Mitomycin, ifosfamide, and cisplatin in unresectable non-small-cell lung cancer: effects on survival and quality of life

PURPOSE

Chemotherapy for non-small-cell lung cancer (NSCLC) remains controversial. We describe the two largest reported, randomized, parallel trials designed to determine whether the addition of chemotherapy influences duration and quality of life in localized, unresectable (mitomycin, ifosfamide, cisplatin [MIC]1 trial) and extensive (MIC2 trial) disease.

PATIENTS AND METHODS

Ambulatory patients with NSCLC, aged 75 years or younger, with localized disease, were randomized in MIC1 to receive up to four cycles of chemotherapy (CT: mitomycin 6 mg/m(2), ifosfamide 3 g/m(2), and cisplatin 50 mg/m(2)) every 21 days, followed by radical radiotherapy (CT + RT) or radiotherapy (RT) alone. Extensive-stage patients were randomized in MIC2 to identical chemotherapy plus palliative care (CT + PC) or palliative care (PC) alone. Short-term change in quality of life (QOL) was assessed in a subgroup of patients. Data from the two trials were combined to allow multivariate and stratified survival analyses.

RESULTS

Seven hundred ninety-seven eligible patients were randomized, 446 in MIC1 and 351 in MIC2. MIC CT improved survival in both trials (significantly in MIC2). The median survival time in MIC1 was 11.7 months (CT + RT) versus 9.7 months (RT alone) (P =.14); whereas in MIC2, median survival time was 6.7 months (CT + PC) compared with 4. 8 months (PC alone) (P =.03). QOL, assessed in 134 patients from start of trial to week 6, showed improvement with chemotherapy and deterioration with standard treatment. In the combined analysis of 797 randomized patients, the positive effect of MIC on survival was significant overall (P =.01) and after adjusting for prognostic factors (P =.01).

CONCLUSION

MIC chemotherapy prolongs survival in unresectable NSCLC without compromising QOL.

Early effects of hormone replacement therapy on bone

Estrogen replacement is currently the preferred therapy for postmenopausal osteoporosis, although its mechanism of action remains poorly understood. Its primary action on bone is generally considered to be antiresorptive, but there is evidence in animals to suggest a stimulatory effect on bone formation. We have now attempted to detect a similar effect in humans by administering hormone replacement therapy (estradiol valerate 2 mg/day and dydrogesterone 5 mg/day given in a continuous, combined manner) to ten postmenopausal women. We carried out histomorphometric analyses of transiliac bone biopsies after quadruple tetracycline labeling, which was commenced before and continued during the first 4 weeks of hormone replacement therapy. Biochemical markers of bone turnover suggested that bone resorption decreased, but no significant effects on histomorphometric parameters of bone formation were detected. We conclude that hormone replacement therapy at the dose given does not stimulate bone formation in the iliac crest as assessed by histomorphometry.

Nonsurgical management of acute jejunal diverticulitis: a review

BACKGROUND

Diverticular disease of the colon and its complications are well known and readily considered when patients present with the proper clinical scenario. Conversely, complications of small bowel diverticula are very uncommon entities and are not often thought of as a cause of bleeding, obstruction, or an acute abdomen.

OBJECTIVE

To report two patients presenting with an acute abdomen caused by acute jejunal diverticulitis who were treated nonsurgically as opposed to surgically as the literature dictates.

METHODS

Two patients presented with sudden onset of acute periumbilical pain that had increased progressively over 1-2 days before admission. An emergent CT scan performed in each patient with localized peritonitis revealed "collections" consistent with abscess cavities. One patient was treated with antibiotics alone and the other with a combination of antibiotics and percutaneous CT-guided aspiration. CT-guided needle aspiration was performed and the injection of contrast clearly revealed communication with a jejunal diverticulum. Both patients did well and were subsequently discharged without incident or surgical intervention.

CONCLUSIONS

Acute jejunal diverticulitis must be considered in the differential diagnosis of an acute abdominal process and may be successfully treated nonsurgically despite the recommendations of previous reports.

