Contribution of Candida albicans cell wall components to recognition by and escape from murine macrophages.

The pathogenicity of the opportunistic human fungal pathogen Candida albicans depends on its ability to escape destruction by the host immune system. Using mutant strains that are defective in cell surface glycosylation, cell wall protein synthesis, and yeast-hypha morphogenesis, we have investigated three important aspects of C. albicans innate immune interactions: phagocytosis by primary macrophages and macrophage cell lines, hyphal formation within macrophage phagosomes, and the ability to escape from and kill macrophages. We show that cell wall glycosylation is critically important for the recognition and ingestion of C. albicans by macrophages. Phagocytosis was significantly reduced for mutants deficient in phosphomannan biosynthesis (mmn4Delta, pmr1Delta, and mnt3 mnt5Delta), whereas O- and N-linked mannan defects (mnt1Delta mnt2Delta and mns1Delta) were associated with increased ingestion, compared to the parent wild-type strains and genetically complemented controls. In contrast, macrophage uptake of mutants deficient in cell wall proteins such as adhesins (ece1Delta, hwp1Delta, and als3Delta) and yeast-locked mutants (clb2Delta, hgc1Delta, cph1Delta, efg1Delta, and efg1Delta cph1Delta), was similar to that observed for wild-type C. albicans. Killing of macrophages was abrogated in hypha-deficient strains, significantly reduced in all glycosylation mutants, and comparable to wild type in cell wall protein mutants. The diminished ability of glycosylation mutants to kill macrophages was not a consequence of impaired hyphal formation within macrophage phagosomes. Therefore, cell wall composition and the ability to undergo yeast-hypha morphogenesis are critical determinants of the macrophage's ability to ingest and process C. albicans.

Sacral chordoma, gas gangrene and bilateral renal cell carcinomas.

The case history is reported of a 59-year-old man with a locally symptomatic sacral chordoma. During treatment with radical radiotherapy, he developed gas gangrene, which proved rapidly fatal. At post-mortem examination there was evidence of local invasion of the rectum by the tumour and extensive gangrenous myonecrosis (gas gangrene) involving the pelvic tissues and left leg. An unexpected finding was the presence of histologically distinct bilateral renal cell carcinomas. Neither gas gangrene nor renal cell cancer has been reported previously in association with sacral chordoma.

Can long-term survival be improved in patients with small-cell lung cancer (SCLC) and good performance status? Medical Research Council Lung Cancer Working Party.

Results from a long-term follow-up suggest that in patients with limited small-cell lung cancer (SCLC) and normal performance status intensive alternating chemotherapy and radiotherapy improve long-term survival rates. In a non-randomised study, 22 patients with SCLC of limited extent and good performance status were prescribed six cycles of etoposide, doxorubicin, cisplatin and cyclophosphamide at 4 week intervals with doses of thoracic radiotherapy following the second, third and fourth cycles. Although only six patients received all their prescribed treatment, nine (41%) were alive at 1 year, seven (32%) at 2 years, six (27%) at 3 years, and four are still alive at, respectively, 42, 47, 50, and 61 months, all four being in the subgroup of eight patients with WHO performance status grade 0 at the start of treatment. In a comparison with similar patients receiving conventionally scheduled chemotherapy and radiotherapy in a concurrent trial, no difference in survival was seen in the patients with performance status grade 1 or 2, but a large difference in favour of the alternating schedule in those with grade 0 status was seen. We encourage other investigators to report the results achieved with intensive treatment in patients with WHO grade 0 performance status at the start of treatment.

An audit of Hickman catheter use in patients with solid tumours.

The purpose of this study was to analyse the use and relative complication rates of Hickman lines inserted by angiographic and surgical routes in patients with solid tumours. Sixty-one patients (median age 55 years; range 21-81) with solid tumours had 71 Hickman catheters inserted. Fifty-three patients had 58 catheters inserted angiographically and eight patients had 13 catheters inserted surgically. Indications were as follows: for administration of infusional chemotherapy (48 patients), poor venous access (nine patients), needle phobia (four patients). The catheters remained in situ for 7981 days (median 105; range 10-750). Immediate complications occurred only in angiographically placed catheters (ten pneumothoraces, one tachydysrhythmia). Pneumothorax was associated with poor nutritional status but not with age, side of insertion or catheter gauge. The median body mass indices (BMIs) were 19.65 kg/m2 and 22.8 kg/m2 in those with and without pneumothorax respectively (P = 0.0045). Five of six patients with BMI < 19 kg/m2 developed a pneumothorax, compared with five of 52 with BMI > 19 kg/m2 (P = 0.0003). The overall sepsis rate was 2.38 per 1000 catheter days. Systemic sepsis was significantly increased for surgically inserted lines (3.94 versus 0.60 per 1000 catheter days; P = 0.001), although there was no significant difference in superficial sepsis (2.36 versus 1.04 per 1000 catheter days; P = 0.22). We conclude that Hickman catheters provide safe, long-term venous access in patients with solid tumours. Angiographic insertion carries a greater risk of acute complications in patients of poor nutritional status but a significantly lower risk of late systemic infective complications.(ABSTRACT TRUNCATED AT 250 WORDS)

