Changing role of chemotherapy in treatment of head and neck cancer

The role of chemotherapy in the management of head and neck cancer includes treatment for recurrent disease and as an adjunct to conventional therapy with radiation and/or surgery in the primary treatment program. The best single agents, methotrexate and cisplatin, used for recurrent disease give response rates of 20 to 50 percent but of short duration. Results may be improved with combination chemotherapy, but often with increased toxicity. Prognostic factors that influence response are discussed. A newer role of chemotherapy in this disease is in the initial treatment program. Pretreatment chemotherapy can debulk these lesions prior to surgery and/or irradiation in up to 80 percent of patients. Controlled trials are in progress to determine the effect on cure rates. Chemotherapy utilized during radiotherapy has resulted in survival benefit in several studies. Post-treatment adjuvant chemotherapy still needs to be evaluated. The potential advantages and disadvantages of chemotherapy used in the initial treatment are discussed. Major strides have been made in the last decade in the treatment of head and neck cancer, and chemotherapy is assuming an increasingly important role.

Dialysis treatment and psoriasis in Europe

One hundred and fifty out of 944 European dialysis centers reported experience with patients suffering from psoriasis. Ninety-three centers returned special questionnaires on 97 patients with end stage renal failure (ESRF patients) and on 49 patients dialyzed for psoriasis but who had normal renal function (NRF patients). Improvement of skin disease was reported in 17 out of 27 NRF patients according to both "objective criteria" and the patients' personal opinions. However, most of these patients had been on dialysis for less than one year (9.9 +/- 11.1 months) which is too short to allow for the spontaneous recurrence of psoriasis. In contrast, 60% of ESRF patients had been on dialysis for 45 +/- 3.1 months. Skin disease definitely improved in 20% of these patients after commencement of dialysis. This proportion is greater than the expected spontaneous long-term remission of psoriasis.

Mortality risk factors in patients treated by chronic hemodialysis. Report of the Diaphane collaborative study

A survival analysis was applied to 1,453 patients treated between 1972 and 1978 in 33 French dialysis centers and prospectively followed up in the computerized Diaphane Dialysis Registry. 198 deaths (overall mortality = OM) were registered, of which 87 (43%) were secondary to cardiovascular complications (cardiovascular mortality = CVM). Risk factors for OM and CVM (p values less than 0.05) were age, male sex, nephroangiosclerosis or diabetic nephropathy as the primary renal disease, elevated systolic and diastolic blood pressure and two weekly dialysis rather then three. In contrast with the results observed for the general population, a high body mass index and elevated cholesterol, triglycerides and uric acid were not found to be associated with significantly increased CVM or OM. On the contrary, low body mass index (less than 20 kg/m2), low cholesterol (less than 4.5 mmol/l) and low mean predialysis blood urea (less than 4.6 mmol/l) were associated with increased OM and CVM, and more especially with high stroke mortality. Results for urea but not for cholesterol remain significant after adjustment for age, sex, weekly dialysis schedule and body mass index. They suggest that, in addition to elevated blood pressure, a poor nutritional state and/or low protein intake may be important factors for explaining the high cardiovascular mortality, particularly for strokes, observed in dialyzed patients.

Management of the pregnant patient with Hodgkin's disease

Fifteen pregnant women with Hodgkin's disease were followed. Five patients had irradiation, 1000 to 3000 rad to the neck, mediastinum, or both, during the second or third trimester with normal outcome of pregnancy. One patient had a spontaneous abortion in the first trimester after radiotherapy of 4400 rad to the breast, an estimated fetal dose of 9 rad. One patient who received chlorambucil throughout pregnancy delivered a normal infant. Six patients had therapeutic abortions; one had early induction of labor. In one patient previously treated for supradiaphragmatic Hodgkin's disease, detection of a supradiaphragmatic relapse was delayed because of pregnancy. We recommend abortion for patients who develop Hodgkin's disease early in pregnancy or who have received chemotherapy or irradiation during the first trimester. During the latter half of pregnancy, asymptomatic disease may be closely followed but early delivery is recommended. Supradiaphragmatic, symptomatic disease can be treated with modified irradiation. For subdiaphragmatic, symptomatic, or extranodal disease, single-agent chemotherapy may be preferable. Treatment requires individualization to insure that the patient will be cured and the fetus protected.

