Adriamycin--an antitumor antibiotic in the treatment of neoplastic diseases

Combination chemotherapy of advanced sarcomas in adults with "CYOMAD" (S7)

Response rates of metastatic soft part sarcomas to chemotherapy have varied from 27 and 44% for our ALOMAD and OMAD protocols to 46-55% reported for CYVADIC. The present combination, CYOMAD, consists of the induction part of ALOMAD (vincristine, high-dose methotrexate with citrovorum factor rescue, Adriamycin and DTIC) alternating with a condensed version of CYVADIC (cyclophosphamide, vincristine, adriamycin and DTIC). Forty-one patients with advanced soft-part sarcomas were entered on the CYOMAD program of whom 36 were considered evaluable. Complete responses (CR) were seen in four patients had partial (PR) in five patients for a major response rate of 25%. Responders had an overall longer survival than nonresponders (20 versus 13 months). Toxicity was substantial with both gastrointestinal side effects and myelosupression common. Possible Adriamycin cardiotoxicity was noted in four patients. Cyomad offered no therapeutic advantage over previous protocols and was even less well tolerated than some.

The treatment of Wilms' tumor: results of the Second National Wilms' Tumor Study

One-hundred-eighty-eight children up to 16 years of age were randomized in the second National Wilms' Tumor Study (NWTS) with tumors that were confined to the kidney and that had been totally excised (Group I). Most fared well whether treated for six or for 15 months with both actinomycin D (AMD) and vincristine (VCR). No postoperative radiation therapy (RT) was given. The two-year relapse-free survival (RFS) and two-year survival rates were 88 and 95%, respectively. Two-hundred-sixty-eight randomized patients with more advanced local lesions (Groups II and III) and 57 with distant metastases (Group IV) had postoperative RT and were scheduled for 15 months treatment with either AMD and VCR (Reg. C) or AMD plus VCR plus Adriamycin (Reg. D). The 77% two-year RFS rate for Reg. D was significantly different from the 63% with Reg. C. As in the first NWTS, patients with tumors of unfavorable histology (UH) had a significantly worse prognosis than those with favorable histology (FH), as did those with positive nodes. Survival rates at two years were 54% for UH vs. 90% for FH, and 54% vs. 82% for those with and without lymph node involvement.

Ewing's sarcoma: ten-year experience with adjuvant chemotherapy

Since May 1970, 67 consecutive patients with primary (nonmetastatic) Ewing's sarcoma were treated with adjuvant chemotherapy (CT) in addition to radiation therapy (RT) or surgery for the primary tumor. The first 19 patients were treated with four-drug sequential CT (T-2). The second protocol was a seven-drug induction combination CT (T-6) followed by T-2 maintenance CT; in both protocols CT was continued for 18 months. The current protocol (T-9) consists of combination CT given continuously for a period of 9 months. Of the entire group of 67 patients, 47 (70%) had axial and proximal lesions (pelvis, spine, rib, humerus, and femur) and 20 (30%) had distal lesions (forearm, leg, and foot); 53/67 (79%) are surviving free of disease 12--118 months (median 41 months) from the start of treatment. Fifteen of 23 (65%) patients with axial lesions, 19/24 (79%) patients with proximal lesions, and 19/20 (95%) patients with distal lesions are free of disease. Disease-free survivors include 28/39 (72%) male patients and 25/28 (89%) female patients. Thirty-four patients had RT, and 33 had surgery or surgery and RT, in addition to chemotherapy, for local treatment. The disease-free survival rate was 76% in the RT group and 82% in the surgery group; failure in the RT group was attributable to local recurrence in 7/34 (21%) patients. Recent experience with T-9 CT has demonstrated that CT given prior to RT or surgery can cause a great reduction in the size of the primary tumor while allowing the pathologically-eroded bone to heal prior to the initiation of RT; this also allows the high-risk patient with an axial primary (pelvis or spine) to tolerate the aggressive CT needed to prevent distant metastases. In addition to dramatically increasing survival in patients with Ewing's sarcoma, combination CT has helped achieve permanent local control. The superior survival rates for all sites of primary tumor are attributable to the early use of aggressive combination CT.

