Current and future drugs for acid-peptic disease: a plethora of opinions on possible mechanisms of action

Sixty-seven invited participants involved in the development, evaluation, and use of therapies for acid-peptic disorders participated in a meeting to discuss the scientific basis for healing actions of ulcer drugs and the prospects for future developments ("Realities of Mucosal Protection in the Upper Gastrointestinal Tract," Lausanne, Switzerland, November 8-10, 1987). Eighty-one key statements were prepared and subsequently analyzed on the basis of a voting system. Of the 45 statements that dealt with existing therapies, only 3 statements showed positive consensus (agreement of two-thirds or more of voters) about mechanisms of ulcer healing. Participants agreed that both (1) hydrogen/potassium adenosine triphosphatase inhibitors and (2) histamine H2 antagonists healed ulcers solely by acid inhibition, and (3) that sucralfate works by topical action. Substantial uncertainty about the mechanisms by which bismuth compounds and antacids heal ulcers was noted as well as their wide range of effects. The mechanism of ulcer healing by prostaglandins and the clinical relevance of antiulcer effects of drugs demonstrated in acute studies with animals were also controversial. There was greater agreement among participants about unexplored drug effects that might produce ulcer healing. Of the 36 such mechanisms surveyed, the most support went to therapies aimed at enhancement of mucosal blood flow, epithelial restitution, and mucosal alkaline secretion or inhibition of luminal pepsin activity. The diversity of opinions among participants suggests a high level of empiricism in the development of ulcer healing drugs apart from those that inhibit acid secretion. This empiricism probably arises from inadequate understanding of processes of mucosal injury and repair.

Hyperglycaemia slows gastric emptying in type 1 (insulin-dependent) diabetes mellitus

In 10 patients with Type 1 (insulin-dependent) diabetes mellitus gastric emptying of a digestible solid and liquid meal was measured during euglycaemia (blood glucose concentration 4-8 mmol/l) and during hyperglycaemia (blood glucose concentration 16-20 mmol/l). Gastric emptying was studied with a scintigraphic technique and blood glucose concentrations were stabilised using a modified glucose clamp. Patients were also evaluated for gastrointestinal symptoms, autonomic nerve function and glycaemic control. When compared to euglycaemia, the duration of the lag phase before any of the solid meal emptied from the stomach (p = 0.032), the percentage of the solid meal remaining in the stomach at 100 min (p = 0.032) and the 50% emptying time for the solid meal (p = 0.032) increased during hyperglycaemia. The 50% emptying time for the liquid meal (p = 0.042) was also prolonged during the period of hyperglycaemia. These results demonstrate that the rate of gastric emptying in Type 1 diabetes is affected by the blood glucose concentration.

Surgery and chemotherapy in the management of placental site tumor

Since 1977 we have managed seven cases of placental site trophoblastic tumor. All patients were treated with hysterectomy. Three patients had preoperative chemotherapy without evidence of response. One of three patients presenting with no evidence of extrauterine spread and one of four presenting with extrauterine pelvic disease have died from metastatic disease on recurrence. One patient with pelvic disease and lung metastases at diagnosis has residual lung nodules, presumed necrotic, 47 months after completing chemotherapy. She received etoposide, methotrexate, and actinomycin D (EMA) alternating weekly with cyclophosphamide and vincristine (CO). Although surgical excision of placental site tumor remains the treatment of choice, EMA/CO chemotherapy may produce the occasional long-term survivor.

The effect of naloxone on lipid-induced pyloric motor response in humans

This study examines whether opioid receptors are involved in the mediation of the pyloric motor response to intraduodenal lipid infusion. Antral, pyloric, and duodenal manometry was performed in seven healthy volunteers with a sleeve/multiple side-hole manometric assembly. Triglyceride emulsion and normal saline were infused alternately into the duodenum through the manometric assembly for two 30-minute periods each. Naloxone was then administered as an IV bolus, 40 micrograms/kg, followed by an infusion of 60 micrograms.kg-1.h-1 that was continued during testing of the duodenal infusates. Before naloxone administration, intraduodenal lipid produced significant increases in the rate of isolated pyloric pressure waves and basal pyloric tone when compared with saline (P = 0.009 and 0.027, respectively). The pyloric motor responses were unchanged after administration of naloxone, indicating that in humans, naloxone-sensitive opioid mechanisms are not involved in the mediation of lipid-induced pyloric motor responses.

