Successful immunotherapy in a murine metastasizing fibrosarcoma model

Antigenic differences were demonstrated between the primary murine fibrosarcoma and its metastases. Immunization with irradiated primary tumor cells (TC) protected C57B1/6J mice against subsequent challenge with those cells, but not against challenge with cells from pulmonary metastases (PMC). Mice immunized with irradiated PMC were protected from challenge with those cells, but not against challenge with TC. Mice with fibrosarcomas produced by the injection of 5 X 10(3) cells from the primary tumor were treated by resection of the tumor-bearing limb (Amp), Amp plus cyclophosphamide (Amp + Cy), Amp plus primary TC (Amp + TC), Amp plus primary TC and from its metastatic variant (Amp + TC + PMC), and with combinations of the last two groups with Cy. Although Amp + Cy improved survival, no animal lived 100 days and metastases increased as compared to controls. Immunotherapy significantly improved survival and decreased pulmonary metastases. Antigen combinations from primary and metastatic tumors resulted in significantly better survival than did a single preparation only from TC. Chemotherapy did not enhance the results obtained with immunotherapy and surgery. Immunity conferred in long-term survivors was permanent.

Patterns of failure after surgical cure of large liver tumors. A change in the proximate cause of death and a need for effective systemic adjuvant therapy

During a period of 7 years, we have aggressively treated liver tumors whether primary or metastatic. Our experience after 43 curative major liver resections has shown an excellent overall survival: 34 of 43 patients still alive a median of 12 months after liver resection (patient ages ranged from 21 to 85 years, median 57 years). Nineteen patients underwent right hepatic lobectomy, 9 trisegmentectomy, 5 left hepatic lobectomy, 5 extended left hepatic lobectomy, 4 right lobectomy plus left lobe wedge resection, and 1 patient underwent a major hilar wedge resection. Two patients died from sepsis and hepatic failure on or before the 60th postoperative day. One patient with no evidence of recurrent colorectal cancer was lost to follow-up after 2.5 years. One patient died without cancer 12 months after left hepatic lobectomy for colon cancer metastases. Cumulative survival for the entire series and for patients after resection of colorectal cancer metastases was the same: 1 year survival 90 percent; 2 year survival 75 percent, and 3 year survival 65 percent. Seventeen of 30 patients remain disease-free after resection of liver metastases. Of the 13 who had recurrence, 8 are still alive. Ten recurrences were outside of the residual liver (predominantly multiple pulmonary metastases). One recurrence was in the right hemidiaphragm, and only three were in the residual or regenerated liver. Serial carcinoembryonic antigen analysis was the best indicator of recurrence in these 13 patients, 12 of whom were asymptomatic. These data confirm that major liver resection can be performed with minimum postoperative mortality (4.7 percent in this series). More importantly, the majority of patients were cured of their liver metastases. The next goal should be the initiation of adjuvant systemic therapy trials after liver resection in such patients.

Tumor-cell heterogeneity in soft tissue sarcomas as defined by chemoradiotherapy

This report documents heterogeneous cell populations within high-grade soft tissue sarcomas in seven patients. The authors observed that, following chemoradiotherapy (five patients) or chemotherapy alone (two patients), surgically resected residual or recurrent sarcoma was found to be of low-grade histology. All chemotherapy was of Adriamycin (doxorubicin)-containing combinations. Seven other patients with regional recurrence after resection of high-grade sarcomas had high-grade recurrent tumors. Five of these patients had received no adjuvant therapy; two with extensive retroperitoneal liposarcomas and gross tumor-involved margins had received chemoradiotherapy. Follow-up ranged from 3 to 60 months (median, 12 months). These findings suggest that high-grade populations of sarcoma cells are more susceptible to chemoradiotherapy, as long as there is minimal residual disease. Low-grade clones of tumor cells may survive such therapy and present as clinical recurrence after initial treatment of low-grade or high-grade soft tissue sarcomas. Surgical resection is warranted for these recurrent lesions.

Characterization of antigenic components from circulating immune complexes in patients with gestational trophoblastic neoplasia

The authors have studied serial circulating immune complex (CIC) levels in 15 patients with gestational trophoblastic neoplasia (GTN) for several reasons. Gestational trophoblastic neoplasia can easily be followed from presentation to remission, and CIC changes can be compared with changes in human chorionic gonadotropin (HCG) which is a specific and quantitative marker of trophoblastic tumor load. Twelve patients with hydatidiform molar pregnancy presented with normal CIC levels (255 delta OD450 +/- 97, mean SE [standard error]) as measured by our antigen nonspecific polyethylene glycol (PEG) turbidity assay. Only after reduction in tumor load as monitored by a fall in HCG did CIC rise. In contrast, three patients with choriocarcinoma presented with significantly elevated CIC levels (513 delta OD450 +/- 147, P less than 0.05 compared to normals) which slowly declined in parallel with HCG levels following evacuation and chemotherapy. Sera at peak PEG-CIC from three patients with molar pregnancy or choriocarcinoma were precipitated with 3.75% polyethylene glycol to concentrate circulating immune complexes. Circulating immune complex levels were fractionated on Sephadex G-200 in an acid buffer (pH = 2.8). An identifiable antigenic component of the CIC in both diseases was found to be paternal HLA antigen. This was demonstrated by the ability of the latest eluting CIC fraction to inhibit paternal lymphocyte lysis using anti-HLA antisera against the husband's HLA tissue type. In each case, this fraction contained no immunoglobulin or beta-2 microglobulin and was antigenically crossreactive with only one of the husband's HLA haplotypes. The authors believe the PEG-CIC assay has allowed them to define the kinetics of host humoral response in GTN, and has provided a method for recovering immunogenic tumor-associated antigens from these complexes which may apply to other solid tumors.

