The influence of initial hemoglobin and blood pressure levels on results of radiation therapy for carcinoma of the prostate

A group of 914 patients with carcinoma of the prostate treated by definitive radiotherapy at Stanford between 1956 and 1985 was studied. Of these, the initial hemoglobin level was recorded in 656 cases and the initial blood pressure in 760 cases. End-points studied in actuarial analyses were survival, disease-specific survival, local control, freedom from distant relapse, and occurrence of late intestinal complications. Although the anemic group (Hb less than 13.5 g/dl) was correlated negatively with survival (p = 0.02), there was no correlation with disease-specific survival or local control. The conclusion was that anemia per se did not affect the outcome of radiation therapy. A pulse pressure greater than or equal to 60 mm Hg was significantly correlated with worse survival (p = 0.01) and local control (p = 0.04), but no correlation was found between systolic and diastolic blood pressure and the end-points measured. Neither anemia nor hypertension were significantly correlated with late intestinal complications.

Heat loss and blood flow during hyperthermia in normal canine brain. II: Mathematical model

A mathematical model for heating and cooling during hyperthermia has been developed from an appropriate solution of a bioheat transfer equation. Predicted cooling rates obtained from the model have been compared with cooling rates obtained from experiments performed on both perfused and non-perfused normal canine brain tissue. The agreement between the predicted and observed cooling rates in non-perfused tissue is satisfactory (within 6-11 per cent) and provides confidence that the conduction process is being accurately represented. The model is then used to estimate the relative contribution of conductive and convective (blood flow) heat loss during cooling for the in vivo experiments. Estimates of blood flow dynamics are made from cooling data taken early and late in a heating course using the model to correct for conductive heat loss. Simplified forms of the bioheat transfer equation are examined. An adequate model for the observed cooling data is one that treats heat loss (both conduction and blood flow) as a heat sink (i.e. an effective perfusion model) rather than an effective thermal conductivity model.

Heat loss and blood flow during hyperthermia in normal canine brain. I: Empirical study and analysis

The effects of blood flow and thermal conduction during microwave hyperthermia were investigated in normal canine brain. Heating was accomplished with an external microstrip spiral antenna and temperature measurements were made using a multichannel fluoroptic thermometry system. In order to determine cooling rates, temperature measurements made during cooling were fitted with a model consisting of a constant value and an exponential term. Data from experiments in both perfused and non-perfused brains could be fitted with this simple model. The resulting cooling rates indicated that heat loss by conduction is comparable to that by blood flow. In another series of experiments, temperature measurements were made during several 1 min cooling intervals in which the power was shut off intermittently during a 35 min heating episode. Results were consistent with a 2-3-fold increase in blood flow rate which occurred gradually throughout the course of heating. Parameters that affect the determination of cooling rates are discussed in terms of the bioheat transfer equation. These investigations demonstrate that a simple heat sink model provides a good representation of the cooling data for the thermal distributions obtained.

Astrocytoma in children: 14 years' experience at Stanford University Medical Center

Between January 1, 1971 and December 31, 1984, 50 children (31 males, 19 females) ages 3 1/2 months to 18 years with primary CNS astrocytoma were seen in the Department of Therapeutic Radiology, Stanford University Medical Center. The actuarial survival and freedom from relapse (FFR) for the treated group is 46%, with a median follow-up of 7.2 years and a maximum follow-up of 14 years. The majority of relapses occurred within the first 2 years of diagnosis, and all relapses occurred at or adjacent to the initial site of tumor. Multivariate analysis revealed that factors correlated with poor survival are high histologic grade (including presence of necrosis) and primary tumor in the brain stem, while the only important prognostic factor associated with an adverse FFR is high histologic grade. Age, sex, degree of surgical resection, and total radiation dose to the tumor are not correlated with outcome. Patients with high-grade tumor were selected to receive whole brain irradiation and/or adjuvant chemotherapy; therefore, the findings of apparent poor prognosis associated with whole brain irradiation and adjuvant chemotherapy actually reflect patient selection. Current therapy is adequate for only half of children with astrocytoma. Thus, continued development of innovative therapies is indicated, particularly for those children with adverse prognostic factors.

