Primary non-Hodgkin's lymphoma of the central nervous system: phase II study of chemotherapy (BVAM) prior to radiotherapy

Ten patients were diagnosed as having primary non-Hodgkin's lymphoma of the central nervous system at University Hospital, Nottingham, between September 1986 and April 1989. None had clinical evidence of HIV-1 infection. All the patients started treatment with chemotherapy (BVAM), designed to cross the blood-brain barrier, followed by radiotherapy. Seven patients completed both chemotherapy and radiotherapy. Dose reduction during chemotherapy was necessary in three patients because of neutropenia. In two of the six patients with solitary tumours, complete resection was achieved surgically prior to treatment. Five of the remaining eight patients (63%) had radiological evidence of a complete response with chemotherapy. The other three patients had no response to chemotherapy but one had a complete response after radiotherapy. The two-year cause-specific survival of the 10 patients was 37%. Two of the three patients who had a postoperative performance status of 0 or 1 (ECOG/WHO) are alive and disease-free at 26 and 46 months from diagnosis. The median survival of the seven patients with a performance status of 2-4 was 10 months with two patients alive and disease-free at 19 and 26 months. The two-year cause-specific survival of these seven patients was 22%.

Postoperative radiotherapy in the management of spinal cord ependymoma

Fifty-eight patients with histologically verified spinal cord ependymomas were treated at the Royal Marsden Hospital and Atkinson Morley's Hospital between 1950 and 1987. The median age in this series was 40 years (range 1 to 79 years) and the male:female ratio was 1.8:1. Ten patients had tumors in the cervical cord and 10 in the thoracic cord; 14 tumors involved the conus medullaris and 24 the cauda equina. Forty ependymomas were grade I and 13 were grades II to IV (in five patients there was insufficient material for grading). Eleven patients underwent biopsy only, 33 had partial or subtotal resection, and 14 had complete resection. Forty-three patients received postoperative radiotherapy. The median follow-up period was 70 months (range 3 to 408 months). Cause-specific survival rates were 74% and 68% at 5 and 10 years, respectively. On univariate analysis, age, histological grade, postoperative neurological function, and era of treatment were significant prognostic factors for survival. The histological grade was the only significant independent prognostic factor. The relative risk of death from ependymoma was 9.0 for patients with tumor grades II to IV compared to grade I (p less than 0.005, 95% confidence interval 2.7 to 30). The survival rates of patients following complete excision were significantly better compared to those after incomplete surgery (p less than 0.025). The majority of completely resected neoplasms were low-grade cauda equina tumors. Despite incomplete surgery, 5- and 10-year progression-free survival rates following radical radiotherapy were both 59%, and cause-specific survival rates were 69% at 5 years and 62% at 10 years. This suggests that radiotherapy may achieve long-term tumor control in over half of those patients with residual spinal ependymoma.

The measurement of the regression of carcinoma of the bladder using ultrasonography and CT scanning during and after radical radiotherapy

In 50 patients receiving radical radiotherapy for carcinoma of the bladder a well-defined tumour was observed in the bladder either by trans-abdominal ultrasonography or by CT scanning prior to treatment. The histological type was transitional cell carcinoma 46, adenocarcinoma 1 and squamous cell carcinoma 3. The cross-sectional area of the tumour in the transverse plane was measured before the start of radiotherapy. In 37 patients serial measurements were made by ultrasonography during and after radical radiotherapy. In three patients no regression was seen during the first 14-27 days of treatment. In 34 patients with transitional cell carcinoma the median area-halving time was 37 days. Serial measurements of the volume of the tumour before, during and after radiotherapy were made by CT scanning in 29 patients. In two patients the tumour progressed with a volume-doubling time of 93 and 108 days, respectively. In 25 patients with transitional cell carcinoma the median volume-halving time was 29 days with a median area-halving time of 44 days. Linear-regression analysis of the initial tumour areas (31 patients) as measured by ultrasonography and CT scanning was performed. The correlation coefficient was r = 0.69. The correlation coefficient for the area halving-times measured both by ultrasonography and CT scanning was r = 0.53 (nine patients). Biphasic regression with a second slower phase with area-halving and volume-halving times of several hundred days was observed in six patients. Calcification of the tumour during and after radiotherapy was observed in several patients. No significant change in the CT number of the tumour was observed after radiotherapy. The median initial tumour volume as measured by CT scanning was 38 (7-211) cm3. The median initial tumour area as measured by ultrasonography was 16 (6-40) cm2. A tumour of median size with a median halving-time would take 120 days (4 months) to regress completely. Cystoscopy within 6 months of the start of radiotherapy is unlikely to be of value because many bladder tumours are continuing to regress during this period of time. Progression of the tumour during or after radiotherapy can be detected either by CT scanning or ultrasonography.

