Current status and future prospects for adjuvant therapy of melanoma

Advances in the treatment of melanoma have resulted mainly from improved surgical management of the primary tumour assisted by a greater appreciation of major prognostic factors in the natural history of the disease. Further improvement in the treatment of melanoma will depend largely on introduction of methods to prevent recurrence of the disease. The present review discusses criteria for selection of patients with a high risk of recurrent disease and the adjuvant treatment that has been used in past studies to prevent recurrences. With few exceptions various regimens of chemotherapy, non-specific immunotherapy with bacterial products or combinations of these treatments have not increased disease free or survival periods. Immunotherapy with various sources of melanoma antigens or with viral lysates of melanoma cells have produced encouraging results in uncontrolled studies and require further evaluation. Several advances appear to provide scope for new initiatives in immunotherapy. These include an appreciation of the role of suppressor cells in regulation of immune responses against tumour cells and possible methods to inhibit their activity. A second is the definition of various lymphokines involved in generation of immune responses (particularly interleukin 2) and development of in vitro methods for large scale production of these factors. Thirdly, methods are becoming available to define the heterogeneity of tumour cells in terms of cell surface antigens or their release of soluble factors which may help select treatments appropriate to each patient.

Ethnic differences in the lymphocyte proliferative response induced by a murine IgG1 antibody, Leu-4, to the T3 molecule

The mitogenic effects of isotypically diverse antibodies to the T3 molecule were examined in genetically diverse population groups. Whereas the OKT3 antibody (IgG2a) was mitogenic for blood mononuclear cells from all individuals tested, the 38.1 antibody (IgM) was consistently nonmitogenic. In contrast, studies of the mitogenic effects of the Leu-4 antibody (IgG1) revealed striking ethnic differences. More than 80% of Caucasians and Negroes were good Leu-4 responders, whereas most individuals of Asian origin, including Indian, Japanese, and Chinese, were either Leu-4 nonresponders or Leu-4 low responders. However, the majority of American Indians, as well as a significant minority of Chinese, were good responders. Cell separation studies confirmed that monocytes govern the different mitogenic effects of the anti-T3 antibodies. The results reveal interesting ethnic differences in monocyte accessory function probably mediated via the Fc-gamma receptor, in the stimulation of T lymphocytes by an IgG1 antibody against the T3 molecule.

Characterization of human granular lymphocyte subpopulations expressing HNK-1 (Leu-7) and Leu-11 antigens in the blood and lymphoid tissues from fetuses, neonates and adults

Three subpopulations of human granular lymphocytes from blood and lymphoid tissues were characterized using combinations of the monoclonal antibodies (mAb) HNK-1 (Leu-7), Leu-11 and VEP13. Each subpopulation was confirmed to possess natural killer (NK) cell functional capability, but a different level of cytotoxic efficiency (HNK-1+leu-11- less than HNK-1+Leu-11+ less than HNK-1-Leu-11+). In adult from 23 healthy donors, the subpopulations with HNK-1+Leu-11-, HNK-1+Leu-11+ and HNK-1-Leu-11+ phenotypes comprised 4.7 +/- 3.0, 8.0 +/- 6.4 and 3.9 +/- 3.5% of mononuclear cells, respectively. Despite their distinct surface marker phenotypes and NK functional ability, all 3 subpopulations exhibited granular lymphocyte morphology. One of these subpopulations, HNK-1+Leu-11-, also expressed the pan-T cell antigen Leu-4. Different patterns were observed in fetal bone marrow and cord blood, where the vast majority of HNK-1+ cells lacked the Leu-11 antigen (HNK-1+Leu-11+ cells). The HNK-1 antigen was not expressed on granulocytes and their precursors, whereas both Leu-11 and VEP13 antigens were expressed on these myeloid cells from fetal bone marrow and cord blood as well as adult bone marrow and spleen. Cell lines of granular lymphocytes cultured in the presence of interleukin 2 all possessed the HNK-1+Leu-4+ phenotype and NK functional capability but lacked the Leu-11 and VEP13 antigens on their surface after 15 days of culture. Although granular lymphocytes expressing the Fc receptors reacting with the mAb Leu-11 and VEP13, are the most functionally active NK cells, the HNK-1+ subpopulation lacking the Leu-11 and VEP13 antigens appears to be an important population (possibly an immature form of granular lymphocytes) for delineating the cell lineage(s) and differentiation of human granular lymphocytes. Although none of the currently available mAb react both inclusively and exclusively with human granular lymphocytes, the combination usage of these antibodies permits a more precise and comprehensive analysis of these subsets.

Preoperative regional chemotherapy and rapid-fraction irradiation for sarcomas of the soft tissue and bone

Conventional treatment for high grade and large sarcomas uses a radical surgical approach, including amputation, in many patients. We evaluated a limb-sparing treatment approach using preoperative regional Adriamycin chemotherapy and rapid-fraction radiation therapy. Thirty patients with soft tissue or skeletal sarcoma were treated in a prospective, nonrandomized clinical trial to evaluate local disease control and limb salvage in these patients who would otherwise require amputation or face a high risk of local recurrence with surgical excision. Almost all patients had large tumors with grade III histologic findings. All patients had a three day intra-arterial regional chemotherapy infusion with Adriamycin (100 milligrams total dose), followed within ten days by rapid-fraction irradiation (3,000 rads over a two week period) prior to surgical excision of the tumor. The size and location of the sarcoma permitted only a marginal resection in one-half of the patients, while the remainder could be excised in a three dimensional en bloc manner. Almost all patients received post-operative systemic Adriamycin chemotherapy (450 milligrams per square meter given intravenously over a six month period). Two of six patients with significant wound complications later required amputation. Only one patient (3 per cent) has had a local recurrence of sarcoma develop after a mean follow-up of 22 months (range nine to 42 months), and 90 per cent of the patients have a useful extremity. The three year survival rate was 68 per cent for soft tissue sarcomas, compared with an expected survival rate of 38 per cent for published historical control studies. The patient with osteogenic sarcoma has a projected 83 per cent survival rate at 18 months after treatment. This multimodality approach is an effective treatment for local disease control in patients with high risk sarcoma. It permits limb salvage in most patients without compromising the survival rates.

Suppression of immunoglobulin synthesis by lymphocyte subpopulations in patients with Crohn's disease

In previous studies, patients with mild or inactive Crohn's disease were found to have increased suppressor T-cell activity. To further characterize suppressor T cells in Crohn's disease, studies were carried out with the use of monoclonal antibodies. Excessive suppressor activity was eliminated by removal of OKT 8+ lymphocytes by complement-mediated lysis. However, the percentage of OKT 8+ (or Leu 2a+) cells and the ratio of OKT 4+ to OKT 8+ (or Leu 3a+ to Leu 2a+) cells were not significantly different from normal. Although the subgroup of patients with increased suppression of immunoglobulin synthesis had a significantly lower mean Leu 3a to Leu 2a ratio than that of normal subjects, in the whole group of Crohn's patients studied, neither the percentage of Leu 2a+ cells nor the ratio of Leu 3a+ to Leu 2a+ cells correlated with excessive suppression of immunoglobulin synthesis. A subpopulation of Leu 2a+ lymphocytes reactive with the monoclonal antibody HNK-1 (Leu 2a+ HNK-1+) was increased in patients with Crohn's disease. Furthermore, elimination of HNK-1-reactive lymphocytes by complement-mediated lysis diminished the excessive suppressor cell function in patients with Crohn's disease. The percentage of Leu 2a+ HNK-1+ lymphocytes correlated significantly with the suppression of pokeweed mitogen-stimulated immunoglobulin synthesis in vitro. Thus, patients with mild Crohn's disease have an increased suppressor cell activity in vitro which correlates with the presence of a subset of lymphocytes that have an HNK-1+ Leu-2a+ phenotype.

