Sleep nasendoscopy: what benefit to the management of snorers?

It has been proposed that sleep nasendoscopy (SN) will improve the success rate of the uvulopalatopharyngoplasty operation by identifying those patients with palatal snoring. The aim of this study was to test the efficacy of SN in the management of snorers who do not have obstructive sleep apnoea. This study compared a group of 26 snorers managed without SN (group A) to a group of 27 snorers managed with SN (group B). The post-operative results of group A were 61 per cent cured, 27 per cent better and 8 per cent unchanged. Group B results were 76 per cent cured, 19 per cent better and 5 per cent unchanged. However, if patients with only palatal snoring had surgery, the results for group B would have been 94 per cent cured, 6 per cent better and 0 per cent unchanged (95 per cent C.I. of difference +0.14, +0.54, p = 0.017). The results confirm the predictive power of SN in identifying success following uvulopalatopharyngoplasty. A simple grading system is suggested to aid in treatment planning. Patients are divided into three categories on SN: palatal snorers, mixed snorers and non-palatal (tongue base) snorers. It is proposed that uvulopalatopharyngoplasty may cure palatal snorers but mixed snorers will need additional therapies to eliminate their snoring although uvulopalatopharyngoplasty may improve the symptoms.

Preferential binding of the novel prostaglandin SC-46275 to canine gastric versus intestinal receptors

Prostaglandins (PGs) in the E-series exhibit potent gastric antisecretory activity, but can also cause diarrhea, which is mediated via PGE receptors. SC-46275, an omega-chain cyclopentenyl analog of the E-type PG enisoprost, was evaluated with other E-PGs for PGE receptor binding activity in gastric and intestinal tissues. SC-46275, enisoprost, misoprostol and PGE1 were first evaluated in enriched canine gastric parietal cells with [3H]misoprostol free acid binding and subsequently with [3H]PGE1 binding in canine intestinal tissues where misoprostol free acid had weak receptor binding activity. The receptor binding potency of SC-46275 (IC50, 0.013 mM) in enriched canine parietal cell preparations was found to be much greater than misoprostol and enisoprost (IC50, 10 and 8 nM), whereas PGE1 had the least potency (IC50, 37 nM). Similar relative potencies for these PGs were also obtained in the inhibition of histamine-stimulated acid secretion in enriched parietal cell preparations. In small intestinal mucosal and muscle membranes, the receptor binding potency of SC-46275 (IC50, 13 and 20 microM) was much less than misoprostol or enisoprost (IC50, 0.39-1.2 microM) and substantially less than PGE1 (IC50, 0.017 and 0.066 microM). This weak binding activity of SC-46275 in intestinal tissues is consistent with its reported weak diarrheagenic activity in the rat. These results suggest that SC-46275 binds preferentially to gastric vs. intestinal PGE receptors and is specific for the EP3 receptors.

Extending the benefit of lipid-regulating therapy to primary prevention

In recent years, a number of published secondary prevention trials have further strengthened the rationale for aggressive lipid-regulating therapy in patients with established coronary artery disease. However, the role of lipid-regulating therapy in primary prevention is less well characterized. Several large primary prevention trials, using a variety of interventions, are ongoing in different populations. These include the Air Force Coronary/Texas Atherosclerosis Prevention Study, the West of Scotland Coronary Prevention Study, the Women's Health Initiative, and the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. These investigations will extend the results of earlier primary prevention trials and further characterize the rationale for intervention.

Reduction of LDL cholesterol by 25% to 60% in patients with primary hypercholesterolemia by atorvastatin, a new HMG-CoA reductase inhibitor

This 6-week, double-blind clinical trial evaluated lipid parameter responses to different dosages of atorvastatin in patients with primary hypercholesterolemia. Atorvastatin is a new 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor under development. After completing an 8-week placebo-baseline dietary phase, 81 patients were randomly assigned to receive either placebo or 2.5, 5, 10, 20, 40, or 80 mg atorvastatin once daily for 6 weeks. Plasma LDL cholesterol reductions from baseline were dose related, with 25% to 61% reduction from the minimum dose to the maximum dose of 80 mg atorvastatin once a day. Plasma total cholesterol and apo B reductions were also dose related. Previously, reductions in LDL cholesterol of the magnitude observed in this study have been seen only with combination drug therapy. In this study, atorvastatin was well tolerated by hyperlipidemic patients, had an acceptable safety profile, and provided greater reduction in cholesterol than other previously reported HMG-CoA reductase inhibitors.

