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We describe three patients with severe refractory cutaneous polyarteritis nodosa, resulting in painful ulcers involving the lower limbs and causing toe necrosis. Due to the severity of the cutaneous manifestations, the three patients received intravenous immunoglobulins at a dose of 1 g/kg/day for 2 days monthly. After the second intravenous immunoglobulin infusion, skin signs dramatically improved and completely healed after the third intravenous immunoglobulin infusion. Our findings indicate that intravenous immunoglobulins can be included in a therapeutic strategy to treat refractory cutaneous polyarteritis nodosa.

Resume Introduction La mise en place de cliniques d’anticoagulants et d’aide a la gestion informatisee des traitements anti-vitamine K (AVK) a permis une amelioration du controle des International Normalized Ratios (INR) et son corollaire, une diminution de la mortalite et de la morbidite hemorragiques secondaires a la prise d’AVK. Nous rapportons les resultats obtenus depuis cinq ans au sein d’un centre de suivi et de conseil des traitements anticoagulants (CSCTA) developpe en medecine liberale ambulatoire qui utilise un logiciel informatique d’aide a la prescription. Methodes Etude de suivi de cohorte regroupant 530 patients de medecine de ville (238 femmes) d’âge moyen 72 ans. Resultats Les troubles du rythme cardiaque (55 %), les valvulopathies et la pathologie thromboembolique (30 %) representaient les principales indications d’anticoagulation. Les patients recevaient du fluindione (80 %), de la warfarine (13 %) ou de l’acenocoumarol (7 %). Les durees de traitement etaient dans 54 % des cas superieures a un an et dans 25 % des cas superieures a trois ans. Les patients passaient en moyenne 72 % du temps dans la cible therapeutique (INR 2–3), 16 % au-dessus et 12 % au-dessous de cette cible. Ces pourcentages etaient respectivement de 82 %, 17 % et 1 % pour toutes cibles confondues (INR 1,5–4,5). Vingt-six hemorragies ont ete repertoriees (4,9 episodes hemorragiques pour 100 patients-annee) dont 1,3 episodes hemorragiques severes pour 100 patients-annee. Quatre accidents thrombotiques ont ete rapportes (0,75 evenements pour 100 patients-annee). Le delai moyen de controle entre deux INR etait de 19 jours pour les patients equilibres. Conclusion Les resultats du CSCTA sont conformes a ceux publies par les cliniques d’anticoagulants en matiere de temps passe dans la zone therapeutique et de complications hemorragiques. L’absence de groupe temoin n’autorisait pas une analyse medico-economique qui aurait permis d’estimer le benefice reel de cette structure.

Resume Introduction Nous rapportons un cas d’erytheme necrolytique migrateur associe a une maladie de Waldmann. Observation Un homme de 55 ans,ayant une maladie de Waldmann depuis 20 ans, a ete hospitalise pour une eruption du tronc et des membres, faite de lesions annulaires a contours polycycliques avec collerette de desquamation peripherique, evocatrice d’un erytheme necrolytique migrateur. Une alimentation enterale hyperprotidique et enrichie en acides gras a entraine une amelioration rapide de son etat cutane. Discussion La maladie de Waldmann est caracterisee par des lymphangiectasies intestinales responsables d’une enteropathie exsudative a l’origine de pertes protidiques et d’un defaut d’absorption des acides gras.La physiopathologie de l’erytheme necrolytique migrateur est imparfaitement comprise. L’hyperglucagonemie ne semble pas etre le seul mecanisme en cause. La survenue d’un erytheme necrolytique migrateur au cours d’une maladie de Waldmann renforce les hypotheses physiopathologiques actuelles suggerant le role de l’hypoprotidemie et du deficit plasmatique en acides amines dans l’erytheme necrolytique migrateur.

Summary Background Impaired regulation of apoptosis is known to be associated with the development of various cancers. Fas receptor (APO-1/CD95) binding to its ligand, Fas-ligand (Fas-L), has been shown to trigger apoptosis in various cell types. Objectives In this study, we examined CD95 and Fas-L expression on primary and metastatic melanoma cells from patients to investigate a potential correlation between these measures of apoptosis and different disease stages. Patients and methods Primary melanoma cells were obtained after surgical resection from 19 patients and metastatic cells from fine-needle aspiration of lymph nodes or palpable subcutaneous lesions in 25 patients. Normal skin cells were obtained at skin biopsy of 10 healthy donors. Results Flow cytometric analysis revealed that CD95 and Fas-L expression was detected in all the kinds of cell studied. In whole cell suspensions, CD95 expression was significantly higher (P , 0·0001) in normal skin cells than in melanoma cells, whatever the stage studied. By contrast, we observed an increase in Fas-L expression in melanoma cells compared with normal ones. Subsequently, using a double staining method, we studied these measures on HMB451 cells, a specific marker for melanoma cells, and found that CD95 expression was significantly higher (Pa 0·0005) in primary than in metastatic cells while Fas-L expression was significantly increased (Pa 0·0004) in metastatic compared with primary cells. Furthermore, a relationship was found between CD95 or Fas-L expression and Breslow thickness; as primary melanoma thickness progressively increased, the percentage of HMB451 CD951 cells decreased while that of HMB451 Fas-L1 cells concurrently increased. Conclusions These results suggest that downregulation of CD95 and upregulation of Fas-L in melanoma might be considered as concomitant with disease progression.

