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EFFECT OF COLCHICINE ON HUMAN TISSUES W. 0. BROWN, M.D.* AND L T . COL. LINDON SEED, M.C., A.U.S. From the Department of Pathology and Surgery, University of Illinois, College of Medicine, Chicago, Illinois T h e effect of colchicine on normal and cancerous tissues in laboratory animals has received considerable study, and some observers have been able to produce, a regression in experimental tumors under colchicine therapy. This action has been attributed to an arrest of mitosis by the drug. 1 Ludford 2 and Brues 3 have studied cells arrested by colchicine and found an absence of the mitotic spindle with clumping and bizarre configurations of the chromatin material. Mild changes are apparently reversible, b u t the more severe ones result in abnormal mutations in t h e nuclei of the daughter cells, or in cell death. T h e number of the cells affected and the severity of the changes vary with the size of the dose, b u t are not directly proportional. T h e literature pertaining to colchicine has been reviewed b y Lits. 4 T h e cells arrested b y colchicine frequently have been referred to as "colchicine figures" and for the sake of brevity this term will be used here to designate similar cells. mm. to 1950, with 40 per cent stab forms. Death occurred on the seventh day after the first dose of colchicine. Necropsy was performed seven hours after death. The right breast was small, firm, and surmounted by several ulcerated tumor nodules. The breast tissue was almost completely replaced by firm pale tumor tissue, and there were several firm axillary metastases measuring up to 2 cm. in diameter. The left breast appeared normal except for an inverted nipple. The lungs contained numerous miliary subpleural metastases. The gastro-intestinal mucosa showed areas of edema and hemorrhage. The heart, liver, kidneys, spleen, pancreas, adrenals, thyroid, internal genitalia, and brain showed no distinctive changes. Microscopically, the tumor of the right breast was a scirrhous duct carcinoma composed of small groups or columns of cells separated by an abundant dense stroma. Colchicine figuresf were numerous, and no normal mitoses were seen. The central portions of the larger tumor islands occasionally showed ischemic necrosis, which was not attributed to colchicine. The metastases to the lungs and axillary lymph nodes had a similar appearance. The left breast showed the usual appearance of cystic disease. There were also numerous colchicine figures in the epithelium of the gastro-intestinal mucosa and in the liver cells (fig. 1). There was degeneration of the basal layer of the epidermis and the inner root sheath of the hair shafts. The stratum granulosum contained a multitude of colchicine figures. The sternal bone marrow was made up almost completely of fat and erythrocytes, with a few normoblasts and lymphoid cells, but the myeloid elements were decreased to the point of extinction. Sections of the popliteal nerve stained T h e report of several cases of inoperable cancers treated with colchicine has appeared previously. 5 I t is the purpose here to present the necropsy findings and histologic studies on three cases of this series in which death occurred during t h e course of treatment. Since the clinical findings have been presented in detail before, 5 only t h e pertinent facts are mentioned here. CASE REPORTS Case 1. D. C , a white female, aged 65, was admitted with an inoperable carcinoma of the right breast. Except for the primary tumor and axillary metastases, the physical examination was negative. She was given a total of 13 mg. of colchicine over a period of four days, and on the fourth day vomiting, diarrhea, and prostration appeared, with an elevation of temperature to 101°F. By the sixth day the leucocyte count of the blood had dropped from 6800 per cu. * Present address, Kern General Hospital, Bakersfield, California. t The term "colchicine figures" is taken to indicate cells from patients treated with colchicine in which the nuclei show abnormal configurations or mitotic patterns that could not readily be interpreted on any other basis. The nuclear changes of cell death which are normally encountered in any rapidly growing tumor or tissue were excluded as far as possible. This cannot always be done accurately on a morphologic basis and the factor of normal expectancy must be considered as well. 189 190 W. O. BROWN AND LINDON SEED with Sudan III and osmic acid showed a slight fatty degeneration of the