Leading indicators of readiness among the general Army and Special Operations Forces: Predictive and psychometric analysis of the Global Assessment Tool

Self-assessments are commonly used to track Army readiness in specialized communities, but they are rarely analyzed for reliability and predictive validity. Before introducing new assessments, existing ones should be reevaluated. We examined the Global Assessment Tool (GAT), an annual Army-required self-assessment with multiple psychosocial and health behavior short scales. Psychometric analyses on nine scales included item response theory (IRT) and measurement invariance models across total Army (n = 743,057) and special operations forces (SOF; n = 3,478) cohorts. Predictive analyses examined demographic-adjusted associations between GAT scales and one-year incident medical non-readiness (MNR). Most scales had adequate reliability, although some exhibited highly skewed distributions, which likely increased measurement error. Most scales exhibited metric and scalar measurement equivalence across total Army and SOF groups. Scores from scales measuring positive characteristics were associated with lower odds of MNR (good coping, flexibility, optimism, positive affect, work engagement, friendship, organization trust; adjusted odds ratios ≤ 0.75); scores from scales measuring negative characteristics were associated with increased odds of MNR (poor sleep, depression, negative affect, loneliness; adjusted odds ratios ≥ 1.4). Associations were similar across Army and SOF cohorts. In conclusion, self-report data can potentially contribute to command surveillance, but iterative quality-checks are necessary after deployment.

Facility-Level Analysis of Twice Daily Radiation Utilization for Limited Stage Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Treatment of limited stage SCLC (LS-SCLC) with twice daily (BID) fractionation (fx) to 45 Gy remains the standard of care for many decades. However, many patients receive once daily (QD) treatment as outcomes appear similar. Recent data have suggested that dose escalation to 60 Gy BID may improve outcomes, stressing the importance of BID delivery for SCLC. In this study, we examined the use of BID fractionation across treatment facilities and hypothesized that a substantial number of centers may never utilize BID treatment.

MATERIALS/METHODS

The National Cancer Database (NCDB) was used to identify U.S. facilities treating LS-SCLC patients with definitive chemoradiation from 2004 to 2019. Included patients had stage I-III disease, received doublet chemotherapy, and did not undergo surgery. All patients received thoracic radiation therapy (RT), defined as QD (59.4-70.2 Gy in 30-39 fx) or BID (45 Gy in 30 fx). Other RT regimens were excluded. Facilities were classified into two cohorts (BID-treating and QD-only) based on whether or not at least one patient received BID treatment over the study period. Facility-level statistics including facility type, geographic location, and facility volume were analyzed. Predictors of BID-treating facility classification were determined using Chi-squared tests and uni/multivariable logistic regression.

RESULTS

From 2004 to 2019, 22,545 LS-SCLC patients were treated by 1,222 facilities. Of the 1,222 facilities, 832 (68%) were BID-treating facilities while 391 (32%) were QD-only facilities. On univariable analysis, facility type (community cancer program, comprehensive community cancer program, integrated network cancer program, or academic program; p = 0.783) and geographic location (Northeast, Midwest, South, West; p = 0.417) were not associated with classification as a BID-treating facility. In contrast, facility volume was significantly associated with classification as a BID-treating facility, with BID use noted in 42.8% of the lowest quartile volume facilities vs. 84.0% of the highest quartile volume facilities (p<0.001). Dichotomized facility type (academic vs. non-academic), geographic location (South vs. other), and facility volume (greater or less than median volume) were included in a multivariable analysis. Facility volume (p<0.001) remained significant while facility type (p = 0.956) and facility location (p = 0.516) remained insignificant.

CONCLUSION

Despite evidence supporting BID fractionation as the standard of care for LS-SCLC, 32% of facilities have never delivered BID treatment over the 15-year study period. Facilities with a low volume of patients are most likely to use QD-only. Barriers to BID treatment adoption will need to be overcome if dose escalated BID fractionation defines a new standard of care for LS-SCLC.

Wound healing following combined radiation and cetuximab therapy in head and neck cancer patients

OBJECTIVE

This study set out to determine if cetuximab treatment increases the risk of wound healing complications when combined with radiation therapy.

METHOD

We performed a retrospective chart review of head and neck cancer patients who received salvage neck dissections between 1999 and 2007, at two academic tertiary care centres. Complications from wound healing were compared between radiation and combined therapy groups.

RESULTS

A total of 35 patients received radiation (n=20) or combined radiation and cetuximab therapy (n=15) prior to neck dissection. The treatment groups were similar in regard to demographic and primary tumour-related characteristics. The time between treatment and salvage neck dissection did not differ between the radiation (3.9 months) and combination treatment (3.0 months) groups (p=0.15). Wound healing complications occurred in 13% (2/15) of the patients treated with radiation and cetuximab and there were no complications in patients who received radiation alone (p=0.20).

CONCLUSION

Cetuximab did not significantly increase the risk of post-surgical wound complications, although a higher absolute number of wound complications was observed in the group treated with cetuximab and radiation therapy, compared with the group treated with radiation alone.

CONFLICT OF INTEREST

This work was supported by a grant from the National Institute of Health (2T32 CA091078-06). One of the authors, JAB, is an occasional consultant and honoraria for ImClone and Bristol-Meyers Squibb.

Concomitant radio-chemotherapy based on platin compounds in patients with locally advanced non-small cell lung cancer (NSCLC): A meta-analysis of individual data from 1764 patients

BACKGROUND

Despite several randomised trials comparing radiotherapy alone with concomitant radio-chemotherapy in patients with locally advanced non-small cell lung cancer (NSCLC), it is not clear whether the addition of chemotherapy improves survival.

PATIENTS AND METHODS

This meta-analysis was based on individual patient data from published and unpublished randomised trials which compared radiotherapy alone with the same radiotherapy combined with concomitant cisplatin- or carboplatin-based chemotherapy. Trials with accrual completed after 2000 were excluded. Trials were sought in electronic databases, clinical trial registries and by additional manual searches. The primary endpoint was overall survival analysed using the log-rank test stratified by trials.

RESULTS

There were twelve eligible trials that included a total of 1921 patients. The data from 3 trials were not available. Therefore, the analysis was based on 9 trials including 1764 patients. Median follow-up was 7.2 years. The hazard ratio of death among patients treated with radio-chemotherapy compared to radiotherapy alone was 0.89 (95% confidence interval, 0.81-0.98; P = 0.02) corresponding to an absolute benefit of chemotherapy of 4% at 2 years. There was some evidence of heterogeneity among trials and sensitivity analyses did not lead to consistent results. The combination of platin with etoposide seemed more effective than platin alone.

CONCLUSIONS

Concomitant platin-based radio-chemotherapy may improve survival of patients with locally advanced NSCLC. However, the available data are insufficient to accurately define the size of such a potential treatment benefit and the optimal schedule of chemotherapy.

Effect of multileaf collimator leaf width on physical dose distributions in the treatment of CNS and head and neck neoplasms with intensity modulated radiation therapy

The purpose of this work is to examine physical radiation dose differences between two multileaf collimator (MLC) leaf widths (5 and 10 mm) in the treatment of CNS and head and neck neoplasms with intensity modulated radiation therapy (IMRT). Three clinical patients with CNS tumors were planned with two different MLC leaf sizes, 5 and 10 mm, representing Varian-120 and Varian-80 Millennium multileaf collimators, respectively. Two sets of IMRT treatment plans were developed. The goal of the first set was radiation dose conformality in three dimensions. The goal for the second set was organ avoidance of a nearby critical structure while maintaining adequate coverage of the target volume. Treatment planning utilized the CadPlan/Helios system (Varian Medical Systems, Milpitas CA) for dynamic MLC treatment delivery. All beam parameters and optimization (cost function) parameters were identical for the 5 and 10 mm plans. For all cases the number of beams, gantry positions, and table positions were taken from clinically treated three-dimensional conformal radiotherapy plans. Conformality was measured by the ratio of the planning isodose volume to the target volume. Organ avoidance was measured by the volume of the critical structure receiving greater than 90% of the prescription dose (V(90)). For three patients with squamous cell carcinoma of the head and neck (T2-T4 N0-N2c M0) 5 and 10 mm leaf widths were compared for parotid preservation utilizing nine coplanar equally spaced beams delivering a simultaneous integrated boost. Because modest differences in physical dose to the parotid were detected, a NTCP model based upon the clinical parameters of Eisbruch et al. was then used for comparisons. The conformality improved in all three CNS cases for the 5 mm plans compared to the 10 mm plans. For the organ avoidance plans, V(90) also improved in two of the three cases when the 5 mm leaf width was utilized for IMRT treatment delivery. In the third case, both the 5 and 10 mm plans were able to spare the critical structure with none of the structure receiving more than 90% of the prescription dose, but in the moderate dose range, less dose was delivered to the critical structure with the 5 mm plan. For the head and neck cases both the 5 and 10 x 2.5 mm beamlets dMLC sliding window techniques spared the contralateral parotid gland while maintaining target volume coverage. The mean parotid dose was modestly lower with the smaller beamlet size (21.04 Gy v 22.36 Gy). The resulting average NTCP values were 13.72% for 10 mm dMLC and 8.24% for 5 mm dMLC. In conclusion, five mm leaf width results in an improvement in physical dose distribution over 10 mm leaf width that may be clinically relevant in some cases. These differences may be most pronounced for single fraction radiosurgery or in cases where the tolerance of the sensitive organ is less than or close to the target volume prescription.

