- Email: [email protected]
LEVAMISOLE IN THE TREATMENT OF CANCER
594 basis. The present findings of abnormal immunoglobulin-A metabolism are further evidence to support this hypothesis.
ciency
This work was Great Britain.
supported by
the Muscular
University Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, and University Department of Pathology, Western Infirmary, Glasgow
Dystrophy Society
of
PETER O. BEHAN
JOHN A. SIMPSON WILHELMINA M. H. BEHAN
HAZARDS OF PARENTERAL GLUCOSE IN NEONATAL LACTIC ACIDÆMIA SIR,-Infantile lactic acidaemia may result from defective activity of pyruvate carboxylase,’ pyruvate dehydrogenase
(p .D.H.), fructose-1,6-diphosphatase,3 phospho-enol-pyruvate carboxykinase,4 or cytochrome-C oxidase’ or from other, unknown, disorders. Our experiences with a patient with severe lactic acidaemia aggravated by parenteral administration of 10% glucose prompt us to report on the hazards of this procedure in metabolic acidosis of unknown origin. A full-term boy (birth-weight 2500 g) was admitted to a regional hospital an hour after birth. Apart from an enlarged firm liver, no’abnormalities were found. Plasma-glucose levels were normal, and feeding was started 3 h after birth. Glucose 5% was given twice, and, subsequently, a humanised-milk formula every 3 h. Respiratory depression occurred 26 h after birth, and an extreme metabolic acidosis was seen (blood pH 6-8). Glucose and bicarbonate were administered after insertion of an umbilical-artery catheter. The patient was referred to our hospital. On admission generalised oedema, petechiae, apathy, Kussmaul respiration, an enlarged liver, and muscular hypotonia were observed. Blood-pressure and peripheral circulation were normal. Deep-tendon, grasping, and suckling reflexes were absent. Chest X-rays revealed cardiomegaly and normal lungs. Blood composition and plasma-glucose were normal. An extreme uncompensated metabolic acidosis was present (artenal pH 6.95; PC02 25 mm Hg; P02 85 mm Hg). Plasma sodium 141 mmol/1, potassium 5.1mmol/l, chloride 95 mmol/l, and calcium 2.6 mmol/l. Plasma-uric acid was 0.91 mmol/1 (normal 023-043 mmol/1). Plasma-lactic-dehydrogenase was elevated at 1040 i.u./ml : isoenzymes (1) 24.55%, (2) 26.5%, (3) 24.7%, (4) 12.9%, (5) 11.4%. Bacteriological examination of blood and cerebrospinal fluid were normal. The most pronounced metabolic abnormalities are given in the
table. Plasma-lactic-acid 1.
(as determined by
gas
chromatography’)
Brunette, M. G., Delvin, E., Hazel, B., Scriver, C. R. Pediatrics, Springfield,
1972, 5, 702. 2. Blass, J. P., Avigan, J., Uhlendorff, B. W. J. clin. Invest. 1970, 49, 423. 3. Hülsmann, W., Fernandes, J. Pediat. Res. 1971, 5, 633. 4. Fiser, R. H., Harris, J. C., Melsher, L., Fisher, D. A. ibid. 1974, 8, 432. 5. Monnens, L., Gabreëls, F., Willems, J. J. Pediat. 1975, 86, 983. 6. Ghadimi, H., Pecora, P. Pediatrics, Springfield, 1964, 34, 182. 7. Wadman, S. K., van der Heiden, C., Ketting, D., Kamerling, J. P., Vliegenthart, J. F. G. Clinica chim. Acta, 1973, 47, 307.
