[Malignant lymphoma with centrofollicular cells associated with pseudomyelomatous lytic bone lesions]

The authors report on 3 cases of malignant lymphoma associated with well-defined lytic lesions of the skull and limbs that were identical to lesions observed in patients with multiple myeloma. In two patients, subcutaneous nodules were found opposite the site of bone lysis. Histologic examination diagnosed centrofollicular cell malignant lymphoma in all 3 cases. The exceptional nature of such lesions in patients with malignant lymphoma is discussed in connection with literature data. The suggested physiopathologic mechanism is secretion of an "osteoclast activation factor" (OAF) by malignant lymphoid B cells.

Effect of dose and repeat intravenous 24 hr infusions of methotrexate on cerebrospinal fluid availability in children with hematological malignancies

This pharmacokinetic study examined the relationship between methotrexate (MTX) dose and drug concentrations in blood and cerebrospinal fluid (CSF) during repeated 24 hr infusions. Two regimens were used: an intermediate dose (ID) of 0.5 g/m2 (7 patients, 23 cycles) and a high dose (HD) of 2.5 g/m2 (8 patients, 39 cycles). Inter-patient variability in the drug concentration was apparent in serum and CSF for both doses. The dispersion was particularly wide in CSF for HD MTX. Considering median values, serum and CSF MTX were linked to dose escalation. Individual CSF/serum drug ratios were not modified by the dose (1.1% for ID MTX versus 1.4% for HD MTX). A potentially cytotoxic drug level in CSF (10(-6) M) was never obtained for ID MTX cycles, but was achieved in 44% of HD MTX cycles: for HD MTX, this corresponded to 88% of patients (7/8). Total body clearance did not modify the degree of CSF MTX passage. A positive, significant correlation (r = 0.62, P less than 0.05) was observed for ID MTX between individual serum and CSF MTX; no such relationship was seen with HD MTX. Individual cycle-to-cycle variations in the MTX concentration were particularly marked in CSF and for HD MTX, without strict concordance with blood levels.

Non-renal urological lymphomas

IVP, US and CT findings for 5 rare cases of non-renal lymphomas of the urinary tract are discussed. The 4 non-Hodgkin lymphomas (NHL) and 1 Hodgkin's disease (HD) involved the ureter (2 cases), bladder (2 cases) and renal pelvis (1 case). US and CT visualised the pyelic lesion (undetected by urography) as wall thickening and detected the two ureteral lesions (which were also revealed by antegrade pyelography for the 1 HD and by retrograde pyelography for an ureteral NHL). One bladder lesion was associated with a renal lesion (CT demonstrated retroperitoneal lymph nodes); the other was a multinodular form infiltrating the entire bladder.

Induction chemotherapy with cis-platinum and 5-fluorouracil for squamous cell carcinoma of the head and neck

One hundred and eight patients with squamous cell carcinoma of the upper aerodigestive tract (UADT) (T3, T4, NO-N3; 17% stage II, 54% stage III, 27% stage IV) were given three courses of chemotherapy before any local treatment. The regimen consisted of cis-platinum 100 mg m-2 on day 1 and 5-fluorouracil 1000 mg m-2 on days 2-6; drugs were administered by continuous infusion. The toxicity of this protocol was acceptable, as 82% of the patients were able to receive the initially scheduled drug dose. The overall response rate of 86.5% included a 35% rate of complete lesion regression. The effect of this regimen on primary tumours was especially remarkable--87.5% responses, including 47.5% complete responses. Results for lymph node metastases were not as good--66% responses, including 33% complete responses. The best results were obtained for tumours of the oropharynx and hypopharynx; oral cavity lesions were the most refractory. For those patients who were subsequently operated on, histological examination of the surgical specimen either confirmed sterilization or demonstrated the persistence of small disease foci. After local treatment, which consisted of radiotherapy alone for 69% of patients, the lesion control rate was 80%. At 18 months follow-up, the survival rate for patients who achieved a complete response with chemotherapy was significantly better than that for patients with a response of less than 50%.

