Vitiligo associated with BCG-methanol extraction residue in malignant melanoma. Report of a case

A pronounced vitiliginous reaction developed at the sites of MER/BCG injections given as an adjuvant immunotherapy to a patient with malignant melanoma. To our knowledge, this is the third report on patients exhibiting vitiligo apparently induced by immunotherapy and the first in association with MER. This association may be a sign for an antimelanocytic effect and may offer a further confirmation for the autoimmune nature of vitiligo.

The effect of methanol extraction residue of BCG on the cellular immune response in patients with malignant melanoma

Twenty-one patients with malignant melanoma stage III and IV were treated by intradermal injections of MER--methanol extraction residue of Baccillus Calmette-Guérin (BCG). Twelve of the patients, all with active disease, received chemotherapy in addition. Tests of skin reactivity to recall antigens and in vitro lymphocyte transformation by phytohemagglutinin (PHA), purified protein derivative (PPD), Canadidine, and Varidase were performed in 19 of the patients before and after the MER therapy. The skin reactivity improved in 8 patients, 5 patients maintained their cutaneous competence, 3 remained incompetent, and in 3 other patients a decrease in reactivity occurred. Improvement or maintenance of cutaneous response was more common in stage III than in stage IV patients. The in vitro lymphocyte stimulation tests have shown that reactivity increased or remained at a high level in 9 of 11 patients in stage III. It dropped or remained low in 2 patients in respect to all antigens used in spite of repeated MER injections. In most patients with stage IV disease no improvement could be detected. MER seems to be a potent immunostimulator in patients in stage III. The side effects were tolerable in all patients and consisted of local reactions and influenza-like symptoms. In 4 patients treated with MER by intralesional injections, transient flattening of nodules occurred but no complete regression was observed.

Comparative study of the endotoxin-stimulated nitroblue tetrazolium test in disease and health

Endotoxin-stimulated nitroblue tetrazolium (NBT) reduction was evaluated in 853 individuals: 270 healthy controls, 334 with various non-neoplastic conditions, 220 with solid non-lymphomatous tumours, and 29 with lymphoma. Each of the above groups was divided into three age subgroups: less than 60, 60-69, and greater than or equal to 70 years. In the controls and in patients with nonmalignant diseases, significantly lower values were recorded for elderly subjects (greater than or equal to 60 years) compared with younger subjects of the same group, whereas in cancer patients the results were independent of age. Under the age of 60, stimulated values for both patient groups were significantly lower than the control values, and in patients with solid non-lymphomatous tumours significantly lower values were attained than in the other patients. NBT reduction in lymphoma patients was comparable to that of the controls. In the elderly (age greater than or equal to 70) no significant differences were noted between patients and controls. It is suggested that stimulated NBT reduction declines with advancing age. While this test clearly demonstrates some leucocyte dysfunction in solid cancer, its value in investigating neutrophil behaviour in elderly subjects is questioned.

Bone scintigraphy in primary tumors of the head and neck

Bones of the face and skull may be involved directly by adjacent primary tumors of the head and neck. Radiography, at present the standard method for detection of bone involvement in such tumors, is not sufficiently sensitive. Of 22 patients who showed bone involvement in scintigraphy, radiography in 15 was initially normal, in 6 the extent of the lesion was not completely shown and only in 3 was it as informative as scintigraphy. Bone scintigraphy should become a standard method for evaluation of the context of bone invasion by tumors of the head and neck.

Spontaneous regression of malignant melanoma

The case of a 47-year-old white female patient has been described with malignant melanoma that started as a node on her right ankle twelve years ago and regressed spontaneously. During the last two years of her life, dissemination of the melanoma appeared in the form of subcutaneous nodes, which regressed spontaneously in successive crops. In the course of her disease there was evidence of distant metastases to the brain. Spontaneous regression seems to have been enhanced by immunotherapy, when most of the metastases had regressed, including those in the brain.

