Nasopharyngeal carcinoma in the young: a combined M.D. Anderson and Stanford experience

From 1956 to 1988, 57 children and young adults (age 4-21 years) with a diagnosis of nasopharyngeal carcinoma were treated at The University of Texas M.D. Anderson Cancer Center (42 patients) and Stanford University Medical Center (15 patients). The male to female ratio was 2:1. Forty-three patients had lymphoepithelioma, seven had undifferentiated neoplasms, and seven had squamous cell carcinoma. Two patients had Stage III disease and the remainder had Stage IV disease at the time of presentation. All patients were treated with primary radiotherapy, and 14 patients also had chemotherapy with combinations of the following drugs: dactinomycin, doxorubicin, bleomycin, cisplatin, cyclophosphamide, fluorouracil, methotrexate, and vincristine. Twenty-six patients are alive 6 to 178 months from the first day of treatment (median 93 months). The 5- and 10-year actuarial survival rates are 51% and 36%, respectively, and the corresponding disease specific survival rates were 51% and 51%. There were no recurrences after 42 months. The patterns of failure were as follows: distant metastasis only, 21 patients; locoregional metastasis only, 1; both, 5. Distant metastases most commonly occurred in bones, lungs, liver, and mediastinal lymph nodes. Chronic treatment-related morbidity was encountered in a significant number of long term survivors. Trends in the data not reaching statistical significance suggest a more favorable prognosis for a) females, b) patients less than or equal to 15 years of age, c) lymphoepithelioma or undifferentiated histologies, d) stages T3-4 NO-1 vs T1-2 N2-3 vs T3-4 N2-3, e) primary tumor dose greater than or equal to 65 Gy and f) patients who received chemotherapy.

Improving radiotherapy for brain tumors

Radiation oncologists treating patients with primary brain tumors are faced with two important issues: How to improve the cure rate over that which is achievable with the current radiotherapy modalities and how to decrease long-term morbidity while maintaining or improving the cure rate. Several new approaches are being studied, including interstitial implants, stereotactic radiosurgery, new radiation modalities, radiosensitizers, hyperthermia, and altered fractionation programs. It is nonetheless important to remember that such innovative radiotherapy must be incorporated into the overall multimodal therapy for patients with primary malignant brain tumors.

Minimizing and measuring lens dose when giving cranial irradiation

Three different techniques of administering cranial irradiation were used to determine the dose to the lens as measured in the Rando phantom. The techniques employed were as follows: (1) the central axis of the radiation beam was placed at the thickest portion of the cranium; (2) the central axis of the radiation beam was placed at the lateral orbital rim (bony canthus); (3) the central axis of the radiation beam was placed at the thickest portion of the cranium but with the beam angled 5 degrees posteriorly away from the eye. Thermal luminescent dosimeters (TLD) were placed in a phantom, at a point determined from a life-sized anatomical section of the plane through the midsection of the eye, to be at the location of the posterior capsule of the lens. In addition, TLDs were placed on the outer surface of the phantom head, directly lateral to the location determined to be where the lens would lie. With equally weighted lateral opposed beams, delivering a midplane dose of 200 cGy, the TLDs at the point of the lens measured 21, 9.9 and 10.6% of the midplane doses from the three techniques respectively. TLDs placed directly lateral to the lens on the surface of the phantom head gave an approximation of the lens dose, particularly when techniques 2 and 3 were used. Isodose curve generated by a General Electric treatment planning computer gave lens doses similar to those of the phantom data for each of the three different radiotherapy techniques. Cranial irradiation should be carried out by either technique 2 or technique 3 to minimize radiation dose to the lens.