Pathophysiology of gastroesophageal reflux. Lower esophageal sphincter dysfunction in gastroesophageal reflux disease

LES dysfunction is the principal mechanism responsible for GER disease. Two main patterns of sphincter dysfunction have been identified: an abnormally high rate of transient LES relaxations, and defective basal LES pressure. Overpowering of a weak LES by pressure transients induced by straining is less common than previously thought, at least under conditions tested thus far. Current evidence suggests that LES dysfunction results primarily from defective neural control, although smooth muscle function may also be impaired. Extrinsic mechanisms, particularly the diaphragmatic crura, also appear to be important during straining. The role of hiatus hernia remains unclear but seems likely to contribute to the pathogenesis of reflux disease by impairing LES function.

Response of canine lower esophageal sphincter to gastric distension

The aim of this study was to localize the region of the stomach responsible for triggering distension-induced transient lower esophageal sphincter relaxation (TLESR). The canine stomach was partitioned into subsegments by a row of buttressed sutures. This separated either the fundus from the lesser curve or the proximal stomach from the antrum. After 1 mo each region was progressively distended while gastroesophageal pressures were monitored. At the time of the first TLESR, gastric wall tension was estimated from the bag pressure and volume. Distension of the intact stomach, lesser curve, or proximal stomach in 12 dogs produced a progressive increase in lower esophageal sphincter (LES) pressure, which was interrupted at low gastric wall tension (29, 35, and 40 mmHg.cm, respectively) by a superimposed TLESR. Background LES pressure fell progressively with distension of the antrum but was unchanged by distension of the fundus alone. Both the fundus and antrum had significantly higher thresholds for triggering TLESR (96 and 105 mmHg.cm). In another two dogs truncal vagotomy performed at the time of gastric partitioning prevented both the change in background LES pressure, and the triggering of TLESR, associated with proximal gastric and antral distension. We conclude that the subcardiac region of the stomach is primarily responsible for triggering TLESR induced by distension and that the effect on background LES pressure depends on the region distended.

Control of belching by the lower oesophageal sphincter

The mechanism that controls venting of gas from the stomach into the oesophagus was studied manometrically in 14 healthy subjects. The stomach was distended abruptly with one litre of carbon dioxide. Gas reflux was characterised by an abrupt increase in basal oesophageal body pressure to intragastric pressure. Reflux of gas from the stomach into the oesophagus occurred during transient lower oesophageal sphincter relaxations that generally had a pattern distinctly different from swallow-induced lower oesophageal sphincter relaxation. Thus, at the onset of an episode of gas reflux lower oesophageal sphincter pressure had relaxed to 3 mmHg, or less, in 96% of instances. After gas loading of the stomach the prevalence of gas reflux was significantly less when the subjects were supine (1.2/10 min) than when they were sitting (6.8/10 min) (p less than 0.001). The lower oesophageal sphincter relaxations associated with most episodes of gas reflux had a distinctive pattern that resembled those of the lower oesophageal sphincter relaxations associated with acid gastro-oesophageal reflux.

Gestational trophoblastic tumours following initial diagnosis of partial hydatidiform mole

11 patients registered with an initial diagnosis of partial hydatidiform mole (PHM) subsequently required chemotherapy for a gestational trophoblastic tumour. In a retrospective review by histopathological examination and measurement of DNA ploidy, the diagnosis was confirmed as PHM in 5 cases and revised to complete hydatidiform mole in 4; in 2 cases there was no evidence of a molar pregnancy. 4 of the patients with PHM had no other known pregnancy before the gestational trophoblastic tumour and in 2 of these patients the tumour was diagnosed histologically as choriocarcinoma. Not all patients in whom PHM was diagnosed at referring hospitals proved to have the condition. Although the risk of a patient with PHM requiring chemotherapy for gestational trophoblastic tumour is of the order of 1 in 200, compared with 1 in 12 after a complete mole, there is no justification for excluding a patient from follow-up after the evacuation of a PHM.

