Adjuvant dendritic cell therapy in stage IIIB/C melanoma: the MIND-DC randomized phase III trial.

Autologous natural dendritic cells (nDCs) treatment can induce tumor-specific immune responses and clinical responses in cancer patients. In this phase III clinical trial (NCT02993315), 148 patients with resected stage IIIB/C melanoma were randomized to adjuvant treatment with nDCs (n = 99) or placebo (n = 49). Active treatment consisted of intranodally injected autologous CD1c+ conventional and plasmacytoid DCs loaded with tumor antigens. The primary endpoint was the 2-year recurrence-free survival (RFS) rate, whereas the secondary endpoints included median RFS, 2-year and median overall survival, adverse event profile, and immunological response The 2-year RFS rate was 36.8% in the nDC treatment group and 46.9% in the control group (p = 0.31). Median RFS was 12.7 months vs 19.9 months, respectively (hazard ratio 1.25; 90% CI: 0.88-1.79; p = 0.29). Median overall survival was not reached in both treatment groups (hazard ratio 1.32; 90% CI: 0.73-2.38; p = 0.44). Grade 3-4 study-related adverse events occurred in 5% and 6% of patients. Functional antigen-specific T cell responses could be detected in 67.1% of patients tested in the nDC treatment group vs 3.8% of patients tested in the control group (p < 0.001). In conclusion, while adjuvant nDC treatment in stage IIIB/C melanoma patients generated specific immune responses and was well tolerated, no benefit in RFS was observed.

Regulatory T cells in psoriatic arthritis: an IL-17A-producing, Foxp3intCD161 + RORγt + ICOS + phenotype, that associates with the presence of ADAMTSL5 autoantibodies.

In psoriatic arthritis (PsA), predisposing class I HLA alleles, the presence of synovial clonally proliferated CD8 + T cells and autoantibodies all point towards the loss of immune tolerance. However, the key mechanisms that lead to immune dysregulation are not fully understood. In other types of inflammatory arthritis, T regulatory cell (Treg) dysfunction and plasticity at sites of inflammation were suggested to negatively affect peripheral tolerance. We here addressed if Treg variances associate with psoriatic disease. We collected clinical data, sera and peripheral blood mononuclear cells from 13 healthy controls, 21 psoriasis and 21 PsA patients. In addition, we obtained synovial fluid mononuclear cells from 6 PsA patients. We studied characteristics of CD4 + CD25 + CD127loFoxp3 + Tregs by flow cytometry and used ELISA to quantify antibodies against ADAMTSL5, a recently discovered autoantigen in psoriatic disease. In comparison with their circulating counterparts, Tregs from inflamed joints express increased levels of ICOS, CTLA-4 and TIGIT. Furthermore, synovial fluid-derived Tregs have a distinct phenotype, characterized by IL-17A production and upregulation of CD161 and RORγt. We identified a subset of Tregs with intermediate Foxp3 expression as the major cytokine producer. Furthermore, ICOS + Tregs associate with PsA disease activity as measured by PASDAS. Lastly, we observed that presence of the Foxp3int Tregs associates with an increased abundance of anti-ADAMTSL5 autoantibodies. Tregs derived from the inflammatory environment of inflamed PsA joints exhibit a distinct phenotype, which associates with loss of peripheral immune tolerance in psoriatic disease.

Activation-induced colocalisation of SCAMP5 with IFNα in human plasmacytoid dendritic cells.

INTRODUCTION: Plasmacytoid dendritic cells (pDCs) are the main producers of type I interferon (IFN) in SLE. pDCs express high secretory carrier membrane protein 5 (SCAMP5). Recent work in transfected HEK cells connects SCAMP5 to the type I IFN secretory pathway. To further study the role of SCAMP5 in IFNα secretion by pDCs, we focused on the subcellular distribution of SCAMP5 in human pDCs freshly isolated from peripheral blood. METHODS: We measured SCAMP5 expression by flow cytometry in peripheral blood mononuclear cells of healthy subjects (n=8). Next, we assessed the colocalisation of SCAMP5 with IFNα in pDCs of healthy subjects (n=4) by evaluating bright detail similarity (BDS) scores using ImageStream technology. RESULTS: We confirm that SCAMP5 is highly expressed by pDCs derived from peripheral blood. In activated pDCs, we show that SCAMP5 colocalises with IFNα (mean BDS 2.0±0.1; BDS >2.0 in 44% of pDCs). CONCLUSION: SCAMP5 colocalises with IFNα in activated human pDCs, in support of a role of this trafficking protein in the secretion of type I IFN by pDCs.

