Enhancement of the potentiation of radiotherapy by platinum drugs in a mouse tumor

Avasopasem manganese synergizes with hypofractionated radiation to ablate tumors through the generation of hydrogen peroxide

Avasopasem manganese (AVA or GC4419), a selective superoxide dismutase mimetic, is in a phase 3 clinical trial (NCT03689712) as a mitigator of radiation-induced mucositis in head and neck cancer based on its superoxide scavenging activity. We tested whether AVA synergized with radiation via the generation of hydrogen peroxide, the product of superoxide dismutation, to target tumor cells in preclinical xenograft models of non-small cell lung cancer (NSCLC), head and neck squamous cell carcinoma, and pancreatic ductal adenocarcinoma. Treatment synergy with AVA and high dose per fraction radiation occurred when mice were given AVA once before tumor irradiation and further increased when AVA was given before and for 4 days after radiation, supporting a role for oxidative metabolism. This synergy was abrogated by conditional overexpression of catalase in the tumors. In addition, in vitro NSCLC and mammary adenocarcinoma models showed that AVA increased intracellular hydrogen peroxide concentrations and buthionine sulfoximine- and auranofin-induced inhibition of glutathione- and thioredoxin-dependent hydrogen peroxide metabolism selectively enhanced AVA-induced killing of cancer cells compared to normal cells. Gene expression in irradiated tumors treated with AVA suggested that increased inflammatory, TNFα, and apoptosis signaling also contributed to treatment synergy. These results support the hypothesis that AVA, although reducing radiotherapy damage to normal tissues, acts synergistically only with high dose per fraction radiation regimens analogous to stereotactic ablative body radiotherapy against tumors by a hydrogen peroxide-dependent mechanism. This tumoricidal synergy is now being tested in a phase I-II clinical trial in humans (NCT03340974).

Stereotactic radiation therapy for canine multilobular osteochondrosarcoma: Eight cases

Radiotherapy is often considered in the management of canine multilobular osteochondrosarcoma (MLO), but its efficacy against bulky MLO tumours is poorly described. This retrospective case series describes the clinical outcomes of pet dogs with MLO treated with a stereotactic radiation therapy (SRT) prescription of 30 Gy in three consecutive daily 10 Gy fractions. Dogs with an imaging (via computed tomography [CT] scan) and/or pathologic diagnosis of MLO were included. Patient demographics, tumour characteristics, radiation plan dosimetry, toxicity and outcome data were obtained retrospectively from the records. The median progression-free survival time (MPFST) and median overall survival time (MST) were calculated using a LOGLOG test. Eight dogs were included. None had evidence of metastasis at the time of SRT. Clinical signs associated with the MLO included a mass noted by owner, stertor, vestibular signs, exophthalmos and abnormal mentation. Of the five dogs that had CT scans performed 3 to 9 months after SRT, tumour volume decreased by 26% to 87% in four dogs and increased by 32% in one dog. Late radiation toxicity was documented in three dogs (VRTOG Grade 1 skin and/or ocular, n = 2; Grade 3 central nervous system, n = 1). Confirmed local disease progression (n = 3; two were treated with a second course of SRT) and suspected pulmonary metastasis (n = 2) occurred 90 to 315 days after SRT. The MPFST was 223 days (interquartile range [IQR]: 144.5-276.5 days). The MST was 329 days (IQR: 241.5-408 days). This protocol was well-tolerated, but the duration of response was short-lived.

Significant Radiation Enhancement Effects by Gold Nanoparticles in Combination with Cisplatin in Triple Negative Breast Cancer Cells and Tumor Xenografts

Gold nanoparticles (AuNPs) and cisplatin have been explored in concomitant chemoradiotherapy, wherein they elicit their effects by distinct and overlapping mechanisms. Cisplatin is one of the most frequently utilized radiosensitizers in the clinical setting; however, the therapeutic window of cisplatin-aided chemoradiotherapy is limited by its toxicity. The goal of this study was to determine whether AuNPs contribute to improving the treatment response when combined with fractionated cisplatin-based chemoradiation in both in vitro and in vivo models of triple-negative breast cancer (MDA-MB-231^Luc+). Cellular-targeting AuNPs with receptor-mediated endocytosis (AuNP-RME) in vitro at a noncytotoxic concentration (0.5 mg/ml) or cisplatin at IC₂₅ (12 μM) demonstrated dose enhancement factors (DEFs) of 1.25 and 1.14, respectively; the combination of AuNP-RME and cisplatin resulted in a significant DEF of 1.39 in vitro. Transmission electron microscopy (TEM) images showed effective cellular uptake of AuNPs at tumor sites 24 h after intratumoral infusion. Computed tomography (CT) images demonstrated that the intratumoral levels of gold remained stable up to 120 h after infusion. AuNPs (0.5 mg gold per tumor) demonstrated a radiation enhancement effect that was equivalent to three doses of cisplatin at IC₂₅ (4 mg/kg), but did not induce intrinsic toxicity or increased radiotoxicity. Results from this study suggest that AuNPs are the true radiosensitizer in these settings. Importantly, AuNPs enhance the treatment response when combined with cisplatin-based fractionated chemoradiation. This combination of AuNPs and cisplatin provides a promising approach to improving the therapeutic ratio of fractionated radiotherapy.

Thermoresponsive fluorinated small-molecule drugs: a new concept for efficient localized chemotherapy

We review the drugs used in combination with hyperthermia for cancer therapy and recent advances on small thermoresponsive molecules.

Clinical development of S-1 for non-small cell lung cancer: a Japanese perspective

For more than a decade, S-1 has been investigated aggressively against non-small cell lung cancer (NSCLC) in Japan. Recently, two randomized phase III trials of S-1 combined with cisplatin (CDDP) or carboplatin (CBDCA) compared with the standard platinum doublet chemotherapy were reported. S-1 and CDDP was noninferior to CDDP and DTX in terms of overall survival (OS) (median survival time [MST] 16.1 versus 17.1 months, respectively; hazard ratio [HR] 1.013; 96.4% confidence interval [CI] 0.837-1.227). Noninferiority of S-1 and CBDCA compared with CBDCA and paclitaxel was also confirmed for OS (MST 15.2 versus 13.3 months, respectively; HR 0.928; 99.2% CI 0.671-1.283). The noninferiority design employed an upper CI limit of HR<1.322 in the former trial and HR<1.33 in the latter. S-1 combined with CDDP or CBDCA was thought to be one of the standard platinum doublet regimens in the first-line setting for patients with advanced NSCLC in Japan. Some additional interesting phase I and II studies have been published in Japan. They include studies of S-1 as first-line chemotherapy when combined with nonplatinum agents; as second-line chemotherapy; within chemoradiotherapy for locally advanced disease; and in the postoperative adjuvant setting. This review will also describe the use of S-1 for the treatment of NSCLC in these settings.

S-1 plus cisplatin with concurrent radiotherapy for locally advanced non-small cell lung cancer: a multi-institutional phase II trial (West Japan Thoracic Oncology Group 3706)

PURPOSE

To evaluate the combination chemotherapy using oral antimetabolite S-1 plus cisplatin (SP) with concurrent thoracic radiotherapy (RT) followed by the consolidation SP for locally advanced non-small cell lung cancer.

PATIENTS AND METHODS

Patients with stage III non-small cell lung cancer, 20 to 74 years of age, and Eastern Cooperative Oncology Group performance status 0 to 1 were eligible. The concurrent phase consisted of full dose S-1 (orally at 40 mg/m/dose twice daily, on days 1-14) and cisplatin (60 mg/m on day 1) repeated every 4 weeks for two cycles with RT delivered beginning on day 1 (60 Gy/30 fractions over 6 weeks). After SP-RT, patients received an additional two cycles of SP as the consolidation phase.

