A novel two-phase bioreactor for microbial hexavalent chromium removal from wastewater

Α novel two-phase bioreactor for the microbial removal of Cr(VI) from wastewater with high chromium concentration (up to 1350ppm) is developed. Among several potential solid-phase adsorbents tested, Cloisite^® 30B, a natural montmorillonite modified with a quaternary ammonium salt that absorbs Cr(VI) in a reversible manner proved to be optimal as the solid phase of the bioreactor. Cloisite^® 30B has no toxicity to the acclimated biomass and keeps the concentration of Cr(VI) ions at sub-inhibitory levels that ensure the efficient microbial removal of Cr(VI). The microbial removal of Cr(VI) was achieved using an acclimated mixed culture developed from anaerobic sludge. The novel bioreactor was operated as a Sequencing Batch Reactor (SBR) under anaerobic and mesophilic conditions for over 200 cycles, without further addition of the solid adsorbent, and led to even 100% removal of Cr(VI) with high removal rates for concentrations ranging from 900-1350mg/L Cr(VI). The reduction of Cr(VI) to the less toxic Cr(III) was proved to be mediated by lactate, generated by a lactic acid bacterium, 99% similar to Pediococcus acidilactici as demonstrated by molecular methods The reduction of Cr(VI) took place extracellularly where it reacts with the lactic acid produced during the process of glycolysis.

Mycoplasma Infection Alters Cancer Stem Cell Properties in Vitro

Cancer cell lines can be useful to model cancer stem cells. Infection with Mycoplasma species is an insidious problem in mammalian cell culture. While investigating stem-like properties in early passage melanoma cell lines, we noted poorly reproducible results from an aliquot of a cell line that was later found to be infected with Mycoplasma hyorhinis. Deliberate infection of other early passage melanoma cell lines aliquots induced variable and unpredictable effects on expression of putative cancer stem cell markers, clonogenicity, proliferation and global gene expression. Cell lines established in stem cell media (SCM) were equally susceptible. Mycoplasma status is rarely reported in publications using cultured cells to study the cancer stem cell hypothesis. Our work highlights the importance of surveillance for Mycoplasma infection while using any cultured cells to interrogate tumor heterogeneity.

Psychosis or Simply a New Manifestation of Neurosyphilis?

The widespread use of antibiotics in recent years has caused a significant reduction in the incidence of neurosyphilis and changes in its clinical features. We present a case that initially presented as persistent headache and untreatable psychosis. Neurosyphilis was diagnosed during the clinical evaluation. Blood serum analyses for syphilis were positive for rapid plasma reagin titres, the Venereal Disease Research Laboratories test and fluorescent treponemal antibody absorption. A lumbar puncture was performed and cerebrospinal fluid analysis resulted in the diagnosis of neurosyphilis. The patient completed a 2-week course of treatment with aqueous crystalline penicillin G and his symptoms subsequently improved. We suggest that neurosyphilis should always be included in the differential diagnosis of untreatable psychosis.

Combined physiological, transcriptome, and cis-regulatory element analyses indicate that key aspects of ripening, metabolism, and transcriptional program in grapes (Vitis vinifera L.) are differentially modulated accordingly to fruit size

BACKGROUND

In wine grape production, management practices have been adopted to optimize grape and wine quality attributes by producing, or screening for, berries of smaller size. Fruit size and composition are influenced by numerous factors that include both internal (e.g. berry hormone metabolism) and external (e.g. environment and cultural practices) factors. Combined physiological, biochemical, and transcriptome analyses were performed to improve our current understanding of metabolic and transcriptional pathways related to berry ripening and composition in berries of different sizes.

RESULTS

The comparison of berry physiology between small and large berries throughout development (from 31 to 121 days after anthesis, DAA) revealed significant differences in firmness, the rate of softening, and sugar accumulation at specific developmental stages. Small berries had significantly higher skin to berry weight ratio, lower number of seeds per berry, and higher anthocyanin concentration compared to large berries. RNA-sequencing analyses of berry skins at 47, 74, 103, and 121 DAA revealed a total of 3482 differentially expressed genes between small and large berries. Abscisic acid, auxin, and ethylene hormone pathway genes were differentially modulated between berry sizes. Fatty acid degradation and stilbenoid pathway genes were upregulated at 47 DAA while cell wall degrading and modification genes were downregulated at 74 DAA in small compared to large berries. In the late ripening stage, concerted upregulation of the general phenylpropanoid and stilbenoid pathway genes and downregulation of flavonoid pathway genes were observed in skins of small compared to large berries. Cis-regulatory element analysis of differentially expressed hormone, fruit texture, flavor, and aroma genes revealed an enrichment of specific regulatory motifs related to bZIP, bHLH, AP2/ERF, NAC, MYB, and MADS-box transcription factors.

CONCLUSIONS

The study demonstrates that physiological and compositional differences between berries of different sizes parallel transcriptome changes that involve fruit texture, flavor, and aroma pathways. These results suggest that, in addition to direct effects brought about by differences in size, key aspects involved in the regulation of ripening likely contribute to different quality profiles between small and large berries.

