Surgical resection of metastatic renal cell carcinoma and melanoma after response to interleukin-2-based immunotherapy

Thirty-one patients with disseminated melanoma or renal cell cancer (RCC) who had a limited relapse or persistent disease after a partial or complete response to interleukin-2 (IL-2)-based immunotherapy underwent resection of progressing tumors or residual sites of disease. There were no surgery-related deaths. The median time to disease progression after resection for patients with RCC (n = 16) and melanoma (n = 15) was 11 and 5 months, respectively. All patients with melanoma had tumor progression within 10 months of surgery. Seven of 16 patients with RCC were free of tumor progression 4 to 44 months after surgery. Three of 12 patients with RCC rendered disease-free by surgery remain disease-free after 2 years. These data suggest that surgical resection is a reasonable option in selected patients who have a relapse after responding to IL-2-based immunotherapy. Although this retrospective study could not determine the relative survival benefits of surgery and immunotherapy, it showed that resection of metastatic disease after a response to immunotherapy can result in significant disease-free survival in patients with RCC but not melanoma.

Sequence-specific resonance assignment and conformational analysis of subtilin by 2D NMR

Subtilin, a 32-amino acid peptide with potent antimicrobial activity, has been isolated from Bacillus subtilis ATCC6633. The chemical structure has been confirmed by the unambiguous sequence-specific assignment of its 1H NMR spectrum. Detailed NMR analysis revealed that subtilin is a rather flexible molecule; the only observed conformational contraints were those imposed by the cyclic structures created by the lanthionine and 3-methyllanthionine residues. These results suggest that in aqueous solution subtilin and the homologous peptide nisin have similar conformations.

Worldwide legal requirements for obtaining corneas: 1990

Cornea transplantation offers the hope of restoring useful vision to millions of individuals worldwide. Yet it is widely used only in certain countries. While a lack of the necessary economic and technical infrastructure is the primary reason in many countries, the legal and social systems pose a similar obstacle in many other more prosperous countries. This article reviews the current laws governing organ and tissue donation throughout the world and distinguishes those that are most successful in obtaining tissue for transplantation.

The use of interleukin-2 and lymphokine-activated killer cells for the treatment of patients with non-Hodgkin's lymphoma

PURPOSE

The study was undertaken to assess whether immunotherapy regimens with bolus high-dose interleukin-2 (IL-2) alone or with lymphokine-activated killer (LAK) cells are active in previously treated, relapsed patients with non-Hodgkin's lymphoma.

PATIENTS AND METHODS

Nineteen patients with low- or intermediate-grade lymphomas were treated with bolus high-dose IL-2 alone (11 patients) or IL-2 with LAK cells (eight patients). IL-2 was administered by intravenous bolus infusion at 720,000 IU/kg every 8 hours. Eight patients had low-grade histologies; 11 patients were intermediate-grade. Eighteen patients had received second- or third-generation combination chemotherapy, and eight had also received radiation. All 19 relapsed after a median of two chemotherapy regimens.

RESULTS

Four responses were observed, three partial and one complete, in patients with follicular histologies who received IL-2 with LAK cells. Response durations were 10, 16, 16, and 26 months, and three responders were re-treated after relapse with subsequent disease control for an additional 16, 39+, and 2+ months, respectively.

CONCLUSION

High-dose, bolus IL-2-based immunotherapy with LAK cells may be an effective treatment for patients with non-Hodgkin's lymphoma and merits further testing with larger numbers of patients in phase II trials.

Immunotherapy with interleukin-2 and alpha-interferon in patients with metastatic renal cell cancer with in situ primary cancers: a pilot study

A total of 12 patients with stage 4 renal cell carcinoma and primary renal tumors in situ was entered into a pilot study using treatment with interleukin-2 and alpha-interferon followed by radical nephrectomy. Of the patients 11 underwent nephrectomy after an initial course of immunotherapy. Ten patients were able to receive a second course of immunotherapy given after nephrectomy. One patient achieved a complete response of lung and mediastinal metastases without any change in the primary renal tumor but after nephrectomy the patient remained in complete remission for greater than 11 months. A total of 3 patients achieved a partial response at some extrarenal sites but they had progression elsewhere. Toxicity was similar to previous experience with this immunotherapy regimen. Therefore, we demonstrated that metastatic tumor regression is possible with primary renal tumors in situ and that aggressive interleukin-2-based immunotherapy can be tolerated in the presence of a large renal tumor.

