A case of merbromin (Mercurochrome) intoxication possibly resulting in aplastic anemia

A patient is described who appeared to be suffering from mercury intoxication caused by local application of merbromin to an operation wound and who developed aplastic anemia, which we ascribed to merbromin.

[Clinical reasoning and decision making in practice. A depressive foreign woman with symptoms of malaise]

A 27-year-old woman was admitted to the hospital with a depression, anaemia and fatigue. She had come from Angola to the Netherlands as a refugee 2 years before this evaluation. As an explanation for her symptoms tropical infectious diseases of parasitic origin were considered, but no clues were found in this direction. The test for trypanosomiasis was considered to be suggestive for an infection in the past (persistent titre 1:200). She was discharged but readmitted 6 months later because of a deterioration of her clinical condition. Magnetic resonance imaging showed bilateral signal abnormalities within the white matter of the brain. On examination no neurological signs or abnormalities were found. Again, no definite diagnosis could be made and the patient was discharged. Because of a further deterioration of her clinical condition she was readmitted a short time later for the third time. On the MRI the white matter lesions had increased. The serum protein electrophoresis was markedly abnormal with an elevated IgM Level. Finally, at a repeated lumbar puncture mobile trypanosomes were found. The diagnosis of 'West African sleeping sickness' was made and the patient was treated with eflornithine. She recovered completely during the next 18 months.

[High dose chemotherapy and stem cell transplant in patients with operable breast cancer and a poor prognosis; not indicated for the time being]

Early breast cancer with multiple tumour-positive axillary lymph glands is still characterised by a considerable mortality despite improvements in surgery, radiotherapy, chemotherapy and endocrine treatment. High-dose chemotherapy and bone-marrow support instead of the usual chemotherapy seemed to be a very promising approach back in the 1980s. Several phase-II studies supported this view and therefore phase-III studies were carried out. In a Cochrane review published at the start of 2003, a meta-analysis of several phase-III studies revealed that the results after high-dose chemotherapy were not significantly better than those after the usual treatment. Two large multicentre studies, one performed in the Netherlands and one in the USA, have recently been published. Neither of the two studies revealed survival differences, although one study demonstrated a significant benefit in actuarial 5-year relapse-free survival. Therefore, the routine clinical application of high-dose chemotherapy cannot be advocated yet.

Aromatase and COX-2 expression in human breast cancers

We have investigated aromatase and the inducible cyclooxygenase COX-2 expression using immunocytochemistry in tumors of a series of patients with advanced breast cancer treated with aromatase inhibitors. Aromatase was expressed in 58/102 breast cancers. This is similar to the percentage previously reported for aromatase activity. Interestingly, aromatase was expressed in a variety of cell types, including tumor, stromal, adipose, and endothelial cells. Since prostaglandin E2 is known to regulate aromatase gene expression and is the product of COX-2, an enzyme frequently overexpressed in tumors, immunocytochemistry was performed on the tissue sections using a polyclonal antibody to COX-2. Aromatase was strongly correlated (P<0.001) with COX-2 expression. These results suggest that PGE2 produced by COX-2 in the tumor may be important in stimulating estrogen synthesis in the tumor and surrounding tissue. No correlation was observed between aromatase or COX-2 expression and the response of the patients to aromatase inhibitor treatment. However, only 13 patients responded. Nine of these patients were aromatase positive. Although similar to responses in other studies, this low response rate to second line treatment suggests that tumors of most patients were no longer sensitive to the effects of estrogen. Recent clinical studies suggest that greater responses occur when aromatase inhibitors are used as first line treatment. In the intratumoral aromatase mouse model, expression of aromatase in tumors is highly correlated with increased tumor growth. First line treatment with letrozole was effective in all animals treated and was more effective than tamoxifen in suppressing tumor growth. Letrozole was also effective in tumors failing to respond to tamoxifen, consistent with clinical findings. In addition, the duration of response was significantly longer with the aromatase inhibitor than with tamoxifen, suggesting that aromatase inhibitors may offer better control of tumor growth than this antiestrogen.

Is platinum-based chemotherapy with paclitaxel effective in optimally debulked patients with advanced ovarian cancer?

