Treatment of advanced breast cancer with aminoglutethimide--response after previous tamoxifen treatment

Thirty-one postmenopausal patients with advanced breast cancer either unresponsive to tamoxifen or progressing after responding to tamoxifen were treated with aminoglutethimide (1 000 - 1 250 mg/d) plus hydrocortisone replacement. The response rate was 33% in patients who had never responded to tamoxifen and 47% in patients who had previously responded to tamoxifen. The overall response rate was 42%. These results show that aminoglutethimide is an effective second-line hormonal treatment for patients with advanced breast cancer.

The value of pleural fluid carcinoembryonic antigen estimation in the diagnosis of malignant tumours of the pleural cavity

Measurement of pleural fluid and blood carcinoembryonic antigen (CEA) concentrations as well as estimations of pleural fluid protein, lactic acid dehydrogenase and sugar levels were carried out in 45 patients with pleural effusions in order to determine the value of these biochemical parameters in the diagnosis of malignant tumours involving the pleural space. The study population included individuals with epithelial and non-epithelial malignant tumours involving the pleural cavity as well as patients with inflammatory effusions and patients with transudates due to cardiac, renal or hepatic disease. Pleural fluid CEA content was the single most useful measurement in distinguishing epithelial malignant tumours from other causes of pleural effusion. In addition, the pleural fluid CEA/blood CEA ratio was greater than 1 in most patients with epithelial cancer of the pleural space, suggesting that local production of CEA is responsible for elevated values in the pleural fluid.

Chemotherapy in porphyria

The clinical courses of 5 patients with hepatic porphyrias (4 with porphyria variegata) who required chemotherapy for disseminated malignant diseases are reviewed. Antineoplastic agents were employed without evidence that these drugs precipitated porphyric crises. It is concluded that the chemotherapeutic approach to these patients should be based on the appropriate treatment for the malignant condition.

Treatment of esophageal cancer with vindesine: an open trial

Fifty-two patients with advanced esophageal cancer have been entered in an open study with vindesine. The regimen consisted of vindesine at a dose of 3 mg/m2 as a continuous infusion over 48 hours followed by 3 mg/m2 iv weekly for 4 weeks and then by monthly maintenance therapy using the same dose. Objective response was seen in 14 (27%) patients. Patients who responded to treatment had significant prolongation of survival. Major pretreatment prognostic factors included performance status and serum albumin concentration. It is concluded that vindesine has definite, although limited, activity against esophageal cancer.

Treatment of acute post-infective polyneuropathy by means of plasma exchange

15 patients with acute post-infective polyneuropathy of the Guillain-Barré type have been treated by means of plasma exchange. The clinical course and outcome of these patients is compared to that in a retrospectively matched control series who were treated with supportive therapy only. All patients had severe rapidly evolving muscle weakness and approximately half the patients in each group required ventilatory assistance. Both the duration of muscle weakness and the hospitalisation time was significantly shorter in the patients treated by means of plasma exchange. These results suggest that plasma exchange is of significant benefit in the treatment of patients with the Guillain-Barré syndrome.

Treatment of advanced head and neck cancer: multiple daily dose fractionated radiation therapy and sequential multimodal treatment approach

Fifty-eight patients with advanced head and neck cancer were entered into a randomised trial comparing chemotherapy (DDP + bleomycin) alone, multiple daily fractionated radiation therapy, and multimodality therapy consisting of chemotherapy plus multiple fractionated radiation therapy. Multimodal therapy gave a significantly higher response rate (69%) than either single-treatment modality. The use of a multiple daily dose fractionation allowed radiation therapy to be completed over 10 treatment days, and the addition of chemotherapy to the radiation treatment did not significantly increase toxicity. Patients receiving multimodal therapy also survived significantly longer (median 50 weeks) than those receiving single-modality therapy (median 24 weeks).

