New avenues in the use of cyclosporine for transplantation. Graft and donor pretreatment

Modification of graft immunogenicity using graft (GPTX) and donor pretreatment (DPTX) has been pursued in an attempt to modify allograft immunogenicity using various immunosuppressive agents. The murine skin allograft and canine renal allograft models were used to study the efficacy of Cyclosporine (Cy A) as a DPTX and GPTX prior to transplantation. Tail skin allografts from C3HHeN male mice were grafted to Balb/c female mouse recipients. Minimal immunosuppression was given to all skin graft recipients. Skin allograft were either GPTX with Cy A, DPTX with either Cy A, methylprednisolone (MP), or cyclophosphamide (CP), or Cy A GPTX and DPTX with the three drugs alone or in combination. Cy A GPTX alone of skin allografts did not significantly prolong survival. DPTX with Cy A significantly prolonged skin graft survival, however, CP or MP alone did not. The various combinations of MP, Cy A, and CP as DPTX and MP, Cy A, and CP DPTX used together with Cy A GPTX also significantly prolonged murine skin allograft survival. Kidney allografts used unrelated mongrel dogs as donors or recipients. Renal transplant experimental groups were either: Non-pretreated and immediately transplanted, nonpretreated and hypothermically stored (HS) for 24 hours in Collins (C-2) solution, GPTX with 12.5 mg Cy A during 24 hr. HS in C-2, DPTX with Cy A (25 mg/Kg), or Cy A DPTX (15 mg/kg) and GPTX during 24 hrs. HS in C-2. Cy A GPTX during HS was sometimes effective in prolonging kidney allograft survival greater than 30 days using only minimal immunosuppression with azathioprine. Cy A DPTX prolonged survival somewhat, but not significantly. Improved results were seen, however, when Cy A DPTX was used together with Cy A graft pretreatment. These results indicate the potential for the successful use of Cy A as a donor and/or graft pretreatment, however, further studies will be necessary to optimize the use of Cy A in these modalities.

Human cryptosporidiosis: spectrum of disease. Report of six cases and review of the literature

Although once regarded exclusively as an animal parasite, Cryptosporidium has emerged during the last decade as a cause of diarrhea in humans. Of the 43 cases of human cryptosporidiosis reported, 27 patients in whom either humoral or cell-mediated immune defects were present had chronic protracted diarrhea that was almost invariably unresponsive to therapy and culminated in death. In contrast, 16 patients with intact immune systems had either self-limited disease or were asymptomatic. Animal exposure was almost exclusively recorded in the latter group. During the last six months at University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, gastrointestinal (GI) tract cryptosporidiosis developed in six homosexual men with acquired immune deficiency syndrome (AIDS). The diagnosis of cryptosporidiosis was established histologically in five patients. In four, cryptosporidial oocysts were detected in the stool. In addition to extensive GI tract cryptosporidiosis, two patients had biliary tract involvement. Multiple chemotherapeutic agents failed to control the disease, and five patients eventually died. Cryptosporidiosis should be considered in the differential diagnosis of diarrhea, in animal handlers or in the severely compromised patient, especially one with AIDS, who has chronic protracted diarrhea.

Nonbacterial thrombotic endocarditis in a male homosexual with Kaposi's sarcoma

Nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, was found at autopsy in a young male homosexual with Kaposi's sarcoma. Vegetations were seen in the mitral and aortic valves. Embolic phenomena and cytomegalovirus infection were noted in the brain, spleen, liver, lung, gastrointestinal tract, and bone marrow. To our knowledge, this is the first reported case of NBTE in a young immunosuppressed homosexual man with Kaposi's sarcoma.

Phase I study of MVE-2 therapy in human cancer

MVE-2, a polymer of maleic anhydride and divinyl-ether (molecular weight, 15,500), was given to 57 patients in a phase I study. The agent was selected for study because it was a potent macrophage activator, interferon inducer, and immunotherapeutic agent in animal tumor models. The drug was administered by iv infusion over a 1-hour period using three schedules of administration: (a) weekly at doses of 25-650 mg/m2, (b) every other week at doses of 500-1200 mg/m2, and (c) every 3 weeks at doses of 1200-1500 mg/m2. No cardiac, pulmonary, hematologic, or hepatic toxicity was observed. There were 25 episodes of asymptomatic proteinuria in 26 patients who received MVE-2 dose levels of greater than or equal to 500 mg/m2. It was not associated with changes in BUN or creatinine. The proteinuria began approximately 4 weeks after the start of therapy and lasted approximately 4-6 weeks after the therapy was terminated. Proteinuria resolved in all patients followed. At present, proteinuria appears to be the major dose-limiting toxicity. None of the patients had a partial or complete response although there was evidence of biologic activity with measurable tumor regression in five patients. No major modification of host defense parameters was noted. Further studies should be directed towards determining the nature of the proteinuria and whether changes in the rate or schedule of administration can modify the proteinuria or increase the host defense modification.

