Oncology 33: 260-264 (1976)
Bleomycin (NSC-125066) Therapy of Responsive Solid Tumors W. J. D urkin; R. P. Pugh ; E. J acobs; L. Sadoff; T h. Pajak, and J. R. Bateman Oncology Service, School o f Medicine and Medical Center, University o f Southern California, Los Angeles, California Ellis Fischel State Cancer Hospital, Columbia, Missouri Cancer Research Institute, University o f California at San Francisco, San Francisco, California Kaiser Permamente, Los Angeles, California
This study was conducted by the Western Cancer Study Group and supported in part by Public Health Service Grant CA-051866 from the National Cancer Institute, Department of Health, Education, and Welfare
Key Words. Bleomycin (NSC—125066) - Response - Toxicity — Testicular carcinoma - Head and neck squamous cell carcinoma
Introduction
Preliminary reports of bleomycin treatment suggested activity in two solid tumors: head and neck squamous carcinoma and testicular carcinoma. These reports have been followed by more extensive trials suggesting response rates in testicular tumors between 30-83 % and in head and neck squamous carcinoma between 0-47% [1—9]. The Western Cancer Study Group undertook the present study to define the activity of bleomycin in these two solid tumor types by comparing two routes of drug administration.
Materials and Methods From February 1971 to June 1973, patients with refractory squamous cell carcinoma of the head and neck region or with metastatic testicular malignancy were eligible for study if they met the following criteria: (1) histiologic proof of either head and neck squamous cell carcinoma or testicular carcinoma; (2) presence of measurable lesions; (3) refractoriness to all other treatment modalities including conventional chemotherapy; (4) no radiation or chemotherapy for four weeks prior to study entry; (5) patients previously treated with Bleomycin were ineligible. Patients were evaluated weekly with a complete history and physical examination, hemoglobin, leukocyte count, dif ferential count, and platelet count. Serum urea nitrogen, uric acid, electrolytes, bilirubin, alkaline phosphatase and SGPT
determinations, urinalysis and chest roentgenograms were done before the study and repeated monthly. To assess the degree of the response, the products of the perpendicular diameters of each measurable tumor were added together. A complete response is defined as the disap pearance of all signs and symptoms of the disease and the appearance of no new lesions for at least one month. A partial response is defined as at least a 50 % reduction in the pretreatment tumor measurements with symptomatic improvement and the appearance of no new lesions for at least one month. The onset of response is dated from the first detectable tumor regression, verified by at least one sub sequent measurement. Relapse is dated from the first detectable tumor growth, verified by further growth on subse quent measurements. Thus, relapse may occur before the tumors re-grow to their pretreatment size. Patients admitted to the study were randomized by the Studies Analysis Center of the Western Cancer Study Group to: (1) bleomycin given intravenously; or (2) bleomycin given intramuscularly. The dose schedule was identical for both routes: 10 mg/m2 twice a week (Monday and Thursday) with no other concur rent anti-neoplastic treatment. Patients were continued until (1) disease progression, (2) development of abnormal respiratory function, or (3) a total dose of 300 mg had been administered. Additional bleomycin beyond this total was permitted at the discretion of the investigator for patients who showed a definite tumor response without evidence of pulmonary toxicity.
Results There were 121 patients entered into study. One patient was excluded from the analysis because the histologic diagnosis upon review was leiomyosarcoma of the testis. There were 29 patients with disseminated testicular carcinoma and 81 patients with head and neck squamous carcinoma considered evaluable. Patients with squamous cell carcinoma were quite symptom atic on entry. Pain was present in 94% of this group while 69% complained of nausea, vomiting, or dysphagia. Local CNS invasions through basal skull erosion was documented in 17 %. Advanced local symptoms from tumor ulceration con sisting of either bleeding or infection occurred in 28.4%.
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Abstract. 110 patients with far advanced head and neck squamous or testicular carcinoma were treated with bleomycin given by intravenous (i. v.) or intramuscular (i.m.) injection according to a randomized assignment. While responses were observed more frequently in patients treated by the intramuscular route, no superiority can be attributed clearly to intramuscular therapy. Responses were seen in 6.2% of head and neck squamous carcinoma patients (5/81; i.m. 3/38, 8% ; i.v. 2/41. 5 %) while 14% of testicular tumors responded (4/29; i.m. 4/13, 29% ; i.v. 0/16, 0% ). Toxicity was, in general, manageable.
