Combination chemotherapy with cis-diamminedichloroplatinum, oncovin, and bleomycin (COB) in advanced head and neck cancer: phase II

Histological vis-a-vis biochemical assessment on the toxic level and antineoplastic efficacy of a synthetic drug Pt-ATP on experimental animal models

Background

Cisplatin, a platinum based anticancer drug has played a vital role in the treatment of cancers by chemical agents, but in view of the serious toxicity including nephrotoxicity of cisplatin, various other platinum based drugs have been synthesized and screened to overcome its toxicity. A Pt-ATP compound was prepared in our laboratory hoping to have reduced or no toxicity along with the potentiality of reducing neoplasm growth.

Methods

A Pt-ATP compound was prepared. It was first screened for its antineoplastic efficacy. Confirming that, subsequent experiments were carried on to test its toxicity on animals, viz. Albino Swiss mice. The animals were randomly divided into four sets – Set I: Erhlich Ascites Carcinoma (EAC) challenged mice; Set II: Normal mice; Set III: Drug treated mice, Set IVA Cisplatin (CDDP) treated mice, Set IV B EAC challenged Cisplatin treated mice. Set I was used to test antineoplasticity of the drug, Set II and Set III for studying drug toxicity and Set IV was treated with CDDP. Set II was used as a control. Animals were sacrificed after 5 days, 10 days 15 days and 20 days of drug administration on the 6^th, 11^th, 16^th and 21^st days respectively for Set I, II and III. Set IVA was sacrificed only on the 16^th day and Set IV B on 6^th and 11^th days. For Set I only tumor cell count and packed cell volume (PCV) of tumor cells were recorded. For Set II and III, aspartate aminotransferase (AST), alanine aminotransferase (ALT) assays were done using serum while blood creatinine and creatine were assayed from blood filtrate. For cytotoxicity assessment liver, spleen and kidney tissues were collected and subjected to scanning electron microscopy (SEM) after extensive treatment. Set IV A was only studied for the biochemical parameters viz. aspartate aminotransferase (AST), alanine aminotransferase (ALT) assays were done using serum while blood creatinine and creatine were assayed from blood filtrate. Set IV B was studied for tumor cell count after treatment with CDDP for 10 days.

Results

Our comparative studies with normal and drug treated animals reveal that the drug does not affect the body weight of the drug treated animals significantly. The biochemical parameters like ALT and AST levels are also within normal limits which rules out hepatotoxicity. The detailed histological studies by SEM reveal that the hepatic, kidney and spleen tissues are not adversely affected by the drug. Comparison of biochemical parameters with the CDDP treated animals show that Pt-ATP is not at all toxic like the CDDP. The Kaplan-Meier analysis of the survival data of Set I has shown promising results with a significance of p < 0.0001.

Conclusion

Set I results are promising and indicating antineoplastic efficacy of the synthesized drug with increased life span of the animals. Biochemical analysis, hematological and SEM studies revealed that the drug was neither nephrotoxic nor hepato-spleeno-toxic under the experimental set up.

The role of chemotherapy in head and neck cancer

We studied the effect of cytoreductive chemotherapy in head and neck cancer and analyzed it in terms of efficacy, remission rates, and duration, as well effect on survival. Single-agent chemotherapy, which formerly was used as a palliative therapy in recurrent and metastatic disease, had little affect on survival. More recently, multi-agent chemotherapy trials have shown significantly higher response rates, but this success has not translated into an added survival benefit. These findings led to the introduction of multi-agent chemotherapy into the induction (neoadjuvant) clinical setting. In these clinical circumstances, better objective response rates were found, particularly in the previously untreated patient. Although this therapy has resulted in better control of local disease, the impact on survival is not yet clear. Adjuvant chemotherapy is most useful in patients who have a high risk of relapse. Therapy appears to decrease its incidence, particularly at distant sites. Finally, chemoradiation trials have shown that this treatment provides a survival advantage, but at the cost of a significant increase in toxicity.