Risk of second cancers after treatment for Hodgkin's disease

We estimated the risk of second cancers among 1507 patients with Hodgkin's disease treated at Stanford University Medical Center since 1968. Eight-three second cancers occurred more than one year after diagnosis, as compared with 15.9 expected on the basis of rates in the general population (relative risk, 5.2; 95 percent confidence interval, 4.2 to 6.5). The mean (+/- SE) 15-year actuarial risk of all second cancers was 17.6 +/- 3.1 percent, of which 13.2 +/- 3.1 percent was due to solid tumors. The risk of leukemia appeared to reach a plateau level of 3.3 +/- 0.6 percent at 10 years, whereas non-Hodgkin's lymphoma continued to increase, to 1.6 +/- 0.7 percent by the end of the follow-up period. The risk of solid tumors did not vary significantly according to treatment category, with the array of neoplasms resembling that previously observed in populations exposed to radiation and in immunosuppressed groups. The risk of leukemia, although elevated after radiation therapy alone (relative risk, 11; 95 percent confidence interval, 1.2 to 38), was much higher after either adjuvant chemotherapy (relative risk, 117; 95 percent confidence interval, 69 to 185) or chemotherapy alone (relative risk, 130; 95 percent confidence interval, 26 to 380). These data suggest that the risk of solid tumors after therapy for Hodgkin's disease continues to increase with time.

Stanford University institutional report. Phase I evaluation of equipment for hyperthermia treatment of cancer

From September 16, 1981, through April 4, 1986, a total of 21 radiative electromagnetic (microwave and radiofrequency), ultrasound and interstitial radio-frequency hyperthermia applicators and three types of thermometry systems underwent extensive phantom and clinical testing at Stanford University. A total of 996 treatment sessions involving 268 separate treatment fields in 131 patients was performed. Thermal profiles were obtained in 847 of these treatment sessions by multipoint and/or mapping techniques involving mechanical translation. The ability of these devices to heat superficial, eccentrically located and deep-seated tumours at the major anatomical locations is evaluated and the temperature distributions, acute and subacute toxicities, and chronic complications compared. Average measured tumour temperatures between 42 degrees C and 43 degrees C were obtained with many of the devices used for superficial heating; average tumour temperatures of 39.6 degrees C to 42.1 degrees C were achieved with the three deep-heating devices. When compared to the goal of obtaining minimum tumour temperatures of 43.0 degrees C, all devices performed poorly. Only 14 per cent (118/847) of treatments with measured thermal profiles achieved minimum intratumoural temperatures of 41 degrees C. Fifty-six per cent of all treatments had associated acute toxicity; 14 per cent of all treatments necessitated power reduction resulting in maximum steady-state temperatures of less than 42.5 degrees C. Direct comparisons between two or more devices utilized to treat the same field were made in 67 instances, including 19 treatment fields in which two or more devices were compared at the same treatment session. The analyses from direct comparisons consistently showed that the static spiral and larger area scanning spiral applicators resulted in more favourable temperature distributions. Three fibreoptic thermometry systems (Luxtron single channel, four channel and eight channel multiple [four] probe array), the BSD Bowman thermistor system and a thermocouple system were evaluated with respect to accuracy, stability and artifacts. The clinical reliability, durability, and patient tolerance of the thermometry systems were investigated. The BSD Bowman and third generation Luxtron systems were found clinically useful, with the former meeting all of our established criteria.

Solitary plasmacytoma of bone: treatment, progression, and survival

Twenty patients with solitary plasmacytoma of bone were treated by radiation therapy. Local control was achieved in 19 and most patients developed systemic myeloma. To evaluate disease progression, 65 patients, including 45 from published series, were analyzed. Younger patients seemed less likely to progress (P = .06), but other clinical characteristics including site of involvement and paraprotein status did not influence progression. After dissemination, patients had a clinical course similar to patients with stage I myeloma, with a median survival of 47 months. Overall, patients with solitary plasmacytoma of bone had an indolent course of disease, with a median survival of 10.7 years and a 5-, 10-, and 20-year survival of 75%, 52%, and 37%, respectively.

