Neoadjuvant concurrent chemoradiotherapy with and without hyperthermia in retroperitoneal sarcomas: feasibility, efficacy, toxicity, and long-term outcome.

PURPOSE: Retroperitoneal (RPS) sarcomas are associated with poor local and abdominal tumor control. However, the benefit of preoperative radio- or chemotherapy alone for these entities is currently unclear. Moreover, as intermediate- and high-grade sarcomas have a tendency toward early metastasis, exploration of neoadjuvant strategies is of high importance. This analysis reports the results of our 20-year single-institution experience with preoperative neoadjuvant concurrent chemoradiation. METHODS: From 2000-2019, 27 patients with intermediate- or high-grade RPS (12 dedifferentiated liposarcoma, 10 leiomyosarcoma, 5 others) were treated with radiotherapy (median dose: 50.4 Gy; range 45-75 Gy) and two cycles of chemotherapy (doxorubicin 50 mg/m2 BSA/d3 q28 and ifosfamide 1.5 g/m2 BSA/d1­5 q28) in neoadjuvant intent. Chemotherapy consisted of doxorubicin alone in two cases and ifosfamide alone in one case. Fifteen patients (56%) additionally received deep regional hyperthermia. RESULTS: The median follow-up time was 53 months (±56.7 months). 92% of patients received two cycles of chemotherapy as planned and 92% underwent surgery. At 5 and 10 years, abdominal-recurrence-free survival was 74.6% (±10.1%) and 66.3% (±11.9%), distant metastasis-free survival was 67.2% (±9.7%) and 59.7% (±11.1%), and overall survival was 60.3% (±10.5%) and 60.3% (±10.5%), respectively. CTC grade III and IV toxicities were leukocytopenia (85%), thrombocytopenia (33%), and anemia (11%). There were no treatment-related deaths. CONCLUSION: Neoadjuvant chemoradiotherapy with and without hyperthermia for retroperitoneal sarcomas is feasible and provided high local control of intermediate- and high-grade sarcoma.

[Side effect management of tyrosine kinase inhibitors in urology : Hypertension]. / Nebenwirkungsmanagement von Tyrosinkinaseinhibitoren in der Urologie : Arterielle Hypertonie.

Tyrosine kinase inhibitors like sunitinib, sorafenib, pazopanib or axintinib are regarded the standard of care in the systemic therapy of metastatic renal cell carcinoma. However, the many side effects associated with this therapy pose challenges for the treating physician and the patient. This review offers an overview of the classification and the treatment of hypertension, which is one of the major side effects induced by all tyrosine kinase inhibitors, in order to improve treatment efficacy and patient compliance.

The clinical significance of anaemia and disturbed iron homeostasis in chronic respiratory failure.

BACKGROUND: Anaemia is a frequent, clinically relevant condition in various chronic diseases. It seems also to be prevalent in patients with chronic respiratory failure (CRF). We studied the characteristics of anaemia in CRF and its associations with clinical outcome. METHODS: In a prospective design, 271 consecutive patients with CRF were evaluated; patients with other conditions often associated with anaemia were excluded. Haematological laboratory and physiological parameters, health-related quality of life (HRQL), dyspnoea and 48-month survival were determined. Anaemia was defined according to WHO [haemoglobin (Hb)< 13 g/l (male); Hb< 12 g/dl (female)] and using an established algorithm. RESULTS: Among 185 patients included, 18.4% showed anaemia, not depending on chronic obstructive pulmonary disease (COPD) vs. non-COPD (17.6% vs. 19.0%; p = 0.851) or on gender [16.5% (female) vs. 19.8% (male); p = 0.702]. Anaemic patients had higher age, creatinine (p < 0.05 each) and erythropoietin levels (p < 0.001), but lower transferrin saturation (TSAT), serum iron and vitamin B12 levels (p < 0.01 each). By definition, most anaemic patients (67.6%) had disturbances in iron homeostasis according to 'anaemia of chronic disease' and/or true iron deficiency anaemia. Hb was independently related to dyspnoea and HRQL, while TSAT ≥ 20% was linked to less dyspnoea and better subjective exercise capability. Non-survivors had lower Hb and serum iron levels (p < 0.05 each). In multivariate analysis, lower serum iron levels and TSAT were independently associated with mortality (p < 0.05 each). CONCLUSION: Anaemia was common in patients with CRF and often because of disturbed iron homeostasis. Hb and TSAT were linked to functional outcome and HRQL. Lower serum iron levels and TSAT were independent prognostic parameters.

