Lithotripter shock wave interaction with a bubble near various biomaterials.

Following previous work on the dynamics of an oscillating bubble near a bio-material (Ohl et al 2009 Phys. Med. Biol. 54 6313-36) and the interaction of a bubble with a shockwave (Klaseboer et al 2007 J. Fluid Mech. 593 33-56), the present work concerns the interaction of a gas bubble with a traveling shock wave (such as from a lithotripter) in the vicinity of bio-materials such as fat, skin, muscle, cornea, cartilage, and bone. The bubble is situated in water (to represent a water-like biofluid). The bubble collapses are not spherically symmetric, but tend to feature a high speed jet. A few simulations are performed and compared with available experimental observations from Sankin and Zhong (2006 Phys. Rev. E 74 046304). The collapses of cavitation bubbles (created by laser in the experiment) near an elastic membrane when hit by a lithotripter shock wave are correctly captured by the simulation. This is followed by a more systematic study of the effects involved concerning shockwave bubble biomaterial interactions. If a subsequent rarefaction wave hits the collapsed bubble, it will re-expand to a very large size straining the bio-materials nearby before collapsing once again. It is noted that, for hard bio-material like bone, reflection of the shock wave at the bone-water interface can affect the bubble dynamics. Also the initial size of the bubble has a significant effect. Large bubbles (∼1 mm) will split into smaller bubbles, while small bubbles collapse with a high speed jet in the travel direction of the shock wave. The numerical model offers a computationally efficient way of understanding the complex phenomena involving the interplay of a bubble, a shock wave, and a nearby bio-material.

Chaetoglobosin A preferentially induces apoptosis in chronic lymphocytic leukemia cells by targeting the cytoskeleton.

Chronic lymphocytic leukemia (CLL) is an incurable malignancy of mature B cells. One of the major challenges in treatment of CLL is the achievement of a complete remission to prevent relapse of disease originating from cells within lymphoid tissues and subsequent chemoresistance. In search for novel drugs that target CLL cells in protective microenvironments, we performed a fungal extract screen using cocultures of primary CLL cells with bone marrow-derived stromal cells. A secondary metabolite produced by Penicillium aquamarinium was identified as Chaetoglobosin A (ChA), a member of the cytochalasan family that showed preferential induction of apoptosis in CLL cells, even under culture conditions that mimic lymphoid tissues. In vitro testing of 89 CLL cases revealed effective targeting of CLL cells by ChA, independent of bad prognosis characteristics, like 17p deletion or TP53 mutation. To provide insight into its mechanism of action, we showed that ChA targets filamentous actin in CLL cells and thereby induces cell-cycle arrest and inhibits membrane ruffling and cell migration. Our data further revealed that ChA prevents CLL cell activation and sensitizes them for treatment with PI3K and BTK inhibitors, suggesting this compound as a novel potential drug for CLL.

A low-voltage spark-discharge method for generation of consistent oscillating bubbles.

Underwater spark-discharge methods have been widely utilized for experimental studies in many fields such as material processing, water treatment, and cavitation bubble dynamics. However, the precise control of bubble size using this method has been difficult. This poses challenges to better understand the complex interactions of non-spherical cavitation bubble growth and collapse, which require fine and careful control of bubble size. A novel low-voltage (60.0 V) underwater spark-discharge method using a metal-oxide-semiconductor field effect transistor is presented here. We are able to repeatedly generate oscillating bubbles of consistent maximum radius, a. The dependency of the total circuit resistance to spark-generated bubble size in this method is discussed.

Interaction of a spark-generated bubble with a rubber beam: numerical and experimental study.

In this paper, the physical behaviors of the interaction between a spark-generated bubble and a rubber beam are studied. Both numerical and experimental approaches are employed to investigate the bubble collapse near the rubber beam (which acts as a flexible boundary) and the corresponding large deformation of the beam. Good agreement between the numerical simulations and experimental observations is achieved. The analysis reveals that the ratio of the bubble-beam distance to the maximum bubble radius influences the bubble evolution (from expansion to collapse) and the beam deformation. The stiffness of the beam plays an important role in the elastic beam response to bubble expansion and collapse. The effect of the vapor pressure on both bubble collapses and beam deflections is also examined. The results from this paper may provide physical insight into the complex physics of the bubble-rubber interaction. The understanding is possibly applicable in biomedicine for drug delivery to tissue, which is a soft material. It is also probably useful in the marine industry where ultrasonic bubbles are generated for the defouling of ship surfaces, which has been coated with an elastic material. There is also potential interest in underwater explosions near elastic structures.