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Within seven days of study entry, five patients died of causes unrelated to drug treatment. The testicular cancer patients, while largely asymptomatic, had generally received either prior extended field radio therapy or previous treatment with chemotherapy. Of the 29 evaluable patients, 27 had previous treatment with chemo therapy while 13 had received extensive extended field radiotherapy. Responses Of the 81 squamous cell carcinoma patients, there were five responders who had a greater than 50 % tumor reduction with one patient achieving a complete remission (table I). The response proportion for the study population was 6.2 % with durations of response lasting two to three months. Responses were more frequent in the intramuscular treatment group (7.9 % versus 4.6 %), but statistical superiority over intra venous treatment was not demonstrable. No patient in the squamous cancer group with pulmonary (20/81, 25%) or hepatic (10/81, 12%) metastases responded (table II). Only one patient with nodal metastasis (1/47, 2.1%) responded. Only one patient with symptoms (1/23, 4.3%) of advanced local disease (tumor ulcer with bleeding or infection) responded. Patients (58/81, 72%) who had documented metastatic disease responded in only 2% (1/58) of cases, while patients who had disease limited to the primary site responded in 17% of the cases (4/23). Two of four patients (50 %) with early local symptoms (pain only) and no evidence of metastasis responded, while only 3.9 % with advanced local symptoms and/or evidence of metastasis responded. In the testicular cancer group, four of the 29 cases (14%) showed a response to bleomycin (three partial, one complete). All responses were seen in the intramuscular treatment group and all had embryonal cell elements (table III). The durations of response ranged from two to three months. No patient with clinically evident nodal metastasis achieved remission status
(0/13). Of 17 patients with extensive prior radiotherapy and/ or extensive prior chemotherapy, none achieved a response (table IV).
Toxicity
Drug toxicity was common, occurring in 67 % of all study cases (table V). Toxic events related to drug administration were noted to occur in 86% of the testicular cancer group Table I. Response by Primary Site (squamous cancer group).
Nasal fo ssa-to tal turbinate maxillary antrum Nasopharynx - total Oral cavity-total lip buccal mucosa floor of mouth gingiva hard palate alveolar ridge retromolar trigone O ropharynx-total soft palate tongue retrotonsillär mucosa tonsil Larynx - total Hypopharynx - total pyriform sinus other unspecified Salivary gland - total All site s-to ta l
Total
Number of responders
Per cent of responders
2 1 1 8 18 3 2 6 7 1 3 2 36 6 13 1 16 2 14 4 10 1 81
0 0 0 0 2 1 0 0 0 1 0 0 1 1 0 0 0 0 2 0 2 0 5
0 0 0 0 11 33 0 0 0 100 0 0 3 17 0 0 0 0 14 0 20 0 6
Table II. Response by extent of disease (squamous cancer group).
Tumor recurrence at primary site Nodal metastasis
present absent
present absent
Pulmonary metastasis Hepatic metastasis Metastasis (any type)
present absent present absent present absent
Tumor ulcer with bleeding or infection
present absent
Metastasis and/or tumor ulcer with bleeding or infection
present absent
Number
Per cent total
Responders
Per cent responders
68 13
84 16
5 0
47 34
58 42
1 4
2 12
20 61
25 75
0 5
0 8
10 71
12 88
0 5
0 7
7.4 0
2 17 (i.m. 11; i.v. 21)
58 72 23 28 (i.m. 9; i.v. 14) (i.m. 11; i.v. 17)
1 4 (i.m. 1; i.v.)
23 58
28 72
1 4
4 7
77 4
95 5
3 2
3.9 50
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whereas toxicity could be clearly ascribed to drug therapy in only 60 % of the squamous cancer patients. In the testicular group, gastrointestinal toxicity occurred in 41% and 38% developed minor skin problems. In the head and neck population, 40% reported minor skin problems while only 24% reported nausea as a drug complication. Patients with head and neck carcinoma were, in general, severely symptom atic an entry and did not tend to note minor toxic events as frequently as the relatively asymptomatic testicular group. Bleomycin was discontinued at the first suggestion of compromise in respiratory function as demonstrated by: (1) symptomatic complaint; (2) abnormal auscultatory finding; or (3) chest roentgenogramm abnormality. An accurate analysis of pulmonary toxicity was largely impossible in the testicular cancer patients since these cases often tended to have large bulky pulmonary metastasis with resulting atelectasis. In the squamous cancer population, pulmonary toxicity occurred in 7.4% and only one patient developed severe symptoms (table VI). The pulmonary toxic patients (mean age 67) were, on the average, 8.3 years older
Table III. Pretreatment clinical characteristics(testiculartumorgroup). Intra venous treatment group (i.v.)
Intra muscular treatment group (i.m.)
Number of patients
16
13
Age (median and range)
34(18-52)
27(17-37)
21 (20-36)
Median time from 1st tissue diagnosis (mo.)