myelin sheaths, but silver stains revealed no axonal changes. ' There were also numerous colchicine figures in the large lymphocytes, or "lymphoblasts" of the lymph nodes, the epithelium of the fallopian tubes, endometrium, and the epithelium of the renal tubules. In the latter instance, an occasional multinucleated cell could be found (fig. 6). Diagnosis: Colchicine poisoning, scirrhous duct carcinoma of the right breast, hypoplasia of the bone marrow. Case 2. R. B., a colored male, aged 44, was admitted with an advanced carcinoma of the rectum. Physical findings were negative except for the rectal tumor. Serologic tests for syphilis in blood were positive. He • received a total of 29 mg. of colchicine over a period of seven days. On the tenth day he was obviously "toxic," the leucocyte count had fallen to 1200 per cu. mm., and there was evidence of consolidation in the right pulmonary base. The patient died on the fourteenth day after colchicine was started with a terminal leucocy tosis of 10,450. Necropsy was performed eight hours after death. Seven and a half centimeters above the anal sphincter was an annular constricting carcinoma which infiltrated the surrounding soft tissues and studded the peritoneum of the recto-vesical fold with metastases. In the cecum and ascending colon were several ulcers measuring up to 1.5 cm. in diameter with edematous hemorrhagic bases. There were confluent areas of bronchopneumonic consolidation in the base of each lung. The gross appearance of the other organs was not significant. Microscopically the tumor was a colloid carcinoma which showed few if any colchicine figures. On the other hand numerous colchicine figures were found in the epithelium of the intestinal mucosa, liver, lymph nodes, and in undifferentiated mesenchymal cells of the intestinal submucosa. None were found in the skin. The bone marrow was markedly hyperplastic, in contrast to the hypoplasia which had undoubtedly been present a few days before. The other organs resembled those of case 1. Diagnosis: Colchicine poisoning, colloid carcinoma of rectum, hypostatic bronchopneumonia. Case 3. A. W., a white male, aged 54, was admitted with a large carcinoma of the left lateral side of the neck. The patient received a total of 28 mg. of colchicine over a period of 64 days with several rest intervals. The first course of treatment caused a marked diminution in size of the tumor, but in the following rest period, growth was resumed with unprecedented rapidity, and after this the tumor was little affected by the drug. Death occurred 19 days after the last dose of colchicine. Necropsy was performed 9 hours after death. There was a large cauliflower-like tumor occupying the greater part of the left lateral aspect of the neck, and produced by broken down lymph node metastases from, a primary tumor of the left faucial tonsil. There were also metastases to the pleura, pharynx, liver, and jejunum. The other organs showed no distinctive changes. Microscopically the tumor was a transitional cell carcinoma, and showed numerous colchicine figures, as well as numerous other cells having several small round micronuclei. Colchicine figures were also present in large numbers in the esophageal mucosa, but were not found in any other tissue. The liver contained numerous normal mitotic figures. Diagnosis: Transitional cell carcinoma of the left faucial tonsil. COMMENT Colchicine does not produce distinctive gross changes in the organs, and the effects of the drug are visible only on microscopic examination. Numerous references were made to "colchicine figures" and in general these were most numerous in the epithelial elements of parenchymatous organs and in lymphoid structures. The cells showing the earliest effects were invariable in the metaphase, and earlier stages could not be detected. The cells showing the least severe changes were usually found in the liver, and these consisted of absence of the mitotic spindle, and a shortening and tendency to clumping of the chromosomes, although the aster arrangement of the metaphase was preserved (fig. 1). A curious observation in connection with the liver was that from this stage, the chromosomes became contracted to minute granules which then were scattered indiscriminately through the cytoplasm, while the cell became swollen by hydropic degeneration and disintegrated (fig. 2). Almost all the liver cells showing colchicine effects were in various stages of this process and very infrequent deviations from this sequence of events could be found. This particular chain of events was prominent in only one other organ, viz.