Nomogram based overall survival prediction in stereotactic body radiotherapy for oligo-metastatic lung disease

BACKGROUND

Radical local treatment of pulmonary metastases is practiced with increasing frequency due to acknowledgment and better understanding of oligo-metastatic disease. This study aimed to develop a nomogram predicting overall survival (OS) after stereotactic body radiotherapy (SBRT) for pulmonary metastases.

PATIENTS AND METHODS

A multi-institutional database of 670 patients treated with SBRT for pulmonary metastases was used as training cohort. Cox regression analysis with bidirectional variable elimination was performed to identify factors to be included into the nomogram model to predict 2-year OS. The calibration rate of the nomogram was assessed by plotting the actual Kaplan-Meier 2-year OS against the nomogram predicted survival. The nomogram was externally validated using two separate monocentric databases of 145 and 92 patients treated with SBRT for pulmonary metastases.

RESULTS

The median follow up of the trainings cohort was 14.3months, the 2-year and 5-year OS was 52.6% and 23.7%, respectively. Karnofsky performance index, type of the primary tumor, control of the primary tumor, maximum diameter of the largest treated metastasis and number of metastases (1 versus >1) were significant prognostic factors in the Cox model (all p<0.05). The calculated concordance-index for the nomogram was 0.73 (concordance indexes of all prognostic factors between 0.54 and 0.6). Based on the nomogram the training cohort was divided into 4 groups and 2-year OS ranged between 24.2% and 76.1% (predicted OS between 30.2% and 78.4%). The nomogram discriminated between risk groups in the two validation cohorts (concordance index 0.68 and 0.67).

CONCLUSIONS

A nomogram for prediction of OS after SBRT for pulmonary metastases was generated and externally validated. This tool might be helpful for interdisciplinary discussion and evaluation of local and systemic treatment options in the oligo-metastatic setting.

KEY MESSAGE

A nomogram for prediction of overall survival after stereotactic body radiotherapy (SBRT) for pulmonary metastases was developed and externally validated. This tool might be helpful for interdisciplinary discussion and evaluation of local and systemic treatment options in the oligo-metastatic setting.

Are timing of chemoradiation and early therapy response as detected by PET prognostic factors of a multimodality treatment approach for NSCLC stage III? (LUCAS-MD)

7532

Background: A randomized multicenter phase III trial was designed to assess if timing of chemoradiation may alter treatment outcome for patients (pts) with stage III NSCLC in a multimodality treatment approach. Additionally, the role of F-18 FDG PET within clinical trials is evaluated for staging, therapy management, molecular radiation treatment planning (MRTP) and early therapy response and its effect on survival as compared to regression grade (RG). Methods: Inclusion criteria: histologically confirmed NSCLC stage IIIA/IIIB. ECOG PS 0–1. Primary end points: OS, DFS. Secondary end points: TTP, QoL, RR. Neoadjuvant treatment: 2–3 cycles of paclitaxel/carboplatin and a block of chemoradiation (45 Gy, 1.5 Gy b.i.d., concomitant paclitaxel/carboplatin) followed by surgery. Randomization: late (Arm1) vs. early (Arm2) chemoradiation. Staging: PET in addition to CT and/or MRI after randomization, second PET after completion of neoadjuvant therapy. Assessment of standardized uptake values (SUV) in primary tumor (PT) and all metastatic lymph nodes (LN). Documentation of involved LN as detected by PET and LN sampling during surgery according to Naruke/ATS-LCSG classification. Evaluation of RG and correlation with PET for PT and each LN. MRTP using fused PET/CT data. Intent to treat analyses using Kaplan-Meier estimates, log rank tests, Cox multivariate models. Results: 210 eligible pts were enrolled (Arm1: 106, Arm2: 104, well-balanced on all factors). Paraoperative lethality 4.3%. Treatment-related deaths in Arm1: 8.3%, in Arm2: 5.9%. Up-staging in 26/210 pts due to distant metastases, down-staging in 5/210 pts resulting in 15% stage migration. Actuarial tumor specific survival after 60 months: complete vs. incomplete metabolic remission: 56% vs. 24% (p =0.005), RG III/IIb (no/less than 10% of vital tumor cells) vs. RG IIa/I (more than 10% vital tumor cells): 61% vs. 25% (p <0.001). Late vs. early chemoradiation: 30% vs. 45% (p =0.313). Multivariate Cox regression for initial SUV: p >0.05. Conclusions: Long-term survivors with early chemoradiation have a trend to better survival being not statistically significant. Metabolic remission correlates well with RG and may predict therapeutic outcome.