OBJECTIVE

Suboptimally debulked patients with advanced ovarian cancer who are treated with a combination of cisplatin plus paclitaxel (TP therapy) have a better survival as compared to patients treated with a combination of cisplatin plus cyclophosphamide (CP therapy), but this advantage has not been demonstrated in optimally debulked patients. We performed a retrospective study to compare the effectiveness of TP therapy and CP therapy in optimally debulked patients.

STUDY DESIGN

From 1991 to 1996, 87 consecutive patients with advanced ovarian cancer treated in the University Hospital Utrecht and the St. Antonius Hospital were included in the study. Overall survival (OS) of patients treated with TP or CP were compared. Multivariable Cox-regression analysis was used to calculate a hazard rate ratio (HRR) for OS.

RESULTS

In the study period, 51 patients were treated with CP, and 36 patients were treated with TP. In the 18 patients with a tumorrest >2cm, there was a clear, but not statistically significant benefit from TP. In 69 patients with a tumorrest <or=2cm, life expectancy was not increased in patients treated with TP as compared to patients treated with CP (HRR 0.9 (95% CI 0.4-1.9)).

CONCLUSION

We could not show that ovarian cancer patients with residual disease of <or=2cm who were treated with TP had better survival as compared to patients who were treated with CP. Taking into account the high costs of treatment with TP, a randomized trial comparing the effects of TP therapy and CP therapy in optimally debulked patients is warranted.

Severe impairment of postprandial cholecystokinin release and gall-bladder emptying and high risk of gallstone formation in acromegalic patients during Sandostatin LAR

BACKGROUND

Acromegalic patients treated three times daily with subcutaneous injections of the somatostatin analogue octreotide frequently develop gallstones, due to suppressed cholecystokinin release and impaired gall-bladder emptying.

AIM

To elucidate the effects of a new long-acting octreotide formulation (Sandostatin LAR) on gall-bladder emptying, cholecystokinin release and gallstone formation.

METHODS

Postprandial gall-bladder and gastric emptying were determined by ultrasonography and cholecystokinin release was measured in seven patients on days 0, 14, 28, and 75 (Sandostatin LAR, 20 mg intramuscularly on days 1, 30, and 60).

RESULTS

During treatment, fasting gall-bladder volumes increased from 26.5 +/- 3.2 mL to 61.4 +/- 7.5 mL, but postprandial cholecystokinin release and gall-bladder emptying (from 63.9 +/- 3.8% to 12.3 +/- 3.5%) were severely suppressed. Gallstones formed in six out of seven patients within 8 months of treatment. Gastric emptying did not change during the therapy.

CONCLUSIONS

The risk of gallstone formation is greatly increased during Sandostatin LAR. This is probably related to profound suppression of cholecystokinin release and gall-bladder emptying.

Flutamide versus prednisone in patients with prostate cancer symptomatically progressing after androgen-ablative therapy: a phase III study of the European organization for research and treatment of cancer genitourinary group

PURPOSE

Time to progression (TTP), overall survival, and quality of life (QL) were compared in patients with hormone-resistant prostate cancer (HRPC) treated with prednisone (5 mg orally, four times a day) or flutamide (250 mg orally, three times a day).

PATIENTS AND METHODS

Symptomatic patients were randomized to receive either prednisone (101 patients) or flutamide (100 patients). Subjective response was assessed based on performance status, the use of analgesics, and the need to apply alternative palliative treatment. Prostate-specific antigen (PSA)-based biochemical response (>or= 50% reduction of baseline PSA) was recorded. At baseline and at 6-week intervals during follow-up, patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30.

RESULTS

There was no difference between the groups in median TTP (prednisone, 3.4 months; flutamide, 2.3 months) or overall survival (prednisone, 10.6 months; flutamide, 11.2 months). In the prednisone group, 56% of the patients experienced a subjective response, compared with 45% in the flutamide group (P: = .18). The median response duration was 4.8 months for prednisone and 4.2 months for flutamide. A biochemical response was observed in 21% and 23% of the prednisone and flutamide groups, respectively. Gastrointestinal toxicity was the reason for trial discontinuation in seven patients receiving flutamide and two patients receiving prednisone. The QL assessment parameters favored the use of prednisone with statistically significant differences in pain, fatigue, role functioning, appetite loss, gastrointestinal distress, and overall QL.

