Adjuvant chemotherapy of bladder cancer: a preliminary report

Adjuvant combination chemotherapy with cyclophosphamide, doxorubicin and cisplatin was administered to 36 patients after cystectomy for bladder cancer. Therapy was tolerated well except for 1 patient who suffered a fatal chemotherapy complication. Indications for adjuvant chemotherapy included vascular invasion of the primary tumor, perivesicular tumor involvement, invasion of adjacent pelvic viscera (vagina and prostate) and nodal metastases. There were 53 concurrently treated patients who did not receive adjuvant chemotherapy despite similar unfavorable pathological indications (high risk control group). Survival rates (61 and 73 per cent, respectively) were not significantly different for those patients treated with adjuvant chemotherapy and an additional group of 158 patients who underwent cystectomy during the study period but who had no adverse pathological findings (low risk control group). Survival rates differed significantly between the low risk (73 per cent) and high risk (38 per cent) control groups (p less than 0.001). Patients with unfavorable histological findings who received adjuvant chemotherapy had a significant survival advantage over the high risk control groups (61 versus 38 per cent, p equals 0.03). These data confirm the predictive value of post-cystectomy pathological findings and suggest that adjuvant chemotherapy with cyclophosphamide, doxorubicin and cisplatin not only prolongs the survival free of disease for patients at high risk for recurrence but it also may ultimately increase the cure fraction of such patients.

Adjuvant estrogen following radiation therapy for stage C adenocarcinoma of the prostate: long-term results of a prospective randomized study

Seventy-eight patients with clinical Stage C adenocarcinoma of the prostate were prospectively randomized to receive either radiation alone or radiation and adjuvant estrogen (diethylstilbestrol). No patient had received any prior definitive treatment for cancer. Forty patients were randomized to receive radiotherapy only and 38 patients to receive radiotherapy and estrogen. The median follow-up for all surviving patients was 14.5 years. Whether analyzed according to the original randomization or according to the treatment actually received, disease-free survival in the adjuvant estrogen group was strikingly and significantly higher than in the radiation-only group. At 5, 10, and 15 years patients receiving adjuvant estrogen had respective disease-free survival rates of 71%, 63%, and 63% compared with 49%, 43%, and 35% in patients having radiation only (p = 0.008). However, because of greater intercurrent disease-related mortality in patients receiving estrogen, there was no improvement in survival. This study suggests that a prospective randomized evaluation of early androgen deprivation with orchiectomy or with one of the nonestrogenic agents should be undertaken and that patients receiving early androgen deprivation should not be included in series reporting on the curative potential of radiation as a single modality.

Transluminal atherectomy for occlusive peripheral vascular disease

Sixty-one patients with occlusive peripheral vascular disease were treated with transluminal atherectomy, a catheter-mediated technique for removal of atheroma. The technique was performed using 7Fr, 9Fr or 11Fr atherectomy catheters. Mean percent diameter stenosis was reduced from 71 to 23%, by removal of 831 atheromatous specimens in 949 passes of the cutting element through 136 stenoses in 61 patients. All specimens removed were sent for histopathologic examination to determine the components of the atheroma removed, which differed for specimens removed from original vs restenotic lesions. Percent stenosis was reduced to less than 45% in 118 of 136 stenoses (87%). Complications included 1 thrombus, which resolved after intraarterial infusion of streptokinase and 1 probable distal embolization without sequelae. Three angiographic dissections occurred without impairment of blood flow. There were no instances of acute occlusion, vascular spasm or vessel perforation. Six-month follow-up angiography was performed showing that patients who had a residual stenosis less than 30% after initial atherectomy had a lower restenosis rate (18%) than patients with initial residual stenoses greater than 30% (52%); this result demonstrated the importance of performing more complete atherectomy. Transluminal atherectomy appears to be an effective, predictable and safe method for removing occlusive atheromatous deposits from peripheral arteries.

