Endemic African Kaposi's sarcoma: clinical and therapeutic implications. 10-year experience in the Johannesburg Hospital (1980-1990)

Endemic African Kaposi's sarcoma is a common neoplastic disorder in the sub-Saharan region of Africa. We present a retrospective analysis of 47 black patients with the endemic African (HIV-negative) variant of Kaposi's sarcoma treated and followed up in the Johannesburg General Hospital between 1980 and 1990. Four patients (8%) presented with simultaneous Kaposi's sarcoma plus malignant lymphoma, indicating a low but significant association with lymphoproliferative disorders. Of 47 patients seen, 29 presented with localized disease and were treated by means of local radiation therapy. Seventeen patients received chemotherapy. The objective response rate was > 80% irrespective of the treatment modality. We conclude that endemic African Kaposi's sarcoma is a chemo- and radiosensitive tumour.

Positive immunostaining for platelet derived growth factor (PDGF) is an adverse prognostic factor in patients with advanced breast cancer

Previous studies suggest a prognostic role for PDGF in patients with breast cancer, with patients with high plasma PDGF levels or positive response to therapy. We have examined a further 58 patients with advanced breast cancer for the presence of tissue PDGF immunostaining. Patients displaying positive tissue immunostaining for PDGF had a highly significant shorter survival (p = 0.002) than patients with no immunostaining. In addition PDGF positive patients treated with combination chemotherapy had a significantly lower response rate (p = 0.05) than PDGF negative patients. These results confirm our previous findings that PDGF may be an important indicator of shortened survival and treatment failure in patients with advanced breast cancer.

Kaposi's sarcoma in renal transplant recipients. Experience at Johannesburg Hospital, 1966-1989

Between August 1966 and December 1989, 989 renal transplant recipients were followed up at the Renal Transplant Unit of Johannesburg Hospital. Seventy-five (7%) patients developed a total of 95 malignancies of which 5 (6%) were Kaposi's sarcoma. All patients received immunosuppressive agents; steroids, azathioprine and/or cyclosporin A. Clinical presentations included both limited skin involvement (1 patient) and disseminated forms of the disease: necrotic oral lesions (1 patient); disseminated skin involvement and lung metastases (1 patient); and widespread skin lesions with lymphadenopathy (2 patients). Four patients responded with complete tumour regression at all sites upon withdrawal of the immunosuppressive drugs. One patient suffered disease progression, and immunosuppression was continued, albeit at reduced dosages. These cases illustrate a relatively rare complication of immunosuppressive therapy. However, complete withdrawal of immunosuppressive drugs may result in sustained complete regression, despite the presence of advanced KS.

A randomised trial of vindesine plus interferon-alpha 2b compared with interferon-alpha 2b or vindesine alone in the treatment of advanced malignant melanoma

60 patients were entered into a randomised study comparing vindesine (3 mg/m2/week) plus interferon-alpha 2b (6 U/m2 3 times per week) to vindesine alone or to interferon alone for the treatment of metastatic malignant melanoma. Patients receiving the combination therapy arm (schedule A; vindesine plus interferon-alpha 2b) showed a complete and partial response rate of 8/20 (40%) which was significantly higher (P < 0.05) than that achieved with either single-agent treatment schedule. In addition, patients receiving the combined treatment schedule had a significantly prolonged survival (median 19 months) when compared to a median of 10 months for interferon alone and 5 months for vindesine alone. The combination was generally well tolerated with only additive toxicity. It is concluded that combination treatment regimens utilising interferons together with chemotherapeutic agents deserve further study in the treatment of metastatic malignant melanoma.

Classical Kaposi's sarcoma in Caucasians in Africa--experience at the Johannesburg Hospital (1978-1992)

The data are scant concerning classical Kaposi's sarcoma (CKS) among the Caucasian population of Africa. A description of the clinical features of 15 such patients, treated and followed up at the Johannesburg General Hospital over a 14-year period (1978-1992) is presented. All patients were negative for the human immunodeficiency virus. After a mean follow-up of 50 months (range: 7-168 months), 2 patients are alive with absent or minimal disease; 1 patient is alive with stable disease and 1 has active disease involving his extremities. Three patients were lost to follow-up but had minimal or no disease when last seen. Five patients died of unrelated causes but also had minimal or no disease at their last visit. One patient died of sepsis related to active KS. Only two patients died of progressive KS. No alterations in humoral or cellular immunity were demonstrated in 2 patients with persistent disease. Four (27%) patients developed lymphoproliferative disorders including non-Hodgkin's lymphoma, Waldenström's macroglobulinemia, Hodgkin's disease and Castleman's disease (angiofollicular lymph node hyperplasia) preceding or following the diagnosis of CKS. These data confirm the indolent nature and good outcome of the classical form of Kaposi's sarcoma among Caucasians in the southern African region. The marked association between CKS and lymphoproliferative disorders warrants a long-term awareness and continued monitoring for these complications.

Lactoferrin and the inflammatory response

Polyclonal antibodies were prepared to purified breast milk lactoferrin and used in an ELISA to measure plasma concentrations in investigations of various aspects of the inflammatory response. They were also used, in situ, to evaluate granulocyte lactoferrin content in disease states. The first series of studies addressed the putative role of lactoferrin in the pathogenesis of the hypoferremic, hyperferritinemic response to acute inflammation. Dissociation between the lactoferrin response and the iron related changes in rheumatoid arthritis and after alpha-interferon administration suggested that the relationship observed in acute and chronic bacterial infection may reflect coincidental effects of inflammatory cytokines. That lactoferrin does not mediate the inflammatory hypoferremic response was established by the finding that bone marrow transplant recipients, post-myeloablation, developed a hypoferremic response during septic episodes despite virtually undetectable plasma lactoferrin concentrations. The second series of investigations employed the plasma lactoferrin concentration as an index of granulocyte activation and function in a number of inflammatory conditions. Markedly increased initial plasma concentrations in acute pneumonia reflecting profound intravascular granulocyte activation were documented to predict sepsis related mortality. Plasma and granulocyte lactoferrin studies established that viral infection is associated with an acquired granulocyte lactoferrin deficiency. Plasma measurements indicated that asthmatics, even when clinically asymptomatic, have evidence of persistent granulocyte activation.