Current treatment of metastatic renal cell carcinoma with xenogeneic immune ribonucleic acid

In 1979 we reported a phase I trial involving 6 patients treated with immune ribonucleic acid for renal cell carcinoma. Since that report 27 patients with stage III or IV renal cell carcinoma have been assessed in a phase II trial. All patients have undergone excision of the primary tumor or superficial metastases, injection of tumor into guinea pigs and harvesting of immune ribonucleic acid. Autologous lymphocytes, obtained by plasmapheresis on an outpatient basis, have been incubated with immune ribonucleic acid and reinfused into the host. Results indicate complete response in 1 patient for more than 61 months, partial response in 5 patients for 6 to 10 months and stabilization in 10 patients for 2 to 8 months, all of whom had progressive disease before the institution of therapy. Six patients with continued progressive disease died at a median of 2 months after therapy. Of 5 patients treated in an adjuvant fashion only 1 has had a relapse from 9 to 18 months after therapy. Patients with pulmonary metastases seem to represent the most favorable group for this passive form of immunotherapy. This therapy would seem to offer reasonable alternatives in selected patients with advanced disease.

Surgical management of locally advanced and recurrent breast cancer

Considerations for surgical treatment of locoregional recurrences of breast cancer are particularly relevant at a time when many primary breast malignancies are being treated in a more conservative manner. The past experience with local recurrence after radical mastectomy was dismal: every patient with recurrence eventually developed systemic disease. Over 80% of such patients died within 2 years. The observations after local recurrence in patients with modified radical mastectomy are generally the same, although those with better prognostic lesions may have a marked delay in mortality. For patients with partial mastectomy and radiation, there are data which suggest that subsequent mastectomy for "in breast" recurrence may salvage approximately 50% of women and achieve long-term freedom from disease. This is a crucial question which will require more patients and time for confirmation. The author reviews patterns of locoregional recurrence after primary treatment of breast cancer, presents a plan for workup of such patients, and describes prognostic factors. The various treatment options, with their results, are discussed, and their dependency on the initial therapy is stressed. For patients with advanced Stage III primary breast cancer (T4 or N2, N3 lesions) and inflammatory carcinoma, a multimodal approach is proposed, with systemic multidrug chemotherapy as the initial treatment. The interlocking roles of surgical resection of the breast and radiation therapy must be considered, depending on the response to chemotherapy. Algorithms for therapy have been constructed to demonstrate the options.

Intraductal carcinoma of the breast

The management of intraductal carcinoma of the breast at the present time is necessarily diverse because there is difficulty in detecting it, as well as understanding its basic biology and natural history. Therapy has ranged from excisional biopsy with or without radiation to radical and extended radical mastectomy. The effects of radiation therapy upon these well-differentiated in situ lesions is undefined. The popularity of total mastectomy stems from a concern for the fate of breast tissue left in situ after removal of the focus of preinvasive carcinoma. Intraductal carcinoma of the breast has been shown to be a multicentric disease process in a large percentage of patients. Indeed, all breast tissue in these patients appears to be at risk for the eventual development of preinvasive and invasive carcinoma. However, the clinical significance of such residual foci of in situ carcinoma or ductal hyperplasia and dysplasia following resection of the breast, as in papillary carcinoma of the thyroid, is still open to question. Similar concern exists for a significant "sampling error" involved in biopsies of lesions of the breast: there were six instances of this in the present series (11 per cent). A "sampling error" of 6 per cent was found in a similar study of a group of patients with intraductal carcinoma. An error rate of 18 per cent was reported in another study. Again, the clinical significance of this "sampling error" remains open to question. The difficulty encountered in evaluating remaining breast tissue after a partial mastectomy has also been reason to consider total mastectomy in these patients. Residual or recurrent carcinoma in such altered breast tissue is difficult to diagnose at an early stage, either by physical examination or by the results of mammography. None of the patients in the present series had axillary nodal metastases and, theoretically, intraductal carcinoma should not be associated with axillary nodal metastasis. The small percentage of patients found to have invasive carcinoma following mastectomy for in situ carcinoma are likely to have minimally invasive lesions with, at most, a 23 per cent incidence of positive axillary nodes. The advantage gained by performing full axillary dissection or extensive nodal sampling in 60 per cent of the patients in this series, as well as in patients in other series, is difficult to ascertain without further study. The most logical choice of therapy would appear to be total mastectomy with limited axillary node sampling.(ABSTRACT TRUNCATED AT 400 WORDS)

Nuclear magnetic resonance for the differentiation of benign and malignant breast tissues and axillary lymph nodes

We have utilized proton T1 (spin-lattice relaxation time) values of Nuclear Magnetic Resonance to study 110 tissue samples obtained from 11 mastectomy specimens. Samples of 1 cm3 from primary tumor sites, nipples, and other breast quadrants, as well as intact lymph nodes were studied and then histologically scored for the presence or absence of carcinoma and, if present, whether it was an isolated microscopic focus (micro). Of 54 samples of breast tissue, 12 contained carcinoma, 5 micro: of 45 lymph nodes, 15 contained metastatic carcinoma, 2 micro; of the 11 nipples, 2 had carcinoma, both micro. For the malignant samples (excluding micro) mean T1 value was 0.47 +/- 0.07 sec, (range 0.39-0.79 sec). For the 72 benign samples (excluding nipple) mean T1 value was 0.26 +/- 0.03 sec (range 0.14-0.36 sec). The 13 tumor-bearing nodes had a mean T1 value of 0.47 +/- 0.03 sec (range 0.40-0.63 sec); mean for the benign nodes was 0.26 +/- 0.007 sec (range 0.19-0.35 sec). The differences were highly significant in each case (p less than 0.001). For micro examples, T1 values were at malignancy threshold levels or just below, except for nipple tissues, where discrimination was poor. For the 20 other malignant samples, there was no correlation between T1 value and the per cent of sample containing malignancy.