Is amputation necessary for sarcomas? A seven-year experience with limb salvage

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula-4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.

Simultaneous combination radiotherapy and multidrug chemotherapy for stage III and stage IV squamous cell carcinoma of the head and neck

Combined simultaneous radiotherapy and multidrug chemotherapy have been utilized in an attempt to eradicate or shrink tumors of the head and neck area in advanced stages to allow subsequent surgical extirpation. Thirty-six patients (1 stage II; 11 stage III; 24 stage IV; 1 unknown primary) were treated with simultaneous radiotherapy and fractionalized doses of bleomycin, adriamycin, and 5-fluorouracil. Thirty of 36 patients completed the treatment schedule. Twenty-nine of 30 (97%) had a 75% or greater response to treatment; 20/30 (66%) had 100% response; 9/30 (30%) had 75% response; and 1/30 had 50% response. Of the 30 patients completing the regimen, 19/30 (63%) are alive three to 27 months later, and 12 (40%) of these have no evidence of disease. Six patients died within four months of initiation of therapy, mostly from complications of their disease. This treatment regimen appears effective in the control of locoregional disease or to produce enough shrinkage of tumor to allow subsequent surgical extirpation.

Management of locally advanced and disseminated breast cancer--chemotherapy

Breast cancer is one of the most responsive of the common solid tumors when systemic therapy is indicated in the treatment of locally advanced or disseminated cancer. Many single agents have been useful in inducing remission in mammary carcinoma, but in recent years various drug combinations have been developed that appear more effective than individual drugs and in some instances with reduced toxicity levels. Adriamycin is the most interesting of the newer drugs and is the most effective single agent. Polychemotherapy of breast cancer was tried years ago, but remained for Cooper to arouse professional interest in multiple-drug therapy. Many modifications of this original five-drug regimens have been tried. One of the most widely used combinations is the CMF program, which includes cyclophosphamide, methotrexate, and 5-fluorouracil. The program that we have come to regard as our standard program in controlled clinical trials (CFP) employs cyclophosphamide, 5-fluorouracil, and prednisone. Toxicity with this program has been clinically acceptable, and in multiple comparative trials we have found no combination with greater therapeutic efficacy.

Relationship of oral complications to peripheral blood leukocyte and platelet counts in patients receiving cancer chemotherapy

Patients undergoing cancer chemotherapy often suffer from oral complications as a result of their disease and its treatment. The effects of the chemotherapy on the bone marrow and oral mucosa, coupled with the patient's immunosuppressed state and altered oral microbial flora, predispose these patients to oral mucositis, infection, and hemorrhage. The oral mucosa appears to mirror the effects of the chemotherapy on the bone marrow, as there appears to be a direct relationship between the changing peripheral blood counts and the status of the oral mucosa.

A trial of bleomycin versus adriamycin in advanced carcinoma of the bladder

Thirty-seven patients were studied in a controlled clinical trial to assess the value of Adriamycin and Bleomycin in the treatment of advanced carcinoma of the bladder. The previously reported high response rates for both drugs were not observed in this trial. Administration of Bleomycin was accompanied by a toxicity rate so high that treatment had to be abandoned. Neither Adriamycin nor Bleomycin, therefore, used as single agents, have a role in the chemotherapy of advanced bladder cancer. Other agents should be investigated and assessed by controlled clinical trials that are disease-orientated rather than drug-orientated.

The management of inadvertent subcutaneous adriamycin infiltration

Once the inadvertent infiltration of Adriamycin occurs, it is recommended to immediately treat the problem. This has been accomplished by wide excision and meshed split thickness skin grafting for resurfacing of the defect. Obtaining a healed wound alleviates the stiffness from lack of motion or ruptured tendons. Pain from the open ulcer, which is prone to infection in the immunosuppressed patient, is lessened. An analogy between pit viper envenomization and Adriamycin infiltration is discussed.

