Oral presentation of lymphoma: case report of T-cell lymphoma masquerading as oral Crohn's disease, and review of the literature.

A 15-year-old male with labial swelling, mouth ulcers and mucosal tags is reported. While the features were clinically consistent with oral Crohn's disease the patient proved to have a fatal T-cell lymphocytic lymphoma.

Pharmacokinetics of 2,5-diaziridinyl-3,6-bis(2-hydroxyethylamino)-1,4-benzoquinone (BZG, NSC 224070) during a phase I clinical trial.

Plasma levels of 2,5-diaziridinyl-3,6-bis(2-hydroxyethylamino)-1,4-benzoquinone (BZQ, NSC 224070) were measured in nine patients after i.v. administration of the drug during a Phase I trial. Our own isocratic high performance liquid chromatographic (HPLC) method with a sensitivity of 3 ng/ml was used to quantify BZQ. Patients receiving 18-60 mg BZQ i.v. showed alpha and beta plasma decays with half-lives of 6.2 +/- 1.5 (mean +/- S.D.) and 24 +/- 4 min respectively. The apparent volume of the central compartment was 12.2 +/- 4.6 l, and the total volume of distribution was 33.6 +/- 11.3 l. The calculated plasma AUCs were linearly related to dose. A marked similarity in kinetic parameters was found for BZQ and diaziquone (AZQ, NSC 182986), another diaziridinylbenzoquinone that has recently completed phase II clinical trials.

Long-term comparison of results of a drug sensitivity assay in vitro with patient response in lymphatic neoplasms.

A short-term differential staining cytotoxicity (DiSC) assay was used to assess the sensitivity of tumor cells in vitro from patients with chronic lymphocytic leukemia (CLL) and non-Hodgkin's lymphoma to various cytotoxic drugs. The results have been correlated with drug sensitivities of the tumors in vivo. The chemosensitivity in vitro of eight patients with CLL was observed for 12 to 42 months. In 44 cases the assay correctly predicted seven sensitive and 30 resistant tumors (84% positive correlations). There were six false predictions of sensitivity and one false prediction of resistance. Repeated testing of patients receiving treatment revealed significant and progressive development of drug resistance, while serial tests on untreated patients with CLL gave unaltered results. The development of cross-resistance to structurally related drugs was observed after treatment and many samples showed a high level of cross-resistance. However, teniposide showed greater activity than etoposide, and mitoxantrone showed greater activity than the anthracyclines. The high level of agreement between laboratory and clinical results suggests that the DiSC assay may have a useful place (1) in guiding the clinician in the selection of drugs for chemotherapy and (2) in giving an added indication of prognosis for an individual with a lymphatic neoplasm.

The influence of sample source and cell concentration on the in vitro chemosensitivity of haematological tumours.

The Differential Staining Cytotoxicity (DiSC) assay has been used to study the effects of sample source and cell concentration on the in vitro chemosensitivity of haematological malignancies. The chemosensitivity of blood and bone marrow samples was significantly associated (P less than 0.001) in 12 cases where both were tested simultaneously. In 8 of the cases, where the in vitro result could be compared with clinical response, the in vitro and in vivo chemosensitivity was in agreement in 7, for both blood and bone marrow samples. The in vitro chemosensitivity of chronic lymphocytic leukaemia blood lymphocytes was dependent on the cell concentration for 4 out of 5 drugs tested. A five fold reduction in cell number resulted in a significantly greater cell kill with 4-hydroperoxycyclophosphamide, a greater cell kill (not significant) with chlorambucil and adriamycin, and a significantly lower cell kill with prednisolone. The cell concentration did not affect vincristine cytotoxicity. These results suggest that sample source is not an important consideration for the in vitro chemosensitivity of leukaemias, but that the cell concentration tested should not be varied from assay to assay if the results are to be used for comparative purposes.

Semi-micro adaptation of a 4-day differential staining cytotoxicity (DiSC) assay for determining the in-vitro chemosensitivity of haematological malignancies.