Gut-associated lymphoid tissue and dimethylhydrazine-induced colorectal carcinoma in the Wistar/Furth rat

Although gut-associated lymphoid tissue in the form of discrete lymphoid patches (LP-GALT) in mammalian intestine in most prominent in the distal ileum, appendix, and, in some species, the cecal appendage, LP-GALT can be found throughout the intestinal tract. LP-GALT appears as single or multiple subepithelial lymphoid follicles covered by a specialized, structurally unique epithelium. In the colon of the Wistar/Furth (W/Fu) rat, LP-GALT appears as aggregates of follicles, or lymphoid patches, that can be detected macroscopically. We studied the relationship between 1,2-dimethylhydrazine- (DMH) induced colon carcinomas and the lymphoid patch associated epithelium in these animals. In addition, we defined the normal distribution of colonic lymphoid patches in both DMH-treated and control rats. Patches were found macroscopically and confirmed by histologic examination at five constant sites: lower pole of cecum, proximal ascending colon, the major colonic flexure, mid descending colon, and the rectosigmoid. There are also the predominant sites of DMH induced carcinomas in W/Fu rats. In 120 DMH-treated animals, 109 colon carcinomas were found. Eight percent were in the lower pole of the cecum, 56% in the proximal ascending colon, 16% at the major flexure, 15% in the mid descending colon, and 5% in the rectosigmoid. Lymphoid patches could often be detected histologically in association with DMH-induced tumors. The depth of tumor invasion was found to correlate inversely with our ability to identify tumor-associated lymphoid patches suggesting that tumors arising at the anatomical sites were lymphoid patches occur progressively destroyed them. Of colon tumors confirmed histologically to be associated with lymphoid patches, 88% were superficial lesions confined to the submucosa and 12% were more extensive but confined to the bowel wall. No lymphoid patches could be found associated with tumors that extended through the bowel wall. Thus, DMH-induced colon carcinomas in W/Fu rats arise at sites containing preexisting LP-GALT with associated specialized epithelium.

Serial circulating immune complex levels and mitogen responses during progressive tumor growth in WF rats

Inbred male WF rats were given im injections of one of two antigenically and histologically distinct syngeneic tumor isografts, adenocarcinoma DMH-W 163 or spontaneous renal cell carcinoma SPK. Serum and peripheral blood lymphocytes were harvested from tumor-bearing and normal age-matched controls before and after isograft challenge at weekly intervals. Serial circulating immune complex (CIC) levels were quantitated by polyethylene glycol (PEG) insolubilization. T-cell mitogen responses to phytohemagglutinin (PHA) and concanavalin A (Con A) were followed serially. Tumor growth was measured at least weekly. PEG-CIC values rose early after tumor injection, increased with tumor growth, and declined in some animals just before death. Mitogen response to PHA was significantly decreased in isografted tumor-bearing rats, particularly at later stages of tumor development, compared to normal uninoculated controls. Responses to Con A were variable, and suppression was not always seen in tumor bearers. In animals that did not have progressive tumor growth after isograft injection, PEG-CIC levels did not change and responses to PHA were not suppressed. Patterns of CIC change and responses to PHA were not affected by differences in tumor histology or growth rates. Thus serial CIC levels measured by the PEG assay correlate with tumor growth and precede nonspecific suppression of T-cell mitogenic response in these animal tumor models.

Long-term hepatic arterial infusion of 5-fluorodeoxyuridine for liver metastases using an implantable infusion pump

Twenty-one patients with liver metastases of various histologies (predominantly colorectal carcinoma) underwent Infusaid pump implantation for long-term hepatic arterial 5-fluorodeoxyuridine (5-FUdR) infusion. Patients received 5-FUdR infusion on a 2-wk cycle alternating with a 2-wk saline--heparin infusion. A dosage of 0.2-0.3 mg/kg/day (average 0.23 mg/kg/day) was infused for a cumulative 5-FUdR administration of 1940 days. Six patients (29%) responded to therapy (five colorectal, one carcinoid); median response duration was 6 mo. Median survival for the treated group was 17 mo from diagnosis of liver metastases and 13 mo from pump implantation. Median survival among the six responding patients was 15 mo from diagnosis of liver metastases and 11 mo from pump implantation. Comparison of survival from the diagnosis of liver metastases of the treated group to ten patients found ineligible for the study by virtue of extrahepatic metastases revealed no significant difference in median (18 mo for ineligible group) or overall survival. However, median survival for the treated group after pump implantation (13 mo) was significantly better than the median survival of the ineligible group after evaluation for this study (4 mo). Toxicities of therapy included fatigue, anorexia, nausea, vomiting, toxic hepatitis, epigastric pain, and diarrhea. No patients died of toxicity, but six patients required hospitalization for management of pain or vomiting. No serious technical complications developed in any patient except separation of the infusion catheter at its junction with the pump in one patient, necessitating pump replacement for continuation of therapy. These survival data suggest identification of new anticancer agents for hepatic arterial infusion.

Interaction of Ia antigen-bearing polymorphonuclear leukocytes and murine splenocytes

Polymorphonuclear leukocytes (PMN) were induced in the peritoneum of a Balb/c mouse by ip injection of Fusobacterium nucleatum (FN) (greater than 95% PMN). A subpopulation of PMN harvested bore Ia surface antigens and stimulated a mixed lymphocyte reaction (MLR) when cultured with C57B1/6J splenocytes. The reaction was blocked by a short prior incubation of PMN with anti-Ia antibody or PMN cell depletion by the same antibody plus complement. The Ia antigen-bearing PMN were capable of antigenic modulation since incubation of PMN for 24 h rendered the cells incapable of stimulating an MLR. The Ia antigen-bearing PMN produced a soluble material that enhanced the phytohemagglutinin (PHA) response of murine splenocytes and the active material was a product of live cells since the supernatants contained no detectable lactate dehydrogenase activity. The data suggest that murine PMN subpopulations, defined by surface Ia antigen, can modulate mitogenic responses by production of an enhancing factor(s).