—the skin. Here, however, there was a great variety of chromatin patterns (fig. 3). A common abnormality, and one that was frequently seen in the lymph nodes and intestinal epithelium, was a clumping of the chromosomes into a pyknotic bar (fig. 4). The mitotic spindle was absent, and unlike the normal equatorial plate of the metaphase, this showed no definite orientation to the long axis of the cell, but lay in various positions. Other chromosomal deformities consisted of clumping into a small intensely pyknotic mass in which no detail could be observed (fig. 5), or arrangement in numerous bizarre forms. Quite frequently small granules EFFECT OF COLCHICINE ON TISSUES could be seen lying at some distance from the main mass. In the renal epithelium of case 1 (fig. 6), and in the tumor of case 3, were multinucleated cells which morphologically resembled 191 the cytoplasm of the "colchicine figures" tended to be more oxyphilic than normal and in those showing the more severe changes, the cell 'was swollen by hydropic degeneration, the cell bounda- Fic. 2. Later stage of colccihine arrest in liver. Cell undergoing disintegration. Case 2. X650 those described by Brues and Jackson, who attributed them to changes produced in the chromosomes of cells temporarily arrested by colchicine, but in which division had resumed after the colchicine inhibition had worn off. In general, ries irregular, and the cytoplasm not infrequently vacuolated. Occasionally colchicine figures were found in the process of disintegration with rupture of the cell membrane and escape of the chromosomal granules into the surrounding area. 192 VV. O. BROWN AND LINDON SEED I t should be emphasized that from the morphologic appearance, colchicine does not appear to produce specific changes characteristic of that drug alone. In routine necropsy material with •*£ numerous. In these instances the cells appear to have started mitosis, but were arrested, and it seems likely that changes in oxygen tension and pH incident to the agonal period could be.re- #' # FIG. 3. Cells of stratum granulosum of epidermis showing colchicine effects. Note various chromosomal patterns. Case 1. X650 FIG. 4. Crypt of Lieberkiihn of intestine. Two cells show colchicine arrest. Case 2. X650 no regard to the cause of death cellular changes indistinguishable from those ascribed here to colchicine are not infrequently found in the spleen and other lymphoid structures, but are much less sponsible for the mitotic arrest. Ludford2 arrived at similar conclusions as regards colchicine, and pointed out that totally unrelated physical and chemical agents may produce the same changes. 193 EFFECT OF COLCHICINE ON TISSUES He suggested that these were merely outward manifestations of changes of the physical state of the cell. What conclusions we have been able to draw from necropsy material support this view. capable of maturation. were still present in the Organs whose cells spread mitotic arrest These nuclear deformities adult cell. have shown rather wideapparently undergo not FIG. S. Tumor cells showing various chromosomal patterns'in cholchicine arrest. Case 1. X975 &L % Fie. 6. Multinucleated giant cell in epithelium of renal tubule in Case 1. Note a second cell which is binucleated. X650 Osgood6 observed that myeloblasts myelocytes in tissue cultures which treated with colchicine frequently bizarre nuclear configurations, but that and prohad been contained they were infrequently a period of intense compensatory proliferation as the inhibitory effects of colchicine wear off. This was observed in the tumor in case 3 and the bone marrow of case 2. 194 VV. 0. BROWN AND LINDON SEED Although colchicine played no part in the death of case 3, which was due to the cancer and its secondary effects, in cases 1 and 2, colchicine was the important causative factor, and nonfatal toxic manifestations have been observed in several other instances. Patients receiving a single dose of colchicine frequently show a slight rise in temperature which never reaches high levels and which usually returns to normal in about 48 hours. They also complain of pain and a sense-of heat at the site of the malignancy, which before might have been painless. Anorexia, nausea, and vomiting, if severe, usually accompany toxicity. General malaise, muscle aches, and pains may be present in mild form from the beginning and may be of little significance, but if severe, usually