Six-year experience of Australia's first dedicated cancer of unknown primary clinic

BACKGROUND

Diagnosis and management of cancers of unknown primary (CUP) remain challenging. This study examines the referral patterns, management and outcomes of patients referred to Australia's first dedicated CUP clinic.

METHODS

Retrospective medical record review was conducted for patients seen at the Peter MacCallum Cancer Centre CUP clinic between July 2014 and August 2020. Overall survival (OS) was analysed for patients with a CUP diagnosis where treatment information was available.

RESULTS

Of 361 patients referred, fewer than half had completed diagnostic work-up at the time of referral. A diagnosis of CUP was established in 137 (38%), malignancy other than CUP in 177 (49%) and benign pathology in 36 (10%) patients. Genomic testing was successfully completed in 62% of patients with initial provisional CUP and impacted management in 32% by identifying a tissue of origin or actionable genomic alteration. The use of site-specific, targeted therapy or immunotherapy was independently associated with longer OS compared to empirical chemotherapy.

CONCLUSION

Our specialised CUP clinic facilitated diagnostic work-up among patients with suspected malignancy and provided access to genomic testing and clinical trials for patients with a CUP diagnosis, all of which are important to improve outcomes in this patient population.

Immune and genomic biomarkers of immunotherapy response in cancer of unknown primary

BACKGROUND

Cancer of unknown primary (CUP) is a heterogeneous group of metastatic cancers where a primary tissue of origin (TOO) is uncertain. Most patients with CUP have limited treatment options and poor survival outcomes. Immune checkpoint inhibitors (ICIs) can be efficacious in some patients with CUP, but the optimal predictive biomarkers are unknown. We therefore assessed immune and genomic biomarkers as well as predicted TOO in patients with CUP, including a subset treated with ICIs.

METHODS

Patients with CUP were subject to gene-expression profiling (GEP) and DNA panel sequencing. Immune and stromal-related gene expression was explored by NanoString, including genes associated with immunotherapy response (IR) in other solid malignancies. ICI responsive cancer types were assigned based on Food and Drug Administration-approved indications, and either detection of a latent primary tumor or the TOO was suspected based on genomics informed pathology review. Tumor mutation burden (TMB) and gene mutations were also assessed.

RESULTS

A total of 219 patients with CUP were included, 215 assessed for TOO in a previous study, with the majority (163) receiving both RNA and DNA tests. Of GEP profiled cases, 33% (59/175) had a high IR gene-expression score. Of the DNA sequenced cases, 16% (32/203) had high TMB (>10 mutations/Mb), including two with mismatch repair deficiency. Low correlation was observed between TMB and an IR score (R=0.26, p<0.001). Among 110 CUPs with a latent primary or suspected TOO, 47% (52/110) belonged to ICI-responsive cancer types. More than half of the CUPs had at least one feature that may predict ICI response (high IR score, high TMB, ICI-responsive cancer type). Among patients with CUP treated with ICIs, 8/28 (29%) responded (2 complete responses and 6 partial responses). Among non-responders, 9 had stable and 11 had progressive disease. All responders had a high IR score (7/8) and/or high TMB (3/8), while most (5/8) belonged to ICI-responsive cancer types. These features were detected at a lower frequency in non-responders and mostly in patients with stable disease.

CONCLUSIONS

A significant fraction of CUP tumors had genomic features previously associated with ICI response. High IR score was the most sensitive predictive feature of ICI response, warranting evaluation in a larger patient series.

A comparison of DNA sequencing and gene expression profiling to assist tissue of origin diagnosis in cancer of unknown primary