Lung function and exercise capacity in survivors of childhood leukaemia

The survival from acute lymphoblastic leukaemia in childhood is now approximately 60-70%, and from acute myeloid leukaemia, up to 50%. However, there is little information on the effects of intensive chemotherapy and radiotherapy used in the treatment of these conditions on lung function and exercise capacity in the long term. Severity survivors of acute leukaemia from one centre in the UK were studied. Measurements of lung volumes, spirometry and transfer factor were made. Each child also performed a standard, symptom-limited maximal exercise test on a cycle ergometer. Predictive equations for indices of lung function and exercise tolerance were calculated from 146 age- and sex-matched control subjects. The results of the survivors of leukaemia were compared to these. There was a significant reduction of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), and transfer for carbon monoxide (DLCO; P < 0.05 for each measurement), in the survivors of leukemia when compared to the control subjects. In addition, there was a mild but significant reduction of both maximal and submaximal indices of exercise capacity in the leukaemic group. A multivariate analysis was carried out to identify those variables acting independently to reduce lung volumes. For FEV1, FVC and TLC, these were craniospinal irradiation, cyclophosphamide and chest complications during treatment. For a reduction in DLCO, the significant factors were administration of anthracyclines, craniospinal irradiation and bone marrow transplantation. Survivors of acute leukemia have impaired pulmonary function and exercise capacity. Long-term cardiopulmonary follow-up may be necessary and new regimens devised which reduce long-term toxicity without compromising survival rates.

Rapid eradication of Helicobacter pylori infection

BACKGROUND/AIMS

Current Helicobacter pylori eradication therapy for peptic ulcer disease usually involves a 2-week course of either a bismuth preparation or omeprazole in combination with antibiotics. We have studied a shorter, 7-day course of treatment to assess efficacy and tolerability.

METHODS

Four hundred and thirty-six patients, in three non-randomized groups, received omeprazole (40 mg mane), amoxycillin (500 mg t.d.s.) and metronidazole (400 mg t.d.s.): 308 patients received the triple combination for 14 days; 80 patients were treated for 7 days; and 48 patients received omeprazole and amoxycillin for 7 days but metronidazole for only 5 days.

RESULTS

Helicobacter pylori was eradicated in 89.5%, 91.1% and 87.5%, respectively (98.3%, 92.9% and 100% of metronidazole-sensitive isolates and 75.6% and 88.2% of metronidazole-resistant isolates in the first two groups). Side effects were significantly more frequent in patients who received 14 days (49%) compared with 7 days of treatment (33%); only 8/308 and 1/128 patients, respectively, failed to complete the course.

CONCLUSIONS

On the basis of efficacy, tolerability and cost, we conclude that a 7-day course of the omeprazole (40 mg mane), amoxycillin (500 mg t.d.s.) plus metronidazole (400 mg t.d.s.) combination is effective therapy for the eradication of H. pylori.

Integrin expression by human epidermal keratinocytes can be modulated by interferon-gamma, transforming growth factor-beta, tumor necrosis factor-alpha, and culture on a dermal equivalent

Receptors of the integrin family are largely confined to the basal layer of keratinocytes, both in human epidermis and in stratified cultures of human keratinocytes. However, suprabasal integrin expression is observed during epidermal wound healing and in psoriatic lesions. We have investigated potential stimuli of suprabasal expression. Addition of transforming growth factor-beta (TGF-beta), interferon-gamma (IFN-gamma), or tumor necrosis factor-alpha (TNF-alpha) to keratinocytes cultured with a 3T3 feeder layer did not induce suprabasal expression. The cytokines caused small changes in the levels of alpha 2 beta 1 or alpha 3 beta 1 on the surface of basal keratinocytes but had no significant effect on the proportion of cells adhering to fibronectin, type IV collagen, and laminin, and did not cause changes in the mobility of integrin subunits on polyacrylamide gels. Injection of TNF-alpha or IFN-gamma intradermally into healthy human volunteers induced an inflammatory response but did not induce suprabasal integrin expression. However, we did observe transient suprabasal integrin expression when keratinocytes were grown on a dermal equivalent consisting of fibroblasts in a collagen gel. One week after raising the cultures to the air-liquid interface, beta 1 integrins were found in all the viable cell layers, with suprabasal cells co-expressing integrins and involucrin; 1 week later integrins were confined to the basal layer. Addition of TGF-beta, IFN-gamma, or TNF-alpha to the dermal equivalents neither induced nor inhibited suprabasal integrin expression. We conclude that suprabasal integrin expression is not induced by the inflammatory cytokines tested, and instead may reflect the proliferation/differentiation status of the epidermis.

