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achieving complete response status. Whether

patients with partial response should also receive prophylactic cranial irradiation re- mains controversial. Finally, half-body radiation in SCLC is an experimental re- rearch technique that has shown some pro- mise but remains quite toxic when combined with systemic chemotherapy.

9. COFBINED TREATMENT MODALITIES

Long-Term Survivors of Small Cell Carci- noma of the Lung. Vogelsang, G.B., Abeloff, M.D., Ettinger, D.S., Booker, S.V. Johns Hopkins Oncology Center, Baltimore, MD 21205, U.S.A. Am. J. Med. 79: 49-56, 1985.

Small cell carcinoma of the lung has been shown to be exquisitely responsive to chemotherapy. Unfortunately, these re- sponses are often short in duration and long-term disease-free survival is in- frequent. This review of the records of all patients with small cell carcinoma of the lung treated on protocol at The Johns Hopkins Oncology Center from 1973 to 1982 showed that 25 of 225 (II.i percent) sur- vived two years or longer. Patients with limited disease (20 of 94) and patients with a complete response (15 of 72) had greater two-year survival than those with extensive disease (five of 131) or par- tial remission (eight of 104). However, 18 of the 25 long-term survivors eventu- ally had relapses, and relapse occurred as late as eight years after diagnosis. This study further emphasizes the impres- sive discrepancy between the rate and magnitude of the initial response and ultimate survival in patients with small cell carcinoma of the lung.

Combined Laser Therapy and Endobronchial Radiotherapy for Unresectable Lung Car- cinoma with Bronchial Obstruction. Allen, M.D., Baldwin, J.C., Fish, V.J. et al. Department of Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, CA 94305, U.S.A. Am. J. Surg. 150: 71-77, 1985.

Over a 4 year period, we refined a pro- tocol for treatment of airway obstruction due to recurrent lung carcinoma. Patients undergo bronchoscopy with the Nd: YAG laser available on standby. If bronchial obstruction is found to be due to extrin- sic compression, an endobronchial catheter is inserted for iridium 192 brachytherapy, treating a cylindrical volume 7.5 to 15 mm in radius. If an endobronchial le- sion is found, the presence of complete versus partial bronchial obstruction de- termines the course of treatment. Total airway obstruction is treated with the

laser until a channel is created and then

an endobronchial catheter is placed for adju- vant endobronchial radiotherapy to treat a cy- lindrical volume 5 mm in radius. Partial air- way obstruction is treated with an endobronchi- al catheter and radiotherapy alone. Segmental obstruction is also treated with a distally placed endobronchial catheter instead of the laser. Using this protocol, we hope to minimize risk to the patient by restricting the use of the laser with its inherent higher potential rate of complications to cases of total obstruc- tion. In addition, we expect to prolong the duration of palliation with endobronchial radio- therapy. The laser is an excellent tool to re- open occluded bronchi, but it is relatively in- effective in producing long-term tumor control. Instead, we have found that placement of a temporary transtracheal endobronchial catheter for radiotherapy is a simple, low-risk proce- dure that can be safely performed even in cri- tically ill patients. The endobronchial ca- theter can provide good to excellent long-term palliation for patients with both partially and totally obstructed endobronchial lesions or malignant extrinsic compression of major airways.

Randomly COntrolled Study of Chemotherapy ver- sus Chemoinmunotherapy in Postoperative Lung Cancer Patients. Yasumoto, K., Yaita, H., Ohta, M., et al. Second Department of Surgery, Kyushu University Medical School, Higashi-ku, Fukuoka 812, Japan. Cancer Res. 45: 1413-1417, 1985.

A randomly controlled study of chemotherapy versus chemoimmunotherapy was performed in pa- tients with operable lung cancer from November 1977 to June 1981. The immunotherapy consisted of an intrapleural instillation of Nocardia rubra cell wall skeleton (N-CWS) followed by serial intradermal N-CWS. A total of 119 pa- tients were entered into this trial. There were 64 evaluable patients in the control group and 52 evaluable patients in the N-CWS group. N-CWS treatment was effective in terms of pro- longation of duration of remission for all operable patients. Although significant impro- vement in the survival rate was not observed in patients at Stages I and II (p < 0.i0), it was observed in the curative operation group (p < 0.05). The mode of recurrence was clas- sified as local recurrence and distant meta- stasis in the curative operation group. The rates of distant metastasis were 34.0 and 18.9%, respectively in the control and the N-CWS groups. The rate of local recurrence was 14.9% in the control group; however, no local re- currence was observed in the N-CWS group. These results indicate the clinical effectiveness of the N-CWS treatment, especially in curatively resectable lung cancer. No serious side effect was observed during this trial.

Combined-Modality Treatment of Inoperable Lung Cancer (iv Immunotherapy, Chemotherapy, and

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Radiotherapy). Robinson, E., Haim, N., Segal, R., et al. National Council for Research and Develop- ment, Israel, Israel. Cancer Treat. Rep. 69: 251-258, 1985.