Long-term Results of a Phase I/II Study of High-Dose Thoracic Radiotherapy With Concomitant Cisplatin and Etoposide in Limited Stage Small-Cell Lung Cancer

This report presents the results from a Mayo Clinic initiated phase I/II study exploring a potentially more aggressive local and systemic approach for treatment of limited-stage small-cell lung cancer (LSSCLC). Five patients with LSSCLC received three cycles of induction cyclophosphamide, etoposide, and infusion cisplatin chemotherapy. This was followed by accelerated hyperfractionated thoracic radiotherapy (AHFTRT) consisting of 30 Gy given as 1.5-Gy fractions twice daily with a 2-week break and then the AHFTRT was repeated. The AHFTRT was given concomitantly with daily oral etoposide and daily intravenous cisplatin. Prophylactic cranial radiation was delivered with the AHFTRT. After completion of the AHFTRT, patients received 4 cycles of oral etoposide maintenance chemotherapy. Follow-up of patients was continued until death or a minimum of 42 months. Three patients had severe toxic responses. No patients completed the entire protocol because of toxicity or progression during treatment. Three patients completed the majority of the protocol except for the four cycles of maintenance etoposide. Four of five patients achieved a complete response. There were two recurrences within the irradiated field, and distant metastases developed in four patients. Acute nonlymphocytic leukemia developed in one patient, who died 2 months later. No patient completed the entire protocol, because of toxicity or progression; therefore, this protocol cannot be recommended for the treatment of LSSCLC.

Phase I study of anti--epidermal growth factor receptor antibody cetuximab in combination with radiation therapy in patients with advanced head and neck cancer

PURPOSE

To evaluate the safety, pharmacokinetics, and efficacy of a chimeric anti-epidermal growth factor receptor monoclonal antibody, cetuximab, in combination with radiation therapy (RT) in patients with advanced squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

We treated 16 patients in five successive treatment schedules. A standard dose escalation procedure was used; three patients entered onto the study at each dose level of cetuximab received conventional RT (70 Gy, 2 Gy/d), and the final three patients received hyperfractionated RT (76.8 Gy, 1.2 Gy bid). Cetuximab was delivered as a loading dose of 100 to 500 mg/m(2), followed by weekly infusions of 100 to 250 mg/m(2) for 7 to 8 weeks. Circulating levels of cetuximab during therapy were determined using a biomolecular interaction analysis core instrument. Human antichimeric antibody response was evaluated with a double-antigen radiometric assay. The recommended phase II/III dose was defined as the optimal cetuximab dose level based on the pharmacologic parameters and adverse events.

RESULTS

The most commonly reported adverse events were fever, asthenia, transaminase elevation, nausea, and skin toxicities (grade 1 to 2 in most patients). Skin toxicity outside of the RT field was not strictly dose-dependent; however, grade 2 or higher events were observed in patients treated with higher dose regimens. There was one grade 4 allergic reaction. Most acute adverse effects were associated with RT (xerostomia, mucositis, and local skin toxicity). No antibodies against cetuximab were detected. All patients achieved an objective response (13 complete and two partial remissions).

CONCLUSION

Cetuximab can be safely administered with RT. The recommended dose for phase II/III studies is a loading dose of 400 to 500 mg/m(2) and a maintenance weekly dose of 250 mg/m(2).

Postnatal development of lateralized motor preference in the African grey parrot (Psittacus erithacus)

The parrot appears to provide a potentially unique animal model of handedness in humans, but few (if any) observational studies of early postnatal development of postural/motor asymmetries have been published. We studied three African Grey hatchlings, raised without human physical contact, for the first 5 months of life. All three animals failed to show consistent postural and/or motor asymmetries until the end of the 4 postnatal week. These results appear to be comparable to data from prior studies with human infants. Delayed development of lateral motor and/or postural preferences may represent an evolutionarily adaptive strategy for altricial animals.

Enhanced apoptosis with combination C225/radiation treatment serves as the impetus for clinical investigation in head and neck cancers

PURPOSE

Epidermal growth factor receptor (EGFr) is overexpressed in a majority of head and neck squamous cell carcinomas, and this overexpression is associated with a poor prognosis. Therefore, EGFr has become the target of investigations aimed at disabling the receptor to determine whether this process leads to improved tumor kill with conventional treatment.

MATERIALS AND METHODS

C225 is an anti-EGFr monoclonal antibody that inhibits receptor activity by blocking the ligand binding site. A panel of human head and neck squamous cell carcinoma cell lines was used to study the combination of C225 and radiation.

RESULTS

It was determined that the combination of C225 (5 microgram/mL) delivered simultaneously with radiation (3 Gy) resulted in a greater decrement in cellular proliferation than either treatment alone. This reduction in proliferation correlated with reduced EGFr tyrosine phosphorylation and a reduction in phosphorylated signal transducer and activator of transcription-3 (STAT-3) protein (known to protect cells from apoptosis). Also, the decrement in proliferation correlated with increased apoptotic events, thereby indirectly linking C225/radiation-induced regulation of STAT-3 protein to apoptosis.

CONCLUSION

This preclinical work serves as important support for the ongoing clinical investigation of C225 and radiotherapy for patients with head and neck carcinomas. The initial results of these clinical studies have been promising.

Unresectable or medically inoperable non-small cell lung cancer: the use of established clinical prognostic factors in making radiation-related treatment decisions

Many physicians consider the prognosis exceptionally poor for patients with localized non-small cell lung cancer who are not eligible for surgery, either because of the extent of their disease or because a coexisting medical condition precludes surgery. Thus, these patients frequently are not offered aggressive curative therapy. However, the disease of many of these patients is potentially curable and should be considered for curative treatment. Although pathologic data from surgical specimens are useful in predicting prognosis, many prognostic factors have also been identified for medically inoperable and locally advanced, unresectable disease. Several of these prognostic factors can and should be used clinically to estimate the risk of lymph node involvement within the clinically uninvolved mediastinum, thereby aiding in the design of radiation therapy fields, and to estimate prognosis, thereby helping to determine which patients should be offered aggressive therapy with curative intent.

Point: the potential importance of elective nodal irradiation in the treatment of non-small cell lung cancer

Patients who receive radiation therapy for non-small cell lung cancer (NSCLC) will require accurate targeting of the grossly involved primary and nodal disease. However, the treatment of grossly uninvolved elective nodal sites that may harbor microscopic occult disease is controversial. In simple terms, physicians are guided by 1 of 2 paradigms when they decide about the use of elective nodal irradiation in NSCLC. First, one may consider that high doses of radiation therapy for the primary and grossly involved lymph nodes represents the most important aspect of treatment and that elective irradiation of potential occult micrometastasis is not necessary because it may limit the doses that can be given to the gross disease. Additionally, this line of thought often includes the belief that most or all patients with occult micrometastasis are not curable. Alternatively, one may consider that the evidence for a dose response, for grossly involved NSCLC, beyond 60 Gy is very limited and that the omission of elective nodal irradiation obviates the chance for cure in many patients. These small deposits of tumor in regional nodes are common, are amenable to low doses of radiation (50 Gy), and treatment of these lesions does result in cures. This review focuses on this latter paradigm and the available evidence to support it.

Postoperative irradiation in non-small cell lung cancer

A growing body of evidence suggests that postoperative irradiation for non-small cell lung cancer may cause life-threatening toxicity and, when the risk of local-regional recurrence is low, the toxicity of irradiation may outweight the benefit. However, many of these studies used outdated, even crude techniques. Although these techniques may be responsible for a significant amount of the toxicity reported in these studies, essentially no randomized or high-quality retrospective study has shown a survival benefit for postoperative irradiation for patients with N0 or N1 disease. The situation for N2 tumors is more positive. Taken as a whole, the available data suggest that, as a worst-case scenario, the net effect of adjuvant irradiation is neutral (with neither a net survival decrement nor a net advantage). As a best-case scenario, postoperative irradiation may improve the chance for long-term survival in patients with N2 tumors.

A prospective evaluation of the timing of postoperative radiotherapy for preventing heterotopic ossification following traumatic acetabular fractures

PURPOSE

Preoperative and immediate postoperative irradiation of traumatic acetabular fractures (TAF), although known to reduce heterotopic ossification (HO), can cause significant organizational and logistic difficulties. We sought to determine an acceptable time interval between surgery and radiation without compromising control, as well as to update our large experience and to further validate our treatment philosophy.

