Abstract OT1-01-02: Pilot trial of a type I polarized autologous dendritic cell vaccine incorporating tumor blood vessel antigen-derived peptides in patients with metastatic breast cancer

BACKGROUND. Cancer vaccines based on tumor-associated antigens are rarely curative in advanced cancer. This limitation relates to the heterogeneity of cancer due to defects in antigen presentation and altered immunophenotypes. Therefore, another method to promote anti-tumor immunity is to prime T cells against tumor-associated stromal cells. We have reported that IL-12 gene-therapy of established HLA-A2neg B16 melanomas in HLA-A2 transgenic (Tg) mice resulted in CD8+ T cell-mediated immunity against the host HLA-A2+ stromal cells within the tumor microenvironment (TME). We have also shown that vaccines based on a subset of tumor blood vessel antigen (TBVA)-derived peptides (DLK1310-318, EphA2883-891, HBB31-39, NRP1433-441, RGS55-13 and TEM1691-700) prevented HLA-A2neg MC38 tumor establishment and promoted the regression of melanomas in HLA-A2 Tg mice by CD8+ T cell targeting of HLA-A2+ pericytes and vascular endothelial cells in the TME.

TRIAL DESIGN. Based on this pre-clinical data, we are undertaking a Susan G. Komen-funded (IIR13261822; IND 15722) IRB-approved clinical trial of chemo-immunotherapy using the immunomodulatory drug gemcitabine (GEM) to suppress tumor infiltrating suppressor cells such as myeloid-derived suppressor cells (MDSC) and regulatory T cells (Tregs) with a dendritic cell (DC) vaccine pulsed with the above six HLA-A2-presented TBVA-derived peptides (DC-TBVA) in 30 HLA-A2+ patients with metastatic breast cancer (MBC). Eligible patients will first undergo leukapheresis for the generation of the DC-TBVA vaccine. Patients will then receive 3 cycles of GEM, 1000 mg/m2 IV on days 1 and 8 of a 21-day cycle for 3 cycles. Patients will then receive the DC-TBVA vaccine administered twice intradermally 7 days apart.

ELIGIBILITY CRITERIA. Patients must be HLA-A2+ and have radiologically measurable MBC, an ECOG performance status of 0-1 and not have any active immune disorders. Prior GEM therapy is acceptable as long as the last dose was ≥ 3 months from registration on this study. Patients may not be on steroids.

SPECIFIC AIMS. The 4 specific aims are to 1) assess the safety of GEM + αDC1-TBVA vaccination, 2) assess the clinical response of MBC to GEM + αDC1-TBVA vaccination, 3) determine the clinical efficacy of GEM + αDC1-TBVA vaccination in generating Tc1 immunity, and 4) correlate changes in MDSC and Tregs with the generation of anti-TBVA Tc1-cell immunity

STATISTICAL METHODS. Clinical response: if the response rate is less than 10%, then there is probability 0.05 or less of accepting the vaccine therapy; if the response rate is bigger than 32%, then the probability of rejecting the combination is less than 0.2. While the secondary goals of the study are exploratory, there is sufficient statistical power to identify moderate to large effects (i.e., there will be statistical power >.80 to detect changes from baseline in the different immune function parameters that are >0.6 standard deviations of the parameter.)

TARGET ACCRUAL. We will enroll 30 patients over 3 years, with the first patient expected to be enrolled in July 2015.

CONTACT INFORMATION. Joseph Baar, MD, PhD. Seidman Cancer Center. E-mail: joseph.baar@uhhospitals.org.

Citation Format: Baar J, Storkus W, Finke J, Butterfield L, Lazarus H, Reese J, Brufsky A, Downes K, Budd GT, Fu P. Pilot trial of a type I polarized autologous dendritic cell vaccine incorporating tumor blood vessel antigen-derived peptides in patients with metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-01-02.

Arrhythmias in the setting of hematopoietic cell transplants

Prior studies report 9–27% of persons receiving a hematopoietic cell transplant develop arrhythmias, but the effect on outcomes is largely unknown. We reviewed data from 1177 consecutive patients {greater than or equal to}40 years old receiving a hematopoietic cell transplant at one center during 1999–2009. Transplant indication was predominately leukemia, lymphoma and multiple myeloma. Overall, 104 patients were found to have clinically significant arrhythmia: 43 prior to and 61 following transplant. Post-transplant arrhythmias were most frequently atrial fibrillation(N=30), atrial flutter(N=7) and supraventricular tachycardia(N=11). Subjects with an arrhythmia post-transplant were more likely to have longer median hospital stays (32 days vs 23, P=<.001,) a greater probability of an ICU admission (52% vs 7%; P<.001), more inhospital deaths (28% vs 3%, P<0.001), and more deaths within one year of transplant (41% vs 15%; P<0.001) than patients without arrhythmia at any time. In a multivariate model including age at transplant, diagnosis, history of pre-transplant arrhythmia, and transplant-related variables, post-transplant arrhythmia was associated with a greater risk of death within a year of transplant (OR 3.5, 95% CI: 2.1, 5.9; P < 0.001). Our data suggest arrhythmias after transplants are associated with significant morbidity and mortality. A prospective study of arrhythmia in the transplant setting is warranted.