Patients with inoperable non-small cell carcinoma of the bronchus were treated by iv methanol extraction residue of bacil- lus Calmette-Guerin (MER) followed by com- bination chemotherapy with methotrexate, doxorubicin, cyclophosphamide, and lomu- stine (MACC). Radiotherapy was added in patients with localized disease. MER was given iv in four weekly courses. The dose ranged between 0.i and 0.8 mg/msup 2/course and was determined according to the skin reactivity to MER. None of the 19 patients treated with iv MER had an objective tumor response during immunotherapy. Five of 16 evaluable patients receiving MACC (31%) achieved partial response. The overall median survival for all 17 patients treat- ed was ii months according to the protocol. During immunotherapy the following side effects were observed: all patients had fever and chills and most had malaise, nausea and/or vomiting, and headache. Transient abnormalities of liver function tests were found in six patients, and in one patient roentgenographic changes sug- gestive of lung granulomas were seen. The side effects were more severe during the first course than in the further treat- ments. Side effects of the MACC combina- tion were comparable to those observed in previously reported studies. Immunological monitoring performed during immunotherapy revealed that iv MER had an unfavorable effect on the immune system. Following four courses there was a decrease in the in vivo skin reactivity to MER and to five recall antigens. Twenty-four hours after the initiation of iv MER there was a ten- dency for decrease in the lymphoprolife- ration to phytohemagglutinin, and increase in the indices of the adherent cell sup- pressor system and the prostaglandin-rela- ted suppressor system, and an increase in the percentage of adherent mononuclear cells. No consistent changes in serum lysozyme were found. A transient increase in the total number of peripheral blood leukocytes and a decrease in the number of lymphocytes were noticed 24 hours after iv MER. Taking into account the results of the immunological studies and the over- all therapeutic results, we do not feel justified in continuing to use this com- bined modality treatment.

Unresectable non Metastatic Squamous Cell Carcinoma of the Lung: Phase II Study of Radical Radiotherapy and Combined Chemo- therapy. Le Chevalier, T., Arriagada, R., Baldeyrou,

P., et al. Comite de Pathologie Thoraciqu~, In- stitut Gustave-Roussy, F 94805 Villejuif Cedex, France. Bull. Cancer 72: 25-29, 1985.

Thirty three evaluable patients with local- ly advanced squamous cell carcinoma of the lung entered a Phase II study combining chemotherapy (Vindesine 1.5 mg/msup 2 dl; CCNU 50 mg/msup 2 d2, 25 mg/msup 2 d3; Cis-platinum I00 mg/msup 2 d3; Clyclophosphamide 200 mg/msup 2 d3, 4, 5) (VCPC) and radical radiotherapy to the primary tumor, mediastinum and supraclavicular nodes. Responders to chemotherapy resumed four additi- onal cycles following radiation therapy. Four- teen patients (42%) presented an objective re- sponse to the first two cycles of VCPC. On final evaluation, 18 patients (54.5%) attained com- plete remission and 6 patients (18%) partial remission. Median survival of all patients was 15.9 months and toxicity was acceptable. We conclude that our results justify a phase III study of combined treatment versus radiotherapy alone.

Combined Surgery, Intraoperative Brachytherapy, and Postoperative External Radiation in Stage III Non-Small Cell Lung Cancer. Hilaris, B.S., Gomez, J., Nori, D., et al. Brachytherapy Service, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, U.S.A. Cancer 55: 1226-1231, 1985.

From March 1977 to December 1980, 318 patients with Stage III non-small cell lung cancer under- went thoracotomy at Memorial Sloan-Kettering Cancer Center. One hundred of these patients, considered for this study, were treated by a multimodality approach consisting of resection and/or intraoperative brachytherapy followed by postoperative external irradiation. The criteria for utilizing intraoperative brachytherapy and postoperative external irradiation were either the presence of residual gross disease (47%) or close resection margins suspected to be in- volved by the tumor (53%). The intraoperative brachytherapy consisted of a temporary iridium 192 implant for subclinical disease in the me- diastinum (median dose, 30 Gy in 3-5 days) and a permanent iodine 125 implant for residual gross disease usually at the primary site (medi- an dose, 160 Gy). All patients received post- operative external beam irradiation consisting of 30 to 40 Gy in 2 to 4 weeks. Seven patients (7%) experienced mild to severe complications after these treatments. The local control, when all gross disease had been removed, was influ- enced by the presence or absence of tumor at the margins of resection (53% and 89%, respec- tively). The local control in the patients with gross residual disease treated by brachytherapy and postoperative external irradiation, (40 Gy in 4 weeks) was 72%. The actuarial overall 5- year survival was 22%. The 5-year survival was better in patients who had all gross disease removed as compared with patients who had gross residual disease (30% versus 13%). The disease-