Antitumor efficacy of lymphokine-activated killer cells and recombinant interleukin 2 in vivo: successful immunotherapy of established pulmonary metastases from weakly immunogenic and nonimmunogenic murine tumors of three district histological types.

We have recently shown that the systemic administration of lymphokine activated killer cells (LAK cells) plus relatively low doses of recombinant interleukin 2 (RIL-2) or the administration of high doses of RIL-2 alone can reduce the number of established pulmonary metastases from the weakly immunogenic MCA-105 sarcoma in mice. We have now analyzed the therapeutic efficacy of these treatments on both weakly and nonimmunogenic tumors of three distinct histological types in two different mouse strains. In all experiments, LAK cells were administered i.v. on days 3 and 6 and RIL-2 was injected i.p. from days 3 through 8 after tumor induction. The MCA-101 sarcoma was completely nonimmunogenic as defined by its inability to successfully immunize C57BL/6 mice. Nevertheless, administration of LAK cells plus 7,500-10,000 units RIL-2 was highly effective in reducing the number of established 3-day pulmonary metastases from this sarcoma [at 7,500 units RIL-2, mean number of metastases 37 +/- 11 (SE); P less than 0.05; at 100,000 units, 2 +/- 1; P less than 0.05] when compared to Hanks' balanced salt solution treated control animals (116 +/- 9). Likewise, RIL-2 alone at doses of 20,000 units/injection or greater had significant antimetastatic effects (77 +/- 12; P less than 0.05). Established 3-day pulmonary metastases from the MCA-38 adenocarcinoma in C57BL/6 mice and the M-3 melanoma in C3H mice were also susceptible to adoptive immunotherapy with LAK cells plus RIL-2 and with high dose RIL-2 alone. Treatment of mice with LAK cells alone or with low doses of RIL-2 alone (less than or equal to 20,000 units/injection) had little if any antitumor effects. LAK cells were tested for cytolytic activity in vitro against tumor target cells of a variety of histological types; there was no discernible relationship between susceptibility to lysis by LAK cells in vitro and therapeutic efficacy in vivo. These findings have thus demonstrated that the successful immunotherapy of established pulmonary metastases with LAK cells plus RIL-2 or with high dose RIL-2 alone includes: tumors that are immunogenic and nonimmunogenic; tumors of distinct histological types such as sarcoma, adenocarcinoma, and melanoma; and tumors in at least two different mouse strains, C57BL/6 and C3H, and that there is little correlation between the in vitro lysability of tumor cells by LAK effectors and the susceptibility of these same tumors to successful immunotherapy in vivo.

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.

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.

TNF-induced modulations of phospholipid metabolism in human breast cancer cells.

Tumor necrosis factor alpha (TNF) is a cytokine that is cytocidal for certain tumor cells and induces necrotic and apoptotic forms of cell death. Flow cytometry and transmission electron microscopy analysis demonstrated that in human breast cancer cells (MCF7) TNF induces cell cycle arrest in G0+G1/S, accompanied by apoptosis. 31P and 13C NMR spectroscopy was applied to study cellular metabolism of MCF7 cells during TNF-induced signal to apoptosis. Deuterated choline and 2H NMR spectroscopy were utilized to monitor the kinetics of the rate limiting reactions in phosphocholine metabolism. The NMR measurements revealed that immediately after administration of TNF, choline transport was inhibited by 52+/-6%. Later (approximately 15 h), the activity of phosphocholine:cytidine triphosphate cytidylyltransferase, a key enzyme in the biosynthesis of phosphatidylcholine, was enhanced two-fold. These two opposing changes led to a decrease in the level of phosphocholine. Throughout these changes the energetic state of the cells, determined by the level of nucleoside triphosphates and the rate of glucose metabolism via glycolysis, remained constant. The results indicate that TNF specifically modulates the kinetics of membrane-bound enzymes of the rate determining steps in phosphatidylcholine biosynthesis, possibly as part of early events involved in apoptosis.

