Darobactin B Stabilises a Lateral-Closed Conformation of the BAM Complex in E. coli Cells

The β-barrel assembly machinery (BAM complex) is essential for outer membrane protein (OMP) folding in Gram-negative bacteria, and represents a promising antimicrobial target. Several conformational states of BAM have been reported, but all have been obtained under conditions which lack the unique features and complexity of the outer membrane (OM). Here, we use Pulsed Electron-Electron Double Resonance (PELDOR, or DEER) spectroscopy distance measurements to interrogate the conformational ensemble of the BAM complex in E. coli cells. We show that BAM adopts a broad ensemble of conformations in the OM, while in the presence of the antibiotic darobactin B (DAR-B), BAM's conformational equilibrium shifts to a restricted ensemble consistent with the lateral closed state. Our in-cell PELDOR findings are supported by new cryoEM structures of BAM in the presence and absence of DAR-B. This work demonstrates the utility of PELDOR to map conformational changes in BAM within its native cellular environment.

Darobactin B Stabilises a Lateral-Closed Conformation of the BAM Complex in E. coli Cells

The β-barrel assembly machinery (BAM complex) is essential for outer membrane protein (OMP) folding in Gram-negative bacteria, and represents a promising antimicrobial target. Several conformational states of BAM have been reported, but all have been obtained under conditions which lack the unique features and complexity of the outer membrane (OM). Here, we use Pulsed Electron-Electron Double Resonance (PELDOR, or DEER) spectroscopy distance measurements to interrogate the conformational ensemble of the BAM complex in E. coli cells. We show that BAM adopts a broad ensemble of conformations in the OM, while in the presence of the antibiotic darobactin B (DAR-B), BAM's conformational equilibrium shifts to a restricted ensemble consistent with the lateral closed state. Our in-cell PELDOR findings are supported by new cryoEM structures of BAM in the presence and absence of DAR-B. This work demonstrates the utility of PELDOR to map conformational changes in BAM within its native cellular environment.

The clinical utility of the Revised European-American Lymphoma (R.E.A.L.) Classification: preliminary results of a prospective study in patients with non-Hodgkin's lymphoma from a single centre

BACKGROUND

The clinical applicability of the Revised European-American Lymphoma (R.E.A.L.) Classification has been demonstrated in several retrospective studies. The present, ongoing study was initiated to evaluate the clinical and pathological utility of the R.E.A.L. Classification compared with the Working Formulation (WF) in a prospective fashion, in an unselected patient population treated at a single institution.

PATIENTS AND METHODS

Prospective data were collected on 596 biopsies from 557 patients referred with an initial diagnosis of lymphoma. After initial histologic review, 465 biopsies from 441 patients were confirmed as non-Hodgkin's lyphoma (NHL), 412 of which could be classified in R.E.A.L. and WF.

RESULTS

According to WF criteria, 25% were low grade, 58% intermediate grade and 2% high grade, 14% could not be allocated to a WF subtype. According to R.E.A.L., 46% were diffuse large B cell, 19% follicle centre lymphoma, 6% marginal zone, 6% small lymphocytic, 4% mantle cell, and 3% T-cell anaplastic large cell. For those with B-cell NHL, 7% were unclassifiable in WF compared with 1% in R.E.A.L. Corresponding figures for T-cell NHL were 68% and 3%, respectively.

CONCLUSIONS

Preliminary results confirm the clinical utility of the R.E.A.L. Classification in a single institution setting, demonstrating that cases were more readily sub-typed in R.E.A.L. compared with WF. Frequencies are comparable with I.L.S.G. data. Further follow up with large patient numbers is on-going to analyse survival data with reference to clinical prognostic factors.

Lymphadenopathy due to amyloid deposition in non-Hodgkin's lymphoma

BACKGROUND

Amyloidosis is a rare complication of non-Hodgkin's lymphoma. Most of the reported patients have had systemic amyloidosis and have died as a result of complications of this disease.

MATERIALS AND METHODS

The clinical cases of two patients with lymphoplasmacytic non-Hodgkin's lymphoma who presented with lymphadenopathy due to localised amyloid deposition are reviewed. Immunohistochemical studies were performed on the amyloid deposits and adjacent lymphoma.

RESULTS

The amyloid deposits in both patients were derived from monoclonal light chains of the same isotype as those expressed by the lymphoma cells and were localised to areas adjacent to the lymphoma despite the presence of circulating light chains. Both patients had an indolent clinical course and treatment appeared to have little influence on the amyloid deposition.