Selecting initial therapy for prostate cancer. Radiation therapy perspective

External-beam irradiation of prostatic cancer was introduced at Stanford in 1956. The program has sought to determine the following: whether prostatic carcinoma can be cured by external beam radiation therapy, with what frequency this can be accomplished, which patients are best suited for irradiation, and what technique best accomplishes the irradiation. This report deals with differences and similarities between radiation therapy and surgery, and emphasizes the selection of patients for irradiation.

Extracutaneous mycosis fungoides

The clinical course of 40 patients with histologically documented extracutaneous mycosis fungoides (ECMF) was reviewed. Thirty one patients had documentation of nodal disease only (Stage IVA). Nine patients had histologic evidence of visceral involvement (Stage IVB). A wide variety of topical, regional and/or systemic therapies were used in the management of these patients. The median survival for the entire group was 14.5 months. Eleven patients (28%) obtained a complete response (CR) and had a median survival of 21 months as compared with 8 months among 29 patients not obtaining a CR. One patient is without evidence of disease (NED) at 10 years. Multiple prognostic factors were examined with respect to survival. Prognostic factors found to be significant at the P = 0.05 level included ECMF at presentation of skin disease (versus at the time of relapse), the ability to achieve a CR, and management incorporating the use of topical therapy, especially electron beam treatment. Tabulation of all trials of chemotherapy either at diagnosis of ECMF or subsequently revealed that cyclophosphamide, vincristine and prednisone (CVP) and cyclophosphamide, vincristine, prednisone, and bleomycin (COP-Bleo) were the most effective chemotherapeutic combinations. In a multivariate analysis with survival as the endpoint, the best model consisted of only two covariates: ECMF at presentation of skin disease, and the use of topical therapy. Other covariates found not to be significant at the P = 0.05 level included age, gender, clinical extent of cutaneous and extracutaneous disease, Stage IVA versus Stage IVB disease, the presence of Sezary cells in the peripheral blood smear, and management incorporating the use of systemic therapy.

Minimal long-term cardiopulmonary dysfunction following treatment for Hodgkin's disease

We studied the long term cardiopulmonary function, at rest and during exercise, of 57 patients who were at least 1 year (mean 5 years) post-treatment for Hodgkin's disease. To establish the maximum degree of dysfunction we studied 40 patients who had extensive intrathoracic disease treated with radiotherapy alone (Exten-X; n = 20) or combined modality therapy (Exten-XC; n = 20). Patients without intrathoracic disease given either prophylactic mantle therapy (Proph-X, n = 10) or no chest irradiation (

CONTROL

n = 7) were used as controls. An abnormal electrocardiogram, by virtue of a conduction defect, was observed in seven patients, six in the Exten-X or Exten-XC groups. Borderline abnormalities including ST-T changes, prolonged QT interval, or axis deviation occurred in 14 patients distributed evenly throughout the groups. Resting mean pulmonary function test values were normal in all treatment groups. Exercise tolerance, as indicated by peak oxygen consumption (VO2), was significantly lower for the Exten-XC group compared to Proph-X (p less than 0.01). However, the mean value of VO2 for group Exten-XC was only 15% below that predicted. Of the 12 patients with abnormally low VO2 (greater than 20% below their predicted value), 11 were in the Exten-X or Exten-XC group with no difference between the two groups. Patients who received radiotherapy to at least one lung field, using either the thin lung block technique or open field irradiation, had significantly lower exercise tolerance than those treated with full thickness blocks (p less than 0.05). Despite these abnormalities only a single patient complained of marked dyspnea. We conclude that extensive treatment to the mantle field, especially when followed by chemotherapy in patients with extensive intrathoracic Hodgkin's disease, can result in minimal cardiopulmonary dysfunction in approximately one-third of patients.