Low-dose cyclophosphamide enhances antigen-specific CD4(+) T cell responses to NY-ESO-1/ISCOMATRIX™ vaccine in patients with advanced melanoma

Clinical outcomes from cancer vaccine trials in patients with advanced melanoma have so far been disappointing. This appears at least partially due to a state of immunosuppression in these patients induced by an expansion of regulatory cell populations including regulatory T cells (Tregs). We have previously demonstrated potent immunogenicity of the NY-ESO-1/ISCOMATRIX™ vaccine in patients with resected melanoma (study LUD99-08); however, the same vaccine induced only a few vaccine antigen-specific immune responses in patients with advanced disease (study LUD2002-013). Pre-clinical models suggest that the alkylating agent cyclophosphamide can enhance immune responses by depleting Tregs. Therefore, we have enrolled a second cohort of patients with advanced melanoma in the clinical trial LUD2002-013 to investigate whether pre-treatment with cyclophosphamide could improve the immunogenicity of the NY-ESO-1/ISCOMATRIX™ vaccine. The combination treatment led to a significant increase in vaccine-induced NY-ESO-1-specific CD4(+) T cell responses compared with the first trial cohort treated with vaccine alone. We could not detect a significant decline in regulatory T cells in peripheral blood of patients 14 days after cyclophosphamide administration, although a decline at an earlier time point cannot be excluded. Our observations support the inclusion of cyclophosphamide in combination trials with vaccines and other immune-modulatory agents.

Evaluation of cyclophosphamide as an immune enhancer for the NY-ESO-1/ISCOMATRIX vaccine in patients with metastatic melanoma

3093^

Background: We have previously demonstrated potent immunogenicity of the NY-ESO-1/ISCOMATRIX vaccine in patients with resected melanoma; however the same vaccine induced only a few vaccine antigen specific immune responses in patients with advanced disease. Therefore, we have enrolled a second cohort of patients with advanced melanoma in the clinical trial LUD2002-013 to investigate whether pre-treatment with the immune-modulator cyclophosphamide could improve the immunogenicity of the NY-ESO-1/ISCOMATRIX vaccine. Methods: LUD2002-013 was an open-label phase II study intended to evaluate the safety and immunogenicity of the NY-ESO-1/ISCOMATRIX vaccine in patients with advanced melanoma. The first cohort of patients received vaccine alone; a second cohort with 19 patients was added after evaluation of responses in Cohort 1 and received vaccine in combination with low-dose cyclophosphamide. Patients received 3 injections of NY-ESO-1 ISCOMATRIX preceded, in Cohort 2, by cyclophosphamide at a dose of 300 mg/m2 every four weeks. Assessment of clinical and immunological responses was undertaken at week 11. Results: Fifteen patients of Cohort 2 completed at least one cycle of vaccination. No objective responses were observed with three patients having stable disease for more than three months. The inclusion of cyclophosphamide into the vaccination protocol did not lead to any significant toxicity. Seven of fourteen patients in Cohort 2 developed a vaccine induced NY-ESO-1 specific CD4 T cell response, a significant increase compared to cohort 1 (p=0.019). No differences were observed in the frequency of vaccine induced antibody or CD8 T cell responses. No change in the frequency of peripheral blood regulatory T cells or myeloid derived suppressor cells was detected. Conclusions: The administration of low dose cyclophosphamide has significantly increased the NY-ESO-1 specific CD4 T cell response of the NY-ESO-1/ISCOMATRIX vaccine in patients with metastatic melanoma. Given the emerging importance of CD4 T cells in tumour regression, the present findings warrant further clinical exploration of combining cyclophosphamide with vaccines and other immune-modulatory agents. Clinical trial information: NCT00518206.

Abstract P3-14-04: Symptomatic DCIS is a risk factor for invasion and should be managed accordingly

Background: The National ABS Guidelines indicate axillary surgery is unwarranted in DCIS but should be offered to patients undergoing mastectomy. Up to 30% of pre-operatively diagnosed DCIS lesions harbour occult invasive cancers at mastectomy.

Methods: To determine if DCIS mode of presentation, size (or other clinical factors such as Grade or HER2 status) predict invasion or nodal involvement, 380 patients undergoing surgery with a DCIS pre-operative (B5) diagnosis were studied. In total 162 patients underwent mastectomy +/− axillary staging for DCIS and 216 conservation surgery between 2008–2011 in one unit.

HER2, oestrogen receptor (ER) and progesterone receptor (PR) expression within primary DCIS were established using immunohistochemistry. HER2 was scored 0 (absent) to 3 (maximum). Scores ≥2 were taken as positive if amplified on FISH testing. ER and PR scored positive if ≥5% of cells stained.

Results: In total 216 had Breast Conservation and 162 Mastectomy with 127 undergoing sentinel lymph node biopsy (111) or subsequent axillary surgery (16).

Of 162 patients undergoing mastectomy for DCIS, 121 (75%) underwent axillary staging, with 9 (7%) having involved nodes.

Screening mammography detected 117 (72%) but 45 (28%) presented symptomatically with a breast mass. Median age at diagnosis was 57.8 years (range 29–94). Women less than 35 years of age had tumours sized greater than 4 cm in 72.3% compared to 59% in older women (p < 0.05).

In total 50 (31%) women with DCIS had occult invasive disease, with an additional 9 (6%) having microinvasion. Young age (p 0.003), - symptomatic presentation (p < 0.001), presence of a palpable mass (p <0.001), ultrasound visibility (p <0.01) and Her2 negativity (p < 0.05) were associated with invasion, however size of DCIS, grade, oestrogen and progesterone receptor status were not.

Sentinel node involvement was associated with symptomatic presentation (p = 0.03) and presence of a palpable mass (p = 0.04) but not DCIS size, grade, age or receptor status.

Conclusion: Symptomatic DCIS presents more frequently with an occult invasive component and nodal invasion. In symptomatic DCIS presenting with a mass lesion.