A glycosulphatase that removes sulphate from mucus glycoprotein.

A novel glycosulphatase has been purified from a mucus glycopeptide-degrading Prevotella from the colon. The purified enzyme removed inorganic [35S]sulphate from 35S-labelled native rat gastric mucus glycoprotein. Desulphation of mucus glycoprotein was initially rapid (19% complete after 10 min) but then plateaued, reaching only 33% after 3 h. Crude periplasmic extracts could remove 79% of the radioactivity as inorganic sulphate. These results suggest that steric hindrance may limit the access of the purified glycosulphatase to the mucus glycoprotein oligosaccharide chains in the absence of glycosidases, and/or that the enzyme may have the wrong specificity for some of the remaining sulphated sugars in the chains. The apparent molecular mass of the enzyme was 111 kDa as judged from gel exclusion chromatography, and it appeared to be composed of two identical subunits. The enzyme was localized in the periplasm of the bacterium, and using pig gastric mucus glycopeptide as a growth substrate markedly increased enzyme levels. Enzymic activity increased at the end of the growth phase. The substrate specificity of the enzyme was tested against low-molecular-mass sulphated molecules. The monosaccharides glucose 6-sulphate and N-acetylglucosamine 6-sulphate were rapidly desulphated, the latter being the major sulphated sugar in some mucus glycoproteins. Lactose 6-sulphate, galactose 6-sulphate, sulphated steroids and unsaturated disaccharide sulphate breakdown products from chondroitin sulphate were not desulphated. Glycosulphatases which can remove sulphate from mucus glycoproteins may play an important role in the degradation of highly sulphated mucus glycoproteins in the digestive tract, and could modify the effectiveness of mucus glycoproteins in mucosal protection.

Measurements of blood flow and exchanging water space in breast tumors using positron emission tomography: a rapid and noninvasive dynamic method.

A noninvasive dynamic method for the measurement of blood flow, using 15O-labeled water and positron emission tomography, has been developed and used to study 20 patients with breast carcinoma. The mean tumor flow was 29.8 +/- 17.0 (SE) ml/dl/min of tissue, while normal breast flow was 5.6 +/- 1.4 ml/dl/min of tissue. The exchanging water space of tissue known as the volume of distribution of the tracer (Vd) was also derived. This is defined as the volume of water in tissue that exchanges with a unit volume of water in arterial blood during the period of the study (7 min). The mean tumor Vd was 0.56 +/- 0.15 ml/ml while normal breast Vd was 0.14 +/- 0.05 ml/ml. The low value in normal breast is partly due to the high fat content of the tissue. The mean flow per unit of exchangeable volume was similar in tumor (52.8 +/- 22.0) and normal breast tissue (45.2 +/- 20.0). This suggests that the major discrepancy seen in measured values of flow between breast tumors and normal breast principally reflects the different composition of the two tissues. This method is rapid and suited for studying the reactivity of human tumor vasculature, so extending studies are being performed on animal tumors.

A Medical Research Council phase II trial of alternating chemotherapy and radiotherapy in small-cell lung cancer. The Medical Research Council Lung Cancer Working Party.

