Inhibition of established pancreatic cancers following specific active immunotherapy with interleukin-2 gene-transduced tumor cells.

Pancreatic cancer has a poor prognosis even when complete resection can be accomplished. Recent studies have demonstrated that the immune system is capable of mounting effective tumor-specific immune responses even against "nonimmunogenic" tumors. The studies reported herein were conducted to determine if induction of tumor-specific immune responses of inhibiting in vivo pancreatic tumor growth could be achieved through active immunization with pancreatic tumor cells genetically engineered to secrete interleukin-2 (IL-2). A relevant poorly immunogenic subcutaneous model of murine ductal pancreatic cancer was first developed using an implantable tumor cell line Panc02 in C57BL/6 mice. Panc02 cells were then genetically engineered to secrete human IL-2 (Panc02/IL2). The ability of irradiated Panc02/IL2 cells to stimulate an immune response capable of rejecting a subsequent tumor challenge was first demonstrated. Ninety percent of animals vaccinated with irradiated parental Panc02 and subsequently challenged with parental Panc02 cells developed tumors by 48 days (mean tumor volume of 234 mm3) compared to only 40% (P < .05, chi square) of animals vaccinated with irradiated Panc02/IL2 and challenged with parental Panc02 (14 mm3, P < .004, tau test). The therapeutic benefit of active immunization in tumor-bearing animals was then examined. Mice with 3-day-old established subcutaneous tumors were administered a series of 4 weekly vaccinations with irradiated Panc02 or Panc02/IL2 cells. A significant reduction in tumor growth was present in those animals vaccinated with Panc02/IL2 (P < .005, tau test) versus Panc02 or saline. Animals whose established tumors regressed following vaccinations with IL-2-secreting Panc02 cells were found to have long-lasting immunity as demonstrated by rejection of a tumor challenge presented over 140 days following inoculation of the primary tumor. We conclude that an immune response capable of inhibiting established pancreatic tumors can be generated by vaccination with IL-2-secreting tumor cells. Furthermore, long-term immunological memory was established in mice that rejected the original established tumor. These studies provide preclinical evidence to support the use of cytokine gene-transduced tumor cell vaccinations in patients with pancreatic cancer.

Active immunotherapy of pancreatic cancer with tumor cells genetically engineered to secrete multiple cytokines.

BACKGROUND: Vaccination of tumor-bearing animals with tumor cells genetically engineered to secrete cytokines including interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) has been shown to induce effective tumor-specific immune responses capable of inhibiting local and metastatic disease. Previous unsuccessful attempts to enhance this immune response by means of the secretion of multiple cytokines possessing different immunologic mechanisms of action may have been due to the inherent inefficiency of the gene transfer systems used. We postulated that tumor cells genetically engineered by means of a novel gene transfer method resulting in high level secretion of both cytokines would be more effective than tumor cells secreting a single cytokine in inhibiting the growth of existing tumors. METHODS: Nonimmunogenic, murine pancreatic cancer cells (Panc02) were engineered to secrete IL-2, IFN-gamma, IL-2 and IFN-gamma, or neomycin phosphotransferase. Mice were inoculated with 5 x 10(5) parental Panc02 tumor cells subcutaneously. Beginning 3 days later, animals then received a series of four weekly vaccinations with irradiated Panc02/Neo, Panc02/IL2, Panc02/IFN, or Panc02/IL-2/IFN. RESULTS: Treatment with Panc02/Neo, Panc02/IL-2, or Panc02/IFN resulted in 0%, 40%, and 30% tumor-free survival, respectively. In contrast, 80% of animals vaccinated with Panc02/IL2/IFN were free of tumor at 100 days. All animals free of disease were resistant to subsequent tumor challenges. CONCLUSIONS: These data show that vaccination with tumor cells that secrete high levels of multiple cytokines was more effective in treating established pancreatic tumors and represents an improvement over existing single cytokine strategies.

Effect of closing dead space on seroma formation after mastectomy--a prospective randomized clinical trial.