METHODS AND MATERIALS

Beginning in June 1995, we began a prospective study, irradiating 152 patients on postoperative days 1, 2, or 3. There were also 17 patients delayed further secondary to medical difficulties.

RESULTS

All patients treated since June 1995 received 700 cGy/1 fx. Fifty-eight patients received radiation within 24 hours of surgery, 41 within 2 days, 53 within 3 days, 13 within 4 days, and 4 were delayed further. Delaying irradiation for up to 4 days postoperatively caused no statistical increase in HO (p = 0.625). Of 263 patients in our retrospective cohort, HO occurred in 5.3% of patients who received irradiation versus 60% of patients who did not.

CONCLUSION

In our prospective study, we noted no perceptible increase in HO with up to a 3-day interval between surgery and radiotherapy. This allows a more structured treatment schedule and allows the patient more time to heal and recover. Updated results from our overall series continue to demonstrate that adjuvant radiation decreases the incidence and severity of HO after TAF.

A phase I study of combined UFT plus leucovorin and radiotherapy for pancreatic cancer

PURPOSE

This Phase I study combines tegafur and uracil (UFT) with leucovorin and conventional radiation for the treatment of pancreatic cancer. The design seeks to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of this regimen as well as to define a future Phase II dose level.

METHODS

Patients with locally advanced and unresectable pancreatic cancer were treated with 45 Gy of radiation therapy. The initial UFT dose was 150 mg/m(2)/day given with leucovorin 90 mg/day, both divided into 3 daily doses for 35 days concurrent with radiation. UFT doses were escalated at increments of 50 mg/m(2)/day. Dose-limiting toxicity (DLT) was defined as Grade 3 or greater nausea, vomiting or diarrhea despite medical intervention; or Grade 3 or greater neutropenia/thrombocytopenia; or Grade 3 or greater hepatic toxicity; or inability of the patient to take 75% or more of the planned UFT/leucovorin; or radiotherapy interruption of greater than 1 week. The MTD for UFT/leucovorin was exceeded by one dose level when a certain dose caused DLT in 2 or more patients of 6.

RESULTS

Five evaluable patients had Stage I resectable disease but had pathologic adenopathy. Seven had Stage II unresectable disease. Compliance with therapy was excellent. At a daily dose of 300 mg/m(2) of UFT, we noticed minimal diarrhea and hematologic toxicity with mild-moderate nausea, anorexia, and fatigue. Three patients had Grade 4 toxicity: 1 had neutropenia on Day 38, 1 had diarrhea on Day 55, and 1 had vomiting on Day 15.

CONCLUSION

Oral UFT/leucovorin and radiation therapy offers patients a viable treatment option for pancreatic cancer. The major known toxicity of diarrhea was tolerable. The MTD was not reached in this study. Our current plan is to expand this into a Phase I/II trial beginning at a UFT dose of 300 mg/m(2) and correlate this with clinical pharmacologic parameters. The potential benefit of long bioavailability and oral delivery of UFT compares favorably with continuous infusion regimens without the added morbidity of a catheter and pump.

Significance of neuron-specific enolase levels before and during therapy for small cell lung cancer

The level of serum neuron-specific enolase (NSE) has been implicated as a prognostic factor for patients with small cell lung cancer (SCLC). A prospective evaluation was undertaken to assess the prognostic significance of pretreatment NSE and treatment-induced minimum NSE values in patients with SCLC. Patients from two Phase III North Central Cancer Treatment Group trials [one for patients with extensive stage SCLC and one for patients with limited stage SCLC] were asked to enter this laboratory correlational trial. Both trials included treatment with four to six cycles of etoposide and cisplatin, and 121 patients (71 extensive stage SCLC and 50 limited stage SCLC) were entered into the present study of NSE. Pretreatment NSE values and treatment-induced minimum NSE values were independent predictors of time to progression and survival in multivariate analysis. Hazard rate modeling allowed the formulation of specific relationships of NSE to time to progression and survival. Pretreatment NSE levels inversely correlated with time to progression and survival in these patients with SCLC. Pretreatment NSE accounted for 28% of the variance in survival. Both pretreatment NSE and treatment-induced minimum NSE were independent prognostic predictors of time to progression and survival.

Combined modality therapy of A431 human epidermoid cancer using anti-EGFr antibody C225 and radiation

BACKGROUND

Monoclonal antibodies (mAb) to epidermal growth factor receptor (EGFr) inhibit tumor cell proliferation and enhance cytotoxicity of chemotherapeutic agents. The purpose of this study was to investigate the interaction of the anti-EGFr antibody C225 combined with radiotherapy (RT) on EGFr expressing A431 human epidermoid cancer cells.

METHODS

Cell proliferation, apoptosis, EGFr expression and phosphorylation, and clonogenic survival were assayed in vitro. A431 tumor growth inhibition and immunohistochemistry analysis of EGFr expression and apoptosis were assessed in vivo.

RESULTS

C225 plus RT produced greater inhibition of A431 cell proliferation than C225 or RT alone which was corroborated by enhanced apoptosis. Similar clonogenic survival occurred following the addition of C225 to RT, although colonies were smaller in the presence of C225. C225 produced inhibition of EGF-induced phosphorylation of EGFr without concurrent down-regulation of surface receptor, which was not altered by RT. Combined treatment of mice bearing tumors demonstrated enhancement of complete regressions, reduction in time to tumor size doubling, and prolongation of survival. Significant apoptosis occurred in xenograft tumors treated with C225 with or without RT.

CONCLUSIONS

These data demonstrate an interaction between C225 and RT. C225-mediated apoptosis and inhibition of EGFr phosphorylation may be critical in the interaction. Studies to define the precise influence of combined modality treatment on the EGFr signal transduction cascade need to be pursued. The combination of growth factor receptor antibodies and RT has potential application in clinical oncology.

Paclitaxel derivatives for targeted therapy of cancer: toward the development of smart taxanes

The pharmacologic efficacy of the promising antitumor agent paclitaxel (Taxol) may be potentially enhanced through derivatization of the drug to a water-soluble tumor-recognizing conjugate. This work reports the design and synthesis of the first tumor-directed derivative of paclitaxel. A 7-amino acid synthetic peptide, BBN[7-13], which binds to the cell surface bombesin/gastrin-releasing peptide (BBN/GRP) receptor, was conjugated to the paclitaxel-2'-hydroxy function by a heterobifunctional poly(ethylene glycol) linker. The resulting conjugate, designated PTXPEGBBN[7-13], was soluble to the upper limit of tested concentrations (250 mg/mL). The conjugate completely retained the receptor binding properties of the attached peptide as compared with those of the unconjugated BBN[7-13]. In experiments with NCI-H1299 human nonsmall cell lung cancer cells, the cytotoxicity of the PTXPEGBBN[7-13] conjugate at a 15 nM dose was enhanced by a factor of 17.3 for 24 h and 10 for 96 h exposure times, relative to paclitaxel. The IC(50) of the conjugate, tested against the same cell line, was lower than the free drug by a factor of 2.5 for both 24 h and 96 h exposures. These results describe, for the first time, the design and synthesis of a soluble tumor-directed paclitaxel prodrug which may establish a new mode for the utilization of this drug in cancer therapy.

Frequency of noncontiguous lymph node involvement in patients with resectable nonsmall cell lung carcinoma

BACKGROUND

This study was undertaken to investigate the patterns of lymph node spread and the frequency of involvement of noncontiguous lymph node stations in patients with nonsmall cell lung carcinoma who had complete surgical resection.

METHODS

All patients who had surgical resection as their sole treatment for nonsmall cell lung carcinoma during the years 1987-1990 were reviewed. All patients were treated similarly. Generally, complete mediastinal lymph node dissection was performed after resection of the primary lesion and N1 lymph nodes. Patients were assessed for patterns of involvement of N1 and N2 lymph node stations. The frequency of noncontiguous involvement of lymph nodes (involvement of N2 lymph nodes without involvement of N1 lymph nodes) was determined. Patient and tumor characteristics were assessed to ascertain whether certain factors were likely to predict this noncontiguous pattern of lymph node spread.

RESULTS

During the 4-year period of study, 336 patients with nonsmall cell lung carcinoma were managed with surgical resection alone. Of the 336, 100 had no involvement of lymph nodes, 108 had involvement of N1 lymph nodes only, 76 had involvement of N1 and N2 lymph nodes, and 52 had involvement of N2 lymph nodes only. Therefore, 52 of all 336 patients (15%) and 52 of 236 patients with lymph node involvement (22%) had noncontiguous lymph node spread. A review of the initial patient and tumor characteristics revealed that patients with a suggestion of enlarged mediastinal lymph nodes on preoperative computed tomography scans of the chest (compared with negative findings) and patients with T1 and T2 lesions (compared with T3 and T4) were more likely to have noncontiguous lymph node spread; the odds ratios (with 95% confidence intervals) were 2.18 (1.01-4.71) and 2.82 (1.36-5.84), respectively.