Medulloblastoma in adults: a review of 47 patients treated between 1952 and 1981

The results of treatment of 47 adults with medulloblastoma are reviewed. For those treated with ortho-voltage radiotherapy between 1952 and 1963 the actuarial 5- and 10-year survival rates were 38% and 23%, respectively. Of those treated with megavoltage radiotherapy between 1964 and 1981, the corresponding 5- and 10-year survival rates were 59% and 53%, respectively. Of patients treated with megavoltage radiotherapy and adjuvant chemotherapy between 1971 and 1981, 76% were alive at 5 years and also at 10 years. Treatment factors associated with an increased survival were complete or subtotal resection of the primary tumor, as opposed to partial removal, a radiation dose to the posterior fossa of 55 Gy or more and the administration of adjuvant chemotherapy. Neither the quality of life, nor the fertility of the surviving patients, have been impaired by the treatment. Six patients (13%) developed metastatic disease outside the central nervous system.

A prospective study of urinary tract infection during pelvic radiotherapy

The frequency of urinary tract infection before and during pelvic radiotherapy was studied prospectively in 172 patients who were not catheterised and had not had instrumentation for at least 4 weeks prior to radiotherapy. The incidence of urinary tract infection prior to radiotherapy was 17% and a further 17% of patients developed a urinary tract infection during radiotherapy. Mid-stream specimens of urine (MSU) should be examined for infection on a weekly basis during pelvic radiotherapy not only to identify this additional 17% of patients but also to detect those patients who have persistent urinary tract infection in spite of treatment with appropriate antibiotics.

Parotid metastases from carcinoma of the breast

Two patients are described in whom a parotid metastasis occurred 10 years after initial treatment for carcinoma of the breast. The parotid is a very unusual site of metastasis and in both patients it was only one detectable. Parotidectomy with post-operative radiotherapy is advocated in this situation not only to obtain local tumour control but to exclude a primary parotid tumour.

Orbital and conjunctival lymphoma treatment and prognosis

115 patients with lymphoid tumours presenting in the orbit were seen between 1970 and 1984. The histological types were high-grade malignant lymphoma--18, low-grade malignant lymphoma--43, and indeterminate lymphocytic lesions--54. Eighteen patients were found to have disseminated lymphoma at presentation. The majority of the patients received radiotherapy to the orbit; local control was achieved in all cases and the ocular morbidity from radiotherapy was low with 11 patients developing lens opacities and 5 a dry eye. Survival of patients with stage I low-grade lymphoma and indeterminate lymphocytic lesions was similar to that of a normal population of the same age distribution. The clinic features and dissemination pattern of the low-grade malignant lymphomata and the indeterminate lymphocytic lesions were identical, suggesting that most, if not all, lymphoid masses presenting in the orbit are neoplastic rather than reactive in nature.

Renal impairment following the combined use of high-dose methotrexate and procarbazine

A major side-effect of high-dose methotrexate is renal toxicity, which may develop unexpectedly despite adequate standard precautions such as hydration and alkalinisation of the urine. The pathogenesis is unclear. Recent reports suggest that the combination of high-dose methotrexate with non-chemotherapeutic agents may cause such renal impairment. Three cases of unexpected renal impairment following the combined use of high-dose methotrexate and another cytotoxic agent, procarbazine, are reported. Possible mechanisms of this interaction are discussed, as are recommendations for future combined administration.

