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NEUROTENSIN AND HEPATOCELLULAR CARCINOMA
687
previously used may improve long-term survival in AML. Indeed, several patients with AML who relapsed after treatment with RATE and RATE-X have entered a second long-term remission following this type of treatment. We therefore agree with the Swiss group that conventional maintenance chemotherapy may be of no benefit but we believe that an increase in the number of long-term survivors may be brought about by increasing the intensity of induction therapy which increases the proportion of patients who enter CR and by using intensive consolidation chemotherapy with a rotating multiple drug regimen to destroy as many leukaemia cells as possible rapidly and so to prevent the emergence of resistant leukaemic cell dones.1O
MRC Leukaemia Unit, Royal Postgraduate Medical School, London W12 0HS
R. E. MARCUS D. CATOVSKY J. M. GOLDMAN A. M. WORSLEY D. A. G. GALTON
NEUROTENSIN AND HEPATOCELLULAR CARCINOMA
Actuarial survival of three groups of AML Maintenance
therapy for
1 year
was
patients in remission.
given to those receiving RATE.
6-TG at the above dosages for 10 days followed by a further identical course after bone-marrow recovery. Two further courses of consolidation therapy were given with the above agents in varying dosage after haematological recovery but no maintenance was given. The third and current protocol ("RATE-82") consists of induction/consolidation with two courses of RATE-X as above followed by consolidation with alternate courses of MAZE (amsacrine, 5-azacytidine, and etoposide, 100 mg/m2 for 5 days) and daunorubicin, cytarabine, and 6-TG to a total of six courses, the final one involving high-dose cytarabine (1 g/m2) for six doses. Remission rates were over 8507o with the two more intensive protocols and remission was achieved more quickly9 (table). The median survival of the group of patients treated with RATE-X was significantly longer than that of the group treated with RATE (p< 0’05) but this is largely due to the higher remission rate obtained with RATE-X. Analysis of the survival curves of the patients who achieved a CR with these two regimens shows that there is no significant difference between patients given RATE plus 1 years’s maintenance (17% survival at 4 and 7 years) and those given intensive induction/consolidation therapy (RATE-X) with no maintenance (32% survival at 4 years, p>0 05). It seems therefore that four courses of intensive chemotherapy are equivalent to 1 year’s maintenance therapy but may be insufficient to increase the cure rate in AML. Results with the current RATE-82 study may be better (figure). 5 patients have completed all six courses and remain in remission between 484 and 735 days; no patient has relapsed off or on treatment, but 1 patient died in CR of haemoptysis due to invasive aspergillosis. Although these are preliminary observations they suggest thp- further courses of consolidation chemotherapy incorporati-new agents and employing high doses of agents
SIR,-In 1980 a patient with hepatocellular carcinoma was found by chance to have a raised plasma concentration of neurotensin-like immunoreactivity (NLI). Our subsequent screening of a series of patients with histologically proven hepatocellular carcinoma demonstrated that 6 of 29 patients had greatly increased fasting plasma concentrations of NLI, in the range 175-750 pmol/l (mean 383±98). The mean concentration of the remaining 23 patients was 29±5 pmol/1. Since most of the patients had underlying cirrhosis, fasting plasma from cirrhotic patients without hepatoma was also assayed for NLI. The mean fasting plasma NLI concentration from 14 such patients was 14±4 pmol/l, while that of a group of healthy subjects of similar age was 16±4 pmol/1. Of the patients with hepatoma, those with high plasma NLI had no specific distinguishing features; 3 had the histological features of the fibrolamellar variant of hepatocellular carcinoma. The suggestion by Dr Collier and his colleagues (March 10, p 538) that a raised plasma NLI concentration may be useful in the diagnosis of fibrolamellar carcinoma may be premature in view of the above findings. Furthermore, of their 5 patients with raised plasma NLI concentrations, only 4 were reported to have the fibrolamellar variant. Predictions relating to the clinical significance of a raised plasma neurotensin concentration may thus be misleading. Raised plasma neurotensin concentrations have been reported in patients with pancreatic endocrine tumoursi and bronchial carcinoma.2 R. WOOD WALTER M. MELIA SUSAN M. WOOD MARK L. WILKINSON YING C. LEE BERNARD PORTMANN STEPHEN R. BLOOM ROGER WILLIAMS
JOHN Liver Unit, King’s College Hospital Medical School, London SE5 8RX; and Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0HS
CONSERVATIVE MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX
SIR,-Your editorial on aspiration of spontaneous pneumothorax (Feb 25) does not mention conservative management. The major reason
for the introduction of intercostal intubation
was
to reduce
length of hospital stay and consequent economic loss.3,4’ We have done a prospective comparison with conservative management in 21 patients presenting with simple spontaneous pneumothorax the
9. Worsley
AM, Catovsky D, Johnson SA, Goldman JM, Donnelly P, Galton DAG. Evaluation of two chemotherapy regimens for the treatment of acute myeloid leukaemia. 3rd International Symposium on the Therapy of Acute Leukaemias
(Rome, 1982):
47.