CONCLUSIONS

Noncontiguous involvement of thoracic lymph nodes occurred in approximately 15% of patients who had complete surgical resection of nonsmall cell lung carcinoma. This factor suggests that lack of involvement of N1 lymph nodes does not rule out mediastinal involvement and provides important information for complete surgical staging.

Factors predicting patterns of recurrence after resection of N1 non-small cell lung carcinoma

BACKGROUND

Although irradiation and chemotherapy are unproved adjuvant treatments for completely resected N1 non-small cell lung carcinoma, previous studies may have been diluted by the inclusion of low-risk patients. Risk factors in this situation, however, are not yet well defined.

METHODS

One hundred seven consecutive patients with complete resection of N1 disease who received no other therapy were studied to identify factors independently predicting the risk of freedom from local recurrence (FFLR), freedom from distant metastasis (FFDM), and overall survival (OS).

RESULTS

Twelve factors were assessed for a potential prognostic relationship with FFLR, FFDM, and OS. Regression analyses revealed that the factors independently associated with an improved outcome were positive bronchoscopic findings (FFLR, p = 0.005), a greater number of dissected N1 nodes (FFDM, p = 0.02), and a lesser T stage (OS, p = 0.01). Classification and regression tree analyses were then used to separate the patients into risk groups.

CONCLUSIONS

Although these results require corroboration in further studies, they may aid the design of trials examining therapies used to decrease rates of local recurrence or distant metastasis.

Patients with stage I non-small cell lung carcinoma at postoperative risk for local recurrence, distant metastasis, and death: implications related to the design of clinical trials

PURPOSE

Patients with pathologically staged American Joint Committee on Cancer stage I (T1 N0 or T2 N0) non-small cell lung cancer have a favorable prognosis after complete surgical resection compared with patients with more advanced stages. Benefits of adjuvant therapy in this setting are unproved. However, there may be subgroups of patients with stage I disease at high enough risk for local recurrence to prompt consideration of adjuvant or neoadjuvant radiation therapy. Likewise, there may be subgroups of patients at high enough risk for distant metastasis to justify the evaluation of chemotherapy.

METHODS AND MATERIALS

From 1987 through 1990, 370 patients undergoing gross total resection of non-small cell lung cancer had stage I disease and received no chemotherapy or radiation therapy as part of their primary treatment. These patients were the subject of a retrospective review to separate patients into high-, intermediate-, and low-risk groups with respect to freedom from local recurrence (FFLR), freedom from distant metastasis (FFDM), and overall survival by using a regression tree analysis.

RESULTS

The 5-year rates of FFLR, FFDM, and survival were 85%, 83%, and 66%, respectively. Regression analyses revealed that the factors independently predicting for a poorer FFLR rate included fewer than 15 lymph nodes dissected and pathologically evaluated (p = 0.002) and the presence of a T2 tumor (p = 0.04). Factors independently predicting for a poorer FFDM rate included a maximal dimension greater than 5 cm (p = 0.02) and nonsquamous histology (p = 0.03). Factors independently predicting for a poorer survival rate included fewer than 15 lymph nodes dissected and pathologically evaluated p = 0.001) and a maximal dimension greater than 3 cm (p = 0.003). Regression tree analyses were used to separate patients into risk groups.

CONCLUSION

Incorporating the aforementioned factors into regression tree analyses, three risk groups were identified with respect to FFLR. Two each were identified for FFDM and for survival. For each of these three end-points, the differences in outcomes for each risk group were found to be both statistically and clinically significant. These risk groups may be useful in the future design of phase III trials evaluating the use of adjuvant chemotherapy and radiation therapy in the stage I setting.

Phase III comparison of twice-daily split-course irradiation versus once-daily irradiation for patients with limited stage small-cell lung carcinoma

PURPOSE

Because small-cell lung cancer is a rapidly proliferating tumor, it was hypothesized that it may be more responsive to thoracic irradiation (TI) given twice-daily than once-daily. This hypothesis was tested in a phase III trial.

PATIENTS AND METHODS

Patients with limited-stage small-cell lung cancer were entered onto a phase III trial, and all patients initially received three cycles of etoposide (130 mg/m(2) x 3) and cisplatin (30 mg/m(2) x 3). Subsequently, patients who did not have progression to a distant site (other than brain) were randomized to twice-daily thoracic irradiation (TDTI) versus once-daily thoracic irradiation (ODTI) given concomitantly with two additional cycles of etoposide (100 mg/m(2) x 3) and cisplatin (30 mg/m(2) x 3). The irradiation doses were TDTI, 48 Gy in 32 fractions, with a 2.5-week break after the initial 24 Gy, and ODTI, 50.4 Gy in 28 fractions. After thoracic irradiation, the patients received a sixth cycle of etoposide/cisplatin, followed by prophylactic cranial irradiation (30 Gy/15 fractions) if they had a complete response.

RESULTS

Of 311 assessable patients enrolled in the trial, 262 underwent randomization to TDTI or ODTI. There were no differences between the two treatments with respect to local-only progression rates, overall progression rates, or overall survival. The patients who received TDTI had greater esophagitis (> or = grade 3) than those who received ODTI (12.3% v 5.3%; P =.05). Although patients received thoracic irradiation encompassing the postchemotherapy volumes, only seven of 90 local failures were out of the portal of irradiation.

CONCLUSION

When TI is delayed until the fourth cycle of chemotherapy, TDTI does not result in improvement in local control or survival compared with ODTI.

Current guidelines for the management of small cell lung cancer

Small cell lung cancer (SCLC) accounts for 20% to 25% of cases of bronchogenic carcinoma and results in pronounced morbidity and mortality in the United States. More than 90% of cases of SCLC are caused by cigarette smoking. Common pulmonary manifestations are dyspnea, persistent cough, hemoptysis, and postobstructive pneumonia. At the time of diagnosis, patients usually have extensive disease. To date, therapeutic approaches have made only modest advances in outcome. Combined modality approaches, such as radiotherapy administered concomitantly with the initiation of chemotherapy, induction chemotherapy followed by radiotherapy administered during the subsequent courses of chemotherapy, sequential chemotherapy and radiotherapy, and courses of radiotherapy split between cycles of chemotherapy, are important for improving survival in patients with SCLC.

Patterns of failure and overall survival in patients with completely resected T3 N0 M0 non-small cell lung cancer

BACKGROUND

Previous studies of patients with surgically resected non-small cell lung cancer and chest wall invasion have shown conflicting results with respect to prognosis. Whether high-risk subsets of the T3 N0 M0 population exist with respect to patterns of failure and overall survival has been difficult to ascertain, owing to small numbers of patients in most series.

METHODS AND MATERIALS

A retrospective review was performed to determine patterns of failure and overall survival for patients with completely resected T3 N0 M0 non-small cell lung cancer. From 1979 to 1993, 92 evaluable patients underwent complete resection for T3 N0 M0 non-small cell lung cancer. The following potential prognostic factors were recorded from the history: tumor size, location, grade, histology, patient age, use of adjuvant radiation therapy (18 of 92 patients), and type of surgical procedure (chest wall or extrapleural resection).

RESULTS

The actuarial 2- and 4-year overall survival rates for the entire cohort were 48% and 35%, respectively. The actuarial local control at 4 years was 94%. Neither the type of surgical procedure performed nor the addition of thoracic radiation therapy impacted local control or overall survival.

CONCLUSION

Patients with completely resected T3 N0 M0 non-small cell lung cancer have similar local control and overall survival irrespective of primary location, type of surgery performed, or use of adjuvant radiation therapy. Additionally, the tumor recurrence rate and overall survival found in this study support the placement of this group of patients in Stage IIB of the 1997 AJCC lung staging classification.

Predictors of subclinical nodal involvement in clinical stages I and II non-small cell lung cancer: implications in the inoperable and three-dimensional dose-escalation settings

PURPOSE

When mediastinal lymph nodes are clinically uninvolved in the setting of inoperable non-small cell lung cancer, whether conventional radiation techniques or three-dimensional dose-escalation techniques are used, the benefit of elective nodal irradiation is unclear. Inclusion of the clinically negative mediastinum in the radiation portals increases the risk of lung toxicity and limits the ability to escalate dose. This analysis represents an attempt to use clinical characteristics to estimate the risk of subclinical nodal involvement, which may help determine which patients are most likely to benefit from elective nodal irradiation.

METHODS

From 1987 to 1990, 346 patients undergoing complete resection of non-small cell lung cancer underwent a preoperative computed tomographic scan revealing no clinical evidence of N2/N3 involvement. Multivariate regression and regression tree analyses attempted to define which patients were at highest risk for subclinical mediastinal involvement (N2) and which patients were at highest risk for subclinical N1 and/or N2 involvement (N1/N2). Immunohistochemical data suggest that the conventional histopathologic techniques used during this study somewhat underestimate the true degree of lymph node involvement; therefore, a third end point was also evaluated: N1 involvement and/or N2 involvement and/or local-regional recurrence (N1/N2/LRR).

