Utility of cell-based vaccines as cancer therapy: Systematic review and meta-analysis

Cell-based therapeutic cancer vaccines use autologous patient-derived tumor cells, allogeneic cancer cell lines or autologous antigen presenting cells to mimic the natural immune process and stimulate an adaptive immune response against tumor antigens. The primary objective of this study is to perform a systematic literature review with an embedded meta-analysis of all published Phase 2 and 3 clinical trials of cell-based cancer vaccines in human subjects. The secondary objective of this study is to review trials demonstrating biological activity of cell-based cancer vaccines that could uncover additional hypotheses, which could be used in the design of future studies. We performed the systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The final review included 36 studies - 16 single-arm studies, and 20 controlled trials. Our systematic review of the existing literature revealed largely negative trials and our meta-analysis did not show evidence of clinical benefit from cell-based cancer-vaccines. However, as we looked beyond the stringent inclusion criteria of our systematic review, we identified significant examples of biological activity of cell-based cancer vaccines that are worth highlighting. In conclusion, the existing literature on cell-based cancer vaccines is highly variable in terms of cancer type, vaccine therapies and the clinical setting with no overall statistically significant clinical benefit, but there are individual successes that represent the promise of this approach. As cell-based vaccine technology continues to evolve, future studies can perhaps fulfill the potential that this exciting field of anti-cancer therapy holds.

Blood group AB increases risk for surgical necrotizing enterocolitis and focal intestinal perforation in preterm infants with very low birth weight

Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are two of the most common emergencies of the gastrointestinal tract in preterm infants with very low birth weight (VLBW, birth weight < 1500 g). Identification of risk factors among these children is crucial for earlier diagnosis and prompt intervention. In this study, we investigated a relationship between ABO blood groups and the risk for surgical NEC/FIP. We genotyped the ABO locus (rs8176746 and rs8176719) in VLBW infants enrolled in a prospective, population-based cohort study of the German Neonatal Network (GNN). Of the 10,257 VLBW infants, 441 (4.3%) had surgical NEC/FIP. In univariate analyses, the blood group AB was more prevalent in VLBW infants with surgical NEC/FIP compared to non-AB blood groups (OR 1.51, 95% CI 1.07–2.13, p = 0.017; absolute risk difference 2.01%, 95% CI 0.06–3.96%). The association between blood group AB and surgical NEC/FIP was observed in a multivariable logistic regression model (OR of 1.58, 95% CI 1.10–2.26, p = 0.013) as well. In summary, our study suggests that the risk of surgical NEC and FIP is higher in patients with blood group AB and lower in those having non-AB blood groups.

Hyper engorged cancer associated macrophage-like cells in circulation predict for multi-organ metastatic disease in solid tumors

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Background: Patients with multiple organ metastases have poorer prognoses than those with a single organ metastasis, are frequently associated with drug resistance, and have higher tumor burden. Engorged (≥50um) Cancer Associated Macrophage-Like Cells (CAMLs) are a circulating stromal cell subtype detected in the blood of patients with solid tumors at high risk for recurrence or progression. While numerous studies have shown that ≥50um CAMLs predict poor clinical outcomes, meta-analysis of these studies have also suggested that hyper engorged CAMLs ≥100um (heCAMLs) may be associated with multifocal metastatic disease and even worse outcomes. In this prospective study, we evaluated the presence of heCAMLs in patients with metastatic disease and demonstrated a strong relationship with multi organ spread, which also correlated with shorter Progression Free Survival (PFS) and Overall Survival (OS). Methods: We prospectively recruited 151 patients with metastatic (m) mbreast (n = 58), mlung (n = 34), mprostate (n = 39), and mrenal (n = 20) cancers. Peripheral blood was collected prior to the induction of new treatment for metastatic cancer. Cells were isolated following standard CellSieve techniques, then imaged and measured in ZenBlue. Multi organ metastasis was defined as spread to ≥2 distant organ sites, or any spread to the brain. Single factor ANOVA was conducted to compare heCAML presence in multi organ metastatic patients versus patients with single organ site metastasis. Univariate and multivariate analysis was run to evaluate for PFS and OS against heCAMLs, and all known clinical parameters. Results: 150 viable samples (excluding 1 failed sample) were obtained. Multi organ metastases were present in 55% (n = 83/150) of patients. heCAMLs were found in 59% (n = 49/83) of the multi organ metastatic population, but only in 16% (n = 11/67) of the single site metastatic cohort (p < 0.001). heCAML presence appeared to differentiate multi organ vs single organ metastases in mbreast (85% vs. 52%, p = 0.006), mlung (71% vs. 26%, p = 0.025), mprostate (75% vs. 37%, p = 0.029), and mRCC (88% vs. 36%, p = 0.025). Further, in all n = 150 patients, heCAML presence predicted a significantly shorter median PFS of 4.5 versus 7.2 months, 24 month PFS (HR = 1.67, 95%CI = 1.13-2.45, p = 0.013), and significantly shorter median OS of 13.1 versus 20.4 months, 24 month OS (HR = 2.05, 95%CI = 1.24-3.39, p = 0.008). Conclusions: We examined a non-invasive prognostic blood based assay to determine its relationship to multi organ metastatic spread as well as its prognostic value in several solid cancers. These results showed patients with heCAMLs had higher rates of multi organ metastases, and appear to predict for shorter PFS and OS. Studies of larger cohorts are needed for prospective validation of these initial findings.

Development of a multiomics and functional drug sensitivity platform to investigate cell type specific drug effects in AML

