Effect of corticosteroid on the antitumor activity of lymphokine-activated killer cells and interleukin 2 in mice.

The adoptive transfer of lymphokine-activated killer (LAK) cells combined with low dose interleukin 2 (IL-2) mediates the regression of established pulmonary metastases in mice and has efficacy in the treatment of human cancer. Systemic administration of high dose IL-2 alone can mediate tumor regression. Cortisone acetate (CA), 25-75 mg/kg, was administered daily to mice receiving high dose IL-2 for 10 days. CA significantly reduced the toxicity induced by IL-2; 38 of 48 mice receiving CA survived compared to 0 of 30 controls (P less than 0.0001). In addition, CA administration caused a decrease in IL-2-induced 125I-labeled albumin leakage in mouse organs. However, CA abrogated the in vivo antitumor effect of high dose IL-2, and to a lesser extent the therapeutic effect of exogenous LAK cells plus lower dose IL-2. Mice treated with 100,000 units of IL-2 showed 98, 63, and 33% reductions of pulmonary metastases in Hanks' balanced salt solution, 25 mg Ca/kg, and 75 mg Ca/kg groups, respectively; treatment with LAK and 7,500 units of IL-2 resulted in reductions of 94, 77, and 57% in these same groups. CA treatment of animals did not affect LAK generation, although the absolute number of LAK precursors was greatly reduced. These results show that although CA can reduce the toxic effect(s) of IL-2, it can be detrimental to successful immunotherapy using this approach.

Combined effects of chemotherapy and interleukin 2 in the therapy of mice with advanced pulmonary tumors.

We have evaluated the effects of chemotherapeutic agents on the toxicity and antitumor benefit of therapy of established murine tumors by high-dose interleukin 2 (IL-2). Cyclophosphamide (Cy), doxorubicin, and bischloroethylnitrosourea were given to normal mice prior to IL-2 administration to test the effects of these agents on IL-2-induced toxicity. Cy at doses of 100 mg/kg and 150 mg/kg completely protected mice from a 100% lethal dose of IL-2, and doses of 50 mg/kg and 150 mg/kg allowed the administration of a median of 4.5 and 10.0 more doses of IL-2, respectively, before death from IL-2 toxicity occurred. Doxorubicin at 8 mg/kg and bischloroethylnitrosourea at 20 mg/kg did not impact on toxicity in IL-2-treated mice. In mice bearing pulmonary metastases of the weakly immunogenic MCA-105 sarcoma, IL-2 increased median survival time from 33 (no IL-2) to greater than 60 days for all doses of IL-2 tested when combined with a single injection of Cy at 75 mg/kg (P less than 0.002). Increasing doses of either Cy or IL-2 produced increasing benefits on survival which were always greater than either treatment alone. These effects of Cy and IL-2 were also seen in mice bearing the nonimmunogenic MCA-101 sarcoma and a murine adenocarcinoma (MCA-38). Doxorubicin and bischloroethylnitrosourea did not consistently enhance the effects of IL-2 treatment. Cy appears to reduce the yield of in vivo generated lymphokine-activated killer cells, but these lymphokine-activated killer cells are still lytic for fresh tumor targets in vitro. Thus, the mechanism of this synergy does not appear to involve stimulation of lymphokine-activated killer cell activity, but may in part involve reduction of tumor burden by the chemotherapeutic agent, an increase in susceptibility of tumor to cellular immune lysis, and/or a decrease in suppressor cell activity mediated by the chemotherapy.

Reduction of toxicity of interleukin-2 and lymphokine-activated killer cells in humans by the administration of corticosteroids.

In order to evaluate the efficacy of dexamethasone (dex) in reducing the toxicity of therapy with lymphokine-activated killer (LAK) cells and interleukin-2 (IL-2), we treated six patients receiving this form of immunotherapy with intravenous (IV) dex, 4 mg every six hours. Compared with a control group of 27 patients not receiving dex with their immunotherapy, these corticosteroid-treated patients were able to tolerate the administration of more IL-2, yet experienced significantly less toxicity. Dyspnea, confusion, fever, mean peak serum creatinine, and bilirubin levels during treatment were significantly reduced in corticosteroid-treated patients, with a corresponding decrease in pruritus in this group as well. Overall weight gain was not different between groups, although a curtailment of weight gain temporally related to dex treatment was seen in some patients. Hematologic side effects, including anemia, eosinophilia, and thrombocytopenia, were not reduced by dex. These results suggest that dex can inhibit at least some of the toxic side effects of LAK cell and IL-2 therapy. Because of the concern that the therapeutic effect may also be abrogated, future studies combining corticosteroids with this form of immunotherapy should be undertaken with caution.