Treatment of recurrent and/or metastatic squamous cell head and neck carcinoma with a combination of vinorelbine, cisplatin, and 5-fluorouracil: a multicenter phase II trial

PURPOSE

Vinorelbine has been demonstrated to be active against squamous cell carcinomas of the head/neck (SCHNC) and lung. This multicenter phase II trial was carried out to evaluate the activity and tolerability of the combination of vinorelbine, cisplatin, and 5-fluorouracil given on an outpatient schedule in a series of 80 patients with recurrent SCHNC.

PATIENTS AND METHODS

Eighty patients with recurrent and/or metastatic SCHNC were treated with a combination of CDDP 80 mg/m2on day 1, 5-FU 600 mg/m2 as a 4-hour infusion on days 2-5, and vinorelbine 25 mg/m2 on days 2 + 8. This cycle was repeated every 28 days. Most patients had oral cavity, larynx, or oropharynx carcinoma (88%). Forty-seven had previously received surgery alone, two radiotherapy alone, and 31 surgery plus radiotherapy. Seventy-two patients had locoregional recurrency, and eight had distant metastases.

RESULTS

According to an intent-to-treat analysis, complete response (CR) of a mean duration of 12.7+ months was achieved in 13% of cases (95% CI 5%-21%), and partial response of 8.3+ months in 45% of patients (95% CI 33%-56%), for an overall response rate of 55% (95% CI 43%-65%). Nine patients (11%) showed no change, and 22 (28%) progressed. Five patients were not evaluable for response and toxicity. CR were seen more frequently in patients pretreated with only surgery than in those who had also received radiotherapy (15% vs. 9%; p = 0.7). No statistically significant differences in response rate according to site of primary tumor were found (p = 0.8, NS). The received dose intensities of 5-FU, CDDP, and VNR were 90%, 92%, and 82%, respectively. The overall survival of the series as a whole was 9.7+ months (range 4-27). Toxicity was generally acceptable. Grades 3 and 4 leukopenia were recorded in 11% and 5% of patients, respectively. Noteworthy was the occurrence of pain at the tumor site after vinorelbine administration in 5 patients.

CONCLUSION

The combination regimen of CDDP, 5-FU and vinorelbine is quite active in the treatment of metastatic and/or recurrent SCHNC. This regimen should be tested as initial treatment in previously untreated patients and compared to a standard regimen in recurrent SCHNC.

Induction chemotherapy in advanced head and neck cancer

Induction chemotherapy, followed by definitive treatment, was performed in patients with advanced squamous-cell carcinoma of the head and neck. In this study, carried out between 1984 and 1991, testing the effectiveness of multimodality therapy in patients with previously untreated advanced (stage III and IV) squamous-cell carcinoma of the pharynx, patients received two different induction chemotherapy regimens: cisplatin, vincristine (Oncovin) plus peplomycin (COP), and cisplatin plus continuous 120-hr 5-fluorouracil (5-FU) infusion (CF) for two courses. Overall response rates (complete response plus partial response) to each of the two induction chemotherapy regimens were high: 76 and 82%, respectively. Superior complete response rate in the group receiving CF therapy was 16% versus 10% for COP therapy. Responders to induction chemotherapy had significantly better survival compared with non-responders. The toxicity of these two regimens was tolerable and manageable. It is indispensable to develop the more efficacious chemotherapy regimen with the potential to induce complete disappearance of tumors in patients with advanced head and neck carcinomas.

A phase II study of cisplatin and continuous infusion of vindesine in metastatic head and neck squamous cell cancer