To evaluate the effect of closing dead space on seroma formation after mastectomy, 39 patients undergoing 40 mastectomies with axillary node clearance were randomized to undergo suturing of skin flaps to underlying muscle or conventional skin closure. Duration of closed suction drainage, 72 h, and shoulder exercises, commencing on the first post-operative day, were standardized for both groups. Closed suction drainage was significantly less (P < 0.05) in the group that had flaps sutured, 272 +/- 46 ml vs 393 +/- 39 ml. Also fewer patients in the flap sutured group developed seromas, 5 (25%) vs 17 (85%) chi 2 = 12.2 P < 0.001. Three patients in the group that had conventional skin closure had breakdown of wound edges, two developing a prolonged serous discharge, while none occurred in the sutured group. A functional range of shoulder motion was attained at 6 months in 14 (70%) patients in the flap sutured group compared with nine (45%) in the conventional skin closure group (P = NS). These results confirm the value of suturing skin flaps to underlying muscle in reducing local morbidity after mastectomy and suggest that this technique should be included in the closure of all mastectomy wounds.

The clinical value of CEA and CA 15-3 in breast cancer management.

The value of tumour-associated antigens CEA and CA 15-3 was studied in patients with breast cancer over a 4-year period. A total of 252 patients with primary or recurrent disease had available and corresponding CEA and CA 15-3 values at diagnosis and during follow-up and were studied in detail. Preoperative and three-monthly serial postoperative levels were measured in each patient. Ten of 11 patients presenting with primary and concurrent metastatic disease had elevated CA 15-3 levels (> 25 I.U./ml) as compared to 6 with CEA (> 5 ng/ml). Fourty-seven patients developed locoregional recurrence of which 15 had concurrent metastatic disease. CA 15-3 was elevated in 14 cases while CEA in 11. Of 32 patients with locoregional recurrence alone, 18 later developed metastatic disease at a mean follow-up time of 17.5 months. There was a significant correlation between CA 15-3 value at locoregional recurrence and time to subsequent metastasis (r = 0.-0.57, P = 0.0133). CEA was elevated in 64%, CA 15-3 in 87% and either marker in 94% of 87 patients diagnosed with metastatic disease. Of 53 patients with serial markers and metastatic disease, 72% (38/53) had rising CA 15-3 levels prior to diagnosis with a mean lead time of 9.9 months. Use of CEA in conjunction improved lead time detection to 83%. This study demonstrates that CA 15-3 is superior to CEA at detecting metastatic disease at initial presentation and during follow-up. Use of CEA in conjunction with CA 15-3 improves the detection of systemic disease.

Varicocele and the horizontal testis: a change in position?

Horizontal lie of the testis has recently been observed in association with varicoceles in a pediatric population. Six children with a varicocele presented to the surgical department during a 6-month period. All had an associated horizontal lie of the testis. In two of these cases, high ligation of internal spermatic veins was performed, after which one reverted to a vertical position with resolution of the varicocele. Seven children who underwent high ligation of a varicocoele over a 5-year period were examined. All were found to have no evidence of the varicocele at follow-up. All but one had a vertical lie. Horizontal lie of the testis in children is a new clinical sign that should alert the examiner to the possibility of an underlying varicocele.

Mammographic needle localisation of impalpable breast lesions.

Refinements in mammography have led to an increased number of needle localised breast biopsies for impalpable breast lesions. This paper review 139 needle guided biopsies from June 1986 to December 1990 in 132 patients. Forty four patients (32%) biopsied had malignant lesions the vast majority (91%) of which were reported as either non-invasive or invasive less than 2 cm in diameter. Fourteen patients in this group had ductal carcinoma in-situ. When compared with 100 consecutive palpable breast carcinomas during the same period, needle localised biopsies had a higher proportion of non-invasive lesions and fewer were associated with lymph node involvement. Needle guided breast biopsy detects carcinoma at an earlier stage and may reduce morbidity and mortality from breast cancer.

Local anaesthetic repair of uncomplicated paraumbilical hernia without sedation: peri-operative pain and patient satisfaction.

