Extraskeletal Ewing's sarcoma. Histologic and ultrastructural observations in three cases

The histologic and ultrastructural morphology of three cases of Ewing's sarcoma of soft tissue are described and the fine structural features of extraskeletal Ewing's sarcoma are compared to those of similar round-cell tumors that are considered in the differential diagnosis. By light microscopy, these tumors are indistinguishable from Ewing's sarcoma of bone. Ultrastructurally, the salient features are also comparable to Ewing's sarcoma of bone and include: 1) absence of surface modifications; 2) cell-contact sites in the form of small thickenings of apposed membranes and large desmosome-like specializations; 3) undifferentiated cytoplasm usually containing abundant glycogen and occasionally nonspecific microfilaments; 4) significant variation in shape and irregularity of nuclear profiles. The ultrastructural features of extraskeletal Ewing's sarcoma are sufficiently distinctive to allow separation from from other small-cell malignant neoplasms in the majority of cases.

Cisplatin, bleomycin, and vinblastine combination therapy of testicular tumors: an analysis

A combination regimen consisting of cisplatin, bleomycin, and vinblastine was evaluated in 86 patients with metastatic testicular tumors. Prior therapy included surgical resection of primary tumor (84 patients), radiotheapy (21 patients), chemotherapy (33 patients). Thirteen patients received prior bleomycin and vincristine or vinblastine. Of 80 evaluable patients 51 achieved complete response (CR) and 26 achieved partial response (PR), for an overall response rate 96.5%. There was no significant difference in response rates or survival with respect to prior therapy, sites of metastatic lesions, and tumor histology. The median survival time was not reached in an observation period of 44+ months. Sixty patients were alive 11+--44+ months, and 57 of these were free of disease. Thirty-two of the 60 patients (53%) had a survival time greater than 20 months. Toxicities included nephrotoxicity (18 patients) leukopenia, (69 patients), thrombocytopenia (nine patients), and anemia (56 patients). Bleomycin-induced pulmonary toxicity was fatal in one patient. Other toxicities included nausea and vomiting, stomatitis, fever, alopecia, and neurological effects.

Improved management of nonseminomatous testis tumors

Two contributions to the management of nonseminomatous germinal cell (NSGC) tumors of the testis are reviewed. First, a midline technique of extended retroperitoneal lymph node dissection (RPLND) has been developed allowing good access to both renal suprahilar zones as well as the traditional hilar and infrahilar areas. This has been employed at Indiana University Medical Center for staging patients with embryonal carcinoma or teratocarcinoma of the testis who had negative preoperative chest tomography. Of 58 consecutive patients from 1965-1975, 30 were Stage A and 28 Stage B. Thirty of 30 Stage A patients survived (100%) and 24 of 28 (86%) operated Stage B patients survived, for an overall survival of 54/58 (93%). The second contribution relates to development of a new combination chemotherapy protocol for Stage C disease. Preoperative Stage C lesions are treated with Platinum, Velban and Bleomycin (PVB). Those who achieve clearance of pulmonary tumors but who have anatomic or serologic evidence of persistent retroperitoneal tumor after PVB chemotherapy are later treated with RPLND. Six of 12 such patients have been rendered tumor free and now enjoy complete remission. Furthermore, 33 of 50 (66%) patients with disseminated Stage C disease achieved initial complete remission using this drug combination. Twenty-six remain in continuous complete remission with no evidence of disease from 2 to 4 years. Seven are alive, in partial remission, and 17 are dead. Improving chemotherapy opens alternative methods of managing advanced testis cancer.

Combined therapy for small cell undifferentiated carcinoma of the lung

Fifty-eight patients with small cell lung cancer were treated from September, 1974, to March, 1976, with combined chemotherapy and radiotherapy. Surgical resection of the lung lesion was performed in three patients, and a number of surgical diagnostic methods were carried out in the remaining patients with unresectable of disseminated lesions. Nineteen patients were from the Veterans Administration Hospital and 39 from Indiana University Medical Center. The median Karnofsky performance status was 60. Thirty-nine patients had extensive disease, and 19 had disease limited to the chest and supraclavicular area. All patients received chest radiotherapy and prophylactic whole brain radiation. Adriamycin, cyclophosphamide, and vincristine were given on day 1 and continued every 3 weeks. There were 27 (48 percent) partial remissions of a median duration of 26 weeks. There were 25 patients (43 percent) with complete remission. The median survival for the entire group was 51 weeks. Six of 58 patients (10 percent) are alive and disease free from 24 to 38 months after treatment. Six of 19 patients with limited disease (32 percent) are presently alive and disease free. This includes one patient in whom surgical resection was performed. Combined therapy influences favorably the prognosis of small cell cancer of the ling, expecially in those patients with limited disease and favorable performance status.