Tiapride is a substituted benzamide with selective dopamine D2 and D3-antagonist properties which appears to have preferential affinity for extra-striatal dopamine receptors. Tiapride is used in the treatment of agitation, aggressiveness and anxiety in the elderly. To define the effects of a single dose of tiapride 100 mg on psychomotor peformance and cognitive functions and electroencephalogram (EEG), a randomized, double-blind, three-way crossover, placebo-controlled study using lorazepam 1 mg as a positive control was carried out in 12 elderly individuals (six women and six men, mean age ± SD: 69 ± 3 years). A 1-week wash-out interval was allowed between each administration. Psychomotor and cognitive functions were assessed using both objective [EEG, critical flicker fusion, simple reaction time, tapping, body sway, continuous performance task (CPT), digit symbol substitution test, Sternberg memory scanning and a learning memory test using word lists] and subjective (visual analogue scales) measures before and up to 6 h after dosing. Tiapride was devoid of any detrimental or sedative effects on EEG and all of the performance tasks used and did not impair memory compared withplacebo. In contrast, a single dose of lorazepam produced significant deleterious effects on psychomotor performance (decrease in tapping and in sustained attention (CPT) and an increase in reaction time and body sway), and sedative effects on EEG (significant increase in delta and decrease in alpha waves) as well as significant impairment in working memory (Sternberg) and anterograde amnesia (decrease in immediate and delayed free recall) up to 6 h after dosing compared with placebo and tiapride. In conclusion, the present study showed that in contrast to lorazepam 1 mg there is no evidence to suggest that a single dose of tiapride 100 mg has any sedative and amnestic effects in the elderly which may interfere with everyday life activities.

We have previously demonstrated that transfected hepatocellular carcinoma cells (Hepa1-6) with one copy (pAGO) and two copies (pYED) of the HSVtk gene, using liposomes, induced cell death of untransfected cells in the presence of ganciclovir (GCV). This phenomenon is called the 'bystander effect'. To determine whether an elevated level of connexin43 increases the bystander effect, we have cotransfected Hepa1-6 cells with a plasmid containing the HSVtk gene driven by the alpha-fetoprotein promoter (pFTK) or pAGO or pYED and connexin43. The results showed that, after GCV treatment, the percentage of growth inhibition was higher (25-30%) in cells cotransfected with HSVtk and connexin43 than in cells transfected only with HSVtk gene. The IC50 of GCV on cells transfected with pFTK/Connexin43 was 17.85-fold lower than cells transfected with pFTK alone. To improve these results, stable connexin43 transduced Hepa1-6 cells were transfected with pFTK followed by GCV treatment. In this case, the cell growth was markedly inhibited as compared with parental cells. Furthermore, we have studied the correlation between the expression of the HSVtk and the connexin43 proteins. Using flow cytometric analysis, scrape loading/dye transfer and immunoblotting assay we found that the cells transfected separately by pAGO, pYED, pFTK and pLTR-Cx43 showed an increase of connexin43 protein. This study indicates that transfecting Hepa1-6 cells with both connexin43 and HSVtk genes up-regulates connexin43 expression which enhances the bystander effect and subsequently tumor cell death.

Fotemustine and dacarbazine constitute the most active single chemotherapeutic agents in the treatment of melanoma. In this phase II study we evaluated the activity and toxicity of a combination of fotemustine, dacarbazine and vindesine as a means of increasing response rate and survival time. Between September 1989 and November 1993, 43 patients with advanced melanoma were treated with a combination of 100 mg/m2 fotemustine on days 1 and 8, 250 mg/m2 dacarbazine on days 15 and 16 and 2 mg/m2 vindesine on days 15 and 16 as induction treatment. After a 5-week rest period, the patients exhibiting a response or stable disease received the same drugs administered once every 28 days as maintenance therapy until either progression or toxicity was observed. Among 41 evaluable patients, there were six complete responses and eight partial responses. The overall response rate was 32% (95% confidence interval: 18-46%), with 8 months median duration of response. Median survival time was 10 months. This regimen was well tolerated. From this large phase II study, we conclude that such a combination is active against advanced malignant melanoma and seems to be more effective than fotemustine or dacarbazine used alone, especially on visceral metastatic sites.

We describe three patients with severe refractory cutaneous polyarteritis nodosa, resulting in painful ulcers involving the lower limbs and causing toe necrosis. Due to the severity of the cutaneous manifestations, the three patients received intravenous immunoglobulins at a dose of 1 g/kg/day for 2 days monthly. After the second intravenous immunoglobulin infusion, skin signs dramatically improved and completely healed after the third intravenous immunoglobulin infusion. Our findings indicate that intravenous immunoglobulins can be included in a therapeutic strategy to treat refractory cutaneous polyarteritis nodosa.

Treatment of certain cancers by interleukin-2 (IL-2) and alpha interferon (INF) is currently widely-used in oncology and serious psychological side effects of such treatments have been reported. This study attempts to describe and analyse such side effects in a series of hospitalized cancer patients. Fifty-two patients undergoing a protocol of cisplatinum, intravenous interleukin-2 infusions and subcutaneous alpha interferon injections for metastatic melanoma and renal cancer were systematically screened for psychiatric disorders before, during and after each of four cycles of 4–5 day EL-2 infusions. Fatigue was constant and treatment-limiting in some cases and was highly correlated with depressive symptoms, which were very frequent at the end of the treatment cycle. Patients regularly showed varying degrees of obtundedness at the height of physical symptoms induced by IL-2. Some patients also had transient, predominantly hallucinatory deliria occurring or persisting several days after the termination of the infusions and complete resolution of concurrent somatic distress; neuroleptics were effective treatment. Certain lymphocyte phenotype counts (total lymphocytes, total CD8 cells, total T3s, stimulated Ts, non-stimulated Ts) correlated negatively with depressive symptomatology whereas fatigue tended to correlate negatively with polymorphonuclear leukocyte counts. Delirium correlated positively with total CD8 cells. Hallucinatory delirium, but not fatigue or depression, seems to be a direct cerebral effect of the interleukin-2α interferon combination that is not merely a consequence of the somatic effects. Patients undergoing lymphokine treatments should be carefully screened for psychological side effects and preventive or curative treatments should be given.

