Nephronophthisis and retinal degeneration in tmem218-/- mice: a novel mouse model for Senior-Løken syndrome?

Mice deficient in TMEM218 (Tmem218(-/-) ) were generated as part of an effort to identify and validate pharmaceutically tractable targets for drug development through large-scale phenotypic screening of knockout mice. Routine diagnostics, expression analysis, histopathology, and electroretinogram analyses completed on Tmem218(-/-) mice identified a previously unknown role for TMEM218 in the development and function of the kidney and eye. The major observed phenotypes in Tmem218(-/-) mice were progressive cystic kidney disease and retinal degeneration. The renal lesions were characterized by diffuse renal cyst development with tubulointerstitial nephropathy and disruption of tubular basement membranes in essentially normal-sized kidneys. The retinal lesions were characterized by slow-onset loss of photoreceptors, which resulted in reduced electroretinogram responses. These renal and retinal lesions are most similar to those associated with nephronophthisis (NPHP) and retinitis pigmentosa in humans. At least 10% of NPHP cases present with extrarenal conditions, which most often include retinal degeneration. Senior-Løken syndrome is characterized by the concurrent development of autosomal recessive NPHP and retinitis pigmentosa. Since mutations in the known NPHP genes collectively account for only about 30% of NPHP cases, it is possible that TMEM218 could be involved in the development of similar ciliopathies in humans. In reviewing all other reported mouse models of NPHP, we suggest that Tmem218(-/-) mice could provide a useful model for elucidating the pathogenesis of cilia-associated disease in both the kidney and the retina, as well as in developing and testing novel therapeutic strategies for Senior-Løken syndrome.

Malformation of Incisor Teeth in Grem2-/- Mice

GREMLIN 2 ( GREM2)—formerly, protein related to Dan and cerberus ( PRDC)—is a potent antagonist of the bone morphogenetic proteins 2 and 4, but little else in known about its functions. We found that Grem2-/- mice developed small deformed mandibular and maxillary incisors, indicating that GREMLIN2 is required for normal tooth morphogenesis. Although DEXA scans suggested that bone mineral density might be increased in Grem2-/- mice, histology did not reveal any evident bone phenotype. Grem2-/- mice did not display any other notable phenotypes evaluated in a high-throughput screening process that encompassed a range of immunologic, metabolic, ophthalmic, and behavioral parameters. Our findings indicate that Grem2 can be added to the growing list of genes that affect tooth development in mice.

Amelogenesis imperfecta and other biomineralization defects in Fam20a and Fam20c null mice

The FAM20 family of secreted proteins consists of three members (FAM20A, FAM20B, and FAM20C) recently linked to developmental disorders suggesting roles for FAM20 proteins in modulating biomineralization processes. The authors report here findings in knockout mice having null mutations affecting each of the three FAM20 proteins. Both Fam20a and Fam20c null mice survived to adulthood and showed biomineralization defects. Fam20b (-/-) embryos showed severe stunting and increased mortality at E13.5, although early lethality precluded detailed investigations. Physiologic calcification or biomineralization of extracellular matrices is a normal process in the development and functioning of various tissues (eg, bones and teeth). The lesions that developed in teeth, bones, or blood vessels after functional deletion of either Fam20a or Fam20c support a significant role for their encoded proteins in modulating biomineralization processes. Severe amelogenesis imperfecta (AI) was present in both Fam20a and Fam20c null mice. In addition, Fam20a (-/-) mice developed disseminated calcifications of muscular arteries and intrapulmonary calcifications, similar to those of fetuin-A deficient mice, although they were normocalcemic and normophosphatemic, with normal dentin and bone. Fam20a gene expression was detected in ameloblasts, odontoblasts, and the parathyroid gland, with local and systemic effects suggesting both local and/or systemic effects for FAM20A. In contrast, Fam20c (-/-) mice lacked ectopic calcifications but were severely hypophosphatemic and developed notable lesions in both dentin and bone to accompany the AI. The bone and dentin lesions, plus the marked hypophosphatemia and elevated serum alkaline phosphatase and FGF23 levels, are indicative of autosomal recessive hypophosphatemic rickets/osteomalacia in Fam20c (-/-) mice.

