Regulatory role of glutathione and soluble sulfhydryl groups in the toxicity of adriamycin

Adriamycin (ADR) has been shown to produce free radicals in NADPH microsomal systems, to increase oxygen consumption of both hepatic microsomes and heart sarcosomes and to stimulate superoxide formation in cardiac, submitochondria particles. These reactive products could produce the cardiotoxicity of ADR by oxidizing various membrane structures, especially if the heart lacks sufficient protective reducing substances such as thiols. We examined 1) the effect of ADR on reduced glutathione (G-SH) levels in various tissues including heart, 2) the ability of the sulfhydryl (SH) donor, cysteamine, to alter soluble SH levels in heart tissue after ADR administration and 3) the effects of SH donors (cysteamine and N-acetyl cysteine and G-SH depletion by diethyl maleate on ADR-induced lethality in Swiss ICR-HA mice. A single injection of ADR (15 mg/kg i.p.) elicited a statistically significant fall in liver (P < .05), heart (P < .02) and erythrocyte (P < .01) G-SH levels. Treatment with cysteamine protected against the fall in soluble SH groups in heart tissue. Cysteamine (50 mg/kg, i.p., every 8 hr for 6 days) or N-acetylcysteine (100 mg/kg, i.p., 1 hr before and 7 hr after ADR) protected against ADR-induced lethality and decreased the appearance of microscopic myocardial lesions. When endogenous levels of G-SH were depleted by diethyl maleate (300 mg/kg i.p., every 8 hr for 4 days), ADR lethality was markedly potentiated. Diethyl maleate alone did not cause death. We conclude 1) ADR significantly lowers G-SH levels in erythrocytes, liver and heart tissue, 2) the lowering of cardiac SH groups by ADR can be prevented by cysteamine and 3) ADR toxicity can be potentiated by diethyl maleate, a G-SH depletor, and reduced by cysteamine or N-acetyl cysteine, SH donors. These results suggest that the G-SH system may be involved in the modulation of ADR-induced toxicity.

5-Fluorouracil, doxorubicin, and mitomycin (FAM) combination chemotherapy for advanced gastric cancer

Sixty-two patients with advanced measurable gastric cancer were treated with a combination chemotherapy program of 5-fluorouracil, doxorubicin, and mitomycin (FAM). Forty-two percent of patients achieved an objective partial response. The median duration of remission was 9 months and the median survival for responding patients, 12.5 months. The median survival for nonresponding patients was 3.5 months; all patients were dead by 8 months after initiation of therapy. The median survival of all 62 patients treated with FAM was 5.5 months. An analysis of possible prognostic variables including initial performance status, resectability of the primary gastric tumor, and histologic differentiation of the neoplasm failed to account for differences in patient response and survival. The FAM regimen was well tolerated, producing only moderate bone marrow suppression. These results show that patients with metastatic gastric cancer can be effectively palliated with FAM chemotherapy. The efficacy of this regimen should now be tested in patients with less advanced stages of this disease.

A phase II trial of ftorafur: adriamycin and mitomycin-C (FAM II) in advanced gastric adenocarcinoma

Fifteen patients with advanced gastric cancer were treated with the combination of Ftorafur, Adriamycin and mitomycin-C (FAM II). Three patients showed partial responses, in five the disease remained stable for at least 3 months and seven showed progression while on treatment. All responding patients showed survival in excess of 12 months. Hematologic toxicity was of only moderate severity. Median white count nadir was 3500 cells/mm3 and median platelet nadir was 187,000 cells/mm3. Four patients had white count nadirs from 2000--2500 cells/mm3 and three had nadirs from 500--1500 cells/mm3; also there were four with platelet nadirs less than 100,000/mm3. However, no drug-related infections occurred and no platelet transfusions were required. The major non-hematologic toxicities of the regimen were nausea, vomiting, dizziness, vertigo, and rhinorrhea. These toxicities were limiting and resulted in termination of the trial because of poor patient acceptance and the failure of the combination to exhibit a therapeutic advantage over the similar combination (FAM) that employed weekly 5-fluorouracil in place of Ftorafur.

