Therapeutic effect and toxicity of adriamycin in patients with neoplastic disease

The Survival Outcomes, Prognostic Factors and Adverse Events following Systemic Chemotherapy Treatment in Bone Sarcomas: A Retrospective Observational Study from the Experience of the Cancer Referral Center in Northern Thailand

This study aimed to assess survival outcomes, prognostic factors, and adverse events following chemotherapy treatment for osteosarcoma and Ewing’s sarcoma. This retrospective observational study was conducted to collect the data of the patients with osteosarcoma or Ewing’s sarcoma who received chemotherapy treatment between 2008 and 2019. The flexible parametric survival model was performed to explore the adjusted survival probability and the prognostic factors. A total of 102 patients (79 with osteosarcoma and 23 with Ewing’s sarcoma) were included. The estimated 5-year disease-free survival (DFS) and 5-year overall survival (OS) probabilities in patients with resectable disease were 60.9% and 63.3% for osteosarcoma, and 54.4% and 88.3% for Ewing’s sarcoma, respectively, whereas the 5-year DFS and 5-year OS for those with unresectable/metastatic disease remained below 25%. Two prognostic factors for osteosarcoma included a response to neoadjuvant chemotherapy and female gender. Ewing’s sarcoma patients aged 25 years and older were significantly associated with poorer survival outcomes. Of 181 chemotherapy treatment cycles, common self-reported adverse symptoms included tumor pain (n = 32, 17.7%), fever (n = 21, 11.6%), and fatigue (n = 16, 8.8%), while common grade III adverse events included febrile neutropenia (n = 13, 7.3%) and neutropenia (n = 9, 5.1%). There was no chemotherapy-related mortality (grade V) or anaphylaxis events.

Bone sarcoma: success through interdisciplinary collaboration

PURPOSE

Osteosarcoma and Ewing sarcoma are the most frequent malignant bone tumours of childhood and adolescence. This review summarizes the oncologist's view of these diseases and their treatment.

METHODS

A non-systematic literature review was performed, the personal impressions and experience of the authors is described.

RESULTS

Local therapy and chemotherapy, each on their own, will not cure patients with malignant bone sarcomas. Together, they present a highly efficacious combination. While the most effective drugs were defined decades ago, progress since then has been limited. It is hoped that substances shown to be active in relapsed disease will be forwarded into even more efficacious frontline treatments. Good palliative therapy is necessary when cure is no longer an option.

CONCLUSION

Close interdisciplinary collaboration is the key to successful treatment of bone sarcomas in paediatric patients.

Tissue distribution of epirubicin after severe extravasation in humans

PURPOSE

As critical parameter after extravasation of cytotoxic vesicants, anthracyclines were determined in removed tissue from patients requiring surgical intervention due to tissue necrosis. We monitored their distribution within the affected lesion to establish a possible dose-toxicity relation.

METHODS

From six patients scheduled for surgery, removed tissue flaps were systematically analysed by HPLC (epirubicin: 5 subjects; doxorubicin: 1 subject).

RESULTS

After extravasation, tissue concentrations were highly variable with an individual anthracycline distribution pattern ranging from a few nanograms up to 17 µg per 100 mg tissue, which indicated a substantial difference in tissue sensitivity among patients. The resection borders coincided with the extension of the erythema and guided the surgical intervention after demarcation of the lesion, which occurred usually 2 or 3 weeks after extravasation. At that time, drug was hardly detected at the resection borders. Wound drains were negative for the extravasated drugs while showing a time profile of vascular growth factors and inflammatory cytokines, which was highly similar to routine surgery. In all six patients, surgical debridement with immediate wound closure led to healing within approximately 2 weeks, when therapy was resumed in all patients with reasonable time delay.

CONCLUSION

Surgical intervention after demarcation of the extravasation lesion allows for almost uninterrupted continuation of treatment independent of the amount of extravasated anthracycline. As even minor amounts of the vesicants may trigger tissue necrosis, preventive measures merit the highest priority.

Adverse cutaneous reactions to chemotherapeutic drugs

Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Although often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. We evaluate a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent unrecognition. Groupings of these reactions include direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.

Upper limb extravasation of cytotoxic drugs: results of the saline washout technique in children

PURPOSE

Extravasation of cytotoxic vesicant drugs is a surgical emergency (within six hours) since this incident can lead to severe skin and soft-tissue damage. Outcomes after the saline washout procedure have been extensively described in adults, but rarely in children. The aim of this study was to evaluate the outcome of early saline washout procedure for upper limb cytotoxic drug extravasation in children.

METHODS

All consecutive children with vesicant drug extravasation were retrospectively reviewed. The saline washout procedure was performed. Cosmetic aspect, residual pain and range of movement were analyzed as well as time to surgery and chemotherapy resumption at last follow-up.

RESULTS

Between 2014 and 2018, 13 cytotoxic vesicant drug extravasations occurred (mean age 8 years (sem 5)), including 11 treated by the saline washout procedure. At mean follow-up of 11 months (sem 7), the patients had no or low pain and ranges of movement were fully conserved. Two patients (one within the six hours' delay) had soft-tissue necrosis leading to extensive reconstructive surgery.

CONCLUSION

The saline washout procedure is safe and easy and significantly reduces the incidence of extensive skin damage. Early referral to a specialized department is essential. However, the key parameter remains prevention by educating medical staff and nurses about these injuries and by training them for early and urgent management.

LEVEL OF EVIDENCE

IV.

Adjuvant and Neoadjuvant Chemotherapy for Osteosarcoma: A Historical Perspective

Osteosarcoma was initially resistant to chemotherapy that worked for Ewing sarcoma and rhabdomyosarcoma as well as other chemotherapeutic agents available in the 1960s. In the early 1970s, responses of osteosarcoma to adriamycin were reported, and at about the same time, so were responses of osteosarcoma to high-dose methotrexate. These agents were introduced into adjuvant therapy due to the dire prognosis associated with apparently localized osteosarcoma. After initial questions regarding the role of chemotherapy delayed its uniform acceptance, there is now general agreement that chemotherapy is primarily responsible for the cure of patients with osteosarcoma when combined with surgical elimination of the primary tumor. Advances with combination chemotherapy later adding cisplatin and ifosfamide have improved ultimate survival. The history of the development of effective chemotherapy combinations at Memorial Sloan Kettering Cancer Center, UT MD Anderson Cancer Center, and the Rizzoli Institute are highlighted, and recent large cooperative group studies are reviewed in the context of those findings.