Chemotherapy of head and neck cancer

Chemotherapy has traditionally been relegated to a late palliative role in the management of head and neck cancer. For advanced disease in patients previously treated with surgery or radiation therapy, methotrexate, which has a response rate of approximately 50%, is the best single agent available. Other orally or systemically administered single agents--such as bleomycin, adriamycin, hydroxyurea, and cis-platinum--produce responses less frequently than methotrexate. Intraarterial chemotherapy with single-agent methotrexate or with combinations--including methotrexate, vinblastine sulfate (Velban), cyclophosphamide (Cytoxan), and 5-fluorouracil (5-FU)--can match the response rate of systemic methotrexate, but all require inpatient treatment and significant technical expertise. Programs utilizing chemotherapeutic combinations have not produced remission rates or durations of remission greater than those achieved with methotrexate alone. Chemotherapy has also been used in combination with other modalities. In two studies, chemotherapy combined with irradiation produced improvement in median or overall survival in comparison to irradiation alone. Many similar studies have been negative. Recent trials of chemotherapy used preoperatively in the treatment of head and neck cancer have not yielded decreased recurrence rates or increased overall survival rates in comparison to surgery alone, but they do appear to have prolonged the disease-free interval following definitive surgery.

A paucity of chronic electrocardiographic changes with adriamycin therapy

Serial electrocardiograms (ECGs) of 49 patients receiving adriamycin were analyzed for the development of persistent changes. The ECG changes were compared with those of a control group of 20 patients receiving other chemotherapeutic drugs, which were comparable to the additional chemotherapy received by the adriamycin patients. The only chronic ECG changes noted with adriamycin over control were the loss of P wave amplitude in the greater than 500 mg/m2 dose subgroup and the clockwise rotation of the precordial QRS in the 250-500 mg/m2 dose subgroup. In contrast, systolic time intervals demonstrated a gradual diminution in left ventricular function at increasing doses of adriamycin. The electrocardiogram itself appears to be of limited value in the assessment of cardiac toxicity with adriamycin therapy.

Teratogenicity of adriamycin and daunomycin in the rat and rabbit

The antitumor drugs adriamycin and daunomycin were evaluated for effects on embryonal and fetal development in the rat and rabbit. Doses of adriamycin ranging from 1-2 mg/kg/day or daunomycin ranging from 1-4 mg/kg/day were administered ip to pregnant rats on days 6-15, 6-9, 9-12 or 12-15 of gestation. Both drugs were teratogenic in the rat, particularly when administered on days 6-15 or 6-9 of gestation. Relatively few anomalies resulted from treatment on days 9-12 or 12-15. On a mg/kg basis, adriamycin was the more potent teratogen, producing major anomalies at doses as low as 1.25 mg/kg. Similar anomalies, but at a lower incidence, were produced by daunomycin at dose levels of 4 mg/kg. Characteristic malformations included esophageal and intestinal atresia, tracheo-esophgeal fistula, hypoplasia of the urinary bladder and various cardiovascular anomalies. Neither drug was teratogenic when given iv to rabbits at doses up to and including 0.6 mg/kg/day on days 6-18 of gestation, but a high incidence of abortion occurred in rabbits treated with adriamycin.

Echocardiography in adriamycin cardiotoxicity

Twenty-six patients receiving adriamycin for osteogenic sarcoma had serial echocardiographic assessments of their left ventricular function. A statistically significant deterioration of function was noted throughout the course. Ventricular function tended to normalize in the period following cessation of adriamycin. The velocity of circumferential fibre shortening (Vcf) and ejection fraction (EF) were the best parameters. Sudden declines in these values resulted in us withholding therapy until the parameters again improved. Fatal congestive heart failure was seen in only one patient. Echocardiography thus provides the clinician with a valuable tool enabling one to improve the therapeutic usefulness of adriamycin by removing much of the uncertainty over the development of cardiotoxicity.

