The role of adjuvant surgery in the combined modality therapy of small-cell bronchogenic carcinoma after a chemotherapy-induced partial remission

Twenty-six patients with a limited-disease presentation of small-cell bronchogenic carcinoma (SCBC) had surgery after achieving a partial remission with three cycles of chemotherapy. Persistent SCBC was found in 15 patients (58%), non-small-cell bronchogenic carcinoma (NSCBC) in six patients (23%), and no malignancy in five patients (19%). Twelve patients have died since surgery. Tumor-node-metastasis (TNM) staging prior to or after chemotherapy was not predictive of outcome, but an N0 status found at pathological examination of the surgical specimen was predictive of long-term survival. Median survival for this group of patients was 25 months. Adjuvant surgery is feasible and may be beneficial.

Histopathology of lung cancer

Lung cancer is a complex problem because there are a number of different histological cell types. Those commonly grouped as bronchogenic carcinoma (epidermoid carcinoma, adenocarcinoma, large cell undifferentiated carcinoma, small cell carcinoma, and adenosquamous carcinoma) account for more than 90% of the new cases and the deaths each year. The natural history of bronchogenic carcinoma suggests that many years pass while the cancer evolves from a pre-cancerous change in the bronchial mucosa, to undetectable microscopic cancer, to preclinical asymptomatic cancer and finally into a full symptomatic cancer, the phase of most lung malignancies in the tissue at diagnosis. Therefore, students of the aetiology of this disease must consider what has happened to patients 5-20 years before lung cancer is diagnosed.

Phase II study of idarubicin in extensive-disease non-small-cell lung cancer

Fourteen patients with extensive-disease non-small-cell lung cancer (E-NSCLC) were treated with oral 4-demethoxydaunorubicin (idarubicin, 4DMDR) at a dosage of 10 mg/m2/day x 5 days every 3 weeks. The median cumulative dose was 110 mg/m2 (range: 50-1,100). Two patients had stable disease for 12 and 56 weeks, respectively, one patient had failed to respond to a doxorubicin hydrochloride (Adriamycin)-containing regimen, and one had had no prior therapy. Twelve of the 14 patients had prior radiotherapy, chemotherapy, or both. Median survival for this heavily treated group was 16 weeks. Myelosuppression was minimal. Nausea and vomiting occurred in 44% of all courses. No cardiac toxicity and no decrease in cardiac ejection fraction was observed. We conclude that 4DMDR is ineffective in heavily treated E-NSCLC patients. However, the drug's activity in untreated patients is unknown. Further study of 4DMDR is indicated in patients who have had no prior chemotherapy or radiotherapy, with routine administration of antiemetic drugs along with pharmacokinetic studies.

Phase II study of tiazofurin (NSC 286193) in the treatment of advanced small cell bronchogenic carcinoma

Fourteen evaluable patients with small cell bronchogenic carcinoma received tiazofurin, an inhibitor of inosine monophosphate dehydrogenase, that progressed after one combination chemotherapy. No objective remission was observed at the dosage of 800 mg/m2 for 5 consecutive days. Toxicity was moderate.

Combined chemoradiotherapy in limited-disease, inoperable non-small cell lung cancer

Forty-three patients with limited-disease, inoperable non-small cell lung cancer received two intravenous courses of cyclophosphamide, Adriamycin, and cisplatin (CAP) chemotherapy over a 6-week period. This was followed by 5 weeks of combined chemoradiotherapy (CCRT) consisting of low weekly doses of CAP for 5 weeks plus 50 Gy continuous X ray therapy (XRT) to the primary tumor site. Chemotherapy was continued until disease progression occurred or until the total dose of Adriamycin reached 450 mg/m2, whichever came first. CCRT improved the response rate [complete response (CR) plus partial responses (PR)] from 25% after two courses of CAP alone to 65% after CCRT. Previous response to two courses of CAP influences response subsequent to CAP plus XRT. A pretherapy weight loss of 6% or greater had a significant adverse effect on both response and survival time. The median survival time for all patients was 50 weeks; patients whose disease responded to treatment survived significantly longer than patients with nonresponding disease. The median time until disease progression was 37 weeks. Twenty-seven patients relapsed. The first sites of relapse were local in 30% of the patients, distant in 56% of them, and both local and distant in 15%. Severe esophagitis occurred in 30% of the patients and was dose-limiting. The administration of CCRT resulted in an improved response rate compared with the rates reported in previous studies of chemotherapy or radiotherapy alone. Further improvement of the CCRT program is needed to increase long-term survival time and to decrease esophageal toxicity.