Chemotherapy Extravasation Management: 21-Year Experience

Chemotherapy extravasation may result in serious damage to patients, with irreversible local injures and disability. Evidence-based standardization on extravasation management is lacking and many institutions do not practice adequate procedures to prevent the severer damages. Our aim was to explore the prevention and treatment of extravasation injuries, proposing a standard therapeutic protocol together with a review of the literature. From January 1994 to December 2015, 545 cases were reviewed (age range, 5-87 years; 282 men and 263 women). Our therapeutic protocol consisted of local infiltration of saline solution and topical occlusive applications of corticosteroids. The infiltrations were administrated 3 to 6 times a week depending on damage severity. Our protocol allowed us to prevent ulceration in 373 cases. Only 27 patients required surgery (escarectomy, skin graft, regional, and free flap). Numerous treatments have been proposed in literature. The antidotes have been discussed controversially and are not considered standard methods for treatment, especially when polychemotherapy is administrated and the identification of the responsible drug is not possible. We proposed the use of saline solution injection to dilute rapidly the drug, thus reducing its local toxic effects. This method is easy to use and always reproducible even when the drug is not known or when it is administrated in combination with other drugs. It is possible to perform it in ambulatory regimen, and, overall, it represents a standard method.

Adriamycin as a Single Agent in Various Forms of Advanced Neoplasia of Adults and Children

This paper reviews the effects of adriamycin (ADM) observed in a series of 485 patients (419 adults and 66 children) treated at the Istituto Nazionale Tumori, Milan, from September 1968 to December 1973. Nine two patients were insufficiently treated to provide meaningful information on drug effects. The drug was administered by rapid intravenous injection through 6 dose schedules. In the last two schedules ADM was administered every 3 weeks at the dose of 20–25 mg/m2 for 3 consecutive days (schedule E) or of 60–75 mg/m2 in a single injection (schedule F). With schedules E and F there was an appreciable decrease in the incidence of stomatitis and of severe myelosuppression. Thrombocytopenia occurred in about 10 % of patients. The overall incidence of cardiomyopathy was 1.9 %. As observed by American investigators, cardiomyopathy occurred especially after a total dose exceeding 600 mg/m2 (17 %) and 4/9 patients died of irreversible heart failure. Congestive failure occurred in 7/9. In 6/9 patients showing cardiomyopathy ADM was administered through schedules E or F. One patient was a child 3 years old and 8 were adults with a mean age of 39 years. Non specific electrocardiographic abnormalities were present in about 10 % of patients during treatment with ADM but only exceptionally were they able to predict subsequent cardiomyopathy. The therapeutic results were promising in several types of previously treated and untreated neoplastic disease. The best responses (complete plus partial remission greater than 50 %) were observed in the group of malignant lymphomas (44%) especially in histiocytic lymphoma (67 %), in Ewing's sarcoma (41 %), Wilms's tumor (55 %), carcinoma of thyroid (45 %), testicular tumors (39 %), neuroblastoma (38 %), naso-pharyngeal carcinoma (29 %), breast cancer (26 %), as well as in the small series of acute and chronic myeloproliferative disorders. Significant regressions were also obtained in transitional carcinoma of urinary bladder (2/6) ovarian carcinomas (29 %), in soft tissue sarcomas (22 %) and in mesothelioma (25 %). A lower rate of substantial tumor response was seen in bronchogenic (15 %) and gastrointestinal carcinomas (22 %) as well as in epidermoid carcinomas of head and neck (10 %). No significant regression was noted in osteogenic sarcomas, chondrosarcoma, renal carcinoma and malignant melanoma. In responsive patients the mean duration of response was usually short. This could be in part explained by the fact that (41 %) of patients had previously been treated with conventional drugs. Our experience shows that ADM is useful in a number of neoplastic diseases, where it produces a prompt tumor regression in responsive patients. The successful results achieved with ADM as a single agent indicate that the drug should be incorporated in several protocols of combination chemotherapy and of combined treatment modalities provided the total dose does not exceed 550 mg/m2.

Triolein Emulsion Infusion Into the Carotid Artery Increases Brain Permeability to Anticancer Agents

BACKGROUND

Triolein emulsion infusion into the carotid artery has been reported to induce temporary and reversible opening of the blood-brain barrier by increasing vascular permeability.

OBJECTIVE

To evaluate the effect of triolein emulsion infusion on brain permeance by anticancer agents.

METHODS

In the doxorubicin study. 2.4 mg/kg doxorubicin was injected immediately after triolein emulsion (1%, 1.5%, and 2%) infusion into rabbit carotid arteries. Two hours later, bilateral hemispheres and eyeballs were harvested, and doxorubicin concentrations were measured fluorometrically. Doxorubicin ratios of ipsilateral/contralateral hemispheres were compared with those of doxorubicin controls by use of the Kruskal-Wallis test followed by the Dunn test. In the cisplatin study, 10 mg/kg cisplatin was injected immediately after 2% triolein emulsion infusion into rat carotid arteries. Ipsilateral hemispheres were harvested 2, 6, 12, 24, and 36 hours after treatment. Time-dependent cisplatin concentrations were determined by liquid chromatography/electrospray ionization-tandem mass spectrometry/mass spectrometry.

RESULTS

Doxorubicin concentrations were significantly higher in ipsilateral hemispheres and eyeballs in all 3 triolein treatment groups than in doxorubicin controls. In the cisplatin study, cisplatin concentrations in the ipsilateral hemispheres peaked at 6 hours after infusion of cisplatin.

CONCLUSION

Brain permeance to anticancer agents was increased by triolein emulsion infusion, which suggests that triolein infusion might be a useful adjuvant treatment for brain tumors.

Luteinizing hormone-releasing hormone targeted poly(methyl vinyl ether maleic acid) nanoparticles for doxorubicin delivery to MCF-7 breast cancer cells

The purpose of this study was to design a targeted anti-cancer drug delivery system for breast cancer. Therefore, doxorubicin (DOX) loaded poly(methyl vinyl ether maleic acid) nanoparticles (NPs) were prepared by ionic cross-linking method using Zn(2+) ions. To optimise the effect of DOX/polymer ratio, Zn/polymer ratio, and stirrer rate a full factorial design was used and their effects on particle size, zeta potential, loading efficiency (LE, %), and release efficiency in 72 h (RE72, %) were studied. Targeted NPs were prepared by chemical coating of tiptorelin/polyallylamin conjugate on the surface of NPs by using 1-ethyl-3-(3-dimethylaminopropyl) carboiimid HCl as cross-linking agent. Conjugation efficiency was measured by Bradford assay. Conjugated triptorelin and targeted NPs were studied by Fourier-transform infrared spectroscopy (FTIR). The cytotoxicity of DOX loaded in targeted NPs and non-targeted ones were studied on MCF-7 cells which overexpress luteinizing hormone-releasing hormone (LHRH) receptors and SKOV3 cells as negative LHRH receptors using Thiazolyl blue tetrazolium bromide assay. The best results obtained from NPs prepared by DOX/polymer ratio of 5%, Zn/polymer ratio of 50%, and stirrer rate of 960 rpm. FTIR spectrum confirmed successful conjugation of triptorelin to NPs. The conjugation efficiency was about 70%. The targeted NPs showed significantly less IC50 for MCF-7 cells compared to free DOX and non-targeted NPs.