Factors affecting the absorption of iron from cereals

Non-haem-iron absorption from a variety of cereal and fibre meals was measured in parous Indian women, using the erythrocyte utilization of radioactive Fe method. The present study was undertaken to establish whether alteration of the phytate and polyphenol contents of sorghum (Sorghum vulgare) affected Fe absorption from sorghum meals, and to assess the influence of fibre on Fe absorption. Removing the outer layers of sorghum grain by pearling reduced the polyphenol and phytate contents by 96 and 92% respectively. This treatment significantly increased the geometric mean Fe absorption from 0.017 to 0.035 (t 3.9, P less than 0.005). The geometric mean Fe absorption from a sorghum cultivar that lacked polyphenols (albino sorghum) was 0.043, which was significantly greater than the 0.019 absorbed from bird-proof sorghum, a cultivar with a high polyphenol content (t 2.83, P less than 0.05). Fe was less well absorbed from the phytate-rich pearlings of the albino sorghum than from the pearled albino sorghum (0.015 v. 0.035 (t 8.4, P less than 0.0005]. Addition of sodium phytate to a highly Fe-bioavailable broccoli (Brassica oleracea) meal reduced Fe absorption from 0.185 to 0.037. The geometric mean Fe absorption from malted sorghum porridge was 0.024 when 9.5 mg ascorbic acid were added and 0.094 when the ascorbic acid was increased to 50 mg (t 3.33, P less than 0.005). This enhancing effect of 50 mg ascorbic acid was significantly depressed to 0.04 by tea (t 38.1, P less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

The relative dietary importance of haem and non-haem iron

A study was undertaken to find out the relative amounts of haem and non-haem iron absorbed from meals in which varying amounts of these substances were present. Four meals, each containing 6 mg of iron but with varying ratios of haem and non-haem iron, were fed to two groups of subjects, each group receiving two meals. The geometric mean percentage absorption of non-haem iron decreased from 18.0% (SD range 14.6-22.3%) to 6.4% (SD range 3.4-11.8%) as the non-haem iron content of the meal increased from 1.52 mg to 5.72 mg--there was therefore little variation in the actual amounts of non-haem iron absorbed from the different meals. In contrast, the geometric mean absorption of haem iron was approximately 20% from all four meals, although the haem iron content varied between 0.28 mg and 4.48 mg. The amount of haem iron absorbed was thus a linear function of the amount of haem iron in the meal. Two points emerged from the study. Firstly, the relative importance of haem iron in overall iron nutrition was confirmed. Secondly, the fact that the pattern of absorption in relation to dosage was so different for haem iron and non-haem iron suggested that a controlling mechanism for non-haem iron absorption may be located at the mucosal surface. This conclusion is based on the fact that haem iron, the percentage absorption of which was found to be independent of the size of the dose, is absorbed into the mucosal cell when still contained within the porphyrin ring and the iron thus bypasses some controlling mechanism at the mucosal border.

Delayed onset of overt porphyria cutanea tarda in a patient on long-term haemodialysis. A case report

After 7 years on haemodialysis, a 37-year-old anephric man developed cutaneous lesions of the hands, arms and face, shown by skin biopsy to be compatible with porphyria cutanea tarda (PCT) (symptomatic porphyria). Elevated levels of plasma uroporphyrin and 7-COOH porphyrin were detected alongside a predominant isocoproporphyrin fraction in the faeces by means of quantitative thin-layer chromatography, confirming the diagnosis of overt PCT. The plasma uroporphyrin did not pass into the dialysate, even after chloroquine therapy. There was no evidence of hereditary PCT, chronic liver disease or iron overload, although the patient had a history of excessive alcohol consumption. The overt PCT developed after 8 months of home dialysis using softened water with high aluminium concentrations and subsided clinically and biochemically when the softened water was replaced by deionized water.

The effects of organic acids, phytates and polyphenols on the absorption of iron from vegetables

1. Non-haem iron absorption from a variety of vegetable meals was studied in parous Indian Women, using the erythrocyte utilization of radioactive Fe method.

2. The studies were undertaken to establish whether Fe absorption could be correlatedwith the chemical composition of the foodstuff.

3. Addition of the following organic acids commonly found in vegetables, improved the geometric mean Fe absorption from a basic rice meal as follows: from 0·028 to 0·085 with 1 g citric acid, from 0·031 to 0·081 with 15 mg ascorbic acid, from 0·048 to 0·095 with 1 g L-malic acid, from 0·041 to 0·096 with 1 g tartaric acid. The only exception was oxalic acid; the addition of 1 g calciumoxalate to cabbage (Brassica oleraceae) was associated with some depression in Fe absorption from 0·320 to 0·195.

4. There was a marked inhibition of the geometric mean absorption when 500 mg tannic acid was added to a broccoli (Brassica oleraceae) meal (0·015v. 0·297). Sodium phytate (2 g) caused a similar, though less profound inhibition (0·035 to 0·152).

