Induction therapy of AML with ara-C plus daunorubicin versus ara-C plus gemtuzumab ozogamicin: a randomized phase II trial in elderly patients.

BACKGROUND: Chemotherapy for elderly patients with acute myeloid leukemia (AML) results in a median overall survival (OS) of ≤ 1 year. Elderly patients often present with cardiac comorbidity. Gemtuzumab ozogamicin (GO) is active in elderly (≥ 60 years) patients with relapsed AML with low cardiac toxicity. PATIENTS AND METHODS: This randomized phase II study compared a standard combination of ara-C and daunorubicin (DNR; 7+3) versus ara-C plus gemtuzumab ozogamicin (7+GO) as the first course of induction therapy. Primary objectives were comparison of blast clearance on day 16, event-free survival (EFS), and remission duration. OS, complete remission (CR), and tolerability were secondary objectives. RESULTS: One hundred and nineteen patients with de novo AML, treatment-related AML, AML with a history of myelodysplastic syndrome (MDS), or high-risk MDS entered the study. Median age of 115 patients (intent-to-treat population) was 69 years. Protocol outlined a second course 7+3 for patients without blast clearance and two courses of high-dose ara-C consolidation upon CR. Both treatments were equally effective in blast clearance, CR, EFS, remission duration, or OS (median: 7+3, 9 months; 7+GO, 10 months). Induction death rate was higher in the GO group due to veno-occlusive disease. CONCLUSION: The study did not show significant superiority of 7+GO over standard 7+3.

Fatty acids in liver microsomal lipids of rats exposed to hypoxia, tetrachloromethane, or both.

Arachidonic and docosahexaenoic acid in hepatic microsomal lipids from male Sprague-Dawley rats are greatly lowered when the animals have been exposed to tetrachloromethane; at the same time, palmitic, oleic and linoleic acid are significantly increased. Hypoxia alone causes similar derangements, but to a lesser extent. These are largely corrected 18 h after exposure; the effects induced by tetrachloromethane are persistent. The increases in 16:0, 18:1 and 18:2 suggest that in both cases microsomal enzymes involved in fatty acid metabolism are inhibited, either reversibly or irreversibly. Reduction of oxygen partial pressure during tetrachloromethane exposure has little effect upon hepatotoxicity as judged by hepatic enzymes in serum; only the onset of their release into the bloodstream is earlier.

Randomized phase III study of gemcitabine and vinorelbine versus gemcitabine, vinorelbine, and cisplatin in the treatment of advanced non-small-cell lung cancer: from the German and Swiss Lung Cancer Study Group.

PURPOSE: To evaluate whether cisplatin-based chemotherapy (gemcitabine, vinorelbine, and cisplatin [GVP]) prolongs overall survival in comparison to cisplatin-free chemotherapy (gemcitabine and vinorelbine [GV]) as first-line treatment in patients with advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Between September 1999 and June 2001, 300 patients with NSCLC stage IIIB with malignant pleural effusion or stage IV disease were randomly assigned to receive GV (gemcitabine 1000 mg/m(2) + vinorelbine 25 mg/m(2) on days 1 and 8 every 3 weeks) or GVP (gemcitabine 1000 mg/m(2) + vinorelbine 25 mg/m(2) on days 1 and 8 + cisplatin 75 mg/m(2) on day 2 every 3 weeks). Primary end point of the study was overall survival. RESULTS: Two hundred eighty-seven patients (GV, 143 patients; GVP, 144 patients) were eligible for analysis. At the time of analysis, April 15, 2002, 209 patients (GV, 103 patients; GVP, 106 patients) of 287 patients had died (73%). No statistically significant difference was observed for overall survival (P =.73; median survival, 35.9 versus 32.4 weeks; 1-year survival rate, 33.6% versus 27.5%) as well as for event-free survival (P =.35; median time-to-event, 19.3 versus 22.3 weeks) between GV and GVP. Two hundred fourteen patients were assessable for best response. The overall response rates were 13.0% for GV versus 28.3% for GVP (P =.004; complete responders, 0% versus 3.8%; partial responders, 13.0% versus 24.5%). Hematologic and nonhematologic toxicity was significantly lower in the GV treatment arm compared with GVP. No statistically significant difference in quality of life was observed. CONCLUSION: In this phase III study, the cisplatin-based GVP regimen showed no survival benefit as first-line chemotherapy in advanced NSCLC when compared with the cisplatin-free GV regimen, which was substantially better tolerated.

