VAPEC-B chemotherapy in the treatment of aggressive non-Hodgkin's lymphoma: a retrospective analysis of 45 patients.

We performed a retrospective analysis on 45 patients who, between January 1989 and October 1993, received VAPEC-B chemotherapy for high and intermediate grade non-Hodgkin's lymphoma. The aim was to assess response and tolerance to treatment. The weekly regimen consisted of: doxorubicin 35 mg/m2 i.v. weeks 1,3,5,7,9,11; cyclophosphamide 350 mg/m2 i.v. weeks 1, 5, 9; etoposide 100 mg/m2 p.o. daily for 5 days, weeks 3, 7, 11; vincristine 1.4 mg/m2 i.v. (2 mg max.) weeks 2, 4, 6, 8, 10; bleomycin 10 mg/m2 i.v. weeks 2, 6, 10; methotrexate 12.5 mg i.t. weeks 1, 5, 9; prednisolone 50 mg p.o. daily for 6 weeks, reduced to 25 mg daily for 6 weeks. The patients treated were aged 22-71 years, 34 (75%) had high grade (Working Formulation) non-Hodgkin's lymphoma (NHL); 11 (24%) had intermediate grade NHL; 25 had Stage III/IV disease; and 14 (31%) had marrow involvement. The majority of patients (76%) received VAPEC-B as first line chemotherapy; the remainder received it for relapsing disease. Follow-up time from completion of VAPEC-B chemotherapy ranged from 6 months to 50 months (median 25). VAPEC-B, as first line therapy, induced a complete response (CR) and partial response (PR) in 79% and 18% respectively, whilst 3% had no response to treatment. VAPEC-B used for relapsing disease produced CR and PR in 64% and 27% respectively, whilst 9% failed to respond. Six patients in PR and five patients in CR have subsequently undergone an autologous bone marrow transplant or a peripheral blood stem cell transplant. In the group who received VAPEC-B first line but did not proceed to transplant (27 patients), five relapsed (three with CNS disease who had not had CNS prophylaxis). Tolerance to treatment was measured by WHO toxicity scores. The haemoglobin (Hb) toxicity median score for all patients was grade 1 (Hb 9.5-10.9 g/dl), and the white cell count (WCC), toxicity score was grade 2 (WCC 2.0-2.9 x 10(9)/l). No platelet toxicity was observed. Ten per cent of patients suffered grade 3 severity infections requiring antibiotics and there was one treatment related death. The majority of patients received VAPEC-B on time, however, 24% patients had a 2-week delay. VAPEC-B chemotherapy is an effective regimen for malignant lymphoma, either as a first line or as a salvage treatment. Although chemotherapy was given weekly, the tolerance to treatment was acceptable, thus making this short regimen a good alternative to CHOP chemotherapy.

Treatment of multiple subcutaneous Nocardia asteroides abscesses with ciprofloxacin and doxycycline.

We report on the successful use of oral ciprofloxacin and doxycycline in the treatment of multiple subcutaneous nocardial abscesses in an immunocompromised patient with active non-Hodgkin's lymphoma. This relatively inexpensive regimen allowed the patient to return home and was not associated with any significant side effects. The patient has shown no sign of relapse of her nocardial infection over an 8-month period on the above regimen.

Psychological response to cancer diagnosis--I. Correlations with prognostic variables.

A prospective, multidisciplinary study of 168 newly diagnosed patients with early breast cancer and Hodgkin's or non-Hodgkin's lymphoma was conducted. Psychological assessments were conducted at 3 and 12 months following diagnosis and correlated with clinical and pathological variables. There was no statistical association between psychological response to breast cancer and any other prognostic variable measured. In lymphoma patients of both groups there was evidence of greater psychiatric morbidity in those with more advanced disease and those who failed to respond to treatment. However there was also no statistical association between any cognitive response category and known prognostic variables. There was no evidence that the patient's gender or type of tumour affected their overall mental adjustment to cancer and the effect described in breast cancer may apply to all types of malignant disease.

Psychological response to cancer diagnosis--II. Evidence for coping styles (coping styles and cancer diagnosis).

One hundred and seventy-eight newly diagnosed patients with breast cancer, non-Hodgkin's or Hodgkin's lymphoma were studied with respect to their cognitive responses to cancer diagnosis. These were examined in relation to anxiety, depression and health locus of control as well as to clinical-pathological variables. Data analysis of cognitive responses alone did not confirm the existence of mutually exclusive categories of response. Analysis of cognitive responses and the other psychological variables combined, however, revealed that four broad coping 'styles' could be delineated: 'positive/confronting', 'fatalistic', 'hopeless-helpless' and 'denial/avoidance', which corresponded to our previously described categories. Lower psychological morbidity was associated with a positive/confronting response to diagnosis and with high internal locus of control, while higher anxiety and depression scores were associated with a hopeless-helpless response to diagnosis and with low internal locus of control. The evidence for coping 'styles' is discussed as well as the implications of the results for the psychological management of cancer patients.

The significance of pancytopenia in miliary tuberculosis.

