10-year update on chemotherapy for non-small cell lung cancer

BACKGROUND

A 1995 meta analysis of chemotherapy in patients with advanced non-small cell carcinoma indicated clinical benefit from cisplatin based chemotherapy. Subsequent studies have aimed to increase the efficacy or decrease the toxicity of chemotherapy.

PATIENT AND METHODS

Illustrative studies and meta analyses of different aspects of chemotherapy which have taken place over the last decade, are reviewed.

RESULTS

The use of novel (third generation) chemotherapy agents has resulted in a further increase in patient survival. Gemcitabine was shown to be associated with an increase in progression free survival when compared to other third generation agents as well as a strong tendency to increased overall survival. An increase in survival was also shown with doublet chemotherapy regimes as compared to the use of single agents only. The use of triplet agent chemotherapy results in no further increased survival, but increased toxicity. Cisplatin is associated with increased survival over carboplatin based chemotherapy regimens when third generation agents are used, but increased nausea and vomiting. Non-platin third generation combinations give equivalent survival to platin-based regimens.

CONCLUSIONS

First line chemotherapy given to patients with advanced NSCLC should be two-drug combination regimen. Non-platin containing regimens may be used as an alternative to platinum based regimens in the first line.

Vinorelbine (NVB) oral (NVBo) in combination with carboplatin (CBDCA) followed by maintenance therapy with single agent vinorelbine oral in stage III/IV non-small cell lung cancer (NSCLC): Final results of a multicenter international phase II trial

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Background: NVB i.v. day 1 (25 mg/ m2) & NVBo day 8 (60 mg/ m2) and CBDCA AUC 5 have been previously studied in chemonaive NSCLC patients (pts) (O’Brien et al, Ann Oncol 2004; 15: 921). We investigated the efficacy and safety of NVBo weekly with CBDCA AUC 5 q3w for 4 cycles(Cy) followed by maintenance therapy with single agent NVBo in non progressive pts. Methods: Inoperable NSCLC stage IIIB, stage IV or delayed relapse of any stage becoming unresectable, KPS ≥ 80%, treated with combination therapy every 3 weeks for 4 Cy: NVBo 60 mg/m2 on days 1, 8 and 15 (Cy1), 80 mg/m2 (Cy2–4) in absence of neutropenia NCI CTC V2 G3/4; CBDCA AUC 5 day 1, administered over 1 hour. Maintenance therapy if pts did not have a PD: NVBo 60 mg/m2 for the first three weekly administrations, followed by NVBo at 80 mg/m2/week until PD. Results: from December 2003 to January 2005 57/56 pts have been registered/treated: median age 61 yrs (37–71); median KPS 90%; male 71.4%; Squamous cell 30%, Adenocarcinoma 50%; Stage III/IV 32.1/62.5% ; median dose intensity NVBo (% RDI) : combination, 50.1 mg/m2/w (67.3%), maintenance 56.2 mg/m2/w (70.2%); pts with NVBo dose escalation from 60 to 80 mg/m2 during combination : 36/52 (69.2%). Tolerance (% of pts with G3/4 NCI CTC V2) : Neutropenia 23.2/44.6; Platelets 16.1/1.8; Hb 19.6/3.6; Nausea 7.1/0; Vomiting 7.1/0; Diarrhea 5.4/0. No G3/4 toxicity was reported for Infection, Bilirubin, Creatinine, Stomatitis, and motor/sensory Neuropathy. Febrile Neutropenia was reported in 5 patients (8.9%). Efficacy: (RECIST) Percent Overall Response rates (n =56 pts) PR 17.9, SD 53.6, PD 23.2, NE 5.4; Progression-Free Survival 4.3 (95% CI [3.1–5.1]) months; Overall Survival 9.7 (95% CI [7.7–11.9]) months. Conclusions: NVBo on a weekly schedule and CBDCA AUC5 in combination therapy for 4 Cy followed by NVBo in maintenance therapy is an effective and safe treatment regimen for advanced NSCLC. The avoidance of further CBDCA administrations after 4 Cy and the use of NVBo as a maintenance therapy until PD has promise as an alternative to the 6 Cy option and calls for further comparative studies.

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Randomised phase III study of intravenous vinorelbine plus hormone therapy versus hormone therapy alone in hormone-refractory prostate cancer

BACKGROUND

Vinorelbine (VRL) has been shown to be active in hormone-refractory prostate cancer (HRPC) in phase II studies, alone or in combination. Its moderate toxicity profile is well tolerated in elderly patients.

PATIENTS AND METHODS

Patients with metastatic prostate cancer, progressive after primary hormonal therapy, were randomised to receive intravenous VRL 30 mg/m2 on days 1 and 8 every 3 weeks, and hydrocortisone 40 mg/day or hydrocortisone alone until disease progression. Centres could choose to add aminoglutethimide 1000 mg/day to hydrocortisone as second-line hormone therapy (HT) for all their patients. Randomisation was stratified by centre. Further chemotherapy was allowed after progression. The primary end point was progression-free survival (PFS). The final analysis was performed on a total of 414 patients. Reported results were all based on intention-to-treat analyses. All progressions and responses were reviewed by an independent panel.