Ocular albinism and hypopigmentation defects in Slc24a5-/- mice

As part of a high-throughput mutagenesis and phenotyping process designed to discover novel drug targets, we generated and characterized mice with a targeted mutation in Slc24a5, a gene encoding a putative cation exchanger. Upon macroscopic examination, Slc24a5-/- mice were viable, fertile, and indistinguishable by coat color from their heterozygous and wild-type litter mates. Ophthalmoscopic examination revealed diffuse retinal hypopigmentation, and a histologic examination of the eye confirmed the presence of moderate-to-marked hypopigmentation of the retinal pigmented epithelium (RPE), ciliary body, and iris pigment epithelium (IPE). Hypopigmentation was most severe in the anterior layer cells of the IPE, where melanosomes were smaller, paler, and more indistinct than those of the anterior stroma and posterior IPE. The pigment granules of the posterior IPE appeared to be nearly as dark as those in stromal melanocytes; however, both cell layers were thinner and paler than corresponding layers in wild-type mice. Ultrastructural analysis of the RPE, IPE, and ciliary body pigmented cells confirmed that mutation of Slc24a5 results in marked hypopigmentation of melanosomes in optic cup-derived pigmented neuroepithelium in the eyes. Milder reductions in melanosome size and pigmentation were noted in neural crest-derived melanocytes. The severe hypopigmentation of neuroepithelium-derived cells in the eyes resulted in a novel form of ocular albinism in Slc24a5-/- mice. Our findings suggest that SLC24A5 may be a candidate gene for some forms of ocular albinism and for the BEY1/EYCL2 locus previously associated with central brown eye color in humans.

Advanced bronchioloalveolar carcinoma: a phase II trial of paclitaxel by 96-hour infusion (SWOG 9714): a Southwest Oncology Group study

BACKGROUND

There are no published prospective trials of chemotherapy for advanced bronchioloalveolar carcinoma (BAC), a subtype of non-small-cell lung cancer for which there is no current standard therapy. This phase II study assesses the efficacy and toxicity of 96-h paclitaxel in chemotherapy-naive patients with advanced BAC.

PATIENTS AND METHODS

Patients with histologically confirmed stage IIIB (with pleural effusion) or stage IV BAC were eligible. Treatment consisted of paclitaxel 35 mg/m2/24 h continuously infused over 96 h (days 1-4) every 21 days for up to six courses.

RESULTS

A total of 58 eligible patients were enrolled. The objective response rate was 14% (all partial responses, 9% confirmed); 40% of patients demonstrated stable disease. The median progression-free and overall survivals were 5 and 12 months, respectively. Grade 3 or greater toxicities included neutropenia/granulocytopenia (43%), febrile neutropenia (12%), infection (22%), and stomatitis/pharyngitis (10%); there were five treatment-related deaths.

CONCLUSIONS

S9714 represents the first prospective multi-institutional cooperative group trial focusing on treatment outcomes in BAC. Studies targeting this population are feasible, and while first-line paclitaxel administered as a prolonged infusion is active in this setting, toxicities limits the utility of this regimen. S9714 serves as a historical control for BAC patients against which future therapeutic approaches can be compared.

Basal cell carcinoma with lung metastasis diagnosed by fine-needle aspiration biopsy

Basal cell carcinoma of the skin is one of the most common types of cancer. Its natural history is one of local recurrence rather than metastatic spread. Certain histologic features and primary tumor size seem to be risk factors for metastases. The diagnosis of metastatic disease imparts a poor prognosis with a short median survival. Treatment is usually in the form of systemic chemotherapy with cisplatin-based combination described as most active agent.

