A phase I trial of pan-Bcl-2 antagonist obatoclax administered as a 3-h or a 24-h infusion in combination with carboplatin and etoposide in patients with extensive-stage small cell lung cancer.

BACKGROUND: Bcl-2 family genes are frequently amplified in small cell lung cancer (SCLC). A phase I trial was conducted to evaluate the safety of obatoclax, a Bcl-2 family inhibitor, given in combination with standard chemotherapy. METHODS: Eligible patients (3-6 per cohort) had extensive-stage SCLC, measurable disease, ≤ 1 before therapy, Eastern Cooperative Oncology Group performance status 0 or 1, and adequate organ function. Patients were treated with escalating doses of obatoclax, either as a 3- or 24-h infusion, on days 1-3 of a 21-day cycle, in combination with carboplatin (area under the curve 5, day 1 only) and etoposide (100 mg m(-2), days 1-3). The primary endpoint was to determine the maximum tolerated dose of obatoclax. RESULTS: Twenty-five patients (56% male; median age 66 years) were enrolled in three dose cohorts for each schedule. Maximum tolerated dose was established with the 3-h infusion at 30 mg per day and was not reached with the 24-h infusion. Compared with the 24-h cohorts, the 3-h cohorts had higher incidence of central nervous system (CNS) adverse events (AEs); dose-limiting toxicities were somnolence, euphoria, and disorientation. These CNS AEs were transient, resolving shortly after the end of infusion, and without sequelae. The response rate was 81% in the 3-h and 44% in the 24-h infusion cohorts. CONCLUSION: Although associated with a higher incidence of transient CNS AEs than the 24-h infusion, 3-h obatoclax infusion combined with carboplatin-etoposide was generally well tolerated at doses of 30 mg per day. Though patient numbers were small, there was a suggestion of improved efficacy in the 3-h infusion group. Obatoclax 30 mg infused intravenously over 3 h on 3 consecutive days will be utilised in future SCLC studies.

Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery.

Over the past decades, major progress in patient selection, surgical techniques and anaesthetic management have largely contributed to improved outcome in lung cancer surgery. The purpose of this study was to identify predictors of post-operative cardiopulmonary morbidity in patients with a forced expiratory volume in 1 s <80% predicted, who underwent cardiopulmonary exercise testing (CPET). In this observational study, 210 consecutive patients with lung cancer underwent CPET with completed data over a 9-yr period (2001-2009). Cardiopulmonary complications occurred in 46 (22%) patients, including four (1.9%) deaths. On logistic regression analysis, peak oxygen uptake (peak V'(O2) and anaesthesia duration were independent risk factors of both cardiovascular and pulmonary complications; age and the extent of lung resection were additional predictors of cardiovascular complications, whereas tidal volume during one-lung ventilation was a predictor of pulmonary complications. Compared with patients with peak V'(O2) >17 mL·kg⁻¹·min⁻¹, those with a peak V'(O2) <10 mL·kg⁻¹·min⁻¹ had a four-fold higher incidence of cardiac and pulmonary morbidity. Our data support the use of pre-operative CPET and the application of an intra-operative protective ventilation strategy. Further studies should evaluate whether pre-operative physical training can improve post-operative outcome.

Role of phagocytosis in the activation of macrophages.

Macrophages were obtained by peritoneal lavage from untreated mice or from mice which had received either Brewer's thioglycollate broth or a suspension of streptococcus A cell walls intraperitoneally 4 days before. 3 h after harvesting, adherent cells from untreated mice were allowed to phagocytose zymosan, formaldehyde-treated sheep erythrocytes, or latex beads. Phagocytosis was stopped after 1 h and culture was continued for up to 10 days. Phagocytosis of zymosan or sheep erythrocytes triggered the immediate release of lysosomal glycosidases, stimulated the synthesis of cellular lactate dehydrogenase, and induced the delayed production and secretion of plasminogen activator . No such changes were observed upon phagocytosis of latex. Although all three particles used were phagocytosed, only zymosan and sheep erythrocytes stimulated glucose oxidation via the hexose monophosphate shunt. Similar findings were obtained in macrophages elicited with streptococcus A cell walls after zymosan phagocytosis. Thioglycollate-elicited macrophages, however, which were already secreting lysosomal hydrolases and plasminogen activator, could not be activated further by zymosan. The results of this study show that macrophages become activated after phagocytosis of particles that stimulate the activity of their hexose monophosphate shunt. The triggering event appears to be the burst of shunt activity itself or shunt-related biochemical reactions rather than phagocytic uptake per se or particle-dependent complement activation by the alternative pathway. Once initiated, macrophage activation proceeds independently of the intracellular fate of the ingested material .