Anticoagulation clinics and computerized management of chronic oral anticoagulation increase the time spent in the therapeutic range with both mortality and morbidity reduction. Usually, anticoagulation clinics are hospital-based medical care centers. We report the five-year results from a general medicine center (CSCTA) using a computer-assisted management.A prospective cohort observational study of 530 primary care patients that were receiving long term oral anticoagulation.Cardiac arrhythmia (55%), heart valve disease and venous thrombo-embolic disease (30%) represented the most common indications of oral anticoagulation. Patients received fluindione, warfarin and acenocoumarol in 80%, 13% and 7%, respectively. The duration of treatment was at least one year in 54% of the cases, and was at least three years in 25% of the cases. The rate of patients that were in average within the therapeutic range (INR 2-3) was 72%, while 12% were under and 16% over the therapeutic range. Corresponding rates were 82, 17 and 1% respectively for all anticoagulation targets (INR 1.5-4.5). Twenty-six bleeding events (4.9 per 100 patient-years) and four thrombotic complications (0.75 per 100 patient-years) occurred. Life-threatening hemorrhage occurred in 1.3 per 100 patient-years. After the equilibration of the anticoagulation, the average delay of control between two consecutive INR was 19 days.The results obtained with CSCTA were similar to those reported by other anticoagulation clinics regarding hemorrhagic complications and time spent in the therapeutic range. In contrast, thrombotic events were less frequent. Because of the absence of a control group, a medico-economic analysis could not be performed.

A variety of molecules with novel mechanisms of action are currently being evaluated for their potential as treatments for sleep disorders. The GABA-A receptor complex remains an important target for hypnotic drugs (eg gaboxadol, indiplon). However, drugs acting through histamine, calcium channels and serotonin receptors may also be of interest for the treatment of insomnia. In the case of the 5HT2A subtype of serotonin receptors, several molecules which improve sleep maintenance and modify sleep architecture by increasing slow wave sleep are currently being tested (eg eplivanserin). Two new drugs with efficacy in excessive sleepiness (modafinil, sodium oxybate) have improved the treatment of this condition. However, the mechanisms of action of these agents are poorly understood. The recent discovery of the hypocretin arousal system in the hypothalamus may aid the identification of additional new drugs. An agonist at receptors for the pineal hormone melatonin is available in some countries (ramelteon) but is currently used only for the treatment of insomnia associated with difficulties of sleep onset. Additional melatonin receptor agonists are being developed and may have potential for treating several conditions including circadian rhythm disorders and depression.

We report a case of necrolytic migratory erythema in a patient with Waldmann's disease.A 55-year-old male patient with a history of Waldmann's disease was hospitalized for a rash on the trunk and limbs comprising annular polycyclic lesions with peripheral scaling evocative of necrolytic migratory erythema. High-protein and fatty-acid-supplemented parenteral feeding led to rapid improvement of the patient's cutaneous lesions.Waldmann's disease is characterized by intestinal lymphatic abnormalities leading to exudative intestinal disease causing protein loss in the bowel lumen and deficient fatty acid absorption. The pathogenesis of necrolytic migratory erythema is not fully understood. Increased serum glucagon does not appear to be the only mechanism involved. The occurrence of necrolytic migratory erythema in a patient with Waldmann's disease supports the current physiopathological hypothesis of the role of decreased plasma protein and amino acid levels in necrolytic migratory erythema.

The clinical activity and toxicity of the triple combination of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ), cyclophosphamide, and cisplatin was assessed in both previously treated and untreated women with advanced ovarian carcinoma. Paclitaxel 175 mg/m2 was administered over 3 hours following standard premedication (prednisolone, dexchlorpheniramine, and cimetidine). Cisplatin 80 mg/m2 and cyclophosphamide 600 mg/m2 were given 6 to 12 hours after paclitaxel. Treatment was given at 3-week intervals for six cycles. Twenty-seven patients entered the study; 23 were evaluable for toxicity and 17 for response. Paclitaxel appeared to add additional efficacy to the standard cisplatin/cyclophosphamide regimen. Both the overall and complete remission rates were very high (88% and 70%, respectively), and histologically confirmed complete remissions exceeded 60%. Longer follow-up is needed to determine the duration of these responses. The primary toxicities included leukoneutropenia, peripheral neuropathy, asthenia, and alopecia. Only two of 23 patients withdrew because of toxicity, however, and only two treatment cycles were complicated by neutropenic fever requiring intravenous antibiotics. No life-threatening toxicities were encountered, although the peripheral neuropathy was poorly and slowly reversible and may have a significant impact on the patients' quality of life.