5. When 3 mg ferrous sulphate was added to different vegetables the geometric mean absorption varied widely. Vegetables of low Fe bioavailability were wheat germ (Triticum aestivum) 0·007, aubergine (Solanum melongena) 0·007, butter beans (Phaseolus lunatus) 0·012, spinach (Spinacea oleraceae) 0·014, brown lentils (Lens culinaris) 0·024, beetroot greens (Beta vulgaris) 0·024 and green lentils (Lens culinaris) 0·032. In contrast, bioavailability was moderate or good with carrot (Daucus carota) 0·098, potato (Solanum tuberosum) 0·115, beetroot (Beta vulgaris) 0·185, pumpkin (Cucurbita mixta) 0·206, broccoli 0·260, tomato (Lycopersicon esculentum) 0·224, cauliflower (Brassica oleraceae) 0·263, cabbage 0·320, turnip (Brassica rapa) 0·327 and sauerkraut 0·327.

6. All the vegetables associated with moderate or good Fe bioavailability contained appreciable amounts of one or more of the organic acids, malic, citric and ascorbic acids.

7. Poor Fe bioavailability was noted in vegetables with high phytate contents (e.g. wheat germ 0·007, butter beans 0·012, brown lentils 0·024 and green lentils 0·032).

8. The fact that a number of vegetables associated with low Fe-absorption turned bluish-black when Fe was added to them, suggested that the total polyphenol content in them was high. The vegetables included aubergine spinach, brown lentils, green lentils and beetroot greens. When the total polyphenol content in all the vegetables tested was formally measured, there was a significant inverse correlation (r 0·859, P < 0·001) between it and Fe absorption. The inverse correlation between the non-hydrolysable polyphenol content and Fe absorption wasr0·901 (P < 0·001).

9. The major relevance of these findings is the fact that the total absorption of non-haem-Fe from a mixed diet may be profoundly influenced by the presence of single vegetables with either marked enhancing or inhibiting effects on Fe bioavailability.

Treatment of metastatic breast cancer in estrogen receptor positive patients. A randomized trial comparing tamoxifen alone versus tamoxifen plus CMF

In a controlled clinical trial, 52 patients with ER positive metastatic breast cancer were randomly assigned to receive initial treatment with either tamoxifen alone followed by sequential cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) after tumour progression of concurrent tamoxifen plus CMF, All 52 patients entered are eligible and 50 patients were currently assessable. Response rates (CR + PR) were similar for the two treatment groups (15/24 tamoxifen alone, 17/26 tamoxifen + CMF). The median durations of survival for the two treatment groups 17.7 months and 17.1 months were also not significantly different. Significant correlations were found between level of ER and response rate and also between level of ER and response duration. From the result of this investigation it would appear that there is no advantage to the addition of chemotherapy prior to an adequate trial of hormone therapy in patients with metastatic ER positive breast cancer.

Unusual aspects of febrile neutrophilic dermatosis (Sweet's syndrome). Case reports

Two patients with febrile neutrophilic dermatosis (FND) of Sweet's syndrome are described. One patient had acute myeloblastic leukaemia and FND antedated any changes in the peripheral blood. The second patient had bullous lesions which healed, with clinical cutis laxa (acquired anetoderma). In this patient FND had persisted for 8 years and histological examination of the skin lesions showed inflammation of the subcutaneous fat. To our knowledge this represents the first report of panniculitis due to FND.

Acute leukaemia in pregnancy. A case report and discussion on modern management

A case of acute myelomonocytic leukaemia in pregnancy with successful outcome is reported. Aspects of management are reviewed, especially with regard to expected complications following cytostatic therapy and the effects on both mother and fetus. The need to determine the optimal time for elective delivery is emphasized. The seasons for formation of an international tumour registry are outlined. The disease can no longer be regarded as invariably fatal for mother and child.

Iron absorption from ferritin and ferric hydroxide

Ferritin and ferric hydroxide represent two forms of iron which are less available for absorption than that present in the 'common pool' of non-haem dietary iron. In the present study the absorption of iron from these two compounds was compared in 35 multiparous women when fed in water, in maize porridge and in maize porridge containing 100 mg ascorbic acid. The geometric mean absorption for 3 mg ferritin iron was 0.7% and for ferric hydroxide, 2.4%. Comparable figures when fed with maize porridge were 0.4% and 0.4% respectively. When 100 mg ascorbic acid was present in the porridge, absorption was enhanced from both sources, being 12.1% for ferritin and 10.5% for ferric hydroxide. These results indicate that the fraction of iron in ferritin and ferric hydroxide that enters the 'common pool' of non-haem dietary iron is profoundly influenced by the nature of the diet. The greater the concentration of enhancing ligands, the closer does the absorption of iron from these compounds approximate that of the non-haem dietary iron pool.