No significant financial relationships to disclose.

The role of F-18 FDG PET within randomized multicenter phase III trials for multi-modality treatment of non-small cell lung cancer stage III

7213

Background: To evaluate the role of F-18 FDG PET within clinical trials for staging, therapy management, molecular radiation treatment planning (MRTP), early therapy response and its effect on survival as compared to histopathologic tumor response, findings in 156 patients with NSCLC are analyzed prospectively in a randomized, open, multicenter phase III trial (LUCAS-MD). Methods: Inclusion criteria: histologically confirmed NSCLC stage IIIA/IIIB. ECOG PS 0–1, adequate hematologic, renal, hepatic function. Primary end points: OS, DFS. Secondary end points: TTP, QoL, RR. Neoadjuvant treatment: 2–3 cycles of chemotherapy with paclitaxel/carboplatin and a block of chemoradiation (45Gy, 1.5Gy b.i.d., concomitant paclitaxel/carboplatin) followed by surgery. Randomization: early vs. late chemoradiation. Staging: PET in addition to CT and/or MRI after randomization. Second PET after completion of neoadjuvant therapy. Assessment of standardized uptake values (SUV) in primary tumor (PT) and all metastatic lymph nodes (LN). Documentation of involved LN as detected by PET and LN sampling during surgery according to Naruke/ATS-LCSG classification. Image fusion of PET with CT data followed by molecular radiation treatment planning. Evaluation of histological regression grade (RG) and correlation with PET for PT and each LN. Statistical analyses: Wilcoxon-, chi-square-, Mantel-Haenszel-test, Kaplan-Meier-method, multivariate Cox-regression. Results: Upstaging in 11 pts. due to distant metastases. Downstaging in 5 pts. Complete vs. incomplete metabolic remission after 48 months: 60% vs. 34% (p = 0.0058). RG III/IIb (no/less than 10% of vital tumor cells) vs. RGIIa/I (more than 10% vital tumor cells) after 48 months: 59% vs. 27% (p = 0.0006). Multivariate Cox-regression for SUV: p > 0.05. Statistical power of the tests: 75% so far. Due to PET findings, the planning target volume for MRTP was reduced substantially in 23%, increased in 10%. Conclusions: Integration of PET in clinical trials enables a more accurate MRTP and therapy management (10% stage migration). Histological regression grade correlates well with metabolic remission as detected by PET. F-18 FDG PET may predict (long term) therapeutic outcome in stage III NSCLC.

No significant financial relationships to disclose.

Prognostic factors in squamous cell carcinoma of the head and neck

Therapy for squamous cell carcinoma of head and neck relies on surgery, radiotherapy and chemotherapy, mostly a combination thereof. In patients treated with curative intent, the intensity of therapy is adapted to the supposed prognosis and should be defined upon prognostic factors. Besides classical prognostic parameters, T, N and M stage, the presence of extranodal growth (extracapsular spread, ECS), tumor volume, lymph node burden, extent of tumor necrosis, histologic grading, but also type of treatment were determined in consideration of prognosis. The p53 status does not correlate with prognosis in most investigations. The tumor hypoxia seems to be of prognostic value, and strategies to overcome the adverse effect are currently investigated. Not all factors are relevant for all types of treatment. Besides ECS, these new factors so far have rarely been used to stratify prospective combined modality treatment according to the risk of locoregional and distant failure.

Thoracic radiotherapy in the treatment of limited disease of small-cell cancer: sequence and fractionation

Since two meta-analyses showed improved survival rates at 3 years of approximately 5%, thoracic radiotherapy is accepted as an essential component of optimal management of limited-disease. However, optimal sequencing, timing, fractionation, dose, and field size still remain a matter of controversy. The issue has changed since the traditional doxorubicin-based chemotherapy has been substituted by cisplatin based regimens which clearly produce less acute toxicity and allow concomitant chemoradiation protocols. Up-front radiotherapy seems to improve 5-years survival rates compared to the traditional sequential modality. Different fractionation schedules and escalated total doses are tested prospectively in order to reduce the intrathoracic relapse rate. Increased intensity of intrathoracic radiotherapy seems to augment long term survival rates.

