[Paraplegia following intrathecal chemotherapy]

The occurrence of major neurologic disturbances is a rare complication of intrathecal cytotoxic drug administration. We describe the case of a 30-year old man with relapsed lymphoblastic lymphoma and CNS involvement who was treated by systemic chemotherapy (ESHAP) and intrathecal injections of methotrexate, cytarabine, thiotepa and hydrocortisone. Thereafter he developed persistent paraplegia with sensory and sphincteric insufficiency. The role of the drug in causing this syndrome was suspected when more common causes, such as a meningeal carcinomatosis, had been excluded by means of CNF analysis and radiological examinations. We review this and other published cases and discuss the possible pathogenesis, as well as the clinical and paraclinical findings in paraplegia following intrathecal chemotherapy. Patients particularly at risk are those who receive intrathecal chemotherapy for over CNS disease rather than as prophylaxis, those who receive several injections and patients who are concomitantly treated with radiotherapy to the brain or systemic high-dose methotrexate or cytarabine.

The effect of adjuvant prednisone combined with CMF on patterns of relapse and occurrence of second malignancies in patients with breast cancer. International (Ludwig) Breast Cancer Study Group

BACKGROUND

The addition of low-dose prednisone (p) to the adjuvant regimen of cyclophosphamide, methotrexate, 5-fluorouracil (CMF) allowed patients to receive a larger dose of cytotoxics when compared with those on CMF alone. However, disease-free survival and overall survival were similar for the two groups. To test the hypothesis that low-dose prednisone might influence the efficacy of the cytotoxic regimen used, the toxicity profiles of the two treatment regimens and the patterns of treatment failure (relapse, second malignancy, or death) were examined.

PATIENTS AND METHODS

491 premenopausal and perimenopausal patients with one to three positive axillary lymph nodes included in International (Ludwig) Breast Cancer Study Group (IBCSG) trial I from 1978 to 1981 and randomized to receive CMF or CMFp were analyzed for differences in long-term outcome and toxic events. The 250 patients assigned to CMF and prednisone received on the average 12% more cytotoxic drugs than those who received CMF alone.

RESULTS

The 13-year DFS for the CMFp group was 49% as compared to 52% for CMF alone, and the respective OS percents were 59% and 65%. Several toxic effects such as leukopenia, alopecia, mucositis and induced amenorrhea were reported at a similar incidence in the two treatment groups. Using cumulative incidence methodology for competing risks, we detected a statistically significant increase in first relapse in the skeleton for the CMFp group at 13 years follow-up with a relative risk (RR) of 2.06 [95% confidence interval (CI), 1.23 to 3.46; P = 0.004]. Patients with larger tumors in the CMFp regimen were especially subject to this increase with a RR for failure in the skeleton of 3.32 (95% CI, 1.57 to 7.02; P = 0.0005). CMFp-treated patients also had a larger proportion of second malignancies (not breast cancer), with RR of 3.34 (95% CI, 0.91 to 12.31; P = 0.09).

CONCLUSIONS

Low-dose continuous prednisone added to adjuvant CMF chemotherapy enabled the use of higher doses of cytotoxics. This increased dose had no beneficial effect on treatment outcome, but was associated with an increased risk for bone relapses and a small, not statistically significant increased incidence of second malignancies. The effects of steroids, which are widely used as antiemetics (oral or pulse injection) together with cytotoxics, should be investigated to identify their influence upon treatment outcome.

Sequential methotrexate and 5-fluorouracil as second-line chemotherapy for advanced colorectal cancer patients pretreated with 5-fluorouracil and leucovorin: a GISCAD study

The biochemical modulation of 5-fluorouracil (5-FU) by means of methotrexate (MTX) and 6-S leucovorin (LV) seems mainly directed at two different intracellular targets, supporting the hypothesis of possible non-cross resistance between these two methods of 5-FU potentiation. Thirty-one patients, all previously treated with 5-FU and LV for advanced colorectal cancer (ACC), were treated with MTX = 200 mg/m2 iv day 1 and 5-FU 600 mg/m2 day 2 with 6-S LV 10 mg/m2 po q 6 h X 6 starting 24 h after MTX, repeated every 2 weeks. Of 30 evaluable patients, 2 Partial Remissions (PR) were achieved (Response Rate = 6.6%; 95% Confidence Interval 0%-14%). Eight patients had disease stabilization (SD). The overall median survival was 5 months (range 1-11). No WHO grade III-IV toxicities were reported. Despite the good tolerability, this combination of MTX, 5-FU and LV rescue has minimal activity in ACC after the failure of 5FU+LV-based chemotherapy.