Hyperkalaemia in prolymphocytic leukaemia--a sometimes spurious result. A case report

A patient suffering from prolymphocytic leukaemia was found to have extremely high serum potassium levels. The mechanism of the apparent biochemical change was investigated and was found to be a spurious abnormality related to in vitro lysis of the large mass of lymphocytes. This in vitro observation has been termed pseudohyperkalaemia and should not be mistaken for genuine disturbances that need treatment.

Treatment of small cell lung cancer: intensive remission induction, radiation therapy, and maintenance chemotherapy

Forty-eight patients with small cell lung cancer were treated with an intensive therapy regimen which included induction chemotherapy with vincristine, adriamycin, procarbazine, and methotrexate. This was followed by radiation therapy given to areas of residual disease after restaging. Maintenance chemotherapy with cyclophosphamide, methotrexate, and procarbazine was then given to patients who had entered complete remission (CR). Fifteen out of 17 patients with limited disease (88%) achieved complete remission. Remission rates for patients with extrathoracic metastases were somewhat lower. Seven of 11 patients (64%) of patients with a single extrathoracic metastatic site achieved CR, while only 6/20 (30%) with multiple extrathoracic metastases went into remission. Median survival for patients who achieved complete remission was 17 months.

Iron nutrition in Indian women at different ages

The iron status of 320 Indian women living in Chatsworth, Durban, who had volunteered for iron absorption studies, was assessed using a number of measurements. These included: radio-iron absorption, the transferrin saturation, the serum ferritin concentration and the haemoglobin concentration. In the sample as a whole, the prevalence of iron deficiency anaemia (haemoglobin concentration less than 12 g/dl, with two or more abnormal measurements of iron status) was 14,4%. A further 26% had depleted iron stores (serum ferritin less than 12 micrograms/l) and 8,4% also had evidence of iron-deficient erythropoiesis (serum ferritin less than 12 micrograms/l and transferrin saturation below 16%). A profile of iron status based on the cumulative frequency distribution of iron stores showed that the sample, with calculated median iron stores of 150 mg and lower and upper 10 percentiles of -355 mg and 655 mg respectively, was significantly more iron deficient than a sample of women studied in Washington State, USA. Of interest was the observation that all measurements of iron status were better in the older age groups, presumably as a result of the cessation of menstruation. In addition, there was evidence that the duration of menstruation, as volunteered in a brief history, had a significant effect on several measurements of iron status. This was particularly true of the serum ferritin concentration and radio-iron absorption, both of which reflect the size of the iron stores.