19( 2-36)
9 ( 3-27)
11 ( 4-17)
Histologic cell type pure seminoma embryonal teratoma choriocarcinoma
0 % (0) 31% (5) 6 % (1) 0 % (0 )
7 % (1) 15 % (2) 30% (4) 15% (2)
0 % (0 ) 25 % (1) 0 % (0) 0 % (0)
0 % (0 ) 31% (5) 0 % (0)
7 % (1) 0 % (0) 23% (3)
0 % (0 ) 0 % (0) 75 % (3)
12% (2) 6 % (1)
0 % (0) 0 % (0)
0 % (0) 0 % (0)
6 % (1)
0 % (0)
0 % (0)
6 % (1 )
0 % (0)
0 % (0 )
92% (12) 23 % (3) 30% (4)
75 % (3) 25 % (1) 0 % (0) 0 % (0 ) 25 % (1)
4
Table IV. Response by prior therapy experience (testicular tumor group). Route: i.v. (16)
Route: i.m. (13)
Responders (4)
Prior radiation therapy extensive moderate none
63% (10) 19% (3) 19% (3)
23% 15% 62%
0 % (0 ) 25 % (1) 75 % (3)
Prior chemotherapy extensive moderate minimum none
38% 6% 50 % 6%
8 % (1) 38 % (5) 46% (6) 1% (1)
0 % (0 ) 50% (2) 50% (2) 0 % (0)
Prior therapy extensive moderate minimum
81% (13) 0 % (0) 19% (3)
31% (4) 38% (5) 31% (4)
0 % (0) 50% (2) 50% (2)
(6) (1) (8) (1)
Extensive prior radiotherapy: Radiation to areas on both sides of the diaphragm with total doses to each side in excess of 3000 rad. Moderate prior radiotherapy: Radiation to one or both sides of dia phragm with only one part delivery 3000 rad or greater. Extensive prior chemotherapy: Three or more prior full drug trials. Moderate prior chemotherapy: Two prior full drug trials. Minimal prior chemotherapy: Only one prior drug trial. Extensive prior therapy: Patient had either extensive radiotherapy or chemotherapy. Moderate prior therapy: Patient had either moderate radiotherapy or chemotherapy not extensive. Minimal prior therapy: Patient had only minimal chemotherapy.
Table V. Overall toxicity summary.
Metastatic sites involved lung 100% (16) liver 19% (3) nodal 50% (8) 12% (2) CNS marrow 0 % (0 ) Karnofsky performance score 90-100 31 % 7 0 - 80 19% 5 0 - 60 19% 3 0 - 40 31%
(5) (3) (3) (5)
7 % (1) 7 % (1) 46% (6) 8 % (1) 23% (3) 23 % (3)
50% 0% 50% 0%
(2) (0) (2) (0)
Grade II Grade III (moderate) (severe)
Grade IV (extreme)
Skin (including mucositis) i.v. 54 16(30% ) i.m. 56 15 (27 %)
6(1 1 % ) 3 (5 % )
1(2 % ) 3 (5 %)
0 (0 % ) 0 (0 %)
G .I. i.v. i.m.
12(22% ) 14(25% )
3 (6 % ) 2 (4 % )
1(2 % ) 0 (0 % )
1(0% ) 0 (0 %)
Hematologic i.v. 54 i.m. 56
5 (9 % ) 1(2 % )
0 (0 %) 0 (0 % )
0 (0 % ) 0 (0 % )
1 (2 % ) 1 (2 %)
Fever i.v. i.m.
54 56
2 (4 % ) 1 (2 % )
2 (4 %) 2 (4 % )
0 (0 % ) 0 (0 % )
0 (0 % ) 0 (0 %)
Pulmonary1 i.v. 38 i.m. 43
2 (5 %) 0 (0 % )
0 (0 %) 2 (4 % )
1 (3 %) 0 (0 % )
0 (0 % ) 0 (0 %)
Grade I (mild)
54 56
1 Testicular tumor group excluded.
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Mixed embryonal mixed embryonal/seminoma embryonal/teratoma embryonal/ choriocarcinoma teratoma/seminoma teratoma/ choriocarcinoma choriocarcinoma/ mixed
Patients responding to treatment
than patients in the same group who did not develop this complication (table VII). No patient with squamous cancer had received prior chest cavity radiation. Patients developing pulmonary fibrosis received an average of 169.5 mg of bleomycin.
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263
Table VI. Pulmonary toxicity*. Patient ID number
Age
Karnofsky performance score (KPS)
Radiotherapy2
Dose
Grade
Outcome
3 44 54 68 74 19 Mean
92 63 62 75 57 53 67
50 70 85 80 66 70 70
local local local local local local local
100 i.m. 135 i.v. 252 i.m. 240 i.v. 170 i.v. 120 i.m. 169.5
II I II I III II II
persisted persisted persisted persisted persisted cleared persisted
1 Testicular tumor group excluded. 2 Local radiation therapy indicates radiation to the primary site and/or to the cervical nodal drainage areas only.