In a non-randomised study in six centres in the UK, 24 patients with previously untreated small-cell lung cancer of limited extent were treated with a regimen of alternating chemotherapy and radiotherapy to assess response, toxicity, and the feasibility of applying such a regimen on a multicentre basis in the UK. The intention was to give six courses of chemotherapy on five consecutive days at 4-week intervals: etoposide 75 mg m-2 on days 1, 2, and 3; doxorubicin 40 mg m-2 on day 1; cisplatin 100 mg m-2 on day 2; and cyclophosphamide 300 mg m-2 on days 2, 3, 4 and 5. A dose of 20 Gy thoracic radiotherapy was to be given following the 2nd and the 3rd courses, and one of 15 Gy following the 4th course. After 12 patients had been admitted, the cisplatin dosage was reduced to 80 mg m-2 because of unacceptable toxicity. Two patients were withdrawn during treatment on review of their histology because their diagnosis was found to be incorrect. Only one patient of the 12 treated with cisplatin 100 mg m-2 was able to complete treatment, compared with five of the eligible ten given the lower dosage. Among the 22 patients with confirmed small-cell disease, a complete response was reported in 14 (64%) and a partial response in a further three (total response rate 77%). Myelosuppression was the commonest serious adverse effect. It occurred in 19 of the 24 patients and gave rise to septicaemia in five, four of whom were receiving the higher cisplatin dose. Sixteen patients required blood transfusion and ten platelet transfusion. Vomiting, oesophagitis, and peripheral neuropathy occurred in 12, four and four patients, respectively, and radiation pneumonitis developed in two. Treatment was considered a contributory cause of death in four. The working party concluded that the alternating regimen was feasible in only a small proportion of centres in the UK, and decided not to embark on a multicentre randomised trial comparing alternating with conventional scheduling.

Antibody guided diagnosis and therapy of brain gliomas using radiolabeled monoclonal antibodies against epidermal growth factor receptor and placental alkaline phosphatase.

Twenty-seven patients with brain glioma were scanned using 123I-labeled monoclonal antibodies against epidermal growth factor receptor (EGFR1) or placental alkaline phosphatase (H17E2). Successful localization was achieved in 18 out of 27 patients. Eleven out of 27 patients were also studied using a nonspecific control antibody (11.4.1) of the same immunoglobulin subclass and observable tumor localization was also achieved in five patients. The specificity of targeting was assessed by comparing images obtained with specific and nonspecific antibodies and by examining tumor and normal tissue biopsies after dual antibody administration. Ten patients with recurrent grade III or IV glioma who showed good localization of radiolabeled antibody were treated with 40-140 mCi of 131I-labeled antibody delivered to the tumor area intravenously (n = 5) or by infusion into the internal carotid artery (n = 5). Six patients showed clinical improvement lasting from 6 mo to 3 yr. One patient continues in remission (3 yr after therapy), but the other five who responded initially relapsed 6-9 mo after therapy and died. No major toxicity was attributable to antibody-guided irradiation. Targeted irradiation by monoclonal antibody may be clinically useful and should be explored further in the treatment of brain gliomas resistant to conventional forms of treatment.

Parotid metastases from carcinoma of the breast.

Two patients are described in whom a parotid metastasis occurred 10 years after initial treatment for carcinoma of the breast. The parotid is a very unusual site of metastasis and in both patients it was only one detectable. Parotidectomy with post-operative radiotherapy is advocated in this situation not only to obtain local tumour control but to exclude a primary parotid tumour.

Treatment of colorectal cancer and other malignancies with continuous infusion of 5-fluorouracil.

Twenty-six consecutive patients with gastrointestinal and other epithelial origin neoplasms were treated with continuous intravenous infusion of 5-Fluorouracil using a portable pump. Out of twenty-four evaluable patients, four achieved complete remission, four a partial response while in twelve patients the disease remained stable. The overall response rate was 33%. Twenty out of the 24 patients achieved significant improvement in their performance status and quality of life. The median survival was 9.5 months. The two more frequently observed toxicities were stomatitis (19.5%) and hand-foot syndrome (15.3%). Our study shows that long-term continuous infusion of 5-Fluorouracil is of palliative value in patients with gastrointestinal and other neoplasma of epithelial origin. The use of portable pumps makes this a practical and cost effective outpatient form of treatment.

High dose chemotherapy with autologous bone marrow rescue in small cell lung cancer.

Twenty five patients diagnosed as having small cell lung cancer (SCLC) were treated with etoposide and cisplatinum. After assessment for tumour response, autologous bone marrow (ABM) was collected from five patients in good clinical state who had shown a partial response (PR) and no bone marrow involvement with tumour. These patients were treated with high dose cisplatinum, etoposide and melphalan and then by ABM infusion. Although all patients (3 with extensive and 2 with limited disease) responded (4 CR and 1 PR), 3 patients with extensive disease relapsed and died of their disease. One patient with limited disease died of infection while pancytopaenic; one patient is alive but has relapsed at eighteen months. Although patient numbers are small, our data support the conclusion that high dose chemotherapy and autologous bone marrow rescue has a very small role or none at all in the management of patients with extensive or limited stage SCLC.