Secretion of lysosomal hydrolases by stimulated and nonstimulated macrophages.

Peritoneal macrophages were obtained from untreated mice and from mice treated with thioglycollate medium (TA), proteose peptone medium (PP), or a suspension of streptococcus A cell wall material (SA). The biochemical and secretory properties of these cells in long term cultures (up to 2 wk) were compared. TA-elicited macrophages contained more protein, lactate dehydrogenase, lysosomal hydrolases, and in particular, more plasminogen activator than the other cells studied. All types of macrophages studied were found to release considerable amounts of lysosomal hydrolases (beta-glucuronidase, N-acetyl-beta-glucosaminidase, alpha-mannosidase, and acid phosphatase) into the medium. Release was independent of phagocytosis and must, therefore, be regarded as true secretion. In both elicited and nonelicited macrophages, the rates of lysosomal enzyme secretion were virtually identical in the presence and in the absence of serum, and they were not enhanced by increasing serum concentrations. Lysosomal enzyme secretion in macrophages appears to depend on protein synthesis, since it was blocked by low concentrations of cycloheximide which neither affected cell viability nor lowered the intracellular enzyme levels. The amounts of lysosomal hydrolases secreted were highest in TA-elicited macrophages. The rates of secretion of PP- or SA-elicited and of nonelicited macrophages were about one-fourth of that of the TA-elicited cells. This difference, although significant, is much smaller than that observed for the secretion of plasminogen activator which was 20-50 times higher in TA-elicited cells. Acid glycosidases were also found in the peritoneal lavage media used for cell harvesting from both treated and nontreated mice. This indicates that active secretion of lysosomal hydrolases may be an in vivo property of the macrophage.

[Pulmonary rehabilitation: a multidisciplinary and comprehensive intervention]. / La réadaptation pulmonaire: une médecine pluridisciplinaire de pointe.

Pulmonary rehabilitation is an evidence-based, multidisciplinary and comprehensive intervention for chronic pulmonary diseases, adressed to symptomatic patients and to patients with impairment of activities of daily life. The major outcomes of this intervention are an increased exercise capacity, a decrease in dyspnea and thereby a better quality of life. Underweight patients may benefit from a caloric and protein supplementation. Smoking cessation programs should be integrated in any pulmonary rehabilitation program.

[Bochdalek hernia: a rare cause of dyspnea and abdominal pain in adults]. / La hernie de Bochdalek, cause rare de dyspnée et de douleurs abdominales chez l'adulte.

We present here a case of a sixty year old man with a symptomatic hernia of Bochdalek. Its diagnostic was long to be established because this type of congenital diaphragmatic hernia is rare and mainly occurs in neonates. However when looking at a patient with dyspnea and lasting atypical abdominal pain, such a diagnosis has to be looked for, even if such a clinical entity is extremely rare in adults.

Intracellular parasite killing induced by electron carriers. II. Correlation between parasite killing and the induction of oxidative events in macrophages.