RESULTS

Regression analyses revealed that the following factors were independently associated with a high risk of more advanced disease: positive preoperative bronchoscopy (N2, p = 0.02; N1/N2, p < 0.0001; N1/N2/LRR, p < 0.001) and tumor grade 3/4 (N1/N2/LRR, p < 0.01). A regression tree analysis was then used to separate patients into risk groups with respect to N1/N2/LRR.

CONCLUSION

In inoperable non-small cell lung cancer, the patients for whom mediastinal radiation therapy may most likely be indicated are those with a positive preoperative bronchoscopy, especially with large (> 3 cm) primary tumors.

[Sensitivity to etoposide of human malignant glioma cell lines. Mechanisms of action]

AIM OF THE STUDY

Etoposide, a Topoisomerase II inhibitor agent, is currently being explored as a therapeutic agent for brain tumors. The aim of this experimental study was to compare the in vitro etoposide sensitivity of human glioma cells vs human squamous cell carcinoma (SCC) cells.

MATERIAL AND METHODS

Twelve human cell lines (six malignant glioma cell lines and six head and neck SCC cell lines) were used for this comparative study. A standard colony formation assay was used to assess cell survival. Since Topoisomerase II is the critical target for etoposide, it was of interest to determine Topoisomerase II activity and etoposide induced inhibition of Topoisomerase II activity for the glioma cells vs the SCC cells.

RESULTS

Except for etoposide-induced inhibition of Topoisomerase II activity, no difference was found for etoposide sensitivity and Topoisomerase II activity between the both type of cells.

CONCLUSION

These results suggested that the Topoisomerase II reactive agents may prove to be clinically a useful drug for patients presenting with malignant gliomas.

Ionizing radiation-induced MEK and Erk activation does not enhance survival of irradiated human squamous carcinoma cells

PURPOSE

Ionizing radiation (IR) triggers several intracellular signaling cascades that have commonly been regarded as mitogenic, including the Raf-MEK-Erk kinase cascade. In addition to promoting proliferation, activated MEK and Erk may also prevent cell death induced by cytotoxic stimuli. Because Raf, MEK, and Erk are activated by IR in some tumor cell lines, this suggests that IR-induced activation of the kinase cascade may enhance the survival of irradiated cells.

METHODS AND MATERIALS

IR-induced activation of MEK and Erk was assessed in irradiated UM-SCC-6 cells, a human squamous carcinoma cell line. Activation of MEK and Erk was blocked with the pharmacological inhibitor of MEK activation, PD098059. Clonogenic survival was assessed in irradiated UM-SCC-6 cells that were pretreated with nothing or with the MEK inhibitor.

RESULTS

In UM-SCC-6 cells, IR doses as low as 2 Gy rapidly activated MEK and Erk. Pretreatment of the cells with the pharmacological inhibitor of MEK activation, PD098059, effectively blocked IR-induced activation of MEK and Erk. However, inhibition of the kinase cascade did not affect the clonogenic survival of irradiated cells in either early or delayed-plating experiments.

CONCLUSION

Taken together, these results suggest that although MEK and Erk are rapidly activated by IR treatment, these protein kinases do not affect the clonogenic survival of irradiated UM-SCC6 cells.

Bronchial carcinoid tumors: importance of prognostic factors that influence patterns of recurrence and overall survival

PURPOSE

To analyze bronchial carcinoid characteristics that might influence patterns of disease recurrence and overall survival in patients with these tumors.

MATERIALS AND METHODS

In a retrospective review, the actuarial rates of local relapse, regional relapse, and overall survival were determined in patients who had undergone resection of bronchial carcinoid tumors. The evaluable files for 87 patients (50 male, 37 female; age range, 15-82 years) who underwent resection of bronchial carcinoid cancer at the authors' institution between 1980 and 1993 were reviewed for pathologic findings, extent of disease, and recurrence patterns after surgery.

RESULTS

The actuarial 4-year overall survival, local control, and regional control rates in the entire cohort of patients were 89%, 92%, and 94%, respectively. Univariate analyses revealed that an atypical histologic pattern was the only tumor-related factor that substantially affected local and regional control. Atypical histologic pattern and tumor size were among the multiple factors that independently affected overall survival.

CONCLUSION

Atypical histologic findings in patients who had undergone complete resection of bronchial carcinoid tumors were associated with increased local-regional disease recurrence and decreased survival compared with recurrence and survival in patients with typical histologic findings.

Impact of beam energy and field margin on penumbra at lung tumor-lung parenchyma interfaces

PURPOSE

To determine the characteristics of the penumbra in the region of the lung tumor-lung parenchyma interfaces for various radiation beam energies and various field margins.

METHODS AND MATERIALS

A phantom simulating the thoracic cavity with a tumor arising within the lung parenchyma was irradiated with opposed 6-, 10-, and 18-MV photon beams. Beam profiles were obtained at the tumor's surface and midplane using radiographic film. The field edge varied from 0.0 to 3.5 cm from the gross tumor volume. The effective penumbra (distance from 80 to 20% dose) and beam fringe (distance from 90 to 50% dose) were measured. Clinically acceptable beam profiles were defined as those in which no point of the planning target volume (gross tumor volume plus a 1-cm margin) received less than 95% of the central tumor dose.

RESULTS

Mean effective penumbra and beam fringe were found to differ in a statistically significant manner with respect to energy, but not with distance from field edge to gross tumor volume. With the field edge < or = 1.5 cm from the gross tumor volume, no energy provided an acceptable dose distribution, as defined above. With the field edge 2 cm from the gross tumor volume, 6 and 10 MV provided acceptable dose distributions, but 18 MV did not. With the field edge > or = 2.5 cm from the gross tumor volume, all energies provided acceptable dose distributions.

CONCLUSION

For irradiation of lung carcinomas in which the planning target volume includes a margin of normal lung tissue, 6- and 10-MV opposed beams yield a superior dose distribution with respect to penumbra at the tumor's surface and midplane, with the field edge placed 2 cm from the gross tumor volume. To achieve an equivalent distribution with 18-MV photons, a distance of 2.5 cm from field edge to the gross tumor volume is necessary, leading to an increase in normal lung tissue irradiated.

Adjuvant radiotherapy for squamous cell carcinoma of the tongue base: improved local-regional disease control compared with surgery alone

PURPOSE

The purpose of this retrospective study is to present the results of postoperative adjuvant radiotherapy after primary surgery for squamous cell carcinoma of the tongue base and to compare these results to those obtained with surgery alone.

METHODS

Between 1974 and 1993, continuous-course postoperative radiotherapy was delivered to 24 patients (Adjuvant Radiotherapy Group). Results were compared to those from a group of 55 patients treated with surgery alone (Surgery Group).

RESULTS

Characteristics of the two groups were similar, except that a larger proportion of patients in the Adjuvant Radiotherapy Group had higher pathologic TNM stages. Ipsilateral neck control (87% vs. 68%, p = 0.04), contralateral neck control (100% vs. 76%,p = 0.002), relapse-free survival (64% vs. 46%,p = 0.04), and control above the clavicles (80% vs. 48%, p = 0.007) were significantly higher in the Adjuvant Radiotherapy Group compared to those in the Surgery Group (5-year figures shown).

CONCLUSION

The use of adjuvant radiotherapy after surgical resection of tongue base squamous cell carcinoma significantly decreased the rate of local-regional recurrence and improved relapse-free survival compared with surgery alone but did not alter cause-specific or overall survival.

The possible advantage of hyperfractionated thoracic radiotherapy in the treatment of locally advanced nonsmall cell lung carcinoma: results of a North Central Cancer Treatment Group Phase III Study

BACKGROUND

A three-arm Phase III randomized trial was performed to compare response rates, time to local or distant progression, and survival for patients with unresectable (Stage IIIA or IIIB) nonsmall cell lung carcinoma treated with standard fractionated thoracic radiotherapy (SFTRT) versus accelerated hyperfractionated thoracic radiotherapy (AHTRT) with or without combination etoposide and cisplatin chemotherapy.

METHODS

This trial was initiated in 1992 by the North Central Cancer Treatment Group. Patients with Stage IIIA or IIIB nonsmall cell lung carcinoma were eligible. They were randomly assigned to either SFTRT (6000 centigray [cGy] in 30 fractions) or AHTRT (150 cGy twice daily to a total dose of 6000 cGy, with a 2-week break after the initial 3000 cGy); the AHTRT was given alone or with concomitant cisplatin (30 mg/m2, Days 1-3 and 28-30) and etoposide (100 mg/m2, Days 1-3 and 28-30).

RESULTS

A total of 110 patients were entered on study. Eleven patients were declared ineligible or off study on the day of study entry. This analysis was confined to the 99 eligible patients. This article reports mature follow-up, because more than 80% of the patients have died. The median follow-up of living patients was 2.5 years. There were suggestions of improvement in the rates of freedom from local recurrence and survival for patients treated with AHTRT (with or without chemotherapy) as opposed to SFTRT (P = 0.06 and P = 0.10, respectively). The improvement in survival associated with AHTRT (with or without chemotherapy) was statistically significant for the subgroup of patients with nonsquamous cell carcinoma after adjustment for other potentially confounding factors (P = 0.02). No differences in freedom from systemic progression or survival were found in a comparison of AHTRT with chemotherapy and AHTRT without chemotherapy.