RESULTS

Fifty-five patients were registered between November 2006 and December 2007. Of the 50 patients for efficacy analysis, the median age was 64 years; male/female 40/10; Eastern Cooperative Oncology Group performance status 0/1, 21/29; clinical stage IIIA/IIIB 18/32; and adenocarcinoma/others 20/30. There were 42 clinical responses including one complete response with an objective response rate of 84% (95% confidence interval [CI], 71-93%). The 1- and 2-year overall survival rates were 88% (95% CI, 75-94%) and 70% (95% CI, 55-81%), respectively. The median progression-free survival was 20 months. Of the 54 patients for safety analysis, common toxicities in the concurrent phase included grade 3/4 neutropenia (26%), thrombocytopenia (9%), and grade 3 esophagitis (9%) and febrile neutropenia (9%). In one patient, grade 3 pneumonitis was observed in the consolidation phase. There were two treatment-related deaths caused by infection in the concurrent phase.

CONCLUSIONS

SP-RT showed a promising efficacy against locally advanced NCSLC with acceptable toxicity.

3D conformal radiotherapy and cisplatin for recurrent malignant glioma

PURPOSE

To determine the maximum tolerated dose of 3D conformal radiotherapy in combination with Cisplatin for patients with recurrent malignant gliomas.

METHODS

From 1999-2003, nine patients with recurrent malignant glioma received fractionated radiotherapy and Cisplatin (20 mg/m2/d IV on days 1-5) in a Phase I radiation dose escalation trial. Three sequential dose levels were evaluated: 25 Gy, 30 Gy, and 35 Gy, using 5 Gy fractions. All patients received prior external beam radiation (median dose 59.4 (20-60) Gy) and five patients received prior chemotherapy.

RESULTS

Six male and three female patients were enrolled with a median age of 52 years, and a median Karnofsky performance status score of 70. The median re-irradiated tumor volume was 18.9 (0.1-78.5) cm3 and the median follow-up was 8.8 (3.2-31.2) months. One patient (30 Gy/ 6 fractions) experienced medically reversible acute grade 3 toxicity. A second patient (35 Gy/ 7 fractions) experienced acute grade 2 toxicity and histology showed tumor and radiation effect. A third patient (25 Gy/ 5 fractions) experienced late grade 3 toxicity from radiation necrosis. The radiological responses consisted of complete response (1 patient), partial response (1 patient), and stable disease (2 patients). The median overall survival was 8.8 months (95% CI 8.0-9.9), and the median disease free interval was 2.0 months (95% CI 1.4-4.4). Seven patients received chemotherapy following re-irradiation and Cisplatin.

CONCLUSION

The maximum tolerated dose of 3D conformal fractionated radiotherapy was 30 Gy in 6 fractions with low dose Cisplatin, which was well tolerated in terms of acute toxicity for our patient population. This regimen demonstrated only modest efficacy in the treatment of recurrent malignant glioma. Combinations of conformal re-irradiation and other systemic agents may merit investigation. Currently our recommended dose is 30 Gy in 6 fractions for selected patients.

Carboplatin and tegafur-uracil concomitant with standard radiotherapy in the management of locally advanced head and neck cancer

INTRODUCTION

We undertook a prospective study to determine the feasibility, toxicity, response and survival rate of simultaneous chemotherapy (CT) and radiotherapy (RT) for locally-advanced head and neck cancer.

MATERIAL AND METHODS

Fifty eight patients were treated with carboplatin (i.e. 100 mg/m(2)) weekly, tegafur-uracil (UFT) (oral 400 mg/m(2)) daily and simultaneous treatment with a cobalt-60 source of radiation (total dose 65-70 Gy).

RESULTS

Forty six patients (79%) received the total dose of RT while CT was delayed or reduced in 31 patients (53%). Grade 3-4 toxicity observed was mucositis in 27 (47%), leukopenia in 10 (17%), anaemia in 5 (9%), and diarrhoea in 4 (7%) patients. The objective response rate was 74%; 24 complete response (41%) and 19 partial response (33%). Overall, there are 11 patients (19%) disease-free, 7 (12%) alive with disease, 35 have died of progressive disease (60%) and 3 (5%) from other causes. There were 2 toxic deaths (3%). Median time to progression was 10 months and median survival was 18.4 months.

CONCLUSIONS

The use of carboplatin and UFT concomitant with radiotherapy has, in our study, a slightly lower activity than other chemo-radiotherapy protocols, especially with respect to complete responses, but with no significant differences in overall survival or disease-free survival rates.

Twice-daily radiotherapy as concurrent boost technique during two chemotherapy cycles in neoadjuvant chemoradiotherapy for resectable esophageal carcinoma: Mature results of phase II study

PURPOSE

To determine the toxicities of neoadjuvant chemoradiotherapy using a three-drug regimen (cisplatin, 5-fluorouracil, and paclitaxel) and a conventional radiotherapy (RT) schedule combined with a concurrent boost technique during chemotherapy cycles, and to determine the rate of tumor response, overall survival, and impact of pathologic tumor response on survival.

METHODS AND MATERIALS

The eligibility criteria included resectable adenocarcinoma or squamous cell carcinoma (T2-T3N0-N1M0), performance score < or =2, and no significant comorbidities for trimodality therapy. Chemotherapy consisted of two cycles of cisplatin, 5-fluorouracil, and paclitaxel. A concurrent boost technique was used in RT for 2 levels of radiation doses: 58.5 Gy in 34 fractions within 5 weeks to the gross tumor volume and 45 Gy in 25 fractions within 5 weeks to the clinical target volume by administering a boost dose of 13.5 Gy in 9 fractions, 1.5 Gy/fraction, as a second daily fraction for 9 days on Days 1-5 and 29-32 of the chemotherapy cycles.

RESULTS

We enrolled 46 patients in the study. The paclitaxel dose was started at 75 mg/m(2) (n = 7) and escalated to 125 mg/m(2) (n = 5), at which point, dose-limiting toxicities occurred. Thereafter, paclitaxel at 100 mg/m(2) was used for an additional 34 patients. Toxicities included Grade 4 neutropenia (22%), febrile neutropenia requiring hospital admission (20%), Grade 3 (48%) and Grade 4 (7%) acute esophagitis, and paclitaxel-associated anaphylaxis (4%). Of the 46 patients, 3 (6.5%) died of treatment-related complications, 1 of pneumonia during induction therapy and 2 of postoperative complications (5% of the 40 patients who underwent resection). The histopathologic tumor response was a pathologic complete response (pT0N0) in 18 (45%) of 40 patients who underwent resection and 18 (39%) of all 46 registered patients. Minimal residual disease (pT1N0) at the primary site was present in 5 (11%) and residual disease in 23 (50%) of all 46 patients. The minimal follow-up for all long-term survivors (n = 16) was 5.5 years. The median survival time was 34 months, and the overall survival rate was 57%, 50%, and 37% at 2, 3, and 5 years, respectively. The 5-year overall survival (56% vs. 24%, p = 0.0214) and disease-free survival (48% vs. 6%) were significantly better statistically for patients with a pathologic complete response and minimal residual disease than for those with residual disease. All long-term survivors beyond 5.5 years without recurrence accrued from patient cohorts with a pathologic complete response or minimal residual disease.

CONCLUSION

An incorporation of twice-daily RT as a concurrent boost to the conventional daily RT schedule during chemotherapy cycles is feasible and warrants additional study for radiation dose intensification. Such research would be prudent for both improved long-term survival and organ preservation in esophageal carcinoma.

Uracil/Tegafur Plus Cisplatin with Concurrent Radiotherapy for Locally Advanced Non-Small-Cell Lung Cancer

PURPOSE

To evaluate the efficacy and toxicity of a novel combination treatment using concurrent radiotherapy with cisplatin plus UFT, which is comprised of uracil and tegafur, in locally advanced non-small cell lung cancer (NSCLC) patients.

EXPERIMENTAL DESIGN

In this Phase II trial, patients with unresectable stage III NSCLC were treated with the oral administration of UFT (400 mg/m(2)/d tegafur) on days 1-14 and days 29-42 whereas 80 mg/m(2) cisplatin was administered i.v. on days 8 and 36. Radiotherapy, with a total dose of 60 Gy, was delivered in 30 fractions from day 1.

