Diagnostic ultrasonography in acute cholecystitis. In a 12-month period 100 patients with clinical evidence of acute disease of the gallbladder were studied in hospital by grey-scale ultrasonography. During the same hospital admission it was possible to correlate results of ultrasonography with operative findings in 66 patients. In 52 patients the ultrasonographic diagnosis of gallstones was proved to be correct. There were no false-positive results. In seven patients the ultrasonographic report of a normal gallbladder without stones was also confirmed. In two patients, the report of a normal gallbladder without stones was erroneous. In two more patients the scan was indeterminate and stones were found at operation. In the remaining three patients echogenic material was reported and at operation minute stones and "sludge" were found. No complications resulted from the ultrasonography. The study showed that grey-scale ultrasonography is a reliable, rapid and safe technique for detecting gallstones in patients with a clinical diagnosis of acute cholecystitis.


Re-evaluation of thrombectomy in the management of iliofemoral venous thrombosis. The authors studied 15 patients with iliofemoral venous thrombosis up to 8 years after the diagnosis was made, to determine whether there was late deterioration in venous function following thrombectomy. Twelve patients were treated by venous thrombectomy and anticoagulants and 3 by anticoagulants alone. Eight of the 12 patients subjected to thrombectomy had an excellent result with limbs that were considered normal. This did not confirm earlier reports which indicated that good early results were not maintained. In 4 of the 12 surgically treated patients minor symptoms of leg pain and swelling were present which also did not progress with time. In all patients treated by anticoagulants alone major symptoms of leg pain and severe swelling persisted. Three of the four patients with persistent minor symptoms after venous thrombectomy were found at operation to have left iliac vein compression syndrome. Only one of eight patients having an excellent clinical result had this syndrome.


Effect of cimetidine on chronic gastric ulcers produced experimentally in rats. The authors have studied the effects of cimetidine on the healing of chronic gastric ulcers induced in rats. Gastric ulcers were produced by topical application of 60% acetic acid to the serosal surface of the lesser curvature of the stomach. Oral administration of cimetidine, 150 mg/kg daily, in two divided doses for a maximum of 14 days failed to produce any significant acceleration of healing.


Diarrhea and medullary carcinoma of the thyroid. The authors present the case of a 34-year-old woman with disseminated medullary carcinoma of the thyroid to emphasize the value of calcitonin assay in the diagnosis of this condition despite the absence of a thyroid mass and negative scans. An increased concentration of serum carcino-embryonic antigen was confirmed. The diarrhea associated with the disease did not respond to indomethacin in this patient suggesting that in some cases of medullary carcinoma diarrhea is not due to excessive production of prostaglandins.


Antidepressants in the general hospital. An approach to the use of antidepressant medication in the general hospital is presented. The type of depression most likely to respond to chemotherapy is described, categories of available antidepressant agents are discussed, and relevant pharmacologic aspects are outlined. This paper suggests clinical guidelines for the use of these drugs, particularly in medical and surgical patients.


Management of colonic and rectal injuries. In managing a colonic or rectal injury the surgeon must decide whether it is acceptable to have feces passing over a suture line or anastomosis. If it is, resection and anastomosis or simple oversewing of the bowel can be done. If it is not, there are four choices: (a) closure of the wound, drainage and proximal diversion; (b) primary closure or resection and anastomosis of the wound with exteriorization; (c) formation of a double-barrelled colostomy; and (d) resection of the injured colon with formation of an end-colostomy and a mucosal fistula or a Hartmann procedure. The surgeon's choice should be dictated by the severity of the injury, the degree of fecal contamination and the general condition of the patient.


Adult-onset Still's disease.

Adult-onset Still's disease. Four adults with an illness similar to the systemic variant of juvenile rheumatoid arthritis seen in children (Still's disease) are described. All four had fever, an erythematous maculopapular rash, splenomegaly and arthritis. The arthritis was asymmetric and involved only a few joints simultaneously. Erosive arthritis developed in one patient. Three patients had a sore throat, two had pleurisy and pericarditis, and one had transient abnormalities of liver function. The laboratory features included anemia, leukocytosis and high leukocyte counts in the synovial fluid. High titres of rubella hemagglutination-inhibiting antibody were detected in two patients, one of whom was found to have rubella virus in the urine. Only one patient responded well to therapy with acetylsalicylic acid; the other three were given prednisone therapy, and two continue to require it.


Cancer of the bladder in Alberta: a urologic audit review. A review was conducted of 660 cases of cancer of the bladder diagnosed in two periods, 1960--62 and 1968--70. A significant increase in the incidence of bladder cancer in both sexes, paralleling the trends in other parts of North America, was found. During the second period the disease was diagnosed earlier and, once diagnosed, was apparently treated more successfully. Overall 5-year survival rates increased from 57% to 70% for patients with stage O or A  disease, but were relatively constant, at about 36%, for patients with stage B1 or B2 disease. The survival rate for patients with stage O or A disease appeared to improve without clearly defined changes in treatment. Prospective randomized treatment trials are needed to properly assess the value of definitive and adjunctive methods of treatment.


Pulmonary veno-occlusive disease: antemortem diagnosis from roentgenographic and hemodynamic findings. A 17-year-old boy with pulmonary veno-occlusive disease underwent Swan--Ganz catheterization. A normal pulmonary capillary wedge pressure was recorded in the presence of severe pulmonary arterial hypertension and roentgenographic evidence of pulmonary venous congestion. This triad of findings permitted an unequivocal diagnosis of pulmonary veno-occlusive disease, which was later confirmed at autopsy. The hemodynamics of this condition and of others included in the differential diagnosis are presented schematically.


Campylobacter enteritis.

Campylobacter enteritis. Campylobacter jejuni/coli has recently become recognized as a common bacterial cause of diarrhea. Infection can occur at any age. The usual incubation period of campylobacter enteritis is 2 to 5 days. Fever, diarrhea and abdominal pain are the most common clinical features. The stools frequently contain mucus and, a few days after the onset of symptoms, frank blood. Significant vomiting and dehydration are uncommon. A rapid presumptive laboratory diagnosis may be made during the acute phase of the illness by direct phase-contrast microscopy of stools. Isolation of the organism from stools requires culture in a selective medium containing antibiotics and incubation under reduced oxygen tension at 42 degrees C. The organism persists in the stools of untreated patients for up to 7 weeks following the onset of symptoms. Erythromycin may produce a rapid clinical and bacteriologic cure, and should be used to treat moderately to severely ill patients as well as patients with compromised host defences. The emergence of erythromycin-resistant strains requires close monitoring. The epidemiologic aspects of campylobacter enteritis will be fully understood only when methods become available for differentiating strains of C. jejuni/coli. The historical background and current knowledge of campylobacter enteritis are reviewed in this paper.


Continuous intravenous arabinosyl cytosine infusions delivered by a new portable infusion system. Eighty-six patients with acute leukemia were given 116 continuous intravenous arabinosyl cytosine (Ara-C) infusions (for 24 to 432 hours) with a new portable infusion device. The infusor is powered by interchangeable elastomeric 25 ml balloon reservoirs loaded from standard syringes. The reservoir contents are discharged at nearly constant pressure through an adjustable resistance element, thereby providing flow rates from 0.4 to 2.0 ml/hour. Serum levels of labeled Ara-C delivered by the infusor were found to achieve steady-state therapeutic levels within 24 hours. The average-flow-rate-to-indicator-setting ratio determined for each infusion via scalp vein needles was 0.9 +/- 0.2. Delivery through catheters was more reliable and an average-flow-rate-to-indicator-setting ratio of 0.1 +/- 0.1 was observed. The therapeutic effectiveness of Ara-C in combination with other agents was not compromised by this delivery system. Eleven of 14 patients who received all their induction Ara-C through the infusor achieved complete remission.


Factors that affect response to chemotherapy and survival of patients with advanced head and neck cancer. A review of 164 patients with far advanced head and neck cancer, treated by a cytotoxic chemotherapy over a ten year period, at WAyne State University, Detroit, Michigan, was done in an attempt to determine factors that may influence the response to chemotherapy and subsequent survival. Response rate to methotrexate was 28%, 5-FU 31%, and porfiromycin 13%. Improved responses were noted with combination chemotherapy. Patients who failed to first line therapy rarely responded to other single agent or combination chemotherapy. Those who did not have prior surgery and/or radiotherapy had better results from drug therapy. Patients with good performance status at the time of initial chemotherapy, had better response to treatment (32% vs. 13% PR & CR) and longer survival (28 weeks vs. 9 weeks, p = 0.01) when compared to those with poor status. Patients who responded to chemotherapy have better survival compared to nonresponders (29 weeks vs. 16 weeks, p = 0.002). This information may prove helpful in future planning of multidisciplinary approach in the treatment of patients with head and neck cancer.


Thyroid neoplasia following irradiation for medulloblastoma: report of two cases. Thyroid neoplasms occurred in two patients 14 and 18 years after treatment with radiation for medulloblastoma. One patient has a papillary cancer and the other patient had multiple adenomas and a Hurthle cell adenoma. In addition, the latter case had foci of hyperplasia plus a microfollicular transformation, which has not been described in association with prior thyroid irradiation. The radiation doses delivered to the thyroid through posterior cervical spinal ports (2000--3000 roentgens) fall within the upper range of radiation dosage associated with induction of neoplastic changes within the thyroid.


Central nervous system changes complicating the use of radiotherapy for the treatment of a nasopharyngeal neoplasm in a diabetic patient. A case is reported of a diabetic patient with a nasopharyngeal neoplasm who developed radiation induced brainstem damage even though irradiated at a conventional time-dose-volume relationship. The clinical course was correlated with autopsy findings which revealed radiation changes in the brainstem consisting primarily of vascular hyalinization with foci of infarction, edema, and demyelination. Atherosclerotic changes were conspicuously absent and therefore not the case of the alterations. The changes occurred three months after completion of therapy, which was more rapid than expected for radiation injury. It is hypothesized that diabetes may have predisposed the patient to this severe complication of standard therapy. More needs to be learned concerning the relationship between diabetes mellitus and radiation complications. Perhaps a modified time-dose relationship should be considered.


Opium: a potential urinary bladder carcinogen in man. Evidence is presented that opium addition is a risk factor for cancer of the bladder. A case-control study of 99 bladder cancer patients admitted to Nemazee Hospital in Shiraz, Iran was evaluated. Cancer patients and controls, matched by age and sex, were analyzed as to their opium and/or cigarette smoking habits. A high correlation between opium addiction and bladder cancer has been observed. This evidence significantly exceeded the one observed in relation to cigarette smoking only. The sex ratio for this cancer site, from hospitalized cases in Southern Iran, is estimated to be about nine male cases per one female case. This high male to female ratio was attributed to the greater addiction of males to opium. It was concluded that opium and, more likely, its pyrolysis derived fractions may represent potential bladder carcinogens in man.