Physician perceptions and practice patterns regarding fertility preservation in hematopoietic cell transplant recipients

Physician practice variation may be a barrier to informing hematopoietic cell transplant (HCT) recipients about fertility preservation (FP) options. We surveyed HCT physicians in the United States to evaluate FP knowledge, practices, perceptions and barriers. Of the 1035 physicians invited, 185 completed a 29-item web-survey. Most respondents demonstrated knowledge of FP issues and discussed and felt comfortable discussing FP. However, only 55% referred patients to an infertility specialist. Most did not provide educational materials to patients and only 35% felt that available materials were relevant for HCT. Notable barriers to discussing FP included perception that patients were too ill to delay transplant (63%), patients were already infertile from prior therapy (92%) and time constraints (41%). Pediatric HCT physicians and physicians with access to an infertility specialist were more likely to discuss FP and to discuss FP even when prognosis was poor. On analyses that considered physician demographics, knowledge and perceptions as predictors of referral for FP, access to an infertility specialist and belief that patients were interested in FP were observed to be significant. We highlight variation in HCT physician perceptions and practices regarding FP. Physicians are generally interested in discussing fertility issues with their patients but lack educational materials.

Randomized trial of peribulbar triamcinolone acetonide with and without focal photocoagulation for mild diabetic macular edema: a pilot study

OBJECTIVE

To provide pilot data on the safety and efficacy of anterior and posterior sub-Tenon injections of triamcinolone either alone or in combination with focal photocoagulation in the treatment of mild diabetic macular edema (DME).

DESIGN

Prospective, phase II, multicenter, randomized clinical trial.

PARTICIPANTS

One hundred nine patients (129 eyes) with mild DME and visual acuity 20/40 or better.

METHODS

The participants were assigned randomly to receive either focal photocoagulation (n = 38), a 20-mg anterior sub-Tenon injection of triamcinolone (n = 23), a 20-mg anterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 25), a 40-mg posterior sub-Tenon injection of triamcinolone (n = 21), or a 40-mg posterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 22). Follow-up visits were performed at 4, 8, 17, and 34 weeks.

MAIN OUTCOME MEASURES

Change in visual acuity and retinal thickness measured with optical coherence tomography (OCT).

RESULTS

At baseline, mean visual acuity in the study eyes was 20/25 and mean OCT central subfield thickness was 328 mum. Changes in retinal thickening and in visual acuity were not significantly different among the 5 groups at 34 weeks (P = 0.46 and P = 0.94, respectively). There was a suggestion of a greater proportion of eyes having a central subfield thickness less than 250 mum at 17 weeks when the peribulbar triamcinolone was combined with focal photocoagulation. Elevated intraocular pressure and ptosis were adverse effects attributable to the injections.

CONCLUSIONS

In cases of DME with good visual acuity, peribulbar triamcinolone, with or without focal photocoagulation, is unlikely to be of substantial benefit. Based on these results, a phase III trial to evaluate the benefit of these treatments for mild DME is not warranted.

Phase I/II clinical trials for relapsed elderly acute leukemia patients: Importance of performance status at re-induction. A single center retrospective experience

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Background: Relapsed/refractory acute leukemia patients (pts) have a poor outcome and should be considered for enrollment on clinical trials. Elderly (≥ 60 yr) acute leukemia patients often are excluded from phase I/II cytotoxic agent re-induction chemotherapy trials due to concerns for treatment-related toxicity. Methods: Pts with relapsed/refractory acute leukemia who were enrolled on three consecutive phase I/II clinical trials at University Hospitals of Cleveland were evaluated for outcome data including complete response (CR), serious adverse events, and overall survival (OS). Outcome data was compared for pts age ≥ 60 yr versus < 60 yr. Pts with ECOG Performance Status (PS) 0 to 3 were eligible and there was no age limitation. Results: Between 1994 and 11/2005, 96 acute leukemia pts median age 60 yr (range 19–78) were enrolled: 29 pts received phase I topotecan-etoposide; 31 pts received phase I fludarabine, carboplatin, and topotecan (FCT); and 37 pts received phase II FCT plus thalidomide. In univariate analysis, PS at therapy initiation, mean # prior treatments, and disease status at time of treatment were not statistically different between older and younger pts ( Table ). Using Kaplan-Meier method, early treatment-related mortality and OS were similar in pts age ≥ 60 yr compared to pts < 60 yr ( Table ). Mean # ≥ grade 3 toxicities and CR also were similar in both groups ( Table ). In univariate (p = 0.001) and multivariate (p = 0.0004) analyses by Cox modeling, pts PS 0–1 had better OS than PS 2–3 (PS 0–1: 30-day survival 98% and 1 yr survival 24% versus PS 2–3: 30-day survival 81% and 1 yr survival 6%). Conclusions: Poor PS is an important negative predictor of outcomes in relapsed/refractory acute leukemia pts. Advanced age should not exclude pts from cytotoxic re-induction chemotherapy trials.

[Table: see text]

No significant financial relationships to disclose.

Signal perception during performance of an activity under the influence of noise

Usually the perception of acoustic signals is investigated under conditions where the subjects pay full attention to the signals. It can be assumed that the threshold of signal perception is much higher if the attention has simultaneously to be focused on the execution of any kind of other activity. In the following experiment subjects have to perceive acoustic signals while solving different arithmetical tasks at the same time. The results (number of perceived signals, number of arithmetical tasks solved, reaction time, and solving time) show that the threshold of signal perception rises while other tasks are being performed simultaneously. Consequences for the recognition of warning signals in occupational safety and in traffic conditions are discussed.

Randomized, multicenter, open-label study of pegfilgrastim compared with daily filgrastim after chemotherapy for lymphoma

PURPOSE

The primary objective was to assess the duration of grade 4 neutropenia (neutrophil count < 0.5 x 10(9)/L) after one cycle of chemotherapy with etoposide, methylprednisolone, cisplatin, and cytarabine in patients randomly assigned to receive one dose of pegfilgrastim or daily filgrastim after chemotherapy. Febrile neutropenia, neutrophil profiles, time to neutrophil recovery, pharmacokinetics, and safety were also assessed.

