The value of interventional radiology in clinical trial teams: experience from the BATTLE lung cancer trials.

AIM: To report on the multidisciplinary approach, focusing specifically on the role of the interventional radiologist (IR), used to support the Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) and BATTLE-2 trials. MATERIALS AND METHODS: Patients who underwent percutaneous image-guided biopsy for the BATTLE and BATTLE-2 trials were reviewed. A radiology-based, three-point, lesion-scoring system was developed and used by two IRs. Lesions were given a score of 3 (most likely to yield sufficient material for biomarker analysis) if they met the following criteria: size >2 cm, solid mass, demonstrated imaging evidence of viability, and were technically easy to sample. Lesions not meeting all four criteria were scored 2 with the missing criteria noted as negative factors. Lesions considered to have risks that outweighed potential benefits receive a score of 1 and were not biopsied. Univariate and multivariate analyses were performed to evaluate the score's ability to predict successful yield for biomarker adequacy. RESULTS: A total of 555 biopsies were performed. The overall yield for analysis of the required biomarkers was 86.1% (478/555), and 84% (268/319) and 88.9% (210/236) for BATTLE and BATTLE-2, respectively (p=0.09). Lesions receiving a score of 3 were adequate for biomarker analysis in 89% of cases. Lesions receiving a score of 2 with more than two negative factors were adequate for molecular analysis in 69.2% (IR1, p=0.03) and 74% (IR2, p=0.04) of cases. The two IRs scored 78.4% of the lesions the same indicating moderate agreement (kappa=0.55; 95% confidence interval [CI]: 0.48, 0.61). CONCLUSIONS: IRs add value to clinical trial teams by optimising lesions selected for biopsy and biomarker analysis.

A pilot study evaluating predictors of postoperative outcomes after major abdominal surgery: Physiological capacity compared with the ASA physical status classification system.

BACKGROUND: This pilot study compared the risk predictive value of preoperative physiological capacity (PC: defined by gas exchange measured during cardiopulmonary exercise testing) with the ASA physical status classification in the same patients (n=32) undergoing major abdominal cancer surgery. METHODS: Uni- and multivariate logistic regression models were fitted to measurements of PC and ASA rank data determining their predictive value for postoperative morbidity. Receiver operating characteristic (ROC) curves were used to discriminate between the predictive abilities, exploring trade-offs between sensitivity and specificity. RESULTS: Individual statistically significant predictors of postoperative morbidity included the ASA rank [P=0.038, area under the curve (AUC)=0.688, sensitivity=0.630, specificity=0.750] and three newly identified measures of PC: PAT (% predicted anaerobic threshold achieved, <75% vs > or =75%), DeltaHR1 (heart rate response from rest to the anaerobic threshold), and HR3 (heart rate at the anaerobic threshold). A two-variable model of PC measurements (DeltaHR1+PAT) was also shown to be statistically significant in the prediction of postoperative morbidity (P=0.023, AUC=0.826, sensitivity=0.813, specificity=0.688). CONCLUSIONS: Three newly identified PC measures and the ASA rank were significantly associated with postoperative morbidity; none showed a statistically greater association compared with the others. PC appeared to improve predictive sensitivity. The potential for new unidentified measures of PC to predict postoperative outcomes remains unexplored.

Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis.

We conducted a meta-analysis to examine the effect of intraoperative monitoring of neuromuscular function on the incidence of postoperative residual curarisation (PORC). PORC has been considered present when a patient has a train-of-four (TOF) ratio of < 0.7 or < 0.9. We analysed data from 24 trials (3375 patients) that were published between 1979 and 2005. We excluded data on mivacurium from this meta-analysis because only three studies had examined the incidence of PORC associated with its use. Long- and intermediate-acting neuromuscular blocking drugs had been given to 662 and 2713 patients, respectively. Neuromuscular function was monitored in 823 patients (24.4%). A simple peripheral nerve stimulator was used in 543 patients, and an objective monitor was used in 280. The incidence of PORC was found to be significantly lower after the use of intermediate neuromuscular blocking drugs. We could not demonstrate that the use of an intraoperative neuromuscular function monitor decreased the incidence of PORC.

Tumor-stimulated release of tumor necrosis factor-alpha by human monocyte-derived macrophages.