Antigenic determinant(s) shared by the human Thy 1 and human IgG

A human T cell differentiation antigen (p25) previously described as being the mouse theta equivalent has been examined for shared antigenic determinants with immunoglobulin. A strong cross-reactivity of an antiserum prepared against p25 antigen was established with human IgG subclasses. This antiserum does not react with human IgM or IgA, nor with primate immunoglobulins. The shared determinants appear to be associated with the disulphide-bonded cysteines in the first and third constant domains of the IgG molecule and the 9-112 disulfide bond of Thy 1.

Ineffectiveness of adjuvant chemotherapy using DTIC and cyclophosphamide in patients with resectable metastatic melanoma

A randomized, prospective trial of adjuvant chemoimmunotherapy was compared in a group of 136 patients with melanoma after complete surgical resection of advanced regional metastasis (stage III) or isolated distant metastasis (stage IV). All patients received a 2-year course of nonspecific adjuvant immunotherapy of subcutaneous injections of Corynebacterium parvum (4 mg/m2 divided among the four extremities in 1- to 2-week cycles). Half of the patients also received a 6-month course of dimethyl triazeno imidazole carboxamide (DTIC) plus cyclophosphamide chemotherapy (each at 600 mg/m2 administered intravenously every 3 weeks for nine cycles) while the other half received no chemotherapy. Analysis of the data showed that adjuvant chemotherapy did not provide any demonstrable therapeutic effect, either in terms of disease-free survival or overall survival. No benefit was observed in subgroups of patients categorized by disease stage, site of metastasis, or sex. The drugs did cause a substantial rate of morbidity, however, since 42% of the patients had severe nausea and vomiting, while 13% had hair loss. The C. parvum was well tolerated in almost all patients. This is a particularly high-risk group for subsequent metastases since only 24% of the patients were free of disease for 1 year and 12% after 2 years. Adjuvant DTIC and cyclophosphamide had no observable therapeutic effect on this population of high-risk patients with melanoma.

Management of cutaneous melanoma in the United States

Melanoma is an especially important malignant disease for surgeons to know about, since it can be cured with surgical treatment if diagnosed at an early stage. In the American College of Surgeons Melanoma Survey of 4,545 melanoma patients diagnosed during 1980, the typical melanoma was relatively thin (less than 1.5 millimeters), not ulcerated (except in 9 per cent) and did not invade into the reticular dermis or beyond (level IV or V). The melanomas were most commonly located on the trunk in men and on the lower extremities in women. Eighty-eight per cent of the patients had no clinical evidence of metastases to regional nodes or to distant sites at the time of initial diagnosis. Only a small proportion (1 per cent) of patients in the survey were black and in most of these patients, their melanoma were located on the feet or hands. The treatment of melanoma was surgical in 92.5 per cent of the patients, with the majority of patients undergoing a wide excision of the melanoma as the initial form of treatment. Only one-fifth of the patients underwent elective regional node dissection for suspected micrometastases, and most of these patients had a tumor thickness exceeding 1.5 millimeters or a lesion invading to the reticular dermis (level III, IV or V). While the Breslow Microstaging Method is now recognized as the most important parameter that predicts the clinical course of the patient, this parameter was reported in only 45 per cent of the patients in the survey. The natural history of melanoma is changing, since the disease is increasing in frequency and becoming more curable. Surgical treatment should be tailored to the biologic aggressiveness of each individual patient's melanoma. This can be estimated by integrating such prognostic factors as the melanoma thickness, the presence or absence of ulceration, the level of invasion, the anatomic site and the gender of the patient.

Metastases to the upper levels of the axillary nodes in carcinoma of the breast and its implications for nodal sampling procedures

An axillary lymphadenectomy is important for the staging and treatment of metastatic disease in patients with carcinoma of the breast, especially since the nodal status is a primary criterion for using systemic adjuvant chemotherapy. As more conservative operations combined with radiation therapy have been increasingly used for selected patients with carcinoma of the breast, an axillary node sampling instead of a complete axillary dissection has been advocated by some oncologists. However, the possibility exists that node "sampling" understages patients who would otherwise have received adjuvant chemotherapy to improve their chances for cure. We retrospectively examined this hypothesis in a group of 72 patients with documented nodal metastases who had a radical mastectomy (modified or Halsted). Overall, 18 of 72 patients (25 per cent) had metastatic involvement confined to the upper axillary nodes (Levels II and III). Of the patients with no clinically palpable nodes, 32 per cent had metastatic nodal involvement confined to the upper nodes. Medial quadrant lesions exhibited this tendency more than lateral quadrant lesions (50 versus 20 per cent). Larger primary tumors were associated with an increasing likelihood of involved nodes; however, even 14 per cent of the smallest primary lesions of the breast (less than 2 centimeters) had metastases exclusively to the upper axillary region. Since approximately 40 per cent of the patients with carcinoma of the breast have nodal metastases and since 25 per cent of these metastases are confined to the upper portion of the axilla, it is estimated that at least 10 per cent of all women with carcinoma of the breast (25 X 40 per cent) would be understaged by an axillary node sampling procedure.

Prostaglandin E2-mediated suppression of cellular immunity in colon cancer patients

The immune regulation of phytohemagglutinin (PHA) and concanavalin A (Con A) mitogen responses by prostaglandin (PG)-producing suppressor monocytes was examined in 57 patients with colorectal cancer and 55 normal individuals. The blood lymphocyte responses to either PHA or Con A were significantly depressed in 74% of patients compared to normal controls. The mean PHA response for the patients was significantly lower than that for controls (17,649 versus 25,549 cpm, P = 0.02), while the mean Con A response for the patients was also depressed but not as significantly (13,551 versus 18,623 cpm, P = 0.09). The depression of immune competence was greatest in older patients and those with metastatic disease. The addition of indomethacin (1 microgram/ml) to cell cultures of both patients and normal individuals enhanced the mitogen response, suggesting that PGE-producing suppressor cells were operative in both groups. Among the patient group, however, a differential modulation of the immune response by indomethacin was observed. Thus, the addition of indomethacin restored the PHA response in patients almost to normal levels, while the Con A increase was less pronounced. Even after indomethacin treatment, the Con A proliferative response by lymphocytes was significantly depressed in patients as compared to controls (P = 0.002). To prove that indomethacin was blocking excessive PG production by suppressor monocytes in colon cancer patients, we directly measured PGE2 production by peripheral blood mononuclear cells (PBMCs) using a radioimmunoassay. PBMCs from the patients produced significantly greater amounts of PGE2 compared to controls (10.1 versus 5.1 ng/ml, P = 0.0001). This comparison was still significant after adjustment for age and sex. The increased PGE2 production appeared to be selective, since the levels of two other arachidonic acid metabolites, PGF1 alpha and thromboxane B2, were the same or less than control levels. PG-mediated immune suppression of mitogenesis thus appears to be abnormally increased in colon cancer patients, particularly for the PHA response. This abnormality was partially corrected in vitro by incubation of the PBMCs with indomethacin, a prostaglandin synthetase inhibitor.

Immune response against vaccinia virus in rhesus monkeys: no evidence for primary MHC-restricted cytolytic T cells

Rhesus monkeys were tested in vitro for their cellular immune response after infection with vaccinia virus, employing lymphocyte preparations from various lymphoid tissues. Although virus-infected target cells were lysed by lymphoid cells from immunized, but not from uninfected, rhesus monkeys, we could neither find evidence for MHC-restricted T cells nor for antibody-dependent cellular cytotoxicity. Kinetics of target cell lysis, the killing patterns of immune lymphocytes measured on syngeneic, allogeneic, and xenogeneic target cells, and the influence of protein A on cytotoxic activity in vitro suggest induction predominantly of natural killer cells in vivo which exhibit lytic activity on virus-infected target cells in vitro.

