The impact of amortization of gene therapies funding on the results and conclusions of CEMs and BIMs

BACKGROUND

Gene replacement therapy (GRT) is a treatment method used to combat or prevent various diseases. Its high one-off cost constitutes a major obstacle for successful market access. This paper aims to assess and discuss the applicability of amortization in models, such as cost-effectiveness models (CEMs) and budget impact models (BIMs) informing HTA recommendations and reimbursement decisions.

METHODS AND FINDINGS

A hypothetical CEA and BIA were considered. The objective was to compare the GRT with and without amortization. A straight-line amortization model was used. The CEM and BIM were considered and assessed based on two set of scenarios: considering different amortization duration or different discounting rate. The impact of amortization against the total cost of gene therapy was assessed for all the scenarios. The cost difference between GRT with and without amortization in relation to its total cost was -$58,855, thus amortization does not have a significant impact on the results and conclusions of the cost-effectiveness analysis. For BIM in the base case, amortization had no impact on the results.

CONCLUSION

Amortization has negligible impact on the results of CEM and total BIM and no impact on the conclusions from the model. One exception is the budget impact in case of an amortization period longer than the time horizon of BIM, where a half of the GRT price is moved beyond the model time horizon. Amortization has a distinguishing effect from an accounting perspective, but it does not have any implication for payers.

Gene Therapy Evidence Generation and Economic Analysis: Pragmatic Considerations to Facilitate Fit-for-Purpose Health Technology Assessment

Gene therapies (GTs) are considered to be a paradigm-shifting class of treatments with the potential to treat previously incurable diseases or those with significant unmet treatment needs. However, considerable challenges remain in their health technology assessment (HTA), mainly stemming from the inability to perform robust clinical trials to convince decision-makers to pay the high prices for the potential long-term treatment benefits provided. This article aims to review the recommendations that have been published for evidence generation and economic analysis for GTs against the feasibility of their implementation within current HTA decision analysis frameworks. After reviewing the systematically identified literature, we found that questions remain on the appropriateness of GT evidence generation, considering that additional, broader values brought by GTs seem insufficiently incorporated within proposed analytic methods. In cases where innovative methods are proposed, HTA organizations remain highly conservative and resistant to change their reference case and decision analysis framework. Such resistances are largely attributed to the substantial evidence uncertainty, resource-consuming administration process, and the absence of consensus on the optimized methodology to balance all the advantages and potential pitfalls of GTs.

Neuroimaging of chronotype, sleep quality and daytime sleepiness: Structural T1-weighted magnetic resonance brain imaging data from 136 young adults

The dataset contains structural T1-weighted magnetic resonance brain imaging data from 136 young individuals (87 females; age range from 18 to 35 years old) along with questionnaire-assessed measurements of trait-like chronotype, sleep quality and daytime sleepiness. The recruitment criteria excluded individuals with self-reported history of psychiatric or neurological conditions and current medication use. All the brain imaging sessions were performed between 5:20 PM and 8:55 PM in order to control the effect of time of day on acquired images. The data is mostly useful to scientists interested in circadian rhythmicity. It can be deployed in large-scale multicenter meta-analyzes investigating the structural brain correlates of chronotypes in humans. Additionally, the data could be of use in investigations into the effects of sleeping habits and latitude on brain anatomy.

An overview of health technology assessments of gene therapies with the focus on cost-effectiveness models

BACKGROUND

Gene therapies can treat, prevent, or cure a disease by changing the expression of a person's genes. They are an innovative strategy for treating genetic disorders; however, they are still emerging on the market access and in the healthcare system. Health technology assessment (HTA) agencies have not yet elaborated any standardised approach for assessing gene therapies; therefore, significant differences can be seen during HTAs carried out in various countries. In this review, we focused on submitted economic models of gene therapies approved for use by the US FDA and EMA with the aim to provide a comprehensive summary of how selected HTA bodies assessed the cost-effectiveness of gene therapies. An additional objective was to examine and discuss differences in the methods used in economic models across countries and drugs.

METHODS

We identified economic models of gene therapies from six countries (NICE, IQWiG, SMC, HAS, CADTH, ICER) and focused on nine agents (Glybera, Imlygic, Strimvelis, Yescarta, Kymriah, Luxturna, Zynteglo, Zolgensma, Tecartus). Details of cost-utility evaluations and budget impact models were reviewed and extracted.

RESULTS

Overall, 983 publications were identified, and 17 studies were included for the analysis. Reviewed evaluations of gene therapies differed in terms of the study perspective, discounting, extrapolation of outcomes based on limited and immature data, time horizon, and adequate estimation of benefits in terms of quality-adjusted life-years. Methods of economic evaluations were in line with the current recommendations; however, long-term follow-up studies are still missing.

CONCLUSIONS

Discrepancies in an economic evaluation of gene therapies between different HTA bodies are rooted in a lack of general assessment frameworks specific to gene therapies. Although challenges were resolved by adjustments to the currently used value assessment framework, new methodological approaches would be useful. In addition, to improve the methods and quality of an evaluation, further research would be valuable.

Surgical treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) in Europe and throughout the world is currently increasing. This is caused by an increase in the number of patients with alcoholic liver damage, metabolic syndrome, and by increasing incidence of hepatitis B and C.From January 1, 2004 to December 31, 2013, resection or radiofrequency ablation of the liver was done in 360 patients with benign lesions or malignant tumors of the liver. In 28 patients HCC was diagnosed and histologically confirmed (7.8 %). Seven patients had HCC associated with liver cirrhosis (25 %), and 21 patients were without histologically confirmed cirrhosis (75 %). R0 resection was done in 18 (64 %) patients.Surgical complications occurred in 6 (21 %) patients and reoperation due to tumor relapse or progression was done eight times in 6 (21 %) patients. One-year and five-year patients' survivals were 64 % and 10 %, repectively, and did not statistically differ from the survival of the whole set of patients with tumor diseases in the given time period. In the future it will be possible to improve the long-term survival of patients with HCC by using screening methods for presymptomatic diagnosis of HCC, precise preoperative diagnosis and efforts for R0 resection (Tab. 1, Fig. 4, Ref. 11).

Different types of errors in saccadic task are sensitive to either time of day or chronic sleep restriction

Circadian rhythms and restricted sleep length affect cognitive functions and, consequently, the performance of day to day activities. To date, no more than a few studies have explored the consequences of these factors on oculomotor behaviour. We have implemented a spatial cuing paradigm in an eye tracking experiment conducted four times of the day after one week of rested wakefulness and after one week of chronic partial sleep restriction. Our aim was to verify whether these conditions affect the number of a variety of saccadic task errors. Interestingly, we found that failures in response selection, i.e. premature responses and direction errors, were prone to time of day variations, whereas failures in response execution, i.e. omissions and commissions, were considerably affected by sleep deprivation. The former can be linked to the cue facilitation mechanism, while the latter to wake state instability and the diminished ability of top-down inhibition. Together, these results may be interpreted in terms of distinctive sensitivity of orienting and alerting systems to fatigue. Saccadic eye movements proved to be a novel and effective measure with which to study the susceptibility of attentional systems to time factors, thus, this approach is recommended for future research.

