Recommended guidelines for submission, trimming, margin evaluation, and reporting of tumor biopsy specimens in veterinary surgical pathology.

Neoplastic diseases are typically diagnosed by biopsy and histopathological evaluation. The pathology report is key in determining prognosis, therapeutic decisions, and overall case management and therefore requires diagnostic accuracy, completeness, and clarity. Successful management relies on collaboration between clinical veterinarians, oncologists, and pathologists. To date there has been no standardized approach or guideline for the submission, trimming, margin evaluation, or reporting of neoplastic biopsy specimens in veterinary medicine. To address this issue, a committee consisting of veterinary pathologists and oncologists was established under the auspices of the American College of Veterinary Pathologists Oncology Committee. These consensus guidelines were subsequently reviewed and endorsed by a large international group of veterinary pathologists. These recommended guidelines are not mandated but rather exist to help clinicians and veterinary pathologists optimally handle neoplastic biopsy samples. Many of these guidelines represent the collective experience of the committee members and consensus group when assessing neoplastic lesions from veterinary patients but have not met the rigors of definitive scientific study and investigation. These questions of technique, analysis, and evaluation should be put through formal scrutiny in rigorous clinical studies in the near future so that more definitive guidelines can be derived.

Inactivation of the p16 cyclin-dependent kinase inhibitor in high-grade canine non-Hodgkin's T-cell lymphoma.

The significance of p16/Rb tumor suppressor pathway inactivation in T-cell non-Hodgkin's lymphoma (NHL) remains incompletely understood. We used naturally occurring canine NHL to test the hypothesis that p16 inactivation has specific pathologic correlates. Forty-eight samples (22 T-cell NHL and 26 B-cell NHL) were included. As applicable, metaphase- or array-based comparative genomic hybridization, Southern blotting, promoter methylation, and Rb phosphorylation were used to determine the presence, expression, and activity of p16. Fisher's exact test was used to test for significance. Deletion of p16 (or loss of dog chromosome 11) was restricted to high-grade T-cell NHL (lymphoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified). These were characterized by a concomitant increase of tumor cells with Rb phosphorylation at canonical CDK4 sites. Rb phosphorylation also was seen in high-grade B-cell NHL (diffuse large B-cell lymphoma and Burkitt-type lymphoma), but in those cases, it appeared to be associated with c-Myc overexpression. The data show that p16 deletion or inactivation occurs almost exclusively in high-grade T-cell NHL; however, alternative pathways can generate functional phenotypes of Rb deficiency in low-grade T-cell NHL and in high-grade B-cell NHL. Both morphologic classification according to World Health Organization criteria and assessment of Rb phosphorylation are prognostically valuable parameters for canine NHL.

CD20 expression in normal canine B cells and in canine non-Hodgkin lymphoma.

We examined the expression of CD20 in normal canine peripheral blood mononuclear cells, normal canine spleen, and canine non-Hodgkin lymphoma (NHL) to determine the feasibility of using this antigen as a diagnostic aid and as a possible target for therapy. An antibody generated against a C-terminal (intracytoplasmic) epitope of human CD20 recognized proteins of 32-36 kd in normal and malignant canine lymphocytes. This antibody showed restricted membrane binding in a subset of lymphocytes in peripheral blood, in the B-cell regions from a normal canine spleen and lymph node, and in malignant cells from 19 dogs with B-cell NHL, but not from 15 dogs with T-cell NHL. The patterns of CD20 reactivity in these samples overlapped those seen using an antibody that recognizes canine CD79a. This anti-CD20 antibody is therefore suitable as an aid to phenotype canine NHL. In contrast, normal canine B cells were not recognized by any of 28 antibodies directed against the extracellular domains of human CD20 (including the chimeric mouse-human antibody Rituximab) or by any of 12 antibodies directed against the extracellular domains of mouse CD20. Thus, the use of CD20 as a therapeutic target will require the generation of specific antibodies against the extracellular domains of canine CD20.

Feline inflammatory polyps: historical, clinical, and PCR findings for feline calici virus and feline herpes virus-1 in 28 cases.