Alteration in DNA binding pattern of conformationally locked NC(O)N system: A spectroscopic investigation

The binding mode of a conformationally locked NC(O)N planar system with deoxyribonucleic acid (DNA) is investigated using various spectroscopic and enzymatic assays. Compound 1 and its four different salts (comp. 2-5) were prepared for this purpose. They showed certain changes in their respective DNA-compound complex at ground state and excited state as measured by UV-vis and fluorescence emission spectra. The Stern-Volmer quenching constant (KSV) for the neutral species (1) is found 8545 M(-1), whereas, for its salts 2, 3, 4 and 5 the quenching constants were 33510 M(-1), 11352 M(-1), 19693 M(-1) and 27270 M(-1) respectively. Nevertheless, the binding constant values remain comparable in neutral and salt forms except for 5. To elucidate the reason we took their CD spectra and ran a topoisomerase I (Topo I) assay. These experimental data revel the fact that compound 1 (neutral form) binds at the minor groove of DNA, whereas, its salt (2) has an extended intercalating property.

Subsequent Neoplasms in Adult Survivors of Childhood Genitourinary Tumors

Treatment for childhood genitourinary tumors such as Wilms tumor, rhabdomyosarcoma, and germ cell tumors has progressed to the point that cure can be expected in many cases. However, survivorship is often coupled with a variety of late effects, of which subsequent neoplasms may be the most concerning if not the most life threatening. Here, we review current literature to assess and report issues relating to subsequent neoplasms in patients with a history of childhood genitourinary tumors, including causative factors, overall risks, the most prevalent subsequent neoplasms, and current recommendations for surveillance and screening.

Metformin protects cardiomyocyte from doxorubicin induced cytotoxicity through an AMP-activated protein kinase dependent signaling pathway: an in vitro study

Doxorubicin (Dox) is one of the most widely used antitumor drugs, but its cumulative cardiotoxicity have been major concerns in cancer therapeutic practice for decades. Recent studies established that metformin (Met), an oral anti-diabetic drug, provides protective effects in Dox-induced cardiotoxicity. Met has been shown to increase fatty acid oxidation, an effect mediated by AMP activated protein kinase (AMPK). Here we delineate the intracellular signaling factors involved in Met mediated protection against Dox-induced cardiotoxicity in the H9c2 cardiomyoblast cell line. Treatment with low dose Met (0.1 mM) increased cell viabilities and Ki-67 expressions while decreasing LDH leakages, ROS generations and [Ca2+]i. The protective effect was reversed by a co-treatment with compound-C, an AMPK specific inhibitor, or by an over expression of a dominant-negative AMPKα cDNA. Inhibition of PKA with H89 or a suppression of Src kinase by a small hairpin siRNA also abrogated the protective effect of the low dose Met. Whereas, with a higher dose of Met (1.0 mM), the protective effects were abolished regardless of the enhanced AMPK, PKA/CREB1 and Src kinase activity. In high dose Met treated cells, expression of platelet-derived growth factor receptor (PDGFR) was significantly suppressed. Furthermore, the protective effect of low dose Met was totally reversed by co-treatment with AG1296, a PDGFR specific antagonist. These data provide in vitro evidence supporting a signaling cascade by which low dose Met exerts protective effects against Dox via sequential involvement of AMPK, PKA/CREB1, Src and PDGFR. Whereas high dose Met reverses the effect by suppressing PDGFR expression.

Protective effect of the edible brown alga Ecklonia stolonifera on doxorubicin-induced hepatotoxicity in primary rat hepatocytes

OBJECTIVES

As part of our efforts to isolate anti-hepatotoxic agents from marine natural products, we screened the ability of 14 edible varieties of Korean seaweed to protect against doxorubicin-induced hepatotoxicity in primary rat hepatocytes.

METHODS

Among the crude extracts of two Chlorophyta (Codium fragile and Capsosiphon fulvescens), seven Phaeophyta (Undaria pinnatifida, Sargassum thunbergii, Pelvetia siliquosa, Ishige okamurae, Ecklonia cava, Ecklonia stolonifera and Eisenia bicyclis), five Rhodophyta (Chondrus ocellatus, Gelidium amansii, Gracilaria verrucosa, Symphycladia latiuscula and Porphyra tenera), and the extracts of Ecklonia stolonifera, Ecklonia cava, Eisenia bicyclis and Pelvetia siliquosa exhibited significant protective effects on doxorubicin-induced hepatotoxicity, with half maximal effective concentration (EC50) values of 2.0, 2.5, 3.0 and 15.0 μg/ml, respectively.

KEY FINDINGS

Since Ecklonia stolonifera exhibits a significant protective potential and is frequently used as foodstuff, we isolated six phlorotannins, including phloroglucinol (1), dioxinodehydroeckol (2), eckol (3), phlorofucofuroeckol A (4), dieckol (5) and triphloroethol-A (6). Phlorotannins 2 ∼ 6 exhibited potential protective effects on doxorubicin-induced hepatotoxicity, with corresponding EC50 values of 3.4, 8.3, 4.4, 5.5 and 11.5 μg/ml, respectively.

CONCLUSION

The results clearly demonstrated that the anti-hepatotoxic effects of Ecklonia stolonifera and its isolated phlorotannins are useful for further exploration and development of therapeutic modalities for treatment of hepatotoxicity.