Antibody guided targeting of non-small cell lung cancer using 111In-labeled HMFG1 F(ab')2 fragments.

Immunoscintigraphy using F(ab')2 fragments of tumor-associated monoclonal antibody HMFG1 was performed in 14 patients with primary and metastatic non-small cell carcinoma of lung cancer. The antibody was conjugated with diethylenetriamine pentaacetic acid and labeled with 111In. Quality control studies showed efficient incorporation of 111In onto antibody (5 mCi/mg), no significant loss of immunoreactivity, and in vitro and in vivo stability. The optimal time for imaging was between 48 and 72 h. Following i.v. administration, serum activity fell rapidly (t1/2a = 2.5 +/- 1.3 (SD) h; t1/2b = 42 +/- 4.5 h). The majority of the radioactivity was associated with the plasma and not with the blood cells. All patients had a significant concentration of 111In in the liver (approximately 20% of the injected dose, 48 h postadministration). No toxicity was encountered. No human antimurine-IgG antibody was detected in any of the patients within 4 months of follow-up, even in patients receiving two administrations of F(ab')2 fragments. Localization of all primary lesions and the majority (80%) of metastatic lesions was achieved. Seven of 14 patients were also studied using a 111In-labeled nonspecific antibody (Fab')2 fragment (4C4). In three patients the specificity index was higher than the other four (P less than 0.05). We conclude that although successful targeting of 111In-labeled (Fab')2 fragments of HMFG1 can be achieved in patients with non-small cell carcinoma of lung, observable tumor localization can also be achieved using a nonspecific antibody. Based on these findings, we recommend that in order to demonstrate specific radioimmunolocalization, patients with lung and possibly other tumor types should be studied using both specific and nonspecific antibodies.

Antibody-guided irradiation of advanced ovarian cancer with intraperitoneally administered radiolabeled monoclonal antibodies.

Twenty-four patients with persistent epithelial ovarian cancer after chemotherapy with or without external beam irradiation, were treated with intraperitoneally administered 131I-labeled monoclonal antibodies HMFG1, HMFG2, AUA1, H17E2, directed against tumor-associated antigens. Acute side effects were mild abdominal pain, pyrexia, diarrhea, and moderate reversible pancytopenia. One patient developed a subphrenic abscess requiring surgical drainage. Eight patients with large volume disease, ie, greater than 2 cm tumor diameter, did not respond to antibody-guided irradiation and died of progressive disease within 9 months of treatment. Sixteen patients had small-volume (less than 2 cm) disease at the time of treatment with radiolabeled antibody. Seven patients failed to respond, and of nine initial responders, four patients remain alive and free from disease 6 months to 3 years from treatment. Analysis of the data on relapse indicated that doses greater than 140 mCi were more effective than lower doses. We conclude that the intraperitoneal administration of 140 mCi or more of 131I-labeled tumor-associated monoclonal antibodies represents a new and potentially effective form of therapy for patients with small-volume stage III ovarian cancer.

Absence of irradiation induced ischaemic temporal lobe damage in patients with pituitary tumours.

This study was undertaken to confirm the belief that modern day external beam radiotherapy for patients with pituitary tumours should not be associated with any ischaemic temporal lobe damage. Using the oxygen-15 steady state inhalation technique and positron emission tomography regional temporal lobe blood flow, oxygen extraction fraction and oxygen utilisation were measured in 10 normal volunteers and 11 patients with pituitary tumours treated by irradiation. The patients were studied between 1 and 10.9 years after radiotherapy. We found that temporal lobe oxygen utilisation in the irradiated group (mean 2.11 +/- 0.23 ml of O2/100 ml tissue/min) did not differ from the normal group (mean 2.13 +/- 0.26 ml of O2/100 ml tissue/min). This suggests that total doses of between 35 and 56 Gy, delivered in fractions of less than 2 Gy, can be given to a pituitary tumour without demonstrable damage to normal temporal lobe.

Dexamethasone treatment of brain tumor patients: effects on regional cerebral blood flow, blood volume, and oxygen utilization.

Regional values for cerebral blood flow, blood volume, oxygen extraction fraction, and oxygen utilization were measured, using PET, in 10 brain tumor patients before and after treatment with dexamethasone. Dexamethasone treatment decreased cerebral blood flow and blood volume and increased the fractional extraction of oxygen throughout the brain without affecting oxygen utilization. Dexamethasone probably causes direct vasoconstriction of cerebral blood vessels.