Standardized exercise oximetry predicts postpneumonectomy outcome

BACKGROUND

We have developed a safe, simple, and easily performed standardized exercise oximetry outpatient test to assess patients undergoing lung resections. We studied its ability to predict outcome after pneumonectomy in 46 consecutive patients over a 5-year period.

METHODS

Room air oximetry is initially performed at rest. The patient then begins to exercise on a stair-stepper apparatus (Stamina Stepper), which provides uniform resistance to stepping. Oxygen saturation values are noted at 10, 20, and 30 steps, equivalent to climbing three flights of stairs. Group 1 consisted of the patients who either had a resting saturation less than 90%, or desaturation greater than or equal to 4% during exercise. Group 2 consisted of all patients who had a preoperative forced expiratory volume in 1 second of 60% or less. Group 3 consisted of all patients who had a predicted postoperative forced expiratory volume in 1 second of 40% or less. Group 4 consisted of patients who had a predicted postoperative diffusing capacity of 40% or less.

RESULTS

There were four deaths (8.6%), 12 patients (26%) remained in the intensive care unit 4 or more days, and 11 patients (23%) suffered major morbidity. Desaturation during exercise (group 1) significantly predicted longer intensive care unit stay (p = 0.0002) and incidence of major morbidity (p < 0.0001). Groups 2, 3, and 4 were not significantly predictive of either longer intensive care unit stay or major morbidity.

CONCLUSIONS

Standardized exercise oximetry performed in the outpatient facility is highly predictive of major morbidity and prolonged intensive care unit stay after pneumonectomy.

Asymmetric territorial contests in the European robin: the role of settlement costs

A widespread feature of territorial systems is that residents almost invariably defeat challengers. This phenomenon has been explained by the existence of value asymmetries, variations in resource-holding potential or an 'owners always win' convention. Removal-replacement experiments were performed on 75 robins, Erithacus rubeculato test these hypotheses. The settling behaviour of newcomers was also examined in order to identify energetic costs incurred during territory establishment. In winter, dominance shifted gradually from removed owners to newcomers with increasing time of newcomer residence, and there was a peak in contest duration at 4-7 days. Removals of newcomers, followed by replacement with another newcomer, confirmed that dominance was determined by the time newcomers were in residence rather than the time original owners were absent. These results support the hypothesis that asymmetries in territory value govern the outcome of contests. It is proposed that high singing rates and low foraging rates of newcomers settling boundaries with neighbours contribute to this asymmetry, skewing outcomes in favour of original owners until replacements are fully established. The key result in this study is that the time at which dominance tends to reverse (5-6 days in winter) is predicted by the time taken for newcomers to settle territory boundaries and achieve base-line foraging effort. In spring, original owners become subordinate almost immediately after removal. Reductions in settlement cost for newcomers, and increases in territory value, are proposed to accelerate dominance reversal. Age and sex effects on dominance suggest that the value asymmetry rule is modified by variations in resource-holding potential.

Breast surgery after neoadjuvant treatment. Is it necessary?

The optimum management of women with advanced loco-regional breast cancer (T3-4, N1-2) is controversial. Neoadjuvant therapy in the form of chemotherapy and or radiotherapy is popular and results in an encouraging local response in over 70% of patients. However, should subsequent surgery (either mastectomy or breast conservation treatment) be undertaken in women who respond? We present a prospective evaluation of 15 patients with T3-4, N1-2 tumours (including 1 bilateral cancer) who underwent mastectomy after achieving a complete clinical response to neoadjuvant treatment. All patients had 6 cycles of chemotherapy and 10 also received 50 Gy radiotherapy. In addition to clinical examination, the response to neoadjuvant treatment was assessed by mammography (in all cases) and by magnetic resonance imaging (MR) (in eight patients). Careful histopathological assessment of the breast was undertaken to determine the extent of residual disease. In all patients histological malignancy was recognized within the breast. The size varied from 0.6 to 6.5 cm in maximum diameter with three grade I, eight grade II and five grade III tumours. Axillary lymph nodes were positive in seven patients. In conclusion, surgery is indicated for control of residual disease in locally advanced breast cancer regardless of the response to neoadjuvant treatment. Our preliminary observations suggest a potential role for breast MR in defining the extent of residual disease which may aid in the planning of surgery.