Cancer of unknown primary (CUP) is a syndrome defined by clinical absence of a primary cancer after standardised investigations. Gene expression profiling (GEP) and DNA sequencing have been used to predict primary tissue of origin (TOO) in CUP and find molecularly guided treatments; however, a detailed comparison of the diagnostic yield from these two tests has not been described. Here, we compared the diagnostic utility of RNA and DNA tests in 215 CUP patients (82% received both tests) in a prospective Australian study. Based on retrospective assessment of clinicopathological data, 77% (166/215) of CUPs had insufficient evidence to support TOO diagnosis (clinicopathology unresolved). The remainder had either a latent primary diagnosis (10%) or clinicopathological evidence to support a likely TOO diagnosis (13%) (clinicopathology resolved). We applied a microarray (CUPGuide) or custom NanoString 18-class GEP test to 191 CUPs with an accuracy of 91.5% in known metastatic cancers for high-medium confidence predictions. Classification performance was similar in clinicopathology-resolved CUPs - 80% had high-medium predictions and 94% were concordant with pathology. Notably, only 56% of the clinicopathology-unresolved CUPs had high-medium confidence GEP predictions. Diagnostic DNA features were interrogated in 201 CUP tumours guided by the cancer type specificity of mutations observed across 22 cancer types from the AACR Project GENIE database (77,058 tumours) as well as mutational signatures (e.g. smoking). Among the clinicopathology-unresolved CUPs, mutations and mutational signatures provided additional diagnostic evidence in 31% of cases. GEP classification was useful in only 13% of cases and oncoviral detection in 4%. Among CUPs where genomics informed TOO, lung and biliary cancers were the most frequently identified types, while kidney tumours were another identifiable subset. In conclusion, DNA and RNA profiling supported an unconfirmed TOO diagnosis in one-third of CUPs otherwise unresolved by clinicopathology assessment alone. DNA mutation profiling was the more diagnostically informative assay. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Evaluating the utility of fluorine-18 fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET)/ computed tomography (CT) scan in cancer of unknown primary

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Background: Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumours where standardized diagnostic work-up fails to identify the tissue of origin (TOO). Small studies, to date mainly focused on cervical lymph node squamous cell CUP patients, have shown 18F-FDG-PET/CT can change patient management and identify the TOO. We aimed to describe the Peter MacCallum Cancer Centre experience with 18F-FDG PET/CT in CUP with respect to detection of a TOO and its impact on management. A secondary aim was to compare the overall survival (OS) in patients where TOO is detected with those without TOO detection. Methods: Retrospective analysis of CUP patients treated between 2014-2020. Patients were identified from medical oncology clinics and PET/CT records. Information regarding demographics, clinicopathological details, CUP subtype as per ESMO guidelines, genomic analysis (If known), suspected TOO as per clinician pre- and post-FDG PET/CT, treatment details pre- and post FDG PET/CT and follow-up were collated from electronic medical records. Clinical details and genomic analysis were used to determine the clinically suspected TOO and compared against independent blinded nuclear medicine specialist FDG-PET/CT reads to determine sensitivity, specificity, accuracy and detection rate of TOO. Results: One hundred and forty-seven patients were identified of whom 65% had undergone molecular profiling. The median age at diagnosis was 61 years (range 20-84) and the median follow-up time was 69 months (range, 26–83). The predominant histological subtype was adenocarcinoma (54%). Eighteen percent of patients had a prior cancer history and 29% had a 1st degree relative with a history of cancer. Ninety-three percent were ECOG 0-1, and the dominant metastatic site was lymph nodes (35%). Eighty-one percent were classified as unfavourable CUP subtype as per ESMO guidelines. FDG PET/CT demonstrated a TOO detection rate of 34% with high specificity (98%) and moderate accuracy (78%). FDG PET/CT resulted in a change in management in 22% of patients and identified occult disease sites in 37% of patients. The median OS for all patients was 17.8 months. Median OS was not reached and 12.5 months for favourable and unfavourable CUP subtypes, respectively (p < 0.0001). Median OS when a potential TOO was identified on an FDG-PET/CT scan was 25.4 months compared with 9.1 months when a TOO remained elusive. (p < 0.0001). Multivariable analysis of survival adjusted for age and sex remained significant for FDG-PET identification of TOO (p = 0.004), favourable CUP (p < 0.001) and ECOG ≤ 1 (p < 0.001). Conclusions: 18F-FDG PET/CT plays a complementary role in CUP diagnostic work-up and was able to determine the likely TOO in a third of cases. OS is improved with TOO identification, demonstrating the value of access to a diagnostic PET/CT scan for CUP patients.