Phase i/ii trial of 5-Fluorouracil, leucovorin, Zidovudine and dipyridamole for patients with metastatic colorectal-cancer, renal-cell carcinoma and malignant-melanoma

We conducted a phase I/II trial of 5-fluorouracil (5-FU), calcium leucovorin (LV), zidovudine (AZT) and dipyridamole (DP), (FLAP) in patients with metastatic colorectal cancer, renal cell carcinoma and malignant melanoma. AZT and DP were given to enhance the biochemical modulation and antitumor activity of 5-FU and LV. All patients received 5-FU (370 mg/m(2) i.v. bolus day 0-4), LV (50 mg/m(2) p.o. every 4 h day 0-4) and DP (50 mg/m(2) p.o. every 6 h days 0-27). In the phase I portion of the study, AZT was dose escalated in cohorts of 5 patients each, from 50 mg p.o. every 6 h days 0-27 to the MTD of 200 mg p.o. every 6 h days 0-27. Thirty-three patients received 200 mg of AZT in the phase II portion of the trial. Eleven patients developed grade III and 5 patients developed grade IV leukopenia. Four patients developed grade III and 21 patients developed grade IV neutropenia, with six febrile neutropenic episodes. Six patients experienced grade III anemia and four grade III thrombocytopenia. Diarrhea or stomatitis of greater than or equal to grade III occurred in six and four patients, respectively. Fifty-eight percent (19 of 33) of patients required dose reductions of AZT for hematologic toxicity (13 of 19 in the first treatment cycle). At the 200 mg AZT dose level, there were two partial responses in nine colorectal cancer patients (22%), no objective responses in 14 patients with renal cell carcinoma or in 14 patients with melanoma. FLAP does not have significant activity in melanoma, renal cell carcinoma or 5-FU-treated colorectal cancer patients, although it may have activity in untreated colon cancer.

8-Oxoguanine incision activity is impaired in lung tissues of NSCLC patients with the polymorphism of OGG1 and XRCC1 genes

Decreased repair of oxidative DNA damage is a risk factor for developing certain human malignancies. We have previously found that the capacity of 8-oxo-7,8-dihydroguanine repair was lower in leukocytes of NSCLC patients than in controls. To explain these observations, we searched for mutations and polymorphisms in the OGG1 gene among 88 NSCLC patients and 79 controls. One patient exhibited a heterozygous mutation in exon 1, which resulted in Arg46Gln substitution. Normal lung and tumor tissue carrying this mutation showed markedly lower 8-oxoG incision activity than the mean for all patients. The predominant polymorphism of OGG1 was Ser326Cys. A significant difference was observed in the frequencies of the OGG1 variants between populations of NSCLC patients and controls. The frequency of the Cys326 allele and the number of Cys326Cys homozygotes was higher among patients than controls. In individuals with either Ser326Cys or Cys326Cys genotype 8-oxoG incision rate was lower than in those with both Ser326 alleles, either in lung or leukocytes. Moreover, 8-oxodG level was higher in lung tissue and leukocytes of patients carrying two Cys326 alleles and in leukocytes of patients with the Ser326Cys genotype. We also screened for polymorphisms of the XRCC1 gene. Only heterozygotes of the XRCC1 variants Arg194Trp, Arg280His and Arg399Gln were found among patients and controls, with the frequency of Arg280His being significantly higher among patients. NSCLC patients with Arg280His or Arg399Gln polymorphism revealed lower 8-oxoG incision activity in their lung tissues, but not in leukocytes. We can conclude that the OGG1 Ser326Cys polymorphisms may have an impact on the efficiency of 8-oxoG incision in humans and the XRCC1 His280 and Gln399 may influence the OGG1 activity in tissues exposed to chronic oxidative/inflammatory stress. Higher frequency of the OGG1 Cys326 allele among NSCLC patients may partially explain the impairment of the 8-oxoG repair observed in their leukocytes.

Treatment results of non-varicose bleeding from upper gastrointestinal tract

Treatment results of non-varicose bleeding from upper gastrointestinal tract are changing by improved endoscopic methods and introduction of new drugs in treatment.

OBJECTIVE

Objective of this work was to compare the results in treatment of patients with non-varicose bleeding from upper gastrointestinal tract in two different 5-years periods.

MATERIAL

We hospitalised 229 patients with non-varicose bleeding from upper gastrointestinal tract at the Department of Surgery in Faculty Hospital of Martin in the period 1992-1996. (161 men and 68 women, average age 56.7, patients up to 60 were 42.4%). 203 patients were hospitalised in the years 2003-2008 (146 men and 57 women, average age 61.5, patients up to 60 were 54%).

METHODS

We compared both groups by retrospective analysis and we evaluated differences by using statistical methods (nonparametric test of independence of the qualitative data).

RESULTS

There was only minimal difference in primary conservative and endoscopic haemostasis in both groups. Relaps of bleeding was the same in both groups. Definitive conservative and endoscopic haemostasis was higher by 3.2% in the period 2003-2008 and number of urgent operations decreased by 5.1%. Differences in total mortality were minimal between both groups but postoperative mortality was higher by 5.9% in the years 2003-2008.

CONCLUSION

Number of urgent operations decreased due to improved results in definitive conservative and endoscopic haemostasis in the treatment of non-varicose bleeding from upper gastroinestinal tract. There was no significant change in the relaps of bleeding. There were only minimal changes in total mortality between both groups, but postoperative mortality increased in the second period (Tab. 8, Ref. 35).

Aberrant repair of etheno-DNA adducts in leukocytes and colon tissue of colon cancer patients

To assess the role of lipid peroxidation-induced DNA damage and repair in colon carcinogenesis, the excision rates and levels of 1,N(6)-etheno-2'-deoxyadenosine (epsilondA), 3,N(4)-etheno-2'-deoxycytidine (epsilondC), and 1,N(2)-etheno-2'-deoxyguanosine (1,N(2)-epsilondG) were analyzed in polymorphic blood leukocytes (PBL) and resected colon tissues of 54 colorectal carcinoma (CRC) patients and PBL of 56 healthy individuals. In PBL the excision rates of 1,N(6)-ethenoadenine (epsilonAde) and 3,N(4)-ethenocytosine (epsilonCyt), measured by the nicking of oligodeoxynucleotide duplexes with single lesions, and unexpectedly also the levels of epsilondA and 1,N(2)-epsilondG, measured by LC/MS/MS, were lower in CRC patients than in controls. In contrast the mRNA levels of repair enzymes, alkylpurine- and thymine-DNA glycosylases and abasic site endonuclease (APE1), were higher in PBL of CRC patients than in those of controls, as measured by QPCR. In the target colon tissues epsilonAde and epsilonCyt excision rates were higher, whereas the epsilondA and epsilondC levels in DNA, measured by (32)P-postlabeling, were lower in tumor than in adjacent colon tissue, although a higher mRNA level was observed only for APE1. This suggests that during the onset of carcinogenesis, etheno adduct repair in the colon seems to be under a complex transcriptional and posttranscriptional control, whereby deregulation may act as a driving force for malignancy.

