Comparison of Isogenic Strains Shows No Evidence of Altered Nosocomial Transmission-Competency of Rough, GPL-Negative Mycobacterium abscessus Strains

Mycobacterium abscessus is an emerging pathogen causing severe pulmonary infections. While environmental in origin, in the clinical setting M. abscessus often changes to a Rough phenotype associated with severe non-remitting infections. Clinical isolates baring mutations in glycopeptidolipid-synthesis genes, leading to the Rough phenotype, were suggested to have increase bacterial virulence while possibly showing reduced transmissibility on fomites. We set to determine whether an isolated glycopeptidolipid (GPL) defect affects transmissibility. We used transposon technology to create a fully isogenic Rough (GPL-defective) (Tn_4099c) and compare it to the isogenic parent strain (ATCC 19977). Survival on fomites was determined by spotting, drying, and retrieving the isolates at designated time points. This was repeated as a competition experiment using a mixture of differentially fluorescent M. abscessus 19977 (Smooth) and the Tn_4099c mutant (Rough). Survival ability in chlorhexidine solution (Septal Scrub Teva) was performed using a disinfectant killing-assay for mycobacteria. Despite significant bacterial killing in all assays, we found no survival advantage to either GPL-defected Rough or GPL-reserved Smooth morphotype-both on fomites and in chlorhexidine. Our findings suggest that while transmission fitness may be altered due to some within-host evolutionary changes, decreased transmissibility of clinical strains cannot be attributed to the GPL-synthesis defect alone. Further studies are needed to determine the effect of other mutations on the transmission potential of M. abscessus in the clinical setting. IMPORTANCE Mycobacterium abscessus is an emerging pathogen causing severe pulmonary infections. In the clinical setting, M. abscsssus undergoes molecular and genetic changes associated with increased virulence. Specifically, bacterial defects in glycopeptidolipid (GPL) synthesis, creating the "Rough" colony phenotype, have been associated with increased virulence, yet were also presumably observed to have decreased survival on fomites, leading to reduced transmissibility. We set to determine whether GPL-synthesis defects are indeed responsible for reduced transmissibility of clinical isolates. We compared fully isogenic GPL-disrupted versus GPL-preserved strains, and demonstrated no survival advantage for either strain on fomites. Additionally, neither isolate had a survival advantage in chlorhexidine, a widely used disinfectant in health care settings. Our findings suggest that reduced transmissibility of clinical isolates, should it be found, cannot be attributed to GPL-synthesis mutations. While clinical isolates may show changes in transmission potential, more studies are needed to investigate the mechanisms leading to these phenotypic changes.

EttA is likely non-essential in Staphylococcus aureus persistence, fitness or resistance to antibiotics

Background

Tolerance to antibiotics and persistence are associated with antibiotic treatment failures, chronic-relapsing infections, and emerging antibiotic resistance in various bacteria, including Staphylococcus aureus. Mechanisms of persistence are largely unknown, yet have been linked to physiology under low-ATP conditions and the metabolic-inactive state. EttA is an ATP-binding cassette protein, linked in Eschrechia coli to ribosomal hibernation and fitness in stationary growth phase, yet its role in S. aureus physiology is unknown.

Results

Using whole genome sequencing (WGS) of serial clinical isolates, we identified an EttA-negative S. aureus mutant (ettA^stop), and its isogenic wild-type counterpart. We used these two isogenic clones to investigate the role of ettA in S. aureus physiology in starvation and antibiotic stress, and test its role in persistence and antibiotic tolerance. ettA^stop and its WT counterpart were similar in their antibiotic resistance profiles to multiple antibiotics. Population dynamics of ettA^stop and the WT were similar in low-nutrient setting, with similar recovery from stationary growth phase or starvation. Supra-bacteriocidal concentration of cefazolin had the same killing effect on ettA^stop and WT populations, with no difference in persister formation.