Gastroduodenal motility during the delayed gastric emptying induced by cold stress

We have assessed the changes in gastroduodenal motility responsible for the delay in gastric emptying produced by cold stress. Antropyloroduodenal pressures were recorded in 7 healthy volunteers, concurrent with scintigraphic measurement of gastric emptying. The manometric assembly incorporated a sleeve sensor located across the pylorus and side holes in the antrum and the duodenum. When approximately 25% of a 100-g 99m Tc-labeled ground beef burger had emptied from the stomach, a standardized cold pressor test was applied. This consisted of 60-s immersions of the left hand in iced water (4 degrees C), with 15-s rest periods between immersions, for up to 20 min. Cold stress was associated with slowed emptying from the total stomach (median, 17% before stress vs. 2% during stress; p less than 0.01) and the proximal stomach (9% before vs. 3% during; p less than 0.01). Retrograde movement of the solid meal from the distal to the proximal stomach was observed in 4 subjects. Cold stress increased the number of isolated pyloric pressure waves (p less than 0.05), and decreased the number of antral (p less than 0.01) and propagated antropyloroduodenal pressure waves (p less than 0.05). Phase 3-like duodenal activity occurred in 2 subjects during the first 5 min of stress; otherwise there was a reduction in the number of duodenal pressure waves during stress (p less than 0.05). Basal pyloric pressure was not elevate before, during, or after stress. We conclude that in addition to the previously reported antral inhibition, cold stress is associated with changes in pyloric and duodenal motility and, in some subjects, in the intragastric distribution of food. These modifications in gastroduodenal motility are likely to contribute to the delay in gastric emptying produced by this stimulus.

Luminographic detection of von Willebrand factor multimers in agarose gels and on nitrocellulose membranes

Two methods for visualization of vWf multimers were compared with respect to sensitivity and detection of normal vWf and vWd variants IIA, IIB, IIC, IID, IIE, and IIF. Autoradiography and luminography after electrotransfer of vWf multimers onto nitrocellulose showed comparable sensitivity with vWf:Ag detectable after 1:500 dilution of normal plasma. The least sensitive method was luminography in agarose gels with vWf:Ag detectable after 1:300 dilution of normal plasma. No difference existed in the banding patterns of plasmas from patients with variant vWd.

Evaluation of patterns of human antral and pyloric motility with an antral wall motion detector

We have examined the hypothesis that isolated pyloric pressure waves occur in the absence of even low-amplitude antral contractions. Antropyloroduodenal motility was recorded in seven healthy adult volunteers. A sleeve/side-hole manometric assembly was positioned across the pylorus with the aid of measurements of transmucosal potential difference. A new sensor consisting of an elliptical wire transducer 2.5 cm long and 1.5 cm in transverse diameter was incorporated into the assembly above the sleeve. This sensor was designed to detect nonlumen-occluding antral contractions. Motility was studied for 45 min under each of three conditions: 1) fasting, 2) after ingestion of a 100-g beef burger, and 3) during and after a 15-min intraduodenal infusion of 25% dextrose at a rate of 4 ml/min. Overall, only 51% of antral transducer deflections were associated with a change in antral side-hole pressures. Eighty-nine percent of antral side-hole pressure waves were associated with an indication of antral wall motion. Of the pressure waves recorded by the sleeve classified as isolated pyloric pressure waves, none was associated with antral transducer deflection during fasting, 1.1% after intraduodenal dextrose, and 18% after the solid meal. Antral contractions were detected by the wall motion detector with greater sensitivity than antral side holes, possibly reflecting the occurrence of nonlumen-occluding antral contractions. With some exceptions during solid gastric emptying, manometrically defined isolated pyloric pressure waves appear to represent truly localized contraction.