In this phase I/II study, we assessed the impact of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) in the treatment of advanced ovarian carcinoma combined with the standard regimen cisplatin/cyclophosphamide given as follows: paclitaxel 175 mg/m2 (over 3 hours perfusion with standard premedication), cisplatin 80 mg/m2 (6 to 12 hours after paclitaxel), and cyclophosphamide 400 mg/m2. From February 1994 to January 1996, 27 patients (median age, 55 years; age range, 35 to 74 years) were entered into the study. Eight patients had distant metastases and 19 had early locoregional disease (stage III, 18 patients; stage IC, one patient). Twenty-two patients had undergone prior surgery (simple biopsy, six patients; optimally debulked, nine patients; suboptimally debulked, seven patients). Twenty-one patients had received no prior chemotherapy and six were previously treated with at least one platinum-based regimen. A maximum of six courses of paclitaxel/cisplatin/cyclophosphamide were given every 21 days. Twenty-three patients were evaluable for toxicity: neutropenia (World Health Organization grade 3/4), 91% of patients; thrombopenia (World Health Organization grade 3/4), 13% of patients; two episodes of neutropenia with fever; and neurotoxicity grade 3, 17% of patients. Alopecia grade 3 was reported in all patients. No hypersensitivity reactions and no cardiac toxicity was observed. Among 17 patients evaluable for response (patients with stage IV disease or stage III suboptimally debulked), 12 (70%) clinical complete responses (CRs) and three (18%) partial responses were observed. Among the 12 patients with CRs, 10 underwent second-look laparotomy and seven of them (70%) achieved a pathologic CR. In the group of 11 chemotherapy-naive patients evaluable for response, eight (72%) achieved a CR and three (28%) achieved a partial response. This combination seems to be safe, with very acceptable toxicity, and also seems to be highly active in the treatment of patients with advanced ovarian carcinoma.

Prognosis in metastatic malignant melanoma is poor because of chemo and radiotherapy resistance. However, some drugs, such as dacarbazine, cisplatinum or fotemustine, a new nitrosourea, have produced a response rate of more than 20%. Combining these drugs increases response rate to 30-40%. Immunotherapy by interferon-alpha 2 shows about 15-20% response rate but interleukin-2 would be more effective especially in combination with cisplatinum and interferon-alpha 2 with 50% response and long survival after cessation of treatment.

The antiviral drug ganciclovir (GCV) is toxic for mammalian cells transfected with the herpes simplex virus thymidine kinase (HSVtk) gene. To improve the results obtained by our group previously on nonviral transfection of tumor cells, we have examined here in vitro virus-free transfection of murine B16 melanoma cells via lipofectamine-nucleic acid complexes carrying either HSVtk gene transcripts or plasmid DNAs containing single and double copies of the HSVtk gene. The HSVtk gene transcripts as well as plasmids containing the HSVtk gene(s) rendered cells sensitive to GCV treatment. Tumor sensitivity to GCV conferred by the HSVtk gene transcripts was of the same level as the sensitivity conferred by plasmid DNAs containing a single copy of the HSVtk gene. However, when the plasmids containing double copies of the HSVtk gene were used, sensitivity to low GCV concentrations increased dramatically. One could appreciate this finding as an essential advantage of the plasmids containing double copies of the HSVtk gene since it allows use of the GCV concentration range which is common in clinical applications.

The involvement of interleukin (IL-) 6 in malignant disease has been investigated in a variety of different malignancies. To evaluate whether serum IL-6 is a useful disease marker in metastatic malignant melanoma (MMM), we studied the time course of endogenous IL-6 secretion in 41 patients treated with cisplatinum, IL-2, and IFN-alpha. Furthermore, the relationship of endogenous IL-6 concentrations to the tumor burden and/or the clinical response was also evaluated. The baseline serum IL-6 levels were significantly higher in patients with MMM than in the control group (P = 0.002). When tumor burden was taken into consideration, we found that IL-6 levels were higher in patients with high tumor burden than in patients with low tumor burden. During treatment in the whole patient population, a higher serum IL-6 level was observed in nonresponding as compared to responding patients at days 7 (P = 0.0005), 21 (P = 0.002), and 35 (P = 0.009). The follow-up of serum IL-6 in patients with MMM according to the tumor burden and clinical response demonstrated that: (a) IL-6 levels were significantly higher at days 7 and 21 in patients with high tumor burden as compared to those with low tumor burden; and (b) IL-6 levels remain significantly higher in nonresponding patients as compared to responding patients regardless of the tumor burden. From these results, we can conclude that endogenous IL-6 may play a role in the failure of IL-2 therapy in such patients, since the very early IL-6 increase is correlated with the tumor mass and nonresponse to biochemotherapy. Therefore, it seems that the early detection of endogenous IL-6 may represent valuable information for monitoring the response to biochemotherapy in patients with MMM.

There is a substantial interest in the role of antineutrophil antibodies since Fc gamma receptors (Fc gamma Rs) have been identified as the target for the majority of such autoantibodies. Antineutrophil antibodies have long been detected by an indirect immunofluorescence technique. Following optimization of the flow cytometric method of detection, we developed three enzyme-linked immunosorbent assays (ELISAs), each specific for autoantibodies against one of the three classes of human Fc gamma R. Fc gamma RI and Fc gamma RII were purified from cultured cells, and Fc gamma RIII was produced as a recombinant molecule. These were then used as capture agents in the respective ELISAs. When applied in parallel to a sizeable group of patients with primary Sjögren's syndrome, both methods established that anti-Fc gamma R autoantibodies were heterogeneous. This finding indicates that different populations of partly cross-reactive antibodies are detectable by these two methods.