The chemotherapeutic treatment of recurrent and/or metastatic squamous cell carcinoma (SCC) of the head and neck (H & N) has a very dismal prognosis, with survival usually not exceeding 1 year. Reported objective response rates vary between 3% and 70%. This difference appears largely attributable to the heterogeneity of the patient populations included in most published Phase II studies in H & N cancer. They usually include together initially metastatic, recurrent, and post primary treatment metastatic disease patients. These patients respond differently to chemotherapy. Because of this situation, we decided to study a more homogeneous patient population consisting of metastatic patients only. Cisplatin (CDDP) and vindesine (VDS) are active agents in H & N SCC. As VDS has a cycle-specific activity, the therapeutic index may be increased if it is administered in a continuous infusion (CI) schedule. Thirty-three patients with metastatic H & N (69% biopsy proven) were treated with a combination regimen including CDDP (100 mg/m2) day 1 and VDS 0.6 to 1 mg/m2 for 96 hours of CI. Thirty-one patients were evaluable for response: five had a complete response (CR; 16%) and 11 had a partial response (PR; 36%) with an overall rate response of 52% (95% confidence limit: 33% to 70%). Median duration of CR was 6.4 months (3 to 19 months) and 4.4 months for PR (3 to 6 months). A decrease in the leukocytes was the main toxicity encountered with this regimen. This combination regimen containing CDDP and CI VDS was well tolerated and active in H & N SCC. The incorporation of an active vinca-alkaloid in neoadjuvant regimens should be considered.

A phase III randomised trial of cistplatinum, methotrextate, cisplatinum + methotrexate and cisplatinum + 5-FU in end stage squamous carcinoma of the head and neck. Liverpool Head and Neck Oncology Group

We describe a phase III trial on 200 patients with end stage squamous cell carcinoma of the head and neck. The patients were randomised to one of four treatment arms: cisplatinum alone, methotrexate alone, cisplatinum + 5-FU and cisplatinum + methotrexate. There was no significant difference in the response rates, but the survival of the cisplatinum arm was significantly better than that of the methotrexate arm. The survival of patients receiving cisplatinum as a single agent was longer than that of patients receiving cisplatinum in combination with methotrexate or 5-FU, but not significantly so. Nausea/vomiting and anaemia were significantly more common in the cisplatinum arms than in the methotrexate arm, but the toxicity of combination regimens was not significantly greater than that of cisplatinum used as a single agent.

Cis-diamminodichloroplatinum plus a 5-day continuous infusion of 5-fluorouracil in the treatment of locally recurrent and metastatic head and neck cancer patients

A group of 23 consecutive patients with biopsy-proven advanced or metastatic head and neck cancer were treated with cisplatinum, 100 mg/m2 i.v., on day 1 plus 5-fluorouracil, 1000 mg/m2, in continuous infusion for 5 days. Most patients (87%) had recurrent or metastatic cancer and were previously treated (78%). Out of 21 evaluable patients we obtained a 42% overall response rate (complete + partial responses) with a mean duration of more than 8 months and a 14% minimal response rate. A stabilization of disease was achieved in 28% of cases, while 14% of patients progressed. This response rate, as well as the duration of response, seems to be similar to those obtained in other series comprising previously treated patients with advanced or metastatic head and neck carcinoma. The toxicity was generally acceptable, with few cases of grade 3 (WHO criteria) toxicity. However most patients required hospitalization because of the length of treatment. In conclusion the response rate and the duration of responses obtained with cisplatinum plus a 5-day infusion of 5-FU in advanced or metastatic pretreated patients is, at present, unsatisfactory, even if the impact on survival is still not entirely clear.

The correlation of specific variables of tumor differentiation with response rate and survival in patients with advanced head and neck cancer treated with induction chemotherapy

The authors have reported previously that conventionally defined grades of tumor morphology do not correlate with tumor response or survival in advanced squamous cell cancers of the head and neck (SCCHN) treated with cisplatinum combination induction therapy. This lack of correlation may be the result of the imprecision and subjectiveness of the conventional grade determination. To examine this possibility, response and survival were correlated with individual parameters of morphologic differentiation in 136 patients with advanced, untreated SCCHN. A multi-variable analysis of degree of keratinization, number of mitotic figures per high powered field, degree of nuclear differentiation, presence of vascular invasion, intensity of inflammatory response, and invasion pattern of the cancer was performed. The grade of each variable was weighted by assigning a score from 1 to 4, with 1 representing the most differentiated and 4 the least. The cumulative score of each specimen was tallied and assigned to one of three groups, less than 12, 12 to 18, and greater than 18, analogous to the conventional grades of well, moderately, and poorly differentiated, respectively. No correlation between the grade of individual morphologic variables and response to chemotherapy was demonstrated, or between tumor response and cumulative score groups. There was no correlation of the grade of individual morphologic variables or cumulative score groups with survival. Only the survival of patients achieving a complete response to chemotherapy was correlated with the cumulative score groups: 2-year survivals of 84%, 70%, and 46% for less than 12, 12 to 18, and greater than 18, respectively. Multi-parameter analysis of individual features of tumor differentiation is not superior to conventional morphologic analysis in predicting response to chemotherapy or survival in patients with advanced SCCHN.