Lymph nodes in the human female breast: a review of their detection and significance.

Our experience led us to test the hypothesis that lymph nodes are not uncommon within the substance of the human female breast mound. The following specimen types and sources were used to survey the presence of intramammary lymph nodes in the human female breast mound: (1) cadaver breasts; (2) community hospital breast specimens; and (3) university and VA hospital specimens. We found true lymph nodes within and associated with breast specific tissue (ie, tissue that includes duct and gland structures), thereby validating the hypothesis posed. We discuss the significance of these findings in terms of our dominant patient care paradigm (the Triple Test-physical examination, imaging, and fine-needle aspiration [FNA]) and the choice of patient care management options. We conclude the following: lymph nodes occur in any quadrant of the breast mound; recognizing the possibility of intramammary lymph nodes is important when choosing between patient management options; intramammary lymph nodes can be sampled by FNA; intramammary lymph nodes can contain various disease processes; and in the Oregon Health Sciences University Multidisciplinary Breast Clinic, these intramammary lymph nodes are commonly identified by imaging methods and are more likely to be sampled by FNA than either by core or excisional biopsy.

Parathyroid carcinoma: diagnosis and clinical history.

BACKGROUND: Parathyroid carcinoma is often over-diagnosed based on histologic appearance alone. We limited the definition of the disease to patients with recurrence, metastases, or frank capsular invasion on histologic examination. METHODS: With these criteria, fourteen cases of parathyroid carcinoma seen at our institution from 1955 to the present were identified. RESULTS: All patients presented with hypercalcemia, and all deaths were due to hypercalcemia. Two patients have been free of disease after initial operation for 31 and 180 months. Six other patients had a prolonged course with a median survival more than 80 months. Two of these patients have undergone one reexcision each for local recurrence, and four have undergone multiple resections for local recurrence or metastases. These reoperations usually resulted in satisfactory, albeit temporary, control of hypercalcemia. Finally, six patients died of disease after an aggressive course, with a short median survival (47 months). Four of these patients were seen in the 1950s before an aggressive approach to metastatic disease was adopted. CONCLUSIONS: The types of clinical courses observed in this study may be more reflective of the varied biologic features of parathyroid carcinoma and the approach to recurrence than of the initial operations. For patients with recurrent or distant disease, an operation appears to prolong survival and palliate the symptoms of hypercalcemia.

Comparison of adrenal and extraadrenal pheochromocytomas.

BACKGROUND: It is commonly believed that extraadrenal tumors (EAT) of the paraganglion system are more likely to be malignant than adrenal tumors (AT) and carry a poorer prognosis. We analyzed 73 paraganglion tumors (PT) to determine whether EATs are more likely to be malignant or have a poorer prognosis than ATs. METHODS: A review of patients with PTs at three institutions was performed. Malignant tumors were defined as those that metastasized. Comparison of the frequencies of malignant tumors was performed by chi-squared analysis. Survival distributions were determined by Kaplan and Meier analysis. Comparison of survival distributions was performed by log-rank analysis. RESULTS: There were 73 patients. There were 51 ATs, of which 24 were malignant, and 22 EATs, of which 11 were malignant (p = 0.82). The 5-year survival rate was 77% for patients with ATs and 82% for patients with EATs (p = 0.29). The 5-year survival rate for patients with malignant ATs was 57%, and 74% for patients with malignant EATs (p = 0.15). There were no significant differences in disease-free survival rates on the basis of tumor site. CONCLUSIONS: We were unable to demonstrate that EATs are significantly more likely to be malignant than ATs. The survival and disease-free survival rates for malignant ATs and EATs are similar, and among malignant tumors, there may be no prognostic value of the anatomic location.