very high and increased further despite therapy. Also several aminoacids were greatly increased. As soon as lactic acidacmia was established, the glucose infusion was withdrawn. Bicarbonate and pharmacological doses of the co-factors of the P.D.H. complex (thiamine-HCI, pantothenic acid, and lipoic acid) were administered parenterally, Nevertheless, the patient’s condition deteriorated. He died 2 h later after sudden cardiac arrest. Necropsy was not allowed. In a small percutaneous liver-biopsy specimen pyruvate decarboxylase was measured by a 14C02 formation from (1-14C) pyruvate and appeared not to be deficient (2.5 m., control 32 I.U.). Another component of the P.D.H. complex involved in the formation of acetyl-CoA could, however, still be deficient. In this type of infantile lactic acidaemia the administration of carbohydrate may result in accumulation of large amounts of pyruvic and lactic acids. Not enough material was available to test this hypothesis. The extreme exacerbation of lactic acidaemia was most probably caused by the parenteral administration of glucose 10%--a routine procedure in treatment of neonatal distress, Although the patient was examined soon after admission, the diagnosis was made too late for controlling the extreme acidæmia with bicarbonate after withdrawal of parenteral glucose, In non-hypoxaemic and normoglycaemic patients with nonrenal severe metabolic acidosis, no parenteral carbohydrate should be given until the organic acid produced is analysed by gas chromatography. In lactic acidxmia a balanced low-carbohydrate diet should be given. In hypoglycaemic non-hypoxxmic severe metabolic acidosis careful administration of carbohydrate and evaluation of its metabolic effects seems necessary,
was
University Children’s Hospital, Het Wilhelmina Kinderziekenhuis, Niewe Gracht 137, Utrecht, and Department of Biochemistry, Erasmus University, Rotterdam, The Netherlands
Rough estimation.
tMean +2s.D.6
R. CH. SENDERS J. M. J. LAMERS S. K. WADMAN
LEVAMISOLE IN THE TREATMENT OF CANCER
SIR,—Dr Rojas and his colleagues (Jan. 31, p. 211) described an increase in the median disease-free interval and an increased survival-rate at thirty months in patients with carcinoma of the breast who had been treated with radiotherapy followed by levamisole. A trial of this drug is in progress in this department in which levamisole has been given as the only treatment in patients with those types of cancer where immune responses might play a part in controlling the disease. Levamisole 50 mg three times daily for three days was repeated every two weeks in most patients, but lately the schedule was changed to 50 mg daily continuously. In 3 children with disseminated neuroblastoma there was no objective effect. Of 4 adults with disseminated malignant melanoma 3 failed to respond, but in the 4th a black subcutaneous mass reduced in size from 4 to 2 cm diameter over two months before regrowing. Nodules of breast carcinoma recurrent on the chest wall after surgery failed to respond in 4 out ofS patients, but in the 5th patient a 1 cm diameter nodule disap peared over the course of three months and remained inpalpable for another four months before reappearing. In 4 out of
ABNORMAL PLASMA-METABOLITES IN INFANT WITH SEVERE LACTIC ACIDAEMIA
*
J. P. VAN BIERVLIET
595 9 patients palpable axillary nodes found shortly after simple mastectomy failed to respond. In 4 patients the nodes reduced to at least half their original size for three, two, two, and one months. In the remaining patient nodes became completely impalpable for nine months before reappearing. Treatment such as radiotherapy or cytotoxic chemotherapy should be avoided unless there is a compelling reason. This is especially so for patients with carcinoma of the breast where depression of immune responses may facilitate the implantation of blood-borne malignant cells at distant sites. A year ago’ you rightly said that "investigators ought now to be organising properly controlled clinical trials." At that time a trial had already been set up in this department where patients who had had a simple mastectomy for carcinoma of the breast and subsequently had no evidence of disease were randomly
allocated
to
The results
receive levamisole alone are
or no
further
treatment.
pending.
Department of Radiotherapy and Clinical Oncology, Queen Elizabeth Hospital, Birmingham *Present address: Department of Radiology, at Dallas, Texas 75235, U.S.A.
