Congenital portosystemic venous shunt.

Congenital portosystemic venous shunts are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation and have been divided into extra- and intrahepatic shunts. They occur during liver and systemic venous vascular embryogenesis and are associated with other congenital abnormalities. They carry a higher risk of benign and malignant liver tumors and, if left untreated, can result in significant medical complications including systemic encephalopathy and pulmonary hypertension. CONCLUSION: This article reviews the various types of congenital portosystemic shunts and their anatomy, pathogenesis, symptomatology, and timing and options of treatment. What is Known: • The natural history and basic management of this rare congenital anomaly are presented. What is New: • This paper is a comprehensive review; highlights important topics in pathogenesis, clinical symptomatology, and treatment options; and proposes an algorithm in the management of congenital portosystemic shunt disease in order to provide a clear idea to a pediatrician. An effort has been made to emphasize the indications for treatment in the children population and link to the adult group by discussing the consequences of lack of treatment or delayed diagnosis.

Primary analysis of a prospective, randomized, single-blinded phase II trial evaluating the HER2 peptide AE37 vaccine in breast cancer patients to prevent recurrence.

BACKGROUND: AE37 is the Ii-Key hybrid of the MHC class II peptide, AE36 (HER2 aa:776-790). Phase I studies showed AE37 administered with granulocyte macrophage colony-stimulating factor (GM-CSF) to be safe and highly immunogenic. A prospective, randomized, multicenter phase II adjuvant trial was conducted to evaluate the vaccine's efficacy. METHODS: Clinically disease-free node-positive and high-risk node-negative breast cancer patients with tumors expressing any degree of HER2 [immunohistochemistry (IHC) 1-3+] were enrolled. Patients were randomized to AE37 + GM-CSF versus GM-CSF alone. Toxicity was monitored. Clinical recurrences were documented and disease-free survival (DFS) analyzed. RESULTS: The trial enrolled 298 patients; 153 received AE37 + GM-CSF and 145 received GM-CSF alone. The groups were well matched for clinicopathologic characteristics. Toxicities have been minimal. At the time of the primary analysis, the recurrence rate in the vaccinated group was 12.4% versus 13.8% in the control group [relative risk reduction 12%, HR 0.885, 95% confidence interval (CI) 0.472-1.659, P = 0.70]. The Kaplan-Meier estimated 5-year DFS rate was 80.8% in vaccinated versus 79.5% in control patients. In planned subset analyses of patients with IHC 1+/2+ HER2-expressing tumors, 5-year DFS was 77.2% in vaccinated patients (n = 76) versus 65.7% in control patients (n = 78) (P = 0.21). In patients with triple-negative breast cancer (HER2 IHC 1+/2+ and hormone receptor negative) DFS was 77.7% in vaccinated patients (n = 25) versus 49.0% in control patients (n = 25) (P = 0.12). CONCLUSION: The overall intention-to-treat analysis demonstrates no benefit to vaccination. However, the results confirm that the vaccine is safe and suggest that vaccination may have clinical benefit in patients with low HER2-expressing tumors, specifically TNBC. Further evaluation in a randomized trial enrolling TNBC patients is warranted.

Safety and Efficacy of Inferior Vena Cava Reconstruction During Hepatic Resection.

BACKGROUND AND AIMS: Patients with liver tumors involving the inferior vena cava have a poor outcome without surgery. Liver resection en bloc with inferior vena cava resection and reconstruction is now performed in many centers. The purpose of this study is to investigate the safety and efficacy of inferior vena cava reconstruction during hepatic resection. MATERIALS AND METHODS: A review of 12 centers reporting 240 patients with combined hepatectomy and inferior vena cava resection and reconstruction for malignant tumors was performed. Sample size, patient characteristics, histological type of the tumor, method of reconstruction, complications, and long-term survival (1-, 2-, and 5-year survival) were evaluated. RESULTS: A total of 240 patients from 12 institutions (male 58%) with mean age 54 years underwent combined liver resection and inferior vena cava resection and reconstruction for colorectal liver metastases (43%), cholangiocarcinomas (26%), hepatocellular carcinomas (19%), leiomyosarcomas (4%), and other tumors (7.9%). Reconstruction included primary closure (35.8%), patch repair (13.3%), or interposition graft (50.8%) In-hospital mortality was 6.25% and overall morbidity was 42.1%. 1- and 10-year survival rates were 79.7% and 28.9%, respectively. CONCLUSION: Tumors arising in or extending to inferior vena cava that require liver resection should be considered for surgery as it can be performed with an acceptable mortality and morbidity in centers with liver transplantation and hepato-pancreato-biliary facilities.