Cellular angiomas of infancy: an ultrastructural study of two cases. Vascular tumors in infants may be clinically disfiguring, requiring surgical intervention. Some of these lesions are histopathologically worrisome, due to increased cellularity and mitotic activity. The interpretation of these lesions is hampered by a surfeit of terminology, although, regardless of the diagnostic name, they are clinically benign. Two such cellular angiomas are reported, one typical and one unusual case. Electron microscopy of both cases demonstrated a heterogeneous cellular composition, primarily endothelial cells and pericytes. In those light microscopic areas of diffuse growth, primitive vascular structures were resolved. Electron microscopy may be diagnostically useful in supporting the light microscopic impression of a vascular tumor.


Undifferentiated intratubular germ cell tumor of the testis: light and electron microscopic study of a unique case. A 34-year-old white man was found to have a nodule on the surface of right testis which turned out to be metastatic embryonal carcinoma within the tunica albuginea. Examination of the orchiectomy specimen revealed extensive undifferentiated intratubular germ cell tumor (carcinoma in situ) with foci of intratubular embryonal carcinoma and seminoma. Ultrastructure of the cells comprising the carcinoma in situ was similar to that of undifferentiated germ cells. The development of intratubular embryonal carcinoma and seminoma in a testis with extensive carcinoma in situ lends further support to the concept that carcinoma in situ or the testis represents an undifferentiated germ cell tumor from which other types of germ cell tumors of the testis may evolve.


Solitary plasmacytoma. I: Extramedullary soft tissue plasmacytoma. The details of 16 patients with extramedullary plasmacytoma are presented. All but one presented with localized disease, and all were treated successfully by radiotherapy. Only one patient developed local recurrence and only one has developed disseminated disease. Radiotherapy is recommended as the primary treatment of choice for these localized radiosensitive tumors. It is suggested that the good prognosis of plasmacytomas of the head and neck, in contrast to plasmacytomas arising at other sites, is related to the observation that a high proportion of these tumors are localized at the time of diagnosis and that very large primary tumors are uncommon.


Solitary plasmacytoma. II: Solitary plasmacytoma of bone. The clinical features and the results of treatment of twelve patients with solitary plasmacytoma of bone (SPB) are reported. The median age at presentation was 53 years and there was a predominance of males. Five patients have developed multiple myeloma (MM), for within three years and one after twelve years. Seven patients have not shown evidence of dissemination, and five are alive 1--15 years (median 9 years) after diagnosis. Two patients had metastases to local lymph nodes. There are no reliable criteria by which patients with truly SPB can be prospectively distinguished from those with occult MM, and it is recommended that all patients with apparent SPB should receive "curative" local therapy.


Short-term tissue culture of human breast cancer: presence of estrogen receptors and 17 beta-estradiol stimulation of RNA synthesis. The stimulation of RNA synthesis induced by estradiol has been studied on 60 breast cancers in short-term cultures. In the same tumors the estrogen receptor (ER) assay was carried out. In 35% of the cases studied the stimulating effect by estradiol in vitro was observed. The frequency of response to in vitro hormone treatment was higher (42%) in ER+ cancers and lower (25%) in ER- cancers. The specificity of the in vitro test was assessed by the use of tamoxifen.


Fluctuation of serum complement levels in children with neuroblastoma. Serum samples from eleven children with neuroblastoma were drawn at diagnosis and again every 15 days or a month after the beginning of treatment over the course of 17 months observation. Twenty healthy children of the same age with no appreciable clinical manifestation were also studied as controls. Investigations included quantitative serum complement levels (total complement hemolytic activity, C3 and C4), anticomplementary serum activity and urine catecholamine levels (VMA and HVA). Complement levels of tumor patients were significantly higher than those of healthy subjects, but fluctuations were seen at different stages of the disease; patients at admission with active tumors or tumor recurrence had higher complement levels than those of patients in remission. Temporary recurrences of the disease were usually accompanied by fluctuations of urinary catecholamines, serum complement levels (mainly C3) and anticomplementary serum activity. At the terminal phase of the disease a drop in complement levels was usually seen, while urinary catecholamines were progressively increasing.


Thyroid carcinoma: a clinical and pathologic study of 125 cases. Retrospective clinicopathological study of 125 thyroid carcinoma cases followed for 9 to 19 years was performed. Case selection for unfavorable histologic type and advanced disease was observed for referred cases. All medullary and anaplastic tumors were in patients over age 40; younger patients all had papillary and follicular carcinoma. Actuarial survival rates showed favorable outcome from papillary carcinoma followed by follicular and medullary or anaplastic tumors. Within the papillary carcinoma group, older age and male sex adversely affected survival; the former appeared related to clinical stage at presentation. Clinically palpable papillary carcinomas that were poorly circumscribed or showed vascular invasion were associated with poorer survival than tumors without these features. For papillary carcinomas under 1.5 cm, soft tissue invasion, vascular invasion, and occult lymph node metastases did not effect disease free survival. Two deaths from thyroid cancer were observed in this group, however, in patients who presented initially and with distant metastases. The biology of these small lesions is briefly discussed.


In situ carcinoma of the vocal cords.

In situ carcinoma of the vocal cords. Eighty-one patients with preinvasive carcinoma of the vocal cord, seen over a thirteen year period, were reviewed histologically and analyzed for response to treatment. Sixty-seven cases were clinically T1 and fourteen cases T2 (by virtue of extension of disease beyond the vocal cord). All patients had mobile cords. Histological criteria for in situ carcinoma and the spectrum of microscopic patterns are presented. Sixty-nine patients were treated by external beam radiotherapy--the remainder by a variety of surgical procedures. Five and ten year actuarial, recurrence-free rates 83% and 75%, respectively for the group treated by irradiation. No difference in local control was observed when analyzed for: 1) dose response, 2) initial extent of disease, 3) treatment plan, or 4) histologic diagnosis. Analysis of failures reveals that 15/17 patients with local failure were salvaged, eleven of these patients requiring laryngectomy. Time to appearance of recurrence ranged from seven to one hundred and seven months.


Effect of secretin and cholecystokinin-pancreozymin on plasma CEA concentration in patients with pancreatic carcinoma and pancreatitis. Plasma CEA concentration before and after administration of secretin and cholecystokinin-pancreozymin has been determined in 89 patients with neoplastic or inflammatory pancreatric disease and other neoplastic and nonneoplastic disorders. The purpose of the study was to expore the specificity and sensitivity of such a provocation tests. Some rise of the plasma CEA concentration after hormonal stimulation could be observed in several patients in the various groups. However, none of the 37 patients with nonpancreatic disease who had a basal CEA concentration of 6 micrograms/l or less had a maximal CEA concentration above 13 micrograms/l after the stimulation whereas 7 out of 31 patients with pancreatic disease (3 with pancreatic carcinoma and 4 with chronic pancreatitis) showed such an elevation of plasma CEA concentration. Thus, the provocation test showed a satisfactory specificity for pancreatic disease but a low sensitivity. It is suggested that the possibility of an effect of physiologically released gastrointestinal hormones should be considered when "unexplained" high CEA values are found in plasma samples from nonfasting patients.


Predictive value of serial carcinoembryonic antigen levels in long-term follow-up of ovarian cancer. The predictive value of serial levels of carcinoembryonic antigen (CEA) in tumor monitoring was examined in 213 patients with ovarian cancer; each patient had been followed-up at monthly intervals for at least 12 months. CEA was not detectable throughout the period of observation in 35% of the patients. In general. patterns showing a disappearance of CEA or persistently low levels were associated with a good prognosis, whereas those showing a reappearance or highly elevated and rising levels were associated with a poor prognosis. A transient reappearance of CEA was observed in 10 patients; this did not appear to be associated with tumor recurrence or progression. "False positive" results were obtained in 6 patients in whom no tumor has been clinically detectable to date. "False negative" results were obtained in 4 patients with obvious tumor progression. In terms of a good or poor prognosis, the use of CEA levels was highly accurate in patients with minimal or no residual disease (97% and 89%, respectively); the rate fell to 62% in patients with extensive disease. As the clinical significance and limitations become better known, serial CEA levels should contribute substantially to the monitoring of patients with ovarian cancer.


Adenocarcinoma in situ of the vagina: a case report. The clinical and pathological features of a case of adenocarcinoma in situ of the vagina diagnosed in a 40-year-old woman with a negative history for intrauterine DES exposure are reported. The lesion was diagnosed 15 months following hysterectomy for in situ squamous cell and in situ adenocarcinoma of the cervix. The vaginal lesion closely resembled colposcopically, cytologically, and histologically previously described cases of cervical adenocarcinoma in situ. The case was of additional interest pathologically because of a focal signet-ring cell component which exhibited extensive pagetoid invasion of the adjacent squamous mucosa. No previously reported examples of vaginal adenocarcinoma in situ could be found. The histogenesis of this entity is briefly discussed.


Carcinoma in a heterotopically auto-implanted nipple. Modified radical mastectomy with transplantation of the nipple in the groin for possible breast reconstruction was performed in a patient. Carcinoma developed in the transplanted nipple. Careful pathological examination of the breast tissue from the site of excised nipple should be carried out. In patients showing presence of tumor cells at that site, nipple transplantation may be deleterious.


Anaplastic seminoma: an analysis of 77 patients. Over a 28 year period, 77 patients with early stage anaplastic seminoma of the testis were treated by orchiectomy and lymphatic irradiation at three Army medical centers. With a median follow-up of 97 months, the 10 year actuarial survival is 96% of Stage I patients and 87% for Stage II patients. For patients with Stage I anaplastic seminoma no survival advantage can be demonstrated for adding mediastinal and supraclavicular irradiation versus para-aortic and pelvic irradiation alone. The addition of retroperitoneal lymphadenectomy to lymphatic irradiation increased the frequency of major gastrointestinal complications without significantly improving survival. Patients with anaplastic seminoma and elevated serum beta-subunit human chorionic gonadotrophin levels have a poor prognosis and should be considered for adjuvant combination chemotherapy. Anaplastic seminoma of the testis has a similar clinical presentation, response to therapy and prognosis compared to typical seminoma and should be managed in the same way.


The staging of testicular tumors.