Induction VBM plus radiotherapy, versus radiotherapy alone for advanced head and neck cancer: long-term results

Between 1978 and 1981, 85 patients with advanced squamous cell carcinoma of the head and neck were randomized to receive induction VBM followed by radiotherapy, or radiotherapy alone. The shortest follow-up is thus 6 years. The median survival of patients receiving induction chemotherapy was 46 weeks, that of the radiotherapy group alone was 75 weeks. As the two groups were not balanced despite randomization, multivariate methods (GLIM) were used to identify significant prognostic factors. These were: response to radiotherapy (P less than 0.001), nodal status (P less than 0.001), age (P less than 0.01), and histological grade (P less than 0.01). Neither treatment with, nor response to, chemotherapy had a significant effect on survival.

A combined treatment for advanced oral cavity cancers

Effects of preoperative chemotherapy with three courses of a combination of bleomycin, vincristine, mitolactol, prednisone, and methotrexate, with a leucovorin rescue, followed by surgery were studied in 43 patients with advanced squamous cell carcinoma of the oral region. Before chemotherapy 34 patients (79%) had Stage III or IV carcinomas whereas nine patients had Stage II lesions. The clinical response was very encouraging: 20 patients (46%) achieved a clinical complete response and 23 patients (54%) were judged as partial responders. Side effects of this chemotherapy were minimal and reversible. Between 15 and 22 days after the last course of chemotherapy patients went to surgery. Wound healing complications did not occur. The surgical specimens were tested microscopically. The microphotographs showed small tumor rests with giant cells bordered by fibrous scar tissue and separated from the healthy tissues. With a median follow-up of 36 months (range, 21-58 months) 74% of patients are alive and 70% remain disease-free. Eleven patients died but only five (11%) because of the failure of therapy. This combined therapy appears both safe and promising treatment for advanced squamous cell carcinomas of the oral cavity. A further follow-up study needed to confirm the promising 5-year results.

The application of a two-stage design for clinical trials in patients with recurrent head and neck cancer

Cytotoxic chemotherapy produces modest benefits for patients with recurrent and metastatic squamous cell carcinoma of the head and neck (SCCHN). Prospective randomized clinical trials have failed to demonstrate unequivocal superiority of aggressive multidrug regimens over single agents. Despite this, phase II trials frequently result in encouraging preliminary observations that compare favorably to historical single-agent data. While providing for a useful method of screening for anti-tumor activity, phase II studies have limited use in determining the relative value of a new treatment program. Results of phase II studies are considerably influenced by patient selection factors and criteria used to establish therapeutic benefits (responses). Furthermore, estimations of true levels of efficacy (response rates) are dependent on sample sizes, which are usually limited in such trials. We propose that newly developed combinations containing at least one known active agent in this disease should be tested in a controlled setting after their toxicity pattern has been well established. The conduct of the usual phase II study in these situations will probably not provide useful new information, since responses are likely to be observed. We describe a two-stage design applied to terminate a trial if at the first stage there is no evidence of improvement over the control arm. This method allows for early termination of studies involving relatively inefficient treatment regimens and, at the same time, continuation of those with a high likelihood to result in significant therapeutic improvements over a control arm. Loss of power is negligible and sample sizes can be reduced significantly. The rationale behind this method and its simplicity are attractive features for a widespread application for new drug development strategies in this and other diseases.

