Expression of transforming growth factor beta receptors in normal human colon and sporadic adenocarcinomas

BACKGROUND & AIMS

An absence or a presence of mutated transforming growth factor (TGF)-beta receptors is a possible hypothesis explaining the resistance of cancer cells to the growth-inhibitory effect of TGF-beta. Mutations involving microsatellite-like regions of the type II TGF-beta receptor have been described in subgroups of colorectal cancers. The aim of this study was to investigate the expression and distribution of TGF-beta receptors in sporadic colorectal cancers and normal tissues.

METHODS

Thirty-three sporadic colorectal cancers and 20 normal colonic tissues were explored by immunohistochemistry for the expression of type I and type II TGF-beta receptors. Eighteen tumor and 20 normal samples were used for radioactive thermocycling and sequencing of the two microsatellite-like regions of the type II receptor.

RESULTS

Both receptors were overexpressed in tumors compared with normal samples. There was a relationship between the abundance of type II receptor expression and the degree of differentiation of the tumors but not the Dukes' staging or the localization of the neoplasias. No mutation was observed in the microsatellite-like regions of receptor II in any of the samples.

CONCLUSIONS

Sporadic colorectal cancers do not show an absence or a presence of mutated TGF-beta receptors that could explain a resistance to TGF-beta-mediated growth inhibition. The pathways to tumorigenesis of sporadic colorectal cancers may be different from those of some hereditary ones.

Hepatitis C virus genotypes: epidemiological and clinical associations. Benelux Study Group on Treatment of Chronic Hepatitis C

In a cohort of 292 chronic hepatitis C patients living in the Benelux countries the relationship between viral genotype and geographical origin, route of transmission, clinical characteristics and severity of liver disease was analyzed. HCV-RNA isolates could be classified by the Line Probe Assay (LiPA) as 1a, 1b, 2, 3, 4 or 5 in 286 (98%) cases. Patients of European origin were predominantly infected with HCV subtype 1b (164/254, 65%, CI 58-70%), as were patients of Asian origin (7/13, 54%). Patients originating from Surinam (South America) had predominantly type 2 (9/10, 90%), whereas Africans were mainly infected with type 4 (7/9, 77%). Blood transfusion was the mode of transmission in 142 (50%) patients, intravenous drug abuse (IVDA) in 40 (14%), occupational needle accident or tattoo in 11 (4%); no obvious source of infection was found in 93 (33%). In patients infected by blood transfusion, subtype 1b was predominant (70%, CI 61-77%), whereas subtypes la and 3 were predominant in those infected by IVDA (25% and 45%, respectively, p<0.001). Cirrhosis was observed in 68 (24%) patients; in multivariate analysis, factors independently related to cirrhosis were: the duration of infection, age and prior hepatitis B. No significant relationship was found between the severity of fibrosis or liver inflammation and the HCV (sub)types. In summary, in this large cohort of patients in the Benelux countries the hepatitis C virus (sub)type present was clearly related to the country of origin and the route of transmission, but not to the severity of liver disease.

Pupillographic assessment of sleepiness in sleep-deprived healthy subjects

Spontaneous pupillary-behavior in darkness provides information about a subject's level of sleepiness. In the present work, pupil measurements in complete darkness and quiet have been recorded continuously over 11-minute period with infrared video pupillography at 25 Hz. The data have been analyzed to yield three parameters describing pupil behavior; the power of diameter variation at frequencies below 0.8 Hz (slow changes in pupil size), the pupillary unrest index, and the average pupil size. To investigate the changes of these parameters in sleep deprivation, spontaneous pupillary behavior in darkness was recorded every 2 hours in 13 healthy subjects from 19:00 to 07:00 during forced wakefulness. On each occasion, comparative subjective sleepiness was assessed with a self-rating scale (Stanford Sleepiness Scale, SSS). The power of slow pupillary oscillations (< or = 0.8 Hz) increased significantly and so did the values of SSS, while basic pupil diameter decreased significantly. Slow pupillary oscillations and SSS did not correlate well in general but high values of pupil parameters were always associated with high values in subjective rating. Our results demonstrate a strong relationship between ongoing sleep deprivation and typical changes in the frequency profiles of spontaneous pupillary oscillations and the tendency to instability in pupil size in normals. These findings suggest that the results of pupil data analysis permit an objective measurement of sleepiness.

