Combined modality therapy utilizing a cisplatin combination for effective chemotherapy in patients with previously untreated head and neck cancer

In patients with locally advanced head and neck cancer, the results of standard definitive treatments of surgery, radiotherapy, or both were disappointing. The local and regional recurrence rates were high, despite adequate surgical resection with negative margins and postoperative radiotherapy to all known or possible disease areas. Combination cisplatin chemotherapy given initially before definitive treatments produced a high overall antitumor response and up to 50 percent clinical complete response. Before answering the question of value of chemotherapy as part of the multimodality treatment, it is important to identify the safest and most form of chemotherapy. The degre of chemotherapy effectiveness is defined by the incidence of clinical and, most important, histologic complete response. To assess this effectiveness, chemotherapy was given before definitive treatments to patients with measurable disease. From our 10 year experience we have concluded that continuing the development of induction chemotherapy, including investigating the timing of such effective treatment and assessing the value of such therapy, is of the utmost importance.

Prognostic significance of tumor growth during radiation therapy

A retrospective review of 282 consecutive patients with squamous cell carcinoma of the head and neck that were seen in the Radiation Oncology Department from January 1, 1980, through December 31, 1983, was performed. From this population a subgroup of six patients was identified that experienced growth of tumor in the radiation field during treatment. All except one of these patients expired from progression of cancer within 16 months. At the time of writing, the one remaining patient has progressive cancer in spite of additional therapy. Growth of cancer in the radiation field during therapy is unusual. It appears to be associated with a very poor prognosis even with aggressive salvage therapy. This observation should be taken into consideration in the medical/surgical management of these patients.

The impact of conventional morphologic analysis on response rates and survival in patients with advanced head and neck cancers treated initially with cisplatin-containing combination chemotherapy

The response to initial treatment with cisplatin-containing combination chemotherapy as well as survival, were correlated with tumor differentiation (well, moderate or poorly differentiated) in 164 patients with advanced, untreated squamous cell carcinoma of the head and neck. Thirty-three percent of the tumors were graded as poorly differentiated, 59% moderately differentiated, and 8% were well differentiated. The overall clinical response rates were nearly equal for the three grades of differentiation: 79% for well differentiated, 86% for moderately differentiated, and 89% for poorly differentiated. The complete response rate was somewhat higher for poorly differentiated tumors: 46% as compared to 32% and 29% for moderately and well differentiated respectively, but the differences were not statistically significant. The median survival for each morphologic group was 22, 16, and 12 months for well differentiated, moderately differentiated and poorly differentiated tumor, respectively (P = 0.097). For patients achieving a complete clinical response to chemotherapy, there was a difference in survival when stratified according to degree of histologic differentiation. Patients who were complete responders and had well or moderately differentiated tumors attained 75% and 38% survival at 36 months, respectively, versus 19% for patients with complete response and poorly differentiated tumors (P = 0.064). The degree of differentiation of previously untreated squamous cell cancers of the head and neck does not conclusively predict tumor response to combination chemotherapy, but may reflect differences in natural history. Survival is improved in patients with differentiated tumors as compared to those with poorly differentiated tumors. Morphologic grading in patients achieving a complete response reveals a decrease in survival for patients with poorly differentiated tumors.

A randomized trial of cisplatin (CACP) + 5-fluorouracil (5-FU) infusion and CACP + 5-FU bolus for recurrent and advanced squamous cell carcinoma of the head and neck

One of the most active chemotherapeutic regimens for treatment of advanced and recurrent head and neck cancer is cisplatin (CACP) + 5-fluorouracil (5-FU) infusion with a response rate of 90% in advanced, previously untreated patients and 70% in patients with recurrent disease. Forty-four patients from two Wayne State University-affiliated hospitals were entered into a randomized trial of CACP (100 mg/m2) day 1 and 24-hour infusion of 5-FU (1000 mg/m2) days 1 through 4 versus CACP (100 mg/m2) day 1 and bolus 5-FU (600 mg/m2) day 1 and day 8. Thirty-eight patients were evaluable for three induction courses. Response for the infusion arm was 72% (4/18 complete response [CR] + 9/18 partial response [PR]). Response for the bolus arm was 20% (2/20 CR + 2/20 PR). The difference in response was statistically significant by chi-square analysis (P less than 0.01). Seventy percent of the patients on the bolus arm experienced leukopenia with several episodes of grades 3 and 4 leukopenia. In addition, 50% of the patients on the bolus arm experienced thrombocytopenia. Stomatitis was more frequent on the infusion arm but it was mild and reversible. The complete responders on either arm have a median survival of 120+ weeks; partial responders, 30 weeks. Cisplatin + 5-FU infusion produces a superior response as initial chemotherapy for three courses compared with CACP and 5-FU bolus.

