy (RT). All patients received four cycles of CT (cyclophosphamide, vincristine, etoposide), followed by split-course RT (55 Gy in 20 fractions over 7 weeks). 410 patients entered the study. 237 patients who completed induction CT + RT and were classified as responders (complete response + partial response) were randomly assigned to arm 1: low dose nIFN-alpha (91 patients); arm 2: maintenance CT, six cycles of CAP (cyclophosphamide, doxorubicin, cisplatin) (59 patients); or arm 3: control arm (no maintenance treatment) (87 patients). Halfway through the study the CAP arm was discontinued. There was no difference in median survival between the groups (IFN: 11 months, CAP: 11 months, control: 10 months), but a clear difference in long-term survival and in survival in the limited disease group, favouring nIFN-alpha maintenance therapy. Proportional hazards regression analysis also showed a significant effect of IFN treatment on survival. Our results suggest a role for nIFN-alpha in maintaining a clinically disease-free status achieved with other treatment modalities.

Disease stabilization by leukocyte alpha interferon and survival of patients with metastatic melanoma

Thirty-one patients, 13 males and 18 females, with metastatic malignant melanoma were treated with human leukocyte interferon (IFN) alpha. The dose was 3 x 10(6) IU daily s.c. for 6 weeks followed by 6 x 10(6) IU/day 3 times a week. Only 1 patient (3%) achieved a partial response (PR) while 14 patients (45%) had disease stabilization for 2-8 months. Three patients experienced mixed responses, where some of the metastases responded, while the others were only stabilized. Interestingly, 1 patient showed regression of lung and disappearance of liver metastases after termination of IFN treatment. Two female patients are still alive without evidence of disease. After IFN they were treated with radiotherapy or surgery. The median survival for all the patients was 48 weeks. Our conclusion is that in IFN therapy long-term follow-up is indicated even in the absence of objective responses. In spite of poor response rate IFN may contribute beneficially to survival in a proportion of patients.

Postoperative radiotherapy of squamous cell carcinoma of the tonsil. Factors influencing survival and time to recurrence

From 1970 to 1988, 40 patients with squamous cell carcinoma of the tonsillar region were treated with surgery and postoperative split-course radiotherapy. The 5-year survival rate for all the patients was 52.5%; the corresponding figure was 100% in stage I, 75% in stage II, 63% in stage III and 15% in stage IV. The local control rate was 100% in stage I, 89% in stage II, 87% in stage III and 38% in stage IV. In the proportional hazards regression analysis T- and N-category and pretreatment Karnofsky index had the strongest association to survival, whereas T- and N-category and total radiation dose were most strongly associated to time to recurrence.

Radical surgery and postoperative split-course radiotherapy in squamous cell carcinoma of the mobile tongue: factors influencing local control and the time to recurrence

During 1981-1988 63 patients with squamous cell carcinoma of the oral tongue (27 females and 36 males) were treated with radical surgery and postoperative split-course radiotherapy. The 3-week rest period was compensated with a 10% increase in the total radiation dose to 66 Gy. The local control rate was 76% in stage I, 71% in stage II, 45% in stage III and 0% in stage IV. Failures were observed in 25 (40%) patients, and 8 patients died of intercurrent diseases. For further analysis the material was stratified in three groups according to the time interval between surgery and postoperative radiotherapy: less than 6 weeks, 6-8 weeks and greater than 8 weeks. The local control rate in the three strata were 75, 57 and 44%, and the 5-year actuarial survival 61, 46 and 30%, respectively. In the logistic regression analysis and the proportional hazard's regression analysis the histologic grade of the primary tumour and the time interval between surgery and the start of radiotherapy were the most important factors influencing respectively local control and time to recurrence. However, it appeared that the lengthening of the time interval was often caused by factors or events which directly can influence the prognosis, such as surgical complications, infections and poor general condition. When cases with such special causes for lengthening of the interval were excluded, the effect of the time interval nearly completely disappeared. It would seem that a final evaluation of the effect of the time interval requires a prospective randomized trial. The same may well hold true for reliable evaluation of the influence of overall treatment time.