Stem cell patterning and fate in human epidermis

Within human epidermis there are two types of proliferating keratinocyte: stem cells, which have high proliferative potential, and transit-amplifying cells, which are destined to undergo terminal differentiation after a few rounds of division. We show that, in vivo, stem cells express higher levels of the alpha 2 beta 1 and alpha 3 beta 1 integrins than transit-amplifying cells and that this can be used both to determine the location of stem cells within the epidermis and to isolate them directly from the tissue. The distribution of stem cells and transit-amplifying cells is not random: patches of integrin-bright and integrin-dull cells have a specific location with respect to the epidermal-dermal junction that varies between body sites and that correlates with the distribution of S phase cells. Stem cell patterning can be recreated in culture, in the absence of dermis, and appears to be subject to autoregulation.

Low serum cholesterol increases the risk of noncardiovascular events: an antagonist viewpoint

Considerable debate concerning the apparent association of low serum cholesterol levels with enhanced noncardiovascular disease mortality has been aired in both scientific and lay publications within the past year. This debate has resulted in some medical experts calling for a moratorium on efforts to reduce serum cholesterol, particularly with drugs, and for a more conservative approach to screening and modifying cholesterol levels for the primary prevention of coronary heart disease (CHD). Observational studies, including the Framingham Heart Study, the Multiple Risk Factor Intervention Trial, the Whitehall Study, and the International Collaborative Group, have not substantiated a cause and effect relationship between "naturally" occurring low serum cholesterol and noncardiovascular disease mortality, such as cancer. Intervention trials designed to lower high serum cholesterol levels by diet and drugs have also not been conclusively shown to produce excess harm that offsets the benefit of reduced CHD events. Several primary and secondary CHD prevention trials, with sufficient numbers of subjects to provide the statistical power to detect potential detrimental effects of lowering cholesterol levels, are currently in progress and will be very helpful in resolving the concern about noncardiovascular disease mortality.

Clinical pharmacokinetics of pravastatin

The hypolipidaemic agent pravastatin differs from other US Food and Drug Administration (FDA)-approved HMG-CoA reductase inhibitors (e.g. lovastatin and simvastatin) because it has greater hydrophilicity, as a result of the hydroxyl group attached to its decalin ring. The hydrophilic nature of pravastatin accounts for its minimal penetration into the intracellular space of nonhepatic tissues, including an apparent inability to cross the blood-brain barrier. The drug is also well tolerated because it is rapidly absorbed and excreted, and does not accumulate in plasma even with repeated administration. Pravastatin is taken up into the liver by an active transport carrier system, and the hepatic extraction ratio is high (0.66). The drug and its metabolites are cleared through both hepatic and renal routes (53 and 47%, respectively). The dual route of elimination reduces the need for dosage adjustment if the function of either of these organs is impaired. Dosage adjustments are also not required on the basis of age or gender. Furthermore, the drug can be given without regard to food intake, an important consideration for compliance since lipid-lowering therapy is generally required long term. The drug is approximately 50% protein bound, and, therefore, compared with other members of its class the tendency for displacement of highly protein bound drugs such as warfarin is decreased. This minimal potential for drug-drug interactions is important for patients who are taking multiple drugs because of concomitant medical problems. However, as with any HMG-CoA reductase inhibitor, caution should be exercised when pravastatin is given with nicotinic acid (niacin), gemfibrozil or cyclosporin, because of increased risk for myopathy in patients receiving combination therapy.

Zoonotic transmission of giardiasis: a case control study

A case control study of locally acquired giardiasis was carried out in a district in East Anglia. Thirty-three primary cases were matched for age and sex with 112 controls selected from Family Health Service Authority registers. An association was shown between giardiasis and contact with farm animals (odds ratio 4.77; confidence interval 1.31-17.38) and pets (odds ratio 14.55; confidence interval 4.18-50.62).