Radiation therapy in endemic (African) Kaposi's sarcoma

PURPOSE

Evaluating the role of radiation therapy in the treatment of the endemic, African variant of Kaposi's sarcoma. A retrospective analysis.

METHODS AND MATERIALS

Between 1978 and 1990, 28 symptomatic African patients with the African Human Immunodeficiency Virus negative type of Kaposi's sarcoma were referred to the Johannesburg General Hospital. Following staging, all patients were treated with radiation therapy. Doses ranged between 8-10 Gy (single fraction) or 14-24 Gy fractionated over 1-3 weeks.

RESULTS

Complete and partial regression of cutaneous lesions was achieved in 9 (32%) and 15 (54%) patients, retrospectively. A complete/near-complete alleviation of symptoms was achieved in all patients. Response rate and duration of response was not influenced by age, radiation modality or schedule. Side effects were minimal.

CONCLUSION

Our study emphasizes the high radiosensitivity of the endemic, African type of Kaposi's sarcoma, indicating its usefulness as the treatment of choice for this disease.

Recurrent spontaneous abortion: histocompatibility between partners, response to immune therapy, and subsequent reproductive performance

PROBLEM

Immunological factors may account for previously unexplained cases of recurrent abortion.

METHOD

After screening 76 couples for causes of recurrent spontaneous abortion and measuring maternal antipaternal immunity, 23 primary spontaneous recurrent aborters were immunized once with their husbands' leukocytes. Testing for antipaternal cytotoxicity was repeated in 21 couples. Seroconversion was significantly less frequent in couples who shared more than one human leukocyte antigen [one of five (20%) versus 13 of 16 (81%), P < .02].

RESULTS

Twelve of 16 women (75%) who became pregnant had live children and five of those have had a second live child. All 12 women who achieved successful pregnancies had become antipaternal cytotoxic antibody-positive after immunization, whereas all four patients who had repeat abortions had failed to seroconvert (P < .001). However, this relationship is not necessarily causative, as the successful group also tended to have fewer previous abortions and less human lymphocyte antigen sharing.

CONCLUSION

Except for transient illness after immunization, one moderately small for gestational age baby and one premature labor at 32 wk, no complications were observed after immunization.

Interferon plus tamoxifen treatment for advanced breast cancer: in vivo biologic effects of two growth modulators

The effects of interferon-alpha (IFN) plus tamoxifen (TMX) in the treatment of advanced breast cancer were assessed. Changes of in vivo biologic determinants including hormone receptors, P24 protein, Ki-67 and growth factor expression were evaluated. Seven patients with advanced, heavily pretreated, breast cancer with accessible disease, underwent biopsy prior to and after sequential treatment with IFN and IFN plus TMX. Clinically 4/7 patients responded to treatment with one complete and three partial remissions. Apart from the favourable response rate the sequential in vivo changes in expression of tumour variables were of considerable interest. IFN treatment consistently increased the expression of the estrogen receptor (ER) and of the estrogen regulated protein P24 while decreasing the expression of the proliferation associated antigen Ki-67. Addition of TMX on the other hand resulted in a reduction of ER expression to pre-IFN levels and a rise in progesterone receptor (PR) expression. When the effect of either IFN or IFN plus TMX on the expression of two growth factors was assessed they were found to be somewhat variable. While PDGF expression tended to be suppressed, there was no clinical correlation with response to therapy. TGF beta expression was found in all patients prior to treatment and while all non-responders showed reduction of TGF beta following treatment, the alterations were variable amongst responders (including two patients with increased expression, one with no change, and one with decreased expression). It is concluded that both IFN and TMX exert multiple effects on the expression of tumour biologic variables and that while the study confirmed some of the predictions from in vitro models, the in vivo effect are more complex than has been appreciated from the models. From the clinical point of view, it might be expected that treatment which enhances the expression of ER in tumours should have a positive effect on the response to TMX.

NOPE for relapsed aggressive diffuse non-Hodgkin's lymphoma

Forty three patients with relapsed, diffuse aggressive lymphoma (Working Formulation Categories G to J) were treated with a combination chemotherapy regimen consisting of mitoxantrone 10 mg/m2 iv day 1, vincristine 1.4 mg/m2 iv day 1 and 14, prednisolone 50 mg/m2 p.o. days 1-5 and etoposide 100 mg/m2 p.o. days 1-5 of each cycle (NOPE). Fourteen patients (34%) achieved complete remission and another 6/43 (15%) achieved a partial response. Factors which significantly affected response were the presence of early stage, absence of systemic symptoms, non-bulky disease and serum LDH value < 350 IU. Four patients are alive and in complete remission from 25+ to 45+ months after completion of therapy. Duration of response and survival was significantly influenced by the duration of the initial response to first chemotherapy. NOPE is an active and safe treatment regimen with a substantial complete remission rate in patients with relapsed non-Hodgkin's lymphoma.

Lack of involvement of T-lymphocytes in the leukaemic population during prolonged chronic phase of Philadelphia chromosome positive chronic myeloid leukaemia

Nine patients with prolonged (> 2 years) chronic phase chronic myeloid leukaemia (CML) were investigated for the presence of T-cell involvement in the leukemic clone. Pure populations of peripheral blood T-cell populations were obtained by culturing separated mononuclear cells in the presence of pokeweed mitogen and IL2, until cultures showed > 99% pure T-cells. Purified T-cells and bone marrow and peripheral blood hematopoietic precursors were analysed for the presence of bcr-abl mRNA transcripts following RNA extraction and message amplification using polymerase chain reaction. In none of the 9 patients was bcr-abl mRNA found in T-lymphocytes while in all cases such transcripts were found in bone marrow and peripheral blood hematopoietic cells. Failure to detect T-cell involvement in patients with prolonged chronic phase CML using techniques designed to enhance even low level involvement of these cell populations supports the view that acquisition of the Ph chromosome abnormality does not occur in the totipotent stem cells but in more committed precursor cell/s with multilineage capacity but which only rarely retain the capacity for T-cell differentiation.

