Treatment discontinuation following low-dose TKIs in 248 chronic myeloid leukemia patients: Updated results from a campus CML real-life study

TKIs long-term treatment in CML may lead to persistent adverse events (AEs) that can promote relevant morbidity and mortality. Consequently, TKIs dose reduction is often used to prevent AEs. However, data on its impact on successful treatment-free remission (TFR) are quite scarce. We conducted a retrospective study on the outcome of CML subjects who discontinued low-dose TKIs from 54 Italian hematology centers participating in the Campus CML network. Overall, 1.785 of 5.108 (35.0%) regularly followed CML patients were treated with low-dose TKIs, more frequently due to relevant comorbidities or AEs (1.288, 72.2%). TFR was attempted in 248 (13.9%) subjects, all but three while in deep molecular response (DMR). After a median follow-up of 24.9 months, 172 (69.4%) patients were still in TFR. TFR outcome was not influenced by gender, Sokal/ELTS risk scores, prior interferon, number and last type of TKI used prior to treatment cessation, DMR degree, reason for dose reduction or median TKIs duration. Conversely, TFR probability was significantly better in the absence of resistance to any prior TKI. In addition, patients with a longer DMR duration before TKI discontinuation (i.e., >6.8 years) and those with an e14a2 BCR::ABL1 transcript type showed a trend towards prolonged TFR. It should also be emphasized that only 30.6% of our cases suffered from molecular relapse, less than reported during full-dose TKI treatment. The use of low-dose TKIs does not appear to affect the likelihood of achieving a DMR and thus trying a treatment withdrawal, but might even promote the TFR rate.

Sirolimus-based graft-versus-host disease prophylaxis promotes the in vivo expansion of regulatory T cells and permits peripheral blood stem cell transplantation from haploidentical donors

Hematopoietic stem cell transplantation (HSCT) from human leukocyte antigen (HLA) haploidentical family donors is a promising therapeutic option for high-risk hematologic malignancies. Here we explored in 121 patients, mostly with advanced stage diseases, a sirolimus-based, calcineurin-inhibitor-free prophylaxis of graft-versus-host disease (GvHD) to allow the infusion of unmanipulated peripheral blood stem cell (PBSC) grafts from partially HLA-matched family donors (TrRaMM study, Eudract 2007-5477-54). Conditioning regimen was based on treosulfan and fludarabine, and GvHD prophylaxis on antithymocyte globulin Fresenius (ATG-F), rituximab and oral administration of sirolimus and mycophenolate. Neutrophil and platelet engraftment occurred in median at 17 and 19 days after HSCT, respectively, and full donor chimerism was documented in patients' bone marrow since the first post-transplant evaluation. T-cell immune reconstitution was rapid, and high frequencies of circulating functional T-regulatory cells (Treg) were documented during sirolimus prophylaxis. Incidence of acute GvHD grade II-IV was 35%, and occurrence and severity correlated negatively with Treg frequency. Chronic GvHD incidence was 47%. At 3 years after HSCT, transpant-related mortality was 31%, relapse incidence 48% and overall survival 25%. In conclusion, GvHD prophylaxis with sirolimus-mycophenolate-ATG-F-rituximab promotes a rapid immune reconstitution skewed toward Tregs, allowing the infusion of unmanipulated haploidentical PBSC grafts.

Phase 3 randomized trial on larynx preservation comparing sequential vs alternating chemotherapy and radiotherapy

BACKGROUND

Both induction chemotherapy followed by irradiation and concurrent chemotherapy and radiotherapy have been reported as valuable alternatives to total laryngectomy in patients with advanced larynx or hypopharynx cancer. We report results of the randomized phase 3 trial 24954 from the European Organization for Research and Treatment of Cancer.

METHODS

Patients with resectable advanced squamous cell carcinoma of the larynx (tumor stage T3-T4) or hypopharynx (T2-T4), with regional lymph nodes in the neck staged as N0-N2 and with no metastasis, were randomly assigned to treatment in the sequential (or control) or the alternating (or experimental) arm. In the sequential arm, patients with a 50% or more reduction in primary tumor size after two cycles of cisplatin and 5-fluorouracil received another two cycles, followed by radiotherapy (70 Gy total). In the alternating arm, a total of four cycles of cisplatin and 5-fluorouracil (in weeks 1, 4, 7, and 10) were alternated with radiotherapy with 20 Gy during the three 2-week intervals between chemotherapy cycles (60 Gy total). All nonresponders underwent salvage surgery and postoperative radiotherapy. The Kaplan-Meier method was used to obtain time-to-event data.