Clinical management of spinal metastases-The Dutch national guideline.

This article is a summary of the revised Dutch multidisciplinary evidence-based guideline 'Spinal metastases' (English translation available at: https://www.oncoline.nl/spinal-metastases) that was published at the end of 2015. This summary provides an easy-to-use overview for physicians to use in their daily practice.

The Dutch national guideline on metastases and hematological malignancies localized within the spine; a multidisciplinary collaboration towards timely and proactive management.

Here, we describe the development of a Dutch national guideline on metastases and hematological malignancies localized within the spine. The aim was to create a comprehensive guideline focusing on proactive management of these diseases, enabling healthcare professionals to weigh patient perspectives, life expectancy, and expected outcomes to make informed treatment recommendations. A national multidisciplinary panel consisting of clinicians, a nurse, a patient advocate, an epidemiologist, and a methodologist drafted the guideline. The important role of patients in the realization of the guideline enabled us to identify and address perceived shortcomings in patient care. The guideline covers not only metastatic epidural spinal cord compression, but also the treatment of uncomplicated metastases and hematological malignancies localized within the spine. The guideline is applicable in daily practice and provides an up-to-date and concise overview of the diagnostic and treatment possibilities for patients suffering from a disease that can have a serious impact on their quality of life. Suggestions for the practical implementation of patient care in hospitals are also provided, including approaches for pursuing proactive management. The crucial role of the patient in decision making is emphasized in this guideline.

Prophylactic vaccines are potent activators of monocyte-derived dendritic cells and drive effective anti-tumor responses in melanoma patients at the cost of toxicity.

Dendritic cell (DC)-based immunotherapy is explored worldwide in cancer patients, predominantly with DC matured with pro-inflammatory cytokines and prostaglandin E2. We studied the safety and efficacy of vaccination with monocyte-derived DC matured with a cocktail of prophylactic vaccines that contain clinical-grade Toll-like receptor ligands (BCG, Typhim, Act-HIB) and prostaglandin E2 (VAC-DC). Stage III and IV melanoma patients were vaccinated via intranodal injection (12 patients) or combined intradermal/intravenous injection (16 patients) with VAC-DC loaded with keyhole limpet hemocyanin (KLH) and mRNA encoding tumor antigens gp100 and tyrosinase. Tumor antigen-specific T cell responses were monitored in blood and skin-test infiltrating-lymphocyte cultures. Almost all patients mounted prophylactic vaccine- or KLH-specific immune responses. Both after intranodal injection and after intradermal/intravenous injection, tumor antigen-specific immune responses were detected, which coincide with longer overall survival in stage IV melanoma patients. VAC-DC induce local and systemic CTC grade 2 and 3 toxicity, which is most likely caused by BCG in the maturation cocktail. The side effects were self-limiting or resolved upon a short period of systemic steroid therapy. We conclude that VAC-DC can induce functional tumor-specific responses. Unfortunately, toxicity observed after vaccination precludes the general application of VAC-DC, since in DC maturated with prophylactic vaccines BCG appears to be essential in the maturation cocktail.

Effective Clinical Responses in Metastatic Melanoma Patients after Vaccination with Primary Myeloid Dendritic Cells.

PURPOSE: Thus far, dendritic cell (DC)-based immunotherapy of cancer was primarily based on in vitro-generated monocyte-derived DCs, which require extensive in vitro manipulation. Here, we report on a clinical study exploiting primary CD1c(+) myeloid DCs, naturally circulating in the blood. EXPERIMENTAL DESIGN: Fourteen stage IV melanoma patients, without previous systemic treatment for metastatic disease, received autologous CD1c(+) myeloid DCs, activated by only brief (16 hours) ex vivo culture and loaded with tumor-associated antigens of tyrosinase and gp100. RESULTS: Our results show that therapeutic vaccination against melanoma with small amounts (3-10 × 10(6)) of myeloid DCs is feasible and without substantial toxicity. Four of 14 patients showed long-term progression-free survival (12-35 months), which directly correlated with the development of multifunctional CD8(+) T-cell responses in three of these patients. In particular, high CD107a expression, indicative for cytolytic activity, and IFNγ as well as TNFα and CCL4 production was observed. Apparently, these T-cell responses are essential to induce tumor regression and promote long-term survival by stalling tumor growth. CONCLUSIONS: We show that vaccination of metastatic melanoma patients with primary myeloid DCs is feasible and safe and results in induction of effective antitumor immune responses that coincide with improved progression-free survival. Clin Cancer Res; 22(9); 2155-66. ©2015 AACR.