Human lower esophageal sphincter pressure response to increased intra-abdominal pressure

We studied the effects of increased intra-abdominal pressure on the lower esophageal sphincter (LES) pressure in 15 healthy subjects. The role of the diaphragm in the genesis of LES pressure during increased intra-abdominal pressure was determined by measuring diaphragm electromyogram (EMG). The latter was recorded using bipolar intraesophageal platinum electrodes that were placed on the nonpressure sensing surface of the sleeve device. We also measured the LES pressure response to increased intra-abdominal pressure during inhibition of the smooth muscles of the LES by intravenous atropine (12 micrograms/kg). Straight-leg raising and abdominal compression were used to increase intra-abdominal pressure. Our results show that the increase in LES pressure during straight-leg raising is greater than the increase in gastric pressure. During abdominal compression, the rate of LES pressure increase is faster than that of the gastric pressure, suggesting an active contraction at the esophagogastric junction. The increase in LES pressure during periods of increased intra-abdominal pressure is associated with a tonic contraction of the crural diaphragm as demonstrated by EMG recording. Atropine inhibited the resting LES pressure by 50-70% in each subject but had no effect either on the peak LES pressure attained during increased intra-abdominal pressure or tonic crural diaphragm EMG. We conclude that 1) there is an active contraction at the esophagogastric junction during periods of increased intra-abdominal pressure and 2) tonic contraction of the crural diaphragm is a mechanism for this LES pressure response.

Pyloric motor function during emptying of a liquid meal from the stomach in the conscious pig

1. In six conscious pigs antral, pyloric and duodenal pressures were recorded with a 5.5 cm sleeve sensor and multiple perfused side holes. The manometric assembly was positioned by dual point transmucosal potential difference measurement. Gastric emptying was measured by drainage of the proximal duodenum through a Thomas cannula. Pressures were correlated with emptying of ingested radiolabelled 5% dextrose. Alteration of emptying was produced by infusion into the more distal duodenum of nutrient and non-nutrient solutions of differing osmolalities. 2. Motor activity of the pylorus and antrum was stimulated by ingestion and modulated by intraduodenal infusion. Duodenal infusion of normal saline was associated with antro-pyloric pressure waves and rapid emptying of the ingested liquid. Duodenal infusion of dextrose, fatty acid, amino acids and hyperosmolar saline was associated with stimulation of isolated pyloric pressure waves, suppression of antral pressure waves and slowing of gastric emptying. 3. The dose-response relationship of these effects was investigated using varying rates of intraduodenal dextrose infusions. The emptying rate of the ingested liquid was inversely related to the rates of delivery of dextrose to the duodenum, directly related to the rate of antro-pyloric pressure waves and inversely related to the rate of isolated pyloric pressure waves. 4. Clearly defined episodes of pulsatile flow produced slightly more than half of the total emptying that occurred. This pulsatile flow was intimately associated in time with antro-pyloric pressure waves. Sequences of isolated pyloric pressure waves were associated with near cessation of emptying. When there were periods of absent pyloric antral pressure waves, flow rates intermediate between the rapid emptying of pulsatile flow during antro-pyloric pressure waves and the near cessation of flow during isolated pyloric pressure waves occurred. 5. The findings suggest a major role for the pylorus in the control of emptying of liquids from the stomach, both as a component of an antro-pyloric peristaltic pump and as a resistor to transpyloric flow during nutrient and hyperosmolar stimulation of duodenal receptors.