Immunological characterization of homosexual males

To help clarify the nature and pathogenesis of the syndrome of severely opportunistic infection associated with immune deficiency in young homosexual males, we investigated the immunological characteristics of a group of 33 young homosexual men. These young men all had the prodrome to the syndrome which included a history of multiple sexual partners and multiple sexually transmitted diseases. In addition, they all had a past history of mild to moderate viral, bacterial, parasitic, or fungal infections and had used recreational drugs. Within this group of patients, there were five men who had Kaposi's sarcoma. Compared to the 21 normal heterosexual individuals, the homosexual men were found to be anergic to a battery of recall antigens (52% versus 19%); to be hyporesponsive to mitogen stimulation (pokeweed, 30.7 x 10(-3) versus 65.3 x 10(-3) cpm, p less than or equal to 0.005; concanavalin A, 32.2 x 10(-3) versus 60.1 x 10(-3) cpm, p less than or equal to 0.006); and to have lower helper T-cells (18% versus 34.6%, p less than or equal to 0.01), inverted helper:suppressor T-cell ratios (0.85 versus 1.92, p less than or equal to 0.01), and an elevated serum thymosin alpha 1 level (1473 versus 524 pg/ml, p less than or equal to 0.001). These data suggest that the immunological defect precedes the syndrome. The mechanism of this phenomenon is unclear; however, the repeated viral infection combined with drug usage may be responsible. The five patients with Kaposi's sarcoma were compared as a group to the other patients without cancer and found to be more severely immunodeficient. This suggests that the immune suppression by the malignant disease is superimposed on the preexisting deficiency.

Immunological studies of male homosexuals with the prodrome of the acquired immunodeficiency syndrome (AIDS)

Homosexual patients who mainly had the prodrome of the syndrome of opportunistic infection and Kaposi's sarcoma were studied immunologically. Patients showed diminished delayed hypersensitivity to recall antigens, diminished lymphocyte blastogenic responses, a suppressor cell for lymphocyte proliferative responses, low helper cells and an inverted helper:suppressor ratio. The patients had low levels of adherent monocytes. NK cell activity and antibody dependent cellular cytotoxicity were normal. Virtually all patients showed elevated serum thymosin alpha 1 levels and elevated serum lysozyme levels. The most consistent findings were the low helper cells, inverted helper:suppressor ratio and elevated serum thymosin alpha 1 and lysozyme. The patients with the prodrome should be subjected to therapeutic research with immunorestorative drugs.

Administration of BCG cell wall skeleton into malignant effusions: toxic and therapeutic effects

Thirty-nine patients with 40 refractory malignant effusions (26 pleural and 14 peritoneal) were treated locally with a nonviable mycobacterial vaccine. The vaccine was administered into the effusion and consisted of BCG cell wall skeleton and trehalose dimycolate attached to oil microdroplets. A dose range of 150--3000 microgram was tested. The overall response rate was 44.0% (complete response [CR] plus partial response [PR]) and was not clearly dose-related. The response rates for each site were 13.6% (CR) and 31.8% (PR) for pleural effusions and 33.3% (CR) and 8.3% (PR) for peritoneal effusions. Toxic effects consisted of fever (40%), serosal pain (37.5%), and increased effusion (27.5%) and were not clearly dose-related. Gastrointestinal toxic effects were seen in 50% of patients treated for peritoneal effusions. Response correlated with prior exposure to BCG vaccine or tuberculosis, and with a febrile response to vaccine administration. This vaccine has a therapeutic effect on both pleural and peritoneal effusions.

Organ distributions and clearance studies of 99mtechnetium-labeled Corynebacterium parvum in patients with leukemia

The clearance, metabolism and localization of Corynebacterium parvum (C. parvum) labeled with 99mtechnetium (99mTc) given intravenously was studied in various leukemia patients to develop the method and to evaluate reticuloendothelial systems (RES) function. A computer program was utilized to characterize the clearance. C. parvum 0.05 mg was labeled aseptically with 10 mCi of 99mTc with a reducing agent. It was injected intravenously over 5 s and clearance was characterized over the next 60 min. The low dose of C. parvum did not cause any symptoms. The blood or plasma clearance time (t 1/2) was in the range of 0.65 to 1.96 min, in eight patients. By whole body imaging, the distribution of C. parvum was found mainly in the liver, and to a much lesser extent in the spleen, lungs, and bone marrow. Nonparticulate 99mTc (which was not sedimented by centrifugation of blood samples at 3000 rpm for 30 min) appeared rapidly in the blood after i.v. injection accounting for more than half of the radioactivity in a few minutes. In vitro incubation of 99mTc labeled C. parvum with saline, whole blood, serum or leukocytes revealed that the release of free 99mTc resulted from the combined action of serum and leukocytes. The rapid clearance will limit the utility of this preparation in characterizing RES function in man and its modification by disease or therapy.

