Adjuvant chemotherapy in the treatment of advanced tumors of the head and neck

Combination Cancer Therapy of a Del1 Fragment and Cisplatin Enhanced Therapeutic Efficiency In Vivo

BACKGROUND/AIM

Combination cancer therapy is currently under investigation. This study examined the effect of cancer combination therapy using the E3 and C1 (E3C1) domains of developmental endothelial locus-1 (Del1) and cisplatin (CDDP) in murine transplanted tumors.

MATERIALS AND METHODS

Mice with transplanted tumors (A431, SCCKN or SCC-4 cells) were injected intraperitoneally with CDDP and injected locally with nonviral plasmid vectors encoding E3C1. Histochemical analysis of the transplanted tumors was then performed to assess the effects on prognosis.

RESULTS

The CDDP+E3C1 injected group had reduced tumor growth and longer survival compared to the CDDP injected group. In addition, cell death was observed in the tumor of the CDDP+E3C1 group.. Furthermore, angiogenesis and increased blood vessels were observed together with stromal development.

CONCLUSION

The CDDP+E3C1 treatment resulted in improved survival and poor tumor stromal development in mice with transplanted tumors.

Two-year survival: preoperative adjuvant chemotherapy in the treatment of cervical cancer stages Ib and II with bulky tumor

The effect of preoperative adjuvant chemotherapy on the 2-year survival rate of patients with locally advanced cervical cancer (stages Ib and II with bulky tumour) was evaluated. The 54 patients first received initial chemotherapy of vinblastine, bleomycin, and cis-platinum in a combined regimen (VBP) and then radical hysterectomy. The overall histologic response rate to chemotherapy of the primary tumor confirmed in the surgical specimen was 81% including microscopic or no evidence of disease (41%, Grade III or IV). A lower than expected incidence of lymph node metastasis (20%) was found. All nodal metastasis was noted in patients with Grades I or II (P = 0.0034). Median follow-up was 36 months (range 26-60 months). Three recurrences (6%) appeared and those patients died of the disease within 24 months. Thus the 2-year tumour-free survival rate was 94%. The patients who had positive nodes more often experienced recurrence (27 vs 0%) and a lower 2-year survival rate (72 vs 100%) (P = 0.0067). All of these recurrences were found in patients with three or more positive nodes. This preliminary study suggest that preoperative adjuvant chemotherapy (VBP) is effective (1) in reducing tumour volume or the stage of the disease, (2) in curing the lymph node involvement, and (3) in improving the 2-year tumour-free survival rate. A prospective randomized study comparing radical surgery alone with preoperative adjuvant chemotherapy followed by radical surgery is in progress.

In vitro antagonism between cisplatin and vinca alkaloids

The effects of the combination of cisplatin and other cytotoxic agents were studied in vitro. When A549 lung cancer cells were treated simultaneously with cisplatin and other cytotoxic agents, cisplatin additively increased the cytotoxic effects of etoposide, mitomycin C, adriamycin, 5-fluorouracil and 1-beta-D-arabinofuranosylcytosine, but antagonised those of vincristine, vindesine, vinblastine and podophyllotoxin. The antagonism between cisplatin and vincristine was also observed with HT29 colon cancer cells. NC65 renal carcinoma cells and A431 epidermoid carcinoma cells when these cells were simultaneously exposed to both agents. When A549 cells were exposed to cisplatin and vincristine sequentially, the antagonism between them was evident when cells were pretreated with cisplatin but not when treated in the opposite sequence. Therefore, when combination chemotherapy including cisplatin and vinca alkaloids is given, possible antagonism between them should be considered, especially in determining the schedule of drug administration.

