A 10-year experience of tamoxifen as primary treatment of breast cancer in 100 elderly and frail patients

Between 1977 and 1983 100 elderly women (median 76.3 years) with breast cancer were treated with tamoxifen as primary therapy. The median follow-up is 59 months. Sixty-eight responded (40 CR and 28 PR) with median response durations of 47 months and 26 months respectively. Twenty-two patients had disease stabilization for a median of 15.5 months and 10 had progressive disease. The median time to best response was 13.5 weeks for patients achieving CR and 14 weeks for those with PR. Oestrogen receptor values were obtained in 37 patients of which two patients had no ER detectable. Sixty-seven per cent of ER-unknown patients responded compared with 74% of ER-rich. Likelihood of response did not appear to depend upon T-stage or age. Survival was better than that of an unmatched historical group treated with surgery/radiotherapy and compares favourably with recent reports. Although 35% have died of breast cancer, 25% died of other causes and 22% remained free of recurrence at the time of reporting or at death. Only 11% underwent subsequent mastectomy/lumpectomy and the most frequent subsequent treatments were radiotherapy to the breast (32%) and further hormonal therapies (40%). Tamoxifen is a practical primary therapy of breast cancer in elderly and frail women obviating the need for surgery in a high proportion of cases.

Modulation of the cluster 1 and mucin antigens in human small cell lung cancer and other epithelial tumour cell lines after treatment with the differentiation inducing agent, sodium butyrate

The expression of the human small cell lung cancer (SCLC) cluster 1 antigen and the human milk fat globule membrane (HMFG) antigen were studied in three SCLC, three lung adenocarcinoma, six ovarian adenocarcinoma and three colorectal adenocarcinoma cell lines before and after culture in the presence of the differentiation inducing agent, sodium butyrate. Before treatment, only SCLC and well differentiated ovarian cell lines expressed the cluster 1 antigen. After 4 days culture with sodium butyrate, expression of cluster 1 antigen was induced in poorly differentiated ovarian, colorectal and lung adenocarcinoma cell lines whereas existing antigen expression was enhanced in SCLC and well differentiated ovarian cell lines. The expression of the HMFG antigen was also modified. Induction of cluster 1 antigen correlated with increased levels of alkaline phosphatase in the treated cell lines, this enzyme being associated with a more differentiated state in colon and ovarian carcinoma cell lines. The pattern of induction of cluster 1 antigen expression suggests that several different epitopes of this antigen are recognised by the ten SCLC cluster 1 antibodies studied.

Establishment and characterisation of two new small cell lung cancer cell lines--one from a patient with previous familial retinoblastoma

Two new small cell lung cancer (SCLC) cell lines have been established. The first, WX330, has been developed from a pleural effusion collected at presentation from a patient with extensive disease. The second, WX331, originated from a liver metastasis collected at post mortem from a patient who died of his SCLC disease. WX330 has been in culture for 4 years and WX331 for 11 months. Both cell lines have typical cytological features of SCLC, WX330 contains dense core granules on electron microscopic examination and both are tumourigenic in nude mice. Cell lines were analysed phenotypically using antibodies submitted to the Second International Workshop on SCLC Antigens by the immunoperoxidase method. WX330 is reactive with a wide range of SCLC and epithelial associated and WX331 with a more restricted group of antibodies of predominantly neuroendocrine and SCLC specificity. WX330 also reacts with an antibody against the multiple drug resistance-associated glycoprotein.

Mitozantrone and prednimustine in the treatment of advanced breast cancer--a toxic regimen with low activity

The combination of mitozantrone and prednimustine has been reported to elicit response rates of around 50% in patients with advanced breast cancer. In the present trial, either three or nine courses of this combination were given to previously untreated patients with advanced breast cancer. Mitozantrone was given at 12 mg/m2 on day 1 and prednimustine was given orally at 130 mg/m2 on days 1-5; treatment was repeated every 4 weeks. A total of 34 patients were treated; the performance status was 0-1 in 29 subjects and 2 in 5 cases. Locoregional disease only was present in 13 patients; 9 showed lung involvement; 8, liver; 3, bone; and 1, stomach involvement. A total of 10 subjects had received no prior hormone therapy. The median disease-free interval from the time of initial diagnosis was 24 months (range, 0-144 months). In all 14/23 patients exhibited an oestrogen receptor level of greater than 20 fmol. Grade 1 nausea and vomiting occurred in 16 patients and that of grade 2-3, in 11 subjects; nausea was prolonged for greater than 10 days in 7 cases. Grade 4 neutropenia occurred in 2 patients. The response rate was 21% (95% confidence interval, 8%-38%). The combination of mitozantrone and oral prednimustine is toxic and displays low activity.