Procurement regimens to reduce ischemia reperfusion injury of vascular grafts.

BACKGROUND: Ischemia reperfusion injury is an important nonimmunological factor contributing to the development of chronic rejection. The aim of this study was to compare different cell culture media in terms of vascular lesion formation after ischemia reperfusion injury. METHODS: BALB/c aortic grafts were incubated in different cell media (endothelial cell growth, ECG, RPMI-1640 and Waymouth/Ham's F12) for various time spans (5, 6.5 and 8.5 h) at 37°C and implanted into syngeneic BALB/c recipients. On day 30 after implantation, histology, immunofluorescence and morphometric measurements were performed. RESULTS: A total of 36 transplants were performed for this study with an overall survival rate of 72.2%. The most frequent complication was thrombosis of the aortic graft (n = 9) and there was one late death due to other courses. All the recipients with vascular grafts incubated in the ECG medium survived and showed no signs of intimal proliferation independent of the time of ischemia. Aortic grafts incubated in the RPMI medium resulted in a reduced recipient survival rate of 66.7% and grafts incubated in the Waymouth medium showed only a 50% survival by day 30. Analysis of the vascular morphology revealed moderate amounts of intimal proliferation within two aortic grafts in this group. CD31 staining revealed superior endothelial cell integrity after incubation with the ECG medium. CONCLUSIONS: Data from the current study suggest that under optimized conditions vascular grafts can be safely kept in tissue culture up to 8.5 h without significant ischemic damage. Differences in vascular integrity and animal survival depended mostly on the respective tissue culture medium used for the storage of the vessel.

Human cytomegalovirus infection leads to elevated levels of transplant arteriosclerosis in a humanized mouse aortic xenograft model.

Recent findings emphasized an important role of human cytomegalovirus (HCMV) infection in the development of transplant arteriosclerosis. Therefore, the aim of this study was to develop a human peripheral blood lymphocyte (hu-PBL)/Rag-2(-/-) γc(-/-) mouse-xenograft-model to investigate both immunological as well as viral effector mechanisms in the progression of transplant arteriosclerosis. For this, sidebranches from the internal mammary artery were recovered during coronary artery bypass graft surgery, tissue-typed and infected with HCMV. Then, size-matched sidebranches were implanted into the infrarenal aorta of Rag-2(-/-) γc(-/-) mice. The animals were reconstituted with human peripheral blood mononuclear cells (PBMCs) 7 days after transplantation. HCMV-infection was confirmed by Taqman-PCR and immunofluorescence analyses. Arterial grafts were analyzed by histology on day 40 after transplantation. PBMC-reconstituted Rag-2(-/-) γc(-/-) animals showed splenic chimerism levels ranging from 1-16% human cells. After reconstitution, Rag-2(-/-) γc(-/-) mice developed human leukocyte infiltrates in their grafts and vascular lesions that were significantly elevated after infection. Cellular infiltration revealed significantly increased ICAM-1 and PDGF-R-ß expression after HCMV-infection of the graft. Arterial grafts from unreconstituted Rag-2(-/-) γc(-/-) recipients showed no vascular lesions. These data demonstrate a causative relationship between HCMV-infection as an isolated risk factor and the development of transplant-arteriosclerosis in a humanized mouse arterial-transplant-model possibly by elevated ICAM-1 and PDGF-R-ß expression.

Scaling law for bubbles induced by different external sources: theoretical and experimental study.

The scaling relations for bubbles induced by different external sources are investigated based on a modified Rayleigh model and experimental observations. The equations derived from the modified Rayleigh model are presented to describe the collapse of bubbles induced by the different external sources such as electrical spark, laser, and underwater explosion. A scaling law is then formulated to establish the scaling relations between the different types of bubbles. The scaling law reveals the fact that the characteristic length scale factor differs from the characteristic time scale factor for the different types of bubbles. It is then validated by our experimental observations of the spark- and laser-generated bubbles as well as the bubbles induced by underwater explosions from previous published reports. With the present scaling law, studies on spark- or laser-generated bubbles as well as their applications (for example, in industrial or biomedical related applications) can benefit from the experiences and information built up over the years in underwater explosion bubbles. Conversely, it is possible to substitute a spark- or laser-generated bubble for an underwater explosion bubble in the study of a large-scale and complex physical problem.

Characterizing bubble dynamics created by high-intensity focused ultrasound for the delivery of antibacterial nanoparticles into a dental hard tissue.