Heterogeneity of natural killer lymphocyte abnormalities in colon cancer patients

p6e monoclonal antibody HNK-1 reacts exclusively with human granular lymphocytes that comprise 16 +/- 1.4% of blood mononuclear cells. In normal individuals, almost all natural killer (NK) and killer (K) cell function resides in this lymphocyte subset. The level of HNK-1+ granular lymphocytes, their stage of differentiation, and NK cell function were examined in 70 colon cancer patients and the results compared with data for 114 age-matched normal individuals. Median levels of granular lymphocytes were significantly depressed in colon cancer patients compared to controls (9% versus 16.5%, P less than 0.0001). Despite the depressed numbers of circulating HNK-1+ cells, NK cell function in the colon cancer patients was essentially the same as in normals (P = 0.78). The HNK-1+ lymphocyte level correlated exactly with NK cell function in about two thirds of normal individuals but only one third of colon cancer patients (P = 0.025). Three possible mechanisms for this dichotomy were examined. First, lymphoid cell subpopulations purified with a fluorescence-activated cell sorter (FACS) were examined for altered NK cell functional activity. HNK-1+ cells from the colon cancer patients exhibited significantly less NK functional activity compared to normals (796 versus 1046 lytic units, P = 0.04). Interestingly, the HNK-1- fraction (predominantly T lymphocytes) had increased NK cell functional activity in the colon cancer patients compared to normals (373 versus 218 lytic units, P = 0.0001). Purified monocytes did not contribute to NK cell functional activity. Second, the functional maturity of the HNK-1+ lymphocytes was correlated with NK activity. Two subsets of HNK-1+ cells were identified by surface membrane markers and purified with the FACS. The more mature HNK-1+ subset (i.e., HNK+Leu-4-M1+) exhibited almost ten times more NK cell functional activity than did the less mature cell fraction (i.e., HNK+Leu-4+M1-) cells in normal individuals (2230 versus 286 lytic units/10(7) cells). Further analysis demonstrated that the ratio of mature to immature HNK+ cells in normal individuals was 3:1, while it was decreased to a 1:1 ratio in colon cancer patients P = 0.005). Third, the influence of prostaglandin-mediated suppression on NK cell activity was examined. PGE2 did not appear to influence NK cell function, since NK cell function was unchanged in vitro in the presence of a prostaglandin synthesis inhibitor.(ABSTRACT TRUNCATED AT 400 WORDS)

Changing trends in cutaneous melanoma over a quarter century in Alabama, USA, and New South Wales, Australia

Clinical and pathologic characteristics of melanoma were compared among 1647 clinical Stage I patients treated at the University of Alabama in Birmingham (USA) and The University of Sydney (Australia) between 1955 and 1980 to determine what changes occurred over a quarter century. Over this period, the number of patients treated annually has increased substantially. There was a steady increase in the proportion of patients presenting with localized disease (clinical Stage I). Melanomas became thinner, less invasive, less ulcerative and thus more curable. They also exhibited more of a radial growth phase. The median thickness of melanomas decreased in Australia from 2.5 mm prior to 1960 to 1.1 mm during the period 1976 to 1980, while in Alabama it has decreased from 3.3 to 1.4 mm. There was a significant increase in melanomas located on the trunk in males and a corresponding decrease in male head and neck melanomas. No significant change in the site distribution was observed for any major anatomical area on female patients. There were minimal differences in the incidence of both clinical and pathologic parameters among melanoma patients in Alabama, USA and in New South Wales, Australia even when accounting for their year of diagnosis. Long-term survival rates in patients with localized disease were found to increase slightly during the 25 year time frame of this analysis. The changes that have occurred are likely due to earlier diagnosis and changes in the biological nature of the disease.

A prospective phase II clinical trial of continuous FUDR regional chemotherapy for colorectal metastases to the liver using a totally implantable drug infusion pump

A prospective phase II evaluation of regional FUDR chemotherapy using a totally implantable drug infusion pump was conducted in 81 patients with colorectal metastases to the liver. The survival results were compared to a historical control group of 129 patients with isolated liver metastases. The two groups were comparable with respect to their dominant prognostic factors. The pump patients received their continuous chemotherapy on an outpatient basis and had an 88% response rate, as evidenced by a fall in their serum CEA levels by one-third or greater after two cycles of chemotherapy. By four criteria, the regional chemotherapy patients had an improved survival rate compared to the control series. First, the 1 year survival and median survival was better for the entire group of pump patients vs. controls (82% vs. 36%, 26 months vs. 8 months, p less than 0.0001). The survival for the regional chemotherapy patients was not influenced by the extent of tumor involvement, whether previous systemic 5-FU was given, or whether the patient had symptomatic disease. Second, the entire group of regional chemotherapy patients (including nonresponders) had a greater 1 year survival compared to the most favorable subgroup of control patients with the following characteristics: normal liver function tests, no symptoms, and only one lobe involved (82% vs. 66%, p = 0.009). Third, a subgroup of 49 pump patients, whose initial treatment for metastatic disease was regional chemotherapy (within 3 months of diagnosis) had a better 1 year survival than an exactly matched group of 49 control patients (67% vs. 30%, p = 0.000003). Fourth, the actuarial survival for all 81 pump patients was significantly better than predicted by a mathematical model constructed to predict the patient's clinical course based upon the seven dominant prognostic variables identified in a multifactorial analysis (82% survival at 1 year vs. 33% predicted survival). While liver metastases could be controlled in most patients, the major cause of death was tumor progression in extrahepatic sites, particularly lung metastases and abdominal carcinomatosis. Although it appears that regional chemotherapy with an implantable pump appears to prolong life by 12 to 18 months more than matched historical controls, these results must be confirmed by a randomized (phase III) prospective clinical trial.

A multifactorial analysis of prognostic factors in patients with liver metastases from colorectal carcinoma

A multifactorial analysis was used to identify the dominant prognostic variables predicting survival rates of 175 patients with hepatic metastases from colorectal carcinoma. Seven of 22 parameters examined simultaneously were found to independently influence the median survival rate in these patients: (1) elevated alkaline phosphatase (p = 0.0004), (2) elevated serum bilirubin level (p = 0.0005), (3) location of hepatic metastases (unilateral or bilateral, p = 0.0022), (4) number of metastatic nodes involved (0, 1-5, greater than 5; p = 0.0148), (5) depressed serum albumin (p = 0.0217), (6) whether or not the primary colorectal tumor was resected (p = 0.0013), and (7) chemotherapy (given or withheld, p = 0.0439). The prothrombin time, serum lactic dehydrogenase, and the number of hepatic metastases also correlated with survival, but they did not independently predict survival rates after other more dominant factors were accounted for. A mathematical equation for predicting an individual patient's clinical course once they developed hepatic metastases was derived from this statistical analysis. In addition, a simple and clinically useful guide for predicting outcome was developed that integrated the two most important risk factors, alkaline phosphatase and bilirubin.

Interleukin 2 receptor expression by activated HNK-1+ granular lymphocytes: a requirement for their proliferation

A subpopulation of HNK-1+ cells was found to express interleukin 2 receptor (IL 2R) as monitored by the anti-Tac monoclonal antibody after lectin or allogeneic cell stimulation. When blood mononuclear cells were stimulated with phytohemagglutinin (PHA) or concanavalin A for 3 days, or with pokeweed mitogen or allogeneic mononuclear cells for 6 days, virtually all of the HNK-1+ cells remained as small resting lymphocytes. One-fourth of these HNK-1+ cells expressed IL 2R, however, usually within 18 hr after stimulation. Neither circulating HNK-1+ cells nor unstimulated HNK-1+ cells in short-term culture expressed IL 2R. Only the subset of HNK-1+ cells that expressed T cell surface markers, such as the sheep erythrocyte receptor and Leu-4 antigen, could be induced to express IL 2R. When long-term cultures of HNK-1+ cells were established with initial PHA stimulation and the continued presence of IL 2, a majority of the cells was found to express the IL 2R. When anti-Tac antibody was added to the long-term cultures, proliferation of the HNK-1+ cells was completely inhibited. These results suggest that entry into growth cycle by this subpopulation of HNK-1+ granular lymphocytes may require two signals: a relatively nonspecific ligand interaction with cell surface glycoprotein(s) to induce expression of IL 2R, and subsequent IL 2 interaction with these specific cell surface receptors.