CONCLUSIONS

These results suggest that treatment of Stage IIIA or IIIB nonsmall cell lung carcinoma with AHTRT with or without chemotherapy may improve freedom from local progression and survival as compared with SFTRT, especially for patients with nonsquamous cell carcinoma. The statistical powers to detect the observed differences in median time to local progression and survival were approximately 55% and 35%, respectively. Therefore, further investigation comparing SFTRT with AHTRT is warranted.

Combined neck dissection and postoperative radiation therapy in the management of the high-risk neck: a matched-pair analysis

PURPOSE

The purpose of this study was to determine the efficacy of postoperative adjuvant radiation therapy with regard to reducing the rate of recurrence in the neck, cancer-related death, and death from any cause in patients with squamous cell carcinoma of the head and neck region metastatic to neck nodes.

METHODS

This was a retrospective review of patients with pathologically confirmed nodal metastases who underwent neck dissection and postoperative adjuvant radiation therapy for squamous cell carcinoma of the head and neck region. Time to recurrence in the dissected area of the neck, any recurrence in the neck, cancer-related death, and death from any cause were estimated with the Kaplan-Meier method. A matched-pair analysis was performed utilizing a cohort of patients who underwent neck dissection without postoperative radiation therapy. The patients from the two cohorts were matched according to previously reported high-risk features for cancer recurrence and death. Cox hazards models for the matched pairs were used to evaluate the relative risk of subsequent recurrence in the dissected side of the neck, any neck recurrence, cancer-related death, and overall survival.

MATERIALS

The medical records and pathologic slides of 95 consecutive patients with pathologically confirmed nodal metastases from squamous cell carcinoma of the head and neck region who underwent neck dissection and postoperative adjuvant radiation therapy between January 1974 and December 1990 were reviewed. Previously published data from 284 patients with squamous cell carcinoma of the head and neck region treated with neck dissection alone between January 1970 and December 1980 were used for a matched-pair analysis.

RESULTS

The relative risks for recurrence in the dissected side of the neck, any neck recurrence (dissected neck or delayed undissected neck metastasis), cancer-related death, and death from any cause for patients treated with operation alone relative to those treated with operation and postoperative radiation were 5.82, 4.72, 2.21, and 1.67, respectively.

CONCLUSION

This study provides evidence that postoperative adjuvant radiation therapy for the high-risk neck can reduce the rate of recurrence within a dissected neck, delayed metastasis within an undissected neck, cancer-related death, and death from any cause.

Etoposide sensitivity of radioresistant human glioma cell lines

PURPOSE

Malignant gliomas display aggressive local behavior and are not cured by existing therapy. Etoposide, a topoisomerase-II-inhibitor agent, is one of the most active and useful antineoplastic agents. However, etoposide is not usually used on these tumors. We undertook an in vitro study to prove that etoposide is a useful drug for malignant gliomas.

METHODS

Five human glioma cell lines were the basis for this study. Following exposure to various concentrations of etoposide, the glioma cell lines were found to be sensitive; the median concentration inhibiting the number of cells by 50% (IC50) was 8.76 microg/ml (range 8-15.8 microg/ml). Since topoisomerase II is the critical target for etoposide, it was of interest to determine the topoisomerase II activity (decatenation of kinetoplast DNA isolated from Cryphtidia fasciculata) and the etoposide-induced inhibition of topoisomerase II activity.

RESULTS

The topoisomerase II activity was homogeneous in glioma cell lines (average of 50% decatenation with 7,000 cells), and topoisomerase II was the target of the etoposide.

CONCLUSIONS

Our results suggest that topoiomerase II-reactive agents may prove to be clinically useful drugs for patients with malignant gliomas.

Spinal cord localization in the treatment of lung cancer: use of radiographic landmarks

PURPOSE

In the treatment of thoracic malignancies with radiotherapy, the critical dose-limiting structure is the spinal cord. Oblique fields typically are designed to exclude the spinal cord, and by convention, the field edge that shields the spinal cord is placed at the anterior border of the vertebral pedicles. Thus, the purpose of our study was to estimate the distance between the field edge and spinal cord in oblique fields that were designed by using the vertebral pedicle as a radiographic landmark.

METHODS AND MATERIALS

The spinal cord of a cadaver was wrapped in wire, and oblique fields were simulated at 15 degree intervals. The distance from the spinal cord to a field edge placed at the anterior border of the pedicle was measured. In the second investigation, a three-dimensional treatment planning system was used to simulate hypothetical fields using actual patient data from computed tomography (n = 10), and measurements identical to those in the anatomical model were made (n = 1,100).

RESULTS

The results of the anatomical and computed tomographic models were in close agreement (mean difference, 0.6 mm). The computed tomographic model predicted a mean field edge to spinal cord distance of 8.7 mm (95% confidence interval, 5.6-11.8 mm) for 30 degree/150 degree oblique fields and 8.0 mm (95% confidence interval, 4.7-11.7 mm) for 45 degree/135 degree oblique fields. This distance was greatest at levels T-1, T-2, and T-11 (8 to 20% greater).

CONCLUSIONS

The mean distance from a field edge placed at the anterior border of a vertebral pedicle to the spinal cord for commonly used oblique angles constitutes a sufficient margin to account for expected differences in daily positional variations and mechanical uncertainties.

Has radiotherapy become too expensive to be considered a treatment option for early glottic cancer?

BACKGROUND

External beam radiotherapy and surgery produce equivalent long-term survival and tumor control in early glottic cancer. The expense and cost of radiotherapy have been challenged.

METHODS

A retrospective review was performed for 57 patients undergoing radiotherapy for glottic cancer. End points included local tumor control, relapse-free survival, cause-specific survival, medical charges, and costs. The results were compared with those of 265 patients who underwent transoral endoscopic removal or an open laryngeal procedure at the same institution.

RESULTS

The local control, larynx preservation, re-treatment, voice quality, relapse-free survival, and cancer death results and medical charges and costs are reported by treatment.

CONCLUSIONS

Radiotherapy provides at least equivalent, if not superior, local tumor control, larynx preservation, voice quality, and survival, compared with the surgical options. Overall medical charges and costs for radiotherapy are similar to transoral endoscopic resection and less than partial vertical laryngectomy.

Effectiveness of postoperative irradiation in stage IIIA non-small cell lung cancer according to regression tree analyses of recurrence risks

BACKGROUND

In the setting of grossly resected stage IIIA (N2 involvement) non-small cell lung carcinoma, the role of adjuvant postoperative thoracic radiation therapy (TRT) remains controversial. This study was initiated to subcategorize these patients into high-, intermediate-, and low-risk groups with respect to local recurrence and survival rates, and to determine whether there were certain subgroups of patients who were particularly likely or unlikely to benefit from postoperative TRT.

METHODS

Two hundred twenty-four patients were studied. A regression tree analysis was used to separate patients who had undergone operation alone into groups that had a high, intermediate, or low risk of local recurrence and death. The effect of adjuvant postoperative TRT then was examined in each of these groups.

RESULTS

The use of adjuvant postoperative TRT (compared with operation alone) was associated with an improvement in freedom from local recurrence and survival for patients who had an intermediate or high risk of local recurrence and death. However, the greatest level of improvement in freedom from local recurrence (p < 0.0001) and survival (p = 0.0002) associated with the use of adjuvant postoperative TRT was in the high-risk group. Similarly, but of lesser magnitude, the intermediate-risk group had improved freedom from local recurrence and survival rates with the use of adjuvant post-operative TRT (p = 0.002 and p = 0.01, respectively). For the low-risk group, the freedom from local recurrence and survival rates were not statistically different between the patients who received adjuvant postoperative TRT and those who underwent observation.

CONCLUSIONS

Patients with non-small cell lung carcinoma involving ipsilateral mediastinal lymph nodes (stage IIIA) who undergo gross resection and who are at either high or intermediate risk for local recurrence and death are likely to benefit from adjuvant postoperative irradiation. The role of radiation therapy in low-risk patients is unclear. Prospective confirmation of these observations is warranted.

The impact of surgical adjuvant thoracic radiation therapy for patients with nonsmall cell lung carcinoma with ipsilateral mediastinal lymph node involvement

BACKGROUND

Previous nonsmall cell lung carcinoma studies have shown that patients with ipsilateral mediastinal (N2) lymph node involvement who underwent surgical resection have a greater local recurrence rate than those with less lymph node involvement (N0, N1). Therefore, it was hypothesized that complete surgical clearance of subclinical lymph node disease is difficult in N2 patients and that adjuvant postoperative thoracic radiotherapy (TRT) may be beneficial.