RESULTS

The 450 patients were randomly assigned to treatment (224 to the sequential arm and 226 to the alternating arm). Median follow-up was 6.5 years. Survival with a functional larynx was similar in sequential and alternating arms (hazard ratio of death and/or event = 0.85, 95% confidence interval = 0.68 to 1.06), as were median overall survival (4.4 and 5.1 years, respectively) and median progression-free interval (3.0 and 3.1 years, respectively). Grade 3 or 4 mucositis occurred in 64 (32%) of the 200 patients in the sequential arm who received radiotherapy and in 47 (21%) of the 220 patients in the alternating arm. Late severe edema and/or fibrosis was observed in 32 (16%) patients in the sequential arm and in 25 (11%) in the alternating arm.

CONCLUSIONS

Larynx preservation, progression-free interval, and overall survival were similar in both arms, as were acute and late toxic effects.

The in vivo targeting of tumor antigens to DCs by administration of transduced autologous lymphocytes results in robust and prolonged immunization: Pre-clinical validation and results of a pilot clinical studies of vaccination for metastatic melanoma

2525

Background: Genetically-modified-lymphocytes (GML) can induce a specific immune response against the transgene product (HSV-TK), when injected into immunocompetent patients (Science 276:1719, 1997). In tumor-bearing mice the infusion of tumor-associated-antigen (TAA)-transduced lymphocytes induced protective immunity and long-term memory. In this experimental setting, the T-cell effectors were generated by a cross-presentation pathway, mediated by host dendritic cells (DCs). Indeed, DCs isolated from lymph nodes of treated mice contained fragments of labeled GML and were able to elicit antigen-specific responses ex vivo. Methods: To validate this novel vaccination strategy in humans, we treated 10 patients affected by stage IIIc/IV MAGE-A3+ melanomas with escalating doses of autologous GML expressing MAGE-A3 and the tracer antigen HSV-TK. HSV-TK allows to monitor the immune status of the patients. Immune responses were monitored by DTH and in vitro T cell assays (semi-quantitative recall assays and ELISPOT). Tumor status was monitored by conventional imaging analyses. Results: No toxicity was reported. From the 10 patients, 9 were clinically evaluable because responding to the tracer antigen HSV-TK. We observed one complete response with vitiligo surrounding the lesions and one long lasting stable disease (50 mo). Moreover, one patient with no evidence of disease remained free of disease at >48 mo. The 3 responding patients experienced both DTH reactivity to MAGE-A3 and sustained increase of circulating CD8+ and CD4+ MAGE-A3-specific effectors. The immune response was long lasting since MAGE-A3-specific effectors were still detectable both in vivo and in vitro 1 year after the last vaccination. Conclusions: We describe a new method for in vivo loading of TAA on DCs that may circumvent the limitations of ex vivo manipulation of DCs. Genetically modified lymphocytes, acting as antigen carriers, efficiently target DCs in vivo in tumor-bearing mice and in melanoma patients, resulting in the generation of TAA-specific effectors that correlate with clinical benefit.

[Table: see text]

Bone marrow mammaglobin expression as a marker of graft-versus-tumor effect after reduced-intensity allografting for advanced breast cancer

We assessed mammaglobin (MMG) gene expression in bone marrow (BM) aspirates from patients with advanced breast cancer who had received a reduced-intensity conditioning and stem cell allografting, in order to detect a graft-versus-tumor effect on micrometastatic disease. Nine patients received a reduced-intensity conditioning with fludarabine, cyclophosphamide, and thiotepa, followed by peripheral blood allografting from HLA-identical sibling donors. Nested RT-PCR analysis with sequence-specific primers for MMG was carried out on a monthly basis on BM samples. Three patients had MMG-positive BM, four patients had MMG-negative BM before allografting, and two were undetermined. In two patients, a clinical response after allografting (partial remission) occurred concurrently with the clearance of MMG expression, at a median of 6 months after allografting, following immune manipulation. In two patients, a prolonged stable disease and negative MMG expression occurred after day +360 from allografting. In two patients, progression of the disease was associated with MMG RT-PCR changing from negative to positive. In one case, a disease response occurring after donor lymphocyte infusion and grade II acute GVHD was heralded by negativization of MMG expression. Although preliminary, these data suggest that a graft-versus-breast cancer effect is detectable on micrometastatic BM disease.

Two familial cases of perianal streptococcal dermatitis

Two cases of perianal streptococcal dermatitis (PSD) occurred in a brother and sister, aged 4 and 6 years, respectively. The diagnosis was confirmed by the detection of group A beta-hemolytic streptococci in the perineal area and pharynx of both patients. We emphasize the importance of a quick and accurate diagnosis of the infection because PSD is frequently confused with other perianal diseases of infancy.

