Ginger for chemotherapy-related nausea in cancer patients: A URCC CCOP randomized, double-blind, placebo-controlled clinical trial of 644 cancer patients

9511

Background: Despite the widespread use of antiemetics, post-chemotherapy nausea and vomiting continue to be reported by up to 70% of patients receiving chemotherapy. Ginger (Zingiber Officinale), an ancient spice, is used by practitioners worldwide to treat nausea and vomiting. We conducted a multi-site, phase II/III randomized, placebo-controlled, double-blind clinical trial to assess the efficacy of ginger for chemotherapy-related nausea in cancer patients at the University of Rochester-affiliated Community Clinical Oncology Program (CCOP) member sites. Methods: Cancer patients who experienced nausea following any chemotherapy cycle and were scheduled to receive at least three additional cycles were eligible. Patients were randomized into four arms: 1) placebo, 2) 0.5g ginger, 3) 1.0g ginger, or 4) 1.5g ginger. All patients received 5-HT3 receptor antagonist antiemetics on Day 1 of all cycles and took three 250mg capsules of ginger or placebo twice daily for six days starting three days before the first day of the next two cycles. Patients reported the severity of nausea during the morning, afternoon, evening, and night on a 7-point semantic rating scale (‘1' = ‘Not at all Nauseated' and ‘7' = “Extremely Nauseated”) for Days 1–4 of each cycle. The goal was to determine if ginger was more effective than placebo in controlling chemotherapy-related nausea in participants given a 5-HT3 receptor antagonist antiemetic. Results: A total of 644 patients were accrued (90% female, mean age = 53). Breast (66%), alimentary (6.5%), and lung (6.1%) cancers were the most common cancer types. Analysis of covariance (ANCOVA) examined change in nausea in the four study arms on Day 1 of cycles 2 and 3. All doses of ginger significantly reduced nausea (p=0.003). The largest reduction in nausea occurred with 0.5g and 1.0g of ginger. Also, time of day had a significant effect on nausea (p<0.001) with a linear decrease over 24 hours for patients using ginger. Conclusions: Ginger supplementation at daily dose of 0.5g-1.0g significantly aids in reduction of nausea during the first day of chemotherapy. Supported by NCI PHS grants 1R25CA10618 and U10CA37420.

No significant financial relationships to disclose.

The Advanced Renal Cell Carcinoma Sorafenib (ARCCS) expanded access trial: Long-term outcomes in first-line patients (pts)

5096

Background: Sorafenib (SOR) doubled median progression-free survival (PFS) versus placebo in a phase III study (TARGETs) for previously treated pts with clear cell renal cell carcinoma (RCC). We report on pts who had not received any prior systemic anti- cancer therapy (1st line) for advanced RCC from the ARCCS program in the US and Canada, which enrolled a broad range of pts. Methods: Pts received SOR 400 mg bid in the ARCCS open-label, nonrandomized treatment protocol if they were =15 years old with advanced (unresectable, recurrent or metastatic) RCC and had ECOG PS 0–2. In the US, ARCCS enrollment ended with SOR approval in 12/05, and pts were transitioned to commercial drug with 1st line pts being eligible for an additional 6-mo follow-up in an extension protocol (EP); Canadian enrollment completed in 8/06. Response evaluation (baseline and =1 post-baseline radiologic assessment) was conducted every 4 wks in the main study and every 8 wks during the EP. Pts without a confirmatory scan were classified as unconfirmed PR. The primary efficacy analysis on PFS was pre-specified to be performed only on the EP-enrolled pts. Results: Of the 2,488 pts valid for safety in ARCCS, nearly 50% were 1st line (n=1239) of which 69% were male with median age 65 yrs; 77% had prior nephrectomy and 29% had prior radiotherapy. Time from diagnoses to treatment was <1 yr for 52% and =1 yr 36% in these 1st line pts. Grade 3 and 4 adverse events with >2% incidence included hand-foot skin reaction 7.7%, fatigue 4.7%, hypertension 3.8%, rash/desquamation 5.2%, dehydration 2.9, diarrhea and dyspnea 2.6%. Confirmed responses are reported in the table ; 15% had unconfirmed PRs. For the 224 1st line pts enrolled in the EP, median PFS was 35.1 wks (95% CI; 32.7, 41.9). Conclusions: SOR toxicity in 1st line pts appeared similar to that in both overall and 2nd line populations previously reported in the phase III study. The PFS among patients enrolled in the EP is encouraging, but may be biased by low enrollment and selection for non-progressors.