Effect of sodium butyrate on glucocorticoid-sensitive and -resistant P1798 lymphosarcoma

This study aims to examine the effect of sodium butyrate on the viability and the level of glucocorticoid receptors and cells cycle progression in glucocorticoid-sensitive and -resistant P1798 cells. Our results indicated that low levels of sodium butyrate had no effect on either the viability or the receptor level. However, high-level (5 mM) sodium butyrate appeared to reduce cell viability as well as the glucocorticoid receptor level. On the other hand, sodium butyrate inhibited cell cycle progression in a dose-dependent manner. This response was similar in both the glucocorticoid-sensitive and -resistant P1798 cells. Results from this study suggested that the sodium butyrate induced effect may be cell cycle related.

Murine studies using polyethylene glycol-modified recombinant human interleukin 2 (PEG-IL-2): antitumor effects of PEG-IL2 alone and in combination with adoptive cellular transfer

A polyethylene glycol-modified form of recombinant human IL-2 (PEG-IL-2) was tested for murine antitumor effects in vitro and in vivo. This PEG-IL-2 was demonstrated to retain the in vitro ability to support T cell proliferation, enhance a mixed lymphocyte reaction, and generate lymphokine-activated killer (LAK) cells. It was found to have a circulating half-life in mice 25 times longer than unmodified recombinant IL-2 (RIL-2). Serum levels were detected up to 60 h after a single intravenous injection. When given as a single, intravenous administration the antitumor effect of this material was similar to multiple, repeated bolus doses of RIL-2. PEG-IL-2 was also found to support the in vivo efficacy of adoptively transferred LAK cells and tumor infiltrating lymphocytes (TIL). Using a congenic TIL (Thy 1.1), persistence of adoptively transferred TIL was found to be prolonged with PEG-IL-2 compared to repeated boluses of RIL-2. Four days after transfer, twice as many Thy 1.1 TIL were recoverable from the lungs of mice given PEG-IL-2. These studies show that PEG-IL-2 is a modified lymphokine with significant antitumor activity in murine systems and is superior to bolus RIL-2 in enhancing the survival of adoptively transferred TIL.

Analysis of monoamines in the cerebrospinal fluid of Chinese patients with Alzheimer's disease

We have established HPLC assay conditions that could measure the levels of 14 monoamines and their metabolites simultaneously. Monoamine levels in cerebrospinal fluids of 12 Chinese patients with Alzheimer's disease were compared with those in samples from patients with benign prostate hyperplasia. Of the 14 monoamines and metabolites, only three were found to be present in all samples. Although the levels of 5-hydroxy-3-indoleacetic acid (HIAA) and homovanillic acid (HVA) in cerebrospinal fluid of patients with Alzheimer's disease were lower, and the levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) higher, as compared to control patients, no significant differences were found between these two groups.

Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma

A retrospective review is presented on 145 patients who underwent limb-sparing surgery and radiation therapy (with or without adjuvant chemotherapy) for their primary soft tissue sarcomas of the extremities on protocol between 1975 and 1986. The focus on our analysis was the acute and long term toxicity of treatment on limb function. The most common acute complication was skin reaction, occurring in 52 patients (36%). Long term (occurring after more than 1 year following all treatment) treatment complications in the extremity were as follows: bone fracture = 6%; contracture = 20%; pain requiring narcotics = 7%; edema greater than 2+ = 19%; moderate to severe decrease in range of motion = 32%; moderate to severe decrease in manual muscle strength = 20%; orthotic device required = 9%; cane or crutch required = 7%; chronic infection = 9%; and tissue induration = 57%. Three amputations for treatment complications were required. Inclusion of more than 50% of the joint in the radiation portal was associated with a higher frequency of contracture. High nominal standard dose (greater than 1760 rets, greater than 63 Gy at 1.8 Gy per fraction) resulted in more painful limbs as well as limbs with increased edema, decreased manual muscle strength, decreased range of motion, and skin telangiectasias. Edema was more often noted in patients with a longer radiation portal (greater than 35 cm), as was tissue induration. Chronic ulcer or infection was more frequently seen in patients with lower extremity tumors and when more than 75% of the extremity diameter was irradiated. Although chemotherapy given concurrent with radiation therapy was associated with a higher number of acute skin reactions, this did not appear to translate into increased long term morbidity. The percentage of patients ambulating without assistive devices and with mild or no pain was 84%. Careful attention to the techniques of radiation therapy may have a significant impact on minimizing acute and long term complications of limb sparing treatment for extremity soft tissue sarcoma.