Survival of patients with localized high-grade soft tissue sarcoma with multimodality therapy. A matched control study

Ten of 16 consecutive patients (63%) with Stages III-IVA soft tissue sarcoma presenting between 1975 and 1978 and treated with surgery, radiotherapy and adjuvant chemotherapy have remained disease-free with a median follow-up of three years (range, 28-68 months). Survival at three years was 86%. However, in the American Joint Committee (AJC) soft tissue sarcoma staging system published in 1977, Grade 3 soft tissue sarcomas were associated with a three-year survival of 35% and almost 90% of the patients destined to fail did so within three years of diagnosis (8). To determine if the observed improvement in survival resulted merely from lesions with favorable prognostic determinants at diagnosis, study patients were matched for stage, histologic type and location of the primary lesion with controls generated from these 1215 carefully reviewed sarcoma patients collected from the data base of the Task Force on Soft Tissue Sarcomas of the AJC. Only control cases whose histology had been reviewed and who had been treated with surgery (with or without radiotherapy) were included in the analysis. Cases survived significantly longer than controls at three years (p less than 0.001) and, in fact, disease-free survival of cases (63%) was superior to overall survival of controls (27%) (p less than 0.01). Our data support the conclusion that patients with high-grade soft tissue sarcoma treated by an experienced multimodality team have a three-year disease-free survival of approximately 63%. The impact of each component of multimodality therapy cannot be determined, and improved survival may result, in addition, from improved diagnostic and staging techniques currently available.

Circulating immune complex levels in patients with gestational trophoblastic neoplasia

The clinical course, human chorionic gonadotropin (HCG) levels, and serial circulating immune complex (CIC) levels in 21 patients with gestational trophoblastic neoplasia (GTN) were correlated for the evaluation of the relationship between CIC levels and trophoblastic tumor burden. CIC levels were normal in 18 of 21 patients at the time of presentation, and 2 of 3 patients who presented with elevated CIC levels had significant comorbid disease (toxemia and hepatitis). Nine patients were followed into gonadotropin remission, and all 9 developed an increase in CIC levels at the time of remission. It was concluded that CIC, at least as measured by two antigen-nonspecific techniques, is generally not elevated at initial presentation in the patient with GTN; this lack of an elevation is probably due to marked tumor antigen excess. Thus the in vivo importance of CIC as a "blocker" of host antitumor response at this stage is doubtful. After effective treatment as HCG levels return to normal, the demonstrated elevation in serial levels of CIC may reflect a return of adequate host immune response at a time of minimal tumor burden.

Surgical treatment of low grade soft tissue sarcomas

Nineteen patients who have undergone surgical resection of low grade soft tissue sarcomas were retrospectively reviewed. Four patients received additional radiation therapy, and 15 did not. Of the 15 patients treated by surgery alone, 4 had positive margins in the original specimen; all 4 had local recurrence within a mean of 42 months. Eleven patients had negative margins. Ten have had no recurrence in a mean of 40 months. One patient had local recurrence at 36 months. Two of the four patients with positive margins were reoperated on and in achieving negative margins have remained disease-free a mean of 84 months. Three patients receiving additional postoperative radiation therapy had positive margins, and all had recurrence in a mean of 36 months. One patient with negative margins who also received radiation therapy is disease-free at 144 months. It appears that tumor-positive margins are associated with a high likelihood of local recurrence, whereas negative margins appear associated with a long disease-free interval and possible cure. Radiation therapy to positive margins did not prevent local recurrence.

Effects of supernatants of polymorphonuclear neutrophils recruited by different inflammatory substances on mitogen responses of lymphocytes

Two different substances, glycogen and thioglycollate, were used to recruit early peritoneal exudate cells (4h). In the acute phase of the inflammatory response the cellular infiltrate is large, and the predominant cell (greater than 95%) is the polymorphonuclear neutrophil. Supernatant had differing effects on lymphocyte responses to the mitogens PHA and LPS, also carried out in serum-free media, depending on recruiting substance and time of culture. While glycogen-recruited PMN supernatant (GPMN-S) always enhanced splenocyte responses to PHA, thioglycollate-recruited cells (TPMN-S) did not produce an enhancing factor until the cells had been in culture for 24 h. Whereas GPMN-S enhanced the splenocyte response to LPS only after 1 or 4 h of culture, TPMN-S failed to have any significant effect. Thymocyte responses to PHA were facilitated by all supernatants. Dilution of the soluble PMN factors resulted in a suppressive effect on splenocyte responses to both PHA and LPS, regardless of whether PMN were recruited by the thioglycollate or glycogen or of the time of cell incubation. These results indicate that PMN-rich cell populations of different types of activity are recruited by glycogen and thioglycollate and that these cells produce factors capable of potentiating, enhancing, or suppressing responses to T- or B-cell mitogens by normal syngeneic lymphocytes.

Peritoneal macrophage alterations caused by naturally occurring mouse hepatitis virus

During routine harvest of murine resident peritoneal cells for macrophage function assays the authors recently noted that mice showed a 3-4-fold spontaneous increase in number of peritoneal cells within 1 week of being placed in one of their animal rooms. While the mice appeared clinically normal, the collected macrophages had highly convoluted membranes, showed enhanced spontaneous tumor cell killing, and showed increased erythrophagocytosis. Histopathologic findings included mild peritonitis and occasional foci of individual hepatocyte necrosis. The results of routine murine serologic studies and bacterial cultures of the peritoneal cavity were negative. Immunosuppressed mice placed in this room showed severe hepatic necrosis within 4 days, and ultrastructural particles characteristic of corona virus could be demonstrated in the necrotic foci. Mouse hepatitis virus (MHV) was isolated from these livers. Untreated mice showed positive MHV titers, as detected by the enzyme-linked immunoabsorbent assay (ELISA) after 21 days in the room. This episode demonstrates that MHV have profound effects on macrophage parameters while causing few clinical signs or histopathologic alterations. Secondly, the complement fixation assay for MHV as included in routine viral screens appears relatively insensitive for detecting outbreaks of MHV.