Dielectric square bandpass design

Two concepts new in square bandpass design make the design process easier and more systematic. One is the use of adjacent high-order rejection bands. The second is the use of effective index ratio. This paper extends the work of L. I. Epstein [J. Opt. Soc. Am. 42 806 (1952): "The Design of Optical Filters"] and A. Thelen [J. Opt. Soc. Am. 50 1533 (1966): "Equivalent Layers in Multilayer Filters"].

Real-time analysis of hippocampal neural activity in the intervals between interictal spikes

Previously the electroencephalogram (EEG) was modeled as consisting of faster, smaller waves superimposed on larger, slower waves. The intent of this study is to modify the program to sample neural activity over specific intervals of time following detection of a distinct wave pattern. The use of conditional sampling is illustrated by considering wave detection following epileptic interictal spikes in the rabbit hippocampus. To create an epileptic focus, small pellets of sodium penicillin suspended in agar were placed on the rabbit hippocampus. This produced regularly recurring, spontaneous, large amplitude discharges, or interictal spikes, at the site of application. Following detection of an interictal spike, the program delayed the onset of a sample period for either 1.0 s or 6.0 s. The neural activity was then sampled for 5.1 s, and fast and slow waves were detected over the sample period. The frequency distribution of waves in four of these 5.1 s intervals was calculated. Comparison of the frequency distributions following the 1.0 s and 6.0 s delays showed no discernible differences. The data illustrate that not all types of neural activity are markedly modified by interictal spikes and suggest that hippocampal cellular populations generate similar waves 1.0 s and 6.0 s after such a spike. Moreover, this experiment illustrates adaptation of the program to sample activity over a limited period of time following detection of a specific cortical waveform.

[Results of one year (1978) of kidney transplantation (author's transl)]

Kidney transplantation in France is not as common as both patients and health authorities would wish. While at least 1 000 transplantations would be required each year, only 550 were done in 1978. The authors report on the experience of a team which for the first time was able to perform 75 transplantations in one year, and bring to the pull of transplantation 74 cadaver kidneys. The 75 patients will be followed up by the same group which operated upon them not only during the post-operative period, but also for many years to come. As far as possible, the team endeavours to transplant kidneys from local donors or sent directly to the surgeons. Such a "regionalisation" of kidney transplantations suffers from the drawback of lesser compatibility, but makes it possible to obtain the expected results.

[Acute renal failure during indomethacin treatment. 6 cases (author's transl)]

Acute renal failure (ARF) was observed in 6 patients under indomethacin treatment. Before receiving the drug 3 patients had normal, and the other 3 slightly elevated plasma creatinine levels. All patients were also treated with diuretics. ARF developed within the first 48 hours of therapy. Four patients had clear-cut oliguria. The renal disorders proved completely and rapidly reversible after treatment was discontinued, except in one female patient who had to undergo peritoneal dialysis for 12 days and in whom moderate aggravation of the pre-existing renal insufficiency persisted on follow up. The ARF was attributed to a sudden fall in renal blood flow due to the inhibitory effect of indomethacin on prostaglandin synthetase. This complication occurs exclusively in patients with renal hypoperfusion secondary to hypovolaemia, with cardiac insufficiency or with intrarenal vascular lesions. Sodium depletion induced by previous or concomitant diuretic treatment increases the risks. The possibility of ARF warrants careful monitoring of urinary output and renal function at the onset of non-steroidal anti-inflammatory therapy in patients with altered or precarious haemodynamics.

Mechanism of cis-platinum nephrotoxicity: I. Effects of sulfhydryl groups in rat kidneys