The staging of testicular tumors. Sufficient information was recorded in the majority of a series of 531 germinal malignancies of the testis, to stage them retrospectively according to the T.N.M. staging system recommended by the U.I.C.C. and compare this with a locally devised scheme. By separately analyzing the commonest pathological types (differentiated seminoma, malignant teratoma intermediate and undifferentiated malignant teratoma) the histological influence on prognosis was minimized in this comparison. The predictive ability and greater simplicity of the Peter MacCallum Hospital system appears to be superior and it is put forward as an advance in staging for consideration when this comes up for review. It is pointed out that reporting results according to a more rigorous staging system can give the impression that survival figures are better than those obtained at another center using less stringent criteria, when in fact the overall results are the same and nothing has been done for the individual patient. This must be allowed for when considering different methods of treatment. Because of the importance of biochemical markers their inclusion in any staging system is essential; however, they are difficult if not impossible to incorporate under the anatomical sections. A separate category is proposed.


A prognostic study of urothelial renal pelvic tumors: comparison between the prognosis of patients treated with intrafascial nephrectomy and perifascial nephroureterectomy. A comparison of the prognosis between 2 series of patients with urothelial renal pelvic tumors is presented. One series comprising 70 patients was operated with intrafascial nephrectomy with extirpation of varying length of the ureter. The other series comprising 38 patients was operated with transabdominal perifascial nephrectomy with homolateral adrenalectomy, total ureterectomy and in 28 patients retroperitoneal lymphadenectomy. The 5-year survival was 51% in the patients operated with intrafascial nephrectomy and 84% in the patients operated with perifascial nephrectomy. The difference in prognosis is statistically significant (p less than or equal to 0.01) and cannot be explained by differences in extent of tumor infiltration, tumor grade or tumor size. The main difference in prognosis between the two series was in patients with high stage tumors (Grabstald stage 3 and 4). The 5-year survival was 74% in patients with stage 3 and 4 tumors in the patients operated with perifascial nephrectomy compared with 37% in the patients operated with intrafascial nephrectomy. Since it is not possible with absolute certainty to determine tumor stage before the operation, an aggressive attitude against urothelial renal pelvic tumors is recommended. Thus the patients should undergo transabdominal perifascial nephroureterectomy including a cuff of the bladder wall and homolateral adrenalectomy. In patient with bilateral tumors, renal insufficiency of tumor in a single kidney parenchyma saving partial resection must be performed.


Bladder carcinoma as a systemic disease. Pne hundred and fifty-one patients with transitional cell carcinoma of the bladder who were evaluated by conventional means preoperatively underwent a radical cystectomy. They were then classified according to the highest known pathological stage, first site of postoperative metastasis and the temporal relationship of the cystectomy to the appearance of the metastasis. Fifty patients developed metastases, 80% of which were proven histologically. Thirty-nine of fifty patients (78%) who developed metastases did so within a year of cystectomy. Extent of local tumor was directly related to the incidence of positive pelvic nodes. Metastases occurred most commonly in lung and bone. Soft tissues of the pelvis were involved in thirteen (16%) of the patients who developed metastatic carcinoma and those patients with positive pelvic nodes were more likely to have these kinds of recurrent disease. These evaluations suggest that the metastases must be present at cystectomy or as a result of it. The data imply the existence of appreciable heterogeneity among patients and/or their invasive bladder carcinoma. Disseminated but silent metastases suggest that a relationship between the primary tumor and the occurrence of metastatic disease may exist. Knowledge of this relationship is very important in planning subsequent therapeutic strategies.


Cancers of the large bowel: associated disorders in individuals. The individual medical histories in the files of the Oxford Record Linkage Study for the years 1963 to 1967 were analyzed to ascertain any previously unsuspected associations between cancers of the large bowel and other diseases in individuals, and to quantify the relative risks of disorders already known to be associated. In males significant associations were shown between cancers of the large bowel and cancer of the prostate. In females, cancer of the colon was associated with breast cancer, and cancer of the rectum with a mixed group of genital cancers. The relative risk of colorectal cancer associated with previous benign neoplasms of the large bowel was 20, and with ulcerative colitis, 25. There was no significant association with appendicitis or long-standing diverticular disease.


Receptor sites for complement and for immune complexes on human nonhemopoietic tumor cells. Tumor cells in primary cultures derived from 11 untreated nonhemopoietic cancer patients were reacted with specifically coated sheep erythrocytes. Rosette formation between tumor and indicator cells was assessed, Eight of the primary cultures reacted positively with both IgG-coated (EAIgG) and with IgM-human complement coated (EAIgMC or EAIgMC 4,3) sheep erythrocytes. EAIgG rosette formation in positive cultures ranged from 25 to 85%, and for EAIgMC/EAIgMC 4,3 reactivity ranged between 22--95%. Rosette formation with E (uncoated) and EAIgM was negligible. These findings suggest that human nonhemopoietic tumor cells may carry on their surface receptor sites for an IgG component of immune complexes and for human complement. These receptor sites may be important in the host-tumor relationship.


Sweat gland carcinoma with syringomatous features: a light microscopic and ultrastructural study. A 76-year-old man presented with a 10-year history of a slowly enlarging lesion of his upper lip. An excisional biopsy revealed a diffusely infiltrating, well-differentiated, sweat gland carcinoma with syringomatous features. The ultrastructural characteristics corresponded to those described for benign syringoma and normal eccrine ducts. A review of the literature emphasized the extreme rarity of this lesion. Sweat gland carcinomas tend to have an indolent history but often manifest aggressive behavior at the time of clinical presentation. The preponderance of anaplastic lesions accounts for a generally unfavorable prognosis.


Hodgkin's cells and attached lymphocytes: a possible prognostic indicator in splenic tumor. After the purification of Hodgkin's cells by a previously reported method from splenic tumor of 8 patients with Stages III or IV Hodgkin's disease, we have examined the proportions of Hodgkin's cells with attached lymphocytes. All patients were studied 3--5 years after staging laparotomy. Four patients had no recurrent disease; 3 had histologically confirmed recurrent disease; and 1 had clinically suspected recurrent disease (enlarged nodes) but has thus far refused further medical study and care. The proportion of purified Hodgkin's cells which had attached lymphocytes was consistently higher in the patients who were clinically free of disease. The possible biological significance of this observation is discussed briefly and would appear to warrant further investigation of this phenomenon in more patients with splenic tumor than are available to us.


Bone marrow metastases without cortical bone involvement in breast cancer patients. Bone marrow involvement by breast carcinoma in the absence of demonstrable bone lesions is unusual. We report six patients with medullary tumor without demonstration of cortical bone abnormality on scan or radiographs. This represents 2.8% of 213 patients with breast cancer in which bone marrow examination was performed and 6.2% of those in which marrow involvement was demonstrated.


A new approach to the differential diagnosis of human malignant melanomas. In an attempt to improve the diagnosis of melanotic tumors, we have compared the diagnosis obtained by histological examination of 216 skin tumors and their metastases with that obtained by using a conjunction of four techniques: tissue culture, cytoenzymology, in situ electron microscopy and 5-S-cysteinyldopa (5-S-CD) assay. In 46 cases the final diagnosis as determined by one or more of these tests differed from the initial histological diagnosis, but was confirmed by repeat histological examination. We conclude that this method presents a valuable new approach to the differential diagnosis of human malignant melanoma.


Electrophoresis of tissue glycosaminoglycans as an aid in the diagnosis of mesotheliomas. The histologic distinction between mesotheliomas and adenocarcinomas on mesothelial surfaces is sometimes difficult. High concentrations of hyaluronic acid in pleural and peritoneal fluids of mesothelioma patients have been reported. This paper describes results of glycosaminoglycan electrophoresis of papain digests of 7 mesotheliomas and 27 other tumors. Either all or almost all demonstrable glycosaminoglycans in mesotherliomas was hyaluronic acid. Control tissues had variable electrophoretic patterns showing other glycosaminoglycans in addition to hyaluronic acid. In the clinical context of differentiating mesotheliomas and adenocarcinomas in tissue samples, this technique seems simple, economical, and relatively specific.


Estrogen receptor values in patients with benign breast disease. Tissue specimens from 55 female patients with benign breast disease were assayed for estrogen receptor. Twenty-one of 55 patients (38%) had tumors which contained significant amounts of estrogen receptor (greater than 10 femtomoles/mg protein). Fibroadenomas possessed estrogen receptor more frequently than fibrocystic disease or other benign breast tumors. Estrogen receptor positivity did not correlate with laterality of the tumor; location or size of the largest nodule. Patients with estrogen receptor positive tumors had a mean age of 26.9 years compared to 36.4 years for patients with estrogen receptor negative tumors (p less than 0.01). Twenty of 46 (43%) premenopausal patients had benign tumors which were estrogen receptor positive compared to zero of 8 postmenopausal patients (p less than 0.05).


Concomitant arteriovenous vascular malformation in skeletal muscle: a clinical, angiographic and histologic study. A vascular malformation in skeletal muscle is described in 4 patients. Pathologically and anatomically, it consists of an abundance of concomitant arteries and veins and thick-walled capillaries. Angiography demonstrates the high vascularity of the lesion, and contrast medium appears early in draining veins indicating arteriovenous shunting. In the angiograms, the highly vascular region displays a certain striation which is due to the presence of muscle fiber bundles running between the pathologic vessels. This angiographic picture suggests benignity: an intramuscular malignant tumor rarely leaves intact muscle fiber bundles passing right through it.


Adrenal cortical carcinoma: a clinical and pathologic study of 49 cases. The clinical and pathologic features of 49 patients with adrenal cortical carcinoma are presented. The series included 26 men and 23 women with a mean age of 34 years. The average duration of symptoms prior to diagnosis was 6.6 months. Eighteen patients (37%) presented with recognizable endocrine syndromes secondary to excess tumor steroid production. Surgical excision was the only mode of therapy to offer any opportunity for prolonged survival. Nine of the 21 patients (43%) with a completely resectable tumor were alive with no evidence of disease an average of 7.2 years postoperatively. Death due to metastatic tumor occurred in 36 of the 49 patients (73%) an average of 8.7 months following diagnosis. Chemotherapy had no apparent effect on outcome while radiotherapy produced an objective palliative response in 50% of treated patients. The average size and weight of the tumors were 12.4 cm and 875.6 g, respectively. The difficulty of precise pathologic classification of certain large adrenal tumors is discussed and the importance of histopathologic features relative to gross morphologic findings is emphasized.


Lymph node metastases with PAS-positive tumor cells and massive epithelioid granulomatous reaction as diagnostic clue to occult seminoma. Two cases of occult seminoma were observed which showed left-sided lymph node metastases without clinically demonstrable testicular tumors. The peculiar histology of the lymph node metastases, namely PAS-positive tumor cells with clear cytoplasm together with a granulomatous stromal reaction, was highly suggestive of seminoma. Despite lack of testicular enlargement in both cases, a left-sided orchiectomy was done. Histologically, intratubular seminomas were found which confirmed the original diagnostic suspicions derived from the morphology of the lymph node metastases. It is concluded, therefore, that in the case of lymph node metastases with the above-mentioned structure, occult seminoma should always be taken into consideration. Because of the modern beneficial therapeutic implications, detection of occult seminoma is very important.