Inflammatory polyps are associated with significant aural or nasopharyngeal disease in cats. It has been proposed that chronic viral infection may induce the masses. Ventral bulla osteotomy (VBO) is usually recommended for definitive therapy but removal of masses from the nasopharynx or external ear canal by traction/avulsion is also used. A retrospective study of 28 cats with inflammatory polyps was conducted to correlate recurrence with mode of therapy. Tissues from 41 polyps were assayed for feline calicivirus and feline herpesvirus-1 by RT-PCR and PCR, respectively. Of the 14 cats initially treated by traction/avulsion, recurrence was detected in five of nine cats with radiographic evidence of bulla disease but none of the cats with normal bullae. Traction/avulsion is a reasonable treatment for inflammatory polyps if the bullae are radiographically normal. Failure to detect feline calicivirus and feline herpesvirus-1 suggests that tissue persistence of these viruses is not associated with the development of inflammatory polyps.

Salivary gland neoplasia in the dog and cat: survival times and prognostic factors.

Twenty-four dogs and 30 cats with histopathologically confirmed salivary gland neoplasia were retrospectively reviewed in a multi-institutional study. The predominant presenting complaint for animals with salivary gland neoplasia was that of a mass being noted by the owner; other common complaints included halitosis, dysphagia, and exophthalmia. Siamese cats were overrepresented, indicating a possible breed predisposition. The most common histopathological type was simple adenocarcinoma. Cats had more advanced disease at diagnosis than did dogs, and clinical staging was prognostic in dogs. The median survival times for dogs and cats were 550 days and 516 days, respectively.

Effects of enalapril versus placebo as a treatment for canine idiopathic glomerulonephritis.

A blinded, multicenter, prospective clinical trial assessed the effects of enalapril (EN) versus standard care in dogs with naturally occurring, idiopathic glomerulonephritis (GN). Twenty-nine adult dogs with membranous (n = 16) and membranoproliferative (n = 13) GN were studied. Dogs were randomly assigned to receive either EN (0.5 mg/kg PO q12-24h; n = 16) or placebo (n = 14) for 6 months (1 dog was treated first with the placebo and then with EN). All dogs were treated with low-dose aspirin (0.5-5 mg/kg PO q12-24h) and fed a commercial diet. At baseline, serum creatinine (SrCr), systolic blood pressure (SBP), and glomerular histologic grade were not different between groups, but the urine protein/creatinine ratio (UP/C) was greater in the EN group compared with the placebo group (8.7 +/- 4.4 versus 4.7 +/- 2.3). After 6 months of treatment, the change in UP/C from baseline was significantly different between groups (EN = -4.2 +/- 1.4 versus 1.9 +/- 0.9 in the placebo group). When data were adjusted for changes in SrCr (SrCr X UP/C) a similar significant reduction was noted ( 2.2 +/- 15.2 versus 8.4 +/- 10.1). The change in SBP after 6 months of treatment also was significantly different between groups (EN = -12.8 +/- 27.3 versus 5.9 +/- 21.5 mm Hg in the placebo group). Response to treatment was categorized as improvement (assigned a value of 2), no progression (assigned a value of 1), and progression (assigned a value of 0). Response was significantly better in the EN group (1.4 +/- 0.8) compared with the placebo group (0.3 +/- 0.5). These results suggest that EN treatment is beneficial in dogs with naturally occurring idiopathic GN.

Tumour cell kinetics as predictors of response in canine lymphoma treated with chemotherapy alone or combined with whole body hyperthermia.

Kinetic parameters including potential doubling time (Tpot), duration of S phase (Ts), labelling index (LI), and DNA index (DI) were obtained from 42 dogs with previously untreated lymphoma. Standard flow cytometric techniques using BrdUrd were employed. All dogs were treated with L-asparaginase and remission was induced in 26 dogs, which were then randomized to receive chemotherapy only (doxorubicin [DOX] alone or with lonidamine) or chemotherapy plus whole body hyperthermia (WBH). Dogs were treated every 3 weeks for up to five treatments and evaluated every 3 weeks for evidence of tumour recurrence. Within this subset of animals there was no difference in outcome based on treatment group. Median values for Tpot, Ts and LI were 3.4 days, 7.23 h and 12.49%, respectively. Dogs that had tumours with LI > or = 20% had a shorter time until recurrence than dogs with tumours characterized by LI < 20%. In dogs treated only with chemotherapy, dogs bearing tumours with longer than median Tpot and Ts values and lower than median LI had significantly longer remission duration than dogs with more rapidly proliferating tumours. Dogs treated only with chemotherapy, which had longer than median Tpot and Ts values and lower than median LI, had significantly longer remission duration than all other dogs in the study. The mechanisms in which kinetics are associated with response to chemotherapy are not clear and vary depending on tumour type and treatment regimen. More work is needed to understand factors involved in cell killing during in vivo hyperthermia.