Treatment with terlipressin as a bridge to liver transplantation in a patient with hepatorenal syndrome

Hepatorenal syndrome is a rapidly lethal complication of cirrhosis. The present case provides further evidence of the efficacy of terlipressin in this context even with concomitant treatment with propranolol. A 56 year old male with HBV related cirrhosis developed renal failure characteristic of hepatorenal syndrome. He was also taking propranolol for primary prophylaxis of variceal bleeding. Terlipressin 6 mg/day was administered during haemodialysis and after 1 week plasma creatinine dropped from 6.2 to 2.8 mg%. Daily urinary volume, plasma sodium and natriuresis dramatically increased during the treatment. Discontinuation of the treatment led to a rapid relapse of renal failure (plasma creatinine from 1.8 to 2.2 mg%) and the drug was readministered until a successful liver transplantation could be performed 1 month after the beginning of the treatment. The patient has now a near normal renal function 3 months after transplantation.

A simple method for carbohydrate-deficient transferrin measurements in patients with alcohol abuse and hepato-gastrointestinal diseases

Carbohydrate-deficient transferrin (CDT) is known to be increased in alcohol abuse. Several methods were developed for its measurement (e.g. isoelectric focusing with Western blotting or immunofixation, anion-exchange chromatography followed by immunoassays). We describe a greatly simplified isoelectric focusing technique which does not require immunofixation. CDT results obtained with this method were compared to other biological markers of alcohol abuse, i.e. mean corpuscular volume (MCV), aspartate aminotransferase (ASAT) and gamma-glutamyl-transferase (GGT), in 55 patients distributed in three groups (i.e. healthy control subjects, control patients suffering from various hepato-gastrointestinal diseases and alcohol abusing patients). Sensitivity and specificity were 33-89%, 61-57%, 89-49% and 83-100% for MCV, ASAT, GGT and CDT, respectively. We conclude that our method is highly suitable for routine clinical use.

[Cap polyposis: a rare syndrome]

We report a case of inflammatory cap polyposis of the colon, a rare syndrome, affecting the rectosigmoid. It was observed in a context of mucous diarrhea. Endoscopic and radiological features consisted of elevated and umbilicated nodular lesions. Histology revealed polypoid lesions containing elongated crypts with superficial abrasions, covered by inflammatory and fibrinoid material. Etiopathogenesis of this new syndrome is unknown.

Trends and differential use of assistive technology devices: United States, 1994

OBJECTIVE

This report presents data on annual estimates of the prevalence of use of selected assistive technology devices for vision, hearing, mobility, and orthopedic impairments, including missing limbs. Also presented are statistics on trends in the prevalence of use of selected mobility assistive technology devices for the years 1980, 1990, and 1994.

METHODS

The data used for this report are from the 1994 National Health Interview Survey on Disability (NHIS-D), Phase I, which was co-sponsored by a consortium of U.S. Federal agencies and private foundations. All estimates are based on data from the NHIS-D, Phase I, which represent the civilian, noninstitutional population of the United States.

RESULTS

An estimated 7.4 million persons in the U.S. household population used assistive technology devices for mobility impairments, 4.6 million for orthopedic impairments (including missing limbs), 4.5 million for hearing impairments (not including impairments fully compensated by hearing aids), and 0.5 million for vision impairments. Use of any mobility device for all ages had the highest prevalence rate at 28.5 per 1,000 persons. There was a positive correlation between an increase in age and the increase in the prevalence rate of device usage; for example, of persons in the age group 65 years and over, the rate of mobility, hearing, and vision device usage was more than 4 times the rate for the total population.

CONCLUSION

Assistive technology use has increased because of population size, age composition changes, and a change in the rate of use. Medical and technological advances along with public policy initiatives have also contributed to increased usage.