PATIENTS AND METHODS

An open-label, randomized, phase II study was designed to compare the effects of a single subcutaneous injection of pegfilgrastim (sustained-duration filgrastim) 100 micro g/kg per chemotherapy cycle (n = 33) with daily subcutaneous injections of filgrastim 5 micro g/kg (n = 33) in patients receiving salvage chemotherapy for relapsed or refractory Hodgkin's or non-Hodgkin's lymphoma.

RESULTS

The incidence of grade 4 neutropenia in the pegfilgrastim and filgrastim groups was 69% and 68%, respectively. In addition, the mean duration of grade 4 neutropenia was similar in both groups (2.8 and 2.4 days, respectively). The results for the two groups were also not significantly different for febrile neutropenia, neutrophil profile, time to neutrophil recovery, or toxicity profile. A single subcutaneous injection of pegfilgrastim 100 micro g/kg produced a sustained serum concentration relative to daily subcutaneous injections of filgrastim. Filgrastim-treated patients received a median of 11 injections per cycle.

CONCLUSION

Pegfilgrastim was safe and well tolerated in this patient population. A single injection of pegfilgrastim per chemotherapy cycle provided neutrophil support with safety and efficacy similar to that provided by daily injections of filgrastim. Once-per-cycle administration of pegfilgrastim simplifies the management of neutropenia and may have important clinical benefits for patients and healthcare providers.

Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant

A 7-month-old infant with cutaneous anthrax developed severe systemic illness despite early treatment with antibiotics. The infant displayed severe microangiopathic hemolytic anemia with renal involvement, coagulopathy, and hyponatremia. These findings are unusual with cutaneous anthrax, but have been described in illness resulting from spider toxin and may delay correct diagnosis. The systemic manifestations of the disease persisted for nearly a month despite corticosteroid therapy, but resolved.

Autotransplants in men with breast cancer. ABMTR Breast Cancer Working Committee. Autologous Blood and Marrow Transplant Registry

The purpose of this study was to determine the outcome of high-dose therapy with autologous hematopoietic stem cell support (autotransplants) in men with breast cancer. We studied 13 men receiving autotransplants for breast cancer and reported to the Autologous Blood and Marrow Transplant Registry (ABMTR) by 10 centers. Six men had stage 2 breast cancer, four had stage 3, and three had metastatic breast cancer. Of twelve tumors tested, all were estrogen receptor positive. Median age at transplant was 50 years. The most common conditioning regimen was cyclophosphamide, thiotepa and carboplatin (n = 5); the remaining eight men received other alkylator-based regimens. Three men received bone marrow, eight received blood stem cells, and two received both for hematopoietic support. All patients had hematopoietic recovery. There were no unexpected regimen-related toxicities. Of 10 men receiving autotransplants as adjuvant therapy, three relapsed 3, 5 and 50 months post-transplant and died 16, 19 and 67 months post-transplant. Seven of 10 are disease-free with median follow-up of 23 months (range 6-50 months). Of three men treated for metastatic breast cancer, one had progressive disease and two recurrent disease at 6, 7 and 16 months post-transplant. In conclusion, results of autotransplants for male breast cancer appear similar to those reported for women receiving autotransplants for breast cancer.

[Long-term patients also need their history. The socio-geographic reconstruction of the life history as social pedagogic method for work with long-term patients]

"Socio-geographic reconstruction" means to recall important places and stations of life, accompanied by another interested person. Students of social paedagogics have created these reconstructions together with long-term psychiatric patients. The method is based on social science participation studies. The aim is the rediscovering and reacquiring the prepsychiatric biography of the patients as well as the understanding of this history by the students. The focus of interest is not the "history of illness" but the "history of life" as it was connected with family, school, work and leisure time.

Phase I trial of high-dose mitoxantrone plus cyclophosphamide and filgrastim in patients with advanced breast carcinoma

PURPOSE

To determine the maximum-tolerated dose (MTD) of mitoxantrone that could be safely used in combination with cyclophosphamide and filgrastim in patients with advanced breast carcinoma.

PATIENTS AND METHODS

Twenty-seven patients with metastatic (n = 24) or locally advanced (n = 3) breast carcinoma received escalating doses of mitoxantrone (16, 20, 24, 28, or 32 mg/m2) plus cyclophosphamide at one of three dose levels: group 1, 1,200 mg/m2; group 2, 2,400 mg/m2; and group 3,600 mg/m2. All patients also received filgrastim 5 micrograms/kg administered subcutaneously beginning on day 2 and continuing until the post-nadir absolute neutrophil count (ANC) was > or = 10,000/microL. Treatment was repeated every 3 weeks if the ANC was > or = 2,000/microL and platelet count > or = 90,000/microL for a maximum of six cycles. Dose escalation occurred within each group if zero of three or one of four patients had dose-limiting toxicity during the first cycle.

RESULTS

The MTD of mitoxantrone was 24 mg/m2 in group 1, less than 16 mg/m2 in group 2, and 28 mg/m2 in group 3. Neutropenia was dose-limiting, and cumulative neutropenia and thrombocytopenia occurred with continued therapy. Nonhematologic toxicity consisted predominantly of nausea, vomiting, alopecia, and fatigue. Three patients (11%) had a > or = 10% decrease in the left ventricular ejection fraction (LVEF), one patient (4%) had a decrease in the LVEF below normal, and none developed clinical congestive heart failure. Of patients with stage IV breast carcinoma who had not received prior chemotherapy for advanced disease, objective responses occurred in nine of 20 (45%), and the median response duration was 5 months.

