The partial recovery of kidney function in chronic uremia patients during hemodialysis treatment

Out of 432 patients placed on the treatment with hemodialysis (HD) for terminal renal failure (TRF) at the All-Union Nephrologic Center from January 1, 1978 to December 31, 1987, 17 patients manifested partial recovery of renal function, which enabled dialysis treatment to be discontinued for a time. Among the 17 patients with noticeable improvement of renal function, 8 presented with lupoid rapid-progressing glomerulonephritis (RPGN), 2 with RPGN associated with hemorrhagic vasculitis, 1 with idiopathic RPGN, 4 with chronic glomerulonephritis (CGN), 1 with chronic pyelonephritis, and 1 with polycystic kidneys. In 11 patients with RPGN, the rate of renal failure progression, expressed by the regression coefficient, was much higher among those in whom HD treatment was discontinued that in the group of patients without renal function recovery. In the 4 patients with CGN, renal function was recovered after the correction of marked disorders of purine metabolism, whereas in the 1 patient with chronic pyelonephritis and in the 1 with polycystic kidneys after urinary infection elimination. According to the ultrasonography data, out of the 17 patients with partial recovery of renal function, the size of the kidneys turned out normal in 14 patients.     

Endocarditis-associated rapidly progressive glomerulonephritis mimicking vasculitis: a diagnostic and treatment challenge

BackgroundInfective endocarditis (IE)-associated rapidly progressive glomerulonephritis (RPGN) is rarely reported. Sporadic case reports have noted the diagnostic and therapeutic challenge in IE-associated glomerulonephritis because it may masquerade as idiopathic vasculitis.MethodsPatients with clinical diagnosis of IE-related RPGN in a tertiary hospital in China between January 2004 and May 2021 were identified and retrospectively reviewed.ResultsTwenty-four patients with IE-associated RPGN were identified. All patients presented with fever and multiorgan system involvement on top of heart and kidneys, spleen (79%, 19/24), skin (63%, 15/24), lung (33%, 8/24) and nervous system (17%, 4/24). Six of the 24 patients (25%) were initially suspected to have ANCA-associated or IgA vasculitis. Forty-five percent of patients are seropositive for ANCA. Renal histology showed mesangial and/or endocapillary hypercellularity with extensive crescents in most patients. C3-dominant deposition was the predominant pattern on immunofluorescence and pauci-immune necrotising crescentic glomerulonephritis was observed in one case. All patients received antibiotics with or without surgery. Six patients received immunosuppressive therapy before antibiotics due to misdiagnosis and seven patients received immunosuppressive therapy after antibiotics due to persistence of renal failure. Three of the 24 patients died due to severe infection. All the surviving patients had partial or complete recovery of renal function.ConclusionIE-associated RPGN is rare and the differential diagnosis from idiopathic vasculitis can be challenging due to overlaps in clinical manifestations, ANCA positivity and absence of typical presentations of IE. The prognosis is generally good if antibiotics and surgery are not delayed. The decision on introducing immunoruppressive treatment should be made carefully on a case by case basis when kidney function does not improve appropriately after proper anti-infective therapy.

Key messages

• Infective endocarditis associated RPGN is rare and differentiating it from idiopathic vasculitis can be challenging due to overlap in clinical manifestations, ANCA positivity and occasional absence of typical manifestations of infective endocarditis.
• Kidney function usually responds to antibiotic therapy alone.
• Immunosuppressive therapy may be beneficial in carefully selected patients whose kidney function does not improve with antibiotics alone.

     

Cytapheresis for the treatment of myeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis: report of five cases.