The effect of terminal ileal triglyceride infusion on gastroduodenal motility and the intragastric distribution of a solid meal

The infusion of triglyceride emulsions into the terminal ileum in concentrations that approximate those found in malabsorption results in the slowing of gastric emptying. The aim of this study was to characterize the changes in gastroduodenal motility responsible for this effect. Antropyloroduodenal pressures in 8 healthy volunteers were recorded with a manometric assembly incorporating a sleeve sensor across the pylorus and side holes in the antrum and duodenum. Each subject ingested a 100-g, 99m Tc-labeled solid meal; when approximately 25% of the meal had emptied from the stomach, a triglyceride emulsion (20% Intralipid) was infused into the terminal ileum at 1 ml/min for 45 min. Gastric emptying slowed markedly 15-30 min after the start of the lipid infusion (p = 0.01), and there was retrograde movement of the solid meal from the distal to the proximal portion of the stomach. During lipid infusion, there was a decrease in antral (p = 0.01), duodenal (p less than 0.05), and propagated antropyloroduodenal pressure waves (p less than 0.05) and an increase in isolated pyloric pressure waves (p less than 0.05). The rate of gastric emptying correlated with antral pressure waves (r = 0.92, p less than 0.001), duodenal pressure waves (r = 0.80, p less than 0.01), and propagated pressure waves (r = 0.88, p = 0.0025) and correlated inversely with the number of isolated pyloric pressure waves (r = -0.60, p = 0.05). The changes in antral, pyloric, and duodenal motility and the intragastric redistribution of a solid meal associated with ileal lipid infusion are likely to contribute to the delay in gastric emptying caused by this stimulus.

Relationship between fluctuations of pH and pressure in the human stomach and duodenum

The normal patterns of pressure activity in the antrum, pylorus and duodenum and associated pH changes were monitored in 9 healthy volunteers under fasted conditions and after ingestion of 300 ml of chocolate milk. The manometric assembly incorporated three side holes in the antrum, four side holes in the duodenum, a sleeve sensor positioned across the pylorus, and pH electrodes situated in the terminal antrum and proximal duodenum. The most common motor pattern recorded under fasting conditions consisted of regular co-ordinated contractions, most of which involved the antrum and duodenum, showed evidence of propagation and was associated with transient decreases in duodenal pH and transient increases in antral pH. Ingestion of milk changes the motor pattern to one that was composed of pressure waves which were confined to the pylorus with few or no pressure waves in the terminal antrum or proximal duodenum. Isolated pyloric pressure waves were gradually replaced by propagated antropyloroduodenal contractions which were associated with transient decreases in duodenal pH. Isolated pyloric pressure waves were not associated with episodes of duodenal acidification under fed conditions.

Australian clinical trials of omeprazole in the management of reflux oesophagitis

Two multicentre clinical trials of omeprazole in peptic oesophagitis were recently completed in Australia. In the first trial, omeprazole, 20 or 40 mg daily (n = 31), was compared with placebo (n = 32) in 63 patients. After 4 weeks, 81% of the omeprazole-treated patients were healed, as determined endoscopically, compared with 6% of the placebo-treated patients (p less than 0.0001). When the two doses of omeprazole were compared, there was a significant therapeutic advantage for the 40 mg dose at 4 weeks but by 8 weeks there was no significant difference between the two doses. This study included a 6-month surveillance phase in 107 endoscopically healed patients after cessation of omeprazole therapy. By 6 months, erosive or ulcerative oesophagitis had recurred in 82% of these patients. In the second trial, 165 patients with erosive or ulcerative oesophagitis were first healed with omeprazole, 20 mg daily. Of these patients, 159 were then enrolled in a maintenance therapy trial and randomized to three groups: ranitidine, 150 mg b.i.d., omeprazole, 20 mg daily, or omeprazole weekend therapy (i.e. omeprazole, 20 mg daily, on Friday, Saturday and Sunday only). Patients were followed for a maximum period of 12 months or until relapse. Neither ranitidine nor weekend therapy with omeprazole was effective in maintaining patients in remission. However, omeprazole, 20 mg daily, was a highly effective maintenance therapy with 89% of patients in remission after 12 months compared with only 25 and 32% for ranitidine and weekend omeprazole, respectively. All three regimens were well tolerated.