Kaposi's sarcoma after alpha-interferon treatment for HIV-negative T-cell lymphoma

A 54-year-old HIV-negative patient suffering from T-cell lymphoma of Lennert's lymphoma (Lel) type was treated for 13 months with interferon alpha-2b. While on treatment with interferon the patient demonstrated suppression of total and CD4+ lymphocytes to levels < 0,5 and 0,2 x 10(9)/l, respectively. Although interferon was successful in controlling the lymphoma the clinical course was complicated by the rapid development of aggressive, fatal Kaposi's sarcoma shortly after cessation of interferon treatment. It is suggested that the immunosuppressive effect of interferon therapy (or the T-cell lymphoma or both) may have played a role in the development of Kaposi's sarcoma as a second malignancy.

Tissue platelet derived-growth factor (PDGF) predicts for shortened survival and treatment failure in advanced breast cancer

In a study of plasma and tissue platelet derived growth factor (PDGF) concentration in patients with breast cancer, elevated levels of plasma PDGF were found in a significant proportion, 11/37 (30%), of patients. Sixteen patients (43%) had tumors which expressed PDGF-AA and 6 patients had tumors which in addition expressed the BB isoform of PDGF. All patients with elevated plasma levels of platelet derived growth factor had tumors which expressed the growth factor on immunohistochemical staining of tumor cells. Furthermore there was a significant correlation between plasma levels of platelet derived growth factor and the intensity of tissue staining. Patients with stage four breast cancer with tumors which were positive for platelet derived growth factor had a significantly lower response rate to chemotherapy as well as significantly shorter duration of survival. In addition, patients with stage four breast cancer who had elevated plasma PDGF levels had a significantly shorter survival. These results indicate that elevated plasma levels of platelet derived growth factor in patients with breast cancer are derived from the tumor cells and suggest that platelet derived growth factor may play a significant role in control tumor cell growth.

Interferon-alpha induced autoimmune hepatitis in a patient with Philadelphia chromosome-positive chronic myeloid leukemia with cytogenetically normal T lymphocytes

We report the occurrence of autoimmune hepatitis after treatment with interferon-alpha in a patient with Philadelphia chromosome-positive chronic myeloid leukemia. Cytogenetic and molecular genetic studies of the T lymphocytes in this patient demonstrated that the T lymphocytes were not part of the leukemic clone. The role of interferon in the production of autoimmune abnormalities is reviewed.

Erythropoietin response in anaemic patients with multiple myeloma and other lymphoid malignancies infiltrating the bone marrow

Immunoreactive erythropoietin levels were measured in 42 patients with lymphoid malignancies with anaemia and bone marrow involvement. Results were compared to a control group of 16 patients suffering from anaemia due to other causes. Significant inverse correlations between serum erythropoietin level and haemoglobin concentration were shown for the patients with lymphoid malignancies and also for the control subjects. Overall, the erythropoietin levels of patients with lymphoid malignancies with bone marrow infiltration and with normal renal function did not differ significantly from erythropoietin levels of the anaemic controls. We conclude that anaemia in patients with lymphoproliferative disorders with bone marrow infiltration and normal renal function is caused primarily by a diminished/inadequate response to erythropoietin at the level of the target cell.

High-dose chemotherapy: therapeutic potential in the age of growth factor support

The steep dose-response curve for most chemotherapeutic drugs and the need to overcome tumor resistance has resulted in renewed interest in the use of high-dose chemotherapy. Bone marrow rescue has allowed the dose-limiting barrier of hematopoietic suspension to be overcome. However, despite such salvage methods and the use of blood products and effective antibiotics, myelosuppression remains a major obstacle to treatment. The use of recombinant colony-stimulating factors in combination with bone marrow following high-dose chemotherapy may well shorten the period of neutropenia and reduce the frequency of neutropenia-related complications, thus making high-dose treatment more acceptable.

Plasma lactoferrin content in neutropenic patients: effects of treatment with recombinant granulocyte-macrophage colony-stimulating factor

Plasma lactoferrin content was measured before and after therapy with recombinant granulocyte-macrophage colony-stimulating factor in five patients with aplastic anaemia, six with myelodysplasia, and three with prolonged, severe, chemotherapy-induced neutropenia. Before therapy plasma lactoferrin content was uniformly low. However, patients with aplastic anemia and those with chemotherapy-induced neutropenia had a normal lactoferrin:neutrophil ratio. The low levels of plasma lactoferrin thus reflected the low granulocyte mass. On the other hand, patients with myelodysplasia also had reduced lactoferrin:neutrophil ratios, suggesting qualitative/quantitative abnormalities of neutrophil lactoferrin production. After treatment with granulocyte-macrophage colony-stimulating factor, plasma lactoferrin levels increased in patients with aplastic anemia and in those with chemotherapy-induced neutropenia who showed a neutrophil response to treatment. In these patients, the lactoferrin:neutrophil ratio became elevated, suggesting increased synthesis/release of lactoferrin from neutrophils. However, patients with myelodysplasia continued to show depressed lactoferrin:neutrophil ratios, even when there had been an increase in granulocyte count, suggesting persistent abnormalities of neutrophil lactoferrin production/release. The implications of these findings for treatment of neutropenic patients with granulocyte-macrophage colony-stimulating factors are discussed.