CONCLUSION

In symptomatic HRPC, treatment with prednisone or flutamide leads to similar rates of TTP and overall survival and no difference in subjective or biochemical response. The QL results favor the use of low-cost prednisone in patients with HRPC.

[Fabry disease: data from four families]

In 1988 three families were described in this journal with Fabry's disease, an X-linked recessive lysosomal storage disorder caused by the deficiency of alpha-galactosidase A. A fourth family contained four affected men of whom one was unavailable for evaluation. The other three had the same mutation in de alpha-galactosidase gene, notably Gln386Stop, leading to the change of a glutamine codon into a stop codon. Genetic investigation in one of the other families revealed the Met72Arg mutation. The classical symptoms of the disease (angiokeratomata, acroparaesthesias, hypohidrosis and lucid areas in the cornea) are frequently only recognized after a doctor's delay that may be as long as decades. The recognition of this disease is even more important now, as therapeutic possibilities are in sight.

Strongyloides stercoralis infection: how to diagnose best?

Four patients are described with a Strongyloides stercoralis infection. Several techniques to diagnose this infection are discussed. The so-called Baermann method is emphasised. Especially in chronic infections the combination of serology and the Baermann method seems the best diagnostic approach. Treatment with albendazole or ivermectin are suggested treatments.

A patient with diabetes insipidus and periorbital swellings; Erdheim-Chester disease

Erdheim-Chester disease is a rare multisystem disease in which a progressive xanthogranulomatous infiltration of several tissues can be seen. We describe a woman, known to have diabetes insipidus for ten years, with periorbital, retroperitoneal, mediastinal, axillar and inguinal involvement. On histological examination a granulomatous infiltration of fatty tissue and striated muscle was seen, consisting of Touton giant cells, histiocytes with foamy cytoplasm and lymphocytes. Immunohistochemical staining with CD-1a and S-100 was negative and on electron microscopy no Langerhans granules were seen. These findings led to the diagnosis of Erdheim-Chester disease. She had a good response on steroids. Because of some similar clinical features of Langerhans cell histiocytosis and Erdheim-Chester disease, a histiocyte disorder seems the most probable cause.

Serum and urine levels of tamoxifen and its metabolites in patients with advanced breast cancer after a loading dose and at steady-state levels

PURPOSE

To compare serum and urine levels of tamoxifen and metabolites after a loading dose and at the steady state.

METHODS

A loading dose of 160 mg of tamoxifen was given to 14 patients with advanced breast cancer. Thereafter a regular daily dose of 30 mg of tamoxifen was given. Serum and urine levels of tamoxifen and metabolites were measured by high-performance liquid chromatography and compared with levels determined in 31 patients with advanced breast cancer at the steady state at a daily dose of 30 mg of tamoxifen.

RESULTS

Serum and urine levels (24-h values) of tamoxifen and metabolites were lower (P < 0.05) after a loading dose than at the steady state. The difference was most pronounced for the metabolites, whereas the tamoxifen loading-dose level was near the steady state.

CONCLUSION

Tamoxifen steady state can be reached in 1-2 days by the administration of a loading dose of 160 mg of tamoxifen for 2 days. Tamoxifen metabolite steady-state levels are reached regularly after 4 or more weeks during application of a loading dose. Very little tamoxifen or metabolites are excreted into the urine.

[Taxoids in ovarian and breast carcinoma: the role of the medical profession and the government]

After registration in 1993/1995 of paclitaxel and docetaxel for the treatment of ovarian and mammary carcinomas, the costliness of these drugs caused Dutch hospitals to adopt different policies for their use. This prompted the Minister of Health to ask the professional group of oncological internists to draw up a guideline for the use of taxoids, following which the government decided to supply extra money for the hospitals to use according to this guideline. Meanwhile new, contradictory study results have become known, still unpublished and in part originating from studies not yet conclude. The pharmaceutical industry advocates terminating the current research and maintaining the existing indications. However, patients are entitled to unbiased, complete research findings. The pathway for introducing new expensive drugs should be as follows: the professionals determine the indications for the new drug, the government pays attention to the financial consequences. The pharmaceutical industries should have no voice in the relevant decision-making.