Oxidative stress and 8-oxoguanine repair are enhanced in colon adenoma and carcinoma patients

Oxidative stress is involved in the pathogenesis of colon cancer. We wanted to elucidate at which stage of the disease this phenomenon occurs. In the examined groups of patients with colorectal cancer (CRC, n = 89), benign adenoma (AD, n = 77) and healthy volunteers (controls, n = 99), we measured: vitamins A, C and E in blood plasma, 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) and 8-oxo-7,8-dihydroguanine (8-oxoGua) in leukocytes and urine, leukocyte 8-oxoGua excision activity, mRNA levels of APE1, OGG1, 8-oxo-7,8-dihydrodeoxyguanosine 5'-triphosphate pyrophosphohydrolase (MTH1) and OGG1 polymorphism. The vitamin levels decreased gradually in AD and CRC patients. 8-OxodG increased in leukocytes and urine of CRC and AD patients. 8-OxoGua was higher only in the urine of CRC patients. 8-OxoGua excision was higher in CRC patients than in controls, in spite of higher frequency of the OGG1 Cys326Cys genotype, encoding a glycosylase with decreased activity. mRNA levels of OGG1 and APE1 increased in CRC and AD patients, which could explain increased 8-oxoGua excision rate in CRC patients. MTH1 mRNA was also higher in CRC patients. The results suggest that oxidative stress occurs in CRC and AD individuals. This is accompanied by increased transcription of DNA repair genes, and increased 8-oxoGua excision rate in CRC patients, which is, however, insufficient to counteract the increased DNA damage.

Involvement of oxidatively damaged DNA and repair in cancer development and aging

DNA damage and DNA repair may mediate several cellular processes, like replication and transcription, mutagenesis and apoptosis and thus may be important factors in the development and pathology of an organism, including cancer. DNA is constantly damaged by reactive oxygen species (ROS) and reactive nitrogen species (RNS) directly and also by products of lipid peroxidation (LPO), which form exocyclic adducts to DNA bases. A wide variety of oxidatively-generated DNA lesions are present in living cells. 8-oxoguanine (8-oxoGua) is one of the best known DNA lesions due to its mutagenic properties. Among LPO-derived DNA base modifications the most intensively studied are ethenoadenine and ethenocytosine, highly miscoding DNA lesions considered as markers of oxidative stress and promutagenic DNA damage. Although at present it is impossible to directly answer the question concerning involvement of oxidatively damaged DNA in cancer etiology, it is likely that oxidatively modified DNA bases may serve as a source of mutations that initiate carcinogenesis and are involved in aging (i.e. they may be causal factors responsible for these processes). To counteract the deleterious effect of oxidatively damaged DNA, all organisms have developed several DNA repair mechanisms. The efficiency of oxidatively damaged DNA repair was frequently found to be decreased in cancer patients. The present work reviews the basis for the biological significance of DNA damage, particularly effects of 8-oxoGua and ethenoadduct occurrence in DNA in the aspect of cancer development, drawing attention to the multiplicity of proteins with repair activities.

Consideration of endoscopic retrograde cholangiopancreatography in cases of acute biliary pancreatitis

AIM

The important question to be answered in all cases of ABP is whether or not a calculous biliary obstruction is still present. Answering this question conditions subsequent management, including the need for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the relationship between persistent common bile duct stone (CBDS) and laboratory values, and dilation of bile duct in order to find possible significant associations in patients with acute biliary pancreatitis (ABP).

METHODS

Retrospectively, statistical evaluation of a group of 76 patients with ABP who had received early ERCP.

RESULTS

The prevalence of choledocholithiasis in patients > 70 years old was 54.2%, in patients < or = 70 years old it was 36.5%. Following cholecystectomy, CBDS was present in 81.8% of patients, p = 0.005. The probability of CBDS occurrence in patients > 70 years old with bile duct dilation was 81.3%; in the absence of bile duct dilation CBDS was not present, p < 0.001. The probability of CBDS occurrence in patients 70 years old with bile duct dilation was 57.7%, in the absence of bile duct dilation CBDS was present in 15.4%, p = 0.002. In patients with bile duct dilation predictive factors are as follows: bilirubin (Bi), after excluding patients with acute cholecystitis and cholangitis, p = 0.05; alanine aminotransferase (ALT) in patients 70 years old, p = 0.004; gamma-glutamyl transferase (GMT) in patients > 70 years old, p = 0.02.

CONCLUSIONS

ERCP is indicated in patients with ABP if biliary obstruction is present and the presence of a ductal stone is suspected. From our results it is clear that the predictive parameter for choledocholithiasis is the dilation of the bile duct and previous cholecystectomy. In patients with bile duct dilation possible predictive factors are Bi, ALT, and GMT (Tab. 1, Fig. 8, Ref. 20).

DUHOCAMIS: a dual hollow cathode ion source for metal ion beams

In this paper we describe a novel ion source named DUHOCAMIS for multiply charged metal ion beams. This ion source is derived from the hot cathode Penning ion gauge ion source (JINR, Dubna, 1957). A notable characteristic is the modified Penning geometry in the form of a hollow sputter electrode, coaxially positioned in a compact bottle-magnetic field along the central magnetic line of force. The interaction of the discharge geometry with the inhomogeneous but symmetrical magnetic field enables this device to be operated as hollow cathode discharge and Penning discharge as well. The main features of the ion source are the very high metal ion efficiency (up to 25%), good operational reproducibility, flexible and efficient operations for low charged as well as highly charged ions, compact setup, and easy maintenance. For light ions, e.g., up to titanium, well-collimated beams in the range of several tens of milliamperes of pulsed ion current (1 ms, 10/s) have been reliably performed in long time runs.

An alternative approach to carbon nanotube sample preparation for TEM investigation

A two-stage replication technique (positive replica) is shown to be suitable for transmission electron microscopy (TEM) examination of carbon nanotubes (CNTs) and other one-dimensional nanostructures in their longitudinal direction. This method enables handling the fragile nanostructures, is fast and simple and allows to study the growth mechanism of nanofeatures, including the early stages of their growth. CNTs may also be examined when the growth layers are very thin, and even when only a few nanotubes are on a substrate. Replicas can be taken from various substrate shapes covered with nanostructures and from minute or specifically selected areas of the substrates. CNTs extracted by the replica are not disturbed, and their nanostructures are preserved. It is demonstrated that using positive replicas, HRTEM images from the nanosized carbon forms can also be obtained.

Efficacy and toxicity of dose-adjusted EPOCH-rituximab in adults with newly diagnosed Burkitt lymphoma

8035

Background: Burkitt Lymphoma (BL) is a rare and highly aggressive lymphoma, characterized by a high tumor proliferation rate. While the standard therapy of BL is highly effective, it involves intensive, multi-agent chemotherapy that is associated with considerable treatment-related toxicity and mortality, especially in older patients. We hypothesized that the regimen DA-EPOCH may be effective in BL, based on the observation that it overcomes the adverse effect of high proliferation in diffuse large B-cell lymphoma. Methods: We investigated DA-EPOCH-rituximab (R) in untreated BL in an attempt to maintain the high cure rates of standard therapy with minimal treatment related toxicity. Eligible patients had a diagnosis of untreated BL and could be HIV negative or positive with HIV negative patients (n=13) receiving 6 cycles of DA-EPOCH-R as previously described (Blood 99: 2685, 2002) and HIV positive (n=6) patients receiving 3–6 cycles of DA- EPOCH-R for 1 cycle beyond CR for a minimum of 3 cycles. All patients received intrathecal methotrexate prophylaxis and outpatient therapy where possible. Results: The characteristics of 19 enrolled patients are: median age (range) 29 (18–66) and ECOG PS 1(1–3); stage III/IV 10 (53%); LDH > N 11 (61%); male sex 15 (79%); extranodal sites 13 (68%) and ileocecal disease 13 (68%). No patients so far had CNS involvement at diagnosis. Response is CR/CRu in 100% of patients with one patient receiving consolidative radiotherapy to a site of residual disease. OS and PFS are both 100% and EFS 93.3% at a median potential follow-up time of 29 months. Toxicities were fever/neutropenia in 16%, grade 4 neutropenia in 47% and grade 3/4 thrombocytopenia in 22% of cycles. There was one case of tumor lysis syndrome and no treatment related deaths. Conclusions: DA-EPOCH-R is highly effective in BL. It appears to be associated with much lower toxicity compared to standard high-dose regimens and may significantly advance the therapeutic index of BL treatment. Accrual continues.

