Bleomycin treatment of the tumors of penis and scrotum

[French ccAFU guidelines - update 2020-2022: penile cancer]

OBJECTIVE

- To update French oncology guidelines concerning penile cancer.

METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.

RESULTS

- Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organ-sparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.

CONCLUSIONS

- Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.

Modified-BEP Chemotherapy in Patients With Germ-Cell Tumors Treated at a Comprehensive Cancer Center

OBJECTIVES

Bleomycin, etoposide, and cisplatin (BEP) is the most common and successful chemotherapy regimen for germ-cell tumor (GCT) patients, accompanied by a bleomycin-induced dose-dependent lung toxicity in certain patients. In an attempt to reduce bleomycin-toxicity, we developed a modified-BEP (mBEP) regimen.

MATERIALS AND METHODS

Between August 2008 and February 2018, 182 unselected mainly testicular GCT patients (39 with adjuvant purpose and 143 with curative purpose) received a tri-weekly 5-day hospitalization schedule with bleomycin 15 U intravenous (IV) push on day 1 and 10 U IV continuous infusion over 12 hours on days 1 to 3, cisplatin 20 mg/m IV, and etoposide 100 mg/m IV on days 1 to 5. Pulmonary toxicity was assessed through chest computed tomography scan and clinical monitoring.

RESULTS

Median number of mBEP cycles was 3 (range: 1 to 4). In the curative setting, according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic system, 112, 21, and 9 patients had good-risk, intermediate-risk, and poor-risk class, respectively; 66 (46%) patients had complete response (CR), 67 (47%) had partial response (52 of whom became CR afterwards), 6 (4%) had stable disease (that in 3 became CR afterwards), 3 (2%) progressed, and 1 (1%) died of brain stroke. At a median follow-up of 2.67 years (interquartile range: 1.23-5.00 y), 1 and 5-year overall survival and progression-free survival were 99% and 95%, and 90% and 88%, respectively. In the entire patient population, there was grade 3/4 neutropenia in 92 patients (51%), febrile neutropenia in 11 patients (6%), grade 1/2 nausea in 74 patients (41%), and no death due to pulmonary toxicity.

CONCLUSION

In GCT patients, our mBEP-schedule would suggest an effective treatment modality without suffering meaningful pulmonary toxicity.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020: tumeurs du pénis French ccAFU guidelines — Update 2018—2020: Penile cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.008. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.008. That newer version of the text should be used when citing the article.

Bleomycin alone and in Combination with Methotrexate in the Treatment of Carcinoma of the Esophagus

The therapeutic results of Bleomycin (BLM) administered alone (29 patients) and in combination with Methotrexate (5 patients) in advanced carcinoma of the esophagus are reviewed. The drug was injected intravenously in five different dose schedules (table 1), as described in previous publications. In combination BLM was given twice weekly at the dose of 10 mg/m2/week intravenously for 1 month. Courses were repeated after an interval of 2–3 weeks. Of 34 patients given BLM alone or in combination, 23 were untreated. The overall response in the group treated with BLM alone was 52 % (table 2). However, complete remission was seen only in 1 patient and more than 50 % remission in 3 patients (CR + PR > 50 %: 14 %). The highest incidence of response was observed with the first dose schedule employed (3/3). The fifth schedule, which is similar to that used by Japanese investigators (10 mg/m2 twice weekly) induced regression in 7/17 patients. The median duration of response ranged in the different schedules from 1 to 2 months. In the small series treated with BLM + MTX 4/5 patients showed regression (CR 1, PR > 50 % 2) with a median duration of 2.7 months. In patients treated with BLM alone pulmonary toxicity confirmed through repeated chest X-rays was observed in 12/29 patients (41 %) after a minimum of 80 mg/m2 and a maximum of 220 mg/m2. This exceedingly high incidence of lung toxicity in relation to the five treatment schedules was as follows: first schedule 3/3, second 1/3, third 1/3, fourth 2/3, fifth 5/17. In 2 patients (both treated with the first dose-schedule) pulmonary toxicity contributed to the cause of death (total dose 120 mg/m2). This report shows that BLM alone produced regressions in about 50 % of patients with advanced epidermoid carcinoma of the esophagus. However, both quality and duration of regression failed to indicate in the present series a useful role of BLM in the control of esophageal carcinoma. The combination of BLM with MTX probably deserves further trials.