Prognostic factors in chronic myeloid leukaemia--importance of staging or disease biology

The presenting clinical, haematological and cytogenetic features of 215 patients with a haematological diagnosis of chronic myeloid leukaemia (CML) were analysed with a view to defining prognostic factors. Of the 215 patients, 166 (77%) were found to be Philadelphia chromosome (Ph')-positive. The frequency of Ph' and complex Ph' abnormalities was similar for black and white patients. Black patients, however, had a significantly higher frequency of additional clonal chromosome abnormalities at presentation compared with whites (15/87 v. 1/79). Blacks also tended to present with more advanced disease, lower haemoglobin values, higher white cell counts, larger spleens and a higher frequency of lymphadenopathy and leukostasis. Median duration of survival from diagnosis of Ph'-positive patients was 44 months for whites and 30 months for blacks. The poorer survival of the black patients was in part accounted for by the poor survival of patients with additional clonal chromosomal abnormalities over and above Ph'. Black patients with only simple Ph' or complex Ph' had a similar survival to whites. In a multivariate analysis, the significant factors determining survival were: (i) the presence of additional clonal chromosomal abnormalities; and (ii) peripheral blast count over 5%, platelet count outside the normal range and haemoglobin value less than 10 g/dl. These factors defined subgroups of patients with median survival ranging from 12 months to 62 months. The inclusion of patients with variable prognoses needs to be taken into account when evaluating the results of new treatment modalities for CML.

High-dose etoposide in treatment of metastatic breast cancer

High-dose etoposide (1,500-2,500 mg/m2) was used for the treatment of 23 previously treated patients with advanced breast cancer. Six of 23 (26%) showed objective regression with a median duration of response of 5 months. Responses were seen at all sites apart from bone. Response was related to dose level with 11/23 responses of measurable lesions occurring at doses greater than or equal to 2,000 mg/m2 as compared to 2/23 responses at a dose of 1,500 mg/m2. The treatment regimen was able to be given on an outpatient basis with only routine supportive measures. High-dose etoposide may come to play a role in high-dose combination chemotherapy regimens for advanced breast cancer.

Platelet-derived growth factor (PDGF) in plasma of breast cancer patients: correlation with stage and rate of progression

Plasma levels of platelet-derived growth factor (PDGF) were measured in 58 female patients with breast cancer and in 9 normal female control subjects by means of a specific radioimmunoassay. Levels in normal control subjects were all below the lower limits of detection by the assay (1.56 fmol/100 microliters plasma). Two of 17 (12%) patients with stage 2 breast cancer had detectable plasma levels. Among patients with Stage 4 breast cancer 13/41 (32%) had significantly elevated levels (greater than 2 times the lower limit of sensitivity of the assay). Patients with elevated PDGF levels had a significantly greater degree of metastatic involvement and significantly shorter survival. Apart from being a marker of aggressive high bulk breast cancer, PDGF may be involved in the acceleration of growth of some metastatic breast tumors.

In vitro maintenance of a new ovarian cancer cell line in protein-free media: a potential model for autonomous growth and tumor progression

A new cell line UWOV2 (pf) capable of long-term growth in the absence of any added serum protein, exogenous growth factor, insulin or transferrin, is described. The original cell line (UWOV2 and UWOV2 (sf), adapted to grow in serum-free conditions) was derived from the ascitic tumor of a patient with ovarian carcinoma. Under continuous culture conditions further adaptations have occurred enabling UWOV2 (pf) to maintain anchorage-dependent growth without requiring exogenous anchorage or growth factors. These cells produce a structured extracellular matrix which acts as an adhesive substrate for the UWOV2 (pf) cells themselves as well as for a number of other long-term cell lines including NRK and 3T3 cells. Furthermore, while UWOV2 (pf) cells produce a transforming growth factor beta (TGF beta)-like growth factor, they appear to be only partially dependent on autocrine growth stimulation, and other mechanisms for autonomous growth stimulation appear to exist. This cell line may be a useful model for the study of progressive growth autonomy in human tumors.

Treatment of malignant ascites due to recurrent/refractory ovarian cancer: the use of interferon-alpha or interferon-alpha plus chemotherapy in vivo and in vitro

Intraperitoneal treatment with interferon (IFN) for malignant ascites due to advanced ovarian carcinoma refractory to chemotherapy gave an objective response rate of 36% (7/19 patients treated). In vitro studies demonstrated that cytotoxicity of peripheral blood monocytes/macrophages was stimulated by IFN. However, peritoneal exudate cells obtained after intraperitoneal treatment with interferon were not stimulated to kill autologous tumour cells. Clinical response was therefore most probably due to a direct inhibitory effect of IFN on growth of malignant cells rather than due to an immune modulatory effect. Using a newly established ovarian cancer cell line (UWOV1), synergy between the growth inhibitory/antitumour effects of IFN and cisplatin was demonstrated at clinically achievable concentrations of each agent. IFN plus cisplatin proved to be more effective than intraperitoneal cisplatin alone in control of peritoneal carcinomatosis. The response rate was 5/7 (77%) for combined modality therapy vs. 2/9 (22%) for intraperitoneal chemotherapy alone. Both in vitro and in vivo studies suggest a role for interperitoneal therapy for control of refractory ascites in ovarian cancer.

Interferon (IFN) alpha inhibits cell proliferation of UWOV2 cells without down-regulation of transferrin receptors

It has been suggested that growth inhibition of cells by interferons may be mediated through interferon induced down-regulation of transferrin receptor expression. We describe a continuously growing cell line UWOV2 (pf) which expresses cell surface transferrin receptor but is able to grow in the absence of transferrin. This cell line is sensitive to the growth inhibitory effects of interferon alpha. Interferon alpha induced growth inhibition is not, however, accompanied by modulation of transferrin receptor expression suggesting that transferrin receptor modulation is not an essential component of the growth inhibitory effect of interferons.

The value of estrogen and progesterone receptor determinations in advanced breast cancer. Estrogen receptor level but not progesterone receptor level correlates with response to tamoxifen

Four hundred fifteen patients with metastatic breast cancer with known hormone receptor status received primary treatment with tamoxifen. Measured values for the estrogen receptor (ER, i.e., with estrogen binding) followed a continuous distribution (range, 3 to 1000 fmol/mg of protein). These values correlated positively with age. The response to treatment with tamoxifen correlated with the ER level, with response rates of approximately 80% when the ER level was greater than 30.1 fmol/mg of protein. Two hundred eighteen (218 of 415, 52%) patients had progesterone receptor (PR) values greater than 10 fmol/mg. The PR positivity correlated with the ER level. Patients with PR levels greater than 10 fmol/mg of protein (124 of 226, 55%) had a significantly higher response rate than those with values less than 10 fmol/mg of protein (45 of 189, 24%). However, in a multivariate analysis including both receptor levels, age, site, and number of metastases, only the ER level was significant in predicting the response to treatment with tamoxifen. A quantitative estimation of the ER level thus is the best predictor of response to hormonal treatment with tamoxifen for advanced breast cancer.