RESULTS

Seventy patients were enrolled and eligible, as follows: 57 males/13 females; mean age 61 ranging from 36 to 74; performance status 0/1:45/25; stage IIIA/IIIB, 14/56. A complete response was observed in two patients and a partial response in 54 patients, and the overall response rate was 81% (95% confidence interval; 70-89%). The median survival, the 1- and 2-year survival rates were 16.5 months, 67% and 33%, respectively. Grade 3/4 leukopenia occurred in 14%/1% of the patients. Grades 3 non-hematological toxicities were only reported in three patients with nausea, two with esophagitis and one with pneumonitis whereas no grade 4 non-hematological toxicity was observed.

CONCLUSIONS

UFT plus cisplatin with concurrent radiotherapy is considered to be a feasible and effective treatment for locally advanced NSCLC patients. Additional study of this concurrent chemoradiotherapy is warranted.

A phase II trial of concurrent chemoradiation therapy followed by consolidation chemotherapy with oral etoposide and cisplatin for locally advanced inoperable non-small cell lung cancers

We report a phase II study to evaluate the survival rate, response rate and toxicity of concurrent chemoradiation therapy (CCRT) followed by consolidation chemotherapy (CT) with oral etoposide and cisplatin for patients with locally advanced inoperable non-small cell lung cancer (NSCLC). Fifty-four patients with locally advanced inoperable NSCLC who had received no prior therapy were enrolled into this trial between May 1995 and December 2000. Treatment consisted of two cycles of concurrent CT and four cycles of consolidation CT with oral etoposide (50 mg/m2) on days 1-14 during the CCRT courses and on days 1-21 during the consolidation CT courses, plus cisplatin (75 mg/m2 i.v.) on day 1 of a 28-day cycle. Conventional radiotherapy (1.8 Gy/fraction, 63 Gy over 7 weeks) was delivered from day 1 of the CT. Fifty-two patients were evaluable for response. Twelve patients (22%) achieved complete responses, and 32 patients (60%) achieved partial responses, for an overall response rate of 82% with a median duration of response of 9.1 months. Forty-three per cent developed grade 4 haematological toxicity, 11% grade 3 or 4 oesophagitis and 7% grade 3 or 4 lung toxicity. There were two treatment-related deaths, one from radiation pneumonitis and the other from sepsis. After a median follow-up duration of 50 months (range 20-85), the median overall survival time was 15.3 months (95% CI, 9.7-20.8), and the 1-, 2-, 3-, and 5 year overall survival rates were 62, 40, 30 and 16%, respectively. The duration of median progression-free survival was 12.3 months (95% CI, 7.4-17.3), and the 1-, 2-, 3-, and 5-year progression-free survival rates were 47, 40, 29 and 23%, respectively. Thus, concurrent conventional chest radiotherapy with oral etoposide plus cisplatin followed by consolidation CT led to an encouraging survival rate and prolongation of the time to progression, with moderate toxicity in patients with locally advanced inoperable NSCLC.

Evaluation of cisplatin in combination with a biologic response modifier in a murine mammary carcinoma model

The purpose of this study was to determine the efficacy of intracavitary cisplatin against local regrowth and metastasis after resection of a murine mammary carcinoma and the ability of a biologic response modifier (Virulizin) to enhance chemotherapy. C3H-HeJ mice were injected with Gollin-B tumor cells. Once growth reached 8 mm, tumors underwent marginal resection and the mice were assigned randomly to intraperitoneal (i.p.) cisplatin, Virulizin, a controlled release cisplatin-impregnated sponge (OPLA-Pt), a combination of treatments or no treatment and were evaluated for local regrowth, metastasis, and toxicity at 14 or 60 days after surgery. A possible beneficial interaction was seen between OPLA-Pt and Virulizin at 14 days. All cisplatin groups had significant advantages over controls in all variables measured with OPLA-Pt displaying significant advantages over i.p. cisplatin in local recurrence rate, tumor score, survival time, and delay in regrowth at 60 days. No toxicity related to either cisplatin or Virulizin was observed.

Preoperative concurrent chemoradiotherapy for stage IIIA non-small cell lung cancer

Thirty-one patients with stage IIIA non-small cell lung cancer (NSCLC) were treated with preoperative concurrent chemoradiotherapy (CCRT) followed by surgery. The treatment protocol could not be completed in eight patients. The acute hematologic toxicities of grade III or IV occurred in 48.4%, (15/31) after the first chemotherapy cycle, and in 39.1% (9/23) after the second cycle. The most common non-hematologic toxicity was radiation esophagitis. Surgery was attempted in 23 patients and successful in 22 patients (resection rate = 71.0%. Pathologic complete response and down-staging were achieved in 13.6% (3/22) and 68.2% (15/22). The median survival period, 2-year overall survival, local control and disease-free survival rates of all 31 patients and of 22 patients who underwent surgery were 19 months, 37.2%, 49.1%, 35.5%, and 19 months, 43.2%, 51.8%, 25.6%, respectively. On the basis of our observations, preoperative CCRT followed by surgery for stage IIIA NSCLC has resulted in outcomes comparable with those in previous reports.

Lack of effectiveness of radiotherapy combined with cisplatin in patients with locally advanced pancreatic carcinoma

BACKGROUND

Cisplatin has been reported to enhance the cell-killing effect of radiation. The current study was conducted to evaluate the efficacy and toxicity of radiotherapy combined with cisplatin in patients with locally advanced pancreatic carcinoma.

METHODS

Forty-one patients with pancreatic carcinoma that was unresectable but confined to the pancreatic region were treated with external beam radiation (50.4 grays [Gy] in 28 fractions over 5.5 weeks) and daily cisplatin (5 mg/m(2)/day as a 30-minute infusion just before each radiation fraction). Maintenance 5-fluorouracil (5-FU) (500 mg/m(2)) given once weekly was initiated 1 week after the completion of the chemoradiotherapy and continued until disease progression or unacceptable toxicity.

RESULTS

Of the 41 patients, 31 (76%) completed the scheduled course of chemoradiotherapy. The median survival time was 7.7 months, and the 1-year survival rate was 36%. The median progression free survival time was 5.8 months. The first site of failure was distant metastases in 25 patients, locoregional recurrence in 6 patients, and both sites in 1 patient. The major toxicity was leukocytopenia and nausea/emesis.

CONCLUSIONS

Radiotherapy with daily cisplatin appears to be inferior to conventional chemoradiotherapy using 5-FU in patients with locally advanced pancreatic carcinoma.

Combined-modality therapy in the nonsurgical management of unresectable stage III non-small cell lung cancer

Combined chemotherapy and radiation for patients with unresectable non-small cell lung cancer has recently been associated with a survival advantage compared with radiation alone; however, despite this apparent improvement in survival, the optimal strategy to combine these two modalities has not yet been defined. Both local tumor control and distant micrometastatic disease remain problems, limiting the curative ability of current combined-modality programs. Over the past year, accelerated radiation schedules have been shown to improve both local tumor control and survival in a selected patient population compared with standard radiotherapy. Some work has centered on the incorporation of novel chemotherapy agents into combined-modality regimens, with encouraging results from phases I and II. Finally, although the benefit for combined-modality therapy has generally been limited to good performance status of patients with minimal weight loss, some data have shown the feasibility of the combined approach in high-risk patient populations. Several ongoing cooperative group phase III trials will help to better define the optimal approach to manage this high-risk patient population.

Radiosensitization by intratumoral administration of cisplatin in a sustained-release drug delivery system

PURPOSE

Effects of combining local irradiation and intratumoral (i.t.) administration of cisplatin (CDDP) in a sustained-release drug delivery system (epi gel) were studied in a murine SCCVII squamous cell carcinoma model in mice.