CONCLUSIONS

Non-Hodgkin's lymphoma may be associated with localised amyloidosis secondary to local production and deposition of amyloid from monoclonal light chains synthesised by the lymphoma cells. This is a rare cause of lymphadenopathy which does not respond to treatment of the underlying lymphoma.

PACE BOM chemotherapy: a 12-week regimen for advanced Hodgkin's disease

BACKGROUND

This study was designed to evaluate the efficacy and toxicity of a 12-week alternating weekly chemotherapy regimen for advanced Hodgkin's disease. Consolidative irradiation of residual masses was used in selected cases.

PATIENTS AND METHODS

Eighty-three patients with newly diagnosed advanced Hodgkin's disease (bulky stage IIA, stage IIB-IVB) or with progressive disease after extended field radiotherapy for early stage disease were included in this study. The patients were treated for 12 weeks with PACE BOM comprising oral prednisolone together with intravenous doxorubicin, cyclophosphamide and etoposide alternating weekly with intravenous bleomycin, vincristine and methotrexate. Limited field adjuvant radiotherapy was also given to 21 patients with localised persistent radiological abnormalities visible on chest X-ray after chemotherapy. The study end points were overall survival, failure free survival (FFS) and toxicity, particularly with respect to reproductive function.

RESULTS

With a median post treatment follow up of 52 months the actuarial 5-year overall survival is 90% (confidence interval 81%-95%) and FFS is 64% (52%-74%). This treatment was well tolerated and fertility was maintained in a high proportion of young adults.

CONCLUSIONS

The brief duration PACE BOM regimen with or without radiotherapy appears to be comparable in efficacy to other doxorubicin containing regimens, with a favourable toxicity profile. Randomised clinical trials are now needed to evaluate the role of this and comparable initial treatment approaches to advanced Hodgkin's disease.

Epstein-Barr virus and familial Hodgkin's disease

Several studies suggest that the Epstein-Barr virus (EBV) is etiologically linked to Hodgkin's disease (HD). This study was undertaken to examine the role of EBV in familial HD (FHD). Among 60 FHD patients from 27 families with two or more cases per family, we tested available paraffinized tumor tissues from 46 cases by in situ hybridization for EBV-encoded RNA (EBER1) expression. Thirteen of 46 FHD patients (28%) had EBER1 expressed in the Reed-Sternberg cells. Concordance rate of EBV positivity was evaluated among 34 first-degree related pairs from 17 families for which both cases had available paraffinized tumor tissues. Only two of 17 pairs were concordant for EBER1 positivity. There was no excess of positive concordance (P = .18). Serologically, FHD patients had higher geometric mean antibody titers (GMTs) to the viral capsid antigen (VCA) and early antigen D (EA-D). There was no difference in seroprevalence between patients and control groups, nor was there concordance in elevated serology among 15 pairs of first-degree related FHD cases. Young adult unaffected family members (UFM) may not react to EBV in the same way as the general population as evidenced by the lower titer of VCA, although not statistically significant, and significantly lower titers of EA-D, compared with age-matched controls. While EBV might have some role in a subset of HD, lack of concordance of EBER1 expression and EBV serology among the FHD cases in the same family suggest that EBV does not play an important role in FHD.

A complicated case of metastatic teratoma. Growing teratoma syndrome and cerebral metastasis

All patients presenting with metastatic teratoma should be regarded as potentially curable and this case demonstrates the multiple treatment modalities which are often needed in the management of such patients. Increasing experience with cisplatin based combination chemotherapy has led to the development of prognostic factors which are used to determine the intensity of treatment given to individual patients. Surgical intervention plays a very important role in the management of residual disease at the completion of chemotherapy. Recognition of the growing teratoma syndrome and the importance of early surgical excision is illustrated by this case. Isolated CNS relapse may occur because the CNS may act as a sanctuary site in patients receiving systemic chemotherapy, but does not preclude long term disease free survival.

Immuno-, lectin-, and enzyme-histochemical characterization of human bone marrow endothelium

"Homing" of hematopoietic progenitor cells to the bone marrow occurs during the clinical practice of bone marrow transplantation. Its mechanism is unknown, although adhesive interactions between hematopoietic cells and sinusoidal endothelium in the bone marrow may be implicated. Studies of human bone marrow endothelial cells have previously been limited by the lack of markers for these cells. In this report, we describe positive staining of bone marrow endothelial cells from human bone marrow trephine biopsies with antibody to factor VIII-related antigen (FVIIIR-Ag) (Dako, High Wycombe, UK), the plant lectin Ulex europaeus agglutinin-I (UEA-I), and two mouse monoclonal antibodies, BMA120 and QBEND/10. In addition, alkaline phosphatase could be demonstrated in the majority of marrow endothelial cells using a novel enzyme histochemical technique. These studies defined the marker profile of human marrow endothelium. The results of this study will facilitate the isolation and culture of human marrow endothelial cells for in vitro studies of their roles in hematopoietic stem cell homing.