Structural features of aminoquinolines necessary for antagonist activity against botulinum neurotoxin

Certain aminoquinoline antimalarial compounds, such as chloroquine, antagonize the paralytic actions of botulinum neurotoxins (BoNT). These studies have been extended to determine the critical structural groups necessary for synthetic aminoquinolines to have antagonist activity against BoNT. Isolated mouse hemidiaphragms were maintained at 36 degrees C and indirectly stimulated; the resulting isometric twitch tensions were recorded as a measure of synaptic function. The muscles were exposed to the test compounds before being treated with a challenge concentration of BoNT (typically 0.2 nM of serotype A). The time to onset of 50% muscle paralysis due to BoNT was used to assess quantitatively the efficacy of the test compounds, which were then ranked on the basis of the concentrations necessary to delay paralysis by a specified time increment. Of the compounds tested, those having a 7-chloro-4-aminoquinoline configuration, similar to chloroquine (or the structurally similar 6-chloro-9-amino acridine group in quinacrine), were most effective. Truncation of the alkyl-amino-alkyl group from chloroquine and conversion of the 4-amino nitrogen to a primary amine did not significantly alter its effectiveness as a BoNT antagonist. However, the 6-chloro- or 8-chloro- isomers of chloroquine were essentially ineffective. These results suggest that aminoquinolines antagonize the paralytic actions of BoNT through interaction with a selective, stereospecific site that is not well correlated with antimalarial activity.

[How to follow treated and untreated chronic hepatitis B and C]

Viral hepatitis B and C are important causes of chronic liver disease, cirrhosis and hepatocellular carcinoma. Indications for the treatment of these two forms of chronic viral hepatitis are outlined as well as the practical modalities for the follow-up.

Identification of a recombinant synaptobrevin-thioredoxin fusion protein by capillary zone electrophoresis using laser-induced fluorescence detection

Capillary zone electrophoresis (CZE) was utilized to identify a synaptobrevin-thioredoxin fusion protein (TSB-51). TSB-51 is a substrate for cleavage by botulinum toxin B at the Q(76)-F(77) site. TSB-51 was derivatized with a fluorophore, CBQCA [3-(4-carboxy-benzoyl)-2-quinoline-carboxaldehyde], for 4 h at room temperature. Optimal conditions for CZE separation of the TSB-51-CBQCA complex were determined: buffer (sodium borate), pH (9.0), applied voltage (25 kV), temperature (25 degrees C) and forward polarity. SDS-PAGE showed that TSB-51 had a molecular mass of approximately 19 kDa. The protein was transferred to PVDF membrane and sequenced by the Edman degradation method verifying the first twelve amino acids as SDKIIHLTDDSF. TSB-51 was also collected during CZE separation and subsequently sequenced yielding the first three amino acids as SDK. This CZE-LIF method coupled with the CBQCA derivatization, fraction collection and Edman sequencing allowed for identification of the recombinant protein, a fast separation run time and utilization of small volumes of peptide (1.5 ng protein/23.6 nl injection). This method will be used for monitoring the endopeptidase activity of botulinum toxin B on TSB-51.

Increased transaminases in psychiatry: a case report

We report the case of a patient admitted to the hospital with psychiatric troubles. Soon after admission, he presented severe hepatitis of unknown origin. Careful review of the charts, transvenous liver biopsy, right heart and hepatic pressure measurements, negative toxicologic and viral screenings were highly suggestive of hypoxic hepatitis. Indeed, the patient had previously been treated for a decompensated cardiomyopathy and medications stopped prior to the current admission. Without clear clinical evidence of heart failure he presented a brief malaise two days before the increase in liver enzymes. Holter heart recording showed afterwards bouts of ventricular tachycardia. Treatment with Dobutamine and antiarrythmics led to a rapid decrease of transaminase levels and recovery in liver function. Unfortunately, he died three weeks later from his cardiomyopathy. This case illustrates the need for cardiovascular work-up in the context of hepatitis from unknown origin.

