Fixed versus response-adapted MOPP/ABVD chemotherapy in Hodgkin's disease. A prospective randomized trial

BACKGROUND

The optimal number of chemotherapy courses in responding patients with advanced-stage Hodgkin's disease (HD) is unknown.

PATIENTS AND METHODS

With minimizing chemotherapy and thereby reducing late complications as the objective, patients with advanced HD were randomized to receive either 4 full MOPP/ABVD courses or treatment up to complete remission (CR). Forty-seven patients were given the fixed (FT) and 41 patients the individual treatment (IT). The two groups were balanced according to age, histopathology and sex, although stage IVB dominated in the IT group (20 vs. 8).

RESULTS

Sixty-six of 88 patients (75%) achieved CR. No difference between the two treatment groups in the proportion of stage IVB patients was seen when those achieving CR, i.e., the efficacy population were compared. The mean number of single chemotherapy courses given was 3.7 of MOPP and 3.5 of ABVD in the FT group, compared to 2.6 of MOPP and 2.5 of ABVD in the IT group (p < 0.001). The predicted progression-free survival at 10 years was 81% in the FT and 68% on the IT arm, respectively (p < 0.05). No statistically significant difference in cause-specific 10 year survival was observed (82% and 83%, respectively; p = 0.18). Long-standing CRs were achieved following minimal chemotherapy.

CONCLUSIONS

Since there are no available methods to identify long-term disease-free survivors among CR patients following a limited induction treatment, we suggest that the policy of giving 3-4 full MOPP/ABVD courses should continue. The price for such an approach is the overtreatment of a subset of already cured patients.

Immune parameters in a longitudinal study of a very old population of Swedish people: a comparison between survivors and nonsurvivors

As a part of an ongoing longitudinal investigation, this study examined relationships between survival and selected immune system parameters in a sample (n = 102) of very old individuals (86-92 years at the time of initial immune system data collection). Analyses were performed comparing initial time-point measurements from those individuals who were alive (n = 75) and those who were deceased (n = 27) two years after initial data collection. Immune system measurements consisted of determination of peripheral blood lymphocytes and lymphocyte subsets, as well as T-cell responses to activation by Concanavalin A. Cluster analysis identified a subgroup associated with nonsurvival which indicated characteristics that included: poor T-cell proliferative responses, high CD8 percentages, and low CD4 and CD19 percentages. This multivariate analysis suggested that combinations of immune system parameters predict two-year survival otherwise not apparent when single immune system parameters were evaluated in the elderly.

Sequence analysis of echoviruses in a major antigenic region eliciting enteroviral cross-reactive antibodies

The amino acid sequence of an antigenic region known to elicit cross-reactive enteroviral IgG antibodies in VP1 is known for poliovirus and cox-sackievirus A and B. However, no corresponding data has been available for prevalent echovirus serotypes with great clinical impact. Such information was obtained by amplification of this region of the echovirus genome by PCR using biotinylated primers. The amplicon was subjected to solid phase sequencing using the dideoxy chain-termination method. Translated amino acid sequences for residues 26-55 of VP1 of the echoviruses revealed that the known cross-reactive region is highly conserved also in the echovirus serotypes.

Continuity and discontinuity in the anti-V3 IgG response of human immunodeficiency virus type 1-infected persons in a cross-sectional and longitudinal study using synthetic peptides

The principal neutralization domain (PND) of the V3 region of human immunodeficiency virus type 1 (HIV-1) gp120 is central to HIV pathogenesis. The IgG antibody response to PND was followed in 15 HIV-1-infected persons from southern Sweden over 2-5 years using 32 synthetic V3 peptides. Five peptides had amino acid sequences derived from isolates from each of 5 patients. Sera obtained simultaneously with isolate almost always reacted strongly with these cognate peptides; however, reactivity was undetectable in 1 patient's serum and short lived in the sera of another, indicating inducible holes in the antibody repertoire, which would facilitate dissemination of the corresponding virus strains. Reactivity to other V3 peptides correlated with sequence similarity to the cognate peptide. Strong, stable reactivity to peptides with sequences similar to a south Swedish V3-consensus was accompanied by transient activity to less similar ones. The latter may reflect viral variation, B lymphocyte clonal depletion, or both. Certain IgG responses appeared to preclude others, suggesting clonal dominance.