Thalamocortical projection from the parafascicular nucleus to layer V pyramidal cells in frontal and cingulate areas of the rat

Thalamocortical projections originating from the parafascicular nucleus were reinvestigated using biocytin or biotylinated dextran amine as anterograde tracers in the rat. After stereotaxic injection of the marker in the lateral part of the parafascicular nucleus, labelled ascending fibres were observed running ipsilaterally to the frontal motor and anterior cingulate areas. Labelled fibres gave rise in layer VI to a plexus of thin ramifications ending in layer V, where sparse boutons en passant and terminaux were seen in close apposition to pyramidal cells. Few retrogradely labelled pyramidal somata, contacted by labelled varicosities, were also observed. Electron microscopy demonstrated the synaptic nature of the labelled contacts, displaying asymmetrical junctions and a round vesicular content. The direct loop parafascicular-motor cortex-parafascicular may be of great functional significance in motor control.

Orienting-like reaction after ibotenic acid injections into the thalamic centre median nucleus in the cat

The excitotoxin ibotenic acid was injected bilaterally into the intralaminar centre median nucleus of chronically implanted cats in order to study the effects of early excitation of centre median population on electrographic correlates of behavioral states and to compare them to those induced by injection into intralaminar centralis lateralis nucleus, previously shown. Immediately and during the first 24h after injection, highly aroused behavior with electrocortical activation, myoclonic jerks, enhancement of ocular movements and ponto-geniculo-occipital waves were observed. Surprisingly, in contrast to the increase of REM sleep episodes in centralis lateralis cases, REM sleep was obliterated. The injection sites were histologically confirmed. The different connectional properties of the two intralaminar population may explain the differential results. 5. In conclusion, the present behavioral observations and electrographic findings taken together with the known afferent and efferent projections suggest that the caudal group of intralaminar nuclei is involved in orienting-like behavior.

Epirubicin, cisplatin, and continuous infusion 5-fluorouracil is an active and safe regimen for patients with advanced gastric cancer. An Italian Group for the Study of Digestive Tract Cancer (GISCAD) report

BACKGROUND

A Phase II confirmatory multicenter trial was performed to evaluate a combination of epirubicin, cisplatin, and continuous infusion 5-fluorouracil (ECF) in treating patients with advanced gastric cancer.

METHODS

Fifty-three patients with locally advanced (n = 7) or metastatic (n = 46) gastric cancer received a dose of epirubicin (50 mg/m2) and cisplatin (60 mg/m2) intravenously every 21 days for eight cycles with 5-fluorouracil (200 mg/m2/day) by intravenous continuous infusion for 21 consecutive weeks, administered through a central line using an external pump.

RESULTS

Eight complete responses and 22 partial responses (response rate = 56%, 95% confidence interval +/- 13) were achieved. Twelve patients had stable disease. The median duration of response was 10 months (range, 3-21 months), and the median survival for all the patients was 9+ months (range, 2-28 months). Overall toxicity, which was primarily hematologic, was mild with only three patients requiring hospitalization for neutropenic fever. No death due to toxicity occurred.

CONCLUSIONS

This study found that the ECF regimen is substantially active in treating patients with advanced gastric cancer and has a favorable pattern of toxicity. This schedule clearly deserves randomized comparative trials for palliation of metastatic disease and for adjuvant purposes.

Nucleus reticularis thalami and neocortical paroxysms in the rat

The role of the nucleus reticularis thalami in spike-wave discharges in rats with genetic absence epilepsy has already been demonstrated. This study further investigated the role of the nucleus reticularis thalami in paroxysmal synchronizations in Sprague-Dawley rats; this strain shows no propensity to epileptic activity. Electroencephalographic patterns were followed in chronically implanted, unrestrained rats. After both electrolytic and chemical unilateral lesions, stereotaxically placed in the anterolateral sectors of this nucleus (verified post mortem), abnormal electroencephalographic rhythms (high-voltage polyspikes and spike-wave complexes) were recorded from the frontoparietal cortex, primarily in the contralateral hemisphere. Stereotyped discharges at 3 Hz developed progressively from multiple spikes within the alpha frequency range through the lengthening of the wave component. The excessive synchronized activity recorded from the intact hemisphere was of greater amplitude and occurred slightly earlier than from the lesioned hemisphere. These EEG patterns were associated with behavioural manifestations closely resembling those seen during absence seizures in humans. Bilateral lesions did not induce paroxysmal activity, both hemispheres being characterized by dominant delta/theta activity without signs of EEG-synchronized sleep. The seizures may thus have been due to disinhibition of the contralateral reticularis nucleus, recently shown to project to the reticularis nucleus of the other side in rats. This working hypothesis is supported by callosal cuts. The results indicate that the reticular neurons exert a control over neocortical paroxysmal activity even in animals which do not present genetic absence epilepsy.