Hypertrophic osteoarthropathy in a blesbok (Damaliscus dorcas phillipsi).

A 4.5-yr-old female blesbok (Damaliscus dorcas phillipsi) was radiographed following the appearance of lameness and swelling of the right front fetlock. Radiographic interpretation at that time was osteoarthritis caused by periosteal proliferation of the right metacarpus with periarticular osteophytes surrounding the fetlock. No treatment was initiated. Gradual abdominal enlargement over several months was interpreted as evidence of pregnancy. Six months after the initial lameness complaint, the blesbok suddenly collapsed and was unable to stand. Physical examination revealed a large firm mass occupying most of the abdomen that was found to be inoperable. Following exploratory laporotomy, the blesbok was euthanized. At necropsy, the mass weighed 17 kg. It had probably caused the animal's collapse. Histologically, the bony lesions of the right metacarpus, seen radiographically at the previous examination, were consistent with hypertrophic osteoarthropathy and may have been a sequela of the intra-abdominal mass.

Doxorubicin alone or in combination with asparaginase, followed by cyclophosphamide, vincristine, and prednisone for treatment of multicentric lymphoma in dogs: 121 cases (1987-1995).

OBJECTIVE: To determine response rate and remission as well as survival times for dogs with multicentric lymphoma treated first with doxorubicin alone or in combination with asparaginase and then with cyclophosphamide, vincristine sulfate, and prednisone (CVP) and to identify prevalence of toxicoses associated with this protocol and factors associated with prognosis. DESIGN: Retrospective case series. ANIMALS: 121 dogs. PROCEDURE: Variables evaluated for prognostic value were initial response rate to chemotherapy, age, breed, sex, body weight, histologic grade, clinical stage and substage, previous corticosteroid treatment, and serum calcium concentration. RESULTS: Median overall remission and survival times for all 121 dogs were 205 and 237 days, respectively. Response rate (complete or partial response) was 88%. Ten dogs were hospitalized because of toxicoses associated with doxorubicin, and 19 dogs were hospitalized because of toxicoses associated with CVP. Asparaginase favorably influenced the initial response rate, but did not significantly influence overall remission of survival times. Initial response rate to chemotherapy, body weight, clinical substage, and serum calcium concentration was found to have prognostic value. CLINICAL IMPLICATIONS: For dogs with multicentric lymphoma, treatment with doxorubicin alone or in combination with asparaginase and then with CVP resulted in an acceptable response rate and low prevalence of toxicoses.

Effects of embedded tungsten-bismuth-tin shot and steel shot on mallards (Anas platyrhynchos).

We assessed the potential for embedded steel and tungsten-bismuth-tin (TBT) shot to adversely affect health of mallards (Anas platyrhynchos). Ducks were implanted with three number four steel (n = 19) or TBT (n = 20) shot pellets in their pectoral muscles. None of seven hematology parameters measured differed in response to treatment (P > or = 0.17). At necropsy 1, 2, 4, and 8 wk posttreatment, we observed only localized tissue reactions to embedded steel or TBT shot. Reactions differed grossly: after wk 1, embedded steel shot were enveloped in 0.5 to 2 mm grayish capsules, whereas TBT shot were surrounded by thinner (< 0.5 mm), translucent capsules. Corrosion of steel shot was apparent. Microscopic lesions associated with steel shot were characterized by moderate to severe histiocytic and lymphocytic inflammation and considerable particle deposition, whereas histiocytic inflammation was mild and particle deposition minimal in TBT lesions. Overall scores of inflammation at steel shot implant sites were greater (P < or = 0.043) than at TBT sites during wk 1 and 8. Inflammation at steel implant sites was relatively consistent over the 8-wk period, but decreased (P = 0.0017) at TBT sites by wk 8. Weights of steel shot recovered from muscle tissue declined logarithmically (R2 = 0.978, P = 0.0014) over 8 wk, but TBT shot weights remained unchanged (P = 0.255). Embedded TBT shot, as compared to steel, resisted corrosion and induced comparatively mild inflammatory responses in mallard muscle tissue. However, inflammatory reactions to both embedded steel and TBT shot were localized and had no detectable systemic effects on mallard health under experimental conditions.