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Background: Understanding the heterogeneity of AML is necessary for developing targeted drugs and diagnostics. A key measure of heterogeneity is the variance in response to treatments. Previously, we developed an ex vivo flow cytometry drug sensitivity assay (DSA) that predicted response to treatments in myelodysplastic syndrome. Unlike bulk cell viability measures of other drug sensitivity assays, our flow cytometry assay provides single cell resolution. The assay measures a drug’s effect on the viability or functional state of specific cell types. Here we present the development of this technology for AML, with additional measurements of DNA-Seq and RNA-Seq. Using the data from this assay, we aim to characterize the heterogeneity in AML drug sensitivity and the molecular mechanisms that drive it. Methods: As an initial feasibility analysis, we assayed 1 bone marrow and 3 peripheral blood AML patient samples. For the DSA, the samples were cultured with six AML standard of care (SOC) compounds across seven doses, in addition to two combinations. The cells were stained to detect multiple cell types including tumor blasts, and drug response was measured by flow cytometry. For the multi-omics, the cells were magnetically sorted to enrich for blasts and then assayed using a targeted 400 gene DNA-Seq panel and whole bulk transcriptome RNA-Seq. For comparison with BeatAML, Pearson correlations between gene expression and venetoclax sensitivity were investigated. Results: In our drug sensitivity assay, we measured dose response curves for the six SOC compounds, for each different cell type across each sample. The dose responses had cell type specific effects, including differences in drug response between CD11b+ blasts, CD11b- blasts, and other non-blast populations. Integrating with the DNA-Seq and RNA-Seq data, known associations between ex vivo drug response and gene expression were identified with additional cell type specificity. For example, BCL2A1 expression was negatively correlated with venetoclax sensitivity in CD11b- blasts but not in CD11b+ blasts. To further corroborate, among the top 1000 genes associated with venetoclax sensitivity in BeatAML, 93.7% had concordant directionality in effect. Conclusions: Here we describe the development of an integrated ex vivo drug sensitivity assay and multi-omics dataset. The data demonstrated that ex vivo responses to compounds differ between cell types, highlighting the importance of measuring drug response in specific cell types. In addition, we demonstrated that integrating these data will provide unique insights on molecular mechanisms that affect cell type specific drug response. As we continue to expand the number of patient samples evaluated with our multi-dimensional platform, this dataset will provide insights for novel drug target discovery, biomarker development, and, in the future, informing treatment decisions.

Breast cancer grade and clinical benefit in patients with advanced breast cancer treated with an engineered whole tumor cell-targeted immunotherapy alone or in combination with checkpoint inhibition

3033

Background: SV-BR-1 is a breast cancer cell line derived from a grade II (moderately differentiated) tumor. SV-BR-1 was transfected with the CSF2 gene (encoding GM-CSF) to form SV-BR-1-GM. SV-BR-1-GM expresses HLA class I & II antigens and has functional antigen-presenting cell activity, directly stimulating CD4+ T cells in an HLA-DR restricted fashion. The SV-BR-1-GM regimen consists of low-dose cyclophosphamide (300 mg/m2) to reduce immune suppression, intradermal inoculation with irradiated SV-BR-1-GM (20x106 cells divided into 4 sites) and interferon-α2b (10,000 IU into each inoculation site ~2 & 4 days later) to boost the response. Here, we evaluate the impact of tumor grade on clinical benefit following treatment with the SV-BR-1-GM regimen. Methods: Patients with advanced breast cancer were treated with either the SV-BR-1-GM regimen alone or with the SV-BR-1-GM regimen with pembrolizumab. For the SV-BR-1-GM regimen alone, cycles were administered every 2 weeks x 3 and then monthly, while combination with pembrolizumab (200 mg IV 1-5 days following SV-BR-1-GM inoculation) administered cycles every 3 weeks. Tumor restaging was every 6-12 weeks. Results: 33 patients were enrolled. The treatment was generally safe with inoculation site pruritis, erythema and induration the most common adverse events. 23 patients had grade III (poorly differentiated) tumors, 9 had grade II tumors and one had a grade I (well differentiated) tumor. None of the patients with grade III tumors exhibited clinical benefit. 7 patients with grade I/II tumors received the SV-BR-1-GM regimen alone, 2 received the SV-BR-1-GM regimen with pembrolizumab and 1 received both regimens. As noted in the Table, 7 patients experienced clinical benefit including all 3 patients treated in combination with pembrolizumab. This included 6 patients with stable disease and one with a partial response. Conclusions: The SV-BR-1-GM regimen with or without pembrolizumab appears safe and able to induce clinical benefit even in very heavily pre-treated patients with low or intermediate grade advanced breast cancer. Clinical trial information: NCT03328026 . [Table: see text]

Abstract P3-09-08: Efficacy and safety of a modified whole tumor cell targeted immunotherapy in patients with advanced breast cancer alone and in combination with immune checkpoint inhibitors

Background: SV-BR-1-GM is a GM-CSF transfected breast cancer cell line, exceptional for having antigen-presenting capability expressing both HLA I and II. We report clinical efficacy, safety, and immunologic correlates of response from our initial Phase I/II trial and initial data from our trial of SV-BR1-GM in combination with immune checkpoint inhibitors. Methods: We enrolled patients with recurrent and/or metastatic breast cancer refractory to standard therapy. Patients received cyclophosphamide 300 mg/m2 2-3d prior to intradermal injection of SV-BR-1-GM (20-40 × 106 cells divided into 4 sites) and IFNα into the inoculation sites (10,000 IU/site) ~2 & 4 days subsequently. Cycles were q2 weeks x3 then qmo x 3. Adverse events (AE) were evaluated after each inoculation. Immunologic responses were measured by delayed type hypersensitivity (DTH) after each inoculation with humoral and cellular responses evaluated ~q3 mo. Disease response was evaluated radiographically q3 mo and as clinically indicated (clinical trial NCT03066947). A similar regimen was used with SV-BR-1-GM in combination with pembrolizumab (200 mg IV) with cycles every 3 weeks (Phase I/II study NCT03328026). Results: In Phase I/IIa (NCT03066947), 23 patients underwent 1 - 8 cycles of treatment. Tumor regression was seen in 3 patients, all of whom matched SV-BR-1-GM at least at one HLA allele. There were no related serious adverse events. The most common adverse event was minor local irritation at the inoculation site. Clinical data are shown in the table. A measurable DTH response was present in 21 patients. Of patients who developed a DTH response and had at least one HLA match, the tumor regression rate was 33% and for those with 2 HLA matches 67%. We saw evidence of antibody responses in 3 of 5 patients evaluated to date. Especially in responders after treatment, blood lymphocytes showed increased cytokine secretion (including ITAC, IFNγ, IL-6 & IL-8) following stimulation with antigens expressed in SV-BR-1-GM. 21/23 patients had expression of PD-L1 in identified circulating cancer-associated cells, and expression levels increased with treatment. Therefore, a combination study with pembrolizumab was initiated. Data on the first 6 patients shows that the regimen is clinically active and safe. One patient with a robust DTH response had evidence of tumor regression in liver metastases. This study is ongoing and is being modified to evaluate combination therapy with the PD-1 inhibitor INCMGA00012 and the IDO inhibitor epacadostat. Conclusions: SV-BR-1-GM appears to be safe and well-tolerated. Contrary to conventional wisdom, SV-BR-1-GM can produce regression of metastatic breast cancer correlating with an immunologic response and HLA matching. Combination therapy with checkpoint inhibitors is ongoing.