Daily amifostine given concomitantly to chemoradiation in head and neck cancer. A pilot study

BACKGROUND

In patients with loco-regionally advanced head and neck cancer conventionally fractionated radiotherapy alone results in poor loco-regional control and survival rates. Treatment intensification by simultaneous administration of cytotoxic drugs produces higher acute morbidity. Therefore chemical radioprotection of normal tissues may be of clinical benefit.

PATIENTS AND METHODS

In a pilot study patients with advanced nonresectable head and neck cancer treated with conventionally fractionated radical radiotherapy (60 to 66 Gy total doses) and concomitantly given 5-fluorouracil as protracted venous infusion, 250 mg/sqm/24 h over the entire treatment period were given amifostine 300 mg absolutely before each fraction. Acute treatment related morbidity was scored according to CTC classification and loco-regional control and survival rates were estimated. Comparison was made with a historical control group of identical chemoradiation but without amifostine application.

RESULTS

Chemoradiation induced oral mucositis was delayed and showed significant lower degrees at all 10 Gy increments (p < 0.05) except 60 Gy and over (p > 0.05). No significant toxicity was recorded with respect to blood pressure, serum calcium, potassium, hematologic parameters, emesis, nausea or body weight loss. Progression free survival and overall survival probability at 2 years were not statistically different in both cohorts.

CONCLUSION

Amifostine given before each fraction of radiotherapy over 6 weeks has no cumulative toxicity, was well tolerated and may reduce treatment induced oral mucositis. No tumor protective effect was observed.

Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: a randomized multicenter study

PURPOSE

A prospective randomized multicenter trial was performed to evaluate the contribution of simultaneously administered chemotherapy (CT) and radiotherapy (RT) in previously untreated patients with unresectable stage III/IV head and neck cancer.

PATIENTS AND METHODS

Patients with locoregionally advanced head and neck cancer were treated either with RT alone (arm A) or simultaneous RT plus CT (RCT; arm B). RT was identical in both arms and administered in three courses with 13 fractions of 1.8 Gy each twice daily. During one course, from day 3 to 11, 23.4 Gy was delivered. In arm B, cisplatin (CDDP) 60 mg/m2, fluorouracil (5-FU) 350 mg/m2 by intravenous (i.v.) bolus, and leucovorin (LV) 50 mg/m2 by i.v. bolus were given on day 2, and 5-FU 350 mg/m2/24 hour by continuous infusion and LV 100 mg/m2/24 hours by continuous infusion were given from day 2 to 5. Treatment was repeated on days 22 and 44; a total RT dose of 70.2 Gy was administered. Treatment breaks were scheduled from days 12 to 21 and days 34 to 43.

RESULTS

From 1989 to 1993, 298 patients were enrolled and 270 patients were assessable. Acute mucositis grade 3 or 4 was more frequent in arm B (38%) than in arm A (16%) (P < .001). Total treatment time was significantly longer in arm B than in arm A (P < .001) due to prolonged breaks. According to hematologic toxicity, scheduled drug doses were given in 74% of patients for the second course and 46% for the third course. The 3-year overall survival rate was 24% in arm A and 48% in arm B (P < .0003). The 3-year locoregional control rate was 17% in arm A and 36% in arm B (P < .004). Both arms showed similar distant failure patterns (arm A, 13 of 140; arm B, 12 of 130). Serious late side effects were not significantly different between treatment arms (arm A, 6.4%; arm B, 10%; not significant).

CONCLUSION

Concomitant CT offered improved disease control and survival in advanced head and neck cancer patients. Due to increased acute toxicity, more supportive care is demanded when CT is given simultaneously. Increased total treatment time does not exert a negative impact on outcome in this combined modality regimen.

[The inhalation versus systemic prevention of pneumonitis during thoracic irradiation]

BACKGROUND

Pneumonitis is a typical subacute reaction of healthy bronchial tissue to thoracic irradiation. The purpose of the present trial was to show whether prophylactic application of steroids in the course of and following radiotherapy would reduce the incidence of pneumonitis.