Mechanisms of human CD5 modulation and capping induced by murine monoclonal antibody T101

We have previously demonstrated that the murine monoclonal antibody T101 induces antigenic modulation when infused into patients with chronic lymphocytic leukemia and cutaneous T-cell lymphoma. In this paper, we extend our studies of T101-induced modulation and compare it to T101-induced capping. We found that, in contrast to antigenic modulation, capping occurred only in the presence of secondary anti-mouse IgG antisera and was altered by drugs that affect the cellular cytoskeleton or energy metabolism. F(ab')2 fragments of T101 induced antigenic modulation with kinetics similar to those of intact T101, but Fab-induced modulation proceeded more slowly and required the continual presence of Fab throughout the incubation. Experiments with radioiodinated T101 demonstrated that initial internalization of the antibody is followed by rapid efflux of intact, immunoreactive T101 from the cells. These data indicate important differences between capping and modulation and suggest that these two phenomena proceed by different mechanisms. More importantly, the data have implications for the potential therapeutic use of monoclonal antibody immunoconjugates.

Percutaneous absorption and excretion of alachlor in rhesus monkeys

The percutaneous absorption and excretion profile of alachlor were evaluated in rhesus monkeys. A preliminary study demonstrated that an average of 86.7 and 9.7% of the administered dose was recovered in the urine and feces, respectively, following intravenous administration of radiolabeled alachlor to rhesus monkeys. In subsequent studies, diluted and undiluted emulsifiable concentrate (EC) and microencapsulated (ME) formulations of radiolabeled alachlor were applied to a 40-cm2 shaved abdominal area and allowed to remain on the skin for 12 hr. The radioactivity excretion profiles in all animals were comparable. In all cases, approximately 88% of the absorbed dose was eliminated via the urine, primarily within the first 48 hr. Comparison of the amount of radiolabel recovered in the topical studies with that recovered following intravenous administration indicated that an average of 8.5 and 3.7% of the alachlor in the topically applied EC and ME formulations, respectively, was absorbed.

Medical castration using megestrol acetate and minidose estrogen

Sixty-two men who presented with previously untreated metastatic carcinoma of the prostate (D0: 10 patients; D1: 29 patients; D2: 23 patients) received oral megestrol acetate (80 mg twice daily) and minidose estrogen (diethylstibestrol 0.1 mg or ethinyl estradiol 0.05 mg once daily) as a means of achieving total androgen ablation (testicular and adrenal). A high incidence of feminizing side effects (70-74%), a higher than expected rate of cardiovascular complications (18%), an unexpected need for cortisone replacement (13%), and failure of patients with Stage D2 disease to obtain results better than those of standard therapy during the first year of observation suggest this regimen offers no advantage over other more conventional therapy.

Nutritional value of wet corn gluten feed for sheep and lactating dairy cows

Experiments were conducted to determine digestibility of wet corn gluten feed in sheep and effect of wet corn gluten feed on DM intake, milk production, and milk composition by dairy cows. In Trial 1, six wethers were fed wet corn gluten feed at maintenance and ad libitum for determination of nutrient digestibility by the conventional 7-d total collection technique. The sheep ate 1.32 times maintenance at ad libitum intake and no significant differences were found in digestibility due to intake. Digestibilities of DM, organic matter, energy, CP, ether extract, ADF, NDF, and hemicellulose averaged 70.3, 73.0, 73.7, 78.3, 72.8, 51.4, 58.1, and 60.4%, respectively. Mean total digestible nutrients for both treatments was 70.3. In Trial 2, 12 Holstein cows in mid to late lactation were allotted to a 4 x 4 Latin square design. Cows were fed a total mixed ration twice daily. Wet corn gluten feed was fed at 0 (control), 10, 20, and 30% of the total ration DM. There were no significant treatment effects on DM intake, milk yield, or milk composition. Dry matter intake (kg/d), milk production (kg/d), and percent milk fat were 21.4, 22.9, and 3.71, respectively, for control; 21.4, 23.0, and 3.80 for the 10%; 21.0, 23.1, and 3.71 for the 20%; and 21.0, 23.2, and 3.89 for the 30% wet corn gluten feed.

Detection of tumors with 19F magnetic resonance imaging

Previous 19F magnetic resonance imaging studies showed that the reticuloendothelial system can be imaged with an emulsion of perfluorooctyl bromide (PFOB). Similar techniques can be used to detect previously implanted RIF-1 tumors in mice after intravenous PFOB administration. Accumulation of PFOB within these neoplasms is due to egress of the emulsion through tumor capillary fenestrations. This is the first report in which 19F MRI and PFOB are used to detect tumors. This technique may allow clinical detection of cancer with 19F MRI.