Gemcitabine, vinorelbine and cisplatin combination chemotherapy in advanced non-small cell lung cancer: a phase II trial.

The purpose of this phase II trial was to investigate the efficacy and safety of a combination chemotherapy with gemcitabine, vinorelbine and cisplatin in the first-line treatment of advanced non-small cell lung cancer (NSCLC). Patients with NSCLC stage IIIB or IV disease received 1000 mg/m(2) gemcitabine and 25 mg/m(2) vinorelbine on days 1 and 8 and 75 mg/m(2) cisplatin on day 2, every 3 weeks. From December 1998 to May 1999, 31 patients (21 stage IV and 10 stage IIIB disease), with a median age of 59 years (range 40-72 years) were enrolled. The overall intent-to-treat response rate was 45% (95% confidence interval (CI): 27-64%) with 2 complete responders (CR) and 12 partial responders (PR), 7 patients had stable disease and 10 progressed. Median survival was 12.8 months (95% CI: 6.5-12.8+ months), median time to progression was 5.1 months (95% CI: 3.5-7.7 months), and the 1-year survival rate was 52.9% (95% CI: 36.7-76.2%). Patients with stage IIIB disease had a significantly longer overall survival than patients with stage IV disease (P=0.05). Transient World Health Organization (WHO) grade IV leucopenia, anaemia and thrombocytopenia occurred in 3 (10%), 2 (6%) and 3 (10%) patients, respectively. The predominant non-haematological toxicities were alopecia and nausea/vomiting. 15 patients (48%) had WHO grade II and III alopecia and 14 patients (45%) nausea/vomiting. The combination of gemcitabine, vinorelbine and cisplatin has demonstrated major antitumour efficacy in advanced NSCLC with a manageable toxicity profile.

Gemcitabine and vinorelbine as first-line chemotherapy for advanced non-small cell lung cancer: a phase II trial.

The purpose of this phase II study was to investigate the efficacy and safety of gemcitabine plus vinorelbine as first-line chemotherapy in patients with advanced non-small cell lung cancer (NSCLC). Eligibility criteria included cytologically or histologically confirmed NSCLC (stage IIIB or IV), no previous chemotherapy, and bidimensionally measurable disease. Patients received 1000 mg/m(2) gemcitabine and 30 mg/m(2) vinorelbine on days 1, 8 and 15 every 4 weeks up to eight courses. From December 1997 to November 1998, 70 patients (59 stage IV and 11 stage IIIB disease), with a median age of 59 years (range 38-74 years) were enrolled. The intent-to-treat response rate was 41% (95% confidence interval (CI) 30-54%) with 1 complete responder (CR) and 28 partial responders (PRs), 15 patients had stable disease (SD) and 26 progressed (PD). Median survival was 8.3 months (95% CI 6.0-9.9 months), median progression-free survival (PFS) was 4.8 months (95% CI 3.9-5.5 months), and 1-year survival rate was 33.5% (95% CI 24.0-46.8%). Patients received a total of 229 cycles. Haematological and non-haematological toxicities were moderate. Transient World Health Organization (WHO)-grade IV leucopenia and thrombocytopenia occurred in 13 (6%) and two (1%) cycles, respectively. The predominant non-haematological toxicity was local reactions of the veins in 19 (27%) patients (WHO-grade II and III). Neurotoxicity was infrequent, non-cumulative, and reversible. The combination of gemcitabine and vinorelbine has demonstrated activity in metastatic NSCLC, with response and survival rates similar to those of cisplatin-based regimens and a more favourable toxicity profile that is well tolerated in an outpatient setting.

Carbon tetrachloride metabolism in vivo and exhalation of volatile alkanes: dependence upon oxygen partial pressure.