Procollagen-III in serum, plasminogen activation and fibronectin in bronchoalveolar lavage fluid during and following irradiation of human lung

In the search for predictors of late radiation-induced lung injury we studied procollagen type III peptide concentration (P-III-P) in serum as well as fibronectin and plasminogen activation in bronchoalveolar lavage (BAL) fluid during and following irradiation of human lung. The patients received either high-dose hemithorax irradiation for pleural mesothelioma (11 patients) or high-dose irradiation with individually shaped fields for non-small cell lung cancer (12 patients). The severity of radiation fibrosis was assessed clinically from CT scans 6 months and 12 months after treatment. Four scores were used: severe, moderate, mild, or normal. Radiological lung injury varied from "severe" (9 patients) to near absence of injury-"normal" (6 patients). Serum levels of P-III-P, when measured weekly during the 5-week period of radiotherapy or at several time-points after treatment, did not show consistent changes, nor did the levels correlate with the score for radiation fibrosis as assessed by CT scanning. Changes in fibronectin levels or in markers of plasminogen activation in BAL fluid did not correlate with the development of late lung injury. The levels of BAL fluid plasmin and plasminogen activator as assessed zymographically, but not the free net enzyme values, showed a tendency to be elevated in patients with severe radiation-induced lung injury, suggesting a possible role for inhibitors of the plasminogen activation cascade in the process of radiation-induced lung injury.

The effect of fractionated irradiation on cell kinetics

The effects of single and split-dose irradiation were compared by in vitro experiments on HeLa cells. Changes in rate of cell proliferation were detected by flow cytometry, simultaneously determining the DNA content and the bromodeoxyuridine incorporation of individual cells. Cell cultures were irradiated with either a single dose of 1-6 Gy or with a corresponding dose divided into multiple fractions given at 1-6-h intervals. A dose-dependent accumulation of cells in G2/M phase was observed. The method was sensitive enough for the detection of G2/M block even after 1 Gy. The block disappeared completely within a 24-h follow-up time at dose levels up to 3 Gy. Interestingly, no differences in cell kinetics were observed between the single and split-dose regiments. This approach proves to be valuable in evaluating novel fractionation models and the effects of radiation on the cell kinetics of human tumor cells.

Radiographic chest assessment of lung injury following hemithorax irradiation for pleural mesothelioma

To characterize the nature, extent and time-course of radiation-induced lung injury, and to evaluate the usefulness of serial chest radiographs in this assessment, we studied 253 chest radiographs of 46 patients with pleural mesothelioma given hemithorax irradiation according to one of four different regimens: I 20 Gy; II 55 Gy; III hyperfractionation 70 Gy; IV hyperfractionation 35 Gy followed by local hypofractionation 36 Gy. Lung injury on the chest radiograph was graded from 0 (none) to V (maximal) based on the degree of loss of aerated lung tissue. Grade I changes were present 1-2 mths after radiotherapy in regimens II-IV. Grade V injury had developed in all but 3 out of 4 patients of the 20 Gy group by 6-12 months after irradiation. The extent and time-course of radiation-induced lung injury could be defined by serial chest radiographs alone. However, the documentation of tumour status and/or infections needed additional imaging or laboratory investigation, especially when grade IV-V lung injury was present. For research protocols evaluating radiation-induced lung injury serial chest X-rays are recommended at the following time-points: before treatment and 2, 6 and 12 mths after treatment, with additional computerized tomographic (CT) scans as required for differential diagnosis.

Radiographic chest assessment of lung injury following hemithorax irradiation for pleural mesothelioma

To characterize the nature, extent and time-course of radiation-induced lung injury, and to evaluate the usefulness of serial chest radiographs in this assessment, we studied 253 chest radiographs of 46 patients with pleural mesothelioma given hemithorax irradiation according to one of four different regimens: I 20 Gy; II 55 Gy; III hyperfractionation 70 Gy; IV hyperfractionation 35 Gy followed by local hypofractionation 36 Gy. Lung injury on the chest radiograph was graded from 0 (none) to V (maximal) based on the degree of loss of aerated lung tissue. Grade I changes were present 1-2 mths after radiotherapy in regimens II-IV. Grade V injury had developed in all but 3 out of 4 patients of the 20 Gy group by 6-12 months after irradiation. The extent and time-course of radiation-induced lung injury could be defined by serial chest radiographs alone. However, the documentation of tumour status and/or infections needed additional imaging or laboratory investigation, especially when grade IV-V lung injury was present. For research protocols evaluating radiation-induced lung injury serial chest X-rays are recommended at the following time-points: before treatment and 2, 6 and 12 mths after treatment, with additional computerized tomographic (CT) scans as required for differential diagnosis.

