Five-year follow-up of a prospective randomised multi-centre trial of weekly chemotherapy (CAPOMEt) versus cyclical chemotherapy (CHOP-Mtx) in the treatment of aggressive non-Hodgkin's lymphoma. Central Lymphoma Group.

BACKGROUND: Weekly alternating regimen known as CAPOMEt is compared to standard cyclical chemotherapy (CHOP-Mtx) in aggressive non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: Three hundred and eighty-one patients with aggressive NHL were randomised to receive either cyclophosphamide, doxorubicin, vincristine, prednisone and methotrexate (CHOP-Mtx) on a cyclical basis or a weekly regimen incorporating the same drugs with the addition of etoposide (CAPOMEt). RESULTS: After pathological review, 281 patients were deemed eligible. At the census date of 31 March 1994, 158 patients were alive with a median follow up of 5.9 years (minimum 3.0 years). Analysis of all patients and eligible patients showed no significant treatment differences in the rates of complete remission (CR), failure free survival (FFS) or overall survival (OS) between the two arms. The actuarial median OS was 24 months for CAPOMEt compared with 31 months for CHOP-Mtx, with five-year actuarial survival rates of 37% and 43%, respectively. Myelosuppression was significantly more severe with CHOP-Mtx and neurotoxicity was much more common with CAPOMEt. CONCLUSION: Weekly CAPOMEt is equally effective as standard cyclical CHOP-Mtx treatment in aggressive NHL.

Failure of patients to attend a medical outpatient clinic.

Failure of patients to attend outpatient clinics is common and costly. In one consultant's general medical and gastrointestinal outpatient clinic, 38% of new patients failed to keep at least one appointment, 17% did not attend for their first outpatient consultation and, of these, 59% failed to keep a second appointment sent to them. Of the patients who did attend for their first consultation 12% did not keep their next two appointments. Failure to attend was more common in men, young patients, patients from certain inner city areas, patients on the lists of certain general practices, and those who had already defaulted once. Possible background reasons for default are discussed, suggestions for further study proposed, and an attempt made to look for ways to reduce the extent of the problem.

A pilot study of ChlOPhEPP-B--a weekly regimen for patients with untreated advanced or recurrent Hodgkin's disease.

Twenty-five patients with either previously untreated advanced Hodgkin's disease (HD) or with relapsed disease were treated with an intensive weekly chemotherapy regimen (ChlOPhEPP-B) in which the myelosuppressive combinations of epirubicin and chlorambucil, and procarbazine and etoposide alternated at two-week intervals, interspersed with vincristine and prednisolone and then vincristine, prednisolone and bleomycin in a four-week cycle. Of the previously untreated patients (n = 14), 12 (86 per cent) showed a complete response (CR); in the previously treated patients (n = 11), CR was achieved in five (46 per cent). Toxicity was predictable and not evidently more severe than with more standard regimens. Neutropenia leading to treatment delay and/or dose reduction was seen in 11 patients (44 per cent) but severe neutropenia (WHO grade 4) was documented in only six patients (24 per cent) for a cumulative total of nine treatment weeks (1.8 per cent of the total treatment time). Dose reductions for neutropenia were applied in relation to 11 of the 379 weekly treatment points (2.9 per cent). Delays in treatment, for any reason, averaged 3.65 weeks per patient. The study demonstrated the feasibility of a more intensive weekly multidrug schedule. This approach may be applicable in the treatment of advanced HD and represents a further option in the strategy of treating relapsed disease.

Case report: hepatobronchial fistula complicating amoebiasis, treated by percutaneous catheter drainage.

We report the case of a 41-year-old man who presented with hepatic amoebiasis 18 months after visiting the Far East. His progress was initially complicated by a bronchohepatic fistula which was further complicated by secondary bacterial infection. The fistula persisted and only resolved following percutaneous catheter drainage, thereby avoiding open surgery.

Twin-track studies of ifosfamide and mitoxantrone (I-M) in recurrent high grade non-Hodgkin's lymphoma and Hodgkin's disease. Yorkshire Regional Lymphoma and Central Lymphoma Groups.