CONCLUSION

In combination with 600 mg/m2 of cyclophosphamide and filgrastim, the MTD of mitoxantrone is 28 mg/m2, a dose that is approximately twofold to 2.8-fold higher than the conventional dose used without a hematopoietic growth factor.

Sequential administration of recombinant human interleukin-3 and granulocyte-macrophage colony-stimulating factor after autologous bone marrow transplantation for malignant lymphoma: a phase I/II multicenter study

Preclinical studies of recombinant human interleukin-3 (rhIL-3) and granulocyte-macrophage colony-stimulating factor (rhGM-CSF) have shown enhancement of multilineage hematopoiesis when administered sequentially. This study was designed to evaluate the safety, tolerability, and biologic effects of sequential administration of rhIL-3 and rhGM-CSF after marrow ablative cytotoxic therapy and autologous bone marrow transplantation (ABMT) for patients with malignant lymphoma. Thirty-seven patients (20 patients with non-Hodgkin's lymphoma and 17 patients with Hodgkin's disease) received one of four different treatment regimens before ABMT. Patients were entered in one of four study groups to receive rhIL-3 (2.5 or 5.0 micrograms/kg/day) administered by subcutaneous injection for either 5 or 10 days starting 4 hours after the marrow infusion. Twenty-four hours after the last dose of rhIL-3, rhGM-CSF (250 micrograms/m2/d as a 2-hour intravenous infusion) administration was initiated. rhGM-CSF was administered daily until the absolute neutrophil count (ANC) was > or = 1,500/microL for 3 consecutive days or until day 27 posttransplant. The most frequent adverse events in the trial included nausea, fever, diarrhea, mucositis, vomiting, rash, edema, chills, abdominal pain, and tachycardia. Three patients were removed from the study because of chest, skeletal, and abdominal pain felt to be probably related to study drug. Four patients died during the study period because of complications unrelated to either rhIL-3 or rhGM-CSF. The median time to recovery of neutrophils (ANC > or = 500/microL) and platelets (platelet count > or = 20,000/microL) was 14 and 15 days, respectively. There were fewer days of platelet transfusions than seen in historical control groups using rhGM-CSF, rhG-CSF, or rhIL-3 alone. In addition, there were fewer days of red blood cell transfusions compared with historical controls using no cytokines or rhGM-CSF. These data indicate that the sequential administration of rhIL-3 and rhGM-CSF after ABMT is safe and generally well-tolerated and results in rapid recovery of multilineage hematopoiesis.

Comparison of preparative transplantation regimens using carmustine/etoposide/cisplatin or busulfan/etoposide/cyclophosphamide in lymphoid malignancies

Most bone marrow transplantation preparative regimens use total body irradiation as one component. Recently, however, two non-total body irradiation containing autologous bone marrow transplantation preparative regimens have been evaluated in patients with lymphoid malignancies. The first regimen consisted of carmustine, etoposide, and cisplatin; some patients also received involved-field radiotherapy to sites of prior disease. Of the 79 patients with relapsed or refractory lymphoma who participated in this study, 57 (72%) achieved a complete remission and 40 (51%) remain in complete remission. Treatment-related deaths occurred in five patients (6%). The second preparative regimen evaluated consisted of busulfan, etoposide, and cyclophosphamide and included 21 patients with Hodgkin's lymphoma, non-Hodgkin's lymphoma, or acute lymphocytic leukemia. Sixteen patients (76%) achieved complete remission and 12 (57%) remain disease free. The regimen-related mortality rate in this study was 14%. The three treatment-related deaths were all due to pulmonary toxicity. The results of these clinical trials indicate that both the carmustine/etoposide/cisplatin regimen and the busulfan/etoposide/cyclophosphamide regimen are effective in treating lymphoid malignancies. Treatment-related toxicities and deaths are significant, but not prohibitive. Accordingly, these new preparative regimens deserve further evaluation in the treatment of patients with lymphoma or leukemia.

Prevalence of platelet transfusion reactions before and after implementation of leukocyte-depleted platelet concentrates by filtration

To determine the impact of platelet leukodepletion by filtration on the overall prevalence of reported transfusion reactions associated with platelet concentrates, we audited platelet transfusion reactions after infusion of platelet concentrates reported at University Hospitals of Cleveland over 6 months before (interval 1, July 1, 1989 to December 31, 1989) and after (interval 2, July 1, 1990 to December 31, 1990) implementation of the Pall PL 50 filter on our adult Hematology-Oncology inpatient unit (Division 60). Thirty-two (1.7%) of 1,901 random, pooled platelet transfusion events resulted in blood bank transfusion reaction workups in interval 1, compared to 90 (5.3%) of 1,704 in interval 2 (p < 0.001). The Division 60 service accounted for more of our hospital-wide platelet reactions after implementation of the filter in interval 2 (84%) than before filtration in interval 1 (42%), p = 0.002. The prevalence of reaction workups for Division 60 was 0.6% for interval 1, compared to 4.3% for interval 2 (p < 0.001). No differences were found between interval 1 and interval 2 for the rate of discontinuation of platelet transfusion (36 vs. 32%, p = 0.14), rate of premedication for platelet transfusion (72 vs. 65%, p = 0.6), percentage of direct antiglobulin test-positive reactions (17 vs. 5.4%, p = 0.09), percentage showing icteric/hemolyzed serum (15 vs. 4.4%, p = 0.09), or reactions believed to be due to red blood cell incompatibility (8.8 vs. 1.1%, p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Controlled-release morphine bioavailability (MS Contin tablets) in the presence and absence of food