Diploid predominance and prognostic significance of S-phase cells in malignant mesothelioma

70 histologically verified, malignant mesotheliomas were analysed by flow cytometry for DNA content and S-phase fraction (SPF) of tumour cells. 60% (42/70) were DNA diploid. 18 of the 28 aneuploid tumours were near-diploid with DNA indices of 1.3 or less. SPF could be calculated in 51 cases. SPF was significantly higher in aneuploid (median 16.0%) than in diploid tumours (median 5.6%). DNA ploidy was not a prognostic determinant; survival was the same for both aneuploid and diploid tumours. SPF, however, was significantly correlated (P = 0.039) with prognosis. Patients who had tumours with a low SPF survived almost twice as long as those with a high SPF. Thus malignant mesothelioma has a peculiar DNA ploidy pattern compared with many other solid tumours, with a predominance of diploid or near-diploid type cells. As in many other tumours, SPF may be used as a clinically relevant prognostic indicator.

Treatment of advanced breast cancer with 20 mg toremifene, a phase II study. Preliminary communication

Fourteen postmenopausal women with estrogen-receptor positive advanced breast cancer and no prior cytostatic treatment received 20 mg toremifene daily as a single dose after a loading dose (120----60----60 mg) for the first 3 days. All were evaluable and had undergone at least 6 weeks' treatment. Results were: no complete remissions (CR), 3 partial remissions (PR), 8 no change (NC) and 3 cases of progressive disease (PD). Three patients had mild side effects: nausea, insomnia, sweating and arm pain.

Safety and efficacy of toremifene in breast cancer patients. A phase II study

46 postmenopausal women with estrogen receptor positive breast cancer entered a phase II study with a novel antiestrogen, toremifene. Patients had either recurrent or primarily inoperable advanced disease. No prior or concurrent cytostatic or hormonal treatment was allowed. Eight patients (17%) achieved complete response (CR), 17 (37%) partial response (PR) and 13 (28%) had stabilization of their disease at least for three months. The mean durations of responses were 52 +, 53 + and 27 + weeks, respectively, with 5 patients in CR, 6 in PR and 1 with no change (NC) still continuing the treatment. No significant differences could be seen in response rates according to the concentration of estrogen receptors or presence of progesteron receptors in this group of patients. Toxicity was not a problem, in general, the treatment was well tolerated. Two side effects (sweating and vertigo) were classified as severe and one patient after achieving PR interrupted the treatment because of tremor.

Natural interferon-alpha alone and in combination with conventional therapies in non-small cell lung cancer. A pilot study

Fourteen previously untreated patients with non-small cell lung cancer (NSCLC) were treated with natural interferon-alpha (IFN) in combination with conventional therapies. The planned dose of IFN was 6 x 10(6) IU/d.i.m. 5 days a week for 12 weeks. After 12 weeks of IFN monotherapy patients with M0 disease underwent twice-daily fractionated radiotherapy (RT), 55 Gy/4F/30 d, while IFN continued. Patients with M1 disease received 3 cycles of chemotherapy (CT) concomittantly with IFN. CT consisted of cisplatinum (P) 90 mg/m2 i.v. on days 1, 28, and 56 and of vindesine (VDS) 3 mg/m2 i.v. once a week 5 times and every other week thereafter for up to 8 courses. Thirteen patients were evaluable for response and toxicity. There were 9 patients with epidermoid, 3 with adeno- and one with large cell carcinoma. In 12 of 13 patients, the disease remained stable for 1 month during IFN monotherapy and one acheived a minimal response, which lasted 4 weeks. Of seven patients who completed the 12-week course of IFN monotherapy, 4 achieved stable disease (SD) and 3 had progressive disease. Three patients received RT and one received CT in combination with IFN as their subsequent treatment. There were 3 partial responses (2/3 after RT + IFN, 1/1 after CT + IFN), and 1 SD. Fatigue and weight loss were the most severe side-effects during IFN monotherapy. The combination of IFNs with conventional therapies might be clinically useful. We recommend further testing in larger studies.