Prognostic factors for survival in soft tissue sarcoma

Between 1975 and 1984, 125 cases of histologically confirmed soft tissue sarcomata (STS) were registered in the Department of Clinical Oncology in Edinburgh. Of these, 100 were eligible for analysis of prognostic factors. The overall 5-year survival rate was 21.5%. Univariate analysis demonstrated that extent of surgery, radical versus palliative or no radiotherapy, mass as a presenting symptom, metastases at presentation, site, histological type, mitotic activity, grade and UICC stage all had a statistically significant effect on survival. Analysis using the proportional hazard regression model was performed on the 87 patients for whom all variables were recorded. When all histological and clinical features and treatment modalities were included in the model then radiotherapy, surgery, necrosis, sex and mitoses were identified as independent prognostic variables. When symptoms and treatment were excluded then the multivariate analysis identified sex and mitotic activity as independent parameters. For the 33 superficial STS with tumour size recorded multivariate analysis revealed size, necrosis and cellularity as independent prognostic variables. For the 31 deep STS histological type, sex, surgery and radiotherapy were identified as independent prognostic parameters.

Immunocytological detection of residual marrow disease at clinical remission predicts metastatic relapse in small cell lung cancer

A panel of monoclonal antibodies against neural and epithelial associated antigens was used to examine bone marrow from patients in clinical remission from small cell lung cancer (SCLC). A standard peroxidase-antiperoxidase technique and Ficoll-Hypaque enrichment were used to detect SCLC-like cells at the 1-2% level of contamination in 8 of 12 patients who were disease free by conventional criteria, including routine marrow cytology and histology and endobronchoscopic biopsy or cytology. Six of these patients ultimately relapsed, with metastatic sites found between 2 and 6 months after restaging. Furthermore, 6 patients had undergone chemointensification including autologous marrow rescue with radical irradiation to the primary lung tumor. Four of these 6 subsequently relapsed, also with metastatic sites. Of the 4 patients without bone marrow metastases at restaging using this technique, 2 relapsed, with cells found at the primary site, and 2 remained in complete remission. Serum free cell culture was attempted in 9 of 12 cases and SCLC-like cell colonies grew, in suspension, in 4. The SCLC-like nature of these cells has been confirmed by electron microscopy in 1 case and by repeat immunocytochemistry for small cell associated antigens in 3 cases. Bone marrow positivity using these techniques appears to predict a high risk of metastatic relapse regardless of further therapy.

Allele losses on chromosome 17 in human epithelial ovarian carcinoma

16 epithelial ovarian carcinomas (12 serous, 2 mucinous and 2 endometrioid) and 2 benign ovarian adenomas were studied using recombinant DNA technology to compare loci on chromosome 17 in germ-line and tumour DNA. Four polymorphic probes mapping to 17p and one mapping to 17q were used. There was a high frequency of allele loss on 17q/(77%) and a slightly lower frequency on 17p (69%). These findings probably indicate loss of tumour suppressor genes which are of fundamental importance in the genesis or progression of epithelial ovarian carcinomas.

Potentiation of cisplatin by alpha-interferon in advanced non-small cell lung cancer (NSCLC): a phase II study

Studies in experimental human lung cancer models have suggested that interferon may enhance significantly the response to some cytotoxic drugs. We have performed a phase II study of cisplatin (100 mg/m2 q.21 or 28 days) and alpha-2 interferon (3 or 5 MU three times weekly) in 68 patients with advanced non-small cell lung cancer and good performance status. As toxicity was acceptable, the dose of interferon and schedule of cisplatin were increased at the midpoint of the study. 46% (11/24) of patients with squamous carcinoma responded and an overall partial response rate of 30% was attained in 60 evaluable patients. There was no potentiation of haematological, renal or neurological toxicity but nausea and vomiting were severe. These results suggest that the combination has activity in this usually refractory disease.

A phase II trial of mitomycin C and 5-fluorouracil as second-line therapy in advanced breast cancer

Fifty-five patients who had relapsed or progressed from chemotherapy for advanced disease were treated with mitomycin C and 5-FU on a 6 weekly regimen. After a median of 2 cycles of therapy the overall response rate was 12% with no complete responses. Significant leucopenia but no thrombocytopenia was seen and despite the low overall response rate the regimen was tolerable and did produce responses in patients primarily resistant to Adriamycin combination chemotherapy. Low overall activity indicates the need for more effective second line treatment.

Prognosis at presentation of small cell carcinoma of the lung

Prognostic factors in 411 patients with small cell lung carcinoma have been retrospectively analysed. Univariate analysis of continuous variables showed that prognosis was worse with deteriorating performance status, extensive disease, positive bone scan, increasing age, elevated total white cell count, alkaline phosphatase, lactate dehydrogenase, and decreased serum chloride and albumin. Low serum sodium was less clearly associated with poor survival. Cox multivariate regression showed that performance status, disease extent, age and raised lactate dehydrogenase and white cell count were independent prognostic factors. When disease extent was excluded from analysis, performance status, age, total white cell count, lowered serum chloride and raised lactate dehydrogenase were significant independent prognostic variables.