Total Number Developing Pulmonary toxicity Per cent
Under 50
50-59
60-69
70 +
16
29
22
14
0 0
2 7
2 9
2 14
1 Testicular tumor group excluded.
Myelosuppression was uncommon and mild in all but two patients. One of these patients had received a transfusion of compatible lymphocytes 30 days prior to treatment with bleomycin. This patient after 52 mg developed severe myelosuppression with sepsis and, subsequently, died. Autopsy findings were compatible with a graft versus host reaction. The other severely myelosuppressed patient also developed leukopenia (1,900) followed by sepsis and death. Although toxic events occurred more often in the intra venously treated patients, there was no statistical difference.
Discussion Recent reports suggest that low prolonged serum concentra tion may be more effective than high intermittent concentra tions of bleomycin [10]. This hypothesis is supported by the fact that higher response proportions were observed in the intramuscular treatment groups in both the squamous cancer population and in the testicular cancer group. These differ ences, while statistically significant, are only suggestive since major imbalances were observed in the randomization. Extensive prior treatment and high tumor burden have been considered to be negative prognostic response variants [11]. Our data generally support these considerations. In the testicular tumor group, no patient with extensive prior radio therapy or extensive prior chemotherapy responded. In the squamous cancer group, patients with high tumor burdens as evidenced by metastasis rarely responded. In the testicular tumor group, patients with high tumor burdens as evidenced
by clinically evident nodal metastasis did not respond. This suggests a possible future role for bleomycin as an ’’adjuvant” to primary treatment. A ’’consolidation agent” role for patients achieving significant drug induction remission is also a consideration. Some reports have suggested that primary tumor site in head and neck cancer is important. This was not observed in this study. Histologic subtype was noted in the testicular tumor group to be a prognostic variant of response in that only patients with embryonal cell elements in their neoplasms responded. This has also been suggested in other studies [12].
Conclusions In the experience of the Western Cancer Study Group, the following conclusions seem warranted: (1) Extensive disease and extensive prior treatment are negative prognostic variants of response for bleomycin treatment. (2) Embryonal cellular elements in testicular neoplasia was noted to be a favorable prognostic variant. (3) Age is a predisposing factor to the development of pulmonary fibrosis. (4) Intramuscular administration was suggested to be superior to the intravenous route; the results are inconclusive because of imbalances in pretreatment characteristics. (5) While definite antitumor activity was noted in both tumors studied, bleomycin as a single agent can only be considered marginally effective in testicular and in head and neck squamous carcinomas.
References 1 2 3
Mathe, G.: Study of the clinical efficiency of bleomycin in human cancer. Brit. med. J. ii: 634 (1970). Bonadonna, et al.: Clinical trials with bleomycin in lymphomas and solid tumors. Europ. J. Cancer 8 :205-213 (1972). B lum, R. H.; Carter , S. K., and A gre , K.: A clinical review of bleomycin-a new antineoplastic agent. Cancer 31: 903 (1973).
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Table VII. Frequency of pulmonary toxicity by age*.
264 Clinical summary of bleomycin (Bristol Labs. 1974). Bull, F. A. et al.: Bleomycin in squamous cell carcinoma. Med. J. Austr. 2:704(1972). 6 G rey , P. and M ichaels, L.: Bleomycin in advanced squamous cell carcinoma of head and neck. Med. J. Austr. 2:246 (1972). 7 Mosher , M. D.; D e Conti, R. C., and B ernino, J. R.: Bleomycin therapy in advanced Hodgkin’s disease and epidermoid cancers. Cancer 30:5 6 (1972). 8 O hnuma, T. et al.: Clinical study with bleomycin: tolerance to twice weekly dosage. Cancer 30:9 1 4 (1972). 9 H alnan, K. E. et al.: Early clinical experience with bleomycin in the United Kingdom in series of 105 patients. Brit. Med. J. iv: 635 (1972). 10 Samuels, M. E. et al.: Continuous intravenous bleomycin (NSC-125066) therapy with vinblastine (NSC-49842) in stage III testicular neoplasia. Cancer Chemother. Rep. 59: 563-570 (1975).
11
12
13
Z elen , M.: Importance of prognostic factors in planning therapeutic trials. Cancer therapy: prognostic factors and criteria of response (Stauguet, Raven 1975). C arter , S. K.: Testicular neoplasms: Prognostic factors and criteria of response. Cancer Therapy: prognostic factors and criteria of response (Stauguet, Raven 1975). Karnofsky, D. A. and Burchenal , J. H.: The clinical evaluation of chemotherapeutic agents in cancer. Evaluation of chemotherapeutic agents (MacLeod Columbia University Press 1949).
