Immunohistochemical features of HLA-DR antigen expression and lymphoid infiltrates in gastric carcinoma after low-dose interleukin-2 and mitomycin C

We immunohistochemically evaluated lymphoid cell infiltration and HLA-DR antigen expression in gastric tumor tissue obtained from advanced gastric cancer patients 1 day after the completion of the treatment with mitomycin C (MMC) 12 mg/m2 i.v. on day 1 and recombinant interleukin-2 (IL-2) i.v. every 12 h from day 4 through day 8. Then the results were compared with those in 11 patients pretreated with MMC alone, 5 treated with IL-2 alone, and 24 untreated patients. Widespread lymphoid infiltration was observed in 17% of untreated tumors, 27% of MMC-pretreated tumors, and 40% of tumors treated with IL-2 alone. However, 71% of carcinomas pretreated with MMC plus IL-2 exhibited widespread infiltration. The frequency of cases with high-grade infiltration of CD4+ cells was significantly higher in either group of patients treated with MMC alone or MMC plus IL-2. Because the CD8+ cell infiltration was not significantly altered, the ratio of CD4+ to CD8+ cells estimated as being > 1 was more frequently noted in patients given MMC alone or MMC plus IL-2, as compared with untreated control. Furthermore, 86% of tumors pretreated with MMC plus IL-2 exhibited positive HLA-DR antigen expression, whereas 29% of untreated carcinomas did so. MMC or IL-2 alone did not significantly increase HLA-DR expression. These results indicate that the combination of low-dose of IL-2 with MMC enhances the intensity of lymphoid cell infiltration in tumors, with the predominance of CD4+ cells, and HLA-DR antigen expression on tumor cells in patients with advanced gastric carcinoma.

Increased peptidylglycine alpha-amidating monooxygenase activity in cerebrospinal fluid of patients with multiple sclerosis

Peptidylglycine alpha-amidating monooxygenase (PAM) plays a key role in the biosynthesis of many biologically active neuronal and endocrine peptides that possess alpha-amide function at their C-terminus. Using D-Tyr-Val-Gly as the substrate, we measured PAM activity levels in the cerebrospinal fluid (CSF) and serum of patients with a variety of neurological diseases. PAM activity in the CSF was significantly increased in patients with multiple sclerosis (MS), especially during the active stage, compared with that in patients with other neurological diseases (p < 0.05). Levels of CSF PAM activity were not correlated with protein levels in CSF or with level of serum PAM activity. Since PAM is present not only in neurons but also in oligodendroglia, it is possible that the increase in CSF PAM activity in patients with MS may stem from massive demyelination and oligodendroglial destruction.

Enhanced induction of lymphokine-activated killer activity following a single dose of cisplatin in cancer patients

The effects of intravenous cisplatin (CDDP) administration on the generation of lymphokine-activated killer (LAK) activity in peripheral blood mononuclear (PBM) cells were investigated in cancer patients. The ability of PBM to generate LAK activity was significantly augmented 3, 5 and 7 days after a single dose, 50 mg m-2, of CDDP injection when compared to that before injection. NK activity of PBM was not altered. The distribution of lymphocyte subsets exhibited no significant change following CDDP injection, except CD2+ cells. However, the ability of monocytes in PBM to produce TNF-alpha was significantly enhanced 5 days after the drug administration, although IL-1-alpha and IL-1-beta production was not augmented.

[Reoperation for transposition of the great arteries: mid-term results and reoperation after arterial switch operation]

The arterial switch operation for transposition of the great arteries is now widely accepted as the therapeutic method of choice. As of December 1993, a total of 162 patients underwent the arterial switch. There were 100 patients with transposition and intact ventricular septum, 48 with a ventricular septal defect, 14 with ventricular septal defect and arch anomalies (coarctation: 11, interruption: 3). Early and late mortality were 3.7% (6 patients) and 4.5% (7 patients), respectively. Postoperative pulmonary stenosis (> 30 mmHg) was noted in 33 patients (22%), aortic regurgitation (> mild) in 20 (13%), supravalvular aortic stenosis (> 20 mmHg) in 5 (3%) and mitral regurgitation (> mild) in 5 (3%). Reoperation was performed in 27 patients with no mortality. Mean interval between the switch and the reoperation was 30 months. Twenty-three patients with pulmonary stenosis underwent patch plasty of pulmonary artery. Two children with severe aortic regurgitation underwent aortic valve replacement. Two patients who had undergone one-staged repair for interruption complex were reoperated due to supravalvular aortic stenosis and pulmonary stenosis. Actuarial survival and freedom from reoperation at 9 years were 90% and 69%, respectively.