Uninephrectomy increases kidney beta2-microglobulin: can it play a role in the progression of kidney damage?

Beta2-microglobulin (beta2M) is highly accumulated by the kidneys of normal rats. The aim of this study was to verify if uninephrectomy can modify the renal uptake of labeled beta2M. For this purpose the radioactivity of plasma and those of the remaining kidney, liver and urine have been measured in uninephrectomized rats (NX) and in controls (C) at different times after the injection as i.v. bolus of 131I-beta2M. The experiments were performed in 114 Sprague-Dawley male rats. Fifty seven animals underwent right nephrectomy, the other animals being the C. NX and their C were divided in 3 groups, studied 2, 4 and 6 weeks after nephrectomy, respectively. Part of the animals were sacrificed 12 min after the injection of labeled beta2M (peak-time, i.e. time of highest kidney accumulation of 131I-beta2M in the normal rat) and part 10 min later. The results demonstrate that: - uninephrectomy increases plasma retention of 131I-beta2M - kidney uptake (total and per gram) is always higher in NX - liver uptake (much lower than that of kidney) is not influenced by uninephrectomy - urine excretion of radioactivity is minimal in both NX and C. The behavior of beta2M is similar to that we previously observed with alpha1-microglobulin and lysozyme. The higher kidney content of some low mw proteins after uninephrectomy could play a role in the progressive reduction of renal function determined by the reduction of renal mass.

Treatment of early-stage Hodgkin's disease with four cycles of ABVD followed by adjuvant radio-therapy: analysis of efficacy and long-term toxicity

BACKGROUND AND OBJECTIVES

The use of combined modality therapy in early-stage Hodgkin's disease can spare staging laparotomy and reduces the risk of relapse compared to radiation alone. This paper reports on the efficacy and long-term events of a combined modality approach consisting of a brief course of chemotherapy followed by adjuvant radiotherapy, without laparotomy, in early-stage Hodgkin's disease.

DESIGN AND METHODS

This study included 78 patients with Hodgkin's disease (20 in stage I and 58 in stage II); 60% had mediastinal enlargement (12% had bulky disease) and 5% had subdiaphragmatic disease. Their median age was 33 years (range: 15-64) and median follow-up 60 months. The treatment program consisted of four cycles of ABVD followed by adjuvant radiation to involved sites (43 patients) or involved and contiguous sites of disease (35 patients); radiation doses ranged from 30 to 36 Gy to uninvolved and involved sites, respectively; bulky disease received up to 44 Gy. Gonadal function in women was assessed by hormonal tests and evaluation of menses; young men were given the opportunity to have their semen cryopreserved.

RESULTS

The treatment program was completed in a median of 6.2 months (range: 5-10). The complete remission rate was 88% after 4 courses of ABVD and 98.7% after adjunctive RT. The 5-year relapse-free survival was 97% and overall survival 98%; three patients died, one of disease progression and two of small cell lung carcinoma. Long-term events included three cases of pulmonary fibrosis with symptomatic interstitial disease, one case of dilated cardiomyopathy with cardiac failure (all had received mediastinal radiation) and four cases of dysthyroidism. Fertility was preserved in young women, with three subsequent normal pregnancies. Second neoplasms included two small cell lung carcinomas and one breast carcinoma.

INTERPRETATION AND CONCLUSIONS

In early-stage Hodgkin's disease, four cycles of ABVD followed by adjuvant radiotherapy produced a 5-year overall survival of 98%. Prolonged monitoring for therapy-related long term complications is mandatory in these potentially curable patients.

Rituximab (IDEC-C2B8): validation of a sensitive enzyme-linked immunoassay applied to a clinical pharmacokinetic study

Rituximab is a chimeric monoclonal antibody (MAb) directed against the B-cell CD20 antigen that has been approved for therapy of relapsed and resistant follicular non-Hodgkin's lymphoma (NHL). This study describes the development and validation of a highly sensitive, rapid, accurate, precise enzyme-linked immunosorbent assay (ELISA) to measure Rituximab serum concentrations. This study also describes the application of the ELISA method to a pharmacokinetic study in a homogeneous group of patients with follicular lymphoma who received 4 weekly doses of MAb at the standard dose of 375 mg/m2 as consolidation of chemotherapy. In the patients in this study, the median Rituximab serum concentrations increased during therapy, and showed a slow decline during the posttreatment period. The Rituximab elimination half-life of approximately 20 days accounts for the demonstrated accumulation of MAb in serum samples. Because previous pharmacokinetic studies showed a correlation between Rituximab serum levels and tumor response, the ELISA method used in this study, which allows a precise control of serum concentrations, could be useful for predicting the final response to the MAb and for selecting patients able to benefit from higher dosage or repeated drug administration.

