A pilot study of sphincter-sparing management of adenocarcinoma of the rectum.

After analysis of 26 prospectively accrued patients with distal rectal adenocarcinomas who underwent sphincter preservation treatment, we have concluded that tumors that invade only the submucosa can safely be treated with surgery alone and that tumors that invade the muscularis or further can be safely treated with surgery combined with chemoradiotherapy. None of the patients had either local or distant recurrence, with a median follow-up of 21 months. All patients have been fully continent. The results, although preliminary, imply that resection of distal rectal adenocarcinoma with sphincter preservation, and adjuvant therapy when appropriate, have achieved local and distant control equal to the conventional Miles' abdominoperineal resection, but without the need for a permanent colostomy.

Generation of suppressor macrophages during the human autologous mixed lymphocyte reaction.

The suppression of a mixed lymphocyte culture (MLC) by cells generated in an autologous mixed lymphocyte reaction (AMLR) is an in vitro assay which has been used to monitor immune regulation by T cells in patients with suspected autoimmune disorders. We found that the cells generated in an AMLR which were predominantly responsible for the suppression of an MLC were not T cells, but rather large, low density cells bearing macrophage cell surface determinants (M1 & M5). Generation of these cells appeared not to require either E-rosette positive T cells, or cell division, as gamma-irradiated E-rosette negative cells cultured alone for 6 days gave rise to these cells as well. Enrichment for the large AMLR-generated cells by discontinuous density gradient separation yielded a population of cells which were highly suppressive compared to the smaller cells, the majority of which bore T cell surface markers and which had little effect or even enhanced an MLC. Peripheral blood mononuclear cells cultured under similar conditions, but without prior separation and irradiation of the E-rosette negative cells also were shown to generate a population of large suppressor cells bearing M1 and M5 determinants. These findings suggest that these large macrophage-like suppressor cells are not an artifact of cell separation by rosetting with sheep erythrocytes and that such cells as well as T cells may be critical in the regulation of immune responses in vivo as well as in vitro.

Milk-sensitive and eosinophilic gastroenteropathy: similar clinical features with contrasting mechanisms and clinical course.

We studied 12 children with peripheral eosinophilia, iron deficiency anemia secondary to blood loss in the stools, protein-losing enteropathy, and eosinophilic infiltration of the stomach and small intestine. On the basis of immunologic features and responses to therapy, these patients could be divided into two groups. In the first group the disease was transient, presented in the first year of life, remitted on withdrawal of milk from the diet, and was not associated with IgE-mediated immediate hypersensitivity (milk-sensitive enteropathy). In contrast, the second group, which we termed eosinophilic gastroenteropathy, represented patients with a chronic disease that had its onset later in childhood, did not respond to dietary manipulations, was associated with atopy and IgE-mediated immediate hypersensitivity reactions to food, and required corticosteroid therapy to establish remission and control. The mechanism by which food causes gastrointestinal damage appears to be different in these two groups even though the clinical syndromes are similar.

Prevention of granuloma development in the mouse by using T cell hybridoma products.

The ability of an azobenzenearsonate (ABA)-specific suppressor T cell factor, a soluble extract from first order suppressor T cells (Ts1), and suppressor molecules produced by a long-term T cell hybridoma to regulate ABA-specific granuloma formation was studied. ABA-derivatized syngeneic spleen cells (ABA-SC) administered subcutaneously induced persistent delayed-type hypersensitivity (DTH) responses, detected by footpad swelling and hapten-specific granuloma formation by 72 and 96 hr after challenge with ABA-bovine serum albumin coupled to polyacrylamide beads (ABA-BSA-PAB). Soluble factors from ABA-specific Ts1 prevented DTH and granulomatous development after subcutaneous administration of ABA-SC. Moreover, the in vivo administration of a factor that is derived from a Ts1 functioning hybrid cell line induced a second set of suppressor cells (Ts2) that upon transfer to syngeneic ABA-primed mice were able to inhibit granuloma formation in the footpad, as well as in the gastrointestinal tract after challenge with ABA-BSA-PAB. These experiments demonstrate the dependence of the granulomatous reaction on T cell-mediated events, as well as the potential therapeutic efficacy of an antigen-specific suppressor T cell factor and a hybridoma T cell product in limiting antigen-specific granuloma formation in vivo.