Multiple lymphocyte transformation tests by phytohemagglutinin in healthy individuals: transient episodes of decreased lymphocyte blastogenesis

146 serial determinations of spontaneous and phytohemagglutinin-induced lymphocyte transformation as measured by tritiated thymidine incorporation, were performed in 24 healthy individuals. 9 persons were studied intensively during a mean period of 40 days and the other 15 underwent random investigations during a period up to 10 months. Transient episodes of significant decreased lymphocyte transformation were revealed in 14 persons (58.4%) with regard to the spontaneous blastogenesis and in 11 subjects (45.8%) with regard to PHA-induced reactivity. The occurrence of the decreased values in PHA responsiveness was significantly higher in the intensively studied group compared to the randomly investigated one (p = 0.001). The probability of detecting one low PHA-related response in a normal subject was 11%. In only half of the cultures with low spontaneous blastogenic response did a simultaneous decrease in PHA-induced lymphocyte transformation occur. In addition to the currently used stimulation index, a new index termed the Blastogenic Cumulative Index is proposed. It is defined as the sum of the logarithms of the dpm values of the spontaneous and the PHA induced lymphocyte transformation. The CI is suggested to describe lymphocyte blastogenic function more accurately, and due to its simplicity warrents further study. Other indices for lymphocyte blastogenesis determination are discussed.

Granuloma formation in patients after injection of methanol extraction residue (MER-GCG)

Nine patients with advanced cancer who were receiving the methanol extraction residue of BCG (MER-BCG) intradermally or intratumorally underwent biopsies from the injected sites or from locally enlarged lymph nodes. Most preparations showed a chronic granulomatous reaction consisting of lymphocytes, histiocytes, and epithelioid cells as well as either Langhans's or foreignbody type giant cells, or both. The degree of granuloma formation and giant cell infiltration varied. In only one case did the reactions consist merely of chronic lymphocytic and histiocytic inflammation with no granuloma formation. Examination of melanoma nodules injected with MER showed, in addition to granulomas, large numbers of giant cells penetrating the tumour.

Spontaneous and stimulated nitroblue tetrazolium tests of leukocytes from patients with solid malignant tumors

Histochemical nitroblue tetrazolium (NBT) reduction tests, spontaneous and endotoxin-stimulated, were performed on samples of blood from 202 adult patients with solid neoplastic tumors and 37 healthy control subjects. The patients were classified according to activity of the disease, chemotherapy, and presence of bacterial infection. The NBT test did not prove helpful in detecting the latter condition in these patients. Low median spontaneous reduction values were recorded for patients with active malignancies, or receiving chemotherapy, compared with controls or cured patients without chemotherapy. Stimulated reduction values were significantly lower for all groups of patients than for controls, although for those apparently cured and untreated, stimulated reduction attained significantly higher values than for the other patients. A leukocyte dysfunction caused by both the underlying disease and its chemotherapy is assumed, and the usefulness of the endotoxin-stimulated NBT reduction test in detecting this dysfunction is stressed.

Community dentistry: developmental discussion approach

In 1960, Blackerby asked the question "Why not a department of social dentistry?". Since that time most of the dental schools in the United States have made some attempt at establishing such a department. Various names were given to these departments, but the one that appears to be in the forefront is the Department of Community Dentistry. Since that time each school with such a department has strived to develop various innovative methods of teaching community dentistry to its students. When the amount of time is taken into consideration, unlike the biological and clinical sciences, time allotted to community dentistry is minimal. However, at The University of Michigan students spend 232 hours in community dentistry, which necessitates development of creative teaching techniques to maintain their interest. This paper discusses one such technique which has proven to be successful over the past 3 years. Emphasis is placed on utilizing a modified method of the developmental discussion approach in teaching a course in community dentistry to 3rd-year dental students.