Medical management of radiation enteritis--an algorithmic guide

An algorithmic guide to the differential diagnosis and management of late radiation enteritis is proposed. The proposition is based on physiological principles and clinical experience rather than on published reports. Too few patients with late radiation enteritis are seen in most oncology centres for a large prospective trial of the algorithm to be set up, but we hope it will stimulate further investigation.

Ocular morbidity after radiotherapy of orbital and conjunctival lymphoma

One hundred and fifteen patients were treated for lymphoma of the conjunctiva and orbit between 1970 and 1984. One hundred and twelve patients received radiotherapy to the orbit, of whom 73 (65 per cent) had at least one year of follow-up by an ophthalmic surgeon. Patients with low-grade lymphomas (97) mostly received 30 Gy in 15 fractions to the orbit over a period of 3 weeks. Those with high-grade lymphomas (18) mostly received 40 Gy in 20 fractions over 4 weeks. Most were treated using anterior and lateral radiation fields to the orbit with shielding of the cornea and lens. This technique delivered a mean lens dose of 15 Gy. The early and late ocular and orbital morbidity in these patients was low. Eight radiation-induced cataracts developed of which only six interfered with vision. None has needed cataract surgery. No patients developed radiation retinopathy and only 5 had disorders of ocular lubrication.

The regression of tumors of the head and neck treated with neutrons

Measurements were made of the exponential regression of cervical nodes from 44 patients with squamous carcinoma of the head and neck and of 20 salivary gland tumors treated with neutrons (7.5 MeV). In 80% of patients, the tumor regressed exponentially from the first day of treatment; in 20% of patients there was an initial shoulder followed by exponential regression. The volume-halving times were calculated and found to vary widely for each histological type. There was no correlation of the volume-halving time either with the differentiation of the squamous carcinomas or with the initial tumor volume. The mean volume-halving time for squamous carcinoma of the head and neck was 20.8 days; for malignant pleomorphic adenomas of the parotid gland the mean volume-halving time was 122.6 days.

Spinal extradural angiosarcoma occurring after treatment for Hodgkin's disease

An extradural angiosarcoma was found invading the L3 and L4 nerve roots. An angiosarcoma has not previously been reported in this situation. The tumour was diagnosed eighteen years after the patient presented with Hodgkin's disease and was possibly induced by the treatment given for this disease.

Compression of oesophagus by tortuous dilated aorta

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Multiple Smith-degradations of carcinoembryonic antigen (CEA) and of asialo CEA

Carcinoembryonic antigen (CEA) and asialo CEA were subjected to multiple Smith-degradation (i.e., for each degradation, application in sequence of periodate oxidation, borohydride reduction, and mild hydrolysis with acid; borohydride-t was substituted for unlabelled borohydride). High yields of modified glycoproteins were obtained at each stage. After three complete degradations and a further periodate-borohydride-t treatment, the carbohydrate content of CEA and of asialo CEA had decreased from 45-50% to 11-12% (i.e., 90% removal of carbohydrate). Glycerol was always one of the products obtained after each degradation, but threitol and erythritol were not detected. The second degradation caused a substantial loss of 2-acetamide-2-deoxyglucose, which is consistent with the location of some of this monosaccharide towards the terminal (non-reducing) end of the oligosaccharides. The "core" region of the oligosaccharides is composed of galactose, mannose, and 2-acetamido-2-deoxyglucose. After the fourth oxidation, 2-acetamido-2-deoxyglucose was 50-60% of the total content of residual carbohydrate. After the first degradation, there was a progressive loss in antigenic activity, but this was associated with a small amount of hydrolysis of the protein moiety of CEA.