Widespread cytomegalovirus gastroenterocolitis in a patient with acquired immunodeficiency syndrome.

This case report documents extensive gastrointestinal cytomegalovirus infection in a patient with acquired immunodeficiency syndrome, presenting as diarrhea and involving stomach, duodenum, and colon. Endoscopic biopsy specimens and cultures were essential to make the diagnosis and to distinguish the illness from inflammatory bowel disease. A careful search for other potential pathogens was made as well. The discussion includes a review of literature regarding cytomegalovirus involvement of the gastrointestinal tract.

Impaired natural killer cell activity in patients with inflammatory bowel disease: evidence for a qualitative defect.

The natural killer cell lymphocyte may represent an important element in immune defense. Since host defense may be abnormal in patients with inflammatory bowel disease, we assessed natural killer cell function in 34 patients with ulcerative colitis and Crohn's disease. Lymphocytes from 31 of 34 patients (91%) exhibited decreased natural killer cell activity (mean cytotoxicity +/- SEM was 25% +/- 7.5% of the mean normal values, p less than 0.01). Disease activity, type of disease, and steroid therapy had no influence on these values. None of the 10 age-matched disease controls with other intestinal inflammatory conditions had natural killer cell activity outside the normal range. The numbers of circulating killer cells present in patients with impaired activity were quantified using a cytofluorometric detection system. All patients tested had normal numbers of cells binding nonaggregated immunoglobulin G (Fc receptor positive) despite decreased natural killer cell activity. It appears that by using this cytofluorometric detection technique, decreased natural killer cell activity is not the consequence of diminished numbers of natural killer cells.

Defective autologous mixed-lymphocyte reaction and suppressor cell generation in patients with inflammatory bowel disease.

Impaired regulation of immune function may contribute to the abnormal immune responses associated with idiopathic inflammatory bowel disease. We examined the autologous mixed-lymphocyte culture in inflammatory bowel disease patients because this reaction may reflect self regulation of immune responses in vivo and results in activation of suppressor T cells in vitro. We also examined suppressor T-cell generation in two separate assays. In contrast to healthy and disease controls who had normal values, the autologous mixed-lymphocyte culture response was diminished in 44 of 51 (86%) patients with inflammatory bowel disease, independent of disease type, activity, or steroid therapy. Fourteen of 17 inflammatory bowel disease patients (83%) had decreased suppressor T-cell generation. These results show a distinct abnormality in autologous mixed-lymphocyte culture reactivity and in generation of suppressor cells in inflammatory bowel disease. Such impaired immune regulation may be partly responsible for the immunologic aberrations observed in patients with inflammatory bowel disease.

An analysis of peripheral blood and salivary polymorphonuclear leukocyte function, circulating immune complex levels and oral status in patients with inflammatory bowel disease.

In an earlier case report, we described a 28-year-old man with active Crohn's disease and rapidly progressive alveolar bone loss, who presented with enhanced peripheral blood polymorphonuclear leukocyte activity as assessed by phagocytosis and lysis of a target bacterium. To assess the significance of this finding, peripheral blood polymorphonuclear leukocytes (PMN) from thirty patients with active or inactive inflammatory bowel disease (IBD) were examined for spontaneous and stimulated hexose monophosphate shunt (HMS) activity. Analysis revealed the PMN from active IBD patients displayed greater metabolic activity than PMN from inactive IBD patients, which in turn were more active than PMN from normal subjects. Since circulating immune complex (CIC) levels might be of importance in the in vivo activation of PMN, analysis of serum CIC levels via polyethylene glycol 6000 precipitation was carried out. This indicated that active IBD patients had higher levels of CIC activity then inactive IBD patients. Ten of these patients were evaluated for spontaneous HMS activity by salivary PMN. As compared to controls, comparable numbers of salivary PMN from IBD patients displayed an average of 45% less activity than control salivary PMN. Analysis of the oral status of 10 IBD patients referred to the Peter Bent Brigham Dental Clinic indicated that two patients had overt oral pathoses apparently attributable to IBD. These two patients also had the highest CIC levels observed in the 30 serum samples tested.

