Cutaneous metastases from laryngeal carcinoma

The authors describe a case of cutaneous metastases from a squamous cell carcinoma of the laryngeal vestibule. The skin lesions, which consisted of nodules localized to the forehead and left arm, appeared 2 years after diagnosis of the primary tumor. The skin manifestations preceded lung metastases by 5 months.

Doxorubicin distribution in human breast cancer

Using a high-performance liquid chromatographic method coupled with fluorimetric detection, we evaluated plasma pharmacokinetics of doxorubicin (DX) and tissue distribution in seven patients suffering from locally advanced breast cancer. Tumor biopsies were performed 30 minutes and 24 hours after DX injection. In addition at 48 hours, during surgery, biopsies were obtained from primary breast cancer, nodes, and other accessible tissues, and DX concentrations were analyzed. A triexponential equation gave the best fit for plasma levels and the values (mean +/- SE) were: elimination half-life, 37.6 +/- 4.9 hours; volume of distribution, 605 +/- 61 L/m2; and clearance 200 +/- 27 ml/min/m2. There was greater interindividual variability in tumor DX concentrations than in plasma concentrations. DX reached much higher (range at 48 hrs, 1.54-14.17 micrograms/g) and longer-lasting concentrations in tumor than in plasma. At 48 hours tumor concentrations were 55.2-337.4 times the plasma concentrations. DX concentrations in normal breast were lower or similar to those in breast carcinoma. DX levels were very low in fat and skin, slightly higher in muscle, and very high in normal or metastasized lymph nodes.

Alternating tamoxifen and medroxyprogesterone acetate in postmenopausal advanced breast cancer patients--short and long term endocrine effects

The endocrine effects of alternating tamoxifen and medroxyprogesterone acetate have been evaluated in 26 post-menopausal patients with metastatic breast cancer. Endocrine evaluations included the RIA determination of plasma levels of sex-hormone binding globulin, follicle-stimulating hormone, luteinizing hormone, estradiol, prolactin, cortisol, and testosterone. The evaluation of the study parameters at different intervals during therapy indicates that with this schedule an alternate sequential effect on the endocrine system is achievable because each drug exerts its own endocrine activity that is completely reversed when the other drug is administered. We can hypothesize that the same alternate activity as seen on the endocrine system could be obtained also on other tissues and organs including tumors.

Sequential combination of tamoxifen and high dose medroxyprogesterone acetate: therapeutic and endocrine effects in postmenopausal advanced breast cancer patients

A sequential combination of tamoxifen and medroxyprogesterone acetate has been evaluated in 42 postmenopausal untreated patients with metastatic breast cancer. Patients received tamoxifen 10 mg b.i.d., days 1-14, followed by medroxyprogesterone acetate 500 mg b.i.d., days 15-28, orally in an alternating sequence until progression. Twenty-two out of 40 evaluable patients showed an objective response to treatment (55%, 95% confidence limits 38-75%). A significantly higher response rate was observed in patients with age greater than or equal to 70 years, with soft tissue dominant lesions and with only one metastatic site. Median time to progression was 41 weeks and the median survival time 88 weeks. In 4 cases treatment was discontinued because of severe toxicity while in the remaining patients no toxicity (20 patients) or mild side effects (17 patients) have been observed. After 2 months of therapy, this combination showed a progestogenic effect on the endocrine parameters inducing a significant decrease of SHBG, gonadotropins, testosterone and cortisol. These preliminary clinical results and the moderate toxicity of the sequential combination support the need to further investigate this approach.