Contemporary Chemotherapy and Radiotherapy for Inguinal Metastases of Carcinoma of the Penis: A Case Report

A case is reported of a 76 year old patient with inoperable lymph node metastases from cancer of the penis. Methotrexate and bleomycin chemotherapy and concurrent irradiation were administered. The patient achieved a complete remission and is disease-free 30 months after therapy. The treatment was well tolerated.

Modeling DNA damage-induced pneumopathy in mice: insight from danger signaling cascades

Radiation-induced pneumonitis and fibrosis represent severe and dose-limiting side effects in the radiotherapy of thorax-associated neoplasms leading to decreased quality of life or - as a consequence of treatment with suboptimal radiation doses - to fatal outcomes by local recurrence or metastatic disease. It is assumed that the initial radiation-induced damage to the resident cells triggers a multifaceted damage-signalling cascade in irradiated normal tissues including a multifactorial secretory program. The resulting pro-inflammatory and pro-angiogenic microenvironment triggers a cascade of events that can lead within weeks to a pronounced lung inflammation (pneumonitis) or after months to excessive deposition of extracellular matrix molecules and tissue scarring (pulmonary fibrosis).The use of preclinical in vivo models of DNA damage-induced pneumopathy in genetically modified mice has helped to substantially advance our understanding of molecular mechanisms and signalling molecules that participate in the pathogenesis of radiation-induced adverse late effects in the lung. Herein, murine models of whole thorax irradiation or hemithorax irradiation nicely reproduce the pathogenesis of the human disease with respect to the time course and the clinical symptoms. Alternatively, treatment with the radiomimetic DNA damaging chemotherapeutic drug Bleomycin (BLM) has frequently been used as a surrogate model of radiation-induced lung disease. The advantage of the BLM model is that the symptoms of pneumonitis and fibrosis develop within 1 month.Here we summarize and discuss published data about the role of danger signalling in the response of the lung tissue to DNA damage and its cross-talk with the innate and adaptive immune systems obtained in preclinical studies using immune-deficient inbred mouse strains and genetically modified mice. Interestingly we observed differences in the role of molecules involved in damage sensing (TOLL-like receptors), damage signalling (MyD88) and immune regulation (cytokines, CD73, lymphocytes) for the pathogenesis and progression of DNA damage-induced pneumopathy between the models of pneumopathy induced by whole thorax irradiation or treatment with the radiomimetic drug BLM. These findings underline the importance to pursue studies in the radiation model(s) if we are to unravel the mechanisms driving radiation-induced adverse late effects.A better understanding of the cross-talk of danger perception and signalling with immune activation and repair mechanisms may allow a modulation of these processes to prevent or treat radiation-induced adverse effects. Vice-versa an improved knowledge of the normal tissue response to injury is also particularly important in view of the increasing interest in combining radiotherapy with immune checkpoint blockade or immunotherapies to avoid exacerbation of radiation-induced normal tissue toxicity.

Chemotherapy for penile and urethral carcinoma

Although surgery is the mainstay of curative treatment of carcinomas of the penis and urethra, there is a role for systemic cytotoxic chemotherapy for locally advanced, unresectable, or metastatic tumors. Although this field is limited by a paucity of clinical trials or prospective data, the available single institutional retrospective reviews indicate that multi-agent cisplatin-based combination chemotherapy regimens have significant activity and may allow curative surgery for patients with otherwise unresectable tumors. Toxicity remains a concern in this typically older patient population, and clearly new regimens are necessary. This article reviews the available literature on chemotherapy for carcinoma of the penis and urethra in the neoadjuvant, adjuvant, and metastatic setting.

[Treatment of lymph nodes in epidermoid carcinoma of the penis: review of literature by the Committee of Cancerology of the French Association of Urology-External Genital Organs Group (CCAFU-OGE)]

INTRODUCTION

Invasive lymph nodes are an independent factor of prognosis and essential for the survival of patients with cancer of the penis. The aim of this article is to analyse published research results on the diagnosis and treatment of lymph nodes in cancer of the penis.