Ototoxicity from cis-platinum in patients with stages III and IV previously untreated squamous cell cancer of the head and neck

Forty-four patients were evaluated for ototoxicity following treatment with the chemotherapeutic agent cis-platinum. Statistically significant hearing changes at 2,000 Hz (p less than 0.001); 4,000 Hz (p less than 0.05); and 8,000 Hz (p less than 0.001) were observed. Chi-square analysis demonstrated that at 8,000 Hz patients who had lower than average thresholds prior to chemotherapy were more likely to experience greater threshold shift than those patients whose pre-chemotherapy thresholds were higher than average. In this patient sample, there was no significant correlation shown between serum creatinine levels and ototoxicity.

Improved complete response rate and survival in advanced head and neck cancer after three-course induction therapy with 120-hour 5-FU infusion and cisplatin

In a series of three consecutive pilot studies carried out between 1977 and 1981 at Wayne State University, Detroit, Michigan, designed to test the feasibility of multimodality therapy in patients with previously untreated advanced squamous cell carcinoma of the head and neck, patients received three different induction chemotherapy regimens: cisplatin + Oncovin (vincristine) + bleomycin (COB) for two courses; 96-hour 5-fluorouracil (5-FU) infusion and cisplatin for two courses, or 120-hour 5-FU infusion + cisplatin for three courses. Over-all response rates (complete response + partial response) to each of the three induction chemotherapy regimens were high: 80%, 88%, and 93%, respectively. Superior complete response rate in the group receiving three courses of 120-hour 5-FU infusion + cisplatin was 54% versus 29% for COB and 19% for two-course 96-hour 5-FU infusion + cisplatin (P = 0.04). Significant survival advantage at 18 months minimum follow-up for the group receiving three courses of 120-hour 5-FU + cisplatin induction therapy was found. Actual T and N stage may influence the clinical complete response rate. Responders to initial chemotherapy have significantly better survival as compared to nonresponders regardless of subsequent surgery and/or radiotherapy. These studies show that a multimodality approach to management of advanced head and neck cancer is feasible. Superior complete response rate and survival in one of the treatment groups suggest that choice of induction chemotherapy regimens and/or number of courses is of prime importance in such multimodality treatment programs.

Newt lung ciliated cell models: effect of MgATP on beat frequency and waveforms

Highly coupled newt lung ciliated cell models were used to study the effects of MgATP concentration on ciliary beat frequency and waveform. Models were prepared from ciliated lung cells of the newt Taricha granulosa by trypsin dissociation of the epithelium, demembranation with Triton X-100, and reactivation with MgATP, as described previously [Weaver and Hard, 1985]. Beat frequencies were measured stroboscopically. Ciliary waveforms of reactivated models and intact mucociliary epithelial sheets were determined by single frame analysis of high-speed movies. Waveform parameters calculated included the durations of the effective and recovery strokes, the angular swings and angular velocities of the ciliary base and tip, the position of the bend along the ciliary shaft during the recovery stroke, the velocity of recovery stroke bend propagation, and the ratio of the duration of recovery stroke bend propagation to the duration of the recovery stroke itself. We found that beat frequency varied biphasically in response to MgATP at 21 degrees C, as shown previously for isolated, individual, newt lung axonemes. Apparent Fmax (maximum beat frequency) and Km values of 25 Hz and 0.14 mM, and 35 Hz and 0.47 mM, respectively, were obtained for each linear segment of the biphasic double reciprocal plot. Demembranation did not alter either ciliary waveform or the pattern of coordination. In this system, metachrony is antilaeoplectic and ciliary waveform appears to be regulated independent of beat frequency.

Isolation of newt lung ciliated cell models: characterization of motility and coordination thresholds