A comparison of cis-platinum-vindesine and cis-platinum-etoposide combined with radiotherapy for previously untreated localized inoperable non-small cell lung cancer

Seventy-two previously untreated patients with localized inoperable non-small cell lung cancer were randomized to a study comparing the efficacy of cis-platinum-vindesine (P-VDS) and of cis-platinum-VP16 (P-VP16), both combined with split-course radiotherapy. Fifty-nine patients were evaluable for response after the minimum requirement of two chemotherapy cycles. Both arms were further randomized to two split intervals, 3 or 5 weeks. The response rate to chemotherapy only (three cycles) was 66% for P-VDS and 50% for P-VP16. Radiotherapy increased the response rates to 83 and 67%, respectively. A Karnofsky score of 80% or more and the 3-week split interval were significant positive prognostic factors. Of all patients, 66% had local or combined recurrences and 17% relapsed at a distant site only. Since the 2-year survival rates are not strikingly better than those obtained by radiotherapy alone, we feel that these regimens should be restricted to further investigations of the role of chemotherapy in the treatment of different clinical presentations of NSCLC.

Trimetrexate and cyclophosphamide for metastatic inoperable nonsmall cell lung cancer

To determine the maximum tolerated dose (MTD) of trimetrexate glucuronate in combination with cyclophosphamide in patients with metastatic or inoperable nonsmall cell lung cancer (NSCLC), trimetrexate in dosages ranging from 3 to 13.5 mg/m2/day was administered intravenously (IV) to 27 patients for 5 days in combination with cyclophosphamide, 600 mg/m2, on day 1. Patients received between one and six courses of treatment at 3 week intervals, 69 treatment courses in all. Hematological toxicity was mainly mild anemia (81%), leukopenia (67%), and thrombocytopenia (52%). Nonhematological toxicity included nausea and vomiting (67%), mucositis (30%), and urticaria or rash (22%). The incidences of leukopenia and mucositis were dose related. The MTD of trimetrexate in combination with cyclophosphamide was 7.5 mg/m2/day. The dosage chosen for the Phase 2 study, based only on the hematological dose limiting toxicity, was 10.5 mg/m2/day. Of 31 patients with previously untreated metastatic or inoperable NSCLC who have entered in the Phase 2 study, 22 are evaluable for clinical efficacy (World Health Organization criteria, 1979). Treatment was discontinued in four patients because of toxicity. One patient refused further therapy. Four patients are too early to evaluate. Five patients had confirmed partial responses (23%), 12 patients achieved stable disease (54%), and five patients had progressive disease. Results suggest that trimetrexate 10.5 mg/m2/day in combination with cyclophosphamide is active against previously untreated NSCLC. Dose limiting toxicity was mucositis and myelosuppression. An 11 item linear analogue scale assessing quality of life during treatment indicated this combination was well accepted by patients and did not compromise quality of life. The Phase 2 study is continuing.

Inoperable non-small cell lung cancer: radiation with or without chemotherapy

We report a randomized multicentre study of split-course radiotherapy (RT), with or without combination chemotherapy (CT), in 238 patients with inoperable non-small cell lung cancer (NSCLC), previously untreated, confined to one hemithorax and the mediastinal nodes. In both treatment groups RT consisted of 55 Gy in 20 F given over 7 weeks with a 3-week rest interval. CT consisted of the 3-drug regimen CAP: C = cyclophosphamide 400 mg/m2, A = adriamycin 40 mg/m2, P = cisplatin 40 mg/m2; 2 cycles of CAP given before RT, one during the rest interval and six after RT. Seventy per cent in the RT arm and 67% in the RT-CT arm had epidermoid carcinoma. No significant difference was apparent between the RT and the RT-CT arms with respect to objective response rates (CR + PR) (44 and 49%, respectively), median duration of response (278 and 320 days), local failure (31 and 20%), distant progression (23 and 20%) or median survival (311 and 322 days). The survival figures showed an almost significant (P = 0.05) therapeutic advantage of the combined regimen with stage IIIM0 disease. Progressive disease was the cause of death in 92% and 88%. We conclude that chemotherapy did not contribute significantly to either local control or survival as compared to radiotherapy alone.