RESULTS

PFS was significantly prolonged in the VRL plus HT arm compared with the HT alone arm, according to the statistical hypothesis of the protocol (P=0.055 in the two-sided log-rank test with a pre-specified significance level of 10%). The 6-month PFS rates were 33.2% versus 22.8%, and the median durations of PFS were 3.7 versus 2.8 months. In the multivariate Cox analysis, which included age, Karnofsky performance status (PS), haemoglobin, alkaline phosphatase at study entry and number of prior hormonal treatments, the P value was decreased to 0.005. The prostate-specific antigen (PSA) response rate (> or =50% decline sustained for at least 6 weeks) was significantly higher for VRL plus HT compared with HT (30.1% versus 19.2%; P=0.01). Clinical benefit, defined as a decrease in pain intensity or analgesic consumption or an improvement of Karnofsky PS for at least 9 weeks, and at least stable assessment in the other two, was also more frequently observed in patients who received VRL plus HT versus HT alone (30.6% and 19.2%; P=0.008). There was no statistical difference in overall survival. Forty-three per cent of patients in the HT arm received at least one line of further chemotherapy after progression, compared with 28% of patients in the VRL-based arm. Aminoglutethimide did not seem to result in better efficacy for either arm. VRL plus HT was well tolerated, with a median administered relative dose intensity of 90%; grade 4 neutropenia occurred in 6.5% of patients and non-haematological toxicity was rare.

CONCLUSIONS

The combination of VRL and hydrocortisone compared with hydrocortisone alone resulted in improved clinical benefit, PFS and PSA response rate. This therapeutic gain is similar to that previously reported with mitoxantrone in combination with low-dose corticosteroids. There was no gain in survival; however, the combination is well tolerated in this elderly group of patients, who often present cardiac co-morbidities, and therefore offers an active and safe therapeutic option for patients with hormone-refractory prostate cancer.

Docetaxel as neoadjuvant therapy for radically treatable stage III non-small-cell lung cancer: a multinational randomised phase III study

BACKGROUND

Docetaxel (Taxotere) is a potent anticancer agent, with proven efficacy as first-line therapy in non-small-cell lung cancer (NSCLC). The aim of this large randomised multicentre phase III study was to evaluate docetaxel in the neoadjuvant (pre-operative) setting.

PATIENTS AND METHODS

Patients with stage IIIA or locally treatable IIIB NSCLC were randomly assigned to receive neoadjuvant docetaxel (n = 134) or no chemotherapy (n = 140) before surgery/curative-intention radiotherapy. Patients received up to three 3-weekly cycles of docetaxel (100 mg/m(2)) as 1-h intravenous infusions.

RESULTS

Median survival was 14.8 months in the docetaxel group and 12.6 months in the control group. Median times to disease progression were 9.0 months (docetaxel arm) and 7.6 months (control arm). There were three complete responses and 25 partial responses in patients treated with docetaxel who were evaluable for response (n = 101). Docetaxel was well-tolerated: 103 patients (77%) received all three planned cycles. The major toxicity was grade 4 neutropenia (69 patients, 55%) and neutropenic fever (eight patients, 6%). Radiotherapy was well-tolerated after docetaxel administration.

CONCLUSIONS

Neoadjuvant docetaxel is generally well-tolerated and shows a promising trend towards longer survival in patients with NSCLC.

Malignant pleural mesothelioma: a phase II trial with docetaxel

Current cytotoxic therapy has been of limited benefit to patients with malignant pleural mesothelioma. Single agent chemotherapy has been extensively evaluated in small series of phase II clinical trials, with disappointing responses. Docetaxel, an effective taxane in the treatment of advanced breast cancer and non-small-cell lung cancer, was administered intravenously at a dose of 100 mg/m2 every 3 weeks to 30 chemotherapy naive patients with malignant pleural mesothelioma in a prospective multi-institutional phase II clinical trial. An objective response rate (partial responses) of 10% was documented. Additionally, 21% of the patients had minor responses (intention-to-treat analysis). Three patients died within 2 weeks post-first cycle of therapy, although only one patient's death was directly attributed to the investigational drug, whilst in the majority of the patients, manageable and treatable toxicities were encountered. In this phase II clinical trial, docetaxel proved to be mildly effective in the treatment of patients with malignant pleural mesothelioma.

Modeling tumor and treated lung volume influences in the irradiation of non-small-cell lung cancer patients

PURPOSE

The proposal of a hypothetical model in patients treated by irradiation for non-small-cell lung cancer show the dependence of local tumor control and patient cure rates on the volume of tumor and irradiated lung tissue.

RESULTS

The local tumor control rates from conventional doses of irradiation decreases and the metastases rate increases with the tumor volume. Dose escalation will increase the potential cure rates (product of the local control and the freedom from metastases rates). Any potential gain will, however, be modified by the effect of irradiation on normal lung. Studies indicate that this is dependent on the volume of lung irradiated above a threshold dose.

CONCLUSION

A clinically significant and measurable increase in cure rates from dose escalation may be seen in smaller tumors. This is unlikely to occur in larger tumors, although dose escalation to a restricted volume combined with effective systemic chemotherapy is one of the options that may be explored. The relevance of modeling and future studies of tumor and normal tissue volume effects, will increase from the widespread usage of the dose-volume histogram.

Radical cystectomy for invasive bladder cancer--a local experience

OBJECTIVES

The aim of this study of patients undergoing cystectomy for invasive transitional cell carcinoma of the bladder was to compare clinical and pathological staging and to review factors that predict survival.

PATIENTS

Sixty-three patients (73% male) underwent radical cystectomy between January 1988 and February 1994. The mean age was 61 years (range 33-77 years).