Citation Format: William Williams, Shaker R Dakhil, Jarrod P Holmes, Saveri Bhattacharya, Carmen Calfa, Ajay Kundra, Daniel L Adams, Diane DaSilva, George E Peoples, Vivek Sunkari, Markus Lacher, Charles L Wiseman. Efficacy and safety of a modified whole tumor cell targeted immunotherapy in patients with advanced breast cancer alone and in combination with immune checkpoint inhibitors [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-08.

Real-time monitoring of circulating stromal cells in the blood to predict responsiveness of new-line therapies in metastatic breast cancer

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Background: Cancer associated macrophage like cells (CAMLs), a circulating stromal cell subtype, has been shown as an independent prognostic indicator of survival in late stage metastatic breast cancer when cells enlarge to ≥50µm. However, no study has evaluated the clinical relationship between changes in CAML size and their ability to predict treatment response. While CAMLs are prognostic for progression, we hypothesized that monitoring changes in CAMLs after initiation of therapy may be predictive for responsiveness of new treatment regimens. Methods: A prospective 12 months blind multi-institutional pilot study was undertaken to evaluate CAMLs before, and after, induction of a new line of investigational therapy based on CT scans. Patients with progressive metastatic breast cancer (n = 29) who had failed at least 2 prior therapies were recruited. A baseline (BL) blood sample was taken prior to induction of a new therapy and a 2nd sample (T1) taken after initiation (~30 days). Blood was filtered by CellSieve filtration.The quantities and sizes of CAMLs were analyzed based on PFS hazard ratios (HRs) by censored univariate analysis. Results: CAMLs were found in 97% of BL samples and 93% of T1 samples. At first CT scan, after the assigned dose of investigational treatment, 17 of 29 patients had clinical progression with 14/17 (82%) patients having an increased CAML size and 3/17 (18%) having a decreased CAML size. The remaining 12 of 29 patients saw clinically stable, or regression, of disease with 10/12 (83%) having decreased CAML size and 2/12 (17%) having increased CAML size. Overall CAML size change after therapy induction was 83% accurate at predicting response or progression based on CT scans. Further, patients with increasing CAML size at T1 had a 4 month mPFS vs 10 month mPFS for decreasing CAMLs, with a lower 12 month PFS HR = 3.7 (95%CI = 1.5-10.1, p = 0.020). Conclusions: Our data suggests that in metastatic breast cancer, monitoring CAMLs changes over the first 30 days of treatment accurately predicts responsiveness of disease to new treatments. Further, we suggests using blood sampling may increase the clinical value of blood based diagnostics by rapidly predicting the benefit of subsequent therapies.

Safety and efficacy of a phase I/IIa trial (NCT03066947) of a modified whole tumor cell targeted immunotherapy in patients with advanced breast cancer

e14026

Background: SV-BR-1-GM is a GM-CSF transfected breast cancer cell line which expresses HLA class I & II antigens and has functional antigen-presenting cell activity. Prior studies suggest that partial matching of the HLA type of the patient with SV-BR-1-GM may be predictive of tumor regression. Methods: Subjects received low-dose cyclophosphamide 2-3d prior to ID injection of irradiated SV-BR-1-GM (20 million cells divided into 4 sites) and interferon-α into the inoculation sites ~2 & 4 days subsequently. Cycles were q2 weeks x 3 then q mo. Results: A total of 30 patients were screened and 23 inoculated (Table). The patients were heavily pretreated with a median of 4 prior chemo/biological therapy regimens. There were no serious or unexpected adverse events. Local injection-site irritation was the most common toxicity. Objective tumor regression was seen in 3 patients, all of whom matched SV-BR-1-GM at least at one HLA locus: one patient with regression or clearing of 20 lung metastases; one with reduction in cutaneous involvement of the breast from 80% to 30% and one with regression of a breast lesion. Another 3 patients had decreases in circulating cancer-associated macrophage-like cells (CAMLs), which has been shown to correlate with tumor stage. They also all matched at least at one HLA allele. Circulating tumor cells and circulating epithelial cells were present in low numbers and tended to parallel trends in CAMLs which were present in larger numbers. CAMLs in 21/23 patients stained positive for PD-L1. Patients with tumor regression had robust DTH responses to SV-BR-1-GM. Conclusions: SV-BR-1-GM in this regimen appears to be safe and well-tolerated and is associated with objective regression of metastatic breast cancer and/or with decreases in circulating cancer-associated cells in 6/23 (26%) or patients. HLA matching may be a predictor of response. Clinical trial information: NCT03066947. [Table: see text]

Targeted tumor-derived cellular immunotherapy in advanced breast cancer patients induces initial immune responses and tumor regression

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Background: SV-BR-1-GM is a GM-CSF secreting breast cancer cell line which also expresses HLA class I & II antigens. In a previous clinical trial, a partial response of widely metastatic breast cancer was seen in a patient who allele-matched SV-BR-1-GM at HLA-DRB3. Here we report regression of metastatic breast cancer and efficacy analysis with immunologic correlates in subjects of a Phase I/IIa trial of SV-BR-1-GM in patients with advanced breast cancer. Methods: 24 patients with recurrent and/or metastatic breast cancer refractory to standard therapies have been dosed with SV-BR-1-GM in a Phase I/IIa trial. Patients who have undergone at least one cycle of SV-BR-1-GM therapy were analyzed. Patients first received low-dose cyclophosphamide, then intradermal injection of SV-BR-1-GM (20-40x106 cells/four sites) with interferon-α injected into inoculation sites (10,000 IU/site) ~2 & 4 days subsequently. Immunologic responses were measured by delayed type hypersensitivity (DTH) after inoculation and IgG titers of antibodies against SV-BR-1 were measured in sera samples collected prior to and after the first dose of SV-BR-1-GM by flow cytometry. Results: 24 patients have been inoculated with SV-BR-1-GM cells with no unexpected adverse events. None of the patients exhibited immediate hypersensitivity to SV-BR-1. DTH response was recorded in 18 subjects till date, of these, 61% exhibited DTH to cell inoculations. The patient with the most marked DTH response, 01-002, also had a clinical response with regression of multiple lung metastases. Two other patients had evidence of tumor regression (tumor regression is matched SV-BR-1-GM at least at one HLA allele). Sera samples from 6 patients were evaluated and found to contain anti-SV-BR-1 antibodies. Conclusions: SV-BR-1-GM in this regimen appears to be safe and well-tolerated. Initial analysis of SV-BR-1-GM showed significant DTH and antibody responses. HLA matching improves the response rate and is being evaluated as a predictor of response. Clinical trial information: NCT03066947.