Interleukin 2 receptor expression by activated HNK-1+ granular lymphocytes: a requirement for their proliferation

A subpopulation of HNK-1+ cells was found to express interleukin 2 receptor (IL 2R) as monitored by the anti-Tac monoclonal antibody after lectin or allogeneic cell stimulation. When blood mononuclear cells were stimulated with phytohemagglutinin (PHA) or concanavalin A for 3 days, or with pokeweed mitogen or allogeneic mononuclear cells for 6 days, virtually all of the HNK-1+ cells remained as small resting lymphocytes. One-fourth of these HNK-1+ cells expressed IL 2R, however, usually within 18 hr after stimulation. Neither circulating HNK-1+ cells nor unstimulated HNK-1+ cells in short-term culture expressed IL 2R. Only the subset of HNK-1+ cells that expressed T cell surface markers, such as the sheep erythrocyte receptor and Leu-4 antigen, could be induced to express IL 2R. When long-term cultures of HNK-1+ cells were established with initial PHA stimulation and the continued presence of IL 2, a majority of the cells was found to express the IL 2R. When anti-Tac antibody was added to the long-term cultures, proliferation of the HNK-1+ cells was completely inhibited. These results suggest that entry into growth cycle by this subpopulation of HNK-1+ granular lymphocytes may require two signals: a relatively nonspecific ligand interaction with cell surface glycoprotein(s) to induce expression of IL 2R, and subsequent IL 2 interaction with these specific cell surface receptors.

Involvement of the cytotoxic/suppressor T-cell subset in liver tissue injury of patients with acute and chronic liver diseases

So far, phenotypic and functional analyses of cytotoxic lymphocytes in viral hepatitis, as well as in primary biliary cirrhosis, have focused on circulating lymphocyte subpopulations, whereas their occurrence and distribution at the involved site, namely the liver, remain largely unknown. In the present study, monoclonal antibodies were used to characterize both circulating and liver-tissue-infiltrating lymphocyte subsets in acute cytomegalovirus hepatitis, in chronic B-virus hepatitis, and in primary biliary cirrhosis. Special emphasis was laid on the cytotoxic/suppressor T-cell subset. Total T cells were identified by the monoclonal antibody T411. The monoclonal antibody T811 was used to identify the cytotoxic/suppressor T-cell subset, which comprises virus-specific, altered self, and alloreactive cytolytic T lymphocytes and their precursors, a fraction of killer and natural killer cells. Furthermore, killer and natural killer cells were identified more specifically by the monoclonal antibody. HNK1. Irrespective of the number of cytotoxic/suppressor T cells in peripheral blood, these cells (T811 phenotype) were accumulated in the liver at the site of tissue injury. The preponderance of this lymphocyte subset at the site of tissue injury suggests an important role for these cells in the mechanism leading to tissue injury.

The impact of surgical quality control in multi-institutional group trials involving adjuvant cancer treatments

Quality control involving surgical treatment in multi-institutional cancer trials is important because the results of postoperative adjuvant therapy might be obscured by inadequate surgery or pathologic examination of the specimen. In 1975, the Southeastern Cancer Study Group (SEG) initiated a randomized clinical trial of adjuvant immunotherapy (Corynebacterium parvum vs. bacillus Calmette-Guerin) in melanoma patients with nodal metastases. During the course of reviewing the results several years later, 20 of 136 patients (15%) entered into this study were judged as surgically ineligible. The reasons were: 1) biopsy of a metastatic node only without any subsequent regional lymph node dissection (12 patients), 2) partial lymph node dissection (six patients), or 3) too few nodes surgically removed or pathologically identified in the specimen (six patients). All 20 patients were entered into the study by medical oncologists. Thirteen of these 20 surgically ineligible patients have relapsed so far; many were taken off the study as "immunotherapy failures," when, in fact, they were surgical failures. Compared to the 116 surgically eligible patients, the 20 ineligible patients had a shorter median survival (4 months vs. 25 months) and a lower 1-year disease-free survival rate (36% vs. 62%, p = 0.01). The two groups were balanced equally with respect to prognostic factors. Because of these findings, minimum surgical and pathologic guidelines were established for each adjuvant therapy protocol in the SEG. Surgical quality control was reviewed by a surgeon in each institution prior to randomization and again by a surgical investigator centrally. Pathologic criteria were also defined more precisely. The problems with surgically ineligible patients have since been virtually eliminated. Quality control measures for surgical patients entered into cooperative group trials is an essential part of the protocol design and data review. In order to evaluate properly the impact of adjuvant therapy, each clinical trial must comprise a uniform group of surgically treated patients.

Depressed levels of granular lymphocytes with natural killer (NK) cell function in 247 cancer patients

The HNK-1 (Leu-7) monoclonal antibody was used to enumerate and characterize the level of blood granular lymphocytes in 247 cancer patients. The results were compared to 146 control individuals. A fluorescence-activated cell sorter was used to purify blood HNK-1+ cells from cancer patients. The monoclonal antibody identified a homogeneous population of granular lymphocytes with greater than 95% purity. Conversely, virtually 100% of HNK-1- cells from cancer patients were agranular lymphocytes. These results were the same as previously observed in normal individuals, where the HNK-1+ cell fraction contained all the lymphocytes with spontaneous cytotoxicity in natural killer (NK) and killer (K) cell assays. The level of HNK-1+ cells in cancer patients correlated significantly with the patient's age and sex, with older individuals having higher levels and male patients containing a higher proportion than female patients. The levels in the cancer patients were significantly lower than normal controls (p = 0.04). When the results were subdivided by the histologic type of cancer, additional differences were noted. Compared to age and sex-matched controls, significantly depressed levels of HNK-1+ granular lymphocytes were observed in 49 patients with colon cancer (9.7% vs. 15.8%, p = 0.0001), 18 patients with lung carcinoma (11.7% vs. 27.0%, p = 0.0001), 24 patients with breast carcinoma (12.0% vs. 15.5%, p = 0.04) and 64 patients with head and neck carcinoma (15.9% vs. 19.1%, p = 0.05). However, there were no significant differences overall in the average HNK-1+ cell level of 66 patients with melanoma (13.0% vs. 13.5%, p = 0.75) and nine patients with sarcomas (15.8% vs. 14.3%, p = 0.71). Thus, this important subpopulation of granular lymphocytes with NK and K cell function was significantly depressed in most cancer patients. Accounting for the patient's age and sex and the histologic type of cancer was critical to interpreting the results.

A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients

This study reports the results of a prospectively randomized trial for treatment of carcinoma of the breast comparing standard (Halsted) radical mastectomy to a modified radical mastectomy. Three hundred eleven patients with primary operable carcinoma of the breast were entered in a surgical and adjunctive chemotherapy trial in Alabama between 1975 and 1978. A total of 91 surgeons participated (all Diplomats of the American Board of Surgery and Members of the American College of Surgeons). All operative reports, pathology and therapy were reviewed by referees. Histologically node positive patients were randomized after operation to receive melphalan or C.M.F.(cytoxan, methotrexate, and 5-FU) for 1 year. After a median follow-up of 5.5 years, there was no significant difference in disease-free survival or in overall survival between the two groups. There was a trend toward improved 5-year survival rates in the radical mastectomy group compared to the modified radical mastectomy group (84% vs. 76%, p = 0.14). There was also an increased incidence of local wound recurrence in those patients receiving modified radical mastectomy, but the differences were not statistically significant (p = 0.09). Longer follow-up will be necessary to evaluate these results more fully.