RESULTS

Of the patients 14% had clinical and 24% pathological stage T1 disease; figures for T2 disease were 24% and 6%, respectively, for T3 disease 46% and 45%, and for T4 disease 16% and 25%. For T1 and T4 disease the clinical stage predicted the pathological stage in over 80% of cases, and for patients with T3 disease the predictive value of clinical staging was 68%; in no patient with clinical stage T2 disease was this confirmed at cystectomy. The prevalence of tumour infiltration of the lymph glands on histological examination of the cystectomy specimen correlated more closely with pathological stage than with clinical stage. For clinical and pathological staging, respectively, the prevalences were 0% and 0%, for T1, 27% and 0% for T2, 20% and 29% for T3, and 40% and 38% for T4. The overall survival rate (life-table method) was 33% at a median follow-up of 42 months in the surviving patients. No patient with tumour infiltration of the lymph glands survived. Survival also correlated more closely with pathological than with histological stage. For clinical and pathological stage T1 disease the 5-year survival rates were 73% and 91%, respectively; for T2 the rates were 27% and 75%, for T3 32% and 31%, and for T4 28% and 29%. The operative mortality rate was 2% and the rate of recurrence of local disease 10%.

CONCLUSIONS

Survival after cystectomy correlates more closely with pathological than with clinical stage of disease. The accuracy of clinical staging in T2 disease is poor. Cystectomy is the standard against which other treatments for bladder cancer must be measured.

Combined cisplatin and gemcitabine for non-small cell lung cancer: influence of scheduling on toxicity and drug delivery

The scheduling of cytotoxic chemotherapy has important bearing on the toxicity and ability to deliver chemotherapy at or close to full dose. We report new data on the influence of different schedules of cisplatin and gemcitabine on toxicity and drug delivery in phase II studies of non-small cell lung cancer. Patients in six phase II studies had standard entry criteria for advanced non-small cell lung cancer. Whereas gemcitabine was given on days 1, 8, and 15 of a 28-day cycle in all these studies, the scheduling of cisplatin varied and was given either on day 1, day 2, day 15 (in two studies), or days 1, 8, and 15 (in two studies). The protocol dose per infusion for gemcitabine was 1,000 mg/m2 (five studies) and 1,500 mg/m2 (one study); for cisplatin, it was 100 mg/m2 when given once per cycle and 30 mg/m2 when given on days 1, 8, and 15. Similar dose reduction schedules were implemented in the event of grade 3 or higher drug toxicity for all studies except for the day 1 cisplatin study, in which the dose was omitted for grade 2 thrombocytopenia. Nonhematologic toxicity was very low. Hematologic toxicity was moderate, and in patients who developed grade 3 or 4 toxicity, there was no hemorrhage from thrombocytopenia and neutropenic sepsis was rare. The incidence of grade 3 or 4 thrombocytopenia with the day 1, day 2, day 15 (two studies combined), and days 1, 8, and 15 (two studies combined) cisplatin regimens was 50%, 52%, 26%, and 38%. The incidence of grade 3 or 4 neutropenia with these four regimens was 51%, 37%, 56%, and 49%, respectively. Although the hematologic toxicity might appear relatively similar, it represents the toxicity at the administered rather than the intended (protocol) dose, because drug delivery was reduced or omitted in the event of grade 3 or 4 toxicity. Differences between the schedules are revealed by analysis of the actual dosages delivered. The median dosage of gemcitabine per scheduled infusion was statistically higher with the day 15 cisplatin regimens (combined) compared with any of the other regimens treating at 1,000 mg/m2 (P < .003, z-score). The dose with the day 1, day 2, day 15, and days 1, 8, and 15 cisplatin regimens was 664, 829, 889, and 774 mg/m2, respectively. Both the percentages of cycles in which gemcitabine infusions were given at full dose and in which there were no omissions of gemcitabine infusions (including infusions with dose reductions) were statistically higher in the day 15 cisplatin regimen than with any of the other regimens (P < .0001, chi-square test). The percentage of cycles containing full-dose gemcitabine with the day 1, day 2, day 15, and days 1, 8, and 15 cisplatin regimens was 24%, 44%, 75%, and 46%, respectively. The percentage of cycles in which there were no omissions of gemcitabine infusions for the four regimens above was 32%, 55%, 83%, and 72%, respectively. Apart from the once-weekly regimen (days 1, 8, and 15) in which the protocol gemcitabine dose was 1,250 mg/m2, the day 15 cisplatin schedule allowed for the highest median concentration of gemcitabine. More importantly, the day 15 cisplatin schedule provided the longest duration of gemcitabine exposure, which is particularly important for its activity as gemcitabine is a phase-specific agent. The day 15 cisplatin schedule is associated with the best dose intensity and the longest median duration of exposure to gemcitabine, and best meets the goal of administering both agents at full doses in combination.

Primary chemotherapy for stage 2 testis cancer

To evaluate the efficacy and toxicity of primary chemotherapy in patients with stage 2 (retroperitoneal lymph node metastases) testis cancer, 20 consecutive patients referred to Groote Schuur Hospital between September 1992 and March 1994 were reviewed. There were 10 patients with non-bulky non-seminomatous germ cell tumour (NSGCT), 5 with bulky NSGCT and 5 with bulky seminoma. The treatment regimen consisted initially of 4 cycles of cisplatin, etoposide and bleomycin. Patients with NSGCT and a residual mass after chemotherapy subsequently underwent retroperitoneal lymph node dissection (RPLND) and those with seminoma underwent a low dose of irradiation to the mass. In 7 (70%) of the 10 patients with non-bulky NSGCT, there was a complete response to chemotherapy and 3 patients underwent limited RPLND. One patient relapsed at follow-up but remains clear of disease after salvage therapy. The survival rate is 100% at a median follow-up of 60 months (range 12-143 months). In 5 patients with bulky NSGCT there was no complete response to chemotherapy. Three have undergone limited RPLND. The survival rate is 52% at a median follow-up of 130 months (range 108-152 months). In 5 patients with bulky seminomas, the survival rate is 100% at a median follow-up of 55 months (range 29-92 months). Toxicity has been modest except for 1 patient who died postoperatively in the early part of the study. Four patients have fathered children after treatment. We conclude that primary chemotherapy is the treatment of choice for patients with stage 2 testis cancer.