Neutrophil function in cured cancer patients

Spontaneous and endotoxin-stimulated nitroblue tetrazolium (NBT) dye reduction was evaluated in 86 individuals cured of various types of solid malignancies and in 55 healthy adults. Oxygen consumption tests, at rest and during phagocytosis, were performed with polymorphonuclear leukocytes of 22 patients and 10 controls, chosen at random. The results revealed an impaired capacity of patients' neutrophils to reduce NBT. The decrease in the stimulated reduction values was more pronounced (p less than 0.0005) than in spontaneous values (p less than 0.01), and was also noticed in patients who had been treated by surgery alone and in those with a disease-free interval of 10 years or more. Oxygen consumption by patients' leukocytes was similar to that of controls. The present results, especially those of the endotoxin-stimulated NBT test, might reflect a neutrophil dysfunction in cured cancer patients. The nature of such an abnormality and its possible clinical implication are still obscure.

Treatment of lung cancer by radiotherapy, chemotherapy, and methanol extraction residue of BCG (MER): clinical and immunological studies

Fifty-one patients with advanced lung cancer were divided at random into two groups. One group of 29 patients received the methanol extraction residue (MER) of Bacille-Calmette-Guerin (BCG) in addition to radiotherapy and/or chemotherapy. The other group of 22 patients was treated by radiotherapy and/or chemotherapy alone. The immune status of the patients was evaluated by skin tests to three recall antigens and KLH and by in vitro lymphocyte stimulation to PHA and three recall antigens. The immune status of both groups was similar before and after conventional treatment. The cutaneous reactivity, as well as the in vitro lymphocyte reactivity, became stronger in the MER-treated group, as compared with the control group. The MER-treated patients had less distant metastases. In a comparable clinical stage the survival in the MER treated group was slightly but not significantly better. This study has shown that MER stimulates the immune response, can be well tolerated and has few side effects. Therefore, MER treatment of patients with minimal tumor load can ethically be done with hope of obtaining better results.

Laryngeal carcinoma associated with multiple additional primary tumors. Immunologic studies

Four malignant tumors and one benign in a 76-year-old man appeared. Three of the neoplasms were in the respiratory system, and one was a bladder carcinoma; all were linked to heavy smoking habits. The patient underwent immunologic investigations consisting of in vivo testing for cutaneous reactivity, in vitro lymphocyte blastogenesis studies, T- and B-cell level studies, and serum immunoglobulin level studies. The studies have demonstrated anergy to recall antigens, decreased lymphocyte responses to phytohemagglutinin, and low levels of peripheral T-lymphocytes. The serum immunoglobulins were at the upper limit of the normal. The relationship between the patient's immunologic status and the occurrence of multiple primary neoplasms is discussed.

A preliminary study of intravenous methanol extraction residue of BCG in treatment of advanced cancer

Twenty-four patients with advanced cancer not reacting to conventional therapy were treated with 97 courses of i.v. MER (methanol extraction residue of BCG). MER was administered by i.v. infusion over a 4-h period, twice a week, in dosages varying from 0.05 mg to 1.25 mg. The skin reactivity to 5 recall antigens was evaluated in the patients. All patients except 4 were anergic. Twelve patients had no side-effects. Anergic patients had less side-effects than ergic patients. The side-effects recorded in the others were fever, chills, vomiting and tachycardia. The reaction subsided within 24 h after treatment and was tolerable for most patients. In 2 patients an objective improvement was observed. No changes in cutaneous reactivity, renal and hepatic functions were found. A significant increase in peripheral leucocyte count was noted in two patients and slight a increase in the remainder.

Computer-aided tumour classification and treatment selection in breast cancer

In order to provide a common basis for treatment decisions and the future evaluation of breast cancer therapy, the breast cancer protocol used in our clinic was formulated for the computer. A system for the simulation of clinical reasoning was used which allows the physician to express the medical logic as a series of inferences to be confirmed or rejected on the basis of Boolean combinations of medical criteria. The system enables the physician to rearrange these criteria into a questionnaire for complete and accurate recording of patient data. These data are then fed into the computer to produce a patient status report and treatment recommendations. The data from 26 patients in various stages of breast cancer have been processed by the computer and the computer's conclusions compared to the assessment made by a junior physician in our department. In three cases the staging was not identical, in 15 cases the treatment decisions were not identical and in all cases investigations were left out by the physician. The system has been of considerable value in standardising patient examination and treatment and in training inexperienced physicians.