The hematopoietic toxicity of regional radiation therapy. Correlations for combined modality therapy with systemic chemotherapy

Using circulating granulocyte-monocyte precursor colony-forming units in culture (CFUc) numbers as a probe along with standard blood count (CBC), the authors have quantitatively examined the hematopoietic toxicity of conventionally fractionated radiation therapy (RT) when combined with concurrent systemic chemotherapy or when used alone. Among 20 patients with limited stage small cell lung cancer receiving systemic chemotherapy with cyclophosphamide, CCNU, and methotrexate, the addition of involved field chest RT resulted in increased hematopoietic toxicity as judged by increased need for platelet transfusion (P less than 0.05) and decreased frequency of measurable CFUc (P less than 0.04). Among 22 patients receiving regional radiotherapy alone consistent hematopoietic toxicity was also observed. This toxicity, although generally of only mild to moderate clinical significance, was detected earlier and to a greater degree in patients who required radiation to larger treatment volumes, who had significant amounts of bone marrow in the port, and who had a high percentage of cardiac output flowing through the port. These data suggest that the hematopoietic toxicity of regional radiotherapy may be additive to that of concurrent systemic chemotherapy and may occur more promptly and to a greater degree when treatment volumes are larger or incorporate increased amounts of marrow volume or cardiac output.

Development of infundibular obstruction after percutaneous pulmonary balloon valvuloplasty

A 14 month old boy with suprasystemic right ventricular pressure secondary to pulmonary valvular stenosis and anular size of 10 mm underwent percutaneous balloon valvuloplasty with a 12 mm balloon. Right ventricular pressure almost doubled after valvuloplasty and the electrocardiogram revealed development of severe right ventricular strain. Both findings persisted on the following day. A postvalvuloplasty right ventriculogram demonstrated a severe systolic infundibular obstruction not present before. The patient underwent surgical relief of infundibular obstruction; successful opening of the pulmonary valve by the balloon valvuloplasty was observed. It is concluded that a balloon size 20% larger than anular size can be safe in human subjects and that infundibular obstruction may appear or even worsen after balloon valvuloplasty. Such an obstruction may be related to the severity of pulmonary valvular obstruction and a hypercontractile infundibulum.

Occult arrhythmias as the etiology of unexplained syncope in children with structurally normal hearts

We evaluated six children for syncope of unknown etiology between March, 1983, and March, 1984. All had undergone previous neurologic evaluation which was normal. Cardiac examination, chest roentgenograms, and two-dimensional echocardiograms were also normal in all of the patients. Abnormal noninvasive findings in five patients included Mobitz type II atrioventricular (AV) block (one patient), sinus bradycardia (three patients), and supraventricular tachycardia (one patient). Four patients had one or more abnormal findings at invasive electrophysiologic study including evidence of sinus node dysfunction (three patients), AV node dysfunction (three patients), and distal His-Purkinje system disease (two patients). All children had a normal right heart hemodynamic catheterization. We conclude that arrhythmias are an important cause of syncope in some children with an otherwise normal heart when neurologic causes have been excluded.

Antiemetic efficacy of levonantradol compared to delta-9-tetrahydrocannabinol for chemotherapy-induced nausea and vomiting

The antiemetic efficacy of im levonantradol, a synthetic cannabinoid, given at a dose of 1 mg every 4 hours, was compared to oral delta-9-tetrahydrocannabinol (THC) given at a dose of 15 mg every 4 hours in a double-blind crossover study. Twenty-six patients receiving emetogenic cancer chemotherapy were evaluated. For each drug, 28% of treated patients had no nausea. The median number of emetic episodes with levonantradol was 2.0 versus 3.0 for THC (P = 0.06). Side effects occurred in 91.7% and 97.3% of levonantradol and THC patients, respectively, with drowsiness and dizziness most commonly seen. Side effects were generally well-tolerated, with only 13.9% of levonantradol and 21.6% of THC patients discontinuing treatment because of side effects. Levonantradol appears to be at least as effective an antiemetic as THC and is the only cannabinoid available for parenteral use.