The feasibility of epidural anesthesia without endotracheal intubation for abdominal surgery in patients over 80 years of age

To evaluate the efficacy of a single application of epidural anesthesia without endotracheal intubation for elderly patients over 80 years of age, the data on 108 patients who underwent abdominal surgery were analyzed for the occurrence of postoperative complications. These patients were classified into two groups according to the type of anesthesia performed: 66 received epidural anesthesia alone (Group I) and 42, general anesthesia under endotracheal intubation (Group II). There were no lethal pulmonary complications in Group I, whereas 2 patients (4.8%) died of respiratory failure resulting from pulmonary complications in Group II. The incidence of postoperative pulmonary complications in Group I was 6.1%, which was significantly lower than the 28.6% observed in Group II (p < 0.005). The occurrence of pulmonary complications in Group I was not related to the operating time, while pulmonary complications frequently occurred in patients who underwent lengthy operations in Group II. These findings suggest that a single application of epidural anesthesia would improve the overall safety in performing abdominal surgery in elderly patients over 80 years of age.

Neuroleptic malignant syndrome occurring after an emergency operation for traumatic duodenal perforation: report of a case

Neuroleptic malignant syndrome (NMS) is a potentially fatal complication which may develop in psychiatric patients taking neuroleptic drugs. We report herein the successful treatment of a 33-year-old schizophrenic man, prescribed neuroleptic drugs, who underwent an emergency operation for traumatic duodenal perforation with a retroperitoneal infection. Five days after the operation, he began to demonstrate clinical features consistent with NMS such as high fever, abnormalities in vital signs, leukocytosis, and an elevated serum level of creatine phosphokinase; however, these findings were first presumed to be secondary to either the preexisting tissue injuries or to postoperative complications. A definite diagnosis of NMS was thus delayed until muscle rigidity and autonomic instability became evident. After a tentative diagnosis of NMS had been made, sodium dantrolene, a drug used specifically for the treatment of NMS, was administered and the patient's condition remarkably improved. Since NMS can be induced by either interrupting the course of neuroleptic drugs or by the additional administration of sedative drugs, and since its mortality rate is high if prompt and appropriate treatment is not carried out, surgeons should bear in mind the possibility of NMS developing postoperatively in psychiatric patients.

Lymphokine-activated killer cell activity of peripheral blood, spleen, regional lymph node, and tumor infiltrating lymphocytes in gastric cancer patients

Lymphokine-activated killer (LAK) cell activity of peripheral blood mononuclear cells (PBM), spleen cells (SPC), regional lymph node cells (LNC), and tumor-infiltrating lymphocytes (TIL), induced by activation with interleukin 2 (IL 2) for 4 days, was evaluated in patients with gastric carcinoma. TIL exhibited the lowest LAK activity and the cytotoxicity of LNC was significantly lower than that of either PBM or SPC. There was no difference between PBM and SPC. Then, there were significant correlations of LAK activity among PBM, SPC, and LNC, whereas poor correlations were observed in the cytotoxicity between TIL and PBM, SPC, or LNC. Phenotypic analysis of each cell population was performed before and after activation with IL 2. Before culture, the cells mediating natural killer (NK) activity such as CD16+, CD56+, and CD57+ cells were few in LNC and TIL. However, CD56+ and CD57+ cells in TIL were increased after culture. Then, CD4+Leu8+ and CD8+CD11+ cells, which identify suppressor cell function, were not elevated in LNC or TIL, as compared to that in PBM or SPC. Further, the proportions of OKIa1+ and CD25+ cells expressing T-cell activation and IL 2 receptor were uniformly increased in all cell populations after culture. These results indicate the differential reactivity of each lymphocyte population to IL 2 and fundamental dysfunction of LNC and, especially TIL, suggesting the specific influence of the local tumor environment on the lymphocyte function in the area in patients with gastric carcinoma.