Weekly gemcitabine and monthly cisplatin for advanced non-small cell lung carcinoma

Most chemotherapy for non-small cell lung cancer (NSCLC) currently includes combination chemotherapy based on cisplatin. Gemcitabine is a nucleoside analog with demonstrated activity against NSCLC, yet it has low toxicity. This phase II study was designed to examine the efficacy of a combination chemotherapy regimen consisting of gemcitabine followed by cisplatin. The patient population comprised 53 patients with pathologically confirmed locally advanced or metastatic NSCLC. Gemcitabine 1,000 mg/m2 was administered on days 1, 8, and 15 and cisplatin 100 mg/m2 was given on day 15. Chemotherapy was administered every 28 days. Of the 50 patients evaluable for response, there were two complete responses (4%) and 24 partial responses (48%). The median duration of response was 8.5 months, median survival was 13 months, and the 1-year survival rate was 61%. The regimen was generally well tolerated. World Health Organization grade 3 leukopenia occurred in 28.8% of patients, while grade 3 and 4 neutropenia occurred in 38.8% and 19.2% of patients, respectively. Grade 3 and 4 thrombocytopenia was seen in 13.3% and 7.7% of patients, and grade 3 and 4 anemia occurred in 11.5% and 1.9% of patients, respectively. Alopecia and oral toxicity was mild, although most patients experienced mild nausea and vomiting. Relatively few patients required dose modifications for any of the three weekly doses of chemotherapy. We conclude that the combination of gemcitabine and cisplatin is an effective regimen for NSCLC, resulting in high response and survival rates. Additional prospective randomized studies with other cisplatin-based combination chemotherapy regimens are warranted.

Gemcitabine in the treatment of elderly patients with advanced non-small cell lung cancer

Gemcitabine is active against non-small cell lung cancer (NSCLC), with single-agent response rates of 20% or more in previously untreated patients. Its mild toxicity profile suggests that it should be well tolerated by older patients. To assess the impact of age on the efficacy and tolerance of gemcitabine, the results of four phase II trials of single-agent gemcitabine for the treatment of NSCLC were analyzed retrospectively. Starting doses for gemcitabine ranged from 800 to 1,250 mg/m2/wk, and in all studies gemcitabine was administered weekly for 3 weeks followed by a 1-week rest period. Response rates, toxicity, and dose delivery were compared for two age groups, less than 65 years (255 patients) or > or = 65 years (105 patients). The pretreatment characteristics for both patient groups were well balanced. Overall response rates were 16% and 24% for the younger and older patients, respectively (P = .072). Median survival and 1-year survival rates were 8.1 months and 27% and 9.1 months and 36%, respectively, for patients aged less than 65 years and > or = 65 years. Hematologic and nonhematologic toxicities were similar for both age groups. The number of cycles associated with dose reductions or dose omissions and the mean number of treatment cycles administered were also similar. In summary, gemcitabine is active and well tolerated in elderly patients with NSCLC, and is a promising new alternative for the treatment of this patient population.

Weekly gemcitabine with monthly cisplatin: effective chemotherapy for advanced non-small-cell lung cancer

PURPOSE

The aim of this study was to examine the efficacy of a regimen of initial gemcitabine followed by cisplatin in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Fifty-three patients (36 men and 17 women; age range, 35 to 74 years) were enrolled. Patients had bidimensionally measurable disease. Gemcitabine (phase-specific agent) was administered on days 1, 8, and 15 at a dose of 1,000 mg/m2. Cisplatin (cycle-specific agent) was administered on day 15 (100 mg/m2). Chemotherapy was administered in 28-day cycles.

RESULTS

Of 53 patients enrolled, 50 were assessable for response. The overall response rate was 52%. There were two complete responses (4%) and 24 partial responses (48%). The median survival duration was 13 months and the 1-year survival rate was 61%. The regimen was generally well tolerated. World Health Organization (WHO) grade 3 and 4 neutropenia occurred in 38.8% and 19.2% of patients, respectively. Grade 3 and 4 thrombocytopenia occurred in 13.3% and 7.7% of patients, respectively. Most patients experienced mild nausea and vomiting. Few patients had hair loss and oral toxicity was mild. Relatively few patients required dose modifications for any of the three weekly doses of chemotherapy. For the first two cycles of chemotherapy, the dose-intensity per infusion was 947 mg/m2 for gemcitabine and 85 mg/m2 for cisplatin.

CONCLUSION

This regimen of gemcitabine and cisplatin was effective, with high response and survival rates and few dosage modifications during its administration. Prospective randomized studies with other cisplatin-based combination chemotherapy regimens are indicated.