MATERIALS AND METHODS

The epinephrine injectable gel was used as a drug delivery system. Intratumoral pharmacokinetics of CDDP was studied by using 195mPt-CDDP. The tumor volume quadrupling time (TVQT) and tumor growth delay (TGD) time were used to evaluate the antitumor efficacy of treatment regimens.

RESULTS

The concentration and residence of 195mPt-CDDP was significantly higher in tumors treated with 195mpt-CDDP/epi gel than in tumors treated with 195mPt CDDP gel or 195mPt-CDDP suspension. Intratumoral administration of CDDP/epi gel (4 mg/kg) produced an average TGD time of 15.5 +/- 2.8 days, which was 5.2 - 7.4 times longer than CDDP suspension i.t. or i.p. When combined with a single dose of radiation (10 Gy), i.t. administration of CDDP/epi gel was 2.0 - 3.6-fold as effective as administered i.t. in suspension (39.2 +/- 4.1 vs. 19.8 +/- 3.9 days of TGD, P < 0.05) or i.p. in solution (39.2 +/- 4.1 vs. 11.0 +/- 1.6 days, P < 0.001) in inhibiting tumor growth and produced 20-60% complete remission of tumors. When combined with fractionated irradiation, pre-irradiation CDDP administration was more effective than post-radiation administration (26.7 vs. 12.1 days of TGD, P < 0.05). Mice treated with CDDP/epi gel i.t. alone or in combination with irradiation, had little systemic toxicity.

CONCLUSIONS

Intratumoral administration of CDDP using the sustained-release drug delivery system is an efficient and safe method to maximize the drug concentration in tumor, minimize the systemic toxicity and enhance antitumor efficacy of irradiation.

A pilot trial of hyperfractionated thoracic radiation therapy with concurrent cisplatin and oral etoposide for locally advanced inoperable non-small-cell lung cancer: a 5-year follow-up report

PURPOSE

To improve the outcome of patients with locally advanced inoperable non-small cell lung cancer (NSCLC), we conducted a pilot trial of concurrent chemoradiation therapy using a cisplatin and oral etoposide regimen given concurrently with hyperfractionated radiation therapy.

METHODS AND MATERIALS

In this single-institution pilot trial, we enrolled 23 patients with inoperable Stage IIIa (4) and IIIb (19) NSCLC. Treatment consisted of two cycles of chemotherapy with oral etoposide 50 mg one day alternating with 50 mg b.i.d. (50 mg/day if BSA is < 1.70 m2) on days 1-21 and intravenous cisplatin (40 mg/m2) on days 1 and 8 of a 28-day cycle. Radiation therapy was given twice a day (1.2 Gy per fraction), 5 days a week, to a total dose of 69.6 Gy in 58 fractions over 6 weeks.

RESULTS

Overall, 18 (78%) of the 23 patients completed the chemotherapy as planned and 21 (91%) received thoracic irradiation per protocol. One patient died of radiation pneumonitis. Fourteen (78%) of 18 evaluable patients achieved objective responses. The median survival duration was 9.3 months for all patients and 20.2 months for 15 patients who had no more than 5% weight loss. After a minimum follow-up of 5 years, five patients (1 IIIa, 4 IIIb) are still alive and disease-free, which gives an actual 5-year survival rate of 22%. Four of the five 5-year survivors were among those who completed the treatment as planned.

CONCLUSION

This long-term survival outcome compares favorably with that of other chemoradiation therapy trials and even with those reported in multimodality trials including surgery. These results suggest that intensive concurrent chemoradiation therapy is feasible, and some patients with locally advanced inoperable NSCLC may enjoy long-term survivorship following nonsurgical therapy.

Chemotherapy for non-small cell lung cancer: the experience of the Lung Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer

The Lung Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer was founded in 1981. During the past 15 years, the group has participated in the development of treatment of non-small cell lung cancer with chemotherapy. The group performed standard phase II studies of new drugs and phase III studies with new and active drugs. Furthermore, the group performed studies combining chemotherapy with treatment for localized disease.

Combined-modality treatment of locally advanced non-small cell lung cancer: incorporation of novel chemotherapeutic agents

The role of multimodality management in locally advanced non-small cell lung cancer (NSCLC) continues to evolve and is a subject of ongoing clinical research. Induction chemotherapy followed by surgical resection with or without thoracic radiotherapy has proved superior to surgical resection alone in patients with ipsilateral mediastinal (N2) disease. Whether surgery alone still plays a role in these patients is the subject of an ongoing intergroup study. As no definitive, optimal effective chemotherapy regimen currently exists for NSCLC, future studies will attempt to incorporate novel and active agents like the taxanes, irinotecan, vinorelbine, and gemcitabine into combined-modality therapy for locally advanced NSCLC. Thoracic radiation therapy by itself provides local control and effective palliation of tumor-related symptoms but has minimal impact on the survival of patients with locally advanced disease. Novel schemes such as hyperfractionated radiotherapy and continuous hyperfractionated accelerated radiotherapy are currently being investigated and appear promising but need to be tested in combination with chemotherapeutic agents. Randomized studies have demonstrated the benefit of concurrent or sequential chemoradiation in selected patients with a good performance status and minimal weight loss. The exact sequence of combined-modality therapy has yet to be determined. The combination of paclitaxel and platinum compounds has shown impressive activity in advanced NSCLC in both phase II and III randomized studies. We have incorporated weekly low-dose paclitaxel and carboplatin with concurrent thoracic radiation in treating patients with locally advanced, inoperable NSCLC, and long-term follow-up has shown remarkable survival rates. Confirmation of these phase II combined-modality studies is needed. Combination sequential chemotherapy followed by concurrent chemoradiation in patients with advanced NSCLC has the potential to improve overall survival by increasing both local and distant control.

Oral platinum analogue JM216, a radiosensitizer in oxic murine cells

This study was designed to compare radiosensitization by the oral platinum compound JM216 with cisplatin. RIF1 mouse tumour cells were treated at various doses and at various exposure times with JM216 and irradiated 15 min before the end of drug exposure. The fraction of cells surviving treatment was assessed by colony formation. Results were compared with those for equivalent treatments with cisplatin. JM216 alone showed exponential killing of RIF1 cells, being approximately three times less efficient than cisplatin on a molar basis. For radiosensitization studies, drug doses used gave approximately 50 or 90% cell killing alone. No radiosensitization was seen after 2-h drug exposures, but significant radiosensitization occurred after 1- and 0.5-h exposures (shorter times required proportionally higher drug doses, giving equivalent drug kill). The enhancement ratio and time dependence were similar for the two platinum compounds, reaching 1.5 at the highest concentrations tested. Drug DNA adduct formation was assessed using immunocytochemistry with the NKI-A59 antiserum raised to cisplatin-DNA adducts. The antiserum was shown to recognize JM216-DNA adducts in a dose-dependent manner and maximum nuclear staining was found to be correlated with cell kill for both drugs. However, neither the level of staining at the time of irradiation nor at the time of maximum adducts correlated with radiosensitization, indicating that the number of DNA adducts did not determine radiosensitization. Intracellular glutathione levels were shown to be decreased by the drug, but only by approximately 50%, implying that this was not the cause of the increased radiosensitivity. In summary, JM216 was shown capable of radiosensitizing a platinum-sensitive tumour line to an extent similar to cisplatin. Radiosensitization was exposure-time and drug-concentration dependent, but was not dependent on DNA adduct levels nor glutathione depletion. In contrast, cell kill after drug alone was well correlated with adduct levels. These data suggest that JM216 could replace cisplatin in combined radiotherapy-chemotherapy studies, and also indicate that the NKI-A59 antibody could be used to monitor exposure levels in vivo.

Continuous infusion of carboplatin during conventional radiotherapy treatment in advanced squamous carcinoma of the cervix uteri IIB-IIIB (UICC). A phase I/II and pharmacokinetic study

OBJECTIVE

A prospective, single-arm phase-I/II trial performed to assess the efficacy and toxicity of the concomitant use continuous infusion of low-dose carboplatin and pelvic conventional radiotherapy in patients with locally advanced squamous cell carcinoma of the cervix.