Ultrasound of the axilla and breasts should be a requisite preoperative assessment for all women. Moreover, sentinel node biopsy should be considered in patients with DCIS and a mass lesion.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-14-04.

Abstract PD04-06: Molecular Phenotypes of DCIS predict Invasive and DCIS recurrence

Introduction: Molecular phenotypes of invasive breast cancer predict early recurrence and survival. DCIS exhibits similar phenotypes but their frequency and clinical significance remain uncertain. To determine whether molecular phenotypes of DCIS predict recurrence, 273 women (median age 57 years) with primary DCIS who were screened for or entered DCIS trials (Iressa/Lapatinib/ERISAC) in one unit from 1990–2010 were studied.

Methods: HER2, oestrogen receptor (ER) and progesterone receptor (PR) expression within primary DCIS were established using immunohistochemistry within the trial protocols. HER2 was scored 0 (absent) to 3 (maximum). Scores ≥2 were taken as positive if amplified on FISH testing. ER and PR scored positive if ≥5% of cells stained. 64.2% patients were ER positive, 43.3% were HER2 positive and 31.8% were high-grade lesions. 94 underwent mastectomy whilst 185 had BCS.

Results: There was an overall recurrence rate of 20.14% after a median follow-up period of 74 months (range 12–240). Of these recurrences, 36.4% were invasive. Conservation surgery (BCS) was used in 185 women who suffered 47 recurrences. Molecular phenotype predicted local recurrence by Log Rank analysis (P < 0.01) and invasive recurrences (P < 0.016) overall and in the BCS group remained predictive of invasive recurrence (p <0.005) and overall recurrence (p < 0.001).

Immunoediting and persistence of antigen-specific immunity in patients who have previously been vaccinated with NY-ESO-1 protein formulated in ISCOMATRIX™

BACKGROUND

NY-ESO-1 protein formulated in ISCOMATRIX™ results in CD4+, CD8+ T cell and antibody-mediated immunity. We evaluated persistence of immunity, relapse-free survival and tumour antigen expression upon relapse in patients vaccinated in an earlier trial.

METHODS

Immunity was measured in 28 patients with resected NY-ESO-1-expressing tumours (melanoma 25, breast 3) 252-1,155 days (median = 681) after vaccination. In the earlier vaccination, trial patients received NY-ESO-1 with ISCOMATRIX™ adjuvant at three protein doses 10 μg, 30 μg or 100 μg (n = 14); 100 μg NY-ESO-1 protein (n = 8) or placebo (n = 6), together with 1 μg of intradermal (ID) NY-ESO-1 protein twice for DTH skin testing. Immune responses assessed in the current study included antibody titres, circulating NY-ESO-1-specific T cells and DTH reactivity 2 days after DTH skin testing with NY-ESO-1 protein (1 μg) or peptides (10 μg). Relapse-free survival was determined for 42 melanoma patients. On relapse NY-ESO-1 and HLA, class I was assessed by immunohistochemistry in 17.

RESULTS

Persisting anti-NY-ESO-1 immunity was detected in 10/14 recipients who had previously received vaccine with ISCOMATRIX™ adjuvant. In contrast, immunity only persisted in 3/14 who received 100 μg un-adjuvanted NY-ESO-1 protein (3/8) or 2 μg DTH protein (0/6) P = 0.02. Hence, persisting NY-ESO-1 immunity was associated with prior adjuvant. Tumour NY-ESO-1 or HLA class I was downregulated in participants who relapsed suggesting immunoediting had occurred.

CONCLUSION

Immunoediting suggests that a signal of anti-tumour activity was observed in high-risk resected melanoma patients vaccinated with NY-ESO-1/ISCOMATRIX™. This was associated with measurable persisting immunity in the majority of vaccinated subjects tested. A prospective randomised trial has been undertaken to confirm these results.

Invasive Lobular Carcinoma: Imaging Characteristics, Size at Presentation and Bilaterality

Aims: Invasive Lobular Carcinoma (ILC) is often described as elusive to standard imaging modalities and usually requiring mastectomy to obtain clear margins. Its reputation of being bilateral has been disputed by most recent studies. The aim of this study is to investigate whether the radiological diagnosis of ILC at first symptomatic presentation is more difficult than that of Invasive Ductal Carcinoma (IDC) in a modern breast clinic; also whether its size, surgical treatment at presentation and bilaterality is different from IDC and its subtypes.Materials & Methods: The radiological codes given to all new symptomatic patients with invasive breast cancer, presenting at the breast clinic of St Mary's Hospital and undergoing surgery as first treatment, (n=754), were collected prospectively between 1998 and 2005 and final mastectomy rates were also recorded. Histological reports of all synchronous and metachronous bilateral cancers presenting with at least one tumour between 1998 and 2007 were analyzed (n=65).Results: ILC was given suspicious radiological codes as often as IDC (90% vs 93%). On final histology, ILC measured on average 3.6cm compared to 2.5cm for IDC (p<0.05). There was a trend of ILC requiring mastectomy more often (51% vs 43%). 12.7% of patients with at least one ILC diagnosis have developed bilateral breast cancer compared to 4.5% of patients who have never had an ILC diagnosis (p<0.05).Results IDCILCMixedSpecialUnknownTotalNo of patients551 (73%)86 (11%)52 (7%)62 (8%)3 (0.4%)754Age (mean)5861596157.659Mastectomy191 (43%)36 (51%)23 (49%)13 (25%) 263Breast conservation257 (58%)36 (51%)24 (51%)41 (77%) 358Size cm (mean)2.53.62.52.0-2.7USS suspicious473 (93%)72 (90%)41 (90%)42 (76%)2 (100%)630MMG suspicious412 (81%)58 (73%)39 (80%)43 (80&)2 (100%)554 Conclusions: ILC is as easy to diagnose radiologically as IDC in symptomatic breast patients. However, ILC is larger at first presentation. In our database, ILC identified a subgroup of breast cancer patients who have a 3-fold higher risk of developing bilateral breast cancer of various histological types.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4015.