The effect of glucagon on esophageal peristalsis and clearance

The effect of 0.5 mg intravenous glucagon on esophageal peristalsis and transit of water and barium was studied in nine healthy subjects by concurrent videofluoroscopy and manometry. Glucagon lowered manometric peristaltic amplitude in both mid- and distal esophagus. This reached significance (p = 0.0075) in the distal 3 cm of the esophagus 2 min after the injection. The efficiency of esophageal stripping was also reduced (increased proximal escape on fluoroscopy), and became significant (p = 0.05) at 2 min after the injection of glucagon.

Effect of cisapride on postprandial gastro-oesophageal reflux

We studied the effect of cisapride on oesophageal motor function and postprandial gastro-oesophageal reflux in a randomised, double blind, placebo controlled crossover study. In 16 patients with symptomatic gastro-oesophageal reflux, cisapride 10 mg orally and placebo were studied on separate days according to identical protocols. Cisapride and placebo were given 30 minutes before a standard meal. Each study day was preceded by corresponding three day oral loading of cisapride (10 mg tds) or placebo. Lower oesophageal sphincter pressure, oesophageal body motility and oesophageal pH were monitored for 30 minutes before and three hours after the meal. Plasma cisapride concentrations were measured before and after dosing on both study days. With cisapride treatment, the plasma cisapride levels ranged from 48.1 (5.0) to 75.9 (6.9) ng/ml. Plasma levels were undetectable during placebo treatment. Cisapride enhanced acid clearance but had no significant effect on the duration of acid exposure, the rate of reflux episodes, the pattern of lower oesophageal sphincter pressure associated with the reflux episodes, basal lower oesophageal sphincter pressure or oesophageal peristalsis. These findings do not suggest a major role for cisapride, at the dosage tested, for the control of troublesome postprandial gastro-oesophageal reflux.

Motor mechanisms associated with slowing of the gastric emptying of a solid meal by an intraduodenal lipid infusion

The aim of this study was to define better the motor phenomena associated with the slowing of gastric emptying by a duodenal lipid infusion. Antral, pyloric and duodenal motility were recorded in 10 healthy subjects with a manometric assembly which incorporated multiple perfused side-holes and a sleeve sensor positioned astride the pylorus. The gastric emptying of a standard solid meal and the distribution of the ingesta between the proximal and distal stomach were monitored with a radionuclide technique. A triglyceride emulsion was infused into the duodenum for 45 min once 25% of the meal had emptied. The infusion caused significant slowing in the rate of gastric emptying (P less than 0.01). This slowing in gastric emptying was associated with the suppression of pressure waves in the distal antrum (P less than 0.01) and proximal duodenum (P less than 0.01), the induction of pressure waves isolated to a narrow pyloric segment (P less than 0.01), and a redistribution of ingesta from the distal to proximal stomach. These findings suggest that pressure waves isolated to the pylorus, changes in the intragastric distribution of ingested food, and changes in proximal duodenal motility may all act in concert with changes in antral motility to regulate the gastric emptying of solids.

A scanning electron micrographical study of root surfaces and subgingival bacteria after hand and ultrasonic instrumentation

The effects of hand and ultrasonic instrumentation on root surface topography and subgingival plaque were studied. One approximal subgingival root surface on each of two single rooted teeth of six patients was root planed. The opposing proximal surfaces were not treated and served as controls. On each patient, the two test surfaces were randomly treated by hand or ultrasonic instrumentation (Cavitron) until clinically smooth. The teeth were extracted, divided into mesial and distal sides, and processed for scanning electron microscopy (SEM). The observations were restricted to an area 2 mm by 3 mm just coronal to the plaque-free zone. The root surfaces were scanned by SEM, both at low (x 100) and at higher magnifications (x 5000). At low power, a photomontage was produced of the surface area of the test teeth. At low magnifications (x 100, x 500), the topography resulting from hand instrumentation appeared smooth with parallel scratches compared to scaly but flat surfaces with occasional deep gouges with the ultrasonic method. At high magnifications (x 5000), tooth surfaces were similar in topography when instrumented by either hand or ultrasonic methods. Root surfaces were covered in some areas by a fibrillar-like membrane that resembled fibrin. Individual bacteria were found on the surfaces of this material. On other areas not covered by this membrane, bacterial plaque was only observed when tooth surfaces had not been contacted by either hand or ultrasonic instrumentation.