[Gastric pull-up in pharyngo-esophageal reconstruction: a personal experience]

During the five-year period from 1992 to 1997 a total of 62 patients with advanced hypopharyngeal carcinoma extended to the cervical esophagus came to our attention. Of these 42 (67.7%) were deemed operable and of these 31 (23 males, 8 females; age range 48 to 74 years; mean age 58.5 years) underwent total pharyngolaryngoesophagectomy and gastric pull-up reconstruction. Post-operative mortality was seen in 3 cases (9.7%). In addition, the following complications were encountered: dehiscence of the anastomosis (3 cases), neck hemorrhage (2 cases), pyloric stenosis (1 case). Two patients required intraoperative splenectomy to stop the hemorrhage caused by gastric mobilization and one required thoracic drainage, again because of hemorrhage. The average period of hospitalization was 36 days (range: 20 to 63 days). Per os feeding was restored from 20 to 63 days after surgery (average 20 days). Three patients (9.6%) showed functional failure--that is the inability to feed without the nasogastric probe. To date 10 patients (32.2%) are alive and disease free at an average 18.8 months after surgery (min. 1 month, max. 66 months); 7 patients (22.5%) are alive but not disease free; 11 (35.5%) passed away (in addition to the 3 post-operative cases) and 10 (32.2%) of these deaths were due to recurrence while 1 patient was still disease free at the time of autopsy. In conclusion the authors feel that total pharyngolaryngoesophagectomy with gastric pull-up is a safe treatment; i.e. with an acceptable mortality rate. Post-operative morbidity is high but the final functional outcome is good and, in most cases, can certainly improve the quality of the patients' remaining life. Even though prognosis is quite severe, with average survival of around one year, some of our patients are still alive and disease free 4-5 years after treatment.

The risk of acute leukemia in patients treated for Hodgkin's disease is significantly higher aft [see bined modality programs than after chemotherapy alone and is correlated with the extent of radiotherapy and type and duration of chemotherapy: a case-control study

BACKGROUND AND OBJECTIVE

Patients treated for Hodgkin's disease have an increased risk of developing subsequent acute leukemia. This co-operative study was conducted to assess the relative risk associated with several candidate factors including age, splenectomy, combined modality therapy and cumulative drug dose including alkylating agents and nitrosurea derivatives.

DESIGN AND METHODS

This study evaluated the risk of acute leukemia according to pretreatment variables and therapy modalities among 1659 patients treated for Hodgkin's disease and followed for a median time of 10 years. Both case-control and actuarial risk studies were performed. Median age was 34 years (range: 12-83); 53% of patients were splenectomized. As to the overall therapy, 348 patients (21%) were given radiotherapy (RT) alone, 375 (23%) chemotherapy (CT) alone (including MOPP, MOPP + ABVD or MOPP + ABVD + lomustine); 936 (56%) received both CT and RT, either as primary or salvage treatment.

RESULTS

The overall 15-year actuarial risk of leukemia was 4.2%; the hazard function curve showed two peaks of risk at the 3th and the 8th year from the initiation of therapy and no leukemia beyond the 12th year of follow-up. Risk of leukemia was 0.3% after RT alone, 2.8% after CT alone (2.2% after MOPP; 4.4% after MOPP + ABVD + lomustine), and 5.4% in patients given combined modality therapy (10.2% for RT + MOPP; 15.6% for RT + MOPP + lomustine). No leukemia occurred after ABVD alone and the risk was low (0.6%) when neither mechlorethamine nor lomustine were utilized. Patients who had received extended radiotherapy including abdomen and pelvis in addition to MOPP showed a significantly higher risk of leukemia compared to those given limited RT + MOPP (P = 0.01). Case-control analysis indicated advanced stage, type and duration (> 8 months) of CT and extension of RT as significant risk factors for leukemia. Compared to RT alone, the odds ratio was 5.9 after MOPP + extended RT, and 8 when a lomustine-containing regimen was used, as well. Neither age nor splenectomy were independent risk factors for leukemia; splenectomy was influential only when patients had been given MOPP chemotherapy, as well.

INTERPRETATIONS AND CONCLUSIONS

Both case-control and actuarial analyses indicated that: a) combined modality therapy with MOPP and extensive RT (including abdomen and pelvis), and the use of lomustine added to the leukemogenic risk of MOPP alone; b) programs without mechlorethamine, procarbazine and lomustine were almost devoid of leukemogenic risk.