Hig hintensity focused ultrasound (HIFU) has been applied for drug delivery in various disease conditions. Delivery of antibacterial-nanoparticles into dental hard tissues may open up new avenues in the treatment of dental infections. However, the basic mechanism of bubble dynamics, its characterization, and working parameters for effective delivery of nanoparticles, warrants further understanding. This study was conducted to highlight the basic concept of HIFU and the associated bubble dynamics for the delivery of nanoparticles. Characterization experiments to deliver micro-scale particles into simulated tubular channels, activity of ultrasonic bubbles, and pressure measurement inside the HIFU system were conducted. Subsequently, experiments were carried out to test the ability of HIFU to deliver nanoparticles into human dentine using field emission scanning electron micrographs (FESEM) and elemental dispersive X-ray analysis (EDX). The characterization experiments showed that the bubbles collapsing at the opening of tubular channels were able to propel particles along their whole length. The pressure measured showed sufficient negative and positive pressure suggesting that the bubble grew to a certain size before collapsing, thus enabling the particles to be pushed. The FESEM and EDX analysis highlighted the ability of HIFU to deliver nanoparticles deep within the dentinal tubules. This study highlighted the characteristics and the mechanism involved of the bubbles generated by the HIFU and their capability to deliver nanoparticles.

The dynamics of a non-equilibrium bubble near bio-materials.

In many medical treatments oscillating (non-equilibrium) bubbles appear. They can be the result of high-intensity-focused ultrasound, laser treatments or shock wave lithotripsy for example. The physics of such oscillating bubbles is often not very well understood. This is especially so if the bubbles are oscillating near (soft) bio-materials. It is well known that bubbles oscillating near (hard) materials have a tendency to form a high speed jet directed towards the material during the collapse phase of the bubble. It is equally well studied that bubbles near a free interface (air) tend to collapse with a jet directed away from this interface. If the interface is neither 'free' nor 'hard', such as often occurs in bio-materials, the resulting flow physics can be very complex. Yet, in many bio-applications, it is crucial to know in which direction the jet will go (if there is a jet at all). Some applications require a jet towards the tissue, for example to destroy it. For other applications, damage due to impacting jets is to be prevented at all cost. This paper tries to address some of the physics involved in these treatments by using a numerical method, the boundary element method (BEM), to study the dynamics of such bubbles near several bio-materials. In the present work, the behaviour of a bubble placed in a water-like medium near various bio-materials (modelled as elastic fluids) is investigated. It is found that its behaviour depends on the material properties (Young's modulus, Poisson ratio and density) of the bio-material. For soft bio-materials (fat, skin, brain and muscle), the bubble tends to split into smaller bubbles. In certain cases, the resulting bubbles develop opposing jets. For hard bio-materials (cornea, cartilage and bone), the bubble collapses towards the interface with high speed jets (between 100 and about 250 m s(-1)). A summary graph is provided identifying the combined effects of the dimensionless elasticity (kappa) and density ratio (alpha) of the elastic materials which will result in a nearby oscillating bubble jetting towards, splitting or jetting away from the elastic material interface. Since the phenomenon of a bubble jetting away from an elastic material as it collapses has not been reported before in the literature, experiments were performed to validate the numerical observation. A bubble is created in a heavy fluid (hydrofluoroether (HFE)) using a laser pulse. The bubble collapses near the elastic material polydimethylsiloxane (PDMS). The experimental results obtained are compared with the corresponding simulation. The simulation provides spatial and temporal details about the bubble dynamics beyond experimental limits and can therefore be considered as a very useful tool to get a better understanding of the physics involved.

BCMSUN, a candidate gene for B-cell chronic lymphocytic leukemia and mantle-cell lymphoma, has an independently expressed homolog on 1p22-p31, BCMSUN-like.

The most frequent chromosomal imbalance in B-cell chronic lymphocytic leukemia (B-CLL) and mantle-cell lymphoma (MCL) is loss of material from 13q14.3. BCMSUN (previously Leu2, t4, cDNA 1B4) is one of 3 proposed candidate genes isolated from the minimally deleted region. We identified a homolog of BCMSUN, termed BCMSUNL (for BCMSUN-like). Radiation-hybrid mapping with a PCR-amplified fragment and fluorescence in situ hybridization with 2 PAC clones containing coding information for BCMSUNL revealed its localization at 1p22-p31. Interphase fluorescence in situ hybridization, however, revealed that the BCMSUNL gene locus is not part of the critical deletion region of 1p22 in MCLs. Analysis of DNA sequences derived from the respective PAC clones and available in public databases uncovered an intronless structure of BCMSUNL. Compared to BCMSUN, the new gene lacks exon 2 and shows 90.3% homology on the nucleic acid level. Both genes are expressed in peripheral blood lymphocytes from healthy donors as well as B-CLL and MCL tumors, with retention of genetic material at 13q14.3. Therefore, analysis of the candidate tumor-suppressor gene BCMSUN at 13q14.3 must be based on assays that distinguish between the 2 homologous genes.