Abstract P2-09-09: Initial safety and efficacy of a phase I/IIa trial of a modified whole tumor cell targeted immunotherapy in patients with advanced breast cancer

Background: SV-BR-1-GM is a GM-CSF transfected breast cancer cell line which expresses HLA class I & II antigens. In a previous clinical trial, a partial response of widely metastatic breast cancer was seen in a patient who matched SV-BR-1-GM at HLA-DRB3*02:02. Here we report the safety and efficacy analysis with immunologic correlates of response in the initial patients in a phase I/IIa trial of SV-BR-1-GM in patients with advanced breast cancer

Methods: This phase I/IIa trial enrolled patients with recurrent and/or metastatic breast cancer refractory to standard chemotherapy/targeted-therapy. Patients received low-dose cyclophosphamide 2-3d prior to intradermal injection of SV-BR-1-GM (20x106 cells divided into 4 sites) and interferon-α into the inoculation sites (10,000 IU/site) ˜2 & 4 days subsequently. Cycles were 2 weeks x3 then q mo x 3. Adverse events (AE) were evaluated after each inoculation and graded via CTCAE v4.03. Immunologic response was measured by delayed type hypersensitivity (DTH) after each inoculation. Disease response was evaluated radiographically q3 mo and as clinically indicated (clinical trial NCT03066947).

Results: To date, twenty-two patients have been enrolled and 17 have been inoculated for a total of 39 SV-BR-1-GM inoculations given. Per inoculation, the maximum related AE was grade 1 in 64%, grade 2 in 7.7%, and grade 3 in 7.7%. There were no related grade &gt;3 or unexpected AE. Efficacy data is available on the first six (Table). Tumor regression was seen in 2 patients. 01-002 presented with liver, bone and 20 classic miliary lung metastases (up to 9mm). This subject previously received 7 chemotherapy regimens. She matched SV-BR-1-GM at Class I & II HLA loci. Imaging at 3 mo showed virtually complete regression of all 20 identifiable lesions in the lungs. This response was maintained at 6 mo but the subject was taken off protocol because of disease progression (liver and bone). 01-005, matching HLA-A*24:02, had notable regression of cutaneous lesions, but progressed in pleural and pericardial effusions, had irreversible cardiac arrest (unlikely related). DTH increased in 01-002 from 4mm (first dose) to 47mm (8th dose). Three of 3 patients evaluated developed antibodies responses (as measured by flow cytometry with SV-BR-1) including 01-002. Interleukin 8 also increased in 01-002.

Conclusions: SV-BR-1-GM in this regimen appears to be safe and well-tolerated. In this initial exploratory analysis, SV-BR-1-GM can produce regression of pre-treated metastatic breast cancer correlating with an immunologic response. HLA matching is being evaluated as a predictor of response.

PatientAgeMetastatic Sites# Prior RegimensHLA Matches# of CyclesTumor Regression?01-00146Pleura, Lymph Nodes7 chemo/bio, 5 hormonalDRB3*02:021No01-00273Lung, Liver, Bone6 chemo, 1 hormonalA*24:02, DRB3*02:028Lungs01-00554Lymph nodes, Pleura, Skin3 chemo/bioA*24:022Skin02-00170Lymph nodes1 chemo/bioNone1No02-00361Bone, Brain3 chemoNone6No02-00474Lymph nodes, Cutaneous3 chemo/bio, 1 hormonalDRB3*02:022Lost to Follow-up

Citation Format: Bhattacharya S, Holmes JP, Calfa C, Lukas J, Tan-Chiu E, Clifton GT, Peoples GE, Lacher M, Wiseman CL, Williams WV. Initial safety and efficacy of a phase I/IIa trial of a modified whole tumor cell targeted immunotherapy in patients with advanced breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-09.

Surgery for Pediatric Ureteropelvic Junction Obstruction-Comparison of Outcomes in Relation to Surgical Technique and Operating Discipline in Germany

INTRODUCTION

 Surgery for ureteropelvic junction obstruction (UPJO) is performed by both pediatric surgeons (PS) and urologists (URO). The aim of this study was to analyze treatment modalities for UPJO and results in relation to the surgical technique and the operating discipline in Germany.

MATERIALS AND METHODS

 Data of patients aged 0 to 18 years were extracted from a major public health insurance (covering ∼5.7 million clients) during 2009 to 2016 and were analyzed for sociodemographic variables, surgical technique, and treating discipline. Logistic regression analysis was performed for the risk of a complication within the first postoperative year.

RESULTS

 A total of 229 children (31.0% female) were included. Laparoscopic pyeloplasty (LP) was performed in 58 (25.3%) patients (8.6 ± 6.4 years), and open pyeloplasty (OP) was applied in 171 (74.7%; 4.6 ± 5.9 years). LP was the dominant technique in females (p < 0.02); males preferentially underwent OP (p < 0.02). Length of hospital stay was 4.3 days (p = 0.0005) shorter in LP compared with that in OP, especially in children ≤ 2 years (6.7 days, p = 0.007). PS operated on 162 children (70.7%), and URO performed surgery on 67 patients (29.3%). The mean age of children operated by PS (3.5 ± 4.7 years) was significantly younger compared with that operated by URO (10.8 ± 6.5 years, p < 0.0001). Complication rates were independent of surgical technique or treating specialty.

CONCLUSION

 In Germany, UPJO was treated by LP in 25.3% of patients, which was associated with a shorter length of stay, especially in children ≤ 2 years. Complication rates were independent of the operating specialty and surgical technique. Therefore, LP should be further promoted for the treatment of UPJO in small children.

Abstract OT3-01-06: A phase I/IIa study of the whole-cell vaccine BriaVax™ in metastatic or locally recurrent breast cancer patients (NCT00095862)

BACKGROUND: BriaVax™ (formerly SV-BR-GM-1) is a breast cancer cell line transfected to release GM-CSF. Under FDA BB-IND 10312, the vaccine was tested in 3 metastatic breast, 1 metastatic ovarian cancer patients refractory to previous therapy. Patients received 20 million viable cells ID at 4 sites 48-72 hours after low-dose cyclophosphamide, 300 mg/m2 . Mean cell count was 22.8 x10^6 (18.8-27.6). Mean viability was 90.6%, (84-94%). Interferon-alpha (10,000 u) was injected into each inoculation site after 48 and 96 hrs. The protocol permitted 3 inoculations at 2 week intervals, then, if not showing clearly progressive disease, 3 more inoculations monthly. All patients were stable after 3 injections (2 months). However, Pt A002 enjoyed complete tumor regression of a progressing lung metastasis and near-complete response of multiple breast lesions (see below). Nonetheless, she relapsed widely 3 months after finishing the sixth and final injection per protocol. After obtaining FDA permission inoculations resumed. All metastases, including CNS, again showed prompt but subtotal regression after 3 immunizations (see Wiseman C and Kharazi A; The Breast Journal 2006). Toxicity was minimal and the overall survival of the 4 patients was 35 months.