The role of paclitaxel in the management of coelomic epithelial carcinoma of the ovary: a review with emphasis on the Gynecologic Oncology Group experience

Coelomic epithelial carcinoma of the ovary, the most common cause of death from cancer of the female genital tract in the United States, presents most commonly as advanced (stage III or IV) disease. Management consists of aggressive surgical cytoreduction followed by combination chemotherapy, until recently, a platinum compound plus an alkylating agent. The recent identification of the activity of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) offers the potential to improve further the management of patients with advanced disease. That this agent might enhance current front-line therapy is supported by its unique mechanism of action and by the significant numbers of responses reported in patients clinically resistant to the platinum compounds: more than 20% of these patients responded to paclitaxel as salvage therapy in four different phase II trials. These observations led to a phase I Gynecologic Oncology Group trial that showed that paclitaxel 135 mg/m2 over 24 hours followed by cisplatin 75 mg/m2 could be given every 3 weeks. This group then compared six cycles of the identified regimen with six cycles of standard cisplatin/cyclophosphamide chemotherapy given every 3 weeks in a phase III trial in 388 previously untreated patients with large-volume (residual nodules > 1 cm after surgery) disease. The results show the superiority of the paclitaxel/cisplatin regimen: overall response rate 77% versus 62%, clinical complete response 54% versus 33%, frequency of achieving a grossly disease-free state at second-look laparotomy 40% versus 22%, progression-free survival 18 versus 13 months, and overall survival 38 versus 24 months. Thus, paclitaxel/cisplatin is the new standard of care for patients with advanced ovarian carcinoma. Current phase III studies explore further the role of paclitaxel in front-line therapy: the relative merits of single-agent versus combination chemotherapy, the role of interval surgical cytoreduction combined with paclitaxel/cisplatin, the value of carboplatin-based versus cisplatin-based combinations with paclitaxel, the significance of the paclitaxel infusion length (3 v 24 v 96 hours), and the value of more dose-intense combinations.

The platinum compounds and paclitaxel in the management of carcinomas of the endometrium and uterine cervix

Endometrial carcinoma and squamous cell carcinoma of the cervix are common invasive neoplasms of the female genital tract. Early diagnosis of a majority of patients has resulted in high cure rates for both diseases. In the last two decades, a growing number of active systemic drugs have been identified. Cisplatin has been extensively studied in both neoplasms and has clear activity (20% response rate in endometrial carcinoma and 23% response rate in squamous cell carcinoma of the cervix). Recently, paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) has been shown to be clearly active in both (35% response rate in endometrial carcinoma and 17% response rate in squamous cell carcinoma of the cervix). The apparent clinical non-cross-resistance between paclitaxel and cisplatin in other neoplasms like ovarian carcinoma makes combinations including these two agents of great interest. In endometrial carcinoma, a phase I trial of cisplatin plus doxorubicin plus escalating paclitaxel doses is being performed by the Gynecologic Oncology Group (GOG). Based on the outcome of this study, a future randomized trial will compare the current standard, doxorubicin plus cisplatin, with either a combination of cisplatin, doxorubicin, and paclitaxel or a two-drug regimen of paclitaxel plus cisplatin. In squamous cell carcinoma of the cervix, a logical approach to the incorporation of paclitaxel into front-line therapy for advanced or recurrent disease is a phase III trial of the best regimen from GOG protocol 110 (cisplatin with or without either ifosfamide or dibromodulcitol) versus the same drugs plus paclitaxel. In addition, the GOG is conducting a phase I trial of paclitaxel given concomitantly with radiation in the hope that the resulting regimen will be an arm of a future randomized study in patients with locoregionally advanced disease (stages IIB through IVA). The ultimate role of paclitaxel in the management of patients with these two neoplasms awaits the results of these efforts.

Carcinoma of the uterine cervix: current status and future directions

Based on rigorous interpretation of current evidence, systemic therapy has two roles in the management of carcinoma of the uterine cervix. In patients with advanced or recurrent disease, single-agent chemotherapy constitutes the treatment of choice. The most extensively studied agents are the platinum compounds. Either cisplatin or carboplatin represents a reasonable choice for first-line treatment. There appears to be no significant influence of either dose or schedule on patient benefit. Other agents with clear-cut activity include ifosfamide, dibromodulcitol, and doxorubicin. At this time, there is no scientific basis for the use of combination chemotherapy in advanced or recurrent carcinoma of the cervix. In patients with locoregionally advanced disease (stages IIIB or IVA), radiation plus either hydroxyurea or a combination of cisplatin plus 5-fluorouracil offers an advantage over radiation alone in terms of progression-free interval and survival. In patients with more limited disease, there is no defined role for systemic therapy at the present time. Three goals constitute the focus for current investigational efforts: (1) continued efforts to identify additional highly active drugs are needed; (2) the development of effective combination chemotherapy depends on the use of logically designed combinations of active drugs in well-designed phase III trials with single-agent therapy as the control; and (3) phase III trials seeking more effective combinations of systemic therapy with surgery and/or radiotherapy should continue for not only locoregionally advanced disease but also for more limited carcinoma of the cervix.