Circumscribed spontaneous heterotopic ossification in the soft tissues simulating sarcoma

Eight cases are described of circumscribed heterotopic ossification in the soft tissues characterised by spontaneous onset, no history of trauma, and rapid course which have frequently led to a mistaken preoperative diagnosis of highly malignant tumour. The terminology differentiates it from myositis ossificans, which is a different entity. The authors emphasize the need for accurate evaluation of all the clinical and radiographic data in order to avoid an erroneous diagnosis of extraosseous osteogenic sarcoma or parosteal osteogenic sarcoma. In this regard, both radiography and histological examination demonstrate the so-called zoning pattern, namely a radiolucent central zone corresponding to the more immature area and consisting of fibrous tissue with active histiofibroblastic proliferations and a radiopaque peripheral area, where ossification is more mature the closer it gets to the periphery. Histological specimens obtained exclusively from the central area may lead even the most expert pathologists to a diagnosis of fibrosarcoma or osteogenic sarcoma. Finally, the pathogenetic aspects of the anomaly are discussed, as well as those concerned with the differential diagnosis from other types of heterotopic ossification.

Cisplatin and 5-fluorouracil combination chemotherapy in advanced and/or metastatic colorectal carcinoma: a phase II study

The possible synergism of cisplatin (P) and 5-fluorouracil was studied in 38 consecutive patients with advanced or metastatic colorectal carcinoma. Cisplatin 60 mg/m2 i.v.q. 4 weeks and fluorouracil 600 mg/m2 i.v. weekly were administered for at least 2 cycles, on an out-patient basis, to 24 males and 14 females with a median age of 57 years and a median PS of 80 (Karnofsky). Evaluable lesions were: primary unresectable tumor in 2 patients, local recurrence in 11, liver, lung, bone and soft tissue metastases in 21, 7, 2 and 3 patients respectively. With a median number of 3 cycles administered to 35 evaluable patients, 6 partial responses, 16 unchanged and 13 progressions were observed. Responses were observed in the liver (2 patients), lungs (1) and soft tissues (3). Median remission duration was 15 weeks, median duration of 'unchanged' was 12 weeks. The overall median survival was 24 weeks (30.5 weeks for responders and 22.5 weeks for non-responders). Six patients were pretreated with chemotherapy not containing cisplatin (mainly adjuvant 5-FU). None of them responded. Toxicity was very tolerable with moderate nausea, vomiting and alopecia in the majority of the patients; bone marrow toxicity was generally mild with no blood transfusions required, no complications of myelosuppression (sepsis or bleeding) and no chemotherapy-related deaths. In this experience the combination of low dose cisplatin with fluorouracil, does not appear to significantly enhance 5-FU toxicity and the response rate is not superior to that reported with 5-FU alone. However, better designed schedule combinations with optimal doses, sequences and exposure time of the 2-drug regimen, seem necessary to obtain the biochemical events that support the potentiation.

Combination of amikacin and ceftazidime as empiric treatment of febrile leukopenic patients affected by solid tumors

A combination of amikacin and ceftazidime was used as initial empiric therapy for the treatment of 25 evaluable febrile episodes (temperature greater than or equal to 38.5 degrees C) in leukopenic adult patients (wbc less than or equal to 1,000/mm3) with solid tumors, characterized by poor prognosis because of low performance status (median Karnofsky score: 50) and progressive disease (76% of cases). Nineteen (76%) of the 25 episodes responded to the initial empiric antibiotic combination. In the microbiologically documented infections, there was no significant difference in the response rate between bacteremia (67%) and localized infections (81%). The response in localized infections caused by gram-negative organisms (81%) was similar to that obtained in gram-positive organisms (82%), whereas gram-positive bacteremia responded better than gram-negative (100 vs 50%). No serious side effects were observed. Reversible nephrotoxicity occurred in 12% and hypokalemia in 20% of the patients treated. This antibiotic combination is a safe and efficacious empiric therapy for infections in leukopenic patients with solid neoplasia.