Metabolism of carbon tetrachloride in rats at atmospheric and reduced oxygen pressure has been determined indirectly by its disappearance from the inhaled air; it is inversely related to oxygen concentration and increases with decreasing partial pressure, as expected for reductive dehalogenation; oxygen partial pressure has been reduced to about a third of normobaric conditions. Concurrently exhalation of ethane and pentane as indication of lipid peroxidation has been monitored, showing a drastic increase when the oxygen partial pressure is reduced in the presence of carbon tetrachloride. Time course and duration of these processes indicate that the total metabolism of carbon tetrachloride is limited by the concomitant destruction of cytochrome P-450; also, oxidative destruction of polyunsaturated fatty acids apparently does not proceed beyond the end of metabolic activation of carbon tetrachloride. The molar ratios of the amount of metabolized carbon tetrachloride to the amounts of exhaled hydrocarbons lead to the same conclusion, namely that "lipid peroxidation" in this case does not proceed as an autocatalytic, self-propagating chain reaction.

Erosive arthritis and posterior uveitis in Behçet's disease: treatment with interferon alpha and interferon gamma.

Very few patients with Behçet's disease (BD) have been treated with interferon alpha (IFN alpha) or interferon gamma (IFN gamma) to date. We report the successful longterm treatment of a female German patient with erosive arthritis and posterior uveitis with IFN alpha and IFN gamma sequentially and in combination.

Eosinophilia-myalgia syndrome: findings at MR imaging and proton spectroscopy of the lower leg.

Five magnetic resonance (MR) studies of the lower leg were performed in three patients with eosinophilia-myalgia syndrome (EMS). The 1H spectroscopic and imaging findings were compared with seven examinations of age-matched healthy controls. Standard imaging with proton density-, T1-, and T2-weighted spin-echo (SE) sequences at 1.5 T showed marked atrophy of the calf muscles and slightly increased signal strength of muscle tissue in T2-weighted SE images. The application of frequency selective chemical shift imaging (SENEX) exhibited skin changes similar to those of scleroderma with increased water content and thickened cutis in the water selective images. In one patient the tibialis muscles showed irregular structures, but no fatty degeneration as demonstrated in the fat selective images. Proton signals from volume elements of (20 mm)3 within the soleus and gastrocnemius muscle were recorded by the PRESS localization method. A reduction of the creatine/water and the choline/water ratios was found in the 1H spectra from the EMS patients compared to the controls. Localized 1H spectroscopy exhibited modified distributions of the lipid signals in two EMS patients with slightly elevated signals from unsaturated fatty acids. The transverse relaxation of choline and creatine signals was accelerated in both examinations of one patient compared with the healthy controls.

Sacroiliitis in sarcoidosis: case reports and review of the literature.

We report the occurrence of bilateral sacroiliitis in 2 cases of biopsy-proven sarcoidosis. Tuberculosis was excluded by tuberculin testing and bronchoalveolar lavage in both cases. In the literature, 5 cases of sacroiliitis and sarcoidosis have thus far been described, but in all tuberculosis was not excluded (tuberculin testing was not performed or revealed a positive test result). In 1 of these cases tuberculosis was even simultaneously suspected to be present. In all previous cases, antituberculous or other antimicrobial agents were given. Previously reported cases of sacroiliitis in sarcoidosis are briefly reviewed, and possible relations between seronegative spondylarthropathies, slow bacterial infections, sarcoidosis and other granulomatous diseases are discussed.

[Cryoglobulinemia in chronic hepatitis C. Improvement by alpha-interferon is independent of virus elimination]. / Kryoglobulinämie bei chronischer Hepatitis C. Besserung durch alpha-Interferon unabhängig von der Viruselimination.

BACKGROUND: During the last few years, the association of mixed cryoglobulinemia with chronic viral infections has gained increasing interest. Chronic hepatitis C seems to play a major role. As alpha-interferon is an established therapy for chronic hepatitis C, it was also tried successfully in cryoglobulinemia type II, associated with chronic hepatitis C virus infection. PATIENTS: The course of 3 patients with cryoglobulinemia type II and chronic hepatitis C is presented. RESULTS: Two patients received immunosuppressive therapy prior to alpha-interferon without success. In all cases, remission or improvement of the cryoglobulinemia was noticed with alpha-interferon, but none of the patients cleared the hepatitis C virus. Although the treatment was well tolerated, two patients developed neurologic resp. psychiatric side effects, probably due to alpha-interferon. CONCLUSION: From our results and from data reported previously, immunomodulating treatment with alpha-interferon can be recommended for therapy of virus-associated cryoglobulinemia rather than the "classical" treatment with immunosuppressive agents. The specific side effects of alpha-interferon have to be monitored carefully.