Chemotherapeutic management of head and neck cancer

The use of chemotherapy in patients with head and neck cancer is increasing. In patients with recurrent head and neck cancer, a large number of chemotherapeutic drugs have shown antitumor activity. These drugs are discussed, and factors which influence response rate and survival are examined. New agents and treatment, including specific agents for combination chemotherapy, are presented. There has been a search for new treatments or procedures in patients with previously untreated and locally advanced cancer of the head and neck. The results, including studies of combined modality therapy and chemotherapy after surgery, are discussed. Chemotherapy in tumor of the salivary glands is briefly discussed, followed by an examination of intra-arterial therapy.

Factors predicting response of end stage squamous cell carcinoma of the head and neck to cisplatinum

Cisplatinum significantly prolongs survival in end stage head and neck cancer but only 30-40% of patients respond. Many receive chemotherapy with little or no benefit and it would obviously be advantageous to determine in advance those patients likely to benefit. In 2 phase III trials of chemotherapy in end stage disease, 129 patients have been treated with cisplatinum, either alone or in 2-drug combination with bleomycin, methotrexate or 5-fluorouracil. Factors analysed in the entire group were age, sex, site, previous treatment, performance status and the use of cisplatinum in combination. A high albumen and oro- or nasopharyngeal site were significantly favourable, while a hypopharyngeal, middle ear, skin or paranasal site were all significantly unfavourable. In the separate analysis of the subgroup with recurrent disease, site of recurrence and time to recurrence were analysed in addition to the factors named above. Although similar trends to those in the entire group were observed none reached significant levels. In the subgroup with advanced previously untreated disease, histological grade was analysed in addition to the above factors. Good performance status emerged as significantly favourable. The emerging trends provide some insight regarding outcome but are not sufficiently clearcut to allow a decision to be made on who should and who should not be treated.

Combination of surgery, irradiation, and hyperthermia in treatment of recurrences of malignant tumors

Management of recurrent tumors after initial treatment by surgery, radiotherapy, and sometimes chemotherapy is a formidable challenge. Proximity of tumor to critical organs (e.g., carotid artery in recurrent head and neck tumors) often makes radical surgery impossible. Prior definitive course of radiation therapy precludes delivering a second radical course of irradiation. In the Division of Radiation Oncology, Washington University, we have used combined postoperative hyperthermia and modest dose radiotherapy to treat 23 patients with recurrent tumors and postoperative residual disease. Generally, 3200 to 4000 cGy was delivered in eight to ten fractions in 4 to 5 weeks, in combination with eight to ten sessions of minimum tumor heating to 42.5 degrees to 43 degrees C for 60 minutes, twice a week as stated in the results. Follow-up period was one to 5+ years. Of the 23 patients treated, only three failed within the treatment volume.

Phase II clinical trial of the combination VP-16, bleomycin, and cis-diamminedichloroplatinum in patients with advanced upper aerodigestive squamous cell carcinoma

Fifteen patients with advanced upper aerodigestive carcinomas of squamous cell histology received the three-agent cytotoxic regimen of VP-16, bleomycin, and cis-diamminedichloroplatinum (CDDP) administered as a continuous 120-h infusion. The objective response rate was 40%. Median times to progression and survival were 3.2 months and 4.3 months, respectively. Hematologic and gastrointestinal toxicities were relatively transient and manageable. Our experience indicates that this three-drug program does not offer a substantial therapeutic advantage compared with more conventional single agent cytotoxic approaches for advanced head and neck cancer.

The effect of chemotherapeutic agents on human oral squamous cell carcinoma transplanted to nude mice: a histologic study

Clearly differentiated squamous cell carcinomas were transplanted to the backs of nude mice; tumor cells of a human tongue carcinoma cell line were used. Animals bearing tumors that measured at least 4 mm in diameter were treated with either methotrexate (MTX), cis-diamminedichloroplatinum II (CDDP) or bleomycin intraperitoneally for 5 days. Histologic evaluation of tumors obtained 24 hours after the last injection revealed degenerative and necrotic morphology in all treatment groups. The histologic alterations were observed prior to any clinical evidence of tumor shrinkage. The most impressive changes were found in CDDP-treated tumors, with creation of large pseudocysts containing necrotic material and cell debris. Pseudocyst formation was less obvious in MTX-treated animals and was absent in bleomycin-treated tumors. Drug treatment had no obvious influence on the keratinization in tumors. The findings suggest that the nude mouse model may be useful for the histologic determination of drug-induced effects on tumors in human beings.