Recommendations for the analysis of the effect of treatment on the development of second malignancies. Use of the person-years method for evaluating the association between treatment of a primary cancer and subsequent development of a second malignancy is reviewed. For this type of analysis, the risk of developing a second malignancy is implicitly assumed to remain constant during each patient's follow-up period; this assumption is shown to be inappropriate. When the oncogenic potential of two or more treatments is compared, results are biased unfavorably against the use of intensive treatments that prolong life. Misinterpretation of the oncogenic potential of such treatment regimens can therefore occur, and two alternative statistical techniques are proposed, each for use in a commonly encountered experimental situation. These fairly classic methods of survival analysis are recommended to ascertain the relationship between treatment and development of a second cancer.


Cystic cerebellar astrocytomas in childhood. Thirty-nine patients with low grade cystic cerebellar astrocytomas were treated at the University of Washington and Children's Orthopedic Hospital in Seattle, Washington, between 1955 and 1977; 29 were treated with partial or complete resection alone, and 10 received radiation therapy after various types of surgical procedures. With a mean follow-up time of 7 years, the survival rate for patients who had complete resections of their primary disease was 100%. The relapse-free survival rate was 82%. The relapse-free survival rate for patients treated primarily with partial resection alone was 36%. Postoperative irradiation after partial resection for both primary and recurrent disease resulted in a relapse-free survival rate of 83%. If complete tumor excision is not possible, postoperative radiation therapy is recommended following partial resection.


Rhabdomyosarcoma arising in a pineal teratoma. Pineal teratomas are relatively uncommon intracranial neoplasms. A rhabdomyosarcoma developed in a pineal teratoma in a 14-year-old boy and was rapidly fatal despite radiation therapy. This is the second reported case of a pineal teratoma giving rise to a rhabdomyosarcoma.


Tumors of the eye and adnexa in the Sudan. 854 lesions involving the eye and adnexa in the Sudan were studied as regards their frequency, sex and age incidence, site, pathologic types and geographic and racial distribution. Of 279 primary malignant tumors (frequency ratio 4.3%), conjunctival squamous carcinoma was the commonest (50.4%) while retinoblastoma formed 20.8%, basal cell carcinoma 6.1% and malignant melanoma 4.6%. Conjunctival carcinoma and allied epithelial lesions occurred much more predominently in Northern than in Southern Sudan and no basal cell carcinoma of the eyelids was recorded in the latter. Retinoblastoma and melanoma showed certain tribal predilections. Most cases of Burkitt's lymphoma occurred in Southern Sudan. It is concluded that geographic and racial factors play important roles in determining the frequency and pattern of eye neoplasms in the Sudan.


Gestational choriocarcinoma and thyrotoxicosis. A case of a 26-year-old woman with metastatic choriocarcinoma and clinical and biochemical thyrotoxicosis is described. This represents the eighth reported case of the association of choriocarcinoma and thyrotoxicosis. Serial monitoring of serum thyroxine (T4) and thyroid stimulating hormone (TSH) levels correlated precisely with the beta sub-unit human chorionic gonadotropin (hCG) level and the quantitation of host tumor burden. The development of a hypermetabolic syndrome in patients with choriocarcinoma may be due to secondary thyrotoxicosis from either the TSH-like activity of hCG or from the concomitant production of molar thyrotropin by the tumor.


Carcinoid tumor of the prostate associated with adenocarcinoma. A case of carcinoid tumor associated with adenocarcinoma arising in the prostate was studied. The results confirmed the presence of argentaffin cells. The significance of their presence and relationship to functional adenocarcinoma of the prostate are discussed.


Clinical examination of the breasts by nonphysicians: a viable screening option? After four years of annual screening 10,566 women, physical examination (PE) by nurse clinicians is as effective in detecting suspect cases as is the examination of surgeons and the general medical community of Cincinnati. Carefully performed physical examination has found 45% of the extant cancers detected. Twenty-eight percent of the cancers detected by PE were minimal lesions. One-third of all the minimal cancers currently detectable were discovered by PE.


Childhood bronchial mucoepidermoid tumors: a case report and review of the literature. A bronchial mucoepidermoid tumor in a 13-year-old female was studied by light and electron microscopy. This is the seventh reported case of this rare bronchial neoplasm in a person less than 16 years of age and the only case, in any age group, which has been studied ultrastructurally. All reported cases of bronchial mucoepidermoid tumors in childhood have been histologically of the low grade (well differentiated) variety with a benign clinical course. Although there are histological features which distinguish this lesion from the even rarer bronchial mucous gland adenoma, the clinical features and biological potential of the two lesions in this age group appear to be identical. The optimal surgical therapy for bronchial mucoepidermoid tumors and mucous gland adenomas, when occurring in children, is identical. There must be total removal of either lesion with the sacrifice of as little normal lung as possible. When technically possible, a sleeve resection of the involved bronchus is recommended; however, in most cases, the location of the lesion requires a lobectomy for complete removal.


Leiomyosarcomas of the small intestine.

Leiomyosarcomas of the small intestine. Small bowel leiomyosarcomas are uncommon but potentially curable tumors often diagnosed at an advanced stage. Twenty such lesions were studied, and 19 of these produced symptoms and signs. Clinical findings included abdominal pain in 17 (85%), rectal bleeding in 8 (40%), anemia in 7 (35%), intraperitoneal perforation in 6 (30%), and abdominal mass in 4 (20%). Various abdominal x-ray examinations revealed nonspecific abnormalities (ileus, bowel obstruction, abdominal mass) in about half the cases in which they were obtained, but in only one instance was the correct diagnosis of small bowel tumor made preoperatively. Five of 12 patients undergoing resection in hope of cure survived five years. These tumors tend to metastasize by hematogenous dissemination, peritoneal implantation, local invasion, and, uncommonly, lymphogenous spread. Wide small bowel resection with adjacent mesentery is suggested for most lesions. Five year survival following resection approximates 50% in reported series.


Lung carcinoma arising in bronchopulmonary sequestration. A squamous cell carcinoma arising in intralobar bronchopulmonary sequestration of the right lower lobe is described in a 69-year-old man. One other reported case was found. Other complications of bronchopulmonary sequestration include nonspecific infections and tuberculosis.


Primary low grade adenocarcinoma occurring in the inguinal region. An unusual case of primary adenocarcinoma occurring in the inguinal region of an elderly woman is reported. It appeared to have arisen from the mesothelium of the canal of Nuck. It recurred and involved one inguinal lymph node three years after the diagnosis and seven years after the initial appearance of the mass. The absence of associated peritoneal tumor distinguishes this case from other reported primary malignant neoplasms of the hernial sac.


5-drug adjuvant chemotherapy for breast cancer. A series of 41 patients at the MGH who received 5-drug chemotherapy, cyclophosphamide, methotrexate, 5-fluorouracil, vincristine and prednisone, (CMF VP) as adjuvant to surgical treatment of operable breast cancer with 4 or more positive axillary nodes is compared to an analogous group of patients treated with cyclophosphamide, methotrexate and 5-fluorouracil (CMF) reported by Bonadonna et al. in an effort to assess the contribution of the treatment program to disease control. The MGH pattern of disease free survival closely parallels that of Bonadonna. Median disease-free survival among the 24 patients who have not recurred is 27 months; among those who recurred 18 months. The analogous medians for treated patients in the Bonadonna study are 24 months and 16 months, as compared to 27 months and 8 months for his nontreated controls. The treatment program, carried out over a two year period, was well tolerated with excellent patient compliance. There was no significant impact, however, in the disease-free survival of postmenopausal patients. While use of this regimen improved disease-free survival in premenopausal individuals, it is clear that a great deal of room for improvement exists, and newer regimens should be investigated.


5-fluorouracil, adriamycin, and mitomycin-C (FAM) combination chemotherapy in the treatment of advanced gastric cancer. Thirty-six patients with advanced measurable gastric cancer were treated with a new combination chemotherapy program consisting of 5-fluorouracil, Adriamycin and mitomycin-C (FAM). Fifty percent of patients achieved an objective partial response. The median duration of remission was 9.5 months and the median survival for responding patients was 13.5 months, with 2 remaining alive at 14 and 26 months. The median survival for nonresponding patients was 3.0 months and all were dead by 6 months after initiation of therapy. The median survival of all 36 patients treated with FAM was 5.5 months. An analysis of possible prognostic variables including initial performance status, resectability of the primary gastric tumor and histologic differentiation of the neoplasm failed to account for differences in patient response and survival. The FAM regimen was well tolerated, and produced only moderate bone marrow suppression. These results demonstrate that some patients with advanced gastric cancer can be effectively palliated with FAM chemotherapy. Phase III trials are warranted to assess the effect of the FAM regimen on the survival of patients with advanced gastric cancer.


Chemosensitivity of human bladder cancer cells in long-term culture and clinical responses to the selected anticancer drug. In vitro sensitivity of an established cell line from human urinary bladder cancer to various chemotherapeutic agents was determined by 14C-leucine incorporation into the target cells. Of 12 drugs tested, Carboquone, Neocarzinostatin, Actinomycin D, Adriamycin, Mitomycin C and Chromomycin A3 produced intensive cytotoxic effects, while Thio-Tepa, Bleomycin, 5-Fluorouracil and Vincirstine were less cytotoxic, Intravesical instillation of Carboquone, one of the most toxic agents in vitro, resulted in complete or partial tumor remission in 6 of 9 patients with bladder cancer. Prophylactic effects of periodic intravesical Carboquone were also indicated in 7 of 8 patients who had experienced recurring superficial bladder tumors.


Desacetyl vinblastine amide sulfate induced ineffective erythropoiesis. Ineffective erythropoiesis occurred during desacetyl vinblastine amide sulfate (VDS) therapy of a patient with metastatic Ewing's sarcoma. The peripheral blood was characterized by anisocytosis, poikilocytosis and reticulocytopenia. Bone marrow showed megaloblastic red cell hyperplasia with nuclear fragmentation, binuclearity and abnormal metaphases. Radioiron incorporation into red cells was markedly decreased. Electron microscopy showed red cell surface changes previously called ropalocytosis. Normal erythropoiesis promptly resumed when VDS treatment was withheld. Although less common than leukopenia, red cell abnormalities are part of the spectrum of vinca alkaloid toxicity.


Blurring of vision: a previously undescribed complication of cyclophosphamide therapy. Five children with cancer treated with high dose cyclophosphamide experienced blurring of vision. In three patients, the blurring lasted less than one hour and disappeared, abruptly, but in the other two, it was prolonged, lasting three and 14 days with gradual improvement. In all five complete restoration of normal vision occurred. We have not found other reports of this association in the literature.