CAPE/PALE salvage chemotherapy for Hodgkin's disease patients relapsing within 1 year of ChlVPP chemotherapy

BACKGROUND

Patients with advanced Hodgkin's disease failing to achieve complete remission with chemotherapy or developing disease progression within 1 year have a poor prognosis with salvage chemotherapy.

PATIENTS AND METHODS

Twenty-five patients fulfilling the above criteria after failing treatment with ChlVPP (chlorambucil, vinblastine, procarbazine and prednisolone) or its variant were treated with a new salvage regimen CAPE/PALE (cyclophosphamide, adriamycin, prednisolone, etoposide and lomustine), given for 6 courses at three weekly intervals.

RESULTS

Thirteen of the 25 patients (52%) achieved complete remission. After a minimum follow-up period of 38 months five of these patients remained free from disease progression. This regimen was very well tolerated.

CONCLUSIONS

CAPE/PALE produces results comparable to other salvage regimens in Hodgkin's disease. New strategies are however required for this patient group.

Prednisolone, cytosine arabinoside, lomustine (CCNU), etoposide and thioguanine (PACET) combination chemotherapy for relapsed or refractory non-Hodgkin lymphoma

27 patients with relapsed/refractory non-Hodgkin lymphoma (NHL) received combination chemotherapy with prednisolone, cytosine arabinoside, lomustine (CCNU), etoposide and thioguanine (PACET). 25 patients are evaluable for response. 7 (26%) obtained a complete response and one (4%) a partial response. The median survival for the entire group was 6 months. 2 patients are currently alive without disease, 1 of whom has received further therapy. The regimen was intensely myelosuppressive, but was well tolerated. The complete response rate and median survival figures are comparable to previous studies of salvage therapy confirming the poor prognosis for relapsed NHL and emphasising the need for prospective randomised studies.

Adult lymphoblastic lymphoma: high incidence of central nervous system relapse in patients treated with the Stanford University protocol

Twelve adult patients with non-leukaemic lymphoblastic lymphoma were treated with combination chemotherapy and central nervous system prophylaxis according to the protocol developed at Stanford University. Despite strict adherence to the Stanford protocol, 4 of 12 patients relapsed in the CNS, all with meningeal disease. Only four of the 12 patients are in continuing complete remission 6 to 88 months from the completion of induction therapy. These results are inferior to those previously reported for this regimen, and fail to confirm the high rate of control of CNS disease.

Intensive weekly combination chemotherapy for patients with intermediate-grade and high-grade non-Hodgkin's lymphoma

High response and overall survival rates have been reported for second- and third-generation combination chemotherapy regimens used in the treatment of advanced intermediate- and high-grade non-Hodgkin's lymphoma (NHL). Results with methotrexate with leucovorin, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) chemotherapy have been particularly impressive, although this regimen produces considerable toxicity. We have devised a similar regimen, which differs from previously reported weekly regimens in that it includes etoposide given at 14-day intervals. The doses of methotrexate and prednisolone were lower in our regimen than those used in MACOP-B. Alternating cycles of cyclophosphamide, doxorubicin, and etoposide (week 1) and methotrexate, bleomycin, and vincristine (week 2) were given for a total of 12 weeks, with continuous oral prednisolone and prophylactic antibiotics. We report here the first 61 patients entered onto this study. The overall response rate is 84% (57% complete remission [CR], 27% partial remission [PR]). With a median follow-up of 32 months for surviving patients, the actuarial overall survival at 3 years is 47%, and the failure-free survival is 45%. The dose-limiting toxicity of this regimen was mucositis. Five deaths occurred during chemotherapy, two of which were due to sepsis. The dose intensities of cyclophosphamide and doxorubicin in this regimen are considerably lower than those in MACOP-B. However, because of the inclusion of etoposide, the projected average relative dose intensity for our regimen is higher than that for MACOP-B. Our regimen has produced inferior results to those reported for MACOP-B. This may be because the addition of etoposide has failed to compensate for the lower doses of doxorubicin and cyclophosphamide. Alternatively, it may reflect differences in the presenting features of the patient populations.