Recovery of zeta-chain expression and changes in spontaneous IL-10 production after PSA-based vaccines in patients with prostate cancer.

Circulating T lymphocytes of patients with prostate cancer have been reported to have functional deficits, including low or absent zeta-chain expression. To determine whether these functional impairments could be reversed by prostate specific antigen-based vaccination therapy, 10 patients treated with recombinant human prostate specific antigen plus GM-CSF and eight others receiving prostate specific antigen plus oil emulsion in two pilot clinical trials were evaluated prior to and after vaccination for several immunologic end points, including zeta-chain expression and cytokine production by circulating T cells as well as the frequency of T cells able to respond to prostate specific antigen in ELISPOT assays. The flow cytometry assay for zeta-chain expression was standardized to allow for a reliable comparison of pre- vs post-vaccination samples. Prior to therapy, the patients were found to have significantly lower zeta-chain expression in circulating CD3(+) cells and a higher percentage of zeta-chain negative CD3(+) and CD4(+) cells than normal donors. The patients' peripheral blood mononuclear cells spontaneously produced more IL-10 ex vivo than those of normal controls. After vaccination, recovery of zeta-chain expression was observed in 50% of patients in both clinical trials. Also, spontaneous IL-10 secretion by peripheral blood mononuclear cells decreased following immunotherapy in patients treated with prostate specific antigen and GM-CSF. The frequency of prostate specific antigen-reactive T cells was detectable in 7 out of 18 patients vs 4 out of 18 patients prior to vaccination. Only one of 18 patients was a clinical responder. The vaccine had stimulatory effects on the patients' immune system, but post-vaccine immune recovery could not be correlated to progression-free survival in this small cohort of patients with prostate cancer.

Dendritic cells for specific cancer immunotherapy.

The characterization of tumor-associated antigens recognized by human T lymphocytes in a major histocompatibility complex (MHC)-restricted fashion has opened new possibilities for immunotherapeutic approaches to the treatment of human cancers. Dendritic cells (DC) are professional antigen presenting cells that are well suited to activate T cells toward various antigens, such as tumor-associated antigens, due to their potent costimulatory activity. The availability of large numbers of DC, generated either from hematopoietic progenitor cells or monocytes in vitro or isolated from peripheral blood, has profoundly changed pre-clinical research as well as the clinical evaluation of these cells. Accordingly, appropriately pulsed or transfected DC may be used for vaccination in the field of infectious diseases or tumor immunotherapy to induce antigen-specific T cell responses. These observations led to pilot clinical trials of DC vaccination for patients with cancer in order to investigate the feasibility, safety, as well as the immunologic and clinical effects of this approach. Initial clinical studies of human DC vaccines are generating encouraging preliminary results demonstrating induction of tumor-specific immune responses and tumor regression. Nevertheless, much work is still needed to address several variables that are critical for optimizing this approach and to determine the role of DC-based vaccines in tumor immunotherapy.

Decreased zeta chain expression and apoptosis in CD3+ peripheral blood T lymphocytes of patients with melanoma.