Second-line chemotherapy for recurrent carcinoma of the ovary

Despite relatively high response rates to chemotherapy for ovarian carcinoma, most patients eventually will have progressive disease that will require additional therapy. Most efforts to study such second-line or "salvage" chemotherapy have been single-arm trials of small numbers of patients, which report widely variable response rates, relatively short response durations, and short survival times. Only recently have certain critical patient characteristics been recognized as important in determining appropriate therapy as follows: (1) the extent and volume of disease at recurrence and (2) the type and duration of response to prior chemotherapy. Patients with small-volume disease confined to the peritoneal cavity have a far better chance of achieving a response to second-line chemotherapy with subsequent prolonged survival than do those with bulky disease or disease outside the abdomen. Perhaps even more critical is the distinction between those patients whose neoplasm is still "clinically sensitive" to the platinum-containing compounds (initial response to platinum-based therapy and relapse more than 6 months after cessation of treatment) and those with "clinically resistant" disease (progression during or within 6 months of front-line platinum-based therapy). Those considered clinically sensitive to platinum-based therapy should be retreated with a platinum-containing regimen at the time of recurrence. Those with evidence for resistance should receive alternative treatment with one or more drugs capable of inducing responses in such patients. These drugs currently include: taxol, ifosfamide, and hexamethylmelamine.

The role of ifosfamide in gynecologic cancer

Ifosfamide exhibits promising activity in a variety of gynecologic neoplasms. In carcinoma of the ovary, the drug shows clear-cut activity, effecting responses in patients who have proven clinically resistant to cisplatin-based combination chemotherapy. In carcinoma of the cervix, the drug also appears to be highly active, both as a single agent and in combination with other agents, such as the platinum compounds. The drug is active in uterine sarcomas and appears to be the most active agent studied to date in mixed mesodermal sarcomas of the uterus. The drug's role in combination with other agents in the treatment of all of these neoplasms is under study, but cannot be determined from currently available data on combination therapy. Its activity in other gynecologic tumors, such as endometrial carcinoma and ovarian germ cell tumors, is also indeterminate at present. Although further studies are needed, current evidence supports the contention that ifosfamide is a major new active drug in the management of gynecologic cancers.

Phase II evaluation of menogaril (NSC-269148) in non-small cell lung carcinoma. A Southwest Oncology Group study

Forty-five patients with non-small cell lung cancer were treated in a phase II trial with menogaril 200 mg/m2 IV every twenty-eight days by a one-hour infusion. One partial response was noted while twenty-two patients had stable disease (51%). Progressive disease was noted in the remaining twenty-two patients. There was one fatal complication due to pancytopenia and pneumonia. Otherwise, the drug was reasonably well tolerated. At this dosage and schedule, menogaril has no substantial anti-tumor activity for patients with non-small cell lung cancer.

Ifosfamide in the management of gynecologic cancers

Ifosfamide, an alkylating agent chemically similar to cyclophosphamide, has been tested both as a single agent and in combination therapy for a variety of gynecologic cancers. In celomic epithelial carcinoma of the ovary, single agent ifosfamide yields response rates ranging from 19% to 79% and, most significantly, responses in patients who are refractory to cisplatin. Use in combination with both cisplatin and carboplatin has been reported, but the relative merits of these two combinations are indeterminate at present. In carcinoma of the cervix, response rates for ifosfamide alone range from 20% to 40% in patients who have not received prior chemotherapy. Very high response rates from 67% to 86% have been reported with ifosfamide in combination with platinum compounds with or without other agents such as doxorubicin and bleomycin. No studies have yet demonstrated superiority of combination therapy. Data from the Gynecologic Oncology Group demonstrate activity for ifosfamide alone in mixed mesodermal sarcomas of the uterus. Finally, anecdotal data note responses in endometrial carcinoma and germ cell carcinomas of the ovary. Thus, it appears that ifosfamide has significant activity in a variety of gynecologic cancers and deserves further testing as a part of combination chemotherapy in at least celomic epithelial carcinomas of the ovary, cervix carcinomas, and mixed mesodermal sarcomas of the uterus.