Laboratory correlates of chemoimmunotherapy with low-dose recombinant interleukin-2 and mitomycin C in patients with advanced carcinoma

Based on our clinical findings that the ability of cancer patients to generate lymphokine-activated killer (LAK) cells was remarkably augmented after mitomycin C (MMC) administration, we designed a treatment regimen that consisted of MMC 12 mg/m2, i.v. on day 1 and recombinant interleukin-2 (IL-2) 700 U/m2, i.v. every 12 hr from day 4 through day 8. Of 29 patients with advanced carcinoma treated with this regimen, 10 had a partial response (PR) and 4 had a minor response. The correlation of hematological and immunological changes associated with this treatment with the antitumor response to this therapy was investigated. Pretreatment values of total white blood cell and lymphocyte counts, and the level of increase of eosinophil counts in responder patients who showed a PR, were significantly greater than those in nonresponder patients. However, there was no correlation between clinical response and cytotoxic activities of peripheral blood mononuclear (PBM) cells, including NK and LAK activity, and the ability to generate LAK cells after the treatment. The capacity of adherent cells in PBM to produce IL-1-beta was increased after the treatment in both responders and nonresponders, whereas IL-1-alpha production was not increased. In addition, a significant increase in the ability to produce TNF-alpha was observed only in responders, indicating the correlation of TNF-alpha production with clinical response to this therapy. Since these correlations had been reported in the previous studies using IL-2, the present results suggested that the therapeutic effectiveness of this therapy against advanced carcinoma, is due to IL-2 probably augmented by its combination with MMC. In addition, these parameters might be predictive of therapeutic efficacy of this treatment.

Cytotoxic cell function and phenotypic analysis of peripheral blood mononuclear cells in cancer patients treated with low-dose interleukin-2 and mitomycin C

We previously found that the ability of peripheral blood mononuclear cells (PBM) of cancer patients to generate lymphokine-activated killer (LAK) cells became remarkably augmented after mitomycin C administration. On the basis of the clinical findings, we designed a treatment regimen comprised of 12 mg/m2 mitomycin C i.v. on day 1 and 700 U/m2 recombinant interleukin-2 (IL-2) i.v. every 12 h from day 4 through day 8. Of 25 patients with advanced carcinoma, 9 had a partial response and 3 had a minor response. Cytotoxic cell function, including natural killer activity, lymphokine-activated killer (LAK) activity, and the ability to generate LAK cells, and lymphocyte subsets in PBM was measured 1 day before and after either the first or second course of this therapy. The relationship between these parameters and the clinical antitumor response to this treatment was examined. Although the cytotoxic activities were significantly augmented after either the first or second treatment course, no positive correlation was observed between the changes in these cytotoxic activities and the clinical response to this therapy, when patients who either showed a partial response or whose disease remission was partial or minor were defined as responders. Further, phenotypic analysis showed a significant increase in CD2+, CD3+, CD4+ and CD4+Leu8- cells after the first course, and CD25+ cells after either the first or second course of this treatment. The percentages of CD2+ and CD25+ cells were significantly elevated only in responders but not in nonresponders, suggesting the increase in these subsets was related to clinical response.

Effect of voluntary exercise on urinary excretion of catecholamines after traumatic shock in rats

Thirteen rats were kept in cages equipped with running wheels for 10 months (exercise group), and 12 rats were kept in cages without running wheels during the same period (control group). Rats in both groups were subjected to a Noble-Collip drum trauma (40 rpm, 350 revolutions in total) after the 10-month conditioning period. Urine output, urinary epinephrine (E), and norepinephrine (NE) were measured until the seventh day after the trauma. Urine output decreased after the trauma in both groups to the same extent, but the recovery of urine output after trauma was accomplished faster in the exercise group than in the control group, and diuresis after trauma was seen only in the exercise group. Urinary E increased in both groups within 24 hours after trauma, but the increase in the exercise group was significantly less than in the control group. The amount of NE excreted depended somewhat on the urine volume, but there was no significant difference in changes in urinary NE after trauma between the groups. These results suggest that rats bred in an active condition suffered less severe traumatic shock accompanied by a reduced sympathoadrenal activity as compared with rats bred in a relatively sedentary condition.

Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique

The influence of epidural neural blockade on postoperative insulin resistance was studied using the euglycaemic insulin clamp technique. Eighteen patients undergoing elective upper abdominal surgery of moderate severity were allocated to two groups: group G patients underwent operation under general anaesthesia, and postoperative pain was relieved by systemic administration of analgesia; and group E patients received epidural analgesia during surgery and epidural morphine postoperatively. In each patient the euglycaemic insulin clamp test was performed twice: several days before surgery and on postoperative day 1. Peroperative catecholamine and cortisol responses were also measured to investigate possible endocrine mechanisms of the insulin resistance. Glucose disposal (M) decreased in both groups on postoperative day 1 at plasma insulin concentrations ranging from 1.2 to 10.0 milliunits ml-1, resulting in the downward shift of dose-response curves. However, this downward shift was significantly smaller in group E than in group G patients. Urinary adrenaline excretion increased markedly on the day of operation in group G, but was significantly inhibited in group E. Urinary noradrenaline excretion increased mainly on postoperative day 1 in group G, but was significantly inhibited in group E. Plasma cortisol response was lower in group E than in group G during and shortly after operation, and was significantly inhibited in group E on postoperative day 1. These results indicate that insulin resistance after elective abdominal surgery is due to a postreceptor deficit in glucose utilization, as indicated by the downward shift of the dose-response curves. This disturbance in glucose metabolism was reduced by epidural analgesia, the results being associated with inhibited catecholamine and cortisol responses.

Effects of indomethacin on endocrine responses and nitrogen loss after surgery

In 14 patients who had elective gastrectomy, 50 mg of indomethacin was administered intrarectally every 6-8 hours after operation until postoperative day 3. Body temperature, plasma cortisol and glucagon concentrations, blood glucose level, urinary catecholamine level, and urinary nitrogen excretion level were compared with those of 16 patients who did not receive indomethacin. Postoperative fever was significantly reduced by indomethacin. Plasma cortisol levels in the indomethacin-treated group were significantly lower on postoperative days 2 and 3. Postoperative increases in plasma glucagon and blood glucose levels were not influenced by indomethacin administration. Urinary epinephrine excretion tended to be inhibited, and urinary norepinephrine excretion was significantly inhibited in the indomethacin-treated group after operation. Urinary nitrogen excretion levels during the observation period were significantly less in the indomethacin-treated group. The cumulative urinary nitrogen level from postoperative days 1-3 in the indomethacin-treated group was 82% of that in the control group. These results indicated that fever reduction by indomethacin after surgery resulted in reduced protein loss, associated with attenuated cortisol and catecholamine responses.

Effects of epidural administration of local anaesthetics or morphine on postoperative nitrogen loss and catabolic hormones

To examine the effects of postoperative epidural analgesia with local anaesthetics or morphine on the excess nitrogen loss after upper abdominal surgery and to assess the roles of catabolic hormones in the nitrogen loss, urinary excretion of nitrogen and catecholamines and plasma concentrations of cortisol and glucagon were measured in three groups of patients undergoing elective gastrectomy. Group G patients received the operation under general anaesthesia, and their postoperative pain was relieved by intermittent injections of analgesics. Group PE received prolonged epidural analgesia with local anaesthetics during and after surgery. Group EM received epidural analgesia intra-operatively and epidural morphine postoperatively. Urinary nitrogen excretion during the first three postoperative days was significantly less in the PE and EM groups than in the G group, and the PE group excreted slightly less nitrogen than the EM group. In the G group, urinary excretion of adrenaline increased mainly on the day of operation, and noradrenaline chiefly on postoperative days. These catecholamine responses were almost completely abolished in the PE group, and significantly inhibited in the EM group. Plasma cortisol response was most remarkable shortly after the operation and then decreased in all groups, but was significantly lower in the two epidural groups than in the G group throughout the study. Plasma glucagon increased postoperatively in all groups, and the increase was less pronounced in both epidural groups than in the G group. These results suggested that an elevated sympathetic activity, represented by increased noradrenaline excretion and elicited by painful nociceptive and sympathetic nervous afferents, is responsible for the postoperative nitrogen loss which is mediated by glucagon and cortisol.