Use of magnetic folate-dextran-retinoic acid micelles for dual targeting of doxorubicin in breast cancer

Amphiphilic copolymer of folate-conjugated dextran/retinoic acid (FA/DEX-RA) was self-assembled into micelles by direct dissolution method. Magnetic iron oxide nanoparticles (MNPs) coated with oleic acid (OA) were prepared by hydrothermal method and encapsulated within the micelles. Doxorubicin HCl was loaded in the magnetic micelles. The characteristics of the magnetic micelles were determined by Fourier transform infrared (FT-IR) spectroscopy, thermogravimetric analysis (TGA), transmission electron microscopy (TEM), and vibrating sample magnetometer (VSM). The crystalline state of OA-coated MNPs and their heat capacity were analyzed by X-ray diffraction (XRD) and differential scanning calorimetry (DSC) methods, respectively. The iron content of magnetic micelles was determined using inductively coupled plasma optical emission spectrometry (ICP-OES). Bovine serum albumin (BSA) was used to test the protein binding of magnetic micelles. The cytotoxicity of doxorubicin loaded magnetic micelles was studied on MCF-7 and MDA-MB-468 cells using MTT assay and their quantitative cellular uptake by fluorimetry method. TEM results showed the MNPs in the hydrophobic core of the micelles. TGA results confirmed the presence of OA and FA/DEX-RA copolymer on the surface of MNPs and micelles, respectively. The magnetic micelles showed no significant protein bonding and reduced the IC₅₀ of the drug to about 10 times lower than the free drug.

Extravasation injuries in adults

Insertion of an intravascular catheter is one of the most common invasive procedures in hospitals worldwide. These intravascular lines are crucial in resuscitation, allow vital medication to be administered, and can be used to monitor the patients' real-time vital parameters. There is, however, growing recognition of potential risks to life and limb associated with their use. Medical literature is now replete with isolated case reports of complications succinctly described by Garden and Laussen (2004) as "An unending supply of "unusual" complications from central venous catheters." This paper reviews complications of venous and arterial catheters and discusses treatment approaches and methods to prevent complications, based on current evidence and endeavours to provide information and guidance that will enable practitioners to prevent, recognise, and successfully treat extravasation injuries in adults.

The kinetics of blood brain barrier permeability and targeted doxorubicin delivery into brain induced by focused ultrasound

Focused ultrasound (FUS) combined with a circulating microbubble agent is a promising strategy to non-invasively disrupt the blood-brain barrier (BBB) and could enable targeted delivery of therapeutics that normally do not leave the brain vasculature. This study investigated the kinetics of the BBB permeability using dynamic contrast-enhanced MRI (DCE-MRI) and the resulting payload of the chemotherapy agent, doxorubicin (DOX). We also investigated how the disruption and drug delivery were affected by a double sonication (DS) with two different time intervals (10 or 120 min). Two locations were sonicated transcranially in one hemisphere of the brain in 20 rats using a 690 kHz FUS transducer; the other hemisphere served as a control. For BBB disruption, 10 ms bursts were applied at 1 Hz for 60s and combined with IV injection of a microbubble ultrasound contrast agent (Definity; 10 μl/kg). DOX was injected immediately after the second location was sonicated. The transfer coefficient (K(trans)) for an MRI contrast agent (Gd-DTPA) was estimated serially at 4-5 time points ranging from 30 min to 7.5 hrs after sonication using DCE-MRI. After a single sonication (SS), the mean K(trans) was 0.0142 ± 0.006 min(-1) at 30 min and was two or more orders of magnitude higher than the non-sonicated targets. It decreased exponentially as a function of time with an estimated half-life of 2.22 hrs (95% confidence intervals (CI): 1.06-3.39 hrs). Adding a second sonication increased K(trans), and with a 120 min interval between sonications, prolonged the duration of the BBB disruption. Mean K(trans) estimates of 0.0205 (CI: 0.016-0.025) and 0.0216 (CI: 0.013-0.030) min(-1) were achieved after DS with 10 and 120 min delays, respectively. The half-life of the K(trans) decay that occurred as the barrier was restored was 1.8 hrs (CI: 1.20-2.41 hrs) for a 10 min interval between sonications and increased to 3.34 hrs (CI: 0.84-5.84 hrs) for a 120 min interval. DOX concentrations were significantly greater than in the non-sonicated brain for all experimental groups (p<0.0001), and 1.5-fold higher for DS with a 10 min interval between sonications. A linear correlation was found between the DOX concentration achieved and the K(trans) measured at 30 min after sonication (R: 0.7). These data suggest that one may be able to use Gd-DTPA as a surrogate tracer to estimate DOX delivery to the brain after FUS-induced BBB disruption. The results of this study provide information needed to take into account the dynamics BBB disruption over time after FUS.

Chemotherapeutic adjuvant treatment for osteosarcoma: where do we stand?

AIM

Since the introduction of chemotherapy, survival in localised high-grade osteosarcoma has improved considerably. However, there is still no worldwide consensus on a standard chemotherapy approach. In this systematic review evidence for effectiveness of each single drug and the role of response guided salvage treatment of adjuvant chemotherapy are addressed, whereas in a meta-analysis the number of drugs in current protocols is considered.

METHODS

A systematic literature search for clinical studies in localised high-grade osteosarcoma was undertaken, including both randomised and non-randomised trials. Historical clinical studies from the pre-chemotherapy era were included for comparison purposes.

RESULTS

Nine historical studies showed a long-term survival of 16% after only local treatment. Fifty single agent phase II studies showed high response rates for adriamycin (A, 43%), ifosfamide (Ifo, 33%), methotrexate (M, 32%), cisplatin (P, 26%) but only 4% for etposide (E). In 19 neo-adjuvant studies the mean 5-year event free survival (EFS) was 48% for 2-drug regimens and 58% for ⩾3 drug regimens, with a 5-year overall survival (OAS) of 62% and 70%, respectively. Meta-analysis showed that ⩾3 drug regimens including methotrexate plus adriamycin plus cisplatin (plus ifosfamide) (MAP(Ifo)) had significant better outcome (EFS: HR=0.701 (95% confidence interval [95% CI]: 0.615-0.799); OAS: HR=0.792 (95% CI: 0.677-0.926) than 2-drug regimens, but there was no significant difference between MAP and MAPIfo (or plus etoposide). Salvage of poor responders by changing drugs, or intensifying treatment postoperatively has not proven to be useful in this analysis.

CONCLUSION

Meta-analysis in patients with localised high-grade osteosarcoma shows that 3-drug regimens, for example MAP are the most efficacious drug regimens.