Expression of T-cell receptor- or Fcgamma receptor III-associated signal-transducing zeta chain is important for the functional integrity of immune cells. We found that significantly higher proportions of circulating CD3+ T cells as well as natural killer cells had low or absent expression of the zeta chain in patients with advanced melanoma than in normal donors (P < 0.0005). Decreased zeta expression was always observed in a small subset of circulating CD3+ T cells that were in the process of apoptosis, i.e., bound Annexin V or were terminal deoxynucleotidyl transferase-mediated nick end labeling positive. Up to 80% of T cells in the peripheral blood of patients with melanoma were Fas+, with the mean percentage of Fas+CD3+ cells significantly higher in patients (P < 0.004) than normal controls. These Fas+CD3+ T cells were found to preferentially undergo apoptosis. Annexin V binding, the loss of Fas expression from the cell surface as well as zeta down-regulation, which are associated with early apoptosis, were detected in a proportion of circulating Fas+CD3+. In Jurkat cells incubated with agonistic anti-Fas antibody (CH-11), a rapid loss of Fas expression from the cell surface coincided with Annexin V binding and preceded the loss of zeta chain during early apoptosis. In a subset of Jurkat cells coincubated with human melanoma cells, Annexin V binding and zeta degradation as well as DNA fragmentation were observed, indicating that the tumor induced T-cell death. Triggering of death receptors expressed on activated T lymphocytes was accompanied by the loss of zeta expression. On the other hand, soluble factors secreted by melanoma cells induced down-regulation but no apoptosis in activated normal T cells. In the circulation of patients with melanoma, apoptosis of immune effector cells may be related to the state of chronic activation, resulting in the up-regulation of death receptors and increased susceptibility to apoptosis.

Proinflammatory cytokines and CD40 ligand enhance cross-presentation and cross-priming capability of human dendritic cells internalizing apoptotic cancer cells.

Human monocyte-derived dendritic cells (DC) can ingest apoptotic tumor cells (ATC) and present tumor-associated antigens (TAA) to T cells, leading to the generation of tumor-specific cytotoxic effector cells (Cancer Res 2000;60:3542-9). To further augment antitumor effector cell responses, attempts were made to modify antigen presentation and cross-priming of T cells by DC fed with ATC. Proinflammatory cytokines (PC), CD40 ligand (CD40L) and/or interferon-gamma (IFN-gamma) were found to markedly enhance the immunogenicity of TAA presented by DC. While PC upregulated expression of major histocompatibility complex class I/II and costimulatory molecules on the surface of DC, CD40L +/- IFN-gamma increased interleukin (IL)- 12 and to a lesser extent, IL-15 production by DC. Additionally, lactacystin, a specific proteasome inhibitor, significantly abrogated the effects of IFN-gamma and, in part, also those of CD40L or PC. The ability of DC + ATC to cross-prime TAA-inexperienced ("naive") T cells was significantly enhanced by PC and CD40L or CD40L + IFN-gamma, but not by IFN-gamma alone. These results indicate that future vaccines for patients with cancer incorporating DC fed with ATC could be made more effective by the addition of proinflammatory cytokines or CD40L +/- IFN-gamma to improve the DC function.

Generation of tumor-specific T-lymphocytes by cross-priming with human dendritic cells ingesting apoptotic tumor cells.

It has been suggested that dendritic cells (DCs) are capable of ingesting apoptotic tumor cells (ATCs) and presenting tumor-associated antigens to immune cells. We evaluated the potential of human DCs, which have ingested ATCs, to serve as a source of antigenic epitopes for presentation to T cells specific for PCI-13, a squamous cell carcinoma of the head and neck cell line. Immature DCs (DCimm) generated in the presence of interleukin 4 and granulocyte machrophage colony-stimulating factor from peripheral blood monocytes of HLA-A2+ healthy donors were incubated in the presence of ATCs. Uptake of ATCs by DCs was monitored by flow cytometry and confocal microscopy after 2-18 h of coincubation. When DCs were matured (DCmat) in the presence of proinflammatory cytokines, their capacity to uptake ATCs was reduced. Responses of PCI-13-specific CD8+ T cells to unmodified PCI-13 cells and to DCimm or DCmat +/- ATCs or +/- tumor lysates were tested in gamma-IFN enzyme-linked immunospot and cytotoxicity assays. Unmodified tumor cells were found to be the best stimulators of antitumor activity of the established T-cell line, and ATCs alone were minimally stimulatory. However, DCs that ingested ATCs were able to present tumor antigens to CTLs, and DCimm and DCmat were almost equally stimulatory. When DCs plus various tumor-derived preparations were used as antigen-presenting cells with autologous HLA-A2+ T cells obtained from normal donors, DCs that had ingested ATCs were more effective in generating CD8+ CTLs than tumor cells alone or DCs pulsed with tumor lysates. The results indicate that human DCs fed with ATCs and then matured effectively generated T cell-mediated antitumor responses in vitro.