[Completely implantable infusion pump. A new therapeutic possibility for selected patients with liver tumors]

The action of floxuridine depends greatly on its concentration for treatment of liver metastases of colorectal carcinomas and other tumors. In isolated liver metastases it is best infused regionally in order to achieve a high concentration and to reduce systemic toxicity, particularly as it is almost entirely extracted by the liver. A totally implantable infusion pump has established itself as an effective, safe and reliable device of regional chemotherapy with floxuridine for palliative treatment of selected patients with metastases of colorectal carcinomas and other tumors. Life expectancy of patients with metastases of colorectal carcinomas was prolonged by 12-18 months when compared to a precedent control group without regional chemotherapy. This results require confirmation in a randomised phase III study. Patients with hepatocellular carcinoma can be treated with intraarterial doxorubicine and floxuridine infusions. Preliminary results are encouraging. The implantable system represents a major advance in drug administration, not only for the treatment of malignant disease but also a large number of other diseases. Continuous infusion of drugs using an implantable pump system will probably achieve greater importance in the future in the treatment of cancer.

Patient risk factors and surgical morbidity after regional lymphadenectomy in 204 melanoma patients

A series of 204 melanoma patients were studied six months or longer after regional lymph node dissection of the neck (N = 48), axilla (N = 98) and groin (N = 58) in order to determine the degree of morbidity and analyze for risk factors associated with these procedures. Only one-quarter of the patients experienced wound-related, short-term complications that were common at all sites; however, these rarely resulted in long-term functional deficits. Seromas (22%), temporary nerve dysfunction or pain (14%), and wound infections (6%) were the most frequent short-term complications. Wound complications extended the mean hospital stay by 0.6 to 4.8 days. Residual lymphedema of the leg was measurable in 26% of groin dissection patients after six months or longer; most of the edema was confined to the thigh. Only 8% of patients had significant functional deficit from lymphedema. The risk of developing at least one complication for all patients was increased for obese patients (P = 0.05) and increasing age (P = .01). These risk factors should be considered when evaluating melanoma patients for regional lymph node dissection.

Natural killer cells in systemic lupus erythematosus. Abnormal numbers and functional immaturity of HNK-1+ cells

A monoclonal antibody, HNK-1, that detects a differentiation antigen on human granular lymphocytes with natural killer (NK) activity was used to enumerate this subpopulation in the peripheral blood of 14 patients with systemic lupus erythematosus (SLE). Nine patients had severely decreased numbers of HNK-1+ cells, 3 patients had elevated levels of HNK-1+ cells, and 2 patients had appropriate numbers of HNK-1+ cells compared with the levels in 112 normal controls. All SLE patients exhibited low NK killing ability against K562 target cells compared with controls. An increased proportion of the HNK-1+ cells was categorized as immature granular lymphocytes in over 50% of the SLE patients because their HNK-1+ cells coexpressed the OKT3 antigen and contained a paucity of cytoplasmic granules. The numbers of HNK-1+ cells or the HNK-1+ OKT3+ subgroup did not correlate with steroid therapy. This evidence suggests that levels of HNK-1+ lymphocytes are abnormal and functionally immature in most SLE patients. Longitudinal studies conducted over several months on a number of SLE patients demonstrated fluctuations in the ratio of mature and immature HNK-1+ cells and total HNK-1+ cells. Additional patients tested over longer periods of time will have to be studied to determine whether the proportion of mature NK cells (HNK-1+ OKT-) and immature NK cells (HNK-1+ OKT3+) will be useful in predicting the clinical course of disease.

In vitro propagation of cultured human natural killer cells expressing the HNK-1 differentiation antigen and spontaneous cytotoxic function

Human natural killer (NK) cells expressing the HNK-1 differentiation antigen were established in long-term tissue culture for over 3 months. The fluorescence-activated cell sorter-purified HNK-1+ cells required both phytohemagglutinin and exogenous interleukin 2 to propagate in long-term culture. After 2 weeks of culture, virtually all of the growing cells exhibited the surface membrane phenotype associated with immature HNK-1+ cells, since they simultaneously expressed the HNK-1, Leu-4 and Leu-2a but lacked the M1. Leu-3a and T6 antigens, and Fc gamma receptors. They exhibited a lymphoblastoid appearance, contained cytoplasmic granules, and exhibited spontaneous cytotoxic function against a broader spectrum of target cells than did fresh HNK-1+ cells from the same donor. Cultured HNK-1+ cells lacked antibody-dependent cell-mediated cytotoxic (ADCC) function, while fresh HNK-1+ were fully capable of ADCC function. On the other hand, cultured HNK-1- cells were lymphoblasts without cytoplasmic granules or NK cytotoxic function. The cultured HNK-1+ cells gradually lost their HNK-1 antigen expression over time, although the expression of other surface antigens (e.g., Leu-4 and Leu-2a) was unchanged. With prolonged culture (greater than 2 months), they also exhibited decreasing cytotoxic function and a diminished number of cytoplasmic granules. They were eventually indistinguishable from HNK-1- cells after 3 months of culture. These observations were not influenced by adding interferon-gamma to the cultures. The results demonstrate that the immature form of NK cells (that express T cell antigens) preferentially proliferate in long-term cultures when incubated with phytohemagglutinin and interleukin 2.

Suppressor cell function of human granular lymphocytes identified by the HNK-1 (Leu 7) monoclonal antibody

The HNK-1 (Leu 7) differentiation antigen defines a subpopulation of human granular lymphocytes with natural killer (NK) and K cell function. In this study, we investigated whether HNK-1+ cells, identified with the monoclonal antibody and purified with a fluorescence-activated cell sorter (FACS), could function as suppressor cells. The results demonstrated that purified HNK-1+ cells efficiently suppressed both PWM-induced IgG production by B cells and T cell proliferation in mixed lymphocyte reactions (MLR). Manifestation of this suppressor cell activity required immune complex activation and was partially sensitive to 2000 rad irradiation. This suppressor cell activity was predominantly mediated by a subset of HNK-1+ cells that have previously been shown to have maximum NK function and lack expression of the E rosette (ER) receptor and T cell antigens (e.g., T3 and T8). Thus, HNK-1+ER- cells suppressed a MLR by an average 52%; HNK-1+ER+ were one-half as efficient, causing an average 23% suppression. For comparison, we also examined the characteristics of Leu 2a+ suppressor T lymphocytes. In contrast to HNK-1+ cells, unactivated Leu 2a+ cells suppressed both B and T cell responses. This suppressor activity was not augmented by immune complex activation and was absolutely radio-sensitive in PWM assays. HNK-1+ cells, especially the HNK+ER- subset, can therefore mediate suppressor cell function in addition to their spontaneous cytotoxic function. Furthermore, some of their suppressor cell properties are distinct from those attributed to other types of suppressor lymphocytes.