Parafascicular nucleus-raphe projections and termination patterns in the rat

Thalamic projections from the parafascicularis nucleus to the raphe system were studied by means of anterograde techniques, utilizing both biocytin and dextran amine in rats. Both tracers injections in the parafascicularis nucleus resulted in the labeling of descending bundles of fibers running along the brainstem. Labeled terminal fields were found in all the raphe nuclei except the nucleus raphe pallidus. Three different types of labeled terminals (numerous small boutons, less numerous large claw-like terminals, varicosities in close apposition to blood vessel walls) originating from the parafascicular nucleus were present in the raphe system. Ultrastructural data suggest an inhibitory nature for the parafascicular-raphe projections. Our results confirm and extend previous retrograde data by indicating the trajectories, the terminal fields, the fine structure of terminal axonal arborizations and boutons. Based on previous retrograde data and our observations, we conclude that the relationship between the parafascicular nucleus and raphe system is reciprocal and concerns most of the raphe nuclei, suggesting that parafascicularis cell population may be involved in many of the functions ascribed to the raphe system.

Oral etoposide as second-line chemotherapy for colorectal cancer: a GISCAD study. Gruppo Italiano Studio Carcinomi Apparato Digerente

Twenty-one patients with advanced colorectal cancer, all previously pretreated with a fluoropyrimidine-based regimen, received oral etoposide: 100 mg/die for 21 consecutive days, every three weeks. No objective response was achieved; 6 pts had a short-lasting stabilization of their disease. Toxicity was substantial and mainly represented by myelosuppression and alopecia. Protracted administration of etoposide is inactive as second-line treatment of colorectal cancer.

5-fluorouracil by protracted subcutaneous infusion. A pilot study

A feasibility study of 5-fluorouracil (5-FU) delivered by long-term subcutaneous infusion (SCI) was carried out in 10 patients with advanced malignancies refractory to conventional treatment. 5-FU: 200 mg/m2/day was administered by an external infusor (Baxter 5 or 7 Multiday) connected with a 21-gauge needle placed in the thoracic wall. Treatment was continued until progression of disease or toxicity. WHO grade II to III mucositis was experienced by two and one patients, respectively. Grade II diarrhea developed in one patient. Local toxicity was substantial but painless and manageable; skin ulceration was experienced by two patients. A total of 88 weeks of therapy was delivered with a median of 8.8 weeks for each patient (range 2 to 16). Two patients (breast and colorectal cancer) achieved a partial remission; two additional cases showed a > 50% decrease in tumor marker levels. In conclusion, the administration of 5-FU by SCI deserves further evaluation, especially in clinical circumstances in which venous access is limited by thrombosis or technical concerns.

Myelo-ablative therapy with peripheral blood progenitor cell (PBPC) support in patients with haematological malignancy

BACKGROUND

Myelo-ablative therapy with peripheral blood progenitor cell (PBPC) support is increasingly being used in patients with haematological malignancy considered to be at high risk for recurrence. The results of this approach, in comparison with the previous experience at St. Bartholomew's Hospital (SBH) using autologous bone marrow transplantation form the basis of this report.

PATIENTS AND METHODS

42 patients (age range 18-63 years, median 42 years), deemed to have a poor prognosis with conventional therapy received myelo-ablative therapy with PBPC support. Diagnoses comprised: non-Hodgkin's lymphoma (NHL): 16 patients, Hodgkin's disease (HD): 9, Multiple Myeloma (MM): 12, and solid tumours (ST): 5. PBPC were mobilised using adriamycin: 35 mg/m2 i.v. on day 1 and etoposide 100 mg/m2 orally, days 1-5, followed by G-CSF: 5 micrograms/kg, subcutaneously, for a median of 7 days (range 6-9 days).