Effects of epidural analgesia on scalp-recorded somatosensory evoked potentials to posterior tibial nerve stimulation

The effect of epidural analgesia with plain bupivacaine 0.5% on somatosensory evoked potentials (SEP) to electrical stimulation of the posterior tibial nerve was examined in six patients. Epidural analgesia significantly increased onset time and latencies of the early components in SEP, while the amplitudes decreased. These results suggest that SEP may be valuable in the objective evaluation of possible differential neural effects of local anaesthetic agents following epidural or intrathecal administration.

Role of the splanchnic nerves in endocrine and metabolic response to abdominal surgery

The splanchnic nerves are inevitably stimulated during upper abdominal surgery and this may produce various responses. To assess the role of splanchnic nerve stimulation on the endocrine-metabolic responses to abdominal surgery, intra-operative splanchnic nerve blockade was carried out in 12 patients undergoing elective gastrectomy under general anaesthesia and the results compared with those of patients undergoing gastrectomy under general anaesthesia or epidural analgesia alone. In the splanchnic blockade group, intra-operative increase in plasma cortisol, glucose, FFA (free fatty acids) and urinary adrenaline excretion were significantly less than that of the general anaesthesia group. This inhibitory effect of splanchnic blockade on these endocrine-metabolic responses was almost the same as, but slightly less remarkable than, that of high spinal epidural blockade. Urinary noradrenaline excretion reached the highest level on the first postoperative day in the general anaesthesia group. This noradrenaline response was significantly inhibited in the splanchnic group as well as in the epidural group. These results appeared to indicate that mechanical stimulation to the splanchnic nerve due to operative manipulation is largely responsible for the endocrine-metabolic responses in abdominal surgery. The results also suggested that, in addition to the splanchnic nerve stimulation, conscious pain perception is responsible for catecholamine release.

Influences of splanchnic nerve blockade on endocrine-metabolic responses to upper abdominal surgery

Twelve patients undergoing gastrectomy received combined epidural and splanchnic nerve blockade (Group E&S), and changes in plasma ACTH, cortisol, glucose and FFA were compared with those undergoing gastrectomy under general anaesthesia (Group G) or epidural analgesia alone (Group E). Plasma ACTH increased in all groups on the day of operation and was significantly higher in Group G than the other groups. Levels of ACTH in Group E&S were lower than Group E, but the differences were not significant. Cortisol response in Group G was most pronounced and prolonged. This cortisol response was significantly attenuated in Group E and was further inhibited in Group E&S. Blood glucose and FFA increased in Groups G and E during the operation but the increase was significantly less in Group E. In Group E&S, glucose and FFA concentrations showed practically no change throughout the study, being significantly lower than in Group E. The results indicated that the splanchnic nerve is responsible for producing endocrine-metabolic responses to gastric surgery even under epidural blockade.

[Intra-arterial infusion through 2 routes in liver (primary and metastatic cancer]

Patients with unresectable liver cancer (primary and metastatic) were treated with a newly-devised arterial infusion chemotherapy using Cis-DDP and its antidote Sodium thiosulfate (STS). The patients consisted of 4 with primary hepatoma and 1 with metastatic liver cancer originated from intestinal cancer. For the purpose of reducing unfavourable side effects without changing anticancer effect, Cis-DDP was infused into hepatic artery through the catheter while STS being administered systemically. According to Koyama and Saito's criteria, 2 of 5 patients showed partial response (PR) and the others showed no change (NC). The median survival time after onset of therapy was 6.6 months ranging from 2 to 11 months in all the patients. The myelosuppression and renal toxicity, which were considered to be the most serious side effects of Cis-DDP, were not found and liver function was not affected in all the patients. However, all the patients complained of nausea and vomiting. Thus, our experience has indicated that this newly devised infusion chemotherapy is a promising method for treating unresectable liver cancer, although further efforts are necessary for reducing the gastrointestinal toxicity.