Polyadenylic acid metabolizing enzyme levels during induction of differentiation in a human leukemia T-cell line with phorbol ester.

Induction of differentiation of MOLT3 cells with 12-O-tetradecanoylphorbol-13-acetate (TPA) was found to affect the activity levels of the polyadenylic acid [poly(A)] metabolizing enzymes. TPA administration at a concentration of 16 nM resulted in an increase of poly(A) exonuclease and poly(A) polymerase activities after 2 and 2.5 hours, respectively, and in a decline to control levels thereafter. Cordycepin, an inhibitor of poly(A) polymerization, prevented the increasing binding of OKT11A monoclonal antibody induced by TPA treatment, whereas TPA-induced reduction in OKT6 monoclonal antibody binding persisted. The alterations in the poly(A) metabolizing enzyme activities following treatment of the cells with TPA, as well as the inhibitory effect of cordycepin, may suggest that these enzymes may be involved in the regulation of the differentiation process.

Polyadenylic acid polymerase activity in normal and leukemic human leukocytes.

Soluble polyadenylic acid [poly(A)] polymerase and poly(A) nucleases content of normal human blood lymphocytes and leukemic blood cell populations was determined. Blood lymphocytes from seven normal individuals were used as controls. Leukemic cells were obtained from 69 patients with various types of acute and chronic leukemias. Chronic lymphocytic leukemias presented poly(A) polymerase values with a mean of 9 +/- 4 (S.D.). Although most of the chronic lymphocytic leukemia cases presented poly(A) polymerase activities similar to those of normal lymphocytes (3 +/- 3), a small number fell into the specific activity values of acute leukemias, which were significantly higher and covered a wider range. The mean values for acute myeloblastic, acute monoblastic, and acute lymphoblastic leukemias were 53 +/- 50, 21 +/- 8, and 29 +/- 14, respectively. A statistically significant difference was found between chronic and acute leukemias (p less than 0.01). The observed differences in poly(A) polymerase levels of acute lymphoblastic leukemia versus chronic lymphocytic leukemia persisted after fractionation of the crude extracts and, furthermore, they could not be attributed to differences in the levels of poly(A)-degrading enzymes [poly(A) endo- and exonucleases]. Fractionation of leukemic extracts on Sephadex G-75 revealed two molecular forms of poly(A) polymerase activity.

Granulocyte-macrophage colony-stimulating factor improves immunological parameters in patients with refractory solid tumours receiving second-line chemotherapy: correlation with clinical responses.

In this report, we studied the immunorestorative properties of subcutaneously administered granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients with refractory solid tumours receiving second-line chemotherapy. Such patients exhibit abnormal immune responses in vivo and in vitro and, therefore, it was of interest to examine the effect of GM-CSF-induced immunomodulation on clinical response. We examined patients with primary malignant carcinomas (head and neck, n = 10; urogenital tract, n = 17; penis n = 6; colorectal, n = 8) who were treated with carboplatin (JM8), 300 ng/m2 on days 1 and 22, leucovorin (LV), 200 mg/m2 plus 5-fluoracil (5-FU), 500 mg/m2 on days 8, 15 and 29 and four cycles of daily injections with placebo or GM-CSF, 300 micrograms/day on days 3-6, 10-13, 17-20 and 24-27. Peripheral blood was collected from the patients one day after the end of each of the four-cycle injections with placebo or GM-CSF, namely on days 7, 14, 21 and 28. Peripheral blood mononuclear cells (PBMC) were tested in the autologous mixed lymphocyte reaction (AMLR) and for natural killer (NK) or lymphokine-activated killer (LAK) cell activity. Cytokine levels in serum were measured by immunoenzymatic (ELISA) assay. A total of 21 patients received a four-cycle regimen with GM-CSF (Group 1) and 20 were similarly treated with placebo (Group 2). All received standard chemotherapy as outlined above. Before GM-CSF treatment, all patients exhibited increased serum levels of interleukin-1 (IL-1 beta), tumour necrosis factor-alpha (TNF-alpha), IL-6 and prostaglandin E2 (PGE2) and decreased serum levels of IL-2. Cellular immune responses (AMLR, NK- and LAK-cytotoxicity) were also low in all patients. Five patients from Group 1 had a PR (partial response), 2 patients had CR (complete response), and 14 patients had stable disease. Seven patients from Group 2 showed progressive disease, 3 had a PR and 10 had stable disease. All immune parameters were significantly improved during treatment in Group 1 but remained unchanged or even deteriorated in Group 2. Administration of GM-CSF during treatment of cancer patients with conventional chemotherapeutic drugs results in a marked potentiation of deficient cellular immune responses in vitro and a change towards normalisation of cytokine serum levels. The results reported herein support the use of GM-CSF as immunopotentiator during chemotherapy, but more patients must be studied before definite conclusions can be drawn.