Chemotherapy in ovarian carcinoma: present role and future prospects

Epithelial carcinoma of the ovary is characterized by presentation at an advanced stage, spread primarily by an intraperitoneal (IP) route, and relative sensitivity to chemotherapy. An initial surgical approach is essential to proper staging of the disease process and to aggressive cytoreduction, which in turn improves response to chemotherapy and survival. The use of chemotherapy is the mainstay of definitive therapy after completion of the initial surgery. A large number of drugs have activity against the disease, with the most important single category of agents being the platinum compounds. Studies by the Gynecologic Oncology Group (GOG) document the superiority of cisplatin-based combination chemotherapy over single alkylating agents and combinations that do not include cisplatin. The current regimen of choice is a two-drug combination of cisplatin plus cyclophosphamide. Efforts to improve results further focus on enhancing dose intensity of the drug combination through either escalating intravenous (IV) doses or administering cisplatin via an IP route. Also offering an opportunity for further improvement of therapeutic results are three drugs identified as having activity in patients no longer candidates for cisplatin: carboplatin, ifosfamide, and taxol. Biologic agents, such as alpha-interferon, also have potential roles in future combination therapy. The management of patients with limited (stage I or II) disease is based on studies of the GOG and the Ovarian Cancer Study Group, which indicate that this population can be divided by prognostic factors into a group at low risk for recurrence and a group at high risk. Those at low risk require only surgery, whereas those at high risk should receive either IP radioactive chromic phosphate or systemic chemotherapy following surgery. The future prospects for additional improvement of results in all patients appear bright on the basis not only of studies of dose intensity and IP therapy but also of efforts directed at overcoming multidrug resistance and at devising noninvasive means of assessing disease status.

Ovarian carcinoma: the role of chemotherapy

Maximum surgical effort will yield improved survival and response to subsequent therapy in patients with minimal residual disease (less than 2 cm diameter of any remaining nodule). Systemic therapy is the mainstay of later management. Studies have focused on single-agent v combination chemotherapy, optimal combination, dose intensity, and route of administration. In advanced disease, studies of the Gynecologic Oncology Group (GOG) demonstrate the superiority of cisplatin based combination chemotherapy over a single alkylating agent in regard to overall response, clinical complete response, response duration, and survival. Subsequent GOG and other studies suggest that a two-drug combination of cisplatin and cyclophosphamide is therapeutically equivalent to more toxic three- and four-drug combinations. Whether continued escalation of drug dose intensity beyond usual clinical schedules yields incremental gain in benefit remains under study. Administration of drug, particularly cisplatin, via the intraperitoneal (IP) route produces objective responses in patients who have progressed after prior cisplatin based therapy. Whether IP therapy is superior to IV therapy as first-line treatment is under investigation. In limited disease, patients can be assigned to low- and high-risk groups based on careful surgical staging. Patients with low-risk limited disease have a 5-year disease-free survival exceeding 95% with no adjuvant therapy. Those with high-risk disease, even with IP chromic phosphate or systemic melphalan, have a relapse rate of 20% or more after a similar period. The potential role of cisplatin based combination therapy in such patients is under study. Future improvement in results depends on current investigations of noninvasive methods for diagnosis and evaluation, better definition of the value of greater dose intensity and alternate route of administration, the value of methods for choosing appropriate drugs, the development of new agents, and methods to overcome drug resistance.

Concurrent chemotherapy and radiotherapy for limited small-cell carcinoma of the lung: a Southwest Oncology Group Study

This pilot study in limited-stage small-cell carcinoma of the lung using concurrent cisplatin (Platinol) and etoposide (VePesid) chemotherapy with radiotherapy has yielded a high complete response rate in 23 of 40 patients evaluable for response. Five of these responders have survived greater than 2 years off all therapy with a stable, high performance status. Median survival of all patients is 18 months. Toxicity has been acceptable, the most common being neutropenia. Radiation toxicities include 17 of 40 patients experiencing mild to moderate esophagitis, with one severe toxicity; and three of 40 patients developing mild to moderate radiation pneumonitis. The high complete remission observed with this program and the long tumor-free interval seen off maintenance therapy deserve further exploration. Toxicities appear only moderately greater than with other programs currently utilized.