Phase II study of esorubicin (4'-deoxydoxorubicin) in locally advanced or metastatic head and neck carcinoma

Sixteen patients with locally advanced or metastatic head and neck cancer were treated with esorubicin (4'-deoxydoxorubicin) at a dose of 30-35 mg/m2 i.v. every 3 weeks. One patient was lost to the follow up after one cycle, whereas in the 15 evaluable cases a total of 34 courses were administered (median per patient: 2, range: 1-6). Pretreatment for parameter lesions consisted of radiotherapy in 5, chemotherapy in 3 and both treatments in 1 patients respectively. Overall, one partial response, one stable disease and 13 progressions were documented. Severe (grade 3 and 4) leukopenia, thrombocytopenia and anemia were noted in 3, 1 and 1 patients respectively. The only patient developing leukopenia and thrombocytopenia of grade 4 subsequently died because of pneumonia. On the other hand, non-hematologic toxicity was generally mild. At this dose and schedule, esorubicin demonstrated an activity less than 20% in head and neck cancer and therefore, no further evaluation is warranted.

Normolipemic eruptive cutaneous xanthomatosis

We describe a form of diffuse, rapidly self-healing xanthomatosis with the clinical and ultrastructural features of hyperlipemic xanthoma but occurring in a subject with normal lipid metabolism and with no associated systemic disorders.

A freeze-fracture study of the enteropathy associated with dermatitis herpetiformis: a comparative investigation with coeliac disease

Jejunal biopsies from patients with either dermatitis herpetiformis or coeliac disease were freeze-fractured and compared with normal jejunal biopsies. The intestinal mucosa of the normal biopsies showed a normal structure, with well-developed and tightly packed microvilli; in dermatitis herpetiformis and coeliac disease degenerative changes of the intestinal mucosa occurred. These changes appeared to be segmental in dermatitis herpetiformis and diffuse in coeliac disease. Emphasis is placed on changes in the tight junctional net at the base of the microvilli, which could represent cellular damage related to increased intestinal permeability to macromolecules in these diseases. An interpretative hypothesis for these observations is presented.

Paroxysmal supraventricular tachycardia during treatment with cisplatin and etoposide combination

We report a case of a 60-year-old woman affected by squamous lung carcinoma, who developed paroxysmal supraventricular tachycardia during cisplatin and etoposide combination chemotherapy. Cisplatin toxicity on cardiac electrical activity is discussed. This observation might suggest caution when cisplatin is used in patients with cardiac disease or pretreated with other potential cardiotoxic antineoplastic agents.

Cell kinetics as a prognostic marker in node-negative breast cancer

The relevance of cell kinetics of the primary tumor as a marker of biologic aggressivity was verified on a series of 258 patients with operable breast cancer without nodal and distant metastases, who underwent radical mastectomy without any other treatment until relapse. The cell proliferative rate, evaluated in vitro on fresh tumor material and expressed as 3H-thymidine labeling index, was found to be an important discriminant of metastatic potential. Patients with slowly proliferating tumors showed a higher probability of 6-year relapse-free survival in comparison to those with fast-proliferating tumors (80.5% versus 59.6%, P = 0.00004). This finding was true for premenopausal and paramenopausal (P = 0.00005) as well as for postmenopausal patients (P = 0.01). The kinetic variable was also a discriminant of 6-year survival for the overall series (P = 0.003) and for premenopausal and paramenopausal patients (P = 0.003) regardless of the type of treatment after relapse. These findings show the relevance of the kinetic variable as an important prognostic marker in breast cancer.

Phase II study with amsacrines (m-AMSA and m-AMSA lactate) in refractory lymphomas

A total of 70 patients with malignant lymphomas refractory to one or more chemotherapeutic regimens were treated with iv amsacrines (m-AMSA and m-AMSA lactate). Of 58 evaluable patients, 12 had Hodgkin's disease and 46 had non-Hodgkin's lymphoma. Twenty-nine of the evaluable patients received m-AMSA and 29 received m-AMSA lactate. The amsacrines were recycled every 3 weeks. The doses of m-AMSA were 90-120, 70, and 25-30 mg/m2/day for 3 days, respectively. All patients treated with m-AMSA lactate received a single dose of 225 mg/m2. In Hodgkin's disease, the response rate was 58.3% (one complete response among 12 patients), and in non-Hodgkin's lymphoma, the response rate was 30.4% (six complete responses among 46 patients). The median duration of response was 3 and 5 months, respectively. The response rate was unfavorably affected by the presence of extra-nodal disease and a Karnofsky performance status less than 80. There was no important difference in the incidence and duration of response between m-AMSA and m-AMSA lactate. After vomiting, myelosuppression was the most frequent observed toxic effect. One patient showed an unexpected fatal bone marrow aplasia following the first course of 90 mg/m2. This study indicates that m-AMSA and m-AMSA lactate are active and moderately toxic in previously treated malignant lymphomas. Thus, amsacrines could be effectively incorporated into salvage polydrug regimens.

