[Alternating non-cross resistant multi-drug chemotherapy against malignant lymphoma (CAMBO-VIP)--consideration of the dose intensity]

Dose intensity defined as the amount of drug used per unit time, expressed as mg/m2/week, was reported to be a significant determinant of antitumor activity of single or combined drugs in cancer chemotherapy. We formulated a 12 week high dose intensity chemotherapy (CAMBO-VIP) for the treatment of advanced non Hodgkin's lymphoma with aggressive histology. The treatment consists of weekly alternate administration of myelosuppressive and non-myelosuppressive agents. Doxorubicin was administered every other week in combination with either cyclophosphamide, etoposide or ifosfamide. On the weeks in between, non-myelosuppressive vincristine was given with either methotrexate with leucovorin rescue or bleomycin. Prednisolone was given for the first and the last 4 weeks. Dose reduction and treatment delay were kept minimal for the purpose not lowering dose intensity. As of February 1990, 32 patients (pts), median age 52, entered the study, 29 of whom completed the treatment. There were 3 incomplete cases, in which 2 were due to interruption of the treatment at 5 and 6 weeks, respectively and 1 due to a half dose given because of the old age. CR was obtained in 29 pts (90.6%). Relapse occurred in 3 (10.4%) with the median follow-up of 12 months. Two year disease-free survival (DFS) was estimated to be 76.0% for all the patients and 83.9% for CR patients. Toxicity of CAMBO-VIP was moderate with no chemotherapeutic death. Myelosuppression was severe but of short duration, requiring virtually no dose reduction. Treatment delay was 3 days, median, and maximally 28 days. The average actual dose intensity calculated from given amount of drugs and treatment duration was as high as 90% of the protocol dose intensity. Dose intensity of CAMBO-VIP protocol is highest, equaling to that of MACOP-B, among representative series of reported lymphoma protocols. A highly significant correlation was observed between 9 drug relative dose intensity and DFS of the patients treated with each protocol. Significance of dose intensity as an independent prognostic factor, however, should be determined, by a prospective carefully designed stratified randomized studies.

[Changes in platelets and blood coagulation during prolonged ECLA with a heparin bonded hollow fiber membrane lung]

Effects of the heparin bonded artificial membrane lung and circuit on blood coagulation were investigated during prolonged extracorporeal lung assist on goats. A veno-venous bypass ECLA was performed on 18 goats up to 10 days. Twelve of them (Group I) were with a heparin bonded device and the other six (Group II) were with the usual device. In Group I, heparin was continuously infused at a rate of 15.2 units.kg-1.hr-1 to maintain the activated coagulation time, ACT, at around 130 sec., while in Group II, 25.5 units.kg-1.hr-1 of heparin was necessary to maintain ACT at about 200 sec. to prevent blood coagulation in the bypass circuit. Platelets decreased significantly in Group I (by 50% of pre ECLA value) as well as in Group II, but aggregation activity in Group I was higher than in Group II. Fibrinopeptide A and antithrombin III showed no significant difference between the two groups. Autopsy showed no significant pathological findings. ECLA, with a heparin bonded surface, showed excellent blood compatibility and required only a little systemic administration of heparin. The heparin bonded bypass circuit will enable safer ECLA even in patients with some bleeding sites.

[Renal function of ectopic ureteral opening repaired by ureterocystoneostomy]

Two girls (4 and 3-year old) visited our out-patient service complaining of daytime and nighttime enuresis. Both were diagnosed as ectopic ureteral opening to the vagina with a concomitant dysplastic kidney on the left side. These anomalies were repaired by ureterocystoneostomy according to a modified Grégoir's method. In the first case, three months later, DIP visualized left upper urinary tract which had not been seen before, but enhanced CT scan, renogram and scintigraphy with Tc-DMSA showed no change. In the second case, three years later, examination results were the same as in the first case. There was no renal development. Surgical repair of ureterocystoneostomy was valuable, with small surgical damage and cosmetic merit for the girls. Furthermore, renal function will be maintained at the same level or slightly higher than that before the operation.

T-cell malignancy following B-cell lymphoma in remission

A T-cell malignancy developed in a 64-year-old man with recurrent B-cell lymphoma after one and a half years of remission. Immunophenotypic and DNA analyses confirmed clonality and cell lineage of both lymphoid malignancies. Sequential development of B- and T-cell malignancies in this patient may be an example of biclonal lymphoma or treatment-related secondary lymphoma. However, another possibility would be the existence of a transformed lymphoid stem cell that underwent intraclonal conversion from B- to T-cell lines.

[A case of transitional cell carcinoma in a pyelocaliceal diverticulum]

A 63-year-old man visited our hospital because of painless macrohematuria. Drip infusion pyelography and retrograde pyelography revealed a space-occupying lesion with extravasation of contrast medium to upper caliceal system. A computed tomographic study revealed an intrarenal solid moiety and further more, arteriography showed the arterial encasement and fine neovascularity of the lesion. On gross section of the extirpated kidney, a cystic cavity measuring 3 by 3 cm existed at the upper pole and apparently channeled to the upper caliceal system. Small stones were found in the cystic cavity. Histopathologically, the wall of the cavity was covered with layered squamous cells and a part of the wall developed metaplasic transitional cell carcinoma proliferation which invaded into the renal parenchyma and renal pelvis, as well.