cis-Diamminedichloroplatinum (CP), an important chemotherapeutic agent, produces acute renal failure by an unknown mechanism. Other heavy metals, such as mercury, are thought to be nephrotoxic by reacting with sulfhydryl (SH) groups. To investigate the mechanism of CP nephrotoxicity, F344 rats were injected once with 6 mg of CP per kg. After 96 hr, the blood urea nitrogen rose to 140 mg/100 ml. The SH concentration in control kidneys was 20.4 +/- 0.1 muml/g wet weight. Total renal SH groups decreased to a maximum of 14% at 120 hr (P less than .01). The fall in SH groups was entirely due to a decrease of protein-bound SH groups. Cell fractionation studies showed that the greatest decline of SH groups occurred in the "mitochondrial" and "cytosol" fractions. These fractions also had the highest Pt concentrations. There was no stoichiometric relationship between Pt accumulation and the change in SH groups. Furthermore, in vitro studies demonstrated that CP does not directly interact with SH groups. To determine if the change in renal SH groups was nonspecific effect of acute injury, renal failure was induced with glycerol (5 g/kg i.m.). Total SH groups per kidney increased after glycerol. These results indicate that the decrease in renal SH groups produced by CP is not due to nonspecific tubular necrosis. The present findings suggest the possibility that the nephrotoxic effects of CP may be related to depletion of SH groups. However, a direct cause-effect relationship has not been established.

Mechanism of cis-platinum nephrotoxicity: II. Morphologic observations

Light microscopy, transmission electron microscopy and scanning electron microscopy were used to characterize the morphologic alterations and to localize the site of injury within the kidney 1, 2, 3, 5 and 7 days after the intraperitoneal injection of cis-diamminedichloroplatinum. Pathologic alterations were evident 3 days after the injection of the drug and were localized to the S3 segment of the proximal tubule situated in the outer stripe of the outer medulla. A spectrum of changes was seen in this S3 segment which included a thinning or focal loss of brush border, cellular swelling, condensation of the nuclear chromatin and focal areas of necrosis. After 5 days, widespread tubular necrosis of the S3 segment in the outer stripe was the predominant finding. Necrotic tubular epithelial cells could be seen detaching from the basal lamina and being sloughed into the tubular lumen. Only a bare basal lamina remained in many areas. Regeneration of the S3 segment was seen after 7 days and was characterized by tubules with widely dilated lumens which were lined by many low-lying epithelial cells. The observation that cis-diamminedichloroplatinum exerts its nephrotoxic effect on the S3 segment of the proximal tubule located in the outer stripe of the outer medulla demonstrates that the pattern of injury produced by this antitumor drug is similar to that associated with other nephrotoxic and ischemic models of acute renal failure.

[Cerebral venous thrombosis, complication of the nephrotic syndrome (author's transl)]

The occurence of arterial and, more frequently, venous thrombosis in patients with the nephrotic syndrome is well documented. Several factors are involved among which the fall in plasma albumin, the rise of several coagulation factors, platelet hyperreactivity, decrease of antithrombin III. We report here the first case, to our knowledge, of a dural sinus thrombosis, complicating a nephrotic syndrome with minimal glomerular changes. The difficulties of such a diagnosis and the key value of carotid angiography to establish it are emphasized. The use of anticoagulants can prevent this complication.

[Society of Nephrology, Computer Technology Commission. Dialysis computer program. VI. - Survival and risk factors]