Short- and long-term efficacy of cyclosporin administration in patients with acute severe ulcerative colitis. Belgian IBD Group

Cyclosporin (CsA) has been proposed in the management of patients with acute ulcerative colitis (UC) in whom standard therapy failed and who were candidates for colectomy. Seven academic hospitals contributed to this retrospective study that included 29 patients (median age: 33 y. (15-74 y.); 12 females and 17 males). The median duration of the disease was 4 y. (0.3 to 33 y.). Before initiating CsA, patients were unresponsive to treatment including i.v. corticosteroids (n = 29), 5-ASA or salazopyrine (n = 19), azathioprine (n = 3), antibiotics (n = 14). The i.v. mean dose was 4 mg/kg/day and was adapted to blood level. Concomitant treatment included corticosteroids (n = 27). The median duration of i.v. CsA administration was 10 days (4 to 41 days). At the end of CsA administration, a global improvement was described in 20 patients while a surgery had to be performed immediately in 8 patients because of exacerbation of symptoms (n = 7) or perforation (n = 1). One other patient (74 y.) died because of Pneumocystis carinii infection. For the responders, maintenance therapy included: tapering dose of steroids (n = 12), azathioprine (n = 12), 5-ASA or salazopyrine (n = 10), methotrexate (n = 1) or oral CsA (n = II). The median duration of follow-up was 12 months (4 to 48 months). Among the 20 responders, 7 were subsequently referred for colectomy either electively (n = 3) or because of recurrence of the disease (n = 4). Among the 12 patients treated by azathioprine as a maintenance therapy, only 3 had to be referred for surgery (25%). Among the 8 patients who did not receive azathioprine, 4 were subsequently referred for a colectomy (50%) (NS). In patients with acute refractory UC who received CsA, the short-term efficacy (avoidance of immediate colectomy) was obtained in 20 out of 29 patients (69%). However, after a median follow-up of 12 months, only 13 patients were colectomy free (45%).

Protection by the heavy metal chelator N,N,N',N'-tetrakis (2-pyridylmethyl)ethylenediamine (TPEN) against the lethal action of botulinum neurotoxin A and B

The ability of N,N,N',N'-tetrakis (2-pyridylmethyl)-ethyenediamine (TPEN) to protect against botulinum neurotoxin (BoNT) A and B was examined in vivo in mice. To determine the protective efficacy of TPEN, mice were injected i.p. with TPEN as a single bolus or as multiple injections 30 min before and 0, 2, 4 and 6 hr following i.v. challenges with BoNT-A or -B. TPEN treatment did not alter the 24 hr lethality of BoNT but did produce a significant delay in the time to death. For a moderate dose of serotype A (20 LD50), five divided doses of TPEN prolonged the time to death from 7.8 +/- 0.4 hr to 9.9 +/- 0.5 hr. For serotype B, examined under comparable conditions, the prolongation of the time to death was from 6.1 +/- 0.2 hr to 9.4 +/- 0.6 hr. The range of TPEN doses that could be examined in vivo was limited by its acute toxicity. Although low doses of TPEN (< or = 10 mg/kg) were well tolerated, higher doses (> or = 30 mg/kg) led to ataxia, loss of coordination, convulsions and death in 20.3 min or less. In clonal NG108-15 cells, TPEN was found to produce cytotoxicity as revealed by increases in the secretion of the marker enzyme lactate dehydrogenase (LDH), and enhanced reactivity with the vital dye trypan blue. From LDH concentration-response data determined 24 hr after addition of TPEN, the threshold concentration for observing cytotoxicity was 10 microM and the IC50 was 19.8 microM. At the highest TPEN concentration tested (100 microM), cytotoxicity was detected 8 hr after TPEN addition and increased in severity over a 3 day period. The cytotoxicity in NG108-15 cells appears to be distinct from the rapid-onset toxicity observed in whole animals. These results suggest that TPEN may be of potential benefit in delaying the lethal actions of BoNT-A and -B, but its use is limited by its initial and delayed toxicity. Since the therapeutic and toxic actions of TPEN are both related to zinc chelation, the use of TPEN would need to be restricted to low doses as part of a combination therapy.