No significant financial relationships to disclose.

Treatment and biology of lymphomatoid granulomatosis

8029

Background: LYG is a rare angiocentric-destructive process with EBV+ B-cells and reactive T-cells. LYG is graded with grades I-II showing rare-moderate large EBV+ B-cells (usually polyclonal or oligoclonal) and grade III showing numerous large EBV+ B-cells (usually monoclonal), likely reflecting progressive transformation. Historically, steroids and/or chemotherapy have a 14 mos median survival. Methods: We are investigating Interferon-a (I-a) for grade I/II and dose-adjusted EPOCH ±Rituximab (R) for grade III LYG. Results: Characteristics of 53 pts are: male sex 68%; median age (range) 46 (17–67) and median ECOG P.S. 1 (0–3). Disease sites include lung 98%, CNS 38%, kidney 15%, skin 17%, liver 19% and nodes 4%. On study LYG grades are I-30%, II-26% and III-44%. Prior treatment was none-28%, chemotherapy± R-34%, and steroids alone-40% of pts. For grades I/II, I-a is begun at 7.5 million IUs TIW and escalated as tolerated until disease regression and continued 1 yr after CR. Of 31 patients treated with I-a, PFS is 62% at the median f/u of 5.3 yrs. Of 25 evaluable pts (3 NE; 3 TE), 60% had sustained CR for a median of 60 mos (4–175). In 9 pts who progressed on I-a, grade III was found in 5. Thus, in 20 pts with only grade I/II, 75% had sustained CR with I-a. In 11 evaluable pts with CNS disease, 81% achieved remission with I-a alone. The median time to remission is 9 mos (3–40) and median I-a dose is 20 MIU (7–40). Among 24 pts receiving DA-EPOCH±R, PFS is 40% at the median f/u of 28 mos. Of 21 evaluable pts (2 NE, 1 TE), 66% achieved CR. OS of all 53 pts is 68% at the median f/u of 4 yrs. Median EBV viral loads in 29 pts at study entry were 18 copies/10e6 genome equivalents (0–22727) (normal<200). Lymphocyte subsets in 30 pts showed a median CD4–428 (24–2322) and CD8–165 cells/mm3 (42–1316). In 12 pts in CR and with serial values, the mean CD8 cells (131 ± 44) (p2= 0.013) but not CD4 cells (65 ± 75) increased with treatment. Conclusions: High dose I-a produces sustained remissions in grade I/II LYG and is effective in CNS LYG. DA-EPOCH±R can produce durable CRs in grade III LYG. We hypothesize LYG emerges in a compromised immune milieu and undergoes progressive transformation if not effectively treated. Historical results suggest steroids may allow transformation by compromising immune function.

No significant financial relationships to disclose.

A phase II study of the efficacy and toxicity of alemtuzumab for the therapy of human T cell lymphotrophic virus-1 (HTLV-1)-associated adult T-cell leukemia/lymphoma (ATL)

2535

Background: HTLV-1-associated ATL is an aggressive lymphoproliferative disorder with limited effective therapy. Alemtuzumab is a humanized monoclonal antibody directed against CD52. High levels of CD52 are expressed on the surface of ATL cells. Preclinical studies in the MET-1 mouse model of ATL showed alemtuzumab to be highly active. Methods: A single institution open-label phase II study examining the response and toxicity of alemtuzumab in patients with ATL. Eligibility criteria: HTLV-1-associated ATL (chronic, acute and lymphoma type), ≥10% CD52+ malignant cells, measurable disease, age ≥18 years, AGC ≥1000/μL, platelets ≥50,000/μL, adequate physiologic status and informed consent. Results: Ten (10) patients, 6 with leukemia, 4 with lymphoma, 8 Afro-Caribbean, 1 African-American and 1 Japanese, 7 women, 3 men, median age 49 years (range, 36–62), all having received previous treatments including CHOP (7), other monoclonal antibodies (5), radioimmunotherapy (2), and radiation (1), median WBC 48,500/μL (leukemia Pts.) received alemtuzumab standard induction followed by 30 mg 3 times weekly for a minimum of 4 weeks and maximum of 12 weeks. All patients experienced infusion reactions (grade, 1–3) including hypotension, fever, rigors, chills, pruritus and urticaria; however, no patient required discontinuation of treatment. All patients developed grade 4 lymphopenia, and transient cytomegalovirus (CMV) antigenemia. Four (4) patients with leukemia responded (1 CR, 3 PR). No patient with lymphoma responded. Conclusions: Alemtuzumab has antitumor activity in HTLV-1-associated adult T cell leukemia and is well tolerated. Lymphomatous ATL appears unresponsive to alemtuzumab. The reason for this is unknown; however, antibody levels achieved in lymph nodes may be suboptimal. Accrual continues.

No significant financial relationships to disclose.

Nelson's Syndrome - 46 Years Later: Clinical Experience with 37 Patients

OBJECTIVE

Pituitary tumours occurring after bilateral adrenalectomy for Cushing's disease (Nelson's syndrome) are frequently aggressive, so an early diagnosis and careful management are of prime importance. For a new insight into this entity it is necessary to analyse the factors predisposing to its development and the course of the disease, as well as the methods of diagnosis and modalities of treatment.

PATIENTS AND METHODS

Thirty-seven patients with Nelson's syndrome were observed, 32 women and 5 men, aged 16 to 61 years at the time of pituitary tumour detection (at present, 27 to 82 years old). The diagnostic methods included clinical observation, imaging examinations (X-ray studies, CT, MRI), hormonal evaluation (especially ACTH and cortisol levels during replacement therapy) and ophthalmologic investigations. Neurosurgery was the main method of treatment.

RESULTS

The clinical analysis indicated that young age at the time of adrenalectomy, pregnancy, insufficient replacement therapy and fulminant course of Cushing's disease were the main factors predisposing to Nelson's syndrome. MRI appeared to be the most valuable imaging method, as this detected Nelson's tumours in the microadenoma stage in 7 patients. Plasma ACTH levels varied between 32.6 pmol/l in an early phase to 2 000 pmol/l in the full-blown syndrome. Absolute temporal scotomas found in ophthalmologic examinations were an early abnormality. The best results after therapy were obtained in patients treated by neurosurgery using a transsphenoidal approach in an early stage.

CONCLUSIONS

MRI, ophthalmologic examination and plasma ACTH determination were the most valuable investigations for early diagnosis of Nelson's syndrome. Early neurosurgery offered the best outcome in our group of patients.

