Seven-drug polychemotherapy in the treatment of advanced and recurrent squamous carcinoma of the female genital tract

Chemotherapy for advanced or recurrent cervical cancer

The primary treatment options for cervical cancer are surgery and radiation for more than a century. However, over the last 40 years chemotherapy has been building up its reputation in the management of cervical cancer in various forms such as chemoradiation, neoadjuvant chemotherapy, and palliative chemotherapy for advanced or recurrent disease. Among these, in this review, chemotherapy for advanced or recurrent cervical cancer will be discussed.

Bleomycin, methotrexate, and CCNU in locally advanced or recurrent, inoperable, squamous-cell carcinoma of the vulva: an EORTC Gynaecological Cancer Cooperative Group Study. European Organization for Research and Treatment of Cancer

OBJECTIVE

To investigate tumor response rate and treatment toxicity of a modified combination chemotherapy consisting of bleomycin (B), methotrexate (M), and CCNU (C) for patients with locally advanced, squamous-cell carcinoma of the vulva (not amenable to resection by standard radical vulvectomy) or recurrent disease (after incomplete resection). Tumor resectability was reassessed in patients who had responded to chemotherapy.

METHODS

The regimen consisted of bleomycin 5 mg intramuscular (im) days 1-5, CCNU 40 mg per os (po) days 5-7, and methotrexate 15 mg po days 1 and 4 during the first week. During weeks 2-6 the patient was administered bleomycin 5 mg im days 1 and 4, and methotrexate 15 mg po on day 1 of the week. This 6-week cycle was repeated at 49-day intervals.

RESULTS

Twenty-five eligible patients with a median age of 66 years (range, 39-82 years) were entered in this phase II trial. Twelve patients had primary locally advanced disease, 13 patients had a locoregional recurrence, and all received up to three BMC cycles. Two complete and twelve partial responses were observed (response rate, 56%; 95% confidence limits, 35-76%). The BMC regimen was associated with major hematological side effects and mild signs of bleomycin-related pulmonary toxicity. At a median follow-up of 8 months, 3 patients were alive, 18 had died due to malignant disease, 2 had died due to toxicity, and 2 had died due to intercurrent disease and unknown cause. The median progression-free survival was 4.8 months and the median survival was 7.8 months. The 1-year survival was 32% (95% confidence limits, 13-51%).

CONCLUSION

The present data confirm the therapeutic activity of the BMC regimen in locoregionally advanced or recurrent squamous-cell carcinoma of the vulva. Following neoadjuvant chemotherapy, the overall response rate was 56%. BMC is an outpatient treatment that may play a role in the palliative therapy of advanced or recurrent vulva cancer.

Chemotherapy for advanced and/or recurrent cervical cancer

A combination of bleomycin, vincristine, mitomycin-C, and cisplatin was used to treat 39 patients with advanced and/or recurrent cervical cancer. Twenty patients showed an objective response (complete or partial) with a mean duration of 14.8 months. The overall response rate was 58.8%. Twelve patients are still alive and in remission 7-36 months after the start of chemotherapy. Toxicity was acceptable.

Tumor cell kinetics-directed chemotherapy for advanced squamous carcinoma of the cervix

Cell cycle phase specific chemotherapeutic agents may be less effective treatment for metastatic or recurrent cervical carcinoma because most solid tumors contain very low cell growth fractions. Maximum therapeutic advantage may be accomplished through the use of a multiple drug protocol whose schedule is based on phase specificity of drug action and tumor cell kinetics. Preliminary data indicate that administration of a synchronizing agent, followed by cell kinetics analysis using flow microfluorometry techniques, allows a second agent to be scheduled at a time in the cell cycle when it would be most effective. These observations are based on the clinical response of 11 patients treated with kinetics-directed regimens (derived from direct kinetics measurements) or kinetics-based protocols (derived from empirical or historical data).

Phase II and pharmacokinetic study of high-dose methotrexate in the treatment of advanced gynecologic malignancy. A Southwest Oncology Group Trial

Fifteen patients with advanced or recurrent gynecologic malignancy were treated with high-dose methotrexate (HDMTX) (1-8 g/M2) and citrovorum factor rescue (10-100 mg/M2). One complete response (13%) and two improved responses occurred in eight patients (25%) with squamous cell carcinoma and one of seven patients (14%) with nonsquamous nontrophoblastic carcinoma had stable disease for 7 months. The median duration of survival in the squamous group was 9 months and in the nonsquamous groups 6.5 months. Mean serum MTX concentrations were proportional to the doses administered and typical two compartment plasma disappearance curves were seen. Adverse toxic reactions were not observed at serum MTX levels less than 7.8 X 10(-7) M at 24 hr and 1 X 10(-7) M at 48 hr post-MTX. Hematopoietic toxicity occurred most frequently with leukopenia observed in 19.5% of courses. Hepatic, renal, gastrointestinal, and dermatologic toxicities were observed infrequently. Drug-induced nephrotoxicity occurred in one patient and possibly related leukoencephalopathy occurred in another patient. On the basis of the relatively low response rate observed in this trial and the high expense of HDMTX therapy, the value of such therapy may be limited in advanced nontrophoblastic gynecologic cancer.

Chemotherapy for advanced recurrent carcinoma of the cervix. A report on the treatment of 22 patients

In 22 patients with advanced squamous-cell carcinoma of the cervix, chemotherapy with adriamycin and methotrexate was attempted. Remission occurred in five patients, being complete in two of these. The median duration of remission was 8 months. In eight patients, the course of the disease was stabilized for at least 3 months. The median survival time was 3 months for the group of "failures', 11.5 months for those with stable disease, and 21 months for patients in remission. The most favourable course of the disease was observed in the two patients with complete remission; they survived for 31 and 32 months, respectively, after the start of chemotherapy.

Chemotherapy for squamous carcinoma of the cervix: doxorubicin--methyl CCNU

Treatment was initiated for metastatic or recurrent squamous carcinoma of the cervix with a combination of doxorubicin and methyl CCNU in 37 patients. Results after at least one full course of chemotherapy were fully evaluated in 31 of these patients. The objective response rate of 45.1 per cent obtained with this therapy compared favorably with those obtained by other authors using single or multiple agents. This chemotherapy regimen may need to be modified to improve patients' tolerance. The improved survival rate and high number of complete remissions demonstrated in this pilot study show promise for this type of chemotherapy in the future.