MATERIALS AND METHODS

Between January and July 1994, a total of 12 patients consecutively diagnosed to have squamous cell carcinoma of the cervix uteri stages IIB-IIIB UICC-TNM (five patients, IIB; and seven patients, IIIB) entered the study. All patients were evaluated by a gynecologist and a radiation oncologist and were submitted to standard pretreatment staging procedures. Radiation was delivered with 10-MeV photon beams with the shrinking-field technique. The patients received 2 Gy radiotherapy daily, 5 fractions per week, up to a planned total of 60 Gy in 6 weeks to the primary tumor and 46 Gy in 4 weeks to the whole pelvis. Irradiation was performed using four fixed orthogonal fields. One intracavitary insertion, 8 Gy to point A (dose rate, 1.1 Gy/h), was performed immediately after external pelvic irradiation. Carboplatin (12 mg/m2/day) was also administered in a continuous infusion, starting 1 day before the first fraction of radiotherapy. The platinum in plasma and urine, as well as the platinum concentration in the cytosols of lymphocytes and tumor, was measured weekly.

RESULTS

A complete response was seen in nine (75%) of the 12 patients. Of the nine patients who achieved a complete remission, only one had subsequent failure in the pelvis. The total pelvic failure rate was 33.3% (four of 12 patients). With a median follow-up time of 20 months, the actuarial survival rate at 24 months was 64.8%. All patients completed the treatment without major protocol violations. Grade-2 leukopenia (in nine patients) and grade-1 nausea and vomiting (in five) were the most common acute toxicities. There was one grade-3 hematologic toxicity. Grade-3 late complications were observed in 16.6% of cases (two of 12 patients). On days 28 and 42 of the treatment, the mean total platinum plasma concentrations were 491 micrograms/L (SD = 129) and 672 micrograms/L (SD = 160), and the ultrafilterable fraction was 8-10%. At the same time points, the concentration in lymphocytes was constant at 21 picograms (pg) platinum/lymphocyte. The levels of platinum concentration measured on days 14 and 28 in the cytosols of tumor cells were 0.3 microgram/g (SD = 0.1) and 0.93 microgram/g (SD = 0.2).

CONCLUSION

The combination of continuous infusion of carboplatin and radiotherapy at the aforementioned doses in patients with locally advanced cervical carcinoma resulted in a relatively low frequency of significant acute and late complications. Platinum in normal tissue (picograms per lymphocyte) was stable from week 1 of treatment, whereas the platinum steady state in plasma and in tumor cells was not reached in 6 weeks and was below that required in vitro to produce radiopotentiation. Further studies to determine the optimal dose of carboplatin and irradiation are needed prior to the initiation of phase-III studies.

Prospective trial of combined hyperfractionated radiotherapy and bronchial arterial infusion of chemotherapy for locally advanced nonsmall cell lung cancer

PURPOSE

This article is a prospective trial of hyperfractional radiotherapy with bronchial arterial infusion of anticancer drugs to treat locally advanced bronchogenic cancer. The treatment results, the complications of bronchial arterial infusion, the failure patterns, the relationship of technical aspects of delivery of radiotherapy, and the protocol of anticancer drugs are presented.

METHODS AND MATERIALS

One hundred and twenty-six patients with locally advanced bronchogenic cancer, treated from January 1988 to January 1990, were divided randomly into four groups in our hospital. Group 1: combination of hyperfractional radiotherapy with bronchial arterial infusion of anticancer drugs (30 cases); Group 2: combination of conventional radiotherapy with bronchial arterial infusion of anticancer (33 cases); Group 3: combination of systemic chemotherapy and split-course radiotherapy (33 cases); Group 4: conventional radiotherapy only (30 cases).

RESULTS

All the patients were followed for 3 years. The 1-year survival rates for Groups 1, 2, 3, and 4 are 80, 63.6, 48.5, and 30%, respectively. The 2-year survival rates for Groups 1, 2, 3, and 4 are 23.3, 15.15, 9.1, and 6.6%, respectively. The 3-year survival rates for Groups 1, 2, 3, and 4 are 10, 3.3, 0, and 0%, respectively.

CONCLUSION

This study demonstrated that the combination of hyperfractional radiotherapy with bronchial arterial infusion anticancer drugs can be performed safely and effectively for locally advanced bronchogenic carcinoma.

Concurrent irradiation and intratumoral chemotherapy with cisplatin: a pilot study in dogs with spontaneous tumors

PURPOSE

A preliminary study was undertaken to determine whether the addition of a collagen gel in the formulation of cisplatin for intratumoral administration of cisplatin affected platinum plasma concentrations. A second study was undertaken to determine the local effects of intratumoral administration of cisplatin mixed with collagen given concurrently with irradiation.

METHODS AND MATERIALS

Twelve dogs with advanced stage tumors were administered a dose of 0.25 mg of cisplatin per kg of body weight intratumorally with or without collagen using a two-period crossover design. Twelve additional dogs received concurrent irradiation (48 Gy) delivered in 12 fractions over 4 weeks and intratumoral cisplatin chemotherapy given the first day of each week at a dose of 0.5 mg of cisplatin per cm3 of tissue.

RESULTS

The cumulative cisplatin plasma concentrations varied over time from dog to dog, but the use of collagen in the formulation significantly reduced the systemic exposure of cisplatin. For the dogs given intratumoral cisplatin and irradiation, complete responses were observed in 10 dogs. Seven dogs had local recurrence. One dog had tumor recurrence in the radiochemotherapy field and six dogs had recurrence at the margin of the radiochemotherapy field, but within the irradiation field. Normal tissue reactions were similar in the radiochemotherapy field and in the margin treated with radiation only. Cumulative effect of repeated intratumoral administration on plasma concentration of cisplatin was not observed.

CONCLUSIONS

These findings provide support for an extended investigation of this combined regimen. The lack of systemic toxicity associated with intratumoral administration of cisplatin mixed with collagen may allow a safe clinical evaluation of the interaction between cisplatin and radiation.

Improvement of combined modality therapy with cisplatin and radiation using intratumoral drug administration in murine tumors

The aim of these studies was to increase the therapeutic ratio by achieving higher tumor concentrations of cisplatin during the course of a fractionated irradiation treatment. Specific goals were to test, firstly, whether multiple drug injections could be replaced by a single slow release implant of cisplatin, and secondly, whether the therapeutic potential of the combined treatment could be increased by administering the drug intratumorally. Drug administration routes tested were intraperitoneal (i.p.) of drug in solution, intratumoral (i.t.) of drug in solution, and intratumoral of drug in a slow release formulation. The latter consisted of a hydrogel polymer formulated into rods which were implanted into the center of subcutaneous tumors. For drug alone, both i.t. routes (solution or polymer) produced higher therapeutic gains than i.p. administration, as judged by tumor growth delay for a given weight loss. When combined with radiation, dose response curves were always shifted to lower doses and were steeper than for radiation or drug alone, although isobologram analysis indicated additivity. In a first series, drug enhancement ratios ranged from 1.6 to 2.6, and were highest for the i.t. groups. In a second series, X-ray enhancement ratios ranged from 1.1 to 1.7, with overlap between results from the different routes. Therapeutic ratios, however, were highest for the i.t. groups in both series. Slow release rods produced the highest therapeutic gains in the first series, while i.t. administration of drug in solution was approximately as effective in the second series.(ABSTRACT TRUNCATED AT 250 WORDS)

Weekly cisplatin plus external beam radiotherapy and high dose rate brachytherapy in patients with locally advanced carcinoma of the cervix

PURPOSE

Prospective, single arm, Phase I/II trial performed to assess the efficacy and toxicity of the concomitant use of weekly cisplatin and pelvic radiotherapy in patients with locally advanced carcinoma of the cervix.