Tumor necrosis factor-alpha (TNF) release by monocytes and macrophages may be an important determinant of the physiologic response of the host to neoplastic disease; however, the mechanisms which regulate TNF release by macrophages in hosts with neoplastic diseases are poorly understood. The purpose of this study was to determine if cell membranes and growth medium from human leukemia cell lines and solid tumor cell lines induced TNF release by cultured human blood monocyte-derived macrophages. The capacity for TNF release and direct tumor killing was highest in monocytes cultured for 7 to 11 days. Cell membranes and culture media from K562 erythroleukemia and several small cell lung carcinoma cell lines, including H82, induced the release of up to 1500 TNF units per 10(6) macrophages over 24 hr. By contrast, allogeneic peripheral blood lymphocytes, cell membranes from normal mixed donor peripheral blood leukocytes, or growth medium from normal embryonic lung fibroblasts induced the release of little or no TNF during culture up to 24 hr, suggesting that this macrophage response was specific for tumor cells. Release of TNF by tumor-stimulated macrophages was gradual, peaking 24 hr following the addition of stimuli. Induction of macrophage TNF release was concentration dependent, with half-maximal TNF levels induced by 12.5 and 25 micrograms/ml cell membranes prepared from K562 and H82, respectively. Pretreatment of tumor cell membranes with polymixin B, which inhibits many of the actions of endotoxin, failed to neutralize tumor induction of TNF, suggesting that endotoxin was not responsible for this activity. Depletion of macrophages by treatment with 3C10 monoclonal antibody and complement abrogated tumor-induced TNF release, indicating that macrophages were the source of the secreted TNF. HPLC analysis of H82 growth medium demonstrated a single peak of macrophage activating activity with approximate 40-kDa molecular weight. We have demonstrated that cell membranes and growth medium from some human leukemia and solid tumor cell lines, but not from normal human cells, induce human peripheral blood monocytes and monocyte-derived macrophages to release functionally active TNF. This process may contribute to the host response to some neoplastic diseases.

Warming macrophages to febrile range destabilizes tumor necrosis factor-alpha mRNA without inducing heat shock.

We have previously reported that sustained tumor necrosis factor (TNF)-alpha expression is suppressed by temperatures in the febrile range in human macrophages. In this study, we examined the mechanisms of high-temperature-induced macrophage TNF suppression in the RAW 264.7 macrophage cell line. Incubating lipopolysaccharide (LPS)-stimulated RAW 264.7 cells at 40 degrees C reduced TNF secretion by 92% and peak TNF mRNA levels by 43% compared with cells incubated at 37 degrees C (P < 0.05) but did not affect levels of glyceraldehyde-3-phosphate dehydrogenase, beta-actin, or interleukin-6 mRNA. TNF mRNA half-life, measured after transcriptional arrest with actinomycin D, was reduced from 21.8 +/- 3.6 min in LPS-stimulated RAW 264.7 cells at 37 degrees C to 16.0 +/- 1.8 min at 40 degrees C (P < 0.03), but these cells at 40 degrees C did not alter transcription rate or TNF mRNA polysome association. TNF mRNA destabilization occurred at temperatures below the threshold (43 degrees C) for the generalized heat shock response in these cells. We conclude that heating macrophages to febrile-range temperatures attenuates sustained TNF expression by modulating posttranscriptional processing, including acceleration of TNF mRNA decay.

Evidence that cultured airway smooth muscle cells contain bradykinin B2 and B3 receptors.

We examined bradykinin-induced 45Ca2+ efflux and prostaglandin synthesis in guinea pig tracheal smooth muscle cells maintained in tissue culture. We also studied the effects of a B1 receptor agonist and antagonist, a B2 receptor antagonist, and the cyclooxygenase inhibitor indomethacin. In cultured smooth muscle cells, bradykinin (0.1 nM to 10 microM) stimulated efflux of 45Ca2+ and induced the synthesis of prostaglandin E2 and the prostacyclin metabolite 6-keto-prostaglandin F1 alpha. DesArg9-bradykinin, a B1 receptor agonist, had no effect on 45Ca2+ efflux or prostaglandin synthesis, and no responses to bradykinin were unaffected by the B1 receptor antagonist desArg9-[Leu8]-bradykinin. Indomethacin (1 microM) abolished bradykinin-induced prostaglandin synthesis but was without effect on 45Ca2+ efflux. NPC 567 (DArg[Hyp3,DPhe7]-bradykinin), a B2 receptor antagonist, had no effect on bradykinin-induced 45Ca2+ efflux, but abolished prostaglandin synthesis. Unlike in membranes prepared freshly from guinea pig tracheal smooth muscle, the B2 receptor antagonist inhibited completely (Ki, 12 nM) binding of [3H]-bradykinin to membranes prepared from cultured tracheal smooth cells. These data suggest that tracheal smooth muscle cells, maintained in culture, express B2 receptors that mediate bradykinin-induced prostaglandin synthesis. The observation that bradykinin-induced efflux of calcium ions was unaffected by B1 or B2 antagonists provides further evidence that airway smooth muscle may contain a novel B3 receptor.

The role of 3' poly(A) tail metabolism in tumor necrosis factor-alpha regulation.

In unstimulated RAW 264.7 macrophage-like cells, tumor necrosis factor-alpha (TNF-alpha) mRNA was transcribed and accumulated in the cytoplasm, but the TNF-alpha transcripts failed to associate with polysomes, and TNF-alpha protein was not detected. Stimulation with lipopolysaccharide (LPS) induced an increase in TNF-alpha transcription, cytoplasmic TNF-alpha mRNA accumulation, polysome association, and secretion of TNF-alpha protein. This process was associated with a 200-nucleotide increase in the apparent length of the TNF-alpha mRNA. The difference in TNF-alpha mRNA size was caused by marked truncation of the 3' poly(A) tail in unstimulated cells. Fully adenylated TNF-alpha mRNA appeared within 15 min of LPS stimulation. We speculate that removal of the poly(A) tail blocks initiation of TNF-alpha translation in unstimulated macrophages. LPS inactivates this process, allowing synthesis of translatable polyadenylated TNF-alpha mRNA.