Hodgkin's disease in children: treatment with low dose radiation and MOPP without staging laparotomy: a preliminary report. Twenty-seven children with previously untreated Hodgkin's disease (CS I-2, II-13, III-3, IV-9) were given three cycles of MOPP to induce a remission which was consolidated with extended field radiation (2000--3500 rad) and three cycles of MOPP. Surgical staging was discontinued. Twenty-five of 27 children have not relapsed (range 15+--64+ months; median 39+ months); two children have died, one of uncontrolled Hodgkin's disease and one of acute infection while in complete remission. Actuarial 3 and 5 year survival rates and relapse-free rates are 91%. The merits of this treatment approach are discussed.


Metastatic chondroblastoma: report of an unusual case treated with radiotherapy. Although most chondroblastomas are cured by limited surgical procedures, occasional lesions behave more aggressively and may even metastasize. We report here an unusual case of chondroblastoma, characterized by slow growth, two clinical recurrences following attempts at excision, and pulmonary metastases after a total course of 34 years. This tumor was moderately radiosensitive, as it decreased 50% in size 6 months after a dose of 4000 rads in 4 weeks. Review of the literature suggests that aggressive chondroblastomas may show several types of behavior. Most lesions are unusually aggressive from their inception, displaying local invasion and early recurrence. Other lesions, such as the present case, continue to grow slowly and may eventually metastasize if inadequately resected. This latter type of behavior may exemplify the natural history of untreated chondroblastoma.


Rapid determination of methylated purines in DNA treated with N-methyl-N-nitrosourea using high-performance liquid chromatography. A method for determining methylated purine bases in [3H]N-methyl-N-nitrosourea (MeNOUr) treated DNA is described. The method combines reversed-phase high performance liquid chromatography (HPLC) of methylated DNA after hydrolysis in dilute acid with the determination of radioactivity in the fractionated eluates. The peaks of the respective methylated purines were indentified by the use of internal standards. The method allows quantitative separation of 3-methyl-adenine (m3Ade), 7-methyl-adenine (m7Ade), 3-methyl-guanine (m3Gua), 7-methyl-guanine (m7Gua) and O6-methyl-guanine (m6Gua) within 20 min. Thus the total time required for determination of methylated purines is limited only by radioactivity measurements in the respective fractions.


Photodynamic inactivation of cancer cells in vitro. Effect of irradiation temperature and dose fractionation. Human cancer cells in vitro (NHIK 3025), derived from a carcinoma in situ are inactivated when exposed to visible light in the presence of hematoporphyrin. Irradiation at 4 degrees C results in much more efficient inactivation than irradiation at 37 degrees C. Furthermore, a given total light dose is more efficient when it is fractionated than when it is given in a single exposire. These findings may be taken advantage of in future photochemotherapy of cancer.


Suramin enhancement of the chemotherapeutic actions of cyclophosphamide or adriamycin of intramuscularly-implanted Ehrlich carcinoma. The chemotherapeutic action of cyclophosphamide or adriamycin monotherapy on hyperdiploid Ehrlich carcinoma was compared with that of sequential combinations of suramin and cyclophosphamide and suramin and adriamycin. The chemotherapeutic action of the suramin-cyclophosphamide combination or of the adriamycin-surmin combination was significantly enhanced when the combination partners were applied at definite intervals.


Effect of L-alpha-amino-gamma-guanidinobutyric acid on melphalan therapy of the L1210 murine leukemia. About half the mice administered a lethal inoculum of L1210 leukemia become 60-day survivors when treated with an appropriate dose of melphalan. Leucine completely abolishes this long-term survival by interfering with melphalan uptake into the tumor cells. L-alpha-Amino-gamma-guanidinobutyric acid, the lower homolog of arginine, promotes melphalan uptake in vitro only in the presence of leucine. When administered to mice with melphalan and a dose of leucine which negates the 50% cure rate of melphalan, it reduces the therapeutic interference of leucine. However, L-alpha-Amino-gamma-guanidinobutyric acid alone does not improve melphalan therapy, suggesting that endogenous leucine can play only a minor role in interference with therapy of the L1210 leukemia.


Lack of oestradiol-DNA binding in mouse embryo cell cultures or following rat-liver microsomal metabolism. Oestradiol-17beta was compared to benzo[a]pyrene (BP) for its ability to bind to the DNA of mouse embryo cells in culture or to DNA added to a rat liver microsomal incubation mixture. No significant binding was found in embryo cells (at least 100-fold less than for BP). Microsomal incubation resulted in apparent oestradiol binding to a reisolated DNA-containing complex, but most of this was lost when the DNA was freed of RNA and protein.


Lymphocyte fluorescent profiles (LFP): a possible screening technique in neoplasia. A technique involving fluorescent protein staining and microfluorometry has been developed for measuring the lymphocyte fluorescent profile (LFP) of peripheral blood lymphocytes. In contrast to normal humans who display a regular bell-shaped curve, the profile from patients with cancer is irregular, showing a bimodal distribution of fluorescence, with a significant population of cells fluorescing at a higher relative intensity. It is suggested that this elevation in protein concentration is due to an immune response to the presence of a neoplasm, and thus this technique may prove to be a useful indicator of malignancy.


Intranuclear rodlets in undifferentiated carcinomas of salivary glands in strain A mice in a study involving a tobacco specific nitrosamine, N-nitrosonornicotine. Undifferentiated carcinomas of the salivary glands were found in 2 of 44 (4.5%) strain A mice injected intraperitoneally with a tobacco specific nitrosamine, N-nitrosonornicotine (NNN). The presence of intranuclear rodlets (INR) in the salivary carcinomas provided the first demonstration of such structures in a non-neuronal tumor in mice. Two types of rodlets were exhibited; one was composed of fibrillar filaments arranged in bundles, and the other was much thicker, branching in form. These INR appeared to be closely associated with nuclear chromatin or nucleoli.


Interferon and spontaneous cytotoxicity in man. III. Effect of interferon on lymphocytes and target cells in vitro. Human leukocyte interferon (IF) was tested for its capacity to modify the spontaneous cytotoxicity of human peripheral lymphocytes for allogeneic target cells in vitro. Pretreatment of lymphocytes with IF augmented their cytotoxicity whereas pretreatment of the target cells did not increase but possibly decreased their sensitivity to the spontaneous cytotoxicity of lymphocytes.


Forssman-like antibody levels in sera of patients with lung cancer. Sera of normal individuals or patients with lung cancer were assayed for Forssman-like antibody by a quantitative and specific method using ethylenediaminetetraacetate-containing buffer to inactivate complement in the test serum. It was shown that although Forssman-like antibody levels were distributed widely, (a) the levels of young (20 to 45 years of age) normal subjects of Blood Groups A and AB were lower than those of Blood Groups O and B, (b) the levels of old (60 to 80 years of age) normal subjects were lower than those of young normal subjects of Blood Groups O and B, and (c) the levels of old lung cancer patients were lower when compared to age-matched normal individuals of their blood group.


Formation of methotrexate polyglutamates in rat hepatocytes. Polyglutamate derivatives of [3H]methotrexate (MTX) were detected in freshly isolated rat hepatocytes in suspension within 15 min after exposure to the folate analog. The rate of polyglutamate synthesis remained constant for at least one hr, and the polyglutamate derivatives accounted for an increasing proportion of the intracellular radiolabel with time. After initial exposure to 1 micron [3H]MTX, polyglutamate derivatives of Mtx continued to be synthesized even after the extracellular [3H]-MTX concentration had been reduced 20-fold. Prolonged exposure of hepatocytes in primary culture to 1 micron [3H]MTX resulted in the formation of longer-chain polyglutamate derivatives of MTX. The present studies demonstrate another important biosynthetic capacity of the freshly isolated hepatocyte and suggest the usefulness of this system for studying the mechanism of, and controlling factors in, the synthesis of polyglutamate derivatives of MTX. The ramifications of the formation of MTX polyglutamates on drug cytotoxicity in general and hepatotoxicity in particular are considered.


Regression of human tumors established in nude mice after continuous infusion of thymidine. A system for the continuous infusion of thymidine solutions in nude mice has been developed. High doses (0.5 to 1.0 ml/mouse/hr) of a 28.5-mg/ml thymidine solution (444 to 888 mg/kg/hr) can be administered continuously for 96 to 140 hr. The preliminary results indicate that it is possible to induce total tumor regression of human heterotransplants established in nude mice of one human teratocarcinoma, five different human melanomas, and one human lung carcinoma and to inhibit to a large degree the growth of two human breast carcinomas by multiple (two to eight) cycles of infusion. The life span of the thymidine-treated animals has been significantly increased compared to that of control animals.


Modification by adenosine of the effect of adriamycin on myocardial cells in culture. The cardiotoxic effects of Adriamycin (ADM) were studied utilizing mammalian myocardial cells in culture as a model system. ADM inhibited cell growth and the rhythmic contractions characteristic of these cells. Because a possible involvement of energy metabolism in the action of ADM was suggested previously, the adenylate energy charge and phosphorylcreatine mol fraction were determined in the ADM-treated cells. The adenylate energy charge was found to be significantly decreased, while the phosphorylcreatine mol fraction was not. Such disparity suggests an inhibition of creatine phosphokinase. The addition of 1 mM adenosine to the myocardial cell cultures markedly increased the adenosine triphosphate concentration but not the adenylate charge. In the ADM-treated cells, the addition of adenosine increased both the adenosine triphosphate concentration and the adenylate charge, and, concomitant with this increase, the functional integrity of the cells in terms of percentage of beating cells and rate of contractions was maintained.


Enhancement of radioresponse of a mouse mammary carcinoma to combined treatments with hyperthermia and radiosensitizer misonidazole. The regrowth delay of a transplanted syngeneic mouse mammary carcinoma designated MT2 was used to estimate the effects of three-fold combination treatments: X-irradiation; hyperthermia and radiosensitizer; and misonidazole (Ro-07-0582). The experiment entailed five groups of experimental mice: untreated control; X-rays alone; X-rays plus hyperthermia (42--43 degrees); X-rays plus misonidazole; and X-rays plus hyperthermia plus misonidazole. X-Ray treatments consisted of 4000 rads administered locally to the tumors in two equal fractions at a 48-hr interval. Misonidazole (0.67 mg per g body weight) was injected i.p. 30 min before exposure to X-irradiation. Hyperthermia was administered 10 min prior to and for 17 min during irradiation. The regrowth delay factor of 3.9 was obtained by administering combined treatments of the three agents (X-rays plus hyperthermia plus misonidazole). The enhancing effect on a syngeneic mouse mammary adenocarcinoma by the modality of treatment herein described lends support to the usefulness of combining X-rays with other agents in the treatment of neoplasms.