Current chemotherapy of advanced non-small cell lung cancer

Systemic chemotherapy for patients with a good performance status and advanced non-small cell lung cancer may result in prolonged survival and improved quality of life. However, few single agents have an activity of more than 15% and they have significant toxicity. Cisplatin is widely regarded as the single agent of choice. Compared with single-agent therapy, two-drug combinations generally provide higher response rates although survival benefit is marginal. Three-drug combinations generally provide no additional efficacy benefit and are associated with greater toxicity. A cisplatin-based combination with one other agent provides the best currently available therapeutic index. Chemotherapy may also improve the patient's quality of life. The toxicity of current chemotherapy is an important factor and there is a clear need for new cytotoxic agents with equivalent or greater activity yet a more acceptable toxicity profile.

Bioavailability and pharmacokinetic characteristics of dexniguldipine-HCl, a new anticancer drug

Dexniguldipine-HCl is a new dihydropyridine derivative with antineoplastic activity and potency for overcoming multidrug resistance. In this pharmacokinetic study the bioavailability of 3 doses of an oral formulation of dexniguldipine was to be determined. Fourteen patients with malignant disease not eligible for higher priority treatment and sufficient general condition were included. In 12 patients all pharmacokinetic investigations were available for evaluation. A single 4-h infusion of 2 mg per kg body weight of dexniguldipine was given as reference. Thereafter 3 increasing oral dosages (750, 1,500, 2,250 mg/d) were given on a 3-time daily basis for 3 consecutive weeks. On day 7 (under steady state conditions) of each period, a pharmacokinetic profile was done. Absolute bioavailability at the 3-dose levels was 3, 4, and 5%, respectively, thus slightly increasing with dose, but generally low. After intravenous administration terminal half life was 22.4 h, clearance 36.9 l/h and volume of distribution 1,193 1. Toxicity was tolerable with main adverse events being loss of appetite, nausea, and vomiting. Cardiovascular effects and a decrease in serum calcium were reported in several patients. Patients were allowed to continue treatment if a benefit was expected, and 2 patients showed tumor regression during treatment. One patient with renal cell carcinoma achieved a partial remission. Bioavailability of this oral formulation seems too low for routine clinical use, despite the fact that clinical effects have been observed.

Palliative radiation for stage 3 non-small cell lung cancer--a prospective study of two moderately high dose regimens

Eighty four patients from Groote Schuur Hospital and Frere Hospital East London were entered into a prospective randomised trial between January 1990 and December 1993. All the patients possessed non-small cell carcinoma (NSCLC) of the lung too extensive for radical irradiation and World Health Organization performance status 0-2. The patients were randomised to receive either 35 Gy in 10 fractions (43 patients) or 45 Gy in 15 fractions (41 patients). In the patients treated to 35 Gy and 45 Gy, the median survival was 8.5 months in both groups, the symptomatic response rate was 68% and 76% and the incidence of moderate to severe radiation oesophagitis was 23% and 41% respectively. The latter approached statistical significance (P = 0.07, chi square). There was no evidence of a dose response effect on survival in the moderate dose range in patients treated palliatively for locally advanced NSCLC.

A prospective randomised study in limited disease small cell carcinoma--doxorubicin and vincristine plus either cyclophosphamide or etoposide

A prospective randomised study was undertaken in patients with limited disease small cell carcinoma of the lung (SCCL), which compared doxorubicin, 50 mg/m2, and vincristine, 2 mg i.v. (intravenously) on day 1, with either cyclophosphamide, 800 mg/m2 on day 1 (CAV) or etoposide, 60 mg/m2 i.v. on day 1 and 120 mg/m2 orally on days 2-5 (AVE). Responding patients were to receive six cycles of chemotherapy at 3 weekly intervals followed after 2 weeks by mediastinal irradiation. Response rates and toxicity were evaluated by the chi square or Fisher's exact test and survival by the logrank test. 81 patients were entered into the study, 38 of whom received CAV and 43 received AVE. In the patients treated with CAV and AVE, the overall response rate was 61% (confidence limit (CL), 45-71%) and 74% (CL, 61-87%) respectively, the complete response rate was 32% (CL, 17-47%) and 51% (CL, 36-66%), respectively (P = 0.07) and the median survival was 12 and 14.5 months, respectively (P = 0.15). In the patients treated with CAV and AVE, the incidence of grade 3 and 4 leucopenia was 29% (CL, 15-43%) and 9% (CL, 0-18%), respectively (P = 0.025). No patient developed doxorubicin cardiomyopathy. These findings support the role of etoposide in first line chemotherapy for SCCL. AVE is among the more efficacious regimens for SCCL and also has a relatively low toxicity.

Synchronous contralateral adrenal metastasis from renal cell carcinoma: a 7 year survival following resection

Solitary contralateral adrenal metastasis from a renal cell carcinoma is distinctly unusual but aggressive surgical resection alone can produce long-term survival.

The effect of irradiation on lung function and perfusion in patients with lung cancer

PURPOSE

To prospectively study the changes in lung function in patients with lung carcinoma treated with relatively high doses of irradiation.

METHODS AND MATERIALS

Lung function was assessed prior to and at 6 and 12 months following radiation therapy by a clinical dyspnea score, formal pulmonary function tests (lung volume spirometry and diffusion capacity) as well as an ipsilateral hemithorax lung perfusion scan. Changes in dyspnea score were evaluated by the chi-square and the Fishers exact test. Changes in formal lung function tests were compared with the t-test for dependent data and correlations with the t-test for independent data. Fifty-one patients were entered into the study. There were 42 evaluable patients at 6 months after irradiation and 22 evaluable patients at 12 months after irradiation.