[Primary carcinoma of the thyroglossal duct. 2 case reports]

AA. present two cases of carcinoma arising on thyroglossal duct's cystic. Those carcinomas are a rare event and will be suspected in the patients that present an irregular tumefaction of medial neck's district. Etiology is unknown; is possible that a preceding irradiation on the neck will represent a factor risk. AA. retained that in case of medial neck's district tumefactions is necessary executed a total examination of neck's and head's district, an echography, a thyroid scintigraphy, a thoracic radiography, a panendoscopy and a FNAB. When we found a squamous carcinoma on residual thyroglossal duct the therapy is chirurgical in function of dimension of T and N with following radiotherapy in function of stage (possible lymph node metastasis). When we found a different adenoma is necessary chirurgical removal of tumefactions with hyoid bone's a body resection (Sistrunk's operation) with total thyroidectomy and following Pochin's test for seeking eventual residual with radiometabolic and suppressive therapy.

[The randomized double-blind study of postoperative tonsillectomy pain control by muscle relaxants]

Tonsillectomy is accompanied by 7 to 14 days of pain. We entered 36 patients into a double blind placebo controlled study with dantrolene sodium, lioresal to evaluate modification of tonsillectomy pain and analgesic requirements after tonsillectomy. Patients were randomly assigned either dantrolene or lioresal or placebo orally four times a day for 5 days postoperatively. On a standardized questionnaire the patients recorded pain, activity level, analgesic requirements and side effects. We conclude that there is no significant differences in subjective pain or analgesic requirements between 3 groups. The muscle spasm is not the only factor of tonsillectomy pain. There is the association of other factors: nerve endings, individual sensitivity, local products of inflammation. In conclusion to control tonsillectomy pain we must use drugs with different action.

Epirubicin, methotrexate and bleomycin in the management of recurrent squamous cell head and neck cancer. A GSTTC randomised phase II study

53 patients with squamous cell carcinoma of the head and neck recurrent after initial treatment were entered into a phase II trial of the epirubicin, methotrexate and bleomycin (EMB) combination. The primary objective of the study was to evaluate the activity of this combination. Compliance to EMB and the possible non-cross-resistance to previous cisplatin-containing chemotherapy were secondary objectives. In order to avoid patient selection bias, the study involved randomisation between EMB and a cisplatin-methotrexate-bleomycin (DMB) combination (with EMB: DMB = 2:1). 23 out of 53 (43% +/- 13) EMB patients showed an objective response, lasting a median of 12 (range 4-39) weeks; interestingly, 5 out of 14 (36% +/- 25) patients pretreated with cisplatin plus 5-fluorouracil responded to EMB. The treatment compliance was good and a median of three courses was delivered. No patient refused the treatment after the initial cycle. Leukopenia (47%) and oral mucositis (42%) were the main side effects. DMB produced a response rate of 33% +/- 18 with a median duration of 5 (4-13) weeks. None of the patients previously treated with cisplatin plus 5-fluorouracil responded. 5 patients refused the treatment after the first cycle and a median of two cycles (0-5) was delivered. In conclusion, EMB produced results similar to cisplatin-containing regimens, with a mild to moderate toxicity and a good compliance; the possible non cross-resistance with cisplatin plus 5-fluorouracil deserves further evaluation.

[Mycosis of the paranasal sinuses: a report of 4 cases]

With recent advances in medicine, fungal diseases are not only being better under stood, but are also becoming increasingly important in the management of patients with paranasal sinus disease. Fungal sinus diseases range from allergic fungal sinusitis to invasive and fulminant fungal sinusitis. Although patients often have some predisposing factor, such as local tissue hypoxia or massive fungal ++exposure, most patients are not immuno-compromised. Invasive fungal sinusitis may be treated with the traditional Caldwell-Luc surgical technique or with newer endoscopic procedures. Fulminant fungal sinusitis generally occurs in immuno-suppressed patients and requires aggressive surgical excision and debridement as well as systemic chemotherapy, usually amphotericin B. In this article we review fungal diseases of the paranasal sinuses and present four cases of paranasal fungal sinusitis.

[Hormonal changes during surgical stress. Comparison of isoflurane anesthesia, neuroleptanalgesia, propofol]

Our purpose is to verify if different techniques of general anaesthesia can modify the patient's hormonal response to surgical stress. For this extent 35 patients, undergoing Cottle's septoplasty, were randomly divided into three groups, treated using different anaesthesiological techniques (forane, NLA and propofol). No variation was noted between the three groups regarding cortisol increments, while the patients, in whom forane was used for anaesthesia maintenance, manifested less significant variations in prolactin levels. This may be indicative of good forane protection for surgical stress.