Detection of fastidious mycobacteria in human intestines by the polymerase chain reaction

The aim of this study was to determine whether difficult-to-grow mycobacteria are present in human intestines. Intestinal tissue samples were subjected to both mycobacterial culture and a polymerase chain reaction (PCR) assay. After detection by PCR, species identity was determined by hybridizing the amplified 16S rRNA gene fragments with species-specific oligonucleotides. Intestinal biopsies from 63 patients with noninflammatory bowel diseases (n = 22), Crohn's disease (n = 31), or ulcerative colitis (n = 10) were analyzed. Culture and PCR revealed mycobacteria in four (6%) and 25 (40%) samples, respectively. Samples positive by PCR were negative with all probes specific to nine common cultivable species but were positive with Mycobacterium genavense-specific probe in 68% of cases. Mycobacterial isolates were identified as Mycobacterium gordonae and Mycobacterium chelonae. Findings were similar in Crohn's disease samples compared to non-Chron's disease samples. This study shows that difficult-to-grow mycobacteria can be detected by PCR in large and similar proportions of inflamed intestinal tissue from patients with inflammatory bowel disease and intestinal tissue that appears normal from patients with noninflammatory bowel disease.

[Digestive and extra-digestive complications of nonsteroidal anti-inflammatory drugs. Preventive and curative strategies]

The authors review the digestive ulceration risk factors and the criteria for selecting a non steroidal antiinflammatory (NSAI), included the most recent drugs, such as selective anti-cyclo-oxygenases 2. They actualize the preventive strategies and insist on the values of misoprostol and of slow acting anti-rheumatic drugs. In the case of digestive ulcerations, they plead for the immediate stop of the NSAI and its replacement if necessary by corticosteroids, for the prescription of a proton pump inhibitor (PPI) or mesalazine according to the localisation of the lesion, finally for the eradication within 8 days of Helicobacter pylori.

Prognostic evaluation of patients with parenchymal cirrhosis. Proposal of a new simple score

BACKGROUND/AIMS

The current shortage of organs makes it desirable to establish the prognosis of patients with cirrhosis in order to assess priority for liver transplantation.

METHODS

We compared the utility of two exogenous tests (aminopyrine breath test and lidocaine metabolization test), two clinical parameters (encephalopathy, ascites), 18 endogenous tests and five scores (Pugh, Merkel, Orrego, Adler, Pignon) for predicting 1-year mortality in patients with parenchymal cirrhosis. Retrospective (n=49 out of 63 patients) and prospective (n=38 out of 46 patients) series were included. Univariate, multivariate, receiver operator curves and survival curves were employed.

RESULTS

We found that endogenous tests were more discriminant than exogenous tests. The best parameters of the univariate analysis (encephalopathy, bilirubin, alkaline phosphatase, cholinesterase and bile acids) and their 25th and 75th percentiles were included in an additive new score which turned out to be superior to the five other scores. Prospectively, the sensitivity of our new score compared to the Pugh score was 82% versus 95% (NS) and the specificity was 89% versus 56% (p<0.01).

CONCLUSIONS

Our new simple score appears to be very powerful for predicting prognosis at 1 year for patients with cirrhosis and should be evaluated in other centers.

Cefdinir versus amoxicillin/clavulanic acid in the treatment of suppurative acute otitis media in children

An investigator-blinded, randomized, multicenter study was conducted to compare the efficacy and safety of cefdinir and amoxicillin/clavulanate (amoxicillin/CA) in the treatment of pediatric patients with acute suppurative otitis media. Patients 6 months to 12 years of age were randomized in a 1:1:1 ratio to receive cefdinir 14 mg/kg once-daily, cefdinir 7 mg/kg b.i.d., or amoxicillin/CA 13.3 mg/kg t.i.d. Test-of-cure was determined 11 to 16 days post therapy. Of the 752 patients who entered the study, 665 (88%) completed treatment and 595 (79%) were evaluable. Response rates in the three treatment groups were similar. Overall rates of adverse events were statistically lower in the cefdinir once-daily group than in the amoxicillin/CA group. Diarrhea was the most common adverse event in all treatment groups. Cefdinir given either once-daily or twice-daily is a safe and effective treatment for pediatric patients with acute suppurative otitis media.

Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trial of spironolactone versus placebo

BACKGROUND/AIMS

Diuretic requirements after mobilization of ascites by paracentesis have never been assessed in cirrhosis. It is also unknown whether diuretics increase the incidence of postparacentesis circulatory dysfunction. The aim of this study was to investigate these features and to assess whether measurement of plasma renin activity and aldosterone prior to paracentesis predicts diuretic response after this procedure.

METHODS

Thirty-six patients with non-azotemic cirrhosis and ascites treated by total paracentesis plus i.v. albumin were randomly assigned to receive placebo (n=17) or spironolactone 225 mg/day (n=19) immediately after paracentesis and followed-up for 4 weeks.

RESULTS

Five patients (three in the placebo and two in the spironolactone group) abandoned the treatment prior to ascites recurrence or the end of the study due to complications or lack of compliance. The analysis was performed in the remaining 31 patients. Ascites recurrence was more common in the placebo group (13 cases, 93%) than in the spironolactone group (3 cases, 18%) (p<0.0001) and occurred within the first 2 weeks of follow-up in more than 50% of patients. Patients developing ascites in the spironolactone group had higher levels of renin (14.1, 20.6, 32.4 ng/ml per h) and aldosterone (120, 149, 288 ng/dl) than those who did not develop ascites (renin: 2.0+/-2.1 ng/ml per h; range 0.1-6.8; aldosterone: 43+/-38 ng/dl; range 4-116). Three patients in the placebo group and two in the spironolactone group developed postparacentesis circulatory dysfunction (defined as an increase in renin at the third day after paracentesis greater than 50% over baseline levels up to a value higher than 4 ng/ml per h).

CONCLUSIONS

Patients with cirrhosis treated by paracentesis should receive diuretics immediately after this procedure to prevent early recurrence of ascites. The administration of 225 mg/day of spironolactone is a good empiric treatment for non-azotemic patients with cirrhosis, because it is effective in most cases and does not increase the incidence of postparacentesis circulatory dysfunction. The determination of plasma levels of renin or aldosterone prior to paracentesis predicts the efficacy of spironolactone in the prevention of ascites recurrence.

Fluorometric polymerase chain reaction (PCR) enzyme-linked immunosorbent assay for quantification of immuno-PCR products in microplates

Immuno-polymerase chain reaction (immuno-PCR) allows the detection of protein amounts as low as a few hundred molecules. This enhanced sensitivity is useful for a variety of applications in analytical and biomedical sciences. Application of this technique as a routine method requires the rapid quantification of the PCR products, preferably as an automated readout by microplate-based assays. Here, three methods are compared for detecting such amplified products, i. e., direct staining with a fluorescent intercalating dye, an enzymatic assay utilizing doubly hapten-labeled products, and gel electrophoresis. The enzymatic assay, carried out with either chromogenic or fluorogenic substrate for enzymatic signal amplification, was found to be the most sensitive method. The optimized assay was tested in direct immuno-PCR assays for detecting immunoglobulins (IgG) from mouse and rabbit as well as in a sandwich immuno-PCR assay for detecting recombinant hepatitis B surface antigen (rec. HBsAg). Sensitivity limits were found to be as low as 15 fg (10(-19) mol) IgG, representing a 1000-fold enhancement compared to enzyme-linked immunosorbent assay detection, and about 70 fg (2 x 10(-18) mol) rec. HBsAg, improving the detection limit of currently available methods by a factor of about 700. The well-reproducible enzymatic amplification signal further enhances the sensitivity of immuno-PCR and should render the method suitable for routine laboratories.