Preoperative adjuvant chemotherapy in the treatment of cervical cancer stage Ib, IIa, and IIb with bulky tumor

Thirty-five previously untreated patients with stage Ib, IIa, and IIb squamous cell carcinoma of uterine cervix with bulky mass (more than 4 cm) were treated with initial chemotherapy of vinblastine, bleomycin, and cis-platinum combined regimen (VBP, one to five courses) and subsequent radical surgery. The effectiveness of the preoperative chemotherapy was evaluated in the surgical specimen. The overall clinical response rate was 89% and included a complete response in 16 (46%) and a partial response in 15 patients (43%). There were no differences in the response rate by age, stage, or the geographic contour of the tumor. The number of chemotherapeutic courses correlated well with the response of the primary tumor (P = 0.0004) up to three courses. Histologic examination of the resected primary tumor revealed no evidence of disease (Grade IV) in 44% of complete responders, microscopic foci (Grade III) in 38% (6), and macroscopic disease (Grade II) in 18% (3). Of 15 patients with stage IIb, 11 (73%) had a stage-down. Lymphnode metastases after chemotherapy were found in 26% (9/35) of the patients. All nodal metastases were found among the patients who had a partial response or a stable disease, and none was found in those with a complete response (P = 0.0029). This preliminary study suggests that initial chemotherapy before surgery is effective in reducing tumor volume or stage of the disease providing better circumstances for surgery, offers selection of high-risk groups of patients requiring additional chemotherapy, and might be able to eliminate effectively diseases in lymphnodes and possibly micrometastases. This regimen is now being evaluated to test its impact on survival.

Regional chemotherapy through a saphenous vein graft for the treatment of head and neck cancers

Regional chemotherapy was given through a vein grafted between the common carotid and external carotid arteries to 20 patients who had a variety of advanced head and neck cancers. The objective response rate was 73.6%, which included 36.8% complete response. The median duration of response was more than 10 months. The toxicity was mild and well tolerated. The complication rate associated with the procedure was low. This form of regional chemotherapy has significant advantages over the conventional form that uses drugs given through the retrograde temporal artery because the catheter-related complications are eliminated, the perfusion of the tumor can be maintained consistently, and, consequently, the response rate is high and the duration of response is increased.

Phase II trial of cis-diamminedichloroplatinum (cis-platinum), vincristine, and peplomycin for advanced squamous cell carcinoma

Advanced squamous cell carcinoma of the head and neck, lung, esophagus, and uterine cervix is still a challenging cancer to the medical practice. We have treated 23 such patients with a combination of cis-platinum, vincristine, and peplomycin. Cis-platinum was given at a dose of 60 mg/m2 on day 1, and 1.0 mg/m2 of vincristine was given on day 3, followed 6 hours later by peplomycin 10 mg/day by continuous infusion iv or sc over the next 5 days. This combination was given every 3 weeks. The overall response rate was 71% for 17 evaluable patients, including one complete response. The median duration of response and survival was 2 and 5 months, respectively. Six other patients with esophageal and cervical carcinoma were treated with two cycles of this combination followed by radical radiation therapy or surgery. Five of them achieved significant response prior to radical treatment. Major side effects were nausea, vomiting, alopecia, and mild myelotoxicity, which were acceptable. This regimen, with a high response rate and acceptable toxicity, warrants further investigation.

Adjuvant chemotherapy

At present, adjuvant chemotherapy exerts no significant impact on long-term survival and only occasionally provides brief palliation in head and neck cancer. The major contribution of chemotherapy has been in the preoperative period, when therapy for advanced squamous cell carcinoma may render some patients candidates for curative operations or radiotherapy. This article discusses the use of single-agent chemotherapy, combination chemotherapy, and combination irradiation and surgery as well as the advantages of adjuvant chemosurgery.