A new approach to the therapy of cancer based on the systemic administration of autologous lymphokine-activated killer cells and recombinant interleukin-2.

A new approach to cancer therapy has been developed based on the adoptive transfer of autologous lymphokine-activated killer (LAK) cells and recombinant interleukin-2 (IL-2). Forty-one patients with advanced cancer who have failed all standard treatments were treated in this experimental protocol. Fourteen patients experienced an objective regression of cancer, including one patient with metastatic melanoma who underwent a complete regression. Objective responses were seen in patients with colorectal cancer, renal cell cancer, melanoma, and lung adenocarcinoma. The sites of tumor regression included subcutaneous tissue, lung, and liver. The major side effect of therapy resulted from the administration of high-dose IL-2 and was manifested primarily as fluid retention, resulting in a generalized capillary permeability leak syndrome. This approach to adoptive immunotherapy represents a promising approach to the therapy of patients with metastatic cancer. Attempts to increase the potency and decrease the toxicity of therapy and extend this treatment to patients with smaller tumor burdens are in progress.

Iliac arterial-enteric fistulas occurring after pelvic irradiation.

Fistulas from the iliac artery to the bowel constitute a condition that is often lethal. Excluding fistulas related to vascular grafts, a review of previously reported cases shows that they are most often due to atherosclerotic iliac aneurysms. Three unusual cases of this condition that occurred after high-dose pelvic irradiation for treatment of cancer are presented; in no case was recurrent tumor evident. These cases suggest that high-dose pelvic irradiation can predispose to the formation of iliac arterial-enteric fistulas, particularly if sepsis or inflammation develops. The definitive surgical management of these fistulas entails bowel resection, arterial ligation, and extra-anatomic bypass.

Cirsoid aneurysms of the jejunum. An unrecognized cause of massive gastrointestinal bleeding.

Cirsoid aneurysms (exulceratio simplex Dieulafoy) as a cause of massive gastrointestinal hemorrhage have been known to occur in the stomach. Endoscopy plays an important role in the diagnosis of and therapy for these lesions. We report two cases of a cirsoid aneurysm in the proximal jejunum; two cases have been previously reported in the literature. These lesions have the same pathologic features as gastric cirsoid lesions and cause massive gastrointestinal hemorrhage. Because these lesions are beyond the reach of current endoscopy, surgery was necessary to diagnose and treat the lesions in three of four patients. The fourth patient died after unsuccessful surgical exploration, and the lesion was found post mortem. Jejunal cirsoid aneurysms may be an unrecognized rather than a rare cause of gastrointestinal bleeding. They should be considered in the patient with massive proximal gastrointestinal bleeding in whom the source is not known, especially if angiography suggests a small-bowel site. With the advent of newer forms of endoscopy that can examine the small bowel, the management of these lesions may change; at present, surgery is lifesaving.

Diagnosis of palpable breast lesions in younger women by the modified triple test is accurate and cost-effective.

OBJECTIVE: To study the accuracy and cost of diagnosing palpable breast lesions in younger patients using a modified triple test (MTT: physical examination, ultrasonography instead of mammography, and fine-needle aspiration). DESIGN: Diagnostic test study and cost-effectiveness estimate. SETTING: Multidisciplinary university breast clinic. PATIENTS: Fifty-five women below the recommended age of screening mammography (mean age, 33 years) with unilateral, palpable breast lesions. INTERVENTION: Each lesion was tested by all 3 elements of MTT, and each element was interpreted as benign, suspicious, or malignant. MAIN OUTCOME MEASURES: Patients with MTTs in which all elements were concordant (in agreement) and benign were evaluated clinically (mean follow-up, 11 months). Patients in whom the results of fine-needle aspiration were scored as suspicious or malignant underwent open confirmatory biopsy. RESULTS: Forty-eight patients had concordant benign MTTs, including 14 patients with breast cysts. No cancers developed at the index sites during follow-up, including 5 biopsies done at the patients' request (negative predictive value and specificity, 100%). Fine-needle aspiration and physical examination were more accurate than ultrasonography in the 7 cases in which MTT was nonconcordant. Compared with the criterion standard (physical examination and open biopsy), use of MTT under the conditions of this study could avoid open biopsies in almost all cases, with average savings in charges of up to $623 per case. CONCLUSION: Use of MTT for the diagnosis of unilateral, palpable breast lesions in younger women yields high diagnostic accuracy without the need for routine open biopsy, resulting in an overall reduction in patient charges.