Suppressor cell function of human granular lymphocytes identified by the HNK-1 (Leu 7) monoclonal antibody

The HNK-1 (Leu 7) differentiation antigen defines a subpopulation of human granular lymphocytes with natural killer (NK) and K cell function. In this study, we investigated whether HNK-1+ cells, identified with the monoclonal antibody and purified with a fluorescence-activated cell sorter (FACS), could function as suppressor cells. The results demonstrated that purified HNK-1+ cells efficiently suppressed both PWM-induced IgG production by B cells and T cell proliferation in mixed lymphocyte reactions (MLR). Manifestation of this suppressor cell activity required immune complex activation and was partially sensitive to 2000 rad irradiation. This suppressor cell activity was predominantly mediated by a subset of HNK-1+ cells that have previously been shown to have maximum NK function and lack expression of the E rosette (ER) receptor and T cell antigens (e.g., T3 and T8). Thus, HNK-1+ER- cells suppressed a MLR by an average 52%; HNK-1+ER+ were one-half as efficient, causing an average 23% suppression. For comparison, we also examined the characteristics of Leu 2a+ suppressor T lymphocytes. In contrast to HNK-1+ cells, unactivated Leu 2a+ cells suppressed both B and T cell responses. This suppressor activity was not augmented by immune complex activation and was absolutely radio-sensitive in PWM assays. HNK-1+ cells, especially the HNK+ER- subset, can therefore mediate suppressor cell function in addition to their spontaneous cytotoxic function. Furthermore, some of their suppressor cell properties are distinct from those attributed to other types of suppressor lymphocytes.

A multifactorial analysis of melanoma. IV. Prognostic factors in 200 melanoma patients with distant metastases (stage III)

A multifactorial analysis of 200 cutaneous melanoma patients with distant metastasis (stage III) was performed on 13 clinical and pathological factors using the Cox regression analysis. There were only three dominant prognostic variables that independently predicted the patient's clinical course: (1) number of metastatic sites (1 vs. 2 vs. greater than or equal to 3, p less than 0.00001), (2) remission duration (less than 12 mo vs. greater than or equal to 12 mo, p = 0.0186), and (3) the location of the metastases (visceral vs. nonvisceral vs. combined, p = 0.0192). Factors that were not significant in the multifactorial analysis included the patients' age and sex, the site of the primary melanoma, the sequence of metastases, and all histopathological features of the primary melanoma (thickness, level of invasion, ulceration, growth pattern, pigmentation, and lymphocyte infiltration). For a single metastatic site, the 1-yr survival rate was 36%, while it was only 13% for 2 sites, and 0% for greater than or equal to 3 sites (p less than 0.00001). The 1-yr survival for patients was 40% for nonvisceral sites (skin, subcutaneous, distant lymph nodes) compared to only 11% for visceral metastases and 8% for combined sites (p less than 0.00001). Pulmonary metastases were associated with a significantly higher survival rate than metastatic melanoma in any other visceral site. The most common first site of distant metastases (either alone or in combination) was skin (38%), lung (36%), liver (20%), and brain (20%). The skin, subcutaneous and distant lymph node group was the first site of metastases in 59% of patients. This finding emphasizes the importance of careful physical exams in routine metastatic evaluations. Only a minority (25%) of stage I patients progressed to stage III disease after a median interval of 2.8 years. In contrast, the majority (75%) of melanoma patients with nodal metastases (stage II) progressed to stage III disease after a median duration of only 11 mo. Of the patients who eventually developed stage III disease, 95% of those who initially presented with stage II disease progressed within 3 yr, while stage I patients who progressed to stage III did not reach a 95% cumulative incidence until 8 yr.

Abdominal wound closure. A randomized prospective study of 571 patients comparing continuous vs. interrupted suture techniques

A randomized, prospective study was designed to compare a continuous with an interrupted technique for closing an abdominal incision. Five hundred seventy-one patients were randomized between the closure methods and stratified as to type of wound: clean, clean-contaminated, or contaminated. In mid-line incisions, the dehiscence rate was 2.0% (5/244) for the continuous group versus 0.9% (2/229) for the interrupted group. The difference was not statistically significant. Ventral hernias formed in 2.0% (4/201) of the continuous group vs. 0.5% (1/184) of the interrupted group. The type of wound had no influence on the results. In oblique incisions, 0% (0/39) of wounds closed continuously dehised while 2% (1/50) of incisions closed interruptedly dehised. No ventral hernias formed. Further analysis of the data indicated that dehiscence was more likely related to improper surgical technique than to the method of closure. An abdominal incision could be closed with a continuous suture in approximately half the time required for placing interrupted sutures (20 vs. 40 minutes). A continuous closure is preferred because it is more expedient and because it has the same incidence of wound disruption compared with an interrupted closure.

Differentiation stages of human natural killer cells in lymphoid tissues from fetal to adult life

Virtually all human granular lymphocytes expressed the HNK-1 differentiation antigen when examined in lymphoid compartments from adults, neonates, and fetuses. The HNK-1+ cells were distinguishable into three subsets having distinct antigenic phenotypes: HNK+T3-M1-, HNK+T3+M1-, and HNK+T3-M1+. Thus, greater than 70% of the HNK-1+ cells from 13-17 wk fetuses (less than 0.2% of nucleated cells) lacked T cell antigens (e.g., T3, T8, T4, and T6) and the M1 myeloid antigen. Morphologically, the HNK+T3-M1- cells consisted of three different types: small granular lymphocytes (less than 10% of HNK-1+ cells), agranular small lymphocytes with a narrow rim of cytoplasm (70-80%), and agranular giant cells (greater than 15 micrometers) with considerable neutrophilic cytoplasm (15%). The purified fetal HNK-1+ cells exhibited a low level of cytotoxicity against K562 target cells. On the other hand, almost all of HNK-1+ cells in neonatal tissues as well as adult bone marrow, lymph node, and thymus, exhibited the HNK+T3+M1- phenotype, contained sparse cytoplasmic granules, and had an intermediate level of NK functional activity. Only adult blood and spleen contained a majority of mature HNK-1+ cells. These cells had an HNK+T3-M1- phenotype, abundant cytoplasmic granules, and maximum NK function. We propose that human NK cells may generate from a separate cell lineage and that they alter their phenotype, morphology, and functional capability during differentiation.

Excessive prostaglandin E2 production by suppressor monocytes in head and neck cancer patients

The proliferative response of peripheral blood mononuclear cells (PBMC) to the mitogens PHA and Con A significantly depressed in 86% of 45 head and neck cancer patients compared with 44 normal controls. This depression of immune competence was greatest in older patients and in those with more advanced disease stages. The abnormal mitogen responses could be restored toward normal (especially with Con A stimulation) by incubating the cells with either of two prostaglandin synthetase inhibitors (indomethacin or RO-205720). This augmentation of immune response was independent of other factors, including the primary tumor site, disease stage, treatment (surgery, radiation therapy, or chemotherapy) or the patients's age or race. The most likely explanation for this depressed level of immunocompetence was an excessive production of PGE2 by suppressor cells. This was confirmed by the finding that PBMC from patients produced more PGE2 than PBMC from normal individuals (8.4 ng/ml vs. 5.2 ng/ml, p=0.002). This difference was greatest among patients less than 60 years of age whose cultured PBMC produced 91% more PGE2 than controls (p less than 0.0007). Virtually all of the PGE2 was produced by a population of monocytes defined by a monoclonal antibody and purified with a fluorescence-activated cell sorter. Patients with epidermoid cancer of the head and neck thus have an abnormality of immunoregulatory monocytes that can contribute significantly to their depression of cellular immunity by elaborating prostaglandin E2. This abnormality could be partially corrected in vitro by incubating their PMBC with a prostaglandin synthetase inhibitor.