Two-dimensional echocardiographic assessment of pulmonary artery and aortic arch anatomy in cyanotic infants

To determine the feasibility and accuracy of noninvasive assessment of pulmonary artery and aortic arch anatomy, a prospective two-dimensional echocardiographic evaluation was performed in 20 consecutive cyanotic infants before cardiac catheterization and angiography. The echocardiographic assessment was correct with the following frequency: detection of left aortic arch in 13 of 13 infants, detection of right aortic arch in 7 of 7, identification of patent ductus arteriosus in 13 of 13 (one false positive finding), identification of a right pulmonary artery in 20 of 20, identification of a left pulmonary artery in 19 of 20, identification of the confluence of the right and left pulmonary arteries in 19 of 20 and identification of a main pulmonary artery in 14 of 16 (two false positive diagnoses by echocardiography). Echocardiographic estimates of arterial diameters were slightly smaller than those obtained by angiography. Mean vessel size (echocardiographic/angiographic diameter) was as follows: transverse aortic arch 8.6/10.6 mm, main pulmonary artery 5.7/6.3 mm, right pulmonary artery 4.1/4.2 mm and left pulmonary artery 4.2/3.9 mm. It is concluded that although two-dimensional echocardiography tends to underestimate vessel size, the qualitative assessment is adequate for planning a systemic to pulmonary artery anastomosis in selected infants with cyanotic forms of congenital heart disease.

Therapy for multiple myeloma with alternating non-cross-resistant chemotherapy combinations: heterogeneity of tumor responsiveness

Thirty-five previously untreated patients with multiple myeloma were treated with a 60-week course of alternating, potentially non-cross-resistant chemotherapy combinations (melphalan and prednisone; vincristine, cyclophosphamide, doxorubicin, and prednisone; and carmustine, melphalan, and prednisone), alternating every 15 weeks in an attempt to prevent the development of drug resistance. The overall objective response rate (greater than 50% decrease in M protein) was 60% and six patients (17%) had a complete disappearance of the M protein. After 60 weeks, chemotherapy was discontinued in 17 responding or stable patients until relapse occurred from 4 to 39 months later (median, 12 months). Patients relapsing late (greater than 12 months after discontinuation of therapy) responded more frequently than those relapsing earlier to the reinstitution of the same chemotherapy program. The overall response rate and the actuarial median survival of 26 months in the 35 patients do not differ from the results reported recently with nonalternating combinations given until clinical tumor progression. The failure of this study to prolong survival by using alternating regimens may be due to (a) the likely possibility that the initial two regimens are not actually non-cross-resistant in most myeloma patients, and (b) the long interval between the alternating regimens, particularly in the face of the low response rate to the initial regimen of melphalan and prednisone.

Combination chemotherapy with doxorubicin and mitomycin C in non-small cell bronchogenic carcinoma. Severe pulmonary toxicity from q 3 weekly mitomycin C

Forty-five patients with advanced, measurable, or evaluable non-small bronchogenic carcinoma (NSCBC) were treated with doxorubicin and mitomycin C combination chemotherapy. The first 27 patients received doxorubicin 50 mg/m2 I.V. every 3 weeks and mitomycin C 10 mg/m2 I.V. every 3 weeks. Because of severe cardiopulmonary toxicity in seven patients, with four otherwise unexplained deaths, the next 18 patients were treated with the mitomycin C dose reduced to 10 mg/m2 every 6 weeks. Overall, 11 patients (25%) responded, with one complete and 10 partial remissions. Eight responses (30%) were observed in the patients who received mitomycin C every 3 weeks and three responses (17%) were found in those given mitomycin C every 6 weeks (p less than 0.5), with no cardiopulmonary toxicity in the latter group. The median survival was 21 weeks for the entire group of patients, with the group receiving mitomycin C every 3 weeks living a median of 15.5 weeks and those given mitomycin C every 6 weeks surviving 35.5 weeks (p less than 0.025). We conclude that there is a higher tumor response rate but more cardiopulmonary toxicity and shorter survival among the group receiving mitomycin C every 3 weeks compared to those receiving mitomycin C every 6 weeks. Future studies should consider this toxicity of mitomycin C administered on an every-3-week schedule.