Topical application of valrubicin has a beneficial effect on developing skin tumors

Valrubicin is a second generation anthracycline characterized by an excellent safety profile presenting no skin toxicity or necrosis upon contact. In its current liquid formulation (Valstar; Indevus Pharmaceuticals, Lexington, MA), it is approved solely for the treatment of bladder cancer. Recently, valrubicin was incorporated in a cream formulation rendering this drug available for topical application. The cytostatic property of valrubicin can, thus, be employed for treating hyperproliferative skin diseases as was recently described for psoriasis. In the present study, the effect of topical application of valrubicin was investigated in skin tumor development; we hypothesized that valrubicin may be employed in treating actinic keratosis, a hyperproliferative skin condition that may transform into malignancy. A two-stage chemical mouse skin carcinogenesis model that represents the multistage etiology of human skin cancer-from developing papillomas to squamous cell carcinoma (SCC) was used. Moreover, two human skin SCC cell lines: DJM-1 and HSC-1 were cultured, to further investigate the effect of valrubicin in vitro. Cell viability was assessed by adenosine triphosphate presence, proliferation as proliferative cell nuclear antigen expression and apoptosis as cytokeratin 18 cleavage, caspase activation, poly-adenosine diphosphate-ribose-polymerase cleavage and bax and bcl-2 regulation. Valrubicin significantly inhibited tumor formation in the mouse skin carcinogenesis model and significantly decreased cell viability of the cultured human skin SCC cells. In both mouse skin and SCC cells, proliferation was significantly decreased. Apoptosis was significantly increased in SCC cells but unchanged in the treated mouse skin at study completion. This study demonstrated that topical application of valrubicin has a beneficial effect in treating developing skin tumors.

Skeletal Muscle for Endomyocardial Biopsy: Comparable Stress Response in Doxorubicin Cardio-myopathy

In the present study, we compared the cell damage response in skeletal and cardiac muscle tissue when exposed to doxorubicin. This was carried out by means of a less invasive informative substitute to endomyocardiac biopsy based on Hsp70 immunodetection and a subcellular analysis of the nucleolus. Male Sprague Dawley rats (62 g body weight) were randomly distributed into 3 group, the control and doxorubicin I and doxorubicin II groups, in which 15 and 25 mg/kg body weight of doxorubicin (0.1 ml, i.v.) was administered, respectively. After 15, 30, 45 and 60 minutes, portions of the left and right ventricle wall and interventricle wall, together with skeletal muscle from the posterior and anterior member, were prepared for Hsp70 immunodetection by Western blot analysis and ultrastructural study using the thin cut technique. Differential cell response between the control and treated groups was observed in Hsp70 immunodetection and at the subcellular level. In the control group, the Hsp70 recognition levels and typical normal nucleolar morphology were similar, while the treated groups showed variable-dependent Hsp70 recognition and segregation of nucleolar components, forming ring-like figures of a variable-independent nature. Comparison of cardiac and skeletal muscle tissue cell response to doxorubicin toxic aggression revealed parallelism in terms of Hsp70 accumulation in certain regions of both tissues (15 mg/kg body weight of doxorubicin), which suggests that replacing endomyocardiac biopsy analysis with skeletal muscle analysis may be a safe option.

Beta-adrenergic receptor mediated protection against doxorubicin-induced apoptosis in cardiomyocytes: the impact of high ambient glucose

Recent studies have demonstrated that the beta2-adrenergic receptor (beta2AR)-Galphai signaling pathway exerts a cardiac antiapoptotic effect. The goals of this study were to determine the intracellular signaling factors involved in beta2AR-mediated protection against doxorubicin-induced apoptosis in H9c2 cardiomyocyte and explore the impact of high ambient glucose on the antiapoptotic effect. Under physiological glucose environment (100 mg/dl), beta2AR stimulation prevented doxorubicin-induced apoptosis, which was attenuated by cotreatment with wortmannin, a phosphoinositide 3-kinase (PI3K) inhibitor, or transfection of a dominant-negative Akt. Inhibition of Src kinase with 4-amino-5-(4-chlorophenyl)-7-(t-butyl)pyrazolo[3,4-d] pyrimidine or cSrc small interfering RNA 32 also attenuated the antiapoptotic effect. Inhibition of platelet-derived growth factor receptor (PDGFR) with AG1296 reversed the beta2AR-induced antiapoptotic effect. Transfection of an active Src cDNA (Y529F) alone was sufficient to render the cells resistant to apoptosis, and the resistance was blocked by wortmannin. Transfection of an active PI3K minigene (iSH2-p110) alone also induced resistance to apoptosis, and the resistance was reversed by an Akt-inhibitor but not by AG1296. High ambient glucose (450 mg/dl) caused two major effects: 1) it significantly reduced betaAR-induced PDGFR phosphorylation, Src kinase activity, and activation of PI3K signaling pathway; and 2) it partially attenuated beta2AR-induced antiapoptotic effect. These data provide in vitro evidence supporting a signaling cascade by which beta2AR exerts a protective effect against doxorubicin-induced apoptosis via sequential involvement of Galphai, Gbetagamma, Src, PDGFR, PI3K, and Akt. High ambient glucose significantly attenuates beta2AR-mediated cardioprotection by suppressing factors involved in this cascade including PDGFR, Src, and PI3K/Akt.

Cytotoxic drug use in treatment of dogs and cats with cancer by UK veterinary practices (2003 to 2004)

OBJECTIVES

To describe the range and frequency of cytotoxic drugs prescribed within UK veterinary practices to treat dogs and cats with cancer, determine the effect of practice demographic variables on this practice and determine the frequency with which intravenous catheters were used during administration of parenteral cytotoxic drugs.

METHODS

A postal survey of 1838 veterinary practices providing care for dogs and cats within the UK.

RESULTS

Prescription of cytotoxic drugs to treat dogs and cats with cancer during the preceding 12 months was reported by 70.8 per cent practices. The most widely prescribed agents were cyclophosphamide (65.4 per cent) and vincristine (63.5 per cent). Twenty-three per cent of responding practices had prescribed an antitumour antibiotic and 8.3 per cent had prescribed a platinum agent. The median frequency of prescription was between once a month and once every three months. Increasing frequency and range of cytotoxic drug prescription were associated with practice employment of higher numbers of veterinary surgeons and increased levels of pet insurance among practice clients. Almost a quarter of practices administering vesicant parenteral cytotoxic drugs failed to always use intravenous catheters to do so.

CLINICAL SIGNIFICANCE

Prescription of cytotoxic drugs, and therefore the potential for occupational exposure of staff, was widespread among UK veterinary practices providing care for dogs and cats.

Paravasation von Zytostatika

A variety of antineoplastic agents is associated with toxicity to healthy tissue and therefore represents a hazard for patients in case of extravasation. The most common risk factors include patient associated and iatrogenic risk factors. Due to the possible complications after extravasation, the knowledge of these risk factors is the basis for prevention, which is of utmost importance. A classification of antineoplastic agents according to the type of tissue damage includes the categories vesicant, irritant, and non-vesicant. Dependent on the extravasated agent, a series of emergency measures should be considered, preferably adhering to a standard operation procedure. There is good evidence for the successful use of antidotes to some antineoplastic agents. These antidotes are dimethylsulfoxide or hyaluronidase, often combined with topical measures such as cooling or application of heat. The application of sodium bicarbonate, sodium thiosulfate, and heparin is not recommended, whereas the usefulness of corticosteroids is still a matter of controversial discussions. Ambiguity in the management of extravasation is often a consequence of limited clinical evidence. Due to our deficient knowledge about some of the administered cytotoxics, there is ongoing need for action even after decades of therapy with antineoplastic agents.