Chromosomal aberration and sister-chromatid exchange frequencies in peripheral blood lymphocytes of a large human population sample. II. Extension of age range

We have previously reported on a cytogenetic-epidemiological study of chromosomal aberration and sister-chromatid exchange (SCE) frequencies in peripheral blood lymphocytes (PBL) of a cohort of 353 healthy employees of the Brookhaven National Laboratory (Bender et al., 1988). This sample has now been increased in order to extend the age range represented and, incidentally, the representation of non-white subjects. In total, the data now include chromosomal aberration information from 108,950 cells and SCE information from 25,397 cells from 613 samples from 493 subjects. Neither the mean frequencies of any of the chromosomal aberration types nor the mean frequency of SCE have changed notably through the addition of the new subjects and samples. The mean age at sampling of the population is now 43.1 years with a range of from 1.1 to 83.7 years. However, we still find no significant relationship of the frequency of any conventional aberration category to age with the single exception of the dicentric chromosome, which now shows a positive regression (p = 0.001). The raw mean SCE frequencies show a statistically significant increase with subject age, but when cigarette smoking status is taken into account, no significant age relationship is found. As with the earlier samples, neither aberration nor SCE frequencies was influenced by race. Mean SCE frequencies, measured in non-smokers, were about 5% higher in females than males. Only one aberration category, "supernumerary acentric fragment", was significantly related to sex. This "aberration", known to constitute early centromere separation of an X chromosome, is much more common in females than in males and, in the females, increases significantly with increasing subject age.

Randomised trial comparing prednimustine with combination chemotherapy in advanced ovarian carcinoma

A total of 76 patients with advanced epithelial ovarian carcinoma were randomised to receive 6 months of treatment with either a combination of hexamethylmelamine, 5-fluorouracil, cisplatin and prednimustine or prednimustine alone following initial surgery. Pathologically confirmed response rates were 35% for combination chemotherapy and 28% for prednimustine, and the overall survival was identical for the two groups. Seven patients achieved a pathologically defined complete response, one of whom relapsed at 8 months; the others remain disease-free 18-36 months (median, 23 months) after presentation. The extent of initial surgery significantly affected the survival of patients receiving prednimustine but not of those receiving combination chemotherapy. Prednimustine can produce durable responses in advanced ovarian cancer using a schedule that results in negligible toxicity.

Lomustine, vindesine and bleomycin (LVB) used in the treatment of relapsed advanced Hodgkin's disease. A prospective study on behalf of the East of Scotland and Newcastle Lymphoma Group (ESNLG)

Sixty-three patients with relapsed advanced Hodgkin's disease were treated with lomustine (CCNU), vindesine and bleomycin (LVB). Age range was 17-72 years, with 38 males and 25 females. Thirty patients achieved complete remission (CR) with a median duration of 24+ months (range 3-55). Nineteen continue in unmaintained CR. CR rates were highest for those patients who relapsed greater than 6 months after first line treatment and for those at second or subsequent relapse. CR rates were higher in those with nodal only relapse. Twenty-seven patients were non-responders and six were partial responders. These 33 patients were subsequently changed to alternative chemotherapeutic regimes and 26 failed to respond to any therapy and have since died. Only one patient is in unmaintained complete remission. The regimen was well tolerated by patients, and easy to administer. It produced no serious episodes of toxicity. We conclude that LVB is of value in the management of relapsed advanced Hodgkin's disease especially in chronic relapsing patients, and where relapse occurs greater than 6 months after the first line treatment. We are presently unsure whether it offers any advantage over reintroduction of first line treatment in the latter group.

Immunoassay of CA125 in ovarian cancer: a comparison of three assays for use in diagnosis and monitoring

There is increasing evidence to support the use of CA125 in the follow-up and management of patients with ovarian cancer and several commercial kits are now available for its measurement. This study investigated and compared the performance of three of them: an enzyme immunoassay (EIA) and an immunoradiometric assay (IRMA) from Abbott Diagnostics, and an IRMA from CIS, U.K. One hundred and thirty-two serum samples from 42 patients with advanced epithelial ovarian cancer were thawed once and assayed for CA125 using each kit. Both IRMAs performed better than the EIA in terms of CV, sensitivity, specificity, and accuracy. The results confirm the usefulness of CA125 as a marker for ovarian cancer. However, discrepancies between results using different kits suggest the need for improved standardization.