Request reprints from: W. J. D urkin, MD, University of Albama in Birmingham, University Station, Birmingham, Alabama 35294 (USA)
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Durkin et a!.: Bleomycin in Responsive Solid Tumors
Bleomycin (NSC-125066) Therapy of Responsive Solid Tumors W. J. D urkin; R. P. Pugh ; E. J acobs; L. Sadoff; T h. Pajak, and J. R. Bateman Oncology Service, School o f Medicine and Medical Center, University o f Southern California, Los Angeles, California Ellis Fischel State Cancer Hospital, Columbia, Missouri Cancer Research Institute, University o f California at San Francisco, San Francisco, California Kaiser Permamente, Los Angeles, California
This study was conducted by the Western Cancer Study Group and supported in part by Public Health Service Grant CA-051866 from the National Cancer Institute, Department of Health, Education, and Welfare
Key Words. Bleomycin (NSC—125066) - Response - Toxicity — Testicular carcinoma - Head and neck squamous cell carcinoma
Introduction
Preliminary reports of bleomycin treatment suggested activity in two solid tumors: head and neck squamous carcinoma and testicular carcinoma. These reports have been followed by more extensive trials suggesting response rates in testicular tumors between 30-83 % and in head and neck squamous carcinoma between 0-47% [1—9]. The Western Cancer Study Group undertook the present study to define the activity of bleomycin in these two solid tumor types by comparing two routes of drug administration.
Materials and Methods From February 1971 to June 1973, patients with refractory squamous cell carcinoma of the head and neck region or with metastatic testicular malignancy were eligible for study if they met the following criteria: (1) histiologic proof of either head and neck squamous cell carcinoma or testicular carcinoma; (2) presence of measurable lesions; (3) refractoriness to all other treatment modalities including conventional chemotherapy; (4) no radiation or chemotherapy for four weeks prior to study entry; (5) patients previously treated with Bleomycin were ineligible. Patients were evaluated weekly with a complete history and physical examination, hemoglobin, leukocyte count, dif ferential count, and platelet count. Serum urea nitrogen, uric acid, electrolytes, bilirubin, alkaline phosphatase and SGPT
determinations, urinalysis and chest roentgenograms were done before the study and repeated monthly. To assess the degree of the response, the products of the perpendicular diameters of each measurable tumor were added together. A complete response is defined as the disap pearance of all signs and symptoms of the disease and the appearance of no new lesions for at least one month. A partial response is defined as at least a 50 % reduction in the pretreatment tumor measurements with symptomatic improvement and the appearance of no new lesions for at least one month. The onset of response is dated from the first detectable tumor regression, verified by at least one sub sequent measurement. Relapse is dated from the first detectable tumor growth, verified by further growth on subse quent measurements. Thus, relapse may occur before the tumors re-grow to their pretreatment size. Patients admitted to the study were randomized by the Studies Analysis Center of the Western Cancer Study Group to: (1) bleomycin given intravenously; or (2) bleomycin given intramuscularly. The dose schedule was identical for both routes: 10 mg/m2 twice a week (Monday and Thursday) with no other concur rent anti-neoplastic treatment. Patients were continued until (1) disease progression, (2) development of abnormal respiratory function, or (3) a total dose of 300 mg had been administered. Additional bleomycin beyond this total was permitted at the discretion of the investigator for patients who showed a definite tumor response without evidence of pulmonary toxicity.
Results There were 121 patients entered into study. One patient was excluded from the analysis because the histologic diagnosis upon review was leiomyosarcoma of the testis. There were 29 patients with disseminated testicular carcinoma and 81 patients with head and neck squamous carcinoma considered evaluable. Patients with squamous cell carcinoma were quite symptom atic on entry. Pain was present in 94% of this group while 69% complained of nausea, vomiting, or dysphagia. Local CNS invasions through basal skull erosion was documented in 17 %. Advanced local symptoms from tumor ulceration con sisting of either bleeding or infection occurred in 28.4%.
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Abstract. 110 patients with far advanced head and neck squamous or testicular carcinoma were treated with bleomycin given by intravenous (i. v.) or intramuscular (i.m.) injection according to a randomized assignment. While responses were observed more frequently in patients treated by the intramuscular route, no superiority can be attributed clearly to intramuscular therapy. Responses were seen in 6.2% of head and neck squamous carcinoma patients (5/81; i.m. 3/38, 8% ; i.v. 2/41. 5 %) while 14% of testicular tumors responded (4/29; i.m. 4/13, 29% ; i.v. 0/16, 0% ). Toxicity was, in general, manageable.