Interleukin-2-responsive wound-infiltrating lymphocytes in surgical adjuvant cancer immunotherapy

Wound-infiltrating lymphocytes (WIL) were assessed in murine models of localized sarcoma and carcinoma to evaluate the role of interleukin-2 (IL-2)-responsive lymphocytes in adjuvant immunotherapy. Following tumor resection, IL-2 or diluent was injected at the surgical site for 6 days. Surgical site tissues were harvested and digested in a triple enzyme mixture, and single cell suspensions were prepared. Thy 1.2+ lymphocytes were isolated by incubating cells with monoclonal anti-Thy 1.2 antibody-coated magnetic beads. Lymphocyte-bead complexes were extracted with a magnet and cultured in medium containing IL-2 (100 units/ml) for 1-3 weeks. Perioperative IL-2 immunotherapy led to a three- to four-fold increase in WIL yield. WIL from IL-2-treated mice also demonstrated enhanced cytolysis of the autologous tumor and bound to activated endothelial cells with greater avidity than did the controls. We conclude that perioperative IL-2 therapy augments the yield, as well as the cytolytic and adhesive properties, of wound-infiltrating lymphocytes.

Intratumoral interleukin-2 immunotherapy: activation of tumor-infiltrating and splenic lymphocytes in vivo

Direct intratumoral injection of interleukin-2 (IL-2) was evaluated in a murine model. Balb/c mice received 5 x 10(4) Line 1 alveolar carcinoma cells (L1C2) by subcutaneous injection. On the third day following tumor implantation, mice received injections of IL-2 (5 x 10(3)-5 x 10(4) units) or diluent twice daily, either by i.p. or intratumoral injection, 5 days/week for 3 weeks. Intratumoral injection of 5 x 10(4) units IL-2 significantly reduced tumor volume (P < 0.05 versus control), increased median survival time (P = 0.0001), and resulted in a 23.5% cure rate (P = 0.008). There were no long-term survivors in the other treatment groups. Both tumor-infiltrating lymphocytes (TIL) and splenic lymphocytes isolated directly from IL-2-treated mice demonstrated enhanced cytolytic activity compared to diluent-treated controls. To determine whether non-T-cell-mediated antitumor responses were active in our model, intratumoral immunotherapy was evaluated in athymic Balb/c nu/nu mice. In order to decrease the recruitment of lymphocyte precursors, nude mice were splenectomized and received cyclophosphamide prior to tumor injection and IL-2 therapy. Intratumoral IL-2 immunotherapy also significantly decreased tumor volume in these immunodeficient mice (P < 0.02), but did not lead to long-term survival. We conclude that both TIL and splenic lymphocytes are activated in vivo in response to intratumoral IL-2 immunotherapy, suggesting that intratumoral therapy with IL-2 activates both local and systemic antitumor responses.

Eosinophilic Granuloma of Atlanto-Occipital Joint

An isolated eosinophilic granuloma at the craniocervical junction was treated by an extreme lateral surgical excision, bone grating, and radiotherapy with good outcome.

A reappraisal of the causes of hemoptysis

We reviewed the records of 264 patients who underwent fiberoptic bronchoscopy for unexplained hemoptysis to determine the various causes of hemoptysis. Bronchogenic carcinoma (29%), bronchitis (23%), and idiopathic hemoptysis (22%) accounted for the majority of causes of hemoptysis. In contrast to older studies, the incidence of hemoptysis secondary to tuberculosis and bronchiectasis has decreased. Although our patient population is predominantly male and elderly, our data may well be representative of more recent epidemiologic trends in causes of hemoptysis.