METHODS

A retrospective review was performed to determine the local recurrence and survival rates for patients with N2 disease undergoing complete surgical resection with or without adjuvant TRT. Between 1987 and 1993 at the Mayo Clinic, 224 patients underwent complete resection of N2 nonsmall cell lung carcinoma. More than one mediastinal lymph node station was sampled in 98% of patients; 39% then received adjuvant TRT (median dose, 50.4 grays).

RESULTS

The median follow-up time was 3.5 years for the patients who were alive at the time of the analysis. The surgery alone versus surgery plus TRT groups were well balanced with respect to gender, age, histology, tumor grade, number of mediastinal lymph node stations dissected or involved, and involved N1 lymph node number. There were slightly more patients with right lower lobe lesions (compared with other lobes), patients with multiple lobe involvement, and patients with only one N2 lymph node involved in the surgery alone group. After treatment with surgery alone, the actuarial 4-year local recurrence rate was 60%, compared with 17% for treatment with adjuvant TRT (P < 0.0001). The actuarial 4-year survival rate was 22% for treatment with surgery alone, compared with 43% for treatment with adjuvant TRT (P = 0.005). On multivariate analysis, the addition of TRT (P = 0.0001), absence of superior mediastinal lymph node involvement (P = 0.005), and fewer N1 lymph nodes involved (P = 0.02) were independently associated with improved survival rate.

CONCLUSIONS

This study, which to the authors' knowledge is the largest evaluating adjuvant TRT in N2 nonsmall cell lung carcinoma, suggests that adjuvant TRT may improve local control and survival.

Utility of screening procedures for detecting recurrence of disease after complete response in patients with small cell lung carcinoma

BACKGROUND

Studies evaluating the efficacy of routine follow-up testing in detecting disease recurrence in treated lung carcinoma patients are lacking.

METHODS

To investigate this subject, the authors studied 115 patients who had previously been entered on North Central Cancer Treatment Group (NCCTG) small cell lung carcinoma clinical trials, had achieved a complete response after chemotherapy/radiotherapy treatment, and subsequently developed disease progression. The authors included 58 patients with limited stage and 57 patients with extensive stage disease. Follow-up testing on these clinical trials was scheduled at 4-month intervals in the first year and every 6 months thereafter. At each visit, testing included a clinical history, physical examination, chest X-ray, chemistry group, and hematology group. Patients' records were evaluated to determine the first test(s) to identify disease recurrence, whether the recurrence was diagnosed at the time of routine follow-up or between scheduled follow-up evaluations, the sites of recurrence, and patient outcome.

RESULTS

Recurrences occurred in 56 patients (49%) in the first follow-up year, 51 (44%) in the second year, and 8 (7%) after 2 years. Recurrences were signaled by clinical histories in 71% of patients, by physical examinations in 10%, chest X-rays in 12%, and abnormal chemistry testing in 6%. Although 41% of recurrences were detected at scheduled clinical visits, 59% of patients had disease recurrence signaled by symptoms that prompted interval visits between scheduled appointments. At last follow-up, all the patients in this study had died (median survival, 115 days [range, 1-793 days] after diagnosis of recurrence), supporting the lack of curative therapy for patients with recurrent small cell lung carcinoma.

CONCLUSIONS

These data, demonstrating that clinical histories and physical examinations are the most fruitful means of detecting evidence of recurrent lung carcinoma, are consistent with data regarding the follow-up of other curatively treated cancers, such as breast carcinoma and melanoma. Chest X-rays in asymptomatic patients detect recurrences in a small proportion of patients, whereas routine blood tests appear to be of little value.

Postoperative localization of porta hepatis and abdominal vasculature in pancreatic malignancies: implications for postoperative radiotherapy planning

PURPOSE

To evaluate changes in preoperative and postoperative positions of structures used to define target volumes (i.e., pancreatic bed, porta hepatis, local-regional lymph nodes) for postoperative irradiation of pancreatic malignancies as defined by abdominal computed tomographs.

METHODS AND MATERIALS

Eleven consecutive patients who had Whipple resection and postoperative irradiation for pancreatic cancer were evaluated. Preoperative and postoperative computed tomographs of each patient were evaluated for the position of the portal vein bifurcation and the origin of the celiac axis and superior mesenteric artery. The length along the x (medial-lateral position) and y (anterior-posterior position) axes was determined with calipers to the closest millimeter. Length along the z axis (cephalad-caudad position) was determined with the computed tomographic sectional interval between images. Statistical significance of the change in the structure's position along the x, y, or z axis between preoperative and postoperative computed tomographs was assessed with the paired t-test.

RESULTS

Evaluation of the preoperative and postoperative positions of the portal vein, celiac axis, and superior mesenteric artery along the x, y, and z axes revealed a statistically significant change in the location of the portal vein and celiac axis postoperatively. The median change of the celiac axis in the anterior-posterior position was significant (p = 0.0047), but the mean change was only 2 mm and not considered clinically significant. The median change for the portal vein was 0.97 cm and 1.07 cm along the y and x axes, respectively, and was significant (p = 0.008 and p = 0.0001). The range in position change for the portal vein was 0.0 to 2.0 cm along the y axis and 0.4 to 1.9 along the x axis. The remaining mean changes in position along all axes for all the structures were less than 3 mm (not statistically significant).

CONCLUSIONS

The mean position of the portal vein-porta hepatis after Whipple resection is approximately 1.0 cm medial and 1.0 cm posterior compared with its preoperative position. These data suggest that postoperative abdominal computed tomographs are useful in determining treatment volumes of nodal drainage basins after Whipple resection of pancreatic malignancies.

Laryngeal chondrosarcomas: the Mayo Clinic experience

BACKGROUND

Laryngeal chondrosarcomas occur infrequently. Their management is often guided by inferences made from the management of sarcomas arising from more commonly afflicted organs.

METHOD

A retrospective analysis of patients with laryngeal chondrosarcomas treated at the Mayo Clinic between 1959 and 1992 was performed to assess prognostic factors and outcomes after various treatments.

RESULTS

A total of 20 patients received treatment during this time period. All chondrosarcomas were low grade; 19 involved the cricoid cartilage and one arose in the supraglottic larynx. Initial treatment consisted of local excision (often subtotal removal) alone in 12 patients (60%), hemilaryngectomy in 2 (10%), near total laryngectomy in 2 (10%), and total laryngectomy in 4 (20%). Six patients (30%) had local recurrence: five initially had local excision and one had hemilaryngectomy. All local recurrences or tumor progression developed >3 years after initial treatment. Salvage surgery was performed in five of the six patients who had local recurrence, and the other patient was observed. Of the five patients who had salvage surgery, three required another resection because of a second recurrence.

CONCLUSIONS

These results suggest that initial conservative subtotal laryngectomy should be explored further because this treatment may provide long-term voice preservation in most patients, and patients who experience a recurrence after local excision often have been given several years of voice preservation.

The significance of the sequence of administration of topotecan and etoposide

PURPOSE

Often the best method of integrating chemotherapeutic agents is unknown. Recently there has been interest in the use of combinations of the topoisomerase II inhibitors and the topoisomerase I inhibitors as these agents have shown individual activity in malignancies such as non-small-cell lung cancer. This study examined the interaction of the topoisomerase II inhibitor etoposide with the topoisomerase I inhibitor topotecan (Tpt) in V79 cells (hamster lung fibroblast cells) to determine the optimal method of delivering these agents.

METHODS AND RESULTS

Cell survival was assessed by colony formation. Synergistic interactions were assessed by the median effect principle in which a combination index (CI) of less than one suggests a synergistic interaction. The V79 cells were exposed to sequential 24-h incubations with the two chemotherapeutic agents. Initially, equitoxic doses of the two agents were delivered (i.e. 0.0275 microg/ml of topotecan alone or 0.089 microg/ml of etoposide alone resulting in a surviving fraction of 70%; Tpt:etoposide ratio 1: 3.2). It was determined that a sequence-dependent synergistic interaction (CI < 1) resulted at a lower level of cytotoxicity if the etoposide exposure followed the Tpt exposure compared to the opposite sequence. This same effect was seen after treatment of cells with various concentration (microg/ml) ratios of Tpt: etoposide (1:4.0, 1:1, 2.5:1).

CONCLUSIONS

These results suggest that maximum synergy occurs for the delivery of etoposide following Tpt exposure (compared to the opposite sequence) and these findings may have important clinical implications.