Effects of alpha-interferon on iron-related measurements in human subjects

Subcutaneous administration of alpha-interferon to normal volunteers caused hypoferraemia and hyperferritinaemia. There was, however, no concomitant rise in other components of the acute-phase response, including the serum C-reactive protein value, the granulocyte count and the plasma lactoferrin concentration. In fact, the latter two dropped significantly. The hypoferraemic response could be prolonged when a second dose was given 48 hours after the initial one. This hypoferraemic response may play a role similar to that induced by interleukin-1, which limits the proliferation of invading micro-organisms or neoplastic cells. The present findings may therefore have relevance to the clinical mechanism of action of the interferons.

Tumor factors predicting for prognosis in metastatic breast cancer. The presence of P24 predicts for response to treatment and duration of survival

Fifty-one patients with metastatic breast cancer were investigated to determine tumor parameters with prognostic significance. Investigations included determinations of P24 content by immunocytochemical means using a monoclonal antibody to P24 protein; immunocytochemical analysis of estrogen and progesterone receptors; ploidy analysis by flow cytometry, and histologic grading. There were significant correlations between the presence of P24 and estrogen receptor, between histologic grade and P24 expression, and between estrogen and progesterone receptors. Of the tumor factors investigated only P24 protein was, however, of prognostic significance. Patients with P24-positive tumors had a significantly higher rate of response to treatment as well as more prolonged duration of response and duration of survival from diagnosis of metastatic disease. None of the other variables investigated were significantly predictive of outcome. P24 protein may be a useful predictor of prognosis in metastatic breast cancer.

Estimation of PR and ER by immunocytochemistry in breast cancer. Comparison with radioligand binding methods

Immunocytochemical assays for progesterone receptor (PR) using monoclonal antirabbit PR antibodies (PR-ICA) and for estrogen receptor (ER) (ER-ICA) were compared with radioligand binding (dextran-coated charcoal [DCC]) methods for receptor determination in patients with breast cancer. Immunocytochemical staining for PR was exclusively nuclear in localization. In this regard, PR staining is similar to previous findings for ER; PR-ICA showed a sensitivity of 89% and specificity of 100%. ER-ICA was also 89% sensitive and similarly specific. There was good correlation between the degree and intensity of staining and quantitative binding of radioligand. Receptor-positive tumors, however, show considerable variation of immunocytochemical staining, suggesting heterogeneity of cellular PR content. The availability of an immunocytochemical assay for PR increases the discriminatory potential for these methods of receptor determination.

Effect of alpha-interferon, 17 beta-estradiol, and tamoxifen on estrogen receptor concentration and cell cycle kinetics of MCF 7 cells

The interaction of alpha-interferon, 17 beta-estradiol, and tamoxifen on estrogen receptor content, growth fraction, proliferative rate, and total protein synthesis of MCF 7 cells was investigated under culture conditions (minus phenol red and at low concentrations of "stripped" fetal calf serum) allowing for direct stimulation of proliferation by estrogens. Exposure to estradiol alone resulted in a decrease of estrogen receptor content as measured by immunoassay, an increase of the proportion of cells in S phase, and increases in cell proliferation as well as total protein synthesis. alpha-Interferon treatment resulted in cell cycle arrest with reduced proliferation, an increase of estrogen receptor content, but a decrease in the rate of total protein synthesis. Pretreatment with alpha-interferon inhibited the estrogen induced stimulation of cell growth as well as the associated decrease of estrogen receptor content. Tamoxifen treatment resulted in decreased cell proliferation and decrease of estrogen receptor content and of total protein synthesis. These results suggest that the estrogen receptor concentration of MCF 7 cells is growth fraction related. Pretreatment with alpha-interferon enhanced the inhibitory effect of tamoxifen on cell proliferation while preventing the tamoxifen induced reduction of estrogen receptor content. The synergistic effect of alpha-interferon and tamoxifen are most marked following 72 h pretreatment with interferon, when the maximum interferon induced increase of estrogen receptor concentration is evident. The mechanism is thus due probably to an increase of cellular receptor as a ligand for tamoxifen binding and suggests a possible role for the clinical use of interferons combined with tamoxifen.

Mitoxantrone for refractory and relapsed acute leukemia

Seventy-seven patients with relapsed or refractory acute leukemia and three with acute blastic chronic myeloid leukemia (CML) were treated in an open Phase II study using mitoxantrone 12 mg/m2 intravenously daily X 5 days. Complete remission (CR) was achieved in 32 of 80 (40%), including 23/45 (52%) with relapsed acute nonlymmphocytic leukemia (ANLL), four of 12 (33%) with relapsed acute lymphocytic leukemia ALL, four of 17 (24%) with ANLL refractory to daunorubicin + cytosine arabinoside, and one of three (33%) with refractory ALL. None of the patients with acute blastic CML achieved CR. Median survival time for all patients was 121 days. Median duration of complete response was 303 days with ten of 32 patients in continuing CR for periods varying from 44+ to 1210+ days. Apart from moderately prolonged hematologic suppression toxicity was mild and subjective side effects were tolerable. Mitoxantrone is an active agent in the treatment of acute leukemia and demonstrates incomplete cross resistance with duanorubicin. Mitoxantrone should be considered for first-line therapy in ANLL.