Induction therapy in head and neck cancer. A comparison of two regimens

Seventy-two patients with advanced resectable head and cancer received two courses of induction chemotherapy before definitive therapy. Forty-six patients were treated with platinol, Oncovin (vincristine), and bleomycin. Twenty-six received Platinol (cisplatin), Velban (vinblastine), and 5-fluorouracil (5-FU). Although both regimens had an overall response rate of 80% or more, the bleomycin-containing regimen had a higher complete response rate and better long-term disease control, with greater than 60% probability of remaining disease-free (36 month minimum follow-up). As given in this regimen, the 5-FU regimen was well tolerated but had a higher incidence of stomatitis and a low rate of complete responses. When the two regimens were compared to a historical control, the regimen with Platinol, Oncovin, and bleomycin was significantly better.

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 phase II clinical trial of the combination mitomycin C, adriamycin, and cis-diamminedichloroplatinum in patients with advanced upper aerodigestive cancer

Twenty-seven patients with assessable, regionally advanced, or metastatic upper aerodigestive cancer of diverse histology received a combination of mitomycin C, adriamycin, and cis-diamminedichloroplatinum. All patients had previously received extensive surgery and/or radiation therapy. We observed an overall 46% partial response rate (12/26). This included seven of 15 (47%) responders with squamous cell carcinoma. Six of those seven patients responded within the initial month of treatment. For all study participants, the median time to progression and survival was 3.8 months and 7.3 months, respectively. Moderate-to-severe nausea, vomiting, anorexia, and alopecia were the most common toxicities. Myelosuppression (WBC less than 4,100 cells/mm3) and thrombocytopenia (PLTS less than 130,000 cells/mm3) occurred in 100% and 71% of the 21 patients with nadir data recorded, respectively. There were no episodes of sepsis nor did we detect any meaningful impairment in renal function. This regimen is active in the previously treated head and neck cancer patient and can be conveniently administered on an outpatient basis with acceptable and manageable side effects.

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.

Three-year results of combined modality therapy in locally advanced, resectable squamous cell carcinoma of the head and neck

Results of a combined therapy, consisting of preoperative chemotherapy, radical resection and postoperative irradiation, of 51 locally advanced, previously untreated, resectable squamous cancers of the head and neck are reported. The overall response rate to chemotherapy was 58.5% (with 33% complete remissions) and higher in carcinomas of the oral cavity and hypopharynx than of the supraglottis and oropharynx. Three year survival was 53% for the entire group, 75% for hypopharyngeal, 58% for oral, 50% for supraglottic and 32% for oropharyngeal lesions, in responders to chemotherapy statistically significant higher than in non responders and only 18% in the fifteen patients who developed recurrences.

Predictive factors for tumor response to preoperative chemotherapy in patients with head and neck squamous carcinoma. The Head and Neck Contracts Program

The high tumor response rates associated with intensive chemotherapy in previously untreated patients with advanced head and neck squamous cell carcinoma (HNSCC) led to the initiation of a multi-institutional National Cancer Institute trial. This trial used preoperative chemotherapy in patients with resectable Stage III and IV squamous cell carcinoma of the oral cavity or larynx/hypopharynx. Response rates, toxicity, and a variety of patient and tumor characteristics were analyzed to determine which factors might be useful in predicting tumor response to preoperative chemotherapy. Two hundred eighty-two patients received one course of preoperative cisplatin and bleomycin chemotherapy and were evaluable. There were 22 complete responses (CR) and 114 partial responses (PR) at the primary site (48% response rate). Of 197 patients with clinically positive regional adenopathy, 29 CRs and 73 PRs were observed (52%). Toxicity associated with the chemotherapy regimen was minimal. Primary tumor and regional node responses to chemotherapy were strongly correlated. No significant differences were found in primary or nodal response rates with respect to differing tumor site, stage, histologic differentiation, patient performance status, nutritional status, leukocyte count, hemoglobin level, age, sex, or alcohol use. Primary tumor response, however, was significantly related to T classification (P = 0.048). Nodal response was strongly associated with N classification and nodal size (P = 0.02 and P = 0.075, respectively). These findings suggest that, of the patient and tumor characteristics analyzed, none were more useful in predicting tumor response than clinical tumor staging parameters.