Adoptive immunotherapy as an adjunctive treatment to thoracic irradiation for pulmonary tumor deposits in mice

The study was performed to determine whether local thoracic irradiation (LTI) causes accumulation of adoptively transferred peritoneal exudate (PE) cells in the lung and whether such treatment improves the response of tumor deposits in the lung to LTI. Tumors in the lung were generated by sarcoma SA-NH cells injected i.v. into syngeneic (C3Hf/Kam mice. Exposure of mice to a single dose of gamma-rays ranging from 2 to 10 Gy caused a dose-dependent decrease in the number of alveolar exudate cells. Also, LTI caused a dose-dependent reduction in the number of lung tumor nodules in mice that were treated with tumor cells 4 days before irradiation. Adoptive i.v. transfer of syngeneic PE cells several hours or 2 days after LTI not only restored the radiation-depleted alveolar exudate cells to their normal levels but also led to an accumulation of transferred cells in the irradiated lung to a several-fold excess of the normal value. Maleic anhydride-divinyl ether-2-activated PE cells accumulated in the irradiated lung much more than normal PE cells and exerted antitumor activity in normal mice and in mice exposed to LTI. Their antitumor action, however, was much more pronounced in the latter, resulting in the augmentation of radioresponse of tumor nodules by a factor of 1.23. The better antitumor action of activated PE cells in mice given LTI can be ascribed to accumulation of these cells in the irradiated lung. Thus, these results show that the irradiation of the lung predisposes this tissue to accumulation of lymphoid cells, which can be beneficial in the therapy of malignant tumors by combinations of radiotherapy and adoptive immunotherapy.

Quantitative VEP analysis in children with cortical visual impairment

Children with cortical visual impairment (CVI) usually have a typical clinical presentation. However, in some cases, it may be useful to have confirmatory evidence based on objective electrophysiologic information. To achieve this, we examined some mathematically derived parameters constructed from 20 channel visual evoked potential (VEP). A group of 30 children diagnosed with CVI by clinical and CT findings was compared to a normal control group of 52 children. Each recorded VEP was mathematically transformed using Hjorth's source derivation, to reduce reference contamination and enhance local features. The area under the response curve, computed for each channel within a fixed time window, was used as a measure of the response activity at that channel. These areas were then used to construct several parameters ("R values") describing ratios of activities between different recording electrode areas. Some of these ratios provided good separation between patient and control groups, especially for children older than 5 years of age; in particular CVI patients were found to have a low occipital-to-parietal activity ratio. This finding, together with the observed age independence of the R values in the normal population, their ease of computation and possible physiological interpretability, suggest that R values could be used as confirmatory diagnostic measures.

Molecular genetics in pulmonary emphysema

A vast array of new methods in molecular genetics are providing insights into problems at the cell and molecular level. Their applications in lung disease is unbounded. However, they are only methods. They are the right methods for certain kinds of questions and the wrong methods for other kinds of questions.

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

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

A predictive assay for human tumor cellular response to hyperthermia using dansyl lysine staining and flow cytometry

The heat response of five human tumor biopsies has been examined using the fluorescent probe dansyl lysine and multiparameter flow cytometry. Dansyl lysine has previously been shown to possess specificity for heat killed mammalian cells. The human tumors tested included a cervical squamous cell carcinoma, malignant melanoma, colon adenocarcinoma, ovarian carcinoma, and a mesothelioma. The samples were excised, mechanically disrupted into single cell suspensions and heated in vitro for various lengths of time at 45 degrees C. The cells were returned to 37 degrees C incubation for 12 to 15 hours prior to staining with dansyl lysine. The fraction of cells staining dansyl lysine was quantitated by flow cytometry after gating on high forward angle light scatter and 90 degrees C light scatter. This gate excluded much of the normal cell contamination within the tumor sample. The data show that the heat response of human tumor biopsies varied significantly, with cervical carcinoma and malignant melanoma being the most resistant and the mesothelioma and ovarian carcinoma the most heat sensitive. Finally, evidence is presented for the expression of thermotolerance in ovarian carcinoma and mesothelioma biopsies pre-heated in vitro. Dansyl lysine appears to be useful in measuring the intrinsic cellular heat sensitivity of human tumors and in determining the kinetics of decay of thermotolerance following an initial heat exposure.