Involved field radiotherapy or chemotherapy in the management of stage I nodal intermediate grade non-Hodgkin's lymphoma

Early stage intermediate grade non-Hodgkin's lymphoma (NHL) is frequently treated with chemotherapy alone or in conjunction with radiotherapy. We have managed clinical Stage I nodal, intermediate grade NHL with involved field radiotherapy alone for non-bulky (less than 5 cm post-surgery) disease or combination chemotherapy alone for more bulky disease. Forty-three patients were treated between 1978 and 1989. Of the 30 patients with non-bulky disease treated with radiotherapy, 29 (97%) achieved complete remission (CR). Thirteen (42%) patients relapsed after radiotherapy and ten of these achieved a further CR (durable in eight) following salvage chemotherapy. Eleven patients with bulky disease received combination chemotherapy with nine (82%) attaining CR (durable in eight). Two patients with bulky disease received radiotherapy-both achieved CR, but have relapsed and died of lymphoma. Overall actuarial 5 year survival for the total group is 77% with a median follow-up of 30 months (range 3-119 months). The 5 year actuarial survival for the 30 patients with non-bulky disease treated with radiotherapy is 86% at a median follow-up of 39 months (range 8-119 months). The 4 year actuarial survival of the 11 patients treated with chemotherapy is 60% with a median follow-up of 25 months (range 3-55 months). We conclude that involved field radiotherapy alone is efficacious for clinical stage I patients with non-bulky nodal intermediate grade NHL and that patients relapsing after radiotherapy are adequately salvaged by chemotherapy. Patients with bulky disease have an inferior survival and should receive combination chemotherapy.

Life-threatening airway obstruction at the presentation of Hodgkin's disease

Mediastinal involvement from Hodgkin's disease is common. Significant symptoms resulting from disease at this site are less common and only rarely does severe airway obstruction occur. The authors report six cases of Hodgkin's disease in which life-threatening airway obstruction was a major feature of the clinical presentation and early clinical course. The literature describing this complication is reviewed. General anesthesia with endobronchial intubation should be avoided if at all possible in patients with airway obstruction and alternative methods of diagnosis and management are discussed.

Results of the first ESMO examination in medical oncology, London 1989

Since 1989, a Certification in Medical Oncology is offered to ESMO members on the basis of their professional curriculum vitae and of their scores in a multiple choice examination. The first session took place in London, U.K., in September 1989, during ECCO 5. One hundred and twenty-five ESMO members were evaluated by means of 60 multiple choice questions covering various aspects of medical oncology, such as tumor diagnosis, prognosis and treatment, drug pharmacology and toxicity, histology and cytology, epidemiology, carcinogenesis and tumor biology. The mean percent of correct answers was 77.4. The best results were obtained with questions dealing with chemotherapy. Scores of 40% or less were obtained in 8 questions, including 2 questions on AIDS related tumors. A similar examination is available in 1990 and will be prepared yearly in the future. It is hoped that this European ESMO Certification will contribute to lessen the professional discrepancies between oncologists of European countries and improve the level of oncological training in Europe.

Tactile detection of slip: surface microgeometry and peripheral neural codes

1. The role of the microgeometry of planar surfaces in the detection of sliding of the surfaces on human and monkey fingerpads was investigated. By the use of a servo-controlled tactile stimulator to press and stroke glass plates on passive fingerpads of human subjects, the ability of humans to discriminate the direction of skin stretch caused by friction and to detect the sliding motion (slip) of the plates with or without micrometer-sized surface features was determined. To identify the associated peripheral neural codes, evoked responses to the same stimuli were recorded from single, low-threshold mechanoreceptive afferent fibers innervating the fingerpads of anesthetized macaque monkeys. 2. Humans could not detect the slip of a smooth glass plate on the fingerpad. However, the direction of skin stretch was perceived based on the information conveyed by the slowly adapting afferents that respond differentially to the stretch directions. Whereas the direction of skin stretch signaled the direction of impending slip, the perception of relative motion between the plate and the finger required the existence of detectable surface features. 3. Barely detectable micrometer-sized protrusions on smooth surfaces led to the detection of slip of these surfaces, because of the exclusive activation of rapidly adapting fibers of either the Meissner (RA) or the Pacinian (PC) type to specific geometries of the microfeatures. The motion of a smooth plate with a very small single raised dot (4 microns high, 550 microns diam) caused the sequential activation of neighboring RAs along the dot path, thus providing a reliable spatiotemporal code. The stroking of the plate with a fine homogeneous texture composed of a matrix of dots (1 microns high, 50 microns diam, and spaced at 100 microns center-to-center) induced vibrations in the fingerpad that activated only the PCs and resulted in an intensive code. 4. The results show that surprisingly small features on smooth surfaces are detected by humans and lead to the detection of slip of these surfaces, with the geometry of the microfeatures governing the associated neural codes. When the surface features are of sizes greater than the response thresholds of all the receptors, redundant spatiotemporal and intensive information is available for the detection of slip.