Clinical and cellular pharmacology in relation to solid tumours of childhood

Our understanding of the clinical and cellular pharmacology of drugs commonly used in the treatment of childhood cancer have increased greatly over the past two decades. However, with the exception of childhood acute lymphoblastic leukaemia (ALL), our current knowledge of factors such as inter-patient pharmacokinetic variability and cellular determinants of chemosensitivity has not been utilized in the design of integrated clinical studies. Recent pre-clinical and clinical evaluation of the topoisomerase I inhibitors topotecan and irinotecan has highlighted the potential importance of pharmacological factors in their effectiveness as cytotoxics. In this review, the clinical and cellular pharmacology of vincristine, actinomycin D, doxorubicin, cyclophosphamide, ifosfamide, cisplatin, carboplatin and etoposide will be discussed in relation to the major paediatric solid tumours. For each disease type, knowledge of the clinical and cellular pharmacology of a candidate drug will be related to pharmacodynamic responses such as response, toxicity and prognosis. For diseases such as Wilms' tumour, osteogenic sarcoma and Ewing's tumour, histological response to initial induction chemotherapy is of prognostic significance, and the depth of response is increasingly recognised as an important determinant of prognosis for high-risk neuroblastoma. For several of these tumour types, the dose-intensity of chemotherapy may be an important variable in determining prognosis. However the relationship between pharmacokinetic variability, cellular pharmacology and the major determinants of chemosensitivity to those drugs employed in first line therapy is unknown. The study of these relationships, by means of up front window studies in children who present with high-risk disease, may be as important as the introduction of new agents. Indeed, the optimisation of current therapies may be required to allow a fully informed selection of those children for whom novel therapies are truly needed. Funding and international collaboration at the clinical and scientific level would be required to achieve these aims.

Genomic medicine and neuroblastoma

Neuroblastic tumors are a broad biological and clinical spectrum of neoplastic disease that has long captured the attention of clinicians and scientists alike. It is the most common solid extracranial tumor in children and accounts for 8-10% of all childhood tumors. Tumors are derived from neural crest cells and neural differentiation is common. Neuroblastoma is unique in that it presents with at least three distinct patterns of disease. Locoregional disease (Stage 1, 2, 3) does not metastasize to bone or bone marrow. Stage 4 is a systemic disease with widespread metastasis that responds to chemotherapy but many develop resistance. Stage 4s presents in infancy, is widespread and can spontaneously regress with no intervention, leaving a focus of fibrosis or calcification. Prognosis correlates with age, stage and tumor biological profile. The goal of this review is to provide an overview of the disease and highlight diagnostic, prognostic and therapeutic advances in neuroblastoma. Recommendations and resources for the evaluation and treatment of this disease are outlined.

Reducing the morbidity from extravasation injuries

Extravasation is defined as the leakage of solutions from the vein. This may cause damage to surrounding tissue during intravenous fluid administration. Extravasation has an incidence of 5% of all cytotoxic drug administrations. In the authors' hospital, a protocol has been set up using the dilution flush-out technique. Extravasation packs containing cannulae, normal saline, hyaluronidase, and instructions on how to manage extravasation injuries, accompanied by an audit sheet to assist follow-up, have been introduced to allow the treatment of extravasation at the ward level in an attempt to reduce morbidity from the injury. Between December 1997 and December 1999, 18 adult patients were identified with extravasation injuries after the administration of cytotoxic medication. Seventeen were treated immediately according to the protocol. One, however, was not. Patients were followed-up for 6 months after injury. The 17 patients treated immediately needed no further surgical intervention, whereas the 1 patient not treated needed a split skin graft to cover the defect. The authors recommend the placement of "extravasation packs" on all wards where cytotoxic drugs are prescribed and that all staff members are familiar with this regime. These steps help to reduce the morbidity of a potentially damaging injury.

Anthracyclines in haematology: pharmacokinetics and clinical studies

The activity of anthracyclines in the treatment of a wide spectrum of haematological malignancies has long been established. Differences in the pharmacokinetic and pharmacodynamic properties of these drugs have resulted in the selection of individual compounds for particular indications while the recent reformulation of anthracyclines in liposomal preparations seems likely to significantly alter their range of activity and toxicity. The problems related to cumulative cardiotoxicity secondary to anthracycline exposure can be ameliorated by the use of dexrazoxane and a number of agents may prove to have a role in altering their cellular resistance to their cytotoxic actions.

Treatment recommendations for osteosarcoma and adult soft tissue sarcomas

During the past 20 years, dramatic improvements have been obtained in the treatment of localised osteosarcoma of the extremities, both in the rates of disease-free survival and in quality of life. Twenty years ago 80 to 90% of the patients died, in spite of mutilating surgery, but now about 75% survive and avoid the necessity of amputation. This is due to the introduction of very effective combined treatments, mostly also using preoperative chemotherapy. One of the major issues is that of intensive preoperative chemotherapy, which improves both limb salvage and survival. A multidisciplinary approach is necessary to obtain good results. When the role of adjuvant or neoadjuvant chemotherapy is not accurately defined for soft tissue sarcomas, particular emphasis is given to the staging of the diseases and to the important role of local treatment in the survival of these patients. A combination of radiation therapy and surgery is strongly recommended.

Extravasation injuries

The leakage of cytotoxic drugs, intravenous nutrition, solutions of calcium, potassium, bicarbonate and even 10% dextrose outside the vein into which they are delivered is known not only to cause skin necrosis but also to precipitate significant scarring around tendons, nerves and joints. In this review of 96 patients with extravasation injuries seen between 1987 and 1992 at St Thomas' Hospital, Mount Vernon Hospital and The Hospital for Sick Children, Great Ormond Street, several patients required extensive reconstruction and in some, despite this, extravasation injury has rendered a limb virtually useless. Two techniques, liposuction and saline flushout, are described to remove extravasated material while conserving the overlying skin. Analysis of flushout material confirmed that the extravasated material was actually being removed. Forty four of the study group in whom noxious materials were known to have extravasated underwent such early treatment. The results in this group were quite striking--the majority (86%) healed without any soft tissue loss at all. The early referral and treatment of extravasation injuries is, therefore, recommended.