Factors affecting the absorption of iron from Fe(III)EDTA

1. The modification of iron absorption from Fe(III)EDTA by agents known to promote or inhibit absorption was examined in 101 volunteer multiparous Indian women. Fe absorption from Fe(III)EDTA was compared with absorption of intrinsic food Fe in a further twenty-eight subjects. Finally the urinary excretion of radio-Fe after oral administration of 59Fe(III)EDTA was studied in twenty-four subjects and evidence of intraluminal exchange of Fe was examined. 2. Fe absorption from maize porridge fortified with Fe(III)EDTA was more than twice that from porridge fortified with FeSO4 . 7H2O. 3. Although bran decreased Fe absorption from FeSO4 . 7H2O approximately 11-fold, it had no significant effect on Fe absorption from Fe(III)EDTA. Nevertheless tea, which is a more potent inhibitor of Fe absorption, decreased absorption from Fe(III)EDTA 7-fold. 4. Fe absorption from Fe(III)EDTA given in water was only increased 40% by addition of 3 mol ascorbic acid/mol Fe but by 7-fold when the relative proportions were increased to 6:1. This enhancing effect was blunted when the Fe(III)EDTA was given with maize porridge. In these circumstances, an ascorbate:iron value of 3:1 (which doubles absorption from FeSO4 . 7H2O) produced no significant increase in Fe absorption, while a value of 6:1 produced only a 2 . 5-fold increase. 5. Fe absorption from Fe(III)EDTA was not altered by addition of maize porridge unless ascorbic acid was present. 6. Less than 1% of 59Fe administered as 59Fe(III)EDTA was excreted in the urine and there was no inverse relationship between Fe absorption and the amounts excreted (r 0 . 58, P less than 0 . 05). 7. Isotope exchange between 59Fe(III)EDTA and 59FeSO4 . 7H2O was demonstrated by finding a similar relative value for the two isotopes in urine and erythrocytes when the two labelled compounds were given together orally. This finding was confirmed by in vitro studies, which showed enhanced 59Fe solubilization from 59FeSO4 . 7H2O in maize porridge when unlabelled Fe(III)EDTA was added. 8. Although Fe absorption from Fe(III)EDTA was marginally higher it appeared to form a common pool with intrinsic food iron in most studies. It is postulated that the mechanism whereby Fe(III)EDTA forms a common pool with intrinsic food Fe differs from that occurring with simple Fe salts. When Fe is present in the chelated form it remains in solution and is relatively well absorbed because it is protected from inhibitory ligands. Simple Fe salts, however, are not similarly protected and are absorbed as poorly as the intrinsic food Fe. 9. It is concluded that Fe(III)EDTA may be a useful compound for food fortification of cereals because the Fe is well absorbed and utilized for haemoglobin synthesis. The substances in cereals which inhibit absorption of simple Fe salts do not appear to inhibit absorption of Fe from Fe(III)EDTA.

Effect of diet on the rate of iron accumulation in idiopathic haemochromatosis

There is still controversy concerning the effects of increasing the dietary intake of iron on iron nutrition. This debate has not only centered on the question of efficacy but also on that of safety. At particular potential risk are those individuals with disorders such as idiopathic haemochromatosis, who absorb iron excessively from the diet. Data obtained in the present study and in several other investigations suggest that subjects homozygous for the mutant gene responsible for the disorder would develop clinical features of the disease at a younger age were the dietary iron intake to be increased. Iron stores in affected heterozygotes would increase but the size of the stores would probably equilibrate long before they had reached massive proportions. While these conclusions are drawn from a number of studies, there are enough unanswered questions to make it mandatory for any future fortification programmes, whether they be directed at the entire population or only at certain segments of it, to be carefully monitored. This can currently be achieved with serial plasma ferritin measurements, since the concentrations mirror the size of iron stores in the body.

Iron absorption in patients on regular dialysis therapy

Various haematological, ferrokinetic and iron absorption measurements were carried out on 15 patients with chronic renal failure who were undergoing regular haemodialysis. There was no evidence that the rate of iron absorption was impaired significantly by the depressed erythropoietic activity present in these patients. In contrast, there was a significant inverse correlation between the rate of iron absorption and the serum ferritin concentration, which has been shown to be an index of the size of the iron stores. This relationship, which was shown with both small (3 mg) and large (50 mg) doses of ferrous iron, was no different from that previously noted in subjects with normal renal function. These results suggest that iron deficiency in patients with chronic renal failure undergoing regular haemodialysis can be adequately prevented or treated with oral iron therapy, since the absorptive mechanism for iron appears to be normal.

Tamoxifen and hypercalcaemia. A case report

A patient is reported in whom hypercalcaemia developed when adjuvant hormonal treatment with tamoxifen (Nolvadex) was instituted. The response to withdrawal of the drug and the recurrence of hypercalcaemia on rechallenge with tamoxifen make a causal relationship between hypercalcaemia and tamoxifen therapy probable. Some of the mechanisms of development of hypercalcaemia in cases of breast carcinoma are discussed, and the literature on hypercalcaemia and tamoxifen therapy is reviewed.

Bone marrow damage due to melphalan and other cytostatic agents

The case histories of 4 patients who developed bone marrow damage after therapy with melphalan are described. In 3 patients bone marrow damage manifested initially as a sideroblastic anaemia which was later followed by acute myeloid leukaemia. The last patient developed a dyserythropoietic anaemia with leucopenia, but thus far there has been no further progression. None of the 4 patients had any haematological abnormality prior to the melphalan therapy. Two were suffering from carcinoma of the breast and 2 had ovarian neoplasms. The fact that melphalan was given as adjuvant therapy in all 4 patients prior to the development of the haematological abnormalities supports the concept that it was of aetiological importance. These findings are in line with a number of reports in the literature in which acute leukaemia has developed in subjects treated for malignant tumours (especially multiple myeloma and ovarian cancer) with melphalan.