Detection of chromosomal imbalances in leiomyosarcoma by comparative genomic hybridization and interphase cytogenetics.

Leiomyosarcomas comprise a group of malignant soft-tissue tumors with smooth-muscle differentiation. In this study, 14 cases of leiomyosarcoma were screened for changes in relative chromosome copy number by comparative genomic hybridization. A high number of imbalances (mean, 16.3; range, 6-26) was detected, with chromosomal gains occurring about twice as much as losses. The most frequent gains were found in 5p15, 8q24, 15q25-->q26, 17p, and Xp (43% to 50%), whereas the most frequent losses were found in 10q and 13q (50% and 78%, respectively). Twenty high-level amplifications affecting 15 different chromosomal subregions were detected in nine different tumors. In three leiomyosarcomas, sequences on chromosome arm 17p were found to be highly amplified, with a minimal overlapping region on subbands 17p12-->p11. We further discovered that the Smith-Magenis syndrome critical region on 17p11.2 is included in the 17p amplicons of two leiomyosarcoma cases. Using probes flanking this genetically unstable region, a mean of 14 and 22 signals per nucleus, respectively, was detected in both leiomyosarcomas by fluorescence in situ hybridization. In conclusion, this analysis identifies a number of characteristic chromosomal imbalances in leiomyosarcomas and provides evidence for the localization of potential oncogenes and tumor suppressor genes active in leiomyosarcoma genomes.

Genomic imbalances including amplification of the tyrosine kinase gene JAK2 in CD30+ Hodgkin cells.

Comparative genomic hybridization was applied for a comprehensive screening of frequently occurring net gains and losses of chromosomal subregions in small populations of CD30+ Hodgkin cells and their morphological variants. In 12 Hodgkin's lymphomas, recurrent gains were detected on chromosomal arms 2p, 9p, and 12q (in six, four, and five tumors, respectively) and distinct high-level amplifications were identified on chromosomal bands 4p16, 4q23-q24, and 9p23-p24. In Hodgkin cells with 9p23-p24 amplification, fluorescence in situ hybridization revealed an increased copy number of chromosomal sequences spanning the tyrosine kinase gene JAK2. Several of the imbalances described, in particular a gain in chromosomal arm 9p that includes JAK2 amplification, are similar to the genomic changes detected in primary mediastinal B-cell lymphoma.

Analysis of chromosomal imbalances in sporadic and NF1-associated peripheral nerve sheath tumors by comparative genomic hybridization.

Peripheral nerve sheath tumors arise either sporadically or in association with neurofibromatosis type 1 (von Recklinghausen's neurofibromatosis, NF1) or type 2. In this study, comprehensive screening for relative chromosome copy number changes was performed on 10 benign and 19 malignant peripheral nerve sheath tumors (MPNSTs) by applying comparative genomic hybridization (CGH). In benign tumors, no chromosomal imbalances were found by CGH, whereas in MPNSTs chromosomal gains and losses were frequently detected. No differences regarding the frequency and distribution of chromosomal imbalances were observed between the 13 sporadic and 6 NF1-associated MPNSTs analyzed. In both, the number of gains was significantly higher than the number of losses, suggesting a predominant role of proto-oncogene activation during MPNST progression. Candidate regions with potentially relevant proto-oncogenes included chromosomal bands 17q24-q25, 7p11-p13, 5p15, 8q22-q24, and 12q21-q24; those with putative tumor suppressor genes were 9p21-p24, 13q14-q22, and 1p. High-level amplifications were restricted to sporadic tumors and affected eight different chromosomal subregions. In three of these MPNSTs, identical subregions on chromosomal arms 5p and 12q were coamplified. This study revealed a number of new characteristic chromosomal imbalances and provides a basis for molecular identification of oncogenes and tumor suppressor genes of pathogenetic relevance in both sporadic and NF1-associated MPNSTs. Genes Chromosomes Cancer 25:362-369, 1999.