PATIENTS AND METHODS

Fifty-seven patients receiving thoracic irradiation for bronchial carcinoma were assigned to 2 therapeutic groups; half of the patients were given 10 mg of oral prednisolone per day, while the other half received daily inhalative beclomethasone. All patients were evaluated for radiographic signs of pneumonitis. Thirty-two patients received additional investigations for pulmonary diffusion capacity of carbon monoxide.

RESULTS

The overall incidence of pneumonitis was 17.6% (10/57 patients). Neither total radiation dose nor mode of fractionation did significantly contribute to the incidence of pneumonitis. Those patients showing a pulmonary diffusion capacity for carbon monoxide of less than 60% prior to radiotherapy had a significantly higher risk of developing pneumonitis (4/7) than patients with a higher diffusion capacity (3/25, p = 0.026). In follow-up period we did not see significant changes in diffusion capacity neither with patients who developed pneumonitis nor with those patients showing no evidence of pulmonary injury. Comparing the chest X-ray there were less radiographic changes consistent with pneumonitis in the inhalative beclomethasone (2/28) than in the oral prednisolone group (8/29, p = 0.045).

DISCUSSION

In order to reduce the incidence of pneumonitis in patients receiving thoracic irradiation we support a continuous application of steroids in the course of and following radiotherapy. The inhalative use of beclomethasone has proved to be superior to oral prednisolone due to better local efficacy and decreased unwanted side effects.

[The radiochemotherapy of advanced head-neck tumors--what is certain?]

BACKGROUND

Loco-regional control and survival after radical conventionally fractionated radiotherapy remains poor in advanced squamous cell head and neck cancer. Therefore during the last 2 decades new modalities were investigated including unconventional fractionation and radiochemotherapy.

PATIENTS AND METHODS

The literature is reviewed and results of a novel protocol of the German Cancer Society ARO 89-1 applying chemotherapy and radiotherapy synchronously are analysed in order to define the current role of chemotherapy in the treatment of newly diagnosed loco-regionally advanced head and neck cancer.

RESULTS

Despite high response rates achieved by induction chemotherapy ultimate survival has not changed in the vast majority of studies reported. Provided the loco-regional disease is controlled 3 courses of active combination chemotherapy reduce the incidence of distant metastases from 25% to 15%. In a prospective randomized multicenter study with 270 evaluable patients conducted from 1989 to 1993 3 courses of split course accelerated radiotherapy were compared with 3 courses radio-chemotherapy. After combined modality loco-regional control increased from 17% to 34% (p < 0.014) and overall survival from 24% to 48% (p < 0.0003). Also fast alternating protocols yield improved loco-regional control rates but not improved survival. When 5-FU is given simultaneously to irradiation continuous infusion rendered superior to bolus injection. Except bleomycin cytotoxic drugs do not increase incidence or severity of chronic radiation sequelae. The total treatment duration considered crucial in radiotherapy alone seems less important in combined modality protocols.

CONCLUSION

Sequential radio-chemotherapy protocols should be omitted in favour of simultaneous or fast alternating protocols. Since the latter are more toxic compared to sequential radio-chemotherapy or radiotherapy alone supportive care is mandatory. Future trials should determine new prognostic factors in order to individualize therapy.

[Current status of therapy of CNS metastases of germ cell tumors]

The incidence of CNS metastases in germ cell tumors is 2-5% and in very advanced disease over 20%. We report on 37 patients in whom CNS metastases were diagnosed with the CAT scanner. Twenty-nine patients were subsequently treated. In 19 cases, treatment consisted of radiotherapy, 1 patient was only operated on, and in 9 cases patients received combined surgery and radiotherapy. Two patients had seminomatous germ cell tumors, 27 patients non-seminomatous tumors. HCG levels were high in 11 cases. In 31 patients the disease was in the advanced stages; in 6 the disease was at the early stage. If there was just a solitary tumor, operation was the preferred mode of treatment. Radiotherapy consisted of 50 GY whole-brain irradiation, with a tumor saturation up to 60 GY. In 2 cases we suspected radiogenic necrosis. There were no other severe side effects. Of the 37 patients, 4 obtained a long-term cure (observation time 34-90 months). Therapy must take all methods of treatment into consideration and should only be carried out in fully equipped medical centers. Only then can we hope to obtain long-term cures in individuals with this usually fatal disease.