Importance of ascorbic acid in the absorption of iron from infant foods

The absorption of fortification iron from an infant milk formula and from 3 infant cereals was studied in 121 multiparous women. The mean absorption was less than 3.2% when no added ascorbic acid was present. The nature of the iron compound added to infant cereals did not seem to influence the amount absorbed. Absorption was significantly improved when ascorbic acid was added, the mean increase being threefold with an iron:ascorbic ratio of 1:1.5 molar and more than sixfold with a ratio of 1:3 molar (about 10 mg ascorbic acid per mg iron).

Iron absorption from maize (Zea mays) and sorghum (Sorghum vulgare) beer

1. Iron absorption from maize (Zea mays) and sorghum (Sorghum vulgare) beer was more than twelve-fold greater than from a gruel made from the constituents used to prepare the beer. 2. The effect of changes occurring during brewing were investigated. These changes include a decrease in the solid content, and the formation of 30 ml ethanol/1 and 5 ml lactic acid/1. 3. The presence of solid material was found to inhibit Fe absorption markedly, especially when the solid content was 100 g/l or more. 4. The presence of ethanol potentiated Fe absorption but the effect was only modest in gruels with a high solid content. 5. Fe absorption from a 2 ml lactic acid/l solution was four-fold greater than from a hydrochloric acid solution of the same pH. When lactic acid was added to a gruel containing 200 g solids/l the mean absorbtion rose from 0.4 to 1.2 %. 6. In a direct comparison, Fe absorption from beer was significantly better than from a gruel of similar pH containing lactic acid. 7. The results suggest that at least three factors are responsible for the enhanced Fe absorption from maize and sorghum beer. These include the removal of solids during fermentation and the presence of ethanol and of lactic acid in the final brew. 8. In order to reproduce the way in which beer is brewed domestically in Fe containers, a study was done in which beer was prepared in the presence of Fe wire. Under such circumstances Fe was rapidly dissolved and the final Fe concentration of the brew was 89 mg/l. However, the nature of the Fe-containing compound or compounds was not elucidated.

Combination chemotherapy of metastatic breast cancer: a randomized trial comparing the use of adriamycin to that of Vinblastine

Two regimens of chemotherapy for metastatic breast cancer were compared in a randomized controlled fashion. Regimen 1 consisted of cyclophosphamide, vinblastine, methotrexate and 5-fluorouracil (CVMF). Regimen 2 consisted of cyclophosphamide, adriamycin, methotrexate and 5-fluorouracil (CAMF). The patient population consisted of both black and white postmenopausal females who had not received any prior chemotherapy. Objective responses were observed in 25/57 patients treated with CVMF and in 28/51 patients treated with CAMF. Neither race nor choice of chemotherapeutic regimen affected prognosis, although there were differences in the pattern of metastatic involvement between the two racial groups. The median duration of survival of patients who responded to therapy has not yet been reached but will be in excess of 12 months.

The diagnosis and management of hairy-cell leukaemia

Over a 4-year period 203 patients with various types of leukaemia were treated by the Haematology Unit at the Johannesburg Hospital. Ten of them were suffering from the condition known as hairy-cell leukaemia or leukaemic reticulo-endotheliosis. They were all men, and ranged in age from 29 to 67 years (mean 56 years). The majority presented with pancytopenia, and there was invariably splenomegaly, while lymphadenopathy was rare. Hairy cells were identified microscopically in the peripheral blood of 7 patients and in 5 the specific cytochemical marker, tartrate-resistant acid phosphatase, was present. In addition, in a further 2 patients this feature, which was not identified in the peripheral blood, was found in the splenic cells. The bone marrow trephine biopsy specimens characteristically showed extensive lymphoid infiltration associated with a dense disordered deposition of reticulin fibres. Electron microscopical and immunological studies proved to be of doubtful diagnostic value. Splenectomy was carried out on 9 patients, and there was tumour involvement in all the spleens removed. Two patients died from septicaemia, the one before splenectomy and the other 9 months after the operation. The 8 remaining patients have had their subjective symptoms alleviated and their peripheral blood indices have been improved by splenectomy, and none has required further treatment for periods now ranging from 7 to 41 months.