Altered cytokine regulation in the lungs of cigarette smokers.

Cigarette smoking is the major factor responsible for chronic obstructive lung disease, but it occurs in only a minority of smokers. Smoking is associated with increased susceptibility to pulmonary infections and with a neutrophil- and macrophage-rich inflammation of the small airways. We compared concentrations of tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 in bronchoalveolar lavage fluid (BALF) and measured the capacity of BALF macrophages to release TNF and IL-6 in vitro in nine smokers (19.1 +/- 4.2 pack-years; mean +/- SE) and nine nonsmokers. Compared with nonsmokers, BALF from smokers contained more cells (65.3 +/- 13.2 versus 27.2 +/- 4.8 x 10(6); p < 0.02), but much lower concentrations of IL-6 (1.8 +/- 1.0 versus 15.9 +/- 5.8 pg/ml; p < 0.05). The two smokers with the highest number of BALF cells had increased BALF concentrations of interleukin-8 (IL-8), but there was no difference in BALF IL-8 concentrations between the two groups (p = 0.08). Compared with BALF macrophages from nonsmokers, cells from smokers released less TNF (211 +/- 77 versus 1,406 +/- 348 units per 10(8) cells; p < 0.01) and IL-6 (5.8 +/- 2.6 versus 64.9 +/- 23.3 hybridoma units per ml; p < 0.02) during a 6-h incubation with lipopolysaccharide (LPS). We conclude that even in young, healthy smokers the pulmonary microenvironment is markedly abnormal, characterized by depressed levels of IL-6, macrophages that have a markedly depressed capacity for LPS-induced cytokine release and, in some smokers, increased concentrations of IL-8.

Increased activity of interleukin-6 but not tumor necrosis factor-alpha in lung lavage of premature infants is associated with the development of bronchopulmonary dysplasia.

Although considerable evidence suggests that bronchopulmonary dysplasia (BPD) is the result of prolonged inflammation and impaired healing of the immature lung, the mediators that regulate inflammation in neonatal lung injury have not been completely elucidated. We examined whether the cytokines IL-6 and tumor necrosis factor-alpha (TNF) interact to modulate a cascade of cell-cell signaling events involved in inflammation contributing to the development of BPD. To determine the relative activities of these cytokines in neonatal lung injury, lung lavage samples were serially obtained from 1 to 28 d from 11 infants with self-limited respiratory distress syndrome (RDS), 19 infants with evolving BPD, and 10 control infants ventilated for nonpulmonary reasons. On the first day of life, there were no differences in antigenic IL-6 concentrations in lavage fluids among the BPD, RDS, and control groups, but IL-6 activity determined by the 7TD1 proliferation assay was 15-fold and 6.6-fold higher in lung lavage of infants who developed BPD compared with activities in lavage from control and RDS infants, respectively (control, 49.4 +/- 17.6; RDS, 117.3 +/- 59.6; BPD, 779.5 +/- 212.6 x 10(3) hybridoma units/L, mean +/- SEM, p = 0.02). This suggests that pathways for inactivating or inhibiting IL-6 that may be present in the lungs of RDS and control infants may be deficient in BPD infants. IL-6 activity remained elevated in lavage of BPD infants for the first 2 wk and declined to low levels by d 28.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential effects of hyperthermia on macrophage interleukin-6 and tumor necrosis factor-alpha expression.

The pyrogenic cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) appear in the circulation during infections and injuries, but TNF-alpha and IL-6 are regulated differently in macrophages. We compared the effects of elevated temperatures within the usual febrile range on the expression of TNF-alpha and IL-6 in vitro in lipopolysaccharide (LPS)-stimulated human macrophages derived from peripheral blood monocytes (HuMoM phi). During an 18-h incubation at 37 degrees C with 5 ng/ml LPS, these cells released 5,030 +/- 1,460 pg TNF-alpha/10(6) cells (means +/- SE) and 1,380 +/- 280 pg IL-6/10(6) cells. In LPS-stimulated HuMoM phi incubated at 40 degrees C, TNF-alpha release was almost completely inhibited (76 +/- 76 pg TNF-alpha/10(6) cells; P < 0.01 compared with LPS-stimulated HuMoM phi at 37 degrees C), but release of IL-6 was preserved (1,600 +/- 780 pg IL-6/10(6) cells). Western and Northern analyses showed that levels of TNF-alpha mRNA and cell-associated and secreted TNF-alpha protein were decreased, but IL-6 expression was unchanged at 40 degrees C in LPS-stimulated macrophages. Incubating HuMoM phi at 40 degrees did not alter their viability after 18 h but induced a 75-fold increase in levels of the inducible heat-shock protein 72 (HSP-72) mRNA in the face of a 56% inhibition in total protein synthesis. Our results show that IL-6 expression persisted at incubation temperatures in the upper end of the physiological range that induced heat shock and attenuated the expression of functionally active TNF-alpha in LPS-stimulated HuMoM phi.