METHODS AND MATERIALS

Between December 1988 and April 1991, 50 previously untreated patients with bulky, locally advanced, squamous cell carcinoma entered the study. All patients were evaluated by a gynecologist and a radiation oncologist and were submitted to standard pre-treatment staging procedures. The International Federation of Gynecology and Obstetrics stage distribution was as follows: IIA three patients, IIB seventeen, IIIA two, IIIB 25, and IVA three. Radiotherapy consisted of 46 Gy external beam irradiation plus three high dose rate intracavitary treatments given on a weekly basis to a total dose of 30 Gy to point A. Cisplatin 30 mg/m2 was also given weekly starting on day 1 of radiotherapy.

RESULTS

With a median follow-up time of 27 months, complete response was seen in 88% (44/50) of the patients. The actuarial survival rate at 44 months was 65%. Total pelvic failure rate was 26% (13/50). Of the 44 patients who achieved a complete remission, only seven have failed in the pelvis. Distant disease was observed in 24% of the cases. Treatments were well tolerated with no patient requiring an interruption in the radiotherapy. However, the incidence of late gastrointestinal toxicity was high, with 10 patients developing a rectal ulcer (four colostomies for severe bleeding), two patients a small bowel obstruction, and two patients a recto-vaginal fistula. Moreover, gastrointestinal complications appeared sooner than expected, at a median follow-up time of 11 months after completion of treatment.

CONCLUSION

The combination of weekly cisplatin and radiotherapy appears to be a very effective regimen for patients with locally advanced carcinoma of the cervix, but resulted in a relatively high frequency of late gastrointestinal complications.

Radiation and simultaneous cisplatin in non-small cell lung cancer

PURPOSE

Phase III non-small cell lung cancer trials comparing radiation and simultaneous single agent cisplatin-radiation, as well as, Phase II trials of cisplatin containing combination regimens and concurrent thoracic radiation used as preoperative or as definitive therapy in stage III non-small cell lung cancer are reviewed.

METHODS AND MATERIALS

The prognostic significance of the new international staging system with respect to clinical Stage III disease is described and discussed in this review because it has important implications for clinical trials. The results of four randomized Phase III trials and one Phase II trial which evaluated radiation therapy and single agent cisplatin are reviewed. The data from studies of combination chemotherapy and concurrent thoracic radiation observed in two consecutive Rush University Phase II trials and in a randomized Phase II Mayo Clinic trial are described. Eight phase two studies in which thoracic radiation and simultaneous cisplatin containing combination chemotherapy were given as preoperative treatment are compared.

RESULTS

Studies evaluating the prognostic significance of the new staging system (IIIa vs IIIb) have shown conflicting results. In Rush University trials there has been a significant difference for IIIa versus IIIb and in particular the tumors which are invading the mediastinum or chest wall without obvious mediastinal lymph node metastases appear to have the best prognosis. Similarly randomized trials evaluating curative doses of thoracic radiation therapy with or without current single agent cisplatin have shown contradictory results. One of the four randomized trials have shown superior survival with patients treated with radiation and simultaneous daily cisplatin. Toxicity with cisplatin combination chemotherapy regimens and split course radiation has been acceptable. In Phase II non-surgical trials preoperative treatment consisting of cisplatin containing combination regimens given simultaneously with thoracic radiation have shown that this type of combined modality therapy is feasible and that the rates of resectability appear to be higher than would be expected with surgery alone. Survival results from six of these studies appear to be superior to results reported for radiation or surgery alone.

CONCLUSION

Additional data are needed to determine the prognostic significance of the new staging system for clinical Stage III non-small cell lung cancer patients. Similarly, additional Phase III trials will be required to determine the role of thoracic radiation and concurrent single agent cisplatin, as well as, concurrent cisplatin combination regimens. Treatment with preoperative radiation and concurrent cisplatin containing combination therapies is feasible and relatively safe. Phase III trials are needed to determine the impact of neoadjuvant chemoradiation therapy and surgery in Stage III patients.

Report of phase II trial of concurrent chemoradiotherapy with radical thoracic irradiation (60 Gy), infusional fluorouracil, bolus cisplatin and etoposide for clinical stage IIIB and bulky IIIA non-small cell lung cancer

PURPOSE

To assess the response rate, median and long-term survival of patients (pts) with locally advanced, initially inoperable non-small cell lung cancer (NSCLC) treated on a phase II study of radical thoracic radiotherapy (TRT) and concurrent radiosensitizing chemotherapy.

METHODS AND MATERIALS

From 3/87 to 7/90, 41 previously untreated patients at Fox Chase Cancer Center with locally advanced non-small cell lung cancer, 24 with bulky clinical Stage IIIA, and 17 with IIIB disease, received concurrent thoracic radiotherapy (60 Gy/2.0 Gy/d in 6 weeks) and 2 cycles of infusional 5FU (640-800 mg/m2/24 hrs x 5 d); cisplatin (20 mg/m2 qd x 5); and etoposide (50 mg/m2 d 1, 2, 5) administered days 1 and 28 of TRT.

RESULTS

Forty of 41 were evaluable. Response rate was 90%, with radiographic CR in 20%. Thirteen pts (33%) underwent thoracotomy and complete resection with clinical downstaging in 10, including three pathologic CR's. Overall median survival was 14 months and 2-year survival was 38% with no difference between CS IIIA and IIIB pts (p = 0.2224). At median potential follow-up of 42 months, 8/40 pts. (20%) are alive and progression-free, including 4 of 13 resected pts. The chief toxicity was esophagitis, occurring in 32 pts. (80%), Grade 3-4 in 21 (52%), with 13 (33%) requiring hospitalization and 7 (18%) needing TPN. Grade 3-4 granulocytopenia was noted in 20 pts. (50%) with ten episodes of fever mandating intravenous antibiotics. Cardiac ischemia was documented in 2 (5%). Of 13 thoracotomy pts, six underwent lobectomy without perioperative mortality; 3 of 7 pneumonectomy pts died post-operatively, two from broncopleural fistula, and one from ARDS.

CONCLUSION

This aggressive regimen produced a 2-year survival (38%) comparable to the best arm of cancer and leukemia groups B study 8433, which administered radical thoracic radiotherapy after protoadjuvant vinblastine and cisplatin in similar and earlier stage non-small cell lung cancer patients. Toxicity, particularly esophagitis, was severe, but of short duration. An unacceptably high complication rate was seen following pneumonectomy, but not lobectomy.

Combined-modality therapies for non-small cell lung cancer

Regionally advanced stage III non-small cell lung cancer (NSCLC) accounts for nearly 40% of all presentations of NSCLC. In the past, such patients received radiotherapy alone, but the median and long-term survival durations were disappointingly poor. Past attempts at combining chemotherapy and radiation were also disappointing, and were troubled by low doses of radiation or orthovoltage equipment or both. Recently, cisplatin-containing regimens have shown some efficacy in stage IV disease. The response rate for these combinations in stage III disease is nearly double that in stage IV disease. The greater response in stage III has led to a series of trials of sequenced chemotherapy and radiotherapy for treatment of regionally advanced (unresectable stage IIIA and IIIB) NSCLC. Several randomized trials have now shown a statistically significant advantage for the combined modality over radiation alone regarding time to treatment failure, median survival duration, and percent of long-term survivors. Other trials have focused on the concurrent use of chemotherapy and radiotherapy. Several pilot studies have suggested that concurrent cisplatin plus chest irradiation can produce apparently beneficial results with respect to local control and are the subject of ongoing clinical trials. At the University of Maryland Cancer Center, we have combined weekly carboplatin 100 mg/m2 with concurrent chest irradiation. The preliminary results are very encouraging. The toxicity of this treatment program is very manageable, and preliminary data suggest excellent local control and survival. Other pilot studies have suggested that combination chemotherapy with concurrent radiotherapy is also technically feasible.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy enhanced by cis-platinum in stage III non-small cell lung cancer: a phase II study

From January 1984 to December 1986, 94 patients with unresectable, locally advanced, non-small cell lung cancer (NSCLC) were treated to assess both the efficacy and the toxicity of a combined modality treatment including radiation therapy (45 Gy/15 fractions/3 weeks) and daily low dose cDDP (6 mg/m2). The overall response rate for the 90 evaluable patients was 54.3% with 16.6% of complete responses. At a minimum follow-up of 4 years, the overall median survival time was 12 months. Provided adequate hydration is ensured, the cDDP regimen chosen as a radiosensitizer can be safely combined with radiation therapy.