Relationship between the neurotoxicity of the hypoxic cell radiosensitizer SR 2508 and the pharmacokinetic profile

Complete pharmacological data from 71 patients treated on the phase I trial of SR 2508 were analyzed to see if the dose-limiting toxicity of peripheral neuropathy is related to the individual patient's pharmacokinetic profile. In a retrospective analysis, the risk of toxicity was best predicted by using the bivariate model of total drug exposure and the time over which the treatment course was given. Drug exposure [area under the curve (AUC)] for a single treatment was calculated by the integral over time of the serum concentration of SR 2508. Since the AUC was constant during the course of a patient's treatment, the total drug exposure (total-AUC) was estimated by the product of the AUC times the number of drug administrations. While the clinical efficacy of hypoxic cell sensitizers remains to be proven, SR 2508 is better tolerated than its predecessors, misonidazole and desmethylmisonidazole, as three times the amount of SR 2508 can be given. If this model is confirmed in the current phase II and III trials, the probability of developing neuropathy would be predictable for an individual patient from measurements made at the time of the first drug dose, allowing for the adjustment of drug schedule to avoid all but minor toxicity.

Treatment of lymphoblastic lymphoma in adults

Forty-four adult patients with lymphoblastic lymphoma (LBL) were treated according to one of two protocols. Both included (1) induction with cyclophosphamide, doxorubicin, vincristine, prednisone, and L-asparaginase; (2) CNS prophylaxis; and (3) maintenance therapy with methotrexate (MTX) and 6-mercaptopurine. In the second protocol, CNS prophylaxis began earlier than in the first protocol and included cranial irradiation and intrathecal (IT) MTX rather than simultaneous high-dose systemic and IT MTX. The overall response rate was 100% (95% complete). With a 26-month median follow-up, the 1-and 3-year actuarial freedom from relapse (FFR) for the composite patient group was 70% and 56%, respectively. The incidence of CNS relapse was reduced from 31% in the first protocol to 3% in the second protocol (P = .04, Gehan). Patients can be assigned retrospectively to low (n = 19) and high (n = 25) risk prognostic groups, as indicated by a multivariate analysis of pretreatment prognostic factors. High-risk is defined by Ann Arbor stage IV disease with bone marrow or CNS involvement or initial serum lactate dehydrogenase (LDH) concentration of greater than 300 IU/L (normal, less than 200). FFR of low- and high-risk groups at 5 years are 94% and 19%, respectively (P = .0006). Low-risk patients are highly curable using this approach to adult LBL. More intensive treatment for high-risk patients is warranted.

Factors predicting survival in adults with stage I and II large-cell lymphoma treated with primary radiation therapy

The records of 148 consecutive patients with Ann Arbor stage I and II large-cell lymphoma treated with primary radiation therapy with or without adjuvant chemotherapy were analyzed retrospectively for pretreatment prognostic variables and results of treatment. For patients treated with radiation to fields on one side of the diaphragm, the 5 year freedom-from-relapse rate was 25% and the survival rate was 35%, but for those given additional transdiaphragmatic radiation or for those given radiation plus adjuvant chemotherapy, the rates were both approximately 67%. In a multivariate analysis, the only significant pretreatment prognostic variables were the number of sites of involvement and bulk of disease, with relapse as the endpoint. For patients treated with radiation to both sides of the diaphragm or with radiation plus adjuvant chemotherapy, the 5-year freedom-from-relapse rate was 82% for the group with a favorable prognosis (with less than three sites of involvement and a mass size of less than 10 cm) and 55% for those with an unfavorable prognosis.

