Measurements regarding a combined therapy concept for ophthalmic tumors consisting of brachytherapy and x-rays.

Objective.We present a novel concept to treat ophthalmic tumors which combines brachytherapy and low-energy x-ray therapy. Brachytherapy with106Ru applicators is inadequate for intraocular tumors with a height of 7 mm or more. This results from a steep dose gradient, and it is unfeasible to deliver the required dose at the tumor apex without exceeding the maximum tolerable sclera dose of usually 1000 Gy to 1500 Gy. Other modalities, such as irradiation with charged particles, may be individually contraindicated. A dose boost at the apex provided by a superficial x-ray therapy unit, performed simultaneously with the brachytherapy, results in a more homogeneous dose profile than brachytherapy alone. This avoids damage to organs at risk. The applicator may also serve as a beam stop for x-rays passing through the target volume, which reduces healthy tissue dosage. This study aims to investigate the suitability of the applicator to serve as a beam stop for the x-rays.Approach.A phantom with three detector types comprising a soft x-ray ionization chamber, radiochromic films, and a self-made scintillation detector was constructed to perform dosimetry. Measurements were performed using a conventional x-ray unit for superficial therapy to investigate the uncertainties of the phantom and the ability of the applicator to absorb x-rays. The manufacturer provided a dummy plaque to obtain x-ray dose profiles without noise from106Ru decays.Results.The phantom is generally feasible to obtain dose profiles with three different detector types. The interaction of x-rays with the silver of the applicator leads to an increased dose rate in front of the applicator. The dose rate of the x-rays is reduced by up to 90% behind a106Ru applicator. Therefore, a106Ru applicator can be used as a beam stop in combined x-ray and brachytherapy treatment.

[Accreditation in pathology. Systematic presentation and documentation of activities in pathology]. / Akkreditierung in der Pathologie. Systematische Darstellung und Dokumentation der Tätigkeiten in der Pathologie.

In the last ten years, almost 60 departments of surgical pathology were accredited in Germany according to DIN EN ISO/IEC 17020. Accreditation in pathology was accompanied by the adoption of a highly dynamic process, which requires staff to be more aware of quality and to introduce a quality-oriented system. The accreditation body in turn needed to consider all the duties, responsibilities and processes in surgical pathology and was supported in this regard by the Sector Committee of Pathology and Neuropathology of the DGA German Association for Accreditation. In this review we illustrate the various problems associated with accreditation in surgical pathology by answering eight questions that have arisen over many years of activity. These include the registration and appropriate presentation of the scope of accreditation, the terminology, as well as the extent and depth of documentation. A department of pathology applying for accreditation is required to document the entire step-wise process leading to a surgical pathological diagnosis.

[Accreditation in pathology]. / Akkreditierung in der Pathologie.

Certification and accreditation describe two different procedures. Certification confirms the conformity of a product, process or service to specified requirements. It does not demonstrate technical or diagnostic competence. Accreditation, on the other hand, is the formal recognition by a third party that a department of anatomical pathology is competent to carry out all the steps involved in tissue processing that lead to the diagnosis formulated by the pathologist. This includes the technical and diagnostic competence to produce valid diagnoses. An accredited department of anatomical pathology does not require any additional certification. In the last few years 55 departments of anatomical pathology were accredited in Germany according to DIN EN ISO/IEC 17020 including private practices, as well as departments of community hospitals and universities. In these cases, more than 150 assessments were carried out. The expertise gained during these assessments is used in the formulation of a guidance document for the interpretation of the DIN EN ISO/IEC 17020 and was written by the Sector Committee of Pathology and Neuropathology of the DAP, which comprises members of the Berufsverband Deutscher Pathologen e. V. and the Deutsche Gesellschaft für Pathologie e. V.. These accreditations have initiated a process of standardization and harmonization in anatomical pathology, which prepares German pathologists for future challenges in patient management and individualized therapy, e.g. providing clinically relevant information through the use of predictive biomarkers.

Co-cultivation of rat pneumocytes and bovine endothelial cells on a liquid-air interface.