The role of radiation therapy in stages A2 and B adenocarcinoma of the prostate

Between 1965 and 1982 definitive external beam radiation therapy was given to 114 patients with clinically Staged A2 (32 patients) and B (82 patients) adenocarcinoma of the prostate. These patients were not considered to be surgical candidates because of age, comorbidity or disease extent, or because they had refused surgery. Total prostatic doses ranged from 60 to 70 Gy. For 90 surviving patients, follow-up duration ranged from 32 to 188 months with a median of 5 years. The 5- and 10-year uncorrected survival rates for all patients, which were 89% and 68% respectively, were no different from the survival expectation of age-matched men in the general population. Disease-free survival rates at the same time periods were 89% and 86%. There were no significant differences in disease-free survival between Stage A2 and Stage B. Four patients (3.5%) developed local recurrence. Bone metastases, which occurred in 9 of 11 treatment failures were the predominant cause of failure. An analysis of 11 potential prognostic factors was fruitless. Pelvic node irradiation did not improve the outcome. The incidence of complications was acceptable. Anorectal problems developed in 20% of patients and urinary manifestations occurred in 20%, and only 2 patients (1.8%) developed serious problems. We concluded that localized external beam high-energy radiation therapy provides excellent local control for disease limited to the prostate, with survival rates that rival those of radical surgery.

Prophylactic furosemide in severe respiratory distress syndrome: blinded prospective study

To further characterize the place for furosemide in the treatment of newborn infants with respiratory distress syndrome requiring mechanical ventilation, we conducted a blinded, prospective study comparing early prophylactic use (1 mg/kg every 12 hours for four doses beginning at 24 hours of age) with prn use of this drug. Prophylactic administration of furosemide produced no beneficial effect on any measure of pulmonary function compared with use of this drug as needed (prn). However, patients receiving the prophylactic furosemide regimen were found to have more rapid postnatal weight loss, higher pulse rate, and greater sympathomimetic drug requirement during the period of diuretic administration. Patients in the prophylactic group did not demonstrate the moderate expansion in plasma volume between 48 and 96 hours of age seen in the control group. These data suggest that the prophylactic regimen produced an undesirable degree of volume depletion. Further studies should be conducted to develop objective criteria for the selection of the subgroup of patients with respiratory distress syndrome who may benefit from furosemide.

The diagnostic utility of the keratin profiles of hepatocellular carcinoma and cholangiocarcinoma

A total of 32 hepatocellular carcinomas (HCC), 10 cholangiocarcinomas (CC), one combined HCC-CC, and 10 adenocarcinomas metastatic to the liver were studied immunohistochemically using AE1 and Cam 5.2, monoclonal antikeratin antibodies with different specificities. AE1 recognizes keratins with molecular weights of 56.5, 50/50', 48, and 40 kd (keratin nos. 10, 14, 15, 16, and 19, according to Moll's catalog), and labels many epithelia, including bile duct epithelium, but not hepatocytes. Both biliary epithelium and hepatocytes are stained by Cam 5.2, which reacts with keratins of molecular weights 50, 43, and 39 kd (corresponding to keratin nos. 8, 18, and 19). Tissues were formalin fixed, paraffin embedded, and a three-stage immunoperoxidase technique was employed. Of 32 pure HCCs, 29 were unreactive with AE1 yet were positive with Cam 5.2. The intensity and extent of immunostaining with Cam 5.2 did not correlate with tumor grade. In contrast to the HCCs, all 10 CCs and the 10 hepatic metastases were strongly positive with both AE1 and Cam 5.2. The combined HCC-CC was also labeled by both antibodies. We conclude that most HCCs express an immunohistochemical keratin profile identical to that of nonneoplastic hepatocytes, which differs from the keratin patterns of bile ducts, CCs, and metastatic adenocarcinomas from a variety of primary sites. These differences in immunoreactivity with antikeratin antibodies may prove useful in diagnostic surgical pathology.

New multi-provider leaders emerge

Several multi-unit provider groups may realize their dreams of vertical integration within five years through mergers and close affiliations with other market leaders. This article identifies new role models who have emerged from among these urban, not-for-profit hospital groups. Renewed interest in this subject makes them potential conference speakers.