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The taxane-enhancer STA-4783 induces Hsp70 expression and apoptosis via an oxidative stress mechanism

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Background: STA-4783 is an inducer of Hsp70 expression and apoptosis that recently completed a successful Phase II clinical trial in melanoma. In a double-blind, randomized, controlled trial in patients with Stage IV disease, STA-4783 plus paclitaxel doubled progression-free survival compared to paclitaxel alone (Perspectives in Melanoma X and the Third International Melanoma Research Congress, 2006). The mechanism by which STA-4783 synergizes with paclitaxel is not fully understood. To identify the major pathway modulated by STA- 4783 in vitro, a transcriptional profiling analysis of drug-treated melanoma cells was performed. Methods: Transcriptional profiling was performed on Hs294T and MDA-MB-435 melanoma cell lines treated with STA-4783. The induction of Hsp70 RNA and other human genes was monitored by Real Time-PCR (RT-PCR) analysis. Measurement of reactive oxygen species (ROS) was performed in human cells using the Carboxy-H2DCFDA probe. Levels of apoptotic cell death were determined by flow cytometry analysis using an Annexin V specific probe. Results: Transcriptional profiling revealed that STA-4783 induced the expression of numerous gene families known to be regulated by oxidative stress, including heat shock proteins and metallothioneins. STA-4783 induced the generation of ROS in cells resulting in the oxidation and activation of the Carboxy-H2DCFDA fluorescent probe. The antioxidants N-Acetyl Cysteine (NAC) and Tiron potently blocked the induction of Hsp70 RNA and apoptotic cell death. Conclusions: STA-4783 induces oxidative stress in cells resulting in Hsp70 induction and apoptotic cell death. Although STA-4783 initially induced a transient protective response, apoptotic cell death occurred due to sustained oxidative stress. Cancer cells produce more ROS than normal cells and are thus more sensitive to insults that induce oxidative stress. The induction of ROS in melanoma cells by STA-4783 may therefore enhance the efficacy of paclitaxel in vivo. STA-4783 belongs to a novel class of anticancer agents that induce cell death by pushing the cancer cell beyond its oxidative stress breaking point.

[Table: see text]

Phase II randomized trial of docetaxel plus cetuximab or bortezomib in patients with advanced NSCLC and performance status (PS) 2—CALGB 30402

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Background: There is no standard treatment for patients (pts) with advanced NSCLC and PS 2. Docetaxel (D) is active and well tolerated on a weekly schedule. Cetuximab (C) and Bortezomib (B) are new agents with activity in NSCLC. We explored these two new combinations in PS 2 pts. Methods: In a multi-center randomized phase II trial, untreated pts with advanced NSCLC and PS 2 were randomized to D 30 mg/m2 d1,8,15 q. 28 days in combination with either C 400 mg/m2 week 1 then 250 mg/m2 weekly, or B 1.6 mg/m2 d1,8,15 q. 28 days for 4 cycles. Pts with CR/PR/SD were allowed to continue C or B until PD. The study was non-comparative and the primary endpoint was progression-free survival (PFS) rate at 6 months. The trial had a type I error of 0.0746 and power of 0.9 to differentiate a 6-mo PFS of <20% vs. >42%. Results: 64 pts were enrolled between 7/05 and 9/06. 5 were ineligible and 3 never received protocol treatment. Results are reported for 55 pts (27 D+C; 28 D+B). Most pts had stage IV adenoCa and 13% had brain metastases. Median age was 70 (range, 35–88) and 65% were male. Response: 10.5% for D+C and 13.6% for D+B. Median PFS was 3.1 mo for D+C and 1.8 mo for D+B. PFS rates at 4 mo (data not yet mature for 6-mo): 33% and 28%, respectively. Median survival: 3.8 mo for D+C and 3.3 mo for D+B. Gr 3/4 hematologic toxicity was 17% in both arms. Gr 3/4 non-heme toxicities were 44% in D+C and 36% in D+B arm. 5 pts died of treatment-related toxicities (3 D+C; 2 D+B). Conclusions: These results confirm the poor prognosis associated with a PS of 2. Based on our preliminary analysis, neither combination produced results that justify further research in this subset of patients. The treatment of PS 2 patients with advanced NSCLC remains a vexing problem and new approaches are urgently needed.