Effect of captopril on the cytological and biochemical changes induced by adriamycin

Captopril, an angiotensin-converting enzyme inhibitor, was evaluated for its antimutagenic potential. Male Swiss albino mice (6-8 wk old) were treated orally with different doses of captopril dissolved in water for 7 days. Some of the mice in each group were injected ip with adriamycin (ADM; 15 mg/kg body weight) and killed after 30 hr. Femoral cells of mice were collected and studied for reduction of micronuclei. Proteins, RNA and DNA were determined in hepatic cells. Captopril pretreatment was found to reduce ADM-induced micronuclei in polychromatic cells and increase the quantity of protein, RNA and DNA in hepatic cells. The inhibition of clastogenicity observed may be due to free-radical scavenging action of captopril.

Inhibition of adriamycin-induced micronuclei by desferrioxamine in Swiss albino mice

Swiss albino male mice, 6-8 weeks old, were treated i.p. with different doses of desferrioxamine dissolved in water for 7 days. Some of the mice in each group were injected i.p. with adriamycin (15 mg/kg) and killed after 30 or 24, 48 and 72 h. The femoral cells of mice in different groups were collected and studied. Desferrioxamine treatment failed to affect the incidence of micronuclei at doses of 125-250 mg/kg/day. Pretreatment with desferrioxamine was found to provide significant protection against adriamycin-induced micronuclei without interfering with its cytotoxic potential.

Enhanced tumor targeting of doxorubicin by ganglioside GM1-bearing long-circulating liposomes

Doxorubicin (DXR) was encapsulated in long-circulating liposomes, composed of ganglioside GM1 (GM1)/distearoylphosphatidylcholine (DSPC)/cholesterol (CH) (0.13:1:1 in molar ratio) and sized to approximately 100 nm in mean diameter, with 98% entrapping efficiency by the transmembrane pH gradient method. Free DXR, DXR-DSPC/CH and DXR-GM1/DSPC/CH liposomes were injected intravenously into Colon 26 tumor-bearing Balb/c mice via the tail vein at a dose of 5.0 mg DXR/kg. DXR-GM1/DSPC/CH liposomes gave a higher blood level of the drug than did DXR-DSPC/CH liposomes or free DXR up to 24 hours after injection, and the area under the blood concentration-time curve (AUC) for DXR-GM1/DSPC/CH liposomes was 1.5 or 526 times higher than that for DXR-DSPC/CH liposomes or free DXR, respectively. DXR-GM1/DSPC/CH liposomes gave a decreased DXR concentration in the reticuloendothelial system (RES) of the liver and the spleen. Both liposomal formulations effectively reduced the DXR concentration in the heart as compared with that in the case of free DXR. At 6 hours after i.v. injection, DXR-GM1/DSPC/CH liposomes provided an approximately 3.3- or 9-fold higher peak DXR level in the tumor as compared with DXR-DSPC/CH liposomes or the free drug, respectively. These high tumor levels of DXR appear to reflect the prolonged residence time of the liposomes. The results suggest that encapsulation of DXR in GM1-bearing long-circulating liposomes will be useful for cancer chemotherapy.

DMSO protects against adriamycin-induced tissue necrosis

Inadvertent extravasation of Adriamycin (Adria) can result in severe tissue necrosis. The mechanism of this tissue damage is believed to be the release of free radicals into the tissue. Topical applications of dimethylsulfoxide (DMSO) used after Adria extravasation have been shown to decrease ulcer size. This may be due to DMSO's ability to scavenge free radicals. However, effective topical therapy requires prompt recognition of extravasation, which is often difficult. We hypothesized that the delivery of Adria in low concentrations DMSO would reduce Adria-induced ulcer size and ulcer incidence caused by Adria extravasation. To test this hypothesis, 180, male Sprague-Dawley rats were randomly allocated into three treatment groups of 60 each. All three groups received intradermal injections of Adria (1 mg) diluted in 0.5 cc of saline (Group 1), 10% DMSO (Group 2), or 20% DMSO (Group 3). Rats were observed for 4 weeks. Ulcer incidence (%) and size of ulcers (mm2) were assessed over time. Area of skin ulceration was calculated as the product of the two greatest diameters. Statistical evaluation of the differences in incidence and ulcer size between Group 1 and Groups 2 or 3 were evaluated using analysis of variance. Delivery of Adriamycin in 10 or 20% DMSO resulted in a statistically significant (P less than 0.001) decrease in the incidence of ulceration caused by intentional Adria extravasation.

Electrocardiographic changes and arrhythmias after cancer therapy in children and young adults

Transient electrocardiographic changes and arrhythmias are known to be acute manifestations of cardiotoxicity secondary to cancer therapy with anthracyclines or cardiac irradiation. However, despite the known risk of late cardiac dysfunction in survivors of childhood cancer therapy, the risk of clinically important electrocardiographic abnormalities and arrhythmias after treatment is unknown. Standard 12-lead and 24-hour ambulatory electrocardiograms were recorded in 73 patients who received anthracyclines alone, 24 who received cardiac irradiation alone, and 27 who received both anthracyclines and cardiac irradiation. The mean age of the patients was 15 years. Mean cumulative anthracycline dose was 282 mg/m2 in patients who received anthracyclines alone and 244 mg/m2 in patients who received both anthracyclines and cardiac irradiation. Analysis of the 12-lead and 24-hour electrocardiograms demonstrated increased frequency of QTc prolongation, supraventricular premature complexes, supraventricular tachycardia, ventricular premature complexes, couplets and ventricular tachycardia (all p less than 0.001) when compared with an age-matched healthy population. Most patients had abnormalities limited to single supraventricular or ventricular premature complexes; however, potentially serious ventricular ectopy, including ventricular pairs and ventricular tachycardia, were noted in patients with cumulative doses greater than 200 mg/m2. Electrocardiographic abnormalities and arrhythmias are not limited to the acute phase of treatment with anthracyclines and cardiac irradiation. Survivors of childhood malignancy who received anthracyclines or cardiac irradiation, or both, probably should undergo ambulatory electrocardiographic monitoring as part of their follow-up to detect potentially life-threatening arrhythmias.

