Surrogate in vitro activation of innate immunity synergizes with interleukin-7 to unleash rapid antigen-driven outgrowth of CD4+ and CD8+ human peripheral blood T-cells naturally recognizing MUC1, HER2/neu and other tumor-associated antigens.

Effective adoptive immunotherapy has proved elusive for many types of human cancer, often due to difficulties achieving robust expansion of natural tumor-specific T-cells from peripheral blood. We hypothesized that antigen-driven T-cell expansion might best be triggered in vitro by acute activation of innate immunity to mimic a life-threatening infection. Unfractionated peripheral blood mononuclear cells (PBMC) were subjected to a two-step culture, first synchronizing their exposure to exogenous antigens with aggressive surrogate activation of innate immunity, followed by γ-chain cytokine-modulated T-cell hyperexpansion. Step 1 exposure to GM-CSF plus paired Toll-like receptor agonists (resiquimod and LPS), stimulated abundant IL-12 and IL-23 secretion, as well as upregulated co-stimulatory molecules and CD11c expression within the myeloid (CD33+) subpopulation. Added synthetic long peptides (>20aa) derived from widely expressed oncoproteins (MUC1, HER2/neu and CMVpp65), were reliably presented to CD4+ T-cells and cross-presented to CD8+ T-cells. Both presentation and cross-presentation demonstrated proteasomal and Sec61 dependence that could bypass the endoplasmic reticulum. Step 2 exposure to exogenous IL-7 or IL-7+IL-2 produced selective and sustained expansion of both CD4+ and CD8+ peptide-specific T-cells with a predominant interferon-γ-producing T1-type, as well as the antigen-specific ability to lyse tumor targets. Other γ-chain cytokines and/or combinations were initially proliferogenic, but followed by a contractile phase not observed with IL-7 or IL-7+IL-2. Regulatory T-cells were minimally propagated under these culture conditions. This mechanistically rational culture sequence, effective even for unvaccinated donors, enables rapid preparation of T-cells recognizing tumor-associated antigens expressed by the majority of human cancers, including pancreatic cancers, breast cancers and glioblastomas.

Long-term renal function after donor nephrectomy: secondary follow-up analysis of the randomized trial of ketorolac vs placebo.

OBJECTIVE: To evaluate the long-term safety of a novel continuous infusion of ketorolac vs placebo after laparoscopic donor nephrectomy. METHODS: We performed a secondary analysis of a previously reported randomized controlled trial conducted from October 7, 2008, to July 21, 2010. Patients aged 18-75 years received a continuous infusion of either ketorolac (treatment [n=57]) or normal saline (control [n=54]) for 24 hours immediately after laparoscopic donor nephrectomy. Serum creatinine levels were measured at 1- and 1.5-year follow-ups. Glomerular filtration rate was calculated preoperatively, postoperatively, and at 1- and 1.5-year follow-ups using the Chronic Kidney Disease Epidemiology Collaboration equation. Glomerular filtration rates were compared between treatment and control groups using 2-sample t tests. RESULTS: Data analysis for the 111 donor nephrectomy patients showed that glomerular filtration rates decreased in both groups over time, but changes were not clinically significant. No difference was found in glomerular filtration rates (in mL/min/1.73 m2) between treatment and control groups at 1-year follow-up (89.29 vs 87.94 mL/min/1.73 m2; P=.58) or at 1.5-year follow-up (88.54 vs 90.25 mL/min/1.73 m2; P=.51). CONCLUSION: The novel provision of continuous steady-state ketorolac is safe for postoperative pain control in patients after donor nephrectomy, with no change in glomerular filtration rates between treatment and control groups acutely and at up to 1.5-year follow-up.

Preoperative imaging for early-stage cutaneous melanoma: predictors, usage, and utility at a single institution.

BACKGROUND: Preoperative imaging for early-stage cutaneous melanoma is not recommended by current guidelines. Our goal was to investigate our institutional usage and utility. METHODS: Patients with clinically node-negative cutaneous melanoma undergoing surgery with sentinel lymph node biopsy were identified retrospectively. Any melanoma-related imaging after diagnosis and before surgery was considered a staging study. RESULTS: Five hundred fifteen studies were performed in 409 of 546 (75%) patients. Chest x-rays was performed in 70% and advanced imaging in 14% (computed tomography imaging, magnetic resonance imaging, ultrasound, and positron-emission computed tomography imaging). No metastatic lesions were identified. A Breslow thickness greater than 4 mm (odds ratio = 6.46 vs <1 mm; 95% confidence interval, 2.07 to 20.15) and male sex (odds ratio = 2.62 vs female; 95% confidence interval, 1.26 to 5.46) were associated with an increased likelihood of advanced imaging. CONCLUSIONS: Preoperative imaging was performed in the majority of patients with node-negative melanoma, with 14% undergoing advanced studies. No metastatic lesions were identified, confirming the limited utility in this setting.

A double-blind randomized controlled trial of continuous intravenous Ketorolac vs placebo for adjuvant pain control after renal surgery.

OBJECTIVE: To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS: A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS: The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION: Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.