Rhabdomyosarcoma: the Stanford experience using a TNM staging system

Seventy-four patients with rhabdomyosarcoma were initially staged according to the Intergroup Rhabdomyosarcoma Study (IRS) grouping classification and then retrospectively using a TNM staging system based on the initial clinical extent of disease. The TNM system includes T1, tumor confined to site or organ of origin; T2, regional extension beyond the site of origin; N0, normal lymph nodes; N1, lymph nodes containing tumor; M0, no evidence of metastases; and M1, distant metastases. All patients received combination chemotherapy, and more than 90% received radiation therapy as part of their initial treatment program with curative intent. Fifty-three of 74 patients (72%) were group III according to the IRS system, indicating unresectable or gross residual tumor. A more uniform distribution was achieved using the TNM system. Freedom from relapse (FFR) was 43% and the actuarial survival rate was 47% for the entire study group at 10 years. All but one relapse occurred within 3 years of initial diagnosis, and only three of 38 relapsed patients were salvaged. All TNM stage I patients are surviving disease free. Among patients having stages II, III, and IV disease by the TNM system, FFR was 53%, 26%, and 11%, and the survival rates were 47%, 36%, and 33%, respectively. Thirty-two of 74 patients (43%) had evidence of lymph node involvement at presentation, and 28 (88%) of these had primary lesions that extended beyond the site of origin (T2 primary). Histologic subtype and primary site had little impact on outcome in a multivariate analysis, and T stage was identified as the single most significant covariate correlated with survival; a model composed of both T stage and M stage was the best one for predicting relapse. The presented data support a study using a prospectively assigned TNM staging system based on the initial clinical extent of disease for use in future therapeutic trials.

Neurologic dysfunction in patients treated for small cell carcinoma of the lung: a clinical and radiological study

The neurologic dysfunction in 7 patients treated for small cell carcinoma (SCC) of the lung by combination chemotherapy and prophylactic brain irradiation was evaluated. The disease appeared to be a diffuse encephalopathy frequently affecting the higher cortical functions. Five out of seven patients had progressive dysfunction leading to death in 1 to 26 months; one patient had stabilization of symptoms followed by death in 21 months, probably from the neurologic disease as well as SCC; one patient's symptoms improved. The clinical course of the neurologic disorder seemed different from the known reactions to brain irradiation and from the other neurologic syndromes associated with lung cancer. The relative contributions of cranial irradiation and treatment with chemotherapeutic agents in producing the neurotoxicity are not known. Computed tomographic (CT) brain scans done after the onset of symptoms did not show any focal signs or necrosis. However, there was a suggestion of progressive increase in intracranial fluid volume on the scans. The incidence of the disorder, 10.2% among a group of 49 patients, suggests the need for prospective studies to evaluate the problem.

Late relapse among patients treated for Hodgkin's disease

Of 1360 consecutive patients with Hodgkin's disease treated at Stanford University, 1312 patients (96%) had complete remission, but 424 patients had a relapse. Fifty-five patients had relapses 36 months or more after completion of therapy. The actuarial risk of relapse in patients disease-free 3 years after therapy was 12.9%. The occurrence of late relapse was significantly related to stage I disease and nodular sclerosis histologic subtype. Late relapse was detected in 88% of patients by history, physical findings, or chest radiographs. Most patients with stage III and IV disease had late relapses in previously irradiated nodes or extranodally, but patients with stage I and II disease had late relapses primarily in unirradiated nodes. Disease-free survival after salvage therapy for late relapse was similar to that seen after treatment of earlier relapse. Prolonged surveillance of patients for late relapse is necessary after treatment of patients with Hodgkin's disease.

Combination of external beam irradiation and multiple-site perineal applicator (MUPIT) for treatment of locally advanced or recurrent prostatic, anorectal, and gynecologic malignancies

We have devised a single after-loading applicator, the Martinez Universal Perineal Interstitial Template (MUPIT), which has been used in combination with external beam irradiation to treat 104 patients with either locally advanced or recurrent malignancies of the cervix, vagina, female urethra, prostate, or anorectal region. Twenty-six patients treated for prostate cancer are excluded because of their short follow-up. Local failure developed in 13 of the 78 remaining patients (16.6%)--major complications developed in 4 patients (5.1%). Follow-up has been 1 year to 7 1/2 years; 60/78 patients have been followed for more than 2 years. All local recurrences and complications occurred before 18 months. The device consists of two acrylic cylinders, an acrylic template with an array of holes that serve as guides for trocars, and a cover plate. In use, the cylinders are placed in the vagina and/or rectum or both and then fastened to the template so that a fixed geometric relationship among the tumor volume, normal structures, and source placement is preserved throughout the course of the implantation. Appropriate computer programs have been developed to calculate the dose from these implants. The advantages of the system are (a) greater control of the placement of sources relative to the tumor volume and critical structures, as a result of the fixed geometry provided by the template and cylinders, and (b) improved dose-rate distributions obtained by means of computerized optimization of the source placement and strength during the planning phase. We conclude that the local control rate (83.4%) with low morbidity (5.1%) achieved with the combination of external beam irradiation and MUPIT applicator in these patients with locally advanced malignancies represents an improvement over previous published results with other applicators.