Split-course versus continuous radiotherapy. Analysis of a randomized trial from 1964 to 1967

A randomized clinical trial was performed from 1964 to 1967 to compare the therapeutic results of split-course external beam radiotherapy with those of continuously fractionated treatment. Altogether 439 consecutive patients with carcinoma of larynx, nasopharynx, hypopharynx, oropharynx, oral cavity, oesophagus and urinary bladder were included in the series. 227 patients received split-course treatment and 212 were treated by the continuous-course method. In the split-course treatment there was a 2-3 weeks' interruption after 25-30 Gy. This break was compensated by a 10% increase in the total dose. For each tumour site local control and failure rates for the 2 treatment techniques were similar. No significant differences in 5- and 10-year survival were noted. Acute side effects were milder in all patients treated with split-course. The occurrence of late reactions was similar in both treatment groups. However, severe late reactions in the urinary bladder were somewhat more frequent in patients treated with split-course technique; the difference was not statistically significant. We conclude that there were no significant differences in local control, long-term survival and late normal tissue reactions between the treatment groups. The acute normal tissue reactions were milder in the split-course treated groups. We still regard split-course as a useful treatment modality provided the interruption is compensated with about 10% increase in total dose. However, more studies are needed to show which tumours proliferate during prolonged radiotherapy.

Vincristine-cyclophosphamide, the classical two-drug regimen for small-cell lung cancer, evaluated in a randomized study with vindesine

We performed a randomized study from February 1979 to August 1981 in patients with small-cell lung cancer (SCLC) with the aim of defining the potential advantages of replacing vincristine (VCR) with vindesine (VDS), at that time a new semisynthetic vinca alcaloid, in the classical two-drug combination cyclophosphamide (CTX)-VCR. A total of 116 previously untreated patients were admitted to the study. Of 104 patients evaluable for response, 49 had limited disease and 55 extensive disease. Patients received 10 mg/kg CTX i.v. on days 1-4 and either 1 mg VCR i.v. or 2 mg/m2 VDS i.v. on days 1 and 4, and repeatedly every 4 weeks for 12 courses. In addition, the patients with limited disease received split-course radiotherapy (30 Gy/10 F, 3 or 5 weeks rest, 25 Gy/10 F, total treatment time 7 or 9 weeks) to the primary tumor, the mediastinum, and the supraclavicular areas between the second and third cycles of chemotherapy. The response rate to the first two chemotherapy cycles was 47% (4 complete response [CR] and 22 partial response [PR]) to CTX-VCR and 47% (4 CR and 19 PR) to CTX-VDS. Subsequent to radiotherapy the response rate increased to 93% for CTX-VCR and 100% to CTX-VDS, respectively, in the patients with limited disease. Local recurrence and/or progression occurred in 49% of limited disease responders and in 96% of extensive disease responders. In responders with limited disease, the first site of relapse was loco-regional in 25% for the VDS group as opposed to 15% in VCR group. In the patients with extensive disease, the corresponding figures were 62% for the VDS and 50% for the VCR group. Median duration of remission in all patients treated with CTX-VCR was 132 days compared to 203 days in the CTX-VDS group (not significant, NS). Median survival was 338 days for CTX-VCR vs. 342 for CTX-VDS in patients with limited disease, and 214 days for CTX-VCR vs. 312 days for CTX-VDS in extensive disease (NS). One-year survival figures were 47% for CTX-VDS and 35% for CTX-VCR patients. Two-year survivals were 4 and 9%, respectively. Neurotoxicity was the main toxic manifestation in both treatment groups. Severe peripheral neuropathy (grade 4, World Health Organization [WHO]) did not occur with either drug regimen. Treatment was discontinued because of grade 2-3 neuropathy in one patient after 6 cycles of CTX-VCR and in five patients after 1-6 cycles of CTX-VDS.(ABSTRACT TRUNCATED AT 400 WORDS)