Treatment patterns after poly-ADP ribose polymerase (PARP) inhibitors in epithelial ovarian cancer patients

OBJECTIVES

The primary objective of this study was to describe treatment patterns after poly-ADP ribose polymerase (PARP) inhibitor in patients with epithelial ovarian cancer. Secondary objectives were to evaluate duration of response, time to first subsequent therapy, progression-free survival and overall survival.

METHODS

This was a retrospective analysis of patients with epithelial ovarian cancer treated with PARP inhibitor therapy at six Australian gynecological oncology centers. Eligible patients were identified via clinics, trial databases and pharmacy dispensing logs between January 2005 and September 2019. Information regarding clinico-pathological characteristics and treatment outcomes were collated from medical records.

RESULTS

A total of 85 patients with epithelial ovarian cancer were identified. Of these, 61% had germline BRCA1/2 mutations, 9% had somatic BRCA1/2 mutations, 5% had confirmed homologous recombination deficiency and 25% were BRCA1/2 wildtype mutations. A total of seventy-seven (91%) patients received chemotherapy after PARP inhibitor, with fifty-six (72.7%) of these patients receiving platinum-based chemotherapy. Four patients (5%) had a complete response, 15 (20%) a partial response, 15 (20%) stable disease and 41 (55%) progressive disease. Median duration of response to chemotherapy was 7.0 months (range 0.2-20.4). Median time to first subsequent therapy was 17.6 and 15.1 months in patients who received a PARP inhibitor as maintenance therapy and treatment, respectively. Median progression-free survival of first line treatment after PARP inhibitor was 9.6, 3.5 and 4.6 months for platinum doublet, single agent platinum and non-platinum chemotherapy, respectively. Adjusting for age and FIGO (Federation of Gynecological Oncologists classification) stage progression-free survival did not differ between treatment groups (p=0.14). Median overall survival for the cohort was 69 months, and patients with platinum sensitive ovarian cancer had improved survival compared with those with platinum refractory or resistant disease.

CONCLUSION

Platinum doublet chemotherapy resulted in non-significant improved progression-free survival compared with other regimens, suggesting potential independent mechanisms of resistance between PARP inhibitor and platinum compounds.

Evaluating the impact of dose reductions and delays on progression-free survival in women with ovarian cancer treated with either three-weekly or dose-dense carboplatin and paclitaxel regimens in the national prospective OPAL cohort study

OBJECTIVES

To determine the impact of chemotherapy dose reductions and dose delays on progression-free survival (PFS) in women with ovarian cancer receiving first line chemotherapy in a real world prospective cohort study.

METHODS

Patients with newly diagnosed epithelial ovarian (or peritoneal, fallopian tube) cancer enrolled in a national Australian prospective study, OPAL, who commenced three-weekly carboplatin (AUC 5 or 6) and paclitaxel 175 mg/m² (CP) or carboplatin (AUC 5 or 6) and dose-dense weekly paclitaxel 80 mg/m² (DD-CP) were eligible. Primary endpoint was PFS.

RESULTS

634 evaluable patients, 309 commenced CP and 325 DD-CP. Patient's age was similar in the two groups (median 62 years, range 21-79). All planned chemotherapy doses were completed by 66% vs 40% (p < 0.001) in the CP and DD-CP groups respectively. There was at least one treatment delay in 28% vs 58% (p < 0.001) in the CP and DD-CP groups, respectively, and 29% vs 49% (p < 0.001), respectively, required at least a 15% dose reduction for either carboplatin or paclitaxel. Median PFS was 29.2 [22.9, 43.8] and 21.5 [19.4, 23.1] months in the CP and DD-CP groups respectively. Adjusting for age, histology and FIGO stage PFS did not differ between treatment groups. Median PFS was similar in patients irrespective of dose reduction or dose delay.

CONCLUSION

Patients receiving DD-CP required more dose reductions and delays due to haematological toxicities and lower completion rates than CP without significant difference in median PFS between CP and DD-CP. Median PFS was similar in patients irrespective of dose reduction or dose delay.