Extensive non-small cell lung cancer treated with mitomycin, cisplatin, and vindesine (MiPE): a Southwest Oncology Group Study

Ninety-seven previously untreated patients with metastatic non-small cell lung cancer were treated with combination chemotherapy consisting of mitomycin (10 mg/m2) on Day 1, cisplatin (50 mg/m2) on Days 1 and 22, and vindesine (3 mg/m2) on Days 1 and 22 (MiPE). MiPE was repeated at 6-week intervals until disease progression or unacceptable toxicity. The overall response rate was 33%. There were seven complete responses (7%) and 25 partial responses (26%). The median progression-free interval for responding patients was 7 months. Median survival for all patients was 5 months, with 16% surviving 1 year. One patient died from sepsis while neutropenic. The results with MiPE treatment for patients with non-small cell lung cancer compare favorably to other mitomycin-vinca combinations previously tested in the Southwest Oncology Group.

Effect of alternating combination chemotherapy on survival of ambulatory patients with metastatic large-cell and adenocarcinoma of the lung. A Southwest Oncology Group Study

Using a randomized prospective trial design, chemotherapy with 5-fluorouracil, vincristine, and mitomycin C (FOMi) was compared with cyclophosphamide, doxorubicin, and cisplatin (CAP) and with FOMi alternating with CAP (FOMi/CAP) in 452 eligible patients with metastatic large-cell undifferentiated and adenocarcinoma of the lung. Objective responses were obtained in 26%, 17%, and 22% of patients treated with FOMi, CAP, and FOMi/CAP, respectively. The median survival was similar for FOMi, CAP, and FOMi/CAP therapies (20, 24, and 23 weeks, respectively), but the overall survival (log rank test), 1-year survival, and remission duration were longer for FOMi/CAP-treated patients. Survival was significantly longer for fully ambulatory FOMi/CAP-treated patients compared with either FOMi (P = .01) or CAP (P = .04). Younger patients treated with full doses of therapy responded more often than older patients receiving reduced drug doses (26% and 11%, respectively; P = .003). A prognostic factor regression analysis of all eligible patients indicates that sex, performance status, stage, and treatment assigned were important independent variables determining survival (P less than .05). Toxicity was comparable in each treatment group.

Nutrition, cancer, and aging: an annotated review. II. Cancer cachexia and aging

The interactions of cancer and malnutrition are discussed with the focus on aging. To establish whether the elderly are more likely to develop cancer cachexia and its complications, this review encompasses the pathogenesis of malnutrition in cancer; the age-related alterations of appetite, gastrointestinal function, energy expenditure, and protein turnover; the diagnosis of malnutrition; and the effectiveness of nutritional support in the elderly. Although metabolic and physiologic changes induced by cancer and age appear synergistic in causing cachexia, more frequent complications of malnutrition have not been observed in the geriatric cancer patients. This may be due to only a small proportion of the elderly with cancer being enrolled in clinical studies or to a reduced cachexia-inducing ability of tumors in these patients. A limited number of studies indicate nutritional replenishment is obtainable in malnourished elderly by hyperalimentation. As restoration of the lean body mass may be slower in older patients, early institution of nutritional support is recommended in malnourished elderly or elderly at risk for malnutrition during neoplastic treatment.

Nutrition, cancer, and aging: an annotated review. I. Diet, carcinogenesis, and aging

The interrelationships of diet and carcinogenesis are discussed with the focus on aging. To establish whether the elderly are more susceptible to dietary carcinogens and whether dietary prevention of cancer is a reasonable goal for this population, the mechanisms of chemical carcinogenesis, the age-related metabolic and physiologic changes, and the current cancer preventive dietary strategies are reviewed. Vulnerability to dietary carcinogens results from a combination of factors that may increase or decrease the occurrence of cancer in the elderly, and it is, therefore, a very individualized feature, unpredictable when based solely on a subject's age. Dietary prevention of cancer may be effective in advanced age, and the dietary guidelines of the National Academy of Sciences should be implemented in this population.