Human phosphoribosylpyrophosphate synthetase: radioimmunochemical quantitation in erythrocytes and fibroblasts

PRPP synthetase catalyzes the synthesis of PRPP, a regulatory substrate in the pathway of purine nucleotide synthesis de novo. We have developed a specific assay for quantitative determination of PRPP synthetase immunologically cross-reactive material in human erythrocyte and fibroblast extracts. The sensitivity of the radioimmunoassay (0.3% and 0.08% of normal mean cross-reactive material in erythrocytes and fibroblasts, respectively) was equivalent to that of the enzymatic activity assay, but enzyme protein initially present in relatively inactive monomeric and smaller aggregated forms was radioimmunochemically measurable. The radioimmunoassay was utilized in conjunction with the enzymatic assay to study normal PRPP synthetase and PRPP synthetases from five affected male patients (in four families) in whom inherited enzyme superactivity was associated with increased rates of PRPP and purine nucleotide synthesis and gout with excessive uric acid excretion. Despite increased enzymatic activities in patients' cell extracts, values for cross-reactive material were within the ranges measured in the respective normal cell extracts. Thus, calculated absolute specific activities (nmol/hr/mg cross-reactive material) of patients' PRPP synthetases were substantially greater than those of normal PRPP synthetase. Moreover, absolute specific activities in hemolysates from both patients and normal individuals were in close agreement with the enzyme-specific activities measured in preparations of erythrocyte PRPP synthetase purified to homogeneity from the corresponding patient or normal source. These findings provided evidence for the accuracy and specificity of the radioimmunoassay and supported previous evidence for increased maximal reaction velocity as the basis of superactivity of the patients' enzymes.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic evaluation of phosphoribosylpyrophosphate synthetase activities in hemolysates

Superactivity of phosphoribosylpyrophosphate (PRPP) synthetase is one of several hereditary enzyme abnormalities associated with gout and excessive uric acid excretion. Although measurement of PRPP synthetase activities in erythrocyte lysates should provide a practical means to detect abnormalities of the enzyme, reported values for normal individuals have varied considerably. We describe a radioisotopic procedure for measurement of PRPP synthetase activities in dialyzed hemolysates under a variety of conditions permitting evaluation of enzyme catalytic function and responsiveness to inhibitors and activators. Utilizing this procedure, enzyme activities for normal individuals were higher than generally reported, a difference attributable in part to the following measures undertaken to assure accuracy in activity determinations: precise control of pH of reaction mixtures, provision of verified excesses of the auxiliary enzyme adenine phosphoribosyltransferase, and measurement of all of the radiolabeled products of the assay. Under each condition of measurement, enzyme activities in 44 normal individuals, 13 patients with gout and normal uric acid excretion, and 10 patients with gout and uric acid overproduction were indistinguishable. In four additional individuals with uric acid overproduction, however, excessive enzyme activities were identifiable at all inorganic phosphate concentrations, but responses to purine nucleotide inhibitors were normal. In hemolysates from a patient with an inhibitor-resistant PRPP synthetase, an altered pattern of inorganic phosphate activation and diminished nucleotide inhibitor response was demonstrated. Our studies confirm the ability of the assay procedure to detect kinetically distinct variant forms of PRPP synthetase. Application of this procedure should aid in evaluation of the prevalence of derangements of PRPP synthetase among patients with gout and uric acid overproduction.

Ependymoma, glioblastoma, and acute leukemia in a child

A 5-year-old boy developed an ependymoma; 3 years later, after chemotherapy and radiotherapy, he developed glioblastoma multiforme and acute myeloblastic leukemia. His maternal grandmother had died at a young age of colon cancer. Since ependymoma is not known to predispose to other cancers, the unusual sequence of malignant disease may have been due to combined therapy in a susceptible host.