Radiotherapy of prostatic carcinoma: long- or short-term efficacy (Stanford University experience)

Results of a study that began at Stanford in 1956 demonstrate that long-term, disease-free survival can be achieved following appropriate irradiation in patients with prostatic carcinoma. However, the investigation has also uncovered several powerful prognostic indicators, such as the extent of anatomic involvement, histologic pattern, particularly as described by Gleason; and presence or absence of lymphnode metastases. To illustrate the importance of these parameters, the author presents data that correlate survival with the anatomic extent of the primary tumor and the Gleason pattern scores. Of the staged patients, 64 have been subjected to post-therapeutic biopsy of the prostate 18 months or more following therapy. A correlation also seems to exist among clinical stage, lymph node involvement, and subsequent biopsy status. The implication of this finding in the development of more aggressive therapeutic approaches will be discussed.

The potential benefits of therapeutic splenectomy for patients with Hodgkin's disease and non-Hodgkin's lymphomas

Thirty-four patients with Hodgkin's disease and non-Hodgkin's lymphoma underwent therapeutic splenectomies to improve hematologic tolerance for chemotherapy. The mean age was 40 years; there were 16 males and 18 females. Fourteen had Hodgkin's disease, 19 had non-Hodgkin's lymphoma, and 1 had malignant histiocytosis. Nineteen had palpable splenomegaly, 19 had marrow involvement and 20 had splenic involvement by lymphoma. The following data were analyzed before and after splenectomy: mean white blood cell count (WBC) and platelet count on planned first day of cycle, delay ratio of chemotherapy delivery and percent maximal dose rate. Thirteen patients had non-Hodgkin's lymphoma, splenomegaly and positive bone marrow and showed significant benefit in all of the aforementioned parameters. Of the patients with prior irradiation, only those who completed their radiation greater than six months prior to splenectomy showed benefit. Ten patients had Hodgkin's disease, negative bone marrow and no splenomegaly. This group showed significant improvement in mean platelet count but more limited benefit in delay ratio and percent maximal dose rate. Thus, selected patients with lymphoma who are experiencing delays in chemotherapy because of poor count tolerance may benefit from splenectomy.

Philosophy and quality control. Workload recording--why your laboratory should be in the data bank

The CAP Workload Recording (WLR) Method is the only widely accepted and validated method for recording laboratory workload. Here, the author details how unit values are assigned, how and by whom the data are used, how to quality control the data, and why an adequate comparative data base, such as the CAP Computer Assisted WLR Program, is so important to laboratories.

The role of radiation therapy in the management of stage III follicular lymphomas

Between 1961 and 1982, 66 patients with stage III follicular small cleaved (FSC) and follicular mixed small cleaved and large cell (FM) lymphoma were treated at Stanford University. Treatment consisted of total-lymphoid irradiation (TLI) to a total dose of about 4,000 rad in 61 patients or whole-body irradiation (WBI) followed by boost irradiation to sites of involvement in five patients. In addition, 13 patients treated with TLI received adjuvant chemotherapy, consisting of six cycles of cyclophosphamide, vincristine, and prednisone (CVP). Median follow-up was 9.6 years. Kaplan-Meier actuarial survival at five, ten, and 15 years was 78%, 50%, and 37%, respectively. Freedom from relapse at five and ten years was 60% and 40% with no relapses after ten years. In a prospective randomized study of 16 patients who all underwent staging laparotomy comparing TLI with or without adjuvant chemotherapy with CVP, there was no significant difference in either survival or freedom from relapse between the two groups. Patients with limited stage III disease (without B symptoms, less than five sites of involvement, and maximum size of disease less than 10 cm) had an excellent prognosis with a 15-year survival and freedom from relapse of 100% and 88%, respectively. Radiation therapy may be a potentially curative modality in patients with stage III follicular lymphomas.