[Gardner's syndrome: a case report]

The Gardner syndrome (GS) is a dysplasia in which neoformations in the intestines, soft tissue and osseous tissue are associated. Since extra-intestinal manifestations, in particularly osteomas, appear promptly even in infants, and above all in the light of the possibility of malignant degeneration, the presence of mandibular osteomas indicates the necessity of carrying out investigations in order to ascertain the eventual existence of an intestinal polyposis typical of GS. This study describes a typical case of GS diagnosed merely upon suspicion of the existence of the syndrome in a patient who came to our Department with a mandibular osteoma. The study underlines the importance not only of carrying out investigations in order to ascertain the presence of GS (rectocolonoscopy), but also that of studying the relatives of the patient in light of the fact that this particular dysplasia is transmitted genetically.

In vivo detection of somatostatin receptors in patients with functionless pituitary adenomas by means of a radioiodinated analog of somatostatin ([123I]SDZ 204-090)

The recent availability of a Tyr3-substituted octreotide (SDZ 204-090) for radioiodination has allowed somatostatin (SRIH) receptor binding to be studied in vivo, and receptor-positive tumors of different origins to be visualized with a gamma-camera. This prompted us to investigate whether this compound could be used for external imaging of functionless pituitary adenomas displaying SRIH receptors. Eight patients with functionless pituitary adenomas, three patients with acromegaly, and three with macroprolactinoma were injected iv with 123I-labeled Tyr3-octreotide and then scanned with a gamma-camera. Positive scans were obtained in the three acromegalics and in two of the eight patients with functionless pituitary tumors. The patients with macroprolactinoma had negative scans. The diagnosis of functionless pituitary adenomas was confirmed by light and electron microscopic examination as well as immunocytochemical studies. In vitro binding of [125I]Tyr11-SRIH to cell membranes was evaluated in four functionless and three GH-secreting adenomas removed from seven of the patients. All of the GH-secreting as well as one of the four functionless adenomas had high affinity SRIH-binding sites, without differences in number or affinity, whereas SRIH-binding sites were not detected in the others. Positive scans were observed only in patients bearing tumors with high affinity SRIH-binding sites. In conclusion, [123I]Tyr3-octreotide appears to be a promising tool for singling out, in vivo, patients with functionless pituitary tumors displaying SRIH receptors who might potentially benefit from octreotide treatment.

[Diagnostic, clinical and therapeutic aspects of primary transitional cell carcinoma of the prostate]

Transitional cell carcinoma is a rare neoplasm with an reported incidence of 2%. It is biologically different from adenocarcinoma in that it is not hormonally responsive and it is not associated with an elevated serum acid phosphatase. It is marked by local invasiveness and distant metastases. Transitional cell carcinoma has its origin at the level of the periurethral ducts in the area of the junction of the cylindrical and transitional epithelium. Transitional cell carcinoma can be distinguished from adenocarcinoma and carcinoma endometriode exclusively for its histological aspect. Various therapies have been used to treat transitional cell carcinoma but with poor results. Surgical treatment is still today the most efficient with a surviving average of 2 years. The Authors report 3 new cases, discussing diagnostic, clinical and therapeutical aspects of this rare neoplasm.

Evaluation of technetium 99m cyclobutylpropylene amine oxime as a potential brain perfusion imaging agent for SPET

Technetium 99m d,l-cyclobutylpropylene amine oxime (99mTc-CBPAO) has been developed as a brain-imaging agent for single photon emission tomography (SPET). 99mTc-CBPAO can be prepared using a simple labelling procedure suitable for routine clinical use. It has a high in vitro stability, as has been demonstrated by high-pressure liquid chromatography (HPLC) analysis. This shows that 3 h after labelling, less than 5% of the primary lipophilic complex which is capable of crossing the blood-brain barrier (BBB) converts to a secondary hydrophilic complex. Brain uptake (% dose/g wet tissue) of 99mTc-CBPAO, determined at 5 and 30 min after injection in two groups of six adult male Sprague-Dawley rats, was found to be 0.74 +/- 0.06 and 0.73 +/- 0.13 (mean +/- SD), respectively. These values are not significantly different from those obtained repeating the experiment with 99mTc-labelled hexamethylpropylene amine oxime (99mTc-HMPAO) (0.72 +/- 0.15 at 5 min and 0.88 +/- 0.24 at 30 min after injection). Since the rat brain uptake of 99mTc-CBPAO remained unchanged for a period of time suitable for tomographic study, the comparison of the two tracers was extended to two groups of ten patients. The latter were affected by neurological and psychiatric disorders and were studied with SPET. Human brain uptake (% dose/cc cortical grey matter) of 99mTc-CBPAO and 99mTc-HMPAO were 3.04 +/- 0.57 and 4.22 +/- 0.46 (mean x 10(-3) +/- SD x 10(-3), respectively, with a 32% significant difference. In two other groups of five patients, the first transit time-activity curves of the two tracers were compared.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasonic diagnosis of the central hyperechogenic area in lymph nodes. A sign of benign lymphadenopathy]