PURPOSE: Paraumbilical hernia (PUH) is a common condition that usually requires surgical repair. However, there is a dearth of literature on this surgery performed under local anaesthesia (LA) without the use of sedation. The aims of this study were to assess peri-operative pain and patient satisfaction in patients undergoing PUH repair using LA without sedation. METHODS: All patients having PUH repair under a single consultant between January 2010 and December 2011 were eligible to participate. If eligible for both, patients chose either general anaesthetic (GA) or LA repair. If only eligible for either LA or GA, they were offered this anaesthetic modality. Visual analogue scales were used to report peri-operative pain (10 point score) and satisfaction (%). Results were compared by grade of surgeon (higher surgical trainee (HST) versus consultant). RESULTS: A total of 63 patients underwent PUH repair (31 GA; 32 LA). Of them, only 28/32 of LA repair patients agreed to participate. LA and GA patients had equivalent age and sex distribution. LA patients had a lower body mass index (BMI) than GA [27.1 (3.7) versus 30.3 (5.1), p = 0.007]. The median length of LA procedure was 24 (17.5-30) minutes. The median LA solution infiltrated was 25 (20-32) ml. Peri-operative pain scores were low [1.1 (0.3-2.9) %] and patient satisfaction was high [96 (91-99) %]. There were no differences in pain, patient satisfaction, duration of procedure and amount of LA infiltrated with increasing BMI. Comparing HST to consultant, the former took longer [30 (25-36) versus 20 (16-24) minutes, p = 0.0007], infiltrated more LA [34.5 (26-47) versus 20 (19-25.5) ml, p = 0.0039], and patients reported more pain [2.75 (1.0-4.95) versus 0.4 (0.2-1.7) %, p = 0.029], but overall satisfaction was equivalent [95.5 (89-99.25) versus 96.3 (92.25-99) %, p = 0.684]. CONCLUSION: Open mesh PUH repair using LA without sedation is associated with low peri-operative pain and very high satisfaction when either a higher surgical trainee or a consultant grade is operating.

Perioperative fluid management: prospective audit.

BACKGROUND: Postoperative fluid management is a core surgical skill but there are few data regarding current fluid management practice and the incidence of potential fluid-related complications in general surgical units. We conducted a prospective audit of postoperative fluid management and fluid-related complications in a consecutive cohort of patients undergoing midline laparotomy. METHODS: Over a 6-month period, the peri-operative fluid management of 106 consecutive patients was prospectively audited. Serum electrolyte data, fluid balance data, co-morbidities, operative and anaesthetic variables and quantities of fluid and electrolytes prescribed were recorded. The development of fluid-related and other complications was noted. RESULTS: There were no correlations between routinely available fluid balance parameters and the quantities of fluid and electrolytes prescribed, suggesting that doctors do not consult fluid balance data when prescribing. Fifty-seven patients (54%) developed at least one fluid-related complication. These patients received significantly greater volumes of fluid and sodium each day postoperatively. They had higher rates of other non-fluid-related complications and death. They had a longer hospital stay. In a multivariate model, mean daily fluid load predicted the development of fluid-related complications. CONCLUSION: Fluid prescription practice in general surgical units is sub-optimal, resulting in avoidable iatrogenic complications. Involvement of senior staff, education and possibly the introduction of prescribing protocols may improve the situation.

Flow volume loops in patients with goiters.

Plain radiology is the standard means of assessing upper airway obstruction in patients with goiters. Flow volume loop curves will provide additional information, because they allow a quantitative assessment of airflow dynamics in the respiratory cycle. Fifty-one patients had flow volume loops performed before and after thyroidectomy. There was a significant increase in the maximum inspiratory flow rate (3.9 +/- 0.2 versus 4.9 +/- 0.2 L/second, p less than 0.01) after thyroidectomy. Eight of twelve patients with normal tracheal radiology had improved airflow dynamics in the postoperative period. The flow volume loop curve is a simple noninvasive means of assessing airflow dynamics in patients with goiters and may be superior to conventional radiology.

CA 15-3 in patients with locoregional and metastatic breast carcinoma.