RESULTS

A total of 67 PBPC collections were performed, 1 being 'sufficient' (i.e. mononuclear cells > or = 1.5 x 10(8)/kg and CD34+ cells > or = 1 x 10(6)/kg) in 21 of the 42 patients. The median time to haematological recovery following reinfusion of PBPC was 13 days for both neutrophils > 0.5 x 10(9)/l and platelets > 20 x 10(9)/l (ranges: 8-27, and 8-48 days, respectively) which is significantly shorter than for patients in the historical control group. Supportive care requirements were also significantly reduced, as was the duration of hospital stay i.e., median 19 days (range 12-73 days) compared with 29 days (range 9-180 days).

CONCLUSION

These results confirm rapid blood count recovery following myelo-ablative therapy with PBPC support and the feasibility of this approach.

Effect of systemic adjuvant treatment on first sites of breast cancer relapse

Adjuvant systemic treatment for resectable breast cancer changes the natural history of the disease but provides only a small and delayed effect on survival. Evaluation of the types of first relapse avoided by available treatments may explain why effects on mortality are small and appear late during follow-up. In randomised clinical trials done by the International Breast Cancer Study Group (IBCSG) between 1978 and 1985, 2108 patients with node-positive disease received more-effective treatments (6 or more cycles of cyclophosphamide, methotrexate, fluorouracil and prednisone; with or without tamoxifen, or tamoxifen and prednisone alone), and 722 patients received less-effective treatments (no treatment or a single cycle of chemotherapy). 3 main categories of first site of relapse were defined and evaluated by cumulative incidence analysis: local or regional, and distant soft tissue, bone, and viscera. The more-effective treatments reduced the cumulative incidence of first relapse in local or regional and distant soft tissue sites at 10 years from 36% to 18% (p = 0.0001); first relapse in bone and viscera was not altered by the more-effective treatments. These results were similar for premenopausal and postmenopausal women, and for patients with oestrogen-receptor-positive or oestrogen-receptor-negative tumours. Adjuvant systemic treatments in current use improve patient outcome mainly by reducing the incidence of first local or regional and distant soft-tissue relapses, while first recurrences in bone or viscera are influenced much less. More intensive treatments at present being tested in clinical trials might affect bone and visceral relapses and have a greater and earlier influence on survival.

Diaphragm reinnervation by laryngeal motoneurons

Inspiratory activity of the paralyzed diaphragm was restored by reinnervation with brain stem laryngeal motoneurons. In 10 anesthetized cats, the right recurrent laryngeal nerve (RLN) was cut and anastomosed to the distal stump of either one or both roots (C5-C6) of the ipsilateral phrenic nerve. Three to four months later, reinnervation was assessed under deep anesthesia by the reappearance in the paralyzed diaphragm of 1) direct electromyographic (EMG) responses after electrical stimulation of the RLN and 2) spontaneous inspiratory bursts. Serial radiography, performed on five animals, revealed diaphragmatic excursions of comparable amplitude on the normal and reinnervated sides. Six to twelve months after anastomosis, laparotomy (performed under Nembutal anesthesia) allowed inspection and EMG recording of the spontaneous inspiratory contractions of the reinnervated areas and their sustained responses to tetanic RLN stimulation. Inspiratory discharges showed a ramplike recruitment similar to that of the normal diaphragm. Although the RLN contains a number of expiratory axons, multiple-site recordings disclosed expiratory EMG discharges only once. Histological analysis confirmed the substitution of phrenic axons by regenerating RLN fibers.

Marked overproduction of non-cyclooxygenase derived prostanoids (F2-isoprostanes) in the hepatorenal syndrome

In spite of extensive searching for clues to the pathogenesis of the hepatorenal syndrome (HRS), its cause remains an enigma. The renal dysfunction in HRS has been attributed to intense but reversible renal vasoconstriction. This has engendered the hypothesis that the renal vasoconstriction is caused by a circulating factor. Patients with HRS exhibit chronic endotoxemia and may have tissue hypoxia, an environment conducive for the formation of free radicals. Recently, we discovered a series of novel prostaglandin (PG) F2-like compounds, termed F2-isoprostanes, that are produced in vivo as products of free radical catalyzed lipid peroxidation independent of the cyclooxygenase enzyme. One of these compounds, 8-epi-PGF2 alpha, has been found to be an extremely potent renal vasoconstrictor. Therefore, we quantified levels of these prostanoids in patients with HRS and compared them to various control groups. Plasma levels of these compounds were markedly elevated only in patients with HRS (113 +/- 30 pg/ml) (p < 0.01) compared to normal controls (19 +/- 7 pg/ml), patients with compensated liver disease (20 +/- 4 pg/ml), patients with decompensated liver disease (22 +/- 4 pg/ml), and patients with chronic renal failure (23 +/- 4 pg/ml). The increased levels of these compounds are unlikely the result of reduced hepatic and renal clearance of the compounds since levels are not markedly increased in patients with either decompensated liver disease or chronic renal failure alone. Whether F2-isoprostanes are the elusive mediators responsible for the renal vasoconstriction in HRS remains to be established. However, these findings do suggest that oxidant injury may be a fundamental abnormality involved in the pathogenesis of HRS.