No significant financial relationships to disclose.

Does an oral analgesic protocol improve pain control for patients with cancer? An intergroup study coordinated by the Eastern Cooperative Oncology Group

BACKGROUND

Cancer pain is highly prevalent and commonly undertreated. This study was designed to determine whether dissemination of a clinical protocol for pain management would improve outcomes in community oncology practices.

PATIENTS AND METHODS

A pain management protocol was developed based on accepted guidelines. After baseline assessment, oncology practices were randomly assigned to 'analgesic protocol' (AP) sites, where oncologists implemented the guidelines in a group of lung or prostate cancer patients, or to 'physician discretion' (PD) sites, where customary treatment was continued. Patients treated on protocol and a comparison group of patients with pain due to breast cancer or myeloma were monitored for change in pain using the Brief Pain Inventory, and for change in other symptoms or mood.

RESULTS

The protocol terminated early because of poor accrual. We compared groups using proportions of patients who had no or mild pain at follow-up. Although measures of protocol adherence did not suggest the occurrence of major practice change, the proportion of lung or prostate cancer patients with no or mild pain increased significantly from baseline for those treated at AP sites compared with those treated at PD sites. There was no significant difference between the breast and myeloma patients treated at AP sites versus those treated at PD sites.

CONCLUSION

A protocol for cancer pain management can improve pain control. Diffusion of these benefits to other patients was not confirmed. Given the small sample size, these findings require confirmation in a larger trial.

Phase I study of gemcitabine and carboplatin in advanced non-small cell lung carcinoma

BACKGROUND

This phase I study was designed to determine the maximum tolerated dose of carboplatin with a fixed dose of gemcitabine without growth factor or hematopoietic precursor support.

METHODS

Nineteen patients with previously untreated non-small cell lung cancer (NSCLC) were treated at three dose levels. Initially, the gemcitabine dose was 1000 mg/m(2) given on days 1 and 8. Of the first five patients treated with carboplatin AUC 4, three experienced dose limiting toxicity (DLT). The study was, therefore, amended to decrease the dose of gemcitabine to 800 mg/m(2) given on days 1 and 8 in a 21-day cycle.

RESULTS

Dose limiting toxicity (neutropenia and thrombocytopenia) were seen at dose level 2A (carboplatin AUC=5). Thus, no further dose escalation was performed. Grade 3 and 4 toxicities were seen as follows: leukopenia in five of 18 (28%); neutropenia, four of 18 (22%); and thrombocytopenia, four of 18 (22%) evaluable patients. Grade 3 or 4 anemia occurred in one of 18 (6%) patients and no neutropenic fever or treatment related mortality was observed. Partial responses were seen in six patients and one patient with evaluable disease had an objective response. The overall response rate was 37% (seven of 19). Six other patients had stable disease. A total of 89 courses were administered with a median of five courses per patient (range: two to six courses). The median time to progression for all patients was 3.7 months. The median overall survival was 7.4 months with four patients still alive (median follow up 13.5 months). The survival at 6 months and 1 year is 64 and 23%, respectively.

CONCLUSION

The maximum tolerated dose (MTD) in this group of patients was defined as carboplatin AUC 4 when administered with gemcitabine 800 mg/m(2) on days 1 and 8 of a 21-day schedule.

Hydrocortisone with or without mitoxantrone in men with hormone-refractory prostate cancer: results of the cancer and leukemia group B 9182 study

PURPOSE

Approximately 40,000 men die each year of hormone-refractory prostate cancer (HRPC). The results of treatment with chemotherapy have been disappointing to date, with no trials demonstrating a benefit with respect to survival duration. Corticosteroids and mitoxantrone each have been shown to be active agents in this disease. The purpose of this study was to demonstrate an advantage of mitoxantrone and hydrocortisone (M+H) over hydrocortisone alone with respect to survival duration.

PATIENTS AND METHODS

Two hundred forty-two patients with HRPC were randomized to receive either M+H or hydrocortisone alone. Patients were monitored for survival, time to disease progression, time to treatment failure, response, and quality-of-life (QOL) parameters.