Use of carcinoembryonic antigen in small cell lung cancer. Prognostic value and relation to the clinical course 1

Carcinoembryonic antigen (CEA) was measured in 147 patients at diagnosis of small cell lung cancer; 17% of patients with limited disease and 51% with extensive disease had an abnormal CEA level (greater than 10 ng/ml). The median level was higher in extensive than in limited disease (11 ng/ml and 5.8 ng/ml, respectively; P less than 0.001). Multivariate analysis showed CEA level greater than or equal to 50 ng/ml to be an adverse prognostic factor (P = 0.02); median survival at this level was shorter than at less than 50 ng/ml (7 and 46 weeks, respectively; P = 0.002). No consistent directional changes of follow-up CEA values were observed in patients with initially normal CEA levels, but normalization of levels occurred in complete responders. We recommend that CEA be measured in this disease at diagnosis as an additional prognostic factor and that patients with abnormal initial CEA levels have follow-up measurements to aid in evaluating response.

Randomized trial of three combinations of cisplatin with vindesine and/or VP-16-213 in the treatment of advanced non-small-cell lung cancer

One hundred sixty-seven evaluable patients with non-small-cell lung cancer were randomized to receive high-dose cisplatin and vindesine (PVD), or cisplatin and VP-16-213 (etoposide epipodophyllotoxin) (PVP), or cisplatin with VP-16-213 and vindesine (PVPVD). The patient distribution and characteristics were similar in all the treatment arms. The response rate differences (35% in PVD arm, 30% in PVP arm, and 22% in PVPVD arm) were not statistically significant (P = .33). Response durations were 43 weeks in the PVD arm, 20 weeks in the PVP arm, and 27 weeks in the PVPVD arm. Median survival was 29 weeks in the PVD and PVP arms and 28 weeks in the PVPVD arm. Median survival time of responding patients was 76 weeks in the PVD arm and 65 weeks in the PVP arm; 78% of patients were alive at 22+ to 87+ weeks follow-up in the PVPVD arm. Myelosuppression was similar in all three treatment arms. Significantly more azotemia occurred in the PVD arm than in the PVP and PVPVD arms (P = .002), and significantly more neuropathy in the PVD and PVPVD arms than in the PVP arm (P = .003 and .005). All the treatment arms have similar antitumor activity in non-small-cell lung cancer, but the PVP combination is slightly less toxic than the PVD and PVPVD treatment arms.

Prospective evaluation of thymosin fraction V immunotherapy in patients with non-small cell lung cancer receiving vindesine, doxorubicin, and cisplatin (VAP) chemotherapy

One hundred five patients with advanced non-small cell lung cancer were randomized to receive thymosin fraction V immunotherapy during remission induction chemotherapy with vindesine, doxorubicin, and cisplatin (VAP). Fifty-four patients received VAP alone. Fifty-one patients received VAP + thymosin. Both groups were comparable; most patients were male, with a good performance status and with the diagnosis of adenocarcinoma. Among 99 evaluable patients, response was seen in 24 (2 CRs, 22 PRs) of 53 (45%) patients treated with VAP and 10 (all PRs) of 46 (22%) patients treated with VAP + thymosin (p = 0.03). VAP-treated patients responded better than those treated with VAP + thymosin in each tumor category: adenocarcinoma, 50% of 36 patients versus 22% of 27 patients; squamous cell carcinoma, 29% of 14 patients versus 21% of 13 patients; undifferentiated carcinoma, 67% of three patients versus 17% of six patients. Median survival duration was 34 weeks versus 25 weeks in favor of the VAP-treated group (p = 0.14). Thymosin treatment resulted in decreased graft-vs.-host reaction (p = 0.01) and increased suppressor effect on normal mitogen response to Con-A (p = 0.17). The activity of VAP chemotherapy is comparable with the most effective multidrug regimens of the present time in patients with advanced non-small cell tumors. The addition of thymosin immunotherapy appeared to have a negative effect on the activity of VAP.

Chemotherapy for advanced adenocarcinoma and squamous cell carcinoma of the lung with etoposide and cisplatin

Forty-one patients with unselected advanced non-small cell lung cancer were treated with a combination of etoposide and cisplatin. A response rate of 19%, a 78-week median survival of responders, and a 36-week overall median survival were observed.

Is staging of cancer of value?

Complete and accurate classification of all cases of cancer is essential for planning optimal management, estimating prognosis, communicating about individual patients or groups of patients, comparing results of various treatments and evaluating cancer control programs. For most types of cancer, the stage, or the anatomic extent of the cancer, is as important as other characteristics such as the primary site of the tumor, the histologic cell type, and the grade of the malignancy. The TNM system of staging recommended by the American Joint Committee on Cancer and the International Union against Cancer is used throughout the world, and there is convincing evidence of its value in selecting treatment and estimating prognosis. For example, Stage I squamous cell or adenocarcinoma of the lung is almost always amenable to surgical resection and five-year survival rates of about 70% are being reported by many cancer centers. In contrast, stage III lung cancer is usually not resectable and the five-year survival rate of this group is less than 10%.