To minimize the adverse effects of high-dose administration of steroids and cyclophosphamide in patients with myeloperoxidase (MPO) antineutrophil cytoplasmic antibody (ANCA), granulocytapheresis (GCAP) or leukocytapheresis (LCAP) was performed to reduce inflammation. Four patients with rapidly progressive glomerulonephritis (RPGN) and one patient with pulmonary hemorrhage due to MPO-ANCA-associated vasculitis were treated by cytapheresis. The prednisolone (PSL) dose was 0.28 +/- 0.15 mg/kg/day (mean +/- SD) (range 0.18-0.50 g/kg/day). In the 4 RPGN patients, the peak serum creatinine level was 3.7 +/- 1.9 mg/dl (range 1.7 to 5.6 mg/dl). GCAP was performed in 3 RPGN patients and in 1 pulmonary hemorrhage patient. LCAP was performed in 1 RPGN patient. In the 4 RPGN patients, renal function improved after combined therapy with cytapheresis and corticosteroids. In the pulmonary hemorrhage patient, evidence of pulmonary hemorrhage on chest computed tomography scanning diminished after combined therapy with cytapheresis and corticosteroids. Cytapheresis, when combined with a low-dose or intermediate-dose PSL regimen, is effective in the treatment of ANCA-associated vasculitis.     

Apheresis for MPO-ANCA-associated RPGN-indications and efficacy: lessons learned from Japan nationwide survey of RPGN

A national survey concerning rapidly progressive glomerulonephritis (RPGN) was conducted in Japan between 1989 and 2000 and resulted in the registration of 715 patients with RPGN. Among the documented patients, the most frequent primary disease was primary pauci-immune crescentic glomerulonephritis (n = 283), and the second most frequent was microscopic polyangitis (n = 127). Overall, 370 patients had MPO-ANCA, and 23 patients had PR3-ANCA. We found that both renal and patient survivals were significantly worse in patients with MPO-ANCA-associated RPGN than patients with PR3-ANCA. Fifty-three patients received apheresis therapy with various combinations of immunosuppressive regimens. They had higher serum creatinine, higher CRP, and a higher frequency of complicated pulmonary involvements as compared to the controls without apheresis therapy. In dialysis-dependent patients, no additional benefit from apheresis therapy was observed. Only pulmonary renal syndrome patients with CRP > 6 mg/dl at presentation showed a slightly better prognosis (patient survival with apheresis; 66.7%, without apheresis; 56.7%). Furthermore, a rapid MPO-ANCA titer reduction was observed in patients treated with apheresis. Patients with MPO-ANCA-associated RPGN were older, and had more chronic and sclerotic lesions than patients with PR3-ANCA-associated RPGN. Based on these findings, we suggest that a lower dose of immunosuppressant should be considered in order to avoid opportunistic infection. In this situation, cytapheresis is the treatment of choice. Nevertheless, in patients with an aggressive form of RPGN with rapid deterioration of renal function like the PR3-ANCA-associated RPGN, or pulmonary renal syndrome complicated severe inflammation, or relapses with high MPO-ANCA titer, we conclude that apheresis therapy should be considered.     

急进性肾炎的诊治进展

急进性肾小球肾炎(rapidly progressive glomerulonephritis,RPGN)以急性肾炎综合征伴肾功能急剧恶化为临床特征,病理为新月体肾炎.早期诊断主要依靠血清免疫学检查及尽早肾活检.早期治疗应根据病理类型及患者情况采用个体化的治疗方案,包括强化治疗和免疫抑制治疗.     

84例成人Evans综合征临床资料分析

目的 探讨成人Evans综合征的初始临床特征,各种治疗方法 的疗效及病程.方法 对84例成人Evans综合征患者(男20例,女64例)应用激素、丙种免疫球蛋白、免疫抑制剂多药联合治疗,中位随访17.5(0.03～140)个月,观察患者起病特征及临床疗效.结果 所有患者均接受激素加或不加静脉丙种免疫球蛋白初始治疗.47例患者单用激素治疗,其中38例达完全缓解(CR)和部分缓解(PR).中位随访12个月,92.1%的患者复发.28例对激素耐药或出现严重出血的患者随后给予免疫抑制剂治疗,89.3%的患者获得CR或PR.中位随访8个月,84%患者复发.结论 Evans 综合征难治且易复发,联合治疗可能是治疗Evans综合征的有效手段.     