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.

Mutational analyses of BRCA1 and BRCA2 in Ashkenazi and non-Ashkenazi Jewish women with familial breast and ovarian cancer.

In Ashkenazi (East European) Jews, three predominant mutations in BRCA1 (185delAG and 5382insC) and BRCA2 (6174delT) account for the majority of germline mutations in high-risk breast and/or ovarian cancer families. Among non-Ashkenazi Jews, the 185delAG, Tyr978Ter, and a handful of "private" mutations have been reported anecdotally within both genes. In this study we attempted to determine the spectrum of BRCA1 and BRCA2 mutations in high-risk Jewish individuals, non-carriers of any of the predominant Jewish mutations. We employed multiplex PCR and denaturing gradient gel electrophoresis (DGGE) analysis for BRCA2, and combined denaturing high performance liquid chromatography (DHPLC) and protein truncation test (PTT) for BRCA1, complemented by DNA sequencing. We screened 47 high-risk Jewish individuals, 26 Ashkenazis, and 21 non-Ashkenazis. Overall, 13 sequence alterations in BRCA1 and eight in BRCA2 were detected: nine neutral polymorphisms and 12 missense mutations, including five novel ones. The novel missense mutations did not co-segregate with disease in BRCA1 and were detected at rates of 6.25% to 52.5% in the general population for BRCA2. Our findings suggest that except for the predominant mutations in BRCA1 and BRCA2 in Jewish individuals, there are only a handful of pathogenic mutations within these genes. It may imply novel genes may underlie inherited susceptibility to breast/ovarian cancer in Jewish individuals.

Serum insulin-like growth factor-binding protein-2 (IGFBP-2) is increased and IGFBP-3 is decreased in patients with prostate cancer: correlation with serum prostate-specific antigen.

Insulin-like growth factors (IGFs) are potent mitogens that stimulate the growth of prostate cells. In serum, IGFs circulate bound to IGF-binding proteins (IGFBPs), which modulate their proliferative action. We studied the electrophoretic pattern of IGFBPs in the serum of patients with prostate cancer and in individuals with increased serum levels of prostate-specific antigen (PSA) in the absence of prostate malignancy. Serum IGFBP-2 was dramatically increased in patients with metastatic prostate cancer compared with healthy controls (23.83 +/- 6.93% vs. 2.95 +/- 0.52% of total serum IGFBPs; P < 0.02). A moderate rise in IGFBP-2 was also observed among patients with increased PSA without malignancy. In contrast, a decrease in serum IGFBP-3 was detected in most patients with metastatic prostate cancer (68.2 +/- 9.1% vs. 95.4 +/- 0.9% of total serum IGFBPs; P < 0.02) and was more pronounced in advanced cases. A highly significant correlation between serum IGFBP-2 and PSA levels was found (r = 0.62; P < 0.002), with a significant negative correlation between serum PSA and IGFBP-3 (r = -0.63; P < 0.002). We suggest that IGFBPs may be involved in growth modulation of prostate malignancy and that alterations in their serum levels may serve as a marker for prostate cancer.

Common origin of the I1307K APC polymorphism in Ashkenazi and non-Ashkenazi Jews.

A common germline missense mutation within the APC gene, I1307K, has recently been described in Ashkenazi Jews. We detected this polymorphism in two non-Ashkenazi Jewish women using denaturing gradient gel electrophoresis (DGGE), and hypothesized that in Jewish individuals it might not be restricted to Ashkenazim, and actually reflect a common ancestral polymorphism. To test this notion we performed allelic pattern determination using APC-linked markers in these two women and in nine Ashkenazi carrier controls. The pattern of the intragenic markers, as well as a single downstream marker 30-70 Kb from the APC gene was identical in all individuals, regardless of ethnic origin. We conclude that the I1307K polymorphism in Jewish individuals, is not restricted to Ashkenazim and probably reflects a founder mutation.