Chromosomal DNA cytophotometry in 20q- nonspecific myeloid disorders. DNA cytophotometry was used to quantify the chromosomal alterations in the bone marrow and blood of three patients with nonspecific myeloid disorders. All patients possessed a population of cells with a morphologically abnormal chromosome 20, del(20)(qll). In two of the patients, the abnormal chromosome 20 showed nearly identical DNA measurements with a net loss of 0.37% of the total autosomal DNA in one patient and 0.38% in the second. The third patient had a net loss of only 0.25% of the autosomal DNA. Analysis of the DNA content of the long arm and short arm of the abnormal No. 20 indicated that all three cases had chromosomal material added to the short arm (0.10 to 0.14% of the autosomal DNA). About 0.50% of the autosomal DNA was deleted from the long arm in two of the patients; only 0.35% of the autosomal DNA was deleted from the long arm in the third case. Within the limit of resolution, there is no evidence that the material lost has been translocated intact to another chromosome. The origin of the 20q- chromosome as the result of an incomplete pericentric inversion is suggested.


Occurrence of a low-molecular-weight calcium-binding protein in neoplastic liver. A calcium-binding protein was detected in the cytosol of Morris hepatomas 7288, 5123tc (h), 5123tc, and 7795. This protein could not be detected in adult Buffalo liver, 24-hr regenerating liver, or 18- to 20-day-old fetal liver. The amount of this protein present was not clearly related to the growth rate of the tumors studied, although there was more in a faster growing tumor (5123tc) than in the slowest (7795). The protein from the four tumors was apparently identical. The calcium-binding protein was heat stable and was not the calcium-dependent regulator of cyclic nucleotide phosphodiesterase. It had an apparent molecular weight of less than 12,500.


Effects of adriamycin and cyclophosphamide treatment on induction of macrophage cytotoxic function in mice. The effects of i.p. and s.c. Adriamycin and cyclophosphamide treatment of BALB/c x DBA/2F1 mice were studied alone and in combination with immunotherapeutic agents, pyran copolymer and Bacillus Calmette-Guérin, on macrophage cytotoxic ability, As assessed by direct viable cell counts of MBL-2 leukemia cells, both Adriamycin and cyclophosphamide produced growth-inhibitory macrophages. This function after s.c. cytostatic treatment peaked at Day 1 and decreased progressively, attaining normal control values by Day 6. When adjuvants, such as pyran and B. Calmette-Guérin, were administered i.p. simultaneously with s.c. Adriamycin or cyclophosphamide, adjuvant-induced cytotoxic function was not markedly affected. A better knowledge of the influence of cytostatic agents alone or combined with immunoadjuvants on macrophage cytotoxic ability may be useful in designing more effective chemoimmunotherapy protocols.


Inhibition of N-n-butyl-N-(4-hydroxybutyl)nitrosamine-induced urinary bladder cancer in rats by administration of disulfiram in the diet. The objective of this study was to determine if disulfiram would influence the induction of urinary bladder cancer in rats given N-n-butyl-N(4-hydroxybuty)nitrosamine (BHBN). Adult male Wistar rats were divided into: Group 1, control diet, 30 rats; Group 2, control diet plus 0.025% BHBN in the drinking water, 60 rats; Group 3, control diet containing 0.5% disulfiram, 30 rats; and Group 4, control diet containing 0.5% disulfiram plus 0.025% BHBN in the drinking water, 60 rats. The animals were kept on these regimens for 15 weeks and then were transferred to and maintained on control diet. The average total intake of BHBN was 1.21 g/rat for Group 2 and 1.23 g/rat for Group 4. The cumulative incidences of bladder cancer at 25 weeks after initial exposure to BHBN were: Group 1, 0 of 9; Group 2, 27 of 27; Group 3, 0 of 9; and Group 4, 0 of 27. At termination of the experiment (32 to 42 weeks), the final bladder cancer incidences were: Group 1, 0 of 30 (0%); Group 2, 57 of 57 ()00%); Group 3, 0 of 24 (0%); and Group 4, 7 of 55 (13%). Except for a carcinoma of the renal pelvis in one rat in Group 2 and the bladder tumors in Groups 2 and 4, tumors were not detected in other organs of any of these rats. It was concluded that disulfiram significantly inhibited the induction of bladder cancer in rats exposed to BHBN. The mechanism of action of disulfiram in this process is under investigation.


Immunological block to synthetic alpha-melanocyte-stimulating hormone: melanocyte interaction by antibodies isolated from cell-column immunoadsorbents. Antibodies to formalin-fixed, syngeneic melanoma cells were prepared in mice, purified by immunoaffinity chromatography, and tested for binding activity to viable melanoma cells. The radiolabeled antibodies detected congruent to 9 X 10(6) melanoma antigenic sites/cell. The calculated average association constant (Ka) for the antibody population was 7 to 10 X 10(7) M-1. The antibody was shown to block the binding of melanocyte-stimulating hormone in competitive cell surface binding studies. Results are discussed conceptually in terms of the potentially important role that the humoral immune response may play in the phenomenon of tumor progression.


Synthesis of the glucuronic acid conjugate of methylazoxymethanol. The glucuronic acid conjugate of methylazoxymethanol was synthesized by oxidizing the primary alcohol of the glucose moiety of cycasin (methylazoxymethanol-beta-D-glycopyranoside) to a carboxylic acid. The oxidation was carried out by bubbling oxygen gas through a cycasin solution in the presence of a platinum-on-carbon catalyst. A band at 1715 cm-1, not present in the cycasin infrared spectrum, appeared in the spectrum of the oxidized cycasin product, establishing the presence of a carboxylic acid group. The oxidation product is methylazoxymethanol-beta-D-glucosiduronic acid because, when hydrolyzed with Escherichia coli beta-glucuronidase, it produced methylazoxymethanol and glucuronic acid and also indicated retention of the beta-linkage of cycasin. Varying quantities of the synthesized methylazoxymethanol-glucosiduronic acid, injected into Wistar rats of both sexes and of varying weights, were not acutely toxic. The compound was mutagenic to Salmonella typhimurium when preincubated with E. coli beta-glucuronidase, but not when preincubated with bovine liver glucuronidase.


Effect of delay in administration of 13-cis-retinoic acid on the inhibition of urinary bladder carcinogenesis in the rat. The effect of a delay in starting 13-cis-retinoic acid treatment on the inhibition of urinary bladder carcinoma induced by N-butyl-N-(4-hydroxybutyl)nitrosamine was studied in male Fischer 344 rats. Animals received a total p.o. dose of either 1200, 1800 or 2400 mg N-butyl-N-(4-hydroxybutyl)nitrosamine over a period of six weeks. At either one, five, and nine weeks after the last N-butyl-N-(4-hydroxybutyl)nitrosamine intubation, animals were started on a diet supplemented with 13-cis-retinoic acid (240 mg/kg of laboratory chow) or continued on laboratory chow. Animals were killed at one year after the first carcinogen intubation for histological evaluation of the bladder. Feeding of 13-cis-retinoic acid reduced the incidence, average number, and severity of transitional cell carcinomas as well as hyperplasia and cellular atypia. Furthermore, even a nine-week delay in starting the retinoid feeding did not diminish the ability of 13-cis-retinoic acid to inhibit bladder carcinogenesis.


Cell cycle phase-specific cytotoxicity of the antitumor agent maytansine. The objective of this investigation was to study the effects of maytansine on the cell cycle kinetics of HeLa cells. The results of this study indicate that maytansine is a very potent mitotic inhibitor and that it has no effect on macromolecular synthesis. Maytansine-induced cytotoxicity was dependent upon the position of the cell in the cell cycle. Mitotic and G2 cells are most sensitive to this agent, while G1 phase cells are the most resistant, with S-phase cells being intermediate. Small (0.82 X 10(-8) M) fractionated doses given at an interval of 8 hr have been found to be more cytotoxic than was a large (1.63 X 10(-8) M) single dose. In evaluating the drug combinations, we observed that the schedule in which 1-beta-D-arabinofuranosylcytosine treatment was followed by maytansine treatment exhibited greater cell kill than the reverse sequence. No schedule-dependent effects were observed when maytansine was tried in combination with Adriamycin.


Toxicity of metabolic benzo(a)pyrenediones to cultured cells and the dependence upon molecular oxygen. The three quinone metabolites of carcinogenic benzo(a)pyrene, the isomeric benzo(a)pyrenediones (6, 12; 1,6; 3,6), are toxic to cultured hamster cells at low concentrations. The reduction in cell number, observed after treatment with these metabolites, is the result of both direct cell killing and the inhibition of growth, since DNA synthesis is inhibited very early after treatment with benzo(a)pyrene 1,6-dione when little cell death has occurred. The rate of RNA synthesis was also inhibited by treatment of cells with benzo(a)pyrene 3,6-dione. These actions of the benzo(a)pyrenediones toward hamster cells can be eliminated or substantially reduced by the removal of oxygen from the growth medium and atmosphere in which the cells are incubated. In contrast, anaerobic conditions do not reduce the cytotoxicity observed with the alkylating agent ethyl methanesulfonate. These results support the hypothesis that benzo(a)pyrenediones, and other biologically active quinones, owe their activity to oxidation-reduction cycles involving quinone, hydroquinone, and molecular oxygen; the reactive reduced oxygen radicals and semiquinone radical formed during these cycles may be responsible for the observed cellular injury and inhibition of cellular processes.


Cytotoxicity of an 125I-labeled DNA-binding compound that induces double-stranded DNA breaks. [125I]Iodorivanol (6,9-diamino-2-ethoxy-5-[125]iodoacridine) has been prepared by direct iodination of rivanol (6.9-diamino-2-ethoxyacridine). In vitro binding of [125I]iodorivanol to PM2 DNA resulted in induction of double-stranded DNA breaks following decay of the 125I atom, presumably in the same way as decay of 125I atoms in 125I-labeled DNA causes double-stranded DNA breaks. Treatment of mouse L-cell cultures with [125I]iodorivanol resulted in a cell kill, the extent of which was dependent on the 125I specific activity and the duration of exposure. A clonogenic assay was used to quantitate cell kill. It was concluded that at least some of the [125I]iodorivanol in the culture medium was taken up by the cells, transported to the nucleus, and bound to DNA and that subsequent decay of the 125I atoms induced double-stranded DNA breaks in the genome, with consequent loss of viability. 125I-labeled DNA-binding compounds are suggested as a novel class of cytotoxic agents.