Conclusions

Lack of ettA does not affect S. aureus antibiotic resistance, beta-lactam tolerance, resilience to starvation or fitness following starvation. We conclude the role of ettA in S. aureus physiology is limited or redundant with another, unidentified gene. WGS of serial clinical isolates may enable investigation of other single genes involved in S. aureus virulence, and specifically persister cell formation.

Small bowel faeces sign in patients without small bowel obstruction

AIM

To evaluate frequency and clinical relevance of the 'small bowel faeces' sign (SBFS) on computed tomography (CT) in patients with and without small bowel obstruction (SBO) presenting with acute abdominal or acute abdominal and flank pain.

METHODS

Abdominal CTs of consecutive patients presenting to the emergency department with abdominal or flank pain over a 6 month period were retrospectively reviewed by six radiologists, independently, for the presence of the SBFS. Examinations with positive SBFS were further evaluated in consensus by three radiologists, blinded to the final diagnosis. The small bowel was graded as non-dilated (<2.5 cm) and mildly (2.5-2.9 cm), moderately (3-4 cm) or severely (>4 cm) dilated. The location of SBFS and presence of distal small bowel collapse indicative of SBO was recorded. Imaging findings were subsequently correlated with the final diagnosis via chart review and compared between patients with and without SBO.

RESULTS

Of 1642 CT examinations, a positive SBFS was found in 100 (6%) studies. Of 100 patients with a positive SBFS, 32 (32%) had documented SBO. The remaining 68 patients had other non-obstructive diagnoses. SBFS was located in proximal, central, distal and multisegmental bowel loops in one (3.1%), eight (25.0%), 21 (65.6%) and two (6.3%) patients with SBO, and in zero (0%), 10 (14.7%), 53 (77.9%) and five (7.4%) of patients without SBO (p<0.273). The small bowel was non-dilated and mildly, moderately or severely dilated in one (3%), five (16%), 20 (62%) and six (19%) patients with SBO, and in 61(90%), seven (10%), zero (0%) and zero (0%) patients without SBO. Normal or mildly dilated small bowel was seen in all (100%) patients without SBO, but only in six (19%) of 32 patients with SBO (p<0.0001). Moderate or severe small bowel dilatation was seen in 26 (81%) patients with SBO (p<0.0001), but it was absent in patients without SBO. Distal small bowel collapse was found in 27 (84.4%) of 32 patients with SBO, but not in patients without SBO (p<0.0001). A combination of SBFS, moderate or severe small bowel distension and distal collapse was found in 23 (71.9%) patients with SBO (p<0.0001), but was not found in patients without SBO.

CONCLUSION

A SBFS is more frequent in patients presenting with acute abdominal/flank pain without bowel obstruction. When seen in association with moderate or severe small bowel dilatation, a SBFS is significantly more common in patients with SBO. When a SBFS is associated with normal or mildly dilated small bowel, the majority of patients have no bowel obstruction.

Sequential phase II trials of fluorouracil and interferon beta ser with or without sargramostim in patients with advanced colorectal carcinoma

BACKGROUND

Preclinical and early clinical trials suggested that the biologic agent interferon beta ser (IFN beta ser) may augment the anticancer activity of 5-fluorouracil (5-FU). The current studies were undertaken to explore the optimal schedule of IFN beta ser and to determine whether the hematopoietic growth factor sargramostim (granulocyte-macrophage colony-stimulating factor) could reduce the hematologic and gastrointestinal toxicities of the chemotherapy.

METHODS

Three sequential, single-institution phase II trials using different regimens were initiated. Patients were required to have advanced, histologically documented colorectal carcinoma with no prior chemotherapy; to have adequate bone marrow, renal, and hepatic function; to be fully ambulatory; and to give informed consent. All patients received 5-FU, 750 mg/m2 intravenously as an infusion daily for 5 days, followed by 5-FU, 750 mg/m2, as an intravenous bolus every week beginning day 15. Patients in arm A received IFN beta ser, 9 MU subcutaneously, three times a week. Patients in arm B received IFN beta ser, 9 MU subcutaneously every day. Patients in arm C were treated exactly as in arm B but also received sargramostim, 250 micrograms subcutaneously on days they did not receive 5-FU. Beginning day 15, all patients received IFN beta ser exactly 10 minutes before receiving the 5-FU bolus.