Left renal vein division in abdominal aortic aneurysm operations. Effect on renal function.

We examined the effect of left renal vein (LRV) division during abdominal aortic aneurysm operations on renal function during the recovery period. Fifteen patients with LRV division were compared with 26 patients in whom the LRV was not ligated. These two groups of patients did not differ significantly in any of their preoperative characteristics, operative management, or postoperative complications. Preoperative, highest postoperative, and predischarge levels of plasma urea and creatinine, as well as urinary sediment, were compared in both groups. Left renal vein division could not be implicated as a cause of renal function deterioration and was found to be a safe, useful adjunct to abdominal aortic aneurysm surgery.

Avoiding diarrhea after subtotal colectomy with primary anastomosis in the treatment of colon cancer.

BACKGROUND: Subtotal colectomy has been criticized as causing increased frequency of stool passage, thus adding to the patients' morbidity. We review our experience with subtotal colectomy and determine the factors affecting postoperative diarrhea. STUDY DESIGN: One hundred thirty-six patients with colon cancer were treated by primary subtotal colectomy. Of these, 30 percent underwent an emergency resection; 15 percent, semi-emergency resection; and 55 percent, elective subtotal colectomy. There were 29 complications and 3 deaths. RESULTS: The incidence of complications was higher when the operation was carried out on an emergency or semi-emergency basis. In assessing the patients' increased postoperative stool frequency, there was no difference between the groups; but, the length of the remaining colon and the resected terminal ileum had a significant effect on postoperative diarrhea. If less than 10 cm of terminal ileum is resected and more than 10 cm of colon is left above the peritoneal reflection, there is a marked decrease in the incidence of diarrhea after subtotal colectomy. CONCLUSIONS: Subtotal colectomy is an acceptable treatment for left colonic carcinoma, electively as well as in emergency situations. Postoperative diarrhea can be minimized by attention to the length of small bowel and sigmoid that are resected.

Sentinel lymph node involvement--a predictor for axillary node status with breast cancer--has the time come?

AIMS: Axillary node dissection for breast cancer is important for staging and its prognostic value. Sentinel nodes are defined as the first nodes into which the primary cancer drains. This study investigates whether identification, removal and pathological examination of these nodes indicates whether the completion of axillary lymphadenectomy is required. METHODS: Using a vital dye injected at the primary tumour site, we were able to identify sentinel nodes in 96 out of 98 women examined. RESULTS: An average number of 2.7 +/- 1.2 nodes per patient were identified as sentinel nodes. In 83% of cases there was a correlation between the involvement of the sentinel nodes and the rest of the axillary nodes. In 14% of patients the sentinel nodes were the only nodes involved with tumour. In three cases the sentinel nodes were negative, but other axillary nodes were tumour-positive. CONCLUSION: The major problem in routine application of this method to the decision to perform axillary lymph node dissection (ALND) is the time needed for pathological identification of lymph node involvement by tumor.

Hemorrhagic complications encountered on a surgical service. A 7 year survey.

An analysis of 205 episodes of bleeding encountered during a 7 year period by the staff of a surgical service has been described. Of 168 postoperative bleeding episodes, 80 were associated with anticoagulant or antiaggregant treatment, 51 were caused by technical error, and 37 were associated with sepsis. Of 18 hemorrhages after invasive procedures, 12 were associated with anticoagulants. In the whole series, in 33 of 111 episodes in patients receiving antithrombotic drugs, there was some deviation from standard accepted protocols. Bleeding occurred in the surgical wound or at the site of operation or puncture in 154 instances. Some of the bleeding episodes, especially at other sites, presented in an unusual manner and posed a diagnostic problem. Bleeding was responsible for death or contributed to death in 11 patients, and in 32 patients, it caused operation or reoperation. Other short- and long-term morbidity was also caused. As in many complications, prevention is of the essence.