Effect of steroids and nitric oxide on pituitary hormone release in ovariectomized, peripubertal rats

The purpose of this study was to determine the effects of the duration of steroid depletion on the steroid-induced luteinizing hormone and prolactin surges in ovariectomized, peripubertal female rats. Additionally, the role of nitric oxide (NO) in mediating the surge responses was determined. Peripubertal, 6-week-old, female Sprague-Dawley rats were ovariectomized. One or three weeks later, animals were injected with 17β-estradiol (50 μg, sc) followed 48 h later by progesterone (2.5 mg, sc). Effects of NO were examined by administeringl-arginine (300 mg/kg, ip). The response of ovariectomized, adult females to steroid treatment was also determined.

One and three weeks after ovariectomy, steroid replacement produced an LH and prolactin surge in peripubertal animals. However, both the magnitude and duration of the LH surge was greater 3 weeks after ovariectomy. Whilel-arginine significantly enhanced the magnitude of the LH surge 1 week after ovariectomy, by 3 weeksl-arginine caused a decrease in the duration, but not the magnitude of the surge. In contrast,l-arginine did not affect either the magnitude or duration of the prolactin surge one week after ovariectomy, but diminished the magnitude after 3 weeks of steroid depletion. In adults, steroids induced significant increases in both LH and prolactin. These results demonstrate that sensitivity to NO stimulation of LH, but not prolactin secretion, is modulated by the duration of gonadal steroid hormone depletion. The differences in the responsiveness of LH and prolactin to steroid-induced stimulation in peripubertal animals demonstrate that these hormones are regulated by NO through different mechanisms.

The significance of clinical markers in the prediction of hemodynamic and cardiac complications of capnoperitoneum in patients at risk

OBJECTIVES

The aim of this prospective study was to find out the predictive value of concomitant diseases of cardiovascular system (CVS), lungs and kidneys as well as metabolic diseases to be able to anticipate the potential origin of hemodynamic and cardiopulmonary complications as a result of insufflated CO2 peritoneum.

METHODS

The study investigated eleven patients at the anaesthetic risk of ASA III-IV and cardiac risk of NYHA II-III in whom elective laparoscopic surgical intervention had been indicated.

RESULTS

We have found out that the significance of the increase in biologic ANP markers, catecholamines and PRA was not sufficient to signal the deepening of cardiac dysfunction, latent cardiac failure or hemodynamic disorder (p > 0.01). The courses of regression lines have shown the dependence on the increased IAP (intra-abdominal pressure) of capnoperitoneum in PRA and adrenaline. The reactions of biologic markers correlated with reactions of clinical hemodynamic markers of BP and HR. We have proved that the increased level of IAP causes a significant increase in CVP (p < 0.01) being one of the factors determining the preload of right ventricle (RV) and in coincidence with intact transpulmonary circulation also the optimal function of left ventricle (LV).

CONCLUSION

Our investigation of peroperative clinical and biologic markers of hemodynamics and neuroendocrine response to operative stress and development of CO2 peritoneum has proved that the course of laparoscopic operations in patients in the risk group of ASA III-IV and NYHA III does not necessarily have to be deteriorated by complications. It can be assumed that increased values of biologic markers regulate the neurohumoral response in the physiologic range and do not predict a severe CVS dysfunction within its course. (Tab. 2, Fig. 3, Ref. 22.)

Pseudoaneurysm of the gastroduodenal artery as a cause of obstructive jaundice

A 35-year-old man presented to our emergency room with asymptomatic jaundice. A physical exam revealed a palpable mass with audible bruit in the epigastrium. Total serum bilirubin was 21.7 mg%. A real time sonography/Doppler examination showed widening of the biliary tree (common bile duct diameter of 13 mm) and a mass in the pancreatic head with turbulent flow. Arteriography of the celiac axis revealed a pseudoaneurysm of the gastroduodenal artery. A ligation of the gastroduodenal artery was performed surgically, and the aneurysmal cavity was explored and emptied. An intraoperative cholangiography showed slight stenosis of the common bile duct distally, and so a choledochojejunostomy was performed. The patient's recovery was uneventful. A follow-up angiogram revealed the short stump of the gastroduodenal artery and no aneurysm or extravasation of dye. A follow-up ultrasound showed the common bile duct measuring 5.5 mm. The bilirubin level dropped to normal values. The patient was discharged on 12 days after surgery. Ten months following surgery he was doing well. The pathology, diagnosis, and treatment of such cases are briefly discussed.

Statistical dependence of clinical data on the chosen treatment of patients with a multivessel coronary artery disease

BACKGROUND

In this study we tried to check which clinical data are connected with the choice of treatment in patients with a multivessel coronary artery disease.

MATERIAL AND METHODS

The data of 137 patients with a multivessel coronary artery disease, were analysed retrospectively. The patients were divided into three groups: treated conservatively, CABG and PTCA. Multivessel coronary artery disease was recognised when there were atherosclerotic changes in more a 2 vessels with a not less a 2 mm in diameter. Patients with previous CABG or a left main coronary artery disease were excluded. The data were analysed by means of several methods, variance analysis, correlation analysis, discriminant functions, chi-square test and T-Student test.

RESULTS

For treatment decision making in multivessel coronary artery disease of statistical significance were: the state of the left anterior descendent artery below the first diagonal branch, the state of the first diagonal branch and peripheral parts of the left anterior descendent artery and right coronary artery, the systolic function of the antero-lateral, apical and phrenic segments of the left ventricle, the global left ventricular ejection fraction in angiography and echocardiography, local systolic disturbances of the left ventricular observed in echocardiography, the coexistence of symptoms of heart failure as well as unstable angina.

CONCLUSION

Treatment decision making will always depend not only on diagnostic procedures but also on all the clinical data about the patient and the experience of coworking cardiology and surgery centres.

Immunoneutralization of endogenous opioid peptides prevents the suckling-induced prolactin increase and the inhibition of tuberoinfundibular dopaminergic neurons

Previous studies have shown that the endogenous opioid peptides, acting at specific opiate receptor subtypes, are involved in the suckling-induced prolactin secretory response. The prolactin increase elicited by suckling is due, at least in part, to an inhibition of tuberoinfundibular dopaminergic (TIDA) neurons in the hypothalamus. We investigated the effects of immunoneutralization of dynorphin, leu-enkephalin and met-enkephalin on the suckling-induced prolactin increase and on the activity of the TIDA neurons in lactating female rats between days 7 and 12 postpartum. Rats were injected into the right lateral ventricle with antiserum specific for one of these three peptides. Control rats were administered equal amounts of immunoglobulin proteins. Suckling produced a profound and significant increase in prolactin levels, as well as a decrease in DOPA accumulation in the median eminence of lactating rats. Administration of immunoglobulin concentrations of up to 3.6 microg did not inhibit the prolactin secretory response to the suckling stimulus and did not prevent the suckling-induced inhibition of TIDA neurons. Antisera to all three endogenous opioid peptides abolished the suckling-induced prolactin increase and prevented the inhibition in DOPA accumulation in the median eminence. Thus, the endogenous opioid peptides, dynorphin, leu-enkephalin and met-enkephalin, are essential for the prolactin secretory response to suckling and inhibition of TIDA neuronal activity is at least one of the mechanisms of action utilized by these peptides.