Phase II studies of ifosfamide alone and in combination in cancer of the cervix

A series of phase II studies using ifosfamide (IFX) as a single agent and in combination with cisplatin and bleomycin (BIP) in advanced and recurrent cervical cancer have been coordinated at the West Midlands CRC Clinical Trials Unit (Birmingham, UK). The aims of these studies were to identify single agents and combination regimens that may be of value for palliation and have potential for use as neoadjuvant and adjuvant therapy at the time of primary treatment. A total of 79 patients with disease non-amenable to radical local therapy were treated with single-agent IFX or the BIP combination. In 30 patients treated with single-agent IFX, 10 objective responses (30%) were seen, with 1 complete response. In 49 patients treated with BIP, 34 objective responses (69%) were seen, with 10 complete responses (20%). Toxicity included alopecia, nausea and vomiting, myelosuppression, infection, reduction in renal function and disturbance of consciousness. These data indicate that IFX is highly active in cervix cancer and, in combination with bleomycin and cisplatin, can be used for effective palliation and cytoreduction in greater than 70% of patients. IFX-containing regimens have potential for use as neoadjuvant and adjuvant therapy in patients at high risk of recurrence with conventional treatment. These hypotheses are currently being tested in prospective randomised trials.

Neoadjuvant bleomycin, ifosfamide and cisplatin in cervical cancer

Patients with advanced and bulky early-stage cancer of the cervix have an unfavourable prognosis, which may be improved by initial neoadjuvant, cytoreductive chemotherapy. In a phase II study, coordinated at the West Midlands CRC Clinical Trials Unit, Birmingham, using ifosfamide (IFX) in combination with cisplatin and bleomycin (BIP) in advanced and recurrent cervical cancer, we demonstrated a response rate of 69%. This regimen produces rapid responses with acceptable toxicity and has potential for use as neoadjuvant therapy prior to radical radiotherapy in patients presenting with advanced and bulky early-stage disease. In an initial pilot study of this approach, 13 of 19 patients (68%) with primary inoperable disease showed significant tumour regression prior to radical local radiotherapy. Interim analysis of the first 66 patients entered into a randomized study evaluating the value of this approach has shown complete clinical tumour resolution after radical radiotherapy in 24/32 patients (75%) treated with up to three cycles of BIP prior to radiotherapy vs 19/34 patients (56%) treated with radiotherapy alone. There was no evidence that neoadjuvant chemotherapy enhances the acute toxic effects of pelvic radiotherapy. This approach has the potential for improving the outlook in patients with poor-prognosis primary disease.

Glucocorticoids impair bone resorptive activity and viability of osteoclasts disaggregated from neonatal rat long bones

It is generally believed that glucocorticoids cause osteoporosis through a combination of decreased bone formation and increased bone resorption. However, the direct effect of glucocorticoids on osteoclasts has not been determined. We therefore tested the effects of hydrocortisone and dexamethasone on bone resorption by osteoclasts disaggregated from neonatal rat long bones. Hydrocortisone and dexamethasone caused a dose-dependent inhibition of osteoclastic bone resorption in the range 10(-7) to 10(-5) M, and 10(-9) to 10(-6) M, respectively, at concentrations likely to occur during therapy and disease. Inhibition of bone resorption was found to be associated with impaired osteoclast survival: osteoclast numbers were reduced to approximately 25% of control values by 10(-6) M hydrocortisone and 10(-7) M dexamethasone. Osteoclast cytotoxicity by glucocorticoids was completely antagonized by progesterone, which itself had no effect on osteoclast survival. Analysis of the time course of these inhibitory effects showed a nonsignificant reduction in survival by 6 h and marked inhibition of survival by 12 h. We could detect no specific changes in osteoclast morphology in association with this impaired viability. The relative potencies of the glucocorticoids for impairment of osteoclast viability was similar to their relative affinities for binding the glucocorticoid receptor, and this, together with inhibition by progesterone, suggests a receptor-mediated mechanism. Such a receptor-mediated cytotoxic action of glucocorticoids has only previously been reported with lymphoid cells. The sensitivity of osteoclasts to the lethal effects of glucocorticoids suggests that glucocorticoids may have a role in physiology as inhibitors of osteoclastic bone resorption.