Long-term results in combined-modality treatment of small cell carcinoma of the lung

Fifty eight patients with small cell carcinoma of the lung were treated with a combined-modality regimen: chemotherapy with adriamycin, cyclophosphamide, and vincristine; BCG immunotherapy; radiotherapy to the lung primary and prophylactic cranial irradiation. Ninteen patients had limited disease, and 39 had extensive disease. There were 27 (48%) partial remissions and 23 (41%) complete remissions, and median survival was 51 wk. Initial performance status and extent of disease had a definite effect on survival. Only 1 patient developed CNS metastases on prophylactic cranial irradiation. Five of 19 patients (26%) with limited disease remain alive and in complete remission at 26-45+ mo. It is becoming clear from this and other recent studies that we can significantly prolong median survival in small cell lung cancer. However, even more important is the fact that limited-extent small cell lung cancer may be a potentially curable disease.

Long term effect of cis-diamminedichloride platinum (CDDP) on renal function and structure in man

To examine CDDP induced nephrotoxicity in patients with testicular carcinoma, we measured renal function prior to therapy and at six month intervals for twelve months in fifteen patients and twenty-four months in seven patients. CDDP was given iv at 20 mg/M2 per day for five days at three week intervals. Eight patients received three courses, four received four courses and three received more than four courses. The mean creatinine clearance +/- SD prior to treatment was 112 +/- 12 ml/min. By six months, it had decreased to 68.5 +/- ml/min (p less than 0.01) and it remained at that level. Plasma creatinine and blood urea nitrogen increased significantly. Subjects receiving other potential nephrotoxins in addition to CDDP developed a greater decrease in creatinine clearance (p less than 0.05). Proteinuria and functional tubular disturbances were not observed. Microscopic features were characterized by hydropic degeneration of the renal tubular epithelium, thickened tubular basement membranes and mild interstitial fibrosis. Electron microscopy revealed phagolysosomes filled with flocculent material. CDDP resulted in a permanant, nonspecific renal injury in our patients. Although the renal injury has remained subclinical, future courses of CDDP may lead to clinically important chronic renal failure.

The effects of prior exposure to bleomycin on the incidence of pulmonary toxicities in a group of patients with disseminated testicular carcinomas

The incidence of pulmonary toxicities in 12 patients with prior exposure to bleomycin (BLM) was compared to the incidence of pulmonary toxicities in a matched group of 73 patients with state II or IV testicular carcinomas treated with a regimen containing vinblastine, bleomycin, and cis-diamminedichloroplatinum. The comparison demonstrates that prior exposure to bleomycin constitutes a significant risk factor and that the risk is additive; ie, prior doses should be added to current doses to determine the cumulative dose-related probablity of development of pulmonary toxicities.

Effects of variations in renal function on the clinical pharmacology of bleomycin administered as an iv bolus

The clinical pharmacology of bleomycin administered as an iv bolus has been studied in a homogeneous group of patients receiving a single regimen containing bleomycin, vinblastine, and cis-dichlorodiammineplatinum (II). These studies demonstrated that in patients with creatinine clearances greater than or equal to 35 ml/minute, the serum (or plasma) terminal elimination half-life of bleomycin was approximately 115 minutes. In patients with creatinine clearances less than 25-35 ml/minute, the terminal elimination half-life increased exponentially as the creatinine clearance decreased. The volume of distribution was approximately 20 liters, and was unaffected by changes in the creatinine clearance. The microbiologic assay and radioimmunoassay employed gave equivalent results.

Treatment of metastatic germ-cell tumors in men with adriamycin, vincristine, and bleomycin

Twenty-five patients with metastatic germ-cell tumors were treated with a combination of adriamycin, vincristine, and bleomycin. Fifteen patients (60%) had previously received radiation therapy, chemotherapy, or both. Twenty patients (80%) responded to treatment, with eight (32%) patients achieving a complete remission (CR) and 12 (48%) patients achieving a partial remission (PR). The median duration of response for the patients with PR was 4 months, whereas four patients with a CR remain alive without evidence of disease for greater than 3 years after the initiation of treatment. Responses were observed in all tumor categories and apparently were not influenced by prior therapy. Side effects included gastrointestinal toxicity, alopecia, neuropathy, skin changes, mucositis, and myelosuppression (more severe in previously treated patients). Though moderate success was demonstrated for this chemotherapy regimen, it does not appear as effective as more recent regimens including vinblastine and bleomycin.