Mouse peritoneal macrophages infected with Leishmania parasites were exposed in vitro to the electron carriers methylene blue (MB), toluidine blue 0 (TB), phenazine methosulfate (PMS) and crystal violet (CV). This led to parasite destruction without harm to the macrophages. The kinetics of intracellular killing depended on both the drug concentration and the duration of exposure; over 80% of the microorganisms were inactivated within 2.5 min of incubation of the parasitized cells with 10(-4) M MB. On a molar basis, the drugs were considerably more active against intracellular compared to free parasites, suggesting that the macrophages themselves play a role in the observed anti-parasite toxicity. Intracellular killing by macrophages exposed to MB, TB and PMS correlated with the stimulation of oxygen uptake and hexose monophosphate shunt activity in the cells. Cytochrome c markedly inhibited MB-induced intracellular parasite destruction as well as completely blocking parasite killing in macrophages activated by lymphokines, pointing to O-2, H2O2 or products derived therefrom as possible mediators of macrophage toxic activity in both instances. Cytochrome c did not protect free parasites from the direct toxicity of the drug, however. Lipopolysaccharide promoted parasite destruction by lymphokine-activated macrophages, but failed to do so for electron carrier-stimulated cells. These observations suggest that intracellular killing induced by electron carriers results from a direct interaction of the drugs with cellular redox systems, leading to the generation of oxygen metabolites toxic for the parasites.

Phagocytosis stimulates the release of a slow reacting substance in cultured macrophages.

1 A slow-reacting substance (SRS) was released from non-elicited mouse peritoneal macrophages during phagocytosis of zymosan particles, whereas no detectable SRS was produced by resting cells. 2 The macrophage SRS induced a delayed and slow contraction of the guinea-pig ileum but not of the chick rectum. 3 The myotonic activity was antagonized by low concentrations of FPL 55712 (sodium 7-[3-(4-acetyl-3-hydroxy-2-propylphenoxy)-2-hydroxypropoxy]-4-oxo-8-propyl-4H-1 -benzopyran-2 carboxylate) but was not affected by mepyramine or hyoscine, and was not associated with tachyphylaxis. 4 SRS release was increased by indomethacin and was abolished by the lipoxygenase and cyclooxygenase inhibitor, BW755C (3-amino-1-[m-(trifluoromethyl)-phenyl]-2-pyrazoline). 5 Addition of exogenous arachidonic acid or cysteine enhanced SRS production.

Phagocytosis-stimulated macrophages. Production of prostaglandins and SRS-A, and prostaglandin effects on macrophage activation.

Quiescent mouse peritoneal macrophages which phagocytose, and which respond to phagocytosis with a sudden elevation in hexose monophosphate shunt activity, immediately release into the medium oxygen metabolites, arachidonic acid oxygenation products, and lysosomal hydrolases. Such cells subsequently differentiate and acquire the properties of inflammatory macrophages. The latter process appears to be under the control of prostaglandin E2 and possibly other cyclooxygenase products which are formed as a consequence of phagocytosis and seem to act as feed-back inhibitors.

Induction of plasminogen activator secretion in macrophages by electrochemical stimulation of the hexose monophosphate shunt with methylene blue.

Resident peritoneal macrophages were obtained from untreated mice and were cultured in medium 199 with or without 5% acid-treated fetal bovine serum. Three hours after harvesting, redox compounds--i.e., methylene blue, methyl viologen, or nitro blue tetrazolium--were added to the cultures of adherent cells. After 1 hr, the cells were washed and culturing was continued in the absence of redox compounds. The effects of the redox compounds were tested by assaying for hexose monophosphate (HMP) shunt activity and for plasminogen activator secretion, and the results were compared with the effects induced by phagocytic stimuli. Methylene blue caused a concentration-dependent stimulation of the HMP shunt, whereas methyl viologen and nitro blue tetrazolium were ineffective. Shunt stimulation by methylene blue was followed, after a lag of 2-4 days, by plasminogen activator secretion. The rate of secretion was dependent on the methylene blue concentration used. Methyl viologen and nitro blue tetrazolium were again ineffective, whereas phagocytosis of zymosan or sheep erythrocytes, which stimulates the HMP shunt, induced plasminogen activator secretion at rates similar to those induced by methylene blue. These results add further evidence to our hypothesis that the HMP shunt-dependent metabolic burst is involved in macrophage activation. Because methylene blue mimics the action of zymosan it appears that shunt stimulation by itself initiates the activation process independently of phagocytosis.

Inhibition of interleukin-1 release by IX 207-887.