H. W. C. WARD*
University of Texas Health Centre
a, y, AND d DETERMINANTS IN LIVER CELLS OF
HBsAg CARRIERS SIR,-Hepatitis-B surface antigen (HBsAg) has a common two doublets of other detergroup-specific determinant a and minants-d or y and w or 1.23Besides being present in the patients’ sera, HBsAg has been detected in the cytoplasm of infected liver cells/ HBsAg is thought to be of viral origin, and the different subtypes adw, ayw, adr, and ayr might represent several strains of hepatitis-B virus.1 Thus it was supposed not only that HBsAg subtyping would be possible in patients’ sera but that the antigens representing the subtypes could also be demonstrated in infected liver cells. Fresh-frozen liver-biopsy specimens of both adw and ayw carriers were investigated by an indirect immunofluorescence (I.F.) technique, using guineapig anti-adw and anti-ayw antisera as a first step (obtained by immunising the guineapigs with pooled adw or ayw positive sera), followed by fluoresceinlabelled rabbit anti-guineapig antiserum. Anti-human activity 5 was removed by immunoadsorption as described previously. Normal liver tissue gave negative results using this t.F. system. Liver-biopsy specimens from 25 carriers (12 adw and 13 ayw positive serologically) were used. In each specimen ground-glass hepatocytes, staining positive with the modified orcein method, were observed (fig. 1). Electron microscopy of several specimens revealed characteristic tubular structures in the cytoplasm (fig. 2). Strong Of. was obtained in the 12 adwpositive specimens when anti-adw antiserum was used. However, the same specimens gave weak or no I.F. when anti-ayw antiserum was applied. Conversely, ayw-positive specimens gave strong I.F. with anti-ayw antiserum and weak or no I.F. with anti-adw antiserum. To test the presence of the a determinant in the cytoplasm of the liver cells, monospecific guineapig anti-a serum was prepared and studied in the same indirect I.F. system. Of. with anti-a was not found in any of the specimens, despite high titres of a determinant in the patients’ sera. It is highly improbable that the a determinant is masked in the cytoplasm by antibodies, since anti-IgG and anti-complement i.F. was negative in the liver-cell cytoplasm of all biopsy specimens. One explanation might be that host proteins, de1.
Lancet, 1975, i, 151.
Fig. 2-Electron micrograph of ground-glass hepatocyte.
Cytoplasm contains tubular (G). N=nucleus. (x47 500).
structures
(T)
and
glycogen particles
rived from liver-cell constituents, participate in the formation of a and w determinants of HBsAg.Another possibility is that the expression of HBsAg as an antigen depends on its conformational status, as suggested by previous findings.7 In that case one can assume that expression of the a and w determinants occurs only after polymerisation of capsid subunits, whereas the y and d determinants already have a more final structure in the cytoplasm. Support for this hypothesis is given by electron-microscopy studies of HBsAg-positive serum and liver cells. While numerous 20 nm particles can be observed in the sera, these particles have not been detected in between the coarse tubular structures in the cytoplasm of ground-glass hepatocytes. The practical importance of these findings is that human anti-HBsAg antisera, which often contain appreciable anti-a activity only, can give false-negative results when used in I.F. studies on liver-biopsy specimens of HBsAg-positive patients. Also, when animal antisera are used for Of. on HBsAg, these sera should contain antibody activity against the d and/or y determinants of HBsAg. Departments of Pathology and Internal Medicine, University of Groningen, Oostersingel 59, Groningen, The Netherlands
H. J. HOUTHOFF B. HOUWEN
2. Le Bouvier, G. L. J. infect.Dis. 1971, 123, 671.
3. Bancroft, W. H., Mundon, F. K., Russell, P. K. J. Immun. 1972, 109, 842. Hadziyannis, S., Gerber, M. A., Vissoulis, C., Popper, H. Archs Path. 1973,
4
96, 327. 5. Houwen, B., Goudeau, A., Dankert, J. J. immun. Meth. 1975, 8, 185.
M., Lippin, A. Proc. natn. Acad. Sci. U.S.A. 1974, 71, 2663. 7. Vyas, G. N., Rao, K. R., Ibrahim, A. B. Science, 1972, 178, 1300.