Fifty-seven patients, initially diagnosed as having advanced high grade non-Hodgkin's lymphoma (NHL) or Hodgkin's disease (HD) refractory to first-line treatment or in relapse, were treated with ifosfamide 6 g/m2, infused over 48 h, followed by mitoxantrone 12 mg/m2. The regimen repeated at three-weekly intervals. Of 33 patients with NHL evaluable for response, 10 (30 per cent) achieved complete remission and six partial remission, giving an overall response rate of 48 per cent. Two patients subsequently went on to bone marrow transplant (BMT)--one allogeneic and the other autologous. Of 18 patients with HD evaluable for response, seven (39 per cent) achieved complete remission and six partial remission, giving an overall response rate of 72 per cent. Two of this group also went on to BMT (both autografts). The principal toxicity was neutropenia, though central nervous system changes were observed in 10 patients. The possibility of increasing the safety of the regimen by increasing the time of infusion to 72 h is discussed. Given the need to offer alternative treatment to patients in these categories, this combination (I-M) is of value in relapsed patients, especially where options are limited because of previous multi-drug treatment. Remissions may not be prolonged but allow the effective application of additional intensive treatment including bone marrow transplantation.

Ifosfamide and mitoxantrone (I-M) in relapsed and refractory high grade non-Hodgkin's lymphoma and Hodgkin's disease.

Fifty-five patients, initially diagnosed as having advanced high grade non-Hodgkin's lymphoma (NHL) or Hodgkin's disease (HD) refractory to first-line treatment or in relapse, were treated with ifosfamide 6 g/m2, infused over 48 h, followed by mitoxantrone 12 mg/m2. The regimen repeated at three-weekly intervals. Of 32 patients with NHL evaluable for response, 10 (31 per cent) achieved complete remission and five partial remission, giving an overall response rate of 47 per cent. Two patients subsequently went on to bone marrow transplant (BMT)--one allogeneic and the other autologous. Of 17 patients with HD evaluable for response, six (35 per cent) achieved complete remission and six partial remission, giving an overall response rate of 71 per cent. Two of this group also went on to BMT (both autografts). The principal toxicity was neutropenia, though central nervous system changes were observed in 10 patients. Given the need to offer alternative treatment of patients in these categories, this combination (I-M) is clearly of value in relapsed patients especially where therapeutic options are limited because of previous multi-drug treatment.

Gonococcal arthritis complicated by acute pericarditis and pericardial effusion.

A woman of 23 presented with a painful, swollen left knee. A thick yellow fluid aspirated from the joint cavity grew Neisseria gonorrhoeae. Central pleuritic chest pain and ST segment elevation developed 48 hours after presentation. These signs and symptoms of pericarditis had settled two months after the acute illness.

Acne vulgaris and malignancy.

Seventy patients with lymphomas and leukaemias were interviewed. Details of past acne vulgaris were recorded and a clinical examination performed. A history of acne was less common in the patients than in matched controls. In addition, fewer patients had received treatment prescribed by a medical practitioner for their acne than had the controls. Examination revealed fewer patients with acne. These results suggest a reduced incidence of acne or its more severe forms in patients who have developed lymphomas and leukemias, and provide some support for the hypothesis that increased exposure or response to P. acnes, as appears to occur with acne, could confer protection against malignant disease.

Hepatic tumors with hyperglucagonemia. Response to treatment with human lymphoblastoid interferon.

A 62-year-old man had necrolytic migratory erythema in association with hyperglucagonemia and multiple hepatic tumors. A diagnosis of metastatic glucagonoma was made. He was treated with human lymphoblastoid interferon given subcutaneously in the dose of 2.8 to 7.1 X 10(6) IU/day. This produced a considerable fall in plasma glucagon and resolution of the associated rash. The treatment was continued for 10 weeks over a 4-month period. Computed tomography demonstrated a reduction in hepatic tumor mass.

Leucocyte zinc in non-Hodgkin's lymphoma and Hodgkin's disease.

Zinc status and the effect of zinc supplementation were assessed in groups of patients with non-Hodgkin's lymphoma and Hodgkin's disease; patients were either untreated or in remission. In the patients in remission, plasma zinc was normal; and whereas 30% of untreated patients had low plasma zinc, the group as a whole did not differ from normal. For mononuclear cell zinc, the range of values in the disease group was far wider than in controls, but there was no significant difference between the means of the groups. Granulocyte zinc was significantly lower in both the groups of patients in remission from non-Hodgkin's lymphoma and Hodgkin's disease compared with the control group. Significant increases were found in the plasma copper, ceruloplasmin, and the copper-to-zinc ratio in several of the patient groups. Plasma zinc increased by 23% with zinc supplementation (50 mg elemental Zn/day), but there was no effect on mononuclear cell or granulocyte zinc. Apart from granulocyte zinc, there is little evidence of zinc deficiency in non-Hodgkin's lymphoma or Hodgkin's disease. However, the presence of depleted granulocyte zinc levels could modify the immune function of this cell population.

Amyloid myopathy and myeloma: response to treatment.