TRIAL DESIGN: 9 patients will be accrued, toxicity (and also response) will be reviewed; unless there are prohibitive serious adverse events, 15 more patients will then be accrued.

ELIGIBILITY: Inclusion Criteria: Patients must have histological confirmation of breast cancer with recurrent and/or metastatic lesions via investigational site. Patients with new or progressive breast cancer metastatic to brain will be eligible if they meet other conditions. Patients must be 18 years of age or older, have expected survival of at least 4 months, adequate performance status (ECOG 0-2). Patients may be maintained on hormonal therapy provided there is clear evidence of tumor progression and have provided written informed consent.

Exclusion Criteria: Concurrent or recent chemotherapy (within 3 weeks), XRT within 3 weeks, may have had immunotherapy in the past (off within 3 weeks), or general anesthesia/major surgery (within 3 weeks). Patients must have recovered from all known or expected toxicities from previous treatment and passed a treatment-free “washout” period of 3 weeks before starting this program (8 weeks for persons receiving nitrosourea or mitomycin). History of clinical hypersensitivity to GM-CSF, interferon, yeast, beef, or to any components used in the preparation of the experimental vaccine. Additional criteria to be provided on request.

SPECIFIC AIMS: To evaluate the number, frequency, duration, and relation of toxicity events to BriaVax™ (formerly designated as SV-BR-1-GM), as defined by CTCAE and additional tests; to evaluate tumor response and durability; to assess immune responses to vaccine; to archive blood and urine for future analysis; to measure quality of life with the SF-36 questionnaire.

For further information, call the BriaCell Corporate Office (US) at 888-485-6340

Acknowledgments: Dr. Gerhard Bauer, Dr. Saeid Babaei, the St. Vincent Medical Center, and Dr. George Peoples for advice and guidance.

Citation Format: Wiseman CL, Lacher M. A phase I/IIa study of the whole-cell vaccine BriaVax™ in metastatic or locally recurrent breast cancer patients (NCT00095862) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-01-06.

Comparison of environmental risk factors for esophageal atresia, anorectal malformations, and the combined phenotype in 263 German families

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and anorectal malformations (ARM) represent the severe ends of the fore- and hindgut malformation spectra. Previous research suggests that environmental factors are implicated in their etiology. These risk factors might indicate the influence of specific etiological mechanisms on distinct developmental processes (e.g. fore- vs. hindgut malformation). The present study compared environmental factors in patients with isolated EA/TEF, isolated ARM, and the combined phenotype during the periconceptional period and the first trimester of pregnancy in order to investigate the hypothesis that fore- and hindgut malformations involve differing environmental factors. Patients with isolated EA/TEF (n = 98), isolated ARM (n = 123), and the combined phenotype (n = 42) were included. Families were recruited within the context of two German multicenter studies of the genetic and environmental causes of EA/TEF (great consortium) and ARM (CURE-Net). Exposures of interest were ascertained using an epidemiological questionnaire. Chi-square, Fisher's exact, and Mann-Whitney U-tests were used to assess differences between the three phenotypes. Newborns with isolated EA/TEF and the combined phenotype had significantly lower birth weights than newborns with isolated ARM (P = 0.001 and P < 0.0001, respectively). Mothers of isolated EA/TEF consumed more alcohol periconceptional (80%) than mothers of isolated ARM or the combined phenotype (each 67%). Parental smoking (P = 0.003) and artificial reproductive techniques (P = 0.03) were associated with isolated ARM. Unexpectedly, maternal periconceptional multivitamin supplementation was most frequent among patients with the most severe form of disorder, i.e. the combined phenotype (19%). Significant differences in birth weight were apparent between the three phenotype groups. This might be attributable to the limited ability of EA/TEF fetuses to swallow amniotic fluid, thus depriving them of its nutritive properties. Furthermore, the present data suggest that fore- and hindgut malformations involve differing environmental factors. Maternal periconceptional multivitamin supplementation was highest among patients with the combined phenotype. This latter finding is contrary to expectation, and warrants further analysis in large prospective epidemiological studies.

Duhamel versus transanal endorectal pull through (TERPT) for the surgical treatment of Hirschsprung's disease

For the surgical treatment of Hirschsprung's disease, several surgical techniques are used to resect the distal aganglionic colon. Two frequently used techniques are the Duhamel procedure and the transanal endorectal pull-through procedure. During the '8th Pediatric Colorectal Course' in Nijmegen, November 2015, a workshop was organized to share experiences of both techniques by several experts in the field and to discuss (long term) outcomes. Specifically, the objective of the meeting was to discuss the main controversies in relation to the technical execution of both procedures in order to make an initial assessment of the limitations of available evidence for clinical decision-making and to formulate a set of preliminary recommendations for current clinical care and future research.

Early complications after esophageal atresia repair: analysis of a German health insurance database covering a population of 8 million

The treatment of esophageal atresia is not centralized in Germany. Therefore, high numbers of departments are involved. Data on the results of esophageal atresia repair from Germany are lacking. The aim of this study was to evaluate the early postoperative results after repair of esophageal atresia based on unbiased data of a German health insurance. We aimed to determine whether characteristics of the departments had an impact on outcome and compared the results from this study with the literature data from centers with a high caseload. Data of a German health insurance covering ∼10% of the population were analyzed. All patients who had undergone esophageal atresia repair from January 2007 to August 2012 were included. Follow-up data of 1 year postoperatively were analyzed. The potential impact of various characteristics of the treating surgical institutions was assessed. Results were compared with the latest international literature. Seventy-five patients with esophageal atresia underwent reconstructive surgery in 37 departments. The incidences of anastomotic leak (3%) and recurrent tracheoesophageal fistula (7%) were comparable with the literature (both 2-8%). Anastomotic stricture required dilatation in 57% of patients (mean 5.1 ± 5.6 dilatations) comparing unfavorably to most, but not all international reports. During 1-year follow-up, 93% of the patients were readmitted at least once (mean 3.9 ± 3.1 admissions). The incidence of complications did not correlate with any of the characteristics of the treating institutions such as academic affiliation, the number of consultants, beds, and preterm infants treated per year (all P > 0.05). Based on unbiased data, postoperative results after repair of esophageal atresia in Germany are comparable with recently published reports from international single centers. A correlation between the complication rate and characteristics of the treating institutions was not identified.