Enhancement of radiation effects by alpha interferon in the treatment of small cell carcinoma of the lung

The effects on lung tissue and tumor of natural human alpha interferon (IFN) and radiotherapy were investigated in a multimodality treatment program for selected patients with small cell carcinoma of the lung (SCLC). Interferon was given first as a single agent, then concomitantly with radiotherapy to 12 previously untreated patients with limited disease. At disease progression outside the chest, interferon was discontinued and combination chemotherapy was initiated. In the first series, 7 patients received a high interferon induction dose (800 X 10(6) IU i.v. over 5 days) followed by low-dose maintenance therapy (6 X 10(6) IU i.m. TIW), median total dose 1380 X 10(6) IU (range 794-2074). At local progression, split-course radiotherapy, 55 Gy/20 F/7 wk, was added to interferon therapy. In the second series, 5 patients received low-dose interferon from the start (6 X 10(6) IU i.m. daily) combined with twice-a-day fractionated radiotherapy 44 Gy/40 F/4 wk. Median total dose of interferon in this series was 698 X 10(6) IU (range 354-828). Tumor response and normal tissue reactions were evaluated by monthly chest X rays, 3-monthly CT scans, restaging bronchoscopies and by serial respiratory function tests. Autopsy specimens from both lungs within and outside the radiation field were systematically evaluated when available. After the completion of radiotherapy, there were 4/7 CR in the high-dose IFN group compared to 3/5 CR in the low-dose IFN group. Rapid shrinkage of huge tumor masses was observed. At 2 months post radiotherapy radiological grade III fibrosis occurred in 4/7 patients in the high-dose and 1/5 patients in the low-dose group. Lung function studies showed a significant decrease in diffusing capacity and in lung volumes. Seven patients died within 12 months from start of interferon treatment, one of them from treatment complication. At autopsy the tumor area was in most cases replaced by severe fibrosis. Outside the radiation field lung fibrosis was mild. Our results suggest enhancement of radiation effect by interferon with a possible dose and/or schedule dependence of interferon and radiotherapy and call for more clinical studies of IFN and radiotherapy in combination.

Radiation pneumonitis and fibrosis following split-course radiation therapy for lung cancer. A radiologic and physiologic study

Radiographic signs of radiation pneumonitis and fibrosis were assessed and pulmonary function monitored in lung cancer patients after two different split-course radiation therapy schedules, one with a rest interval of 3 weeks and the other with a rest interval of 5 weeks, the total radiation dose being the same in both treatments (55 Gy/20 fractions/7 or 9 weeks). Post-mortem findings were analysed when available. Spirometric measurement of vital capacity, determination of diffusing capacity for carbon monoxide (DL) and alveolar volume with the single breath technique, and determination of regional distribution of lung perfusion by two different techniques, radiospirometry and gamma camera digital display following intravenous injection of 133Xe, were carried out before and at various times after the completion of irradiation. Of the physiologic parameters, only DL showed a significant decrease 6 as well as 9 months post-treatment (p less than 0.05). No difference between the two treatment schedules could be shown with regard to grade or time pattern of radiologic changes or decrease in DL. The findings suggest that measurement of DL may be of value in monitoring patients included in research protocols for radiation therapy of lung cancer as well as in selection of patients for this treatment.

Human leukocyte interferon as part of a combined treatment for previously untreated small cell lung cancer