The sixth report of the "Diaphane Dialyse Informatique" Program concerns 2,518 adult patients (age 15 and over) treated by chronic hemodialysis or hemofiltration in 33 French dialysis centres between June 1972 and December 1978. 1) The number of centers participating to the program is progressively increasing. Overall duration of follow-up represents 4,192 patient-years, allowing precise evolutive studies of terminal renal failure treated by hemodialysis. 2) Mean age at start of treatment continues to increase. Among 709 patients who started treatment in 1977-1978, 8,8 p. 100 of men and 11 p. 100 of women were over 69 years old. 3) Patients with diabetic nephropathy represent 4,4 p. 100 of all patients dialyzed between 1972 and 1978 and 5,9 p. 100 of the patients starting treatment in 1977-1978. 4) The percentage of patients temporarily treated by peritoneal dialysis before hemodialysis decreases from 32,9 p. 100 in 1973-1974 to 15,9 p. 100 in 1977-1978. 5) In 1978, 65,3 p. 100 of patients are dialyzed 3 times a week with a mean weekly duration of 14,0 h for male and 12,9 for female. 73 p. 100 of the patients are dialyzed during the night. 6) Disposable parallel plate hemodialyzers (71,8 per cent of dialysis sessions in 1978) and hollow fiber hemodialyzers (11,6 per cent) progressively replace disposable coil dialyzers and non disposable Kiil dialyzers. 7) Transient hypotensive episodes during dialysis sessions remain the most frequent complications (21,7 per cent of sessions in 1978). Transient hypotensive episodes are more frequently observed with coils than with parallel plate hemodialyzers or with hollow fiber dialyzers. 8) Mean diastolic blood pressure (DBP) +/- SD is 101,9 +/- 21,7 mmHg at start of dialysis and 81,4 +/- 11,8 mmHg when dialysed. During the course of treatment 28,7 per cent of the patients receive long term antihypertensive treatment. In spite of dialysis and antihypertensive treatments 11 per cent of all patients followed up maintain DBP greater than or equal to 95 mmHg. 9) Viral hepatitis remain the most prominent infectious problem with 30 per cent of patients being chronic Hbs antigen carriers. 10) Annual death rate calculated in the 2,518 patients dialyzed between 1972 and 1978 (78/1000) is 12 times superior to the death rate of the French population, adjusted for sex and age to the dialysis population. 43,1 per cent of deaths are of cardiovascular origin. Risk factors for overall mortality are age, sex (male), existence of a vascular or diabetic nephropathy, twice weekly dialysis strategy, elevation of systolic or diastolic blood pressure during the course of dialysis treatment, hypocholesterolemia and to a lesser extent hypotriglyceridemia. On the contrary, hypercholesterolemia, hypertriglyceridemia and hyperuricemia do not appear as risk factors for overall mortality or cardiovascular mortality. These results plead for a perfect control of hypertension and to the extension of thrice weekly dialysis for the whole population of patients treated by maintenance hemodialysis.

[Generic symptoms of Hodgkin's disease in relation to other prognostic criteries (author's transl)]

In 1967-1973, 74 patients with histologic classified Hodgkin's disease were treated in Marburg. We proved the incidence of the most important prognostic criteries: stage, histologic type and clinical symptoms. These criteries are evaluated as equally significant and independent. The B-symptoms, fever, weight loss and night sweats we found in 24 patients, 18 (75%) of them were in stage IV. In the remaining 6 patients in stage II and III, the B-symptoms were followed by relapse or generalisation. We think that the good correlation to the stage means, that clinical symptoms as prognostic signs are not independent.

24-hour infusion of cis-platinum in head and neck cancers

Eighteen patients with advanced squamous cell cancer of the head and neck were treated with cis-diamminedichloroplatinum in a 24-hour infusion. The most frequent dose used was 80 mg/m2 repeated every three weeks. Six were treated preoperatively for Stage III or IV disease, and twelve were treated for recurrent disease. The overall response rate was 72% with one complete remission, greater than 50% regression in six patients, and 25--50% regression in six patients. Toxicity was minimal: creatinine greater than 2 in 6% of courses, leukopenia in 9%, anemia in 29%, vomiting in 76%, and documented minimal hearing loss in one patient. Plasma and urine platinum levels during infusion are presented. The dosage of 80 mg/m2 administered over 24 hours gives a response rate in head and neck cancers equivalent to that reported with higher doses given by rapid infusion, and toxicity is minimal.

Mortality and morbidity of reusing dialysers. A report by the registration committee of the European Dialysis and Transplant Association

The practice of reusing dialysers in renal units in the UK was surveyed by examining the patient questionnaires returned to the EDTA registration committee for 1976 and by a special questionnaire sent to all UK renal units. Altogether 65.6% of the 1785 patients treated with non-disposable dialysers and 49.6% of the 1109 treated with disposable dialysers reused their equipment. Reuse of dialysers caused some morbidity but no mortality. Most centres where disposable dialysers were used accepted that their reuse was necessary because of financial constraints and was ethically defensible.

Cis-platinum chemotherapy in head and neck cancers

Sixteen patients with advanced head and neck carcinomas were treated with cis-diaminedichloro platinum chemotherapy; seven preoperatively and nine for recurrent disease. Cis-platinum was given by 24-hour infusions of 80 mg/m2 every three weeks. There was 50% regression in 38% (6) of the patients; another 38% (6) had 25% to 50% regression. Toxicity was minimal, with vomiting occurring in 75% (12) of the courses, renal toxicity in 6% (2), leukopenia in 13% (4), thrombocytopenia in 9% (3), and anemia in 31% (10). Of the seven patients who had serial audiograms, only one experienced ototoxicity. Cis-platinum, given by 24-hour infusion, was effective in reducing tumor bulk in 75% (12) of the patients, with advanced head and neck carcinomas, without undue morbidity.