Abnormal regulation of parathyroid hormone release by calcium in secondary hyperparathyroidism due to chronic renal failure

Dispersed parathyroid cells were employed to study calcium-regulated parathyroid hormone (PTH) release in severe secondary hyperparathyroidism due to chronic renal insufficiency. Cell preparations were obtained from 16 parathyroid glands of 6 patients undergoing subtotal parathyroidectomy for parathyroid bone disease and/or hypercalcemia. The effects of increasing ambient calcium concentration on immunoreactive PTH release in vitro were assessed and compared with results observed in cells prepared from 7 adenomas and 6 normal parathyroid glands. There was no difference in maximal PTH release for the 3 types of tissue (mean +/- SEM, 8.48 +/- 1.9 , 8.1 +/- 3, and 10.1 +/- 0.78 ng/10(5) cells. h respectively). In 14 of 16 hyperplastic glands, 6 of 7 adenomas, and all of the normal glands, PTH release was inhibited more than 50% by 2-3 mM calcium (suppressible glands). Of the normal glands, half of the maximal inhibition of PTH release (the set-point) occurred at less than 1.03 mM calcium in 5 of 6 cases. In 12 of 14 suppressible hyperplastic glands and all of the 6 suppressible adenomas, on the other hand, the set-point was 1.03 mM or higher (p less than 0.01 and P less than 0.002, respectively). Thus, in severe secondary parathyroid hyperplasia due to chronic renal insufficiency, there is frequently an increase in the set-point for calcium without a change in the maximal secretory rate per cell. Abnormal calcium-regulated PTH release at the cellular level, therefore, is not limited to parathyroid neoplasia (i.e. adenoma or primary hyperplasia), but may occur in secondary hyperplasia as well.

Calmodulin in dispersed human parathyroid cells

We investigated the presence and several of the properties of calmodulin in human parathyroid cells. Boiled extracts of such cell preparations contained a heat-stable factor causing a 2- to 3-fold calcium-dependent stimulation of calmodulin-deficient phosphodiesterase activity, which was parallel to that due to pure porcine calmodulin. This activation could be totally blocked by 10(-4) M trifluoperazine, with half-maximal inhibition at 3 X 10(-5) M, similar to the effects of this phenothiazine on porcine calmodulin. These results suggested the presence of calmodulin in human parathyroid cells. By comparison with known quantities of porcine calmodulin, human parathyroid cells contained 9-208 ng calmodulin/10(6) cells. The content of calmodulin in 3 normal parathyroid glands [65 +/- 8 (+/- SEM) ng/10(6) cells] did not differ significantly from that of 12 adenomas (61 +/- 16 ng/10(6) cells). Cells from 7 glands showing secondary hyperplasia, however, had significantly greater levels of calmodulin (164 +/- 11 ng/10(6) cells) than either normal cells or adenomas (P less than 0.001 and P less than 0.005, respectively). Extracts of human parathyroid cells caused half-maximal stimulation of phosphodiesterase activity at 1.1-4.8 microM free calcium. The concentrations of calcium half-maximally activating phosphodiesterase (Ka) did not differ significantly for normal or abnormal cells (3.3 +/- 0.03 vs. 2.6 +/- 0.33; P greater than 0.3). Moreover, in 2 cases in which normal parathyroid tissue was obtained from patients with adenomas, the Ka values for calcium for the normal and abnormal cells were similar (3.3 vs. 2.5 and 3.4 vs. 2.5 microM, respectively). Finally, there was no significant correlation between either the content of calmodulin or the Ka for calcium and the set-point for calcium [the calcium concentration causing half-maximal inhibition of parathyroid hormone (PTH) release] or the maximal rate of PTH secretion for dispersed parathyroid cells. These results suggest that human parathyroid cells contain calmodulin, but provide no evidence for a role of this protein in the abnormal calcium-regulated PTH release in hyperparathyroidism.

Abnormal calcium-regulated PTH release in normal parathyroid tissue from patients with adenoma

The regulation of parathyroid hormone (PTH) secretion by calcium was studied in normal and abnormal parathyroid tissue from five patients with a parathyroid adenoma. Dispersed cells were prepared from the adenoma and from a portion of a normal parathyroid gland and were incubated for two hours with varying concentrations of calcium. PTH release as a function of the concentration of calcium was determined by radioimmunoassay (C-terminal). Cells from the normal glands showed a lower set-point for calcium (the concentration of calcium causing half of the maximal inhibition of PTH release) than those from the adenomas in four of five cases. Moreover, both set-point and maximal PTH release at low concentrations of calcium were significantly lower in normal glands from patients with an adenoma than in normal glands from patients with normal calcium homeostasis (0.77 +/- 0.04 [SEM] versus 0.99 +/- 0.03 mM calcium and 3.4 +/- 0.43 versus 10.1 +/- 0.78 ng/10(5) cells/hr, respectively). These observations may explain, in part, the transient hypocalcemia frequently seen in patients after removal of a parathyroid adenoma. In addition, they suggest that the set-point for calcium and maximal PTH release in normal parathyroid tissue may be altered by prior exposure to chronic hypercalcemia or other physiologic variables. Finally, the "normal" set-point that we have noted previously in parathyroid tissue from some patients with primary parathyroid hyperplasia may be inappropriately high for the hypercalcemia seen in those cases.