High dose intensity combination chemotherapy for advanced epithelial ovarian carcinoma: results of a pilot study

Retrospective studies have recently demonstrated a significant correlation between dose intensity of chemotherapy and response rates and survival in various diseases including epithelial ovarian carcinoma. As part of a proposed randomised trial to assess the effect of dose intensity on outcome in ovarian carcinoma, a pilot study has been undertaken to determine the toxicity and efficacy of the high intensity therapy. Nineteen patients with advanced ovarian carcinoma received initial treatment with cisplatin 120 mg m-2 i.v. day 1, and cyclophosphamide 1,000 mg-2 i.v. day 1, given at 21-day intervals for six cycles. The average relative dose intensity of this therapy is 1.14 when compared with the CHAP regimen. Severe toxicity was experienced by most patients. The median received average relative dose intensity was 0.90, with only one patient receiving treatment to the proposed intensity. Randomised studies of the effect of dose intensity in ovarian carcinoma are essential, but an initial step must be to assess whether the proposed high dose treatment can be delivered.

Involvement of the ileocaecal region by non-Hodgkin's lymphoma in adults: clinical features and results of treatment

Between January 1977 and January 1988, 19 patients with non-Hodgkin's lymphoma (NHL) involving the ileocaecal region were cared for by the CRC Wessex Medical Oncology Unit. Fifteen of these patients had primary ileocaecal NHL (stages IE or IIE) and four had secondary involvement of this region (stage IV). The commonest clinical presentation was with abdominal pain and a palpable mass in the right iliac fossa. Bulky (greater than 10 cm) disease was a particularly common feature, and complete surgical removal was possible in only seven patients. All patients had intermediate (18) or high grade (one) NHL using the Working Formulation. The commonest histological subtype was diffuse large cell. Seventeen patients received postoperative therapy, comprising local radiotherapy in one and combination chemotherapy in the remaining 16. Eleven of the 19 patients remain disease-free 6-60 months from diagnosis. Because of the high incidence of bulky disease at this site, postoperative therapy may be indicated, even for patients with apparently completely excised stage I disease.

Peripheral T cell lymphoma: value of bone marrow trephine immunophenotyping

Bone marrow infiltrates taken from 11 patients with peripheral T cell lymphoma were immunophenotyped as T cell lymphoma using monoclonal antibodies on frozen bone marrow trephine biopsy specimens. In nine these were taken at diagnosis and in two after failure of treatment to eradicate lymphoma in the marrow. Patterns of infiltration were as follows: diffuse (n = 4), interstitial (n = 1), nodular (n = 1), focal (n = 5). All cases were CD3 positive and 10 were CD2 positive; five lacked expression of either CD5 or CD7, or both markers. In nine the determination of T cell phenotype depended on analysis of the frozen bone marrow trephine biopsy specimen as there was no other biopsy tissue available for study. In the other two cases there was agreement between the immunophenotypes seen in lymph node and bone marrow infiltrates.

ChlVPP chemotherapy in advanced Hodgkin's disease

Between March 1978 and January 1987 54 patients with advanced Hodgkin's disease (HD) or relapse following radiotherapy (RT) for Hodgkin's disease have been treated with combination chemotherapy consisting of chlorambucil, vinblastine, procarbazine and prednisolone (ChlVPP). A subgroup of five patients with bulky mediastinal disease received mantle RT in addition to ChlVPP chemotherapy. Forty-two patients (77.8%) entered complete remission with 33 (61.0%) remaining in unmaintained remission and 44 (81.5%) alive at a median follow up of 51 months (range: 22-103). The treatment was generally well tolerated with minimal toxicity. ChlVPP is effective first-line treatment for Hodgkin's disease with results which may be comparable to those achieved for MOPP but with significantly less toxicity.

Bilateral testicular germ cell tumours: an increasing incidence and prevention by chemotherapy

Of 120 patients with germ cell tumours of the testis, 6 (5%) developed contralateral tumours; 63 patients received cisplatin-based combination chemotherapy for metastatic disease and none developed contralateral disease. By contrast, of 57 patients treated with orchiectomy alone or abdominal radiotherapy, 5 (8.8%) developed contralateral disease.