Abnormalities in oxygenation, coagulation, and fibrinolysis in colonic blood of horses with experimentally induced strangulation obstruction.

OBJECTIVE: To measure arterial and venous blood gas, coagulation, and fibrinolysis variables in blood from isolated segments of control and ischemic large colons for the purpose of identifying variables for rapid, indirect assessment of colonic mucosal injury. DESIGN: Variables were determined at specific intervals during the 4-hour study (3 hours of ischemia and 1 hour of reperfusion). ANIMALS: Seven clinically normal horses between 2 and 15 years old. PROCEDURES: Horses underwent laparotomy and occlusion of the lumen and vasculature of the mid-portion of the pelvic flexure of the large colon. During ischemia of 1 randomly-chosen colonic segment, variables were measured to determine colonic mucosal damage and were compared with histologic scores of colonic biopsy specimens. RESULTS: Significant (P < 0.05) differences from control values were observed over time for venous pH, PCO2, PO2, oxygen saturation, oxygen content, arteriovenous oxygen difference, and lactate and glucose concentrations. Mean histologic scores of biopsy specimens obtained from ischemic colons were significantly (P < 0.05) greater (indicating greater damage) than those from control colons, and increased significantly (P < 0.05) with duration of ischemia. CONCLUSIONS: Venous lactate, oxygen saturation, and PO2 values were the most significant predictors of the severity of histologic damage within the ischemic colons (R2 = 0.661). CLINICAL RELEVANCE: Venous blood gas and lactate values in the large colon are good predictors of the amount of intestinal damage incurred during 3 hours of ischemia, and may be clinically useful for the rapid determination of colonic viability.

Prospective characterization of the clinicopathologic and immunologic features of an immunodeficiency syndrome affecting juvenile llamas.

The clinicopathologic and immunologic features of 15 llamas affected with juvenile llama immunodeficiency syndrome (JLIDS) are described. Healthy adult (n = 10) and juvenile (n = 10) llamas served as controls. JLIDS llamas were characterized by wasting, and clinically apparent, repeated infections were frequently observed. The median age at which a health problem was first perceived was 11.6 months. All 15 affected llamas died or were killed, and JLIDS was confirmed at necropsy. The median duration of illness was 3.5 months. Lymphocyte blastogenesis assays showed suppressed responses (particularly to Staphylococcus sp. Protein A) in JLIDS llamas. No evidence of retroviral infection was detected. Mild, normocytic, normochromic, non-regenerative anemia, low serum albumin concentration and low to low-normal globulin concentrations were typically found on initial clinical evaluation. Lymph node biopsies showed areas of paracortical depletion. All llamas affected with JLIDS had low serum IgG concentrations, pre-vaccination titers against Clostridium perfringens C and D toxoids of < or = 1:100, and no titer increase following vaccination.

The role of interleukin-12 in acquired immunity to Mycobacterium tuberculosis infection.

The early phase of acquired cellular immunity to Mycobacterium tuberculosis infection is mediated by the emergence of protective CD4 T lymphocytes that secrete cytokines including interferon-gamma (IFN-gamma), a molecule which is pivotal in the expression of resistance to tuberculosis. Recent evidence demonstrates that infection with M. tuberculosis induces peripheral blood mononuclear cells to release the cytokine interleukin-12 (IL-12), a molecule that promotes the emergence of T-helper type-1 (Th1), IFN-gamma-producing T cells. We demonstrate here that IL-12 mRNA expression was induced by M. tuberculosis infection both in vivo and in vitro and that exogenous administration of IL-12 to mice transiently resulted in increased resistance to the infection. IL-12 also increased the production of IFN-gamma by both splenocytes derived from infected animals treated in vivo and by antigen-stimulated CD4 cells from untreated infected animals, with maximal effects at times associated with the expansion of antigen-specific CD4 T cells in vivo. In the absence of a T-cell response, as seen in SCID mice or nude mice, IL-12 only slightly augmented the moderate bacteriostatic capacity of these immunocompromised mice. Neutralization of IL-12 by specific monoclonal antibodies resulted in a reduction in granuloma integrity and slowing of the capacity of the animal to control bacterial growth.