Human gamma-lipotropin radioimmunoassay: identification of immunoreactive gamma-lipotropin in human plasma and tissue

Disagreement exists concerning the relative contributions to total plasma immunoreactive human lipotropin (hLPH) made by h beta LPH and its amino-terminal fragment, h gamma LPH [h beta LPH-(1-58)]. Using an antiserum (R1547) which requires the free COOH-terminal Asp58 residue of h gamma LPH for full affinity and reacts only 1% as well with h beta LPH and antisera (R3 and G106) that react with both LPHs, we examined gel chromatography eluate fractions of plasma extracts from one normal subject under basal conditions and another after metyrapone administration, of plasma or plasma extracts from patients with ACTH/LPH hypersecretion of various causes, of an extract two normal pituitary glands, and an extract of an ectopic ACTH/LPH-secreting tumor. Immunoreactive h gamma LPH was always a major, frequently the predominant, and sometimes the only immunoreactive LPH observed. We also observed in plasma or tissue of two patients with ectopic ACTH/LPH syndrome a peptide whose immunoreactivity and apparent molecular size were consistent with those of octadecapeptide human beta MSH, a molecule that is not thought to exist in normal man. These studies demonstrate that h gamma LPH is a major LPH component in plasma and tissues and indicate that the h gamma LPH RIA provides a reliable estimate of the h gamma LPH concentration in plasma without prior chromatography.

In vivo and in vitro effects of xenogeneic immune ribonucleic acid in patients with advanced renal cell carcinoma: a phase I study

Based upon demonstration in our laboratory of repeated prevention of pulmonary metastases by adjuvant immune ribonucleic acid in animal preparations, xenogeneic immune ribonucleic acid was given in a phase I study to patients with advanced renal cell carcinoma. Six patients were treated with intravenous infusions of autologous lymphocytes incubated in vitro with immune ribonucleic acid extracted from splenocytes of guinea pigs immunized with the patient's own tumor. Serial peripheral blood lymphocytes were obtained during and after each treatment with immune ribonucleic acid for in vitro evaluation of cell-mediated cytolysis by 51chromium release assay and 125iodine iododeoxyuridine assay against allogeneic renal cell carcinoma targets and melanoma targets. Neither toxicity nor enhancement of tumor growth was observed. All patients demonstrated significantly increased cell-mediated cytolysis against allogeneic renal cell carcinoma targets but no change against melanoma targets. Increased cell-mediated cytolysis could be demonstrated in individual blood samples after incubation with immune ribonucleic acid. Further, progressive in vivo effect was demonstrated in in vitro assay of serial peripheral blood lymphocytes before each successive exposure to immune ribonucleic acid. Increased cell-mediated cytolysis persisted in peripheral blood lymphocytes up to 9 months after therapy. Although without controls 1 patient had complete response and 2 patients had partial responses (8 to 18 months). Two patients had stabilization of the disease for 3 to 4 months and 1 patient had progression of cerebral metastases. One patient is alive 24 months after therapy. These results would favor the institution of a randomized prospective trial in patients with advanced renal cell carcinoma or lesser tumor burdens.

Evaluation of palliative procedures for pancreatic cancer

In a retrospective review of 51 patients undergoing palliative procedures for carcinoma of the pancreas from 1974 to 1979, cholecystoenterostomy was as effective as choledochoenterostomy. Patients with loops had the same incidence of cholangitis as those with Roux-Y limbs. Prophylactic gastroenterostomy was not performed routinely. Few patients needed a later gastroenterostomy for progressive cancer.

Application of polyethylene glycol turbidity assay to detection of circulating immune complexes in cancer patients

A rapid, reproducible immune complex screening assay was used to quantitate levels of circulating immune complexes in the sera of normal subjects, patients with documented increases in immune complexes from rheumatoid arthritis, patients with clinically or microbiologically documented infections, and patients with cancer. Although wide variations in individual values within the groups were noted and the concurrent elevation of polyethylene glycol-circulating immune complex levels by infection was documented as expected, significant differences were found in the values in patients with cancer compared with those in normal subjects. The overall clinical application of polyethylene glycol-circulating immune complex screening is discussed and current application of screening of serial sera samples from individual patients for correlation with measurable tumor volume is proposed.

Anticoagulants, venous thromboembolism, and the cancer patient

The records of 32 cancer patients who were treated with heparin sodium and warfarin sodium for thromboembolic disease were reviewed. Standard techniques for anticoagulation were neither safe nor effective. Sixteen patients experienced 21 different hemorrhagic complications. Eight patients had major hemorrhages that led to cessation of therapy or death. Six of 32 patients had pulmonary embolisms while receiving anticoagulants. It is suggested that venous interruption may be a safer and more effective method of prophylaxis against pulmonary embolism in cancer patients.

Analysis of recurrence patterns following curative resection for carcinoma of the colon and rectum

The records of 525 patients with adenocarcinoma of the colon and rectum were reviewed. Two hundred and eighty-five patients were evaluable following complete curative resections. These patients were evaluated for patterns of recurrence. The over-all recurrence rate was 78 of 285, 27 per cent. The over-all recurrence rate by site was 24.0, 10.0, 11.5 and 35.0 per cent for the right, transverse and left colon, the sigmoid and the rectum, respectively. The over-all failure rate by stage was 13 per cent for Stage A, 11 per cent for Stage B1, 32 per cent for Stage C1, 37 per cent for Stage B2-3 and 56 per cent for Stage C2-3. The over-all failure rate as related to Stages A, B1, C1, B2-3 and C2-3 and to site of primary disease was: right--zero, 9, 33, 28 and 43 per cent, sigmoid--11, 15, 40, 52 and 62 per cent; rectal group--29, 14, 40, 46 and 60 per cent as related to respective stages. There was one failure among the five patients with Stage B2-3 disease in the transverse group and two failures among the nine patients with Stage B2-3 and one failure in the one patient with Stage C2-3 within the left colon group. Individual types of failure were compiled. Lesions involving the rectum and sigmoid colon had a significant local-regional component to relapse. Tumors of the right, transverse and the left colon had a significant distant recurrence rate. Factors of primary site, age at diagnosis, extent of disease and histology were reviewed as to the over-all recurrence and specific failure sites. From this analysis, a schema involving patterns of failure as related to primary site and stage within the colon, rectum and sigmoid were developed.