Usefulness of the triple test score for palpable breast masses; discussion 1012-3.

HYPOTHESIS: The triple test score (TTS) is useful and accurate for evaluating palpable breast masses. DESIGN: Diagnostic test study. SETTING: University hospital multidisciplinary breast clinic. PATIENTS: Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000. MAIN OUTCOME MEASURES: Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up. INTERVENTIONS: The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255). RESULTS: All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign. CONCLUSIONS: The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.

Accurate evaluation of palpable breast masses by the triple test score.

BACKGROUND: We previously reported that the triple test (physical examination, mammography, and fine needle aspiration) for palpable breast masses yields 100% diagnostic accuracy when all 3 components are concordant (all benign or all malignant). However, 40% of cases are nonconcordant and require open biopsy. OBJECTIVE: To evaluate our experience with the triple test to develop a method to further limit the need for surgical biopsy. DESIGN: Diagnostic test study. SETTING: University hospital multidisciplinary breast clinic. PATIENTS: Two hundred fifty-nine patients with 261 palpable breast masses studied between 1991 and 1997. INTERVENTION: The triple test was prospectively applied to each breast mass. Each component of the triple test was assigned 1, 2, or 3 points for a benign, suspicious, or malignant result, respectively, yielding a total triple test score (TTS). MAIN OUTCOME MEASURES: The TTS was correlated with subsequent histopathologic examination results. RESULTS: Eighty-eight masses had a TTS of more than 6 points; all had malignant histopathologic characteristics. One hundred fifty-two masses had a TTS of 4 points or lower; all were benign. In both groups, diagnostic accuracy and predictive value were 100%, with P<.001. Twenty-one masses had a TTS of 5 points; of these, 13 (62%) were benign and 8 (38%) were malignant. CONCLUSIONS: The TTS reliably guides evaluation and treatment of palpable breast masses. Masses that score 6 points or higher are malignant and should undergo definitive therapy; masses that score 4 points or lower are benign and may be clinically followed up. Only those masses that score 5 points (8% of our database) require open biopsy.

An improved method of needle localized biopsy of nonpalpable lesions of the breast.

We have created a modified technique of localization biopsy of the breast that more easily identifies the position of the wire tip after placement and before biopsy. After wire placement, metallic skin markers are placed on the nipple and wire entry site. The patient is then positioned on a roentgenography table in the same position to be used during biopsy. A supine roentgenogram of the breast is obtained. At the time of the biopsy, this roentgenogram is aligned with the corresponding markers on the skin of the patient and the position of the wire tip is noted. A curvilinear incision along Langer's lines can then be made at that site. This procedure was used in 53 consecutive biopsies of nonpalpable mammary lesions. In all instances, the biopsy incisions were independent of the wire insertion sites and in each instance, the lesion was excised in a single specimen. Compared with other techniques, our method is simple, inexpensive, requires no special equipment and results in only a minimal increase in radiation dose to the breast (50 millirad). The decrease in the amount of tissue dissection without decreasing accuracy afforded by our technique can improve compliance with the American Cancer Society's recommended surgical guidelines for breast preservation therapy.

Office-based wire-guided open breast biopsy under local anesthesia is accurate and cost effective.