The interaction of buthionine sulphoximide (BSO) and the topoisomerase I inhibitor CPT-11

Buthionine sulphoximide (BSO)-induced depletion of glutathione (GSH) was found to be associated with an increased sensitivity to CPT-11 (topoisomerase I-reactive agent) in V79 hamster lung fibroblast cells. When V79 cells were exposed to 2.5 mM BSO for 28 h beginning 4 h prior to a 24 h coincubation with CPT-11, cytotoxicity was increased compared with CPT-11 alone. It was determined that BSO resulted in a G1 cell cycle arrest and a decrease in the percentage of cells in S-phase. Since CPT-11 is known to be S-phase-specific, this BSO-induced cell cycle redistribution did not appear to account for the chemosensitisation of CPT-11. Additionally, BSO did not alter intracellular accumulation of CPT-11, conversion of CPT-11 to its active metabolite SN-38, or efflux of either CPT-11 or SN-38 from the cell. Finally, BSO resulted in a slight reduction, rather than an increase, in the number of stabilised DNA-topoisomerase I complexes induced by CPT-11. Therefore, these results suggest that BSO-induced sensitisation of V79 cells to the cytotoxic effects of CPT-11 occurs by a mechanism independent of the stabilisation of DNA-topoisomerase I complexes.

Neutrophil activation in jugular venous blood during carotid endarterectomy

OBJECTIVES

Neutrophils may play an important role in cerebral ischaemia. We investigated whether neutrophil activation can be detected in cerebral venous blood during the mild cerebral hypoxia and reperfusion that occurs during carotid cross clamping and declamping for endarterectomy. DESIGN, SETTING AND MATERIALS: The ipsilateral jugular bulb was cannulated at operation in 16 patients undergoing carotid endarterectomy. Blood was taken immediately prior to and 30 seconds following internal carotid cross clamping; then immediately prior to, 30 s and 2 m following declamping. Blood was also taken from a peripheral vein in the foot. Intracerebral oxygen saturation (CsO2) was measured continuously by near infrared cerebral spectroscopy. Neutrophil activation was measured by flow cytometric detection of fluorescence to hydrogen peroxide in unstimulated cells and phorbol myristate acetate stimulated cells, and expressed as mean fluorescent intensity (MFI).

OUTCOME MEASURES

Neutrophil activation and cerebral oxygenation.

MAIN RESULTS

CsO2 fell from 68% (95% Confidence interval 64%-72%) to 63% (59%-68%) following carotid cross clamping (p < 0.05, repeated measures analysis of variance). This recovered slightly during the cross clamp period to 64% but only returned to preclamp levels following declamping (p > 0.05). Neutrophil hydrogen peroxide generation by stimulated neutrophils rose significantly from 0.79 mean fluorescent intensity (0.53-1.19) to 1.46 (0.98-2.20) but no there was no further rise following cross clamp release. There was no significant neutrophil activation in the peripheral samples.

CONCLUSIONS

These results indicate that even mild cerebral hypoxia is associated with priming of neutrophils in cerebral venous blood.

Radiation therapy for glottic cancer using 6-MV photons

BACKGROUND

It has been recommended that cobalt-60 or 4-MV photons be used when treating glottic cancer with radiation therapy. Underdosing may occur when using higher energy photons, particularly when the anterior commissure is involved. The authors report their experience using higher energy photons (6 MV) for the treatment of glottic cancer.

METHODS

Between January 1975 and July 1991, 73 patients with Tis, T1, T2, or T3 glottic tumors underwent radiation therapy with curative intent. Cobalt-60 or 4-MV photons were used to treat the cancers of 30 patients, and 6-MV photons were used to treat 43 patients. Clinical records were reviewed retrospectively to determine patterns of treatment failure, cancer deaths, and local tumor control in the 43 patients receiving treatment with 6-MV photons. Patients were followed until death or for a minimum of two years.

RESULTS

Treatment failures were: local recurrence, one patient; local recurrence and distant metastasis, one patient; delayed neck metastasis, two patients; and delayed neck metastasis with distant metastasis, one patient. Three patients who had treatment failure are alive and free of cancer after salvage treatment. Two patients died of neck and distant metastases. The 2-year initial local tumor control rate was 94.8%.

CONCLUSIONS

Glottic cancer can be treated successfully with 6-MV photons. Local tumor control is similar to that reported using cobalt-60 or 4-MV photons.

Assessing the interaction of irradiation with etoposide or idarubicin

OBJECTIVE

To compare the interactions of two topoisomerase II inhibitors, etoposide and idarubicin, with irradiation.

DESIGN

Two mathematical modeling systems were used to assess the interactions.

METHODS AND RESULTS

Hamster lung fibroblast cells (V79) were exposed to etoposide or idarubicin for 24 hours before or immediately after irradiation. Post radiation treatment with etoposide or idarubicin resulted in radiosensitization, as demonstrated by a decrease in the mean inactivation dose. Exposure to either drug before irradiation resulted in no radiosensitization. The first mathematical modeling system used was isobologram analysis. This analysis revealed a synergistic interaction if etoposide exposure followed irradiation. The interaction from the combination of irradiation and preradiation etoposide was within the envelope of addivity. Irradiation and postradiation idarubicin exposure also resulted in an interaction within the envelope of addivity, whereas preradiation idarubicin exposure resulted in a slightly less than additive interaction. Next, analyses were performed by the median effect principle. Synergistic interactions were demonstrated for combinations of etoposide and irradiation as well as idarubicin and irradiation. Synergistic interactions were more likely when drug exposure (either idarubicin or etoposide) followed irradiation. Experiments at various ratios of radiation dose to drug concentration showed that the likelihood of a synergistic interaction increased as the drug concentration increased relative to the radiation dose.

CONCLUSION

The interaction of irradiation with topoisomerase II-reactive agents should be further explored in human tumor cell lines.

Long term results of a phase I/II study of aggressive chemotherapy and sequential upper and lower hemibody radiation for patients with extensive stage small cell lung cancer

BACKGROUND

A Phase I/II study of an aggressive six-drug chemotherapy regimen followed by the use of sequential hemibody radiation therapy as a possible non-cross-resistant systemic treatment was undertaken for patients with extensive stage small cell lung cancer.

METHODS

The 20 enrolled patients received 7 cycles of cyclophosphamide-based chemotherapy. The first cycle consisted of cyclophosphamide, doxorubicin, etoposide, vincristine, and lomustine. Subsequent cycles used a regimen of doxorubicin alternating with cisplatin. Thoracic radiation was delivered in a split-course fashion during the first week of chemotherapy cycles 5 and 6 (2000 cGy in five fractions during each week). Prophylactic cranial radiation was delivered in a split-course fashion during the first week of chemotherapy cycles 2 and 3 (1700 cGy in 5 fractions during each week). After the 7 cycles, patients received 600 cGy upper hemibody radiation followed by 800 cGy lower hemibody radiation.

RESULTS

Nineteen of 20 patients were evaluable for toxicity and response to treatment. Hematologic toxicity accounted for treatment delays or decreased doses in 16 of 19 patients. Thirteen patients completed the initial 7 cycles; progressive disease was the only reason for discontinuing treatment. Two patients had fatal hematologic complications after lower hemibody radiation. Three patients had severe or greater peripheral neurologic toxicity, two had severe central neurologic toxicity, and one had severe cardiac toxicity. Of 19 patients, 9 achieved a complete response; median survival was 11.5 months. Five-year progression free survival and 5-year overall survival were 27% and 16%, respectively.

CONCLUSIONS

This aggressive regimen is feasible for patients with extensive stage small cell lung cancer; however, hematologic-related mortality after lower hemibody radiation suggests that future investigations should be initiated at lower initial doses of lower hemibody radiation. Long term survival of the patients suggests that sequential hemibody radiation treatment warrants further investigation.

Prophylactic cranial irradiation in limited-stage small cell lung cancer

BACKGROUND

The role of prophylactic cranial irradiation (PCI) for patients with limited-stage small cell lung cancer (LSSCLC) remains a controversial issue. This study evaluated PCI in patients with LSSCLC who achieved a complete response to initial chemotherapy.

METHODS

A retrospective case study of all nonprotocol patients with LSSCLC examined at our institution from 1982 to 1990 was performed. Of the 67 nonprotocol patients who were treated with combination chemotherapy (cyclophosphamide-based) and thoracic radiotherapy during those years, 43 achieved a complete response. Twenty-four patients received prophylactic cranial irradiation (PCI+) (25-36 Gy in 10-16 fractions), and 19 did not (PCI-) at the physician's or patient's discretion.

RESULTS

The distribution of prognostic factors between the PCI+ and PCI- groups was well balanced. Of the PCI+ patients, the 2-year actuarial freedom from relapse in the central nervous system was 93% versus 47% for the PCI- patients (log rank analysis, P = 0.001). An initial central nervous system relapse developed in 2 of the 24 PCI+ patients as the only site of failure versus 7 of 19 PCI- patients (P = 0.003). The 2-year actuarial overall survival was 50% for the PCI+ patients versus 21% for the PCI- patients (P = 0.01). The addition of prophylactic cranial irradiation was the only significant factor contributing to an improvement in time to central nervous system relapse and survival for the PCI+ patients. There were five patients alive at the time of this report, and all received prophylactic cranial irradiation. None had cognitive or neurologic impairment.

CONCLUSIONS

Prophylactic cranial irradiation may contribute to improved survival in patients with LSSCLC who achieve a complete response after chemotherapy and thoracic radiation therapy.