[Adriamycin in low weekly doses. Latest therapy of advanced cancer of the breast]

Thirty-four patients with heavily pretreated advanced breast cancer received adriamycin in weekly doses of 12 mg/m2. Twenty-two patients (18 assessable) had a performance status greater than or equal to 3 (WHO scale). There were 5 (28%) partial responses, 7 (39%) minimal responses, 3 cases (17%) with no change and 3 (17%) with progressive disease; the mean duration of response was superior to 9 months (range: 3-12 months). In the remaining 12 patients, who had resisted a previous multidrug regimen containing adriamycin, there were 3 (25%) partial responses, 2 (17%) minimal responses, 4 cases (33%) with no change and 3 (25%) with progressive disease; the mean duration of response was superior to 5 months (range: 3-11 months). More than 600 weekly injections were administered with only minor blood and digestive tract toxicities. No alopecia was recorded. The total cumulative dose of adriamycin was superior to 900 mg/m2 in 8 patients; none had clinically evident cardiac toxicity. Adriamycin extravasation with subsequent tissue necrosis occurred on 10 occasions due to the frequency of administration; this problem was solved by the systematic installation of central venous catheters.

[Hermansky-Pudlak syndrome. Apropos of a case]

A new case of Hermansky-Pudlak syndrome is reported. Clinical, ophthalmological, hematological and dermatological explorations are all described in detail, with emphasis placed on the risks of non-recognition of the syndrome. The ocular albinism is associated with a cutaneous syndrome of highly variable expression and a thrombopathy generally without frank clinical consequence. The quasi spontaneous meningeal hemorrhage noted in this case is unusual. Literature data on this syndrome is reviewed and its main features are described.

Altered pharmacokinetics and clinical consequences of low dose methotrexate plus cisplatin in the treatment of advanced head and neck cancer

Thirty-two patients with head and neck carcinoma received a multidrug chemotherapy protocol including low dose methotrexate (LDMTX) (30 mg/m2) and cisplatin as their initial treatment. A sensitive immunoenzymatic technique was used for systematic MTX blood monitoring (0-56 hr) in all patients. The MTX-related side effects observed in 15 patients (47%) were significantly associated with an increase in systemic drug exposure occurring early during drug infusion. The average end-of-infusion concentration varied from 8 X 10(-7) M for nontoxic patients to 1.45 and 3.12 10(-6) M for moderately and severely toxic patients respectively. The area under the curve (AUC) (0-56 hr) was also directly related to the increase in side-effects. Total body clearance was reduced in an inverse manner. Volumes of distribution and terminal elimination half-lives were not related to the presence or intensity of MTX side-effects. Based on these data, the institution of folinic acid rescue adapted to the MTX blood concentration, a measure previously not suggested for LDMTX, completely prevented severe toxicity in a subsequent series of 26 patients without modification of the response rate.

Clinical and pharmacokinetic evidence of a life-threatening interaction between methotrexate and ketoprofen

Co-administration of ketoprofen was found in 4 of 118 cycles of high-dose methotrexate (MTX) analysed retrospectively in thirty-six patients. All 4 cycles were characterised by severe MTX toxicity, which was fatal in three cases. Simultaneous administration of ketoprofen was associated with prolonged and striking enhancement of serum MTX levels. There were no abnormalities in MTX kinetics or evidence of MTX toxicity when ketoprofen was given at least 12 h after completion of high-dose MTX infusion. The kidney may be the site of drug interaction. This high-risk association between MTX toxicity and ketoprofen may also apply to other non-steroidal anti-inflammatory drugs.

Clinical pharmacokinetic study of 5-FU in continuous 5-day infusions for head and neck cancer

Twenty-nine previously untreated patients with head and neck carcinoma received a total of 63 cycles of an initial chemotherapy protocol combining cis-platinum (100 mg/m2 on day 1) and continuous 5-day infusion of 5-FU (1000 mg/m2/24 h) from day 2 to day 6. This protocol was repeated on day 16 and day 31. Two daily blood samples obtained from all patients every day during 5-FU administration were analyzed by HPLC to determine the 5-FU concentrations. In the majority of cases a constant elevation was observed in total 5-FU cycle exposure (C X T) from cycle to cycle. A close relationship was demonstrated between elevated 5-FU C X T values (over 30 000 ng h ml-1) and the frequency of cycles in which signs of toxicity (myelosuppression, mucositis, diarrhea) were observed. By contrast, no obvious association was noted between response to treatment and systemic 5-FU exposure.