RESULTS

Treatment in both arms was well tolerated. Although there was a delay in time to treatment failure and disease progression in favor of M+H over hydrocortisone alone, there was no difference in overall survival (12.3 months for M+H v 12.6 months for hydrocortisone alone). There was an indication that QOL was better with M+H, in particular with respect to pain control.

CONCLUSION

M+H generated more frequent responses and a delay in both time to treatment failure and disease progression compared with hydrocortisone alone. In addition, there was a possible benefit of M+H with respect to pain control over hydrocortisone alone. No improvement in survival was observed. Although M+H could be viewed as a palliative option for patients with HRPC, new drugs and novel strategies are needed to improve survival for this disease.

Dose-response trial of megestrol acetate in advanced breast cancer: cancer and leukemia group B phase III study 8741

PURPOSE

To investigate whether dose escalation of megestrol acetate (MA) improves response rate and survival in comparison with standard doses of MA.

PATIENTS AND METHODS

Three hundred sixty-eight patients with metastatic breast cancer, positive and/or unknown estrogen and progesterone receptors, zero or one prior trial of hormonal therapy, and no prior chemotherapy for metastatic disease were prospectively randomized into three groups. The groups of patients received either MA 160 mg/d (one tablet per day), MA 800 mg/d (five tablets per day), or MA 1,600 mg/d (10 tablets per day).

RESULTS

Patient characteristics were well balanced in the three treatment groups. Three hundred sixty-six patients received treatment and were included in the analyses. The response rates were 23%, 27%, and 27% for the 160-mg, 800-mg, and 1,600-mg arms, respectively. Response duration correlated inversely with dose. Median durations of response were 17 months, 14 months, and 8 months for the 160-mg, 800-mg, and 1,600-mg arms, respectively. No significant differences in the treatment arms were noted for time to disease progression or for survival; survival medians were 28 months (low dose), 24 months (mid dose) and 29 months (high dose). The most frequent and troublesome toxicity, weight gain, was dose-related, with approximately 20% of patients on the two higher-dose arms reporting weight gain of more than 20% of their prestudy weight, compared with only 2% in the 160-mg dose arm.

CONCLUSION

With a median follow-up of 8 years, these results demonstrate no advantage for dose escalation of MA in the treatment of metastatic breast cancer.

Mechlorethamine, vincristine, and procarbazine chemotherapy for recurrent high-grade glioma in adults: a phase II study

We undertook a phase II study of combination chemotherapy with mechlorethamine (nitrogen mustard) 6 mg/m2 intravenously day 1 and day 8, vincristine 2 mg intravenously day 1 and day 8, and procarbazine 100 mg/m2 orally days 1 through 14 (MOP) in adults with recurrent high-grade glioma. There were 31 patients entered and 27 patients assessable for response. The median age was 49 years old. All patients had prior maximal radiotherapy, and eight had previous chemotherapy. Responses were determined based on clinical and computed tomographic (CT) scan/magnetic resonance imaging (MRI) criteria. The response rate (partial response [PR] plus objective qualitative response [OQR] plus complete response [CR]) was 52% with one CR. The response rate was higher in patients with anaplastic astrocytoma as compared with glioblastoma multiforme (P less than .05). The median duration of response was 42 weeks. Median survival for all assessable patients was 30 weeks, and for responders, it was 60 weeks. Response was correlated with ability to decrease dexamethasone doses and improved performance status. Toxicity was mainly hematologic with leukopenia being common. There was one treatment-related death from listeria meningitis, and two patients developed Pneumocystis carinii pneumonia. There were three episodes of neutropenic fever. We conclude that MOP is active and merits further investigation in adult high-grade glioma.