indicate toxicity, and prostration is a terminal affair. Probably the greatest single danger from colchicine administration is agranulocytosis and aplastic anemia,7 which was the chief cause of death in cases 1 and 2. The hypostatic pneumonia in case 2 is considered merely secondary to the agranulocytosis. Less severe forms of this complication occurred during the treatment of other cases in which the condition was recognized and the drug stopped in time for the patient to effect a recovery. The necessity for frequent and complete blood studies while the patient is under colchicine treatment cannot be over-emphasized. In blond individuals the drug may have a depilatory effect and may render the patient almost bald, but this is readily appreciated in view of the cellular changes in the skin and hair follicles. This phenomenon was not observed in colored patients whose skin and appendages do not appear very sensitive to colchicine. A peripheral neuritis as evidenced by myelin degeneration of the peripheral nerves occurred in case 1, but whether this can be attributed to colchicine or not cannot be stated. I t is our impression, however, that it can. I t should be emphasized that the tumor in each of the three cases cited was inoperable. I t was also well known that the colchicine effect could not be developed unless the dose of the drug was large enough to approach toxic amounts. SUMMARY 1. Colchicine exerts a toxic effect on living cells which commonly results in the arrest of the process of mitosis at an early stage, usually the metaphase, with the production of bizarre and abnormal nuclear configurations, and frequently leading to cell death. 2. The effect of colchicine is general, and selective only in the sense that those tissues which have the highest rates of cell division and metabolism are effected first, i.e. bone marrow, tumors, skin, lymphoid structures, etc. 3. Colchicine produces no characteristic morphological changes which are specific for that drug alone, and similar changes may be observed under widely varying circumstances. 4. Colchicine is a dangerous drug and should be used with extreme care. One of the greatest dangers apparently lies in its depressant effects on the bone marrow, and its administration should be accompanied by frequent blood studies. A finding that has not been mentioned before is the occurrence of a peripheral neuritis in association with colchicine administration. REFERENCES 1. (a) LlTS, F . J . , K.IRSCHBAUM, A., AND STRONG, L . (b) (c) (d) (e) C.: The action of colchicine on malignant lymphoid neoplasm in mice of an inbred strain. Proc. Soc. Exper. Biol, and Med., 38: 555, 1938. LlTS, F.: Contribution a l'fitude des reactions cellulaires provoquecs par la colchicine. Compt. rend. Soc. de biol., 115: 1421, 1934. CLEARKIN, P. A.: Effect of colchicine on normal and neoplastic tissues in mice. J. Path, and Bact., 44: 469, 1937. AMOROSO, E. C.: Colchicine and tumor growth. Nature, 135: 266, 1935. DUSTIN, A. P.: Effect of karyoklastic poisons on animal tumors; Effect of colchicine on grafted mouse sarcoma of Crocker type. Bull. Acad, roy. de m6d. de Belgique, 14:487,1934. (f) PEYRON, ALBERT, LAFAV, BERNARD, AND POU- MEAU-DELILLE, GUY: Regression of papillary epithelioma in rabbits (Shope's Tumor) under the action of colchicine. Compt. rend. Acad. d. sc, 205: 378, 1937. (g) PEYRON, ALBERT, POUMEAU-DELILLE, GUY, AND LAFAY, BERNARD: Malignant evolution of papillary epithelioma in rabbits and its mode of regression under the action of colchicine. Compt. rend. Soc. de biol., 126: 685, 1937. 2. LUDFORD, R. J.: The action of toxic substances upon the division of normal and malignant cells in vitro and in vivo. Arch. f. exper. Zellforsch., 18: 411, 1936. 3. BRUES, A. M., AND JACKSON, E. B.: Nuclear abnor- malities resulting from inhibition of mitosis by colchicine and other substances. Am. J. Cancer, 30: 504,1937. E F F E C T OF COLCHICINE ON TISSUES 195 4. LlTS, F. J., KlRSCHBAUM, A., AND STRONG, L. C : Action of colchicine on a transplanted malignant lymphoid neoplasm in mice of the C3H strain. Am. J. Cancer, 34: 196, 1938. 6. OSGOOD, E . E., AND BRACHES, G E O . J.: 5. SEED, L., SLAUGHTER, D. P., AND LIUARZI, L. R . : 7. DIXON, W. E., AND MALDEN, WALTER: Colchicine Effects of colchicine on human carcinoma. gery, 7: 696,1940. Sur- Culture of human marrow; Studies of the effects of the Roentgen rays. Ann. Int. Med., 13: 563, 1939. with special reference to its mode of action and effect on bone marrow. J. Physiol., 3 7 : 50, 1908.