The role of ifosfamide in cervical cancer

A series of phase II studies using ifosfamide as a single agent and in combination with cisplatin and bleomycin (BIP) in advanced and recurrent cervical cancer were coordinated at the West Midlands Cancer Research Campaign Clinical Trials Unit, Birmingham, UK. The aim of these studies was to identify single agents and combination regimens that might be of value for palliation and have potential for neoadjuvant and adjuvant therapy in primary treatment. Ninety-eight patients were studied. Seventy-nine patients with disease not amenable to radical local therapy were treated with single-agent ifosfamide or the BIP combination. In 30 patients treated with single-agent ifosfamide, ten objective responses (33%) were seen, with one complete response. In 49 patients treated with BIP, 34 objective responses (69%) were seen, with ten complete responses (20%). Eleven (79%) of 14 patients with primary inoperable disease had at least a 50% reduction in tumor bulk before radical local radiotherapy. Toxicity resulted in alopecia, nausea and vomiting, myelosuppression, infection, reduction in renal function, and disturbance of consciousness. There was no evidence that neoadjuvant chemotherapy enhanced the acute toxic effects of pelvic radiotherapy. These data indicate that ifosfamide is highly active in cervical cancer and that in combination with bleomycin and cisplatin, it can be used for effective palliation and cytoreduction in around 70% of patients. Ifosfamide-containing regimens have potential for use as neoadjuvant and adjuvant therapy in patients at high risk of recurrence with conventional treatment. These hypotheses are currently being tested in prospective randomized trials.

An ultrasound window to perform scanned, focused ultrasound hyperthermia treatments of brain tumors

A series of calculations and tests were performed on polyethylene, polystyrene, acrylic, and a commercially available polymethyl methacrylate cranioplastic to determine which material would best serve as an acoustical window in the skull. The purpose of the window is to transmit focused ultrasound to treat brain tumors with hyperthermia. Each material was evaluated based on its ability to transmit power and to protect the brain. The results revealed that, of the four materials tested, polyethylene transmitted the largest percentage of incident power and is the toughest and best suited material to protect the brain. Further physical tests showed that a polyethylene plate does not significantly distort the sound field. Finally, acute and chronic dog tests (supported by theoretical calculations) using the polyethylene as an acoustical window through the skull showed that it will not reach temperatures greater than the target hyperthermia temperature (42 degrees C) at the required intensity levels unless the tumor is near the skull and the skin surface is not cooled. Since polyethylene effectively transmits power without distorting the sound field of overheating in dog tests, it may now be used in Phase 1 clinical ultrasound hyperthermia tests on human patients. However, the chronic animal studies indicated that the collagen which composes the dura thickens under the cranioplasty and absorbs increasingly greater amounts of power with time. A thick layer of organized fibrous tissue also formed on the external surface of the cranioplasty, filling in the cavity formed by the exterior surface of the cranioplasty and by the excision of the temporalis muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

MR of visual pathways in patients with neurofibromatosis

MR was performed on six patients clinically diagnosed as having neurofibromatosis. Owing to its multiplanar capability, MR greatly helped determine the extent of visual pathway disease. We attempted to find specific optimal pulse sequences for evaluating the prechiasmatic, chiasmatic, and retrochiasmatic visual system at 0.35 T. Using spin-echo techniques, we evaluated a T1-weighted sequence (TR 300 msec/TE 35 msec), an intermediate T2-weighted sequence (TR 1500 msec/TE 35 msec), and a T2-weighted sequence (TR 1500 msec/TR 70 msec). We found that the orbital and intracanalicular optic nerves were most accurately and easily seen with the T1-weighted sequence axially and coronally; the chiasm was best seen with the intermediate T2-weighted coronal sequence; and the retrochiasmatic visual pathway was optimally evaluated with T2-weighted spin-echo technique.

Demonstration of cavernomatous transformation of the portal vein by magnetic resonance imaging

A case of cavernomatous transformation of the portal vein demonstrated by magnetic resonance (MR) imaging is reported. Correlative images on scintigraphy and ultrasound are included. As in other vascular abnormalities, MR imaging is capable of depicting the findings noninvasively.