Liposomal Methotrexate in the Treatment of Murine L1210 Leukemia

To assess the therapeutic effectiveness of methotrexate (MTX) when administered in a liposome carrier, mice bearing intracranial L1210 leukemia were tested with liposomal MTX, free MTX, or saline. Single i.p. injections of liposomal MTX at doses of 5 mg/kg and 2.5 mg/kg prolonged survival of mice bearing intracranial L1210 leukemia. The same doses of the free drug did not prolong survival of the tumor-bearing mice. This system may have clinical application not only for MTX, but also other polar anticancer agents in the treatment for central nervous system malignancy.

Cisplatin therapy in recurrent childhood brain tumors

Twenty-two patients with brain tumors were initially treated with surgery, radiation therapy, and/or adjuvant chemotherapy. Histologic diagnosis included 11 gliomas, seven ependymomas, one dysgerminoma, one teratocarcinoma, one pinealoma, and one small cell tumor. At recurrence, documented on computerized tomographic scan, cisplatin (60 mg/m2/day iv X 2) was given every 3-4 weeks. Seventeen patients received two or more courses and were considered to be evaluable for response. Response parameters included change in the size of tumor on computerized tomographic scan and/or in clinical findings. Four patients had complete response, five had partial response, four had stable disease, and four had disease progression. Toxic effects were manageable. The number of patients with grade 3-4 toxic reactions, by category, were: thrombocytic, ten; leukocytic, four; renal, five; metabolic, four; gastrointestinal, none; and neurologic, seven. Two of the 14 patients tested had grade 3-4 ototoxicity. Acute fluid retention with decreased serum electrolytes and serious but reversible changes in the mental status, which were experienced in earlier patients, decreased in severity with increasing experience of the investigator. In summary, cisplatin appears to be active in a spectrum of brain tumors and should be studied further for therapeutic efficacy.

Dynorphin(1-10)amide: a potent and selective analog of dynorphin(1-13)

Dynorphin(1-10)amide was more potent than Dynorphin(1-13) in inhibiting the twitch of the mouse vas deferens (IC50 of Dynorphin(1-10)amide = 0.3 nM and IC50 of Dynorphin (1-13) = 4.0 nM). Binding assays indicated that two opioid peptides had similar profiles in that they enhanced dihydromorphine (DHM) binding in picomolar concentrations but displaced DHM binding in nanomolar concentrations (IC50 for Dynorphin(1-10)amide = 5 nM). In the mouse tail-flick assay, however, Dynorphin(1-10)amide showed a more selective action on morphine-induced analgesia. Although Dynorphin(1-10)amide had no significant analgesic activity by itself, it differed from the (1-13) analog by neither potentiating nor antagonizing morphine in naive animals. In tolerant animals, on the other hand, 50 microgram of this analog administered icv shifted the ED50 of morphine from 43.0(33.0-55.9) to 17.0 (12.4-23.3). Thus, Dynorphin(1-10)amide appears to be a more potent and selective analog of Dynorphin(1-13).

Virilizing hepatoblastoma: precocious sexual development and partial response of pulmonary metastases to cis-platinum

A 42/3 year old boy with hepatoblastoma presented with precocious sexual development and an abdominal mass. During the course of disease, serial endocrinologic laboratory investigations were done, along with alpha-fetoprotein levels. A significant correlation is noted in these values at diagnosis, postsurgery, and later during a relapse. Ectopic production of chorionic gonadotropins by the tumor is evident. After extensive surgical resection, chemotherapy was started because of metastases. Although the primary tumor failed to respond, the pulmonary metastatic disease showed a greater than 50 percent response rate with cis-platinum.

The influence of protected passive mobilization on the healing of flexor tendons: a biochemical and microangiographic study

The purpose of this investigation was to determined the effects of protected passive mobilization on the repair processes of healing flexor tendons. The total DNA content of the healing tendon and tendon sheath was correlated with their vascularity over a twelve week period. A gradually increasing range of passive motion between the 21st and 84th days after operation was associated with reorientation of the blood vessels to a more normal pattern, a steady increase in sheath and repair site cellularity compared with the immobilized and control tendons. The altered vascularity reflected a stimulation of tendon scar remodeling, and the increased DNA signified an acceleration in tendon maturation.