Prevalence and diversity of constitutional mutations in the p53 gene among 21 Li-Fraumeni families

The entire coding sequence of the p53 gene was analysed for the presence of mutations in 12 families conforming to a restricted definition of Li-Fraumeni syndrome (classic LFS) and nine families with features of LFS conforming to a broader definition. Mutations were detected in seven families. Six were point mutations with one each affecting codons 175, 180, and 220 and three affecting codon 248. The seventh was a deletion/insertion mutation in exon 4. Germline mutations in p53 were a feature of families which included children with rhabdomyosarcoma and/or adrenal cortical carcinoma. Germline p53 mutations were detected in six of the nine families with such tumors. An analysis of these 7 mutations, together with 34 published examples, showed that more than one-half were transitions at CpG dinucleotides, suggesting that the majority of germline p53 mutations may arise as a result of spontaneous events. The most common cancers occurring in the 41 families with germline p53 mutations, in common with classic LFS, were bone and soft tissue sarcoma, breast cancer, brain tumors, leukemia, and adrenocortical carcinoma, although less than one-half of the probands with germline p53 mutations came from classic LFS families. More than one-half of the cancers overall and nearly one-third of the breast cancers were diagnosed before 30 years of age. These observations have important implications for asymptomatic carriers of germline p53 mutations, and there is a need for international collaboration in the development of protocols for the management of such families.

Integrin expression and function in HPV 16-immortalised human keratinocytes in the presence or absence of v-Ha-ras. Comparison with cervical intraepithelial neoplasia

Keratinocytes express several receptors of the integrin family which regulate both adhesion and differentiation. We have investigated whether HPV immortalisation, which changes the growth and differentiation properties of keratinocytes, is associated with altered integrin expression or function. We compared two HPV 16-immortalised lines of human keratinocytes, up and vp, with the normal keratinocyte strains, u and v, from which they were derived and with upr, obtained by transfection of up with viral Harvey ras. Immunofluorescence, immunoprecipitation and flow cytometry demonstrated that up and vp had lower levels of integrins than u and v, the reduction in up being greater than in vp. Up and vp also had reduced levels of mRNA encoding the beta 1 integrin subunit. Reduced expression of the alpha 5 beta 1 and alpha 2 beta 1 integrins was correlated with reduced adhesion to fibronectin and collagen in up but not in vp and there were no significant differences between the normal and immortalised cells in adhesion to laminin. Reduced integrin expression was correlated with decreased motility, up showing a greater reduction in motility than vp. Introduction of activated ras into up had no effect on integrin levels, cell motility or tumorigenicity in nude mice; the only difference between up and upr was that upr showed increased adhesion to fibronectin. Examination of eight biopsies of cervical intraepithelial neoplasias with evidence of HPV infection revealed reduced or discontinuous integrin expression in the most severe lesions. We conclude that both in vivo and in culture keratinocytes the impaired differentiation that is associated with the presence of HPV is correlated with reduced integrin expression.

Genitourinary tumors in the families of children with renal tumors

The occurrence of genitourinary tumors in the relatives of a population-based series of 218 children diagnosed with renal tumors was investigated. Family data on 92% (176 of 192) of Wilms' tumor (WT) patients and 77% (20 of 26) of other renal tumor patients were obtained. In all, 21 genitourinary tumors in first-degree relatives in 19 families were ascertained, together with 30 such tumors in second-degree relatives. Ten families were diagnosed with multiple genitourinary tumors, although none of these manifested familial WT. It is proposed that a small proportion of families of children with renal tumors has a genetic predisposition to develop genitourinary tumors and that these tumors may represent further manifestations of the pleiotropic effects of the WT1 gene or of other genes involved in WT predisposition.

An outbreak of infection with Salmonella enteritidis phage type 4 associated with the use of raw shell eggs

A community outbreak of Salmonella enteritidis phage type (PT) 4 infection, associated with eating food from a sandwich bar in Colchester, occurred in July 1991. One hundred and forty-four people were reported with food poisoning, of whom 132 met the clinical case definition. Three cohort studies of 92 people showed that illness was associated with the consumption of food containing mayonnaise. S. enteritidis PT4, indistinguishable by plasmid profile analysis, was isolated from stool samples from 83 people, food items including egg shells from the sandwich bar, and birds taken from the egg producing farm which supplied the eggs. This was the largest recorded outbreak of S. enteritidis PT4 infection in recent years associated with eggs produced in the United Kingdom. Existing advice on avoiding the use of raw eggs in uncooked dishes had not been followed. This outbreak highlights the importance of training in the implementation of this advice.