Safety and cost effectiveness of a 10 x 10(9)/L trigger for prophylactic platelet transfusions compared with the traditional 20 x 10(9)/L trigger: a prospective comparative trial in 105 patients with acute myeloid leukemia.

In 105 consecutive patients with de novo acute myeloid leukemia (French-American-British M3 excluded), we compared prospectively the risk of bleeding complications, the number of platelet and red blood cell transfusions administered, and the costs of transfusions using two different prophylactic platelet transfusion protocols. Two hundred sixteen cycles of induction or consolidation chemotherapy and 3,843 days of thrombocytopenia less than 25 x 10(9)/L were evaluated. At the start of the study, each of the 17 participating centers decided whether they would use a 10 x 10(9)/L prophylactic platelet transfusion trigger (group A/8 centers) or a 20 x 10(9)/L trigger (group B/9 centers). Bleeding complications (World Health Organization grade 2-4) during treatment cycles were comparable in the two groups: 20 of 110 (18%) in group A and 18 of 106 (17%) in group B (P = .8). Serious bleeding events (grade 3-4) were generally not related to the patient's platelet count but were the consequence of local lesions and plasma coagulation factor deficiencies due to sepsis. Eighty-six percent of the serious bleeding episodes occurred during induction chemotherapy. No patient died of a bleeding complication. There were no significant differences in the number of red blood cell transfusions administered between the two groups, but there were significant differences in the number of platelet transfusions administered per treatment cycle: pooled random donor platelet concentrates averaged 15.4 versus 25.4 (P < .01) and apheresis platelets averaged 3.0 versus 4.8 (P < .05) for group A versus group B, respectively. This resulted in the cost of platelet therapy being one third lower in group A compared with group B without any associated increase in bleeding risk.

Immunomagnetic enrichment of disseminated epithelial tumor cells from peripheral blood by MACS.

Disseminated epithelial tumor cells have been detected in the bone marrow and blood of cancer patients by means of immunocytochemical or immunofluorescent staining of cytocentrifuge slides, multiparameter flow cytometry, and reverse transcriptase-polymerase chain reaction. However, it is hardly possible using such methods to detect tumor cells at a frequency below 10(-6). To increase the sensitivity of these detection techniques we have developed a new technology for the enrichment of disseminated epithelial tumor cells from hematopoietic cell samples by high-gradient magnetic cell sorting (MACS). Cells are permeabilized and fixed and carcinoma cells are magnetically labeled specifically with an anti-cytokeratin 8 monoclonal antibody (mAb) directly conjugated to superparamagnetic microbeads. Magnetically labeled cells are enriched on high-gradient magnetic columns. Tumor cells are detected in the enriched cell fraction by flow cytometry, fluorescence microscopy, or immunocytochemisty. In this study we demonstrated the method using a model system in which five to 5,000 cells from a breast cancer cell line were seeded into blood cell samples from a healthy donor containing 1.2 x 10(8) leukocytes. Tumor cells were 10,477+/-4242 (n=25)-fold magnetically enriched, and 57.7%+/-16.9% (n=33) of the initially seeded tumor cells were recovered. Applying the method to 20-40 mL blood samples from patients with advanced carcinomas of the breast, prostate, colon, rectum, or lung, we were able to detect between one and 6.8 x 10(4) cytokeratin-expressing tumor cells in 21 of 34 patients. This corresponds to frequencies of tumor cells between 6.8 x 10(-9) and 1.1 x 10(-3) among nucleated cells in the original sample. Enriched tumor cells were further analyzed for expression of tissue-specific and prognostic markers such as breast mucin glycoproteins, erbB2, and CD44v6 for additional characterization and to confirm their tumor origin. The technique described could become a valuable tool for the quantification and molecular characterization of metastatic carcinoma cells in hematopoietic tissue, and may ultimately prove useful in the diagnosis, prognosis, and monitoring of patients with carcinoma.

[Analysis of chromosome copy number changes in leiomyosarcoma through molecular cytogenetic methods]. / Analyse numerischer Chromosomenveränderungen in Leiomyosarkomen durch molekular-zytogenetische Methoden.