The use of leukocyte cell line culture supernatant for skin reaction testing in malignant melanoma

A study was conducted to determine some of the potential applications of a human leukocyte culture supernatant or "lymphokine" preparation in cancer patients. The application evaluated in this study was the use of this preparation as a skin test reagent for evaluation of the inflammatory response following intradermal injection. The preparation was derived from the supernatant of a long-term cultured lymphoblastoid cell line with migration inhibition factor (MIF) and other lymphokine activities. Dose response, histology and toxicity studies were done in 53 patients with malignant melanoma stage IIIB and IV. A dose response curve was observed for both erythema and induration at 12 and 24 hours, but not at 48 hours. An optimal intradermal dose for eliciting inflammation was determined and found to be five units. Histopathological evaluation of biopsy specimens showed a mixed cell reaction including granulocytes, eosinophils, lymphocytes and monocytes differing in lymphocyte content from the classical delayed type hypersensitivity (DTH) reaction in man. Compared with the response to recall antigens, only a weak correlation with the DTH response to the recall antigens was found. Our results support the conclusion that lymphokines may be used in the future to evaluate the ability to develop nonspecific inflammation in cancer patients, and that this inflammatory response can be obtained in a number of patients no longer capable of responding to recall antigens.

Response of malignant melanoma to plasma exchange, surgical debulking, and Corynebacterium parvum

A 48 year old man with extensive cutaneous and subcutaneous metastatic malignant melanoma responded to treatment by repeated plasma exchanges, partial surgical debulking of tumor masses, and intravenous Corynebacterium parvum. Circulating immune complexes were measured by the serum C1q binding method. Tumor regression coincided with serum C1q binding reduction to normal levels. Clinical relapse was preceeded by recurrent elevation of serum C1q binding activity.

The combined effect of radiotherapy and neuraminidase-treated tumor cells on 3-methylcholanthrene-induced fibrosarcoma

Active immunotherapy with tumor cells treated in vitro with Vibrio cholerae neuraminidase (VCN) plus mitomycin C augments the antitumor effects of local x irradiation in the treatment of firmly established methylcholanthrene-induced fibrosarcoma, MC-43, in syngeneic C3H/HeJ female mice. In most experiments, the inhibition of tumor growth was greater when VCN-treated tumor cells were combined with local irradiation than could be achieved with VCN-treated tumor cells or local irradiation alone. Even in those experiments in which the immunotherapeutic effect of VCN-treated cells was negligible, the combination of radiotherapy and immunotherapy appeared to be greater than irradiation alone. Similarly, total permanent regression of established tumors occurred more frequently after combined therapy than after immunotherapy or radiation therapy alone.

Experimental cancer immunotherapy: modification of tumor cells to increase immunogenicity

Firmly established transplantable C3H/HeJ mammary carcinomas can be inhibited by host challenge with Vibrio cholerae neuraminidase (VCN)-treated tumor cells. The effect is totally immunospecific, even VCN-treated tumors bearing shared mammary tumor virus (MTV) antigen cannot induce the regression. Thus, VCN is capable of increasing the immunogenicity of the private, unique-unshared tumor antigens on mammary carcinomas; VCN is incapable of increasing the immunogenicity of the shared MTV-associated tumor antigen even in syngeneic C3HeB/FeJ MTV-free mice. The immunoregressive effect of VCN-treated tumor cells can be augmented by subtotal or total surgical excision of large transplantable tumors. Spontaneous mammary tumors in retired breeder C3H/HeJ female mice can be made to regress by two immunological maneuvers: (1) repeated intratumor injections of VCN and/or BCG; and (2) total excision and immunotherapy with VCN-treated autochthonous mammary tumor cells. The use of VCN-treated transplantable mammary tumor cells sharing the MTV-associated antigen was not better than excision alone. The evidence supports the idea that active specific immunotherapy of spontaneous tumors with VCN-altered tumor cells may require the use of autochthonous cells.

Modifying the immunogenicity of cell membrane antigens. Tumors and transplants

The immunogenicity of an antigenic cell is a distinctly different property from its antigenic composition. Two clinical problems might well be beneficially affected by modifying the immunogenicity of cell membrane antigens: Can the immunogenicity of tumor-specific antigens on malignant cells be increased so that effective immunity to the tumor will lead to its destruction? Conversely, can the immunogenicity of histocompatibility antigens on grafted organs be minimized so that they will survive a foreign host? Evidence is accumulating to indicate that under certain conditions a tumor vaccine can be developed utilizing autochthonous tumor cells, removed from the host, chemically modified in vitro, and reinjected into the original host which will effectively, augment specific immunologic defenses against residual tumor cells. Similarly, the moderately immunosuppressed host will tolerate grafts after suitable immunogenic modification in vitro. Both approaches may have ready clinical application, even before the mechanisms have been worked.