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

Adjunctive chemotherapy to radical radiation therapy in the treatment of advanced nasopharyngeal carcinoma

Sixty-eight consecutive patients with previously untreated nasopharyngeal carcinoma (NPC) with advanced cervical lymph nodal metastases were studied retrospectively for the effectiveness of combining chemotherapy with radical radiation therapy (RT). In 1981 and 1982, 36 patients were treated with radical radiation therapy alone (arm 1). In 1983, 13 patients were given 2 courses of VBMF prior to RT (arm 2). In 1984, 19 patients were given radical RT sandwiched between 2 courses of PVBMF before and 2 after (arm 3). The three arms were comparable in patient characteristics with similar stages of the disease, sex, age distribution, and rates of completion of the prescribed treatments. There was no significant difference in actuarial or disease-free survival between arm 1 and 3 or arm 2 and 3, but arm 1 compared favorably with arm 2 in actuarial survival (X2 = 9.533, p = 0.002). The distant relapses in arms 2 and 3 occurred at significantly shorter times after diagnosis than those in arm 1 (t = 4.1083, p = 0.0001). Postponement of radiation therapy by chemotherapy might have accounted for the earlier distant relapses in arm 2 and 3. Radiation therapy alone given in radical dose had been demonstrated to achieve significantly more complete responses in cervical nodal metastases than either forms of chemotherapy (VBMF or PVBMF) given just two courses prior to radiation therapy (p less than 0.00003). More controlled clinical trials must be completed before acceptance of chemotherapy as part of a standard radical treatment for advanced nasopharyngeal carcinoma with advanced cervical lymph nodal metastases. In all future trials, closer integration in time sequence between the two treatment modalities is indicated. Meanwhile cervical nodal status (CR vs, PR plus NR) at the end of any treatment was shown to be of paramount prognostic significance.

Impact of antitumor therapy on nutrition

Surgery, radiation, and chemotherapy can result in further deterioration in nutritional status in patients who are frequently malnourished as a consequence of their underlying malignancy. Many of the effects are transient, and patients who have a good performance status may exhibit minimal alterations in nutritional parameters during the course of treatment. However, antitumor treatment may enhance morbidity, and in some, it leads to mortality if patients are in poor nutritional status ab initio. Such malnourished patients must be recognized prior to initiation of treatment, and steps must be taken to maintain adequate nutrition. The known toxic effects of many cancer therapeutic regimens must be weighed against their potential benefits.

Management of advanced stage squamous cell carcinoma of the head and neck

Squamous cell tumors of the head and neck make up 5% of tumors diagnosed in this country. The combination of excessive tobacco and alcohol use is the most common causative factor for these tumors. Their natural history is characterized by a tendency for early local-regional recurrence and the late appearance of distant metastases. A significant proportion of patients present with advanced (stage III or IV) disease, which has a poor prognosis when treated with surgery and radiotherapy. The use of adjuvant chemotherapy with surgery and radiotherapy in previously untreated patients holds promise for improving cure rates in patients with this disease. The use of chemotherapy in patients with recurrent head and neck tumors results in response in approximately one third of patients. The majority of these responses are partial and short-lived, but those patients achieving a complete remission appear to have a significant prolongation of survival. The combination of chemotherapy and radiotherapy in patients with advanced disease is being tested in a number of trials. It is hoped that this combination will increase the response rate and result in prolonged survival.

Treatment complications after sequential combination chemotherapy and radiotherapy with or without surgery in previously untreated squamous cell carcinoma of the head and neck

One hundred consecutive patients with previously untreated advanced squamous cell carcinoma of the head and neck were treated with induction combination chemotherapy followed by definitive surgery and/or radiotherapy, and were evaluated for radiotherapy related toxicity. The induction regimen consisted of cisplatin, bleomycin and methotrexate/leucovorin. Acute toxicity consisted predominantly of mucositis and weight loss, and was mild or moderate by degree in 94% of patients. Six percent of patients experienced severe or life threatening acute toxicities. Two acute toxic deaths were noted in this series, one from a combination of mucositis, weight loss and infection and one from hypoglycemia of unknown origin. Thirty-five percent of patients had radiation treatment interrupted briefly because of acute toxicity. Toxicity was greatest in patients who were nonresponders to induction chemotherapy and such may have been related to the continued presence of advanced tumor. Radiotherapy dose, surgical intervention and age did not have an impact on the presence or degree of acute toxicity. Late toxicities included: hypothyroidism in 32% of patients tested: osteoradionecrosis in 5% of patients, associated primarily with a composite resection (4 of 5 cases); and soft tissue ulcerations in 3%. Taken together, these data indicate that induction combination chemotherapy did not significantly increase the toxicity of subsequent radiotherapy with or without surgery.