SUMMARY OF CLINICAL EXPERIENCE OF THREE REGIMENS IN AML
AM, Galton DAG. Acute myeloid leukaemia: Is consolidation therapy necessary? Br J Haematol 1984; 56: 361-64. 1. Blackburn AM, Bryant MG, Adrian TE, Bloom SR. Pancreatic tumors produce
10. Worsley
neurotensin.J 2. Wood
Clin Endocrinol Metab 1981; 52: 820-22. SM, Wood JR, Ghatei MA, Lee YC, O’Shaughnessy D, Bloom SR. Bombesin,
somatostatin and neurotensin-like immunoreactivity in bronchial carcinoma. J Clin Endocrinol Metab 1981; 53: 1310-12. 3. Bernhard WF, Malcolm JA, Berry RW, Wylie RH. A study of the pathogenesis and management of spontaneous pneumothorax. Dis Chest 1962; 42: 403-12. 4. Klassen KP, Meckstroth CV. Treatment of spontaneous pneumothorax: prompt expansion with controlled thoracotomy tube.JAMA 1962; 182: 1-5.
previously used may improve long-term survival in AML. Indeed, several patients with AML who relapsed after treatment with RATE and RATE-X have entered a second long-term remission following this type of treatment. We therefore agree with the Swiss group that conventional maintenance chemotherapy may be of no benefit but we believe that an increase in the number of long-term survivors may be brought about by increasing the intensity of induction therapy which increases the proportion of patients who enter CR and by using intensive consolidation chemotherapy with a rotating multiple drug regimen to destroy as many leukaemia cells as possible rapidly and so to prevent the emergence of resistant leukaemic cell dones.1O
MRC Leukaemia Unit, Royal Postgraduate Medical School, London W12 0HS
R. E. MARCUS D. CATOVSKY J. M. GOLDMAN A. M. WORSLEY D. A. G. GALTON
NEUROTENSIN AND HEPATOCELLULAR CARCINOMA
Actuarial survival of three groups of AML Maintenance
therapy for
1 year
was
patients in remission.
given to those receiving RATE.