Clinical impact of tissue of origin testing and mutation profiling in the Solving Unknown Primary Cancer (SUPER) national prospective study: Experience of the first two years

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Background: Cancer of unknown primary (CUP) has a poor prognosis with a median survival of less than 12 months. SUPER is a prospective cohort study designed to create a national biobank of patients (pts) with no confirmed primary site following diagnostic work-up. Tumor and blood samples undergo mutational profiling for actionable mutations using the 386 gene PeterMac Comprehensive Cancer Panel (CCP) plus CUPGuide, a microarray gene-expression site-of-origin assay. We aimed to determine the clinical impact of CUPGuide and CCP profiling. Methods: 172 pts were enrolled between 2013-2015. Baseline demographics, treatments, investigations and clinico-pathological characteristics were collected over 12 months. Clinicians completed clinical management questionnaires before and after receiving results. Results: Molecular analysis was performed for 124/172 (72.1%) pts with sufficient DNA and/or RNA. CUPGuide was completed for 97/124 (78.2%); primary site predictions were made in 84/97 patients (86.6%). The most common primary site predictions were lung, gastric, ovary and breast. CUPGuide predictions resulted in a change in management in 10/84 (12%) of cases and confirmed current management already commenced by the clinician in 53/84 (63%). Mutation profiling was completed in 103/124 (83.1%) pts with actionable mutations found in 11 pts, 4 of whom received subsequent targeted therapy. Testing was considered to have a clinical impact in 70/120 cases (58%): either resulting in a change in treatment (n = 14), diagnosis of a pathogenic germline finding (n = 8) or a moderate/high confidence tissue of origin prediction (n = 58). There were two deaths prior to the availability of the CUPGuide results and eleven deaths prior to availability of the CCP results. Conclusions: Molecular analysis for CUP pts has clinical impact in the majority of cases. Timeliness of return of results, drug access and insufficient tissue for testing are barriers to greater impact that need to be addressed to improve the care of pts affected by CUP.

High-dose selective serotonin reuptake inhibitors in OCD: a systematic retrospective case notes survey

This article presents a systematic, retrospective case-note survey of a specialist obsessive-compulsive disorder (OCD) outpatient service. We explore the frequency of 'high-dose' selective serotonin reuptake inhibitor (SSRI) prescribing and describe clinical outcomes in a naturalistic clinical setting. Patients receiving high doses were compared with 'control' cases at the following three time-points: referral, initiation of high-dose SSRI and last clinical assessment.Twenty-six (13.5%) out of 192 patients received high-dose treatment for 3-364 weeks (mean 81.5 weeks; SD = ±95.1). At referral, high-dose patients were significantly more likely than controls to be male, and to have received Cognitive Behavioural Therapy (CBT), although illness severity and complexity did not differ. At initiation of dose escalation, however, high-dose patients were significantly more symptomatic than controls (Yale-Brown Obsessive Compulsive Scale score [Y-BOCS 25.4 vs. 17.7]). At the last assessment, patients on high-dose treatment showed significant within-group improvements (Y-BOCS 25.35 vs. 20.95), although endpoint scores for the high-dose group remained significantly higher than control patients treated for a matched period (Y-BOCS 21.0 vs. 15.5), suggesting enduring treatment-resistance. Frequency of adverse effects did not significantly differ between the two groups. Our results suggest that high-dose SSRI was associated with clinical improvement and well-tolerated in a particularly refractory OCD sample.

Obsessive-compulsive disorder in UK clozapine-treated schizophrenia and schizoaffective disorder: a cause for clinical concern

The association between schizophrenia and obsessive-compulsive disorder (OCD) is complex. This study systematically examined a UK cohort of clozapine-treated individuals with schizophrenia/schizoaffective disorder. Fourteen of 59 cases (24%) scored positively on item H of the Mini-International Neuropsychiatric Interview (MINI) for OCD. The mean Yale- Brown Obsessive-Compulsive Scale (Y-BOCS) score in MINI-positive cases was 17.6 (SD+/-6.3). Sixty-four percent scored 16 or more on the Y-BOCS, representing clinically meaningful illness severity. Seven (50%) patients with OCD had previously received the diagnosis by their treating clinicians and were already receiving with selective serotonin re-uptake inhibitors (SSRIs) treatment. OCD cases scored significantly worse than their non-OCD counterparts on the Abnormal Involuntary Movement Scale (P=0.01) and the Simpson Angus Scale (SAS; P=0.01). There was also a non-significant trend toward higher ratings for OCD cases on the Clinical Global Impression-Schizophrenia scale (P=0.06). Comparing the OCD cases taking SSRI (n=7) with those not on SSRI (n=7), significant differences emerged on the SAS (P=0.03). Our results suggest that OCD is common among patients receiving clozapine for schizophrenic disorders and that the comorbidity is associated with greater motoric impairment. The role of medication in this condition remains unclear.