6. Neurath, A. R., Prince, A.
ciency
This work was Great Britain.
supported by
the Muscular
University Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, and University Department of Pathology, Western Infirmary, Glasgow
Dystrophy Society
of
PETER O. BEHAN
JOHN A. SIMPSON WILHELMINA M. H. BEHAN
HAZARDS OF PARENTERAL GLUCOSE IN NEONATAL LACTIC ACIDÆMIA SIR,-Infantile lactic acidaemia may result from defective activity of pyruvate carboxylase,’ pyruvate dehydrogenase
(p .D.H.), fructose-1,6-diphosphatase,3 phospho-enol-pyruvate carboxykinase,4 or cytochrome-C oxidase’ or from other, unknown, disorders. Our experiences with a patient with severe lactic acidaemia aggravated by parenteral administration of 10% glucose prompt us to report on the hazards of this procedure in metabolic acidosis of unknown origin. A full-term boy (birth-weight 2500 g) was admitted to a regional hospital an hour after birth. Apart from an enlarged firm liver, no’abnormalities were found. Plasma-glucose levels were normal, and feeding was started 3 h after birth. Glucose 5% was given twice, and, subsequently, a humanised-milk formula every 3 h. Respiratory depression occurred 26 h after birth, and an extreme metabolic acidosis was seen (blood pH 6-8). Glucose and bicarbonate were administered after insertion of an umbilical-artery catheter. The patient was referred to our hospital. On admission generalised oedema, petechiae, apathy, Kussmaul respiration, an enlarged liver, and muscular hypotonia were observed. Blood-pressure and peripheral circulation were normal. Deep-tendon, grasping, and suckling reflexes were absent. Chest X-rays revealed cardiomegaly and normal lungs. Blood composition and plasma-glucose were normal. An extreme uncompensated metabolic acidosis was present (artenal pH 6.95; PC02 25 mm Hg; P02 85 mm Hg). Plasma sodium 141 mmol/1, potassium 5.1mmol/l, chloride 95 mmol/l, and calcium 2.6 mmol/l. Plasma-uric acid was 0.91 mmol/1 (normal 023-043 mmol/1). Plasma-lactic-dehydrogenase was elevated at 1040 i.u./ml : isoenzymes (1) 24.55%, (2) 26.5%, (3) 24.7%, (4) 12.9%, (5) 11.4%. Bacteriological examination of blood and cerebrospinal fluid were normal. The most pronounced metabolic abnormalities are given in the
table. Plasma-lactic-acid 1.
(as determined by
gas
chromatography’)
Brunette, M. G., Delvin, E., Hazel, B., Scriver, C. R. Pediatrics, Springfield,
1972, 5, 702. 2. Blass, J. P., Avigan, J., Uhlendorff, B. W. J. clin. Invest. 1970, 49, 423. 3. Hülsmann, W., Fernandes, J. Pediat. Res. 1971, 5, 633. 4. Fiser, R. H., Harris, J. C., Melsher, L., Fisher, D. A. ibid. 1974, 8, 432. 5. Monnens, L., Gabreëls, F., Willems, J. J. Pediat. 1975, 86, 983. 6. Ghadimi, H., Pecora, P. Pediatrics, Springfield, 1964, 34, 182. 7. Wadman, S. K., van der Heiden, C., Ketting, D., Kamerling, J. P., Vliegenthart, J. F. G. Clinica chim. Acta, 1973, 47, 307.