BACKGROUND: The value of circulating CA 15-3 levels was assessed in 129 patients with recurrent breast carcinoma. METHODS: Patients were divided into four subgroups, according to the following: Group A, locoregional recurrence alone; Group B, locoregional and subsequent systemic recurrence; Group C, combined locoregional and systemic recurrence; and Group D, differing sites of systemic disease. RESULTS: One of 14 patients with locoregional disease alone had increased levels of CA 15-3 (> 25 U/ml). However, 96% of patients (22 of 23 patients) with combined local and systemic disease had increased tumor marker levels. The difference in CA 15-3 levels in patients with combined disease compared with patients with local disease alone was statistically significant (117.0 versus 17.5 U/ml, respectively; P < 0.02). Twenty-four patients with locoregional recurrence later had distant metastasis develop. In this group, patients with an increased CA 15-3 value had a significantly shorter lead time to the development of distant metastases compared with patients with normal tumor marker levels (20.8 +/- 3.3 versus 10.3 +/- 2.7 months, respectively; P < 0.03). CA 15-3 values at diagnosis were increased in 88% of 115 patients with metastatic disease. There was no significant difference in CA 15-3 levels among metastases to lung, liver, and bone nor was there any difference between single and multiple sites of distant metastasis. CA 15-3 is an excellent marker for systemic recurrence of breast carcinoma. CONCLUSIONS: Increased levels and no clinical evidence of recurrence strongly indicate the presence of occult metastatic disease.

Reasons underlying negative mammography in patients with palpable breast cancer.

It is well recognized that a negative mammogram report does not exclude the presence of breast carcinoma. This study examines the accuracy of mammography in patients with palpable breast cancer. In particular, the study evaluates the reasons underlying negative mammography in breast cancer. All patients with Paget's disease, carcinoma in situ lesions or lesions infiltrating skin were excluded. A total of 291 patients presenting with palpable breast carcinoma underwent mammography prior to biopsy. False negative reports occurred in 16.5% (48). The sensitivity of mammography increased with age, from 70% (14/20) in 31-40-year-olds to 91% (113/124) in women over 60 years. Retrospective review of false negative mammograms showed that 30% of these were deemed normal while 20% were obvious oversights. The remaining 50% showed subtle radiographic abnormalities, consistent with but not diagnostic of malignancy.

Active immunization with tumor cells transduced by a novel AAV plasmid-based gene delivery system.

Ex vivo genetically engineered cytokine-secreting tumor cell vaccines have been shown to prevent metastatic disease in animal models of lung and breast cancer. Because of the inefficiency of existing modes of gene delivery in transducing primary human tumor cells, it has been difficult to clinically apply this strategy. In this study, liposome-mediated delivery of an adeno-associated virus (AAV)-based plasmid containing the sequence for murine gamma-interferon (gamma-IFN) (pMP6A-mIFN-gamma) was used to generate cytokine-secreting murine tumor cell vaccines. High levels of gamma-IFN and elevated class I major histocompatibility complex expression after transfer of pMP6A-mIFN-gamma into the murine lung cancer cell line, D122, was demonstrated. The efficiency of gene transfer was determined by two different methods and was estimated to be 10-15%. Irradiated gamma-IFN D122 cells generated by this novel gene delivery system (D122/pMP6A-mIFN-gamma) and also by standard retroviral methods (DIF2) were administered as weekly vaccinations by intraperitoneal injection to animals bearing 7-day-old intrafootpad D122 tumors. Hindlimb amputation was performed when footpad diameters reached 7 mm, and lungs were harvested 28 days later. Animals vaccinated with gamma-IFN-secreting D122 cells produced by AAV-based plasmids delivery demonstrated a significant delay in footpad tumor growth when compared with controls and DIF2 cells. Fifty-seven percent of animals vaccinated with D122/pMP6A-mIFN-gamma were free of pulmonary metastases 28 days after amputation, significantly improved from the 0, 7, and 15% observed in animals vaccinated with irradiated parental D122 cells, irradiated D122 cells lipofected with an empty-cassette vector (pMP6A), or DIF2 cells, respectively. These results and the ability to transfer genes with this delivery system to a broad range of tumor types support its use in the generation of cytokine-secreting tumor cell vaccinations for use in clinical trials.