A method for analysing lymphocyte surface antigens.

A method is described for isolating and characterizing external lymphocyte surface proteins. Intact 125I-labelled tonsillar lymphocytes were incubated with antilymphocyte serum, solubilised with NP-40 precipitated with Staphylococcus aureus and the labelled proteins analysed on SDS polyacrylamide gels. The molecular weights of the proteins labelled in this way were compared with those of surface antigens labelled by the galactose oxidase method. This method may also be used for isolation of surface receptor molecules which lose their stereochemical structure upon solubilisation of the cells.

A method of increasing EA positive cells in mouse spleen lymphocytes.

Treatment of mouse spleen lymphocytes with a high concentration of trypsin (1 mg/ml) increases the number of EA positive cells to include nearly all the B lymphocytes. It seems that all B lymphocytes express Fc receptors but in some cells these are hidden by other proteins present on the cell surfaces.

Fluorescent labelling of proteins of lymphocyte plasma membranes.

Fluorescamine has been used for labelling proteins present on the surface of normal human peripheral blood lymphocytes. Under the conditions of study, 12 labelled proteins could be detected by SDS gel electrophoresis. This method may be of value in biochemical studies of lymphocyte membranes.

A simple hemagglutination method for the detection of cell surface antigens.

A rapid, easy and reproducible hemagglutination method is described for the detection of cell surface antigens. This method can be used for the determination of cell subpopulations and the screening of monoclonal antibody-secreting hybridomas. Fresh or paraformaldehyde-fixed cells, which have previously been labeled with an appropriate monoclonal antibody (of known or unknown specificity), are reacted with human erythrocytes coupled with the second antibody (rabbit anti-mouse immunoglobulins), in a round bottomed 96-well microtiter plate. The presence of specific agglutination and the end-point of serial dilutions of the labeled cells with unlabeled ones give an approximate estimation of the percentage of cells reacting with the monoclonal antibody under examination. The hemagglutination results correlate well with the results obtained using a conventional immunofluorescence method.

The use of nylon fibre as a method of separating human lymphocyte subpopulations.

When the mononuclear cell population separated from normal human blood is passed through a nylon fibre column, monocytes and surface Ig bearing cells are retained; the eluted cells are a mixed properties. It appears that a proportion of the T cells eluted form EA-rosettes, and the eluted cell subpopulation includes non-T cells which share with B cells the ability to bind both EA and aggregated human IgG.

The use of nylon wool for the isolation of T lymphocyte subpopulations.

A simple method for the affinity isolation of lymphocyte subpopulations using nylon wool as a solid phase matrix is described. This matrix was coated with an acid-treated IgG fraction of polyclonal antibodies against mouse immunoglobulins. Using this approach, a simple isolation procedure for lymphocyte subpopulations, yielding purities higher than 95% was developed. The method can be used on a large scale for positive and negative cell selection, with very little non-specific binding. The isolated populations are fully functional.

A colorimetric assay for the determination of 5'-nucleotidase activity.