A semi-micro differential staining cytotoxicity (micro-DiSC) assay has been developed to determine the in-vitro chemosensitivity of haematological cancers. The method comprised isolation of leukocytes from blood or bone marrow, drug exposure and culture for 4 days in 1 ml tubes arranged in the microtitre format. Drug-induced tumour cell kill was determined by differential staining of live and dead cells, such that the former could be morphologically identified. Tumour cell viability was calculated by reference to an internal standard of fixed duck red blood cells. Up to 15 drugs at 5-6 concentrations each could be set up at a time in the assay within one hour of receipt of a sample, using only 10(7) viable cells. A result was obtained in 38 of 40 samples received. The assay is of potential use for the routine prediction of clinical response to cytotoxic drugs in haematological cancers and warrants wider investigation.

In vitro determination of tumour chemosensitivity in haematological malignancies.

A four-day tumour chemosensitivity assay of potential use in predicting tumour response to cytotoxic drugs has been developed for haematological cancers. The method comprised isolation of white cells from peripheral blood or bone marrow aspirates, drug exposure and incubation for 4 days. Drug-induced tumour cell kill was assessed by differential staining of live and dead cells such that the former could be morphologically identified. Tumour cell viability was subsequently calculated by reference to an internal standard of fixed duck red blood cells. Over 30 drugs have been tested in vitro, all of which have shown a dose response relationship in vitro and given a good scatter of sensitivities from patient to patient within the concentration ranges tested. In 27 cases where the in vitro chemosensitivity could be compared with the in vivo response, there were 7 true positive comparisons (sensitive in vitro and in vivo), 17 true negative comparisons (resistant both in vitro and in vivo) and 3 false positive comparisons (sensitive in vitro, resistant in vivo). A result was obtained in 38 of 50 samples received, comprising 16 of 18 chronic lymphocytic leukaemias, 11 of 20 acute lymphoblastic leukaemias, 5 of 5 acute myeloid leukaemias and 6 of 7 myelomas. The assay appears to show considerable promise as a tumour chemosensitivity test and warrants wider investigations.

Comparison of the fed and fasting states on the absorption of melphalan in multiple myeloma.

Melphalan absorption was studied over three consecutive days in five patients with multiple myeloma. On 1 day melphalan (approximately 7 mg/m2 = 10-12 mg) was administered IV, on 1 day PO fasting, and on 1 day PO after a standard breakfast. The order was different for each patient to minimise trends that might affect absorption. Melphalan concentrations were determined by high-pressure liquid chromatography and fitted to biexponential equations by computer. The parameters of these equations were in broad agreement with previously published data, and melphalan absorption varied between patients. Considerable differences were observed in the melphalan concentration curves between the 'PO fed' and 'PO fasting' days: on the PO fed days the delay before absorption started was longer (1.1 +/- 0.5 h as against 0.3 +/- 0.1 h); peak plasma levels were one-third the value (65 +/- 15 ng/ml; 195 +/- 80 ng/ml) and occurred at twice the time after administration (2.8 +/- 0.8 h; 1.3 +/- 0.3 h); and areas under the curve were smaller 10.8 +/- 4.7 min X micrograms/ml; 23.8 +/- 13.8 min X micrograms/ml). There was a significant difference between the fraction of the dose of melphalan absorbed on the PO fed day (0.49 +/- 0.20) and on the PO fasting day (0.93 +/- 0.22), with P less than 0.005. This work suggests that melphalan should be taken first thing in the morning to obtain greatest absorption.

An assessment of a short-term tumour chemosensitivity assay in chronic lymphocytic leukaemia.

A 4-day tumour sensitivity assay of potential use in predicting tumour response to cytotoxic drugs has been investigated in patients with chronic lymphocytic leukaemia. The method comprised isolation of white cells from peripheral blood, drug exposure and incubation for 4 days. Drug-induced tumour cell kill was assessed by differential staining of dead and live cells such that the latter could be morphologically identified, with subsequent calculation of tumour cell viability. Concentrations of drug for use in the assay were chosen for chlorambucil (2 micrograms ml-1), 4-hydroperoxy-cyclophosphamide (2 micrograms ml-1)--which was used in vitro in place of cyclophosphamide--prednisolone (0.5 microgram ml-1) and vincristine (0.1 microgram ml-1), to give a scatter of values which was in good agreement with clinical expectations. In 21 cases where the in vitro result could be compared with the in vivo response, there were 4 true positive comparisons (sensitive in vitro, sensitive in vivo), 15 true negative comparisons (resistant both in vitro and in vivo) and 2 false positive comparisons (sensitive in vitro, resistant in vivo). A result was obtained in 86% (65/76) of samples received. The assay appears to show considerable promise as a tumour chemosensitivity test and warrants wider investigation, including prospective in vivo/in vitro correlations that could be based on the results presented here.