Patients with miliary tuberculosis accompanied by a pancytopenia rarely survive their disease. If the peripheral blood picture does recover it has been taken as an indication that there is no underlying haematological disease, and so re-examination of the bone marrow is not performed. A case is described where resolution of the pancytopenia occurred but a persisting haematological disease remained. Aspects of haematological disease associated with tuberculosis are discussed.

A toxicity study of recombinant interferon-gamma given by intravenous infusion to patients with advanced cancer.

Eighteen patients with solid tumours were treated with human recombinant interferon-gamma at escalating dose levels starting at 1 X 10(6) units/m2 per infusion and rising through 3 X 10(6), 6 X 10(6), 9 X 10(6) and 22 X 10(6) to a maximum of 110 X 10(6) units/m2 per infusion. The IV infusions were given three times a week over a 4-week period. Side effects were seen in all patients, but were mild except at the highest dose. Acute dose-related effects included pyrexia, tiredness, thirst, chills and rigors. Chronic dose-related effects included anorexia, lethargy, weakness, disorientation, a trace of proteinuria and minimal rises in liver enzymes. In addition, effects were observed which were not related to dose. These included headache, nausea and vomiting, backache, myalgia, flatulence and a mild, transient reduction in neutrophils and erythrocytes. At the highest dose level dose-limiting toxicity was observed, consisting in severe tiredness and anorexia, hypotension, disorientation and changes on the electrocardiograph. Overall, toxicity was similar to that seen with preparations of interferon-alpha, except that no tolerance to the effects of interferon-gamma was noted. We observed less hepatic and haematological toxicity, but also recorded flatulence, handcramps and electrocardiograph changes, which have not been reported with interferon-alpha. When given according to this regimen, doses of 22 X 10(6) units/m2 per infusion of recombinant interferon-gamma were generally well tolerated by the patients.

'Numismatist's pneumonitis.' A case of acute nitrogen dioxide poisoning.

A case of acute nitrogen dioxide toxicity is described, together with its management and a review of the possible complications.

Referrals to psychiatrists in a general hospital--comparison of two methods of liaison psychiatry: preliminary communication.

Patients on a general medical ward were offered a liaison psychiatric service with 'unlimited' access, in which referrals were accepted from nurses, other paramedical staff and junior doctors in addition to senior medical staff. This new service (method II) was compared with the usual liaison service (method I, referrals initiated or approved by senior medical staff only) which was continued in parallel on a comparable general medical ward. Method II resulted in a threefold increase in referral rate and led to a significant alteration in the types of problem attracting referral. Despite the much higher rate of method II referrals, however, similar percentages of referrals by both methods were offered psychiatric follow up. The results do not support the commonly held belief that it is the failure of ward staff to recognize psychiatric morbidity which accounts for the low rate of referrals to many psychiatric liaison services.

Towards a psychobiological model of cancer: biological considerations.

The control of tissue homeostasis is extremely complex and many factors contribute to the growth and development of tumours. Although the immune system has been regarded as an essential intermediary between putative psychological factors and the development or restraint of malignant tumours, this review indicates that many other possible mechanisms also exist. Current aspects of tumour biology, immunology and hormonal control systems are reviewed, and detailed psychobiological mediating mechanisms are considered at each stage of tumour development. An approach to the future investigation of this difficult field is proposed.

Coping and cancer prognosis.

Psychological responses to a diagnosis of breast cancer, assessed three months post operatively, are related to outcome 10 yr after operation. These results confirm the findings previously reported at 5 yr. The need for further study into the nature of the reported psychological response categories and the likely mediating mechanisms is emphasized.

Emotional control and autonomic arousal in breast cancer patients.

Thirty breast cancer patients and 27 "healthy" controls were compared for differences in personality, reported emotional state and autonomic responses occurring under conditions of acute experimental stress. The data indicated that breast cancer patients were more likely than a control group to report a tendency to control emotional reactions, particularly anger, and to respond to stress using a repressive coping style. Emotional state reported at different points throughout the procedure suggested that the breast cancer group experienced more anxiety and disturbance but were more inclined to inhibit their reactions. There were no differences between the groups on autonomic measures but within the breast cancer group increased electrodermal activity was significantly associated with a tendency to respond to stress using a repressive coping style. The results are discussed in relation to psychobiological models of cancer.

Albright's syndrome associated with a soft-tissue myxoma and hypophosphataemic osteomalacia. Report of a case and review of the literature.

We report a rare case of Albright's syndrome associated with both a soft-tissue myxoma and hypophosphataemic osteomalacia. Renal tubular function was preserved, except for glycosuria. Serum levels of 1,25(OH)2 vitamin D3 were normal. Excision of the myxoma did not influence the biochemical abnormalities, nor did standard doses of vitamin D3 or 1 alpha-OH vitamin D3. The previously reported cases of hypophosphataemic osteomalacia associated with fibrous dysplasia and mesenchymal tumours are reviewed and the underlying mechanism discussed.

Tetany and osteolysis in light chain myeloma with amyloidosis.

A patient is described with light chain myeloma and amyloidosis in whom 2 unusual complications occurred, diffuse osteolytic lesions and tetany. These observations extend the previously recognized clinical spectrum of this disorder.