MATERIAL AND METHOD

Bibliographic research on Medline was carried out using the terms penile carcinoma, lymph node dissection, lymphadenectomy, survival, chemotherapy and radiotherapy.

RESULTS

The risk of lymph node metastasis depends on the stage of the primitive tumour, its histological grade, the presence of venous and lymphatic embolus and the presence of palpable lymph nodes (classification into risk groups by the European Association of Urology [EAU]). A diagnosis of suspected adenopathy based on clinical examination associated with FNA biopsy is essential. No medical imaging (tomodensitometry, NMR, PET-scan) has proven to be superior to clinical examination. The search for the sentinel lymph node although interesting remains to be defined, especially in patients who have no palpated adenopathy but are at risk of metastasis. Not only is surgery on inguinal lymph nodes the only reliable way of confirming an invasive metastatic lymph node, it also plays a therapeutic and prognostic role for patients who have a tumour of the penis which risks spreading to lymph nodes (intermediate or high risk according to EAU). The act should always be two-fold. The type of dissection is in function with the clinical examination: a radical inguinal dissection is recommended in the case of palpated adenopathy and a modified inguinal dissection is recommended if there is no palpated adenopathy, this should be radicalised in the case of metastatic adenopathy on histological examination. Neo-adjuvant or adjuvant chemotherapy would appear to play a interesting role when combined with surgery for certain patients without there being currently being precise consensus because of the lack of documented cases. The same goes for external radiotherapy on inguinal lymph nodes which seems to play a role in local controls of the lymph node disease though increases morbidity risks of surgical intervention.

CONCLUSION

Lymph node dissection alone has a therapeutic role in patients who have reached metastasis of lymph nodes (stage pN1). However, it remains insufficient for patients who have metastatic infiltration of more than 2 lymph nodes (stage > or =pN2). Consequently, it would seem important to develop multimodal approaches in the treatment of these patients in order to increase the rate of response to treatment.

Multimodality therapy in penile cancer: when and which treatments?

OBJECTIVES

Metastatic penile cancer typically comes to attention while the clinical extent of disease is limited to the inguinal or pelvic lymph nodes. Primary surgical management of lymph node metastases achieves tumor control and long-term survival for only a small percentage of these patients. To determine the optimal use of multimodality treatment in locally advanced penile cancer, we conducted a literature review.

METHODS

Relevant English-language literature was identified with the use of Medline; additional cited works not detected on the initial search were also reviewed.

RESULTS

There is an emerging strategy of preoperative (neoadjuvant) combination chemotherapy to improve the progression-free survival of penile cancer patients with bulky regional lymph node metastases. Radiotherapy for inguinal metastases and postoperative (adjuvant) radiation for selected patients has also been effective in this setting.

CONCLUSIONS

In patients with lymph node metastases, the benefit of ilioinguinal lymphadenectomy may be extended by the addition of neoadjuvant chemotherapy. Postoperative radiotherapy can be offered depending on the amount of residual disease after chemotherapy. Chemo-radiotherapy has been successful in squamous cell cancers from other sites (vulva and anal canal) and may be considered for unresectable penile cancer.

Bleomycin-induced pulmonary toxicity in chemotherapy for testicular cancer

Bleomycin is an antibiotic agent with antitumour activity, discovered in 1966 by Umezawa et al. Today, bleomycin is commonly used in chemotherapy for various tumour types. In testicular cancer especially, bleomycin is one of the key drugs in induction chemotherapy. It has the advantage of less myelotoxicity; however, its severe and potentially fatal pulmonary toxicity has limited its dose intensity. Several clinical trials have focused on eliminating bleomycin from the regimen or reducing the bleomycin dose for testicular cancer patients with good prognosis. However, the results indicate that bleomycin is still an essential component of induction chemotherapy when only three courses are administered. This review will focus on bleomycin-induced pulmonary toxicity in chemotherapy for testicular cancer, followed by a brief review of recent basic understanding of the pathogenesis of lung fibrosis.