Elevated serum creatine kinase BB levels in patients with small cell lung cancer

Clinical tumor specimens and cultures of small cell lung cancer (SCLC) produce 10- to 100-fold higher quantities of the BB isoenzyme of creatine kinase (CK-BB) (EC 2.7.3.2) than did other types of lung cancer. Serum CK-BB levels were evaluated in 105 newly diagnosed, previously untreated patients with SCLC. All patients were thoroughly staged, including 42 patients with limited-stage and 63 patients with extensive-stage disease. Serum CK-BB was elevated (greater than 10 ng/ml) in 27 patients (26%) (range, 11 to 522 ng/ml; median, 40 ng/ml). Only 1 of 42 patients with limited disease had an elevated serum CK-BB, while 26 of 63 (41%) of patients with extensive disease did. When patients were subgrouped according to the number of metastatic sites detected in pretreatment staging, a significant association between the presence of an elevated serum CK-BB and the number of metastatic sites was observed (p less than 0.005). No association between the presence of metastatic disease in a specific site and an elevated serum CK-BB could be detected. After adjusting for the number of metastatic sites, survival among patients with a normal pretreatment CK-BB was significantly better than in patients with an elevated CK-BB (p = 0.014). Sequential serum CK-BB determinations in 33 patients revealed an excellent correlation between clinical response to therapy and serum CK-BB levels. Continuous SCLC cell lines established from 13 patients in this study all expressed high levels of CK-BB. These data suggest that serum CK-BB determinations may be of value in estimating the extent of tumor dissemination, assigning prognosis, and monitoring response to therapy in patients with SCLC.

A comparison of computed tomography and radionuclide scanning for detection of brain metastases in small cell lung cancer

Neurologic history and examination, radionuclide brain scans (RN), and computed tomographic brain scans (CT) were performed at diagnosis and sequentially in 153 consecutive patients with small cell lung cancer (SCLC) to assess the sensitivity and accuracy of these screening methods and to determine whether the early detection of brain metastases influences survival. CT scans (sensitivity, 98%; positive predictive accuracy, 98%) were superior to RN scans (sensitivity, 71%; positive predictive accuracy, 86%) in patients with or without neurologic signs or symptoms. However, CT scans were positive in only 6% of asymptomatic patients at diagnosis and 13% of asymptomatic patients after systemic therapy. Brain metastases detected by CT scan were the sole site of extensive-stage disease in 6% of patients at diagnosis. Despite the enhanced ability of CT scans to detect asymptomatic lesions, survival after therapeutic cranial irradiation was similar for asymptomatic and symptomatic patients. The results suggest that CT brain scans should be used routinely in SCLC patients with neurologic signs or symptoms, at diagnosis (when treatment decisions are based on stage), and at six-month intervals in patients with prior brain metastases and in whom erratic follow-up is likely.

Safety and efficacy of continuous intravenous morphine for severe cancer pain

To study the efficacy and safety of continuously administered intravenous morphine for cancer pain unrelieved by standard narcotic therapy, bolus intravenous injections of 2 to 5 mg of morphine were given every 10 minutes until pain relief was achieved. Within the next hour, continuous intravenous morphine infusion was begun with the hourly dose equal to the cumulative bolus dose. Respiratory rate, pulse, blood pressure, arterial blood gas values, mental status, and pain relief were recorded at baseline and during the study period. A reduction in arterial oxygen pressure (PaO2) and/or increase in arterial carbon dioxide pressure PaCO2 of more than 20 percent of baseline values occurred, during the first 24 hours of infusion, in a minority of patients. This did not require changes in hourly morphine dose. Despite subsequent increases in morphine dose, blood gas values tended to remain at or return toward baseline values. Severe toxicity occurred during one trial and was heralded by bradypnea and marked somnolence. Major pain relief was achieved in 11 of 15 trials. Therefore, continuous intravenous morphine is effective and safe therapy. Bradypnea associated with marked somnolence is a cause for dose reduction.

Combined therapy for stage III-IV head and neck cancer: preliminary results

As part of a combined modality treatment program using chemotherapy, surgery, and/or radiotherapy, 25 patients with previously untreated stage III or IV head and neck cancer received initial combination chemotherapy. Pathologically confirmed complete remission was noted in nine patients (36%). The overall objective major response rate (with all patients included in analysis) was 68%. The chemotherapy regimen included bleomycin, cisplatin, vinblastine, methotrexate, and 5-fluorouracil. A novel concept of drug scheduling was used, based on chemotherapy-induced improvement in RBC deformability. The underlying concept is that improved RBC deformability results in improved capillary blood flow and thereby, increased drug delivery to tumor cells. Treatment resulted in moderate hematologic and renal toxicity with no treatment-related deaths. This exceptionally high, pathologically confirmed complete response rate will hopefully provide a mechanism by which combined modality therapy can adequately be tested for its ability to prolong survival of patients with advanced head and neck cancer.