Treatment of stage D2 prostatic cancer refractory to or relapsed following castration plus oestrogens. Comparison of aminoglutethimide plus hydrocortisone with medroxyprogesterone acetate plus hydrocortisone

A total of 59 patients with advanced prostate cancer relapsed from or refractory to castration plus oestrogen were treated in a randomised trial comparing 1000 to 1250 mg aminoglutethimide + 40 mg hydrocortisone (AG + HC) with 500 mg medroxyprogesterone acetate + 40 mg hydrocortisone (MPA + HC). A significantly higher objective response rate and better symptomatic control was noted in patients treated with AG + HC (31%) compared with those treated with MPA + HC (3%). The median time to treatment failure was also significantly longer for patients treated with AG + HC. These findings suggest a role for AG in the treatment of advanced prostate cancer. While both second-line hormone treatment regimens resulted in significant suppression of adrenal androgen secretion, the differences in response rate could not be explained by alterations in peripheral blood hormone levels. AG in high doses may have cellular effects which require further study.

Response to second-line hormone treatment for advanced breast cancer. Predictive value of ploidy determination

Twenty-two patients who previously responded to first-line hormonal therapy were evaluated for factors which would predict for response to second hormonal manipulation. Investigations performed at progression after initial hormone response included immunocytochemical estimation of estrogen and progesterone receptors as well as flow cytometric analysis of tumor ploidy. Approximately 50% of patients were found still to be estrogen receptor positive at relapse from first-line hormone treatment. Progesterone receptor had, however, usually become negative. Nine of the 22 patients responded to second-line hormonal therapy. Second hormone responses occurred with equal frequency among hormone receptor-positive and hormone receptor-negative patients. Tumor ploidy, as determined by flow cytometric study did, however, predict for response. Eight of 12 patients with diploid tumors responded to second-line hormone therapy whereas only one of ten with aneuploid tumors responded. Flow cytometric analysis appears to be a promising technique for prediction of second hormone response after relapse from first-line hormone manipulation.

Detection of P24 protein in human breast cancer: influence of receptor status and oestrogen exposure

The expression of oestrogen regulated protein, P24, was investigated in 69 breast cancers. At initial evaluation P24 protein was detected significantly more frequently and was present in significantly higher concentration in oestrogen receptor positive than in receptor negative tumours. There was, however, no correlation between P24 staining and progesterone receptor, tumour ploidy or proliferative index. Nineteen patients received a short course of treatment with diethylstilboestrol. Following treatment with oestrogen, P24 staining became positive in 7/13 tumours previously negative for P24, including six tumours which were oestrogen receptor negative. Oestrogen administration also caused an increase of the proliferation index in 12/19 tumours, including 5/7 that were oestrogen receptor positive and 7/12 that were oestrogen receptor negative. In some instances oestrogenic stimulation of proliferation occurred together with increased P24 expression; in other instances proliferation index increased without induction of P24 synthesis. The in vivo effects of oestrogen in clinical breast cancer thus appear to show dissociation between enhancement of protein synthesis and cellular proliferation.

The promotive effect of soy sauce on iron absorption in human subjects

The effects on iron absorption of a traditionally fermented Japanese soy sauce added to soy and rice meals were assessed. The addition of soy sauce to a soy flour meal could not overcome the strong inhibition of iron absorption (geometric mean absorption 7.2 per cent with soy sauce vs. 8.7 per cent without, P = 0.5). However, soy sauce added to a rice meal instead of soy flour significantly improved the geometric mean iron absorption (13.9 per cent with soy sauce vs. 5.2 per cent with soy flour, P = 0.002) and had a promotory effect on absorption from a rice meal alone (11.4 per cent with soy sauce vs. 3.5 per cent without, P = 0.0002). Although soy sauce contains appreciable amounts of organic acids, the addition of 340 mg lactic acid to rice did not enhance iron absorption (3.1 per cent with lactic acid vs. 2.2 per cent without, P = 0.11). The promotory effect of soy sauce on iron absorption appears to be due not only to its lack of soy protein content but may also be due to the presence of fermentation products other than organic acids.

Establishment and characterization of two new human ovarian cancer cell lines UWOV1 and UWOV2 and a subline UWOV2 (Sf) growing in serum-free conditions: growth characteristics, biochemical, and cytogenetic studies

The establishment, growth, and characterization of two new continuously growing human ovarian cancer cell lines (UWOV1 and UWOV2) as well as a subline (UWOV2 Sf) grown in chemically defined, serum-free medium are described. The cell lines were derived from ascitic tumors of two patients suffering from cystadenocarcinomas of the ovary. Both UWOV1 and UWOV2 lines grow in anchorage-dependent fashion as monolayers, whereas UWOV2 (Sf) forms multilayered domelike structures. Cytogenetic studies revealed nonrandom abnormalities involving chromosomes 1 and 11 in all three cell lines. Secretion of soluble collagen was detected in all three lines. In addition, UWOV2 (Sf) produces and secretes large amounts of extracellular matrix material with an ordered fibrillar structure which may function as an attachment factor for the serum-free cells. These cell lines seem to be useful for further studies of the biology of human ovarian cancer.

Light chain restriction analysis of bone marrow plasma cells in patients with MGUS or 'solitary' plasmacytoma: diagnostic value and correlation with clinical course

Twenty-eight patients with a diagnosis of 'solitary' plasmacytoma or with gammopathy but with nondiagnostic morphologic examination of the bone marrow were investigated using a short-term bone marrow culture technique which enriched for the plasma cell fraction. The percentage of monotypic plasma cells in these plasma cell enriched cultures was correlated with the subsequent clinical course. The majority of patients with plasmacytoma and a significant number of those with gammopathy but with otherwise non-diagnostic investigations were found to have a monoclonal plasma cell component of greater than 20%. There was a significant correlation between the percentage of monoclonal plasma cells as detected by bone marrow culture and subsequent progression to disseminated myeloma. These results indicate that early bone marrow involvement can be detected by means of plasma cell culture prior to morphologic identification of marrow plasmacytosis and that short-term plasma cell culture distinguishes patients with early, low bulk myeloma from those with monoclonal gammopathy of uncertain significance (MGUS).

Adriamycin cellular transport: methodological aspects

A rapid and simple method for determination of cellular uptake of adriamycin is described. The method is based on the principle that active uptake is proportional to alterations of drug distribution, measured as a fraction of time, between suspending medium and cells, the volume of each having been accurately determined. Cellular drug uptake can be calculated by the use of a simple distribution formula. This method represents a compromise between indirect measurement of the loss of drug from suspending medium and direct measurement of drug uptake following cell separation, washing, and lysis. This method should be applicable to the measurement of cellular uptake of a wide range of drugs.