[Results of photon therapy of malignant tumors of the parotid gland]

Between 1971 and 1982 86 patients have been treated because of a malignant tumor of the parotid gland. 64 patients have been irradiated after complete (n = 49) or incomplete (n = 15) first resection. 12/64 (19%) relapsed locally. The loco-regional tumor control rate five and ten years after postoperative radiotherapy is 72%, 85% after complete resection, and 22% after incomplete resection (p less than 0.01). Tumor size and nodal disease are of prognostic value. Disease-free survival in patients without lymph nodes is 53%, with lymph node metastases 31% after five years (p less than 0.05). Small tumors (T1, 2) have a better local control rate compared to locally advanced tumors (five years: 83% vs. 53%, p less than 0.05). No difference was found neither for the total dose nor the histology of the tumor. Distant metastases became apparent after median eleven months.

[The results of simultaneous radio-chemotherapy in advanced head and neck tumors]

Patients suffering from locally advanced squamous cell carcinoma of the head and neck were treated with three courses of simultaneous radio-chemotherapy. Chemotherapy consisted of cis-platinum, 60 mg/m2 i.v. on day 2; 5-FU, 350 mg/m2 i.v. bolus on day 2; leucovorin calcium, 50 mg/m2 i.v. on day 2; 5-FU, 350 mg/m2/24 hrs continuously infused over 96 hrs from day 2 to day 5 and leucovorin calcium, 100 mg/m2/24 hrs continuously infused over 96 hours from day 2 to day 5 each course. Radiotherapy was administered from day 3 to day 11. 23.4 Gy were given in 13 fractions, twice a day with a minimum interval of four hours. This schedule was repeated on days 22 and 44. The total radiation dose amounted to 70.2 Gy/51 days. From 1984 to 1986, 62 patients were entered in this prospective trial. Three patients deceased due to massive hemorrhage during therapy, one patient was not eligible due to a second malignancy. 5/58 evaluable patients had a UICC-Stage III cancer, 53/58 had a UICC-Stage IV cancer. 48/58 (81%) showed a clinically complete response to therapy, 10/58 (17%) achieved partial response three months after the end of treatment. In 16/58 patients loco-regional cancer was not controlled (minimum follow-up 2 years), in 12/58 distant metastases occurred. Loco-regional control rate is estimated at 66% +/- 7% (Kaplan Maier).

Cisplatin, fluorouracil with leucovorin calcium enhancement, and synchronous accelerated radiotherapy in the management of locally advanced head and neck cancer: a phase II study

In a phase II study, patients with locally advanced squamous cell carcinoma of the head and neck were treated with simultaneous chemoradiotherapy. Treatment was divided into three courses. Chemotherapy consisted of cis-diamminedichloroplatinum (II) (cisplatin [cis-DDP]) 60 mg/m2 intravenously (IV), fluorouracil (5-FUra) 350 mg/m2 IV, and folinic acid (leucovorin calcium [FA]) 50 mg/m2 IV on day 2 as bolus, and 5-FUra 350 mg/m2 over 24 hours and FA 100 mg/m2 over 24 hours on days 2 through 5. Radiotherapy consisted of 23.4 Gy over nine days divided into 13 fractions of 1.8 Gy each delivered twice a day from day 3 through day 11. This regimen was repeated on days 22 and 44. Total radiation dose amounted to 70.2 Gy over 51 days. Between August 1984 and October 1986, 62 (modified AJCC stage III, four; IV A, eight; IV B, 50) consecutive patients were entered in the study. Three patients died during treatment due to tumor hemorrhage. Of 59 patients, 48 (81%) achieved a clinically complete response (cCR); 11 (19%) achieved a partial response (cPR). Mean follow-up of the surviving patients was 29+ (24 to 44) months. Actuarial 2-year survival probability is 52%, including three early deaths from tumor bleeding. Tumor and neck nodes control rates at 2 years were 92% for stage III and IV A patients and 65% for stage IV B patients. Patients with cCR had a significantly better 2-year tumor and neck nodes control probability compared with patients who achieved cPR after therapy (P less than .001). Six patients developed distant metastases. Overall toxicity was tolerable, mucositis particularly was not a limiting factor.