The treatment of malignant histiocytosis

Twenty-four consecutive cases of malignant histiocytosis (MH) treated at Stanford Medical Center between 1973 and 1983 have been reviewed. Most patients presented with systemic symptoms (91%) and advanced disease (stage IV, 80%). Multiple organ involvement was common. In six cases, pathologic tissue was further characterized by frozen section immune histochemistry, using a panel of monoclonal antibodies known to react with monocytes and macrophages, as well as a variety of hematopoietic cells. One case expressed a mature monocyte/macrophage phenotype; three cases were considered null cell or primitive lesions; and two cases were identified as probable T cell lymphomas. Seven patients underwent splenectomy. Two patients died prior to any treatment. Twenty-two patients were treated with CHOP (cyclophosphamide, Adriamycin, vincristine, prednisone) +/- bleomycin (B), +/- midcycle high-dose methotrexate (HD-MTX) with leucovorin rescue. Seven patients received prophylactic intrathecal MTX. Of 22 evaluable patients, there was a 68% complete response rate (CR), a 23% partial response rate (PR), and a 9% no response rate (NR). Median duration of CR was 30+ months; median duration of PR was 2.4 months. Median survival for patients attaining a CR has not been reached v 3 months for the PR and NR groups. For all 24 patients, median survival was 2 years, with a 5-year actuarial survival of 40%. Multivariate analysis revealed that a platelet count less than 150,000 (P Cox = .005) and the dose of drug delivered (P Cox = .057) were the most important prognostic factors. Prophylactic intrathecal MTX therapy and splenectomy did not influence survival. Although MH is an aggressive disease with a poor prognosis, it is potentially curable. Systematic and aggressive treatment should further improve the outcome.

Gas-chromatographic determination of mexiletine with a nitrogen-selective detector

The authors present a procedure for the determination of mexiletine in serum. The drugs are extracted under basic conditions into n-heptane/isobutanol (96/4 by vol) and then extracted again into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, reextracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas chromatography with a nitrogen-selective detector. By use of two internal standards, diphenhydramine and p- chlorodisopyramide , concentration and instrument response are related linearly from 500 micrograms/L to 4.0 mg/L. Interferences from other drugs also are eliminated by using two internal standards. Within-run precision (CV) was 5% at the 1 and 2 mg/L concentration: between-run precision was 10% and 5% at those respective concentrations. Interference studies indicate that most commonly prescribed basic drugs will not interfere with this procedure.

Clinical relevance of immunologic phenotype in diffuse large cell lymphoma

The immunologic phenotypes of 78 diffuse large cell lymphomas were determined by an immunoperoxidase technique using a panel of monoclonal antibodies. The phenotypes were correlated with clinical and morphological parameters by univariate and multivariate analysis. Forty-one lymphomas (53%) expressed immunoglobulin (Ig+). Of the 37 cases that did not express immunoglobulin (Ig-), 9 expressed T cell antigens. Although the T cell phenotypes were antigenically heterogeneous, all cases represented mature T cell phenotypes. The majority of the remaining 28 cases expressed the B cell-associated antigen, B1. At 5 yr, actuarial survival for the Ig- patients was 63%, compared with 15% for the Ig+ patients. A significantly greater proportion of patients with Ig+ lymphomas were over the age of 65 at diagnosis. All of the 9 patients with marrow involvement were Ig+. Multiple factors were analyzed by the Cox regression procedure for their impact on survival, including antigenic profile, histologic grade, morphological classification, and numerous clinical parameters previously recognized to be of prognostic significance. In this analysis, stage, age greater than 65 yr, systemic symptoms, and marrow involvement had the greatest influence on survival. The survival difference between Ig- and Ig+ patients is explained by a higher proportion of Ig+ patients with these unfavorable prognostic factors. With our current immunologic methods, retrospective cell phenotyping analysis has not provided independent prognostic significance in diffuse large cell lymphoma. A prospective evaluation of similarly treated patients is needed to characterize the influence of phenotype fully and to determine its potential usefulness for therapy.