Protective mechanisms against the antitumor agent bleomycin: lessons from Saccharomyces cerevisiae

Bleomycin is a small glycopeptide antibiotic used in combination therapy for the treatment of a few types of human cancer. The antitumor effect of bleomycin is most likely caused by its ability to bind to DNA and induce the formation of toxic DNA lesions via a free radical reactive (Fe.bleomycin) complex. However, the chemotherapeutic potential of bleomycin is limited, as it causes pulmonary fibrosis and tumor resistance at high doses. The chemical structure and modes of action of bleomycin have been extensively studied and these provide a foundation towards improving the therapeutic value of the drug. This review provides a first account of the current state of knowledge of the cellular processes that can allow the yeast Saccharomyces cerevisiae to evade the lethal effects of bleomycin. This model organism is likely to provide rapid clues in our understanding of bleomycin resistance in tumor cells.

Prevention of bleomycin-induced pulmonary fibrosis after adenovirus-mediated transfer of the bacterial bleomycin resistance gene

A serious limitation in the use of the DNA-cleaving, antitumoral-antibiotic, bleomycin during chemotherapy is pulmonary toxicity. Lung injury induced by bleomycin is characterized by an increased deposition of interstitial extracellular matrix proteins in the alveolar wall that compromises respiratory function. Several drugs have been tested in animal models to prevent the pulmonary toxicity of bleomycin, but have not led to a useful clinical treatment because of their adverse effects on other tissues. We have shown that transgenic mice expressing Streptoalloteichus hindustanus (Sh) ble bleomycin resistance protein in pulmonary epithelial cells in the lungs are protected against bleomycin-induced toxicity in lungs. In the present study, we used intranasal administration by adenovirus-mediated gene transfer of the bleomycin resistance Sh ble gene to mouse lung for prevention of bleomycin-induced pulmonary fibrosis. We constructed recombinant adenoviruses Ad.CMVble and Ad.RSVble harboring the bleomycin resistance Sh ble gene under the control of the cytomegalovirus early promoter and the Rous sarcoma virus early promoter, respectively. Transgene expression was detected in epithelia of conducting airways and alveolar septa by immunostaining with a rabbit polyclonal antibody directed against the bleomycin resistance protein and persisted for the duration of drug treatment; i.e., up to 17 d. No toxic effect was seen in adenovirus-treated mice. Pretreatment of mice with Ad.CMVble or Ad.RSVble completely prevented collagen deposition 42-133 d after bleomycin treatment, as measured by lung OH-proline content. Histologic studies indicated that there was little or no lung injury in the adenovirus/bleomycin-treated mice compared with the bleomycin-treated mice. These observations may lead to new approaches for the prevention of bleomycin-induced pulmonary fibrosis.

Treatment of cancer of the penis--a review

Cancer of the penis is a rare neoplasm and physicians should be aware of this condition. Early diagnosis and prompt treatment can lead to excellent results for low stage, low grade lesions. Herein, we discuss the clinical features, staging and management guidelines for this tumour.

Drug-induced pulmonary disease

Administration of more than 40 separate pharmacologic agents has been associated with some form of pulmonary toxicity. This problem is becoming more significant every year. Occasionally, effective modes of therapy must be withdrawn because of undesirable pulmonary side effects, putting patients at risk for potentially lethal diseases. Pulmonary parenchymal damage due to drugs is an especially troublesome problem because irreversible pulmonary disease may occur. Mechanisms of pulmonary parenchymal tissue damage by drugs are unclear. It appears that some drugs induce direct tissue injury in addition to indirect tissue damage through amplification of pulmonary inflammation; other drugs cause pulmonary alterations solely through indirect mechanisms. Common clinical syndromes associated with drug-induced pulmonary parenchymal disease include pneumonitis/fibrosis, hypersensitivity lung disease, and noncardiogenic pulmonary edema. Less common patterns of pulmonary parenchymal injury by drugs include bronchiolitis obliterans and a pulmonary renal syndrome. Risk factors for pulmonary injury due to pharmacologic agents are partially defined but not entirely understood. To date, there are no adequate tests for early detection of pulmonary damage by drugs, although research into this area is active. This review discusses mechanisms and clinical features of drug-induced pulmonary parenchymal injury to aid the clinician in recognizing and understanding these syndromes.