Cancer patients treated with sunitinib or sorafenib have sufficient antibody and cellular immune responses to warrant influenza vaccination.

PURPOSE: The tyrosine kinase inhibitors sorafenib and sunitinib have efficacy in several types of cancer. Recent studies indicate that these agents affect the immune system. The way it affects the immune response to influenza vaccination is unknown. The aim of this study was to elucidate the specific immune response to seasonal flu vaccination in cancer patients treated with sunitinib or sorafenib. PATIENTS AND METHODS: Sunitinib- or sorafenib-treated cancer patients were vaccinated against seasonal influenza with an inactivated vaccine. Healthy controls and patients with metastatic renal cell cancer (mRCC) without systemic treatment (nontreated mRCC controls) were included for comparison. Antibody responses were measured at baseline, day 8, and day 22 by a standard hemagglutination inhibition assay and cellular T-cell responses at baseline and day 8 by proliferation assay and secretion of cytokines. RESULTS: Forty subjects were enrolled: 16 patients treated with sunitinib, 6 patients with sorafenib, 7 nontreated mRCC controls, and 11 healthy controls. All patients treated with sunitinib and sorafenib developed seroprotection rates comparable with controls. Functional T-cell reactivity was observed in all groups, except for patients treated with sorafenib who showed a decreased proliferation rate and IFN-γ/IL-2 production and increased IL-10 compared with healthy controls. CONCLUSION: We conclude that influenza vaccination should be recommended to cancer patients treated with sunitinib or sorafenib.

15. Discogenic low back pain.

An estimated 40% of chronic lumbosacral spinal pain is attributed to the discus intervertebralis. Degenerative changes following loss of hydration of the nucleus pulposus lead to circumferential or radial tears within the annulus fibrosus. Annular tears within the outer annulus stimulate the ingrowth of blood vessels and accompanying nociceptors into the outer and occasionally inner annulus. Sensitization of these nociceptors by various inflammatory repair mechanisms may lead to chronic discogenic pain. The current criterion standard for diagnosing discogenic pain is pressure-controlled provocative discography using strict criteria and at least one negative control level. The strictness of criteria and the adherence to technical detail will allow an acceptable low false positive response rate. The most important determinants are the standardization of pressure stimulus by using a validated pressure monitoring device and avoiding overly high dynamic pressures by the slow injection rate of 0.05 mL/s. A positive discogram requires the reproduction of the patient's typical pain at an intensity of > 6/10 at a pressure of < 15 psi above opening pressure and at a volume less than 3.0 mL. Perhaps the most important and defendable response is the failure to confirm the discus is symptomatic by not meeting this strict criteria. Various interventional treatment strategies for chronic discogenic low back pain unresponsive to conservative care include reduction of inflammation, ablation of intradiscal nociceptors, lowering intranuclear pressure, removal of herniated nucleus, and radiofrequency ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal criteria for a positive treatment advice. In particular, single-needle radiofrequency thermocoagulation of the discus is not recommended for patients with discogenic pain (2 B-). Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans, does meet the (2 B+) level for endorsement. There is currently insufficient proof to recommend intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a study protocol. Future studies should include more strict inclusion criteria.

Nitric oxide synthase inhibitor blocks light-induced phase shifts of the circadian activity rhythm, but not c-fos expression in the suprachiasmatic nucleus of the Syrian hamster.