Combination chemotherapy with doxorubicin and lomustine. Treatment of refractory Hodgkin's disease

Ten patients with advanced Hodgkin's disease refractory to combination therapy with nitrogen mustard, vincristine sulfate, procarbazine, and prednisone (MOPP) were treated with a combination of doxorubicin hydrochloride and lomustine. Toxicity was acceptable. Five patients (50%)attained complete remission (median duration, 15 months). Three patients attained a partial remission (median duration, four months). Survival ranged from three to more than 40 months, and five patients are still alive. One patient remains disease-free after a course of radiation therapy to a site of localized nodal relapse. The doxorubicin-lomustine regimen has induced meaningful remissions in a patient population with very refractory disease.

Chemotherapy for disseminated testicular cancer

Fifty patients with disseminated testicular cancer were treated with a three-drug combination consisting of cis-diaminedichloroplatinum, vinblastine, and bleomycin. Three patients were considered unevaluable due to early death. This chemotherapy regimen produced 74 per cent complete and 26 per cent partial remissions. Furthermore, five patients in partial remission became disease-free following the surgical removal of residual disease, producing an overall 85 per cent disease-free status. Toxicity, although significant during remission induction with cis-platinum, vinblastine, and bleomycin, was usually manageable. Maintenance therapy with vinblastine and BCG was very well tolerated, and only two patients in complete remission have experienced a relapse on maintenance therapy, one of whom had a central nervous system relapse. Thirty eight of these patients remain alive, and 32 remain alive and disease-free 6+ to 30+ months. We feel that this regimen represents a major advance in the management of patients with disseminated testicular cancer.

Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy in disseminated testicular cancer

Fifty patients with disseminated testicular cancer were treated with a three-drug combination consisting of cis-diamminedichloroplatinum, vinblastine, and bleomycin. Three patients were considered inevaluable due to early death. This chemotherapy regimen produced 74% complete and 26% partial remissions. Furthermore, five patients with partial remission became disease-free after surgical removal of residual disease, producing an overall 85% disease-free status. Toxicity, although significant during remission induction with cis-platinum, vinblastine, and bleomycin, was usually manageable, although there were two drug-related deaths during this period. Thirty-eight of these patients remain alive and 32 remain alive and disease-free at 6 + to 30 + months. We believe this regimen represents a major advance in the management of patients with disseminated testicular cancer.

Combination chemotherapy for disseminated malignant melanoma with DTIC, vincristine, and methyl-CCNU

Thirty patients with disseminated melanoma were treated with DTIC (250 mg/m2 for 5 consecutive days every 3 weeks), methyl-CCNU (175 mg/m2 orally every 6 weeks), and vincristine (1.4 mg/m2 weekly x 6 and then every 3 weeks). Seven patients died within 3 weeks of the start of chemotherapy. There was a 30% response rate (seven partial and two complete remissions) for all patients and a 39% response for evaluable patients. The median survival was 45 and 18 weeks respectively for responders versus non-responders and 22 weeks for all evaluable patients.

Cardiac arrest due to hyperkalemia following therapy for acute lymphoblastic leukemia

A patient with acute lymphoblastic leukemia with a large tumor burden is presented. Following successful chemotherapy, the patient experienced a cardiac arrest presumably due to hyperkalemia in association with hyperuricemia. The implication of these findings for patients with responsive hematological malignancies is discussed.

Improved chemotherapy in disseminated testicular cancer

Two combination chemotherapy regimens for disseminated testicular cancer are described. Our present regimen of platinum vinblastine and bleomycin has been highly successful, producing 16 complete (80 per cent) and 4 partial (20 per cent) remissions. Furthermore, 2 patients have been rendered free of disease by the surgical removal of residual disease, making the effective complete remission rate in these 20 patients 90 per cent. Of these patients 16 are alive and 14 are free of disease for more than 8 to more than 20 months. Despite the significant toxicity during the first 12 weeks of this therapeutic regimen it usually was manageable and maintenance therapy produced minimal toxicity. We believe that this regimen is a major advance in the management of patients with disseminated testicular cancer.