5-fluorouracil, adriamycin, and mitomycin-C (FAM) combination chemotherapy in the treatment of advanced gastric cancer

Thirty-six patients with advanced measurable gastric cancer were treated with a new combination chemotherapy program consisting of 5-fluorouracil, Adriamycin and mitomycin-C (FAM). Fifty percent of patients achieved an objective partial response. The median duration of remission was 9.5 months and the median survival for responding patients was 13.5 months, with 2 remaining alive at 14 and 26 months. The median survival for nonresponding patients was 3.0 months and all were dead by 6 months after initiation of therapy. The median survival of all 36 patients treated with FAM was 5.5 months. An analysis of possible prognostic variables including initial performance status, resectability of the primary gastric tumor and histologic differentiation of the neoplasm failed to account for differences in patient response and survival. The FAM regimen was well tolerated, and produced only moderate bone marrow suppression. These results demonstrate that some patients with advanced gastric cancer can be effectively palliated with FAM chemotherapy. Phase III trials are warranted to assess the effect of the FAM regimen on the survival of patients with advanced gastric cancer.

The role of computed tomography in the staging of bladder cancer

Computed tomography of the pelvis has been performed in 60 patients with epithelial bladder tumours. The CT findings have been compared with the clinical staging (T-stage), lymphography (N-stage) and wherever possible the surgical staging (P-stage). Although the intraluminal tumour was visualised in a high proportion of examinations, the greatest value of CT is in the accurate delineation of the extravesical extension of the growth. This is likely to be the primary role of CT in the staging of bladder cancer. Difficulties in detecting invasion of contiguous organs, particularly the prostate, and the failure to demonstrate nodal involvement within the pelvis were noted. The technique has clear advantages over more invasive investigations and the additional information provided over and above clinical staging is seen as a major advance in the assessment of these tumours.

5-Fluorouracil, adriamycin, and mitomycin-C (FAM) chemotherapy for adenocarcinoma of the lung

Twenty-five patients with advanced measurable adenocarcinoma of the lung were treated with combination chemotherapy consisting of 5-fluorouracil, adriamycin, and mitomycin-C (FAM). Objective response (1CR, 8PR) was obtained in 36% of patients. The median duration of response was 7.0 months and the median survival for responders is greater than 8.5 months. Five responders are alive 5.5 to 23.5 months after starting therapy. Three of four patients evidencing stabilization of disease are alive at 10-23 months. Non-responding patients had a median survival of 2.5 months and none lived beyond seven months. Tumor response and survival suggested correlation with initial performance status and limited disease. The FAM regimen was tolerated well, with moderate bone marrow suppression and gastrointestinal symptoms being the only clinically significant toxicities. These results indicate that patients with advanced pulmonary adenocarcinoma can obtain objective tumor regression with FAM chemotherapy.

Association of breast cancer with meningioma: report of two cases and review of the literature

We report two cases of breast cancer in whom meningioma subsequently developed and provide a brief review of the literature. A hormonal interrelationship is suggested. The knowledge of this potential association is important in the interpretation and treatment of patients with breast cancer who develop central nervous system manifestations.

Lymphography in alveolar soft part sarcoma

Alveolar soft part sarcoma is a rare tumour found in musculofasculofascial planes, most often in the lower limbs of young adults. The tumour shows a characteristic orderly cellular arrangement and the few mitoses belie the often rapid progress of the disease. Cytoplasmic crystals unique to this tumour may be demonstrated. The need for thorough investigation of the patient as an initial staging procedure and to provide a prognostic forecast is emphasised. Isotope scanning of the bones, brain and liver is indicated. Two cases are reported which demonstrate the value of lymphography. The nodal features found were: 1. Enlargement of a lymph node of normal interal architecture. 2. Almost complete nodal replacement by tumour. 3. Pseudolymphomatous appearances. Follow up films are required, after an interval, to show the progress of the disease or response to therapy.