Defining remission by cut off score on the MADRS: selecting the optimal value

BACKGROUND

Remission from major depression may be conceptualised in terms of a cut-off score on an appropriate rating scale. Candidate values proposed hitherto have not been directly validated.

METHOD

The relationship between The Clinical Global Impression Scale for Severity (CGI-S) and the Montgomery-Asberg Depression Rating Scale (MADRS) was explored in 684 major depressed patients (1114 observations). The value on the MADRS which had greatest concordance with remission, as defined by the CGI-S, was computed using two models. Concordance between clinician and patient judgements of global illness were also compared.

RESULTS AND CONCLUSION

The two models yielded optimal definitions of remission of <9 and <10 on the MADRS. Either value offers a workable operationalisation of remission and there is little to choose between them.

CLINICAL RELEVANCE

The data confirm that MADRS <10 should provide the clinician with a valid, and reasonably objectifiable, target for remission

How does the threshold score to enter a major depression trial influence the size of the available patient population for study?

BACKGROUND

This paper describes the relationship between entry criteria and eligible population for inclusion in Major Depression (MD) clinical trials. Inclusion criteria for a MD study typically require patients to pass a threshold score on a depression rating scale, most commonly the HAM-D or MADRS. A Score To Enter (STE) of > or = 17 on the HAM-D 17-item scale is a typical value, although higher values (i.e. > or = 22 or even > or = 25 points) are often used. It is commonly supposed that patients with higher baseline scores form a more sensitive sample for discriminating active drug from placebo.

METHOD

We present data from a sample of depressed hospital outpatients and describe their general characteristics. We then introduce a model, based upon this sample, which predicts the impact of STE on eligible trial population.

RESULTS AND CONCLUSION

A small increase in STE has a marked effect on eligible population: an increase in HAM-D (17 item) STE from 17 to 21 and 25 reduces the eligible population by 42 and 76%, respectively. These predictions are reasonably robust when our model is validated with known clinical trial data.

CLINICAL RELEVANCE

Our findings have major implications for planning and managing Major Depression trials as higher STEs substantially restrict the proportion of patient eligible for study.

Risk assessment for people with mental health problems: a pilot study of reliability in working practice

INTRODUCTION

This paper describes a pilot study of reliability in the risk assessment of people with mental health problems. Specifically, we explore the evidence for professional and gender bias in ratings, in addition to the general level of agreement between raters.

METHOD

Six professional groups (psychiatrists, junior psychiatric doctors, nurses, community psychiatric nurses, social workers and occupational therapists) participated in the study and rated 159 patients on a nine-item scale which assessed different components of risk.

RESULTS

Contrary to some earlier work, we found no clear evidence that any one group consistently rated more extremely than any other group. Women were more cautious than men in their ratings, and this concurs with previous studies. Finally, a reliability study of randomly selected pairs of raters showed only moderate levels of agreement and, in some instances, the levels of disagreement were high enough to warrant concern.

CONCLUSION

These findings are discussed in the context of current risk assessment practice and the problems associated with investigating reliability in naturalistic settings and designing appropriate rating tools for risk. (Int J Psych Clin Pract 2002; 6: 73-81).

Efficacy, safety and tolerability of combined administration of lithium and selective serotonin reuptake inhibitors: a review of the current evidence. Hertfordshire Neuroscience Research Group

Several case reports have engendered concern about the safety of coadministering lithium and selective serotonin reuptake inhibitor (SSRI) antidepressants and there are theoretical reasons to suppose that lithium and serotonergic antidepressants may be associated with dangerous interactions. Systematic reports regarding combination therapy with lithium and SSRI antidepressants were assimilated for the purpose of this review. Although there are many publications, few are directly informative as to safety and tolerability. A total of 503 patients are considered in systematic reports and, among these, no serious or life-threatening adverse events can be identified. Such data as there are demonstrate little potential for toxic interactions between lithium and SSRIs, although new, non-serious, adverse events do frequently arise. The evidence for the efficacy of addition of lithium to SSRIs in treatment refractory depression is only provisional.