Relapse after response to interleukin-2-based immunotherapy: patterns of progression and response to retreatment

The initial site of disease relapse was identified for 79 patients with metastatic renal cell cancer (RCC), melanoma, colon cancer, or non-Hodgkin's lymphoma (NHL), who had achieved partial or complete responses to one of five IL-2-based immunotherapy regimens. The initial site of relapse was evenly distributed between pre-existing sites of disease (33%), new sites of disease (38%), or both (29%). There was no difference in the distribution of recurrences between patients with partial or complete responses. Fifty-one patients with prior complete or partial responses were retreated with additional IL-2-based therapy following tumor progression. Five of 51 patients retreated following relapse developed new partial responses. There were no complete responses. Three patients with NHL were retreated with IL-2 and LAK cells and all achieved a second response, while only 2 of 48 patients with other histologic diagnoses reresponded. It is concluded that after a partial or complete response to IL-2-based immunotherapy, patients who relapse do so equally at new and pre-existing sites of disease. A response to retreatment following tumor progression may be attained in patients with NHL, while a new response is unlikely for patients with melanoma and RCC.

The nonapproved use of medications

The need for new treatments for both established and recently described disorders has heightened awareness of the drug approval process. In particular, many ophthalmologists have questioned the ramifications of using approved drugs in nonapproved settings (such as apraclonidine) and the means of obtaining investigational drugs for patient use. The authors review the legal structures established to address these concerns and recommended approaches ophthalmologists can take to minimize their exposure to legal complications.

The clinical diagnosis of splenomegaly

Assessing for the presence of splenomegaly is an important component of the physical examination. Although several methods of palpation and percussion of the spleen have been described, until recently they have not been validated by noninvasive imaging techniques such as ultrasonography, radionuclide scanning, and computed tomography that offer objective means to assess splenomegaly. We review the literature comparing various physical examination techniques with noninvasive imaging modalities and conclude that palpation and percussion of the spleen are complementary but frequently insensitive and that further studies are needed to evaluate the efficacy of specific diagnostic methods.

Effects of short and long-lasting diabetes mellitus on mouse brain monoamines

Concentrations of monoamines and their metabolites were investigated in various brain regions of 3, 50, and 100 days diabetic mice. An increase in the content of norepinephrine was observed in the pons-medulla and striatum in short-term (3 days) diabetic mice, and could be sustained for 100 days and 50 days, respectively. In the hypothalamus and cortex, the increase of norepinephrine was observed in both 50 and 100 day diabetic mice, but that of cerebellum was only observed in the 100 day diabetic mice. The concentration of dopamine was increased in the striatum both in short-term and long-term (50 and 100 days) diabetic mice, that of pons-medulla and cortex was increased in the long-term diabetic mice. Concentrations of the acidic metabolites of dopamine, dihydroxyphenylacetic acid and homovanillic acid were decreased in the hypothalamus, hippocampus and striatum, while increased in the pons-medulla and cortex. 5-Hydroxytryptamine concentration was increased in the hypothalamus, hippocampus, pons-medulla and cortex progressively from short-term to long-term diabetic mice. However, the concentration of its acidic metabolite, 5-hydroxyindoleacetic acid, was decreased in the hypothalamus, hippocampus, striatum, pons-medulla and cortex. These data suggest that diabetes is associated with a significant disturbance of brain monoamine metabolism. This disturbance was not generalized but related to some specific areas of the brain and some of these alterations were progressive from short term to long term diabetes.

Sequential 1H NMR assignments and secondary structure of an IgG-binding domain from protein G

Protein G is a member of a class of cell surface bacterial proteins from Streptococcus that bind IgG with high affinity. A fragment of molecular mass 6988, which retains IgG-binding activity, has been generated by proteolytic digestion and analyzed by 1H NMR. Two-dimensional DQF-COSY, TOCSY, and NOESY spectra have been employed to assign the 1H NMR spectrum of the peptide. Elements of regular secondary structure have been identified by using nuclear Overhauser enhancement, coupling constant, and amide proton exchange data. The secondary structure consists of a central alpha-helix (Ala28-Val44), flanked by two portions of beta-sheet (Val5-Val26 and Asp45-Lys62). This is a fundamentally different arrangement of secondary structure from that of protein A, which is made up of three consecutive alpha-helices in free solution (Torigoe et al., 1990). We conclude that the molecular mechanisms underlying the association of protein A and protein G with IgG are different.

Adjuvant therapy for adult patients with soft tissue sarcomas

Soft tissue sarcomas are relatively uncommon malignant tumors in the adult population. These malignant tumors arise largely from the connective and supportive tissues in various anatomic sites. Adjuvant radiation therapy can be combined with conservative, non-amputative surgical procedures to achieve a high frequency of tumor control in most primary sites. In spite of local tumor control, a high proportion of patients will subsequently die from distant metastases. Randomized trials of adjuvant chemotherapy for such adult sarcomas are inconclusive. They suggest a possible benefit for patients with high-grade lesions of the extremities. Several trials indicate a possible local control advantage. However, because of potential morbidity of adjuvant chemotherapy, its use at this time should be restricted to clinical trials.