Thoracotomy as adjuvant to chemotherapy in metastatic osteogenic sarcoma

This is a review of the experience at Memorial Hospital using chemotherapy combined with surgical excision for control of pulmonary metastases in osteogenic sarcoma. Effective multiple drug chemotherapy was able to control small deposits of osteogenic sarcoma in the lung, making surgical resection of residual visible nodules worthwhile. Surgical resection was most successful for solitary nodules or where multiple nodules were shrunk or at least prevented from growing by chemotherapy. Eight percent of these patients with pulmonary metastases initially or subsequently showed bilateral lung disease. When two or more nodules were found at th oracotomy, they were never confined to one lobe. For these reasons, wedge resections or segmental resections were the most commonly indicated procedures. Results justify an aggressive surgical approach to these lesions including multiple wedge resections of all lesions found at thoracotomy, chest wall resection and multiple bilateral thoracotomies. Chemotherapy alone cannot be expected to cure metastatic osteogenic sarcoma of the lung, but combined with surgical resection of residual disease the results are encouraging.

Topical instillation of doxorubicin hydrochloride in the treatment of recurring superficial transitional cell carcinoma of the bladder

Thirteen patients with recurring stage A transitional cell carcinoma of the bladder were treated with monthly bladder instillations of doxorubicin hydrochloride. Follow-up at 3-month intervals has shown excellent control of tumor recurrence with complete remissions for up to 21 months in 2 patients. The median for remission in 8 of 13 patients has been 10 months. Two patients with bladder papillomatosis were treated successfully by the same method.

Low-dose Adriamycin remission maintenance therapy for pediatric solid tumors

A low-dose maintenance schedule of Adriamycin was evaluated in six children whose metastatic solid tumors regressed following toxic induction therapy with Adriamycin. Three of these children are now disease-free more than one year following discontinuation of therapy. Adriamycin can be given on a low-dose maintenance schedule free from alopecia, fever, stomatitis, myelosuppression and recognizable cardiomyopathy. Further studies of similar schedules are warranted.

Adjuvant multiple drug chemotherapy for osteosarcoma of the extremity

Results of treatment for osteosarcoma of the extremity have been poor with metastases usually causing death within 2 years following diagnosis. Because of the great risk of development of metastases, 20 patients have received adjuvant chemotherapy with Adriamycin, cyclophosphamide and high-dose methotrexate-leucovorin rescue for up to 12 months following amputation for osteosarcoma. Sixteen of these patients are surviving; 11 are free of evident tumor from 6 to 34 months following amputation. Five patients were found to have pulmonary metastases while receiving chemotherapy and three patients developed metastases following completion of chemotherapy. One patient died following her third treatment with high-dose methotrexate-leucorovin rescue. Other toxicity included nausea, vomiting, mucosal ulcerations, infections, hematologic abnormalities, changes in kidney and liver functions tests, and minor coagulation abnormalities. The natural history of osteosarcoma may have been modified by the use of these agents for periods exceeding the median time to predicted detection of pulmonary metastases. Microscopic metastases of some patients were eradicated by this adjuvant chemotherapy. For patients who developed metastases, these metastases were delayed in their time of detection and in their number at the time of detection.

Treatment of advanced bladder cancer with adriamycin and 5-fluorouracil

The cytotoxic drug combination of adriamycin and 5-fluorouracil has resulted in a 35% objective response in 20 patients with advanced bladder cancer. This has been achieved with minimal toxicity and on an out-patient basis. If the survival rate of patients with invasive bladder cancer is to be improved it seems likely that some form of systemic treatment will need to be added to the local measures currently in use. Further studies of different chemotherapeutic agents should help to define an effective and safe form of adjunvant therapy.