Plasmapheresis in the treatment of rapidly progressing glomerulonephritis

The authors are of the opinion that plasmapheresis (PP) combined with immunosuppressant therapy is an effective and a relatively safe method for the treatment of rapidly progressing glomerulonephritis (RPGN). Introduction of PP in multimodality treatment of RPGN made it possible to arrest rapidly progressing renal failure in all 6 treated patients. After PP treatment was over, renal function was recovered completely in 3 patients. One patient manifested the retention of renal failure of medium degree while rare hemodialysis sessions permitted one to control water-electrolyte disorders. In two patients the discontinuation of PP treatment resulted in the progress of renal failure. The data obtained do not make it possible to relate the improvement of renal function exclusively to the action of PP, since all the patients received immunosuppressants. Nevertheless, in 2 cases, the improvement could be attributed to PP, for its discontinuation in these patients (without any changes in the remaining treatment) brought about again the progress of renal failure.     

Recent advances of clinical and basic research in rapidly progressive glomerulonephritis

Rapidly progressive glomerulonephritis(RPGN) is the most severe form of glomerulonephritis. Recently, a variety of highly specific therapeutic methods has been considered due to advances in our understandings of molecular and cellular mechanisms of glomerular crescentic formation. Although the prognosis of the patients with RPGN has improved these days, treatment related opportunistic infection and relapse are still matters of concern. Especially, in Japan, the prevalence of older patients with MPO-ANCA related RPGN is extremely high compared to other countries. To improve the prognosis of Japanese patients with RPGN, a prospective randomized trial with specific protocol for older patients with MPO-ANCA related RPGN should be conducted.     

伊马替尼治疗伴有嗜酸粒细胞增多的髓系肿瘤疗效观察

目的 评价伊马替尼治疗伴有嗜酸粒细胞增多的髓系肿瘤的疗效.方法 对8例有PDGFRα基因异常的伴嗜酸粒细胞增多的髓系肿瘤及1例慢性嗜酸粒细胞白血病,不另做分类(CEL,NOS)患者门服伊马替尼100 mg/d或400 mg/d进行疗效观察.结果 中位随访16(6～26)个月,血液学缓解率100%,其中完全血液学缓解(CHR)率87.5%,部分血液学缓解率12.5%.完全分子生物学缓解(CMR)率85.7%,FIP1L1-PDGFRα融合基因转阴中位时间4(1.5～8)个月.3例获得CMR后停药,停药后中位随访时间12(9～22)个月,均未复发.伊马替尼不良反应轻微,轻度骨髓抑制发生率37.5%,中位发生时间6(4～9)d.结论 伊马替尼治疗有PDGFRα基因异常的伴嗜酸粒细胞增多的髓系肿瘤有较高的CHR和CMR,起效迅速,不良反应轻微,患者易于耐受.     

Informative value of immunomembrane indicator of glomerulonephritis activity and effectiveness of membranostabiliser dimephosphon]

AIM: Study of effectiveness of dimephosphone with regard of the kind and degree of membrane disorders in various clinicomorphological forms of active glomerulonephritis (GN). MATERIALS AND METHODS: 170 patients with nephrotic, nephritic GN have undergone a complete nephrological examination. Informative value of immunological, morphological and membrane (phospholipids, lipid peroxidation) indicators of GN and lupus nephritis (LN) activity was analysed. RESULTS: Membrane destabilisation and GN activity were correlated. Membrane destabilization was also associated with dislipid- and disproteinemia, disturbances of renal function. This can be used for diagnosis of GN activity and its rapid progression. Dimephosphone monotherapy was found effective in correction of immunomembrane disturbances in minimally active GN and hormone-resistant forms irrespectively of the activity forms. Combination of dimephosphone with prednisolone and/or cytostatics proved more effective than dimephsphone monotherapy or conventional treatment with glucocorticoids and/or cytostatics without dimephosphone in respect of frequency of remission and early remission achievement in various types of activity and clinicomorphological forms of GN. CONCLUSION: Combination of dimephosphone with glucocorticoids and/or cytostatics is more effective than monotherapy or combined treatment with glucocorticoids and cytostatics in the treatment of GN of different clinicomorphological forms, hormone-resistant among them, and types of activity.     

