Preliminary trial of combination therapy with adriamycin and radiation in sarcomas and other malignant tumors

Treatment of soft tissue sarcoma: a European approach

This article discusses the treatment of adult soft tissue sarcoma (excluding gastrointestinal stromal tumor), analyzing the principles underlying treatment and the results of surgery, radiotherapy, and chemotherapy. The focus is on the European approach in particular, and ongoing studies are summarized.

[Chemotherapy of soft tissue sarcoma in the adult]

The goal of postoperative treatment in adult soft tissue sarcoma is local control, and in high-risk patients prevention of distant failures. Radiation therapy is essential after non-radical surgery. The role of adjuvant chemotherapy on improvement of overall survival remains to be evidenced; however, recent meta-analysis data have confirmed its impact on both local and metastatic evolution of the disease. Because for both radiotherapy and chemotherapy, delay of treatment may be crucial for efficacy following tumor excision, concomitant radiochemotherapy should be considered. Review of the literature as well as personal results showed the feasibility of postoperative radiochemotherapy in adult soft tissue sarcoma, even when the chemotherapeutic associations used included an anthracycline. Prospective study of radiochemotherapy should be performed in order to assess its real impact in terms of efficacy and toxicity.

Preoperative multimodality treatment for soft tissue sarcomas

BACKGROUND

Frequently, soft tissue sarcomas (STS) do not present until they are large, thus making local control difficult. Consequently, different methods of preoperative cytoreduction should be evaluated.

METHODS

This study evaluated a 10-day preoperative regimen of intraarterial doxorubicin (10 mg/m2/d), with concomitant radiation therapy (25 Gy), administered to 55 adult patients with either Stage T2 (n = 41) or distal Stage T1 (n = 14) STS. Seven of the tumors were low grade. All patients were treated by the Division of Surgical Oncology at the University of Illinois between 1978-1991.

RESULTS

This regimen was successful and obviated the need for amputation in 47 patients who underwent wide soft tissue excision, an initial limb-salvage rate of 87%. Complications related to the therapy occurred in 26% of patients, which resulted in additional operative procedures in 7%. The mean follow-up time was 94 months. The 5-year overall survival rate was 69%, with a disease-free survival rate of 51%. Local control was unsuccessful in 15% of the patients. Three additional patients required amputation for recurrent disease (n = 2) or complications of therapy (n = 1), resulting in an ultimate limb-salvage rate of 81%.

CONCLUSIONS

The long-term results of this preoperative protocol for adults with limb-threatening STS appears to justify the utilization of a multimodality approach. This preoperative regimen was useful in minimizing limb loss in patients with limb-threatening STS. However, intraarterial doxorubicin administration is associated with significant morbidity, and its role in multimodality treatment of STS requires further clarification.

Intra-arterial cisplatin with or without radiation in limb-sparing for canine osteosarcoma

METHODS

Forty-nine dogs with spontaneously occurring osteosarcoma underwent limb-sparing surgery after preoperative therapy consisting of intra-arterial cisplatin alone or intra-arterial cisplatin in combination with doses of radiation from 20-40 Gy in 10 fractions. All resections were marginal, and the defect was repaired with a cortical allograft.

RESULTS

Local tumor control was strongly influenced by the percent necrosis in the excised specimen. Overall, the estimated 1-year local recurrence rate was approximately 32% (by life-table estimate). Dogs with less than 75% necrosis had an estimated 1-year recurrence rate of 65%; those with greater than 75% necrosis had an estimated 1-year recurrence rate of 15% (P = 0.004, by log-rank test). Local recurrence was influenced by the radiation dose. Dogs receiving 28 Gy or less had an estimated 50% 1-year recurrence rate, and those receiving 32 Gy or more had an estimated 8% 1-year recurrence rate (P = 0.03, by log-rank test). Normal host bone more frequently became necrotic at doses of 36 Gy or more.

CONCLUSIONS

Intra-arterial cisplatin in combination with moderate doses of radiation (32 Gy) can achieve a high percent tumor necrosis while maintaining host bone viability. Survival was limited by distant metastasis but was lengthened by treatment compared with some earlier findings.

Concomitant continuous infusion chemotherapy and radiation

Attempts to duplicate the cytotoxic effect of oxygen on radioresistant tissues spurred a search by radiation oncologists for other radiosensitizing techniques. This led to large-scale investigations using neutrons and other heavy particle radiations, hyperthermia, altered fractionation schedules, and the systemic use of the halogenated pyrimidines and the electron-affinic compounds. Unfortunately, the promise that the nitroimidazole compounds would selectively sensitize the radioresistant tumor cells and prove to be an effective systemic agent has not been borne out in clinical trials thus far. Existing pharmokinetic and cytokinetic studies have suggested that continuous infusion chemotherapy given concomitantly (CCIC) with irradiation (RT) acts synergistically, resulting in a significant increase in tumor cell killing. These observations have been supported by clinical research studies treating certain epithelial cancers that have resulted in considerably higher locoregional control rates and improved survival. Although initially used in treatment of only advanced or inoperable epithelial carcinomas, CCIC and RT are now being employed in the treatment of lower staged cancers as an organ-sparing procedure. Carcinoma of the anus treated by anteroposterior (AP) resection alone have reported 5-year survival rates of 30% to 60%. CCIC and RT using 5-fluorouracil (5-FU) and mitomycin C have achieved a local control rate of 90% to 100% and a 5-year survival rate of 80% to 86% with sphincter preservation in 90% of these cases. The 5-year survival rate in advanced urinary bladder carcinoma is 25% to 30% for either radiation or surgery and 42% when combined in a preoperative radiation schedule. Using 5-FU CCIC and RT, the local control rate of transitional cell carcinoma of the bladder has been 71% to 86% with a 5-year survival of 62%. 5-FU CCIC and cisplatin and RT used in the treatment of Stages III and IV carcinoma of the cervix yields a locoregional control of 74% compared with the radiation alone local control of 63% for Stage III and 30% for Stage IV disease. Advanced head and neck and paranasal sinus carcinomas treated by cisplatin CCIC and RT show improved tumor clearance even in the presence of bone destruction. A complete response rate of 87% has been reported with the use of cisplatin CCIC and hyperfractionated radiation. Hyperfractionated radiation also appears to improve the local control of advanced head and neck cancers over patients treated with single fractions of radiation with 66% surviving at 22 months.(ABSTRACT TRUNCATED AT 400 WORDS)