RESULTS

There were 81 patients enrolled: 19 in arm A; 40 in arm B; and 22 in arm C. Myelosuppression and diarrhea were the most common toxicities. Increasing the frequency of IFN beta ser administration in arm B resulted in a doubling of the rate of diarrhea from 11% to 22%, and the addition of sargramostim in arm C failed to reduce this. Sargramostim did reduce the incidence of grade 3 to 4 leukopenia, but this did not allow intensification of dosing or result in improved response or survival among patients in arm C. IFN-mediated fatigue was also common, occurring in 37% to 43% of patients. Patients receiving IFN beta ser on the intermittent schedule tolerated full-dose therapy longer than those on the daily schedule (10 weeks versus 5 weeks, P < 0.01). The response rates in the three arms were 21%, 35%, and 27%; there was no difference in median survival (15 months for all three arms).

CONCLUSIONS

The combination of 5-FU and IFN beta ser was active in patients with advanced colorectal carcinoma, and survival with this regimen was comparable to or better than that with other modulating regimens. The intermittent schedule of IFN beta ser was better tolerated than than the daily schedule.

Endoleaks after endovascular graft treatment of aortic aneurysms: classification, risk factors, and outcome

PURPOSE

Incomplete endovascular graft exclusion of an abdominal aortic aneurysm results in an endoleak. To better understand the pathogenesis, significance, and fate of endoleaks, we analyzed our experience with endovascular aneurysm repair.

METHODS

Between November 1992 and May 1997, 47 aneurysms were treated. In a phase I study, patients received either an endovascular aortoaortic graft (11) or an aortoiliac, femorofemoral graft (8). In phase II, procedures and grafts were modified to include aortofemoral, femorofemoral grafts (28) that were inserted with juxtarenal proximal stents, sutured endovascular distal anastomoses within the femoral artery, and hypogastric artery coil embolization. Endoleaks were detected by arteriogram, computed tomographic scan, or duplex ultrasound. Classification systems to describe anatomic, chronologic, and physiologic endoleak features were developed, and aortic characteristics were correlated with endoleak incidence.

RESULTS

Endoleaks were discovered in 11 phase I patients (58%) and only six phase II patients (21%; p < 0.05). Aneurysm neck lengths 2 cm or less increased the incidence of endoleaks (p < 0.05). Although not significant, aneurysms with patent side branches or severe neck calcification had a higher rate of endoleaks than those without these features (47% vs 29% and 57% vs 33%, respectively), and patients with iliac artery occlusive disease had a lower rate of endoleaks than those without occlusive disease (18% vs 42%). Endoleak classifications revealed that most endoleaks were immediate, without outflow, and persistent (71% each), proximal (59%), and had aortic inflow (88%). One patient with a persistent endoleak had aneurysm rupture and died.

CONCLUSIONS

Endoleaks complicate a significant number of endovascular abdominal aortic aneurysm repairs and may permit aneurysm growth and rupture. The type of graft used, the technique of graft insertion, and aortic anatomic features all affect the rate of endoleaks. Anatomic, chronologic, and physiologic classifications can facilitate endoleak reporting and improve understanding of their pathogenesis, significance, and fate.

Imaging of the vascular system for endovascular grafting and other procedures

Success of endovascular therapy largely depends on accurate imaging before, during, and after the procedure. The vascular system can be evaluated noninvasively with computed tomography (CT), magnetic resonance (MR) imaging, and duplex ultrasound (US), or invasively with angiography and intravascular ultrasonography (IVUS). Noninvasive methods are preferred for both preprocedure screening and postprocedure follow-up, whereas invasive imaging modalities constitute an essential part of the endovascular procedure. Invasive techniques are also used in preprocedural or postprocedural evaluation when noninvasive methods are unable to obtain important diagnostic information, or when the confirmation of noninvasive imaging findings is desired. Specific roles of these modalities for endovascular treatment of aortoiliac aneurysms are discussed.