Flagellate pigmentation from intrapleural bleomycin. A light microscopy and electron microscopy study

A case is presented of a 65-year-old white man with left pleural mesothelioma treated with a single intrapleural instillation of bleomycin for cavitary sclerosis. One month later the patient developed pigmented flagellate streaks on his arms and chest wall. To our knowledge, this is the first case in the literature showing these typical pigmentary changes in which a single small dose of bleomycin acted as an intrapleural sclerosing agent.

Influence of coacervation-inducing agents and cooling rates on the preparation and in vitro release of bleomycin hydrochloride microcapsules

Two types of coacervation-inducing agents (EVA, PIB) and three cooling rates (0.01998, 0.03482 and 0.06725 degrees C/min) affecting the preparation, micromeritic and drug release properties of bleomycin hydrochloride microcapsules were investigated. Particle size distribution of microcapsules induced by EVA significantly depended on the cooling rate, but that induced by PIB was independent of the cooling rate. Higher viscosity of PIB led to a smaller particle size of microcapsules than when EVA was used. The surface topography of the microcapsules for both types of coacervation-inducing agents was obviously different. We found that the release behaviour of bleomycin hydrochloride from the microcapsules also depended on the type of coacervation-inducing agent and the cooling rate. In general, the slower the cooling rate the more prolonged the release of the drug. Higuchi matrix model was followed for bleomycin hydrochloride released from the microcapsules. T50 of both types of microcapsules decreased with the increase of the cooling rate. To simulate the absorption behaviour of the GI tract, the continuous flow dialysis method was modified for drug release from the microcapsules. The data indicate that the diffusion of the dissolution medium and dissolved drug through the ethylcellulose wall of the microcapsules is the rate-limiting step before dialysis. This also implies that the release rate of the drug from dosage form significantly determined the absorption in the GI tract.

Squamous cell carcinoma of scrotum

Squamous cell carcinoma of the scrotum is a rare malignancy in the United States. This series includes the eighth reported case of this lesion in a black American. Surgery still remains the only effective therapeutic modality. The use of sentinel and superficial inguinal node biopsies was important in determining whether or not radical ilioinguinal lymphadenectomy was needed in 2 patients.

The treatment of bilateral ulcerated lymph node metastases from carcinoma of the penis. A case report

A 44-year-old patient with histologically proven bilateral ulcerated lymph node metastases from a carcinoma of the penis was treated by sequenced combined chemotherapy and radical irradiation. Methotrexate and bleomycin were administered at weekly intervals for 5 weeks, followed by radiation with a split-course coning-down technique. The patient remains well and clinically disease-free 63 months after commencing therapy.

Sequential trials of methotrexate, cisplatin and bleomycin for penile cancer

Methotrexate, bleomycin or cisplatin was used to treat 21 patients with advanced bidimensionally measurable epidermoid carcinoma of the penis. Patient characteristics were similar in all 3 drug trials. Drug therapy was continued with each agent until the disease progressed. Significant tumor regression was observed in 8 of 13 men (61 per cent) treated with methotrexate, 3 of 12 (25 per cent) treated with cisplatin and 3 of 14 (21 per cent) treated with bleomycin. Responders tended to be younger than nonresponders (median age 48 versus 59 years, respectively, p less than 0.05) and lived a median of 8 versus 2 months, respectively (p equals 0.03). Cross-resistance was not encountered among the 3 drugs. Future trials might investigate combination regimens of all 3 agents.

Bleomycin in the treatment of recalcitrant warts

Bleomycin is gaining increasing popularity in the treatment of warts, but its efficacy has not been examined in well-controlled studies. We evaluated bleomycin in a double-blind placebo-controlled crossover study in recalcitrant warts treated unsuccessfully by conventional methods. Patients were assigned alternately to placebo or bleomycin groups and treated by intralesional injections of bleomycin, 1 U/ml, or saline, at 2-week intervals. If warts persisted, patients were changed after two injections to the alternate group and retreated with up to two further injections. Forty patients entered the study. Of 151 warts treated with intralesional bleomycin, 123 were cured after one or two injections (81%). The cure rate for plantar warts (60%) was lower than that for periungual warts (94%) and warts elsewhere on the extremities (95%). Fifty-five warts were injected with normal saline; none was cured. Responding warts showed a hemorrhagic eschar and healed without scarring, atrophy, or pigmentary change. Pain was usually mild and patient acceptance superior to that with liquid nitrogen. There was no evidence of systemic toxicity. Bleomycin is highly efficacious in the treatment of recalcitrant warts, is convenient, and has high patient acceptance. Long-term safety requires further study.