Endocrine function in small cell undifferentiated carcinoma of the lung.

The endocrine status of 106 patients with undifferentiated small cell carcinoma of the lung was evaluated before treatment was begun. Almost one half of the patients had evidence of abnormal control of the secretion of adrenal cortical steroids, manifested by loss of diurnal rhythmicity or dexamethasone suppressibility. Only two had the clinical syndrome of ectopic ACTH secretion. Evidence of inappropriate secretion of vasopressin was found in 38% of the patients, most of whom also had abnormalities of corticosteroid secretory pattern. About one half of the patients had evidence of abnormal glucose tolerance, and many also had a paradoxical rise of plasma growth hormone concentration after glucose administration. The levels of the other hormones studies were normal. The pattern of hormone abnormality observed in these patients appears to be relatively specific for small cell undifferentiated carcinoma, and is different from that observed in other pulmonary tumors. Patients with abnormal control of plasma cortisol had a worse prognosis than those with normal adrenal function, largely because of decreased response rates to chemotherapy. Other endocrine abnormalities were of no prognostic significance.

Measurement of plasma melphalan at therapeutic concentrations using isocratic high-performance liquid chromatography.

A sensitive isocratic high-performance liquid chromatographic (HPLC) method for the measurement of melphalan in plasma is presented. It requires an extraction step using columns of XAD-2 resin before injecting the clarified methanol eluate directly into the HPLC system. The HPLC system uses an isocratic mobile phase containing an ion-pair reagent, and a sensitive fixed-wavelength (254 nm) monitor with a noise specification of less than 2 . 10(-5) absorbance units peak to peak. The concentration of melphalan was followed in a patient with multiple myeloma on day 1 and day 4 of a four-day course of the drug. Little difference was detected between the two curves with terminal half-lives of 71 and 68 min respectively and areas under the curve of 1.08 and 1.15 min . microgram/ml . (mg dose)-1.

The effect of alkylating agents and other drugs on the accumulation of melphalan by murine L1210 leukaemia cells in vitro.

The effect of cytotoxic and other drugs on the accumulation of melphalan by L1210 murine leukaemia cells was studied. We have confirmed that uptake is an active process competitively inhibited by L-leucine. In 36 experiments in amino acid-free medium the mean concentration of melphalan taken up was 225 pmoles/10(6) cells. High pressure liquid chromatographic analysis showed that the majority of the drug is present as free native melphalan. 1,3-Bis(2-chloroethyl)-1-nitrosourea (BCNU) was the only drug that stimulated accumulation, but without significant effect on influx or efflux rates. Busulphan, chlorambucil, cyclophosphamide, interferon, methotrexate and prednisolone had no effect on accumulation after 30 min melphalan transport. Adriamycin, CCNU, methyl CCNU, mustine and vincristine all impaired melphalan accumulation as did the non-cytotoxic drugs aminophylline, chlorpromazine and ouabain. Adriamycin, aminophylline, chloropromazine, indomethacin and ouabain all reduced melphalan influx.

Pharmacokinetics of oral and intravenous melphalan during routine treatment of multiple myeloma.

Plasma melphalan levels have been measured in nine (mostly stage IIIA) multiple myeloma patients after therapeutic doses of drug had been given p.o. and i.v. A new isocratic high-pressure liquid chromatographic (HPLC) method with a sensitivity limit o 5 ng/ml was used to quantify the melphalan. Patients receiving 8-28.5 mg melphalan i.v. showed alpha and beta plasma decays with half-lives of 7.7 +/- 3.3 (mean +/- S.D.) and 83 +/- 14 min respectively. The apparent volume of the central compartment was 12.8 +/- 4.3 1, and the total volume of distribution was 0.62 +/- 0.21 l/kg. Very variable absorption was seen in the same patients after receiving 5-12 mg melphalan p.o. The half-life of the absorption phase varied from 2.1 to 62.1 min (22.8 +/- 18.1 min) with delays (before absorption started) of 0-113 min. The fraction of dose absorbed varied from 0.32 to 1.03 (0.72 +/- 0.23), and the half-life of the beta phase was 92 +/- 27 min. The type of breakfast eaten before p.o. melphalan was found to correlate with the fraction of drug absorbed.