The bioavailability of a single, orally administered, 30-mg controlled-release morphine tablet (MS Contin Tablet; The Purdue Frederick Company, Norwalk, Conn.) was compared after fasting or a high fat meal in this single dose, randomized, crossover study involving 24 healthy male subjects. There was no significant (p greater than 0.05) difference in the mean extent of morphine absorption over 24 hours in the presence or absence of food (area under the plasma concentration vs. time curve [AUC(0,24)], fed = 107% of fasted). Time to maximal concentration (Tmax) was similar (p greater than 0.05) in the two treatment groups; the mean Tmax for fed volunteers was 2.5 hours versus 2.4 hours for fasted volunteers. The two regimens did not differ significantly (p greater than 0.05) with regard to maximal morphine concentration (Cmax); mean Cmax for fed subjects was 8.22 ng/ml whereas mean Cmax for fasted subjects was 8.53 ng/ It was concluded that consumption of a high fat meal did not affect either the rate or extent of morphine absorption, or any of the other pharmacokinetic parameters tested, following administration of MSC.

A multi-investigator clinical evaluation of oral controlled-release morphine (MS Contin tablets) administered to cancer patients

The analgesic efficacy of oral controlled-release morphine (MS Contin Tablets; MSC) and its influence on quality of life, including parameters of nighttime sleep and daytime functioning, were evaluated in this open-label, sequential study in cancer patients. Seventy patients completed this multi-investigator study; each patient was assigned to one of two dosing protocols, as determined by their previous analgesic regimen. Evaluations were made at baseline (when patients were receiving their previous analgesic regimen) and again on the second visit, after a dosage level of MSC sufficient to control pain was reached for a minimum of two weeks. There were no significant (p greater than 0.17) differences in incidence of nausea, vomiting, or drowsiness experienced by patients during treatment with MSC and during previous analgesic regimens. A senna and docusate sodium preparation (Senokot-S Tablets; SKS) was used to alleviate opioid-induced constipation; consequently there was a significantly lower (p = 0.02) incidence of constipation during treatment with MSC. A moderate relationship between opioid dose and laxative consumption was observed. Pain intensity was significantly (p = 0.0001) decreased, and quality of nighttime sleep and daytime functioning were significantly (p = 0.0001) increased compared with baseline values. Patients' overall quality of life improved significantly (p = 0.0001) during treatment with MSC when compared to their previous analgesic regimens. In conclusion, the therapeutic merits afforded by MSC coupled with proper dose titration were perceived by the patients to be superior to those provided by their previous medications. The benefits of less frequent dosing combined with potent analgesic effect plus the aggressive use of laxatives resulted in a global improvement in quality of life for the patients involved in this study.

Tricyclic 2,4-diaminopyrimidines with broad antifolate activity and the ability to inhibit Pneumocystis carinii growth in cultured human lung fibroblasts in the presence of leucovorin

A selected number of 1,3-diaminobenzo[f]quinazolines and 1,3-diamino-5,6-dihydrobenzo[f]quinazolines, which may be viewed as tricyclic analogues of the lipid-soluble antifolates pyrimethamine (PM), metoprine (DDMP), and etoprine (DDEP), were tested as inhibitors of purified dihydrofolate reductase (DHFR) from WI-L2 lymphoblasts, and as inhibitors of the growth of Streptococcus faecium ATCC 8043 and L1210 murine leukemia cells in culture. In addition, these tricyclic compounds were tested for antimalarial activity against Plasmodium berghei in mice, and for the ability to inhibit the growth of Pneumocystis carinii trophozoites in WI-38 human lung fibroblast cultures in the presence of leucovorin (LV). The most potent analogues were those with chlorine substitution in the ring distal to the 2,4-diaminopyrimidine moiety. Fully aromatic compounds tended to be more active than those in which the 5,6-bond was reduced, suggesting that planarity favors binding to the DHFR active site and may be favorable for cellular uptake. Several of the 2,4-diaminopyrimidine analogues showed greater potency than PM, DDMP or DDEP, and were more nearly comparable to the bicyclic 2,4-diaminopyrimidine antifolates trimetrexate (TMQ) or piritrexim (BW301U), which are known to be selectively toxic to P. carinii in the presence of LV. Two of the tricyclic compounds, 1,3-diamino-8-chlorobenzo[f]quinazoline and 1,3-diamino-9-chlorobenzo[f]quinazoline, proved to have activity similar to TMQ and BW301U in this system.

Computed tomography-guided retroperitoneal biopsies

A retrospective review was performed on consecutive patients who had a computed tomographic (CT) biopsy of the retroperitoneum at University Hospitals of Cleveland. Biopsies were performed using a 20-gauge Chiba needle (University Medical Instruments Corp, Ballston Spa, NY) and a 14-gauge Tru-Cut needle (Baxter Pharmaseal, Valencia, CA). The results included success rate, failure, and complications, and were determined by a review of patient charts, surgical results, and autopsy results. The 20-gauge needle aspirations were accurate in suggesting the diagnosis in 20 of 22 cases of metastatic disease and ten of 15 cases of lymphoma. Using the 20-gauge needle, it was not possible to make a specific diagnosis in any of the lymphoma patients or for unusual benign disorders. With the 14-gauge Tru-Cut needle, the correct diagnosis was made in 13 of 13 cases of metastatic disease, ten of 11 cases of lymphoma, and two of 2 cases of unusual benign disorders. It was also possible to make the specific diagnosis of the lymphoma type in ten of 11 cases. The only complication was a small subcutaneous hematoma following a biopsy with a 20-gauge Chiba needle.