very high and increased further despite therapy. Also several aminoacids were greatly increased. As soon as lactic acidacmia was established, the glucose infusion was withdrawn. Bicarbonate and pharmacological doses of the co-factors of the P.D.H. complex (thiamine-HCI, pantothenic acid, and lipoic acid) were administered parenterally, Nevertheless, the patient’s condition deteriorated. He died 2 h later after sudden cardiac arrest. Necropsy was not allowed. In a small percutaneous liver-biopsy specimen pyruvate decarboxylase was measured by a 14C02 formation from (1-14C) pyruvate and appeared not to be deficient (2.5 m., control 32 I.U.). Another component of the P.D.H. complex involved in the formation of acetyl-CoA could, however, still be deficient. In this type of infantile lactic acidaemia the administration of carbohydrate may result in accumulation of large amounts of pyruvic and lactic acids. Not enough material was available to test this hypothesis. The extreme exacerbation of lactic acidaemia was most probably caused by the parenteral administration of glucose 10%--a routine procedure in treatment of neonatal distress, Although the patient was examined soon after admission, the diagnosis was made too late for controlling the extreme acidæmia with bicarbonate after withdrawal of parenteral glucose, In non-hypoxaemic and normoglycaemic patients with nonrenal severe metabolic acidosis, no parenteral carbohydrate should be given until the organic acid produced is analysed by gas chromatography. In lactic acidxmia a balanced low-carbohydrate diet should be given. In hypoglycaemic non-hypoxxmic severe metabolic acidosis careful administration of carbohydrate and evaluation of its metabolic effects seems necessary,
was
University Children’s Hospital, Het Wilhelmina Kinderziekenhuis, Niewe Gracht 137, Utrecht, and Department of Biochemistry, Erasmus University, Rotterdam, The Netherlands
Rough estimation.
tMean +2s.D.6
R. CH. SENDERS J. M. J. LAMERS S. K. WADMAN
LEVAMISOLE IN THE TREATMENT OF CANCER
SIR,—Dr Rojas and his colleagues (Jan. 31, p. 211) described an increase in the median disease-free interval and an increased survival-rate at thirty months in patients with carcinoma of the breast who had been treated with radiotherapy followed by levamisole. A trial of this drug is in progress in this department in which levamisole has been given as the only treatment in patients with those types of cancer where immune responses might play a part in controlling the disease. Levamisole 50 mg three times daily for three days was repeated every two weeks in most patients, but lately the schedule was changed to 50 mg daily continuously. In 3 children with disseminated neuroblastoma there was no objective effect. Of 4 adults with disseminated malignant melanoma 3 failed to respond, but in the 4th a black subcutaneous mass reduced in size from 4 to 2 cm diameter over two months before regrowing. Nodules of breast carcinoma recurrent on the chest wall after surgery failed to respond in 4 out ofS patients, but in the 5th patient a 1 cm diameter nodule disap peared over the course of three months and remained inpalpable for another four months before reappearing. In 4 out of
ABNORMAL PLASMA-METABOLITES IN INFANT WITH SEVERE LACTIC ACIDAEMIA
*
J. P. VAN BIERVLIET
595 9 patients palpable axillary nodes found shortly after simple mastectomy failed to respond. In 4 patients the nodes reduced to at least half their original size for three, two, two, and one months. In the remaining patient nodes became completely impalpable for nine months before reappearing. Treatment such as radiotherapy or cytotoxic chemotherapy should be avoided unless there is a compelling reason. This is especially so for patients with carcinoma of the breast where depression of immune responses may facilitate the implantation of blood-borne malignant cells at distant sites. A year ago’ you rightly said that "investigators ought now to be organising properly controlled clinical trials." At that time a trial had already been set up in this department where patients who had had a simple mastectomy for carcinoma of the breast and subsequently had no evidence of disease were randomly
allocated
to
The results
receive levamisole alone are
or no
further
treatment.
pending.
Department of Radiotherapy and Clinical Oncology, Queen Elizabeth Hospital, Birmingham *Present address: Department of Radiology, at Dallas, Texas 75235, U.S.A.