Melan-A-specific cytotoxic T cells are associated with tumor regression and autoimmunity following treatment with anti-CTLA-4

PURPOSE

Ipilimumab is a monoclonal antibody that blocks the immune-inhibitory interaction between CTL antigen 4 (CTLA-4) and its ligands on T cells. Clinical trials in cancer patients with ipilimumab have shown promising antitumor activity, particularly in patients with advanced melanoma. Often, tumor regressions in these patients are correlated with immune-related side effects such as dermatitis, enterocolitis, and hypophysitis. Although these reactions are believed to be immune-mediated, the antigenic targets for the cellular or humoral immune response are not known.

EXPERIMENTAL DESIGN

We enrolled patients with advanced melanoma in a phase II study with ipilimumab. One of these patients experienced a complete remission of his tumor. The specificity and functional properties of CD8-positive T cells in his peripheral blood, in regressing tumor tissue, and at the site of an immune-mediated skin rash were investigated.

RESULTS

Regressing tumor tissue was infiltrated with CD8-positive T cells, a high proportion of which were specific for Melan-A. The skin rash was similarly infiltrated with Melan-A-specific CD8-positive T cells, and a dramatic (>30-fold) increase in Melan-A-specific CD8-positive T cells was apparent in peripheral blood. These cells had an effector phenotype and lysed Melan-A-expressing tumor cells.

CONCLUSIONS

Our results show that Melan-A may be a major target for both the autoimmune and antitumor reactions in patients treated with anti-CTLA-4, and describe for the first time the antigen specificity of CD8-positive T cells that mediate tumor rejection in a patient undergoing treatment with an anti-CTLA-4 antibody. These findings may allow a better integration of ipilimumab into other forms of immunotherapy.

Regulatory T-cell-mediated attenuation of T-cell responses to the NY-ESO-1 ISCOMATRIX vaccine in patients with advanced malignant melanoma

PURPOSE

NY-ESO-1 is a highly immunogenic antigen expressed in a variety of malignancies, making it an excellent target for cancer vaccination. We recently developed a vaccine consisting of full-length recombinant NY-ESO-1 protein formulated with ISCOMATRIX adjuvant, which generated strong humoral and T-cell-mediated immune responses and seemed to reduce the risk of disease relapse in patients with fully resected melanoma. This study examines the clinical and immunologic efficacy of the same vaccine in patients with advanced metastatic melanoma.

EXPERIMENTAL DESIGN

Delayed-type hypersensitivity responses, circulating NY-ESO-1-specific CD4(+) and CD8(+) T cells, and proportions of regulatory T cells (Treg) were assessed in patients.

RESULTS

In contrast to patients with minimal residual disease, advanced melanoma patients showed no clinical responses to vaccination. Although strong antibody responses were mounted, the generation of delayed-type hypersensitivity responses was significantly impaired. The proportion of patients with circulating NY-ESO-1-specific CD4(+) T cells was also reduced, and although many patients had CD8(+) T cells specific to a broad range of NY-ESO-1 epitopes, the majority of these responses were preexisting. Tregs were enumerated in the blood by flow cytometric detection of cells with a CD4(+)CD25(+)FoxP3(+) and CD4(+)CD25(+)CD127(-) phenotype. Patients with advanced melanoma had a significantly higher proportion of circulating Treg compared with those with minimal residual disease.

CONCLUSIONS

Our results point to a tumor-induced systemic immune suppression, showing a clear association between the stage of melanoma progression, the number of Treg in the blood, and the clinical and immunologic efficacy of the NY-ESO-1 ISCOMATRIX cancer vaccine.

Incidence and clinical presentation of neurosyphilis: a retrospective study of 81 cases

Aim of the report was the study of the clinical features of neurosyphilis in the last 40 years (1965-2005). The investigation was based on the retrospective review of patients with neurosyphilis hospitalized in our hospital from 1965 to 2005 (period A: 1965-1984 and B: 1985-2005). Eighty one patients with neurosyphilis were studied. Typical forms represent 68.6% of cases of neurosyphilis in period A. In period B, 85.7% of the cases are presented with atypical clinical patterns. Typical forms of the disease were no longer common, while atypical and masked clinical patterns prevailed. Neuropsychiatric symptoms were the most common manifestations of the disease.

A long, naturally presented immunodominant epitope from NY-ESO-1 tumor antigen: implications for cancer vaccine design

The tumor antigen NY-ESO-1 is a promising cancer vaccine target. We describe here a novel HLA-B7-restricted NY-ESO-1 epitope, encompassing amino acids 60-72 (APRGPHGGAASGL), which is naturally presented by melanoma cells. The tumor epitope bound to HLA-B7 by bulging outward from the peptide-binding cleft. This bulged epitope was not an impediment to T-cell recognition, however, because four of six HLA-B7(+) melanoma patients vaccinated with NY-ESO-1 ISCOMATRIX vaccine generated a potent T-cell response to this determinant. Moreover, the response to this epitope was immunodominant in three of these patients and, unlike the T-cell responses to bulged HLA class I viral epitopes, the responding T cells possessed a remarkably broad TCR repertoire. Interestingly, HLA-B7(+) melanoma patients who did not receive the NY-ESO-1 ISCOMATRIX vaccine rarely generated a spontaneous T-cell response to this cryptic epitope, suggesting a lack of priming of such T cells in the natural anti-NY-ESO-1 response, which may be corrected by vaccination. Together, our results reveal several surprising aspects of antitumor immunity and have implications for cancer vaccine design.