The aim of the study was to use a virus-free system to transfer the Herpes Simplex Virus-thymidine kinase (HSV-TK) gene in mice bearing melanoma tumours. B16 Fl murine melanoma cells were injected subcutaneously. On days 11 and 14, an intratumoral injection of either naked plasmid containing the HSV-TK gene (PAGO) or PAGO-lipofectamine complexes was given. Ganciclovir (120 mg/kg/day) was given for 5 days starting on day 14. Tumour weight reduction (40-50%) was observed in treated animals versus different control groups. Moreover, histopathological analysis on tumours showed large areas of cavitary necrosis (85%) in treated groups compared to controls (10%). Using a simple and safe method, the results presented here demonstrated that virus-free mediated delivery of the HSV-TK gene is efficient in viva in murine malignant melanoma. Copyright 0 1996 Elsevier Science Ltd

Monoclonal light and heavy chain deposition disease is a rare syndrome distinct from light chain amyloid, which is defined by the presence of monoclonal deposits of immunoglobulins in various tissues.A 65-year-old man presented with renal symptoms due to membranoproliferative glomerulonephritis, associated with urticarial papules located on the arms and back. Histological examination of a skin biopsy specimen showed lymphocytic vasculitis. Direct immunofluorescence examination of kidney and skin lesions using anti-gamma 2 and anti-Kappa monoclonal antibodies, showed a similar staining on the basement membrane zone and vessel walls.As far as we know, this is the first documentation of monoclonal light and heavy chain deposition disease associated with a lymphocytic skin vasculitis and renal involvement caused by similar monoclonal deposits of immunoglobulins in the kidney and skin.

SUMMARY Using flow cytometry, cellular IL-2 receptors were studied before and following chemoimmunotherapy combination in 20 patients with metastatic malignant melanoma (MMM). Patients received cisplatin (100 mg m2) at days 1 and 28, recombinant IL-2 by continuous infusion from days 3 to 6, 17 to 21, 31 to 34, and 45 to 49. Interferon-alpha (IFN-α) was given subcutaneously three times weekly. In terms of clinical response, we observed 55% objective response (complete: 15%), When pretreatment blood samples were compared with those of healthy donors, we did not observe any change in low (α chain) and high affinity receptor (α+β) expression. In contrast, intermediate affinity p75 (β chain) expression was decreased significantly (P ≤ 0.0001) in MMM patients. During treatment, we found a dramatic increase of β chain as well as high affinity (α+β) expression in responding patients, as soon as IL-2 therapy began. Furthermore, the increase of β chain expression was limited to natural killer (NK) cells (CD56+). In non-responding patients, on the other hand, increase of both receptors was seen only at day 31. These data suggest the involvement of β chain expression in the mechanism of cell activation after chemoimmunotherapy. Moreover, this early 3 chain expression is correlated with the clinical response to chemoimmunotherapy.

A measurement of cell DNA content would be highly useful in determining the malignant nature of thyroid tumours in cases without distinctive features such as metastases, capsule invasion or emboli. Abnormal cell ploidy can be recognized with flow cytometry, but it is not known whether such results have diagnostic value. We therefore compared--in a double blind prospective study--the results of flow cytometry and pathologic diagnosis in fresh tumoural and non-tumoural thyroid cells.Fifty unselected cold thyroid nodules were obtained from 50 consecutive patients (40 women, 10 men; age 18-80 years; mean 46) who underwent surgery within a 6 month period. Surrounding non-tumoural tissue was also obtained in 46 of them. Cell ploidy and the percentage of cells in each cell phase was determined with flow cytometry for both tumoural and nontumoural tissues. Two pathologists, unaware of the flow cytometric results, independently established the histologic diagnosis according to the WHO classification.The pathologic diagnosis was carcinoma in 7 cases (papillary carcinoma 6, vesicular carcinoma 1) and benign adenomas in 43 (29 macrovesicular, 11 microvesicular, 3 oncocytal). All the non-tumoural tissue samples were diploid. All 7 carcinomas were diploid and 10 of the 43 benign adenomas were aneuploid (4 near-diploid, 3 hyperploid, 1 near-tetraploid, 2 multiploid). The mean proliferation index was increased in 5 diploid tumours.These findings confirm that cell ploidy measured by flow cytometry is of no diagnostic value in the thyroid gland. It was also revealed that aneuploidy in adenomas may be related to tissue rearrangements of undetermined prognostic significance.

SUMMARY Immunological parameters following chemoimmunotherapy combination were studied in 31 patients with metastatic malignant melanoina. They received Cisplatni (100 mg/m2) on day 1 and 28, recombinant IL-2 (rIL-2; Eurocetus) in continuous infusion from day 3 to 6, 17 to 21, 31 to 34 and 45 to 49. Interferon-alpha (IFN-α: Roche) was given subcutaneously three times weekly. No significant change in CD4/CD8 ratio at onset or during treatment was observed between responder (n=19) and non-responder (n=12) patients. Regarding the IL-2 receptor (IL-2R) study, the percent age of cells expressing Tac(p55)receptor did not change either for healthy volunteers (n=20) and patients before any therapy, or between responder and non-responder patients. Concerning serum soluble IL-2R shedding before therapy. we observed A significant increase (P=0·001) in patients (79±40 pM) compared with healthy donors (30±15 pM), but no significant variation was seen between responder and non-responder patients. In contrast, during the treatment, the soluble IL-2R level increased in both groups but, interestingly, a significant difference was found between responder and non-responder patients from day 7 (P

Fifty patients (41 females and 9 males, ranging in age from 12 to 79 years) with systemic lupus erythematosus (SLE) and 20 normal controls were evaluated for the presence of plasma cell-free Fc gamma receptor III (Fc gamma RIII) using an ELISA based upon a sandwich of two monoclonal antibodies. The standard curve was obtained with serial dilutions of recombinant Fc gamma RIII. In the patients, the cell-free Fc gamma RIII levels ranged from to 1.76 micrograms/ml, while it did not exceed 0.21 microgram/ml in the controls. Assuming that the cutoff is 0.25 microgram/ml, 11 SLE patients and no controls had elevated cell-free Fc gamma RIII levels in the serum. Among the SLE patients, the level of cell-free Fc gamma RIII was significantly lower (p = 0.05) in 4 patients with sicca syndrome than in the remaining 46. Furthermore, cell-free Fc gamma RIII levels appeared to be lower in 11 patients with renal involvement than in those without. For the biological parameters, we observed that the 27 patients who presented lymphopenia also had a lower level of cell-free Fc gamma RIII when compared to the 23 patients without lymphopenia (0.09 +/- 0.19 versus 0.35 +/- 0.52 microgram/ml; p = 0.05). Circulating cell-free Fc gamma RIII may originate from shedding by presumably activated polymorphonuclear cells.