Expression and function of the keratinocyte integrins

Human keratinocytes express several adhesive receptors of the integrin family. Expression is normally confined to the basal (proliferative) layer of keratinocytes, both in mature epidermis and during development. Altered expression patterns are observed during wound healing, in psoriasis and in squamous cell carcinomas. Keratinocyte integrins are subject to both transcription al and post-translational regulation and ligand binding ability can be modulated independently of expression. Studies with cultured keratinocytes suggest a variety of functions for the receptors: adhesion to extracellular matrix proteins, intercellular adhesion, stratification, lateral migration and the regulation of terminal differentiation. Three distinct subpopulations of basal keratinocytes, with characteristics of stem cells, transit amplifying cells and cells committed to differentiate, can be distinguished on the basis of differences in integrin expression and function.

Hypoadrenal crisis caused by disseminated histoplasmosis

We report a case of disseminated histoplasmosis presenting with acute renal impairment due to adrenal insufficiency. The finding of bilateral adrenal gland enlargement on abdominal ultrasound examination led to a diagnostic CT-guided adrenal biopsy. Prolonged therapy with amphotericin and itraconazole resulted in a clinical cure, although the patient still requires adrenal replacement therapy.

Patterns of cancer in the families of children with soft tissue sarcoma

BACKGROUND

Childhood soft tissue sarcomas are known to occur in a number of genetic syndromes. This study assesses the proportion of soft tissue sarcoma diagnosed in childhood associated with genetic predisposition to cancer.

METHODS

Information on the occurrence of neoplastic disease was collected for 151 of 179 families of a population-based series of children with soft tissue sarcoma.

RESULTS

Considering the index child as the proband, 5 of the 151 families manifested the classic Li-Fraumeni cancer family syndrome according to standard criteria and a further 10 families showed features consistent with the syndrome. One proband had double primary syndrome cancers. One other family had a sibling pair of childhood cancers, seven families had cancer which had occurred in childhood in other relatives, and three families had adult-onset sarcomas in more distant relatives. In another 16 families, one parent or the other had developed a possible syndrome cancer, or had developed cancer when younger than 60 years of age. Two families showed striking clusters of stomach cancer. Five case children were thought to have been affected with neurofibromatosis.

CONCLUSIONS

Genetic predisposition to cancer was thought to be present in 7% to 33% of families interviewed.

Patterns of cancer in the families of children with soft tissue sarcoma

BACKGROUND

Childhood soft tissue sarcomas are known to occur in a number of genetic syndromes. This study assesses the proportion of soft tissue sarcoma diagnosed in childhood associated with genetic predisposition to cancer.

METHODS

Information on the occurrence of neoplastic disease was collected for 151 of 179 families of a population-based series of children with soft tissue sarcoma.

RESULTS

Considering the index child as the proband, 5 of the 151 families manifested the classic Li-Fraumeni cancer family syndrome according to standard criteria and a further 10 families showed features consistent with the syndrome. One proband had double primary syndrome cancers. One other family had a sibling pair of childhood cancers, seven families had cancer which had occurred in childhood in other relatives, and three families had adult-onset sarcomas in more distant relatives. In another 16 families, one parent or the other had developed a possible syndrome cancer, or had developed cancer when younger than 60 years of age. Two families showed striking clusters of stomach cancer. Five case children were thought to have been affected with neurofibromatosis.

CONCLUSIONS

Genetic predisposition to cancer was thought to be present in 7% to 33% of families interviewed.

Reinfection or recrudescence after apparently successful eradication of Helicobacter pylori infection: implications for treatment of patients with duodenal ulcer disease

Helicobacter pyloris is considered to be aetiologically implicated in gastritis and peptic ulceration, since if H. pyloris infection can be eradicated the risk of subsequent ulcer relapse is markedly reduced. The rate of 'reinfection' following treatment ranges from 0% to 45%, but its origin remains controversial (reappearance of uneradicated original infection or a fresh infection). To distinguish temporary suppression of H. pylori from fresh infection we conducted a retrospective analysis of the criteria used to establish eradication of the original infection in 304 patients. We used the [14C]urea breath test, in which an integrated area under the curve (AUC) value of < 40 in 2 h is considered to indicate eradication of H. pylori in patients tested 1 month after treatment. The results suggest that relapsed infection with H. pylori usually represents recrudescence of the original infection rather than a fresh infection; there was a higher relapse rate in patients with a breath test AUC > 20 < 40, compared with those with an AUC < 20. All 'reinfections' occurred within 24 months of the original treatment. 'Reinfection' was uncommon in patients receiving powerful therapeutic regimens (e.g. triple therapy) compared with those receiving monotherapy or relatively ineffective dual therapy combinations. In patients whose urea breath test remains negative 12 months after treatment the subsequent reinfection rate is only 0.44%/year. This supports the strategy of eradicating H. pylori infection from suitable peptic ulcer patients.