Determination of alkanes in breath to monitor lipid peroxidation in the presence of volatile toxicants and metabolites. An optimized, automatic method.

Determination of alkanes in breath of laboratory animals and humans has become a standard-method for monitoring lipid peroxidation in vivo. Isothermal gas chromatography on Porasil C enables sensitive, rapid and repetitive determination of all C2-C5-hydrocarbons in breath. Volatile toxicants and metabolites, which would coelute with the alkanes of later injected samples, are deviated by using a precolumn. An automatic switching unit controls withdrawal and injection of samples and backflush of the precolumn in a repetitive manner at fixed intervals. This increases accuracy and sensitivity of analysis and enables virtually unattended operation. The system has been applied for a study on the oxygen-dependence of CCl4-metabolism in the rat.

Tetrachloromethane metabolism in vivo under normoxia and hypoxia. Biochemical and histopathological effects relative to alkane exhalation.

About 250 mumol/kg tetrachloromethane is metabolized by male Sprague-Dawley rats receiving a dose of 500 mumol/kg by inhalation. Determination of enzyme activities and histopathological assessment show that various parameters reflecting cellular injury do not differ for the same amount of tetrachloromethane metabolized under different oxygen partial pressures. On the other hand, the amounts of ethane and pentane exhaled under hypoxic conditions are greater than under normoxia. The previously reported differences in the toxicity of tetrachloromethane upon exposure under normoxia or hypoxia seem to be mainly due to the different amounts of tetrachloromethane metabolized under both conditions.

Acetylene, a mammalian metabolite of 1,1,1-trichloroethane.

1,1,1-Trichloroethane (TCE) is a widely used industrial solvent of low acute toxicity. It is slowly oxidized to trichloroethanol and trichloroacetic acid by cytochrome P-450-dependent mono-oxygenases. Increased inhalative uptake by rats under hypoxia and spin-trapping experiments indicate that TCE is also reductively metabolized to a radical intermediate. Acetylene is formed as a metabolite, suggesting transfer of an additional electron to form the corresponding carbene. Hypoxia and induction of mixed-function mono-oxygenases accelerate the formation of acetylene. Experiments performed in vitro with rat liver microsomal fractions yield analogous results.

Binding of trichloromethyl radicals to lipids of the hepatic endoplasmic reticulum during tetrachloromethane metabolism.

Metabolism of tetrachloromethane (carbon tetrachloride) by liver microsomal fraction under anaerobic conditions and in vivo leads to covalent binding of trichloromethyl radicals to lipids. The resulting covalently modified lipids contain two different types of fatty acids: a group of monomeric trichloromethyl fatty acid residues, usually with one double bond less than the precursor fatty acids, and a group of fatty acids that are not sufficiently volatile for gas chromatography. The liquid-chromatographic properties of the latter indicate high molecular mass, presumably due to cross-linking. The chemical structures of the monomeric fatty acids were elucidated, and these support the view that the most significant reactive metabolite of tetrachloromethane is the trichloromethyl radical. The isomer patterns of the monomeric trichloromethyl fatty acids in vitro and in vivo are almost identical, which shows that anaerobic incubation of tetrachloromethane with microsomal fraction very well reflects the processes involved in hepatotoxicity of tetrachloromethane in vivo.

A method for the cryopreservation of liver parenchymal cells for studies of xenobiotics.

An optimized computer-controlled freezing protocol for the cryopreservation of rat liver parenchymal cells was developed. The best survival rates were obtained when a slow cooling rate was used and when the supercooling was interrupted with a shock cooling to initiate ice nucleation. Ten percent dimethyl sulfoxide was added and removed gradually for best results. Thawed rat liver parenchymal cells had a viability, as judged by trypan blue exclusion, of 69% (SD = 6) versus 82% (SD = 7) for freshly isolated cells. The content and activities of the xenobiotic metabolizing enzymes, cytochrome P450, UDP-glucuronosyl transferase, and microsomal and cytosolic epoxide hydrolase, were not affected, whereas a slight reduction of glutathione S-transferase and sulfotransferase occurred. If cryopreserved cells were purified by a Percoll centrifugation after thawing the enzyme activities were not significantly different from those of freshly isolated parenchymal cells and also the viability was 86% (SD = 3). Cryopreserved rat liver parenchymal cells only metabolized about 50% of benzo(a)pyrene compared to freshly isolated cells. It is less likely that the reduction in enzyme activities was due to the cryopreservation procedure than that it was due to the loss of NADPH as a cofactor for cytochrome P450 which then resulted in the decreased xenobiotic metabolism. This cryopreservation protocol was also suitable for a variety of liver parenchymal cells from other species when trypan blue exclusion was used as a viability marker.