Radiotherapy versus radiotherapy enhanced by cisplatin in stage III non-small cell lung cancer

Between January 1987 and June 1991, 173 patients with inoperable non-small cell lung cancer, Stage III, were entered into a randomized trial comparing radiotherapy only (RT) (45 Gy/15 fractions/3 weeks) (arm A) versus RT and a daily low dose of cDDP (6 mg/m2) (arm B). An overall response rate of 58.9% was observed in arm A and 50.6% in arm B, respectively. No differences in the pattern of relapse were noted between the two treatment groups. Median time to progression was 10.6 months for arm A and 14.2 months for arm B. Median survivals were 10.3 months and 9.97 months, respectively. Toxicity was acceptable and no treatment-related death occurred in either treatment schedule. In this study no significant advantage of the combined treatment over radiation therapy only was found. The encouraging results achieved in some trials together with the intractability of the disease suggest that further efforts should be made to optimize clinical trial protocols, perhaps by reviewing the radiobiological and pharmacological basis of the combined treatment.

Combined chemo- and radiosensitivity testing with ifosfamide and ACNU in human lung cancer cell lines

The combination of radiotherapy and cytostatic drugs is of interest in the treatment of several solid tumors. In these preclinical investigations we tested whether ifosfamide and ACNU are able to enhance radiation effects. The experiments were performed by using the MTT assay. Two small cell and 2 non small cell lung cancer cell lines were involved. Ifosfamide, ACNU or both drugs together were tested in 6 different concentrations adjusted to the peak blood level. During the 1 hour drug incubation time, the cell lines were either irradiated with a single dose of 4 Gy or not. The main results were that ACNU possessed only little cytostatic activity in the cell lines under examination. In contrast, ifosfamide caused a dose related cytostatic activity in all cell lines. Concentrations of 26 micrograms/ml (NCC-SCLC H 82) or 10-12 micrograms/ml (3 other cell lines) were able to reduce the surviving cell fraction to less than 50% (IC50). While ACNU showed no clear outlined radiosensitizing properties, ifosfamide reinforced the radiation effects in 3 out of 4 cell lines indicating radiosensitizing properties of this drug. Synergistic effects of ifosfamide and ACNU have not been noticed. These preclinical investigations may constitute the basis for combined ifosfamide and irradiation therapy in future clinical trials.

Role of induction chemotherapy in invasive cervical cancer

The 386 cases of invasive cervical carcinoma treated with radiotherapy alone were statistically analyzed to delineate the high risk factors (HRFs) associated with a significantly high treatment failure rate; they were (1) stages III-IV, (2) lesion greater than or equal to 4.0 cm, (3) small cell carcinoma or adenocarcinoma, (4) stages I-II with lesion greater than or equal to 4.0 cm, and (5) lymphographic evidence of nodal metastasis. Then, chemoradiotherapy (induction chemotherapy plus subsequent radiotherapy) was instituted to 113 invasive cervical carcinoma patients with at least one such HRF. Each patient received two to three cycles of induction chemotherapy at about 3-week intervals. For squamous cell carcinoma, cisplatin, 100 mg/m2 iv, was followed immediately by 5-fluorouracil, 1000 mg/m2, as a 24-hr iv infusion x 5 days. For adenocarcinoma, cisplatin, 70 mg/m2 iv, on Day 1 was followed by cytoxan, 250 mg/m2, on Day 2, and adriamycin, 45 mg/m2, on Day 3. Five-year survival of these patients according to each HRF, in the above order, was 69.1, 67.2, 68.1, 78.3, and 79.5% after chemoradiotherapy, all significantly higher than 57.4, 53.0, 54.5, 48.0, and 48.8% by radiotherapy alone. Drug toxicities such as leukopenia, hepatotoxicity, nephrotoxicity, and hypomagnesemia were seen in 46.5, 53.2, 47.1, and 55.4% of all cycles, respectively. The toxicities altered drug schedule in 191 (61.2%) ongoing induction chemotherapy cycles. Our cisplatin-based induction chemotherapy is considered an effective preradiotherapy adjunct that can reduce treatment failure in HRF-associated invasive cervical carcinoma.

Concomitant evaluation of efficiency, acute and delayed toxicities of combined treatment of radiation and CDDP on an in vivo model

The efficiency, acute and delayed toxicities of different radio-chemotherapeutic combinations were assessed on an in vivo model (Krebs II ascitic carcinoma grafted to female Swiss mice). Mice were given whole abdomen irradiation (WAI) 2.5 to 10 Gy as a single dose (WAI). CDDP was given intraperitoneally at 0.5 to 4 mg/kg dose level, 12 hr before or after WAI. There was a relationship between dose of CDDP and increase of life span (ILS) of mice. However, WAI did not increase the life span. When a single dose of 2 mg/kg CDDP was given prior to a 2.5 Gy WAI, the ILS reached 47%. By contrast, it was only 37% when treatment sequence was reversed. When the WAI dose level was increased to 5 Gy, the ILS was not increased. The jejunal crypt cell number, determined 3 days after the last treatment, was not modified, regardless of the treatment sequence. There was no delayed renal toxicity. The study on the Krebs II ascites model confirms the tumor cell therapeutic potentiation without exacerbation of normal tissue damage.

Early and late effects of cisplatin and radiation at acute and low dose rates on the mouse skin and soft tissues of the leg

The influence of radiation dose rate and drug dose on the combined effects of cisplatin (Cis-diamminedichloroplatinum (II] and radiation on the skin and soft tissues was studied in the C3Hf/SED mice. Localized acute-dose-rate irradiation (ADRI) at 3.345 Gy/min and continuous low-dose-rate irradiation (CLDRI) of the hind leg at 0.028 Gy/min with and without the drug was delivered using a 137Cs laboratory irradiator. Cisplatin at 6 or 11 mg/kg was given by intraperitoneal bolus injection 1 hour before ADRI or by continuous infusion during CLDRI. Acute skin reaction was scored from days 13 to 30 and late skin contraction and leg contracture were measured at days 90, 180, 270, and 360 after treatment. A marked dose-rate effect was observed for these early and late normal tissue endpoints. At a dose of 60 Gy of CLDRI, the dose rate factor (DRF = isoeffect dose at CLDRI/isoeffect dose at ADRI) was 1.82 for acute skin reaction and 1.76 for late skin contraction or leg contracture at day 270. However, there was no significant enhancement of these early and late normal tissue effects by cisplatin at 6 or 11 mg/kg at either acute or low dose rates. Thus neither drug dose nor radiation dose rate had a significant impact on the combined effects of cisplatin and radiation on the mouse skin and soft tissues of the leg.

The response of hypoxic cells in SCCVII murine tumors to treatment with cisplatin and x rays

Possible mechanisms of enhancement of radiation effects by cisplatin, including radiosensitization of hypoxic cells, drug-induced tumor reoxygenation, and inhibition of repair of sublethal radiation damage, were examined in the murine SCCVII model. Combination radiation/drug treatments were most effective when drug exposure preceded irradiation of animals breathing a reduced oxygen atmosphere, indicating that the primary interaction between the modalities was a cisplatin-induced increase in the oxygenation status of the acutely hypoxic cells in those tumors. Delivering cisplatin prior to or immediately after the first of two 5 Gy fractions was more effective than combinations with a single x-ray exposure, suggesting that proper sequences of the combined modalities may augment natural reoxygenation processes.