Treatment of Hodgkin's disease with MOPP chemotherapy: effect of dose and schedule modification on treatment outcome

An analysis of the therapy details of 99 patients receiving primary MOPP chemotherapy for Hodgkin's disease revealed that treatment modification was a frequent occurrence. The mean cumulative dose calculated as a percentage of the projected ideal dose was 76%. Dose modifications of individual components of the MOPP combination were, however, variable and in part reflected disease-related factors, e.g. patients with stage 4 disease received significantly less vincristine than those with less advanced disease. An initial univariate analysis of factors influencing remission showed that the remission rate was significantly lower among those patients who had (a) liver involvement and (b) drug doses less than 75% of the ideal cumulative dose. Among the individual drug dosages, modification of the vincristine dose appeared to be the most significant treatment-related factor associated with lower remission rates. In a multivariate analysis where both disease-related and treatment-related factors were taken into account drug dosage remained a significant prognostic factor. The most important factors adversely affecting initial remission were the presence of liver involvement and reduction of the drug intensity index (cumulative dose divided by cumulative time). Disease-free survival was adversely influenced mainly by the presence of B symptoms and to a lesser degree, but still significantly, by a lower cumulative vincristine dose. Total survival was, however, influenced adversely only by the presence of B symptoms. The quality of MOPP therapy appears to play a significant role in determining the outcome of Hodgkin's disease.

High-dose 4'-epiadriamycin for treatment of breast cancer refractory to standard dose anthracycline chemotherapy: achievement of second responses

High-dose 4'-epiadriamycin chemotherapy (110-150 mg/m2) was administered to 18 patients (95 treatment cycles) with advanced breast cancer refractory to or showing progression after prior treatment with adriamycin containing combination chemotherapy regimens. Thirteen out of 18 patients showed an objective response to therapy including 1 with complete and 12 with partial response. Although haematologic suppression was profound (mean granulocyte nadir 0.3 +/- 0.1 x 10(6)/l) recovery was rapid and there was no evidence of cumulative haematologic toxicity. Cardiac toxicity was not encountered during therapy even after cumulative doses greater than 1,200 mg/m2 of anthracycline drugs. Although the response rate was high, response duration was short (median 5.8 months).

Plasma lactoferrin content in pregnancy

Plasma lactoferrin concentration, leucocyte count, serum prolactin concentration and storage iron status were studied in 313 women at various stages of pregnancy. The mean serum iron value, percentage saturation of transferrin and geometric mean serum ferritin concentrations decreased as pregnancy progressed. In contrast, the total iron-binding capacity showed a highly significant increase with advancing gestation. Plasma lactoferrin concentration showed a mild progressive increase during pregnancy (peaking 29-32 weeks). The increase in lactoferrin concentration was, however, disproportionately small when compared with the concomitant pregnancy-related elevation in leucocyte count. The ratio of plasma lactoferrin concentration to leucocyte count therefore appeared to be abnormally low during pregnancy suggesting an acquired defect of lactoferrin release by leucocytes of pregnant women. It is unlikely that prolactin was the factor responsible for the reduced leucocyte release of lactoferrin. The lactoferrin:leucocyte ratio was already significantly reduced early in pregnancy at a time when prolactin concentration was relatively low. Furthermore, the correlation between prolactin concentration and both lactoferrin concentration and lactoferrin:leucocyte ratio was positive. Pregnancy appears to be associated with an acquired abnormality of leucocyte degranulation, the cause of which is not clear at present.

Clinical relevance of immunophenotypic and immunogenotypic analysis in acute non-lymphoblastic leukaemia

Molecular biology is playing an increasing role in defining pathology today, and has clinical relevance in the routine work-up of patients with malignant diseases, especially those of the blood and lymphatic system. The majority of acute non-lymphoblastic leukaemias (ANLL) express specific myeloid differentiation markers and are terminal deoxynucleotidyl transferase (Tdt) negative. Rarely, some cases are Tdt+ and express the T-cell marker CD7. Although uncommon in Tdt-ANLL, there appears to be a significant incidence of T-cell receptor beta chain (TCR beta) and/or immunoglobulin heavy chain (IgH) gene rearrangements in Tdt+ ANLLs. We have investigated the immunogenotype of 39 patients with ANLL, including 28 from whom immunophenotypic data were available. Thirty-seven of 39 cases had germline IgH and TCR beta genes. Two cases, one with a myeloid/CD7+ CD2+ immunophenotype, had non-germline IgH gene arrangements detectable on Hind III digests only. The possibility of Hind III polymorphisms, or of true somatic gene rearrangement of the IgH gene in these patients, is discussed. Two additional cases had a Tdt+ CD7+ immunophenotype with germline IgH and TCR beta chain genes. Our results confirm the infrequent occurrence of IgH and TCR beta gene rearrangements in ANLL. Expression of Tdt and/or CD7, often in association with IgH gene rearrangements, would appear to identify a subgroup of ANLL patients that respond poorly to standard ANLL therapy and have a poorer prognosis. The diagnostic and prognostic importance of multiparametric analysis in ANLL is emphasised.

Intraperitoneal recombinant interferon-alpha 2b for recurrent malignant ascites due to ovarian cancer

Thirteen patients with malignant ascites due to recurrent ovarian cancer were treated with intraperitoneal interferon 2b (5 mu/m2 escalating to 15 mu/m2, administered twice weekly by indwelling intraperitoneal catheter). The study population included eight patients with ascites only and five patients with ascites plus tumor masses greater than 2 cm in diameter. Five of 13 responded to treatment. All the responses were seen in patients with ascites only. Although tumor mass was an important determinant of response there was also a correlation between clinical response and suppression of colony growth on soft agar after in vitro exposure of tumor cells to interferon-alpha (IFN alpha). The intraperitoneal use of IFN alpha should be explored further in tumors with a predominant intraperitoneal location and microimplantation growth pattern.