Fluorescence in situ hybridization analysis of whole-arm 7;12 translocations in hematologic malignancies

Cytogenetic analysis of one case of acute myeloid leukemia (AML), one of acute lymphoblastic leukemia (ALL), one of refractory anemia with excess of blasts (RAEB), and one of acute mixed lineage leukemia (AMLL) with unbalanced 7;12 translocations mapped the breakpoints to the centromeres on both chromosomes. The rearrangements were interpreted as the whole-arm translocations der(7;12)(q10;q10) in the AML and ALL and der(7;12)(p10;q10) in the RAEB and AMLL. However, further analysis by metaphase and/or interphase fluorescence in situ hybridization (FISH) showed centric fusion only in the AML and ALL. In the RAEB and AMLL, centromeric material from chromosome 7 but not from 12 was present in the derivative chromosome. Whereas the t(7;12) resulted in loss of 12p in all four cases, the corresponding chromosome 7 imbalances differed--monosomy for 7q in the RAEB and AMLL and monosomy for 7p in the AML and ALL. Six hematologic neoplasms with unbalanced whole-arm or near-centromeric 7;12 translocations and seven dic(7;12) with juxtacentromeric breakpoints have been reported previously: 2 AML, 1 RAEB in transformation, and 10 ALL. All karyotypically informative cases had loss of 12p material. All but one of the cases with combined 7p and 12p deletion were ALL, whereas all cases with 7q and 12p loss showed myeloid differentiation. No particular clinical, morphologic, or immunophenotypic features seem to characterize ALLs with t(7;12). AMLs with an unbalanced t(7;12), often together with 5q deletions, might be associated with previous genotoxic exposure and poor prognosis.

Implications of human papillomavirus type for survival in cervical squamous cell carcinoma

In a Swedish series of 107 invasive squamous carcinomas of the cervix, DNA extraction from paraffin-embedded material was successful in 97 cases. The prevalence of human papillomavirus (HPV) in this material was 86.6%, as determined by polymerase chain reaction (PCR) using both consensus and type-specific primers. HPV type 16 was most common (42.3%; other types were 31 (12.3%), 18 (9.3%) and 33 (10.3%). Seventeen cases (17.3%) were positive for the consensus primers only and were regarded as HPV of unknown type. There was no significant difference in corrected survival between patients with HPV-positive or -negative tumors. In the HPV-positive group, patients with tumors containing HPV 33 or HPV 18 had a significantly poorer prognosis than patients with tumors containing other types of HPV DNA (relative hazard 3.18, 95% confidence interval 1.37-7.39, P = 0.007), implying a prognostic significance of HPV type.

Adenosine A2A receptors stimulate acetylcholine release from nerve terminals of the rat hippocampus

The nature of the adenosine receptors involved in the enhancement of acetylcholine release in the hippocampus was studied. The A2A agonist, CGS 21680, increased the veratridine-evoked release of [3H]acetylcholine from hippocampal synaptosomes. This presynaptic effect of CGS 21680 was greater at 3-30 nM than at 100 nM. The excitatory effect of CGS 21680 was antagonised by the A2 antagonist, DMPX (10 microM), and by the A2A antagonist, CSC (200 nM), but not by the A1 antagonist, DPCPX (20 nM). We also found co-expression of A2A and choline acetyltransferase mRNAs in the nucleus of the diagonal band and the medial septum, where the cholinergic cell bodies that project into the hippocampus are located. These results indicate that A2A adenosine receptors are present in cholinergic nerve terminals in the hippocampus and that activation of these receptors enhances acetylcholine release.