A comparison of prognostic factors and surgical results in 1,786 patients with localized (stage I) melanoma treated in Alabama, USA, and New South Wales, Australia

Twelve clinical and pathologic parameters were compared in two series of Stage I melanoma patients treated at the University of Alabama in Birmingham, USA (676 patients) and at the University of Sydney in New South Wales, Australia (1,110 patients). Actuarial survival rates were virtually the same at the two institutions over a 25-year follow-up period. The incidence of thin melanomas (less than 0.76 mm) was also similar at both geographic locations (25% vs. 26%). Other similarities of these two patient populations included the following: 1) tumor thickness (Breslow Microstaging). 2) level of invasion (Clark Microstaging), 3) surgical results, 4) sex distribution, and 5) age distribution. The greatest differences between the two patient populations were their 1) anatomic distribution, 2) growth pattern, and 3) incidence of ulceration. The trunk was the most common site of melanoma, and occurred more frequently among Australian patients (37% vs. 28%). A multifactorial analysis (Cox's regression model) was then performed that included a comparison of the two institutions as a variable (Alabama vs. Australia). The dominant prognostic factors (p less than 0.0001) were 1) ulceration, 2) tumor thickness, 3) initial surgical management (wide excision +/- node dissection), 4) anatomic location, 5) pathologic stage (I vs. II), and 6) level of invasion. The benefit of elective lymph node dissection was demonstrated in both series for patients with intermediate thickness melanoma (0.76 to 3.99 mm.) For melanomas ranging from 0.76 to 1.5 mm in thickness, the benefit of node dissection was primarily in male patients. Survival rates for melanoma at the two institutions were not significantly different in the multifactorial analysis, even after adjusting for all other variable. Thus, the biologic behavior of melanoma in these two different parts of the world was virtually the same, with only minor differences that did not significantly influence survival rates. Long-term follow-up exceeding eight to ten years after surgery is critical in the interpretation of these prognostic factors and the surgical results.

Characterization of HNK-1+ (Leu-7) human lymphocytes. I. Two distinct phenotypes of human NK cells with different cytotoxic capability

Human lymphocytes with NK and K cell activities can be identified by the HNK-1 (Leu-7) monoclonal antibody. In these experiments, subsets of HNK-1+ cells from blood and bone marrow were distinguished by their expression of other cell surface antigens, their morphology, and their NK functional capability. Two-color immunofluorescence analysis revealed that subpopulations of HNK-1+ cells in blood expressed antigens found on mature T cells (e.g., T1, T3, T4, T8), but none expressed antigens characteristic of immature T cells (T6, T9). The majority of HNK-1+ cells (greater than 60%) also expressed a myeloid antigen (M1), whereas a minority (less than 25%) expressed HLA-DR. HNK-1+ cells were separated into T3- and T3+ subsets with the fluorescence-activated cell sorter and analyzed for their morphology and NK cell function. HNK+T3- cells exhibited a high level of NK activity against K562 target cells and contained many cytoplasmic granules. On the other hand, HNK+T3+ cells had low NK activity and a paucity of cytoplasmic granules. The cell sizes of HNK+T3- and HNK+T3+ cells were indistinguishable by light-scatter analysis. When these cell fractions were analyzed further, a reciprocal relationship between T3 and M1 antigen expression was observed. These results thus delineate two distinct subsets of human HNK-1+ cells in blood with different cytotoxic capability: HNK+T3-M1+ and HNK+T3+M1- cells. Analysis of bone marrow cells demonstrated that only 0.7% of the nucleated cells expressed the HNK-1 antigen; virtually all of these cells expressed both the T3 and T8 antigens but lacked the M1 antigen. Thus, a majority of HNK-1+ cell population in blood were T3-M1+, whereas almost all bone marrow HNK-1+ cells were T3+M1-. We propose that these subsets of cells represent different stages in NK cells differentiation.

Characterization of HNK-1+ (Leu-7) human lymphocytes. I. Two distinct phenotypes of human NK cells with different cytotoxic capability

Human lymphocytes with NK and K cell activities can be identified by the HNK-1 (Leu-7) monoclonal antibody. In these experiments, subsets of HNK-1+ cells from blood and bone marrow were distinguished by their expression of other cell surface antigens, their morphology, and their NK functional capability. Two-color immunofluorescence analysis revealed that subpopulations of HNK-1+ cells in blood expressed antigens found on mature T cells (e.g., T1, T3, T4, T8), but none expressed antigens characteristic of immature T cells (T6, T9). The majority of HNK-1+ cells (greater than 60%) also expressed a myeloid antigen (M1), whereas a minority (less than 25%) expressed HLA-DR. HNK-1+ cells were separated into T3- and T3+ subsets with the fluorescence-activated cell sorter and analyzed for their morphology and NK cell function. HNK+T3- cells exhibited a high level of NK activity against K562 target cells and contained many cytoplasmic granules. On the other hand, HNK+T3+ cells had low NK activity and a paucity of cytoplasmic granules. The cell sizes of HNK+T3- and HNK+T3+ cells were indistinguishable by light-scatter analysis. When these cell fractions were analyzed further, a reciprocal relationship between T3 and M1 antigen expression was observed. These results thus delineate two distinct subsets of human HNK-1+ cells in blood with different cytotoxic capability: HNK+T3-M1+ and HNK+T3+M1- cells. Analysis of bone marrow cells demonstrated that only 0.7% of the nucleated cells expressed the HNK-1 antigen; virtually all of these cells expressed both the T3 and T8 antigens but lacked the M1 antigen. Thus, a majority of HNK-1+ cell population in blood were T3-M1+, whereas almost all bone marrow HNK-1+ cells were T3+M1-. We propose that these subsets of cells represent different stages in NK cells differentiation.

Characterization of HNK-1+ (Leu-7) human lymphocytes. II. Distinguishing phenotypic and functional properties of natural killer cells from activated NK-like cells

HNK-1+ and HNK-1- lymphocytes from human blood were sorted with a fluorescence-activated cell sorter and compared for their phenotypic and functional properties. The HNK-1+ cells exhibited virtually no response to either mitogens (PHA, Con A, and PWM) or allogeneic cells, because the 3H-thymidine uptake for HNK-1+ cells was only 1 to 3% of that for HNK-1- cells. On the other hand, the HNK-1- cells responded efficiently to these stimuli and acquired a potent killing activity against K562 and other target cells after stimulation. The proliferating lymphoblasts did not acquire the HNK-1 antigen. These activated HNK-1- cells had a wider spectrum of spontaneous cytotoxicity than did HNK-1+ cells against 12 different target cells. Two distinct populations of effector cells for spontaneous killing can thus be distinguished on the basis of HNK-1 antigen expression. The classically defined NK cells are HNK-1+, whereas effector cells activated by either mitogens or allogeneic cells are HNK-1-. The HNK-1+ cells were not generated from the pool of HNK-1- cells under any of the culture conditions tested. The NK cells defined by the HNK-1 antibody are thus a functionally distinct population of cells. Although some HNK-1+ cells may also express T cell-associated antigens and sheep erythrocyte receptors, they lack some important functional properties ascribed to T cells.

Characterization of HNK-1+ (Leu-7) human lymphocytes. II. Distinguishing phenotypic and functional properties of natural killer cells from activated NK-like cells

HNK-1+ and HNK-1- lymphocytes from human blood were sorted with a fluorescence-activated cell sorter and compared for their phenotypic and functional properties. The HNK-1+ cells exhibited virtually no response to either mitogens (PHA, Con A, and PWM) or allogeneic cells, because the 3H-thymidine uptake for HNK-1+ cells was only 1 to 3% of that for HNK-1- cells. On the other hand, the HNK-1- cells responded efficiently to these stimuli and acquired a potent killing activity against K562 and other target cells after stimulation. The proliferating lymphoblasts did not acquire the HNK-1 antigen. These activated HNK-1- cells had a wider spectrum of spontaneous cytotoxicity than did HNK-1+ cells against 12 different target cells. Two distinct populations of effector cells for spontaneous killing can thus be distinguished on the basis of HNK-1 antigen expression. The classically defined NK cells are HNK-1+, whereas effector cells activated by either mitogens or allogeneic cells are HNK-1-. The HNK-1+ cells were not generated from the pool of HNK-1- cells under any of the culture conditions tested. The NK cells defined by the HNK-1 antibody are thus a functionally distinct population of cells. Although some HNK-1+ cells may also express T cell-associated antigens and sheep erythrocyte receptors, they lack some important functional properties ascribed to T cells.