BACKGROUND: Mammographic abnormalities found to be malignant by stereotactic biopsy still require a wire-guided biopsy (WGB) in most cases. We have previously described a simplified method of WGB that allows the procedure to be done with a minimum of dissection and under local anesthesia in the office setting. We hypothesized that this procedure can be used to produce cost-effective, office-based breast preservation therapy (BPT). METHODS: We reviewed our recent experience with this WGB method to determine applicability and accuracy in the office setting. A cost-effectiveness analysis was also performed to determine potential charge reductions when this method is used to avoid operating room (OR) usage for either lumpectomy or lumpectomy plus sentinel lymph node biopsy (SLNB). RESULTS: Of the 164 biopsies reviewed, 114 (70%) were performed in the office setting under local anesthesia and 50 (30%) were performed in the OR. The most common reasons for choosing the OR setting included performance of biopsy during an unrelated procedure requiring the OR (16 cases), patient preference (12), deep lesions (6), and the inability of the patient to cooperate with local anesthesia (5). The complication rates were similar between the two settings (7% for office-based and 4% for OR; P = 0.697), and in neither setting were any lesions missed. A cost-effectiveness analysis using our Current Procedure Terminology (CPT)-based charges revealed a potential per-case charge reduction of $4,632 for office-based lumpectomy and $4306 for office-based lumpectomy/SLNB, using our method of WGB and local anesthesia, compared with the OR setting. CONCLUSIONS: Office-based WGB using our previously described method is accurate and can be applied to at least 70% of patients. Based on the favorable results of our cost analysis and rising support for SLNB, we anticipate increased utilization of the clinic setting and local anesthesia for BPT in the future.

Synchronous non-small cell lung cancers.

INTRODUCTION: The few series of synchronous lung cancers have included small cell and carcinoid tumors. We wished to determine the prognosis for patients with synchronous non-small cell lung cancer (NSCLC). METHODS: A database of 3034 lung cancer patients was reviewed for synchronous NSCLC. Survival was determined by Kaplan-Meier method and compared by log-rank analysis. RESULTS: There were 27 patients (0.8%). Fourteen were completely resected (CR) and had a 5-year survival rate of 45% The 5-year survival rate for patients whose highest stage tumor was stage I or II was 38%, versus 0% for patients whose highest tumor stage of III (P = 0.01). The 5-year survival rate for patients with two stage I tumors was 41% versus 0% for patients with 2 stage III tumors (P = 0.03). The 5-year survival rate for patients treated with wedge resections was similar to that for patients treated with lobectomies or pneumonectomy (L/P). CONCLUSIONS: We conclude that the prognosis for patients with synchronous NSCLC may not be dismal if both tumors are resectable and stage I or II. Wedge resections are an alternative for those who cannot tolerate L/P.

Usefulness of preoperative lymphoscintigraphy for the identification of sentinel lymph nodes in melanoma.

BACKGROUND: The exact role of lymphoscintigraphy (LS) in the evaluation of sentinel lymph nodes (SLNs) in melanoma is controversial. METHODS: We reviewed our experience with preoperative LS for the determination of the lymph node drainage pattern of clinically node negative primary melanomas, with attention to the rate of ambiguous drainage and the effect of previous wide local excision (WLE). RESULTS: The scans of 87 patients who underwent LS at our institution for evaluation of their primary melanomas from 1995 to the present were reviewed. Fourteen of the primary tumor sites were in the head and neck region, 41 were truncal, and 32 were in the extremities. The average tumor thickness was 2.6 mm. Nine of 14 (64%) head/neck lesions and 12 of 41 (29%) truncal lesions displayed ambiguous drainage, as compared with only 2 of 32 (6%) extremity lesions (P <0.05). Forty-one of the 87 patients (47%) had undergone previous WLE of their primary lesion prior to their LS. The number of draining basins for the WLE and the non-WLE groups were not significantly different, and at least one SLN was found for all WLE cases. CONCLUSIONS: Preoperative LS is important for the treatment planning of SLN biopsy for head/neck and truncal melanomas, but adds little additional information for extremity lesions. Lymph node drainage scans and subsequent SLN biopsies are not contraindicated in the presence of a prior WLE.

Relationships between operative approaches and outcomes in esophageal cancer.