Involvement of the gastrointestinal tract by metastases from germ cell tumors of the testis

Six cases of metastatic germ cell tumors of the testis involving the gastrointestinal (GI) tract are reported. Three cases were primary seminomas, and three were nonseminomatous. All six cases involved the upper GI tract, three occurring at presentation and three at relapse, with a disease-free interval of 3 months to 10 years. Isolated GI involvement did not occur. The presumed mode of spread was by haematogenous dissemination in three and direct extension from paraaortic lymph nodes in three. Symptoms suggestive of involvement were severe abdominal pain secondary to high intestinal obstruction or mucosal ulceration, severe lumbar pain, and symptoms of anemia as a result of clinically evident or occult blood loss. Four patients were now disease-free after chemotherapy, one died of an unrelated illness, and one patient was receiving treatment for relapsing disease.

Clinical features and management of malignant histiocytosis of the intestine

This article documents the clinical course of nine patients diagnosed as having malignant histiocytosis of the intestine (MHI). Five patients had a history of gluten-sensitive enteropathy. This tumor commonly affects the small bowel in a widespread, patchy fashion causing ulceration, stricture formation, and perforation. Metastases to mesenteric nodes, liver, and the bone marrow were common. Although the diagnosis of MHI was often made at laparotomy, surgical resection, even when extensive, was not curative in any case. All nine patients were treated with a variety of chemotherapeutic regimes. This tumor proved chemosensitive, although response was usually brief and difficult to accurately evaluate. Chemotherapy was poorly tolerated because these patients were malnourished. In two cases small bowel perforation occurred, and in one gastrointestinal bleeding occurred after chemotherapy. Eight patients have died of disease from 0 to 16 months after the diagnosis was made, and a single patient is apparently cured 5+ years after completing chemotherapy. Malignant histiocytosis of the intestine has a characteristic clinical course. It is hoped that increased clinical awareness and early diagnosis will improve the outcome.

Surgery after initial chemotherapy for localized small-cell carcinoma of the lung

Despite the high response rates induced by chemotherapy, many patients with limited small-cell lung cancer (SCLC) relapse at the site of primary disease. Failure of radiotherapy to overcome this has led to the use of surgery as part of a combined modality approach. Between December 1981 and December 1985, 189 patients with SCLC were assessed for suitability for surgery after an initial three cycles of chemotherapy (doxorubicin, cyclophosphamide, and etoposide). Fifty-seven were found to have limited disease, and of these, 19 were ineligible or unfit for surgery. Of the 38 eligible patients, 84% had an objective response to three cycles of chemotherapy and 25 were deemed suitable for surgery after restaging. At thoracotomy, four were inoperable, nine had a lobectomy, and 12 had a pneumonectomy. There was no evidence of viable SCLC in four resection specimens (one stage 1, two stage 2, one stage 3 at presentation), no viable SCLC but an entirely separate focus of viable poorly differentiated squamous carcinoma (SqLC) in one, and the remaining specimens contained viable SCLC. Survival of patients selected to undergo tumor resection was excellent (median survival, 33 months; plateau phase, 48% alive at 3 to 5 years), but survival of the entire group with limited SCLC was not dissimilar from that reported in previous series of limited-stage tumor treated with chemotherapy alone. Long-term survival appeared to be largely restricted to those with no evidence of viable SCLC at surgery (no viable SCLC, zero of five relapsed; viable SCLC, 13 of 16 relapsed and/or died). This prospective study confirms the feasibility of the combined modality approach, but suggests that any improvement in overall survival is likely to be small. Until the results from multicenter randomized trials are available, surgery, as part of a combined modality program, should be regarded as experimental.

Extensive stage small cell carcinoma of the bronchus. A randomised study of etoposide given orally by one-day or five-day schedule together with intravenous adriamycin and cyclophosphamide

Fifty-four patients whose disease had been staged as extensive small cell carcinoma of the bronchus were randomised to receive either CAV1 (cyclophosphamide 600 mg m-2 i.v., adriamycin 50 mg m-2 i.v., given on day 1, and etoposide 500 mg m-2 p.o. given on day 3) or CAV5 (cyclophosphamide and adriamycin given as for CAV1, etoposide 500 mg m-2 given in divided dose over days 3-7) on a 21-day schedule. The two regimens proved comparable (CR + PR 55% vs 56%), and the survival curves were virtually superimposable (median survival: CAV1, 8 months; CAV5, 9 months). Only five patients are still alive. The toxicity of the two treatments was similar. The scheduling of etoposide over 1 or 5 days seemed clinically unimportant in this study, perhaps because of concurrent use of other effective chemotherapy drugs.