Incidence, trend, and outcome of bronchogenic carcinoma in Olmsted County, Minnesota, 1935--1974

The 40-year incidence trends of bronchogenic carcinoma in Olmsted County, Minnesota, are presented and analyzed. The incidence in men has risen rapidly with each decade. During the last decade this increase was due to an increase of the rate among men over 65, rates in men under 65 appearing to have plateaued. The incidence in women increased for the first time in the decade 1965 to 1974. During the period 1935 through 1974, rates for all cell types increased in men, with that for squamous cell carcinoma increasing most. In women the recent overall increase was due mainly to an increase of adenocarcinoma, which has been the predominant cell type in women throughout. Among all cases together the 5-year survivorship was 11%, which comprised 24% for squamous cell carcinoma, 11% for large cell carcinoma, 12% for adenocarcinoma, and 0 for small cell carcinoma.

Combination chemotherapy of advanced lung cancer: a randomized trial

A controlled clinical trial comparing two-drug and three-drug combination chemotherapy was performed in 206 patients with advanced bronchogenic carcinoma, comprised of 26.2% with epidermoid carcinoma, 30.1% with small cell anaplastic carcinoma, 27.2% with adenocarcinoma, and 15.6% with large cell carcinoma. Each drug combination consisted of agents with different modes of action and included a cell-cycle-stage nonsensitive and a cell-cycle-state-sensitive agent. The overall response rate was highest for small cell carcinoma (48.2%) and adenocarcinoma (23.6%); it was less than 10% in epidermoid and large cell carcinoma. Similarly, the overall median survival was twice as long for the first two cell types (7 months) as compared with that recorded for the other two cell types (3 1/2 months). The combination of 1 (2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), cyclophosphamide, and methotrexate was shown to be statistically superior to cyclophosphamide and methotrexate with regard to objective respones rate, duration of response, and median survival for adenocarcinoma. Responders lived significantly longer than nonresponders (254 versus 90 days for small cell anaplastic carcinoma patients and 244 versus 184 days for adenocarcinoma patients). No difference in survival or objective response rate was observed between the different treatments for the other two cell types of lung cancer.

Comparison of split-course radiation therapy and continuous radiation therapy for unresectable bronchogenic carcinoma: 5 year results

One hundred and eighty-eight patients with inoperable or unresectable bronchogenic carcinoma were stratified by cell type, TNM staging, and prior surgery and then randomized into two treatment groups: continuous radiation therapy and split-course radiation therapy. There was no difference in clinical or objective improvement in the two groups. Survival rates for cases of squamous cell carcinoma, small cell carcinoma, and adrenocarcinoma were the same after both regimens of therapy. Split-course therapy resulted in a significantly better survival rate in cases of large cell carcinoma but the number of cases was small. We doubt that the difference is clinically significant. Objective roentgenographic response was accompanied by improved survival in squamous cell carcinoma, but not in the other three cell types. Split-course radiation therapy is superior to continuous radiation therapy because it is better tolerated by the patient and because re-examination of the patient prior to the second half of split-course therapy permits the detection of new metastatic disease that has become manifest during the rest period and spares the patient the futile second half of radiation therapy.

Radiographic appearance of bronchial carcinoid

Altman, R. L., Miller, W. E., Carr, D. T., Payne, W. S., and Woolner, L. B. (1973).Thorax, 28, 433-434. Radiographic appearance of bronchial carcinoid. The chest radiographs of 67 patients with bronchial carcinoid were reviewed. Seven had negative radiographs. Fifty-five had single abnormalities, the common manifestations being collapse or pneumonitis (21 patients), a small peripheral mass (20 patients), and a hilar or perihilar mass (11 patients). Five patients had multiple abnormalities, the most common combination being a mass with evidence of bronchial obstruction such as collapse of the related segment or lobe. Comparison with other reports revealed a significant difference in the frequency of the various abnormalities, a difference probably due to chance variations in the locations and to the age of the tumours at the time of diagnosis.

Evaluation of cyclophosphamide (NSC-26271) and 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU; NSC-409962) in the treatment of patients with inoperable or disseminated lung cancer

Forty-eight patients with nonlocalized bronchogenic carcinoma were randomly selected and treated with either 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) or cyclophosphamide (or both). Five of the 48 patients (three who had received BCNU and two who had received cyclophosphamide) responded to initial treatment. Crossover treatment with the alternate drug after unsuccessful treatment with the initial drug resulted in no additional responses. Toxic effects included gastrointestinal upset and myelosuppression and, in general, were acceptable. There was one death after a course of BCNU that was attributable to the myelosuppressive effects of this agent. The medain survival time of the patients who died after treatment was 18 weeks, and the mean survival time was 15 weeks. Survival times were virtually the same for both treatment groups.