Improved outlook for Ewing's sarcoma with combination chemotherapy (vincristine, actinomycin D and cyclophosphamide) and radiation therapy

Vincristine, actinomycin D, and cyclophosphamide (VAC) were administered to 14 patients with Ewing's sarcoma. The primary tumors were treated with radiation therapy and concurrent chemotherapy. Nine patients had no visible metastases at diagnosis: two died following the development of pulmonary metastases and the rest have been free of disease for periods varying from 4 months to 4 1/2 years following completion of treatment. This contrasts with a 27% survival in patients previously treated at this center with single agent chemotherapy. Five other patients had demonstrable metastases at diagnosis: VAC chemotherapy achieved complete regression of pulmonary metastases in three for 9, 9+ and 24+ months, respectively. Following disappearance of tumor in the latter two, pulmonary irradiation was administered in an attempt to consolidate the response, but tumor recurred 6 months later. These patients eventually died of widespread disease although survival appeared prolonged in comparison to that seen in past experience. Chemotherapy was well tolerated, although three patients developed hemorrhagic cystitis, necessitating discontinuation of cyclophosphamide. The data suggest the potential for prolonged control and an increase in the cure rate with this therapeutic approach.

Radiologic recognition of adriamycin cardiotoxicity

A case of congestive heart failure in a child with Wilms' tumor treated Adriamycin is presented and discussed. The role of Adriamycin in the production of cardiotoxicity is reviewed.

Doxorubicin chemotherapy in advanced transitional cell carcinoma

During the past year 25 patients with advanced transitional cell carcinoma were treated with intravenous doxorubicin hydrochloride (Adriamycin), 60 to 75 mg. per square meter of body surface area, every three weeks. Among the 19 evaluable patients, one partial objective remission lasting five months was observed. All 7 patients with bone pain had symptomatic relief and 12 patients had significant subjective improvement lasting an average of six-and-a-half months. Side effects were minimal and consisted of alopecia, mild leukopenia, and mild stomatitis; no significant cardiotoxicity was observed. Doxorubicin hydrochloride appears to have important antitumor activity in advanced urothelial tumors. Controlled clinical trials with this agent alone and in combined drug regimens are needed.

Clinico-pathologic correlation of liver damage in patients treated with 6-mercaptopurine and Adriamycin

Eleven adults with refractory leukemia treated with a combination of 6-mercaptopurine and Adriamycin developed hepatic dysfunction manifested by elevations of serum total bilirubin, alkaline phosphatase, and glutamic oxaloacetic transaminase. Liver tissue obtained at necropsy showed intrahepatic cholestasis (eight cases), hepatocellular necrosis (ten cases), leukemic infiltration (two cases), and fatty change (nine cases). Neither this frequency nor severity of hepatocellular destruction has hitherto been associated with 6-mercaptopurine at the dose levels used in this study, nor has Adriamycin previously been found to be hepatotoxic. It is postulated that Adriamycin potentiated the hepatotoxicity of 6-mercaptopurine in these patients.

Skin ulcers due to adriamycin

Local skin necrosis at the site of intravenous or intra-arterial adriamycin infusion is an infrequent, but serious complication. Ulcers secondary to adriamycin have insidious beginnings, but progress to a much deeper extent than would be expected from their initial appearance. Deep structures, such as tendon or bone, may become exposed. The ulcers are indolent and do not develop a granulation tissue response or epithelialization, as might be expected from their early appearance. Injections of adriamycin in the dorsum of the hand should be avoided when possible, since tendons have little skin cover and the area is difficult to cover with local tissue if there is skin loss. While prevention is important, early surgical treatment may prevent progressive deep involvement and seems warranted when the patient has a life expectancy of months or years. Wide excision of all inflamed tissue is the treatment of choice, with split-thickness skin grafting or flap coverage.

The treatment of Wilms' tumor: Results of the national Wilms' tumor study

The National Wilms' Tumor Study, initiated in 1969, tested competing treatment strategems for patients with tumors ranging from Group (Gp) I (tumors confined to the kidney and totally removed) to Gp IV (remote metastases present at diagnosis). Three hundred and fifty-nine of 606 registered patients were randomized in the trial. Gp I patients under 2 years of age fared well whether postoperative radiation therapy (RT) was or was not added to 15 months' maintenance actinomycin D (AMD). Their prognosis was better than that for older cohorts similarly treated, in whom the difference in relapse rates between treatment groups were suggestive of an RT effect. Combined AMD and vincristine (VCR) gave better results than either agent alone in patients with more advanced tumors (Gps II and III) still confined to the abdomen, all of whom received postoperative RT as well. Preoperative VCR given Gp IV patients in addition to postoperative RT, AMD, and VCR did not improve results. The frequency of mesoblastic nephroma (1%), of bilateral tumors (5%), and of incorrect preoperative diagnosis of Wilms' tumor (5%), the toxicities of the various regimens, and other ancillary data are presented and discussed.