Immune modulatory effects of indomethacin in melanoma patients are not related to prostaglandin E2-mediated suppression

Indomethacin significantly enhances the depressed levels of lymphocyte proliferation to the mitogens phytohemagglutinin and concanavalin A in melanoma patients. We postulated that these results were related to an abnormality in prostaglandin E2 (PGE2)-mediated suppression, since this mechanism has previously has previously been demonstrated in patients with Hodgkin's lymphoma and with head and neck carcinoma. However, the results of three experimental approaches did not support this hypothesis. First, in vitro PGE2 production by cultured blood mononuclear cells was the same in 16 melanoma patients as in 45 normal controls (4.9 versus 4.7 ng/ml). Second, lymphocyte sensitivity to PGE2 for melanoma patients was essentially the same as that for normal controls, since exogenous doses of PGE2 inhibited the mitogen responses to the same degree. Third, another prostaglandin synthetase inhibitor (RO-205720), which is structurally unrelated to indomethacin, did not augment the mitogen response in these patients. Thus PGE2 cannot be implicated as a mediator of immunosuppression in melanoma patients. To further examine the immunomodulatory mechanism of indomethacin, we preincubated the drug with purified populations of either lymphocytes or monocytes, which were then recombined and tested for mitogen response. The results suggested that indomethacin had a direct effect on the responding T lymphocytes rather than an indirect effect on monocytes. These are the first studies demonstrating that indomethacin can act directly as a modulator of cellular immune function, independent of PGE2-mediated suppression.

Natural killer (HNK-1+) cells in Chediak-Higashi patients are present in normal numbers but are abnormal in function and morphology

Children with the Chediak-Higashi (CH) syndrome are known to have abnormalities of natural killer (NK) cell function. We used the HNK-1 monoclonal antibody that reacts specifically with human NK and K cells to distinguish whether this abnormality was due either to a numerical deficiency of NK cells or a defect in their ability to function. In eight CH patients, a significant proportion of their blood mononuclear cells (10--19%) expressed the HNK-1 differentiation antigen. The level of NK cells in the five children with CH syndrome was higher than for age-matched normal controls (15.8% vs. 5.8%, P less than 0.001). When HNK-1+ cells were isolated with a fluorescence-activated cell sorter, the NK cells from CH patients were a homogeneous population of lymphocytes with a single large granule rather than the multiple small granules seen in Nk cells from normal individuals. The purified HNK-1+ cells from the CH patients had minimal NK or K cell function. The CH syndrome thus includes a functionally defective population of NK cells that retain the capability of expressing the HNK-1 differentiation antigen.

A randomized prospective clinical trial of adjuvant C. parvum immunotherapy in 260 patients with clinically localized melanoma (Stage I): prognostic factors analysis and preliminary results of immunotherapy

A total of 260 patients with clinically localized melanoma (Stage I) from 18 medical institutions in the Southeastern Cancer Study Group were randomized to receive either surgical treatment alone, or surgery plus Corynebacterium parvum immunotherapy. A multivariant analysis (Cox regression model) of nine prognostic factors was performed on 110 patients with a minimum of two years follow-up. The dominant prognostic variables were thickness (P = 0.0007) and anatomic location of the melanoma (trunk versus other, P = 0.015). Disease-free survival curves were then calculated for 204 surgically evaluable patients. Overall, there was no significant difference in three-year survival for the two-treatment arms, which was 81% for the adjuvant immunotherapy group compared to 67% for the surgical control group (P = 0.10). The median follow-up period was 24 months (range, 1-60 months). However, when the data was subgrouped by tumor thickness, an apparent benefit of immunotherapy was observed in 49 patients with melanomas greater than 3 mm in thickness. Only five of 23 such patients relapsed after receiving C. parvum. Their three-year disease-free survival was 73%. In contrast, 13 of 26 patients who did not receive immunotherapy have relapsed so far and their three-year disease-free survival was only 33% (P = 0.01). In the 175 patients with melanomas less than 3 mm in thickness, both treatment arms had identical three-year disease-free survival rates of 83%. No significant differences between the treatment arms were observed using other prognostic variables, including the level of invasion. Toxicity to C. parvum injections was minimal in most patients. It is concluded that a prognostic factor analysis is critically important in adjunctive trials of melanoma to determine which dominant variables should be used for analyzing patient subgroups; that C. parvum immunotherapy appears to be associated with an improved disease-free survival rate in the subgroup of patients with melanomas greater than 3 mm thickness (this early encouraging data must still be confirmed with continued patients accrual and a longer observation period); and that patients with melanomas less than 3 mm thickness have a relatively favorable prognosis after appropriate surgical treatment, and immunotherapy does not improve their survival rates.

Molecular comparison of mouse Thy-1 and its human homologue

Physicochemical techniques were used to verify previous immunochemical studies showing homology of the human Thy-1 (formerly p25) antigen and the murine Thy-1 or theta antigen. Peptide maps and amino acid compositions showed close similarity between these two proteins; however, they were not identical. These data confirm that the p25 antigen is the human homologue of mouse Thy-1.

Associations of properdin factor B with melanoma

We investigated 98 melanoma patients and 135 normal controls for differences in phenotype and genotype frequencies at the properdin factor B locus. A significant negative association with the Bf-F allele and melanoma was found, resulting in an estimated relative risk of 0.5. The estimated relative risk for developing melanoma among people with the Bf-FF genotype is 0.07. The Bf-S phenotype was significantly increased among the melanoma sample, with an estimated risk of 6.5. The data suggest association of the Bf locus with a melanoma protection and/or susceptibility gene(s).

Prophylactic lymph node dissection in clinical stage I cutaneous malignant melanoma: results of surgical treatment in 1319 patients

A retrospective study was made of 1319 patients with cutaneous primary malignant melanoma and regional lymph nodes clinically free of disease, whose first definitive surgical treatment was either (a) wide excision of the primary lesion (WE) or (b) wide excision of the primary lesion plus a prophylactic lymph node dissection (PLND). Patients were stratified according to three dominant prognostic factors, as revealed by multifactorial analyses: sex of patient, the anatomical site and thickness of the primary lesion. Of 380 patients who underwent PLND for lymph nodes clinically free of disease, there was microscopic evidence of nodal metastases in 5 per cent. Despite this, prognosis in these patients was nearly twice as good as in those patients undergoing lymph node dissection for clinically involved nodes. Five-year survival rates for all those clinical stage I patients with lesions less than 0.8 mm thick were high irrespective of initial surgical treatment. In men with lesions of intermediate thickness (particularly 1.6-3.0 mm), survival rates for those undergoing PLND were considerably higher than for those undergoing WE. There were no survival benefits of PLND in men with lesions thicker than 3.0 mm. This was in contrast to the situation in women, where PLND was indicated for patients with the thickest lesions. This study has defined three parameters which can serve as useful practical guides for selecting alternative surgical procedures in the management of clinical stage I cutaneous malignant melanoma.

Postnatal expansion of the natural killer and keller cell population in humans identified by the monoclonal HNK-1 antibody

Human natural killer (NK) and killer (K) cells were directly enumerated using a monoclonal antibody (HNK-1) and an immunofluorescence assay. The frequency of cells bearing surface HNK-1 antigen was very low in the newborn (less than 1.0%) and increased progressively through childhood and into adult life. This was correlated with an age-related increase in functional NK and K cell activities. Males had a slightly higher proportion of HNK-1+ cells than females. In addition to HNK-1 expression on the surface membrane, a prominent cytoplasmic expression of HNK-1 antigen was found in some but not all surface HNK-1+ cells. The cytoplasmic accumulation of HNK-1 molecules appeared to occur in more mature cells of this lineage.