Antigen- and receptor-driven regulatory mechanisms. X. The induction and suppression of hapten-specific granulomas.

We have investigated the induction and suppression of granuloma formation elicited by the azobenzenearsonate (ABA) determinant in A/J Mice. ABA-derived syngeneic spleen cells (ABA-SC) administered subcutaneously induced hapten-specific delayed hypersensitivity (DTH), detected by footpad swelling, upon challenge with ABA-bovine serum albumin (BSA) coupled to polyacrylamide beads (PAB). The reactions elicited by ABA-BSA-PAB reached maximal intensity at 24 hours but were relatively persistent and were still marked at 96 hours. Histopathologic examination of footpad responses at 24 and 48 hours after challenge revealed compact collections around beads of mononuclear cells and granulocytes, which were characteristic of DTH reactions. Discrete epithelioid granulomas became apparent by 72 or 96 hours. Unprimed mice or mice primed with ABA-SC and challenged with uncoupled beads did not develop either substantial leukocytic infiltrates or granulomas. Persistent delayed responses were only apparent if the mice were challenged with the homologous hapten-coupled bead, indicating the fine specificity of the reaction. Immune cells were shown to be capable of transferring DTH and granulomatous responsiveness to ABA; the cells were sensitive to anti-Thy 1.2 antiserum and complement, which indicates that the response was thymic-dependent. The intravenous injection of ABA-SC, which is known to induce suppressor cells, prevented the development of DTH or granulomatous responsiveness followinggg subcutaneous immunization with ABA-SC. In addition, the transfer of suspensions containing suppressor T cells into syngeneic mice primed with ABA-SC prevented the development of DTH reactions and granuloma formation followin challenge with ABA-BSA-PAB. Furthermore, only hapten-specific suppressor T cells limited persistent delayed hypersensitivity responses. Having successfully developed granulomas in the footpad, the authors induced and suppressed granulomatous lesions in the gastrointestinal tract in a similar fashion. These experiments establish a model in inbred mice for the study of granulomatous diseases, including those of the gastrointestinal tract.

Monoclonal B lymphocytes in the peripheral blood of patients with inflammatory bowel disease.

Abnormalities in the B lymphocyte population may be relevant to certain altered in vitro immune responses in patients with inflammatory bowel disease. Using a cytofluorometric detection system, we looked for lymphocytes having homogeneous amounts of surface immunoglobulin of only one light-chain class. We studied the peripheral blood lymphocytes from 20 patients with ulcerative colitis and Crohn's disease. Lymphocytes from 12 of 20 patients (60%) with inflammatory bowel disease expressed abnormal light-chain distributions regardless of disease activity, type of disease, or steroid therapy. None of the 15 age-matched normal controls or 12 patients with other intestinal inflammatory conditions showed abnormal light-chain distributions (p greater than 0.01). The data indicate that there are increased numbers of monoclonal lymphocytes in the peripheral blood of some patients with inflammatory bowel disease. One explanation to account for these findings is the possible presence of an abnormality of immune regulation that permits proliferation of such clones.

Human colonic mononuclear cells: studies of cytotoxic function.