Evolution of the infected abdominal aortic aneurysm: CT observation of early aortitis

Infected aortic aneurysm is an uncommon, life-threatening disease. Early surgical treatment is crucial to survival. An early diagnosis could be made on CT in suspected cases, although CT features of infectious aortitis overlap with retroperitoneal fibrosis, hemorrhage, and lymphadenopathy. We report the case of an infected abdominal aortic aneurysm and describe the additional potentially useful CT finding of early infectious aortitis, which helps localize the abnormality to the aortic wall.

Cystic adrenal lesions: CT features

PURPOSE

To define computed tomographic (CT) features of cystic adrenal lesions that differentiate them from similar-appearing adenoma.

MATERIALS AND METHODS

CT scans of 13 cystic adrenal lesions (four endothelial cysts, three benign pseudocysts, one nonspecific benign cyst, one carcinoma, one pheochromocytoma, and three stable lesions with no histologic diagnosis) were analyzed retrospectively. Reports in the literature of 26 benign adrenal cysts were also reviewed.

RESULTS

Mean lesion diameter was 6.2 cm, and six lesions were less than 5.0 cm. Mean attenuation values was 21 HU, and in eight cases it was less than 15 HU. Partial adrenal involvement was noted in six cases. Ten lesions contained wall or septal calcification. Wall thickness was 3 mm or less in nine and exceeded 6 mm in three lesions; one of the latter was cystic carcinoma. Wall enhancement (but no intralesional enhancement) was found in two of six lesions. Of 37 reviewed benign cysts, 19 had mural and seven had central calcification, 28 were unilocular, and seven had high attenuation value. Wall thickness was 3 mm or less in 31 lesions.

CONCLUSION

CT findings of a nonenhancing mass with or without wall calcification allow differentiation of adrenal cyst from adenoma. A small adrenal cyst with near-water attenuation and a thin (< or = 3-mm) wall is likely to be benign.

Differential density of normal renal parenchyma on nonenhanced CT: a new observation

PURPOSE

Nonenhanced CT scans through the kidneys commonly show a difference in radiopacity between the inner peripelvic portion of the renal parenchyma and the more peripheral regions of the renal parenchyma. This normal observation has not been described.

METHOD

We reviewed 50 nonenhanced CT scans. Renal parenchyma was evaluated by both visual inspection and density measurements of inner and outer aspects of the kidneys in 38 and visual inspection only in 12. A narrower window was used to better show density differences (100 W, 35 L). We recorded the indication for the CT, history, and recent blood chemistries.

RESULTS

The inner parenchyma was of greater radiopacity than the outer parenchyma in 35 of 50 cases by visual inspection and in all densitometry cases (38 of 38). There was no correlation with clinical history or blood chemistry.

CONCLUSION

A difference in density between the inner and outer portions of the renal parenchyma is very common and will often be seen if one looks for it. We have not shown an etiology for this difference, and indeed, it may be physiological. One must be aware of this finding to avoid mistaking it for pathology.

Phase II trial of N-(phosphonacetyl)-L-aspartate (PALA), 5-fluorouracil and recombinant interferon-alpha-2b in patients with advanced gastric carcinoma

The aspartate transcarbamoylase inhibitor, N-(phosphonacetyl)-L-aspartate (PALA), synergistically enhanced the cytotoxicity of a combination of 5-fluorouracil (5-FU) and interferon-alpha (IFN) against human colon cancer cell lines in vitro. To test the efficacy of this combination in the clinical setting, patients with locally advanced or advanced gastric carcinoma were treated with the combination of PALA, 5-FU and IFN (PFI). Patients were required to have biopsy-proven disease beyond the scope of surgical resection, measurable disease, no prior chemotherapy, adequate bone marrow, renal and hepatic function, to be fully ambulatory and to have given informed consent. Drug was administered as follows: PALA, 250 mg/m2, 15 min i.v. infusion, days 1, 15, 22, 29, and then weekly; 5-FU, 750 mg/m2 daily x 5 as a continuous i.v. infusion beginning day 2, then at 750 mg/m2 days 16, 23 and 30, then weekly; IFN, 9 MU subcutaneously three times per week beginning day 2. There were 22 patients enrolled. The major toxicities were fatigue and associated neurotoxicity, with acceptable gastrointestinal and haematological toxicities. There was one complete responder (5%) and 3 partial responders (14%); two of these responses were durable (> 3 years). Despite this modest clinical activity, other regimens for advanced gastric cancer such as FAMTX and ELF appear to have greater activity with comparable toxicity.

