A high yield method for the preparative synthesis of coenzyme A by combination of chemical and enzymic reactions

Dried cells of Brevibacterium ammoniagenes are a good enzyme source for the preparative synthesis of CoA from pantothenic acid, L-cysteine and ATP. A problem with this synthesis is that the CoA synthesis is repressed by negative feedback inhibition by CoA to pantothenate kinase, the first step enzyme for the biosynthesis of CoA, which catalyses phosphorylation of pantothenic acid or pantetheine. As the inhibition operates only at this step, a further increased yield is possible if the enzymic phosphorylation step is replaced with chemical synthesis. Yields from phosphorylated substrates are more than 10-times higher than those from pantothenic acid or pantetheine (33 g/l from phosphopantothenic acid with a molar yield of 86%; 115 g/l from phosphopantetheine with a molar yield of 100%).

The role of thoracic and cranial irradiation for small cell carcinoma of the lung

Since 1974, 120 previously untreated patients with small cell carcinoma of the lung seen in Therapeutic Radiology at The Medical College of Wisconsin have been entered into one of 4 successive studies. Study I used thoracic irradiation (TI) alone (4500-6000 rad in 3-6 weeks) with chemotherapy at progression. Study II randomized patients with limited disease to TI (3000 rad in 2 weeks) plus either cyclophosphamide, doxorubicin, vincristine (CAV) or total body irradiation (TBI); patients with extensive disease received TI + CAV. Study III employed prophylactic cranial irradiation (PCI) plus CAV and withheld TI unless there was incomplete response or recurrence. Of 93 evaluable patients from the first three studies, 55 had limited and 38 extensive disease. Study I (37 patients) showed a 62% complete response (CR) rate; 43% failed in the chest, 14% had brain metastases, and the median survival was only 22 weeks in spite of a preponderance of limited disease patients. Study II (27 patients) showed a CR of 59%; 30% had brain metastases and the median survival was 48 weeks. Study II patients (29) had a 69% rate; 72% failed in the chest, 4% with PCI developed brain metastases, and the median survival was 50 weeks. In March, 1979, Study IV was initiated; patients receive PCI (2500 rad in 2 weeks) plus high dose CAV, methotrexate and leucovorin. After 6 cycles, consolidation TI (3750 rad in 3 weeks) is given to patients with complete response. Preliminary results with 27 patients treated on this study show a 67% CR rate, a 41% chest failure rate (but only 11% for the patients who received thoracic irradiation) and no intracranial failures, but a 13% extracranial CNS failure rate. PCI, TI and spinal irradiation may be necessary to maximize the probability of long term disease free survival.

Patterns of failure in treatment of stage I and II diffuse malignant lymphoid tumors

Fifty-nine patients with Stage I and II diffuse malignant lymphoid tumors were irradiated between 1966 and 1979. Seventeen had primary lymph node disease and 42 had extranodal presentations. Local recurrence was noted in 1 of 14 evaluable lymph node presentations and 8 of 36 extranodal distributions. Failures occurred in unirradiated lymph nodes (contiguous or transdiaphragmatic) in 3 of 17 patients with lymph node disease and 6 of 42 with extranodal disease. Dissemination occurred in 4 of 17 lymph node presentations and 6 of 42 extranodal tumors. Local recurrence was low, particularly among lymphatic tumors. There was no identifiable dose effect for local control. Extension to contiguous or distant lymph nodes occurred in 15% of cases. The authors suggest that the transdiaphragmatic lymph nodes be included when treating patients with lymph node tumors. The role of adjuvant chemotherapy remains unproved.

Risk of brain metastasis from small cell carcinoma of the lung related to length of survival and prophylactic irradiation

The problem of brain metastasis from small cell carcinoma (SCC) of the lung has been appreciated for many years, but the magnitude of the problem has been underestimated. Recent studies have shown that the risk of brain metastasis increase as survival is prolonged. Although prophylactic cranial irradiation (PCI) has reduced the frequency of brain metastases, the effect on risk estimates of differences in the periods of observation was not evaluated. From 1974 through 1979, 131 patients with SCC of the lung who had no evidence of brain metastasis by radionuclide or computerized tomographic scan were treated in the Division of Therapeutic Radiology at the Medical College of Wisconsin Affiliated Hospitals. PCI was started in 1977; 57 patients received it and 74 did not. To correct for the differing periods of observation for the two groups, an actuarial calculation of the probability of brain metastasis was used. The calculated rate of clinical failure in the brain for patients who did not receive PCI was 28% at 12 months and 58% at 24 months. The calculated failure rate of the brain for patients who received PCI was 11% at 12 and 24 months. The difference in the probability of brain metastasis between the patients who did or did not receive PCI is highly significant (P less than 0.01). The true benefit of PCI becomes apparent only when the risk of intracranial metastasis is evaluated by methods that correct for incomplete followup. PCI eliminates the progressive increase in the risk of brain metastasis that accompanies increased survival and is important to maximize the probability for cure of patients with SCC.