Serum placental-like alkaline phosphatase (PLAP): a novel combined enzyme linked immunoassay for monitoring ovarian cancer

A new combined enzyme linked immunoassay (ELISA) was developed to measure both serum placental-like alkaline phosphatase (PLAP) activity (PLAPA) and concentration (PLAPC) in the same microtitre plate using an Imperial Cancer Research Fund monoclonal antibody, designated H17E2. PLAP A and PLAP C were determined together with an existing marker, CA125 in 397 serial samples from 87 patients with epithelial ovarian cancer. Retrospective assessment showed the sensitivity to increase from 73% with CA125 alone, to 88% using CA125 and PLAP A, and to 93% with all three markers in 261 samples from the patients with known active disease at the time of sampling. When the results for all 397 samples were included in the analysis, however, the specificity, sensitivity, accuracy and predictive powers of this monoclonal antibody were not sufficiently high to assist in the prospective follow up of patients with ovarian cancer. This was due to a significant number of false positive and false negative results. Our data indicate that PLAP A or PLAP C estimation with H17E2 may, therefore, only be of value in the management of those patients with known active disease who are already known to be "marker positive" for this antigen.

Methylprednisolone, etoposide, vindesine, and chlorambucil (PEEC) alone or alternating with CHOP as initial or salvage therapy for non-Hodgkin's lymphoma

A novel cytotoxic drug combination, PEEC, has been tested in the initial or salvage treatment of lymphomas. The PEEC combination alone is active in high grade or intermediate grade NHL with two complete and two partial remissions out of four patients so treated. When combined with standard CHOP therapy using an alternating regime, seven out of 11 patients obtained a complete remission and four partial remission. Ten patients were well, off treatment, beyond one year from presentation. The combination was less impressive, however, as salvage therapy with two partial responses in a heavily pre-treated group of nine patients.

Characterization and properties of nine human ovarian adenocarcinoma cell lines

Four series of cell lines have been derived from patients with ovarian adenocarcinoma. Nine cell lines have been established at one from a solid metastasis. Six lines were derived from the ascites or pleural effusion of patients with poorly differentiated adenocarcinoma: PEO1, PEO4, and PEO6 from one patient, PEA1 and PEA2 from a second, and PEO16 from a third. Three lines (PEO14 and PEO23 from ascites and TO14 from a solid metastasis) were derived from a patient with a well-differentiated serous adenocarcinoma. Each set of cell lines was morphologically distinct. The five cell lines PEO1, PEO4, PEO6, PEA1, and PEA2 had cloning efficiencies on plastic of 1-2% and only a few cells in these lines expressed alkaline phosphatase or vimentin. Only a low percentage of these cells reacted with the monoclonal antibodies 123C3 and 123A8 but most reacted with OC125. Conversely the cell lines PEO14, TO14, PEO23, and PEO16 were characterized by low cloning efficiency values (less than 0.05%), marked expression of alkaline phosphatase and vimentin, and good reaction with 123C3 and 123A8 but not OC125. These four cell lines also exhibited dome formation. Four of the cell lines, PEO1, PEO4, PEO6, and PEO16, have been xenografted into immune-deprived mice and found to be tumorigenic.

Effect of sodium butyrate and other differentiation inducers on poorly differentiated human ovarian adenocarcinoma cell lines

We have studied the effects of sodium butyrate, retinoic acid, and dimethyl sulfoxide on two human ovarian carcinoma cell lines PE04 and PE01. PE04 cells, after treatment with sodium butyrate at cytostatic doses (2-3 mM for 4 days), exhibited phenotypic changes including induction of alkaline phosphatase and determinants recognized by the monoclonal antibodies 123C3 and 123A8. These effects are not simply the result of cytostasis as they were not produced by dimethyl sulfoxide or retinoic acid. Other markers are also modified by sodium butyrate including lipid, acid mucin, and glycogen. Retinoic acid modulated expression of lipid and CA125, while dimethyl sulfoxide reduced expression of CA125. Other short chain fatty acids such as propionic acid and valeric acid (in addition to butyric acid) also induced alkaline phosphatase and the determinants recognized by 123C3 and 123A8 in PE04 cells. Other differentiation inducers and cytotoxic agents studied did not induce these markers at cytostatic concentrations. The effects of sodium butyrate (and related short chain fatty acids) thus appear to be relatively specific for this cell line.