Adjuvant chemotherapy (CMF) for stage III breast cancer: a randomized trial

A randomized trial of the effect of adjuvant CMF chemotherapy in patients with Stage III breast cancer receiving primary local radiation or local radiation plus surgery, failed to reveal a survival benefit from early systemic treatment. The subset of premenopausal patients receiving chemotherapy did, however, show a significant prolongation of disease-free survival from 23 to 55 months. Overall survival of this subgroup was not increased. The study included the use of two dose levels of CMF to assess whether higher chemotherapy doses would be more effective. No dose effect was observed. Initial local control with radiation therapy or radiation plus surgery was achieved in the majority (90.9%). Distal recurrence and death from metastatic disease were the major causes of treatment failure. Treatment benefit among premenopausal patients was mainly delayed onset of distal metastatic disease. Among premenopausal patients, salvage therapy for metastatic disease appeared more effective in those not previously exposed to systemic treatment.

The routine diagnostic utility of immunoglobulin and T-cell receptor gene rearrangements in lymphoproliferative disorders

Immunophenotypic studies have a well-documented role in the assignment of lineage in the lymphoproliferative disorders. With the exception of mature B-cell disorders, it is difficult to demonstrate clonality by immunophenotypic studies. The advent of specific DNA probes for immunoglobulin and T-cell receptor genes has greatly facilitated the detection of clonality and, to a lesser degree, lineage, in these cases. The authors have evaluated the diagnostic utility of these probes and compared them with standard immunophenotyping in 65 patients with a variety of lymphoproliferative disorders. Their results show a significant correlation (P less than 0.01) between lineage assignment as determined by phenotyping and gene rearrangement studies, with the latter far superior in determining clonality. Furthermore, analysis of gene rearrangements facilitated the documentation of lineage and/or clonality in six cases in which standard techniques had failed. Although the scientific basis of the study of gene rearrangements has been well established, the authors wish to emphasize the role that these techniques have in evaluating problem cases in the routine diagnostic laboratory.

Lactoferrin from human breast milk and from neutrophil granulocytes. Comparative studies of isolation, quantitation, characterization and iron binding properties

The isolation and properties of lactoferrin from human breast milk and from neutrophilic granulocytes were investigated. Human breast milk lactoferrin was purified by means of heparin-sepharose or Cibacron Blue affinity chromatography. Quantitative recovery using these two methods was comparable but Cibacron Blue affinity chromatography allowed for isolation of a more homogenous protein. Lactoferrin could only be isolated from human neutrophilic granulocytes by sequential use of antibody affinity followed by non-specific affinity chromatography. Both breast milk lactoferrin and granulocyte lactoferrin were separated into apo and iron-rich species by SDS polyacrylamide gel chromatography. Iron binding is accompanied by a conformational change in tertiary structure associated with more rapid electrophoretic migration. The isoelectric point of both human breast milk lactoferrin and human granulocyte lactoferrin is 5.5-6.2. Both types of lactoferrin have similar iron binding properties with release of iron from the one binding site occurring at pH 5.2-6.0 while the other binding site holds on to iron down to pH 3.6-3.2. Despite the high affinity for iron the percentage saturation of native lactoferrin is low, that for breast milk lactoferrin averaging 12-25% and that for granulocyte lactoferrin less than 10%.

First-line chemotherapy of advanced breast cancer with mitoxantrone, cyclophosphamide and vincristine

Seventy-five patients with stage 4 breast cancer were treated with a first-line chemotherapy regimen consisting of cyclophosphamide 600 mg/m2, mitoxantrone 12 mg/m2, and vincristine 1.4 mg/m2 (CNV). Objective response was seen in 61/75 (81%) with 17/75 (23%) complete remission (CR). Median duration of response was 38 weeks overall and 51 weeks for patients achieving CR. CNV is an effective regimen for the treatment of advanced breast cancer.

Sequential hormonal therapy and sequential hormonal and chemotherapy for advanced prostatic cancer

Ninety-two patients with D2 prostatic cancer were studied. Initial treatment was with either diethylstilboestrol (DES) or orchidectomy. Response to DES (5/63, 81%) was significantly higher than for orchidectomy (18/29, 62%; p less than 0.01). However, duration of response and duration of survival were not significantly different for the 2 forms of hormonal therapy. Fifty-seven patients were randomised to receive second-line treatment with either medroxyprogesterone acetate (MPA), oral chlorambucil or combination chemotherapy (adriamycin + cyclophosphamide + 5-fluoro-uracil). Response to second-line treatment was similar for all 3 regimens (46% overall response). Most of the responses were disease stabilisation and, although there was symptomatic benefit, response to second-line therapy did not significantly improve survival compared to the survival experience of the group as a whole. It is concluded that palliative second-line treatment for advanced prostatic cancer should consist of the least toxic form of treatment which in this study was second-line hormone administration (MPA).

Lack of a significant independent effect of race on survival in breast cancer

In an analysis of 2033 patients with breast cancer from two population groups presenting to the Combined Breast Clinic of the Johannesburg and Hillbrow Hospitals, black patients were found to present with more advanced stage disease (P much less than 0.0001) and to have a poorer prognosis within each stage than whites (P less than 0.005- less than 0.001). Intrastage inhomogeniety was indicated by the finding that black patients had significantly more advanced T and N categories within stage grouping as compared to white patients (P = 0.013-P less than .001). A multivariate analysis controlling for age, T and N in nonmetastatic showed that when these factors were taken into consideration there was no significant independent effect of race on survival. The data indicate that the poorer prognosis which has been previously reported for black patients probably results from intrastage variability of disease bulk, supporting the use of the TNM rather that the stage grouping system for prognostication. Age differences also were evident when the two population groups were compared, with breast cancer in blacks appearing to present at an earlier age. Further analysis showed that these age differences were related to the age structure of the two populations and that breast cancer probably does not occur at a younger age in black subjects. Ethnic origin, does not appear to play a significant independent role in the prognosis of breast cancer in women.