Stage III nodular lymphoreticular tumors (non-Hodgkin's lymphoma): results of central lymphatic irradiation

Since 1969, 29 previously untreated patients with Stage III nodular malignant lymphoreticular (MLT) have received total central lymphatic (TCL) irradiation. The volume irradiated included the entire abdomen, Waldeyer's ring, and preauricular nodes in addition to the usual regions encompassed by total nodal irradiation. Doses of 2000--3000 rads in three to six weeks were delivered to the nodal regions, liver, and spleen; fraction sizes ranged from 100 to 180 rads. Patients have been followed from one to ten years (median six years). The actuarial survival is 78% at five years, and the disease-free survival is 61%. There is no difference in disease-free survival of the patients with poorly differentiated lymphocytic vs. those with "histiocytic" or mixed cytology. Men and women had disease-free survivals of 82% and 43%, respectively. The long-term follow-up of these patients indicates that prolonged disease-free intervals are common after TCL irradiation, and some patients may be cured.

Local control of intrathoracic disease with chemotherapy and role of prophylactic cranial irradiation in small-cell carcinoma of the lung

Between 1978 and 1979, 39 consecutive patients at the Medical College of Wisconsin were seen with small-cell carcinoma of the lung; of these, 31 were treated with chemotherapy and prophylactic CNS irradiation (2500 rad/10 fractions) and were evaluable after 22 month median follow-up. The intrathoracic primary was not irradiated unless there was no response to chemotherapy or subsequent recurrence. Of the 31 patients, 12 had limited disease (LD) and 19 had extensive disease (ED). Twenty, including all the patients with LD, had a complete response, eight had a partial response, and three were nonresponders. Of 24 patients with complete response at the primary site, 20 subsequently displayed local failure of the intrathoracic primary tumor, most developing disseminated extrathoracic disease simultaneously with or shortly after primary failure. The median survival time (MST) of the evaluable group was ten months with an actuarial one-year survival of 39%. Patients with LD had a median remission duration of 13 months and a MST of 16 months. Three patients are still alive with no evidence of disease at 14, 20, and 27 months. Of 26 patients receiving prophylactic cranial irradiation, all are free of CNS relapse. Chemotherapy alone appears insufficient to permanently control the bulky intrathoracic tumor, leading to the use of "consolidation" irradiation of moderate dose (3750 rad/15 fractions) to follow chemotherapy. Prophylactic CNS irradiation should be used routinely.

Irradiation for inoperable carcinoma of the lung and high performance status

Disagreement continues about the role of immediate irradiation of asymptomatic patients with inoperable lung cancer. Information pertaining specifically to irradiation of asymptomatic patients is scarce. The Medical College of Wisconsin, Milwaukee, reported that survival two years after irradiation was affected by control of the intrathoracic tumor. Ninety-two patients from that study with high performance status (80 to 100 on the Karofsky scale) were evaluated for long-term survival. Of 54 patients (59%) whose tumors were controlled locally by irradiation, 22% survived five years. None of the 38 patients with uncontrolled thoracic disease lived beyond 27 months. Eight patients are alive and well 53 to 100 months after treatment. No specific late complications of irradiation have been seen. Patients having few symptoms with inoperable bronchial carcinoma can live many years if the tumor is controlled by irradiation.