Influence of therapy on local control and survival in stage I and II intermediate and high grade non-Hodgkin's lymphoma

In a consecutive series of 113 patients with localized (Stage I and II) intermediate and high grade non-Hodgkin's lymphoma we have retrospectively analysed patterns of survival and relapse in relation to presenting features and therapy. Two patients were treated by complete surgical excision. Seventy-two were treated by radiotherapy (RT), 19 by chemotherapy (CT) and 20 by combined CT and RT. A number of different chemotherapy combinations were employed. Overall survival for Stage I patients was 68.3% at 5 years and 65.5% at 10 years; for Stage II patients it was 61.2% at 5 years and 52.2% at 10 years. Recurrence-free survival for Stage I patients was 51.4% at 5 years and 42.1% at 10 years; for Stage II patients it was 46.2% at both 5 and 10 years. Local control by radiation was achieved in 59/72 (82%) patients treated with less than 40 Gy and 19/20 (95%) treated with 40 Gy or more. There was no advantage for extended field irradiation when compared with involved field. Eleven of 19 (58%) patients treated by CT alone achieved complete response (CR). For patients responding completely to CT there was no clear advantage for irradiation of originally involved bulky sites. For patients with Stage II and bulky Stage I disease there was a significant (P = 0.05) improvement in recurrence-free survival (RFS) and a trend (P = 0.192) towards improved overall survival for patients treated by CT alone or together with RT compared with RT alone. Independent variables identified by multivariate analysis were age, with better survival for younger patients (P = 0.034) and histopathological group, with better survival for DPDL compared with DH (P = 0.015).

Chromosomal aberrations and sister-chromatid exchanges in lymphocytes from coke oven workers

To test whether coke oven workers, an occupational group known to be at increased cancer risk, manifest increased peripheral blood chromosomal aberration frequencies, we obtained samples from a group of 30 steelworker volunteers, who had worked several years at coke oven jobs. Exposure estimates were made using measurements of work place atmospheric coal tar pitch volatiles and work histories. No statistically significant positive regression of chromosomal aberrations on exposure estimates was found. The data from the coke oven workers were also compared with the obtained concurrently and employing precisely the same laboratory protocol from a group of male Brookhaven National Laboratory employees. The coke oven workers as a group were found to have statistically significantly elevated frequencies of chromatid aberrations and of sister-chromatid exchanges.

Arabinofuranosyl nucleosides induce common fragile sites

The capacities for fragile site induction of three inhibitors of semiconservative DNA synthesis and DNA repair synthesis, aphidicolin, arabinofuranosyl cytosine, and arabinofuranosyl adenosine were compared. Aphidicolin is known to induce type 4 fragile sites, the largest recognized group of common fragile sites. Although the modes of action of these inhibitors vary, both arabinofuranosyl analogs induce type 4 aphidicolin-sensitive fragile sites. An analysis of variance demonstrates that the three inhibitors are not equally capable of inducing significant breakage (P less than 0.01) at all type 4 fragile sites. Induction of type 4 fragile sites appears to be a general consequence of inhibition of DNA polymerization.

Cardiotoxicity of mitozantrone assessed by stress and resting nuclear ventriculography

Fourteen patients with advanced breast cancer were treated with a combination of vincristine, mitozantrone and prednisolone. Before, during and after cessation of treatment radionuclide assessment of ventricular performance was obtained at rest, in response to cold pressor-induced stress and on recovery from stress. Six of 14 patients (46%) developed abnormalities of left ventricular ejection fraction (LVEF). One patient developed clinical signs of cardiac failure. Mitozantrone is an active agent in the treatment of advanced breast cancer but it can produce cardiotoxicity. In this particular middle-aged population, changes in LVEF occurred over a wide range of cumulative doses. Further investigation is required to determine the nature and prognosis of this iatrogenic toxicity.

Low grade stage I and II non-Hodgkin's lymphoma: results of treatment and relapse pattern following therapy

Sixty-four patients (37 stage I and 27 stage II) with low grade non-Hodgkin's lymphoma were treated by surgical excision alone (two patients) or with radiotherapy (53 patients), chemotherapy (five patients) or both (four patients). Actuarial survival was 80.7% at 5 years and 77.9% at 10 years. Actuarial recurrence-free survival at 10 years was 49.4% for stage I and 38.0% for stage II patients. Local control was achieved in 52 out of 56 (93%) patients treated with a radiation dose of 30 Gy or greater. There was no advantage for extended compared with involved, field irradiation. A multivariate analysis identified age, sex, stage and disease site as independent prognostic variables for survival.

Normal G2 chromosomal radiosensitivity and cell survival in the cancer family syndrome

Recent reports have suggested that elevated chromosomal aberration yields following X-irradiation of skin fibroblasts in the G2 phase of the cell cycle are characteristic of affected members of cancer-prone families. These studies propose that this phenomenon is a consequence of impaired DNA repair and might be a useful predictor of genetic susceptibility to cancer. We have tested G2 chromosomal X-ray sensitivity in skin fibroblasts and peripheral blood lymphocytes from members of a kindred with the cancer family syndrome, a disorder in which susceptibility to colon cancer and other epithelial cancers is inherited in an autosomal dominant pattern. Further, using a cell survival assay, we tested cancer family syndrome skin fibroblasts for sensitivity to four classes of mutagens, including X-rays. In the assays used, skin fibroblasts and lymphocytes from both affected and unaffected family members exhibited responses indistinguishable from normal controls. Karyotypic analysis of lymphocytes and fibroblasts revealed no consistent constitutional cytogenetic abnormality. Thus, affected patients with the cancer family syndrome do not have increased sensitivity to irradiation and chemical mutagens and lack a germ-line chromosomal defect.