Inhibition of breast cancer tissue aromatase activity and estrogen concentrations by the third-generation aromatase inhibitor vorozole

In about one-third of advanced breast cancers, estrogen deprivation causes tumor regression. Estrogen concentrations in tumor tissue seem to depend largely on local production. The aromatase enzyme complex is thought to be the key enzyme in this respect. In the present study, the effect of the new third-generation nonsteroidal aromatase inhibitor vorozole (Rivizor) on tumor tissue aromatase activity and estrogen concentrations was evaluated. During 7 days preceding mastectomy, 11 postmenopausal breast cancer patients were treated with 2.5 mg of vorozole once daily. Eight patients could be evaluated. Intratumoral aromatase activity and estrone and estradiol levels were measured and compared to the values of nine untreated postmenopausal breast cancer patients. In treated patients, median tissue aromatase activity was 89% lower than that in controls (P < 0.001). Similarly, median tissue estrone and estradiol concentrations were 64 and 80% lower, respectively, in treated patients (P = 0.001 and P < 0.05, respectively). These results support the hypothesis that depleting the tumor of estrogens, thus impairing estrogenic stimulation, is an important mechanism in the antitumor activity of aromatase inhibitors.

Intravenous leiomyomatosis complicated by Budd-Chiari syndrome

A 76-year-old woman with intravenous leiomyomatosis complicated by Budd-Chiari syndrome is described.

Non-islet-cell tumour induced hypoglycaemia: a case report and review of literature

A 54-year-old man presented with a poorly differentiated adenocarcinoma of the rectum with multiple metastases to the liver. During hospitalization the patient developed periods of hypoglycaemia due to production of "big" IGF-II by the tumour. Possible pathophysiological mechanisms of non-islet-cell tumour-induced hypoglycaemia are discussed.

Primary aortoenteric fistula: report of eight new cases and review of the literature

Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.

The choriocarcinoma syndrome: an emergency

A 36-year-old male patient is described who presented with gynaecomastia, pulmonary nodules and a retroperitoneal mass in combination with a markedly elevated HCG level. A diagnosis of "choriocarcinoma syndrome" was made. Despite a clear response from the tumour to chemotherapy the patient died, at least partially due to delay in treatment. Prompt treatment even without cytological or histological proof is therefore stressed.

Milwaukee shoulder associated with primary hyperparathyroidism

We describe a 69-year-old woman with a Milwaukee shoulder syndrome in the presence of primary hyperparathyroidism. After removal of a parathyroid adenoma, effusion of the shoulder did not recur. We believe that primary hyperparathyroidism and Milwaukee shoulder can be causally related.

The determination of cyclophosphamide and its metabolites in blood plasma as stable trifluoroacetyl derivatives by electron capture chemical ionization gas chromatography/mass spectrometry

A method is described for the determination of the antitumour drug cyclophosphamide and six stable metabolites in plasma of cancer patients, namely dechloroethyl-cyclophosphamide, 4-keto-cyclophosphamide, carboxy-phosphamide, alcophosphamide, nor-nitrogen mustard and the N-chloroethyl-1,3-oxazolidine-2-one, as methyl and/or trifluoroacetyl derivatives by single ion monitoring gas chromatography/mass spectrometry, mostly in the electron capture chemical ionization mode. The isolation of most metabolites was performed by solid-phase C-18 extraction in weakly acidic medium. The phosphoramide mustard isolated under these conditions decomposes readily to the nor-nitrogen mustard during derivatization. The original nor-nitrogen mustard and the chloroethyl-1,3-oxazolidine-2-one were isolated by liquid extraction with ethyl acetate in alkaline medium. Recoveries of 75-99% were measured using spiked blank plasma samples. Quantitation of metabolites in patient plasma samples was performed using two sets of calibration curves for the concentration ranges of 1-100 ng and 0.1-10 micrograms of metabolite per millilitre of original plasma.

[ACTH-producing small-cell lung carcinoma]

Small-cell lung cancer may be accompanied by hypercortisolism due to secretion of adrenal stimulating peptides. This occurs almost exclusively in case of extensive disease. The neuroendocrine cell, from which these tumours may originate, plays an important part in the production of these peptides. Four patients are described with small-cell lung cancer and clinical presentation of hypercortisolism, particularly manifesting itself with hypokalaemia.