Results of whole-brain irradiation for metastases from small cell carcinoma of the lung

Prophylactic brain irradiation significantly reduces the proportion of patients with small cell carcinoma of the lung (SCCL) who develop brain metastases. Therapeutic brain irradiation could be used instead of prophylactic irradiation if it could be delivered promptly after diagnosis of intracranial spread and if it were highly effective. Forty of 188 patients with SCCL seen in the Medical College of Wisconsin Affiliated Hospitals had brain metastases either at initial diagnosis (23 patients) or after treatment (17 patients). Irradiation was administered to the whole brain at doses ranging from 3000 rads in 2 weeks to 4000 rads in 3 weeks. Neurologic function was the same for those patients with initial and delayed metastases and did not correlate with survival. Response to irradiation affected survival. After the diagnosis of brain metastases, survival was the same whether metastases were initially present or were delayed. Eighteen (45%) of the patients died from brain metastases and two (5%) are alive following disease recurrence in the brain. Increasing survival with SCCL due to effective chemotherapy is associated with an increasing failure rate in the brain which may eventually reach the 50% rate found at autopsy. Therapeutic brain irradiation is not sufficiently effective to preclude prophylactic irradiation.

Locally advanced adenocarcinoma of the endometrium: results of irradiation with and without subsequent hysterectomy

From 1965 through 1977, 54 patients with locally advanced adenocarcinoma of the endometrium were treated at the Medical College of Wisconsin Affiliated Hospitals. According to the FIGO-AJC staging system, 39 had Stage II and 15 Stage III disease. Stage II was subdivided into II A-microscopic (28 patients) and II B-clinical (11 patients) involvement of the cervix. Patterns of failure were evaluated, viz. central pelvic, lateral pelvic, and distant. The results confirm an association of increasing grade with increasing stage. Disease-free survival rates at five years are better for Stage II (78%) than Stage III (34%), but are no different for Stages II A (77%) and II B (81%). Pattern of failure and disease-free survival data support the combined irradiation-surgical approach over irradiation alone. Central pelvic failures are reduced by subsequent hysterectomy (6% vs. 20%). Lateral pelvic failures are less frequent when the dose of external pelvic irradiation is 5000+ rads/5-6 weeks compared to less than 5000 rads (4% vs. 20%). In Stage II (corpus et collum) the prognosis is better with preoperative irradiation and abdominal hysterectomy than with irradiation alone (89% vs. 63%). Whenever possible, patients with Stage III disease should be offered irradiation and hysterectomy.

Interaction of thoracic irradiation and chemotherapy on local control and survival in small cell carcinoma of the lung

The records of all patients with small cell carcinoma of the lung seen in the Division of Therapeutic Radiology at The Medical College of Wisconsin from 1971 through 1977 were reviewed. Of 69 patients (34 with limited disease and 35 with extensive disease), 35 received irradiation only, nine received local plus total-body irradiation, and 25 received irradiation plus chemotherapy. In spite of the prompt response of the tumor, 16 of 35 patients who were only irradiated failed locally. Two patients who received local plus total-body irradiation failed in the chest. Only four of 25 irradiation plus chemotherapy patients failed locally in spite of much lower doses of thoracic irradiation. Limited-disease patients who had local control by irradiation had a slight increase (29 vs 22 weeks) in median survival. Patients receiving irradiation plus chemotherapy (three with limited and 22 with extensive disease) survived for a median of 56 weeks if the local tumor was controlled and for a median of 28 weeks if there was local failure. Regardless of therapy, survival beyond the median is greatly influenced by local tumor control.

Dose-time relationships and the local control of small cell carcinoma of the lung

Since 1971, 66 patients with small cell carcinoma of the lung--32 with limited and 34 with disseminated disease--have received irradiation to the primary tumor. There were 20 local failures, 90% of which were apparent within 30 weeks of the start of irradiation. Patients were treated with local irradiation only (32), irradiation plus combination chemotherapy (25), or local plus total body irradiation (9). With local irradiation alone, tumor control increased with increasing biologic dose. When chemotherapy or total body irradiation was added, doses of irradiation that were otherwise insufficient for local control proved to be effective.

Irradiation for bronchial carcinoma: reasons for failure. I. Analysis of local control as a function of dose, time, and fractionation

Radiation therapy is the only potentially curative form of therapy for patients with carcinoma of the lung who are not surgical candidates. Previous studies have evaluated response by evaluating survival. Evaluation of local control of disease is essential if one is to understand and modify therapeutic approaches in an effort to increase survival. Clinical data are presented on 197 patients with primary epithelial tumors of the lung. An analysis of local control data is presented using the concept of nomial standard dose (NSD). If local failure is to occur, it is manifest by 15 months. Survival is affected by the ability or inability to achieve local control. Above a dose of 1450 ret, no correlation between increasing ret dose and increasing local control is observed.