Testicular feminization: radiologic considerations in a unique form of cryptorchidism

A case report of complete testicular feminization is presented. The medical and radiological characteristics of this condition which distinguish it from male cryptorchidism and other disorders of sexual differentiation are discussed. To our knowledge, only three previous case reports have been published in the radiology literature. Our report is the first to describe MRI findings.

Endoluminal therapy with endovascular grafts

The addition of balloon-expandable stents to conventional graft material allows minimally invasive repair of aortic and other aneurysms, arterial occlusions, and arterial trauma. Vascular access can be made at a site far from the pathology.

Endovascular repair of abdominal aortic aneurysm: value of postoperative follow-up with helical CT

OBJECTIVE

Transfemorally placed endoluminal grafts are currently being evaluated as an alternative to open surgery for the treatment of abdominal aortic aneurysms. We determined the value of helical CT for the follow-up of patients treated with this new procedure. The purposes of this study were to determine CT features of a technically successful procedure, detect complications, and compare findings on CT scans obtained 24-48 hr after insertion of the graft with findings on angiograms obtained at the end of the endovascular procedure.

SUBJECTS AND METHODS

Seven patients with large abdominal aortic aneurysms had helical CT within 48 hr after transfemoral insertion of an endoluminal graft. Findings on these CT scans were compared with findings on digital completion angiograms obtained immediately after placement of the graft. Additional follow-up CT scans were obtained for up to 15 months (mean, 8 months). The size of the aneurysmal sac; completeness of perigraft thrombosis; and position, shape, and patency of the device were recorded.

RESULTS

CT scans obtained 24-48 hr after placement of the grafts showed complete thrombosis of the aneurysmal sac in three patients and incomplete thrombosis with patent perigraft channels in the four remaining patients. Angiograms showed a patent perigraft channel in only one patient. Two of four initially patent channels subsequently closed, but one of them recurred. Of four thrombosed aneurysms, two decreased in size, and two were unchanged on later follow-up. Of three aneurysms associated with perigraft channels, two became enlarged and one was stable. On the basis of CT criteria, successful endovascular repair was shown in four (57%) of seven patients.

CONCLUSION

Helical CT is a sensitive means of evaluating the efficacy of endoluminal grafts. Decreased or stable size of the aneurysmal sac without perigraft channels on late follow-up CT signifies technical success. Persistence or recurrence of perigraft channels is the most likely cause of later enlargement of an aneurysm and therefore suggests procedural failure. Helical CT was more sensitive than angiography for detection of perigraft channels that occurred soon after treatment.

Audiological findings in a Phase I protocol investigating the effect of WR 2721, high-dose cisplatin and radiation therapy in patients with locally advanced cervical carcinoma

WR 2721 (ethiofos) protects against the toxic effects of the heavy metal compound cisplatin, which is used in the treatment of solid tumours. In a Phase I protocol designed to determine the maximum dose of WR 2721 which could be tolerated when administered in combination with cisplatin and radiation therapy to patients with cervical carcinoma, 11 patients were evaluated by audiologic testing before and after cisplatin WR 2721 administration in an attempt to identify the degree of ototoxicity. Forty-five per cent were noted to have significant hearing threshold changes, predominantly in the high frequencies. There were no significant changes in the speech frequencies in this series. This contrasts with the greater degrees of ototoxicity observed in controls treated in the same way who received cisplatin without WR 2721 protection.