[Emergency cardiopulmonary bypass for cardiopulmonary-cerebral resuscitation]

Cardiopulmonary bypass (C-P bypass) was performed on two patients who had not responded to conventional cardiopulmonary resuscitation (CPR). The first patient, a 56-y-o male, with bilateral pulmonary thromboembolism repeatedly underwent cardiac massage and electric defibrillation for recurrent ventricular fibrillation. A veno-arterial bypass route was prepared during cardiac massage, and bypass circulation was started 3 hours after the onset of the first ventricular fibrillation. Soon after the initiation of C-P bypass, the physical status and EEG of the patient improved. The patient regained consciousness within a few hours and later underwent open chest pulmonary embolectomy. The second patient, a 44-y-o male, developed refractory cardiogenic shock near the end of aortocoronary bypass graft operation. Under closed chest massage, a femoro-femoral cardiopulmonary bypass operation was started. Soon after the initiation of the bypass circulation and IABP, peripheral circulation improved markedly, and consciousness returned within several hours. Though the first patient finally died from far advanced pulmonary embolism, he was conscious as long as the C-P bypass was continued for two days. In the second patient, the cardiac function gradually improved after the 3rd day. C-P bypass was tapered and discontinued on the 5th day. Emergency veno-arterial bypass for CPR is effective means to maintain life until the cardiopulmonary and cerebral functions are restored. Recent advances in emergency C-P bypass are introduced and a new acronym extracorporeal lung and heart assist, ECLHA, is proposed. Emergency ECLHA with veno-arterial cannulations through percutaneous puncture will become a promising adjunct of cardiopulmonary-cerebral resuscitation in the near future.

[Clinicopathologic analyses of eleven patients with Hodgkin's disease]

Clinicopathologic analyses were performed on 11 patients with histopathologic diagnosis of Hodgkin's disease which was confirmed immunohistochemically with the use of anti-Leu M 1 which is known to be specific to Reed-Sternberg cells. Patients with clinical stage II developed infradiaphragmatic involvement after Mantle field irradiation and should have been treated with extended field irradiation or combined modality therapy because of the possibility of PSIII1. Maintenance VENP therapy seemed to sustain remission but may have caused opportunistic infections. There were no rearrangements in either immunoglobulin or T cell receptor genes studied in two patients.

[The effect of IL-2 and IFN-beta on autologous tumor cell kill by Percoll separated LGL fractions]

Low density fractions of Percoll density gradient centrifugation of peripheral mononuclear cells contained the majority of large granular lymphocytes (LGL). LGL were used for 5-hr 51Cr release cytotoxic assay against autologous tumor cells in 20 patients with hematological malignancies (9AML, 4ALL and 7NHL). Mean % cytotoxicity (% CTX) was 6.0%, and the addition of IFN-beta and IL-2 in the medium induced the significant increase of % CTX to 15.0% and 26.1%, respectively. When LGL cultured in medium containing IFN-beta and IL-2 were assessed for cytotoxicity daily for 8 days, the enhancement of % CTX by IFN-beta was declined in a few days, while the enhancement by IL-2 was sustained for more than 8 days. The pretreatment of LGL with anti Leu-11 (CD16) plus complement abrogated the enhancing effect by IFN-beta or IL-2, but not with anti Leu-1 (CD5) plus complement. When this treatment was done on day 8 of IL-2 cocultivation, anti Leu-11 plus complement suppressed cytotoxicity significantly, and anti Leu-1 plus complement also induced mild suppression. The phenotypic characteristics of cells revealed the significant increase of anti Leu-19+ cells in IL-2 stimulated day 8 cells. High density fractions of Percoll gradient contained mostly T lymphocytes and showed no cytotoxicity against autologous tumor cells. However, cocultivation with IL-2 for 8 days induced the cytotoxicity, associated with increased number of anti Leu-19+ cells. These results suggested that IL-2 induced cytotoxic activity against autologous tumor cells might be related to the increase of anti Leu-19+ cells.

[Lymphocyte cytotoxicity against autologous tumor cells and the effect of interferon-beta on their activities. (1) Evaluation by modification of target tumor cells]

IFN is known to enhance NK activity against cultured cell lines such as K562, but not against frozen autologous tumor cells. In order to obtain increased NK cytotoxicity using IFN-beta, various modifications were performed on autologous tumor cells. IFN-beta induced more enhanced NK cytotoxicity of normal lymphocytes when frozen tumor target cells were cultured for 4-5 days in the medium, or when these cells were treated with Vibrio cholerae neuraminidase (VCN). However, in an autologous setting, IFN-beta did not enhance NK cytotoxicity against either cultured autologous tumor cells or VCN-treated tumor cells. Also, IFN-beta did not enhance cytotoxic T cell activity against autologous tumor cells induced by mixed lymphocyte-tumor cell culture, although IFN-beta was able to induce enhancement of allospecific cytotoxic T cells mediated by mixed lymphocyte culture.