Time-temperature relationship th hyperthermic treatment of malignant and normal tissue in vivo. The effect of hyperthermia on normal and tumor tissue was studied following water bath heating of a methylcholanthrene-induced fibrosarcoma (FSaI) isotransplanted into the feet of C3H mice. The time-temperature relation for the 50% tumor control dose over the temperature range of 41.5--45.5 degrees showed a log linear relationship which followed a biphasically modified Arrhenius plot. At temperatures above 43 degrees, there was a 50% reduction in heating time to obtain the 50% tumor control dose for each 1 degree increase in temperature, corresponding to an activation energy of 140 kcal/mol. At temperatures below 43 degrees, the curve was steeper, with a tendency to double the treatment time for each 0.5 degree reduction in temperature (activation energy, approximately 230kcal/mol). Normal tissue damage in the tumor-bearing foot was estimated at two levels with a 50% response dose assay. Severe normal tissue damage showed a time-temperature relationship similar to the tumor response, thus indicating no variation in therapeutic ratio at different temperatures. However, for slight tissue damage, the therapeutic ratio increased with decreasing temperatures, yielding a better therapeutic ratio at lower temperatures. The time-temperature relationship obtained in the FSaI fibrosarcoma is supported by other studies and points to a general time-temperature relationship for hyperthermic tumor destruction.


Dose-dependent DNA ruptures induced by the procarcinogen dimethylnitrosamine on primary rat liver cultures. The effect of certain procarcinogens, among which demethylnitrosamine (DMN) is included, has been difficult to detect in several short-term assays. An alternative system, in which DMN effects could be easily quantitated, might be useful in studies of chemical carcinogenesis and environmental contamination. To develop such a system, we tested the possibility of measuring the amount of breakage produced by DMN on radiolabeled DNA of primary liver cultures. Rat liver cells were isolated 20 to 24 hr after partial hepatectomy, cultured, and pulse labeled in vitro with [3H]thymidine. Radioactively labeled cultures were treated with DMN or with the direct carcinogen N-methyl-N'-nitro-N-nitrosoguanidine and then lysed directly onto alkaline sucrose gradients. DMN and N-methyl-N'-nitro-N-nitrosoguanidine caused a dose-dependent reduction in the molecular weight of DNA, N-methyl-N'-nitro-N-nitrosoguanidine being approximately 1000 times more potent than DMN. DNA breaks appeared to be carcinogen specific and not due to cell death since treatment with high doses of cycloheximide, a noncarcinogenic hepatotoxic, was without significant effect. Our data indicate that detection of DNA breaks constitutes a more sensitive assay of DMN effects than does unscheduled DNA synthesis in primary liver cultures. Therefore, it could be useful to extend our work to determine the general applicability of quantitation of DNA breaks in liver cells as a short-term assay for the identification of possible carcinogens and procarcinogens.


Metabolism and activation of 2-acetylaminofluorene in isolated rat hepatocytes. The metabolism of 2-acetylaminofluorene (AAF) as well as the activation of AAF to covalently bound and mutagenic intermediates were studied in isolated rat hepatocytes. The cell system readily formed oxidized, deacetylated, and conjugated AAF metabolites. Pretreatments of animals with the inducer beta-naphthoflavone led to increases in phenolic and conjugated as well as covalently protein-bound products. Addition of 4-nitrophenol, a substrate for conjugation, increased the levels of free phenols and inhibited the formation of water-soluble metabolites. At the same time, the rates of covalent protein binding were decreased. Formation of 9-hydroxy-2-acetylaminofluorene could also be demonstrated. The pathway leading to this alicyclic hydroxylated AAF metabolite was not induced by prior beta-naphthoflavone treatment, nor was it inhibited by 4-nitrophenol addition. The cells converted AAF as well as aminofluorene and 2,4-diaminoanisole to mutagenic intermediates which were released into the incubation medium. 2-Aminofluorene was considerably more mutagenic than was AAF in this system. Addition of microsomes increased the mutagenicity of AAF, but not that of 2-aminofluorene or 2,4-diaminoanisole, presumably by deacetylation of N-hydroxy-2-acetylaminofluorene to N-hydroxy-2-aminofluorene.


Phase II study of cis-dischlorodiammineplatinum(II) in stage IVB Hodgkin's disease. A broad phase II study of cis-dichlorodiammineplatinum(II) was conducted. Eight patients with stage IVB Hodgkin's disease were studied. Four of these patients attained an objective partial remission of 7--19+ weeks' duration. The usual time to the occurrence of a greater than 25% response was 1 week. This drug is active in far-advanced Hodgkin's disease with a projected lower limit of response rate from 19% to 21%.


Cytokinetic chemotherapy design for the treatment of advanced lung cancer. Sixty patients with lung cancer, 48 with extensive disease and 12 with regional disease, were treated with cyclophosphamide and methotrexate on a schedule based on cellular kinetics concepts. Initial therapy was with cyclophosphamide (1.1 g/m2 iv) followed by methotrexate (20 mg/m2 orally twice weekly) beginning 9 days later when the tumor was considered to be most susceptible to an S-phase-specific drug. The overall objective response rate was 62% (25% complete responses and 37% partial responses) with an estimated median survival time (MST) of 46 weeks. Seventeen of 19 patients with small cell carcinoma (89%) responded (ten complete responses and seven partial responses). The MST was 62 weeks. The last nine patients entered in the study with small cell carcinoma had an MST of 71 weeks, reflecting additional responses to subsequent treatment. The objective response rate of large cell carcinoma (nine of 16 patients) and adenocarcinoma (ten of 18 patients) was 56%. The MST of patients with the former cell type was longer (57 weeks) than that of patients with the latter cell type (34 weeks). One of seven patients with epidermoid carcinoma responded. The MSTs of patients with a complete response and those with regional disease were 70 and 63 weeks respectively. Patients with a performance status of 0 or 1 survived longer (MST, 56 weeks) than those with a performance status of 2 or 3 (MST, 29 weeks). The mean dose of cyclophosphamide per course was 1.275 g/m2 and the mean nadir leukocyte count per patient was 2890/mm3. The incidence per course of leukocytes less than 1000/mm3 or platelets less than 50,000/mm was less than 3%. Mucositis was common. This schedule provides excellent maintenance therapy without undue toxicity. These survival time distributions compare favorably with those of previous reports, particularly for patients with small cell or large cell carcinoma, regional disease, or complete responses.


Determination of N-(Phosphonacetyl)-L-aspartic acid (PALA) in dog serum and urine by gas chromatography and selected lon monitoring. Methods are described for quantitating N-(phosphonacetyl)L-aspartic acid (PALA), a new antitumor agent presently undergoing clinical evaluation. These methods were developed to measure this compound in serum by gas chromatography using the selectivity of a nitrogen-phosphorus detector and in serum and urine by the gas chromatographic/mass spectrometric technique of selected ion monitoring. PALA and the internal standard, N-(phosphonacetyl)-L-glutamic acid (HOMOPALA), were analyzed as their tetramethyl derivatives. Extraction from the biologic fluids was achieved by first precipitating the protein with acetone and then drying the serum with subsequent washes of acetone and diethyl ether. PALA and HOMOPALA were than extracted from the dried serum into an anhydrous HCL/methanol/tetrahydrofuran solution. After removing the solvent, the extract was reacted with diazomethane to form the tetramethyl derivatives. The feasibility of the method was demonstrated in the dog by comparing the total radioactivity with PALA equivalents determined in blood and urine samples following iv administration of PALA-14C. The range of the analysis was 20.0--200 microgram/ml for the urine samples and 0.5--15 microgram/ml for the serum samples.


Reduction of the renal toxicity of cis-dichlorodiammineplatinum(II) by probenecid. Probenecid, when administered sc to F344 rats 1 hour prior to an iv LD50 dose of cis-dichlorodiammineplatinum(II) (CDPP), reduced significantly the peak BUN and serum creatinine levels which occurred 4 days following CDDP. Renal histopathology was similarly reduced by probenecid pretreatment. In BDF, mice, the LD50 value of CDDP administered ip without probenecid pretreatment was 17 mg/kg; the LD50 dose with probenecid was increased to greater than 19 mg/kg. Probenecid pretreatment did not influence the therapeutic response to CDDP when the letter was administered to BDF mice bearing L1210 leukemia.


Phase II study of anguidine in advanced breast cancer. A phase II evaluation of anguidine was carried out in 30 patients with advanced refractory breast cancer. A dose of 5.0 mg/m2 daily for 5 days was explored. The main toxic effects were nausea and vomiting, fever and chills, hypotension, skin erythema, somnolence, confusion, and lethargy. Myelosuppression was minimal. Among these extensively pretreated patients, there was one partial responder and one additional patient who showed improvement (less than a partial response); both responses occurred in soft tissue sites.


Anthracycline antibiotic pharmacology and metabolism. The anthracycline antibiotics show evidence of numerous interactions with cellular components and participation in several metabolic pathways. Small structural changes in the antibiotic molecule can produce major changes in intracellular localization and interaction. To date, we find that all of the anthracycline antibiotics form free radical intermediates through the catalysis of microsomal and nuclear electron-transport machinery. NADPH cytochrome P-450 reductase catalyzes the free radical formation. The free radical intermediates ("site-specific free radicals") may be causative of both toxicity and pharmaceutic action. The free radical intermediates degrade nonenzymatically to 7-deoxyaglycone metabolites which prove the existence of the free radical in vivo.


Adriamycin cardiotoxicity: a survey of 1273 patients. Valuable information was collected on the medical history and clinical course of 1273 patients entered in clinical trials with Adriamycin (ADR) carried out in 12 European cancer centers. A coded patient form was used for the data collection carried out in each center by a qualified physician following a guideline which was discussed and accepted by all of the participants. The aim of the study was to define the incidence, characteristics, and possible co-factors of the cardiomyopathy (CMP) in patients treated with combination chemotherapy regimens including ADR. The mean total dose of ADR was 268 mg/m2 (range, 15--1251 mg/m2), and 5.1% of the patients received a total dose of greater than 550 mg/m2. A "definite" ADR-related CMP was observed in 1.7% of the cases; another 3% of the cases were reported as "possible" ADR-CMP since the role played by the drug could not be clearly defined. "Definite" ADR-CMP was fatal in eight patients (0.6%) while "possible" ADR-CMP was fatal in 13 patients (1.0%). Among the possible co-factors examined, the following ones were found to be significantly associated with the occurrence of a "definite" ADR-CMP: (a) total dose of ADR; (b) vincristine when given both before and concomitantly with ADR; (c) bleomycin when given before ADR; and (d) radiotherapy to the mediastinum when given concomitantly with ADR. Furthermore, none of 182 patients receiving ADR by slow infusion developed a "definite" ADR-CMP, while 2% of the patients treated by bolus injection did so. The occurrence of a "possible" ADR-CMP was found to be significantly associated with two pre-existing pathologic conditions (electrocardiogram [ECG] abnormalities and hypertension) but not with the treatment-related co-factors for the "definite" ADR-CMP mentioned above. Other variables examined, such as sex, age, cancer type, baseline liver function, and cyclophosphamide treatment, did not seem to influence the risk of ADR-CMP. Data on ECG changes occurring during ADR treatment were also reported and their incidence was found to be strictly related to the frequency of the ECG monitoring.