Correlation Between Depression and Interferon-Beta Therapy in Patients with Multiple Sclerosis: A Systematic Review

Introduction:

Depression is the most frequent psychiatric disorder encountered in patients with Multiple Sclerosis (MS), with a life-time prevalence of approximately 50%. INF-beta (INF-β) shows beneficial effect on the course of MS. Although it has been suggested that interferons may be associated to depression, the validity and the nature of this relationship remain unclear regarding INF-β. The objective of this study is to review the scientific literature in order to elucidate the relationship between depression and INF-β therapy.

Methods:

This systematic review was based on Medline, Embase and, PsycLIT literature searches (through January 2005), supplemented by bibliographical citations in identified papers.

Results:

The majority of studies ruled out a correlation between INF-β1a/1b and depression in MS patients. However, patients with a recent history of depression may be at higher risk for depression particularly in the early phase of treatment (first 6 months), even if they are not depressed at the initiation of medication. There is an association between depressive symptoms and discontinuation of INF therapy but INF-β does not seem to be associated with suicide attempts. Treating patient-reported depression increases adherence to treatment.

Conclusions:

Clinicians should not refrain from including patients with MS in INF-β treatment programs, even those with depression in the past or at the present time. Screening, monitoring, and early antidepressant treatment is necessary to optimize IFN therapy for the majority of patients with MS.

Clinical Implications of Anxiety in Diabetes: A Critical Review of the Evidence Base

Introduction:

Substantial literature supports clinically important associations between anxiety and chronic medical conditions. Diabetes is among the most psychologically and behaviorally demanding chronic medical illnesses. Anxiety has been associated with poor glycemic control, regimen adherence, and with accelerated rates of coronary heart disease in diabetic patients.

Aim:

The aim of this study is to provide an overview of the role of clinically significant anxiety in patients with diabetes mellitus.

Methods:

MEDLINE, EMBASE and PSYCINFO databases were searched using the combined search terms diabetes, diabetes mellitus, anxiety symptoms and anxiety disorders. Published reference lists were also examined. In total 25 studies were identified that fulfilled the inclusion criteria.

Results:

Anxiety was present in 41.7% of diabetic patients. There was no significant difference between those with Types 1 and types 2 diabetes. The rate of elevated symptoms was significantly higher in diabetic women than in diabetic men. General anxiety disorder was the most prevalent of the clinical disorders and was found in 13.2% of the diabetic patients. The rates of the other anxiety disorders were within the range of those reported in community studies. Treatment of anxiety was associated with improved glycemic control, particularly in the subgroup of patients with severe anxiety.

Conclusions:

Emerging data offer a strong argument for the role of anxiety in diabetes. Psychological interventions and/ or pharmacological treatments in patients with diabetes are needed, in order to increase treatment adherence and control of the disease and improve patients’ functioning and quality of life.

Thyroid microcarcinoma during thyroidectomy

INTRODUCTION

We aimed to retrospectively assess the prevalence of microcarcinoma in thyroidectomy specimens from a Greek population and the role of histopathology in determining management of these patients.

METHODS

We used histopathological reports of thyroidectomies performed in a Greek general district hospital. The samples consisted of 191 thyroidectomies performed between January 1997 and July 2001. The female:male ratio was approximately 2:1 and the follow-up period was 327 weeks.

RESULTS

There were 29 microcarcinomas (15.2 percent) with a female:male ratio of 6:1. The prevalence rate in cases with Hashimoto's thyroiditis was significantly higher compared to cases with other benign thyroid pathology (26.8 percent versus 11.9 percent, p-value equals 0.02). Eight microcarcinomas (27.6 percent) were multifocal. The histological type was that of papillary tumour in ten cases (34.5 percent) and follicular in 18 cases (62.1 percent). There were no deaths, recurrences or metastases during the follow-up period.

CONCLUSION

Our results suggest that incidental microcarcinomas are low-risk tumours that do not require routine further intervention. The latter may be necessary for tumours with poor differentiation or for non-incidental microcarcinomas.

A critical region in the mineralocorticoid receptor for aldosterone binding and activation by cortisol: evidence for a common mechanism governing ligand binding specificity in steroid hormone receptors

The amino acids that confer aldosterone binding specificity to the mineralocorticoid receptor (MR) remain to be determined. We had previously analyzed a panel of chimeras created between the MR and the glucocorticoid receptor and determined that amino acids 804-874 of the MR ligand binding domain are critical for aldosterone binding. In the present study a further series of chimeras was created within this region. The chimeras were analyzed by a transactivation assay and [(3)H]aldosterone binding, and the critical region was narrowed down to amino acids 820-844. Site-directed mutagenesis was used to create single and multiple amino acid substitutions in this region. These studies identified 12 of the 16 amino acids that differ in the MR and the glucocorticoid receptor in this region as being critical to conferring aldosterone responsivity. The amino acids that differ in the region 820-844 lie on the surface of the molecule and, therefore, it appears that MR ligand binding selectivity is conferred by residues that do not form part of the ligand binding pocket. Other studies have found that the corresponding regions of the androgen and glucocorticoid receptors are critical for the binding of natural and synthetic ligands, suggesting a common mechanism governing ligand binding specificity. The new chimeras also displayed, as previously reported, a dissociation between cortisol binding and transactivation and, intriguingly, only those that bound aldosterone with high affinity were activated by cortisol, suggesting a common mechanism that underlies specificity of aldosterone binding and the ability of cortisol to activate the MR.