[Lymphocyte cytotoxicity against autologous tumor cells and the effect of interferon-beta on their activities. (2) Evaluation of large granular lymphocytes (LGL)]

Large granular lymphocytes (LGL) were obtained by Percoll density gradient centrifugation of peripheral mononuclear cells from 15 patients with hematological malignancies (10 acute leukemias and 5 non-Hodgkin's lymphomas). Five-hour 51Cr-release cytotoxic assay by LGL was performed against frozen autologous tumor cells in these patients. Mean percentage cytotoxicity by LGL was 5.6%, and this was enhanced to 15.0% by the addition of IFN-beta to the culture medium. A decrease of cytotoxicity was observed when LGL was treated with anti-Leu 11b antibody plus complement, or when LGL was pretreated with the unlabelled K562 as a competitive inhibition assay. The addition of monocytes also induced a decrease of cytotoxicity, suggesting that monocytes may act as a suppressive agent in autologous tumor cell killing by LGL.

[Early phase II trial of bestrabucil in hematological malignancies]

Thirty-three patients with various hematological malignancies were treated with Bestrabucil, the benzoate of an estradiol-chlorambucil conjugate, at doses of 50-300 mg daily p.o., consecutively. Nineteen patients had previously received chemotherapy. Of 29 evaluable patients, there were one CR and three PRs among 6 patients with chronic lymphocytic leukemia, two CRs and one PR among 4 patients with malignant lymphoma, two PRs among 3 patients with adult T-cell leukemia, one PR among 4 patients with macroglobulinemia, one PR for one patient with essential thrombocythemia, and one PR for a patient with chronic myelocytic leukemia. Main side effects included G1 symptoms (14%), estradiol-related symptoms (24%) and myelosuppression (32%).

Randomized controlled study of chemoimmunotherapy of acute myelogenous leukemia (AML) in adults with Nocardia rubra cell-wall skeleton and irradiated allogeneic AML cells

The effect of immunotherapy with Nocardia rubra cell-wall skeleton (N-CWS) on remission duration and survival of adults with acute myelogenous leukemia (AML) was studied in a prospective randomized controlled study. After having been induced into complete remission and having been consolidated, 73 patients were randomized either to maintenance chemotherapy or maintenance chemotherapy plus immunotherapy with N-CWS and irradiated allogeneic AML cells. Thirty-four patients in the chemotherapy group and 32 in the chemoimmunotherapy group were evaluable. Six months after the closure of the study, the immunotherapy showed a borderline beneficial effect on remission duration (P = 0.080) and on survival length (P = 0.098). When the data were analyzed at 30 months after the entry, there was a borderline significant difference in remission duration (P = 0.080) between the two groups, prolonging the 50% remission period by 110 days; but no significant difference in survival length (P = 0.314), although the 50% survival was 168 days longer in the chemoimmunotherapy group. However, there were 4 (18.2%) 5-year relapse-free survivors among 22 patients (11 in each group) who had been diagnosed more than 5 years before the time of the present analysis, and all of them belonged to the chemoimmunotherapy group (P = 0.090). Thus, immunotherapy with N-CWS and irradiated allogeneic AML cells seems to be active in the treatment of adult AML when used for maintenance therapy in combination with chemotherapy.

Extracorporeal lung assist with a single catheter in puppies

We devised a new veno-venous extracorporeal bypass circuit to be used with an artificial membrane lung for respiratory support in the newborn. A roller pump was activated intermittently when the reservoir filled. Capacitance detectors applied to the reservoir regulated blood flow through a thin-walled venous catheter. Extracorporeal lung assist with this circuit was tested on puppies ventilated with air at a rate of 2 to 4 breath/ min. At a mean blood flow rate of 37.2 +/- 12.1 ml/kg min, PaO2 and PaCO2 were maintained in the normal range. Veno-venous extracorporeal lung assist with a single venous catheter may well become an excellent means of neonatal respiratory support in the future.

[A case of congenital vesicovaginal fistula]

Congenital vesicovaginal fistula is very rare and only five cases have been reported so far. This is a report on a case of congenital vesicovaginal fistula in a three-year-old girl. Vesicovaginal fistula was confirmed by cystoscopy and colposcopy. Roentgen examinations, including IVP, CG and CT revealed a left hypoplastic kidney, left ectopic ureteric orifice and left vesicoureteral reflux. Under general anesthesia, the fistula was resected and closed transvesically, and ureterocystoneostomy was performed. Five out of the six cases of congenital vesicovaginal fistula reported worldwide had other congenital complications of the genitourinary system, but the etiology of this anomaly is still unknown.

[Blind-ending bifid ureter: a case report]

This is a report on a case of blind-ending ureter. The patient was a 56-year-old female who had complained of a pain in the left flank. There was no urinary tract infection. Excretory urography revealed a left blind-ending bifid ureter. It was resected and the removed specimen was about 8 cm in length. Histologically, it had all layers of the ureteral structure, but no renal tissue was found. The post-operative course was uneventful. We collected 55 cases of blind-ending bifid ureters reported in Japan including our own and discussed the difference between blind-ending bifid ureter and ureteral diverticulum.