Solid tumor models for the assessment of different treatment modalities. XXI. Comparison of different radiation dose schedules alone or in combination with cyclophosphamide

Effect of hyperthermia and X-irradiation on survival and occurrence of metastases in mice bearing P388 tumor

Survival of P388 lymphoid tumor-bearing mice and the occurrence of metastasis was studied after combined modality treatment with hyperthermia and X-irradiation. P388 ascites tumor cells were treated at 42 degrees C or 43.5 degrees C for 1 hr in vitro and transplanted on B6D2F1 mice intraperitoneally (i.p.) or intramuscularly (i.m.). Hyperthermic treatment at 43.5 degrees C increased the median survival time (MST). Increased life-span (ILS) was found after i.p. transplantation (54%) and after i.m. transplantation (30%). During the life-span of tumor-bearing animals, significantly fewer metastases were observed in liver and spleen after hyperthermia and 5-10% metastasis occurred after transplantation of ascites tumor cells treated at 43.5 degrees C in vitro compared with 90% in the untreated control animals. The lower occurrence of metastasis could not be ascribed to the higher cell-killing effect of hyperthermia. When both modalities were combined the best tumor growth retardation effect was obtained when ascites tumor cells were treated at 43.5 degrees C for 1 hr before being transplanted i.m. and 1 day later locally X-irradiated with 6 Gy. In this case, 77% ILS was found demonstrating a synergistic effect of the two modalities. While X-irradiation alone did not change the occurrence of metastasis, after combined modality treatment it was as low as with hyperthermia alone (5-10%). In connection with the significantly lower occurrence of metastasis, the possible alterations of P388 tumor cell membrane and surface proteins induced by in vitro hyperthermic treatment are discussed.

Experimental studies on interactions of radiation and cancer chemotherapeutic drugs in normal tissues and a solid tumour

The interactions of radiation and seven cancer chemotherapeutic drugs have been investigated in four normal tissues (intestinal crypts, skin, haemopoietic tissue and lung) and in a solid C3H mouse mammary carcinoma in vivo. All experiments were carried out with male C3D2F1 mice. The investigated drugs were adriamycin (ADM), bleomycin (BLM), cyclophosphamide (CTX), 5-fluorouracil (5-FU), methotrexate (MTX), mitomycin C (MM-C) and cis-diamminedichloroplatinum(II) (cis-DDP). Single drug doses were given at different intervals before, simultaneously with and after single doses of radiation. The normal tissue reactions following drug-radiation combinations were found to be highly complex. The interactions varied both quantitatively and qualitatively from drug to drug and from tissue to tissue. The drugs enhanced the radiation response in most cases. However, signs of radioprotection was observed for CTX in skin and for MTX in haemopoietic tissue. The interval and the sequence of the two treatment modalities were of utmost importance for the normal tissue reactions. In general, the most serious interactions occurred when drugs were administered simultaneously with or a few hours before radiation. The radiation-modifying effect of the drugs deviated from this pattern in the haemopoietic tissue as the radiation response was most enhanced on drug administration 1-3 days after radiation. Enhancement of the radiation response was generally less pronounced in the tumour model than in the normal tissues. The combined drug-radiation effect was apparently less time-dependent in the tumour than in the normal tissues.

Advances in pediatric radiotherapy in the last ten years and future proposals

Advances made can be divided into five main categories. Firstly, the problem of geographic miss which has been reduced by delivering effective radiation doses with greater precision. This has been accomplished with more sophisticated diagnostic and therapeutic equipment, immobilization techniques and computerized treatment planning. Second is the recognition of the interplay of radiation and chemotherapy on normal tissue tolerance and local tumor control. This interaction has necessitated reduction in both dose and volume of irradiation. Third is the use of wide field irradiation as a systemic treatment. Fourthly, the utilization of cooperative group trials to define the role of irradiation. Finally, with the improvement in survival has come the recognition of late effects of irradiation in the growing child and the means of reducing such effects. The current role of radiation therapy in childhood malignancies is summarized, controversies are identified, and future prospects explored.

Solid tumor models for the assessment of different treatment modalities: XXIII. A new approach to the more effective utilization of radiotherapy alternated with chemotherapy

This study with the rat hepatoma 3924A demonstrated the marked improvement in tumor cure rates and control of tumor growth that can be achieved by the addition of cyclophosphamide (CP) to multiple fractions of radiation per day (MFD) schedules given intermittently. MFD radiation was delivered over a 2-day period followed by CP (150 mg/kg or 0.9 g/m2) 1 day later; this combined course was repeated at 11-day intervals (to allow for gastrointestinal tract and bone marrow recovery) for a total of 3 courses over a 23-day period. Cure rates of 30, 50 and 60% were achieved with total radiation doses of 4500, 6000 and 7500 rad, respectively, when the MFD radiation was given with CP. No cures and no complete responses were realized when the same intermittent MFD schedules for radiation were employed up to 9000 rad without CP. Other groups of 10 animals each were treated with daily fractions of 100, 150, 188, 250 and 375 rad given on days 0-9, 11-20 and 22-31. A 150 mg/kg or 0.9 g/m2 dose of CP was given after each course of daily radiation on days 10, 21 and 32 in the combined treatment groups. No complete responses or tumor cures occurred with radiation alone given daily for total radiation doses, which were increased from 3000 to 11,250 rad. Only the highest radiation dose given, 375 rad per day to a total of 11,250 rad, resulted in a complete response rate and tumor cure rate of 50% when CP was added. The addition of CP to the daily fractionation schedules reduced the total dose needed to give a growth delay of 100 days by 39% (5600 rad versus 9200 rad). The addition of CP to the intermittent MFD schedules further reduced the total dose needed to give a growth delay of 100 days to 4200 rad. Major improvements in some types of cancer treatment may be realized if we can develop clinical protocols for the alternate use of chemotherapy and radiotherapy as we have done successfully in our experimental program. The finding that intermittent MFD radiation schedules are as effective as daily schedules when given alone suggests that greater flexibility of patient management in clinical radiotherapy may be possible without a major loss of therapeutic effectiveness. These alternated fractionated schedules offer the possibility of optimizing treatment in terms of patient convenience and economy as well as the potential for improving the effectiveness of the interaction of radiotherapy with radiosensitizers, radioprotectors, and hyperthermia in addition to chemotherapy.