Monoclonal Gammopathy (IgM-k) in a Patient with Burkitt's Type Lymphoblastic Lymphoma

We report a Burkitt's type lymphoblastic lymphoma (B-LL) case characterized by an abnormal IgMk immunoglobulin secretion and referred to us on February 12, 1982. The diagnosis has been histologically documented and the pathological stage of the disease (IV B) was determined according to the diagnostic criteria usually employed for the non-Hodgkin's lymphoma (NHL). Serum proteins were determined by electrophoresis and immunodiffusion. The review of the literature has allowed us to ascertain that the presence of a monoclonal IgM peak can be associated with NHL, particularly with those of B cell type and in adult subjects. Up to now, only six IgM B-LL secreting cases have been described. The biological and prognostic significance of this elevated Ig secretion is uncertain; therefore it may be important for the future to evaluate, in B-LL this immunological parameter.

Letterer-Siwe disease in an octogenarian

The case of an 81-year-old woman suffering for about 1 year from a typical form of Letterer-Siwe disease (LSD) is reported. The only important systemic involvement was hepatosplenomegaly. The patient was treated with steroids and vinblastine and then with thymopoietin pentapeptide. This last drug proved useful for decreasing the dose of steroid and thus for checking the appearance of new skin lesions. The ultrastructural investigations, carried out before and after vinblastine, showed the presence in some histiocytosis X cells (HXC) of coated Birbeck granules (BG). Immunoelectron microscopy showed about 90% of HXC to be OKT6+ and the OKT6 labeling of these cells to be similar to that of the Langerhans cells of normal skin. Five percent of OKT6+ cells apparently contained no Langerhans granules.

The morphologic events of blister formation in porphyria cutanea tarda

In porphyria cutanea tarda (PCT), the submicroscopic event causing the formation of spontaneous blisters is the appearance of membrane-limited vacuoles in the superficial dermis. These vacuoles are apparently formed through cytolysis of dermal cells and swelling of the pseudopodia of the basal cells protruding into the dermis, probably as a consequence of photochemically-induced lysosomal damage. The number and size of these vacuoles progressively increase near the cleavage area of the blisters, where their limiting membranes merge and break, giving rise to the cavity of the blister, which is formed under the basal lamina. The presence of coated vesicles along the limiting membranes as well as inside the vacuoles suggests their involvement in the transport of fluids from the damaged vessels, thus contributing to the progressive volume increase of vacuoles themselves.

Freeze-fracture replication technique of human skin

The freeze-fracture replication technique represents one of the most advanced methods for studying the ultrastructure of biological tissues and has given a new dimension to the ultrastructure research. This technique makes it possible to obtain a cast of a fracture surface of frozen preparations. Apart from allowing samples to be examined without being dehydrated, i.e. under conditions very close to those of living state, it has proved especially useful for the analysis of many tissue functions concerned with membrane activity and exchanges between cells and their disturbance in specific disease conditions. Even through good quality replicas had already been obtained back in 1961 (Moor et al. 1961), only after 1970, mainly thanks to the contribution made by Breathnach and his collaborators (Breathnach et al. 1972, Breathnach 1973, Breathnach et al. 1973) was the freeze-fracture replication technique successfully used in the study of the skin, since this tissue had proved especially difficult to process. In this review paper, technical principles will be summarized and the most important findings so far obtained in the study of normal and pathologic skin will be illustrated.