Development of a high-performance, blood-based screening diagnostic to detect early-stage breast cancer

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Background: Limitations of current screening mammography, particularly in younger women, demonstrate the need for an alternative breast cancer screening strategy. A non-invasive, easily interpreted and low cost test should address this need. Methods: Gene expression microarray analysis was carried out on 128 individual tumor samples representing over 20 tumor types, 86 samples representing 31 diverse normal tissue types, 68 tumor cell lines and 97 diverse normal primary cell cultures. Genes were ranked for elevated expression in either: i) a large number and variety of tumors relative to normal tissues, or ii) in breast tumors. Elevated expression was verified for a subset of genes using qPCR in a set of independent RNA samples. Proteins coded by genes elevated in breast cancer samples were analyzed in a retrospective training set of breast cancer patient sera samples with cancer-free patient and benign pathology controls using ELISA or bead-based detection assay. Results: Based on availability of suitable reagents, 25 candidate biomarkers were assessed in patient sera samples (31-227 patient samples per biomarker) using ELISA or bead-based assays. Individually, the performance of individual markers varied (ROC AUC, 0.51 - 0.88); however, when expression levels of the best performing markers were combined, the multiplex test demonstrated high-sensitivity (>80%) and specificity (>90%) in identifying early-stage breast cancer patients. Conclusions: A multiplex, proteomic-based approach may provide for a high-performance, blood-based screening diagnostic for breast cancer.

Early and long term outcome in children with esophageal atresia treated over the last 22 years

BACKGROUND

The survival of infants born with esophageal atresia (EA) is > 90% at present. The purpose of this study was to evaluate early complications and long term outcome in children with EA treated at our institution.

METHODS AND PATIENTS

Retrospective analysis of 111 children with EA undergoing repair of EA or tracheoesophageal fistula (TEF). Assessment of early and intermediate complications as well as long term morbidity and mortality.

RESULTS

Primary anastomosis was performed in 90 (81%) and secondary anastomosis in 7 patients (6%). Gastric transposition was carried out in 14 children (13%). The postoperative mortality was 14/111 (12.6%) and could be estimated by the Spitz classification. At the age of 10 years, 33 patients (72%) were swallowing without problems, 39 children (85%) were eating at least most of the time with pleasure but 19 children (41%) had a body weight less than the 25 (th) percentile. Staged repair by gastric transposition resulted in the least amount of motility dysfunction. Long-term respiratory morbidity was high.

CONCLUSION

The survival of children with EA has improved in the last two decades. For risk assessment the Spitz' classification is valid. Long term gastrointestinal and respiratory morbidity remains high. In children with long-gap EA gastric transposition performed as a staged procedure has satisfactory results and seems superior to techniques preserving the native esophagus.

Association of the interleukin-23 receptor gene variant rs11209026 with Crohn's disease in German children

AIM

Genome-wide association studies have described variants within the interleukin-23 receptor (IL23R) locus to be associated with Crohn's disease (CD) and ulcerative colitis (UC). We investigated the association of rs11209026 (p.Arg381Gln) and rs7517847 (c.799-3588T>G) into German paediatric inflammatory bowel disease (IBD) patients and analysed IL23R transcriptional activity in colonic tissues.

METHODS

The rs11209026 and rs7517847 nucleotide substitutions were determined in 353 German children with IBD (221 CD, 132 UC) and 253 controls using pre-designed TaqMan((R)) SNP genotyping assays. In selected IBD patients and controls, IL23R mRNA expression was measured using real-time PCR.

RESULTS

The prevalence of the rs11209026 A allele was lower in CD patients, but not in UC patients, when compared with controls (1.8% vs 7.1%, p < 0.01). The rs7517847 variant, in contrast, was associated neither with CD nor with UC. IL23R expression was variable in IBD patients compared with controls without significant overexpression or downregulation.

CONCLUSION

Our study provides additional support for the strong protection of the rs11209026 (p.Arg381Gln) variant against paediatric CD. IL23R was expressed in both CD and UC with a great variability. However, expression levels showed no significant association with the disease.

Gastric outlet obstruction after long-term prostaglandin administration mimicking hypertrophic pyloric stenosis

Prostaglandin E1 (PGE1) is widely used in neonates with cyanotic congenital heart disease who depend on the patency of the ductus arteriosus for oxygenation. Side effects of prostaglandin therapy are common and include respiratory depression, generalized flushing, and cardiovascular and neurological effects. Little is known about the complex effects on the gastrointestinal tract. We report on an infant with gastric outlet obstruction after long-term prostaglandin administration. At the age of 1 month, feeding problems developed with projectile vomiting. Ultrasonography showed progressive elongation of the antropyloric channel without wall thickening, which was causing gastric outlet obstruction. Three days after cardiac surgery and cessation of prostaglandin therapy, the infant fed normally and rapidly gained weight. The clinical signs in such patients can mimic hypertrophic pyloric stenosis. Therefore, the sonographic findings should not be confused with pyloric wall thickening to avoid a false diagnosis and unnecessary surgery. The symptoms diminish with cessation of the prostaglandin therapy after a corrective cardiac operation.

Fetal urinary bladder rupture and urinary ascites secondary to posterior urethral valves. A case report

Megacystis is a typical prenatal sonographic finding in cases of lower urinary tract obstruction. Urinary bladder perforation represents a rare complication in this condition. We report on a boy with in utero bladder perforation and urinary ascites secondary to posterior urethral valves. The pre- and postnatal therapy is described and the current literature is reviewed.