A rapid, simple, quantitative and sensitive assay for the determination of 5'-nucleotidase has been developed. The method can be applied to both soluble and membrane bound forms of the leukocyte enzyme. Enzyme activity is determined by colorimetric estimation of NH3 released from adenosine, the product of 5'-nucleotidase activity in the presence of adenosine deaminase. The assay may be performed in microtitre plates and read with an automatic multiscan spectrophotometer. Thus it can be applied to a large number of samples for routine medical and research purposes.

An improved fluorescence assay for the determination of lymphocyte-mediated cytotoxicity using flow cytometry.

The use of the chromium-release assay to determine cytotoxicity of effector against target cells has various limitations mostly due to the inherent properties of the radioactive substance. We have developed an improved flow cytometric method that is able to measure cytotoxicity, based on two fluorescent dyes. Calcein-AM, a non-fluorescent substance which is intracellularly converted to the green fluorescent calcein by esterase activity in viable cells, is initially used to stain target cells. After incubating targets with effectors for 2 h, ethidium homodimer-1, a red DNA stain non-permeable to viable cells, is added. Dead target cells are distinguished by their double (green-red) staining. Data analysis is performed by gating the regions of living target, dead target and living effector cells, based on appropriate controls. Non-specific events are subtracted from the dead target region and the ratio of specific dead target events to total target events is expressed as percent cytotoxicity. The method is used to quantify natural killer (NK) and lymphokine-activated killer (LAK) activities against the human K562 and Daudi cell lines and the murine YAC-1 and L1210 cell lines respectively, as well as cell-mediated lympholysis (CML) exerted by tumor-infiltrating lymphocytes (TIL) against autologous and allogeneic human breast cancer tumor cells. The method is fast, reliable and correlates well with the standard 51Cr-release assay.

Prothymosin-alpha enhances HLA-DR antigen expression on monocytes from patients with multiple sclerosis.

Monocytes from patients with multiple sclerosis (MS) express decreased numbers of class II major histocompatibility complex (MHC) antigens in peripheral blood and are poor stimulators in the autologous mixed lymphocyte reaction (autoMLR). We assessed the effect of prothymosin-alpha (ProT alpha) on the expression of MHC class II antigens by monocytes. Immediately after isolation, monocytes were analyzed for MHC class II antigen expression using a radiolabelled monoclonal antibody specific for a monomorphic determinant on HLA-DR antigens. After incubation with ProT alpha we observed significant increases in HLA-DR antigens on MS monocytes (1.5- to 4-fold increase compared to freshly isolated monocytes). Kinetic analysis revealed that enhancement peaked after 2 days of incubation with ProT alpha. The increase in HLA-DR antigen on MS monocytes resulted in the restoration of the deficient autoMLR in MS patients. This is the first demonstration suggesting a link between HLA-DR antigen expression and cellular immune defects in MS. The significance of low autoMLR responses for T suppressor levels in MS patients is discussed.

Peptides of myelin basic protein stimulate T lymphocytes from patients with multiple sclerosis.

Peripheral blood T lymphocytes from patients with multiple sclerosis (MS) and other neurological diseases (OND) were tested for primary in vitro proliferation in response to four synthetic peptides derived from the sequence of human myelin basic protein (HuMBP) and to HuMBP 45-89 peptide fragment, using a [3H]thymidine incorporation assay. The synthetic peptides used corresponded to residues HuMBP 15-31, 75-96, 83-96 and 131-141 of human myelin basic protein. Significant proliferation of T lymphocytes to peptides was noted only in the MS group (with the exception of peptide 131-141): the majority of control subjects and OND patients did not respond to the above-mentioned peptides. The sensitized T lymphocytes in MS patients displayed the inducer/helper phenotype and required autologous monocytes for optimal proliferation. An anti-HLA-DR monoclonal antibody, directed against a monomorphic determinant of DR molecules, was able to block the responses in a dose-dependent fashion. These results suggest that autoimmune inducer/helper T lymphocytes in the peripheral blood of MS patients may initiate and/or regulate the demyelination process in patients with MS. Furthermore, our data demonstrate that monocytes and HLA-DR molecules are essential for activation of these cells. Finally primary in vitro T cell proliferation to HuMBP synthetic peptide may be used as an additional diagnostic test in MS.

Decreased expression of HLA-DR antigens on monocytes in patients with multiple sclerosis.