Non-Hodgkin's lymphoma of the lung

Non-Hodgkin's lymphoma (NHL) commonly presents with extensive disease involving extranodal tissues. Involvement of the mediastinal and hilar lymph nodes, pleura and lung parenchyma are recognised complications although their incidence is uncertain. However, pulmonary involvement is undoubtedly much less common than involvement at other extra nodal sites. Histologically proven NHL limited to the lung parenchyma, after full staging including computerised tomography and marrow trephines, is extremely rare. We report on two such cases and review the literature.

Chromosomal aberration and sister-chromatid exchange frequencies in peripheral blood lymphocytes of a large human population sample

In order to assess the potential of cytogenetic determinations on peripheral blood lymphocytes as a means of monitoring human populations subject to low level occupational and environmental exposures to chemical mutagens and carcinogens, accurate baseline data are required. Accordingly, we have determined mean frequencies of chromosomal aberrations and of sister-chromatid exchanges, their variances, and the sources of this variance in a cohort of 353 healthy employees of the Brookhaven National Laboratory. A detailed protocol was adopted for blood sampling, lymphocyte culture, cytogenetic preparation and scoring in order to minimize variation from these potential sources. Scoring was divided between the Oak Ridge and the Brookhaven groups with duplicate scoring sufficient to evaluate and minimize the effect of any differences between laboratories or between individual scorers. In all, the data include 71,950 cells scored for chromosomal aberrations and 16,898 cells scored for sister-chromatid exchanges. The mean unadjusted frequency of sister-chromatid exchanges was 8.29 +/- 0.08/cell. As reported in other studies, cigarette smoking very significantly influenced sister-chromatid exchange frequencies; in our study the mean for smokers was 9.0 +/- 0.2, while that for non-smokers was 8.1 +/- 0.1/cell. The mean frequency was statistically higher in females than in males, regardless of smoking status. On the other hand, age of the subject did not significantly influence sister-chromatid exchange frequencies. Curiously, the subject's total white cell count did influence sister-chromatid exchange frequency. No other source of variation was found. The frequencies of chromosomal aberrations of all types were determined. The frequency of the most common unequivocal chromatid type, the chromatid deletion, was 0.81 +/- 0.05%, that of the most common unequivocal chromosome type, the dicentric, was 0.16 +/- 0.02%. No statistically significant influence was found of age or sex, nor of any other parameter tested, on the frequency of any chromosomal aberration type, with the single exception of long acentric fragments, often "supernumerary", believed to represent X chromosomes precociously separated at the centromere. Such fragments were significantly more frequent in samples from females than those from males, and showed a significant positive regression on age.

Expression of human milk fat globule antigens HMFG1 and HMFG2 on ovarian tumours and lung tumours

The patterns of reactivity of the monoclonal antibodies HMFG1 and HMFG2 were studied in epithelial ovarian tumours, small cell lung cancer, and non-small cell lung cancer. Twenty primary, paraffin embedded, ovarian tumours were analysed in addition to freshly obtained ascitic fluids (21), a node aspirate (1), solid metastatic tumours (3), and 6 established cell lines. SCLC tumours comprised paraffin embedded bronchial biopsies (31) and metastatic deposits (7) and fresh tissue from bronchial biopsies (3), pleural aspirates (4), bone marrows (5), node aspirates (6), solid metastatic tumour (3), and 4 cultured cell lines. Antigen expression was heterogeneous for all tumour types studied. However, significant differences in antigen expression were noted with the HMFG2 antibody between primary and metastatic lesions from both ovarian and small cell lung cancer groups.

Clinical applications of immunocytochemistry in the monitoring of the bone marrow in small cell lung cancer (SCLC)

A panel of monoclonal antibodies (MAbs) has been identified which may be useful in detecting SCLC tumour cells and which does not cross-react significantly with normal marrow elements. Compared with conventional techniques this MAb panel markedly increases detection of micrometastases in the bone marrow especially in limited disease and post-chemotherapy in responding patients. There is a close correlation between immunological positivity and the ability to grow SCLC-like cells for variable periods in serum-free culture. In 4 cases SCLC-like cells have been characterized by electron microscopy or by the establishment of SCLC cell lines in continuous culture. The prognostic importance of pre-treatment detection of marrow involvement is unknown. The implications of post-chemotherapy detection of micrometastases are also uncertain but there may be an association with early systemic relapse which may occur regardless of intervention, including high dose intensification with autologous marrow rescue with primary site and CNS prophylactic irradiation.