Intraoperative changes of mucosal pCO2 during gastric tube formation

The formation of a gastric tube after esophagectomy with ligation of the left gastric artery and resection of the lesser curvature is associated with microcirculatory changes, especially in the anastomotic region of the fundus. This influences the healing of the esophagogastrostomy. The presented prospective protocol was designed to assess continuous tonometry as a tool to demonstrate microcirculatory changes during gastric tube formation. In 15 patients with esophageal carcinoma, pCO2 of the gastric mucosa (pCO2i) was measured intraoperatively during formation of a gastric tube. This was done by a nasogastric tube with a silicon balloon connected to a Tonocap recirculating gas analyser. pCO2i measurements were compared for a period of 90 min before and after ligation of the left gastric artery and correlated to the corresponding end expiratory pCO2 (pCO2e). In 14 of 15 patients examined (93.3%), an increase of pCO2i after ligation of the left gastric artery was demonstrated. pCO2i (mean+/-SD) before ligation of the left gastric artery (87 measurements: 40.6+/-7.5 mmHg; range, 29-67 mmHg) was significantly lower (P<0.001) compared to the mean pCO2i after ligation of the left gastric artery (88 measurements: 49.1+/-10.2 mmHg; range, 31-79 mmHg). Continuous tonometry is a valid method to detect changes in mucosal pCO2 during gastric tube formation and should be assessed to monitor the gastric interposition graft during the postoperative course.

Maximizing the sensitivity and specificity of pediatric trauma team activation criteria

BACKGROUND

Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently.

OBJECTIVE

To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department.

METHODS

A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-of-hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calculated.

RESULTS

A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (+/-4.8 SD), and the Injury Severity Score was > or =15 in 9.3%. Trauma team activation criteria were met by 179 patients (36. 4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98. 1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95. 7%.

CONCLUSIONS

Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.

Specific bio-recognition reactions observed with an integrated Mach-Zehnder interferometer

The combination of an integrated Mach-Zehnder-interferometer (iMZI) at the bottom of a fluidic microchannel system with supramolecular interfacial binding layers optimized for biosensing purposes is described. The model system used is based on the highly specific interaction of streptavidin to its 'ligand' biotin: a single monolayer of a correspondingly derivatized silane-compound is formed by a self-assembly procedure on top of the channel rib guiding the light through the channels. Injection of a streptavidin solution which leads to the formation of a protein monolayer of d = 2.8 nm in effective thickness results in a phase shift of the sample light relative to the reference channel of delta phi = 6 pi, in good agreement with the theoretical sensitivity of delta phi/delta df = 2.9 pi/nm for a protein layer (n = 1.45) calculated for the device.

Familial Hodgkin's and non-Hodgkin's lymphoma: different patterns in first-degree relatives

In order to evaluate the importance of genetic susceptibility in Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) we retrospectively analysed 31 families with lymphoma in first-degree relatives containing a total of 65 affected persons. We observed 20 HD/HD, 8 NHL/HD and 8 NHL/NHL pairs with median ages of diagnosis of 27, 36 and 48 years, respectively (p < 0.001). In HD/HD sib pairs were predominant in contrast to parent/child pairs in NHL/NHL (p = 0.04). There was a higher frequency of diseases with impaired immune function in NHL/NHL than in other pairs (p = 0.01). Comparison of ages and times of incidence of the pairs as well as sex-concordance rates are consistent with an age-specific genetic susceptibility to HD, but suggest a time-specific exposure in some NHL-prone families with or without compromised immune function.

Respiratory findings among millwright and machinery erectors: identification of health hazards from asbestos in place at work

Asbestos-associated diseases are prevalent in the construction trades primarily because of the previously widespread use of asbestos-containing insulation materials. Workers in metal-related trades, employed at construction sites and power facilities, but who do not routinely handle such materials as part of their work, may also be at risk for significant asbestos exposure. In order to evaluate such risk, a clinical field survey was conducted of 110 millwright and machinery erectors from the New York metropolitan area. A high prevalence of chest roentgenologic abnormalities was found. Forty-nine (44.5%) of the examined workers had pleural abnormalities consistent with asbestos-induced effects. Eighteen workers showed evidence of unilateral pleural thickening. Duration from onset of employment was significantly longer for those with pleural abnormalities (mean 32.3 years) as compared to those with normal chest radiographs (mean 18.5 years). Thirteen workers (11.8%) had radiographic signs of interstitial lung disease. The workers with pleural abnormalities had lower mean values of restrictive and obstructive lung function parameters than those with normal pleura. Multivariate and logistic regression analyses demonstrated association between duration of employment in the millwright trade and pleural abnormalities which was independent of smoking status. These findings suggest that millwright and machinery erectors employed in work environments where there is potential for primarily indirect exposure to airborne asbestos-containing dust are at risk for adverse effects from such exposure.

T-cell subsets in peripheral blood of patients with newly diagnosed and posttreatment Hodgkin's and non-Hodgkin's lymphomas. Analysis by monoclonal antibody staining and flow cytometry

T-cell subsets in the peripheral blood of patients with Hodgkin's disease (HD) and non-Hodgkin's lymphomas (NHLs) were determined using anti T-cell monoclonal antibodies and flow cytometry. Forty HD patients and 30 NHL patients were evaluated; 76 normal blood donors served as controls. Newly diagnosed (untreated) HD and NHL patients had relatively normal values for percentages of total T-cells, helper cells and suppressor cells; their helper/suppressor ratios were also normal. The total lymphocyte count was normal for pretreatment HD, but lower than normal for NHL. Following treatment, both HD and NHL patients showed significantly decreased helper/suppressor ratios, caused by a significant decrease in the percentage of helper cells in HD patients and a significant increase in the percentage of suppressor cells in the small number of NHL patients studied. A small number of NHL patients, followed without specific treatment (passive follow-up), had relatively normal values for percentages of helper and suppressor cells and total T-cells. For both groups of patients off treatment, it is concluded that the lower helper/suppressor ratios are due to the prolonged effects of treatment (predominantly irradiation).

Exposure of sheet-metal workers to asbestos during the construction and renovation of commercial buildings in New York City. A case study in social medicine

New York City sheet-metal workers have a history of significant exposure to asbestos. Prior to 1972 when the use of sprayed asbestos insulation was banned in New York City, sheet-metal workers involved in building construction were exposed as they worked adjacent to spraying operations. Subsequent to that date, exposure continued as they renovated these same buildings. In 1982 the Occupational Health Program of Montefiore Medical Center and the Albert Einstein College of Medicine initiated a multidimensional asbestos evaluation and intervention program for the sheet-metal industry and union in New York. The long-term goal of the program was to eliminate asbestos exposure through the safe, systematic removal of asbestos in New York City buildings, most likely a legislated solution. In the short term, we attempted to assess and reduce asbestos exposure in the sheet-metal trade by a series of steps consisting of: mortality and morbidity studies; a medical audit of clinical screening services provided to sheet-metal workers; a comprehensive health education program; development of safe work practices; evaluation of personal protective equipment; and investigation into and support of legislative and regulatory solutions to the problem of asbestos contamination of commercial buildings. This intervention can be seen as a case study in the practice of social medicine.