Upper gastrointestinal bleeding due to primary aortoenteric fistula

Primary aortoenteric fistula (PAEF) is a rare but clinically important cause of catastrophic gastrointestinal bleeding. "Herald bleeding" is a characteristic symptom which refers to specific case of upper gastrointestinal bleeding that stop temporarily spontaneously and then proceeds to massive bleeding. We present the case report of a 55-year-old male with PAEF who was admitted due to upper gastrointestinal bleeding. Endoscopic studies were unremarkable and patient underwent exploratory laparotomy. The postoperative course was uneventful. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival of patient with PAEF. Gastrointestinal bleeding combined with a negative endoscopy suggests PAEF. Endovascular operation is an attractive treatment option.

Blood Dendritic Cells Generated With Flt3 Ligand and CD40 Ligand Prime CD8+ T Cells Efficiently in Cancer Patients

Flt3 ligand mobilizes dendritic cells (DCs) into blood, allowing generation in vivo of large numbers of DCs for immunotherapy. These immature DCs can be rapidly activated by soluble CD40 ligand (CD40L). We developed a novel overnight method using these cytokines to produce DCs for cancer immunotherapy. Flt3 ligand-mobilized DCs (FLDCs) were isolated, activated with CD40L, loaded with antigenic peptides from influenza matrix protein, hepatitis B core antigen, NY-ESO-1, MAGE-A4, and MAGE-A10, and injected into patients with resected melanoma. Three injections were given at 4-week intervals. Study end points included antigen-specific immune responses (skin reactions to peptides alone or peptide-pulsed FLDCs; circulating T-cell responses), safety, and toxicity. No patient had a measurable tumor. Six patients were entered. FLDCs were obtained, enriched, and cultured under Good Manufacturing Practice grade conditions. Overnight culture with soluble CD40L caused marked up-regulation of activation markers (CD83 and HLA-DR). These FLDCs were functional and able to stimulate antigen-specific T cells in vitro. No significant adverse events were attributable to FLDCs. Peptide-pulsed FLDCs caused strong local skin reactions up to 60 mm diameter with intense perivascular infiltration of T cells, exceeding those seen in our previous peptide-based protocols. Antigen-specific blood T-cell responses were induced, including responses to an antigen for which the patients were naive (hepatitis B core antigen) and MAGE-A10. MAGE-A10-specific T cells with a skewed T-cell receptor repertoire were detected in 1 patient in blood ex vivo and from tumor biopsies. Vaccination with FLDCs pulsed with peptides is safe and primes immune responses to cancer antigens.

Renal Injury: 5-Year Experience and Literature Review

INTRODUCTION

Appropriate management of renal trauma is controversial. The purpose of this study is to present our 5-year experience in renal trauma and review the literature.

MATERIALS AND METHODS

From 1999 to 2003, 28 patients were identified with renal injuries. 25 (89.3%) of the injuries were caused by blunt trauma, 2 (7.1%) by stab wounds, and 1 (3.6%) by gunshot wound. Methods for diagnosis included ultrasonography (US), computed tomography (CT), diagnostic peritoneal lavage (DPL), combinations of more than one technique or no one of them. The English-language literature about renal trauma was also identified using Medline, and additional cited works not detected in the initial search obtained.

RESULTS

18 patients underwent immediate or during 24 h operation; while 5 nephrectomies were performed. 11 patients with grade I to III injuries were selected for nonoperative management of renal injuries. All complications were noted and studied according to the initial therapeutic management and grade. Follow-up was clinical and radiological. 3 postoperative deaths were observed.

CONCLUSION

The goals of treatment of renal injuries include accurate staging and minimal complications. Surgery can be avoided in most cases of blunt renal injury but there is also a trend towards conservative management of penetrating trauma. Nephrectomy is associated with high-grade renal injuries, while minor renal injuries can safely be managed conservatively.

Striking Immunodominance Hierarchy of Naturally Occurring CD8+ and CD4+ T Cell Responses to Tumor Antigen NY-ESO-1

Immunodominance has been well-demonstrated in many antiviral and antibacterial systems, but much less so in the setting of immune responses against cancer. Tumor Ag-specific CD8+ T cells keep cancer cells in check via immunosurveillance and shape tumor development through immunoediting. Because most tumor Ags are self Ags, the breadth and depth of antitumor immune responses have not been well-appreciated. To design and develop antitumor vaccines, it is important to understand the immunodominance hierarchy and its underlying mechanisms, and to identify the most immunodominant tumor Ag-specific T cells. We have comprehensively analyzed spontaneous cellular immune responses of one individual and show that multiple tumor Ags are targeted by the patient's immune system, especially the "cancer-testis" tumor Ag NY-ESO-1. The pattern of anti-NY-ESO-1 T cell responses in this patient closely resembles the classical broad yet hierarchical antiviral immunity and was confirmed in a second subject.