RESULTS

A worsening of dyspnea score from 1 to 2, which is clinically acceptable, occurred in 50% or more of patients. However, a dyspnea score of 3, which is a serious complication, developed in only 5% of patients. The diffusion capacity (DLCO) decreased by 14% at 6 months and 12% at 12 months) (p < 0.0001). The forced vital capacity and total lung capacity decreased between 6% and 8% at 6 months and 12 months, which was statistically significant. The forced expiratory volume in 1 s decreased between 2 and 3% at 6 month and 12 months, which was not statistically significant. The ipsilateral hemithorax perfusion decreased by 17 and 20% at 6 and 12 months (p < 0.0001). There was no correlation between the initial hemithorax perfusion, or its decrease at follow up and the decrease in DLCO.

CONCLUSION

Lung irradiation results in some loss of lung function in patients with lung cancer with a projected survival of 6 months or more. The pretreatment DLCO assessment should be useful in predicting clinical tolerance to irradiation.

Neo-adjuvant chemotherapy and radical irradiation for locally advanced bladder cancer--a phase 2 study

Eighteen patients with T3 or T4 bladder cancer were treated with neo-adjuvant chemotherapy and radical irradiation. The tumour response was assessed after two cycles of chemotherapy and two further cycles of chemotherapy were given to patients with responding tumours. Each cycle of chemotherapy consisted of cisplatin (60 mg/m2) as well as methotrexate and vinblastine. After chemotherapy, a complete response (CR) was obtained in four (22%) patients and a partial response in eight (44%) of patients. After irradiation, a complete response was obtained in 12 (67%) patients. Four of the 12 patients who achieved a CR relapsed at a minimum follow-up of 3 years. The 3-year continuously disease-free survival rate (with preserved bladders) is 44%. (95% confidence interval = 21-65%.) Altogether, 11 patients are alive (including three who have undergone salvage cystectomy) for an overall 3-year survival rate which is 61%. This approach to therapy is feasible but the local control rate is unsatisfactory.

Adjuvant chemotherapy for stage I non-seminomatous testicular cancer

Developments in the treatment of stage I testicular non-seminomatous germ cell tumours have aimed primarily at reducing morbidity since the introduction of retroperitoneal lymph node dissection. Surveillance after orchidectomy, i.e. follow-up alone with chemotherapy only for relapsed disease, was found to be logistically and psychologically taxing for patients. Risk factors for relapse were, however, identified from analyses of tumour histology of the orchidectomy specimen. Between September 1988 and April 1992, 20 patients with clinical stage I testicular non-seminomatous germ cell tumours and a relatively high risk of relapse were entered into a prospective study of adjuvant chemotherapy. The chemotherapy regimen consisted of 2 cycles of cisplatin, etoposide and bleomycin. Each cycle of chemotherapy lasted 3 days. There have been no relapses at a median follow-up of 31 months (range 12-53 months). Acute and late toxicity have been modest. We have found adjuvant chemotherapy to be effective after orchidectomy in patients with stage I disease with adverse prognostic factors for relapse.

Efficacy and safety profile of gemcitabine in non-small-cell lung cancer: a phase II study

PURPOSE

The aim of this study was to evaluate the efficacy and toxicity of gemcitabine at higher doses than had been used previously in patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Eighty-four patients (65 men, 19 women; age range, 35 to 75 years; mean age, 59 years) with locally advanced or metastatic pathologically documented NSCLC were enrolled. Patients had bidimensionally measurable disease, as defined by computed tomographic (CT) scan or chest x-ray. A total of 28.6% had previously been surgically treated, while 9.5% had received radiotherapy. Fifty-three patients commenced at a dose of 1,000 mg/m2, and 31 at a dose of 1,250 mg/m2. Patients were to receive two dose escalations of 25%, provided that overall toxicity was no worse than World Health Organization (WHO) grade 1 or WHO grade 0 for platelets. Responding patients were reviewed and validated by a blinded oncology review board (ORB) of experts not involved with the study. Of the original 84 patients enrolled, 76 were assessable.

RESULTS

The overall response rate was 20% (95% confidence interval [CI], 11.6% to 30.8%). There were two complete responses (3%) and 13 partial responses (17%). Hematologic toxicity was negligible. WHO grade 3 WBC toxicity occurred in 0.9% of doses and WHO grade 4 in 0.1%. WHO grade 3 and 4 thrombocytopenia occurred in 0.1% and 0.1% of all doses, respectively. Nonhematologic toxicity was minor and easily controlled. Common side effects included peripheral edema, asthenia, and transient malaise.

CONCLUSION

The single-agent efficacy of gemcitabine is equivalent to other agents commonly used to treat NSCLC. Gemcitabine has an unusually mild side effect profile for such an active agent. The nausea and vomiting experienced with gemcitabine are mild and generally well controlled with standard antiemetics; 5-HT3 receptor antagonists are typically not required. The use of gemcitabine does not cause significant alopecia, and hematologic toxicity is modest and unlikely to require hospitalization. Gemcitabine may have a role as monotherapy in patients with inoperable NSCLC.