Simultaneous chemo-radiotherapy with 5-FU/folinic acid/cis-platinum and accelerated split-course radiation in advanced head and neck cancer

In a clinical phase-II trial, 62 previously untreated patients suffering from unresectable stage III (4 patients) and IV (56 patients) squamous cell carcinoma of the head and neck were treated with a simultaneous chemoradiotherapy consisting of a 5-fluorouracil/folinic acid/cis-platinum combination and of an accelerated split-course radiotherapy. As results, 3 patients died from tumor arrosion bleeding during the treatment. The median follow-up time of the surviving patients is 27+ months (range 18-44 months). Forty-eight out of 62 patients (77%) achieved complete remission, and 11/62 patients (18%) partial remission. Presently, 32 patients (52%) are without evidence of disease. The actuarial 3-year overall survival rate (Kaplan-Meier method) out of 62 patients is 53%. The actuarial disease-free survival and local tumor control rates at 3 years are 58% and 72%. Toxicity on oral mucosa was severe but tolerable, bone marrow depression was marked but not life-threatening. In conclusion, this combined simultaneous modality approach is highly effective in locally advanced head and neck cancer. It appears to provide superior survival and local control rates as compared to conventional radiotherapy or sequential chemo-radiotherapy.

[Results of simultaneous radio-polychemotherapy in advanced inoperable cancer of the head and neck]

Sixty untreated patients with advanced carcinoma of the head and neck (stages III = 11 and IV = 49) were treated simultaneously with three cycles of polychemotherapy and radiation. Chemotherapy consisted of cisplatinum (DDP) 60 mg/m2 after prehydration with saline and mannitol, 5-fluorouracil (5-FU) 350 mg/m2 and folinic acid (FA) 50 mg/m2 on day 2 as a bolus and a continuous infusion of 5-FU 350 mg/m2/24 h and folinic acid (FA) 100 mg/m2/24 h from day 2-5. Concomitantly, accelerated hyperfractionated radiation was administered from day 3-11. Two fractions per day with 1.8 Gy each were given, 13 fractions in 9 days. This cycle was repeated two times on day 22 and 44 with an interval without treatment from day 16-21 and 34-43. Total radiation dose was 70.2 Gy in 51 days. Acute toxicities (WHO grade II and III) consisted mainly of leucopenia (75%), thrombopenia (15%), weight loss (mean 5.8 +/- 3.7%) and mucositis (66%). Grade IV was never reached. Except for 3 patients, who died during treatment due to fatal tumor bleeding or carotid rupture, all were able to finish the treatment with reduction in chemotherapy in only 95% (DDP) and 98% (5-FU) with no changes in the radiation protocol. Evaluation of tumor response at 3 months after end of treatment showed 68% complete and 32% partial responses. 5 patients developed distant metastases. Survival with local control after 12 months was 80.8% and 71.3% after 24 months. 1 and 2 years disease-free survival was 70.8% and 62.1%. Total survival irrespective of cause of death was 77.9% and 57.2% after 1 and 2 years. This particular simultaneous radio-polychemotherapy protocol appears to be well tolerable and highly effective in terms of tumor control and survival of advanced stages of head and neck cancer.

[Simultaneous radio- and chemotherapy of squamous cell carcinoma of the esophagus]

Between 1983 and 1986, 41 patients with a squamous cell carcinoma of the oesophagus without hematogenic metastases were treated with a combination of radio- and chemotherapy preoperatively. Treatment consisted of mitomycin C (10 mg/sqm/day 1) and continuous infusion of 5 fluorouracil (1000 mg/sqm/day-day 1 to 4) with a maximum of 1500 mg per day. On day 2 radiotherapy was started. After the administration of 36 Gy all patients were restaged. Nine patients were referred to surgery. In 13 cases surgery was refused, because of inoperability, due to local or distant metastases. In these patients radiotherapy was continued up to 50 to 60 Gy for palliation. Although the disease was confined to the oesophagus no surgery was performed in 19 patients, because of age, enhanced risk of anaesthesia or refusal by the patient. These patients were treated with radiotherapy alone (60 Gy) with curative intention. 32 patients treated without surgery were followed up. For the patients treated with curative intent, the one year survival rate was 62%, the two year survival rate was 42%. Compared to a group treated in 1970 bis 1982 with the same dosage of irradiation without the combination of chemotherapy the median survival could be raized from nine to 24 months, the two year survival rate improved from 18% to 42%. Patients treated for palliation only did not survive the first year after therapy.