Phase II trial of chemotherapy, external and intraluminal radiation plus surgery for oesophageal cancer

A pilot study was performed to assess the feasibility of combining 5-fluorouracil, recombinant alpha-2b-interferon, external radiation therapy and intraluminal high dose rate brachytherapy with surgery in patients with locally advanced esophageal carcinoma. 5-fluorouracil, 750 mg m-2, was administered via continuous 5-day infusion beginning day 1 and weekly thereafter; interferon, 10 mu subcutaneously, was administered three times per week beginning day 1 and sargramostin, 5 micrograms kg-1, was administered on days without 5-fluorouracil. External radiation began on day one using 1.5 daily fractions to 55.5 Gy. Intraluminal brachytherapy was delivered concomitantly once each week for 5 fractions of 4 Gy. None of the first eight patients went to surgery. The external radiation was changed to 1.5 Gy BID to 45 Gy followed by BID intraluminal radiation to 15 Gy. Of the last four patients, there was one case of radiation myelitis. It was found that successful surgery was not possible and excessive toxicities, including radiation myelitis, occurred with this aggressive regimen.

Phase I trial of high-dose infusional hydroxyurea, high-dose infusional 5-fluorouracil and recombinant interferon-alpha-2a in patients with advanced malignancies

The ribonucleotide reductase inhibitor, hydroxyurea (HU), augments the cytotoxic effects of 5-fluorouracil (5FU) in vitro; both drugs are synergistic with interferon-alpha (IFN) in vitro. The aim of this phase I study was to determine the maximal duration of HU, 4.3 g/m2, administered as a parenteral infusion in combination with 5FU, 2.6 g/m2 administered over 24 hrs each week, + IFN, 9 MU, subcutaneously three times per week. There were 26 patients enrolled and evaluable. This included 14 patients with colorectal cancer of whom 13 had been previously treated, and 12 patients with other refractory malignancies (pancreas, cholangiocarcinoma, hepatocellular carcinoma, renal cell carcinoma, and others), of whom 10 were previously untreated. The dose-limiting toxicity of this regimen was myelosuppression. This prohibited dose escalation of HU above the starting dose (24 hrs) on a 6-weeks-on, 2-weeks-off therapy schedule. When filgrastim, 480 microg, was administered subcutaneously on days 3-6, the duration of HU could be extended to 48 hrs on a 2-weeks-on, 1-week-off therapy schedule. There were two instances of fatal infection, one in a patient with a rectovaginal fistula with neutropenic sepsis and the second in a patient with non-neutropenic Clostridium septicum sepsis. All therapy was administered in the ambulatory setting. There were three responders, all among previously untreated patients. High-dose parenteral hydroxyurea, 4.3 g/m2 administered over 24 hrs, can be safely combined with high-dose weekly 5FU, 2.6 g/m2 over 24 hrs + IFN, 9 MU subcutaneously three times per week, without filgrastim in the ambulatory setting. Parenteral hydroxyurea, 4.3 g/m2 over 24 hrs daily x 2 can also be combined with high-dose 5FU + IFN, but requires the addition of filgrastim to avoid severe myelosuppression.

Utility of embolization or chemoembolization as second-line treatment in patients with advanced or recurrent colorectal carcinoma

BACKGROUND

Second-line therapy of patients with colorectal cancer metastatic to the liver is unsatisfactory. One alternative to systemic treatment is therapy directed locoregionally.

METHODS

Twenty-four patients with unresectable colorectal cancer with bulky liver metastases who had failed prior systemic therapy were randomized to treatment with either embolization or chemoembolization. For the embolization group, particulate transcatheter polyvinyl alcohol (PVA) (150-250-microns particles) mixed with full-strength iodinated radiographic contrast was administered under direct fluoroscopic control. In patients randomized to chemoembolization, 5-fluorouracil (750 mg/m2) and recombinant alpha-2a-interferon (Roche Laboratories, Nutley, NJ) (9-MU) were thoroughly mixed into the PVA contrast suspension. Study end points were response to therapy and survival.