Compound IX 207-887 is a novel antiarthritic agent which inhibits the release of interleukin-1 (IL-1) from human monocytes and mouse peritoneal macrophages in vitro at concentrations which are achieved therapeutically in human rheumatoid arthritis and in animal models of arthritis. In the present studies IL-1 activity in conditioned media, homogenates or lysates was monitored using four independent assay systems. Biologically active IL-1 was determined by, a) the induction of latent metalloproteinase-release from rabbit articular chondrocytes, which is relatively specific for IL-1 and b) by a sensitive thymocyte proliferation assay. Immunoreactive IL-1-beta was assayed by RIA and ELISA. In all test systems IX 207-887 significantly reduced both biologically active and immunoreactive IL-1 in culture media, whereas the levels of IL-1 in homogenates or lysates were either unaffected or only marginally reduced. The release of other monokines tested, such as interleukin-6 and tumour necrosis factor-alpha, and the secretion of lysozyme were only marginally influenced. IX 207-887 neither affected the adherence of human monocytes nor markedly inhibited IL-1 or IL-2-induced thymocyte proliferation. In the chondrocyte test no IL-1 antagonistic activity of IX 207-887 could be observed. All of these data indicate that IX 207-887 has the novel property of being an inhibitor of IL-1 release.

Modulation of secretory processes of phagocytes by IX 207-887.

In chronic inflammation, the mediators released by phagocytes are in part responsible for the initiation and perpetuation of the disease. IX 207-887, which is a novel antiarthritic drug, inhibits the release of cytokines from mononuclear cells at concentrations which are achieved therapeutically in human rheumatoid arthritis and in animal models of arthritis. Furthermore, the production of superoxide and release of azurophil and specific granules by N-formyl-Met-Leu-Phe-stimulated neutrophils are significantly reduced. As a consequence, IX 207-887 may break the vicious circle which is manifest in chronic inflammation. In a recent double-blind placebo controlled study IX 207-887 has been shown to be an effective slow-acting drug for use in rheumatoid arthritis.

Effects of cyclooxygenase inhibitors and prostaglandin E2 on macrophage activation in vitro.

The effect of the cyclooxygenase inhibitors, indomethacin and diclofenac, and of PGE2 on either resting or stimulated macrophages was investigated. Peritoneal macrophages were obtained from untreated mice and cultured for 10 days. Macrophage activation was induced by zymosan phagocytosis and was monitored by testing for plasminogen activator secretion and the cellular levels of lactate dehydrogenase, beta-glucuronidase and alkaline phosphodiesterase I. It was found that cyclooxygenase inhibitors activate resting macrophages and enhance the degree of activation obtained after zymosan phagocytosis. Addition of exogenous PGE2, on the other hand, had the opposite effect, it suppressed activation induced either by cyclooxygenase inhibitors, phagocytosis or a combination of both. Cyclooxygenase inhibitors and PGE2 did not affect the hexose monophosphate shunt activity of resting macrophages and had only a minor effect on the respiratory burst occurring during zymosan phagocytosis. It appears, therefore, that the observed changes in the state of activation of the macrophages are not related to hexose monophosphate shunt activity. The described effects suggest that PGE2 and possibly other cyclooxygenase products may function as inhibitory feed-back regulators of macrophage activation.

Stimulation of prostaglandin formation by an antigen- and Ia-restricted T-cell-macrophage interaction.

Stimulation of macrophages by zymosan phagocytosis triggers the respiratory burst and induces an early release of lysosomal hydrolases and E-type prostaglandins (PGE). We have studied whether antigen presentation by macrophages to helper T-cells elicits a comparable sequence of events. Cloned T-helper cells specific for hen egg albumin (EA) were added to histocompatible or histoincompatible resident mouse peritoneal macrophages in the presence of EA or an unrelated antigen, and the changes in biochemical parameters were monitored. The interaction between macrophages. T-helper cells and EA induced the production of PGE, but no release of lysosomal hydrolases or activation of the respiratory burst. In addition T-cell proliferation was observed. By contrast, no proliferation and no biochemical changes were observed when histoincompatible macrophages or unrelated antigen were used. When the experiments were done in the presence of indomethacin to inhibit PGE release, T-cell proliferation was enhanced. These results suggest that the PGE released may exert a feed-back control of the T-cell response.