Bleomycin--mode of action with particular reference to the cell cycle

Over the last four years, investigations into the mechanism of interaction between bleomycin and DNA have been pursued at a rapid pace. This is, no doubt, because of the potential of bleomycin as a tool for molecular biology. It seems likely that the precise nature of the interaction between Fe(II), oxygen and bleomycin will be elucidated in the near future together with the nature of the binding between the complex and DNA. More information on the mechanism of strand scission including the involvement of free radical mechanisms and sequence specificity may also be expected. In contrast to this picture of rapid progress at the molecular level, interest in studies of bleomycin action at the cellular level appears to have waned. This is despite the fact that most of the important questions which have been raised regarding effects of the drug on cell cycle progression, the possibility of a selective action on on-cycling cells and the nature of 'recovery from potentially-lethal damage' remain unresolved. There is no doubt that, for most cell types, bleomycin produces a block at the early G2 stage of the cell cycle. There is considerable doubt, however, as to how many of the cells blocked for a significant period remain clonogenically viable. This question is amenable to being answered using a vital DNA stain, such as Hoechst 33342, and cell sorting but this does not appear to have been done. The relationship between G2 blockage and repair of DNA damage has also not been resolved. Neither has the question of whether or not DNA breaks which remain unrepaired are different in nature from the majority of repairable lesions. The data on the relative sensitivity of exponential and plateau phase cells are conflicting and their in vivo significance unclear. Well designed experiments to examine the bleomycin sensitivity of those cells in solid tumors which survive radiation treatment could help to answer this question. Evidence that the phenomenon of 'recovery from potentially lethal damage' is therapeutically-exploitable is mainly lacking. It would be of great relevance to known whether or not the effect can be observed in normal tissues. However, the evidence that the effect is not simply an artefact of clonogenic assay procedures is scanty and this possibility must be borne in mind.(ABSTRACT TRUNCATED AT 400 WORDS)

Carcinoma of the penis: analysis of 219 cases

Carcinoma of the penis is rare in this country. A total of 219 patients diagnosed to have carcinoma of the penis were analyzed retrospectively. The primary penile lesion was treated by partial amputation in 160 patients. Forty-two patients had inguinal node dissection. Forty-six patients received radiation therapy to the inguinal region. Sixty-five per cent of the patients with no palpable nodes at initial diagnosis survived for six or more years. Twenty-eight per cent of the patients with palpable nodes survived for three to five years, and 15% for six or more years. Ten per cent of the patients died of a second primary tumor.

Carcinoma of scrotum

Twelve patients with carcinoma of the scrotum were evaluated: 9 with squamous carcinoma and 3 with basal cell carcinoma. The presenting complaint was a visible skin lesion; the interval between awareness of this lesion and diagnosis averaged 3.3 years. Three of the 12 patients were black, although this disease previously has been considered rare in blacks. No occupation predominated among the patients in this series, and scrotal carcinoma today may occur as a result of nonspecific factors such as poor hygiene and chronic irritation, rather than industrial exposure. Only 5 of 12 patients were disease-free after treatment; 5 of the others died of squamous carcinoma, 1 died of a postoperative complication, and 1 was lost to follow-up. The most significant correlative with survival was stage at initial diagnosis, indicating the need for a high index of suspicion regarding lesions of the scrotum.

Bleomycin toxicity simulating metastatic nodules to the lungs

Pulmonary nodules may develop following bleomycin therapy, a previously undescribed entity that may simulate metastatic disease. Two asymptomatic patients are reported with nodules that developed following low dose bleomycin treatment for testicular tumors. One patient had previously documented pulmonary metastases that had resolved after chemotherapy. The other patient had nodular-appearing densities on routine chest examination without a history of previous metastatic lung involvement.