The ominous prognosis of metastatic malignant melanoma has led to a large number of clinical treatment trials [1, 2]. Some improvement in terms of response rate seems to have been achieved, but the main question asked by clinicians remains: is there a biological predictive factor for the therapeutic response to IL-2 therapy ? It is now well established that IL-2 plays a pivotal role in the immune response, both in its own receptor expression and other cytokine release. To exert its biological effect, IL-2 interacts with specific membrane receptors. Three types of IL-2 binding sites have been described: a 55 kD protein (α-chain, TAC) low-affinity receptor unable to deliver a signal to the cell, a 70 kD (β-chain) intermediate-affinity receptor which can transduce a signal and a high-affinity receptor made up of both the p 55 and p 70 molecules. More recently a third receptor has been cloned: 7-chain. Moreover, activated T cells release a truncated form of the γ-chain molecule as a soluble Interleukin-2 receptor (sIL-2R) [3, 4]. We report here the study of immunological events both cellular and humoral following CDDP, IL-2 and Interferon-α in 31 patients treated for malignant metastatic melanoma.

Neo-Adjuvant chemotherapy in breast cancer means that chemotherapy is used as the first therapeutic tool and that the locoregional treatment is considered as an adjuvant. The term has been contested and others were proposed, but induction treatment is too specific for the first chemotherapy combination used in leukemia to achieve complete remission. Primary treatment does not encompass the consolidation phase which belongs to our strategy so that even if it is not quite satisfactory we keep the term Neo-Adjuvant which has been coined in the seventies by E. Frei for head and neck cancers.

Psychoneuroimmunology is a fast-growing field that explores the relationship of psychological factors and the immune system. In particular, much research has focussed on the impact of psychological events on immune parameters. An equally interesting but less studied situation, however, is the occurrence of psychological side effects after administration of immune substances in humans. In this regard, lymphokines could be of particular interest, since they are regularly used to treat certain cancers. One such substance is Interleukin-2 (IL-2), which is often infused in metastatic cancer patients at substantial doses over several days. Such infusions represent a unique, « quasi-experimental » opportunity to study the psychological side effects accompanying the lymphokine. However, IL-2 is rarely the sole therapeutic agent used in the cancer setting (Siegel & Puri, 1991). In particular, α-Interferon (INF) is often co-administered.

We have recently shown that serotonin (5-HT) stimulates cortisol secretion from human adrenocortical tissue in vitro through activation of 5-HT4 receptors. The aim of the present study was to investigate the effect of the 5-HT4 agonist racemic zacopride on aldosterone secretion from the human adrenal gland in vivo and in vitro. In vivo studies were conducted on 28 healthy volunteers pretreated with dexamethasone. The subjects received a single oral dose of placebo, 10 micrograms zacopride, or 400 micrograms zacopride. Plasma aldosterone levels increased significantly within 90 min after the administration of 400 micrograms zacopride, remained elevated for 60 min, and gradually returned to the baseline within 180 min. In contrast, the administration of 10 micrograms zacopride or placebo did not modify the aldosterone concentration. No significant changes were observed in renin, ACTH, or cortisol levels. In vitro studies were conducted on perifused human adrenocortical slices. Administration of 20-min pulses of zacopride (from 10(-11) - 10(-6) mol/L) induced a dose-dependent increase in aldosterone secretion. The minimal effective dose was 10(-10) mol/L, and half-maximal stimulation was obtained with a dose of 7 x 10(-8) mol/L. Zacopride was 100 times more potent in stimulating aldosterone than cortisol release. Taken together, the present data suggest that 5-HT-evoked aldosterone secretion involves the activation of 5-HT4 receptors.

A sandwich enzyme-linked immunosorbent assay was developed to assess Fc-gamma receptor III (Fc gamma RIII), based on a combination of two non-competing monoclonal antibodies. This receptor was detectable in the serum of eight out of 23 patients with primary Sjogren's syndrome and two out of 23 normal controls. The proportion of Fc gamma RIII-carrying polymorphonuclear (PMN) cells was lower (P < 0.05) in the patients with cell-free Fc gamma RIII (90.4 +/- 7.5%) than in the remainder (84.8 +/- 8.3%). The PMN cell functions were evaluated and the diminished adherence (71.7, geometric mean) and chemotaxis (1.23) paralleled the Fc gamma RIII release. The relative inefficiency of PMN cells in SS might be due to phagocytosis of immune complexes.

Optimistic results were obtained in the treatment of 39 patients with surgically incurable metastatic malignant melanoma using a regimen including 2 to 3 monthly induction cycles of cis-diamminedichloroplatinum (CDDP), recombinant interleukin-2 (rIL-2) and interferon alpha-2a (IFN alpha-2a). 33 of 39 patients were pretreated with chemotherapy (dacarbazine and/or fotemustine:31, CDDP:6) and 17 of 39 with IFN alpha-2a. Overall response rate was 54% with 13% achieving a complete response for up to 59+ weeks. Moderate to severe side-effects were reversible on rIL-2 cessation and toxicity was manageable in a routine inpatient setting. These results are especially encouraging as they were seen in previously treated patients, classically low responders, including 3 who were resistant to cisplatin or other platinum complexes. The question remains if this regimen bypasses traditional mechanisms of drug resistance.