Class I MHC molecules and doxorubicin resistant P388 murine leukemic cells

The major histocompatibility complex (MHC) encodes cell surface and secreted products involved in immune regulation and function. We have measured Class I MHC expression on doxorubicin (DOX) sensitive (P388/S) and resistant (P388/R84 and R84A) murine tumor cells using a monoclonal antibody to H-2d molecules. The present report shows a correlation between increased Class I MHC (H-2d) expression and drug resistance in P388 cells. Exposure of P388 cells to H-2d antibody diminished H-2d expression, whereas, treatment with murine recombinant gamma-interferon increased H-2d expression. Neither treatment significantly altered cellular DOX resistance or chemosensitivity. Thus, H-2d molecules can be used to identify DOX resistant P388 tumor cells but are probably not involved functionally in drug resistance.

P & T Committee interview: Establishing and maintaining a dynamic formulary

In an exclusive interview with Hospital Formulary, Dr. Stephen Rostand and Mr. Herman Lazarus--the P & T Committee Chairman and Secretary of the University of Alabama Hospital--share their experiences in establishing an effective, functional formulary system. Discussed in this interview are the current activities of this Committee which include: reviewing adherence to an established Committee guideline on an effective antibiotic dosing regimen, creating a more effective adverse drug reaction reporting system, and establishing a computerized program to alert prescribers to the possibility of drug-drug interactions. By their willingness to cooperate, communicate, and remain flexible to medical staff requests, this 15-member Committee has been able to maintain a dynamic formulary.

Ganglioside GD2 specific monoclonal antibody 3F8: a phase I study in patients with neuroblastoma and malignant melanoma

The murine IgG3 monoclonal antibody (MoAb) 3F8, specific for the ganglioside GD2, activates human complement, is active in antibody-dependent cell-mediated cytotoxicity (ADCC), and can target specifically to human neuroblastoma in patients with metastatic disease. In a phase I study, 3F8 was administered intravenously (IV) to 17 patients with metastatic GD2 positive neuroblastoma or malignant melanoma at doses of 5, 20, 50, and 100 mg/m2. Serum 3F8 levels achieved were proportional to the dose of 3F8 infused. However, serum antimouse antibody levels did not increase with the amount of 3F8 administered. Toxicities included pain, hypertension, urticaria, and complement depletion. All acute side effects were controllable with symptomatic therapy. No long-term side effects were detected in patients observed for more than 14 months. None of the 17 patients received any antitumor therapy postantibody treatment. Antitumor responses occurred in seven of 17 patients. These ranged from complete clinical remissions to mixed responses. The murine monoclonal antibody (MoAb) 3F8 has clinical utility for the diagnosis and therapy of neuroblastoma and melanoma.

Vascular graft-associated complement activation and leukocyte adhesion in an artificial circulation

Complement-associated leukocyte adhesion appears to be a consistent in vitro and in vivo finding for many types of polymers; however, very little work has been done on the interaction of leukocytes with vascular graft materials. An in vitro perfusion system was used to study complement and leukocyte activation associated with the following vascular graft materials when tested with human blood: expanded polytetrafluoroethylene (ePTFE), crimped Dacron Bionit (DB) and preclotted Dacron Bionit. A decrease in the total leukocyte concentration with perfusion time was seen for all materials tested, and paralleled leukocyte adhesion to the graft surface as observed by scanning electron microscopy. The most dramatic decrease in leukocyte concentration was observed for the interaction of heparinized whole blood with Dacron. This was due to a selective decrease in neutrophils and monocytes, and was correlated with an increase in both leukocyte adhesiveness and complement activation, as measured by C5a elevation. Inhibiting complement activation by use of the anticoagulant, sodium citrate, curtailed Dacron-induced leukocyte adhesion. Little leukocyte or complement activation was observed for ePTFE or the silicone rubber control regardless of the anticoagulant used.

Unique proliferation-associated marker expressed on activated and transformed human cells defined by monoclonal antibody

The expression, tissue distribution, and preliminary characterization of a cell surface molecule, apparently a glycolipid, recognized by a monoclonal antibody, anti-PAA, were described. This antibody (anti-PAA) was produced by the fusion of myeloma cells NS-1 with spleen cells from a BALB/c mouse, which were sensitized with activated human T-cells generated by allogeneic stimulation in mixed-lymphocyte culture (MLC). Resting human peripheral blood T-cells, B-cells, and monocytes demonstrated weak anti-PAA binding. Binding of proliferating T-cells (phytohemagglutinin- and MLC-activated T-cells) and thymocytes to anti-PAA was two to six times greater than that of resting T-cells. A fifteenfold-increased binding was observed with acute lymphocytic leukemia T-cell lines. Epstein-Barr virus-transformed B-cell lines bound anti-PAA up to sixteenfold greater than resting B-cells. Tumor cell lines of various nonlymphoid origins demonstrated marked reactivity with this antibody. Both benign and malignant cells in hyperplastic tissues, of various origins, bound anti-PAA, whereas their normal, nonproliferating counterparts did not. Normal proliferating cells in these tissues, including cells of the placental chorionic villi and trophoblasts, also bound anti-PAA. Of all lymphoid and nonlymphoid cell lines examined, only chronic lymphocytic leukemia (CLL) cells and some cell lines derived from Burkitt's lymphoma showed weak or no binding. This antibody also failed to react with a variety of nonprimate cell lines. Anti-PAA antibody did not immunoprecipitate any protein from lymphoid tumor cell lines to which it demonstrated a quantitatively high degree of binding, nor did protease treatment of these lines decrease antibody binding. Anti-PAA did, however, bind to glycolipids extracted from these cell lines. Binding of this monoclonal antibody to a minor neutral glycolipid, isolated from the erythroleukemia cell line K562, was about sixfold greater than that of any other K562 neutral glycolipid or ganglioside. Anti-PAA demonstrated weak or undetectable binding to purified, predominant, lymphoid cell membrane's neutral glycolipids and gangliosides. The monoclonal antibody anti-PAA appeared, therefore, to recognize a unique, proliferation-associated, neutral glycolipid present on normal as well as on benign and malignant proliferating cells. The antigen appeared to be universally expressed on proliferating cells from all human tissues with the exception of some Burkitt's cell lines and CLL cells. Nonhuman cell lines, except those for closely related primates, did not express PAA.