Familial erythrophagocytic lymphohistiocytosis: treatment with vinblastine-loaded platelets

Identical twin Caucasian boys, age 3 months, were seen with fever of unknown origin, hepatosplenomegaly, and pancytopenia. The diagnosis of familial erythrophagocytic lymphohistiocytosis (FEL) was suspected after examination of Twin A's bone marrow and confirmed by an open liver biopsy of Twin B. Twin A died shortly after diagnosis despite treatment with vincristine and prednisone. At autopsy, the diagnosis was confirmed. Twin B responded initially to a three-week course of weekly vincristine and daily prednisone, but symptoms soon recurred. In an effort to enhance delivery of chemotherapy to the active macrophage target, platelets were loaded with vinblastine and then administered intravenously to th patient every 7-10 days. There was an encouraging response reflected by the disappearance of symptoms and the return of peripheral blood count to the normal range, although increased number of histiocytes was still demonstrable in his bone marrow. After nine weeks, he lapsed completely and became refractory to treatment. He died of pseudomonas sepsis four months after diagnosis. This is the first known attempt to deliver a chemotherapeutic agent directly to the macrophages in treating this disease and represents an interesting concept that merits further exploration.

Halothane effect on cAMP generation and hydrolysis in rat brain

The volatile anesthetic halothane increased the rate of cAMP generation and decreased the rate of cAMP hydrolysis in rat cerebral cortex and cerebellum. The effect of halothane on the enzymes was reflected in a two-fold rise in cAMP content of cerebral cortical tissue exposed to the anesthetic at 3 vol% for 15 and 30 min. The action of halothane on adenylate cyclase is calcium-independent and different from the action of guanine nucleotides, sodium fluoride and specific transmitters. The Vmax of the enzyme is higher in the presence of the anesthetic. It is suggested that halothane, through conformational changes of the enzyme, renders more catalytic sites operative.

Expression of a chicken chromosomal ovalbumin gene injected into frog oocyte nuclei

Ovalbumin is synthesized by Xenopus oocytes injected with a plasmid containing either the chicken chromosomal ovalbumin gene or a plasmid from which the 5' region of the chromosomal gene has been deleted. However, oocytes injected with a plasmid containing full-length ovalbumin cDNA do not synthesize ovalbumin, despite the fact that at least as much stable, ovalbumin-specific RNA is transcribed from the cDNA as from the chromosomal gene.

Comparison of stainless steel and composite plates in the healing of diaphyseal osteotomies of the dog radius: report on a short term study

The rigid fixation of fractures is generally accepted as the best method to achieve union when open treatment of a fracture is undertaken. This has led to the development of plates that have a greater overall dimension and stiffness compared to earlier plate models, as exemplified by the Lane or Eggers type of plate. In our experience the more rigid plate generally leads to satisfactory union, but also carries with it the risk of refracture, either through a screw hole or across the original fracture after plate removal. Experiments by Uhtoff and Dubuc on experimental animals showed that plate induced osteopenia existed when a rigid plate was applied to an intact or osteomized canine femur. These results provide a possible explanation for the occurrence of late fracture. The study to be described is based on the hypothesis that a rigid plate applied to bone induced localized immobilization osteopenia, which ultimately weakens the bone and leads to the development of late fracture. The study was designed to compare a plate made of stainless steel, which exhibited mechanical stiffness comparable to that of devices presently in use, with a plate made of a composite material, which exhibited decreased stiffness by nearly one order of magnitude. It had been demonstrated by engineering analysis that the less stiff plate would allow the bone to experience normal loading, and it was thought that this loading would modulate the rate and pattern of bone remodeling, thereby resulting in bone of greater strength and size as compared to a more rigidly plated bone.