Ventricular tachycardia during routine treadmill testing. Risk and prognosis

Exercise-induced ventricular tachycardia during exercise testing is considered to increase risk during testing. Moreover, exercise-induced ventricular tachycardia has been considered to confer a poor prognosis although this has not been specifically studied. On a retrospective review of 3351 patients who had undergone routine clinical exercise testing between September 1984 and June 1989, we identified 55 patients with exercise-induced ventricular tachycardia. The mean follow-up was 26 months (range, 2 to 58 months). Fifty patients had nonsustained ventricular tachycardia during exercise testing and one of these patients died due to congestive heart failure during the follow-up period. Five patients had sustained ventricular tachycardia during exercise testing and one died suddenly 7 months after the test. Ventricular tachycardia was reproduced in only two of the 29 patients who underwent repeated exercise testing. Ventricular tachycardia during routine clinical exercise testing occurred rarely (prevalence of 1.5%) and was not associated with complications during testing. The total mortality in the exercise-induced ventricular tachycardia group (3.6%) was not significantly different from the mortality in the entire population (5.1%). Nonsustained ventricular tachycardia occurring during clinical exercise testing is not an independent marker of a poor prognosis.

Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later

Thirty-nine outpatients suffering from chronic pain were studied in a multidisciplinary program. Pain intensity on a visual analogue pain scale (VAPS), sensory decision indices of thermal discriminability, P(A), and pain report criterion, B, age and sex obtained before treatment, were used to predict the patients' status, determined by a follow-up questionnaire 6 mo later. The results showed that patients who were high on the VAPS at intake had shorter pain relief and decreased physical activities on follow-up. Patients with better thermal discriminability had greater pain relief, while those with low pain report criterion, that is, less stoical, demonstrated improved physical activity, and more social and hobby activities. Patients who were less stoical to thermal stimuli (lower pain criterion) took fewer centrally active drugs after treatment. Younger patients showed greater improvement at follow-up. The data indicate that the VAPS, thermal discriminability, and pain report criterion all predict the duration of pain relief after treatment. Nevertheless, each of these variables had its individual character. The VAPS was most efficient in predicting physical activities, thermal discriminability related best to pain relief, and pain report criterion to social and hobby activities as well as drug intake.

The validity of ACT-PEP test scores for predicting academic performance of registered nurses in BSN programs

This study investigated the validity of three American College Testing-Proficiency Examination Program (ACT-PEP) tests (Maternal and Child Nursing, Psychiatric/Mental Health Nursing, Adult Nursing) for predicting the academic performance of registered nurses (RNs) enrolled in bachelor's degree BSN programs nationwide. This study also examined RN students' performance on the ACT-PEP tests by their demographic characteristics: student's age, sex, race, student status (full- or part-time), and employment status (full- or part-time). The total sample for the three tests comprised 2,600 students from eight institutions nationwide. The median correlation coefficients between the three ACT-PEP tests and the semester grade point averages ranged from .36 to .56. Median correlation coefficients increased over time, supporting the stability of ACT-PEP test scores for predicting academic performance over time. The relative importance of selected independent variables for predicting academic performance was also examined; the most important variable for predicting academic performance was typically the ACT-PEP test score. Across the institutions, student demographic characteristics did not contribute significantly to explaining academic performance, over and above ACT-PEP scores.

Gene transfer into humans--immunotherapy of patients with advanced melanoma, using tumor-infiltrating lymphocytes modified by retroviral gene transduction

BACKGROUND AND METHODS

Treatment with tumor-infiltrating lymphocytes (TIL) plus interleukin-2 can mediate the regression of metastatic melanoma in approximately half of patients. To optimize this treatment approach and define the in vivo distribution and survival of TIL, we used retroviral-mediated gene transduction to introduce the gene coding for resistance to neomycin into human TIL before their infusion into patients--thus using the new gene as a marker for the infused cells.

RESULTS

Five patients received the gene-modified TIL. All the patients tolerated the treatment well, and no side effects due to the gene transduction were noted. The presence and expression of the neomycin-resistance gene were demonstrated in TIL from all the patients with Southern blot analysis and enzymatic assay for the neomycin phosphotransferase coded by the bacterial gene. Cells from four of the five patients grew successfully in high concentrations of G418, a neomycin analogue otherwise toxic to eukaryotic cells. With polymerase-chain-reaction analysis, gene-modified cells were consistently found in the circulation of all five patients for three weeks and for as long as two months in two patients. Cells were recovered from tumor deposits as much as 64 days after cell administration. The procedure was safe according to all criteria, including the absence of infections virus in TIL and in the patients.