B7.1 on human carcinomas: costimulation of T cells and enhanced tumor-induced T-cell death.

Human squamous cell carcinomas of the head and neck (SCCHN) do not express the costimulatory molecules B7.1 or B7.2 in situ or in culture. Transduction of B7.1(-) SCCHN cells with the retroviral B7. 1 and neo(r) genes resulted in the expression of high levels of the transgene in these tumor cells. When B7.1(+) SCCHN cells were used as stimulators of autologous or allogeneic PBL in mixed lymphocyte-tumor cultures (MLTC), T-cell proliferation and generation of antitumor effector T cells as well as levels of their lytic activity were significantly increased. At the same time, a proportion of activated T cells seen to undergo apoptosis was found to be significantly higher upon coincubation with B7.1(+) SCCHN than with B7.1(-) SCCHN. Both B7.1(+) and B7.1(-) SCCHN cells were found to express FasL on the cell surface and in the cytoplasm, as well as mRNA for FasL and mRNA for TRAIL. However, expression of the B7.1 transgene did not lead to increased expression of FasL protein on tumor cells. Yet, up to 50% of activated CD28(+) allogeneic T cells, which were CD95(+), showed evidence of DNA fragmentation in JAM and TUNEL assays upon incubation with an excess of B7.1(+) SCCHN for 24 h. Tumor-induced T-cell death was equally and only in part blocked by anti-Fas antibodies in both B7.1(+) and B7.1(-) MLTC. While surface expression of B7.1 molecules on SCCHN cells enhanced T-cell costimulation via B7.1-CD28 interactions, it did not rescue activated T cells from tumor-induced apoptosis. The outcome of MLTC under these conditions was dependent on the ratio of tumor to T cells. Thus, in the presence of an excess of B7.1(+) tumor cells, activated T cells showed increased sensitivity to apoptosis which did not appear to be Fas/FasL mediated. These data are important for the development of B7.1 gene therapy and efforts directed at the generation of effector cells in MLTC.

Generation of PSA-reactive effector cells after vaccination with a PSA-based vaccine in patients with prostate cancer.

BACKGROUND: JBT 1001 is a vaccine used for therapy of prostate cancer (CA), which consists of recombinant prostate-specific antigen (PSA) with lipid A formulated in liposomes. Patients with prostate CA were vaccinated with JBT 1001 emulsified in mineral oil (n = 5) or with the vaccine in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) administered locally at the site of vaccination (n = 5). Frequency of PSA-reactive T cells was measured in peripheral blood mononuclear cells (PBMC) before and after immunization, using an interferon-gamma (IFN-gamma) enzyme-linked immunospot (ELISPOT) assay with autologous dendritic cells (DC) as antigen-presenting cells. The hypothesis tested was that PSA-based vaccines induce T cell responses to human PSA. METHODS: In order to expand precursor cells, in vitro sensitization (IVS) was performed. Microcultures of peripheral blood lymphocytes (PBL) (1 x 10(5)/well) in medium supplemented with interleukin-2 (IL-2) (10 IU/ml) and interleukin-7 (IL-7) (10 ng/ml) were stimulated twice (day 0 and day 7) with monocyte-derived autologous DC, generated by culture with interleukin-4 (IL-4) and GM-CSF and pulsed with PSA (10 microg/ml) at an effector to stimulator ratio of 10:1. ELISPOT assays were performed on day 14 of culture. In addition, PBMC were separated on immunobeads into CD4(+) and CD8(+) subsets for ELISPOT assays performed without IVS. RESULTS: Two patients had PSA-reactive responses before vaccination (frequency range, 1/700-1/4,400). After vaccination, 8/10 patients had measurable PSA-reactive T-cell frequencies, ranging from 1/200-1/1900, using IVS. In contrast, without IVS, but after immunoselection to enrich in CD8(+) and CD4(+) T cells, only 2/10 patients had detectable PSA-reactive T cells after vaccination, at a frequency ranging from 1/2,600-1/4,000. CONCLUSIONS: Vaccination with PSA formulated into liposomes induced T-cell responses in 8/10 patients with prostate carcinoma. The frequency of PSA-reactive precursor T cells was relatively low in the blood of these patients, and IVS, leading to amplification of the precursor cells prior to ELISPOT, was necessary for quantification of the PSA-responding T cells. Cellular responses to PSA were predominantly mediated by CD4(+) T lymphocytes.