The relationship between marrow iron stores, plasma ferritin concentrations and iron absorption

The percentage absorption from a 3 mg dose of ferrous iron was measured in 50 subjects with iron stores that varied over a wide range. Iron status was assessed by a number of measurements, including the haemoglobin concentration, the plasma iron concentration, the total iron-binding capacity, the plasma ferritin concentration and the concentration of non-haem iron in the bone marrow. There were good inverse correlations between the log percentage iron absorption and both the log marrow non-haem iron concentration (r -0.94; P less than 0.001) and the log plasma ferritin concentration (r -0.78; P less than 0.001). In addition, there was a positive ferritin concentration (r +0.84; P less than 0.001). These results suggest that reticuloendothelial iron stores represent an important determinant of iron absorption and that their size can be guaged from the plasma ferritin concentration.

Treatment of advanced head and neck cancer by means of radiation therapy plus chemotherapy--a randomised trial

Fifty-eight patients with advanced head and neck cancer were entered into a randomised trial comparing radical radiation therapy to the primary tumour and associated lymph node areas with a combination of radiation therapy plus chemotherapy. The distribution of tumour types and stages was similar in the two treatment groups. The response rates to radiation therapy alone (50% complete plus parital response) and to radiation therapy plus chemotherapy (60% complete plus partial response) were not significantly different. However, a significant difference in survival was found between the two groups. The median duration of survival for the patients treated by means of radiation therapy alone was 18 weeks; that for the combined therapy was 36 weeks. The combination of radical radiation therapy plus intermittent high-dose chemotherapy was well tolerated and appears to be an approach that warrants further trial.

Further local experience in the treatment of acute non-lymphoblastic leukaemia

Ninety-two patients suffering from various forms of acute non-lymphoblastic leukaemia were seen at the Johannesburg General Hospital between January 1972 and December 1977. Seventy-four completed at least one course of therapy, and were therefore available for evaluation. Three basic regimens were used for inducing remissions. These included daunorubicin and cytosine arabinoside (regimen 1-19 patients); larger doses of daunorubicin together with cytosine arabinoside (regimen 2-29 patients); and a combination of cyclophosphamide, vincristine, cytosine arabinoside and prednisone (regimen 3-22 patients). Regimen 3 was normally used only in older patients. Supportive measures included the use of red cell, granulocyte and platelet transfusions. Complete remission rates with the 3 regimens were 36,8%, 55,1% and 40,9% respectively, with corresponding partial remission rates of 5,2%, 0% and 18,1% respectively. The mean duration of survival in those patients who achieved remission was 10 months, 18 months and 8 months respectively. In addition, a complete remission rate of 28,6% was obtained in 14 patients, 10 of whom had relapsed while being treated with other regimens and who were later treated with an 8-drug combination (TRAMPCOL).

Combination chemotherapy including bleomycin in the treatment of advanced Hodgkin's disease

Fifty-six patients with advanced Hodgkin's disease were treated with a combination of nitrogen mustard, a vinca alkaloid (vincristine or vinblastine), procarbazine, prednisone and bleomycin, given in repeated cycles. Complete remission was achieved in 33 out of 53 evaluable patients (62,5%). The complete remission rate in patients who had received prior radiation therapy alone (65%) was similar to that in previously untreated patients (73%). Patients who had previously received combination chemotherapy, either alone or together with radiation therapy, responded less well to this regimen of therapy, with a complete remission rate of less than 40%. The complete remission rate was not influenced by the histological subtype of the Hodgkin's disease. Twenty-three of the 33 responders (70%) remain in continuous complete remission. The median for this group has not been reached but will be in excess of 24 months. Major bleomycin toxicity was not encountered in this study. Lung function was monitored throughout but no consistent changes were encountered. The degree of haematological toxicity caused by treatment was no greater than would have been expected without bloemycin. Although the results obtained with the 5-drug combination were satisfactory, the follow-up to date does not suggest that the addition of bleomycin to the convention 4-drug regimen has significantly affected the outcome.