Characterization of antigen-specific CD8+ T lymphocyte responses in skin and peripheral blood following intradermal peptide vaccination

Immune responses to cancer vaccines are commonly tested by measuring cutaneous reactions to intradermal (i.d.) antigen. When well-characterized peptide epitopes are injected i.d., infiltrates of CD4+ and CD8+ T lymphocytes are frequently seen. In this study, we have further characterized T cells derived from vaccine-infiltrating lymphocyte (VIL) responses. We found that the infiltrates capable of producing IFN-gamma and cytolytic activity could recognize vaccine peptide, as well as antigen-positive melanoma cells. We studied antigen-specific T cell responses from VILs and peripheral blood in 10 patients who participated in a clinical trial. All patients received systemic Flt3 ligand (20 microg/kg/d) and i.d. peptides: Three NY-ESO-1 peptides, SLLMWITQCFL (157-167), SLLMWITQC (157-165), QLSLLMWIT (155-163); tyrosinase internal peptide YMDGTMSQV (368-376); Melan-A/MART-1 analogue peptide ELAGIGILTV (26-35, E27L substitution); and influenza matrix peptide GILGFVFTL (58-66). In 54 paired VIL and peripheral blood analyses, a good correlation was found between responses in skin and in blood. These cells could be rapidly expanded in a short-term assay and thus appear to be memory T cells. The demonstrated presence of antigen-specific T cells at vaccination sites validates this method of assessing the immune response to i.d. vaccines.

Reversal in the Immunodominance Hierarchy in Secondary CD8+ T Cell Responses to Influenza A Virus: Roles for Cross-Presentation and Lysis-Independent Immunodomination

Immunodominance is a central feature of CD8+ T cell (TCD8+) responses to pathogens, transplants, and tumors. Determinants occupy a stable position in an immunodominance hierarchy (alpha-, beta-, etc.) defined by the frequencies of responding TCD8+. In this paper, we study the mechanistic basis for place-swapping between alpha- (acid polymerase (PA)(224-233)) and beta-determinants (nuclear protein 366-374) in primary vs secondary anti-influenza A virus (IAV) responses in mice. This phenomena was recently correlated with the inability of IAV-infected nondendritic cells (DCs) to generate PA(224-233), and it was proposed that secondary TCD8+ are principally activated by IAV-infected epithelial cells, while primary TCD8+ are activated by IAV-infected DCs. In this study, we show that the inability of non-DCs to generate PA(224-232) is relative rather than absolute, and that the preferential use of cross-priming in secondary anti-IAV responses can also account for the revised hierarchy. We further show that immunodomination of PA(224-233)-specific TCD8+ by nucleoprotein 366-374-specific TCD8+ plays a critical role in the phenomena, and that this is unlikely to be mediated by TCD8+ lysis of APCs or other cells.

The impact of imiquimod, a Toll-like receptor-7 ligand (TLR7L), on the immunogenicity of melanoma peptide vaccination with adjuvant Flt3 ligand

Dendritic cells (DCs) show promise as adjuvants in anticancer immunotherapeutic strategies. Flt3 ligand (FL) is a hematopoietic growth factor that increases the number of immature DCs in the blood and other tissues. We treated 27 patients with metastatic or high-risk resected melanoma with s.c. FL daily for 14 d in three 28 d cycles. Eighteen of these patients also received vaccination with influenza (Flu), Melan-A (Mel), tyrosinase (Tyr), and NY-ESO-1 peptides. To induce local DC maturation, 8 of the vaccinated patients had imiquimod, a Toll-like receptor-7 ligand (TLR7L), applied topically to their vaccine sites. Patients were monitored for clinical and hematological effects. Immune responses were assessed by cutaneous reactivity to vaccination and by the induction of peptide-specific CD8+ T-cells. Eight patients did not complete the protocol due to adverse events related to their cancer. The treatment was generally safe and well tolerated, although some patients developed clinically significant toxicities related to FL. FL induced increases in immature CD11c+ and CD123+ peripheral blood (PB) DCs. Other hematological effects included monocytosis, granulocytosis, and thrombocytosis, which were marked in some patients. Cutaneous reactions to peptide vaccination and circulating peptide-specific CD8+ T-cells were more frequent in imiquimod-treated patients. FL treatment of melanoma patients has pleiotropic clinical and hematological effects. In vivo maturation of FL-generated DCs using imiquimod may increase immune responses to tumor antigens.

A robust human T-cell culture method suitable for monitoring CD8+ and CD4+ T-cell responses from cancer clinical trial samples

Many tumor antigenic determinants have been identified and included in cancer clinical trials. Due to low T-cell frequencies even after vaccination, few T-cell responses can be revealed ex vivo without in vitro stimulation. Various expansion protocols have been employed for this purpose and the outcomes tend to be quite variable, partly due to the high complexity involved in the protocols. Here we systematically studied various common culture conditions including sera, cytokines and feeders and describe a reliable "bulk" culture method that is robust, simpler and more economical. We demonstrated that fetal calf serum (FCS) supported T-cell proliferation better than multiple commercially available pooled human AB sera. IL-2 is critical in our cultures, but IL-7, IL-15 and anti-CTLA-4 in combination with IL-2 did not further enhance T-cell expansion. We typically achieve more than a 40-fold expansion within a 10-day culture period for antigen-specific T cells measured by HLA-peptide tetramer before and after culture. This method was not only validated by multiple operators as a standard operating procedure for monitoring T-cell responses but was also successfully used for discovering novel CD8+ and CD4+ T cells specific to previously unknown epitopes from the NY-ESO-1 tumor antigen.