Prevention of tissue necrosis due to accidental extravasation of cytostatic drugs by a conservative approach

The purpose of the present study was to evaluate comparatively the effectiveness of a conservative approach to treatment, using two therapeutic schedules (with and without sodium thiosulfate (ST), so as to minimize necrosis due to drug extravasation and to avoid the need for reconstructive surgery. The 63 patients entered into this study were separated into two groups; these in group A were treated with hydrocortisone and dexamethasone, and these in group B received the combination plus ST. In both groups, the drugs that had extravasated included doxorubicin, epirubicin, vinblastine, mitomycin C. The healing time varied with the different drugs used and was proportional to the extent of extravasation and to the time at which therapy was begun. The mean healing time for group B, which received ST was about half that for group A, which did not. We conclude that the application of conservative measures during chemotherapy may prevent tissue necrosis due to drug extravasation and the subsequent need for reconstructive surgery. The administration of ST can help in the achievement of this goal.

Clinical oncology: case presentations from oncology centres. 1. Ewing's sarcoma. The London Bone Tumour Service

The management of a case of Ewing's sarcoma of the left proximal humerus in a 15-year-old girl is presented, and the radiological and pathological findings are described. The chemotherapeutic, radiotherapeutic and surgical management of Ewing's sarcoma are discussed with reference to the case.

Chemistry and biology of alpha-fetoprotein

Alpha-Fetoprotein (AFP) is a product of specific fetal tissues and of neoplastic cells of hepatocyte or germ cell origin in adults. This protein belongs to a gene family that is phylogenetically most closely related to serum albumin. Its primary, secondary, and tertiary structural aspects appear similar to the three-domain concept proposed for the latter protein. The primary sequence of AFP departs most widely from serum albumin in the first 135 amino acid residues, with about 42% of the remaining 590 residues of the human proteins being identical. Some evidence exists that there are limited sequence differences in the AFP of a given animal species. AFP shows considerable charge heterogeneity that appears to relate mostly to its glycoid moiety. The proteins of some species such as the rat show more pronounced heterogeneities than that of humans. The variations in extent and type of glycosylations are evidenced by differences in the binding to various lectins. These interactions are being extensively explored in attempts to differentiate the sources of the protein produced by various normal and neoplastic cells and may provide valuable diagnostic methods. AFP, like serum albumin, shows relatively strong binding affinities for a variety of ligands. The most notable difference is the strong preferential binding of polyunsaturated fatty acids by AFP. This protein may play a role in transporting these substances to developing and to malignant cells. Various agents affect the synthesis of this protein both by specific fetal tissues and by neoplastic cells. Marked differences in the responses of cells, particularly those of neoplastic types, are indicative of variations in the genetic factors responsible for control of its synthesis. The subject of the genomic repression of the synthesis of AFP seen in fetal life upon maturation of the liver and the reoccurrence of synthesis upon malignant conversion of hepatocytes and of certain germ cells are of particular interest. The regulation of the closely related AFP and albumin genes is providing a powerful and attractive model to examine molecular events in the activation and inactivation of specific genes during development and in oncogenic processes. Extensive measurements of AFP during pregnancy and in the course of neoplasias, notably hepatoma, are being made to aid in following changes in such developments. Various specific physiological roles for this protein are also being proposed. One of these is its possible action in the regulation of immune processes.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of stabilization temperature on the degradation of adriamycin in albumin microspheres

The effect of stabilization temperature on the degradation of adriamycin HCl during the preparation of albumin microspheres was investigated. The degradation of adriamycin HCl by heating at various temperature with different time interval in dried adriamycin HCl powder, adriamycin HCl aqueous solution, wetted Adriablastina (adriamycin HCl with lactose) powder and Adriablastina aqueous solution was also studied. In the presence of water the degradation of adriamycin HCl was found; whereas, in the absence of water no degradation occurred. The degradation of adriamycin HCl in solution and wetted powder showed a zero order reaction. An increase in temperature increased degradation rate. The rate constant for adriamycin HCl degradation in Adriablastina solution obtained was in good agreement with that in adriamycin HCl solution. It was suggested that the presence of lactose had no interference in the degradation of adriamycin HCl. The zero-order reaction of degradation was attributed to the drug behaved like a suspension. The degradation of adriamycin HCl at various stabilization temperature during the preparation of microspheres had the same tendency as those of the adriamycin HCl solution and the wetted adriamycin HCl powder that were heated by the DSC instrument with the condition similar to the preparation of microspheres.

Cytotoxicity of chlorambucil and chlorambucil-fatty acid conjugates against human lymphomas and normal human peripheral blood lymphocytes

The cytotoxic activity of chlorambucil (Chl) and of chlorambucil-fatty acid conjugates of different degree of unsaturation have been assayed in vitro upon two human lymphoma cell lines and comparatively, upon quiescent and mitogen-activated lymphocytes from healthy blood donors. The cell toxicity observed with Chl-arachidonic acid and Chl-docosahexaenoic acid against lymphoma cells was, at any experimental condition used, equal or higher than the individual toxic potential of either chlorambucil or fatty acids. The two conjugates, like chlorambucil alone, were toxic against mitogen-activated lymphocytes. Contrary to chlorambucil, Chl-arachidonic at any concentration tested, lacked of toxicity towards normal non-activated lymphocytes. Chl-oleic acid conjugate was, whatever the cell species tested, much less toxic than Chl alone. In conclusion, the coupling of chlorambucil with polyunsaturated fatty acids increases: (a) the selectivity against neoplastic versus quiescent lymphocytes and (b) the toxicity for B-lymphoma cells. The selective effect of Chl-fatty acid conjugates is discussed in relation with the expression of an AFP/AFP-receptor autocrine system in malignant lymphoblastoid cells and in mitogen-activated lymphocytes.

Conservative approach to the treatment of chemotherapy-induced extravasation

One of the local complications of certain chemotherapeutic agents is tissue necrosis resulting from extravasation. The purpose of this study was to evaluate the effectiveness of a conservative approach to treatment in order to minimize necrosis and the need for reconstructive surgery. Fifty-three patients entered this study. Twenty-one had old lesions while 32 had recent extravasations. Drugs responsible for the extravasations were doxorubicin, epirubicin, vinblastine, mitoxantrone, and mitomycin C. The basis of treatment was betamethasone ointment, which was applied to the lesion with a tight elastic bandage and was replaced every 12 hours for the first 2 days and then every 24 hours until complete healing. For old lesions a keratolytic ointment was initially applied, whereas in the new lesions multiple subcutaneous injections with hydrocortisone solution preceded the application of betamethasone ointment. None of our patients developed tissue necrosis and sloughing that necessitated surgery. All lesions healed in patients. Healing time varied with the different drugs used and was proportional to the extension of extravasation and to the time when therapy was begun. We conclude that the application of conservative measures in extravasated areas from chemotherapy may avoid tissue necrosis and reconstructive surgery.