Fanconi's anaemia, with special reference to erythrokinetic features

Serial haematological investigations were carried out in 5 patients with Fanconi's anaemia over periods of 6 months--11 years. All the patients were pancytopenic with a depression of the granulocytic and megakaryocytic elements of the bone marrow throughout the greater part of their illnesses. Erythropoietic acitvity was variable. The initial bone marrow examination revealed depressed erythroid function in 3 patients. The erythroid hypoplasia persisted in 2 of them, while in the third, erythroid activity increased with time, possibly as the result of therapy with oxymetholone. Erythroid hyperplasia was present in the remaining 2 patients, both at presentation and throughout the course of the illness. This could not be attributed to treatment in either patient. Six erythrokinetic studies were carried out in the 5 patients at variable intervals after the diagnosis had been made. In 2 studies erythroid activity was unequivocally depressed, while in a further 3 a significant, though probably suboptimal, erythroid marrow response was present. In the final study erythropoiesis was increased but was markedly ineffective in terms of the delivery of viable red cells into the circulation. In vivo counting suggested that some degree of ineffective erythropoiesis was also present in the other patients and studies with 51Cr indicated a shortened red cell survival in all subjects studied. In 2 of them significant splenic sequestration was present. Leukaemic transformation occurred in 2 patients. In 1 of them its development was heralded by the appearance of micromegakaryocytes in the bone marrow.

An investigation into gonadal dysfunction in patients with idiopathic haemochromatosis

Endocrine studies were performed on twelve patients with proven idiopathic haemochromatosis. Basal gonadotrophin levels and/or their responses to LH releasing hormone (LHRH) were low in nine patients, all of whom showed low plasma testosterone levels and clinical evidence of hypogonadism. Those patients with normal gonadotrophin responses had higher testosterone values, suggesting that the poor testosterone secretion was primarily due to inadequate trophic stimulation. No patient showed hypothyroidism of hypothalamic-pituitary origin, while the cortisol response to hypoglycaemia was normal in all six patients studied. GH responses were more variable and difficult to interpret, since the number of the patients studied was small and the degree of hypoglycaemia after insulin was unpredictable.

Pure red cell aplasia

The presentation and clinical course of pure red cell aplasia in 5 patients are described. In 3 of them no concomitant diseases were present, in 1 the condition was associated with the presence of a thymoma, and the remaining patient was suffering from a lymphocytic lymphoma. Pregnancy led to a recurrence of the disorder in 2 patients. The fact that 4 of the patients exhibited unequivocal evidence of other auto-immune disturbances adds further support to the concept that pure red cell aplasia itself has an auto-immune basis.

Patterns of food iron absorption in iron-deficient white and indian subjects and in venesected haemochromatotic patients

The absorption of radioactive iron from a solution of ferrous ascorbate, and from a standard meal containing intrinsically labelled haemoglobin and wheat, was measured in 12 Indian housewives, 18 white hospital patients and 12 subjects with idiopathic haemochromatosis. Eight of the latter had been fully treated by multiple venesections, so that their serum ferritin concentrations were below 25 mug/1. Since the serum ferritin concentrations of the housewives and the hospital patients were comparable, their body iron stores were considered to be depleted to a similar degree. There were no significant differences between the absorptions of ferrous ascorbate or of the haem iron in the standard meal by each group, but the housewives and the hospital patients absorbed significantly less of the non-haem food iron. The mean non-haem food iron absorptions were 36.4%, 5.8% and 18.9% for the treated haemochromatotic subjects, the Indian housewives and the white hospital patients respectively. The discrepancies between the absorptions of the different forms of food iron were highlighted by calculating the ratios between them. The mean non-haem: haem food iron absorption ratio for the group of treated haemochromatotic subjects was 0.98, and for the Indian housewives only 0.18. The white hospital patients did not form a homogenous population: the ratios of the five males and three of the females were greater than 1.0, whereas those of the remaining 10 females were less than 0.5. The results of this study suggest that mal-absorption of non-haem iron from a meal containing bread, presumably due to a defect at the luminal level, may be an important factor in the pathogenesis of iron deficiency in some subjects. The abnormality appears to be particularly prevalent among Indian women living in Durban.

Serum beta-lipoprotein and other specific protein concentrations in patients with immunocytoma

Serum beta-lipoprotein and other specific protein concentrations were measured in 56 patients suffering from multiple myelomatosis, "benign" paraproteinaemia or Waldenström's macroglobulinaemia and in 56 control subjects. The mean level of B-lipoprotein in untreated patients with multiple myelomatosis and macroglobulinaemia was significantly lower than that of the controls. Patients who responded to chemotherapy showed a rapid return to normal of the beta-lipoprotein concentration, while the level remained unchanged in most of those who did not.