The blood-air barrier is a most important functional element of the lung but little information is available about the cells constituting this barrier in vivo. The aim of the present study was to create an in vitro model of the blood-air barrier that would allow investigation of cellular interactions and alveolar metabolism, and would be suitable for in vitro drug screening. Rat pneumocytes and bovine microvascular endothelial cells were grown on opposite sides of microporous polycarbonate filters, as immersion, perfusion and liquid-air interface (LAI) cultures. The effects of culture conditions on cell morphology were examined by light and transmission electron microscopy. For immersion and perfusion co-cultures, both compartments were supplied with culture medium. In contrast, for liquid-air interface studies, only the endothelial cell compartment was continuously supplied with serum-free medium, whilst the type II pneumocytes were ventilated with air. The pneumocytes lost their morphological characteristics when using immersion or perfusion co-cultures. Under liquid-air interface conditions, they retained most of their characteristic morphological features when compared to the intact blood-air barrier. A subset of primary type II pneumocytes retained its differentiated phenotype, with cuboidal morphology, lamellar bodies and apical microvilli. These type II pneumocytes appeared to be connected by tight junctions to cells expressing morphological characteristics of type I pneumocytes. As shown herein, the liquid-air interface co-culture possesses many morphological characteristics of the intact blood-air barrier. In summary, this article describes the design of an artificial blood-air barrier, in which rat pneumocytes were cultivated with bovine microvascular endothelial lung cells on opposing sides of a microporous polycarbonate filter. We conclude that it might be a promising in vitro model for studies of molecular transport via the blood-air barrier, the investigation of repair mechanisms after alveolar injury, or as an in vitro screening system.

Serum albumin (SA) accumulation by bronchogenic tumours: a tracer technique may help with patient selection for SA-delivered chemotherapy.

Systemic toxicity and inadequate tumour uptake of chemotherapeutic agents limit effective therapy of disseminated malignant disease. We seek to use macromolecules for improved delivery of therapeutic agents to tumours, and hope to use radiotracer procedures to identify those malignancies able to accumulate the transport molecule. A literature search identified in vitro and animal experimental data which indicated that serum albumin is taken up in malignancies. Selected cytostatic drugs can be bound to albumin, which suggests the suitability of the molecule as a potential transport vehicle. We therefore evaluated indium-111 labelled human serum albumin (HSA) to determine the frequency of its accumulation in bronchogenic tumours. Single-photon emission tomographic (SPET) images were obtained in 23 patients 48 h after intravenous injection of 1.5 mCi 111In diethylenetriamine penta-acetic acid (DTPA)-HSA. SPET imaging with technetium-99m labelled erythrocytes was included in the protocol to assess the influence which vascularity has on the HSA-based images. All patients went on to surgery. We documented the histological diagnosis, T-stage and differentiation grade. The scintigraphic examination demonstrated HSA uptake in three squamous cell carcinomas and four adenocarcinomas. Of these, six malignancies accumulating HSA had 2.2-5.4 times, the tracer concentrations observed in comparable background regions. Small cell carcinoma failed to accumulate the labelled HSA during the 2-day scintigraphic evaluation. The HSA images did not appear to represent tumour vascularity. T-stage and differentiation grade failed to predict which tumours would demonstrate HSA uptake.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of nonvolatile macromolecules in breath. A possible diagnostic tool?

The analysis of parameters in bronchoalveolar extracellular lining secretions has come into greater use in the diagnosis of diseases of the lung and respiratory passages. The bronchoalveolar lavage (BAL) method is thus used for sampling alveolar fluids or bronchial secretions. However, this method is invasive and therefore cannot be routinely employed for probe sampling. Based on the hypothesis that aerosol particles excreted in human breath reflect the composition of the bronchoalveolar extracellular lining fluid, experiments were performed to concentrate and analyze these aerosols directly using a noninvasive technique. Human exhaled air was directed through a set of cool traps and the condensate of 200 to 400 exhalations examined for nonvolatile components, such as proteins. In experiments conducted with volunteers, the amount of proteins in the breath condensate of 8 healthy individuals (of a total of 10) amounted to between 4 micrograms and 1.4 mg. The proteins were separated by two-dimensional polyacrylamide gel electrophoresis (PAGE) and compared to saliva samples of the respective volunteers. The results suggest that the proteins detected in breath originate partially from the naso-oropharyngeal tract and partially from lower regions of the airways. In clinical tests, the exhaled air of 13 patients suffering from various diseases of the respiratory tract was sampled and analyzed by immunoassays for inflammation parameters, such as interleukin-1 beta (IL-1 beta), soluble interleukin-2 receptor protein, light chain (sIL-2R), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-alpha). In these tests, up to 370 pg IL-1 beta, 120 pg TNF-alpha, and 2,159 U sIL-2R per ml were measured in the breath condensate.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigations concerning the potential for using 1H NMR relaxometry or high-resolution spectroscopy of plasma as a screening test for malignant lung disease.