5-Fluorouracil/folinic acid/cisplatin-combination and simultaneous accelerated split-course radiotherapy in advanced head and neck cancer

In advanced inoperable head and neck cancer radiotherapy alone is unsatisfying. Better results can be obtained by simultaneous 5-Fluorouracil/Cisplatin-chemotherapy and irradiation. The cytotoxicity of 5-Fluorouracil can be enhanced synergistically by adding Folinic Acid in excess. In a clinical phase II trial 62 previously untreated patients suffering from unresectable AJCC-stage III (4 pts.) and IV (58 pts.) squamous cell carcinoma of the head and neck were treated with a simultaneous chemoradiotherapy consisting of high-dose Folinic Acid in addition to a 5-Fluorouracil/Cisplatin combination and of accelerated split-course radiotherapy. As results, three pts. died from tumor arrosion bleeding during the treatment. Median follow up time of the surviving pts. is 27 + months (range 18-44 months). 48/62 pts. (77%) achieved complete remission, 11/62 pts. (18%) partial remission. Presently, 32 pts. (52%) are without evidence of disease. Actuarial three years overall survival rate (Kaplan-Meier method) out of 62 pts. in 53%. Actuarial disease free survival and local tumor control rates at three years are 58% and 72%. Mucositis was severe but tolerable, bone marrow depression was moderate to marked. In conclusion, this combined simultaneous modality approach is highly effective in locally advanced head and neck cancer. It seems to provide superior survival and local control rates as compared to conventional radiotherapy or sequential chemo-radiotherapy or as compared to simultaneous 5-Fluorouracil/Cisplatin and non-fractionated radiotherapy. A comparative phase III study is required.

Accelerated split-course radiotherapy and simultaneous cis-dichlorodiammine-platinum and 5-fluorouracil chemotherapy with folinic acid enhancement for unresectable carcinoma of the head and neck

Thirty-four (6 stage III, 28 stage IV) patients with advanced squamous cell carcinoma of the head and neck were treated by simultaneous radio-chemotherapy. Treatment was divided into three cycles. Chemotherapy consisted of cis-diamminedichloroplatinum(II) (cis-DDP) 60 mg/sqm i.v., 5-fluorouracil (5-FU) 350 mg/sqm i.v. and folinic acid (FA)-50 mg/sqm i.v. on day 2 and 5-FU 350 mg/sqm per 24 h and FA 100 mg/sqm/24 h on days 2-5. Radiotherapy consisted of 23.4 Gy/9 days divided in 13 fractions of 1.8 Gy delivered twice a day from day 3 through day 11. This regimen was repeated on days 22 and 44. Total radiation dose amounted to 70.2 Gy/51 days. Mean follow-up of surviving patients was 21 (14-34) months. 28/32 patients achieved complete response, 4/32 partial response. Actuarial one and two years survival were 88 and 58% including two early deaths from tumour bleeding. Local control rates at one and two years were 87 and 81%, respectively. This protocol produces excellent palliation and the chance of improved long term tumour control. Two patients developed distant metastases. Overall toxicity was tolerable. Since the treatment breaks were inserted after low radiation doses, acute mucositis healed rapidly and was not a limiting factor.