Treatment and outcome of adult patients with primary focal segmental glomerulosclerosis in five UK renal units

BACKGROUND: Focal segmental glomerulosclerosis (FSGS) is the least studied of the causes of idiopathic nephrotic syndrome, and there are few specific guidelines for treatment. AIM: To review data from five UK renal units to investigate whether adult patients with FSGS were treated uniformly, and to examine the effect of treatment on proteinuria and survival. DESIGN: Retrospective record review. METHODS: We examined electronic records of patients with idiopathic FSGS for information on baseline clinical parameters, treatment regimens and outcomes. RESULTS: Of 136 patients with primary FSGS and nephrotic range proteinuria, 76 (56%) were treated with prednisolone and of this group, 59% were treated with additional immunosuppression. Among the treated patients, the total remission rate (complete and partial) was 67%, and one hospital achieved a remission rate of 80%. Treated patients had a significantly higher remission rate than those who were not treated. Remission was associated with a 5-year survival off dialysis of 94%, compared with 53% if remission was not achieved. Baseline serum creatinine and remission were independently associated with survival off dialysis in a multivariate Cox proportional hazards model. DISCUSSION: Patients with primary FSGS and nephrotic range proteinuria, who are treated with corticosteroids, are more likely to enter remission than those who are not treated. Remission rates of up to 80% can be achieved with prolonged treatment, and remission is an independent predictor of survival off dialysis. Patients who do not achieve remission have a poor prognosis. Further clarification of optimal treatment regimens requires additional, prospective studies.     

Continuous venovenous haemofiltration in cancer patients with renal failure: a single-centre experience

Objective To assess the effect of continuous venovenous hemodiafiltration (CVVHDF) in cancer patients with acute renal failure.Patients and methods Retrospective study of all patients with acute renal failure requiring dialysis and treated with CVVHDF in a medical intensive care unit (ICU) from a cancer hospital.Results From January 1997 until December 2002, 32 cancer patients were treated with CVVHDF for acute renal failure. Their characteristics were: male/female 23/9, median age 61 years, haematological/solid tumours 16/16, and median APACHE II and IGS II scores 31/67. The number of organ failures was 1/2/3/4 in respectively 10/6/13/2 patients. Complete, partial or absence of resolution of acute renal failure was noted in 13, 8 and 11 patients. Sixteen patients (50%) died in the ICU and 15 (47%) were discharged alive from the hospital. In univariate analysis, variables statistically significantly adversely associated with hospital mortality were renal failure of renal origin, bone marrow transplant, increasing number of organ failures, reduced lymphocyte count, elevated bilirubin and lower creatinine levels, increased thromboplastin time, younger age, increased APACHE II and IGS II, ARDS and mechanical ventilation. In multivariate analysis, two models were used including either APACHE II or IGS II. The number of organ failures was found as the only significant prognostic factor in both models (p=0.01). Elevated phosphate level was a poor prognostic factor for hospital mortality (p=0.04) in the model including APACHE II.Conclusions In the experience of a single centre, CVVHDF is effective in the treatment of acute renal failure in cancer patients. The increasing number of organ failures was the single independent poor predictive factor for hospital mortality. Cancer characteristics and general gravity scores were not predictive factors.     