In 158 plasma samples, obtained from patients with lung carcinoma, lung metastases, and infectious or inflammatory lung diseases and from healthy controls, the NMR relaxation times T1 and T2 of water protons were measured at a resonance frequency of 20 MHz by pulsed NMR techniques and adjusted to a standardized total plasma protein concentration. For one-third of these samples water-suppressed 500-MHz 1H NMR spectroscopy at 37 degrees C was used (a) to determine the widths of the composite lipid methyl and methylene signals, and (b) to quantitate individual lipid methylene signal components that could be detected in resolution-enhanced spectra. In addition, hematological parameters and the plasma levels of several acute phase proteins and apolipoprotein-A were monitored. No diagnostically significant differences between lung carcinoma patients and patients with nonmalignant lung disease could be found for any of the plasma NMR parameters, nor could T1 or lipid linewidth data distinguish between any patient group and healthy controls. However, the mean T2 was significantly shortened by about 15% for any kind of lung disease compared to healthy controls. Similar but less significant results were found for apolipoprotein-A levels. A linear discriminant function, calculated from the apolipoprotein-A and T2 data, did not improve the differentiation between malignant and nonmalignant lung disease but did improve the discrimination between tumor patients and healthy controls up to a sensitivity and specificity of 80 and 96.5%, respectively. T2 correlates inversely with plasma fibrinogen levels and the blood sedimentation rate and, therefore, appears to monitor a general inflammatory status of a tumor patient rather than the presence or absence of cancer. For all groups except healthy pregnant women, the lipid methylene composite signal linewidth correlates inversely with the fraction of mobile triglyceride present (mainly as VLDL), as estimated from resolution-enhanced spectra.

[Immune status of patients with bronchial cancer]. / Der Immunstatus von Patienten mit Bronchialkarzinom.

The proliferation of lymphocytes, the cell-surface markers of mononuclear cells, and the capacity of T lymphocytes to bind sheep red blood cells were studied in 61 healthy volunteers and 72 patients with small-cell carcinoma, adenocarcinoma, and squamous-cell carcinoma of the lung. The mitogen-stimulated proliferation of the lymphocytes against phytohemagglutinin (PHA) was significantly reduced in patients with small-cell carcinoma. The number of T lymphocytes with T3, T4, T8, and T11 receptors was also reduced, to a degree similar to the E-rosetting rates of patients with small-cell carcinoma. The behavior of the lymphocytes of patients with either adeno- or squamous-cell carcinoma was similar to the normal persons. With regard to prognosis, we could not find significant differences between patients with "limited" and those with "extensive disease".

Alternating versus sequential chemotherapy in small cell lung cancer. A randomized German multicenter trial.

A total of 306 patients with small cell lung cancer (SCLC) were randomized to receive chemotherapy in a sequential or alternating mode. Sequential chemotherapy consisted of eight cycles of cyclophosphamide, Adriamycin (doxorubicin), and vincristine (CAV) and alternating chemotherapy consisted of three cycles (1, 3, 5) of etoposide, vindesine, and ifosfamide (EVI); three cycles (2, 4, 6) of cisplatin, Adriamycin, and vincristine (PAV); and two cycles (7, 8) of cyclophosphamide, methotrexate, and CCNU (CMC). Responsive patients received prophylactic cranial irradiation after three cycles and chest irradiation after eight cycles of chemotherapy. No maintenance therapy was applied to patients achieving complete remission. Minimum follow-up was 2 years. Of the 302 patients evaluable, overall response rate was 59% in the sequential arm and 70% in the alternating arm. Patients treated with CAV had a complete response rate of 21% in contrast to 36% for those receiving alternating therapy. The median survival for all patients was 9.8 versus 11.3 months, for limited disease 11.1 versus 13.4 months, and for extensive disease 8.9 versus 9.9 months, all in favor of the alternating treatment. Two-year survival rate for all patients was 6% versus 9%, for limited disease 11% versus 14%, and for extensive disease 3% versus 6%, all preferring the alternating treatment mode. Progression-free survival demonstrated a strong correlation to the extent of response irrespective of the treatment regimen applied. Toxicity included 11 lethal and 8 life-threatening complications with a higher frequency in the alternating treatment arm. These results suggest that alternating treatment of SCLC with different drug combinations is more effective than sequential application of CAV.

[EPICO in the treatment of small cell bronchial cancer. 3. Intermediate analysis]. / EPICO für die Behandlung des kleinzelligen Bronchialkarzinoms. 3. Zwischenanalyse.