Human leukocyte interferon, HuIFN-alpha (LE), has been tested in combination with radiotherapy and chemotherapy for previously untreated small cell lung cancer. Nine patients with limited disease received high-dose IFN followed by a low-dose regimen; and six patients had a low-dose regimen from the beginning. The high dosage of IFN consisted of 800 X 10(6) IU given as a continuous intravenous infusion for 5 days, followed by 6 X 10(6) IU i.m. three times weekly. If the first site of disease progression was local or in a central nervous system location, radiotherapy (55 Gy/20 F/7 weeks locally and/or 30 Gy/10 F/2 weeks whole brain) was applied and IFN was continued. Chemotherapy was administered only if there was disease dissemination outside the chest. Three patients achieved minor response for as long as 20, 25, and 42 weeks, respectively, with IFN alone. Three of five complete responders to IFN-radiotherapy died 18, 33, and 41 weeks from the start of IFN treatment without chemotherapy. Autopsy did not reveal macroscopic or microscopic tumor at any site, but there was severe radiation pneumonitis. Four of nine patients were administered chemotherapy subsequent to IFN-radiotherapy because of disease dissemination. The median length of survival of the entire group was 41 weeks. On the low-dose regimen, one patient achieved partial response with IFN alone (duration, 12 weeks); of five evaluable patients three achieved complete remission and two partial remission to IFN-radiotherapy, and one of the three complete responders to IFN-radiotherapy died of severe radiation pneumonitis at 21 weeks from the start of IFN treatment. No tumor was detected at autopsy. The study is in progress. Average survival at present is 33 weeks. The results derived from both our studies suggest a growth-delaying effect of HuIFN-alpha (Le) on small cell lung cancer. They also suggest potentiation of radiation by HuIFN-alpha (Le). Memory and psychomotor dysfunction, fatigue, and anorexia were dose limiting with both short-duration, high-dose and long-duration, low-dose IFN therapy. We feel that IFN, as part of a combined multimodality treatment of small cell lung cancer, may play a role by delaying metastatic dissemination.

Hair transplantation in alopecia due to radiation

Two cases of alopecia due to radiation of the scalp are presented in which it has been possible to achieve a technically and cosmetically satisfactory reconstruction by punch hair grafting. This does not mean that every case is suitable, but it does mean that those without contraindications should at least be given a try.

Prognostic value of doubling time in lung cancer

The volume doubling time (DT) of 27 measurable primary pulmonary carcinomas was calculated. The prognostic value of the DT was analysed in relation to survival, age, initial size of the tumour, histology, duration of symptoms, and treatment. The survival was longest in slow-growing carcinomas. Small-cell carcinomas and other anaplastic carcinomas had the shortest DT. A close correlation was found between DT, survival, and Feinstein's symptom-staging.

Induction of aryl hydrocarbon hydroxylase activity and pulmonary carcinoma

Aryl hydrocarbon hydroxylase activity in lymphoblasts from normal Finnish adults and from patients with pulmonary carcinomas and other types of malignancy has been studied by a modification of previously used techniques. High absolute induced aryl hydrocarbon hydroxylase activity was found in 39% of patients with untreated lung cancer but only in 15% of normal people. No increased frequency was found in the control group comprising other malignancies. The diagnosis of pulmonary carcinoma was made at a lower mean age (4.9 years younger) in the individuals with high aryl hydrocarbon hydroxylase activity than in those with low activity. High absolute aryl hydrocarbon hydroxylase activity was dominantly inherited in normal individuals, and the frequency of athe Ahb gene in the Finnish population was 8%.

Unconventional fractionation in clinical radiotherapy

Radiotherapy with decreasing individual tumour doses has been used in treatment of lung metastases and carcinomas. Treatment given with this unconventional schedule is more effective than conventional radiotherapy based upon equal doses and equal intervals. Tumours could be classified into 2 groups according to the shrinkage rate. In the group shrinking more rapidly, tumours totally disappeared in most instances; furthermore in most instances, tumours in this more responsive group could be identified because in the week after the first fraction they had already started to shrink.

Clinical and histological malignancy of adenoid cystic carcinoma

The authors report on 25 cases of adenoid cystic carcinoma of the head and neck region. The tumours were divided into 4 histological malignancy groups. Treatment generally consisted of surgery performed with as large a margin as possible, in combination with split course million volt therapy, about 6,000 rads, usually given preoperatively. It was found that the patients in the groups of lower malignancy generally managed for a comparatively long time without a clinically demonstrable recurrence, while the patients in the groups of higher malignancy relapsed rather quickly and often had metastases. The patients in the groups of higher malignancy also died relatively soon after the histological tumour preparations.