Supraophthalmic carotid infusion with low dose cisplatin and BCNU for malignant glioma

Arterial infusion of select chemotherapeutic agents has been shown to deliver increased drug concentration to brain tumors with reduced systemic toxicity. In this study, nine patients with histologically confirmed malignant glioma received cisplatin 110 mg and BCNU 300 mg fixed dose. All patients had received standard doses of cranial radiation after their initial surgical procedures. In three patients, intraoperative modification of the cerebral circulation was accomplished prior to the actual infusion because the vascular supply of the tumor arose from major arteries other than a single internal carotid artery. Supraophthalmic catheterization technique was employed. No neurological deficits occurred post infusion. The radiographic response rate was 25%. No responses were seen in patients who received less than 69 mg/M2 cisplatin this combination. The longest survival is 11+ months in a patient with anaplastic astrocytoma. Our first thirteen patients received cisplatin 150-200 mg and BCNU 300 mg for each infusion with a response rate of 83% in evaluable patients. Since modest reduction in cisplatin dose dramatically reduced the response rate, future studies should be directed at fine tuning the dose of this drug, or at neutralizing recirculating drug after its high dose first pass through the arterial circulation.

Experiences with sodium thiosulfate after intracarotid infusion of cisplatin and BCNU for malignant gliomas

The treatment of malignant gliomas with cisplatin has been shown to be of benefit. In order to reduce the side effects of the drug, we employed the use of sodium thiosulfate in ten patients one hour after cisplatin infusion and continued for 6 h. Side effects from this population of patients were compared with those side effects experienced with 13 patients not receiving thiosulfate. No real difference in number or severity of side effects from cisplatin was observed between the two groups although nephrotoxicity appeared to be reduced in the patients who received thiosulfate.

Supraophthalmic carotid infusion for recurrent glioma: rationale, technique, and preliminary results for cisplatin and BCNU

The chemotherapeutic agents 1-3 bis(2-chloroethyl)-1-nitrosourea (BCNU) and cis-diamminedichloroplatinum II (cisplatin) have both shown activity against malignant glioma, especially when given by arterial infusion. The combination of these agents given by this method is logical because their individual major toxicities are directed at different organ systems, and because of their differences in restriction by the blood-brain barrier. Both agents are toxic to the eye, and infusion of both agents simultaneously into the internal carotid artery would deliver doses of the drug to the eye which should be associated with an unacceptable level of ocular toxicity. We have developed a technique utilizing a flexible flow-directed catheter with a tip which is manipulated by hydraulic forces for delivery of the drug into the intracranial carotid artery above the origin of the ophthalmic artery, thus sparing the eye from the high concentration of drug during the first pass through the arterial circulation. In 13 patients with recurrent malignant glioma treated by arterial infusion of both agents (cisplatin 150-200 mg, BCNU 300 mg fixed dose), we have had no damage to the ipsilateral eye. Preliminary results of treatment appear to be good, with definite tumor regression following arterial infusion in 10 of 12 radiographically evaluable cases. Median survival to date is 11 months with 3 patients still surviving. The longest survival is 24 months. The supraophthalmic infusion technique protects the eye and the combination of drugs given by arterial infusion produces a high tumor response rate.

Acute leukemia and infections: perspectives from a general hospital

The incidence and etiology of infections in 210 acute leukemics at the University of Mississippi Medical Center between 1962 and 1978 were reviewed. Infections episodes occurred 269 times in 148 patients. In 193 infections, potential pathogens were cultured. Infection was a contributing cause of death in 89 patients. E. Coli, S. aureus, K. pneumoniae, and P. aeruginosa accounted for 58% of the isolates. No unusual patterns of antimicrobial resistance were observed. The outcome of the infections was related to the absence or resolution of neutropenia. Among 48 patients febrile on first admission, four cases of gram-negative pneumonia, two cases of fungal pneumonia, and two cases of pseudomonas cellulitis were diagnosed. We conclude that the etiology of infections was similar to that of cancer centers; multidrug-resistant gram-negative organisms were not prevalent; absence or resolution of neutropenia indicates a good prognosis for outcome of infection; and untreated acute leukemics may acquire opportunistic infections.