A patient with refractory human immunodeficiency virus (HIV)-related immune thrombocytopenic purpura (ITP) was treated with 3G8 (anti-CD16) monoclonal antibody on days 1, 3, and 8 (25, 25, and 50 mg were administered intravenously, respectively). Side effects were those expected after the administration of a xenogenic protein, but a severe bone pain occurred from the second injection. At the time of the initiation of the treatment the platelet count was 20,000/mm3 and the absolute CD4 number was 100/mm3. We obtained a long-term correction of thrombocytopenia and, to a lesser extent, there was a stabilization of CD4 lymphocytes for 18 months. We observed a significant stimulation of natural killer (NK) function and an elevation in the serum level of tumor necrosis factor alpha, interferon gamma, and granulocyte-macrophage colony-stimulating factor. This suggests that in HIV-related ITP the removal of platelets is mediated by low-affinity Fc gamma receptors (CD16). The stimulation of NK function and elevation in CD4+ lymphocytes may be related to the production of cytokines by activated human NK cells through the interaction of their CD16-bearing receptor with the 3G8 monoclonal antibody. This observation warrants confirmation and further clinical trials.

Between 1980 and 1992, 457 consecutive patients with initial breast cancer entered two successive protocols combining neoadjuvant chemotherapy, hormonotherapy (tamoxifen) and locoregional radiotherapy (teleradiotherapy and boost by iridium) as exclusive locoregional treatment. Cytological diagnosis, hormone receptors, cytological grading were provided by fine needle aspiration. Both protocols included velbe, thiotepa, methotrexate, 5FU and adriamycin with some minor differences regarding the schedule of doses and their number during induction and during the consolidation phase. In both studies, over 50% patients had locally advanced breast cancer (IIb, IIIa or IIIb). Chemotherapy induced tumor regression over 50% in 91% patients of the first protocol (30% complete clinical remission CR) and in 94% patients of the 2nd protocol (40% CR): in this protocol 20 poor responders were given a rescue protocol (2 CR; 9 partial remissions). The 5 year actuarial rate of breast preservation is 94% and the 5 year actuarial rate of local relapses is 15%. The cosmetic results according to Danoff are excellent 20%, good 55%, mean 35%. Disease free survival and overall survival compare favorably to published data: they depend on TNM stages, tumor differentiation and chemotherapy induced early tumor regression.

3548 Background: the aim of this study was to evaluate the different Computed Tomography (CT) parameters, characterizing tissue perfusion by contrast medium in metastatis to define their relation w...

Two hundred fifty evaluable patients with breast cancer entered a protocol combining neoadjuvant and consolidation therapy by vinblastine (V), thiotepa (T), methotrexate (M), and 5-fluorouracil (F) (VTMF), with or without Adriamycin (A) (doxorubicin; Adria Laboratories, Columbus, OH), and radiation therapy as exclusive locoregional treatment. Tamoxifen was given to 195 patients (130 postmenopausal and 65 premenopausal) and was omitted in 55 patients (31 postmenopausal and 24 premenopausal). There were 19 Stage I, 86 Stage IIA, 51 Stage IIB, 36 Stage IIIA, and 58 Stage IIIB patients. Primary chemotherapy induced tumor volume regression of more than 75% in 41% of the patients and complete clinical regression in 30% of the patients. The 5-year disease-free survival (DFS) rates were 100% for Stage I, 82% for Stage IIA, 61% for Stage IIB, 46% for Stage IIIA, and 52% for Stage IIIB patients. Among the 72 primary relapses there were 39 distant metastases. The actuarial rate of locoregional recurrence was 13% for T2, 18% for T3, and 19% for T4. At 5 years the rate of breast preservation was 94%. Cosmetic results were excellent or good for most patients. The 5-year overall survival (OS) rates were 95% for Stage I, 94% for Stage IIA, 80% for Stage IIB, 60% for Stage IIIA, and 58% for Stage IIIB. Most patients with breast cancer should be given the option of breast-preserving treatment.

8540 Background and aims: Circulating vascular endothelial growth factors (VEGFs) and their receptors (VEGFRs) were described as prognostic factors in several cancers. The aim of this study is to evaluate the prognostic values of these parameters in metastatic malignant melanoma diseases. Methods and Patients: Using enzyme-linked immunosorbent assays, VEGFs (A, C, D) and their receptors (1, 2, and 3) were measured in sera of 75 patients with metastatic malignant melanoma in comparison to 30 healthy controls. Disease free survival (DFS) and overall survival (OS) were calculated from the beginning of the treatment until either the progression or the death and analyzed using the Kaplan-Meier method. Results: Pretreatment median sVEGF-A, sVEGF-C as well as VEGFR-3 levels were significantly higher in MMM patients as compared to healthy ones p=0.0017, p=0.005, p2=6.64, p= 0.014) and overall survival (χ2=8.03, p= 0.0046). Conclusions: Our results suggest that, in metastatic malignant melanoma patients, soluble VEGF-A and VEGF-R3 pretreatment levels may prospectively identify high-risk patients with a worse prognosis; serum VEGFR-1 level may be a predictive factor of time to progression and overall survival. A multivariate analysis (Cox test) is ongoing in order to confirm if this parameter is an independent prognostic factor. No significant financial relationships to disclose.