Ketoconazole therapy for hormonally refractive metastatic prostate cancer

Twenty-two patients who had progressive metastatic prostatic carcinoma (Stage D2) despite androgen-deprivation therapy (bilateral orchiectomy, 10 cases; bilateral orchiectomy followed by diethylstilbestrol, 7 cases; diethylstilbestrol, 3 cases; combined megestrol acetate and low-dose estrogen, 2 cases) were treated with ketoconazole. Of 19 evaluable patients, 2 (11%) achieved a partial response (for 6 and 8 months) and 7 others (37%) achieved stabilization of disease (for periods of 3-8 months). Of 16 patients in whom pain was a prominent clinical feature, 13 (81%) noted improvement in pain for periods of one to eight months (median 3 months). We conclude that ketoconazole is a useful addition to our current armory for management of patients with metastatic prostatic cancer resistant to prior hormonal therapy.

Viral etiology of testicular tumors

Testicular carcinoma and Hodgkin's disease are among the most frequent malignancies afflicting young men in the 15 to 39-year age group. These malignancies share other epidemiological characteristics as well, including multiple histological tumor types, higher rates of occurrence in white, urbanized populations and upper social classes, relative infrequency among black populations, low but definite familial occurrence and an early geographically acquired lifetime risk irrespective of later migration. Both diseases are increasing in this country. This epidemiological similarity suggests exposure to an infectious agent early in life. The Epstein-Barr virus is known to be oncogenic and neonatal exposure with early infection is believed to be associated with Burkitt's lymphoma in African children. High titers of antibodies to the Epstein-Barr virus capsid antigen also have been reported in a series of studies comparing patients with Hodgkin's disease and controls. Because testicular cancer is epidemiologically similar to Hodgkin's disease and, therefore, might be expected to manifest similar Epstein-Barr virus findings, we performed a viral screen (Epstein-Barr virus, cytomegalovirus, and hepatitis A and B viruses) on blood samples from 56 consecutive patients with clinical stage I germ cell tumors of the testis who had received no active therapy after orchiectomy. Our results show a high incidence (80 per cent) of previous exposure to Epstein-Barr virus and support the hypothesis of a possible infectious origin for testicular carcinoma.

Transvascular flux and tissue accrual of Evans blue: effects of endotoxin and histamine

We investigated the relationship between the pharmacokinetics of exogenous molecules and transcapillary flux by studying the intravascular and tissue content and the histologic distribution of Evans blue in guinea pigs. Pharmacokinetic analysis demonstrated that 87% of the decline in intravascular Evans blue during the first 3 hours after administration was a result of transvascular flux to tissue compartments. Rapidly and slowly equilibrating compartments were identified. Greater than 90% of the clearances in lung and heart were rapid compartment clearances. Histologically, the distribution of Evans blue in these tissues was predominantly extracellular and similar to the distribution of fluorescein-labeled dextran. By contrast, the accumulation in kidney and liver was kinetically similar to characteristics of the slowly equilibrating compartment. This corresponded histologically to the predominant intracellular uptake of Evans blue in these tissues. Generalized increases in capillary permeability were produced by endotoxin or histamine infusion. Both treatments were associated with a more rapid initial decline in intravascular content of Evans blue than was found in control animals. Although the histologic distribution of Evans blue in tissues was not altered, endotoxin was associated with a more rapid appearance of Evans blue in the lung and heart than was seen in controls. We conclude that the initial decline in intravascular content of Evans blue corresponds to the intercompartmental clearance and to transcapillary macromolecular flux. The initial decline in serum concentrations may therefore be useful in studying disorders of generalized capillary permeability. Furthermore, the initial accrual of Evans blue in the lung and heart may be used as a marker of transcapillary macromolecular flux in those tissues.

Use of a balloon-tipped catheter to guide placement of the bioptome sheath in right ventricular percutaneous endomyocardial biopsy

A common problem during biopsy of the right ventricular septum using the flexible King's bioptome is the difficulty of accurately directing the tip of the long biopsy sheath against the septal surface. This can be important in that inadvertent biopsy of the more delicate ventricular free wall may lead to perforation and pericardial tamponade. An alternate method of sheath placement is presented. This involves the use of a No. 5 or 6 French balloon-tipped catheter within the long bioptome sheath in order to facilitate sheath passage and positioning. Catheter positioning is readily accomplished when documented by bioplane fluoroscopy, with alternate or additional two-dimensional echocardiographic position check as desired. Balloon-guided positioning for right ventricular septal biopsy appears to be a simple and safe technique that may be especially useful for relatively inexperienced operators and for patients with abnormal cardiac anatomy for whom endomyocardial biopsy (EMB) might normally be technically difficult.