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Durkin et al.: Bleomycin in Responsive Solid Tumors
Within seven days of study entry, five patients died of causes unrelated to drug treatment. The testicular cancer patients, while largely asymptomatic, had generally received either prior extended field radio therapy or previous treatment with chemotherapy. Of the 29 evaluable patients, 27 had previous treatment with chemo therapy while 13 had received extensive extended field radiotherapy. Responses Of the 81 squamous cell carcinoma patients, there were five responders who had a greater than 50 % tumor reduction with one patient achieving a complete remission (table I). The response proportion for the study population was 6.2 % with durations of response lasting two to three months. Responses were more frequent in the intramuscular treatment group (7.9 % versus 4.6 %), but statistical superiority over intra venous treatment was not demonstrable. No patient in the squamous cancer group with pulmonary (20/81, 25%) or hepatic (10/81, 12%) metastases responded (table II). Only one patient with nodal metastasis (1/47, 2.1%) responded. Only one patient with symptoms (1/23, 4.3%) of advanced local disease (tumor ulcer with bleeding or infection) responded. Patients (58/81, 72%) who had documented metastatic disease responded in only 2% (1/58) of cases, while patients who had disease limited to the primary site responded in 17% of the cases (4/23). Two of four patients (50 %) with early local symptoms (pain only) and no evidence of metastasis responded, while only 3.9 % with advanced local symptoms and/or evidence of metastasis responded. In the testicular cancer group, four of the 29 cases (14%) showed a response to bleomycin (three partial, one complete). All responses were seen in the intramuscular treatment group and all had embryonal cell elements (table III). The durations of response ranged from two to three months. No patient with clinically evident nodal metastasis achieved remission status
(0/13). Of 17 patients with extensive prior radiotherapy and/ or extensive prior chemotherapy, none achieved a response (table IV).
Toxicity
Drug toxicity was common, occurring in 67 % of all study cases (table V). Toxic events related to drug administration were noted to occur in 86% of the testicular cancer group Table I. Response by Primary Site (squamous cancer group).
Nasal fo ssa-to tal turbinate maxillary antrum Nasopharynx - total Oral cavity-total lip buccal mucosa floor of mouth gingiva hard palate alveolar ridge retromolar trigone O ropharynx-total soft palate tongue retrotonsillär mucosa tonsil Larynx - total Hypopharynx - total pyriform sinus other unspecified Salivary gland - total All site s-to ta l
Total
Number of responders
Per cent of responders
2 1 1 8 18 3 2 6 7 1 3 2 36 6 13 1 16 2 14 4 10 1 81
0 0 0 0 2 1 0 0 0 1 0 0 1 1 0 0 0 0 2 0 2 0 5
0 0 0 0 11 33 0 0 0 100 0 0 3 17 0 0 0 0 14 0 20 0 6
Table II. Response by extent of disease (squamous cancer group).
Tumor recurrence at primary site Nodal metastasis
present absent
present absent
Pulmonary metastasis Hepatic metastasis Metastasis (any type)
present absent present absent present absent
Tumor ulcer with bleeding or infection
present absent
Metastasis and/or tumor ulcer with bleeding or infection
present absent
Number
Per cent total
Responders
Per cent responders
68 13
84 16
5 0
47 34
58 42
1 4
2 12
20 61
25 75
0 5
0 8
10 71
12 88
0 5
0 7
7.4 0
2 17 (i.m. 11; i.v. 21)
58 72 23 28 (i.m. 9; i.v. 14) (i.m. 11; i.v. 17)
1 4 (i.m. 1; i.v.)
23 58
28 72
1 4
4 7
77 4
95 5
3 2
3.9 50
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whereas toxicity could be clearly ascribed to drug therapy in only 60 % of the squamous cancer patients. In the testicular group, gastrointestinal toxicity occurred in 41% and 38% developed minor skin problems. In the head and neck population, 40% reported minor skin problems while only 24% reported nausea as a drug complication. Patients with head and neck carcinoma were, in general, severely symptom atic an entry and did not tend to note minor toxic events as frequently as the relatively asymptomatic testicular group. Bleomycin was discontinued at the first suggestion of compromise in respiratory function as demonstrated by: (1) symptomatic complaint; (2) abnormal auscultatory finding; or (3) chest roentgenogramm abnormality. An accurate analysis of pulmonary toxicity was largely impossible in the testicular cancer patients since these cases often tended to have large bulky pulmonary metastasis with resulting atelectasis. In the squamous cancer population, pulmonary toxicity occurred in 7.4% and only one patient developed severe symptoms (table VI). The pulmonary toxic patients (mean age 67) were, on the average, 8.3 years older
Table III. Pretreatment clinical characteristics(testiculartumorgroup). Intra venous treatment group (i.v.)
Intra muscular treatment group (i.m.)
Number of patients
16
13
Age (median and range)
34(18-52)
27(17-37)
21 (20-36)
Median time from 1st tissue diagnosis (mo.)