Combination chemotherapy for small cell carcinoma of the lung.

Sixty-one patients with proven small cell carcinoma of the bronchus were treated by a five-drug pulsed chemotherapy schedule involving cyclophosphamide, vincristine, Adriamycin, methotrexate and prednisolone, given at four-week intervals. The response rate was 60%. All patients also received radiotherapy (4000-5000 rad) to the primary lesion. Survival was identical whether radiotherapy was given first or between the second and third courses of chemotherapy. The survival of responding patients was significantly prolonged as compared both with the non-responders in this series and with a similar group of patients treated only by radiotherapy in this hospital in 1970. The poor results in patients resistant to chemotherapy reflect the fact that 88% of the patients had disseminated disease at the time of diagnosis. The survival of responding patients was not improved over that reported by others as a result of incorporating Adriamycin and prednisolone into the schedule, so there seems no justification for using them in future treatments based on this pattern of chemotherapy. It was possible to identify all responding patients within six weeks of initiating chemotherapy, and a delay of this duration did not affect the efficacy of radiotherapy. Radiotherapy, however, frequently interfered with the subsequent assessment of response to chemotherapy. It therefore seems obligatory to give chemotherapy before radiotherapy in order to determine which patients will benefit from subsequent drug treatment.

Comparison of circulating glycoprotein hormones and their subunits in patients with oat cell carcinoma of the lung and uraemic patients on chronic dialysis.

It has recently been suggested that the measurement of the glycoprotein hormones and their subunits in human serum may serve as biochemical markers of non-endocrine tumours. Using radioimmunoassays for LH, FSH, HCGbeta-, LHbeta- and the common alpha-subunit, significant differences in the levels of these substances could not be detected between patients with oat cell lung tumours and patients with chronic renal failure. However, compared to normal subjects the alpha-subunit levels in serum were elevated in 12% of the male and 30% of the female patients with oat cell carcinoma of the lund and in 80 and 50% of the male and female patients, respectively, with chronic renal failure. The LHbeta-subunit concentration was normal in all tumour patients and none of these patients had detectable (less than 4 ng/ml) levels of HCGbeta-subunit. While such measurements may be of value in relationship to particular neoplasms, it appears that raised levels of glycoproteins and their subunits may be found in other disease states.

The use of deuterated analogs in qualitative and quantitative investigations of the metabolism of cyclophosphamide (NSC-26271).

Ring-deuterated analogs of cyclophosphamide (CP) (4-d2, 5-d, 4,6-d4, and 4,5,6-d6 derivatives) have been used to study the influence of deuterium substitution on the rates of metabolic pathways involving oxidation at C-4, and on the rate of elimination of acrolein from aldophosphamide. The magnitude of the deuterium isotope effect (kH/kD) associated with appropriate C-deuteration has been related to antitumor activity against the ADJ/PC6 murine plasma cell tumor. Isotope effects of 2.2 and 1.8 respectively, for the formation of 4-ketocyclophosphamide (4-keto-CP) and carboxyphosphamide, caused little or no change in antitumor activity (4-d2 and 4,6-d4 analogs compared with CP), but an isotope effect of about 5.3 for the beta-elimination pathway, consequent on 5,5-dideuteration, was paralleled by a marked drop in potency (7-13-fold increase in ED90) of 5,5-dideuterated analogs compared with that of CP. Analogs tetradeuterated in the bis(2-chloroethyl)amino function were used to quantitate CP and 4-keto-CP in human plasma and urine using stable-isotope dilution and direct-insertion electron impact mass spectrometry. The negative optical rotation of CP recovered from human urine after administration of the racemlc drug gave evidence for stereoselectivity in the metabolism.