The cardiotoxicity of adriamycin and daunomycin in children

Eight (16%) of 50 children receiving adriamycin and 2 (3%) of 60 receiving daunomycin had severe cardiomyopathy with congestive heart failure. All 110 patients received cumulative doses of over 500 mg/m2. The incidence was significantly higher in those who also had incidental cardiac radiation. The electrocardiogram, with few exceptions, provided the first indication of cardiac abnormality. There were no deaths from heart failure. Two had thromboembolic episodes. Recommendations are discussed.

Combination chemotherapy with adramycin (NSC-123127) and dimethyl triazeno imidazole carboxamide (DTIC) (NSC-45388) in children with metastatic solid tumors

Combination chemotherapy with adriamycin and DTIC was used in 102 evaluable patients under 15 years of age who had previously treated metastatic solid tumors. Responses, defined as 50% or more reduction in all tumor masses, occurred in 10 out of 27 patients with neuroblastoma, 3 out of 8 patients with Wilms tumor, 7 out 15 patients with Ewing sarcoma, 2 out of 6 patients with osteosarcoma, 5 out of 13 patients with rhabdomyosarcoma, and 15 out of 33 patients with miscellaneous tumors which included a patient who had a complete regression of an extensive juvenile angiofibroma. Response rate to combination chemotherapy with adriamycin and DTIC in patients with Ewing sarcoma was significantly superior to the response rate obtained with adriamycin alone in another Southwest Oncology Group Study. Major toxicity included nausea, vomiting, myelosuppression, high incidence of pneumocystis carinii pneumonia (5 patients) and congestive heart failure (4 patients). There was 7 drug-associated deaths due to sepsis (1), pneumocystis carinii pneumonia (4), and congestive heart failure (2).

Chemotherapy, en bloc resection, and prosthetic bone replacement in the treatment of osteogenic sarcoma

In an attempt to shrink primary osteogenic sarcoma and allow complete surgical removal of the primary tumor, without amputating the involved limb, intensive preoperative chemotherapy with high dose methotrexate (HDMTX) with citrovorum factor rescue (CFR) and adriamycin (ADR) was initiated in 20 patients with biopsy-proven primary osteogenic sarcoma of the distal femur (15 patients) and proximal tibia (five patients). Following intensive chemotherapy, en bloc resection of the primary tumor with prosthetic replacement of the involved bone was planned. After surgery, adjuvant chemotherapy, consisting of HDMTX with CFR, ADR, and high dose cyclophosphamide was given sequentially for 1 year. Of 20 patients with primary osteogenic sarcoma (two with evidence of pulmonary metastases), 18 had primary tumors that could be clinically measured. Of these 18, 17 demonstrated a decrease in the size of primary tumor prior to surgery, while on chemotherapy. To date, 12 of these patients with osteogenic sarcoma of the distal femur have had total femur and knee joint replacement, and three patients with osteogenic sarcoma of the proximal tibia have had total knee replacement. In all 15 patients, surgical margins were grossly and microscopically free of tumor. There has been no evidence of soft tissue recurrence in any of the 15 patients who have undergone surgery for from 2 to 15 months postoperatively. These preliminary results indicate that with the use of aggressive chemotherapy, it is possible to demonstrate objective tumor regression in primary osteogenic sarcoma, allowing the surgeon to perform en bloc resection of tumor and prosthetic replacement of the involved bone. Although the limb is preserved, it is important to stress that extensive surgery yielding tumor-free margins is performed. The ultimate evaluation of this approach to the treatment of primary osteogenic sarcoma awaits longer observation, to determine limb function and the continued disease-free status, once adjuvant chemotherapy is discontinued.