High-performance liquid chromatographic determination of components of bleomycin preparations

A fast and sensitive method was developed for the quantitative determination of at least 10 components of pharmaceutical bleomycin sulfate preparations. The method is based on the reversed-phase high-performance liquid chromatographic (HPLC) separation of the components on a muBondapak C18 column with a mobile phase having a linear gradient of 10--40% methanol in aqueous 0.005 M 1-pentanesulfonic acid at pH 4.3. With this assay, the average standard deviations for components A2 and B2 are 0.92 and 0.87, respectively, for a 7.5--22.5 x 10(-3)-mg sample. Regulatory agencies presently use the official Code of Federal Regulations (CFR) method, which is based on CM-Sephadex column chromatography. It was demonstrated that this CFR method does not separate the bleomycin A2 component from some other minor bleomycin components. After elution from the CM-Sephadex column, the "A2 component" was separated into five components by the HPLC method. Bleomycin A2 is stable under these HPLC conditions.

Effect of pepleomycin on peripheral lymphocytes

The blood lymphocyte population was monitored in 6 patients with advanced malignant tumors who were treated with large doses of a new cytotoxic drug termed pepleomycin. It was observed that the size of the cell population, its cellular composition, mitogen stimulations and natural killer activity did not change in any consistent ways during or after treatment. It is concluded that pepleomycin does not directly affect the lymphocytic population.

Effect of a bleomycin derivative on oral carcinoma. A clinical and immunologic study of five cases

A new bleomycin derivative NK631 was administered in five cases of advanced recurrent oral carcinoma. The visible improvement of the tumor was noted in three cases, and in the cases of lower lip carcinoma the tumor completely disappeared, however, there was no effective change in cases of cervical metastases of the floor of the mouth and tongue carcinoma. The peripheral lymphocyte counts and serum proteins disclosed a characteristic decrease, serum proteins decreased in the albumin fraction and slightly increased in alpha 2-globlin fraction. Main side effects of NK 631 were skin exanthema, alopecia, anorexia, pyrexia, fatigue and bleeding from the tumor lesion. Regarding the lung function, the vital capacity did not change, but PaO and PaCO in blood gas analysis were together observed to slightly decrease, and it may be supposed that the influence of NK631 on the lung function cannot be neglected. T-cell ratio, lymphocyte blastoformation following PHA stimulation, PPD and DNCB skin tests, and phagocytosis test of peripheral leucocytes were studied. The immuno-suppressive effect of KK631 was the same or weak as bleomycin.

Metastatic carcinoma of the penis: complete remission after high dose methotrexate chemotherapy

A case of extensive metastatic epidermoid carcinoma of the penis is reported. Disseminated disease developed after penectomy and lymphadenectomy and it continued to progress while the patient received radiation therapy. Chemotherapy with high dose methotrexate followed by citrovorum factor rescue was instituted. After completion of 10 weekly cycles of treatment there was biopsy-proved complete regression of all lesions, which lasted 9 months when the patient suddenly died of pneumonia completely unrelated to the tumor or chemotherapy treatment. This chemotherapeutic approach deserves additional trial in patients with advanced stages of penile carcinoma.

[Differences in sensitivity of T3, T7, T4 and lambda phages to bleomycin and phleomycin]

In contrast to phage lambda the phages T3, T7 and T4 are not inhibited by as much as 150 microgram bleomycin/ml, while the chemically related antibiotic phleomycin increasingly inhibits the propagation of the phages in the order T4-T3-lambda. 20 microgram phleomycin/ml inhibit T3 by 95%. The resistance against bleomycin is surprising, because 10 microgram BM/ml block completely the colony-forming capacity of the host bacterium. The drug resistance of the phage growth correlates with the weak decrease of phage DNA synthesis, while the host cell DNA synthesis ceases rapidly. In accordance with these data is the in vivo inhibition of Escherichia coli cells and the in vitro degradation of their DNA. However, a contradiction exists between the in vivo resistance of T3 and T4 and the in vitro susceptibility of their DNA against nucleolytical fragmentation by bleomycin. The mechanism of the insensitivity of T3, T7 and T4 against bleomycin is unknown.