Changes in lung function and perfusion after irradiation in patients with lung cancer

The changes in lung function were prospectively studied for patients with lung carcinoma who were treated with relatively high doses of irradiation. Their dyspnoea score, lung volume spirometry, diffusion capacity and ipsilateral hemithorax perfusion were measured at presentation, again between 5 and 6 months after irradiation (Group 1, 36 evaluable patients), and once more between 11 and 12 months (Group 2, 16 evaluable patients). There was a worsening of the dyspnoea score from 1 to 2, in a large percentage of patients, but only 6% developed a dyspnoea score of 3. The largest change in lung function tests was a decrease in the diffusion capacity (DLCO) to 14% at 6 months and 12% at 12 months (statistically significant, P < 0.0001 paired t-test). The forced vital capacity (FVC) and the total lung capacity (TLC) showed a lesser decrease at 6 and 12 months, and the smallest decrease, which was not statistically significant, was in the forced expiratory volume in 1 s (FEV1). There was also a statistically significant decrease in the ipsilateral hemithorax lung perfusion of 16% at 6 months and 20% at 12 months. There was a weak correlation between the decrease in the DLCO and the FEV1 at follow-up. There was no statistically significant correlation between initial perfusion or decreased perfusion and the decrease in lung function. Lung irradiation should be regarded as an ablative form of therapy, analogous to surgery, in patients with a projected survival of 6 months or more. The DLCO is the most sensitive indicator of clinical damage and its pretreatment assessment should be useful in predicting clinical tolerance to irradiation.

Salvage cystectomy after radical irradiation for bladder cancer-prognostic factors and complications

We have studied 46 patients who underwent salvage cystectomy between March 1981 and June 1992 for persistent or recurrent carcinoma after radical irradiation for bladder carcinoma. The overall 5-year survival rate was 43%. There was a higher 5-year survival rate in patients with an incomplete response compared with those with a complete response to their prior irradiation (50 and 36%), in patients with grades 1 or 2 compared with grade 3 histology (75 and 28%), and in patients with T1 or T2 tumours compared with T3 tumours (59 and 32%). The median interval between commencing irradiation and performing cystectomy was 11 months. In the 25 patients with a prior complete response the median interval was 16 months; this was statistically significantly longer than in the 21 patients with an incomplete response (median interval 7 months). A worsening of tumour grade and category was found in some patients when comparing the findings at cystectomy with those prior to irradiation. This was consistently higher in patients with a prior complete response than in those with an incomplete response. There were 3 deaths and 12 non-fatal major complications due to the prior irradiation or surgery, with a mortality rate of 7% and an overall 5-year complications rate of 35%. Only one of the complications occurred in the 13 patients treated with conventional 2 Gy fractions alone (5 fractions/week). Their overall complication rate was statistically significantly lower than that of the others. Salvage cystectomy is indicated for selected patients with persistent or recurrent disease after radical irradiation for bladder cancer. The expectation of a survival rate similar to that found in patients treated with immediate cystectomy may not be justified.

Rising tumour marker during chemotherapy in a patient with an extra-gonadal germ cell tumour--prolonged survival after tumour excision

A 28-year-old white male presented with a palpable abdominal mass and a grossly elevated beta human chorionic gonadotrophin. He refused investigations to establish the pathology and was treated with cisplatin combination chemotherapy. After an initial fall in his marker, it rose while he was on chemotherapy. The tumour was resected which confirmed the presence of a retroperitoneal germ cell tumour (extra-gonadal). He received further adjuvant chemotherapy and is subsequently clear of disease after being off treatment for more than 5 years. Total resection is not usually considered possible in patients with persistent positive markers after induction chemotherapy. This case shows that surgery should be considered as the results of salvage chemotherapy are poor in these patients.

Activity of a short course of interferon alpha for metastatic renal cell carcinoma--a phase-2 study

Twelve patients with metastatic renal cell carcinoma were entered into a phase-2 study of an 8-week course of interferon (INF) therapy. INF was given subcutaneously at a dose of 3 mu, three times per week. The patients were WHO performance status 0-2. A complete response was obtained in two patients (17% response rate), which has been maintained at 23 and 45 months. One of these patients presented with cranial and lung metastases and received cranial irradiation and decradron concurrent with INF. The toxicity of INF has been low. The optimal duration of INF therapy warrants further evaluation.

Chemotherapy, radical irradiation plus salvage cystectomy for bladder cancer--severe late small bowel morbidity

A proportion of patients with invasive bladder cancer are treated with radical irradiation and salvage cystectomy. The use of neo-adjuvant chemotherapy is being widely investigated. Five patients with invasive bladder cancer at Groote Schuur Hospital have undergone salvage cystectomy after neo-adjuvant chemotherapy and radical irradiation. Two of these patients had severe small bowel morbidity while clear of carcinoma and this was fatal in one patient. In our historical series of 30 patients who had salvage cystectomy after radical irradiation alone, there was only one patient with similar small bowel morbidity. There may be an increase in small bowel morbidity from neo-adjuvant chemotherapy in patients who are treated to clinical tolerance by irradiation and who then require a cystectomy.

Testicular cancer and cryptorchidism

The records of 273 patients with germ cell tumours of the testis referred between 1970 and July 1991 were reviewed. There were 25 (9%) black, 40 (14%) mixed race and 214 (77%) white patients. Histology showed seminoma in 53% and non-seminomatous and germ cell tumours in 47% of patients. Maldescent of the testis (MDT) was found in 30 patients--an incidence of 11% overall. MDT was present in 8 of 25 (32%) black, 7 of 40 (18%) mixed race and 15 of 214 (7%) white patients with testicular cancer. The incidence of MDT was statistically significantly higher in both black and mixed race patients compared with white patients. None of the black patients had undergone orchiopexy but 71% of mixed race and 87% of white patients had done so. This resulted in a different pattern of presentation in black compared with mixed race and white patients with MDT and testicular cancer. The mean age was 40 years for black, 32 years for mixed race and 33 years for white patients. Black patients presented with abdominal or inguinal tumours rather than scrotal tumours and they had an increased tendency to present with seminomas.