H. W. C. WARD*
University of Texas Health Centre
a, y, AND d DETERMINANTS IN LIVER CELLS OF
HBsAg CARRIERS SIR,-Hepatitis-B surface antigen (HBsAg) has a common two doublets of other detergroup-specific determinant a and minants-d or y and w or 1.23Besides being present in the patients’ sera, HBsAg has been detected in the cytoplasm of infected liver cells/ HBsAg is thought to be of viral origin, and the different subtypes adw, ayw, adr, and ayr might represent several strains of hepatitis-B virus.1 Thus it was supposed not only that HBsAg subtyping would be possible in patients’ sera but that the antigens representing the subtypes could also be demonstrated in infected liver cells. Fresh-frozen liver-biopsy specimens of both adw and ayw carriers were investigated by an indirect immunofluorescence (I.F.) technique, using guineapig anti-adw and anti-ayw antisera as a first step (obtained by immunising the guineapigs with pooled adw or ayw positive sera), followed by fluoresceinlabelled rabbit anti-guineapig antiserum. Anti-human activity 5 was removed by immunoadsorption as described previously. Normal liver tissue gave negative results using this t.F. system. Liver-biopsy specimens from 25 carriers (12 adw and 13 ayw positive serologically) were used. In each specimen ground-glass hepatocytes, staining positive with the modified orcein method, were observed (fig. 1). Electron microscopy of several specimens revealed characteristic tubular structures in the cytoplasm (fig. 2). Strong Of. was obtained in the 12 adwpositive specimens when anti-adw antiserum was used. However, the same specimens gave weak or no I.F. when anti-ayw antiserum was applied. Conversely, ayw-positive specimens gave strong I.F. with anti-ayw antiserum and weak or no I.F. with anti-adw antiserum. To test the presence of the a determinant in the cytoplasm of the liver cells, monospecific guineapig anti-a serum was prepared and studied in the same indirect I.F. system. Of. with anti-a was not found in any of the specimens, despite high titres of a determinant in the patients’ sera. It is highly improbable that the a determinant is masked in the cytoplasm by antibodies, since anti-IgG and anti-complement i.F. was negative in the liver-cell cytoplasm of all biopsy specimens. One explanation might be that host proteins, de1.
Lancet, 1975, i, 151.
Fig. 2-Electron micrograph of ground-glass hepatocyte.
Cytoplasm contains tubular (G). N=nucleus. (x47 500).
structures
(T)
and
glycogen particles
rived from liver-cell constituents, participate in the formation of a and w determinants of HBsAg.Another possibility is that the expression of HBsAg as an antigen depends on its conformational status, as suggested by previous findings.7 In that case one can assume that expression of the a and w determinants occurs only after polymerisation of capsid subunits, whereas the y and d determinants already have a more final structure in the cytoplasm. Support for this hypothesis is given by electron-microscopy studies of HBsAg-positive serum and liver cells. While numerous 20 nm particles can be observed in the sera, these particles have not been detected in between the coarse tubular structures in the cytoplasm of ground-glass hepatocytes. The practical importance of these findings is that human anti-HBsAg antisera, which often contain appreciable anti-a activity only, can give false-negative results when used in I.F. studies on liver-biopsy specimens of HBsAg-positive patients. Also, when animal antisera are used for Of. on HBsAg, these sera should contain antibody activity against the d and/or y determinants of HBsAg. Departments of Pathology and Internal Medicine, University of Groningen, Oostersingel 59, Groningen, The Netherlands
H. J. HOUTHOFF B. HOUWEN
2. Le Bouvier, G. L. J. infect.Dis. 1971, 123, 671.
3. Bancroft, W. H., Mundon, F. K., Russell, P. K. J. Immun. 1972, 109, 842. Hadziyannis, S., Gerber, M. A., Vissoulis, C., Popper, H. Archs Path. 1973,
4
96, 327. 5. Houwen, B., Goudeau, A., Dankert, J. J. immun. Meth. 1975, 8, 185.
M., Lippin, A. Proc. natn. Acad. Sci. U.S.A. 1974, 71, 2663. 7. Vyas, G. N., Rao, K. R., Ibrahim, A. B. Science, 1972, 178, 1300.
6. Neurath, A. R., Prince, A.