When identifying superficial lymphadenopathies by means of echotomography, the only accepted criterium of evaluation is still dimension. Only lymph nodes with a diameter longer than 0.5 cm are considered as potentially pathological, irrespective of their morphological characteristics. In the past two years an echotomographic study of the surface regions was carried out on 300 patients. Some suffered from unspecific solitary lymphadenopathies; most of the others were affected by stationary neoplasias, mainly situated in the cervical region. In many cases it has been possible to correlate the echotomographic and the histological results. Sixty-nine out of the 300 examined patients had lymph nodes with a central hyperechogenic area. Histology showed these lymph nodes to be the site of reactive hyperplasia. This characteristic has never been found in neoplastic lymph nodes. It has been hypothesized that this spot corresponds to the hilus of the lymph node and that, through its identification, it may be possible to distinguish benign from neoplastic lymph nodes.

Heparin transfer across the rabbit peritoneal membrane

Variable quantities of heparin have been proposed to avoid intraperitoneal clotting during peritoneal dialysis without the risk of systemic effects, because heparin is presumed to be incapable of passing through the peritoneal membrane. This study set out to verify this assumption by using labeled heparin in experimental dialysis in 7 New Zealand white rabbits. Heparin was labeled with 99mTc. Labeling quality, assessed by two chromatographic checks, showed less than 5% of free pertechnetate. Chromatographic determinations showed more than 95 and 80% of labeled heparin in inflow and outflow dialysates and in blood samples respectively. Following sodium thiopental anesthesia, animals underwent three protocols: a single 15 min cycle of time diffusion with heparin 500 U/l (A), 6 successive 15 min cycles with heparin 500 U/l (B), and a single 3 h cycle with heparin 2,500 U/l (C). Labeled heparin was found in blood organs and urine in variable percentages. The total amount of recovered radioactivity ranged from 1.5% (A) to 20% (C) of that introduced. It may be concluded that heparin passes through the peritoneum according to some law dependent on the amount used and the diffusion time.

Intracellular collagen in fibroblasts of Peyronie's disease

Ultrastructural study of fibrotic plaques from six patients with Peyronie's disease disclosed collagen fibrils located within smooth membrane bound cytoplasmic structures in most of the fibroblasts. These cells also contained prominent rough endoplasmic reticulum, which was dilated and filled with electron dense material, and hypertrophic Golgi structures in which occasional collagen fibrils were seen. Vacuoles containing collagen fibrils and amorphous substance or cellular detritus were also observed. Data from the present study support the hypothesis that intracytoplasmic collagen fibril formation is caused by excessive collagen synthesis by fibroblasts of Peyronie's fibromatosis.

["Umbilicate" aspect of some lateral cervical adenomegalies. A possible sign of benign characterization?]

Fifty-one patients were examined by sonography for suspicious cervical adenopathies. In 11 the adenopathies, histologically benign, showed typical "umbilicate" aspect. We present this aspect as a possible benign sign and we advance a pathological interpretation.

Assessment of split renal function with 99mTc-aprotinin

The aim of this work is to correlate the net kidney uptake of 99mTc-aprotinin (TcA) in 103 subjects with separate effective renal plasma flow (ERPF) and some blood chemistry parameters at 90, 180, and 360 min postinjection both in the normal and diseased kidney. Correlations found with separate ERPFs are highly significant at any time (P less than 0.001). However, although the slope of the regression line is steeper at 180 min, r tends to deteriorate slightly with time postinjection and a higher intercept on the y axis; this pattern is more pronounced if diseased kidneys are considered separately. The following are probably related to the renal handling of TcA: Early scans better reflect blood flow to the kidney, while later scans are more related to the metabolism/excretion tubular mechanisms; correlations found with urea, creatinine, urea clearance, and creatinine clearance are highly significant at any time; in 20 additional patients with diseased kidneys, renal uptake measurements done 360 min postinjection first with TcA and then with DMSA showed better correlations with ERPF employing TcA. Our results indicate that TcA is a feasible indicator of split renal function even at 90 min postinjection when a scan is easily carried out on an outpatient basis.