61 patients with untreated small cell lung cancer were treated with a combination of epirubicin 70 mg/m2, cyclophosphamide 1,000 mg/m2 and oncovin 2 mg every 3 weeks. The mean age of patients was 57 years. 51 patients were evaluable. 30 patients were classified to the stage limited disease, 21 patients to extensive disease. 9 complete and 23 partial remissions were achieved (remission rate 64%). The overall survival was 14 months, the mean survival of responders 16 months. 32 patients were alive at the end of the study. Performance status and extent of disease influenced significantly the result of treatment. The cytostatic activity of EPICO is comparable to three other drug combinations. The benefit of EPICO might be the lower cumulative toxicity of epirubicin and therefore enabling a longer duration of treatment.

Inhibition of antibody synthesis and expression of T-cell membrane markers by serum factors of patients with small cell carcinoma of the lung.

Serum of patients with small cell lung cancer as well as serum fractions recovered by column chromatography inhibit the in vitro antibody synthesis in a PWM driven lymphocyte culture system and the capacity of T-lymphocytes to form rosettes with sheep erythrocytes. Utilizing an in vitro antibody synthesis system recomposed of previously separated B-cells and T-helper cells, we could show that the inhibiting high-molecular weight factors (between 40,000 to 60,000 dalton) from the patients' serum are suppressing antibody synthesis by inactivation of T-helper cell function. The mechanisms of inhibition are still unclear. The factors inhibiting E-rosette formation which are in the molecular weight range of 10,000 dalton and lower are not the same as the factors suppressing the antibody production.

Experience with ifosfamide combinations (etoposide or DDP) in non-small cell lung cancer.

In all, 171 patients with histologically verified non-small cell lung carcinoma were treated with ifosfamide 2.0 g/m2 on days 1-5 in combination with (91 patients) etoposide 120 mg/m2 on day 1. Therapeutic regimens were repeated after 4 weeks. Supportive treatment with mesna (20% of the ifosfamide doses at 0, 4, and 8 h) was performed. Cisplatin treatment was supported by mannitol-induced diuretic hydration. The overall response rate of ifosfamide/etoposide was calculated to be 27%, with 1 complete and 24 partial remissions. The median survival time for all patients was 8.5 months, for responders 14 months (P less than 0.05), for patients with no change 9.5 months, and for patients with tumor progression 4 months. With ifosfamide/cisplatin, there were 4 complete and 21 partial remissions (response rate 35%). The median survival time for all patients was 8.3 months, for responders 11.5 months, and for patients with tumor progression 4 months. Age, sex, and histological tumor type had no significant effect on survival. Patients with better performance stage and limited disease lived significantly longer. The main side-effects of the cisplatin combination were vomiting, bone marrow depression, and neuropathy. The etoposide combination was tolerated better. Urotoxicity was not significant, as a consequence of treatment with mesna. The results show that the combination ifosfamide/etoposide or ifosfamide/cisplatin are effective in the treatment of non-small cell lung cancer, being comparable to other combinations of etoposide/cisplatin and vindesine/cisplatin. Because of the better tolerability, the combination ifosfamide/etoposide is superior to cisplatin combinations.

Two randomized trials for alternating polychemotherapy of small cell lung cancer.

Patients with small cell carcinoma of the lung (SCCL) were treated in two multicenter trials with different cytostatic drug regimens including ifosfamide. In the first randomized study, including 306 patients, alternating chemotherapy with VP 16, ifosfamide, vindesine (VPIV), adriamycin, cisplatinum, vincristine (APO), and cyclophosphamide, methotrexate, CCNU (CMCC) was compared against standard treatment with ACO (adriamycin, cyclophosphamide, vincristine). It was shown that the alternating therapy resulted in a higher response rate (88% vs 78%) and a longer median survival time (11 months vs 10 months). Regarding toxicity, VPIV was similar to ACO, whereas APO and CMCC had more side-effects, leading to an increase in the number of drop-outs. In the second randomized study 144 patients were treated either with ifosfamide/VP 16 (IVP) or with cisplatinum/VP 16 (PVP). In the case of no further response, no change, or progression the induction therapy was changed to ACO. Interim analyses show that both regimens have similar therapeutic effects; but higher toxicity was observed in patients treated with cis-platinum/VP 16 than in patients treated with ifosfamide/VP 16. According to the response rate in patients treated with ACO after first-line therapy there was less cross-resistance of IVP than of PVP to ACO.

[Treatment of non-small-cell bronchial carcinoma with cisplatin, ifosfamide, vindesine and VP 16]. / Die Behandlung des nichtkleinzelligen Bronchialkarzinoms mit Cisplatin, Ifosfamid, Vindesin und VP 16.