Membranous Nephropathy: LONG-TERM FOLLOW-UP AND ASSOCIATION WITH NEOPLASIA

Sixty-six patients of all ages whose renal biopsy appearancessatisfied strict criteria for the histopathological diagnosisof membranous nephropathy were studied and followed for a meanof 5-4 years (range 1 to 20 years). From initial investigationseven patients were found to have associated neoplasia, andin two patients the condition followed treatment with a mercurialdiuretic and gold. One patient was Australia antigen positive.Two patients developed renal vein thrombosis, but in both thisappeared to follow not precede their nephrotic syndrome. Inthe remaining 56 patients there was no associated factor. During the follow-up period, approximately one-quarter of thepatients (15) died, nine from renal failure; one-quarter (10)had a persistent nephrotic syndrome, another one-quarter (15)proteinuria of lesser degree. The final one-quarter (16) arenow in complete remission. The prognosis of the 54 patientswith an initial nephrotic syndrome was poorer than the 12 withlesser proteinuria and no oedema at onset; five of 11 childrenwere in complete remission when last seen. All but one of thenine patients who developed terminal chronic renal failure 4to 18 years from onset had an unremitting nephrotic syndrome,and eight of the 10 currently alive with a persistent nephroticsyndrome have reduced renal function. Renal functional deteriorationdid not occur in the absence of proteinuria. There was only slight correspondence between the stage of biopsyappearance, glomerular filtration rate at time of biopsy, timeof the biopsy from apparent onset, or status at last follow-up.Staging is therefore of limited prognostic value. Twenty-twopatients were treated with corticosteroids for 2 to 36 months;we detected no short or long-term benefit when compared to patientsnot so treated. ¹Present address: Princess Alexandra Hospital, Ipswich Road,Woolloongabba, Brisbane, Queensland, Australia.     

Combined 5-fluorouracil, adriamycin and mitomycin C in the management of adenocarcinoma metastasizing to the liver from an unknown primary site

A combination of 5-fluorouracil, adriamycin and mitomycin was used to treat patients with adenocarcinoma metastasizing only to the liver from an unknown primary site. Of the 29 evaluable patients, only three (10.3%) achieved short partial remission for 6-12 weeks and two (6.9%) patients were stabilized for 4 weeks. The partial responders demonstrated a short survival time of 10-22 weeks and the median survival of non-responders was 8 weeks, which was not significantly different from that of responders. It is concluded that, although treatment of patients with metastatic adenocarcinoma of unknown primary site should be individualized, in general systemic chemotherapy for patients presenting with liver metastases is probably not justified.     

The efficacy of high-dose chemotherapy and the transplantation of autologous hemopoietic cells in lymphogranulomatosis

AIM: To determine clinical effectiveness of high-dose polychemotherapy (PCT) and transplantation of autologous hemopoietic cells (TAHC) in patients with lymphogranulomatosis (LGM). MATERIAL AND METHODS: 27 LGM patients aged 16-42 years who have undergone TAHC after high-dose PCT (BEAM--17 patients or CBV--10 patients). 4 patients given high-dose PCT were in the first-second complete remission (CR), 7 patients--in the first partial remission (PR). Prior to TAHC, 8 patients had one, two and more relapses of LGM, and 8 patients had no remission at all. Bone marrow, hemopoietic blood cells and both were transplanted to 17, 2 and 8 patients, respectively. Mobilization of hemopoietic blood cells and stimulation of hemopoiesis after TAHC were achieved using colony-stimulating factors. RESULTS: The treatment resulted in CR or PR (from 6 to 95 months) in 70.4% of patients. The remission duration varied depending on the disease phase at transplantation. Four patients who underwent TAHC in PR maintained it for 13-95 months (median 47.5 months). Lasting remissions (29-59 months) were achieved in 42.9 and 37.5% of patients who underwent TAHC in the first PR or in recurrent LGM. None of the patients was in remission longer than 2 years after TAHC if high-dose PCT was conducted in advanced tumor process due to resistant LGM or inadequate previous treatment. Infectious complications lethality early after the transplantation reached 7.4%(2 patients). CONCLUSION: High-dose PCT followed by TAHC is effective in LGM if the tumor is chemosensitive.     