Circadian rhythms in mammals are entrained to the environmental light cycle by daily adjustments in the phase of the circadian pacemaker located in the suprachiasmatic nuclei (SCN) of the hypothalamus. Brief exposure of hamsters maintained under constant darkness to ambient light during subjective nighttime produces both phase shifts of the circadian activity rhythm and characteristic patterns of c-fos protein (Fos) immunoreactivity in the SCN. In this study, we demonstrate that light-induced phase shifts of the circadian activity rhythm are blocked by intracerebroventricular (i.c.v.) injection of the competitive nitric oxide synthase (NOS) inhibitor, N-nitro-L-arginine methyl ester (L-NAME), but not by the inactive isomer, D-NAME. The effects of L-NAME are reversible and dose-related, and are countered by co-injection of arginine, the natural substrate for NOS. While effects on behavioral rhythms are pronounced, similar treatment does not alter the pattern of light-induced Fos immunoreactivity in the SCN. These results suggest that nitric oxide is a component of the signal transduction pathway that communicates photic information to the SCN circadian pacemaker, and that nitric oxide production is either independent of, or downstream from, pathways involved in induction of c-fos expression.

Is Fos expression necessary and sufficient to mediate light-induced phase advances of the suprachiasmatic circadian oscillator?

Photic stimulation during the subjective night induces the expression of Fos among a discrete population of cells in the suprachiasmatic nuclei (SCN) region of the Syrian hamster. Light appears to stimulate Fos expression only when administered at circadian times (CTs) at which exposure causes a phase shift. Different populations of SCN cells express Fos in response to light pulses that result in phase advances versus phase delays, raising the possibility that different cell populations in the suprachiasmatic hypothalamus participate in light-induced phase advances and delays of the circadian oscillator. Microinjection of excitatory amino acid (EAA) antagonists into the region of the SCN attenuates light-induced phase advances of the free-running activity rhythm and light-induced Fos expression in the hamster SCN. However, injection of N-methyl-D-aspartate (NMDA) at CT 18, which results in a widespread pattern of Fos expression in the hypothalamus that includes the retinorecipient zone of the SCN, does not produce phase advances of the circadian oscillator. The results demonstrate that both light-induced Fos expression and light-induced phase advances are dependent upon EAA neurotransmission within the SCN region. However, expression of Fos in the SCN induced by the EAA agonist NMDA is not sufficient to cause phase advances of the SCN oscillator.

[2 cases of anaphylaxis from droperidol]. / Deux cas d'anaphylaxie au dropéridol.

Following two cases of anaphylactoid reactions during anaesthesia, immunoallergological investigations showed up the responsibility of droperidol, which probably acted by way of an anaphylactic mechanism. In both cases, there were no cardiovascular signs, the main clinical symptom being bronchospasm. The exceptional nature of allergic accidents due to neuroleptic drugs, as opposed to extrapyramidal phenomena, must be underlined. However, these reactions should cast doubts on the safety and usefulness of neuroleptanalgesia.

Morphologic and functional adaptations of large bowel after small-bowel resection in the rat.

Seventy percent small bowel was resected in rats. Two and four weeks later transport of sodium, chloride, and water was examined in cecum and more distal large bowel (colon) using a well-established in vivo luminal perfusion technique. Sham-operated and unoperated rats served as controls. In cecum mucosa grew 29% by two weeks after resection but transport remained unchanged. There were no further adaptive changes by four weeks after resection. Unexpectedly, cecum of all rats secreted water and electrolytes. The mechanism remains unclear. In colon there were no adaptive changes by two weeks after resection but by four weeks colon mucosa increased 14% and luminal absorption increased proportionately. Separate studies showed hexose transport could not be induced in cecum or colon, although we have previously demonstrated its induction in contiguous remnant ileum.

Separation of adaptive mucosal growth and transport after small bowel resection.

In rats 70% of the small bowel was resected with preservation of duodenum and terminal ileum. Two and four weeks later transport of sodium, chloride, water, and galactose was studied in duodenum and ileum. Controls were sham-operated and unoperated rats. There was significant mucosal growth 2 and 4 wk after resection. By 2 wk postresection transport specific activities (transport per gram mucosa) were generally decreased. Mucosal growth compensated only sufficiently so that transport capacities (transport per centimeter segment length) remained unaltered from controls. By 4 wk postresection transport specific activities had either increased or were unchanged from controls. Therefore, in association with mucosal growth, transport capacities increased. The major adaptive increases for electrolytes and water occurred in duodenum; ileum was the site of increased galactose transport. The data indicate that 1) mucosal growth and functional transport changes occur as separate adaptive phenomena and 2) adaptive transport mechanisms are selectively localized to particular regions of the intestine.