Prolonged administration of bleomycin without clinical toxicity. Therapy with 2,700 units over four years

A 26-year-old white man with stage 4-B Hodgkin's disease resistant to conventional chemotherapy obtained complete remission with administration of bleomycin. Maintenance of this remission required continued therapy with bleomycin. The patient received a total of 2,700 units of bleomycin over a 51-month period without signs or symptoms of pulmonary toxicity. Serial studies of pulmonary function have shown a stable forced vital capacity and minimally decreased total lung volume and pulmonary diffusing capacity. This case demonstrates the ability of a patient to tolerate massive cumulative doses ob bleomycin over a protracted period without severe loss of pulmonary function.

Combination chemotherapy with bleomycin, cyclophosphamide and dactinomycin for the treatment of osteogenic sarcoma

Thirteen patients with osteogenic sarcoma were treated with multiple drug chemotherapy consisting of bleomycin, cyclophosphamide and dactinomycin. The dosage schedule used was: bleomycin 12 mg/m2/day, cyclophosphamide 600 mg/m2/day, and dactinomycin 450 microgram/m2/day. All drugs were given intravenously for two consecutive days. Treatment was repeated every 2 weeks. Toxicity included severe nausea and vomiting (managed with antiemetics and intravenous hydration) and manifestations of bone marrow depression. Of 13 patients, eight were previously treated with high dose methotrexate with citrovorum factor rescue, cyclophosphamide and Adriamycin. Of these eight, three patients had objective evidence of tumor regression (37.5%). Five of five previously untreated patients had objective evidence of tumor regression. The overall response rate in osteogenic sarcoma patients to BCD was 61.5%. The combination of BCD appears to be more active against osteogenic sarcoma than cyclophosphamide alone or Adriamycin alone. The relative safety with which BCD can be administered makes this combination a valuable adjunct to high dose methotrexate with citrovorum factor rescue and Adriamycin in the treatment of osteogenic sarcoma.

Clinical pharmacologic and therapeutic studies of bleomycin given by continuous infusion

The clinical toxicology, clinical pharmacology, and therapeutic effects of bleomycin given by continuous intravenous infusion were studied in patients with far-advanced unresectable cancer. The toxicity of bleomycin given by that schedule was qualitatively and quantitatively the same as when it was given by daily intravenous "push"; mucocutaneous toxicity occurred regularly after 7-11 days of infusion. Careful monitoring of pulmonary function revealed minor changes in Total Lung Capacity and Pulmonary Diffusion Capacity in nearly all patients; however, overt pulmonary toxicity occurred in only six patients (5%). 111Indium-labeled bleomycin was used to follow blood levels of bleomycin; it correlated well with the levels determined by microbiologic assay and could be measured at levels lower than could be determined by bioassay. Useful therapeutic responses were seen in a variety of tumors; 30% patients with very far-advanced carcinoma of the cervix demonstrated CR or PR, an incidence higher than has been seen with other regimens. Sixty-nine percent of patients with disseminated germ cell neoplasms of the testis, refractory to bleomycin given by conventional dose schedules, have attained partial remission through the continuous infusion of bleomycin.

Effect of bleomycin on peripheral lymphocytes

Five patients with carcinoma of the penis receiving radiation therapy and injections of Bleomycin were examined to determine whether Bleomycin affects the peripheral pool of lymphoid cells. Total lymphocyte counts were not decreased, but transient reduction of the frequency of thymus-dependent cells occurred in 3 patients. The responses of the lymphocytes to phytomitogens and PPD were temporarily decreased these 3 patients. In 2 subjects the phytomitogen reactivity of the lymphocytes was improved after treatment.

Cytotoxic drug-induced lung disease

Cytotoxic drugs, principally bleomycin, methotrexate and busulfan, have been associated with pulmonary toxicity. Cytotoxic drug-induced lung disease may be difficult to establish with certainty because other causes of pulmonary disease are frequently present. We discuss the clinical, roentgenographic and histologic effects of the administration of bleomycin, methotrexate, busulfan and other cytotoxic agents on the lungs and suggest that these agents may also cause pulmonary malignancies. We note the importance of careful patient monitoring and withdrawal of a demonstrated offending agent.