18004 Background: The presence of metastases is a strong indicator of poor survival in many types of cancer. It has recently been shown that vascular endothelial growth factor-C (VEGF-C), and its receptor Flt-4 (VEGF-R3) are increased in a variety of tumours and may play a pivotal role in the promotion of metastasis. We previously demonstrated that high soluble VEGF-C level was correlated to high tumor burden. Objectives: This study was designed to i) detect and evaluate whether soluble VEGF-R3 play a role in metastatic malignant melanoma patients ii) to determine if they have any relationship with clinicobiological parameters, clinical response and survivals. Methods: Using a sensitive enzyme-linked immunosorbent assays, VEGF-R3 was retrospectively measured in sera of 60 patients with a fully documented history of melanoma disease in comparison with 30 healthy controls. Disease free survival (DFS) and overall survival (OS) were calculated from the beginning of treatment until either the progression (DFS) or death (OS) and analyzed using the Kaplan-Meier method. Results: Pretreatment circulating VEGF-R3 was detectable in all samples from either melanoma patients or healthy donors. Furthermore, median level of sVEGF-R3 was significantly higher (p = 0.000015) in melanoma patients as compared to healthy donors. (38890 vs 30773 pg/ml respectively). No significant association was noted between sVEGF-R3 levels and gender, age or LDH level. Median serum VEGF-R3 level was significantly higher in patients with high tumor burden as compared to patients with low tumor burden (p = 0.045). The pretreatment sVEGF-R3 level was significantly different (p = 0.025) between responder (n = 27) and non-responding patients (n = 33). Lastly, the relapse-free survival was higher in the group with low sVEGF-R3 concentration compared to the high one’s (14.1 vs 11,9 months) as well as for OS (14.3 Vs 12.6 months) but theses differences were not significant (χ2 = 2,30, p = 0.12 & χ2 = 0.74, p = 0.37 respectively). Conclusion: these results suggest that high pretreatment sVEGF-R3 level is related to bad prognosis in melanoma patients. No significant financial relationships to disclose.

8049 Background: Vascular endothelial growth factor (VEGF-A) and its circulating form (sVEGF-A) play a major role in tumor progression and angiogenesis. However, the clinical implications of circulating VEGF-A in metastatic malignant melanoma patients and its role in tumor-associated lymphangiogenesis and lymphatic metastasis remained unclear. Objectives: The aim of this study is to evaluate the potential role of circulating VEGF-A levels in lymphangiogenesis and its usefulness in metastatic malignant melanoma patients. Methods and Patients: using a sensitive enzyme-linked immunosorbent assays, VEGF-A level was measured in sera of 65 patients treated by biochemotherapy with a fully documented history of disease in comparison with 30 healthy controls. Results: A wide range (0- 566 pg/ml) of pretreatment sVEGF-A level was detected in the serum of MMM patients and the median level (40.5 pg/ml) was significantly higher (p=0.0007) than that of healthy donors (7.5 pg/ml). Age, gender and LDH were not associated with sVEGF-A levels. Regarding tumor burden, median pretreatment sVEGF-A level was higher in patients with high tumor burden (n= 40) as compared to patients with low tumor burden (n=25). Furthermore, the most surprising finding of our study was that patients with only lymph node metastasis (n=23) had a significantly (p= 0.021) higher median sVEGF-A levels (45.7 pg/ml) as compared to the 42 patients with different metastatic sites (16.6 pg/ml). Conclusion: these results suggest that sVEGF-A levels may predict lymph node metastasis in metastatic malignant melanoma patients. In addition, it may be promising targets for new therapeutic strategies in melanoma disease. No significant financial relationships to disclose.

7540 Background and Objectives: Angiogenesis is essential for tumor growth & metastasis. It is controlled by angiogenic factors, one of the most important being vascular endothelial growth factor (...

7541 Background: Vascular endothelial growth factor (VEGF) and its receptors (VEGFRs) play an essential role in tumor angiogenesis and are closely related with malignancies. However, the prognostic...

7551 Background and aims: Circulating vascular endothelial growth factor (VEGF), soluble EGFR and soluble interleukin-6 (IL-6) are associated with metastatic malignant melanoma disease. However, their relationship remains unclear. The aims of this study is to correlate serum IL-6 to sVEGF-A, or EGFR levels and to investigate the clinical significance of these parameters on the overall survival in metastatic malignant melanoma. Methods and Patients: using a sensitive enzyme-linked immunosorbent assays, VEGF-A, EGFR and IL-6 were measured in sera of 64 patients with a fully documented history of metastatic malignant melanoma patients in comparison with 30 healthy controls. Results: serum levels of VEGF-A, EGFR, and IL-6 were significantly increased in melanoma patients compared with healthy controls (p

7531 Background: high blood levels of vascular endothelial growth factor (VEGF) appear to be associated with a poor prognosis in advanced cancer, probably as a consequence of its angiogenic and immunosuppressive effects. The prognostic significance of serum VEGF levels and its variation during cancer treatment is still unknown. Objectives: The aim of this study is to evaluate the clinical usefulness of active serum vascular endothelial growth factor (sVEGF-A) levels in metastatic malignant melanoma patients and to investigate the possible relationship between sVEGF-A variations and clinical response during biochemotherapy. Patients and Treatment: The study included 73 patients with a fully documented history of metastatic malignant melanoma. Biochemotherapy consisted of Cisplatinum, rIL-2 and Alpha-interferon in two induction cycles. The assessment of clinical response was performed according to WHO criteria. Sixty seven patients were evaluable: 43 % (29/67) were responding (RC&RP) and 57 % were non-respo...