Considerations on treatment of nephroblastoma. A study of 36 cases

Thirty-six patients with nephroblastoma in Stages I, II and III treated at Radiumhemmet between 1966 and 1973, were analysed. The tumors were classified into three different histological types. All 10 patients in Stage III have developed metastases. All patients in Stages I and II (5 out of 26) who developed metastases had poorly differentiated (histological Type III) tumours. The indications for postoperative irradiation and chemotherapy for the different stages and histological types of the tumour are discussed.

Adriamycin in the treatment of childhood solid tumors. A Southwest Oncology Group study

Ninety-eight children with solid tumors resistant to conventional chemotherapy received adriamycin 90 mg/m2, either as a single intravenous injection or in 6 divided doses administered every 6 hours. Of the 88 evaluable children, 6 (7%) achieved a complete response and 26 (29%) achieved a partial response. Tumors which demonstrated significant response rates were: neuroblastoma (9/18), Wilms' tumor (7/13), rhabdomyosarcoma (4/11), and lymphoma (4/8). The toxicities observed with this regimen included: alopecia, leukopenia, thrombocytopenia, nausea, vomiting, stomatitis, febrile episodes, and ST-segment changes.

Adriamycin in the treatment of childhood acute leukemia. A Southwest Oncology Group study

Sixty-six children with acute leukemia, in advanced stages of their disease and resistant to conventional chemotherapy, received adriamycin for remssion induction. Seventeen of 46 (37%) evaluable children with acute lymphocytic leukemia achieved a complete remission, and 5 (11%) achieved a partial remission. Two of 12 evaluable children with acute myelogenous leukemia achieved a complete remission, while an additional 3 achieved a partial remission. Two children with erythroleukemia also achieved a complete remission. Previous therapy with daunorubicin did not affect the response rate. The main toxicities observed with adriamycin were myelosuppression, fever, nausea and vomiting, stomatitis, alopecia, and cardiac toxicity (ST segment changes and arrhythmias).

Treatment of hepatocellular carcinoma with adriamycin. Preliminary communication

In a Phase II clinical trial, 14 patients with histologically proven primary hepatocellular carcinoma were treated with adriamycin administered intravenously at a dose of 75 mg/m2 every 3 weeks. All 11 evaluable patients responded with 3 exhibiting complete tumor regression after two, three, and five courses of adriamycin respectively. The remission durations for these 3 were 3, 6, and 7 months, and their survivals were 8, 9, and 13 months, respectively. The median survival of the evaluable patients is 8 months (range 1-13 months). The side effects encountered included myelosuppression, anorexia, nausea, vomiting, and alopecia. Adriamycin seems to be an effective agent in hepatocellular carcinoma. Further trials are underway to test its true efficacy both singly and in combination with other drugs in the management of this tumor.

Reduction of doxorubicin (adriamycin) bone marrow toxicity

Doxorubicin (adriamycin), an antineoplastic antibiotic, is a potent suppressant of bone marrow. Previous studies on doxorubicin disposition indicated that its diversion from bone marrow in the first few minutes after administration should result in a marked decrease in total exposure to the drug (concentration X time) with a concomitant reduction in concentration-time-dependent toxicity. To test this hypothesis, the descending aorta of rabbits was occluded just proximal to the iliac bifurcation for 30 min to deprive bone marrow of blood flow. Both these rabbits and the control rabbits were given 5 mg/kg of doxorubicin intravenously, and the total white cell could in peripheral blood was monitored periodically for 15 days. The decrease in toxicity produced by the occlusion was quite evident by comparison of white cell counts and deaths in all groups. A possible mechanism of this effect was shown to be a decreased doxorubicin exposure of bone marrow tissue in the occluded animals as judged by relative doxorubicin concentration-time curves in rabbits with and without the aortic occlusion.

Radiation-adriamycin interactions: preliminary clinical observations

This communication reports four patients treated with the anthracycline adriamycin and irradiation either concurrently or sequentially, who demonstrated apparent augumentation of radiation reactions. Two of these patients demonstrated the so-called "recall" phenomenon.