Demembranated ciliated cell models are useful for studying mechanisms responsible for the regulation of ciliary coordination and waveform. This paper describes procedures for isolating ciliated cells from the newt, Taricha granulosa, by trypsin dissociation, their subsequent demembranation by Triton X-100, and their reactivation with MgATP to produce highly motile, coordinated, ciliated cell models. Reactivation of cell models with a high degree of mechanochemical coupling depended on avoiding mechanical damage and maintaining optimal conditions during all stages of isolation and reactivation. Highly motile models were prepared from cells incubated in trypsin, treated briefly with EDTA, separated by gentle agitation, and concentrated by centrifugation at low gravitational forces. Optimal demembranation and reactivation conditions were similar to those described previously for isolated newt lung axonemes. Under these conditions, nearly 100% of the models were reactivated when provided with MgATP and 90-95% beat with coordinated waves. The ciliary tufts beat at frequencies within the range measured in living cells and their reactivated motility was stable for at least 30 min at constant MgATP. These highly coupled models were used to show (1) that development of coordination in the ciliary tuft occurs at a higher substrate concentration range (10-25 microM) than that required to initiate motility per se (2-10 microM; (2) that outer dynein arms may not contribute to beat frequency at substrate concentrations below 35 microM; and (3) that vanadate has effects both on beat frequency and coordination of the tufts.

Superior clinical response and survival rates with initial bolus of cisplatin and 120 hour infusion of 5-fluorouracil before definitive therapy for locally advanced head and neck cancer

One hundred ninety-one patients were treated by one of three cisplatin-containing multidrug protocols. The initial 77 patients received two courses of cisplatin and vincristine plus bleomycin. The next 26 patients received two courses of 5-fluorouracil and cisplatin, and the final 88 patients were placed on a three course 5-fluorouracil and cisplatin protocol. Overall response rates were similar for each of the three protocols. The complete response rate, however, was much better (54 percent) for three course 5-fluorouracil and cisplatin versus cisplatin vincristine, and bleomycin (29 percent) and two course 5-fluorouracil and cisplatin (19 percent). Survival curves were also better for the three course 5-fluorouracil and cisplatin segment of this nonrandomized pilot study.

Correlation between response to cisplatinum-combination chemotherapy and subsequent radiotherapy in previously untreated patients with advanced squamous cell cancers of the head and neck

Induction chemotherapy, followed by surgery and/or radiotherapy was utilized in patients with advanced squamous cell carcinoma of the head and neck. During these trials, the authors observed that response to chemotherapy predicts further response to subsequent radiotherapy. This study was comprised of 57 patients with 60 separate neoplasms who demonstrated less than complete response (partial or no response) to initial treatment with a combination chemotherapy containing cisplatin. Subsequently radiotherapy, either 5000 rad preoperatively or 6600 rad as definitive therapy, was employed. Forty-one of the 42 tumors with initial partial response to chemotherapy also responded to radiotherapy (97.6%). Only one of the 18 tumors that initially failed to respond to chemotherapy subsequently responded to radiotherapy (5.5%). This observation suggests that patients with head and neck cancer sensitive to initial chemotherapy share parameters that are also radiation sensitive.

Cisplatin and 5-fluorouracil infusion in patients with recurrent and disseminated epidermoid cancer of the head and neck

The combination of cisplatin and 96-hour infusion of 5-fluorouracil (5-FU) was evaluated in 30 patients with recurrent (local and regional) and disseminated histologically proven epidermoid cancer of the head and neck who failed surgery and radiotherapy. Cisplatin 100 mg/M2 intravenous (IV) bolus was given on day 1 with hydration and mannitol diuresis; 5-FU 1000 mg/M2 per day for 96-hour infusion was started immediately after cisplatin on day 1. All patients had measurable lesions. Eight (27%) patients achieved complete response (CR), and 13 (43%) had partial response (PR). Overall response rate was 70% (8 of 30 CR and 13 of 30 PR). Response rate in patients with recurrent local and regional disease was 89% (17/19) with median survival of 32 weeks, while response in patients with disseminated disease was 36% (4/11) with median survival of 24 weeks. Patients with good performance status (PS) (greater than or equal to 70%) had a response rate of 79% (19/24), while those with poor PS (less than 70%) had a response rate of 33% (2/6). Seven patients with recurrent disease who had a response to this chemotherapy went to further salvage surgical procedures. It is concluded that the combination of cisplatin and 5-FU is very effective and well tolerated in these patients, and leads to further salvage in some patients with improved longevity and quality of life.

Adjuvant chemotherapy with cis-diamminodichloroplatinum II and 120-hour infusion 5-fluorouracil in Stage III and IV squamous cell carcinoma of the head and neck

A prospective study was carried out to investigate the effectiveness and toxicity of three courses of combination high-dose bolus CDDP and 120-hour continuous infusion 5-FU every three weeks prior to definitive surgery and/or radiation therapy in 35 patients with locally advanced Stage III and IV squamous cell carcinoma of the head and neck. Twenty-two patients (63%) achieved a CR and 11 (31%) a PR after three cycles of chemotherapy, for an objective response rate of 94%. Toxicity was clinically acceptable. Nausea and vomiting occurred in 23 of 35 (66%) without any patients discontinuing therapy for this reason. Leukopenia in 13 (37%) and reversible azotemia in six (17%). Following three courses of chemotherapy, 13 patients had surgical resection and 12 patients had radiation therapy. Ten of these 35 patients had no pathologic evidence of cancer in the surgical specimen or preradiation therapy biopsy. Only two patients of those achieving a complete objective response have relapsed. However, the median follow-up has been short. The authors concluded that three courses of CDDP and 5-FU is a highly effective and safe adjuvant treatment in patients with advanced carcinoma of the head and neck.