Combination chemotherapy with cisplatin and peplomycin in squamous cell carcinoma of the head and neck

Ninety-three patients with head and neck cancer were treated with combined cisplatin-peplomycin chemotherapy (CP therapy). Cisplatin (CDDP) 50 mg/m2 i.v. (intravenous) or i.a. (intraarterial) over 2 hr was given with hydration and mannitol diuresis on day 1. From day 2 through day 6, peplomycin (PEP) 5 mg/day was administered by 5-hr i.v. or i.a. infusion, or 24-hr continuous hypodermic injection. Of 85 who were evaluable, there were 22 complete responses or CR (26%) and 36 partial responses or PR (42%), with an overall response rate of 68%. Concerning of the route of administration, i.a. infusion obtained the higher CR and overall response rates than i.v. infusion. Effectiveness was clearly greater in previously untreated cases than in cases that had received some previous therapeutic modality. Looking at response in relation to the number of the courses, at least 2 courses of CP therapy are required. Side effects were recognized in 68 out of 87 evaluable cases (78%). Nausea and vomiting were the most common (62%). Renal toxicity was observed in 24% and was mostly transient. From the above results, it is considered that the CP therapy is effective, not only for the palliative treatment of advanced and recurrent cancer of the head and neck, but also as neo-adjuvant chemotherapy of stage III and IV cases.

Preoperative simultaneously administered cis-platinum plus radiation therapy for advanced squamous cell carcinoma of the head and neck

Synchronously administered cis-platinum (cis-DDP) and radiation therapy have been used to treat unresectable squamous cell carcinomas of the head and neck. The purpose of this study was to evaluate the efficacy and tolerance of preoperative adjuvant cis-DDP plus radiation therapy in operable stage III and IV head and neck cancers. Radiation therapy (4,500 rad) was delivered in 180-rad daily fractions. Cis-DDP (20 mg/M2) was given before radiotherapy on days 1-4 and 21-24. Eighteen patients began therapy; 16 completed the combined regimen. Toxicity included stomatitis and WBC below 2,500/mm3. One patient died from therapy of a cerebrovascular accident. Sixteen patients (89%) achieved a complete or partial response to therapy. Complete responses were observed in 13 of 18 primary tumors (72%), and in all three patients with cervical lymphadenopathy. Complete responses were noted for lesions of the nasopharynx, oral cavity, pharynx, hypopharynx, and larynx, for all histologic grades of squamous cell carcinoma. Twelve patients underwent curative surgery. Site-related morbidity occurred in two patients (15%) and a third patient developed postoperative pneumonia. Five of 10 resected primary tumors with preoperative complete responses were pathologically negative for tumor. Concurrent bolus cis-DDP and radiation therapy are well-tolerated and result in impressive tumor reduction. Morbidity after subsequent curative surgery is low, and histologic complete responses are frequent.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary chemotherapy and postoperative adjuvant chemotherapy in the treatment of squamous cell carcinoma of the uterine cervix

Two cases with squamous cell carcinoma of the cervix stage IIB with primary tumor mass about 2 X 2 X 2 cm were treated with primary chemotherapy of cis-platinum, 20 micrograms/m2 body surface intravenously daily for 5 consecutive days. Papanicolaou smear turned negative after two courses of chemotherapy in both cases. One of those was followed by radical hysterectomy with lymphadenectomy which confirmed that there was no evidence of disease by histopathology. The third case with stage IIIB and bulky tumor with involvement of pelvic and left common iliac lymph nodes was treated with simple hysterectomy followed by adjuvant chemotherapy with the same medication described above. Complete responses were obtained in all three cases and they are now doing well in a tumor-free state for 26, 30, and 28 months, respectively.

A randomized prospective comparison of methotrexate with a combination of methotrexate, bleomycin, and cisplatin in head and neck cancer

Combination chemotherapy with methotrexate, bleomycin, and cis-diamminedichloroplatinum (II) was compared to weekly therapy with methotrexate alone in a randomized prospective trial in 163 patients with recurrent or metastatic squamous cancer of the mucous membranes of the head and neck. The combination produced responses in 48% compared to 35% for methotrexate alone, with 16% complete remissions versus 8%, respectively. The difference in overall and complete remission rates is significant (P = 0.04) using a one-sided binary regression test. Median time to disease progression among responders was 5.8 months for the combination and 5 months for methotrexate, and median survival was 5.6 months in each group. Toxicity was similar in the two groups. Ambulatory patients, those without fixed neck nodes and those without distant metastases, responded more often. Poor performance status, distant metastases, history of heavy smoking, and adjacent organ invasion by the primary tumor were associated with shorter survival, as were weight loss, the presence of tumor in the neck, and heavy alcohol consumption. The addition of bleomycin and cisplatin to methotrexate produces more remissions, and especially complete remissions, but has not made a major impact on the course of far-advanced head and neck cancer.