Time- and sequence-dependent responses to cisplatin and radiation in the rat kidney

The influence of time interval and sequence between administration of cisplatin and a radiation dose was studied in the rat kidney. A dose of 10.5 Gy X-rays was given to both kidneys, preceded or followed by a single dose of cisplatin. Two separate experiments were performed. In the first experiment 6.0 mg/kg cisplatin was given, in the second experiment the drug dose was 5.5 mg/kg. A range of time intervals was introduced between administration of drug and radiation, from 7 to 1 days, 12 to 1 h, and 30 to 0 min. Control animals received either modality alone, or were left untreated. Cisplatin alone caused tubular function to decrease very quickly and to remain permanently altered. Changes in glomerular function were only detected after 30 weeks following the higher drug dose. X-rays alone caused measurable alterations in both glomerular and tubular function after 16 weeks. In the combined treatment the influence of time and sequence was significant. If cisplatin was given at 7 to 1 days before X-rays the effect of time was minimal. Administration of cisplatin 12 h to 15 min before irradiation resulted in an increase of radiation damage with decreasing time interval. Total damage sharply decreased when both modalities were given at the same time, and decreased further with increasing time between irradiation and drug administration. It is suggested that in the tubular cells free cisplatin or one of its hydrolysis products may interact with radiation-induced damage, e.g. by interference with repair of sublethal or potentially lethal damage.

Radiotherapy combined with low-dose cis-diammine dichloroplatinum (II) (CDDP) in inoperable nonmetastatic non-small cell lung cancer (NSCLC): a randomized three arm phase II study of the EORTC Lung Cancer and Radiotherapy Cooperative Groups

A randomized Phase II study was carried out to assess the feasibility and tumor response of radiotherapy combined with low dose cis-diammine dichloroplatinum (II), (cDDP), in patients with inoperable non-small cell lung cancer (NSCLC). One hundred patients were treated with either radiotherapy alone (arm I), with radiotherapy plus cDDP given once a week (arm II), or daily (arm III). The endpoints were acute and late toxicity and tumor response. Esophagitis was observed more frequently in the cDDP arms, but was severe in only 4% of the patients. Nausea and vomiting were more frequent and more severe in patients treated with the combination therapy. In 37% they required medication or were intractable (WHO, grade 3-4). There were no deficits in renal function when hydration schemes were used. Lung fibrosis was similar in the three arms, with an average of 75% of which 50% was severe. Response (complete and partial remission) was observed in 21 out of 34 eligible patients in arm I, in 20 out of 30 patients in arm II, and 20 out of 30 patients in arm III. The 1- and 2-year survival data were 38% and 14% for radiotherapy alone, 49% and 17% for radiotherapy and cDDP given once a week, and 50% and 32% for radiotherapy combined with daily cDDP.

IN CONCLUSION

a combination of concomitant cDDP and radiotherapy is tolerable. Based on these results, the study has been continued as a Phase III study with survival as most important end point.

Long-term follow-up of potentiation of radiotherapy by cis-platinum in advanced cervical cancer

Between January 1982 and January 1983 all patients with advanced cervical cancer were randomized into three groups: radiotherapy only (group I), radiotherapy plus weekly cis-platinum (group II), and radiation plus twice-weekly cis-platinum (group III). Better initial central control was observed in group III patients. Long-term survival was similar in the three groups. Potentiation of radiotherapy with cis-platinum failed to show any significant improvement in long-term survival.

The effect of cisplatin on the repair of radiation damage in RIF1 mouse tumours in vivo

The effect of the antitumour agent cisplatin on repair of X-ray-induced damage was studied in RIF1 mouse tumours treated in situ. The response of tumours, assessed by growth delay, to 4 fractions of X-rays given at 5-h intervals was compared with that after single doses. The displacement between the curves was taken as a measure of repair. A single dose of 6 mg.kg-1 cisplatin given 0.5 h before the first fraction resulted in no detectable inhibition of repair despite a significant growth delay caused by drug alone. A dose of 2 mg/kg cisplatin given 0.5 h before each of the X-ray fractions did, however, cause some repair inhibition; a result confirmed by tumour control experiments. The schedule dependence for repair inhibition was the same whether the irradiations were carried out on clamped (fully hypoxic) tumours or under ambient conditions. Significant enhancement of radiation damage was seen after correcting for the effects of drug alone, whether or not repair inhibition occurred. The effects of cisplatin on normal stroma within the tumour (vascular damage) was also investigated by monitoring the regrowth rates of recurrent tumours. In contrast to the effects on tumour cells, no enhancement of damage or inhibition of repair was seen for this assay in the combined treatment schedules.

The influence of cisplatin on the response of mouse kidneys to multifraction irradiation

The aim of these studies was to measure the extent of renal damage after fractionated irradiation in combination with cis-diamminedichloroplatinum(II) (c-DDP) and to determine whether there was any drug-induced inhibition of repair of sublethal X-ray damage. Fractionated irradiations were given either in a short overall treatment time of 2 days or in a total time of one month, in which irradiations were given in the first and fourth weeks only. A single dose of c-DDP was given before the first X-ray dose for treatments in a total time of 2 days and before the first X-ray dose of each week for the split-course treatments. Renal function was measured at monthly intervals (from 18 to 39 weeks after the start of treatment) by clearance of 51Cr-EDTA. The renal damage was always worse after combined treatments (X + c-DDP) than after X-rays alone. A comparison of radiation dose-response curves with and without c-DDP yielded Dose Enhancement Factors (DEFs) of 1.2 to 1.4 for all fractionation schedules, with no trend for an increase in DEF with increasing number of fractions. A Linear-Quadratic (LQ) analysis of the data demonstrated that there was no change in the alpha/beta value for renal radiation damage for the combined treatments compared with X-rays alone (alpha/beta = 2-3 Gy). These results suggest that the increased renal damage which occurred after combined X + c-DDP was due to independent, additive toxicities and not to radiosensitization or inhibition of X-ray repair by the drug.

The influence of cisplatin and unilateral nephrectomy on the response of the rat kidney to irradiation

Cisplatin was administered as a single i.p. dose of 5 mg/kg to WAG/Rij rats at intervals of 7 days or 0.5 h before, or 7 days after graded X-ray doses to the left kidney. The right kidney was surgically removed 4 weeks after irradiation. Renal function was determined by measuring total urine volume excreted in 24 h, urine osmolality and serum urea. The severity of alterations in the various anatomic compartments of the kidney induced by the various treatments were graded histologically. The administration of 2 or 5 mg/kg cisplatin alone did not alter any of the kidney function parameters. Isoeffective radiation doses calculated for each of the functional parameters continuously decreased with increasing time after treatment. Differences between the isoeffective doses for the three combined treatments and for treatment with irradiation alone were only observed for urine osmolality and urine volume which primarily are tubular-related functional parameters. The histopathological grading studies also indicated that enhancement by cisplatin of radiation-induced damage was almost entirely confined to the tubules. The results of this study indicate that the sequence and length of time between treatments is an important variable in the development of cisplatin plus radiation-induced renal injury, but that none of the tested combinations showed a more than additive toxicity.

Postoperative radical radiotherapy with concurrent weekly intra-arterial cis-platinum for treatment of malignant glioma: a pilot study

Twelve patients with histologically proven malignant glioma have been treated with a combination of intra-arterial (IA) cis-platinum (CDDP) and radical radiation therapy (RT). Chemotherapy consisted of intracarotid (IC) CDDP, 40-60 mg/m2, weekly, repeated for 3-5 treatments. Radiation therapy consisted of whole-brain irradiation 5000 cGy in 5 weeks, plus a cone-down boost (1000 cGy in one week) to the primary tumour lesion. Ocular toxicity derived from IC chemotherapy was observed in 3 out of 41 procedures analyzed (7%). Results in tumour response assessed by computed tomography (CT) showed 5 complete remissions, 6 partial remissions and one patient was not evaluable. The median survival time for the entire group was 10 months. Median survival time in patients with complete response is 17 months, and 10 months in patients with partial response. Four patients are still alive with a follow-up ranging from 6+ to 27+ months.