Phase II evaluation of MGBG in non-small cell carcinoma of the lung. A Southwest Oncology Group study

One hundred and eight patients with non-small cell lung cancer were treated in a Phase II trial with MGBG at a dose of 600 mg/m2 i.v. weekly. Partial responses were noted in 3/43 patients with adenocarcinoma and 1/40 with squamous cell carcinoma. No responses were noted in 24 patients with large cell carcinoma. Overall, the drug was reasonably well-tolerated. At this dosage and schedule, MGBG has no substantial antitumor activity for patients with non-small cell lung cancer.

Lung carcinoma: survey of 2286 cases with emphasis on small cell type

Lung carcinoma is the commonest major malignancy in men in the United States and its incidence is increasing rapidly in women. It is estimated that there will have been 117,000 new cases and 101,300 deaths in 1980. The 2286 patients with lung carcinoma admitted to the Hospital of the University of Mississippi from 1955 to 1980 were reviewed by decades of chronology and of life, with respect to age, cell type, sex and racial incidence. The greatest age incidence was in the sixth and seventh decades; cell types overall were epidermoid (45% of the patients), adenocarcinoma (12% of the patients), small (oat) cell (21% of the patients), and others (22% of the patients). There was a steady increase in the incidence of disease in females, adjusted for total hospital admissions, and a less certain increase among black patients. Twenty-eight per cent of 250 patients with small cell carcinoma so studied exhibited some feature of the paraneoplastic or paraendocrine syndromes. In 41 patients with small cell carcinoma treated with multiple drug chemotherapy, there was an overall response rate of 50% and an additional "stable disease" rate of 28%. Mean survival period in this group was 52 weeks, compared with 12 weeks in patients whose diseases went untreated. Clearly, definite progress is being made, not only in our knowledge of the biology of lung carcinoma, in general, but in the treatment of small cell carcinoma in particular.

Oncogenic transformation by by equine herpesviruses. II. Coestablishment of persistent infection and oncogenic transformation of hamster embryo cells by equine herpesvirus type 1 preparations enriched for defective interfering particles

Infection of permissive hamster embryo cells with virus preparations enriched for defective interfering (DI) particles of equine herpesvirus type 1 (EHV-1) resulted in persistent infection and oncogenic transformation. Six cell lines, designated DI-5 to -10, exhibited biological properties (immortality, increased saturation density, growth in soft agar, etc.) inherent to transformed cells, but 2 to 18% of the total cells in these cell lines were shown to release virus as judged by electron microscope studies and infectious center assays. The released virus was shown to be standard EHV-1 and not to contain DI particles as determined by density measurements of the viral DNA in the analytical ultracentrifuge and by interference assays using the released virus. Tumorigenicity studies revealed that inoculation of these persistently infected cells into newborn LSH inbred hamsters resulted in a lethal, fulminating hepatitis, whereas inoculation into older immunocompetent hamsters (+4 weeks) led to the development of metastatic fibrous sarcomas. Tumor cell lines (DI-5T to -10T) established from these sarcomas were shown to be transplantable and virus nonproducers. Hybridization analyses of cellular DNAs from DI transformed and tumor cell lines using 32P-labeled genomic EHV-1 DNA as probes indicated that the whole virus genome was detectable in multiple copies (23 to 45) in the transformed cells and that DNA sequences representing only 43.5 to 56.6% of the virus genome were present in amounts of 2 to 4 copies per cell in the DI tumor cells. Expression of these viral DNA sequences as demonstrated by the detection of virus-neutralizing antibodies, 50% neutralizing dose titers ranging from 1:50 to 1:1,000, in the sera of animals inoculated with either the virus-producing transformed cells or the virus-nonproducing tumor cells. Further, EHV-1-specific proteins were detected in the membrane and the perinuclear region of bothDI transformed and tumor cells by indirect immunofluorescent assays using antisera against EHV-1 structural antigens, EHV-1 nonstructural antigens, or preparations of EHV-1 DI particles. The roles of DI particles in mediating persistent infection and cellular transformation are discussed.