Asbestos disease in sheet metal workers: II. Radiologic signs of asbestosis among active workers

A review of chest x-rays of 707 currently employed New York metropolitan area sheet metal workers found that 29.3% of the workers with 20 years or more of union membership (a surrogate for years of exposure) had radiologic abnormalities characteristic of parenchymal and/or pleural asbestosis, with 18.6% having abnormalities characteristic of parenchymal asbestosis (International Labor Organization [ILO] classification 1/0 or higher) and 17.4% of pleural asbestosis. The prevalence of abnormalities characteristic of either parenchymal and/or pleural asbestosis in the group as a whole was 16.4%, with 10.9% exhibiting signs of parenchymal asbestosis and 9.2% of pleural asbestosis. There was a strong, statistically significant relationship between years in the trade and the prevalence of radiologic abnormalities. These findings underscore the need for medical surveillance of all asbestos-exposed construction workers, including retirees and workers who have had past exposure but who are no longer exposed.

Asbestos disease screening by non-specialists: results of an evaluation

We performed a medical audit of an asbestos disease screening program offered to New York City sheet metal workers by a corporate medical service. The screening program purported to evaluate the health status of workers exposed to asbestos in the past and present during construction and renovation of commercial buildings. Using current Occupational Safety and Health Administration (OSHA) regulations as a benchmark, medical records for more than 800 workers who took the examination between 1982-83 were reviewed; x-ray interpretations of the staff radiologist were compared with the interpretations of specialists in occupational lung diseases. The audit found inadequate record-keeping procedures, a lack of a comprehensive occupational history, poor notification and absence of any form of health education. Further, there was an extreme lack of concordance between the staff radiologist and the specialist readers in the interpretation of x-rays (kappa = .14 for pleural disease and .26 for asbestosis). To an increasing extent, occupational clinical services are being provided by corporate medical groups; such groups may not be familiar with occupational health problems.

Patterns of mortality among commercial pressmen

A proportionate analysis of cause of death in 1,401 commercial pressmen was initiated following a report of a cancer cluster in this group. The study found a significant elevated risk of all cancers [proportionate mortality ratio (PMR) = 127] and cancers of the lymphatic and hematopoietic system (PMR = 122), with non-Hodgkin's lymphomas responsible for much of the excess. Three deaths in the cohort were attributed to myelofibrosis, a rare disease associated with benzene exposure. A significantly elevated PMR was also detected for colorectal cancer (PMR = 171) and, among those employed 20 years or more, for cancers of the liver (PMR = 216) and pancreas (PMR = 162). No excess risk of bladder or lung cancer or leukemia was seen. Proportionate mortality analyses rarely show excess risk of both cancer and heart disease in a working population. Surprisingly, a significantly elevated risk of arteriosclerotic heart disease (PMR = 113) was found in this group. These findings indicate that solvent exposure may be associated with excess mortality risk in commercial pressmen.

Lymphomatoid granulomatosis: an analysis of clinical and immunologic characteristics

Six patients with lymphomatoid granulomatosis were studied. Two patients had eye involvement, a rare manifestation of this disease. Both had complete disappearance of disease in this area after radiation therapy. One patient presented with an autoimmune hemolytic anemia, which remitted completely with chemotherapy. The use of corticosteroids or chemotherapy was effective in bringing about a decrease in pulmonary infiltrates in all six patients, although the duration of response was limited. One patient did have a prolonged period of clinical remission, and died of an unrelated cause. Evidence of profound immunologic abnormalities was found in these patients by a variety of tests. The extensive immunologic dysfunction present in patients with lymphomatoid granulomatosis has not previously been described. Most strikingly, patients with lymphomatoid granulomatosis have a severe impairment in T-lymphocyte function, confirmed by their inability to react to common skin test antigens or dinitrochlorobenzene, decreased in vitro lymphocyte responsiveness to mitogens and antigens and changes in T-cell subset populations. This may account for the frequent development of malignant lymphomas in patients with this condition.

Osteonecrosis in patients with malignant lymphoma: a review of twenty-five cases

A retrospective study of 25 patients with malignant lymphoma who had osteonecrosis of either the femoral or humeral head(s) was undertaken. The common factor present among all patients was the administration of intermittent steroid-containing combination chemotherapy. Seventeen Hodgkin's disease patients received chemotherapy predominantly consisting of an alkylating agent, vincristine, procarbazine, and moderate amounts of prednisone. The non-Hodgkin's lymphoma patients were on various moderate dosage steroid-containing protocols, except three who received prolonged high-dose steroid-containing chemotherapy regimens. Sixteen of the 17 Hodgkin's disease patients and five of the eight non-Hodgkin's lymphoma patients received radiotherapy to the bones that subsequently developed osteonecrosis. Two of the three non-Hodgkin's lymphoma patients who were not irradiated were treated with high-dose steroid-containing chemotherapy regimens. Symptoms developed in patients 12 months and 32 months after completion of chemotherapy and radiotherapy, respectively. Osteonecrosis was a long-term complication of treatment between 1970 and 1979 and occurred in 1.6% of the Hodgkin's disease and 0.12% of the non-Hodgkin's lymphoma patients treated. The authors conclude that the patients at highest risk for this complication are those who receive both radiotherapy to the affected bone(s) and intermittent steroid-containing multiple drug chemotherapy.

Effects of news events on response to a breast cancer screening program

An opportunity to examine the effects of significant, widely reported events on participation in a breast cancer screening program was presented when countrywide public attention was called to breast cancer by reports of the breast surgery of the wives of President and Vice President of United States. These events occurred in September and October 1974 while a breast cancer screening program was underway in the health Insurance Plan of Greater New York. The research design of this program permitted measurements to be made of the participation of the plan's members in the screening before, during, and after these famous mastectomies and of the participants' characteristics during different periods of the research program. In late 1974, when there was great mass media emphasis on breast cancer, participation rates in the breast cancer screening program increased significantly. In the study periods immediately following, however, participation rates declined to previous levels. The increase in Participation rates in late 1974 was fairly uniform among all demographic groups, whether classified by age, education, income, race, or religion. In addition to increases in the participation rate associated with the events of late 1974, there was also an increased tendency among women who were screened to respond readily to mailed invitations to appear for screenings. This increase insensitivity to efforts to win their participation was more pronounced among those groups that this study and other studies have shown are more likely to participate in preventive health programs and to respond more readily to request to participate.