[Symptomatic leukemic infiltration of the lung in acute myeloid leukemia]. / Symptomatische leukämische Infiltration der Lunge als Komplikation einer akuten myeloischen Leukämie.

HISTORY: A 70-year-old woman was admitted with the suspected diagnosis of acute leukaemia. She had complained of decreased physical capacity, nonproductive cough and dyspnoea. INVESTIGATIONS: The blood picture showed leukocytosis of 46/nl, anaemia (haemoglobin 8.8 g/dl) and thrombocytopenia (25 platelets/nl). Differential white count: 10% blast cells, 43% monocytes. Bone marrow smear revealed acute monocytic leukaemia. The chest radiogram showed increased interstitial markings and lung function tests indicated moderate restriction. TREATMENT AND COURSE: The atypical pneumonia was treated with erythromycin, but the respiratory functions deteriorated further within 2 days. Cytostatic treatment had been started on the second hospital day, but the patient died a few hours later in respiratory failure. Autopsy revealed numerous alveolar infiltrates by immature myeloid cells. CONCLUSION: In patients with acute leukaemia and respiratory symptoms, pulmonary involvement should be included in the differential diagnosis and, if present, chemotherapy immediately begun.

Adoptive immunotherapy with tumor-cytotoxic macrophages derived from recombinant human granulocyte-macrophage colony-stimulating factor (rhuGM-CSF) mobilized peripheral blood monocytes.

We examined the mobilization of blood monocytes (MO) with recombinant human granulocyte-macrophage colony-stimulating factor (rhuGM-CSF) with regard to the in vitro generation of MO-derived tumor-cytotoxic macrophages (MAC) for use in adoptive immunotherapy of cancer patients. Eleven patients with progressing metastatic cancer received interferon (IFN)-gamma activated tumor-cytotoxic MAC generated in vitro from autologous MO with and without pretreatment with rhuGM-CSF. RhuGM-CSF was administered subcutaneously at 10 micrograms/kg for 7 days. RhuGM-CSF treatment and adoptive cell transfer were well tolerated, and no toxicity greater than WHO II degrees occurred. Fever was the most common side effect and was seen in all patients during rhuGM-CSF treatment and during 9 of 22 MAC therapies. Bone pain was noted in 5 of 11 patients during rhuGM-CSF therapy. RhuGM-CSF treatment led to a continuous increase in the white blood cell counts and the number of MO within the leukapheresis products. The mean number of transfused MAC was 0.9 x 10(9) without rhuGM-CSF pretreatment and 1.9 x 10(9) after rhuGM-CSF administration. The maximum number of MAC that could be generated was 7.3 x 10(9), but after a dose escalation protocol only up to 2.7 x 10(9) MAC were transfused. Cytotoxicity against U937 cells increased during MO to MAC differentiation, but was decreased in both MO and MAC on treatment with rhuGM-CSF. This study proves the feasibility of reinfusing MAC generated in vitro from rhuGM-CSF mobilized MO.