Effect of epidural analgesia on metabolic response to major upper abdominal surgery

Blood concentrations of glucose, lactate, non-esterified fatty acids (NEFA) and insulin (IRI) were measured in two groups of ten patients undergoing elective gastrectomy under general anesthesia with halothane (Group G) or epidural analgesia extending from Th3-4 to L1-2 without halothane (Group E). The rise in blood glucose and the rise in NEFA in group E during operation were significantly less than in Group G. Blood lactate levels during operation were lower in group E than in group G although the difference was not statistically significant. The increase in IRI/glucose ratio on postoperative day 1 was significantly less in Group E than in Group G, suggesting that insulin sensitivity after surgery was higher in Group E. The postoperative course was uneventful in all subjects. These results suggest that the endocrine-metabolic response to major upper abdominal surgery can be inhibited by epidural analgesia.

Attenuation of adrenocortical response to upper abdominal surgery with epidural blockade

Plasma cortisol concentrations and urinary 17-OHCS excretion were measured in two groups of 15 patients receiving elective gastrectomy under either general anaesthesia or epidural blockade. In another 15 patients receiving epidural blockade, the vagus nerve was blocked by injection of local anaesthetics or by truncal vagotomy, and their cortisol response to gastrectomy was compared with the other two groups. Gastrectomy under general anaesthesia caused a marked increase in plasma cortisol concentrations and in urinary excretion of 17-OHCS. These adrenocortical responses to gastrectomy were significantly inhibited in patients operated upon under epidural blockade extending from T3-4 to L1-2 and continuing for 48 h postoperatively. In patients receiving both epidural and vagus nerve blockade, the plasma cortisol response was the same as in those receiving epidural blockade alone. The results indicated that the adrenocortical response to upper abdominal surgery was safely attenuated, though not abolished, with high spinal epidural blockade continuing for 48 h postoperatively. The vagus nerve was not likely to be playing an important role in the adrenocortical response to gastrectomy.

A new therapeutic antibody removal method using antigen positive red cells. Application to M-incompatible pregnant women

A study was made for the therapeutic removal of red cell antibodies using antigen positive red cells. With preliminary experiments in vitro, the criteria for the optimal absorption of anti-M with O MM red cells were estimated to be the following: an incubation time of 10 min, an incubation temperature of 0-4 degree C (in an ice-water bath), and a red cell-to-plasma ratio of 1:2.5. On the basis of these in vitro experiments, the following procedure was designed. One unit (about 90 ml) of O MM packed red cells was added to a bag containing 250 ml of patient's plasma, the mixture was incubated in an ice-water bath for 10 min. Following centrifugation, autologous plasma from which the antibodies were removed was reinfused. After absorption the titer of anti-M fell from 512 to 4. No variation in the level of other plasma components was detected and no hemolysis was seen. After 2.51 of patient's plasma was treated using the above described method, the antibody titer usually decreased one log2 unit. When this method was compared with exchange plasmapheresis, no significant abnormalities in the immunoglobulin and hemostatic factors could be detected, but a moderate decrease in platelet count was seen after plasmapheresis. Thus, it appears that our method provides a rational therapeutic modality for specifically removing antibodies.

Preoperative physical training for cardiac patients requiring non-cardiac surgery

Clinical significance of preoperative physical training was studied in 29 patients with cardiovascular diseases who were to undergo elective abdominal surgery. The exercise testing on admission revealed that 11 of the 29 were in inadequate physical condition. These 11 underwent a preoperative physical training program which proved to be effective in 7. The incidence of postoperative complications was significantly higher in the 4 patients with inadequate physical fitness than in the 25 patients who were fit. Two cardiac deaths occurred postoperatively in the former group, while no cardiac complication or death was found in the latter group. These results indicate that preoperative physical training is a useful adjunct to regular methods for estimating cardiac risk and also to reduce the risk.