The incidence of metastases after multimodal therapy for cancer of the head and neck

Combined therapeutic regimens integrating chemotherapy, radiation therapy, and surgery are reported to be effective in treating advanced squamous cell carcinomas of the head and neck. The current study evaluates 58 consecutive patients with advanced (T4, N3) head and neck cancers. Forty patients (multimodal group) were treated with 2 courses of chemotherapy (cisplatin 2 mg/kg; methotrexate 280-560 mg/m2 with leucovorin rescue; bleomycin 30 mu X 3) followed by radiation therapy and surgery. Eighteen patients (combined group) were treated with preoperative radiation therapy followed by surgery. In the multimodal group there were 27 (67.5%) partial responses and nine (22.5%) complete responses, for an overall response rate of 90%. Response rates by site of primary lesion were: oral cavity, 11 of 11; oropharynx, 13 of 17; hypopharynx, 5 of 5; and larynx 7 of 7. Distant metastases (skin, lung, bone, central nervous system [CNS]) appeared in 16 patients (40%) (P less than 0.05 versus combined) at a median time of 8.5 months after diagnosis, 15 in patients having a partial (11) or complete (4) response. Thirteen patients (33%) developed distant metastases within 1 year of diagnosis (P less than 0.05 versus combined). In 11 of these patients, the primary lesion and neck disease were resectable. Two thoracotomies were performed for solitary pulmonary metastases; one was resected for cure. Fifteen patients (38%) underwent curative resection; 11 (73%) were alive at 1 year, and ten (67%) were free of disease. Overall survival was 20 of 40 (50%) at 1 year. In the combined group, there were 14 partial responses (78%) and no complete responses. Early distant metastases appeared in two patients (12.5%), at 2 and 6 months after diagnosis. Seven patients (38%) underwent curative resection; six of seven (86%) were alive at 1 year, four of seven (57%) were disease-free. Six of 16 patients at risk (37.5%) survived 1 year. After combined therapy, six of ten patients (60%) with responses to therapy survived 1 year versus 12 of 20 responders (57%) without distant metastases in the multimodal group. It is concluded that multimodal therapy for advanced head and neck cancer results in a higher response rate than with conventional combined therapy. The incidence of early and postoperative distant metastases was increased after the multimodal regimen. At 1 year there were no differences in survival between the combined and multimodal groups for responders without early metastases. Further observation is needed to determine the net long-term effects of this regimen. A prospective randomized comparison of combined and multimodal therapy for advanced lesions is indicated.

Reassessment of technical and biological factors in paranasal sinus carcinoma

Twenty-seven patients with paranasal sinus carcinoma were analyzed. Local control with radiation alone was poor, with most patients failing centrally within the primary site. With preoperative radiation local control is 60%. Previous reports have emphasized failure at superior sites--particularly the orbit. The pattern of local failure in our series is predominantly various medial sites inclusive of intact or exenterated orbit. The surgically nonremovable medial structures are best encompassed by a three-field radiotherapy technique (weighted anterior and two laterals).

Local control in advanced head and neck cancer by combined modalities of treatment

From July 1979 to January 1983, 20 patients with locally advanced head and neck cancer were treated with a combination of chemotherapy and irradiation with or without surgery. A majority of the patients were in the age range of 45 to 54 years. Eighty-five percent of the patients were male. Seventy-five percent of the patients had oral cavity lesions, the tongue being the most common site. Eighty percent of the patients had T4 lesion and 35% had N3 disease in the neck. A majority of the patients had combination chemotherapy, including bleomycin, methotrexate, and cisplatinum (BMP). All patients received irradiation with megavoltage equipment and 55% of patients received a dose of 5,000 to 6,000 rads in 5-6 weeks time. The tumor was converted to be resectable in ten patients. Nine patients (45%) had the neck and primary tumor completely controlled, while six patients (30%) had partial control. Six of the ten patients who had resection had the tumor controlled at the primary site and neck. The median duration of follow-up is 12 months (range, 4-32 months). The median survival of the whole group of patients is 12.5 months. A brief review of the current literature is also done in this paper.