Wilms' tumor in the Li-Fraumeni cancer family syndrome

Scrutiny of the family pedigrees of a population-based series of 176 children diagnosed with Wilms' tumor between 1954 and 1990, along with a review of the literature on the Li-Fraumeni cancer family syndrome, indicate that Wilms' tumor may be an uncommon component of the syndrome and that a small proportion of children with Wilms' tumor may be members of Li-Fraumeni syndrome (LFS) families.

Separation of human epidermal stem cells from transit amplifying cells on the basis of differences in integrin function and expression

The epidermis is believed to contain two types of proliferating cells: stem cells and cells with a lower capacity for self-renewal and higher probability of undergoing terminal differentiation (transit amplifying cells). We report that keratinocytes with characteristics of stem cells can be isolated from cultured human epidermis on the basis of high surface expression of beta 1 integrins and rapid adhesion to extracellular matrix (ECM) proteins. Among keratinocytes there was a log linear relationship between the relative level of beta 1 integrins on the cell surface and proliferative capacity; furthermore, the cells with the highest colony-forming efficiency adhered most rapidly to type IV collagen, fibronectin, or keratinocyte ECM. Proliferating keratinocytes that adhered more slowly had characteristics of transit amplifying cells: after one to five rounds of division, all of their daughters underwent terminal differentiation. Since stem cells can be isolated to greater than 90% purity on the basis of their adhesive properties, it will now be possible to investigate the mechanisms that regulate the fate of their progeny.

Biotype and molecular fingerprints of metronidazole-resistant strains of Helicobacter pylori from antral gastric mucosa

Biotypes, ribosomal RNA gene restriction patterns (ribopatterns), whole-cell protein patterns and plasmid profiles of paired Helicobacter pylori isolates from 17 patients were examined. Each pair comprised a pre- and a post-treatment isolate; nine of the 17 post-treatment isolates were obtained after treatment with tripotassium dicitrate bismuthate (De-Nol) and metronidazole. All strains of H. pylori had identical biotypes, but exhibited diversity between pairs in their molecular fingerprints. Each of the 17 strain pairs had unique ribopatterns; the pre- and post-treatment isolates in most pairs (16 of 17) were similar or identical, irrespective of metronidazole susceptibility. DNA subtype variants were detected in three patient sets. Although nine post-treatment isolates had acquired resistance to metronidazole, most (six of nine) resembled the pre-treatment isolates in their ribopattern, protein and plasmid profiles. No significant correlation was observed between metronidazole resistance and plasmid content in these H. pylori isolates. Emergence of post-treatment metronidazole-resistant isolates of H. pylori was associated only rarely with colonisation by a novel strain or acquisition of a plasmid and, in most patients, probably resulted from spontaneous emergence of resistance in the original infecting strain.

Chemotherapy in the management of infantile fibrosarcoma

Infantile fibrosarcoma (IF) has traditionally been treated with surgery, which may have considerable morbidity. Chemotherapy has been suggested in order to reduce the need for extensive surgery. Nine children with histologically confirmed IF who received chemotherapy are described. Six children were treated with chemotherapy initially, two following conservative surgery, and one following recurrence after surgery. All received vincristine (V) and actinomycin D (A), and six received additional drugs including ifosfamide (I), cyclophosphamide (C), adriamycin (Ad), etoposide (E), and cisplatinum (CDDP). Objective responses were achieved in eight: three responded completely (CR), two responded partially (PR), which allowed conservative surgery, one had stable disease, one had an initial PR, but subsequently had tumour recurrence 1 month after cessation of treatment, necessitating further surgery and chemotherapy, and one had an initial PR but died following local and regional metastases. One child had no response to chemotherapy but is alive with stable residual disease. Thus, five of nine children achieved a CR--three with chemotherapy alone. With the inclusion of chemotherapy as part of their treatment, five children, for whom curative surgery may have resulted in amputation, remain alive with limbs intact. Chemotherapy including V and A should be given to infants with fibrosarcoma in whom curative surgery would be mutilating.