Industrial safety: Acoustic signals for danger situations in factories

To clarify which types of acoustic signals should be used for what danger situations, the relationships between acoustic signals already used in factories and danger situations are investigated. Compatibilities between 20 danger signals (horns, sirens, etc) and 36 situations (e g, fire, accident, etc) are determined with the help of a compatibility scale. Based on mean ratings of 48 subjects, some of these signals can be grouped if the compatibilities between signals and danger situations are similar. Rules for selection of signals are given.

Methotrexate analogues. 21. Divergent influence of alkyl chain length on the dihydrofolate reductase affinity and cytotoxicity of methotrexate monoesters

n-Octyl, n-dodecyl, and n-hexadecyl alpha- and gamma-esters of methotrexate (MTX) were compared with the previously described alpha- and gamma-n-butyl esters and with MTX as inhibitors of dihydrofolate reductase (DHFR) and human leukemic lymphoblasts (CEM cells) in culture. The overall order of activity in both test systems was MTX greater than MTX gamma-esters greater than MTX alpha-esters. In the DHFR assay the activity of the alpha-esters followed the order C4 greater than C8 congruent to C12 greater than C16, whereas for the gamma-esters this order was C4 congruent to C8 greater than C12 greater than C16. On the other hand, the order of cytotoxic activity in culture in both series was C16 greater than C12 greater than C8 greater than C4. Increasing the alkyl chain length in the ester moiety therefore decreases DHFR affinity but increases cytotoxicity. The most potent member of the compounds tested was the gamma-n-hexadecyl ester, whose IC50 against CEM cells was 0.11 microM as compared with 0.025 microM for MTX. In a comparison of the effect of treatment with the gamma-n-hexadecyl ester (10(-5) M, 1 h) on DNA synthesis in CEM and CEM/MTX cells, the latter of which are 120-fold resistant to MTX by virtue of a transport defect, the ester produced only 4-fold less inhibition in the resistant line than in the parental line. These results suggest possible use of this compound or related derivatives in the treatment of MTX-resistant tumors with impaired transport.

Human-human hybrids secreting pneumococcal antibodies

Starting with a nonimmunoglobulin producing human myeloma cell line, we have constructed a human myeloma "analog" (LSM 2.7) which supports the synthesis and secretion of human immunoglobulin in vitro upon fusion with human peripheral blood and spleen mononuclear cells. Fusions between LSM 2.7 and spleen cells obtained from patients immunized against pneumococcal capsular polysaccharides consistently gave rise to hybrids which synthesized and secreted human immunoglobulin. In three of ten independent fusions a large proportion of the hybrid cultures produced specific pneumococcal antibodies. All three spleens which yielded antibody producing hybrids were from patients immunized 3 to 4 days prior to staging splenectomy for Hodgkin's disease. Antibody secreting hybrid cells ceased producing immunoglobulin 28 to 42 days post fusion. However, fusion of a HAT sensitive clone derived from a hybrid which had secreted antibody, with peripheral blood mononuclear cells, resulted in reactivation of specific antibody secretion.

A radioimmunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer

The murine monoclonal antibody OC 125 reacts with an antigen (CA 125) common to most nonmucinous epithelial ovarian carcinomas. An assay has been developed to detect CA 125 in serum. By this assay, only 1 per cent of 888 apparently healthy persons and 6 per cent of 143 patients with nonmalignant disease had serum CA 125 levels above 35 U per milliliter. In contrast, 83 of 101 patients (82 per cent) with surgically demonstrated ovarian carcinoma had elevated levels of antigen. In 38 patients with epithelial ovarian carcinoma monitored on 2 to 18 occasions during 2 to 60 months, antigen levels ranged from less than 1 to more than 8000 U per milliliter. Rising or falling levels of CA 125 correlated with progression or regression of disease in 42 of 45 instances (93 per cent). Determination of CA 125 levels may aid in monitoring the response to treatment in patients with epithelial ovarian cancer.