Experimental evaluation of anthracycline analogs. This review summarizes the preclinical tests conducted to date for experimental evaluation of new anthracycline analogs. Most of the data are derived from the experience at the Istituto Nazionale Tumori, Milan, Italy, at the National Cancer Institute, Bethesda, Md, and at the Farmitalia Research Laboratories, Nerviano, Italy. In vitro cytotoxicity tests are useful for determining the doses to be used in vivo. Antitumor activity tests in mice can be divided into different stages. P388 and L1210 leukemias are generally used in primary screening; the value of adding L1210 leukemia is briefly discussed. Other experimental tumors adopted include disseminated leukemia and transplanted solid tumors. The importance of the route and schedule of treatment is stressed. Drugs should be administered iv in the case of solid tumors, and the schedule of treatment can be adjusted according to the pharmacokinetic properties of the new analog, when these are known. If possible, the parent compound and the new analog should be dissolved in the same solvents. In the toxicity tests, cardiac toxicity deserves particular attention. Until now, the only experimental model in which a number of new anthracyclines have been tested is the rat model proposed by Zbinden. A comparison between cardiotoxicity data obtained in such models and antitumor data obtained in mice shows that cardiac toxicity can be dissociated from the antitumor activity. Knowledge of pharmacokinetic properties of new analogs is of importance for selecting the schedules of treatment and for explaining selective toxic effects.


Structure-activity relationships among daunorubicin and adriamycin analogs. Structural characteristics of Adriamycin and daunorubicin analogs are discussed in terms of three antitumor activity classifications: compounds with potency and efficacy equivalent to or superior to the parent antibiotics, compounds displaying high efficacy but with decreased potency, and compounds in which a key structural change has destroyed all in vivo antitumor activity. It is first concluded that analogs possessing efficacy and potency comparable to the parent antibiotics are quite similar to the parents in structural terms, ie, their hydrophilic character, functional groups, and stereochemistry. Within this group there is suggestive evidence that altered electronic character of the aglycones may be associated with improved cardiotoxicity characteristics. The second general conclusion is that high efficacy accompanied by decreased potency is compatible with a much wider array of structural variants than is high efficacy accompanied by high potency. Thus, analogs with substantially higher or lower lipophilicity than the parent antibiotics, as well as those with an array of ionic characteristics differing from the parents, retained significant efficacy. These characteristics are compatible with the concept of multiple mechanisms of action for the anthracycline antibiotics. In general, structural changes in the sugar side chain are appreciably more compatible with retention of in vivo antitumor efficacy than are changes in the aglycone, both in terms of functional groups and stereochemistry.


Pharmacokinetic, toxicologic, and chemotherapeutic properties of detorubicin in mice: a comparative study with daunorubicin and adriamycin. We have studied the stability, pharmacology, toxicology, and therapeutic activity in mice of detorubicin, a new semisynthetic derivative of daunorubicin. In vitro, detorubicin remains stable under acidic conditions while it is very quickly hydrolyzed into Adriamycin under neutral pH conditions. In vivo, the hydrolysis of detorubicin into Adriamycin occurs in the bloodstream a few minutes after iv injection. The tissue distribution of detorubicin in mice is, however, very distinct from that observed after administration of Adriamycin and daunorubicin. The therapeutic effect of detorubicin on the sc implanted L1210 leukemia is superior to that of daunorubicin and at least equal to that of Adriamycin. Detorubicin can thus be considered a prodrug of Adriamycin with very distinct pharmacokinetic and perhaps therapeutic properties.


The interval-force relationship: a technique for evaluating the cardiac toxicity of anthracycline analogs. The most serious side effect of the anthracycline derivatives is dose-related cardiac toxicity induced during repeated administration. An in vitro method is described which assesses the interval-force relationship in evaluating the contractility of the rat and rabbit heart. Repeated administration of Adriamycin resulted in a progressive decrease in contractility which correlated closely with the cumulative dose administered. This model offers a reliable method to evaluate the effect of new anthracycline analogs on the heart and to study the potential of other drugs or agents to protect against cardiac toxicity.


Electron microscopic studies of the heart and light microscopic studies of the skin after treatment of golden hamsters with adriamycin, detorubicin, AD-32, and aclacinomycin. Golden hamsters received Adriamycin (ADR), detorubicin (DTR), AD-32, or aclacinomycin (ACM) three times weekly at doses extrapolated from optimal doses in L1210 leukemia. Minimal early lesions of the myocardium were detected by electron microscopy in ACM-treated animals. These lesions were aggravated after several weeks of treatment but remained reversible. Lesions in AD-32-treated hamsters were slightly more marked than those seen in ACM-treated animals but were much less severe than those observed in ADR- or DTR-treated animals. Similarly, light microscopy revealed pathologic changes in the skin following ADR or DTR administration. These changes were not seen in animals receiving AD-32 or ACM.


Clinical activity of detorubicin: a new anthracycline derivative. The anthracycline derivatives are intercalating drugs which are of major importance in the treatment of leukemias and in the management of solid tumors. Structural analogs have been prepared by semisynthetic modifications in an attempt to extend the spectrum of antitumor activity and to reduce toxicity (acute myelosuppression and cardiotoxicity). This report concerns our preliminary clinical experience in 111 patients who received detorubicin. Two dose schedules were used in acute leukemia patients. Sequential doses were active in acute leukemia relapses but the mucous membrane toxicity was excessive; more recently, intermittent doses proved active in acute leukemia relapses (one 6-mg/kg dose) and in a patient with resistant Burkitt's lymphoma. In non-Hodgkin's lymphomas, a complete response rate of 71% was achieved with an intermittent schedule (3 mg/kg/day X 3 weeks). A remarkable shrinkage of skin involvement was also observed. Detorubicin showed a high activity in mycosis fungoides (five regressions among six patients) and some activity in soft tissue sarcomas, osteosarcomas, and various solid tumors.


Early clinical trial with quelamycin.

Early clinical trial with quelamycin. Quelamycin (triferric doxorubicin) is a derivative of Adriamycin with different pharmacologic properties. Our phase I clinical study of quelamycin includes 37 patients with a wide spectrum of solid tumors. The recommended dose in good-risk patients is 150 mg/m2, given as a 1-hour infusion every 3 weeks. The dose-limiting factor appears to be myelosuppression, especially leukopenia. Other toxic effects include gastrointestinal intolerance and alopecia. Chills and fever are commonly encountered and might be due to an excess of free iron in currently available preparations. Cardiotoxicity could not be properly assessed. An objective antitumor effect was seen in patients with lung, gastric, colon, and ovarian carcinomas as well as osteogenic sarcoma. Further preclinical and clinical studies with an improved pharmaceutic formulation of the drug are highly desirable.


Iron toxicity studies of quelamycin.

Iron toxicity studies of quelamycin. A previous phase I study demonstrated excessive generalized toxicity (20 of 21 patients) and cardiotoxicity (eight of 21 patients) of single-day intermittent quelamycin (NSC-267703) treatment, and a modified schedule was recommended to overcome this acute toxicity. In the present study, 40 mg/m2 of quelamycin was administered iv on 2 or 3 consecutive days. This 2- or 3-day course was associated with a decrease in the incidence of general symptoms (five of nine patients) and a decrease in cardiotoxicity (none of nine patients). In addition, patients receiving multiple courses of quelamycin were evaluated. Clinical and pathologic findings supported the diagnosis of early hemochromatosis. In conclusion, quelaymcin administration was associated with acute and chronic iron-overloading toxicity. Acute iron toxicity was prevented by the administration of quelamycin at a dose of 40 mg/m2 iv on 3 consecutive days. On the other hand, hemochromatosis was an unexpected finding which requires further investigations before this drug is acceptable for broader studies.


Preliminary phase I study of 4'-epi-adriamycin. A phase I study of 4'-epi-Adriamycin (4'-epi-ADM) was performed in 22 patients with various types of advanced solid tumors. Very preliminary results would indicate that the drug produces a pattern of acute toxicity which is similar to that of Adriamycin. However, the incidence of vomiting, alopecia, and marrow suppression was less pronounced than that of Adriamycin. 4'-Epi-ADM prolonged the systolic time interval, although no patient presented clinical signs of cardiotoxicity. Two patients with renal carcinoma and malignant melanoma showed objective improvement. Present results suggest that further clinical studies with 4'-epi-ADM are indicated.


Initial clinical evaluation of N-trifluoroacetyladriamycin-14-valerate (AD-32), an adriamycin analog. N-Trifluoroacetyladriamycin-14-valerate (AD-32) is superior to Adriamycin in murine L1210 and P388 leukemias and in a number of solid tumor systems, including Ridgway osteogenic sarcoma and Lewis lung carcinoma. In preclinical toxicology studies, AD-32 was less toxic than Adriamycin in both tumor- and non-tumor-being mice and in rabbits. An initial clinical trial was carried out in 23 patients who received a total of 74 courses of AD-32 over a dose range of 100--700 mg/m2 administered at 21-day intervals. Hydrocortisone given during the period of infusion prevented all clinical manifestations of acute toxicity. The AD-32 dose-limiting toxicity, leukopenia, was comparable to that of Adriamycin at a dose of 10:1, but at these equivalently myelosuppressive doses, AD-32 induced less gastrointestinal toxicity and alopecia than Adriamycin and it did not cause local tissue damage following inadvertent paravenous extravasation. Although two responses are reported, the therapeutic activity of AD-32 cannot be assessed because of an inadequate number of patients in any given tumor type. A phase II study is being initiated at a dose of 600 mg/m2 given at 21-day intervals.


Clinical study of aclacinomycin A.

Clinical study of aclacinomycin A. A phase I study of a new anthracycline antibiotic, aclacinomycin A, was performed in a total of 15 patients with advanced malignancy to determine the maximum-tolerated dose. The gastrointestinal toxicity which occurred was not dose-related and was not severe. Epilation and stomatitis were extremely minimal. Both hepatic dysfunction and hematologic toxicity were dose-limiting. A recommended dose for phase II study was determined to be 2.5--3.0 mg/kg (approximately 100--120 mg/m2) given in 3-week intervals. Objective response was observed in two patients with malignant lymphomas.