BACKGROUND: Controversy exists whether patients with esophageal carcinoma are best managed with Ivor-Lewis (IL) or transhiatal (TH) esophagectomy. The TH approach is presumed to be superior with respect to operative time, leak rates, morbidity/mortality, and length of stay (LOS), but may represent an inferior cancer operation compared with formal IL. Accordingly, we reviewed the results of our esophageal resections to compare these outcome parameters for each operative approach. METHODS: We performed a retrospective review of all esophagectomies performed at Oregon Health Sciences University and Portland Veterans Affairs Medical Center between 1987 and 1996. Survival was determined by the Kaplan-Meier method, and comparisons between the IL and TH groups were made with Student's t test, Fisher's exact test, and log-rank analysis. RESULTS: Seventy-eight patients were identified. Forty patients had IL and 38 had TH. Fifty-eight patients had adenocarcinoma, 19 had squamous cell, and 1 had an unknown histology. Mean operative time was 389 minutes for IL versus 275 minutes for TH (P = 0.0001). Leak rates were 7.5% for IL and 13% for TH (P = 0.21). There were no significant differences between IL and TH with respect to other types of complications, operative deaths, blood loss, need for transfusion, LOS, stricture rates, or need for dilatation. Overall mean survival was 12 months. Mean survival rates were 8 months for IL and 12 for TH (P = NS), and were also equivalent when compared by histology and stage for stage. CONCLUSIONS: We conclude that IL and TH are comparable operations with equivalent survival rates. The TH approach did not decrease the incidence of complications, transfusions, leaks, strictures, or subsequent dilatations. Although TH requires less operating room time, this does not translate into a decrease in LOS. Either approach appears to be acceptable depending on surgeons' preferences and appropriate patient selection.

Surgical morbidity in patients with systemic lupus erythematosus.

Thirty-six surgical procedures were performed on 29 patients with systemic lupus erythematosus (SLE). Nineteen cases involved active lupus at the time of surgery and 11 were performed on an emergent basis. Most patients had multiple organ involvement and were on some form of systemic therapy at the time of surgery. Thirty-seven postoperative complications were confined to 20 of these cases. Comparing this complicated group with the remaining 16 uncomplicated cases, the patients in the former group had a higher mean dose of steroid preoperatively, more organ involvement by SLE, and more frequent renal involvement; a higher percentage of the cases in this group were emergent rather than elective. The majority of factors examined failed to show predictive value in the outcome of surgery in lupus patients. We conclude that surgical complications are frequent in SLE patients and have identified four factors predictive of increased morbidity.

Presence of the T-cell activation marker OX-40 on tumor infiltrating lymphocytes and draining lymph node cells from patients with melanoma and head and neck cancers.

BACKGROUND: The OX-40 antigen is a cell surface glycoprotein in the tumor necrosis factor receptor family that is expressed primarily on activated CD4+ T cells. Selective target organ expression of the OX-40 receptor on autoantigen specific T cells has been found in autoimmune disease. In order to evaluate whether OX-40 is expressed on T cells from patients with nodal-draining carcinomas, OX-40 expression was assessed in tumor infiltrating lymphocytes (TILs), draining lymph node cells (DLNCs), and/or peripheral blood lymphocytes (PBLs) of 13 patients with head and neck squamous cell carcinomas and 9 patients with melanomas. METHODS: Cell phenotype was determined by fluorescence cell analysis using a monoclonal antibody to human OX-40, and CD4+ T cell lymphokine production was determined by reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS: Expression of the OX-40 receptor was found in as many as 31% of the TILs and as many as 28% of the DLNCs tested. Conversely, no OX-40 expression was found in PBLs. In addition, CD4+ T cells isolated from DLNCs (but not from TILs or PBLs) secreted a Th1 pattern of cytokines (IL-2, gamma interferon). Co-culture of autologous CD4+ TILs with an MHC class II+ melanoma cell line transfected with OX-40 ligand cDNA resulted in T cell proliferation and in vitro tumor regression. CONCLUSIONS: These findings suggest that OX-40+ CD4+ T cells isolated from tumors and their adjacent draining nodes may represent a tumor-specific population of activated T cells capable of mediating tumor reactivity. These cells may play an exploitable role in future trials of immunotherapy.

Adnexal torsion. An unusual cause of abdominal pain in postmenopausal women.

Adnexal torsion is a rare cause of abdominal pain in older women. Because the presenting symptoms and signs are vague, the diagnosis is not often considered. Lower abdominal pain with nausea and vomiting are usual in patients with torsion. Ultrasonography or computed tomography are useful diagnostic tests. Two case reports of older patients with adnexal torsion are presented to emphasize the diagnostic features of this entity, including lower abdominal pain, nausea and vomiting, and abdominal mass. Although the condition is uncommon, adnexal torsion should be considered in the differential diagnosis of acute abdominal pain.