Efficacy of certain quinolines as pharmacological antagonists in botulinum neurotoxin poisoning

Various 4- and 8-aminoquinolines, which are effective antimalarial agents, were examined as potential pretreatment compounds for prolongation of the time to 50% block of nerve-elicited muscle twitches in isolated mouse diaphragms exposed to botulinum type A neurotoxin. The 4-aminoquinolines (chloroquine, amodiaquine) and quinacrine, an acridine derivative similar to chloroquine, prolonged the time required for botulinum type A neurotoxin to block neuromuscular transmission by more than 3-fold; 8-aminoquinolines (primaquine and WR242511) had no antibotulinum type A neurotoxin activity. Pyrimethamine, an antimalarial drug lacking the quinoline ring structure, was also ineffective. Rank order potencies based on equimolar effective concentrations for the test compounds were quinacrine > amodiaquine > chloroquine > quinine or quinidine. Maximum protection from botulinum type A neurotoxin-induced neuromuscular block was achieved when muscles were exposed to drug prior to or simultaneously with the toxin. A delay of more than 20 min abolished the protective ability of the antimalarial agents, presumably owing to the release of the toxin from endosomes in quantities sufficient to initiate neuromuscular block. All of the test compounds except quinine and quinidine depressed muscle contractions when concentrations exceeded 20 microM. In addition, amodiaquine at 50 microM induced muscle contracture. A combination of agents at low concentrations that act at different steps of botulinum type A neurotoxin poisoning potentiated the prolongation of time to 50% block in an approximately additive fashion. Thus N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine (2 microM) and quinacrine (5 microM), when administered in combination, produced up to a 4-fold increase in time to 50% block. A similar level of protection with quinacrine alone required a 4-fold increase in the aminoquinoline concentration. Although the mechanism of protection by these antimalarial agents is probably through the raising of endosomal pH, the possibility that some of these drugs could also act by inhibiting toxin-induced channel formation cannot be ruled out.

BEACOPP: an intensified chemotherapy regimen in advanced Hodgkin's disease. The German Hodgkin's Lymphoma Study Group

PURPOSE

At present, treatment results for patients with advanced-stage Hodgkin's disease remain unsatisfactory. Standard chemotherapy M(C)OPP (nitrogen mustard (cyclophosphamide). vincristine, procabazine, and prednisone). ABVD (adriamycine, bleomycine, vinblastine, and dacarbacine) or M(C)OPP/ABVD +/- radiotherapy fail to achieve long-term complete remission in 35% to 50% of these patients. The BEACOPP (bleomycin, etoposide, adriamycine, cyclophosphamide, vincristine, procarbazine, and prednisone) regimen was developed to improve treatment results by dose intensification achieved by reduced duration of treatment (time intensification) and addition of etoposide.

PATIENTS AND METHODS

Thirty untreated patients with advanced Hodgkin's disease stage IIB IV according to the Ann Arbor classification were treated with the time intensified BEACOPP regimen. Each patient was scheduled to receive eight cycles of chemotherapy with consolidating radiotherapy to sites of initial bulk disease and to residual tumor remaining after chemotherapy.

RESULTS

All patients were evaluable for assessment of toxicity, treatment response, freedom from treatment failure (FFTF) and survival (SV). Of 30 treated patients, 29 patients received the intended eight cycles of BEACOPP. One patient in clinical CR, terminated the chemotherapy at his own request after six cycles and is at this time, 48 months after the end of treatment, in complete remission. Toxicity was tolerable with WHO grade 3/4 leucopenia in 28% of chemotherapy cycles and one severe (WHO grade 3) infection. No treatment-related death occurred. Cycles could generally be given on schedule. Complete remission (CR) was achieved in all but two patients (93%). At present, only one patient has relapsed. At a median follow-up of 40 months, FFTF-rate is 89% (lower confidence limit: 80%). One patient died due to progressive disease.

CONCLUSION

The BEACOPP regimen is feasible at moderate hematopoeitic toxicity. With a FFTF-rate of 89% at a median follow-up of 40 months, the treatment results are very encouraging. A prospective randomised trial has been initiated to compare the BEACOPP regimen with the standard COPP/ABVD regimen in advanced-stage Hodgkin's disease.