Thoracic herniation and intrathoracic gastric perforation after laparoscopic fundoplication

This case report describes a serious complication after laparoscopic Rosetti fundoplication. Two days postoperatively the proximal part of the stomach herniated into the thoracic cavity where a gastric perforation caused leakage. The patient was reoperated and a new fundoplication was constructed. Postoperatively the patient recovered. Possible mechanisms are discussed.

Polymerase chain reaction for the early diagnosis of cytomegalovirus hepatitis in liver transplant patients

BACKGROUND

In liver transplant (LTX) patients, cytomegalovirus (CMV) hepatitis as a cause of graft dysfunction occurs in 15-25% of the patients. Polymerase chain reaction (PCR), applied to liver biopsy specimens, may increase the ability to detect CMV DNA at a local site. In this study, PCR was used to compare its relation to the development of clinical CMV hepatitis.

STUDY DESIGN

Nested polymerase chain reaction (nPCR), derived from a conserved region of the CMV major immediate-early gene, was used to examine 141 frozen liver biopsies from 61 LTX patients for the presence of CMV DNA. 134 biopsies were obtained from 54 patients with pathological liver function tests within four months after transplantation. The remaining seven patient biopsies were derived from the one-year investigation after LTX and served as controls. The results were compared to virus isolation, antigen detection by immunohistology and in situ hybridization for CMV DNA of the biopsy specimens. Histological examination was performed to verify a diagnosis of viral hepatitis.

RESULTS

CMV DNA was amplified in 11% (15/134) of the biopsies, corresponding to 20% (11/54) of the patients. Virus isolation revealed CMV in 5% (7/134) of the samples. None of the nPCR-negative biopsies was virus culture positive. CMV genomes were detected by nPCR more frequently than CMV hepatitis was diagnosed by using the combination of CMV-specific histopathology and/or immunohistology and/or CMV-positive virus isolation (p < 0.01). However, when this comparison was performed within individual patients, the difference was not significant (p > 0.05). If the results of in situ hybridization were included in the diagnostic criteria of CMV hepatitis, the nPCR was comparable to these, both at the biopsy and the patient levels (p > 0.1 and p > 0.05, respectively). For the diagnosis of CMV hepatitis the negative predictive value of CMV-nPCR was 1.0. The positive predictive value ranged from 0.55 to 0.82 depending on the criteria of CMV hepatitis. The nPCR also detected signs of CMV infection in the liver graft earlier than virus isolation, 11 versus 21 days, respectively, after transplantation.

CONCLUSION

The frequency of CMV DNA positivity, measured by nPCR, was similar to that revealed by other combined methods. We suggest that the combined findings of histological cholangitis and/or lobulitis together with nPCR for CMV DNA can be used as a diagnostic criterion for initiation of antiviral treatment against CMV hepatitis.

Cytogenetically detected clonal heterogeneity in a duodenal adenocarcinoma

A primary duodenal adenocarcinoma, a tumor type for which no previous chromosome data existed, was cytogenetically analyzed after short-term culture. The main tumor mass was localized in the pancreatic head, but the histopathologic examination revealed its duodenal origin. A total of six abnormal, karyotypically unrelated, clones were identified. The largest exhibited clonal evolution and consisted of two subclones with massively rearranged karyotypes in the hypodiploid and hypotetraploid range. Chromosome imbalances brought about by these complex changes were gain of 1q, losses of chromosomes 6 and 9, and total or partial losses of 1p, 3p, 3q, 9p, 10p, 17p, 17q, 18q, 20p, and 20q. The remaining five smaller clones had 1-2 numerical or balanced structural chromosome aberrations. The present study thus revealed yet another epithelial tumor type characterized by karyotypically unrelated clones. For this as for other tumors, the pathogenetic significance of such cytogenetic polyclonality remains uncertain.