Recombinant NY-ESO-1 protein with ISCOMATRIX adjuvant induces broad integrated antibody and CD4(+) and CD8(+) T cell responses in humans

NY-ESO-1 is a "cancer-testis" antigen expressed in many cancers. ISCOMATRIX is a saponin-based adjuvant that induces antibody and T cell responses. We performed a placebo-controlled clinical trial evaluating the safety and immunogenicity of recombinant NY-ESO-1 protein with ISCOMATRIX adjuvant. Forty-six evaluable patients with resected NY-ESO-1-positive tumors received three doses of vaccine intramuscularly at monthly intervals. The vaccine was well tolerated. We observed high-titer antibody responses, strong delayed-type hypersensitivity reactions, and circulating CD8(+) and CD4(+) T cells specific for a broad range of NY-ESO-1 epitopes, including known and previously unknown epitopes. In an unplanned analysis, vaccinated patients appeared to have superior clinical outcomes to those treated with placebo or protein alone. The vaccine is safe and highly potent immunologically.

Immunodominant CD4+ responses identified in a patient vaccinated with full-length NY-ESO-1 formulated with ISCOMATRIX adjuvant

There is increasing evidence showing the involvement of CD4(+) T cells in initiating and maintaining antitumor immune responses. NY-ESO-1 is expressed by various tumors but not normal tissues except testis. We conducted a cancer clinical trial by using full-length NY-ESO-1 protein formulated with ISCOMATRIX adjuvant and injected into patients intramuscularly. Autologous dendritic cells pulsed with NY-ESO-1 ISCOMATRIX in combination with overlapping synthetic peptides were used to identify immunodominant T cells from a vaccinated patient. We show here the identification and characterization of two novel CD4(+) T cell epitopes. T cells specific to these epitopes not only recognized autologous dendritic cells loaded with NY-ESO-1 but also NY-ESO-1-expressing tumor cell lines treated with IFN-gamma. One of the two responses identified was greater than the previously identified immunodominant HLA-DP4-restricted response and correlated with NY-ESO-1-specific CD8(+) T cell induction after vaccination. This T cell response was vaccinated in most patients who expressed HLA-DR2. This study has systematically surveyed patients vaccinated with full-length tumor antigen for a vaccinated CD4 helper T cell response.

Cross-priming of CD8+ T cells by viral and tumor antigens is a robust phenomenon

"Cross-priming" refers to the activation of naive CD8+ T cells by antigen-presenting cells that have acquired nominal antigens from another cell. The biological relevance of cross-priming of CD8+ T cells has recently been challenged (Zinkernagel, R. M., Eur. J. Immunol. 2002. 32: 2385-2392), on the basis that responses are weak or poorly quantitated, and the determinants recognized are undefined. Here we show that cross-priming is a robust process that elicits vigorous primary responses to multiple peptides in two well-defined systems. Our findings support the relevance of cross-priming in CD8+ T cell responses to viruses and tumor cells, and demonstrate that cross-priming elicits CD8+ T cells to determinants generated by the endogenous processing pathway.

Determinants of spironolactone binding specificity in the mineralocorticoid receptor

Spironolactone is a mineralocorticoid receptor (MR) antagonist in clinical use. The compound has a very low affinity for the glucocorticoid receptor (GR). Determinants of binding specificity of spironolactone to the MR were investigated using chimeras created between the ligand-binding domains (LBDs) of the MR and the GR. These chimeras had previously been used to investigate aldosterone binding specificity to the MR. Spironolactone was able to compete strongly for [(3)H]-aldosterone and [(3)H]-dexamethasone binding to a chimera containing amino acids 804-874 of the MR, and weakly for [(3)H]-dexamethasone binding to a chimera containing amino acids 672-803 of the MR. Amino acids 804-874 were also critical for aldosterone binding specificity. Models of the MR LBD bound to aldosterone and spironolactone were created based on the crystal structure of the progesterone receptor LBD. The ligand-binding pocket of the MR LBD model consisted of 23 amino acids and was predominantly hydrophobic in nature. Analysis of this model in light of the experimental data suggested that spironolactone binding specificity is not governed by amino acids in the ligand-binding pocket.

Structural determinants of aldosterone binding selectivity in the mineralocorticoid receptor

The structural determinants of aldosterone binding specificity in the mineralocorticoid receptor (MR) have not been determined. The MR has greatest sequence identity with the better characterized glucocorticoid receptor (GR), which is reflected in their overlapping ligand binding specificities. There must be subtle sequence differences that can account for the MR-specific binding of aldosterone and the shared binding of cortisol. To characterize ligand binding specificity, chimeras were made between the human MR and GR ligand-binding domains (LBDs). Three points were chosen as break points to generate a total of 16 different constructs. These chimeric LBDs were placed in a human GR expression vector containing the GR DNA-binding and N-terminal domains and assayed by co-transfection into CV-1 cells with the mouse mammary tumor virus-luciferase reporter plasmid. Binding of [(3)H]aldosterone and [(3)H]dexamethasone was also measured. All of the constructs that are potently activated by aldosterone contain amino acids 804-874 of the MR. The results of the ligand binding experiments using [(3)H]aldosterone were consistent with the transactivation assay. Cortisol activation of the chimeras was surprisingly complex. Constructs that are activated by cortisol contain either amino acids 804-874 and 932-984 of the MR or amino acids 598-668 and 726-777 of the GR. However, all of the chimeras retained the ability to bind the synthetic glucocorticoid [(3)H]dexamethasone, and cortisol was able to displace [(3)H]dexamethasone binding, suggesting that the differential effects of cortisol on transcriptional activation are caused by an effect that occurs downstream of ligand binding. These results identify a subregion of the MR LBD that confers specificity of aldosterone binding, which contrasts with cortisol binding where differential effects between chimeras appear to be mediated by interactions distal to ligand binding.