The use of deoxyfluoro-D-galactopyranoses in a study of yeast galactokinase specificity

1. 2-Deoxy-2-fluoro-d-galactose, 3-deoxy-3-fluoro-d-galactose, 4-deoxy-4-fluoro-d-galactose, 6-deoxy-6-fluoro-d-galactose and 2-deoxy-d-lyxo-hexose are substrates for yeast galactokinase. 2. The variation in K(m) values for the d-hexose derivatives was not associated with a variation in the value of K(m) for MgATP(2-) indicating that the binding of MgATP(2-) is not modified by the binding of the sugar substrate. 3. Donated H bonds from OH-3, OH-4 and OH-6 and an accepted H bond to OH-2 of the d-hexose are important for the binding of the sugar substrate to galactokinase. 4. Yeast galactokinase exhibits similar kinetics to the galactokinase from Escherichia coli and operates by a similar random sequential mechanism. 5. 4-Deoxy-4-fluoro-d-glucose was neither a substrate for nor an inhibitor of yeast galactokinase.

The effect of substitution at C-2 of D-glucose 6-phosphate on the rate of dehydrogenation by glucose 6-phosphate dehydrogenase (from yeast and from rat liver)

1. The deoxyfluoro-d-glucopyranose 6-phosphates are substrates for both yeast and rat liver glucose 6-phosphate dehydrogenase. 2. The V(max.) values (relative to d-glucose 6-phosphate) were determined for a series of d-glucose 6-phosphate derivatives substituted at C-2. The V(max.) values decreased with increasing electronegativity of the C-2 substituent. This is consistent with a mechanism involving hydride-ion transfer. 3. 2-Deoxy-d-arabino-hexose 6-phosphate (2-deoxy-d-glucose 6-phosphate) showed substrate inhibition with the yeast enzyme but not with the rat liver enzyme. 4. 2-Amino-2-deoxy-d-glucose 6-phosphate (d-glucosamine 6-phosphate) was a substrate for the yeast enzyme but a competitive inhibitor for the rat liver enzyme. 5. Lineweaver-Burk plots for the d-glucose 6-phosphate derivatives with yeast glucose 6-phosphate dehydrogenase were biphasic.

The deoxyfluoro-D-glucopyranose 6-phosphates and their effect on yeast glucose phosphate isomerase

1. The deoxyfluoro-d-glucopyranose 6-phosphates were prepared from the corresponding deoxyfluoro-d-glucoses and ATP by using hexokinase. 2. 3-Deoxy-3-fluoro- and 4-deoxy-4-fluoro-d-glucose 6-phosphate were substrates for glucose phosphate isomerase, and in addition the products of this reaction, 3-deoxy-3-fluoro- and 4-deoxy-4-fluoro-d-fructose 6-phosphate respectively, were good substrates for phosphofructokinase. 3. Some C-2-substituted derivatives of d-glucose 6-phosphate were found to be competitive inhibitors of glucose phosphate isomerase. 4. The possible role of the hydroxyl groups in the binding of d-glucose 6-phopshate to glucose phosphate isomerase is discussed.

The use of deoxyfluoro-D-glucopyranoses and related compounds in a study of yeast hexokinase specificity

1. 2-Deoxy-2-fluoro-d-glucose, 2-deoxy-2-fluoro-d-mannose and 2-deoxy-2,2-difluoro-d-arabino-hexose are good substrates for yeast hexokinase. 2. 3-Deoxy-3-fluoro-d-glucose and 4-deoxy-4-fluoro-d-glucose are poor substrates and have very similar K(m) values (8x10(-2)m). 3. Neither alpha- nor beta-d-glucopyranosyl fluoride is a substrate or inhibitor. 4. Studies with 2-chloro-2-deoxy- and 2-O-methyl derivatives of d-glucose and d-mannose have revealed that little chemical modification is possible at position 2 without substantial loss in substrate binding. 5. The variation in the value of K(m) for the d-hexose derivatives was associated with a corresponding change in the value of K(m) for MgATP(2-) showing that the binding of MgATP(2-) is modified by the binding of the sugar.