Waldenström's macroglobulinemia with the AML/MDS-associated t(1;3)(p36;q21)

Two unusual, and perhaps causally related, clinical and cytogenetic features in a patient with Waldenström's macroglobulinemia are presented. Firstly, during the progression of the primary macroglobulinemia bone destruction and hypercalcemia occurred. Secondly, a t(1;3)(p36;q21) was found as the sole clonal chromosomal abnormality. This translocation is characteristic of acute myeloid leukemia (AML) and myelodysplastic syndromes with a high propensity for progressing to AML. The t(1;3) has previously never been reported in a lymphoproliferative disorder. Since the abnormality is associated with acute transformation of cells of the myelopoietic lineages, it is possible that the t(1;3), found in cells of lymphoid origin in the present case, not only induced the neoplastic process as such but also brought about the unusually malignant tumor progression.

Immune-mediated complications in patients with myelodysplastic syndromes--clinical and cytogenetic features

It has been recognized in recent years that some patients with myelodysplastic syndromes (MDS) develop immune-mediated complications (IMC), but little is known about the correlations to MDS-specific disease features. In a retrospective study of 82 MDS patients, we identified 10 (12%) with IMC (group A) and compared them to the remaining 72 cases (group B). Group A consisted of 5 patients with biopsy-verified skin vasculitis and 1 case each with temporal arteritis/polymyalgia rheumatica, necrotising panniculitis, Hashimoto's thyroiditis, autoimmune thrombocytopenia, and Sweet's syndrome. Survival times, sex ratio and distribution of MDS subtypes were similar in the two groups. The patients in group A were younger than those in group B (median 66 vs. 76 years, p < 0.01). Four patients (40%) in group A had a history of previous genotoxic therapy for malignant disorders. The bone marrow karyotype was evaluated in 62 patients. Clonal chromosomal abnormalities were found more frequently in Group A than in group B (8/9 vs. 26/53, p = 0.03), and complex karyotypes, i.e., three or more aberrations, were also observed to be more common in group A (3/9 vs. 8/53). The results indicate that IMC preferentially develop in patients with secondary MDS, in younger MDS cases, and in patients with cytogenetic abnormalities.

HPV detection in cytological cases with condylomatous or dysplastic changes: a study with PCR and in situ hybridization on cytological material

Cytobrush samples of 80 patients, who previously had a cytological or histopathological diagnosis of condyloma and/or dysplasia were investigated for human papillomavirus infection (HPV) by polymerase chain reaction (PCR) and in situ DNA hybridization technique (ISH). The results were compared with concomitantly obtained cytological Pap-stained smears or, in some cases, histological sections. The time between the diagnosis of the original and the concomitant cytology/histopathology was less than 1 yr. Six additional patients had similar morphological diagnoses 2-4 yr before. Five more cases were included on clinical diagnosis of HPV. Compared with the original morphological diagnoses, 70% of the cases were positive by PCR and/or ISH. The concomitant morphology was not diagnostic of HPV in 44 out of 80 cases (55%), showing a relatively high percentage of cases morphologically normalized in the interval since the first specimen was taken. After detection with PCR, 30 cases (37.5%) were negative for HPV. Only one of the patients with a previous disease 2-4 yr before was HPV positive by PCR and two out of five patients with a clinical diagnosis of HPV. ISH could be performed on 67/80 cases, 43 of which were positive for HPV. There was a good agreement between the results of ISH and PCR, but there were six cases positive by ISH and negative by PCR. In these cases, few infected cells may have escaped detection by PCR. Both methods seem to be able to detect silent HPV infections and comparison with concomitant cytology/histopathology shows that morphology alone is insufficient for HPV detection in these cases.

Human papillomavirus in cell samples from Stockholm Gynecologic Health Screening

We compared the results of cytologic screening of 500 women in the Stockholm Gynecologic Health Control with human papillomavirus (HPV) detection by polymerase chain reaction (PCR) and in situ hybridization (ISH). There were two main age groups, one 30 years and younger and the other 40 years and older. There were relatively more women with HPV infection in the younger group than in the older one (15.7% as compared to 11.1%), but the difference was not significant in our material. Most cases (8/12) with cytologic atypia were HPV positive by PCR. HPV type 16 was most common, followed by types 31 and 18. HPV of unknown types was detected in 43.7% of HPV-positive cases. There was excellent agreement between PCR and ISH in detecting and typing HPV.