MR imaging of multiple sclerosis: comparison with clinical and CT examinations in 74 patients

Magnetic resonance (MR) imaging, the latest test for evaluation of patients with multiple sclerosis (MS), was assessed against clinical evidence in 74 patients with definite or probable MS. MR imaging was positive in 55 (85%) of 65 patients with definite MS but in only one (11%) of nine patients with probable MS. The examination is most likely to be positive when the patient is classified clinically as having definite MS; when the disease is active and not in remission; and if the constellation of symptoms indicates a multiplicity of regions with neurologic dysfunction. The examination was most sensitive for detecting lesions in the cerebral hemispheres, the posterior fossa, and the cervical spinal cord, in that order; it did not detect any lesions in the optic nerves. The paraclinical tests and MR imaging were of equal sensitivity in detecting MS lesions, but the latter method was more specific in localization. Cerebrospinal fluid evaluation was slightly less sensitive than the other two tests. There was no correlation between MR imaging and these examinations. The authors conclude that MR imaging is more sensitive than computed tomography (CT), which was positive in 25% of 59 patients with definite MS; it is always positive when CT is positive; and it probably can replace CT in the diagnosis and follow-up of patients with MS.

Carotid artery and aortic arch imaging with ECG gating in DSA

New computer software for gated digital subtraction angiography imaging was used to study 57 patients over 3 months. Better mask registration on isolated sets of systolic and diastolic images improved image quality. Detail of vessel outline and lesion was better than that seen on non-gated images.

Sensitivity of MRI in metastatic neoplasia: a case report

Serial magnetic resonance imaging (MRI) and computed tomography (CT) were performed on a patient with metastatic lung cancer to brain. Magnetic resonance (MR) visualized two foci of intracerebral metastasis six weeks prior to CT.

Instant oxygen delivery system for manual resuscitators

To help prevent the use of manual resuscitators without supplemental oxygen we developed a device that automatically starts the flow of oxygen when the resuscitators is put into use and then stops the oxygen flow when the resuscitator is returned to its assigned resting place. This instant oxygen delivery valve does not compromise oxygen flowrates from the gas source. We have used this device without problems for several months in our intensive care until.

High-dose cyclophosphamide with autologous marrow transplantation as initial treatment of small cell carcinoma of the bronchus

Sixteen patients with untreated small cell carcinoma of the bronchus received cyclophosphamide in a total dose of 160-200 mg/kg. Autologous marrow transplantation was used to minimise the period of hypoplasia and 2-mercaptoethane sulphonate to prevent urothelial toxicity. The procedure was well tolerated, with predictable and manageable toxicity. Complete radiological and bronchoscopic response was achieved in seven patients and partial response in a further seven. High-dose cyclophosphamide may be a useful initial treatment for this disease.

Lipid Oxidative Stability of Reconstituted Partially Defatted Peanuts1

Changes in tocopherol content, peroxide value and fatty acid composition were measured during storage of reconstituted partially defatted peanuts. These values were compared with those of unreconstituted partially defatted peanuts, whole peanuts and the corresponding oils. Reconstitution effectively inactivated the enzyme lipoxygenase and was destructive on tocopherols, particularly α- tocopherol. The stability of the oil during storage, as measured by the peroxide value, is much greater within the peanuts than in the corresponding extracted oil. No changes in fatty acid composition could be observed in reconstituted partially defatted peanuts. A need for immediate reconstitution following mechanical oil extraction could not be demonstrated as both products had equal oxidative stability.

Evidence for lack of phosphatidic acid and phospholipase D activity in milk

Phosphatidic acid could not be demonstrated when milk was assayed for phospholipase D activity even when lecithin was added. The concentration of "free" choline in milk remained the same before and after addition of lecithin. However, phosphatidic acid and an increased concentration of "free" choline were demonstrated when cabbage phospholipase D was added to raw milk. The concentration of phosphatidic acid and "free" choline in milk increased appreciably when both lecithin and cabbage phospholipase D were added to raw milk. Phospholipase D activity in milk was assayed at 23.5 C, pH 5.6, in the presence of 10% vol/vol of diethyl ether and .015M calcium chloride. "Free" choline was determined by adjusting the acid whey from milk to pH 11 and adding a freshly prepared 3% methanolic solution of ammonium reineckate. The precipitated choline reineckate was washed, dissolved in acetone, and its absorbance measured at 520 nm. The absence or presence of phosphatidic acid was shown by thin-layer chromatography. These results refute a previous report which proposed that both phosphatidic acid and phospholipase D were in milk.