Concurrent radiation and weekly cisplatin for non-small-cell lung cancer--a phase I/II study

A total of 20 patients with loco-regional non-small-cell lung carcinoma were entered into a study of irradiation (3.0 Gy x 15 doses to a total dose of 45 Gy given in 4 fractions per week on days 1, 2, 4 and 5 of each week) and cisplatin given at a dose of 40 mg/m2 on day 3 of each week for a total of three infusions. One patient who had stage 1 disease showed a complete response to therapy and is alive and clear of disease at 35 months. In 19 patients with stage 3 disease, the complete response rate was 16% and the partial response rate was 42%. The rate of 1-year survival was 42% and the rate of 2-year survival was 11%; the median survival of these patients was 11 months. Relapse occurred, mostly at metastatic sites, in 10 of the 11 patients who responded to therapy. Acute toxicity was modest and tolerable by our patients. No severe late toxicity was encountered, and none of the patients developed grade 3 dyspnoea (an inability to walk 100 yards because of breathlessness) while clear of recurrent disease. Changes in lung function observed at follow-up examinations were similar to those seen after irradiation alone. Weekly administration of cisplatin is therefore feasible in patients receiving a continuous course of irradiation. The high relapse rate observed in responding patients indicates the need for evaluation of the efficacy of combination chemotherapy in the adjuvant or neo-adjuvant setting.

A prospective randomised trial of radiation with or without oral and intravesical misonidazole for bladder cancer

Patients with T2 grade 3 and T3 bladder cancer were randomised to be treated with radiation alone (NO MISO) or with radiation and misonidazole (PLUS MISO). Patients in both groups initially received 40 Gy in 2 Gy fractions (5/week). Patients in the NO MISO arm received a further 20 Gy in 2 Gy fractions (5/week). Patients in the PLUS MISO arm received a further 12 Gy in 6 Gy fractions (1/week). MISO was administered orally (3.0 g m-2) and intravesically (1.0 g in 35 ml of solvent) 4 h and 2 h respectively prior to each fraction of 6 Gy. Fifty-eight patients were randomized of whom 53 are evaluable. There is a minimum follow-up of 5 years in the surviving patients. In the NO MISO and PLUS MISO arms, the complete response rate at cystoscopy at 6 months was 63% and 69%, the 5-year survival rate was 41% and 48% and the 5-year local control rate with bladder preservation was 46% and 36% respectively (censored for death from metastases while locally clear). These differences are not statistically significant. Two patients had grade 3 RTOG late bowel complications. Both patients were in the PLUS MISO arm, had undergone salvage cystectomy and subsequently required colostomies for bowel obstruction for a 5-year late complication rate (RTOG grade 3) of 9%. In addition, two patients in the PLUS MISO arm developed wound sepsis post cystectomy. We were not able to demonstrate improved results from the use of oral and intravesical MISO in this study. The number of patients entered are relatively low and large differences would have been required to be detected with a power of 0.80. The use of an unconventional radiation fractionation schedule may have resulted in increased bowel morbidity in patients in the PLUS MISO arm who subsequently underwent cystectomy.

Management of invasive thymoma at Groote Schuur Hospital, Cape Town

Fifteen patients (median age 55 years; range 23-69 years) with macroscopic invasive thymoma or thymic carcinoma were treated at Groote Schuur Hospital between 1969 and 1988. Stage 3 (macroscopically invasive) disease was present in 12 patients (80%) and stage 4 (metastatic disease) in 3 (20%). Ten of the patients with stage 3 disease were treated by combined surgery and full-dose mediastinal irradiation; in 2 resection was not possible and they were treated with irradiation alone. One of the patients with stage 3 disease developed progressive thymoma (median follow-up 74 months). This patient and 2 others died; 1 from mediastinitis after surgery for thymic carcinoma and 1 of unrelated disease. Both patients treated by irradiation alone were free of disease at follow-up. In the patients with stage 3 disease, the relapse rate was 8% (crude) and the 5-year disease-free survival rate 86% (life table). The patients with stage 4 disease received cisplatin-based combination chemotherapy, which was combined with further irradiation and debulking surgery in 2 of the 3 cases. These patients died of malignant disease at between 5 and 42 months, although 1 had a temporary response to chemotherapy. Tumour extent is the most important prognostic factor in these patients. A multidisciplinary approach to therapy is required.

Prospective study of etoposide scheduling in combination chemotherapy for limited disease small cell lung carcinoma

78 patients with limited disease small cell lung carcinoma (SCLC) were entered into a prospective randomised study of two combination regimens (AVE-5 and AVE-1) that differed only in the scheduling of etoposide. Patients in the AVE-5 arm received etoposide intravenously 60 mg/m2 on day 1 and orally 120 mg/m2 on days 2-5 of each cycle. Patients in the AVE-1 arm received etoposide 300 mg/m2 intravenously on day 1. Patients in both arms received doxorubicin and vincristine on day 1 of each cycle. The complete (53% vs. 26%) and the overall (75% vs. 52%) response rates were significantly higher in the AVE-5 arm. Median survival was also increased from 11 to 14 months in this arm. Toxicity was low and similar in both groups. The daily administration of etoposide in low toxicity combination therapy for SCLC is important. This can be conveniently achieved by using etoposide orally.