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.

Hydroxyurea fails to improve the results of MBD chemotherapy in cancer of the head and neck, but reduces toxicity

Thirty-six patients with advanced squamous cancer of the head and neck received chemotherapy with hydroxyurea, 2 g/m2 orally two of three weeks, plus methotrexate, bleomycin, and cisplatin (MBD) on a previously established schedule. Nineteen patients had objective responses, including six complete remissions. Eight of 13 patients with regional disease without prior radiation responded, as did 1 of 3 with distant metastases without prior radiation, and 10 of 20 with recurrent disease after radiotherapy. The median duration of response in those with recurrent or metastatic tumor was 6 months, and median survival was 6.5 months. These results are no better than those previously achieved without the addition of hydroxyurea. Toxicity, however, was milder than had previously been observed with MBD, suggesting that higher doses or more intensive schedules of hydroxyurea could be safely administered together with the other three drugs.

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.

Ototoxicity associated with cis-platinum in three chemotherapy multi-drug regimens

Hearing threshold differences postcis-platinum, relative to precis-platinum levels, were studied in 21 men from a Veterans Administration Medical Center. These patients had previously untreated advanced epidermoid cancers of the head and neck. Each patient received one of three drug combinations: (1) cis-platinum, Oncovin, and bleomycin (n = 9); (2) cis-platinum and 5-fluorouracil (n = 7); or (3) cis-platinum and bleomycin (n = 5). Wide variations in prechemotherapy hearing thresholds prevented analysis among various drug combinations. Therefore, the three groups were pooled to compare the thresholds by frequency. The frequencies tested and analyzed were: 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz, and 8000 Hz. Significant differences were found at 2000 Hz (P less than 0.01) and 8000 Hz (P less than 0.05). Any existing ototoxic effects of cis-platinum may have been overridden by already high prechemotherapy hearing thresholds at 4000 Hz. Since 2000 Hz was most sensitive to the ototoxic effects of cis-platinum it is suggested that this frequency be monitored routinely as a part of standard chemotherapy assessment.

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.

Adjuvant chemotherapy in advanced head and neck cancer. An update

Two courses of triple-agent chemotherapy were given to 47 patients with advanced head and neck cancer. All but one patient with a nasopharyngeal carcinoma had resectable stage III and IV squamous cell carcinoma. Eighty-eight percent of the patients responded to the chemotherapy with a 50 percent or greater decrease in tumor size. Forty-three patients underwent surgical resection and 19 were histologically upgraded to stage II or better (T less than 2 cm, N0). None of these 19 patients have relapsed, with follow-up ranging from 12 to 42 months. In 12 of the 47 patients, recurrent tumor developed within the first 18 months of follow-up.

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.

Bleomycin, cyclophosphamide and radiotherapy in regionally advanced epidermoid carcinoma of the head and neck

We have treated 24 patients with squamous carcinoma of the head and neck and advanced regional (N2-3) disease. The regimen consisted of 3 cycles, each of 28 days. Cyclophosphamide (1 gm/m2 I.V.) was given on day 1, bleomycin (15 u I.M.) on days 2, 4, 9 and 11, and ionizing radiation (60Co, 180 rad/fraction) days 1-5, and 8-12. No therapy was given on days 13-28. After three cycles of therapy, 13 patients had a complete response; following further therapy (surgery, interstitial or external beam radiation), 16 patients were free of disease. However, remissions were not durable and 11/16 patients recurred loco-regionally with a median time to recurrence of 5 months; most (7/11 also developed distant metastases. These patients have biologically aggressive disease and may have a worse prognosis than patients who are Stage IV based on a T4 primary lesion only.