Perforated peptic ulcer--time trends and patterns over 20 years

There are contradictory reports in current world literature regarding incidence of perforated peptic ulcers and male to female ratio in recent years. Old concepts of seasonal periodicity are being questioned. In our report we analyze what is changing with regard to demographical data of patients affected, incidence of perforation of peptic ulcer and ulcer location. This article reviews 441 consecutive cases of this complication of peptic ulcer disease (PUD) treated in our department between January of 1977 and December of 1996. The source of analyzed data are operative reports. Several observations regarding number, age and sex of patients affected and ulcer location have been made.

Peptic ulcer disease before and after introduction of new drugs--a comparison from surgeon's point of view

During the last twenty years we have witnessed a revolutionary change in treatment and diagnosis of peptic ulcer disease (PUD). It was introduction of flexible fiberoptic instruments and new drugs: H-2 blockers, proton pump inhibitors (PPI) and treatment against Helicobacter pylori which affected most significantly the course of this illness. Although indications for surgical intervention have not been changed, practice of surgery in this regard has changed a lot. In this report two periods of time were analyzed and compared: years 1977-81 and 1992-96. Operation reports from the above defined periods were reviewed and all surgeries performed for PUD and its complications have been noted along with data regarding patients and indications for surgery as reported by operating surgeons. There were 360 surgeries for PUD performed in the 1977-1981 period, and 246 in the years 1992-1996. Patients were divided into groups depending on indications for surgery. A significant reduction in the general number of operations performed was noted. The percentage of women operated upon increased. The mean age of patients in all indication groups was higher in the latter period. Patients operated for bleeding tended to be older than those in perforation and intractable disease groups. This was true in both periods of time. The number and percentage of patients operated for perforation increased. The natural course of PUD is changing; intractable disease as an indication for surgery is disappearing, the number of pyloric obstruction patients is diminishing, the incidence of bleeding and perforation remains constant. The mean age of patients and percentage of women is increasing.

CNS involvement in primary mediastinal large B-cell lymphoma

PURPOSE

The risk of CNS involvement by non-Hodgkin's Lymphoma (NHL) has been associated with bone marrow and/or testicular involvement; however, it was recently reported that the number of extranodal sites is a more reliable predictor of CNS disease. Because primary mediastinal thymic large B-cell lymphoma (PMLCL) has a high propensity for involving extranodal sites, we investigated the frequency and pattern of CNS involvement in PMLCL.

PATIENTS AND METHODS

The medical records of 219 patients with aggressive NHL, consecutively entered onto protocols at the National Cancer Institute between 1987 and 1998, were retrospectively reviewed.

RESULTS

Twenty-three patients (11%) had clinical and pathologic features of PMLCL. These patients were young (median age, 29 years), female (61%), and presented with massive mediastinal adenopathy (70%). Extranodal disease occurred at presentation in 70% and at relapse in 93% of patients and involved contiguous intrathoracic structures and/or distant sites, including the lungs, kidneys, liver, adrenals, ovaries, pancreas, and bone. Six patients (26%) developed CNS involvement, two (9%) at presentation and four (27%) at relapse. All had extranodal disease, but only one had bone marrow involvement. Parenchymal and leptomeningeal CNS disease occurred in four and three patients, respectively.

CONCLUSION

CNS involvement in PMLCL is associated with extranodal involvement other than bone marrow and may reflect the unique biology of this disease. The propensity to involve the CNS parenchyma raises the concern that intrathecal prophylaxis may not be effective and suggests that CNS imaging should be considered in patients with extranodal disease.

Orphanin FQ stimulates prolactin and growth hormone release in male and female rats

Intracerebroventricular administration of Orphanin FQ (5.5, 55 or 550 pmol) caused a dose-related increase in prolactin secretion in both male and female rats and stimulated GH secretion in males. The magnitude of the prolactin secretory response was greater in females than in males. These effects of OFQ on prolactin and growth hormone release are the same as the stimulatory effects of the endogenous opioid peptides.

Aplasia cutis congenita of the scalp. Report of 16 cases

BACKGROUND

Aplasia cutis congenita (CCA) is a rare developmental anomaly. Its etiology and pathogenesis remain unclear. There are several hypotheses as to the influence of genetic and external factors on the fetus. Terminology of this anomaly is still a subject of discussion.

OBJECTIVES

This paper describes 16 patients with CCA of the scalp, ranging in age from 3 to 15 years, observed over the period of 15 years. Among them, girls prevailed 9:7. CCA was more common on the vertex rather then in the temporal region 13:3. In one girl multiple malformations were observed.

METHODS

Location, shape, and size of the lesion determined as CCA were analyzed. Detailed history was taken and cytogenetic examination was performed to reveal etiopathogenetic factors. Treatment consisted of excision of the lesion and reconstruction of the scalp with neighboring skin flaps. The excised lesion underwent histologic examination.

RESULTS

No etiopathogenetic factors were found. Histopathologic examinations indicate that the observed congenital scalp anomalies resemble a scar. Surgical treatment produced good cosmetic results.

CONCLUSIONS

Literature on CCA will facilitate physicians to make the right diagnosis. Further accumulation of detailed descriptions on CCA patients may contribute to recognition of etiopathogenesis of this anomaly.

Immunoneutralization of beta-endorphin blocks prolactin release during suckling without affecting tuberoinfundibular dopaminergic neural activity

The effect of immunoneutralization of beta-endorphin on the suckling-induced prolactin increase and on the activity of the tuberoinfundibular dopaminergic (TIDA) neurons was determined in lactating female rats between days 8 - 12 post-partum. Two antisera were used in the immunoneutralization studies. Both were specific for beta-endorphin, exhibiting little cross reactivity with met- or leu-enkephalin or dynorphin. Antisera to beta-endorphin completely abolished the suckling-induced prolactin increase indicating that this endogenous opioid peptide is involved in this response. Suckling significantly inhibited DOPA accumulation in the median eminence and antiserum to beta-endorphin did not prevent this inhibition. Additionally, 5-endorphin antiserum significantly reduced TIDA neural activity even in pup-deprived dams. These results indicate that beta-endorphin is involved in the prolactin secretory response to suckling but that inhibition of TIDA neuronal activity is not its mechanism of action. Other possible mechanisms are discussed.

Early diagnosis of Nelson's syndrome

Nelson's syndrome is a specific form of Cushing's disease treated by bilateral adrenalectomy, presenting with a deep hyperpigmentation caused by a pituitary adenoma (corticotropinoma). These ACTH-secreting tumors are frequently aggressive, so early diagnosis is of prime importance. We have studied 33 patients with Nelson's syndrome, 28 women and 5 men, aged 14-56 yr at the time of adrenalectomy and 16-58 yr at the time of Nelson's syndrome diagnosis (observed for 5-32 yr). Methods of examination included simultaneous adrenocorticotropic hormone (ACTH) and cortisol measurements during routine hydrocortisone replacement therapy, computed tomography (CT), pituitary magnetic resonance imaging (MRI), and visual field examination. The results obtained in a group of six patients diagnosed in the last 3 yr were compared with those obtained in a group of 27 patients examined before 1992. High plasma ACTH levels accompanied by normal serum cortisol concentration were characteristic for a late stage of the disease. Absolute temporal scotomas were an early finding. MRI, especially with the gadolinium enhancement, was superior to CT in demonstrating pituitary microadenomas in Nelson's syndrome. Thus, MRI diagnosis allowed for an early neurosurgical treatment of the patients with Nelson's tumors.