Retrovirus-like activity in an immunosuppressed dog: pathological and immunological findings.

A putative retrovirus was isolated from a dog with a severe, acquired immunodeficiency-like syndrome. The haematological abnormalities and immunological deficiencies included anaemia, leucopenia (lymphopenia and neutropenia), thrombocytopenia, decreased humoral immunity, and ineffective T-cell responses in-vitro. The necropsy findings included generalized lymphoid depletion, severe bone marrow hypoplasia, plasmacytic infiltrates in lymphoid and non-lymphoid organs, and severe secondary infections. Supernates of peripheral blood mononuclear cell cultures from the affected dog contained an agent with manganese-dependent reverse transcriptase (RT) activity that sedimented at a density of 1.122 g/ml. RT activity was also found post-mortem in extracts prepared from the bone marrow, lymph nodes, and small intestine. The lymph nodes and small intestine expressed a 3.8 kb mRNA that was recognized by a bovine leukaemia virus (BLV) pol DNA probe by Northern blotting. DNA isolated from the lymph nodes and small intestine from the affected dog showed distinct band patterns by Southern analysis, suggesting an exogenous retrovirus. The retrovirus could be propagated in normal canine peripheral blood mononuclear cells or short-term canine lymphocyte cell lines in-vitro, and was cytopathogenic for cells of canine, but not human, origin. These results suggest the existence of a pathogenic canine retrovirus capable of producing disease of the type associated with retroviruses in other species.

Multifocal myositis associated with Sarcocystis sp in a horse.

Multifocal myositis was diagnosed in a 7-year-old Quarter Horse gelding on the basis of history and findings on physical examination, serum biochemical analysis, electromyography, and microscopic examination of frozen sections of muscle biopsy specimens. Histologic examination of the muscle specimen revealed multifocal accumulations of histiocytes, lymphocytes, and plasma cells, with attendant myofiber degeneration and necrosis. Parasitic cysts with morphologic characteristics of Sarcocystis sp were found in regions of myocyte degeneration and necrosis, and in regions of normal muscle. Based on a tentative diagnosis of Sarcocystis sp-induced myositis, the horse was treated with trimethoprim/sulfamethoxazole and pyrimethamine for 28 days, phenylbutazone for 5 days, and paddock rest for 30 days. At the end of treatment, the horse had gained 35 kg, its appetite had returned to normal, and muscle mass was returning to normal. Sarcocystis fayeri is the only Sarcocystis sp reported in equine muscle in the United States and is rarely associated with acute myositis or muscle atrophy. The development of clinical signs in this horse could have been the result of an underlying immunosuppression or infection with a particularly pathogenic strain or large infective dose of S fayeri.

Evaluation of prognostic factors for dogs with synovial sarcoma: 36 cases (1986-1991).

Medical records of 36 dogs with synovial sarcoma confirmed by microscopic examination of H&E-stained sections of tissue were selected for retrospective analysis from dogs admitted between 1986 and 1991 to participating institutions of the Veterinary Cooperative Oncology Group. Metastasis was evident at the time of diagnosis in 8 (22%) dogs, and 15 (41%) dogs ultimately developed metastatic tumors. Median survival time for all dogs, as determined by life-table analysis, was 17 months. For dogs that were subsequently treated and became tumor free, the median disease-free interval was 30 months. Nine dogs had previously had localized excision attempted, but all had recurrence of the tumor locally (median, 4.5 months). Of 29 dogs that underwent amputation, including the 9 with localized recurrence, 2 had tumor recurrence on the amputation stump. Most dogs had survival time and disease-free interval of > 36 months after amputation. Four dogs that had received chemotherapy for tumors of advanced clinical stages did not respond to treatment. One dog that had received locally applied radiotherapy after localized excision did not have evidence of tumor recurrence 2 years after radiotherapy. Clinical stage, histologic grade, and a positive result for tests that used cytokeratin immunohistochemical staining significantly (P < 0.05) influenced survival time and disease-free interval. Analysis of data for the study reported here suggested that histologic criteria can be an excellent predictor of dogs that are likely to have tumor recurrence after amputation and that would most likely benefit from aggressive treatment with adjuvants.