The value of lymphography in the management of bladder cancer

228 bilateral pedal lymphograms in patients with bladder cancer have been correlated with the features of the primary bladder tumour and patient survival. In 70 cases, radiographic findings were correlated with operative node histology. The results show that it is not possible to predict accurately which cases have lymphatic spread without this investigation. Positive lymphograms were found in 91 cases, and were associated with a very poor prognosis. Only 6% of patients with unilaterally involved iliac nodes survived 5 years, and all patients with bilateral iliac or para-aortic disease died within 3 years. Histological correlation was found in 90% of cases, and the results indicate that this investigation slightly underestimates the incidence and extent of microscopic lymphatic metastases. It is concluded that this investigation is essential in planning the treatment of infiltrating bladder tumours.

Computerised axial tomography for diagnosis of pancreatic cancer

Computerised axial tomography demonstrated the presence of a mass lesion in the pancreas in 9 (64%) of 14 patients with histologically confirmed pancreatic cancer. Since this was a retrospective analysis, the percentage of false positive and negative results using this technique is not as yet known. The technique appears accurate in detecting abnormal pancreatic masses of 10 cm in diameter or more, however, for masses less than 10 cm in diameter the yield at present is only 33%. With further technical refinement to increase resolution, the automatic computerised transverse axial scan should prove to be an invaluable procedure for the detection of pancreatic carcinoma, in designing radiation therapy ports, and in providing objective information regarding response of therapy and progression of disease.

Chemotherapy of large intestinal carcinoma. Current results and future prospects

Chemotherapy of advanced stages of large bowel cancer has until recently made little progress since the introduction of 5-FU 16 years ago. While survival is improved for patients who respond, 5-FU alone has made little impact on life span of the overall population of patients. Mitomycin-C and the chloroethyl nitrosourea antitumor agents, and in particular methyl-CCNU, have also demonstrated marginal activity in large bowel cancer. Two recently reported controlled clinical trials of combination chemotherapy have demonstrated response rates that are substantially better than those obtained with 5-FU alone; a 43% response rate in colorectal carcinoma has been reported using a combination of 5-FU, BCNU, vincristine, and DTIC, compared to a 25% response with 5-FU as a single agent; a 44% objective response rate with a combination of 5-FU, methyl-CCNU, and vincristine has been reported to be significantly better than 5-FU alone. 5-FU as an adjuvant following surgical resection with curative intent has not prevented tumor relapse; however, it is hoped that future studies employing more effective drug combinations will result in increased number of patients achieving disease free survival.

A review of the role of lymphography in the management of testicular tumours

The pedal lymphographic findings in 260 patients with testicular tumours are reviewed: 117 patients had a seminoma, 105 had a teratoma and 38 combined tumours. 26 percent of seminomas were associated with a positive lymphogram, corresponding figures being 42 percent for teratomas and 53 percent for combined tumours. The role of the lymphogram is (1) to stage the case so that the extent and form of the treatment can be logically assessed, (2) to plan accurately radiotherapy treatment fields, (3) to observe the results of treatment on serial follow-up films, (4) to detect the recurrence of tumour using "re-fill" lymphography if necessary, (5) to show possible unsuspected metastases involving supraclavicular and mediastinal glands, and (6) to give a prognosis, since a negative lymphogram suggests an excellent chance of survival. Three main types of lymphographic appearances are recognized: nodal, mass replacement and "pseudo-lymphomatous". Nodal deposits are most common. Most positive findings are in the para-aortic chain on the same side as the tumour. Iliac involvement is much less common. Seminomas in this series showed a 96 percent crude three-year survival rate. For teratomas and combined tumours the three-year survival rates were 59 percent and 61 percent respectively, but deaths are uncommon in the lymphographically negative Stage I cases. Bone deposits are rare. Only two were found in this series. We do not perform testicular lymphography, but consider there is a useful role for inferior venacavography when there is poor filling of upper para-aortic nodes at lymphography. The importance of taking follow-up films after the initial examination is stressed.