We isolated lymphocytes from the lamina propria of colon from 19 patients with inflammatory bowel disease, colon cancer, and certain benign conditions to determine: (1) if these lymphocytes could mediate mitogen-induced (MICC) and spontaneous cell-mediated cytotoxicity (SCMC), and (2) if there were any differences in cytotoxic effectiveness which could relate to the underlying disease. We found that lamina propria lymphocytes functioned well in MICC reactions with phytohaemagglutinin, but not concanavalin A as the inducing mitogen (specific lysis 28 5% vs 5 3%). Lamina propria lymphocytes did not mediate SCMC (specific lysis 0.3%). Neither the presence of inflammation not the underlying disease of the patient influenced the cytotoxic activity. Peripheral blood lymphocytes from normal subjects and patients performed well in MICC assay with both phytohaemagglutinin and concanvalin A as the inducing mitogen and were equally effective in SCMC reactions.

Dinitrochlorobenzene-induced colitis in the guinea-pig: studies of colonic lamina propria lymphocytes.

Dinitrochlorobenzene-induced colitis in guinea-pigs may be immunologically mediated: animals must be presensitised to dinitrochlorobenzene to develop colitis, sensitivity can be passively transferred by lymphocytes and the injury can be mitigated by immunosuppression. In this study, we examined lamina propria lymphocytes isolated from colons of animals with dinitrochlorobenzene-induced colitis, and appropriate controls. Lamina propria lymphocytes from colitis animals have a greater percentage of rabbit erythrocyte-rosetting cells (T cells) (20.1 +/- 3.0 vs 2.3 +/- 0.8, p less than .01) and a greater capacity to mediate mitogen-induced cellular cytotoxicity with phytohaemagglutinin than lamina propria lymphocytes from normal colon (% specific cytoxicity = 29.4 +/- 8.7 vs 5.0 +/- 4.5, P less than .005). There was no difference in the percentage of rosetting cells or cytotoxicity index of spleen or mesenteric lymph node lymphocytes between the colitis animals and controls. These data suggest that there are changes in the distribution and functional characteristics of lamina propria lymphocytes which correlate with mucosal cell injury in the dinitrochlorobenzene-colitis model.

Impaired mixed-lymphocyte culture reactions in patients with inflammatory bowel disease.

We studied the response of lymphocytes from 43 patients with inflammatory bowel disease to allogeneic stimulation in one-way mixed-lymphocyte cultures. We found that 53% of patients with inflammatory bowel disease, in contrast to 4% of normal and disease controls, had significant depression of mixed-lymphocyte culture response (P less than 0.01). The depression of mixed-lymphocyte culture response was independent of disease activity, duration (more or less than 10 yr), or presence of corticosteroid therapy. Removal of iron-ingesting mononuclear cells (macrophages) resulted in increased mixed-lmyphocyte culture response in 6 of 7 patients tested.

Gluten-sensitive enteropathy. Influence of histocompatibility type on gluten sensitivity in vitro.

We previously developed an in vitro organ culture system in which gluten exerts a toxic effect on intestinal mucosa of patients with active gluten-sensitive enteropathy. Gluten generally inhibits the epithelial cell maturation of intestinal biopsy specimens that otherwise occurs if the tissue is cultured for 24-48 h in a gluten-free medium. However, small intestinal mucosa from 15-20% of patients with proven gluten-sensitive enteropathy fails to manifest the expected gluten-induced damage in vitro. In the present study, we explored the relation between in vitro gluten-induced intestinal damage and the presence of HLA-B8. We determined whether the patients' histocompatibility type (HLA-B8 positive or negative) influenced the ability of gluten protein to inhibit epithelial cell maturation of cultured intestinal biopsy specimens from patients with gluten-sensitive enteropathy. Intestinal biopsies from 21 of 24 patients with gluten-sensitive enteropathy and HLA-B8 showed gluten-induced damage in vitro. On the other hand, intestinal biopsies from only 4 of 16 patients with gluten-sensitive enteropathy but without HLA-B8 showed gluten-induced damage in vitro. The difference in the effect of gluten in vitro between these two groups was statistically significant (P < 0.01). The data show a dichotomy between gluten-induced tissue damage in vivo and in vitro in HLA-B8 negative patients, suggesting that HLA-B8 is important for gluten to manifest a cytotoxic influence in organ culture.