A randomized trial of two doses of granisetron in the treatment of chemotherapy-induced emesis. Dutch results within a multinational study

Granisetron is a new serotonin-receptor antagonist with considerable activity in preclinical models and early clinical studies against drug-induced nausea and vomiting. In a randomized, double-blind trial, two dose levels of granisetron were compared with regard to their efficacy and safety if given to patients receiving emetogenic chemotherapy with or without cisplatin. The present paper reports the Dutch experience with 125 patients included in this international trial. The two dose levels (40 and 160 micrograms/kg given once i.v. prior to chemotherapy) were equally effective in preventing acute emesis and nausea (within the first 24 h); in the group receiving cisplatin doses of 50 mg/m2 or more, 39% of patients had a complete response (no vomiting and mild nausea at most), with a complete response rate of 82% in the patients receiving moderately emetogenic chemotherapy. Sixty-three percent of patients receiving highly emetogenic chemotherapy with a complete response within 24 h lost this response during the next 6 days, as did 20% of the other patients. Headache was the most frequently reported adverse event (18%), followed by constipation (6%) and dizziness (4%). All adverse events were mild and occurred equally frequently at both dose levels. Granisetron at 40 micrograms/kg i.v. given once is effective in the prevention of acute chemotherapy-induced emesis and nausea, in particular in patients receiving moderately emetogenic therapy.

Serum elimination half-life of tamoxifen and its metabolites in patients with advanced breast cancer

In breast cancer patients discontinuing chronic tamoxifen therapy, the serum elimination of metabolites X, Y and E paralleled that of tamoxifen, whereas that of metabolite Z did not. The serum elimination of tamoxifen and metabolites X and B was increased by amino-glutethimide treatment, whereas that of metabolites Z, Y, and E was not.

Hypopituitarism following complicated child birth (Sheehan's syndrome)

We describe two patients with hypopituitarism and a history of severe bleeding or hypotensive shock at the time of child birth. Both patients had a decrease of all or some endocrine functions of the anterior pituitary. Although the frequency of Sheehan's syndrome is low in developed countries, it should still be considered in the differential diagnosis of hypopituitarism. An interval of many years between delivery and time of diagnosis does not exclude the diagnosis.

Bioavailability of cyclophosphamide in the CMF regimen

Cyclophosphamide (CY) was administered to 22 breast cancer patients treated routinely according to the CMF regimen: 75 mg/m3/d x 14 d p.o. CY, 30 mg/m2 days 1 and 8 i.v. methotrexate (MTX) and 500 mg/m2 days 1 and 8 i.v. 5-Fluorouracil (5-FU). The sequence of drug administration was always the same: 1) CY, 2) MTX; and 3) 5-FU. Capillary gas chromatography was performed for determination of CY in blood. Bioavailability (F) could be determined in 14 patients since CY was also administered intravenously in the same dose. The data of systemic exposure of oral CY in the other 8 patients were matched to those of the first 14 in whom bioavailability could be determined. Mean F was 0.85 +/- 0.22 (85% +/- 22%); in 1 patient F was 0.43 (43%). Furthermore, 3 patients treated with only p.o. CY had low estimated F values: 0.45, 0.49 and 0.50. In comparing patient characteristics with pharmacokinetic data, it was concluded that age might have a predictive value for elimination half-life t 1/2 z of i.v. CY. The youngest patients showed shortest t1/2 z and were also amongst those with the lowest F. This indication requires an extension of the study as well as monitoring of CY metabolism as a function of age. For the premenopausal patients this might be of particular importance, since this group is known to be prone to benefit from chemotherapeutic treatment according to the CMF regimen.