Newt lungs: a versatile system for the study of mucociliary transport

Lungs of the newt, Taricha granulosa, provide a versatile system for studying mucociliary transport. The mucociliary epithelium is restricted to a ventral strip of epithelium which extends the entire length of the lung. The transport process can be studied in the isolated lung or in a variety of functional components derived from it. These components include: (1) isolated sheets of the mucociliary epithelium, (2) flattened epithelial sheets grown in long term primary culture, (3) dissociated ciliated and mucous cells, (4) functional, demembranated ciliary tufts, and (5) isolated populations of discrete, demembranated axonemes. The latter two models can be reactivated with MgATP and made to beat at frequencies comparable to those measured in intact cells. Featuring large cells (25-30 microns in diameter) and cilia (12-13 microns in length) in comparison to other mucus-transporting systems, coupled with the ability to perform 'physiological' experiments at ambient temperatures, newt lungs afford a convenient system to study mechanisms involved in the control of ciliary beat frequency, waveform and coordination at several levels of organization.

Cis-platinum and 5-fluorouracil as induction therapy for advanced head and neck cancer

Sixty-one patients were treated with a three course induction regimen of 5-fluorouracil and cis-platinum for advanced squamous cell carcinoma of the head and neck area. Thirty-three patients (54 percent) had complete clinical remission with the administration of these drugs. Twenty-four patients (39 percent) showed a 50 percent or greater reduction in tumor size, for a significant response rate of 93 percent. The toxicities were within acceptable limits, and only three patients did not complete all three courses. Surgery and radiation therapy were supposed to follow the chemotherapy but several patients refused surgery after the disappearance of their lesion. This has created a problem in patient management.

Triple endoscopy. A valuable procedure in head and neck surgery

Synchronous carcinoma in the head and neck, lung, or esophagus may be identified in 10 percent of patients with squamous head and neck carcinoma by routinely performing triple endoscopy (direct laryngoscopy, bronchoscopy, and esophagoscopy) at the time of initial evaluation. In 5.5 percent of patients with squamous head and neck cancer, synchronous lung and/or esophageal cancer was identified. However, in only 1.5 percent of patients was it asymptomatic and would not have been suspected as a result of a thorough history, physical examination, and chest x-ray. The cost-effectiveness of routine triple endoscopy can be questioned, but we think it is indicated to identify those early carcinomas with an excellent chance of cure. The time and money expended to identify these early, asymptomatic cancers is small compared to that spent in treating patients with symptomatic cancer of the same organs, in whom there appears to be a much smaller chance of cure. Multiple superficial squamous carcinomas of head and neck mucosa may be managed by surgical excision, radiation therapy, laser destruction, or cryosurgery. If these methods cannot be applied, combination chemotherapy appears to provide a satisfactory alternative method of short-term control, which we believe merits further clinical investigation.

cis-platinum and 5-fluorouracil as initial therapy in advanced epidermoid cancers of the head and neck

A total of 44 patients with previously untreated Stage IV squamous cell carcinomas of the head and neck were treated with a combination of cis-platinum (100 mg/sq m) and 96-hour infusion of 5-fluorouracil (5-FU) (1,000 mg/sq m/day) in two courses or with cis-platinum (100 mg/sq m) and 120-hour infusion of 5-FU (1,000 mg/sq m/day) in three courses. In the 26 patients receiving the two course regimen, the tumor response rate was 88.5%. In five of the 26 patients complete disappearance of the tumor was achieved; partial remission was obtained in 18 of 26 patients. The main side effects were nausea and vomiting (70%), leukopenia (27%), and mild-to-moderate renal toxicity (27%). In the 18 patients who received the three course regimen of 5-FU and cis-platinum, there were 11 (61%) complete responses, 6 (33%) partial responses, and 1 (6%) minimal response. The incidence of complete response was increased with each course given. No added toxicity was observed with surgery or radiotherapy.