Phase I study of TCNU, a novel nitrosourea

TCNU is a chloroethyl nitrosourea based on the endogenous amino acid taurine. This paper reports its first evaluation in man. Eighty-four patients with refractory cancer received 12 dose escalations from 10-150 mg/m2 TCNU administered orally every 6 weeks. Clinical side-effects were predominantly gastro-intestinal but dose-limiting toxicity was thrombocytopenia. Pharmacokinetic monitoring with an HPLC assay sensitive to the nanogram range demonstrated unchanged TCNU in plasma for up to 8 h following administration. The mean half-life was 60 min. Clinical responses were seen in melanoma (four patients), lung cancer (two squamous, one small cell) and one patient each with renal and stomach cancer. These responses, together with the unusual pharmacokinetic profile of TCNU, warrant exploration in disease-orientated phase II studies at a recommended dose of 130 mg/m2 p.o. q 5 weeks.

Prognosis in small cell carcinoma of the lung--relationship to human milk fat globule 2 (HMFG2) antigen and other small cell associated antigens

Forty fixed tissue sections from patients with small cell lung carcinoma (SCCL) have been stained with a panel of 10 monoclonal antibodies using a peroxidase anti-peroxidase method and the incidence of staining has been compared to patient characteristics at presentation and to survival. An inverse association between HMFG2 staining and survival was found with median survival in HMFG2 negative patients 13 months compared to 8 months for HMFG2 positive patients. No such association was found with the other antibodies and no association was found between staining and disease extent or primary versus secondary deposits with this panel of antibodies. Epidermal growth factor receptor was detected in 3/38 presentation biopsies and in these 3 patients mean survival was only 5 months. Further prospective study of HMFG2 as a prognostic indicator in SCCL is suggested.

Mitoxantrone versus doxorubicin in combination chemotherapy for advanced carcinoma of the breast

One hundred fifteen patients with metastatic carcinoma of the breast were treated in a randomized trial of mitoxantrone (Novantrone, Lederle Laboratories, Pearl River, NY) combined with vincristine and prednisolone (VMP) or doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH) combined with vincristine and prednisolone (VAP). In 100 evaluable patients, the objective response rates were 35% for VMP and 61% for VAP, the complete response rates being 6% and 13%, respectively. In responding patients, median time to progression was 6.2 months for VMP and 7.9 months for VAP. The median survival whether measured from primary diagnosis, first metastasis, or from the start of chemotherapy was similar for both regimens. Toxicity, particularly alopecia, was appreciably lower in the VMP treated patients, but subclinical cardiotoxicity was seen within the scheduled dosage for both combinations. We conclude that VAP is clearly more active, but clinically more toxic than VMP. There is no survival advantage conferred by the more toxic combination. Cardiac toxicity is a potential hazard with either drug combination.

Optimising antiemesis in cancer chemotherapy: efficacy of continuous versus intermittent infusion of high dose metoclopramide in emesis induced by cisplatin

Thirty three untreated patients being given cisplatin received metoclopramide (7 mg/kg) for antiemesis by either continuous or intermittent infusion in a random order. Each patient received intravenous dexamethasone in addition. High pressure liquid chromatography was used to measure plasma concentrations of metoclopramide. The two regimens were evaluated for antiemetic efficacy and the incidence of side effects. The intermittent metoclopramide regimen resulted in peak and trough plasma concentrations of metoclopramide with accumulation at eight hours, while the loading dose and continuous infusion resulted in mean plasma concentrations greater than 0.85 micrograms/ml (2.8 mumol/l) throughout the eight hour period. The continuous infusion was associated with a significant improvement in nausea and vomiting and reduction in diarrhoea. Major control of emesis (two episodes or fewer) was achieved in 27 patients receiving continuous metoclopramide compared with 18 receiving intermittent metoclopramide.

Anti-emetic efficacy of dexamethasone in combination for out-patients receiving cytotoxic chemotherapy

A single blind randomised trial of two different anti-emetic regimens (A and B) was performed in 26 patients with breast carcinoma undergoing emetic i.v. cytotoxic chemotherapy. They all received oral Motival (nortriptylene/fluphenazine) for 48 h after therapy and for regimen A received N-saline i.v. with their cytotoxics whilst for regimen B patients were given 16 mg dexamethasone i.v. Patients were given the alternative regimen at the subsequent course of treatment. They were asked to assess overall nausea and number of vomiting episodes in the 24 h following therapy. There was a statistically significant reduction in both for the regimen containing dexamethasone. This agent causes few side effects and is particularly suited for out-patient use.