6-TG at the above dosages for 10 days followed by a further identical course after bone-marrow recovery. Two further courses of consolidation therapy were given with the above agents in varying dosage after haematological recovery but no maintenance was given. The third and current protocol ("RATE-82") consists of induction/consolidation with two courses of RATE-X as above followed by consolidation with alternate courses of MAZE (amsacrine, 5-azacytidine, and etoposide, 100 mg/m2 for 5 days) and daunorubicin, cytarabine, and 6-TG to a total of six courses, the final one involving high-dose cytarabine (1 g/m2) for six doses. Remission rates were over 8507o with the two more intensive protocols and remission was achieved more quickly9 (table). The median survival of the group of patients treated with RATE-X was significantly longer than that of the group treated with RATE (p< 0’05) but this is largely due to the higher remission rate obtained with RATE-X. Analysis of the survival curves of the patients who achieved a CR with these two regimens shows that there is no significant difference between patients given RATE plus 1 years’s maintenance (17% survival at 4 and 7 years) and those given intensive induction/consolidation therapy (RATE-X) with no maintenance (32% survival at 4 years, p>0 05). It seems therefore that four courses of intensive chemotherapy are equivalent to 1 year’s maintenance therapy but may be insufficient to increase the cure rate in AML. Results with the current RATE-82 study may be better (figure). 5 patients have completed all six courses and remain in remission between 484 and 735 days; no patient has relapsed off or on treatment, but 1 patient died in CR of haemoptysis due to invasive aspergillosis. Although these are preliminary observations they suggest thp- further courses of consolidation chemotherapy incorporati-new agents and employing high doses of agents
SIR,-In 1980 a patient with hepatocellular carcinoma was found by chance to have a raised plasma concentration of neurotensin-like immunoreactivity (NLI). Our subsequent screening of a series of patients with histologically proven hepatocellular carcinoma demonstrated that 6 of 29 patients had greatly increased fasting plasma concentrations of NLI, in the range 175-750 pmol/l (mean 383±98). The mean concentration of the remaining 23 patients was 29±5 pmol/1. Since most of the patients had underlying cirrhosis, fasting plasma from cirrhotic patients without hepatoma was also assayed for NLI. The mean fasting plasma NLI concentration from 14 such patients was 14±4 pmol/l, while that of a group of healthy subjects of similar age was 16±4 pmol/1. Of the patients with hepatoma, those with high plasma NLI had no specific distinguishing features; 3 had the histological features of the fibrolamellar variant of hepatocellular carcinoma. The suggestion by Dr Collier and his colleagues (March 10, p 538) that a raised plasma NLI concentration may be useful in the diagnosis of fibrolamellar carcinoma may be premature in view of the above findings. Furthermore, of their 5 patients with raised plasma NLI concentrations, only 4 were reported to have the fibrolamellar variant. Predictions relating to the clinical significance of a raised plasma neurotensin concentration may thus be misleading. Raised plasma neurotensin concentrations have been reported in patients with pancreatic endocrine tumoursi and bronchial carcinoma.2 R. WOOD WALTER M. MELIA SUSAN M. WOOD MARK L. WILKINSON YING C. LEE BERNARD PORTMANN STEPHEN R. BLOOM ROGER WILLIAMS
JOHN Liver Unit, King’s College Hospital Medical School, London SE5 8RX; and Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0HS
CONSERVATIVE MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX
SIR,-Your editorial on aspiration of spontaneous pneumothorax (Feb 25) does not mention conservative management. The major reason
for the introduction of intercostal intubation
was
to reduce
length of hospital stay and consequent economic loss.3,4’ We have done a prospective comparison with conservative management in 21 patients presenting with simple spontaneous pneumothorax the
9. Worsley
AM, Catovsky D, Johnson SA, Goldman JM, Donnelly P, Galton DAG. Evaluation of two chemotherapy regimens for the treatment of acute myeloid leukaemia. 3rd International Symposium on the Therapy of Acute Leukaemias
(Rome, 1982):
47.
SUMMARY OF CLINICAL EXPERIENCE OF THREE REGIMENS IN AML
AM, Galton DAG. Acute myeloid leukaemia: Is consolidation therapy necessary? Br J Haematol 1984; 56: 361-64. 1. Blackburn AM, Bryant MG, Adrian TE, Bloom SR. Pancreatic tumors produce
10. Worsley
neurotensin.J 2. Wood
Clin Endocrinol Metab 1981; 52: 820-22. SM, Wood JR, Ghatei MA, Lee YC, O’Shaughnessy D, Bloom SR. Bombesin,
somatostatin and neurotensin-like immunoreactivity in bronchial carcinoma. J Clin Endocrinol Metab 1981; 53: 1310-12. 3. Bernhard WF, Malcolm JA, Berry RW, Wylie RH. A study of the pathogenesis and management of spontaneous pneumothorax. Dis Chest 1962; 42: 403-12. 4. Klassen KP, Meckstroth CV. Treatment of spontaneous pneumothorax: prompt expansion with controlled thoracotomy tube.JAMA 1962; 182: 1-5.