Combination therapy with nefazodone and lithium: Safety and tolerability in fourteen patients

Fourteen patients with major depression, resistant to previous pharmacotherapies, were treated by the addition of lithium (target range 0.6-0.8 mmol/l) to nefazodone (≥400 mg/day) and were prospectively monitored for 6 weeks to assess safety and tolerability. There were 42 emergent adverse events-most commonly headache, nausea, gastro-intestinal disturbances, tremor, polyuria/polydipsia, dry mouth and tiredness. Information on ten additional patients receiving combined treatment with lithium and nefazodone was collected by retrospective chart review, and it was found that similar adverse events (tremor, dry mouth and tiredness) had occurred in these patients. We conclude that when lithium is added to nefazodone, new adverse events do occur, but that the treatment is safe and tolerable.

A protocol for the pharmacologic treatment of major depression. A field test of a potential prototype

BACKGROUND

Much attention is being given to developing clinical practice guidelines for management of mental health disorders. The aim of this study was to field test a prototype protocol for the pharmacologic treatment of Major Depression.

METHOD

The protocol consisted of four, six week, treatment phases with critical choices in therapy defined by scores on the MADRS (Montgomery Asberg Depression Rating Scale). Observational data as collected on the behaviour of the protocol in terms of relevance, acceptability, ease of use and effectiveness.

RESULTS

Effectiveness of the protocol was good for those patients who were retained within it, with three quarters of them attaining remission. However more than half of all patients dropped out-non attendance and adverse events being the most common reasons for this.

CONCLUSION

The protocol for the treatment of Major Depression appeared relevant, easy to use and potentially effective.

LIMITATION

Problems with non-adherence by both doctors and patients posed major challenges to the protocol's design. Such difficulties demonstrate the need to field test any proposed design as preconceptions about a protocol's performance may be misplaced.

CLINICAL RELEVANCE

The protocol tested represents progress towards the goal of developing optimal strategies for the use of pharmacotherapeutic agents in the treatment of depression.

A preliminary study to examine the adequacy of long-term treatment of depression and the extent of recovery in general practice

About 1% of patients in general practice take antidepressants for long periods. Many receive repeat prescriptions, without review. It might be assumed that these patients are well and are on adequate maintenance treatment. Our findings refute this assumption; of 78 patients on long-term repeats, only a third were in remission and a fifth had Beck Depression Inventory scores suggesting persisting syndromal major depression. Subtherapeutic dosing of classic tricyclics was the norm rather than the exception. Patients on long term antidepressant treatment need regular review and adequate treatment to ensure remission is maintained.

Studies of intestinal permeability in inflammatory diseases using polyethylene glycol 400

It has been proposed that increased bowel permeability might play a role in the pathogenesis of inflammatory disease. Intestinal permeation was investigated by measuring the 6-hour urinary excretion of polyethylene glycol (PEG) 400 in 40 adult volunteer controls and in patients with inflammatory disease. Of the patients, 15 had Crohn's disease; 7, ulcerative colitis; 2, celiac disease; and 7, rheumatoid arthritis. No significant difference in total urinary excretion over a 6-hour period was found between controls and patients with ulcerative colitis. Patients with Crohn's disease, celiac disease, or with rheumatoid arthritis were found to have significantly decreased urinary excretion of PEG 400. The results of this study indicate that there is no identifiable increase in intestinal permeation as measured by PEG 400 excretion during periods of active inflammatory disease.