Protective effect of sodium-2-mercaptoethanesulfonate on the gastrointestinal toxicity and lethality of cis-diamminedichloroplatinum

cis-Diamminedichloroplatinum (cis-platinum) is an effective and widely used antitumor drug. Patients receiving cis-platinum, however, experience very profound and long lasting gastrointestinal symptoms. The role of intestinal mucosal toxicity in the pathogenesis of these symptoms is unclear. In this study we have investigated the thiol-containing compound mesna (sodium-2-mercaptoethanesulfonate) as a potential antidote to cis-platinum-induced gastrointestinal tract damage. In mice, mesna caused a significant reduction in the gastrointestinal toxicity of cis-platinum assessed by electron microscopy, villus recovery rate, and by disaccharidase estimations. Mesna also significantly reduced serum creatinine levels following cis-platinum. Administration of mesna prior (or immediately following) a 67% lethal dose of cis-platinum protected 87-100% of the animals from the lethal effects. The antitumor efficacy of cis-platinum in L1210 leukemia bearing mice was not affected by coadministration of mesna indicating that the protective effect may be tissue specific. In addition this finding indicates that mesna has potential as an agent which may improve the therapeutic index of cis-platinum in clinical practice.

The clinical pharmacology of mitozantrone

The pharmacological disposition of the anthracenedione mitozantrone has been measured in 11 patients with six different tumour types. Administered at 14 mg/m2 as a 30-min infusion, the drug was assayed by a high-pressure liquid chromatographic technique sensitive to 1 ng mitozantrone/ml plasma. The mean half-lives for mitozantrone in plasma were as follows: alpha, 9.4 min; beta, 1.6 h; gamma, 23 h. The mean volume of distribution (Vd) was 1565 l. For two patients with impaired liver function the T1/2 gamma and Vd were 63.1 h and 4853 l, respectively. Less than 5% of the administered drug was excreted in urine, but two urinary metabolites were identified. These were not influenced by pre incubation of urine samples with beta-glucuronidase or sulphatase, suggesting that neither metabolite is a glucuronide or a sulphate conjugate of mitozantrone. Hepatic metabolism is the major route of elimination of mitozantrone, and caution should be exercised when using this drug for patients with hepatic dysfunction.

Role of 99mTc methylene diphosphonate bone imaging in the management of lymphoma

The role of modern techniques of 99mTc methylene diphosphonate bone imaging in the management of lymphoma patients was assessed by comparing results of 107 bone scans in 16 patients with Hodgkin's disease, and 45 patients with non-Hodgkin's lymphoma to simultaneous radiologic, clinical, and histopathologic features as well as to subsequent disease course. The sensitivity and specificity were both greater than or equal to 0.96 in both Hodgkin's disease and non-Hodgkin's lymphoma and the overall accuracy by site was 98%. The scan proved to be useful in the definition and follow-up of skeletal lymphomatous disease in both symptomatic and asymptomatic patients, and defined abnormalities which were not predicted by either serum alkaline phosphatase activity or the presence of bone marrow involvement. In no patient, however, did the bone scan result by itself alter either initial staging or estimates of extent of disease at the time of relapse. Bone scanning, therefore, cannot be recommended as a screening procedure in patients with lymphoma; rather, this test is best reserved for the definition and follow-up of skeletal metastases in patients with active, concomitant, extraosseous disease.

Acute pancreatitis in association with small cell lung carcinoma: potential pitfall in diagnosis and management

Tumour metastases to the pancreas are a rare but recognized cause of acute pancreatitis, there is a 24-40% incidence of pancreatic involvement from small cell lung cancer in autopsy series but only a very few cases of tumour-induced acute pancreatitis have been described. Chemotherapy has been advocated as the primary therapy in patients with known oat cell carcinoma who develop acute pancreatitis. We describe 2 patients with acute haemorrhagic pancreatitis in association with disseminated small cell carcinoma but without evidence of tumour invasion in the gland and with gall stones present in the gall bladder. Chemotherapy would have been inappropriate therapy for these patients.

cis-Platinum and vindesine in combination in the treatment of non-small cell lung cancer

Sixty-three patients with advanced non-small cell carcinoma of the bronchus were treated with a combination of cis-platinum and vindesine. All patients had measurable disease and were of good performance status; none had received prior chemotherapy or radiotherapy. Thirty-three per cent of patients responded, with five patients achieving complete remission. Median duration of response was 4 months, with a median survival of 14 months in the responsers, compared with 6.5 months in the whole group and 4.8 months in the nonresponders. Severe toxicity was encountered, with alopecia, gastrointestinal toxicity and neurotoxicity common. Myelosuppression and renal toxicity were not dose-limiting. Thus the activity of this drug combination is confirmed, but severe toxicity precludes its widespread use in clinical practice.