RESULTS

Of 24 patients, 13 were randomized to chemoembolization and 11 to embolization therapy. All were assessable for toxicity, response, and complications. Among the first 13 patients treated initially, a suppurative abscess developed in one patient, who died. Eleven subsequent patients were pretreated with oral and intravenous antibiotics without further infectious complications. Five patients had hemorrhagic complications, two of which were serious. The treatment was otherwise well tolerated, with most patients experiencing transient pain, fevers, and elevations in leukocyte counts and liver enzymes, which resolved spontaneously. Computed tomography scans of the liver were used to assess patient response to therapy. There were 6 responders (25%) among the 24 patients treated. No differences in response to treatment or survival between the embolization and chemoembolization groups were noted. With a median follow-up of more than 12 months, the median survival was 9.3 months from the time of embolization therapy.

CONCLUSIONS

Embolization and chemoembolization therapy appear to have antitumor activity as second-line therapy in patients with colorectal carcinoma with bulky liver metastases. Although generally well tolerated, complications of this therapy may be severe. The addition of further patients to this trial will allow a rigorous comparison of embolization alone versus embolization with chemotherapy.

Phase II trial of echinomycin in patients with advanced or recurrent colorectal cancer

Echinomycin is a novel bifunctional intercalating agent derived from Streptomyces echinatus. A phase II clinical trial of echinomycin in patients with advanced, measurable colorectal cancer was initiated to determine the efficacy and toxicities of this agent. Echinomycin, 1.5 mg/m2, was given initially as a 30- to 60-min infusion every 4 weeks. After 4 episodes of anaphylaxis had occurred among the first 14 patients, the schedule was changed to a 24-h infusion, and an additional 16 patients were treated on this schedule. Treatment was given every 3 weeks. A total of 30 patients were eligible and evaluable; there were 3 (10%; 90% confidence interval, 3%-23%) clinical responses lasting 3, 3+, and 12 months, respectively. The most serious toxicity encountered was anaphylaxis, which occurred in 5 patients, although with no serious sequelae. A premedication regimen with dexamethasone, diphenhydramine, and cimetidine and a change of the duration of the infusion to 24 h reduced the incidence of this complication. Grade 2-3 vomiting occurred among earlier patients treated; however, with the 24-h schedule this toxicity was substantially reduced. The sole important case of hematologic toxicity was a single patient with grade 3 thrombocytopenia. Echinomycin employed in this dose and schedule had modest activity against colorectal cancer, comparable with that observed with 5-fluorouracil. Further studies in patients with gastrointestinal malignancies using a 24-h infusion with a dexamethasone premedication regimen similar to that employed prior to administration of taxol may be warranted.

Phase II trial of echinomycin in patients with advanced or recurrent colorectal cancer

Echinomycin is a novel bifunctional intercalating agent derived from Streptomyces echinatus. A phase II clinical trial of echinomycin in patients with advanced, measurable colorectal cancer was initiated to determine the efficacy and toxicities of this agent. Echinomycin, 1.5 mg/m2, was given initially as a 30- to 60-min infusion every 4 weeks. After 4 episodes of anaphylaxis had occurred among the first 14 patients, the schedule was changed to a 24-h infusion, and an additional 16 patients were treated on this schedule. Treatment was given every 3 weeks. A total of 30 patients were eligible and evaluable; there were 3 (10%; 90% confidence interval, 3%-23%) clinical responses lasting 3, 3+, and 12 months, respectively. The most serious toxicity encountered was anaphylaxis, which occurred in 5 patients, although with no serious sequelae. A premedication regimen with dexamethasone, diphenhydramine, and cimetidine and a change of the duration of the infusion to 24 h reduced the incidence of this complication. Grade 2-3 vomiting occurred among earlier patients treated; however, with the 24-h schedule this toxicity was substantially reduced. The sole important case of hematologic toxicity was a single patient with grade 3 thrombocytopenia. Echinomycin employed in this dose and schedule had modest activity against colorectal cancer, comparable with that observed with 5-fluorouracil. Further studies in patients with gastrointestinal malignancies using a 24-h infusion with a dexamethasone premedication regimen similar to that employed prior to administration of taxol may be warranted.