Dialysis and renal transplantation of children in Europe, 1975

The number of new paediatric patients accepted for treatment by regular dialysis and transplantation increased more slowly than in previous years. Survival in children above 10 years appeared to be better with all modes of therapy than in younger children. The only improvement in survival noted among the different treatments was in patient and graft survival of living donor transplants. A quarter of all children transferred to home dialysis were less than 10 years of age. Nephronophthisis and Henoch-Schönlein nephritis emerged as major primary renal diseases. In 1975 the proportion of retransplants in children rose and living donor grafts from fathers were more common than from mothers. Evening dialysis was practised more frequently in both hospital and home dialysis and rehabilitation in these patients seemed to be better than for those dialysed at other times. Renal osteodystrophy was present in at least half of all children dialysed for more than 1 year. The degree of grouth retardation was affected by sex, chronological age and the primary renal disease. Body height on dialysis and after transplantation progressively reduced in the majority of children. Growth seemed to be more impaired in boys than in girls on dialysis. Bone age advanced faster than height age especially in girls. The pubertal growth spurt was usually delayed and depressed on long-term dialysis and the development of genitalia and pubic hair as well as menarche was retarded.

[Dialysis-computer program. IV. Summary report. Epidemiology of complications]

The Diaphane-program instituted under the authority of the French Society of Nephrology has been steadily expanding since 1972. By December 1977, about 1500 patients treated in 30 public and private Dialysis Centres were followed up by this system. Full coverage of expenses is provided by the participating Centres. The statistical work presented in this report involves 1572 adult patients treated between June 1972 and December 1976 in 24 dialysis centres. The amount of collected data and the duration of the observation period permit to build up evolutive profiles of the population of patients treated in France by maintenance hemodialysis, of the various techniques and strategies used and of the main complications recorded in the patients. 1. Mean age of patients at start of dialysis is steadily increasing, from 40.1 years in 1972 to 48.2 years in 1976. 2. The predominance of male patients, constant over each year, may be explained by an increased proportion in man of chronic glomerulonephritis and renal vascular diseases. The sex-ratio in patients with chronic pyelonephritis is close to the one recorded in the French population. 3. The regular decrease of the mean plasma creatinine level at time of first dialysis recorded since 1972, is probably related to an earlier start of treatment. However, 10.6 per cent of the patients taken on treatment in 1975-1976 still had a plasma creatinine greater than or equal to 200 mg/100ml. 18.7 per cent had a diastolic blood pressure greater than or equal to 120 mmHg, and exsudative lesions at eye fundi examination were found in 33.5 per cent. The delay in initiating dialysis treatment may account for the frequency of early acute cardiopulmonary complications such as pulmonary oedema and pericarditis and also for the increase in the mortality rate recorded during the first year of treatment: 12.1 per cent instead of 6.2 per cent during the second year. This particularly relevant for the younger age group of patients. 4. There seems to be some social disparity concerning the detection of renal disease and the conditions under which dialysis treatment is started: chronic renal disease is detected at an earlier stage and dialysis treatment initiated for lower values of plasma creatinine and of diastolic blood pressure in patients belonging to the "higher income" group of population. 5. The percentage of patients dialysed twice a week is steadily increasing, whereas the average weekly dialysis time decreases, being about 15 hours in 1976. Day and evening dialysis replace overnight dialysis. Disposable flat-plate dialysers are used increasingly. 6. Episodes of hypotension and cramps are the incidents most frequently recorded during the dialysis sessions. Risk factors evidenced in the occurrence of hypotensive accidents are: the female sex, age greater than or equal to 55 years in males, orthostatic blood pressure drop at the end of previous dialysis, weight loss of more than 4 per cent of total body weight during dialysis...