Permeability of polyethylene glycol in remnant small bowel after massive intestinal resection.

Studies were designed to determine if permeability of adapted (remnant) small bowel mucosa to polyethylene glycol (PEG) was altered after major intestinal resection. Rats underwent 50% small bowel resection with preservation of duodenum and terminal ileum. Sham-operated animals served as controls. Two and four weeks later we cannulated the portal vein and measured mucosal permeability to luminal [3H]PEG and [14C]PEG in isotonic Ringer solution in remnant proximal or distal in situ closed intestinal loops. A lumen-to-portal blood gradient of at least 1000/1 persisted throughout the one-hour experimental period in both resected and sham-operated animals. Thus the adapted remnant intestinal mucosa was highly impermeable to luminal radiotracer PEG. In separate experiments 2 and 4 weeks after 70% small bowel resection or sham operation, in vivo segments of proximal and distal small intestinal were perfused through the lumen for one hour with hypertonic (800 mOsm) mannitol or NaCl solution containing [3H]PEG. There was equal and almost total recovery of [3H]PEG at the end of the experimental period in resected and control animals. The combined data of all experiments indicate that radiotracer PEG may be confidently used as a luminal water phase marker in transport studies of remnant bowel following intestinal resection.

[Severe anaphylactoid accidents occurring during general anesthesia]. / Accidents anaphylactoïdes graves survenus au cours d'une anesthésie générale.

Four patients were studied following an anaphylactoid accident occurring during general anaesthesia. Histamine release was assessed on clinical signs, basophil degranulation and, in one case, an early serum histamine peak. Past medical history revealed previous allergies in all cases. An immunological study showed that IgE, CH50, C3 and C4 serum levels were within the normal range. Skin reactivity to histamine was normal in all but one case. In every case, one of the drugs used during the anaesthetic gave a positive skin test and was considered as the causative agent. There were discrepancies between the in vitro and in vivo tests of basophil degranulation, a second drug being positive in one case, and several drugs inducing abnormal degranulation reactions in the other cases. The drugs considered as involved in these accidents are noteworthy: suxamethonium (two cases), fluid gelatin (Plasmion) and droperidol. The results are discussed by the authors.

[Immediate hypersensitivity in brucellosis. New data (author's transl)]. / L'hypersensibilité immédiate au cours de la brucellose. Nouvelles données.

The presence of clinical manifestations of the "immediate hypersensitivity" process has been frequently described in veterinarians, bacteriological laboratory technicians and some patients with chronic brucellosis. We have looked for the presence of specific IgE in these conditions. Twenty-four patients, three months at least after the acute phase of their brucellosis, were given exploration of their humoral, cellular and specific immunity against brucellosis. For this purpose, beside usual classical tests: serodiagnosis, total and specific IgE assays, intradermoreaction and lymphoblastic transformation test with specific antigen (PI fraction) and an adaptation of human basophil degranulation test (HBDT) with PI fraction were performed on all 24 patients. Exploration of immediate hypersensitivity allows us to show neither an abnormal increase of hyper-IgE frequency nor an increase of anti-brucella specific IgE. HBDT is positive in 41 p. cent of the patients. It confirms that immediate hypersensitivity exists. HBDT gives justification for trying desensitization which has been proposed in the past. HBDT will possibly allow us to evaluate desensitization effectiveness.

[Two-dimensional immuno-electrophoresis of cephalospinal fluid proteins wih a study of the IgG/albumin ratio in psychiatry (author's transl)]. / Immunoélectrophorèse bidimensionnelle des protéines du liquide céphalo rachidien (LCR) avec étude du rapport IgG/albumine en psychiatrie.

The purpose of this study (about 187 adult psychiatric patients) is to investigate correlations between "organic brain syndrome" (vascular or abiotrophic) and values of CSF proteins (technique of two-dimensional immunoelectrophoresis). The authors show positive correlations between 'vascular' brain syndrome and increase of one alpha 2 globulin, between 'abiotrophic' brain syndrome and decrease in all globulins, the importance of brain damage and increase of IgG/albumin ratio.