Biological basis for the interaction of chemotherapeutic agents and radiation therapy

The ultimate goal of combining chemotherapy and radiotherapy is to improve the therapeutic ratio. When chemotherapy is combined with radiotherapy, improved therapeutic effects may occur as a result of the following: (1) spatial cooperation; (2) enhancement of tumor response with less or no enhancement of normal tissue injury, and (3) diminution of normal tissue injury with less or no diminution of tumor response. Possible mechanisms of interaction between chemotherapeutic agents and radiation that result in an enhanced effect include (1) changes in the slope of the dose response curve, (2) decreased accumulation or inhibition of repair of sublethal damage, (3) decreased recovery from potentially lethal damage, (4) perturbation in cell kinetics with an increase of proportion of cells in the sensitive cell cycle phase and proliferative state, (5) decreased tumor bulk and improved blood supply leading to reoxygenation and recruitment and increased radiosensitivity and chemosensitivity, and (6) increased drug delivery and uptake. The combined effects may be influenced by (1) tumor and normal tissue type, (2) drug type, (3) drug dose and schedule, (4) time sequence between drug and radiation administration, (5) radiation dose and fractionation schedule, and (6) radiation dose rate. Most experimental and clinical data suggest that enhanced tumor effects most often result from simple additivity and therefore do not require direct interaction between drug and radiation, whereas enhanced normal tissue effects are observed most often when drugs are administered in close temporal proximity to radiation. Thus, for the optimal therapeutic effect, it would seem more advantageous to administer chemotherapeutic drugs and radiation in a sequential or alternating manner rather than simultaneously.

Interactions of radiation and cancer chemotherapeutic drugs in a C3H mouse mammary carcinoma

The interactions of radiation and adriamycin (ADM), bleomycin (BLM), cyclophosphamide (CTX), 5-fluorouracil (5-FU), methotrexate (MTX), mitomycin C (MM-C), or cis-diamminedichloroplatinum II (cis-DDP) were studied in a spontaneously arisen C3H mouse mammary carcinoma. The tumour response to drugs alone was evaluated by measuring the tumour to reach a volume 5 times that of the treatment day. CTX resulted in a marked tumour growth delay whereas the other drugs had a modest or uncertain effect. In the combined treatment experiments, drugs were administered as single doses either 15 min before or 4 hours after graded single doses of irradiation. The end point for each treatment was the radiation dose which on an average was required to achieve local tumour control in 50 per cent of the mice (TCD50). The dose effect factor (DEF) was 1.16 for ADM and 1.17 for CTX, the enhanced radiation response being independent of administration before or after irradiation. MM-C also decreased the TCD50 for radiation alone, but its effect was more marked 15 min before (DEF 1.32) than 4 hours after irradiation (DEF 1.18). BLM, 5-FU, MTX, and cis-DDP had no effect on the radiation response neither when administered 15 min before nor 4 hours after irradiation.

Solid tumor models for the assessment of different treatment modalities. XXII. The alternate utilization of radiotherapy and chemotherapy

Major increases in the time between administration of two modalities, radiation and cyclophosphamide (CP), from 1 to 7 days and in the overall time of delivery of 3 courses of combined therapy from 24 to 35 days were carried out in rats with hepatoma 3924A without major loss of therapeutic effectiveness. Cure rates of 50% or greater could be maintained even though treatment was given over much longer time periods. The radiation was given as hyperfractionated, split-course schedules which were devised by increasing the number of 250 rad fractions over a 2-day period. In one series of experiments these 2-day schedules were given at 11-day intervals for 3 courses on days 0 and 1, 11 and 12, 22 and 23; and CP (150 mg/kg) was given 1 day after each of the 3 radiation courses on days 2, 13, and 24. In the second series of experiments radiation was given on days 0 and 1, 14 and 15, 28 and 29; and this was alternated with 3 single doses of CP given 1 week after each of the 3 courses of radiation, on days 7, 21 and 35. Increasing the total radiation dose from 6000 to 7500 rad in the series given CP 1 day after each of three courses of radiation results in an increase in total tumor cure rates from 50% to 60%. The tumor cure rate in the series given CP 7 days after radiation increased from 10% to 70% when the total radiation dose was increased from 6000 to 7500 rad. Increasing the total radiation dose from 6000 to 7500 rad increased the magnitude of the acute skin reaction as well as the duration of recovery. However, the skin reactions for both the 6000 and 7500 rad were acceptable. Host toxicity and normal tissue reaction were within acceptable limits for both modalities. The results of these studies, therefore, indicate that excessive toxicity, one of the major deterrents to the effective combined utilization of these two primary means of cancer management, may be avoided by temporal separation of delivery while maintaining tumor cure rates of 50% or greater.