Cisplatin combination chemotherapy versus chlorambucil in advanced ovarian carcinoma: mature results of a randomized trial

A randomized study to compare the efficacy of combination chemotherapy (cisplatin, doxorubicin, cyclophosphamide: PACe) with chlorambucil (CB) in International Federation of Gynecology and Obstetrics (FIGO) stage III and IV ovarian carcinoma was conducted between May 1979 and October 1983. Patients failing initial CB were subsequently eligible for treatment with PACe. Eighty-nine patients were randomized and 85 were eligible for analysis; as of date, 72 of these patients have died. The majority of patients in this study had bulky residual disease after their initial laparotomy (76%). Complete response (CR) was documented by a second laparotomy after five cycles of combination therapy or 6 to 12 months alkylating agent therapy. The overall response rate (CR plus partial response [PR]) for the combination (PACe, 68%) was significantly higher (P = .0004) than that for the chlorambucil (CB, 26%). However, the median survival was not improved (PACe, 13 months; CB, 11 months) and the survival curves were not significantly different (log rank test P = .25). The results of this study are comparable to preliminary data reported from other similar randomized studies. PACe, as administered in this study, is not indicated as routine therapy in patients with bulky residual ovarian carcinoma.

Cisplatin, adriamycin and cyclophosphamide (PACe) combination chemotherapy in patients with ovarian carcinoma resistant to chlorambucil

Twenty patients with stage III or IV ovarian carcinoma refractory to chlorambucil were treated with IV cisplatin, adriamycin and cyclophosphamide. Two patients achieved CR and four PR, giving an overall response rate of 30%. All patients have since died at 0-18 (median 8) months. Use of this region was associated with marked toxicity, including three drug-related deaths. Second-time drug combinations should be regarded as experimental, and they should probably only be used in selected patients outside of clinical trials.

Bone marrow examination in small cell carcinoma of the bronchus: an unnecessary procedure?

One hundred and thirty-seven patients with small cell carcinoma of the bronchus underwent bone marrow trephine and/or aspirate examination as part of their clinical staging. Twenty-four patients (17.5 per cent) were found to have malignant marrow infiltration. In no case was this an isolated finding of metastatic disease, indeed most patients had gross metastatic spread to liver and/or bone. Marrow infiltration has not been shown to be a major prognostic factor in response to chemotherapy or survival in previous studies. We recommend that this staging procedure be discontinued in routine clinical practice, and instead be confined to specific indications in clinical trials.

Cell kinetics and in vitro clonogenicity of primary colorectal cancer: clinicopathological relationships and the implications for chemotherapy

Cells with the capacity for clonogenic growth in vitro can be isolated from primary human colorectal carcinomas. In this study colonies were grown, composed of cells which expressed epithelial membrane antigen and CEA, confirming their neoplastic character. Adequate growth for assessing the cytotoxicity of drugs for use in clinical chemotherapy regimes was obtained from 64% of the specimens. Colony forming efficiency of the tumour cells was not related to clinical stage or pathological grade of the parent tumour. The S-Phase fraction of the tumour was established in vitro using pulse thymidine labelling. The thymidine labelling index for Dukes' stage A and B tumours was significantly higher (median 15.7%, range 10.1-23.6%) than for Dukes' stages C and D (median 11.7%, range 0.1-13.6%). Colony forming efficiency in vitro was independent of the thymidine labelling index of the tumour. These findings are discussed with reference to the known heterogeneity of colorectal adenocarcinomas.

Second look laparotomy in the management of epithelial cell carcinoma of the ovary

Case histories from 20 patients undergoing postchemotherapy "second look" laparotomy for metastatic epithelial cell carcinoma of the ovary were reviewed in an attempt to evaluate the usefulness of this procedure and its likely impact on patient survival. The patient population comprised 18 patients treated with a combination of cisplatin, adriamycin and cyclophosphamide (PACe) and 2 patients treated with chlorambucil. The findings at second look were often predictable, and related to the adequacy of initial surgery. Complete tumour regression identified a group of patients with a relatively good prognosis. However in most patients residual tumour was found which rarely proved resectable. Second line chemotherapy was poorly tolerated, and appeared to have little impact on the disease particularly after combination chemotherapy had been used initially. There was little evidence that second look surgery itself positively contributed to survival. This procedure and its timing should be regarded as experimental and a suitable subject for randomised clinical trials.