Clinical trial of cisplatin and 5-FU infusion as initial treatment for advanced squamous cell carcinoma of the head and neck

Initial treatment with drug combinations that include cisplatin and bleomycin has been effective in reducing tumor in patients with previously untreated epidermoid cancers of the head and neck. Because of the threat of pulmonary complications from bleomycin, patients with poor pulmonary function were excluded from those studies. We conducted a trial using the combination of cisplatin (100 mg/m2) and a 96-hour infusion of 5-FU (1000 mg/m2/day) and achieved a response rate of 88.5% in 26 patients treated with two courses. Five of these patients had complete remissions and 18 had partial remissions. Nausea and vomiting (experienced by 70% of the patients) was the predominant toxic effect, and 26% experienced leukopenia. Although all patients were initially inoperable, six underwent resection following chemotherapy, and another six underwent resection after chemotherapy and irradiation. Two additional patients were treated with radiation therapy after clinically achieving complete remissions following chemotherapy, and another ten received X-ray therapy after chemotherapy. Cisplatin and 5-FU infusion are effective without being as toxic as bleomycin in patients with previously untreated advanced carcinoma of the head and neck.

Combined modality therapy for advanced head and neck cancer

Seventy-five patients with stage III and IV squamous cell cancer of the head and neck, previously untreated, had two courses of chemotherapy with cis-platinum, Oncovin and bleomycin, followed by radical surgery, radiotherapy or both. Response to chemotherapy (complete and partial) was high (80 percent). In 36 patients radical surgery became possible. The overall survival improved statistically in patients who achieved complete or partial response to chemotherapy compared with those who had minimal or no response. Patients with well to moderately well differentiated cancer, or stage III disease, had a statistically better prognosis than patients with poorly differentiated cancer, or stage IV disease.

67Gallium scanning in talc-induced pulmonary granulomatosis

We describe a case of pulmonary granulomatosis in a user who habitually injected methylphenidate (Ritalin) intravenously; symptomatic and objective improvement occurred with corticosteroid therapy. A scan of the lungs using radioactive 67gallium showed an increased concentration of 67gallium throughout both lungs. There was a reduction in abnormal accumulation of 67gallium, improvement in the arterial oxygen pressure and the diffusing capacity for carbon monoxide, and a reduction in the infiltrate on the chest x-ray film two months after the institution of therapy. Before treatment the patient's symptoms and arterial deoxygenation increased despite the cessation of her drug abuse, thus raising the question of a self-perpetuating inflammatory process in a case of pulmonary deposition of talc.

Triple endoscopy: a neglected essential in head and neck cancer

Surgeons are sometimes embarrassed to discover a second unanticipated cancer while focusing attention on an already evident cancer in the head and neck area, the bronchus, or the esophagus. we began in October, 1976, to do direct laryngoscopy, esophagoscopy, and bronchoscopy on each of the 134 cases admitted to our unit with suspected head and neck cancer. In 10 of the 134 patients in whom triple endoscopy was done, no malignancy was found. Of 24 of 124 (20%) patients with head and neck cancer, 16 patients (13%) had synchronous carcinoma and eight patients (7%) had metachronous carcinoma in this 2-year period. The incidence can be expected to rise steadily with time and mandates "triple endoscopy" on all patients with a suspected cancer in the head and neck area, the bronchus, or the esophagus, as these structures form a closely related unstable field. The discovery of several patients with dysplastic mucosal changes, carcinoma in situ, or very early invasive cancer, not only of the head and neck but also of the esophagus and bronchus, presents new problems of management.

Mouthwash and oral cancer: carcinogen or coincidence?

Among 200 patients with squamous cell cancer of the head and neck, 11 persons abstained from all alcoholic beverages and tobacco. All but one of these 11 patients had used mouthwash many times daily for more than 20 years. Most of them used a brand of mouthwash that contained 25% alcohol. This evidence, along with information from other patients, may be used to confirm or refute the theory that mouthwash may be carcinogenic for susceptible persons.

Lip and laryngeal flaps for reconstruction of the floor of the mouth following glossectomy

Following glossectomy, the reconstruction of the floor of the mouth is a major problem facing the head and neck surgeon. We have devised split-lip and laryngeal mucosal flaps for this. In selected patients, they have a significant advantage over distant skin flaps. The initial postoperative deformity, from the lip being drawn into the mouth, is corrected by a secondary operation with split-skin graft reconstruction of the vestibule. These lip and laryngeal flaps do not require a delay procedure prior to the cancer surgery, and the operating time is considerably reduced. The cosmetic and functional results have been satisfactory.