Evaluation of mitoxantrone for the treatment of lymphoma in dogs.

Mitoxantrone was administered to 74 dogs with lymphoma at a dosage of 5.0 mg/m2 of body surface, IV, every 3 weeks. Thirty-four dogs had failed to respond to prior treatment with chemotherapeutic agents, which included doxorubicin (33 dogs). The remaining 40 dogs had not received prior treatment. Complete remission was determined in 19 of 74 dogs (26%), 10 of which had not received prior treatment. The median duration of remission for these 10 dogs was 94 days (range, 49 to 440 days, with 2 dogs still alive at 370 and 440 days, respectively). Nine dogs that had received prior treatment had complete remission that lasted for a median of 126 days (range, 42 to 792 days, with 1 dog still alive at 792 days). The combined remission rate (complete remission plus partial remission) was 41%. Toxicosis was minimal, developing in only 9 dogs and requiring hospitalization of 2 dogs. We concluded that the complete remission rate ascertained when mitoxantrone was the only treatment administered was low, compared with treatments that involved other chemotherapeutic agents; however, the combined remission rate of 41% indicated that mitoxantrone may be beneficial in the treatment of lymphoma in dogs.

Serodiagnosis of paratuberculosis in sheep by use of agar gel immunodiffusion.

An agar gel immunodiffusion (AGID) test was used over a 3-year period to examine 1,871 serum samples from sheep representing 5 Mycobacterium paratuberculosis-infected flocks and 4 flocks presumed to be uninfected. Of 1,032 sheep, 31 had positive AGID test results (scoring 1 to 5), and 23 of these 31 were necropsied. Infection with M paratuberculosis was confirmed by 1 or more of the following findings: observation of typical lesions on histologic examination of sections of ileum or ileocecal lymph nodes, observation of clumps of acid-fast bacteria in mucosal smears of ileum, and isolation of the organism from feces or tissue. False-positive results on AGID testing were not found in sheep from flocks known to have exposure to Corynebacterium pseudotuberculosis. Diarrhea in infected sheep was observed infrequently; chronic, severe weight loss was the most common sign observed. On histologic examination of tissues from 20 infected sheep, 16 (80%) had diffuse lesions of the ileum and 13 (65%) had acid-fast bacteria in areas of ileal inflammation; 4 had discrete granulomas and peripheral lymphocytic infiltrates in the ileum. Sheep with diffuse lesions tended to have higher mean scores on AGID testing and examination for acid-fast bacteria, compared with those from sheep with more discrete lesions. Bacteriologic culture yielded M paratuberculosis from only 3 sheep with paratuberculosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Coccidiosis as a cause of transmural lymphocytic enteritis and mortality in captive Nashville warblers (Vermivora ruficapilla).

Transmural lymphocytic enteritis was diagnosed in thirteen Nashville warblers (Vermivora ruficapilla) during an epornitic with high mortality. In the intestinal lesions, asexual stages of coccidia were present within lymphocytes and asexual and sexual stages of coccidia were present within intestinal villar epithelium. Ultrastructurally, the infiltrating lymphocytes resembled granular ("intraepithelial") lymphocytes, a cell known to be important in the life cycle of some avian coccidia. Gross and histopathologic features of this enteritis resemble intestinal changes described for Isospora/Atoxoplasma spp. in other passeriformes and lymphoproliferative disease in gold-finches.

Efficacy and toxicity of VAC chemotherapy (vincristine, doxorubicin, and cyclophosphamide) in dogs with hemangiosarcoma.

Fifteen dogs with hemangiosarcoma were treated with a combination of vincristine, doxorubicin, and cyclophosphamide after incisional or excisional biopsy. The median survival for all fifteen dogs was 172 days (mean survival = 316 days). The median survival for those dogs with splenic hemangiosarcoma was 145 days (mean survival = 271 days) as compared with previously published median survival times in dogs with splenic hemangiosarcoma treated with surgery alone of 19 to 65 days. Toxicities included neutropenia (11/15), severe gastroenteritis (4/15), cardiotoxicity (3/15), and sepsis (2/15). The authors conclude that vincristine, doxorubicin, and cyclophosphamide chemotherapy may be an efficacious treatment modality in dogs with hemangiosarcoma and is associated with acceptable toxicity.