A 57 year old female presented with an amyloid myopathy in association with lambda light chain myeloma. Treatment with melphalan and prednisolone resulted in remission of both myeloma and myopathy.

Oesophageal lichen planus.

A 50-year-old woman with severe oral lichen planus complained of painful dysphagia. Fiberoptic endoscopy revealed erosive lichen planus of the oesophagus which responded to treatment with systemic corticosteroids.

A retrospective evaluation of mediastinal tomograms, isotope liver scans, and isotope bone scans in the staging and management of patients with lymphoma.

The influence of mediastinal tomograms and isotope scans of liver and bone on the initial staging and management of patients with lymphoma has been studied. There appears to be only a small role for these investigative procedures, and it is suggested that considerable savings in time and money can be made by a more judicious use of these techniques.

A pilot study of cyclical chemotherapy with high-dose methotrexate and CHOP (MTX-CHOP) in poor-prognosis non-Hodgkin's lymphoma (NHL).

In a pilot study of cyclical chemotherapy in patients with poor-prognosis non-Hodgkin's lymphoma (NHL), high-dose methotrexate (MTX) 1 g/m2 with folinic acid rescue was given as initial treatment and then between cycles of a single-arm CHOP combination administered every 4 weeks. Of 21 patients with previously untreated or minimally treated grade 2 (high-grade) histology stage II/III/IV NHL, 13 (62%) achieved complete remission (CR); the CR rate for stage III/IV patients was 56%. Of all 25 patients with grade 2 stage II/III/IV NHL, including previously treated patients, 16 (64%) achieved CR. The median follow-up of patients who completed treatment is currently 22 months and only 1 relapse has been recorded in the CR group. Only five of 24 grade 2 patients given the initial 'test' MTX failed to show any response, and eight patients achieved partial remission (PR) as a result of this single treatment. The response to MTX-CHOP in nine patients with grade 1 (low-grade) histology NHL was poor; only two achieved CR. These findings lend support to other data which indicate a useful role for MTX in the induction chemotherapy of advanced high-grade NHL, though the optimum dosage and drug sequence have yet to be determined.

Cimetidine: an advance in gastric ulcer treatment?

Sixty patients with endoscopically confirmed gastric ulceration took part in a single-blind trial of cimetidine 1 g daily compared with conventional treatment--namely, carbenoxolone in patients aged under 60 and Caved-(S) in those over 60. Twenty-nine patients received cimetidine: in 12 (41%) ulcer healing was complete after one month, in 26 (90%) healing was complete after two months, and all ulcers were healed after three months of treatment. In the under-60s, ulcers were healed in a greater proportion of patients given cimetidine than in those given carbenoxolone. The difference, however, was significant only at the 5% level, which owing to small numbers was of doubtful clinical validity. In the over-60s cimetidine and Caved-(S) were of similar efficacy. The 54 patients with healed ulcers are being followed up for two years; so far there have been 16 recurrences (30%). Further trials are needed, which should include maintenance treatment aimed at lowering the unacceptably high recurrence rate.

Plasma zinc after myocardial infarction.

Plasma levels of zinc and albumin have been measured for eight consecutive days in patients suffering chest pain due to myocardial infarction or myocardial ischaemia. A substantial diurnal variation has been found in both controls and patients. Plasma zinc falls after myocardial infarction reaching the lowest level on day 2, thereafter returning to normal by day 8. The lowest plasma zinc levels occur within 48 h of a myocardial infarction and in some patients herald the development of a serious cardiac arrhythmia. Plasma albumin falls progressively after myocardial infarction, being lowest on day 8. The fall in plasma zinc is not totally explained by the fall in plasma albumin.

Interpretation of serum creatine kinase in suspected myocardial infarction.

Serum creatine kinase (CK) was measured in blood donors, patients admitted to hospital with suspected myocardial infarction, and healthy hospital personnel to investigate the normal range, the daily variation in healthy people, and the effect of intramuscular injections of pentazocine or diamorphine.There was considerable daily variation in the healthy controls, apparently related to exercise. In defining both the normal range and the significance of day-to-day increases in the serum CK account should be taken of this factor. An upper limit of normal of 210 IU/1. Should apply to previously ambulant patients and of 165 IU/1. to patients previously at rest. An increase greater than 85% in successive daily values is uncommon in health.Intramuscular injections of both pentazocine and diamorphine caused a significant rise in the serum CK in six out of 25 patients. The highest rise observed was from 64 IU/1. to 395 IU/1. Caution is therefore urged in the diagnosis of myocardial infarction from the serum CK values when these intramuscular injections have been given.