Immunofluorescence, cell binding assays and enzyme immunoassays were used to investigate the expression of class II major histocompatibility antigens on peripheral blood monocytes in 67 patients with multiple sclerosis. Monocytes from patients with active disease expressed fewer HLA-DR molecules on their surface than normal monocytes; furthermore the percentage of cells which exhibited detectable amounts of surface HLA-DR antigens was decreased in patients with active multiple sclerosis. During the inactive stage of the disease both deficiencies were milder, probably representing secondary pathogenetic phenomena. Quantitation of monocyte surface HLA-DR antigen expression could be valuable in assessing the clinical disease activity. The demonstration of a molecular defect in patients with multiple sclerosis will improve our understanding of the pathogenesis of the disease.

Dexamethasone caused alterations in poly(A) polymerase levels of a human leukemic cell line.

The effect of glucocorticosteroids upon the poly(A) synthetic and degrading activity has been studied in steroid sensitive and resistant human leukemic cell lines. At least a two-fold increase in the levels of poly(A) polymerase activity was found in soluble, cytoplasmic extracts from the steroid sensitive human malignant T-cells of the MOLT3 line after 24-h treatment with dexamethasone. Longer exposure time of the cultured cells to the steroid resulted in a gradual decrease of the poly(A) polymerase activity level. Pretreatment of the cells with progesterone, a competitive inhibitor of dexamethasone, prevented the dexamethasone induced increase in the level of poly(A) polymerase activity, while progesterone alone had no effect on the enzyme level. In contrast, the levels of poly(A) nucleases activity remained constant following steroid treatment. In the steroid resistant human leukemic B-cell line Daudi no alterations in the poly(A) metabolizing enzymes could be measured in response to dexamethasone. Thus we suggest that poly(A) polymerase levels may be used to predict sensitivity of leukemic cells to glucocorticosteroid treatment.

Establishment and characterization of a B-cell line from a patient with acute lymphoblastic leukemia.

A permanent lymphoblastoid cell line was established from the peripheral blood of a child with acute lymphoblastic leukemia. The cell line, designated SDK, grows in a stationary suspension culture, forming aggregates, in RPMI medium supplemented with 10% FCS, with a doubling time of 50-60 h. Immunologic markers and cytological features suggested that the SDK cells should be identified as being of B-cell origin. The cells failed to form rosettes with sheep erythrocytes, did not express T-cell antigens as defined by monoclonal antibodies, and exhibited surface and cytoplasmic immunoglobulin determinants. Chromosome analysis revealed the presence of three cell populations with (a) 46XY; (b) t(8q-; 14q+) or 2p-; 14q+) and (c) cells with unidentifiable markers. SDK demonstrated susceptibility to TPA-induced differentiation toward plasma cells.

Cytokine serum levels, autologous mixed lymphocyte reaction and surface marker analysis in never medicated and chronically medicated schizophrenic patients.

A number of immunological parameters were studied in 82 DSM-III-R diagnosed schizophrenic patients (53 first drug-naive and 29 medicated chronic patients) as well as 62 healthy blood donors. The serum levels of interleukin-2 (IL-2), interleukin-1 beta (IL-1beta) and tumour necrosis factor-alpha (TNF-alpha) were measured and correlated with cellular immunity, as assessed by the autologous mixed lymphocyte reaction (AMLR). T lymphocyte subsets were also examined. The above immune parameters were reassessed in a subgroup of 11 first-episode, drug-naive patients 1month after neuroleptic medication. IL-2 serum levels were significantly lower, and IL-1beta and TNF-alpha were significantly higher in schizophrenic patients compared with healthy donors (P<0.001); no significant difference was observed between the two patient groups (medicated and not medicated). Abnormal cytokine serum levels were associated with decreased AMLR responses in vitro. Increased percentages of activated CD4+ and CD16+ natural killer cells, as well as cells expressing ICAM-1 adhesion molecules and IL-2 specific receptors, were detected in the patients. Immunophenotype studies revealed a higher percentage of cells expressing IL-2 receptors in medicated chronic schizophrenic patients compared with drug-naive patients. The abnormal cytokine production in vivo, along with the low AMLR responses in vitro, and the high percentage of activated CD4+ lymphocytes presented in this study suggest alterations in the immune system of schizophrenic patients (medicated or not medicated) consistent with immune activation.