Reevaluation of alkaline phosphatase measurement during Hodgkin's disease by electrophoretic isoenzyme separation

Electrophoretic isoenzyme separation provides much more precise information than measurement of alkaline phosphatases (AP). Use of this technique for 83 patients with Hodgkin's disease revealed that the presence of the alpha 1 fraction (alpha 1 AP) was very significantly correlated with the stage of disease extension (P less than 0.01) and above all with the presence of general symptoms (P less than 0.001). Repeat measurements performed during patient follow-up demonstrated a close association between presence of alpha 1 AP and existence of progressive disease. While the mechanism of appearance of this abnormal alpha 1 AP fraction is not linked to Hodgkin-specific liver lesions, this test provides much more interesting data than classical measurement of total alkaline phosphatases (TAP).

Systemic blood levels after intra-arterial administration of microencapsulated mitomycin C in cancer patients

Systemic delivery of mitomycin C (MMC) was studied in 6 patients administered microencapsulated MMC (MMC-mc) by an intra-arterial route (IA): 3 IA liver infusions, 3 IA pelvic infusions. Pharmacokinetic data revealed a lower blood MMC availability (peak plasma levels, AUC 0-4 hours) for the pelvis than for the liver; this was attributed to differences in the blood flow infusion rates at these two sites of administration. Direct comparison of systemic MMC exposure was possible for one patient, who received both IA liver MMC (10 mg in standard form, which served as the control) and IA liver MMC-mc (20 mg the day after). The 65% reduction in MMC-mc bioavailability observed for this patient indicates a quantitative local improvement in exposure to the drug and correlates well with the low incidence of systemic side effects noted in preliminary clinical studies.

Continuous 5-day regional chemotherapy by 5-fluorouracil in colon carcinoma: pharmacokinetic evaluation

Eighteen patients with liver metastasis or locoregional recurrence of colon carcinoma received locoregional treatment by continuous 5-day infusions of 5-FU. 5-FU blood levels were measured by HPLC every day of the cycle at 8 am and 5 pm for a total of 87 cycles. Twelve patients were given the drug by an intra-arterial hepatic (i.a.h.) route, 3 by the portal vein (i.p.v.) and 3 by an intra-arterial pelvic (i.a.p.) route. These three routes were compared in respect of their relative pre-systemic drug uptake and the effect of dose escalation. Both the i.a.h. and i.p.v. routes, but not the i.a.p. route, resulted in a significant reduction in AUC 0-105 h compared to the i.v. route at the same dose range. Increasing the dose led to a modification in circulating 5-FU levels proportional to the dose for the i.v. and i.a.p. routes. By contrast, for the i.a.h. and i.p.v. routes, systemic drug delivery was significantly elevated, out of proportion with the dose, indicating a saturable process. For the i.a.h. route, increasing the 5-FU dose from 780 to 1000 mg m-2 day-1 caused a drop in hepatic extraction from 0.93 (0.90-0.95) to 0.44 (0.21-0.66). Liver saturation mechanisms were also evidenced by a mean increase of 2.6 times for the circulating drug level during the second part of the cycle as compared to the first part (P less than 0.001). The evolution of 5-FU AUC 0-105 h as a function of the dose was exponential (r = 0.75, P less than 0.001). Local extraction consecutive to i.a.p. was non-existent, implying that this route of drug administration has no potential advantage over classical i.v. infusion.

Pseudomonas aeruginosa O-11 folliculitis. Development into ecthyma gangrenosum in immunosuppressed patients

Six immunocompromised patients were shown to exhibit Pseudomonas aeruginosa folliculitis in apocrine regions similar to "swimming pool" folliculitis. The lesions evolved within 24 hours as severe ecthyma gangrenosum. The source of the P aeruginosa, serotype O-11, was found in the water system of the hospital. Clinical identification of the lesions and early treatment is important to prevent severe manifestations.

Plasma levels of 7-hydroxymethotrexate after high-dose methotrexate treatment

Thirteen patients with cancer being treated with high-dose methotrexate (MTX) chemotherapy (350-5,000 mg/6 h IV were entered in this study. Plasma levels of MTX and 7-OHMTX, its main circulating metabolite, were measured by an HPLC technique. 7-OHMTX appears rapidly in the blood, reaching a maximum 6-12 h after the beginning of treatment. The elimination of 7-OHMTX is slower than that of MTX, but the elimination half-lives (24-48 h) are not significantly different: 25.2 h for 7-OHMTX versus 20.3 h for MTX. In all cases, 24 h after starting infusion plasma levels of 7-OHMTX exceeded those of MTX. There was a positive and significant correlation between the dose administered and peak plasma 7-OHMTX. Finally, 7-OHMTX formation was shown to be relatively stable throughout the treatment.