Antibody guided irradiation of brain glioma by arterial infusion of radioactive monoclonal antibody against epidermal growth factor receptor and blood group A antigen.

In a patient with recurrent grade IV glioma of the brain resistant to conventional treatment an antibody guided isotopic scan showed uptake by the tumour of a monoclonal antibody (9A) that was developed against epidermal growth factor receptor but cross reacted with blood group A antigen. As a therapeutic attempt antibody labelled with 1665 MBq (45.0 mCi) iodine-131 was delivered to the tumour area by infusion into the internal carotid artery. Computed tomography showed regression of the tumour after treatment, and an appreciable and sustained clinical improvement was noted without any toxicity. Delivery of irradiation guided by monoclonal antibody delivered by arterial infusion of the tumour area may be of clinical value in the treatment of brain gliomas resistant to conventional forms of treatment.

Positron emission tomography for in-vivo measurement of regional blood flow, oxygen utilisation, and blood volume in patients with breast carcinoma.

Regional blood flow, oxygen extraction ratio, and oxygen utilisation were measured in nine patients with breast carcinoma by means of the oxygen-15 steady-state inhalation technique and positron emission tomography. Regional blood volume was measured by means of tracer amounts of carbon-11-labelled carbon monoxide. The regional blood flow was consistently higher in non-necrotic tumour tissue than in surrounding normal breast tissue or contralateral normal breast. Oxygen utilisation was slightly higher in the tumour. The regional oxygen extraction ratio (ie, the fraction of oxygen extracted from the nutritional blood supply) was appreciably lower in the tumour than in normal breast tissue. These findings suggest that there is, at least on a macroscopic level, no supply-limited impairment of respiration in human breast cancer.

NMR imaging of central nervous system diseases before and after radiotherapy.

Two brain tumors, a foramen magnum tumor and an arterio-venous malformation (AVM) were treated with radiation but without chemotherapy or surgical removal. These cases were monitored by NMR imaging for a period of 16 months after radiotherapy to detect the response of the tumors and brain tissue to radiation. The T1 and T2 of the tumors behaved independently. T1 decreased after radiation related to clinical improvement. T2 did not change to the same degree as T1. An increased T2 area around the tumors and along the lateral ventricle developed about six months in one case and 16 months in the other case after radiotherapy, without associated clinical change in either case.

Measurement of regional cerebral blood flow and oxygen utilisation in patients with cerebral tumours using 15O and positron emission tomography: analytical techniques and preliminary results.

Regional cerebral blood flow and oxygen utilisation have been studied in 8 patients with brain tumours using continuous inhalation of C15O2 and 15O2 and positron emission tomography. The methods used to analyse the regional cerebral pathophysiology are presented. A relative uncoupling between oxygen consumption and blood flow was observed in all tumours as indicated by a decreased regional fractional extraction of oxygen (rOER). This suggest that a major proportion of these tumours had sufficient blood supply to meet oxygen metabolic demand. A decrease of blood flow in grey matter was found both in the affected and contralateral hemispheres of the brain. Matched reductions of flow and oxygen utilisation were observed in oedematous tissue.

Improvement in regional ventilation and perfusion after radiotherapy for unresectable carcinoma of the bronchus.

Ventilation/perfusion scans were obtained in 45 patients with unresectable carcinoma of the bronchus. Of these 45 patients, 35 were reinvestigated shortly after radiotherapy and 17 of them had additional later follow-up studies. Both ventilation and perfusion were always abnormal in the lung affected by the tumor; perfusion was usually more impaired than ventilation. These abnormalities were difficult to detect or to evaluate from the standard chest radiograph. After radiotherapy, ventilation improved in 83% and perfusion in 86% of the patients. This improvement was associated with amelioration of breathlessness, which improved in 74% of the patients. Slow but progressive deterioration of regional ventilation and perfusion were subsequently observed. This was often associated with the development of radiation fibrosis. Spirometric measurements (VC, FEV1) were moderately imparied at the initial assessment (83% and 66% of predicted, respectively), probably due to coexisting chronic airway obstruction, and did not show significant changes after radiotherapy or during the follow-up. Radionuclide studies of regional perfusion and ventilation proved more sensitive and more specific than tests of overall lung function for the functional assessment and follow-up of patients with unresectable carcinoma of the bronchus.