Regional hyperthermic perfusion with cisplatin following surgery for malignant melanoma of the extremities.

BACKGROUND: The study was undertaken to review our experience in the treatment of extremity melanoma with hyperthermic isolated limb perfusion (HILP), using cisplatin as the chemotherapeutic agent. We also evaluated the best timing for regional lymph node dissection in relation to the perfusion. PATIENTS AND METHODS: Sixty patients with advanced malignant melanoma of the limbs were treated with HILP used mainly as an adjuvant treatment. There were 56 lower- and 4 upper-limb HILPs. Cisplatin was used at a dose of 20 mg/L of limb volume. Temperature at the tumor site was 39 degrees C to 40 degrees C. Postoperative complications, disease-free period, and time to recurrence were recorded. RESULTS: There were no deaths related to the procedure. Forty-seven percent of the patients developed local complications; most complications were minor and resolved within 60 days. The local complication rate was higher when HILP was performed shortly after or simultaneously with regional lymph node dissection. None of the patients had systemic complications. Mean survival time from treatment was 87.2 months. Currently, 35 patients (58%) are alive and free of disease 52.7 +/- 22.5 months after HILP. Twelve patients (20%) are alive with recurrent disease, of which 5 recurred locally. The average time (+/- standard error of the mean) to recurrence was 24.5 +/- 13.8 months after perfusion. CONCLUSIONS: HILP with cisplatin is a relatively safe procedure, which seems to increase locoregional control of advanced malignant melanoma of the extremity. Separating the timing of lymph node dissection from HILP by 6 to 8 weeks reduces the complication rate.

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.

The effect of anesthesia type on needle localization breast biopsy: another point of view.

BACKGROUND: Efforts directed at early detection of breast cancer have resulted in an increased incidence of nonpalpable mammographic lesions that warrant excisional biopsy. The most common localization method is by use of the hook wire technique, or needle localization biopsy. Although much has been written about the localization technique, the impact of the method of anesthesia on the accuracy of the biopsy and especially on the completeness of the excision has not been clarified. PATIENTS AND METHODS: We studied 450 needle localization breast biopsies to determine whether the type of anesthesia (local versus general) influenced the accuracy and completeness of the biopsy. We compared 153 biopsies performed under local anesthesia to 297 done under general anesthesia. RESULTS: The use of local versus general anesthesia did not affect accuracy; however, it did determine the inability to achieve clean margins (27.6% versus 7.3%, respectively, P <0.02). It was more difficult to excise completely specimens located deeper than 3 cm in the breast, when the localizing needle travelled more than 3 cm, and when the lesions were of the microcalcification mammographic pattern. CONCLUSIONS: For lesions mammographically suspicious for malignancy, mainly those located deeper than 3 cm, general anesthesia is preferred.

Thromboangiitis obliterans: an old disease in need of a new look.

Almost a century after Buerger's original description of thromboangiitis obliterans, there is still no consensus about diagnostic criteria. The lack of a universally accepted method of diagnosis causes confusion, and mars research efforts. Some authors quote 'hematological disease' as one of the exclusion criteria. But in most recent reports, suspected Buerger patients did not undergo hematological tests to diagnose or rule out any primary or secondary hypercoagulable states. However, immunogenetic studies of Buerger's disease have led to a revived interest in the role of blood coagulation in the pathogenesis of thromboangiitis obliterans. Some association has been suggested between Buerger's disease and the antiphospholipid syndrome, as well as hyperhomocysteinemia. Other thrombophilic conditions have been described anecdotally in patients with Buerger's disease. In view of this developing line of investigation, there is a clear need to redefine the diagnostic algorithm and the criteria for diagnosing Buerger's disease.

Cyclic neutropenia with colonic perforation and nonhealing colocutaneous fistula.