Alpha 1 isoenzyme of alkaline phosphatases. Clinical importance and value for the detection of liver metastases

Measurement of the alpha 1 (fast liver) fraction of alkaline phosphatases in the serum for 217 cancer patients, 92 patients with nonmalignant hepatic affections and 131 controls, revealed that the alpha 1 fraction offers better global value (94%), sensitivity (96%), and specificity (93%) than gamma GT or total alkaline phosphatase determinations for the detection of liver metastases during cancer. Initial data from study of the time of appearance of the alpha 1 fraction reveals that this fraction shows up earlier than rises in the gamma GT or total alkaline phosphatases. Results of a multiparametric study conducted on the alpha 1 fraction and various hepatic enzymatic tests (SGOT, SGPT, GLDH, ALP, gamma GT) indicate that the alpha 1 fraction used alone is better than any other test or combination of tests for biological detection of liver metastases. As concerns the influence of chemotherapy on the appearance of the alpha 1 fraction, the majority of the drugs used for anticancer chemotherapy do not seem to affect measurement of the alpha 1 ALP fraction. The alpha 1 fast liver fraction of alkaline phosphatases, detected by electrophoresis on cellulose acetate, can be considered one of the best known tests for the detection of liver metastases.

Colonic and rectal lymphomas. A report of six cases and review of the literature

In connection with six cases of colorectal lymphomas, including five cases of non-Hodgkin lymphomas (3 primary, 2 secondary), and one case of Hodgkin's disease, the authors review the literature concerning the general features and radiological aspects of these pathologies. The radiological signs observed during barium enemas for non-Hodgkin lymphomas are as follows: a small nodular pattern, frequently with multiple lesions (45.7% of cases), a diffuse or infiltrating pattern (25.4%), a filling defect (22.9%), endo- and exo-luminal images (17.8%), ulcerating patterns (3.4%) and a pure mesenteric form (0.8%). Thus, associated radiological forms are present in 16% of cases. The preferential site is the caecum (52.5% of cases), followed by the rectum (21.2%). Colonic or rectal involvement by Hodgkin's disease is extremely rare. From a radiological viewpoint, the most frequently described pattern in the literature is an infiltrating lesion which may or may not cause stenosis; the most frequent site is the caecum.

Polyamines as biological markers in malignant lymphomas

The urinary polyamines putrescine (PU) and spermidine (SPD) were measured for 67 patients with lymphomas: 48 non-Hodgkin (NHL) and 18 Hodgkin's disease (HD). Monthly repeat measurements were obtained over an average follow-up period of 12.5 months. For NHL, a good association was observed between polyamine levels and the severity of the the stage; the distribution of values between nodular and diffuse forms was also significantly different. No such correlations were seen for HD. The evolution of PU values in time has been shown to reflect disease activity for NHL. Non-specific fluctuating Pu values were found in the case of HD. In the case of 20 patients with NHL undergoing chemotherapy, comparison of polyamine levels before and after chemotherapy allowed differentiation between the population of complete responders to treatment and those with only partial or no response.

Comparative study of gamma glutamyl transferase, alkaline phosphatase and its alpha 1 isoenzyme as biological indicators of liver metastases

Biological detection of liver metastases represents an important factor in the surveillance of the course of cancerous affections. The authors present a report on a potential new indicator, the isoenzyme of alkaline phosphatase migrating to the alpha 1 region (alpha 1 ALP). In comparison to those tests considered the most sensitive at present-gamma glutamyl transferase and total alkaline phosphatase-this alpha 1 isoenzyme appears more sensitive and more specific, capable of detecting 97% of liver metastases with a specificity of 90%.

Dermatomyositis-like syndrome in X-linked hypogammaglobulinemia. Case-report and review of the literature

A case of dermatomyositis-like syndrome is described in a 19-year-old man with a history of Bruton's hypogammaglobulinemia. Although the patient had central-nervous-system manifestations (seizures), no echovirus was isolated in the cerebrospinal fluid, in contrast to previously reported cases. Data for our case and the 15 cases previously reported in the literature are reviewed. HLA typing of our patient revealed the presence of HLA B8 and DR3, which seems to play a major role in juvenile dermatomyositis.