Comparison of three remission induction regimens and two postinduction strategies for the treatment of acute nonlymphocytic leukemia: a cancer and leukemia group B study

Patients with acute nonlymphocytic leukemia were randomized to receive remission induction therapy consisting of seven days of cytosine arabinoside and three days of daunorubicin ("7 + 3") or to receive the same regimen intensified by either the addition of 6-thioguanine or by extension of the administration of cytosine arabinoside to ten days. Additionally, all patients were randomized to receive or not to receive cotrimoxazole antibacterial prophylaxis during the remission induction phase. Neither an increase in intensity of chemotherapy nor the antibacterial prophylaxis increased the remission rate above the 53% for patients treated with the standard "7 + 3" regimen. The second part of this study addressed the issue of the utility of long-term maintenance chemotherapy. To this end, patients were randomized to discontinue all treatment after 8 months of maintenance chemotherapy or to continue maintenance therapy for a total of 3 years. Although there was a transient increase in the relapse rate for patients who discontinued therapy, the proportion of long-term remitters was identical in the two patient groups. Additionally, there is a suggestion of a survival advantage for patients randomized to discontinue all therapy at 8 months.

Intensive remission consolidation therapy in the treatment of acute nonlymphocytic leukemia

A pilot study was conducted to determine the possible efficacy and the toxicities associated with the administration of four courses of intensive consolidation chemotherapy to patients with acute nonlymphocytic leukemia in remission. All therapy was completed within 6 months. The median duration of remission was 22 months, with 45+% of patients in remission at 3 years and few relapses to date thereafter. Sixty percent of patients experienced significant side effects after each course of therapy. The therapy appeared to be particularly efficacious for patients less than 45 years of age, since 65% are alive at 3 years and there is no projection for a median duration of remission as yet. The cytogenetic characteristics of the leukemic cells, the percentage of S phase cells, and the height of the WBC count were the most important prognostic characteristics at diagnosis.

Differences between labeling index and DNA histograms in assessing S-phase cells from a homogeneous group of chronic phase CML patients

The reliability of DNA histogram analysis in accurately estimating S-phase cells from human tumors was tested by comparing the results to those of simultaneously obtained tritiated thymidine labeling index (LI) studies. Patients with chronic myelocytic leukemia (CML) during chronic phase were selected for study because the Philadelphia chromosome (Ph) was the only cytogenetic abnormality in each case and, since it is a balanced translocation, the frequently encountered problem of aneuploidy in human neoplastic cells was avoided. Unfortunately, when 30 CML patients were studied simultaneously by DNA histogram analysis and LI studies, the correlation coefficient between the two results was only r = 0.611. A comparison of three different mathematical programs for DNA histogram analysis showed that none was completely satisfactory. We conclude that DNA histogram analysis does not provide the same data as autoradiographically processed labeling index studies even in patients with Ph-positive CML during the chronic phase when the situation is not complicated by additional aneuploidy.

Epidemics in Renaissance Florence

Epidemics and mortality in 15th and 16th century Florence, Italy, were investigated by use of records of the government-sponsored Dowry Fund. These records contain the date of birth, date of investment, and date of dowry payment or death of 19,000 girls and women. Major epidemics ("plagues") occurred repeatedly. The most severe were in 1430, 1437-38, 1449-50, 1478-79, and 1527-31. Annual death rates of girls enrolled in the Dowry Fund increased by 5 to 10 times in each of these periods. During the last period, at least 20-25 per cent of the population of Florence is likely to have died. Recurrent epidemics accounted for 38 per cent of the total mortality experienced by girls enrolled in the Dowry Fund. The frequency of serious epidemics diminished with the passage of time, and overall mortality declined by about 10 per cent over the 15th and 16th centuries. Epidermic mortality was not consistently related to age. The effects of epidemics were most severe in the summer and autumn. Non-epidemic mortality was also greater in the summer and autumn than in the winter and spring.

T-cell depletion of bone marrow does not inhibit in vitro hematopoiesis

One approach to overcome the problem of histoincompatibility in bone marrow transplantation is to use T cell depleted marrow from a haploidentical donor in an attempt to ameliorate graft-versus-host disease. Since the T cell requirements for normal hematopoiesis are uncertain, experiments were performed to study the effects of E rosette-T cell depletion on in vitro growth of hematopoietic progenitor cells. Marrow mononuclear cells were cultured in a modified CFU-GEMM assay before and after T cell depletion. The number of 7 day granulocytic and erythrocytic colonies, and 14 day granulocytic, erythrocytic and mixed colonies were enumerated and expressed in terms of colonies per 10(5) non T cells plated. T cell depletion did not result in decreased proliferation of any of these progenitors save possibly for 14 day granulocytic colonies in one of four experiments. In two cases, T cell depletion resulted in increased growth of progenitor cells. Three of four patients transplanted with T cell depleted haploidentical marrow cells engrafted. It is concluded that E rosette depletion of T cells from marrow does not decrease the potential of these cells to establish hematopoiesis in vitro or in vivo.