Leiomyosarcoma (LMS) is a rare type of malignant soft tissue tumor occurring predominantly in adults. Up to now only few zytogenetic data resulting from chromosomal banding analyses were obtained from this tumor type. In general, highly complex karyotypes were observed, but no recurrent chromosomal aberrations could be identified. The aim of the present study was to analyze chromosomal imbalances in 14 cases of LMS using comparative genomic hybridization (CGH). Imbalances were detected in all cases analyzed, with chromosomal gains occurring more frequently than losses (9.9 gains/case vs. 6.9 losses/case, respectively). Chromosome arms predominantly overrepresented included Xp (9/14 cases), 5p and 8q (8/14 each), as well as 17p and 17q (6/14 each). Nineteen distinct high level amplifications, indicative for the location of relevant proto-oncogenes in LMS, were identified in nine different tumors. Interestingly, in three cases chromosomal arm 17p was involved. Interphase analysis with probes derived from the commonly amplified region 17p11-p12 revealed, that the tre oncogene is co-amplified and therefore could play a relevant role in LMS development. With regard to losses chromosome 13q was affected in 12/14, 10q in 8/14, and 2p as well as 2q in 7/14 tumors, respectively. The frequent deletions of chromosome 13 with a minimal affected region 13q14-q15 strongly support preliminary molecular evidence, that loss of the RB1 tumor suppressor gene is a critical step in LMS tumorigenesis.

Regulatory sequences of Arabidopsis drive reporter gene expression in nematode feeding structures.

In the quest for plant regulatory sequences capable of driving nematode-triggered effector gene expression in feeding structures, we show that promoter tagging is a valuable tool. A large collection of transgenic Arabidopsis plants was generated. They were transformed with a beta-glucuronidase gene functioning as a promoter tag. Three T-DNA constructs, pGV1047, p delta gusBin19, and pMOG553, were used. Early responses to nematode invasion were of primary interest. Six lines exhibiting beta-glucuronidase activity in syncytia induced by the beet cyst nematode were studied. Reporter gene activation was also identified in galls induced by root knot and ectoparasitic nematodes. Time-course studies revealed that all six tags were differentially activated during the development of the feeding structure. T-DNA-flanking regions responsible for the observed responses after nematode infection were isolated and characterized for promoter activity.

Efficacy of current molecular cytogenetic protocols for the diagnosis of chromosome aberrations in tumor specimens.

Molecular cytogenetics provides a powerful link between molecular genetic analysis and chromosome morphology, allowing one to pinpoint structurally aberrant chromosome regions on the molecular level. Fluorescence in situ hybridization with selected DNA probes allows the design of efficient and sensitive tools for the diagnosis of chromosomal aberrations present in tumor cells. Comparative genomic hybridization (CGH) allows the identification of chromosomal imbalances in a comprehensive manner, and is applied to solid tumors and hematological malignancies in order to (i) identify clonal differences within a specimen, (ii) contribute to tumor classifications, (iii) identify recurrent chromosomal gains and losses as starting points for the characterization and isolation of pathogenetically relevant genes, such as proto-oncogenes and tumor suppressor genes respectively, (iv) identify imbalances of prognostic relevance, (v) detect high-copy-number amplification and other markers of genetic instability, and (vi) analyze chromosomal imbalances during tumor progression.

Epirubicin and ifosfamide in metastatic breast cancer.

In a randomized, phase II trial, we evaluated the effectiveness of continued chemotherapy with epirubicin/ ifosfamide versus unmaintained treatment interruption in advanced metastatic breast cancer. Three hundred fifty-seven patients were enrolled and 331 were evaluable for response. Complete response was achieved in 25 patients (8%) and partial response in 121 patients (37%). Pretreatment status correlated significantly with response (complete and partial response). While 54% of unpretreated patients responded, only 42% of the patients responded who had been pretreated with adjuvant chemotherapy and 33% who had been pretreated in the metastatic stage of disease; 69 patients (21%) had disease progression. Of 11 patients pretreated in both the adjuvant and metastatic setting, only two responded. Toxicity of treatment was mild, with leukopenia being the treatment-limiting factor. Thrombocyte levels were not altered significantly by treatment. Thus, there seems to be room for dose escalation using granulocyte colony-stimulating factor. There was no considerable cardiotoxicity, central nervous system toxicity, or cystitis observed. The low rate of cardiotoxicity appeared to be related to dose fractionation of epirubicin. After randomization of patients to treatment interruption versus continuation of chemotherapy, a longer relapse-free survival was observed for patients who continued chemotherapy (mean relapse-free survival, 2+ months); however, this did not translate into prolonged survival. The cumulative scores of toxicity and quality of life parameters showed increasing superiority for treatment interruption. Therefore, a strategy of treatment until maximum response and subsequent treatment interruption seems to be superior to treatment continuation.