Pharmacokinetics of intravenous and oral cyclophosphamide in the presence of methotrexate and fluorouracil

Cyclophosphamide was administered to 12 breast cancer patients in combination with methotrexate and fluorouracil. Doses prescribed were cyclophosphamide 75 mg/m2, methotrexate 30 mg/m2 and fluorouracil 500 mg/m2 (per square meter body surface). Cyclophosphamide was administered intravenously and orally in aqueous solutions and in tablets in a randomized cross-over trial. Methotrexate and fluorouracil were administered intravenously, methotrexate was given first and then fluorouracil. Assays of cyclophosphamide in blood plasma were performed by capillary gas chromatography. Data of mean bioavailability of cyclophosphamide administered by tablets were suggestive of sufficient absorption. In 2 patients, however, a lower bioavailability of cyclophosphamide was demonstrated. Intra-individual differences in the terminal slope of the plasma decay curves after intravenous and oral administration in some patients decreased the calculated bioavailability of cyclophosphamide, if these values were included in the calculation of cyclophosphamide bioavailability. Compared with the administration of the solutions peak times, lag-times and mean absorption times of cyclophosphamide given in tablets were markedly prolonged. It is concluded that interactions between cyclophosphamide and methotrexate and/or fluorouracil after oral dosing as tablets are different from interactions observed after intravenous administration of cyclosphosphamide.

The bioavailability of Tamoplex (tamoxifen). Part 3. A steady-state study in breast cancer patients

The bioavailability of two tamoxifen preparations (Tamoplex and Nolvadex) was compared in a multiple dose two-way cross-over design in twelve breast cancer patients. The formulations were found to be bioequivalent. Mean steady-state serum levels of tamoxifen and N-desmethyltamoxifen were 133 ng/ml and 242 ng/ml, respectively, at a single daily dose of three tablets of Tamoplex 10 mg and 128 ng/ml and 248 ng/ml, respectively, at a single daily dose of three tablets of Nolvadex 10 mg. While there was a large interpatient as well as intrapatient variability in steady-state levels of tamoxifen and N-desmethyltamoxifen, their ratio appeared to be constant in the individual patient.

Variations in exposure to mitomycin C in an in vitro colony-forming assay

The effect of mitomycin C on two human ovarian cancer cell lines was measured during several exposure times and concentrations using the Human Tumour Colony-forming Assay (HTCA). Changes in exposure time and concentration resulted in considerable differences in tumour cell survival. It is concluded that several exposure times and concentrations are necessary for in vitro sensitivity testing. We suggest alternative criteria derived from pharmacokinetic data in patients instead of one-tenth of the peak plasma level which is the usual practice.

A comparison of two culture techniques: an in vitro & an in vivo tumour colony-forming assay

Twenty-one identical tumour specimens were cultured both in the Plasma-Clot Diffusion Chamber (PCDC) Technique and the Human Tumour Colony-forming Assay (HTCA). The culture results achieved in the PCDC-technique were clearly superior to the HTCA: in the PCDC the mean and median plating efficiency (PE) was 0.156 and 0.147, in the HTCA 0.103 and 0.028%; adequate growth rate in the PCDC-technique was 67% and in the HTCA 38%. Fewer cells were required for plating in the PCDC-technique: 6.4 X 10(4) vs. 2.6 X 10(5) in the HTCA. The mean and median coefficient of variation of the colony numbers in the PCDC-technique appeared much higher: 27.3 and 37.3 vs. 11.2 and 11.1% in the HTCA. The relation between the PEs obtained for the same specimen in the two techniques was compared. No positive correlation was found, which can possibly be ascribed to technical shortcomings in both techniques.

Predictive testing in cancer chemotherapy. II. In vitro

During the last thirty years several in vitro techniques have been developed to predict sensitivity of individual tumours. When the results of these techniques were correlated with the clinical response in larger groups of patients, the accuracy for predicting resistance was greater than for predicting sensitivity. Amongst the culture techniques the colony-forming assays have received much attention. Research with tumour cell lines and the sound biological basis do support this preference on other techniques. Studies on these assays have come from several independent laboratories, who report comparable results. Improvement of the culture technique and more insight into the in vitro pharmacology is needed, before application on wider scale is justified. Colony-forming culture techniques have not only been propagated for individualized chemotherapy, but also for drug screening. New antitumour agents and analogous can be screened in a short time for their sensitivity in many histologic tumour types.

Predictive testing in cancer chemotherapy. I. In vivo

Several in vivo methods have been assessed for their capacity to predict sensitivity for anticancer agents in humans. Standard strategies have been developed for screening purposes. Adjustments of these strategies are frequently suggested in reports in which the correlation between assay results and clinical therapeutic efficacy is analysed. Low predictivity and high costs of these assays are important reasons for changing the screening strategy. In vivo methods which predict the clinical response in the individual patient, are under investigation. Only the results of the subrenal capsule assay (in normal mice) have been correlated with the clinical response in a larger study. The criticism of the method and the low predictivity for sensitivity in a prospective study provide no reason for optimism. Methods which study changes predicting the clinical response in patients are still in a developmental phase.