Lack of relationship between in vitro cell measurements and response to busulfan in chronic myelocytic leukemia

Twenty-three patients with chronic-phase CML have been treated with intermittent courses of busulfan to determine if the duration of unmaintained remission becomes progressively shorter with successive courses of therapy and to determine whether there was a relationship between cluster and colony formation, suicide index of CFUc, labeling index, percentage of cells in S-phase (as determined by cytofluorographic DNA histogram analysis), in vitro sensitivity of the CFUc to busulfan, and response to busulfan therapy. Serial studies in individual patients and the group as a whole revealed no relationship between changes in the cellular parameters described above and response to busulfan. The white blood cell (WBC) doubling time with serial courses of busulfan in individual patients did not always progressively decrease as has been previously reported. In vitro studies of CFUc in chronic-phase CML appear to be of no value in predicting response to busulfan.

Treatment of myeloid blastic crisis of chronic myelogenous leukemia

Patients with myeloid blastic crisis of chronic myelogenous leukemia were treated by chemotherapy or by autologous hematopoietic reconstitution after aggressive chemotherapy. Chemotherapy alone failed to produce a second chronic phase. Autologous transplantation resulted in the establishment of a second chronic phase in two of ten patients treated with a four-drug regimen, while treatment with high-dose cytarabine with or without busulfan resulted in the establishment of a second chronic phase in three of six patients and the return of normal hematopoiesis in a fourth. Consolidation chemotherapy appeared to be beneficial.

In vitro drug sensitivity studies of colony-forming units in culture in chronic myelocytic leukemia: lack of specificity between chronic-phase patients and normal donors

Attempts to eliminate Philadelphia chromosome-positive cells during the treatment of chronic-phase chronic myelocytic leukemia (CML) have been largely unsuccessful, probably due to the lack of specificity of drugs which have been used. In an attempt to develop more specific therapy for CML, an assay for colony-forming units in culture was used to test for differences between CML blood and normal marrow progenitor cells. The following drugs, which have activity in acute nonlymphocytic leukemia, were tested over a range of concentrations achievable in vivo: Adriamycin; 1-beta-D-arabinofuranosylcytosine; aclacinomycin; m(4-acridinylamino)-3-methoxyphenyl methansulfamide; methylglyoxalbis(guanylhydrazone), and 5-azacytidine. [3H]Thymidine suicide indices were also determined. Normal marrow colony-forming units in culture tended to be more sensitive to all the drugs which were tested, although not of statistical significance. There was no difference in the suicide index between CML and normal colony-forming units in culture. It is concluded that the drugs which were tested are not likely to selectively kill CML progenitor cells while permitting normal hematopoietic elements to survive.

In vitro drug sensitivity studies of CFUc in chronic myelocytic leukemia: I. Suicide indices and busulfan sensitivity determinations during the chronic phase

Serial clonogenicity studies employing an agar CFUc culture assay are being performed on cells from CML patients to determine if clonal growth, 3HTdR suicide indices (SI) and in vitro busulfan sensitivity are of prognostic significance in predicting blastic transformation. Initial studies performed on specimens obtained from 20 chronic phase patients were directed at determining whether blood and marrow cells differed in growth pattern, SI, and busulfan sensitivity and whether the cells giving rise to clusters differed from those forming colonies. In comparing marrow to blood cells, there was a correlation between the two with respect to the number of colonies produced and the sensitivity of the clonogenic cells to busulfan. By contrast the SI of blood and marrow clonogenic cells were not correlated. In both blood and marrow, colony forming cells had a higher SI and were more sensitive to busulfan than were cluster forming cells.