Use of Mabtera (rituximab) in treating patients with refractory courses of B-cell lymphoma,along with high-dose chemotherapy and autologous transplantation of hematopoietic stem cells

AIM: To study efficacy of rituximab in patients with resistant B-cell lymphoma on high-dose chemotherapy. MATERIAL AND METHODS: From September 2000 to April 2002 we studied efficacy and tolerance of rituximab at different stages of high-dose chemotherapy. The treatment was given to 10 patients with histologically verified CD20+ non-Hodgkin's lymphoma: diffuse large-cell (n = 4), Berkitt's (n = 2), follicular (n = 3), mantle-cell (n = 1). Five patients with diffuse large-cell lymphoma and Berkitt's lymphoma had a primary resistant course of the disease, one patient with diffuse large-cell lymphoma had a refractory recurrence. Follicular and mantle-cell lymphomas were characterized by a resistant course and large tumor masses. The patients received 1-2 courses of induction chemotherapy with dexa-BEAM with collection of peripheral stem cells followed by high-dose chemotherapy (BEAM-9, CBV + mitoxantron-1) with transplantation of autologous stem blood cells. Rituximab infusion (375 mg/m2) was conducted before the collection of the stem cells, prior to high-dose chemotherapy and in posttransplantation period after recovery of hemopoiesis. RESULTS: 4 patients achieved complete remission, 3-partial remission, 2 had progression and 1-stabilization. In mean follow-up 11 (2-20) months 7 of 10 patients were alive, overall survival being 15 +/- 2.4 months (95% confidence interval 10-19.7), median was not reached. 5 patients are in complete remission: 2 of them without further treatment, 3-after progression and repeat therapy including rituximab and interferon-alpha or rotuximab and CHOP chemotherapy. CONCLUSION: The addition of rituximab can improve the results of high-dose chemotherapy of patients with non-Hodgkin's lymphoma resistant to standard doses of cytostatics. Repeat use of this drug can be effective in some patients with progression after high-dose chemotherapy with rituximab.     

The course and prognosis of mesangioproliferative glomerulonephritis

AIM: A retrospective analysis of a clinical course of mesangioproliferative glomerulonephritis (MPGN) in patients with glomerular deposition of IgA (IgA nephropathy--IgA-N), with glomerular deposition of other Ig to determine prognostic factors of MpGN progression including IgA-N and to examine the patients' sensitivity to immunodepressive therapy. MATERIAL AND METHODS: 2000 patients with primary MPGN followed up from 1980 to 1999 from the disease onset to development of chronic renal failure (creatinine > 2.5 mg%). Factors affecting kidney survival were studied using the Cox regression model, factors predicting sensitivity to immunodepressive therapy--using multiple logistic regression. RESULTS: IgA-N differed by the course and prognosis from other forms of MPGN. In IgA-N urinary syndrome and macrohematuria were encountered more frequently, in other forms of MPGN more frequent was nephrotic syndrome. Prognosis of patients with IgA-N was worse than in MPGN patients without IgA deposition: 10-year "renal survival" (creatinine < 2.5 mg%) was 64 and 97% (p < 0.05), respectively. Prognosis-deteriorating factors for MPGN patients were the following: male sex, nephritis onset in 40-year-olds and older subjects, acute nephritic syndrome (creatinine > 1.5 mg%), high proteinuria, hematuria (> 50 in sight), the presence of synechia and TIC in renal biopsy, location of immune deposits both in the mesangium and basal glomerular membranes. The responders to the immunodepressive therapy had 10-year renal survival 100%. Positive results of immunodepressive therapy were observed significantly more frequently in patients with normal level of creatinine, moderate hematuria, absence of synechias and TIC in renal biopsy, given large total course dose of corticosteroids and cytostatics. Efficiency of oral cyclophosphamide and its intravenous pulse-therapy did not differ significantly. In pulse therapy an average cumulative dose was lower 6 times, side effects occurred 3 times less frequently. CONCLUSION: The importance of morphological information for prognosis and predicting sensitivity of MPGN patients to immunosuppressive therapy necessitates renal biopsy before therapy. Intravenous pulse therapy with cyclophosphamide is preferable as an active treatment in patients with sclerosis in renal biopsy.     