19( 2-36)
9 ( 3-27)
11 ( 4-17)
Histologic cell type pure seminoma embryonal teratoma choriocarcinoma
0 % (0) 31% (5) 6 % (1) 0 % (0 )
7 % (1) 15 % (2) 30% (4) 15% (2)
0 % (0 ) 25 % (1) 0 % (0) 0 % (0)
0 % (0 ) 31% (5) 0 % (0)
7 % (1) 0 % (0) 23% (3)
0 % (0 ) 0 % (0) 75 % (3)
12% (2) 6 % (1)
0 % (0) 0 % (0)
0 % (0) 0 % (0)
6 % (1)
0 % (0)
0 % (0)
6 % (1 )
0 % (0)
0 % (0 )
92% (12) 23 % (3) 30% (4)
75 % (3) 25 % (1) 0 % (0) 0 % (0 ) 25 % (1)
4
Table IV. Response by prior therapy experience (testicular tumor group). Route: i.v. (16)
Route: i.m. (13)
Responders (4)
Prior radiation therapy extensive moderate none
63% (10) 19% (3) 19% (3)
23% 15% 62%
0 % (0 ) 25 % (1) 75 % (3)
Prior chemotherapy extensive moderate minimum none
38% 6% 50 % 6%
8 % (1) 38 % (5) 46% (6) 1% (1)
0 % (0 ) 50% (2) 50% (2) 0 % (0)
Prior therapy extensive moderate minimum
81% (13) 0 % (0) 19% (3)
31% (4) 38% (5) 31% (4)
0 % (0) 50% (2) 50% (2)
(6) (1) (8) (1)
Extensive prior radiotherapy: Radiation to areas on both sides of the diaphragm with total doses to each side in excess of 3000 rad. Moderate prior radiotherapy: Radiation to one or both sides of dia phragm with only one part delivery 3000 rad or greater. Extensive prior chemotherapy: Three or more prior full drug trials. Moderate prior chemotherapy: Two prior full drug trials. Minimal prior chemotherapy: Only one prior drug trial. Extensive prior therapy: Patient had either extensive radiotherapy or chemotherapy. Moderate prior therapy: Patient had either moderate radiotherapy or chemotherapy not extensive. Minimal prior therapy: Patient had only minimal chemotherapy.
Table V. Overall toxicity summary.
Metastatic sites involved lung 100% (16) liver 19% (3) nodal 50% (8) 12% (2) CNS marrow 0 % (0 ) Karnofsky performance score 90-100 31 % 7 0 - 80 19% 5 0 - 60 19% 3 0 - 40 31%
(5) (3) (3) (5)
7 % (1) 7 % (1) 46% (6) 8 % (1) 23% (3) 23 % (3)
50% 0% 50% 0%
(2) (0) (2) (0)
Grade II Grade III (moderate) (severe)
Grade IV (extreme)
Skin (including mucositis) i.v. 54 16(30% ) i.m. 56 15 (27 %)
6(1 1 % ) 3 (5 % )
1(2 % ) 3 (5 %)
0 (0 % ) 0 (0 %)
G .I. i.v. i.m.
12(22% ) 14(25% )
3 (6 % ) 2 (4 % )
1(2 % ) 0 (0 % )
1(0% ) 0 (0 %)
Hematologic i.v. 54 i.m. 56
5 (9 % ) 1(2 % )
0 (0 %) 0 (0 % )
0 (0 % ) 0 (0 % )
1 (2 % ) 1 (2 %)
Fever i.v. i.m.
54 56
2 (4 % ) 1 (2 % )
2 (4 %) 2 (4 % )
0 (0 % ) 0 (0 % )
0 (0 % ) 0 (0 %)
Pulmonary1 i.v. 38 i.m. 43
2 (5 %) 0 (0 % )
0 (0 %) 2 (4 % )
1 (3 %) 0 (0 % )
0 (0 % ) 0 (0 %)
Grade I (mild)
54 56
1 Testicular tumor group excluded.
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Mixed embryonal mixed embryonal/seminoma embryonal/teratoma embryonal/ choriocarcinoma teratoma/seminoma teratoma/ choriocarcinoma choriocarcinoma/ mixed
Patients responding to treatment
than patients in the same group who did not develop this complication (table VII). No patient with squamous cancer had received prior chest cavity radiation. Patients developing pulmonary fibrosis received an average of 169.5 mg of bleomycin.
Durkin et al.: Bleomycin in Responsive Solid Tumors
263
Table VI. Pulmonary toxicity*. Patient ID number
Age
Karnofsky performance score (KPS)
Radiotherapy2
Dose
Grade
Outcome
3 44 54 68 74 19 Mean
92 63 62 75 57 53 67
50 70 85 80 66 70 70
local local local local local local local
100 i.m. 135 i.v. 252 i.m. 240 i.v. 170 i.v. 120 i.m. 169.5
II I II I III II II
persisted persisted persisted persisted persisted cleared persisted
1 Testicular tumor group excluded. 2 Local radiation therapy indicates radiation to the primary site and/or to the cervical nodal drainage areas only.