Adrenal response to serial cosyntropin stimulation after repeated high-dose prednisone administration in patients with lymphoma

To determine if repeated courses of high-dose prednisone given to patients with lymphoma as part of multiple-drug chemotherapy programs would lead to progressive adrenal suppression, serial cosyntropin stimulation tests were performed. Four patients with diffuse histiocytic lymphoma (group 1) received prednisone for 5 days every 3 weeks for five courses, and five patients with Hodgkin's disease (group 2) received prednisone for 14 days every 4 weeks for six courses. Testing was done on Day 1 of each treatment course prior to the administration of therapy and after the final course of chemotherapy. In group 1 patients, there was no evidence of adrenal suppression after any of the courses of prednisone. The plasma cortisol increments after cosyntropin injection were also normal. In the group 2 patients, significant depression of basal plasma cortisol concentrations was observed after the first and fifth courses of prednisone, compared to the pretreatment values. The depression reflected the previous course of prednisone administration only and was not progressive with subsequent courses. The plasma cortisol increments after cosyntropin injection were normal despite depressed basal plasma cortisol levels.

Systemic chemotherapy for a primary germ cell tumor of the brain: a pharmacokinetic study

Systemic administration of most chemotherapeutic agents has been assumed to be ineffective in the treatment of primary and metastatic brain tumors because these agents fail to cross the intact blood-brain barrier. However, agents which fail to penetrate the intact blood-brain barrier may penetrate it under conditions which include the presence of tumor in the central nervous system (CNS) and prior CNS irradiation. This paper reports the results of pharmacokinetic studies of bleomycin, cisplatin, and vinblastine in the CNS of a patient with a primary germ cell tumor of the brain who had received prior radiotherapy. Significant concentrations of bleomycin and cisplatin, but not of vinblastine, were reached in the cerebrospinal fluid (CSF) of the patient following iv administration. The area under the bleomycin CSF concentration times time curve was 25% of the area under the bleomycin plasma concentration times time curve. The areas under two cisplatin CSF curves were 50% and 155% of the areas under the corresponding free cisplatin plasma curves. Moreover, an objective response of the tumor to the chemotherapy was documented. This study provides evidence that, under certain circumstances, significant concentrations of cisplatin and bleomycin may be obtained in human CSF following systemic administration and that it may be possible to treat primary or metastatic CNS tumors with agents effective against systemic tumor of the same histologic type.

In-vitro differentiation of myeloblasts from a patient with acute myeloid leukemia

Although acute myeloid leukemia is characterized by defective granulocytic maturation in vivo, blasts from an occasional patient will differentiate in vitro. Leukemic myeloblasts from a 49-year-old woman who had acute myeloid leukemia were suspended in liquid culture containing McCoy's 5A medium with 15% fetal calf serum. Conditioned medium, prepared from normal human peripheral blood adherent cells incubated with 2-mercaptoethanol in McCoy's 5A medium with 15% fetal calf serum, was added to the cultures at a concentration of 40%. Within six days, cellular differentiation to polymorphonuclear granulocytes was observed. These cells were capable of phagocytosis. Attempts to induce differentiation of leukemic cells in liquid culture will, it is hoped, contribute to the understanding of defective cellular maturation in this disease.

Bilateral endogenous Escherichia coli endophthalmitis

Escherichia coli endophthalmitis developed in a 62-year-old man following an inadequately treated lower urinary tract infection. Treatment with intravenous and local antibiotics and steroids was successful in eradicating the infection, but blindness was not reversed. The pathogenesis and management of secondary bacterial endophthalmitis are reviewed.

Life cycle events in 15th century Florence: records of the Monte delle doti

Records of a dowry investment fund operated by the city of Florence, Italy from 1425-1545 contain information on life cycle events of about 32,000 girls. This information includes date of birth, date and amount of investment, and date of dowry payment or death. In the present study, the first of 19 volumes of these records were used to compute death rates and payment rates (an approximation of marriage rates) and to analyze these rates according to age, time, and socioeconomic status. Usable records were obtained for 1631 girls. There were 315 deaths; death rates per 1000 person-years were 38, 17, 11, 16, and 19 for ages less than 5, 5-9, 10-14, 15-19, and 20+, respectively. Compared to previous and succeeding years, death rates increased 5-10 times in 1437-1438 and 1449-1450, years in which epidemics have been recorded. During these periods of epidemics, death rates were relatively low in the winter months. Death rate were made for 1274 girls. About three-fourths of these payments were made by age 20. Rate of payment increased with amount of investment. Proportionally, births were least frequent during December and January, indicating a deficit of conceptions around the time of Lent.