Therapy of Behçet's disease.

Behçet's disease (BD) is a multisystem vasculitis of unknown origin. In this retrospective study we analyzed the therapy of 32 patients seen between 1978 and 1993 at the Departments of Rheumatology, Ophthalmology, and Dermatology of the Tübingen University Clinic. The aim of this study was to evaluate the efficacy of different therapeutic strategies concerning different organ manifestations of the disease, especially eye disease. A total of 20 patients had cutaneous manifestations or arthritis. Whereas treatment with colchicine (Col), azathioprine (AZA), cyclosporine (CSA), or steroids (Ster) produced only partial remissions, a combination of CSA, AZA, and steroids led to complete remissions. Interferon-gamma (IFN-gamma) therapy led to remission rates of 60% (complete) and 20% (partial). In all, 22 patients had uveitis (posterior or panuveitis). Steroids were effective in only 50% of the patients and Col was partially effective in 66%. AZA induced a remission in 71% of cases and CSA was partial effective in 60%. The threshold combination of AZA, CSA, and Ster induced a complete remission in 66% of the patients. IFN-gamma was ineffective in 80%. IFN-alpha was used in one patient only and induced a complete remission. These results demonstrate that although our patient group is too small to allow significant conclusions to be drawn, in terms of the literature, for mucocutaneous disease and arthritis, IFNs might be the best therapy, whereas for uveitis as well as other more severe features of the disease, CSA or AZA + Ster should be used. If the latter are ineffective, the threefold combination (AZA, CSA, Ster) is probably the most effective alternative. The significance of IFN-alpha will be evaluated in further studies.

Cloning and molecular characterization of a soluble epoxide hydrolase from Aspergillus niger that is related to mammalian microsomal epoxide hydrolase.

Aspergillus niger strain LCP521 harbours a highly processive epoxide hydrolase (EH) that is of particular interest for the enantioselective bio-organic synthesis of fine chemicals. In the present work, we report the isolation of the gene and cDNA for this EH by use of inverse PCR. The gene is composed of nine exons, the first of which is apparently non-coding. The deduced protein of the A. niger EH shares significant sequence similarity with the mammalian microsomal EHs (mEH). In contrast to these, however, the protein from A. niger lacks the common N-terminal membrane anchor, in line with the fact that this enzyme is, indeed, soluble in its native environment. Recombinant expression of the isolated cDNA in Escherichia coli yielded a fully active EH with similar characteristics to the fungal enzyme. Sequence comparison with mammalian EHs suggested that Asp(192), Asp(348) and His(374) constituted the catalytic triad of the fungal EH. This was subsequently substantiated by the analysis of respective mutants constructed by site-directed mutagenesis. The presence of an aspartic acid residue in the charge-relay system of the A. niger enzyme, in contrast to a glutamic acid residue in the respective position of all mEHs analysed to date, may be one important contributor to the exceptionally high turnover number of the fungal enzyme when compared with its mammalian relatives. Recombinant expression of the enzyme in E. coli offers a versatile tool for the bio-organic chemist for the chiral synthesis of a variety of fine chemicals.

[Pancytopenia during low-dose oral methotrexate therapy of psoriatic arthritis]. / Panzytopenie bei niedrig dosierter oraler Methotrexat-Therapie der Arthritis psoriatica.

Pancytopenia and interstitial pneumonia occurred in a 70-year-old woman with psoriatic arthritis and compensated renal insufficiency while she was being treated with low doses of the folic-acid antagonist methotrexate (5 mg weekly). Despite the administration of platelets, red blood cells, antibiotics, acyclovir and folinic acid (100 mg daily), the pneumonia progressed, and the patient died of global respiratory failure.