[Principles of the simultaneous radiation and polychemotherapy in advanced head and neck carcinoma]

Concomitant application of chemotherapeutic agents and radiotherapy increases the tumoricidal effects. In this report the biochemical, cell-kinetic and radiobiological interactions of the simultaneous radio-polychemotherapy are discussed. Systemic chemotherapy consisted of cis-dichlorodiammineplatinum (II) (cis-DDP; 60 mg/sqm), 5-fluorouracil (5-FU; 350 mg/sqm) and folinic acid (FA; 50 mg/sqm) on day 2 and 5-FU 350 mg/sqm/24 hrs and FA 100 mg/sqm/24 hrs on days 2-5. Radiotherapy was applied in 13 fractions of 1.8 Gy delivered twice daily from days 3-11. The regimen was repeated on days 22 and 44, reaching the final dose of 70.2 Gy in 8 weeks. With this protocol, optimal tumor regression was achieved in very advanced squamous cell carcinoma of the head and neck. Survival rate after 2 years was 76.8% with 28/32 complete and 4/32 partial remissions. Using an intensive adjuvant treatment, the overall toxicity was tolerable allowing the application of the full therapeutic dosage in 95% without any interruptions.

[Radiotherapy of medulloblastoma]

Between 1970 and 1985, 29 patients were postoperatively irradiated for medulloblastoma. Eight out of them received only a local irradiation and 21 a complete CNS irradiation. The posterior fossa was saturated up to a dose of 45 to 49 Gy in nine patients and 50 to 55 Gy in twelve patients. The patients treated by complete CNS irradiation show a three-year survival rate of 47% and a five-year survival rate of 40%. A nonsignificant increase of the three-year survival rate is found in patients whose posterior fossa was exposed to a higher radiation dose. Eleven recurrences were observed, and the posterior fossa was involved in seven out of these cases. Four recurrences confined to the spine were found after a dose of 20 to 30 Gy. Remote metastases, preferentially with a skeletal site, were formed in three out of 29 cases.

[Postoperative radiotherapy of supratentorial anaplastic glioma]

Between 1970 and 1983, 149 patients with high grade anaplastic supratentorial gliomas received a postoperative irradiation during primary treatment. 118 out of these patients had an anaplastic astrocytoma, 18 an anaplastic oligodendroglioma, and 13 an anaplastic ependymoma. Most of these patients were treated by irradiation of a great volume with 50 Gy within five weeks, the others by irradiation of the total brain with 50 Gy within five weeks and saturation with 10 Gy within one week. The one-year survival of the total group was 35.5% and the two-year survival 10.6%. Patients at an age of less than 40 years show a significantly longer survival than older patients (one-year survival rates 40% and 30.7%, respectively). Patients suffering from anaplastic tumors with astrocytic and oligodendrocytic differentiation have a comparable prognosis. Patients suffering from anaplastic tumors with ependymal differentiation, however, have prolonged survival times. The therapy results of different treatment methods are discussed using the communications of literature.

Sequential chemo-radiotherapy in locally advanced squamous cell carcinoma of the head and neck

Between 1982 and 1983, 32 patients were treated for locally advanced inoperable squamous cell carcinoma (SCC) of the head and neck in a prospective pilot study. Patients received two to five courses of chemotherapy consisting of methotrexate, bleomycin and cis-dichlorodiammine-platinum (II). Radical radiotherapy was performed two weeks after administration of chemotherapy. Despite the high initial response rate to chemotherapy of 62.5%, long-term results remained poor. After a median follow-up of 10.5 months (3-39 months), 15 patients were still alive, but only 4 were clinically free of disease. Aggressive chemotherapy does not prevent delivery of full-dose radiotherapy for SCC of the head and neck. Furthermore, our study does not suggest that chemotherapy has a great influence on long-term results.

[Diagnosis of benign and malignant tumors of the female breast using single photon emission computed tomography with 99mTc-DTPA]

31 patients with suspicious findings on mammographic films were examined preoperatively by single photon emission computed tomography. A scintigraphic study was performed at 30 and 120 min after i.v. administration of 370 MBq (10 mCi) 99mTc-DTPA. The radionuclide accumulation in both breasts was analyzed quantitatively on transaxial slices using the ROI-technique. In benign lesions (n = 12) as well as in carcinomas (n = 19), an increased 99mTc-DTPA accumulation was found as compared to clinically and radiographically unaffected sides. A radionuclide accumulation exceeding 20% of the contralateral side was considered to indicate malignancy. Thus the sensitivity in diagnosing malignant tumours was 74%, the specificity 64% and the accuracy 70%. In contrast to studies with planar scintigraphic imaging techniques the results clearly show an increased 99mTc-DTPA uptake even in benign breast lesions.