Immunogenicity and cross-protection among B16 melanoma variants with differing proclivities to metastasize

We report here the lack of any relationship between immunogenicity and the potential to metastasize among four B16 melanoma variants. Groups of C57BL/6J mice were immunized with one of four B16 variant lines (maintained by serial IM passage) that were shown in separate experiments to produce the following incidences of pulmonary metastases four to six weeks after isograft excision: M1, 10%-15%; M2 10%-20%; M3, 75%-80%; and M4, 75%-90%. After immunization, mice were challenged with one of the four variant lines in a crisscross fashion. Two challenge doses for each line were chosen on the basis of earlier experiments showing 100% and 50% challenge tumor take in nonimmunized animals. Despite earlier work published from this laboratory showing that splenocytes harvested from immunized mice could distinguish antigenic differences among the B16 variants, we could find no significant difference in immunogenicity or cross-protection among the lines regardless of their metastatic potential. We conclude that no correlation exists between the antigenic differences shown by in vitro splenocyte-mediated cytotoxicity assays among the B16 variants and in vivo immunogenicity or cross-protection experiments. Futhermore, the relationship (if any) between immunogenicity and the ability to metastasize among these B16 variants is not straightforward.

Effect of major small bowel resection on dimethylhydrazine-induced bowel carcinogenesis

We have investigated the effect of distal small bowel resection on chemically induced tumors of the gastrointestinal tract in Wistar/Furth (W/Fu) rats. Dimethylhydrazine (DMH) (20 mg/kg sc once weekly x 16) was commenced 3 months after rats underwent resection of the distal 30 cm of small bowel (one-third resection) or after sham small bowel resection (controls). Fifty weeks after the start of DMH administration, tumors were found in 15 of 25 animals who underwent small bowel resection compared to 9 of 31 animals in the control group (P less than 0.05). After small bowel resection, 8 of 15 tumors occurred at the site of anastomosis but no anastomotic tumors were seen after sham resection. In addition, tumors were larger and more invasive after small bowel resection. These data indicate that major small bowel resection potentiates DMH induced-intestinal carcinogenesis.

Relationship of intestinal obstruction to serial plasma carcinoembryonic antigen levels

Since it has been suggested that colonic obstruction due to carcinoma may play a role in elevations of circulating carcinoembryonic antigen, serial plasma carcinoembryonic antigen levels were studies in 19 patients with intestinal obstruction due to tumor and nontumor causes. Regardless of cause, eight of ten patients with colonic obstruction did not show decreased carcinoembryonic antigen levels after decompression. Two patients with postoperative carcinoembryonic antigen reductions of greater than 40 per cent had ascite removed at operation. Removal of a large volume of carcinoembryonic antigen-rich ascites was thought to contribute to the fall in circulating carcinoembryonic antigen. Six patients with small intestinal obstruction and one patient with large and small intestinal obstruction did not show a reduction in postdecompression carcinoembryonic antigen levels. One patient with Crohn's disease who underwent ileal resection and one with intestinal obstruction due to carcinoma of the ovary who underwent resection at the time of decompression had a greater than 40 per cent reduction in postoperative carcinoembryonic antigen levels. Inflamed intestinal and carcinoma of the ovary are known sources of carcinoembryonic antigen and their removal could explain the decrease in carcinoembryonic antigen. Rehydration, as monitored by plasma osmolality and protein concentration, did not explain changes in plasma carcinoembryonic antigen. Thus, it appears that carcinoembryonic antigen production may play a more significant role in the regulation of circulating carcinoembryonic antigen than the physiopathologic processes associated with obstruction.

Successful treatment of metastatic sarcomas with cyclophosphamide, adriamycin, and DTIC (CAD)

Fifty consecutive adults with sarcoma were treated with Adriamycin (45 mg/m2) on day 1, cyclophosphamide (500 mg/m2) on day 2, and DTIC (400 mg/m2) on days 1 and 2 (CAD). Of the 23 patients with measurable metastatic disease, 4 patients (17%) had a complete response, 9 patients (39%) had a partial response, 5 patients (22%) had stabilization, but 5 patients (22%) did not respond. The actuarial survival of complete and partial responders was 31.5 months compared to 5.5 months for non-responders (P < .005). Chemotherapy doses were escalated to a median lowest white count of 700 cells/mm3. Acute gastrointestinal toxicity and alopecia occurred in all patients. CAD differed from previously reported combinations by omission of vincristine, a two-day dose schedule and dose rate intensification. CAD is recommended for patients with metastatic sarcoma.

Modification of in vitro and in vivo immune function by acute inflammatory cells

The ability of adoptively transferred, syngeneic polymorphonuclear leukocyte-rich (PMNLr) inflammatory cells to influence lymphocyte-mediated cytotoxicity (LMC), complement-dependent cytotoxicity (CDC), and skin allograft survival was studied in a murine model. BALB/c mouse PMNLr, stimulated by i.p. injection of either glycogen (G/PMNLr) or thioglycollate (T/PMNLr), were transferred to other BALB/c mice at the time of primary or secondary immunization with a cellular alloantigen (C57BL/6 spleen cells) or after skin allografting (C57BL/6 tailskin). The metabolic activity of each PMNLr population was determined by measuring glucose utilization in the hexose monophosphate shunt. It appeared that metabolic activity of the T/PMNLr was significantly greater than that of the G/PMNLr. Our results indicate that, while the infusion of G/PMNLr tended to suppress the primary cell-mediated immune response and the secondary humoral immune response, the infusion of T/PMNLr stimulated both of these responses. Furthermore, i.p. infusion of mice with G/PMNLr at a time approximating grafting resulted in prolonged graft survival, but neither T/PMNLr nor syngeneic thymocytes effect graft survival. Our data demonstrate that both cellular and humoral immunity can be modified by acute inflammatory cells. The metabolic status of the acute inflammatory cells seems to be critical in determining their immunoregulatory potential.