The effect of temperature and pH on the stability of human pepsin in stored gastric juice. A method to prevent activity loss

The mechanisms controlling pepsin secretion are controversial. A contributory factor may be storage-dependent effects. We have studied the effects of temperature, pH, and storage time on human gastric pepsin. Gastric juice samples taken from three healthy volunteers under both basal and post-pentagastrin-stimulated (6 micrograms/kg subcutaneously) conditions were separated into four aliquots. Each aliquot was titrated to pH 1, 4, or 6 or left at ambient pH. Aliquots were then stored at 4 degrees C or frozen at -70 degrees C and stored. On days 1, 3, 7, and 28 aliquots were removed and assayed by the kinetic albumin-bromphenol blue method. In a second experiment we determined the effects of different concentrations of glycerol on the preservation of peptic activity. From these experiments we conclude that pepsin is unstable when stored frozen at low pH but not when stored above pH 2. This pH-dependent stability may explain the variable conclusions other workers report on optimal methods of storing gastric juice. In addition, we have confirmed the suitability of glycerol as a preservative of peptic activity and recommend that gastric juice be stored frozen with 11.5% glycerol.

Beclomethasone dipropionate enemas for treating inflammatory bowel disease without producing Cushing's syndrome or hypothalamic pituitary adrenal suppression

Since beclomethasone dipropionate (BDP) is a very potent glucocorticoid and since small oral doses (1 mg) seem to be metabolised (possibly in the gut wall or liver) before they reach the systemic circulation, a study was conducted to find out whether patients with inflammatory bowel disease could be treated with enemas containing small doses of BDP without their acquiring Cushing's syndrome or hypothalamic pituitary adrenal (HPA) suppression. The BDP in the 100 ml enemas used was stable and present in a concentration likely to be therapeutic (0.5 mg/dl). Single overnight BDP enemas, unlike conventional betamethasone (5 mg) enemas, did not interfere with the HPA axis in 6 healthy volunteers. In the double-blind randomised part of the study 2-week courses of BDP or betamethasone enemas were assessed in 9 patients having exacerbations of distal inflammatory bowel disease. The clinical and sigmoidoscopic responses as well as adrenocortical function (judged by the 'Cosyntropin' test) were evaluated on the morning after the last day of a course of enemas. Both types of enemas had similar beneficial effects, but only BDP enemas did not interfere with HPA function. Over a prolonged period, a patient with distal ulcerative colitis had been completely dependent on regular treatment with betamethasone enemas to control his symptoms. Substitution with BDP enemas successfully controlled his bowel symptoms, whilst his cushingoid features and HPA suppression regressed.

Relationship between cortisol and lecithin/sphingomyelin ratios in human amniotic fluid

Amniotic fluid was obtained from 85 women during the last trimester of gastation and analyzed for cortisol by a radioimmunoassay procedure and for lecithin/sphingomyelin (L/S) ratios by a combined thin-layer chromatography densitometer scanning technique. A total of 114 samples were examined. Cortisol values ranged from 38 to 438 ng. per milliliter; L/S ratios ranged from 0.3 to 9.2. Comparison of cortisol levels with L/S ratios by multiple regression analysis gave an "r" value of 0.371. From less than 32 weeks' gestation to 41 or 42 weeks there was an increase in cortisol levels from 139 plus or minus 124 to 290 plus or minus 78 ng. per milliliter whereas the L/S ratios increased from 1.8 plus or minus 2.3 to 3.9 plus or minus 2.0. These data indicate that there is no good correlation between cortisol and L/S ratios in the samples of amniotic fluid analyzed.

Selective benzoylation of benzyl β-l-arabinopyranoside and benzyl α-d-xylopyranoside

Benzoylation of benzyl β-l-arabinopyranoside with 2.2 molar equivalents of benzoyl chloride gave benzyl 2,3-di-O-benzoyl-β-l-arabinopyranoside (65–70%) and benzyl 2,3,4-tri-O-benzoyl-β-l-arabinopyranoside (10–15%). Benzyl α-d-xylopyranoside, under similar conditions, gave benzyl 2,4-di-O-benzoyl-α-d-xylopyranoside (45%), benzyl 2,3-di-O-benzoyl-α-d-xylopyranoside (27%), benzyl 2,3,4-tri-O-benzoyl-α-d-xylopyranoside (15%), and benzyl 2-O-benzoyl-α-d-xylopyranoside (9%). Several new derivatives of benzyl β-l-arabinopyranoside and benzyl α-d-xylopyranoside have been prepared. These benzoates lead to the ready preparation of 4-O-substituted l-arabinose and d-xylose derivatives. These results are compared with those obtained for the selective benzoylation of hexopyranosides.