[Preoperative ultrasonic diagnosis of metastasis to the cervical lymph nodes from otorhinolaryngeal neoplasms]

The results of a study on 30 patients with ear, nose and throat cancers are discussed; a comparison of clinical, ultrasound and histological findings for the preoperatory evaluation of the cervical lymph nodes has been carried out. Ultrasound technique is an excellent method of investigation for the staging "N" of such neoplasms; its contribution is very important for the following therapeutic program.

99mTc-aprotinin: comparison with 99mTc-DMSA in normal and diseased kidneys

Aprotinin (A) and DMSA labelled with 99mTc were compared in patients with normal (NK, n = 12) and diseased kidneys (CRF, n = 13) by means of quantitative serial scans and measurements of blood clearance and urinary excretion. Serial scans only were obtained in additional 13 patients. Scan quality in the NK patients was essentially equal: faster blood clearances, reduced urinary excretions and higher fixations of A in the target compensated for the increased liver uptake. On the other hand, the scan quality in the CRF patients was definitely superior with A, allowing detection of residual functioning parenchyma also in severe kidney failure. Correlation between the net kidney uptake 6 hrs p.i. and the separate hippuran clearance rate was better with A than with DMSA, indicating the feasibility of A in evaluating relative renal function.

99mTc-aprotinin: a new tracer for kidney morphology and function

Aprotinin (Ap), a low-molecular-weight polypeptide (6500 dalton), is a protease inhibitor which is electively and stably accumulated in the kidney. In 112 adult patients, with either uni- or bilateral renal disease with different degrees of renal impairment (from normal GFR to advanced renal failure), renal scans were performed by means of Ap labelled with 99mTc. Highly satisfactory renal scans were obtained in all patients. In 20 patients with renal failure (serum creatinine 1.8-8.5 mg/dl, mean 4.7) a comparison was made of the renal scans obtained with 99mTc-Ap and with 99mTc-DMSA. 99mTc-Ap was slightly better than 99mTc-DMSA, especially in patients with far advanced renal failure. Some aspects of the pharmacokinetics of 99mTc-Ap were studied in 72 cases. In 22 of these patients plasma clearance of 99mTc-Ap was determined by the single injection method using a two-compartment model. In patients with GFR greater than 90 ml/min plasma clearance of 99mTc-Ap was 67.6 +/- 8.4 SD ml/min. A good correlation was observed between plasma clearance of 99mTc-Ap and GFR (r = 0.74). After IV injection 99mTc-Ap was stably fixed by the kidney. Renal radioactivity remained stable between the second and eighth hour after the injection. Urinary excretion of radioactivity measured in 35 patients in the first and in the second 2-h interval after IV injection of 99mTc-Ap was negligible in all patients (2.7 +/- 1.5 SD percent of the dose in the first 2 h; 2.8 +/- 1.4 SD between the second and fourth hour). 99mTc-Ap is an excellent agent for renal imaging. It also seems promising for renal function studies.

99mTc-Aprotinin: Comparison with 99mTc-DMSA in Normal and Diseased Kidneys

Aprotinin (A) and DMSA labelled with 99mTc were compared in patients with normal (NK, n = 12) and diseased kidneys (CRF, n = 13) by means of quantitative serial scans and measurements of blood clearance and urinary excretion. Serial scans only were obtained in additional 13 patients. Scan quality in the NK patients was essentially equal: faster blood clearances, reduced urinary excretions and higher fixations of A in the target compensated for the increased liver uptake. On the other hand, the scan quality in the CRF patients was definitely superior with A, allowing detection of residual functioning parenchyma also in severe kidney failure. Correlation between the net kidney uptake 6 hrs p.i. and the separate hippuran clearance rate was better with A than with DMSA, indicating the feasibility of A in evaluating relative renal function.

Clinical aspects of augmentation enterocystoplasties

Augmentation enterocystoplasty was performed in 28 patients with tuberculous, interstitial, radiation and chronic bacterial cystitis and hypertonic neurogenic bladder. Better results were observed in tuberculous contracted bladders where the extent of bladder resection and the bowel segment used were not related to the surgical outcome. In the other forms, the ileocecal segment is preferable. In our experience patients with neurogenic bladder did not benefit from the procedure. Radiographic and urodynamic studies are valuable for an accurate follow-up; radioisotope scan is also useful in selected cases. Anatomical and surgical causes of failure are discussed. Pharmacologic treatment is useful in partial surgical failure and provides indications for further bladder neck surgery.