Rapidly progressive glomerulonephritis with extensive glomerular crescent formation

Thirty-nine patients with severe crescentic glomerulonephritis and rapidly progressive renal failure were reviewed. Nineteen patients had a focal necrotizing glomerulonephritis, they usually presented with signs of multi-system disease, and eight had histologically-proven microscopic polyarteritis. A second group of 20 patients presented with an acute nephritic syndrome, often with nephrotic features, and had only minor prodromal symptoms. Renal biopsy material showed various forms of proliferative glomerulonephritis in addition to crescents. The most important prognostic feature at admission was renal function: only four of 21 patients who required dialysis recovered any renal function. The prognosis was worse for those with necrotizing glomerulonephritis, of whom two-thirds had oliguria on admission. All patients who were not oliguric, and some with oliguria, were treated with high doses of corticosteroids, usually accompanied by azathioprine and anticoagulants. Seventeen of 18 patients who were not oliguric initially retained or regained renal function, although three subsequently went into renal failure, and three others died of non-renal causes. At the most recent review, 25 of the 39 patients were either dead (16 patients) on dialysis or transplanted (nine patients). Ten were alive with diminished renal function, one had normal renal function but persisting proteinuria, and three were well. Prompt treatment may have contributed to these favourable results in a very severe disease.     

Prednisolone and chlorambucil therapy for idiopathic membranous nephropathy with progressive renal failure

Twenty-one patients with membranous nephro pathy, heavy proteinuriaand progressive renal fail ure were treated with alternatingmonthly cycles of corticosteroids and chlorambucil for six months.Four patients received repeat courses. After a median periodof follow-up of 39 months, three patients had died, six werereceiving renal replace ment therapy or had serum creatinine> 500 µmol/l, and one had progressive renal failure.Eleven patients had either stable or improved renal func tion,as judged by serum creatinine concentration. Of these eleven,four patients were in partial remis sion (daily protein excretion0.2–2.0 g), and two were in complete remission. Therewas a tendency for those who received intravenous methylprednisolone to have a more favourable outcome. There was a high incidenceof side-effects, with significant complications related to drugtherapy observed in >50% of subjects. Although individualpatients appeared to respond well, sometimes dramatically, theseresults are less encouraging than other reports. We would urgecaution in the use of this form of therapy, particularly inolder patients who may have occult neoplasms, impaired glucoseintolerance or pre–existing cardiac disease.     

Efficacy of different chemotherapy programs, indications for surgery and radiotherapy in primary mediastinal B-cell lymphosarcoma

AIM: To evaluate efficacy of treatment of primary mediastinal B-cell lymphosarcoma (PMBLS). MATERIAL AND METHODS: Fifty nine patients with PMBLD were divided into three groups. Group 1 (n = 15) received 8 courses of CHOP, prevention of neuroleukemia and radiotherapy (RT). Group 2 (n = 8)--4 courses of ProMACE-CytaBOM or 1 course of MACOP-B, prevention of neuroleukemia and RT. Group 3 (n = 36)--2 courses of CHOP and 2-3 courses of ESHAP or 3 courses of DexaBEAM, surgical removal of residual mediastinal tumor (RMT), RT. RESULTS: The number of complete remissions in group 1 and 2 was the same (26 and 25%, respectively). Overall 5-year and event-free survivals in groups 1 and 2 were 52 +/- 5 and 13 +/- 5; 62 +/- 5 and 38 +/- 8%, respectively. In group 3 a complete remission was observed in 89% patients (p = 0.01), overall 5-year and event-free survival reached 88 +/- 8 and 85 +/- 7%, respectively. Removal of RMT in time of tumor size stabilization and partial remission (in 12 of 15 cases) led to a complete remission but in progression of the disease (in 3 cases) appeared ineffective. RT resulted in complete remission in 39 of 53 cases, stabilization of tumor growth was in 3 cases, progression--in 10, recurrence--in 1. RT was ineffective in all 4 cases of partial remission. RT use in stabilization of tumor size induced complete remission only in 1 of 7 cases. CONCLUSION: CHOP program is ineffective in PMBLS. Program ProMACE-CytaBOM or MACOP-B is insignificantly more effective than CHOP. Combined therapy is most effective. Surgery is justified in partial remission and tumor growth arrest. RT is indicated in complete remission to achieve its consolidation.