Summary:Liposomal amphotericin (AmBisome) 2 mg/kg three times weekly was compared with placebo as prophylaxis against fungal infection in patients undergoing chemotherapy or bone marrow transplantation (BMT) for haematological malignancies. Prophylaxis began on day 1 of chemotherapy and continued until neutrophils regenerated or infection was suspected. Of 161 evaluable patients, 74 received AmBisome and 87 received placebo. Proven fungal infections developed in no patients on AmBisome and in three on placebo (3.4%) (P ؍ NS). Suspected fungal infections requiring intervention with systemic antifungal therapy (usually amphotericin B) occurred in 31 patients on AmBisome (42%) and in 40 on placebo (46%) (P ؍ NS). Suspected deep-seated infections developed in 21 (28.3%) and 31 (35.6%) patients, respectively (P ؍ NS). Time to develop a suspected or proven deep-seated infection showed a trend in favour of AmBisome (P ؍ 0.11). Fifty patients had fungal colonisation (48 with Candida spp, two with Aspergillus spp) of at least one body site during prophylaxis; 15 patients while receiving AmBisome (20%) and 35 while on placebo (40%) (P Ͻ 0.01). Time to colonisation was significantly delayed in the group receiving AmBisome (P Ͻ 0.05). Treatment-related toxicity was modest and no additional toxicity was observed in patients receiving AmBisome. AmBisome 2 mg/kg three times weekly is safe and reduces fungal colonisation in patients receiving intensive chemotherapy or BMT. However, despite encouraging trends, prophylactic AmBisome did not lead to a significant reduction in fungal infection or in requirement for systemic antifungal therapy. Keywords: AmBisome; prophylaxis; neutropenia More than half the fatal infections in neutropenic patients are due to fungi 1 with candida and aspergillus the most commonly-observed pathogens. fungal infection increases with the severity and duration of neutropenia which, in the case of bone marrow transplantation (BMT) or chemotherapy for the treatment of haematological malignancies, can range from a few days to several weeks. The severe immunosuppression induced by high-dose corticosteroids given to recipients of allogeneic BMT to suppress graft-versus-host disease (GVHD) puts them at additional risk of fungal infections 2-4 whereas for patients receiving autologous stem cell support and treatment with growth factors the risk is much lower.5 This provides a rationale for the prophylactic use of antifungal agents.Orally administered agents such as the imidazoles, or non-absorbable amphotericin B, achieve only local decontamination and have little or no impact on invasive fungal infections. 6 A recent meta-analysis 7 has been conducted of 24 trials in which antifungals were used, either as prophylaxis or as empirical therapy, in patients with cancer complicated by neutropenia. This meta-analysis showed that amphotericin B decreased mortality significantly although the studies were small, as was the difference in the number of deaths. Antifungals as a group decreased the incidence of inv...
Local radiotherapy (RT) alone was compared with radiotherapy plus continuous oral chlorambucil (RT+CHL) for the treatment of localised, low grade non-Hodgkins lymphoma (NHL) in a prospective randomised study of 148 patients. After a maximum of 18 years follow up there was no significant difference in overall survival or disease free survival between the two treatment groups. Age greater than 50 years and low serum albumin at diagnosis correlated with a poor prognosis in the series overall. Over one third of patients with localised, low grade NHL may be cured by RT alone and adjuvant chlorambucil as initial therapy confers no survival advantage.
Alterations in the response of leukaemic cells to apoptosisinducing stimuli may account for resistance to chemotherapy and treatment failure, either by disruption of the apoptotic pathway itself or by altered DNA repair; quiescent cells and those with disrupted cell-cycle checkpoints may also display decreased apoptosis. Quiescence can be induced by the differentiation of myeloid cells, and this led us to investigate whether the modulation of drug-induced apoptosis associated with differentiation might be a model for quiescence-associated resistance generally. We have demonstrated that resistance to idarubicin-induced apoptosis increased with greater duration of incubation of HL60 and U937 cells with ATRA and 1,25(OH) 2 D3 and that this protective effect correlated with the degree of G0/G1 accumulation. In addition, the cytoprotective effects held for other classes of cytotoxic drugs with different mechanisms of action to idarubicin. Prolonged exposure to idarubicin or vinblastine was associated with diminution of the protective effect and re-entry of cells into cycle. The full cytoprotective effect was restored by resupplementation with ATRA or 1,25(OH) 2 D3 during exposure to idarubicin, with concomitant persistence of G0/G1 accumulation. Differentiating agents prevented the accumulation of leukaemic cells at the G2/M checkpoint in response to low concentrations of idarubicin. Understanding how differentiating agents modulate these cell-cycle checkpoints, and how quiescent cells evade apoptosis, may allow the development of therapeutic strategies to limit such apoptosisinhibiting effects and maximise cell kill from chemotherapy. Leukemia (2000) 14, 620-628.
This randomized study was designed to determine whether response to VAD chemotherapy could be prolonged by using rh alpha-2b-interferon (IFN) at a dose of 3 mU three times per week, either concurrently with VAD (VIC) or as maintenance after completion of VAD (VIF). Maintenance IFN was given for 9 months in order for the duration of IFN therapy to be similar in both groups. 72 patients were randomized between December 1988 and August 1993. The majority of patients had poor prognostic features. The objective response rate was similar in each arm, 78% in VIF and 77% in VIC. Of the 56 responders, 33 have relapsed, three died in remission, and 18 proceeded to high-dose therapy, withdrew for other reasons or were lost to follow-up and were censored from analysis at the relevant time point. Only two patients remain in remission (both in partial remission). Median PFS was 15 months for both VIF and VIC, compared with 16.5 months for a historic control group treated with VAD alone (n.s.). The estimated median survival in VIF was 43 months and in VIC 22 months, compared with 45 months in the historic controls (n.s.). These findings indicate that neither maintenance nor concurrent IFN prolongs response to VAD.
It will be inevitable that not all cells will respond to differen- enhanced efficacy in the treatment of certain disorders.
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