Diagnosis and significance of liver metastases in small cell carcinoma of the lung

One hundred fifty-seven consecutive patients with small cell lung cancer seen at the National Cancer Institute over a four-year period underwent a series of pretherapy liver staging procedures to determine optimal means of detection and prognostic implications of hepatic metastases. Liver evaluation included physical examination, liver function tests, and liver scan (radionuclide or computerized tomography [CT]), as well as percutaneous and/or peritoneoscopy-directed liver biopsy when possible (74%). Liver metastases were detected in 26% of patients. Peritoneoscopy was the most sensitive method of liver evaluation and increased the detection of liver metastases when done in a sequential fashion after percutaneous liver biopsy from 18 to a total of 27 patients. Of the noninvasive procedures, radionuclide and CT liver scan were the most accurate concurring with liver biopsy in 87% of patients but permitting correct discrimination of stage in excess of 96% of patients. The accuracy of this noninvasive procedure was enhanced by an algorithm combining the results of radionuclide liver scan with liver function tests to detect patients with high or low likelihood of liver involvement. The survival and response of patients with liver metastases was significantly worse than those without such metastases with no three-year disease-free survivors among patients with liver metastases.

An active chemotherapy regimen for squamous cell lung cancer

A new concept of chemotherapy scheduling was evaluated in 20 patients with inoperable squamous cell lung cancer. The complete plus partial response rate was 85%, with 15% complete responses. The drugs utilized included vinblastine, bleomycin, methotrexate, 5-FU, cisplatin, and leucovorin. The hypothesis leading to the chosen drug schedule was that impaired rbc deformability (RBCD) found in cancer patients may produce stasis of flow in tumor capillary beds and decrease drug delivery to cancer cells. Drug schedules were designed to take advantage of chemotherapy-induced improvement in RBCD. After an initial drug treatment, a second treatment was given when RBCD increased at least 25% over pretreatment values (usually 4-6 days after the first chemotherapy dose). Drug doses were weighted so that more drug was given when RBCD was greatest. Treatment toxicity was predominantly hematopoietic and renal. This type of chemotherapy approach opens up new avenues of investigation in squamous cell cancer and other common neoplasms.

Inflammatory melanoma

Cutaneous inflammatory metastatic carcinoma is a well-documented entity most frequently associated with carcinoma of the breast. We present two patients with extensive inflammatory involvement of the skin overlying dermal lymphatic invasion by metastatic melanoma. The dermal lymphatic invasion and gross characteristics are similar to those previously described in inflammatory carcinoma, suggesting that melanoma should be added to the list of tumors which may result in this condition. As in other cases of inflammatory carcinoma, the recognition of this entity is important with regard to both prognosis and therapy.

Tumor seeding associated with bone marrow aspiration and biopsy

A 53-year-old man with small-cell lung carcinoma underwent bone marrow aspirations and biopsies for tumor staging and harvest for autologous bone marrow infusion. Fourteen months after bone marrow aspiration and biopsy, a subcutaneous lesion grew over the posterior iliac crest, and a biopsy specimen disclosed small-cell carcinoma. To our knowledge, this is the first case report of tumor seeding associated with bone marrow aspirate and biopsy.

"Salvage" radiation therapy for intrathoracic small cell carcinoma of the lung progressing on combination chemotherapy

Thirty-two patients with small cell carcinoma of the lung were given chest radiotherapy to progressive intrathoracic tumor after failing chemotherapy. Two-thirds of these patients received split-course treatment at a dose of 4000 rad in 10 fractions. Sixteen of 25 evaluable patients (64%) had an objective response, but only five responders did not progress within the port during life. Median time to local progression was 16 weeks. Two patients, one of whom was given concurrent chemotherapy, survived greater than 18 months, and one is free of disease at 31+ months. Short-term palliation of chest disease and occasional long-term survival are possible with this regimen, although most patients will die with systemic disease within several months. Small cell carcinoma of the lung is less responsive to irradiation as second-line therapy than as initial therapy, but doses of greater than or equal to 4000 rad can offer symptomatic relief in many cases and, rarely, survival beyond 18 months.