Pilot trial of cisplatin, radiation, and WR2721 in carcinoma of the uterine cervix: a New York Gynecologic Oncology Group study

PURPOSE

A phase I trial of WR2721 was initiated to determine the maximal safe dose for incorporation into a consecutive 5-day schedule of cisplatin administered concurrently with radiation therapy in patients with cervical cancer.

PATIENTS AND METHODS

WR2721 was administered at 340 to 910 mg/m2/d immediately before cisplatin. Cisplatin was administered at 20 mg/m2/d for 5 days every 3 weeks in combination with external-beam radiation therapy and at 100 mg/m2 after each brachytherapy treatment. Pelvic radiation consisted of external-beam therapy to a dose of 39.6 Gy, followed by brachytherapy with cesium 137 tandem and ovoid insertions to deliver 80 Gy to point A and 55 Gy to point B.

RESULTS

Twenty patients were enrolled; 19 were assessable. The dose-limiting toxicity of WR2721 was hypotension. No patients developed serious sequelae, but hypotension required a reduction in the dose of WR2721 at the highest dose level tested. The major grade 3 or 4 toxicities included transient azotemia (five of 19), leukopenia (nine of 19), vomiting (four of 19), and neurotoxicity (two of 19). One patient experienced an anaphylactic reaction to cisplatin.

CONCLUSION

The recommended dose of WR2721 administered in conjunction with cisplatin on a daily x 5 schedule plus radiation therapy is 825 mg/m2/d for 5 days.

Treatment of carcinoma of the esophagus with 5-fluorouracil and recombinant alfa-2a-interferon

BACKGROUND

Combinations of 5-fluorouracil (5FU) and recombinant alfa-2a-interferon (IFN) are synergistic in vitro and have demonstrated activity in colorectal carcinoma, renal cell carcinoma, and urothelial tumors.

METHODS

A Phase II trial of the combination of 5FU, 750 mg/m2 daily x 5 followed by weekly bolus therapy, and IFN, 9 MU subcutaneously three times per week, was initiated in patients with esophageal carcinomas. Patients were required to have biopsy-proven squamous cell or adenocarcinoma of the esophagus, locally advanced or metastatic disease beyond the scope of surgical resection, and adequate performance status, renal, hepatic, and bone marrow function.

RESULTS

Twenty-one patients were enrolled; one patient was inevaluable for response because he had received prior chemotherapy, but was evaluated for toxicity. Eleven patients had metastatic disease, and 10 had locally advanced disease. Thirteen patients had squamous cell carcinoma and 8 adenocarcinoma. Toxicities were acceptable with no serious diarrhea and only two cases of serious stomatitis, although a greater than expected incidence of neurologic toxicity was observed. There were five responders (25%) including two patients with advanced or locally advanced disease rendered pathologically free of disease. One patient, initially considered surgically unresectable, was able to undergo a total thoracic esophagectomy after responding to treatment with 5FU/IFN, at which time only a single microscopic focus of carcinoma in situ was found. She remains alive and free of disease at 18+ months. A second patient who presented with metastatic disease and nearly complete obstruction of the esophagus regained normal swallowing function after treatment with 5FU/IFN; rebiopsy of all lesions revealed the patient to be pathologically free of disease. He survived over 2 years.

CONCLUSIONS

This regimen employing a single cytotoxic agent has activity in esophageal carcinoma. Strategies employing biochemical modulation deserve additional investigation in the treatment of esophageal carcinoma.

An unusual angiographic appearance of aorto-iliac disease presenting as the Leriche syndrome

An unusual angiographic presentation of Leriche syndrome is described that demonstrates short segment occlusions of iliac arteries with bilaterally symmetrical post-stenotic dilatations.