CONCLUSIONS

These studies demonstrate the feasibility and safety of using retroviral gene transduction for human gene therapy and have implications for the design of TIL with improved antitumor potency, as well as for the possible use of lymphocytes for the gene therapy of other diseases.

Clostridium aldrichii sp. nov., a cellulolytic mesophile inhabiting a wood-fermenting anaerobic digester

An anaerobic, mesophilic, spore-forming, cellulolytic bacterium was repeatedly isolated from a wood-fermenting anaerobic digester. Cells of this organism were gram-positive rods, motile with a bundle of polar flagella, and formed subterminal oblong spores. The colonies in agar had an irregular shape with many platelike structures and were greyish white. Cellulose, xylan, and cellobiose served as substrates for growth. Acetate, propionate, butyrate, isobutyrate, isovalerate, lactate, succinate, H2, and CO2 were products of cellobiose fermentation. The optimal temperature and pH for growth were 35 degrees C and 7, respectively. The DNA composition was 40 mol% G + C. The name Clostridium aldrichii sp. nov. is proposed. The type strain is P-1 (= OGI 112, = ATCC 49358).

An improved method for growing murine tumor-infiltrating lymphocytes with in vivo antitumor activity

Tumor-infiltrating lymphocytes (TILs) are host T cells that can be grown from fresh murine and human tumors using interleukin-2 (IL-2) in bulk cultures. These activated T cells have been shown to have significant antitumor activity both in vitro and in vivo. A technique is described for the separation of Thy-1.2-positive TILs from fresh murine tumors using antibody-coated magnetic beads, permitting the examination of growth conditions for these cells. TILs with increased therapeutic efficacy are obtained from the immunogenic MCA 38 and MCA 105 tumors when culture conditions employing low levels of IL-2 (10 vs. 1,000 U/ml) and irradiated autologous tumor restimulation are used. TILs grown under these conditions can mediate a 93% reduction of 3-day-old established pulmonary metastases when as few as 2.5 x 10(5) cells are adoptively transferred with systemic IL-2. These culture conditions are utilized to grow TILs from the nonimmunogenic MCA 102 tumor for which bulk TIL culture methods are unsuccessful. MCA 102 TILs grown in this fashion demonstrate in vivo therapeutic efficacy against established autologous pulmonary metastases.

[Effects of nicardipine on beating rates of cultured myocardial cells]

Nicardipine (Nic) 15 nmol/L had no effects on beating rates of cultured myocardial cells. Nic 75 and 150 nmol/L depressed the beating rates significantly. Rapid standstills occurred earlier and more in 150 nmol/L group than in 75 nmol/L. Both isoproterenol and CaCl2 restored the beating depressed by Nic. However, only CaCl2 prevented the standstill. These results suggest that nicardipine may compete with calcium in excitation-contraction coupling.

A prospective randomized trial evaluating prophylactic antibiotics to prevent triple-lumen catheter-related sepsis in patients treated with immunotherapy

During a 15-month period, 92 patients undergoing 129 treatment episodes of immunotherapy with interleukin-2 (IL-2) alone or with immune cells underwent insertion of central venous catheters (CVCs) in the Surgery Branch, National Cancer Institute. Before each catheter insertion patients were prospectively randomized into one of three treatment groups; therapy with intravenous (IV) placebo using D5W, IV oxacillin, or change of the catheter to a new site every 72 hours. The mean duration of catheterization was 3.8 +/- 1.1 days. No patient in the oxacillin arm developed catheter-related sepsis, while eight patients in the control arms (five, line change, three, placebo) developed catheter-related sepsis (P2 = .050). Seven episodes of catheter-related sepsis were due to Staphylococcus aureus and one was due to Staphylococcus epidermidis. Catheter colonization was reduced significantly in the oxacillin arm versus control arms (P = .0001). Staphylococcus aureus, Staphylococcus epidermidis, and other coagulase-negative Staphylococci were sensitive to oxacillin in 89%, 60%, and 50% of cultures, respectively. No evidence of bacterial overgrowth, candida colonization, or candidemia was observed in these patients. Thus this trial demonstrates that treatment with prophylactic oxacillin can decrease the incidence of catheter-related sepsis in patients undergoing immunotherapy with interleukin-2 (IL-2). To our knowledge this is the first prospective randomized trial to evaluate the prophylactic use of systemic antibiotics in the prophylaxis of CVC sepsis.