Hitherto, the objective of chemotherapy in case of the non-small cell bronchial carcinoma is only of a palliative nature. Thus a critical indication is necessary. This is confirmed by our investigations with the combinations of cis-platinum and ifosfamide (80 patients, remission rate 35%, median survival time of patients with remission 11,5 months), cis-platinum and vindesine (29 patients, remission rate 28%, median survival time of patients with remission 14,5 months), and ifosfamide and vepeside (63 patients, remission rate 27%, median survival time of patients with remission 12 months). The combination ifosfamide-vepeside was much better tolerated by the patients and, with its comparable remission rates and survival times, was superior to the cis-platine combinations. For the chemotherapy of the non-small cell bronchial carcinoma it has to be considered that the treatment result may be more influenced by tumor stage and activity index of the patient than by the therapy method.

Thymoma. A clinicopathologic study of 98 cases with special reference to three unusual cases.

98 thymomas were assessed in respect to clinical manifestations, gross and histologic pathological findings and clinicopathologic correlations. 34% of patients were asymptomatic and thymoma was detected fortuitously. The most common presenting symptoms were related to myasthenia gravis, symptoms due to pressure on mediastinal structures were next in frequency. The symptom-diagnosis interval ranged from 0 to 120 months with a median of 4,5 months and was longer in invasive thymomas (median 6 months) than in noninvasive thymomas (median 2 months). 52% of thymomas were encapsulated and showed no cytologic atypia and were therefore classified as benign encapsulated thymomas. 26% showed gross invasion of peripheral structures and 3% were thymic carcinomas on histologic grounds. Histologically 55% of thymomas were epitheloid cell type, 17% spindle cell type and 20% mixed type thymomas. Epidermoid type thymoma occurred in 3% of the cases. 3 cases showed some unusual morphologic feature: one was localized intrapulmonal, another had an outspread like a mesothelioma, and the third was a basaloid carcinoma with unusual goblet cell metaplasia. In the three cases immunohistological methods were used as a diagnostic tool. The lectins UEA-I, PNA and HPA and an anti-keratin allowed the diagnosis of epithelioma (in 2 cases) and showed some more cellular and structural differentiations (in 1 case).

[Chemotherapy of advanced non-small cell bronchogenic carcinoma with cisplatin and vindesine]. / Chemotherapie des fortgeschrittenen nicht-kleinzelligen Bronchialkarzinoms mit Cisplatin und Vindesin.

29 patients with advanced non-small cell lung cancer were treated with cisplatin and vindesine according to the protocol of Gralla et al. 1 complete and 7 partial remissions were achieved. Because of the short observation time we cannot say anything about duration of remission and survival time of the patients. Toxicity observed during 67 cycles was severe. Because of side effects treatment had to be stopped in 10 patients. According to remission rates this protocol is comparable to other cisplatin combinations.

[Chemotherapy of the non-small cell carcinoma of the lung with ifosfamide and cisplatin]. / Chemotherapie des nicht-kleinzelligen Karzinoms der Lungen mit Ifosfamid und Cisplatin.

80 patients with inoperable non-small cell bronchial carcinoma were treated, at an interval of 4 weeks between them, with ifosfamide (2 g/m2 on days 1-5) and cisplatin (75 mg/m2, day 1). All diagnoses had been confirmed histologically. The course of 72 patients (36 with squamous carcinoma, 25 with adenocarcinoma, two with alveolar-cell carcinoma and nine with large-cell carcinoma) could be evaluated. There were four complete and 21 partial remissions (response rate 35%). In a further 14 patients temporary arrest of tumor growth was registered. Median survival time of all patients was 8.3 months, for those with complete and partial remission 11.5 months. Patients in whom the tumor progressed lived on average 3.9 months. Age and general state of the patients, as well as histological tumor type, had no influence on the results of treatment. Patients in stage IV lived, at seven months, significantly less long than those with only loco-regional spread (11 months). Main side-effects were vomiting, bone-marrow depression and neuropathy. Urotoxicity was not significant, as a result of treatment with mesna. Remission rate and survival time of these patients corresponded with the results obtained with other cisplatin combinations.

Serum ferritin in relation to the course of Hodgkin's disease.

Serum levels of patients with Hodgkin's disease were evaluated during the course of the disease. Significant correlations were seen in relation to the stage of the disease, to sex and to various hematological data. An increase of Fer levels during progression and a decrease during remission was observed. Possible pathogenetic mechanisms are discussed.