Total Number Developing Pulmonary toxicity Per cent
Under 50
50-59
60-69
70 +
16
29
22
14
0 0
2 7
2 9
2 14
1 Testicular tumor group excluded.
Myelosuppression was uncommon and mild in all but two patients. One of these patients had received a transfusion of compatible lymphocytes 30 days prior to treatment with bleomycin. This patient after 52 mg developed severe myelosuppression with sepsis and, subsequently, died. Autopsy findings were compatible with a graft versus host reaction. The other severely myelosuppressed patient also developed leukopenia (1,900) followed by sepsis and death. Although toxic events occurred more often in the intra venously treated patients, there was no statistical difference.
Discussion Recent reports suggest that low prolonged serum concentra tion may be more effective than high intermittent concentra tions of bleomycin [10]. This hypothesis is supported by the fact that higher response proportions were observed in the intramuscular treatment groups in both the squamous cancer population and in the testicular cancer group. These differ ences, while statistically significant, are only suggestive since major imbalances were observed in the randomization. Extensive prior treatment and high tumor burden have been considered to be negative prognostic response variants [11]. Our data generally support these considerations. In the testicular tumor group, no patient with extensive prior radio therapy or extensive prior chemotherapy responded. In the squamous cancer group, patients with high tumor burdens as evidenced by metastasis rarely responded. In the testicular tumor group, patients with high tumor burdens as evidenced
by clinically evident nodal metastasis did not respond. This suggests a possible future role for bleomycin as an ’’adjuvant” to primary treatment. A ’’consolidation agent” role for patients achieving significant drug induction remission is also a consideration. Some reports have suggested that primary tumor site in head and neck cancer is important. This was not observed in this study. Histologic subtype was noted in the testicular tumor group to be a prognostic variant of response in that only patients with embryonal cell elements in their neoplasms responded. This has also been suggested in other studies [12].
Conclusions In the experience of the Western Cancer Study Group, the following conclusions seem warranted: (1) Extensive disease and extensive prior treatment are negative prognostic variants of response for bleomycin treatment. (2) Embryonal cellular elements in testicular neoplasia was noted to be a favorable prognostic variant. (3) Age is a predisposing factor to the development of pulmonary fibrosis. (4) Intramuscular administration was suggested to be superior to the intravenous route; the results are inconclusive because of imbalances in pretreatment characteristics. (5) While definite antitumor activity was noted in both tumors studied, bleomycin as a single agent can only be considered marginally effective in testicular and in head and neck squamous carcinomas.
References 1 2 3
Mathe, G.: Study of the clinical efficiency of bleomycin in human cancer. Brit. med. J. ii: 634 (1970). Bonadonna, et al.: Clinical trials with bleomycin in lymphomas and solid tumors. Europ. J. Cancer 8 :205-213 (1972). B lum, R. H.; Carter , S. K., and A gre , K.: A clinical review of bleomycin-a new antineoplastic agent. Cancer 31: 903 (1973).
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Table VII. Frequency of pulmonary toxicity by age*.
264 Clinical summary of bleomycin (Bristol Labs. 1974). Bull, F. A. et al.: Bleomycin in squamous cell carcinoma. Med. J. Austr. 2:704(1972). 6 G rey , P. and M ichaels, L.: Bleomycin in advanced squamous cell carcinoma of head and neck. Med. J. Austr. 2:246 (1972). 7 Mosher , M. D.; D e Conti, R. C., and B ernino, J. R.: Bleomycin therapy in advanced Hodgkin’s disease and epidermoid cancers. Cancer 30:5 6 (1972). 8 O hnuma, T. et al.: Clinical study with bleomycin: tolerance to twice weekly dosage. Cancer 30:9 1 4 (1972). 9 H alnan, K. E. et al.: Early clinical experience with bleomycin in the United Kingdom in series of 105 patients. Brit. Med. J. iv: 635 (1972). 10 Samuels, M. E. et al.: Continuous intravenous bleomycin (NSC-125066) therapy with vinblastine (NSC-49842) in stage III testicular neoplasia. Cancer Chemother. Rep. 59: 563-570 (1975).
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12
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Z elen , M.: Importance of prognostic factors in planning therapeutic trials. Cancer therapy: prognostic factors and criteria of response (Stauguet, Raven 1975). C arter , S. K.: Testicular neoplasms: Prognostic factors and criteria of response. Cancer Therapy: prognostic factors and criteria of response (Stauguet, Raven 1975). Karnofsky, D. A. and Burchenal , J. H.: The clinical evaluation of chemotherapeutic agents in cancer. Evaluation of chemotherapeutic agents (MacLeod Columbia University Press 1949).
Request reprints from: W. J. D urkin, MD, University of Albama in Birmingham, University Station, Birmingham, Alabama 35294 (USA)
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Durkin et a!.: Bleomycin in Responsive Solid Tumors