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.

Chemotherapy strategies in squamous cell carcinoma of the head and neck

Traditionally, chemotherapy has been utilized in the palliation of patients with recurrent or metastatic squamous cell carcinoma of the head and neck. The introduction of more effective agents has spawned many new multi-drug protocols as the initial therapy of patients with previously untreated advanced cancers (Stages III and IV). The combination of cis-platinum and other active agents given in two to three courses has produced overall response rates of 80 to 90% with clinically complete response rates of 20 to 54%. Many of the complete responders were histologically negative for cancer at the time of resection. The number of courses, stage (T and N), and tumor morphology influenced the complete response rate to combination chemotherapy. Responders to chemotherapy had statistically improved survival as compared to nonresponders. Response to chemotherapy was an excellent predictor for subsequent response to radiotherapy. Utilizing the same combination of chemotherapy, we improved the overall response rate in those patients with recurrent and systemic cancer. Although the median survival is still poor, there is improvement of survival at 25 percentile level. Some of the important factors that may influence the response rate and the survival of these patients are performance status, previous radiotherapy, and whether the recurrence is localized or systemic.

Retreatment of recurrent carcinoma of the head and neck by afterloading interstitial 192Ir implant

From January 1975 to December 1980, 25 patients with persistent or recurrent carcinomas of the head and neck were retreated for palliation at the Division of Radiation Oncology, Mallinckrodt Institute of Radiology. These patients had all undergone extensive previous treatment by surgery and/or radiation. All were retreated with 192Ir interstitial implant with or without external radiation and/or surgical excision. Of 25 patients, 13 had complete response (CR) and 6 had partial response for a follow-up period of 1 to 7 years. Of 13 patients with CR, 6 are alive with no evidence of disease (NED) and two died NED. We present detailed results and discuss our new strategy for such patients.

Non-Platinum-Containing Combination Chemotherapy for Stage III-IV Head and Neck Squamous Carcinoma

From May 1980 to November 1981, 51 consecutive patients with locally advanced, recurrent or metastatic head and neck squamous carcinoma were treated with 2 successive outpatient chemotherapeutic regimens including adriamycin, cyclophosphamide, vincristine, bleomycin, methotrexate and 5-fluorouracil with or without mitomycin-C. A 34% objective response rate was obtained with acceptable toxicity and good patient compliance. The presence of mitomycin-C did not influence response rate. Median survival was 9 months.

A randomized trial of the combination of cis-platinum, oncovin and bleomycin (COB) versus methotrexate in patients with advanced squamous cell carcinoma of the head and neck

A prospective randomized trial was conducted at Wayne State University, Detroit, Michigan, to compare the efficacy of the combination of high-dose cis-diamminodichloroplatinum, Oncovin (vincristine) and bleomycin (COB) to that of weekly methotrexate (MTX) in the induction and maintenance of remission in patients with previously treated advanced squamous cell carcinoma of the head and neck. Complete response (CR) was observed in 11.1% of patients treated with COB and in 8.3% of patients treated with weekly methotrexate. The overall response rate (PR + CR) was 33.3% to methotrexate versus 40.7% to COB. This difference was not significant, nor was the survival of patients treated by either modality. Important variables affecting survival in this study proved to be good performance status (greater than or equal to 70) and response to therapy. Nausea and vomiting were the more common side effects of COB (56%), while hematologic toxicity was more frequent and more severe in the methotrexate arm (75%). Combination chemotherapy with COB is not more effective in producing response or prolonging survival than weekly methotrexate in patients with advanced head and neck carcinoma when both regimens are compared in a randomized study.