Multiple opiate receptor subtypes are involved in the stimulation of growth hormone release by beta-endorphin in female rats

The growth hormone (GH) secretory response to beta-endorphin and the involvement of opiate receptor subtypes in this response were determined in diestrous female rats. The involvement of the mu (mu), delta (delta) and/or kappa (kappa) site was determined by administering specific antagonists for each of these sites prior to beta-endorphin. beta-Funaltrexamine (1 or 5 micrograms) was administered to block mu sites, ICI 154,129 (5 or 25 micrograms) blocked delta sites and nor-binaltorphimine (8 micrograms) blocked kappa sites. The ability of these antagonists to block GH secretion following intravenous morphine administration was also determined. The opiate antagonists and beta-endorphin were administered into the lateral ventricle. A dose-response study for beta-endorphin indicated that 0.5 micrograms beta-endorphin was the minimum stimulatory dose for GH release, producing an approximately 4-fold increase in circulating levels of GH; lower doses of beta-endorphin did not stimulate secretion. All three antagonists were capable of blocking the stimulatory effects of beta-endorphin. These results provide evidence that all three opiate receptor subtypes are involved in the stimulatory effect of beta-endorphin on GH release.

Linking work and domestic problems with police suicide

We reviewed the records of 134 police officers who had undergone their first fitness-for-duty evaluation at our center. Fifty-five percent admitted to previous suicide attempts. We examined possible contributing factors. A logistic regression model correctly classified 79.1% of subjects as to whether or not they attempted suicide. Results indicated that officers reporting marital problems were 4.8 times more likely to have attempted suicide, and 6.7 times more likely if they had been suspended. Interestingly, complaints of being administratively harassed were associated with a lower likelihood that an officer would attempt suicide. Variance explained due to age, race, gender, and substance use was nonsignificant.

High-dose carboplatin and recombinant granulocyte-macrophage colony-stimulating factor in advanced-stage recurrent ovarian cancer

PURPOSE

We investigated whether carboplatin myelosuppression could be favorably modulated by the administration of recombinant granulocyte-macrophage colony-stimulating factor (rGM-CSF) in patients with advanced-stage ovarian cancer.

PATIENTS AND METHODS

Thirty-four patients with advanced-stage recurrent ovarian cancer were treated with high-dose carboplatin (800 mg/m2 per 35-day cycle) and rGM-CSF. rGM-CSF was administered as a daily subcutaneous injection starting 72 hours after the carboplatin dose and continuing until 7 days beyond the WBC nadir. rGM-CSF was administered in a phase I fashion. Seven patients were treated at an rGM-CSF dose of 3 micrograms/kg, 11 at 5 micrograms/kg, 10 at 10 micrograms/kg, and six at 20 micrograms/kg.

RESULTS

rGM-CSF-related toxicities that were not dose-related included nonneutropenic fever, rib pain, acute hypersensitivity reaction, and pericarditis. At the rGM-CSF dose of 20 micrograms/kg, debilitating malaise was seen in four of six patients and this was the dose-limiting toxicity. Patient tolerance of the 3-micrograms/kg and 5-micrograms/kg doses was good, but tolerance was limited for the 10-micrograms/kg dose. Febrile neutropenia was seen in four of seven patients at 3 micrograms/kg, two of 11 at 5 micrograms/kg, two of 10 at 10 micrograms/kg, and one of six at 20 micrograms/kg. Cumulative carboplatin myelotoxicity was blunted only in respect to WBC count, and not for platelets or RBCs. Gastrointestinal bleeding was seen in seven patients. The administered dose-intensity of carboplatin averaged 134 mg/m2/wk for the cohort, or 670 mg/m2 per 35-day cycle. There were two clinical complete responses and eleven partial responses, for a response rate of 38%.

CONCLUSION

rGM-CSF appears to be effective and tolerable at 5 micrograms/kg/d administered subcutaneously, if given with carboplatin doses up to approximately 600 mg/m2 over 35 days. The use of rGM-CSF with high-dose carboplatin is associated with a substantial response rate in poor-prognosis ovarian cancer patients.

Opiate receptor subtype involvement in the stimulation of prolactin release by beta-endorphin in female rats

The prolactin secretory response to beta-endorphin and the involvement of opiate receptor subtypes in this response was determined in both diestrous and postpartum, lactating female rats. The involvement of the mu-, delta- and/or kappa-site was determined by administering specific antagonists for each of these sites prior to beta-endorphin. beta-Funaltrexamine (beta-FNA, 1 or 5 micrograms) was administered to block mu-sites, ICI 154,129 (5, 10 or 25 micrograms) blocked delta-sites and nor-binaltorphimine (norBNI, 8 micrograms) blocked kappa-sites. The ability of beta-FNA and ICI 154,129 to block prolactin secretion following morphine administration was also determined. A dose response study for beta-endorphin indicated that beta-endorphin, at doses as low as 25 ng, was a potent stimulus for prolactin release producing an increase in prolactin that mimicked the suckling-induced prolactin increase. In addition, all three antagonists were capable of antagonizing the stimulatory effect of beta-endorphin in both diestrous and postpartum female rats. These results indicate that beta-endorphin is a potent stimulus for prolactin secretion and that these three opiate receptor subtypes interact to produce its stimulatory effect on prolactin release.

Morphine induced analgesia is attenuated in post-partum lactating rats

The analgesic effects of morphine administration were determined in post-partum, lactating female rats, as well as in intact, cycling females during the diestrous stage of the estrous cycle. All doses of morphine (2.5, 5 and 10 mg/kg, iv) produced a significant analgesic response in both post-partum and diestrous females using the hot water tail immersion latency test. However, the analgesic response in the post-partum females was significantly less than during diestrus at all doses tested. In addition, pretreatment with the mu 1 specific antagonist, Naloxonazine, significantly blunted the analgesic response in diestrous females, but did not significantly affect analgesia in post-partum females. These results indicate that morphine is less effective in producing analgesia in post-partum females. The mu 1 opiate receptor site does not appear to be involved in the analgesia produced during the post-partum period.

Dose-related immunologic effects of levamisole in patients with cancer

PURPOSE

This phase I study was conducted to determine the maximum-tolerated dose (MTD) and the immunologic properties of levamisole in cancer patients when administered alone and in combination with interferon gamma (IFN-gamma).

PATIENTS AND METHODS

Twenty patients with advanced cancer and 36 patients with completely resected melanoma (n = 33) or renal cell cancer (n = 3) received levamisole orally every other day for six doses at 1.0, 2.5, 5.0, or 10.0 mg/kg. Ten days later, patients restarted levamisole and began IFN-gamma 0.1 mg/m2 by subcutaneous injection every other day. Blood samples were collected for measurement of neopterin and soluble interleukin-2 receptor (sIL-2R), and for flow-cytometric analysis.

RESULTS

The MTD of levamisole was 5 mg/kg, and this was not changed by the addition of IFN-gamma. Dose-related increases in serum levels of neopterin and sIL-2R were noted. Multiple doses of > or = 5 mg/kg of levamisole were required to elicit immune changes, which were more prominent in patients with minimal tumor burdens. Increased expression of CD64 and class I and class II major histocompatibility antigens on monocytes was also observed. The combination of IFN-gamma and levamisole did not result in greater immunologic effects than those observed in previous trials of IFN-gamma alone.