[Maintenance hemodialysis and renal transplantation in diabetic patients (author's transl)]

Maintenance hemodialysis and renal transplantation are increasingly used for treating diabetic patients with terminal uremia. Nowadays dialysis techniques may be considered for most of these patients, except those presenting with multiple severe disabling complications. Difficulties in control of glycaemia or of the uremic state or in the management of immunosuppressive drugs in transplanted patients do not, in themselves, constitute special problems in dialysis or transplantation. The high rate of complications and the excess mortality recorded in diabetics, compared with non-diabetic dialyzed or transplanted patients are closely related to the cardiovascular, neurological and microvascular disease that is present to various degress in all diabetic patients. Cardiac and cerebrovascular complications account for most of the deaths. Ocular and neurological status often worsen during dialysis but their stabilization usually occurs after successful transplantation. The choice between therapeutic methods in end-stage uremia must be an individual one for each patient" depending on age, medical and psychological factors and technical feasibility. Renal transplantation gives best results in patients aged less than 50 years and should be carried out early (creatinine clearance 15 - 10 ml/min.) before occurrence of the most disabling complications. If transplantation is not indicated or available, dialysis should be initiated when creatinine clearance is about 10 ml/min. Early multidisciplinary care of uremic diabetics will improve the results of maintenance hemodialysis, the problems and failures of which occur most frequently when treatment is commenced too late in patients with irreversible clinical and/or metabolic conditions.

Prednisone in MOPP chemotherapy for Hodgkin's disease

High remission rates have been produced by MOPP (mustine, vincristine, procarbazine, and prednisone) chemotherapy in patients with advanced Hodgkin's disease, but the prednisone component has caused adverse effects in patients who have undergone radiotherapy. The remission rates and length of remission were reviewed in 211 patients with Hodgkin's disease who received chemotherapy either with or without prednisone. In contrast to the findings of a British study, there were no significant differences in remission rates or length of remission between patients who had received prednisone and patients who had not. There were differences between the British prospective study and this retrospective one, but it is difficult to know what accounted for the substantial differences in the findings.

Dialysis and renal transplantation of children in Europe, 1974

About a third of all children with end-stage renal failure in Europe were accepted for treatment by regular dialysis or transplantation during 1974. The number of specialised paediatric dialysis centres increased. The number of renal transplants also increased, but fewer living donor grafts and retransplants were performed in 1974. The best survival was again observed on home dialysis. Patient survival after a cadaver graft improved. Children more than ten years old appeared to have a better survival on dialysis and a somewhat better graft function than younger patients. Rehabilitation was similar on home dialysis and after transplantation, but full school activity in ordinary school was reported in only 40% of all children on hospital dialysis. Children on haemodialysis tended to dialyse more frequently in 1974, than before, but for fewer hours per week. Hepatitis was still a problem and only a small reduction in the incidence was noted during 1974. Children on dialysis required more blood transfusions than adults. Body growth on haemodialysis was retarded to a similar degree on boys and in girls; 70% of the haemodialysed and 63% of the transplanted children had a growth velocity below the third percentile. Growth rate was noted to fall after the first year on dialysis.

[Chronic renal insufficiency in the terminal stage. Therapeutic possibilities offered by repeated dialysis and transplantation in the absence of selection. Apropos of 136 cases]

Repeated dialysis in hospital or at home, and renal transplantation, carried out mainly with cadaver kidney, should permit in France, in the near future, treatment of all patients with chronic terminal renal failure. This report shows the results obtained between the 1st of November 1972 and the 1st of January 1975 in 136 patients treated without any selection at the Nephrology Department and Renal Transplantation Unit of the Pitié-Salpĕtrière Hospital in Paris, in connection with 20 public and private dialysis centers. 66 patients, i.e. 45% of all, were "high risk" patients, mainly because of their age or cardiovascular condition. The overall percentage of survival rate at 2 years in dialysed patients was 81%. It was 67% in the high risk group and 94% in the others. About half of the deaths occured because of cardiovascular reasons. 82 patients were considered for transplantation. Owing to the lack of donors, the number of transplanted patients was only 21. 19 transplantations were carried out with cadaver kidneys. On the 31st of December 1974, 15 patients, i.e. 71% lived with a functioning transplant. In the reported series, complete rehabilitation was obtained in 30% of cases. The results obtained justify, in our opinion, the policy of non-selection of patients.