Treatment of extensive stage small cell bronchogenic carcinoma. Effects of variation in intensity of induction chemotherapy

Forty-nine consecutive previously untreated patients with extensive stage small cell bronchogenic carcinoma were treated with cyclophosphamide 1,000 mg/m2, doxorubicin 50 mg/m2, etoposide (VP-16-213) 125 mg/m2, and vincristine 1.4 mg/m2 (maximum 2 mg) as induction chemotherapy. Thirty-four patients were given high-intensity therapy, receiving these drugs on both Days 1 and 8 of two or three 21-day induction courses. Fifteen other patients were treated with moderate intensity, receiving these drugs only on Day 1 of two 21-day induction courses. The number and intensity of induction courses were determined by the time of entry into the study. There were 31 complete or partial remissions among the 33 evaluable patients treated with high-intensity therapy (94 percent), including eight complete remissions (24 percent), whereas there were 11 responses (73 percent) including three complete responses (20 percent) among the 15 patients treated with moderate-intensity therapy. There was no marked tendency for the patients in the high-intensity group to have a more favorable response to the induction chemotherapy (p = 0.22), and survival experience was very similar in the two groups (p = 0.92). Overall median survival was 12 months. Within the high-intensity group, there was no significant difference between patients receiving two or three courses of induction therapy with respect to response (p = 0.97) or survival (p = 0.32). There were six induction deaths in the high-intensity induction group (18 percent) and one induction death in the moderate-intensity group (7 percent) (p = 0.59). In addition to the expected hematologic and infectious complications, there were unexpectedly high frequencies of mucositis, reversible congestive heart failure, and severe peripheral neuropathy in patients treated with high-intensity induction. Only two patients, both in the high-intensity group, were alive and free of disease at 24 months. Increasing the intensity of induction chemotherapy with these drugs did not significantly improve response or survival in extensive stage small cell bronchogenic carcinoma.

High-dose methotrexate with leucovorin rescue in patients with unresectable non-small cell carcinoma of the lung

Thirty-one patients with unresectable non-small cell carcinoma of the lung (19 adenocarcinoma, 7 large cell carcinoma, 4 squamous cell carcinoma, 1 mixed histology) were treated with one of two intravenous infusion schedules of high dose methotrexate with leucovorin rescue. First, 14 patients received methotrexate in escalating doses from 1.5 to 12 g/m2 over 6 hours followed immediately with leucovorin 15 mg/m2 for 12 doses every 6 hours; there were no complete or partial responses among these 14 patients. Then, 17 patients were treated with a loading bolus of 50 mg/m2 intravenous methotrexate followed by a 30-hour continuous infusion of 1.5 g/m2. Leucovorin 15 mg/m2 every 6 hours for 12 doses was begun at the end of the infusion. There were 3 partial responses among the 17 patients in this group. The results demonstrate that both 6- and 30-hour infusions of high-dose methotrexate regimens can be given safely to middle aged adult patients, but the overall 10% response rate does not appear to be significantly different than the results with standard-dose methotrexate.

Delayed hypersensitivity skin testing as a prognostic indicator in patients with small cell lung cancer

The prognostic importance of pretreatment delayed hypersensitivity skin test reactivity was determined in 154 newly diagnosed, carefully staged and aggressively treated small cell lung cancer patients. One hundred twenty-one patients were reactive to at least 1 of 5 skin test antigens and 33 were anergic. Skin test reactive patients survived significantly longer than anergic patients. This result was expected since there was a significant trend for reactive patients to have good performance status (P = 0.005) and low tumor burden (P = 0.005) compared to anergic patients. The principal finding of this study was that skin test reactivity was of prognostic utility primarily in otherwise good prognosis patients, i.e., individuals with good performance status and low tumor burden. In this group anergy was associated with significantly shortened survival (P = 0.025). In poor prognosis (poor performance status and high tumor burden) or intermediate prognosis (either poor performance status or high tumor burden) patients skin test reactivity or anergy had no significant influence on survival.