A report on a prospective trial of no initial therapy in patients with initial therapy in patients with asymptomatic favourable prognosis non-Hodgkin's lymphoma

Thirty-one (58 per cent) of a group of fifty-three unselected patients with stage II-IV favourable prognosis non-Hodgkin's lymphoma were regarded as being eligible for a prospective study of no initial therapy. Seventeen of these patients (55 per cent) have required no treatment for periods from 6 + -47 + months, (median 18 months) and fourteen patients have been treated with chemotherapy for progressive disease after a period varying from 3-40 months (median 9.5 months). Selected asymptomatic patients with non-bulky disease may be suitable for no initial therapy. Randomized prospective trials will be needed to test whether survival is affected by delaying therapy.

Combination chemotherapy using high or low dose methotrexate for small cell carcinoma of the lung--a randomised trial

Eighty-three patients with histologically proven small cell carcinoma of the lung were entered into a prospective randomised clinical trial to evaluate two induction regimes. A 'low' dose methotrexate regime which employed three cycles of etoposide, adriamycin and methotrexate given at conventional dosage was compared with a regime which employed three cycles of etoposide and adriamycin together with five courses of high dose methotrexate and folinic acid rescue. All patients achieving a complete response (CR) received prophylactic cranial irradiation. Patients with limited disease who achieved a CR received additional radiotherapy to the primary site. An alternative four drug regime (procarbazine, vincristine, cyclophosphamide and CCNU) was evaluated in patients failing to achieve or subsequently relapsing from a complete response. Response rates for the low dose and high dose methotrexate arms were 54 and 55% respectively with median survivals of 8.6 and 9.7 months. Median survival for complete and partial responders was 20.2 and 11 months respectively. The alternative four drug regime showed limited activity in patients failing to achieve a complete response after primary therapy. We conclude that high dose methotrexate as used in this study has no role in small cell lung cancer. The 'low' dose regime was well tolerated by outpatients, is effective and is suitable for generalised use in the palliation of small cell lung cancer.

Correlations between clonogenicity and prognostic factors in human breast cancer

The pursuit of more effective systemic treatments in breast cancer has been limited by a failure to maintain or grow tumour cells in vitro. This study reports our experience in obtaining clonogenic growth in 54 primary breast cancers obtained at mastectomy. Of 47 assays free of infection, clonogenic growth was achieved in 22 (41 per cent). Only 5 of 23 oestrogen receptor positive tumours grew compared to 14 of 21 oestrogen receptor negative tumours chi 2 = 9.03; P less than 0.01). None of the 5 cytosolic receptor positive tumours contained a nuclear receptor for oestrogen. Growth was not related to tumour stage, menopausal status, age or histological grade. Receptor negative tumours had higher thymidine labelling indices, but these were no different to the tumours grown in the assay.

Poor prognosis non-Hodgkin's lymphoma in the elderly: clinical presentation and management

Thirty-eight patients age 65 years and older with a diagnosis of non-Hodgkin's lymphoma of poor prognostic type were seen over a five and a half year period. These patients represented 19 per cent of our total new patient non-Hodgkin's lymphoma population during this time. Advanced age, coexisting medical illness, widespread lymphoma and poor treatment compliance were common problems. Despite this we were able to render 26 per cent of patients disease-free for periods from 12 to over 48 months. Age should not be considered a bar to staging and effective therapy. Palliative management was unsuccessful, and we believe that treatment should be given with the intention of cure. Features suggesting that a patient was more likely to achieve a lasting complete remission included early stage (I-IIA), a lack of systemic ('B') symptoms, an absence of bone marrow or bulky gastrointestinal tract disease and no pre-existing serious medical condition.

Late recurrence in Hodgkin's disease: a report of two cases

Two cases of Hodgkin's disease are described who relapsed 22 and 19 years after regional radiation therapy. One of the patients also developed a carcinoma of the large bowel soon after first relapse. The importance of long follow-up and documentation of cause of death in Hodgkin's disease is stressed.

Epileptic seizures associated with cisplatin administration

Eighty-one patients with germ cell tumors or ovarian carcinoma were treated over a 4-year period with cisplatin-containing combination chemotherapy. Eight patients (9.8%) experienced epileptic seizures during or within 3 months of this chemotherapy. While a definite causal relationship between the seizures and cisplatin could not be established, we have rarely seen such episodes in relationship to other cytotoxic drugs. A number of possible contributing factors were apparent, including hyponatremia and pretreatment impairment of renal function.