A freeze-fracture study of the human nail plate

This study of freeze-fracture replicas of human nail plate fragments demonstrates that keratin filaments have a width of about 100 A. The 'marginal band' is probably formed by a row of particles, 50 A in diameter, arranged along the inner surface of the plasma membrane. These particles are often masked by keratin filaments. In nonjunctional areas, the plasma membranes are devoid of membrane-associated particles. The only type of junction observed is the desmosome. Even though the modes of keratinization are different, the structures of the keratin pattern, of cell membranes, and of the desmosomes are identical in replicas of wholly keratinized nail and human stratum corneum cells. The ultrastructural differences observed appear to be related to the barrier function carried out by the epidermis and by its desquamation process.

GAp junctions in skin tumors of molluscum contagiosum

Thin section, tracer, and freeze-fracture experiments demonstrate that the infection caused by molluscum contagiosum virus implies alterations of cellular contacts in the epidermis, never before observed in cutaneous viroses. These changes are basically represented by a distinctive variation in particle packing of gap junctions, a greater proliferation of these junctions and the presence of a high amount of intracytoplasmic gap junctions. Skin tumors caused by molluscum contagiosum virus appear to be a convenient model to study the morphological and topological variations as well as the turnover of gap junctions in the epidermis.

Internal organization of plasma membranes during the acantholytic process. A freeze-fracture study

The internal organization of plasma membranes was studied in seven subjects with pemphigus vulgaris and in one subject with familial pemphigus using the freeze-fracture technique. The results obtained seem to suggest that the acantholytic process is produced in a similar fashion whatever the pathogenic agent and that desmosomes represent the "target" membrane specializations in the acantholytic phenomena. The reduction and eventual disappearance of desmosomal particle aggregations is seemingly accompanied by an increase in gap junctions.

Plasma membranes in psoriatic cells. A freeze-fracture study

A freeze-fracture study of affected and unaffected psoriatic skin has demonstrated the presence of marked modification of the plasma membrane in the psoriatic lesion. In the lower layers of the epidermis, an increase of membrane associated particles was observed in many keratinocytes, possibly representing the morphological intramembranous equivalent of changes in the outer cell membrane demonstrated with cytochemical techniques. Furthermore, in the malphighian layer, numerous gap junctions have been found, which may be interpreted as a phenomenon compensating the uncontrolled proliferation, and may represent a point of differentiation between cell proliferation in psoriasis and neoplasia. This technique confirmed the poor tendency to adhesion of keratinocytes in extrajunctional areas, which had already been shown by other morphological techniques.

[Peri-navel intestinal patch-like choristia (author's transl)]

The authors describe an umbilical anomaly marked by confluent erythematous and crusted plaques, spreading beyond the navel limits and histologically regarded as a choristia that is to say a displacement of intestinal tissue within the epidermis. The ultrastructural study investigated the relationship between intestinal cells and keratinocytes. The authors believe that behaviour analogies exist between ectopic intestinal cells and Paget's cells.

[Nonvisualized gallbladder in cholecystography per os: radiotomographic study after a second dose]

Tomography after a second dose of contrast medium gave useful information in 46/57 (81%) cases where the gallbladder was not visualized after a first dose per os. Eight cases are presented in detail.

Ultrastructural changes induced by vinblastine in cutaneous lesions of histiocytosis X

The ultrastructural examination of the skin lesions of 2 typical patients with subacute disseminated histiocytosis X 12, 24, 36, 48 and 72 hours after the intravenous administration of vinblastine enabled us to observe that, after 12-24 hours, there were numerous Langerhans cells undergoing mitosis which had no spindle microtubules but showed fragments of newly forming nuclear membrane, thus demonstrating that mitosis was arrested in anaphase. Later on, in the Langerhans cells mainly, we observed degenerative phenomena (mitochondrial swelling, perinuclear edema and rupture of the plasma membrane) and, finally, a marked reduction in the number of this type of cells were observed.