Pyloric motor response to intraduodenal dextrose involves muscarinic mechanisms

The delivery of dextrose solutions to the duodenum is associated with the stimulation of phasic and tonic pyloric contraction. In this study, the effects of intravenous atropine on the antropyloroduodenal motor responses to intraduodenal infusions of 25% dextrose were assessed in 10 normal volunteers. Antropyloroduodenal pressures were recorded with a manometric assembly incorporating a sleeve sensor spanning the pylorus, and sideholes in the antrum and duodenum. In each experiment, three intraduodenal infusions of 25% dextrose were given at a rate of 4 ml/min, for a median duration of 19 min (range 17-20). During the second dextrose infusion, intravenous atropine was given as a bolus (15 micrograms/kg) followed by an infusion (4 micrograms/kg.min), which was continued until the end of each experiment. Before atropine was given, the pyloric motor response to the second dextrose infusion was not significantly different from the response to the first infusion, but after administration of atropine there was a rapid decrease in the rate of isolated pyloric pressure waves, from 0.8 to 0.1 per minute (p less than 0.05). The isolated pyloric pressure wave response to the third dextrose infusion was completely blocked, and there was a much smaller maximum increase in basal pyloric pressure compared with the first infusion (p less than 0.01). This study indicates that intraduodenal dextrose reproducibly stimulates isolated pyloric pressure waves and increases basal pyloric pressure by mechanisms that involve muscarinic receptors.

Weekly alternating etoposide, methotrexate, and actinomycin/vincristine and cyclophosphamide chemotherapy for the treatment of CNS metastases of choriocarcinoma

Twenty-five patients with CNS metastases of choriocarcinoma were treated with a regimen incorporating etoposide, methotrexate, and actinomycin (EMA) alternating weekly with vincristine and cyclophosphamide (CO). The dose of methotrexate was increased to 1 g/m2. Eighteen patients presented with CNS metastases, or developed them on inappropriate treatment started elsewhere. Following EMA/CO chemotherapy, three patients died within the first 3 weeks, one is alive with active disease, one died with drug resistance, and 13 (72%) patients are surviving disease-free. Two of seven patients (29%) who developed CNS metastases on treatment with EMA/CO or relapsed after EMA/CO are disease-free after additional chemotherapy and surgery. The contribution toward survival of the craniotomy in six of 18 patients treated initially or early with EMA/CO remains unclear, but was crucial to those patients with drug resistance.

The role of low-dose methotrexate and folinic acid in gestational trophoblastic tumours (GTT)

Between 1964 and 1986, 487 patients with gestational trophoblastic tumour (GTT) were treated with methotrexate and folinic acid. The patients comprise two groups: between 1964 and 1974, 126 patients were treated but were not systematically stratified using a prognostic score before the start of treatment. These patients formed part of the 317 women who were analysed to identify a number of prognostic variables (Bagshawe 1976). Retrospective analysis of these 126 patients using these prognostic factors showed that in the true low-risk group 85/88 (96%) are alive while 20/22 (91%) of the medium-risk group and only 5/16 (31%) of the high-risk group are alive. Overall the survival was 110/126 (87%) with a minimum follow-up of 14 years. From 1974 all patients were stratified on admission into prognostic groups. Of the true low-risk patients 347/348 survived (99.7%); 13 patients were underscored and treated as low risk when they should have been treated as medium risk, 12 (92%) of these are alive, but nine (69%) needed to change treatment because of drug resistance. While the overall survival in the 1974-1986 group was 359/361 (99%) with a minimum follow-up of 16 months, the survival in all patients (1964-1986) was 469/487 (96%). Although the survival in these patients is excellent it should be noted that 69/348 (20%) low-risk patients had to change treatment because of the development of drug resistance, and a further 23 (6%) needed to change treatment because of drug-induced toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)