Cyclic neutropenia is an hereditary disorder of white blood cells, characterized by profound neutropenic episodes approximately every three weeks. Septic complications are usually limited to cutaneous and oropharyngeal infections. A 4-year-old boy with known cyclic neutropenia was in shock with neutropenia, clostridial septicemia, and right lower quadrant peritonitis when he was admitted. At the time of laparotomy, inflammation of the cecum, with no gross perforation, was found; no resection or appendectomy was done. He subsequently developed a right lower quadrant abscess that was drained, resulting in a colocutaneous fistula. For the next 8 months his fistula persisted, with intermittent episodes of fever, increased fistula output, and abdominal pain during his neutropenic periods. Standard nonoperative approaches to healing the fistula failed (ie, elemental feeds, total parenteral nutrition, irrigations, antibiotics, and drains). Attempts to medically abolish his neutropenic episodes using lithium, gammaglobulin, and steroids also failed. Ultimately, he underwent an ileocecal resection with primary anastamosis; the operation was done immediately following a neutropenic episode, in order to allow adequate healing of his anastamosis before his next period of neutropenia. Postoperative course was satisfactory, and he remains well after 8 months follow-up. This case, and several similar previously reported cases, illustrate that cyclic neutropenia may present with serious surgical complications. They also underlines the important role that neutrophils play in the healing of enteric fistulae.

Antithrombosis routines and hemorrhagic complications: a seven year survey comparing vascular and general surgical operations.

Prospective monitoring of the occurrence of venous thromboembolism (VTE) and bleeding complications was carried out during a seven year period in a department of general and vascular surgery. Low dose heparin was given by pre-determined criteria to over 1200 patients undergoing general surgical operations, and to almost 700 patients having vascular surgical operations. Over 450 vascular patients received full dose anticoagulation and 3400 patients from both groups received no antithrombotic treatment. Clinically significant major VTE occurred in one percent of all patients. Nine patients died of pulmonary emboli (0.15%). There were 130 patients with bleeding complications (2.2%) half of them severe. Both VTE and bleeding were more common in the vascular patients (1.4 and 3.1% respectively) as compared with general surgery (0.7 and 1.6%). Patients receiving low dose heparin had a 3.4 percent incidence of bleeding but in one half of these cases a technical factor or a breach of the treatment protocol could have contributed to the bleeding. Possible modifications of antithrombosis routines are suggested.

Peripheral nerve section as palliation for severe ischemic foot pain.

Multisensory peripheral nerve divisions were performed in 17 elderly patients with severe ischemia, forefoot pain and non-healing lesions or localised gangrene. They were unsuitable for a vascular reconstructive operation, or for localised foot amputation. The mean age of the patients was 73 years; 13 were males and 10 had diabetes mellitus. All were faced with a major amputation. Considerable pain relief was achieved in all patients but only five patients retained a functional lower extremity for more than 6 months. Of these five one was a diabetic and four were non diabetic. Peripheral nerve section is a useful procedure, but should be applied very selectively and only rarely in diabetic patients.

Portable air mobile life support unit.

The Israeli Air Force Medical Corps has developed a portable Air Mobile Life Support Unit (AMLS) for use in emergency airborne medical evacuations. This unit was designed so that it could be easily moved from one aircraft to another, thus allowing for tactical flexibility and avoiding the necessity for a dedicated ambulance aircraft. The unit is capable of supplying critical care for two patients and supportive care for two less severely injured. Three main functional units comprise the AMLS. These include (1) oxygen ventilation system, (2) cardiac monitoring and defibrillation system, and (3) vacuum pump for aspiration of secretions. Each of these units can be removed and operated independently of the AMLS for field use. Accessories include a control panel, illumination unit and a medical supply cabinet. The AMLS unit may be installed or removed in less than 2 min by two crew men. The AMLS has been operational and successfully used in air evacuations in wartime as well as in peace time. Air Medical crews report that the AMLS has been easily accessed and has operated without any malfunction.