Patterns of recurrence following curative resection of adenocarcinoma of the colon and rectum

This study explores the patterns of recurrence after "curative" operation for colorectal cancer. For an 11-year period, 1960-1971, 281 evaluable patients were resected at the Peter Bent Brigham Hospital. Crude five-year survival in these patients was 49%, but only 10% of those with recurrence lived five years. A total of 69 patients relapsed during their lifetime and 34 additional patients were found to have metastases at death. The initial site of metastases were regional in 23 patients (33%) and distant in 32 (46%). Simultaneous regional and distant metastases were found in 13 (19%) for a total of 65% of patients having initial distant metastases. Approximate recurrence rates by site were: 30% for sigmoid and rectum, 20% for right colon, and 10% for transverse and left colon. Tumor size was a significant determinant of recurrence but did not select for regional or distant sites. Recurrence by Astler-Coller modification of the Dukes-Kirklin classification revealed 10% for A + B1, 33% for B2, 35% for C1, and 50% for C2. More than half of the patients with distant metastases (18/32) had solely hepatic metastases yet the total incidence of liver metastases as the initial site was only 8% of the total. In general, the site of the primary cancer was the most important determinant of the type of recurrence; the stage and site of the primary tumor were most predictive for eventual relapse.

The use and limitations of serial plasma carcinoembryonic antigen (CEA) levels as a monitor of changing metastatic liver tumor volume in patients receiving chemotherapy

Nine patients with liver-predominant or liver-only metastatic adenocarcinoma, who received hepatic intra-arterial and peripheral intravenous chemotherapy, were evaluated to determine if changes in plasma CEA accurately indicated changes in liver tumor volume as estimated from serial liver scan defect sizes, and if the two were quantitatively related. When selected periods of tumor remission or progression were studied during chemotherapy, the index of change of serial CEA values correlated positively (r = 0.764, P = 0.01) with the index of change of liver tumor volume in all 9 cases. Changes in absolute CEA values, however, aid not correlate significantly with changes in absolute liver tumor volumes when assessed either during these selected periods or throughout individual patient courses. Biologic and methodologic factors that influence the quantitative relation between liver tumor volume and plasma CEA are discussed.

Patterns of recurrence following curative resection of adenocarcinoma of the colon and rectum

This study explores the patterns of recurrence after "curative" operation for colorectal cancer. For an 11-year period, 1960-1971, 281 evaluable patients were resected at the Peter Bent Brigham Hospital. Crude five-year survival in these patients was 49%, but only 10% of those with recurrence lived five years. A total of 69 patients relapsed during their lifetime and 34 additional patients were found to have metastases at death. The initial site of metastases were regional in 23 patients (33%) and distant in 32 (46%). Simultaneous regional and distant metastases were found in 13 (19%) for a total of 65% of patients having initial distant metastases. Approximate recurrence rates by site were: 30% for sigmoid and rectum, 20% for right colon, and 10% for transverse and left colon. Tumor size was a significant determinant of recurrence but did not select for regional or distant sites. Recurrence by Astler-Coller modification of the Dukes-Kirklin classification revealed 10% for A + B1, 33% for B2, 35% for C1, and 50% for C2. More than half of the patients with distant metastases (18/32) had solely hepatic metastases yet the total incidence of liver metastases as the initial site was only 8% of the total. In general, the site of the primary cancer was the most important determinant of the type of recurrence; the stage and site of the primary tumor were most predictive for eventual relapse.

Malignant intestinal obstruction

The records of 66 consecutive patients who developed intestinal obstructions after treatment for cancer were reviewed. Approximately one third of the patients were found to have a benign cause of obstruction. The chances that an obstruction was due to cancer were increased if the patient had known metastatic cancer, previous colorectal cancer, if the primary was an advanced stage, and if the interval since treatment of the primary was short. Incomplete obstructions were treated with nasogastric suction. Although resolution of the obstruction on nasogastric suction without operation occurred in 24% of the admissions, 41% of those patients had to be readmitted for surgical relief of recurrent intestinal obstruction. Resolution of an obstruction on nasogastric suction occurred early, and there was little point in continuing a trial of suction for longer than 3 days.

Pigment mutants of Chlamydomonas with deformed plastids and increased levels of chloroplast nucleic acids

The chloroplast ultrastructure of two Chlamydomonas reinhardtii pigment variant mutants, U3N and U3A, is strikingly different from that of the wild type. The mutant chloroplast has greatly lowered levels of chlorophyll a and b, and lacks the usual ordered thylakoid membrane structure. The amount of chloroplast ribosomes is increased, but the pyrenoid and surrounding starch grains appear to be unaltered. Our biochemical analyses have shown that, while the properties of chloroplast DNA, ribosomal RNA, and ribosomes in these mutants appeared to be normal, their relative amounts per cell increased markedly when compared to the wild type. In U3N these increases were approximately 60% for chloroplast DNA and 80% for chloroplast ribosomes. However, the ratio of chloroplast rDNA genes to total chloroplast DNA remained unchanged as shown by DNA-rRNA hybrdization. We propose that (1) The enhanced level of chloroplast ribosomes in these mutants is a direct consequence of the elevated amount of chloroplast DNA. Both of these increases may, in turn, arise from defective mechanism for their control. (2) These mutants grow successfully in the absence of functional photosynthesis, provided an external carbon source is available to them, but functional plastid DNA, ribosomes and protein synthesis may still be a requirement for normal starch metabolism.