CONCLUSION

Levamisole induces dose-related immunologic changes in patients with large or minimal tumor burdens. These changes may be involved in the beneficial effects noted in recent adjuvant trials of levamisole. Ongoing clinical trials should correlate immune changes with response, and trials exploring different schedules of administration using higher, more immunologically active, doses of levamisole should be performed.

The role of the mu(1) opioid receptor subtype in the regulation of prolactin and growth hormone secretion by Beta-endorphin in female rats: studies with naloxonazine

The μ opioid receptor subtype has been reported to mediate the prolactin secretory response to opioids. This receptor subtype has been implicated in the morphine-induced prolactin increase, as well as the prolactin response to μ-specific opioid peptides. Subtypes of the μ receptor have been proposed and the μ(1) , site has been postulated as the receptor subtype involved in the morphine-induced prolactin secretory response. However, the role of this receptor subtype in mediating the endocrine effects of the endogenous opioid peptides has not been characterized. In order to determine the physiological significance of this receptor subtype, animals were pretreated with saline, WIN 44,441-3 (a μ, δ and κ antagonist) or naloxonazine (a μ(1) antagonist) followed by a stimulatory dose of morphine or β-endorphin. A dose response study for β-endorphin was conducted to determine the minimal stimulatory dose of β-endorphin on the prolactin and growth hormone (GH) secretory response. The dose response study indicated that β-endorphin is a more potent stimulus for prolactin release than for GH. A dose as low as 25 ng increased prolactin levels as much as 100-fold in both lactating and diestrous female rats. In contrast, 2.5 μg β-endorphin was required in order to consistently and significantly increase circulating levels of GH by 2- to 3-fold. WIN 44,441-3 antagonized the stimulatory effects of β-endorphin on both prolactin and GH secretion. Naloxonazine pretreatment abolished the morphine-induced prolactin secretory response, without affecting the GH increase in diestrous females. Naloxonazine also antagonized the prolactin response to β-endorphin in both lactating and diestrous females. In addition, it attenuated the GH secretory response but did not totally abolish it. These data indicate that β-endorphin elicits an increase in prolactin release through an opioid specific receptor which appears to be the μ(1) opioid receptor subtype. They further suggest that β-endorphin may increase GH levels, at least partially, via its action at this μ(1) site.

Pilot study of interleukin-2 and lymphokine-activated killer cells combined with immunomodulatory doses of chemotherapy and sequenced with interferon alfa-2a in patients with metastatic melanoma and renal cell carcinoma

BACKGROUND

Experiments in animal tumor models suggest that the antitumor effects of interleukin-2 (IL-2) or IL-2 in combination with lymphokine-activated killer (LAK) cells can be enhanced by chemotherapy agents such as cyclophosphamide or doxorubicin or by the biologic agent interferon alpha.

PURPOSE

We determined the toxicity and clinical response rate of an IL-2-LAK cell regimen modified by the addition of moderate, immunomodulatory doses of chemotherapy and sequenced with interferon alfa-2a (IFN alpha-2a) in patients with metastatic melanoma and renal cell carcinoma.

METHODS

IL-2 (3-6 million units/m2 per day) was administered by continuous infusion on days 0-5 and days 11-16. LAK cells were infused on days 11 and 12 or on days 11, 12, and 14. Low doses of cyclophosphamide (300 mg/m2) and doxorubicin (25 mg/m2) were given on day 9 before the LAK cell infusions. Following the IL-2-LAK cell infusion, IFN alpha-2a (12 million units/m2) was administered for a total of nine doses to complete a cycle of treatment. A total of 89 patients were enrolled in the study.

RESULTS

For each histology, there were eight partial responses in 40 assessable patients, for an overall response rate of 20% (90% confidence interval = 10%-33%). The median response duration was 5 months, although two patients with renal cell carcinoma and one patient with metastatic melanoma had almost complete disappearance of tumor and are still responding after 26+, 22+, and 26+ months, respectively. Toxic effects were severe in patients receiving the highest dose of IL-2 administered in this study and similar to those reported with other high-dose IL-2-LAK cell regimens. Although toxic effects were completely reversible in most patients, there were four treatment-related deaths.

CONCLUSIONS

This regimen is active in patients with metastatic melanoma and renal cell carcinoma and produces meaningful responses in a small percentage of these patients; however, it is not clear whether cyclophosphamide, doxorubicin, and IFN alpha-2a as used in this protocol appreciably augmented the antitumor activity of the IL-2-LAK cell regimen.

Effects of immobilization stress on tuberoinfundibular dopaminergic (TIDA) neuronal activity and prolactin levels in lactating and non-lactating female rats

The effects of immobilization stress on the prolactin secretory response and on the activity of the tuberoinfundibular dopaminergic (TIDA) neurons were determined in intact, virgin female rats on the morning of diestrus or proestrus and in post-partum, lactating female rats. The virgin females exhibited a significant increase in circulating levels of prolactin which was evident by 1 minute and persisted during the immobilization (5 minutes). In contrast, the prolactin secretory response in lactating females was significantly attenuated compared to non-lactating animals. The activity of the TIDA neurons was not altered by the 5 minutes of stress. Even after 30 minutes of immobilization, TIDA neuronal activity was not affected in either the lactating or cycling females. These data suggest that the cycling female rat is capable of a prolactin secretory response to the stressor without inhibition of TIDA neuronal activity. It seems likely that prolactin releasing factors mediate this response. In contrast, stress did not produce a similar prolactin increase during lactation. It seems likely that, during lactation, the pituitary is not sensitive to releasing factors unless the TIDA neurons are inhibited. There appear to be differences in the sensitivity of the pituitary depending on the physiological state of the model employed.

New long-acting bromocriptine (Parlodel MR and Parlodel LAR) in the treatment of pituitary tumours with hyperprolactinemia

In order to assess the efficacy and tolerability of new long acting bromocriptine: Parlodel MR (oral form) and Parlodel LAR (injectable form suitable for repeatable administration) 40 patients (29 women and 11 men) with pituitary tumours with hyperprolactinemia (PRL 70 micrograms/l) were investigated in a double blind study. Patients were divided into 2 groups of 20. In the first group Parlodel R or Parlodel MR in equivalent doses was given, the other group was administered Parlodel R or Parlodel LAR. During the next 6 months 20 patients were treated with Parlodel MR and the other 20 with Parlodel LAR. In all patients pituitary and peripheral hormones, CT scan and visual fields were examined before and after 28 days of bromocriptine treatment. During the next six months 20 patients were treated with Parlodel MR while the other 20 with Parlodel LAR. Serum PRL fell in all patients and values in the normal range were obtained in 36 patients. In 30 out of 35 patients with signs of pituitary tumour in CT scan, a significant tumour shrinkage was observed. Most patients achieved considerable clinical improvement: disappearance of galactorrhoea, resumed menses in women, increased potency in men. There were no difference in efficacy in Parlodel R, Parlodel MR and Parlodel LAR, but in the case of Parlodel LAR the least number of side effects was found. Treatment with long acting bromocriptine-Parlodel MR and LAR of patients with pituitary tumours with hyperprolactinemia is an efficacious, safe and better tolerated method than Parlodel R treatment.