L-folinic acid and 5-fluorouracil in the treatment of advanced breast cancer: a phase II study

BACKGROUND

The combination of 5-fluorouracil (5-FU) and folinic acid (FA) is an active combination for the treatment of advanced breast cancer (ABC). Theoretically, the biologically active isomer of FA, 1-FA, should be more effective than racemic FA in modulating 5-FU activity.

PATIENTS AND METHODS

Thirty-three patients (pts) with ABC, all previously treated with an anthracycline-based combination for advanced disease were treated with 1-FA: 100 mg/m2 i.v. and 5-FU: 370 mg/m2 i.v. for 5 consecutive days every 4 weeks.

RESULTS

Three complete remission (CR) and 11 partial remission (PR) were obtained for an overall response rate of 42% (95% CI = 25-59). Median duration of response was 10 months, median survival was 15 months for responders, 11 months for NC and 3 for PD. Eleven pts experienced a WHO grade III-IV oral mucositis (33%), 6 pts had grade III and one grade IV diarrhea, two pts had grade IV neutropenia resulting in one toxic death.

CONCLUSIONS

In this heavily pretreated population of pts with ABC, this regimen showed an interesting activity with substantial toxicity. Both the response rate and the pattern of side-effects seem similar to those experienced with the racemic mixture of d,1-FA. Modulated 5-FU warrants an increasing consideration in the treatment of breast cancer.

MICE: a new active combination for non-small cell lung cancer

We have treated 38 patients with stage III/IV non-small cell lung cancer with the following regimen: mitomycin-C = 6 mg/m2, ifosfamide = 3 g/m2, cisplatin = 75 mg/m2, vindesine = 3 mg/m2 (MICE), intravenously (i.v.) on day 1, every 3 weeks. Among 26 patients with stage IV disease, 15 obtained a partial remission (PR) (response rate = 57%, 95% confidence interval = 38-76), with a median time to disease progression and a median survival of 4.9 and 7.1 months, respectively. 6 out 7 patients with stage IIIA disease were documented as PR and 5 of them underwent radical surgery with two pathologically confirmed complete remissions. Overall toxicity was substantial but manageable: 3 patients had grade III/IV leucopenia (although 5 patients had neutropenic fever) whereas 13 patients experienced grade II/II anaemia. In conclusion we believe that MICE regimen is an interesting combination and warrants further evaluations both for palliation and in a neoadjuvant setting.

Potentiation of electroencephalographic spindles by ibotenate microinjections into nucleus reticularis thalami of cats

It is well known that the electroencephalogram of the cat in the early stages of slow wave sleep is mainly characterized by rhythmic wave activity at 7-14 Hz, termed spindles, which recur periodically with a slow rhythm of 0.1-0.2 Hz. From early stimulation, decortication and transection studies (see Ref. 14), spindle oscillations were thought to originate in the thalamus. The search for the anatomical substrate of thalamic spindling, however, moved from medial (intralaminar nuclei) to lateral thalamic nuclei, and recently focused on the extreme shell-shaped collection of GABA-ergic cells, the nucleus reticularis thalami. This proposition was based on its structural, hodological, and physiological aspects. There is accumulating evidence that the nucleus reticularis may act as a conditional pacemaker, synchronizing the activity of cortically projecting thalamic neurons. The introduction of glutamate analogues with excitotoxic properties such as ibotenic acid provided the opportunity of studying the immediate effects of chemical excitation of this nucleus on synchronized electroencephalographic activity. We found that, in cats, spindle density was dramatically increased following infusion of ibotenic acid into the rostral pole of the nucleus, supporting the role of this sector in spindle-related rhythmicity.