Distribution and modulation of a human leukemia-associated antigen (CALLA)

CALLA is a 100,000-dalton surface glycoprotein expressed by malignant cells of patients with clinically important subtypes of acute leukemia. Incubation of human leukemic cells expressing CALLA with specific monoclonal antibody (J5) at 37 degrees C causes rapid and selective internalization and degradation of this antigen (antigenic modulation). In these studies we show that CALLA-specific monoclonal antibodies also identify a cell surface glycoprotein having a m. w. of approximately 100,000 on 2 to 6% of nonmyeloid nucleated cells of normal adult bone marrow, on normal fibroblasts in tissue culture, and on cells of several nonhematopoietic human tumor cell lines. J5 antibody similarly modulates the surface expression of CALLA on nonleukemic cell populations, although the extent of modulation at a given concentration of antibody varied considerably. Modulation was almost complete for CALLA on cells of normal bone marrow, but was highly variable for cells of nonhematopoietic cell lines, possibly reflecting variability in antibody access to surface antigen. Using fluoresceinated or iodinated J5 antibody to modulate expression of CALLA on cells of leukemic cell lines, we show that antibody-antigen complexes undergo a temperature-dependent redistribution on the cell surface during modulation to form microaggregates. Antibody as well as antigen is then internalized. Studies of [35S]methionine-labeled cells indicate that synthesis of CALLA continues despite modulation of its surface expression by specific antibody, implying that the presence of CALLA on the cell surface reflects a dynamic equilibrium between the processes of surface expression of newly synthesized glycoprotein and its spontaneous and antibody-mediated clearance. The implications of these observations for immunotherapy are discussed.

Distribution and modulation of a human leukemia-associated antigen (CALLA)

CALLA is a 100,000-dalton surface glycoprotein expressed by malignant cells of patients with clinically important subtypes of acute leukemia. Incubation of human leukemic cells expressing CALLA with specific monoclonal antibody (J5) at 37 degrees C causes rapid and selective internalization and degradation of this antigen (antigenic modulation). In these studies we show that CALLA-specific monoclonal antibodies also identify a cell surface glycoprotein having a m. w. of approximately 100,000 on 2 to 6% of nonmyeloid nucleated cells of normal adult bone marrow, on normal fibroblasts in tissue culture, and on cells of several nonhematopoietic human tumor cell lines. J5 antibody similarly modulates the surface expression of CALLA on nonleukemic cell populations, although the extent of modulation at a given concentration of antibody varied considerably. Modulation was almost complete for CALLA on cells of normal bone marrow, but was highly variable for cells of nonhematopoietic cell lines, possibly reflecting variability in antibody access to surface antigen. Using fluoresceinated or iodinated J5 antibody to modulate expression of CALLA on cells of leukemic cell lines, we show that antibody-antigen complexes undergo a temperature-dependent redistribution on the cell surface during modulation to form microaggregates. Antibody as well as antigen is then internalized. Studies of [35S]methionine-labeled cells indicate that synthesis of CALLA continues despite modulation of its surface expression by specific antibody, implying that the presence of CALLA on the cell surface reflects a dynamic equilibrium between the processes of surface expression of newly synthesized glycoprotein and its spontaneous and antibody-mediated clearance. The implications of these observations for immunotherapy are discussed.

Comparison of a rabbit heteroantiserum and a murine monoclonal antibody raised against a human epithelial ovarian carcinoma cell line

An ovarian carcinoma cell line (OVCA 432) and a B-lymphocyte line (LAZ 446) were established from the same donor. A heteroantiserum (D-100) was prepared in rabbits against OVCA 432 and absorbed with LAZ 446, human AB erythrocytes, and the CX-1 colorectal cell line. After absorption, D-100 reacted by indirect immunofluorescence with six of six epithelial ovarian carcinoma cell lines and cryostat sections of 18 of 18 epithelial ovarian tumors but bound to zero of 12 nonovarian tumor cell lines. Despite a lack of reactivity with nonovarian tumor cell lines, D-100 reacted with epithelial components of normal ovary, fallopian tube, endometrium, endocervix, breast, colon, and epididymis. A murine monoclonal antibody (OC 133) was also raised against OVCA 432 and selected for lack of reactivity with the autologous B-lymphocyte line LAZ 446. OC 133 reacted with six of six ovarian carcinoma cell lines and cryostat sections of seven of 19 ovarian tumors, but it also reacted with five of five nonovarian tumor cell lines. Of 12 normal tissues examined, OC 133 reacted with endometrium and endocervix only. Whereas D-100 bound to serous, mucinous, endometrioid, and clear cell ovarian neoplasms, OC 133 bound only to serous tumors. In developing monoclonal reagents, cell lines may provide a useful source of antigen, but promising antibodies should be screened for reactivity with sections of normal and malignant human tissues.

Novel approach to construction of human "myeloma analogues" for production of human monoclonal antibodies

The production of human monoclonal antibodies has been impeded by the lack of human myeloma cell lines which grow easily, fuse efficiently, clone readily, and continuously secrete large amounts of antibody. A cell line, HM 2.0, was constructed by fusing a HAT-sensitive, nonsecreting, human myeloma cell line, LSM 1.2, with cells from a patient with plasma cell leukemia. In marked contrast to LSM 1.2, which could not support the secretion of immunoglobulin, fusion of HM 2.0 with cells from spleen or peripheral blood routinely resulted in the secretion of antibody to pneumococcal polysaccharides and tetanus toxoid. The fusion efficiency of HM 2.0, as measured by growth of colonies, was greater than 1 per 1.2 X 10(3) peripheral blood mononuclear cells and the number of hybrids secreting specific antibody was greater than 1 per 1.1 X 10(5) mononuclear cells from immunized individuals. This is an improvement over our previously described human "myeloma analogue" LSM 2.7, derived by fusion of a HAT-sensitive, nonsecreting human myeloma cell line, LSM 1.1, with cells from a normal donor, as well as all previously described human lymphoblastoid and myeloma cell lines. These results demonstrate that somatic cell hybridization can be used to modify an existing cell line in such a manner as to yield a "new" cell line with the attributes necessary for the production of human monoclonal antibodies.