A gas chromatographic assay for the determination of 5,6-dihydrofluorouracil and 5-fluorouracil in human plasma

A gas chromatographic assay for the determination of 5-fluorouracil (5-FU) and 5,6-dihydrofluorouracil (FDHU) is described. The selectivity and sensitivity of the method allows the determination of both 5-FU and FDHU in 200 microliters of plasma. Diphenylsuccinimide and chlorouracil were used as external and internal standard, respectively. The assay including the extraction shows a good linearity in the range 0-5000 ng/ml plasma for 5-FU as well as for FDHU. 5-FU and FDHU plasma concentrations of a number of patients with breast cancer treated with 5-FU were determined in order to demonstrate the usefulness of the method.

Pharmacokinetics of the cytostatic drugs used in the CMF-regimen

Forty-one clinical patients were studied on the first day of the first course of the CMF-regimen; administered by a fixed dosage scheme depending solely on body surface area of the patient in question. Parmacokinetic parameters were calculated for each drug: the data were analysed in conformity with the usual pharmacokinetic models. The results indicate a large pharmacokinetic variability, especially for cyclophosphamide (C). The large variability in plasma concentrations of C is presumed to be substantially attributable to the drug formula used.

Induction of chromosomal alterations as an assay for cytostatic drug activity in plasma

Information about the extent and persistence of cytostatic activity in blood plasma after administration of a cytostatic drug into the body is needed for a better evaluation of the inter-individual variations in drug metabolism and disposition. As an assay for cytotoxic activity, a test system was chosen in which Chinese hamster ovary cells (CHO) were incubated with plasma containing active metabolites of cyclophosphamide (from human patients or rats), after which the frequencies of induced sister-chromatid exchanges per cell were determined. The treatment with plasma increased the frequencies of SCEs very effectively at concentrations of metabolites that were negative in the Salmonella typhimurium back-mutation test with strain TA100. The results obtained indicate that the SCE test system offers the possibility to follow the cytotoxic activity of plasma at various time intervals after administration of cyclophosphamide.

Carcinoma of the adrenal cortex causing primary hyperaldosteronism. A case report and review of the literature

A male patient presenting with primary hyperaldosteronism after a three-year delay, was found to have an aldosterone producing adrenocortical carcinoma. Evidence is presented that aldosterone was the only steroid produced in excess. Only six other patients with adrenocortical carcinoma and isolated primary hyperaldosteronism could be traced in the literature. The relation between histology and endocrine functions of the tumor cells is discussed.

Determination of plasma concentrations of underivatized cyclophosphamide by capillary gas chromatography

A sensitive method for the clinical determination of cyclophosphamide in 0.2 ml plasma by capillary gas chromatography with nitrogen-phosphorus detection is described. A detection limit of 50 nl/ml is readily obtainable, which is sufficiently low to measure the cyclophosphamide concentrations occurring in clinical practice. The selection of internal standards and the use of the nitrogen-phosphorus detection system is discussed, as well as eventualities for determination of cyclophosphamide metabolites.

Megakaryoblastic leukaemia (acute myelofibrosis): a report of three cases

Three patients with megakaryoblastic leukaemia are described. All three presented with pancytopenia, a few blast cells in the peripheral blood and absence of overt hepatosplenomegaly. In two of them bone marrow aspiration yielded a dry tap. Histological investigation of the bone marrow indicated that the megakaryocytic cell line was the dominant proliferating lineage. Cytochemical and EM investigation supported these findings. The isomorphic isoenzyme pattern of the elevated serum lactic dehydrogenase might be of diagnostic importance. Despite chemotherapy, there was a rapidly fatal terminal leukaemic phase with high blast cell counts. The differentiation from other haematological malignancies, especially acute (aleukaemic) leukaemias and the accelerated phase of primary (chronic) myelofibrosis, is discussed. The picture appears to be identical with acute (malignant) myelofibrosis.