The encouraging results obtained by Roswit and his associates (4) by combining roentgen irradiation with nitrogen mustard in the treatment of pulmonary carcinoma prompted the writers to undertake this form of therapy between 1950 and 1954. Although the response of pulmonary carcinoma to nitrogen mustard is limited, it is sufficient to suggest that if it were combined with radiation better palliation might then be achieved. Results from irradiation alone are only fair. With the addition of nitrogen mustard, an increase in mean survival from 9.4 months to 12.8 months from onset of symptoms has been reported. In experiments on mice, Karnofsky et al. (2) found that the toxicity of mustard, as measured by its lethal effect, was reduced by preliminary irradiation. In view of this apparent decrease in the effectiveness of the drug, it was decided to give the irradiation following rather than preceding the administration of the mustard, a procedure which had also been tried by others. It gradually became apparent, however, that the magnitude of the systemic reaction, particularly the hernocytic depression, limited the amount of radiation which could be given. Several ways of avoiding this were possible: The dose of mustard could be reduced, there could be a delay between the administration of mustard and irradiation to allow recovery, or the irradiation could be spread over a much longer period of time. None of these seemed desirable, so that in our later patients, the x-ray therapy was given first, followed at once by nitrogen mustard while the tissues were undergoing their fullest radiation reaction. The lower systemic toxicity which could be expected seemed an advantage and Klopp's work (3) indicated that there would be no impairment of effectiveness of the mustard. Material and Methods Our pulmonary cancer series numbered 38 patients, 32 males and 6 females, and included 20 squamous-cell, 8 undifferentiated, and 3 anaplastic carcinomas and 2 adenocarcinomas. The diagnosis in the remaining 5 was based on the finding of neoplastic cells in sputum. In all except 12 obviously inoperable patients exploratory thoracotomy was done, with partial resection of the tumor (19 cases) or pneumonectomy (7 cases). Patients with evidence of generalized carcinoma were not accepted for treatment. No patient with a recorded white blood count under 5,000 received chemotherapy. The radiation was given at 250 kvp, h.v.1, 1.5 mm, Cu, and focal-skin distance 50 cm. The treatment was directed to both the primary tumor and the mediastinum. A tissue dose rate of about 1,000 r per week was maintained. Six patients received intravenous nitrogen mustard initially and 6 following irradiation. The dose was 0.2 mg. per kilogram of body weight on each of four successive nights.
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