Intensive sequential chemotherapy with bleomycin, Oncovin, mitomycin C, and methotrexate followed by adriamycin, cisplatin, and cyclosphosphamide in squamous cell cancer of the head and neck

Twenty-six patients with advanced squamous cell cancer of the head and neck were treated with bleomycin, Oncovin, mitomycin C, and methotrexate (BOMM) for ten weeks. Partial and nonresponders then received adriamycin, cisplatin, and cyclophosphamide (APC) in a planned sequential program. The response rate to BOMM was 65% (19% complete remission, CR). The overall response rate to APC was 20%. Only three of eight nonresponders to BOMM could receive APC and non responded. Six of seven partial responders received APC and only one responded. One complete responder to BOMM received APC at relapse and attained a partial response. The major side effects of BOMM were mucositis and myelosuppression. Patients receiving methotrexate 60-72 hours following the bleomycin infusion had less myelosuppression than patients who were treated 36-42 hours after bleomycin. The toxicities with APC included nausea, vomiting, and myelosuppression. Including a prior series, a total of 45 patients have been treated with BOMM with a 71% response rate (69% in previously irradiated patients). Twenty-eight percent of previously treated patients achieved complete remission, and two of these patients are disease free at 31 and 37 months. Methotrexate dose-rate alteration to low dose twice weekly followed by a single dose of oral leucovorin did not improve the complete or partial response rate when compared to weekly methotrexate administration. The complete remission rate and response duration were also not improved by the planned sequential use of this cisplatin-containing regimen.

Vinblastine, bleomycin and cisplatin for recurrent or metastatic squamous cell carcinoma of the head and neck

Forty-two patients with recurrent or metastatic squamous cell carcinoma of the head and neck were treated with vinblastine, bleomycin, and cisplatin. All patients had received prior surgery, radiation or chemotherapy and all had measurable disease. Forty-five percent of the patients responded with a median duration of response of eight months and median survival of nine months. Six patients (14%) were complete responders and had a median duration of response of 12 months and median survival of 24+ months. Thirteen patients (31%) were partial responders and had a median duration of response of seven months and survival of 13 months. Toxicity was mild with nausea and vomiting occurring in all patients after cisplatin. There were two cases of bleomycin-induced pulmonary fibrosis and two cases of mild renal insufficiency (creatinine clearance level, 45 cc/min). This regimen compares favorably with other published regimens for advanced head and neck cancer.

A randomized comparison of radiotherapy with a radiotherapy--chemotherapy combination in stage IV carcinoma of the head and neck

Between 1975 and 1978, 23 patients with Stage IV, unresectable, squamous cell carcinoma of the head and neck were randomized to receive radiotherapy (RT, 11 patients), or radiotherapy-chemotherapy (RT & CT, 12 patients). The response rate for the 12 RT & CT patients was four complete remissions (CR) and four partial remissions (PR); the 11 RT patients had one CR and three PR. The presence of a responses (CR or PR) significantly enhanced the median survival (14 vs. 5 months; P = 0.005). The duration of objectives remission was longer among the RT & CT patients when compared with RT patients (6 vs. 2.3 months, P = 0.18). The median survival of the RT & CT group was 12 months compared with 5.6 months for the RT group (P = 0.13). One RT & CT patient remains alive with disease at 44 months, one RT patient remains alive without disease at 30 months. The present chemotherapy regimen did not modify the pattern of failure and only marginally increased patient survival. It did, however, increase the response rate. The authors plan to reactivate the trial with modification in the induction chemotherapy and the addition of postradiation maintenance CT consisting of sequential bleomycin and cis-platinum.

Prognostic indicators in induction cis-platinum bleomycin chemotherapy for advanced head and neck cancer

A complete response to induction cis-platinum bleomycin chemotherapy significantly increases the probability of local tumor control and overall disease-free survival. Factors that favor a good response to chemotherapy are tumor histology (well differentiated), location of the primary site (oral cavity and oropharynx), nodal status (N0) and size of the primary lesion (t3 better than T4). Increased cellular maturation after chemotherapy correlates with an improved clinical response. The importance of induction and maintenance chemotherapy in the treatment of advanced head and neck cancer still needs to be determined with larger randomized series. Reliable predictors of therapy outcome are needed for realistic treatment planning, especially when the potential morbidity is considered.

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.