Randomized controlled pilot trial of the rigid and flexing laryngoscope versus the fiberoptic bronchoscope for intubation of potentially difficult airway

BACKGROUND

The flexible fiberoptic bronchoscope (FOB) is viewed as the gold standard device for awake intubation in the difficult airway. The newer rigid flexible laryngoscope (RIFL) was developed for similar indications. In this study we compare these two devices for management of potentially difficult airways after induction of general anesthesia.

METHODS

Adult surgical patients requiring endotracheal intubation and having a predicted difficult airway based on airway examination, BMI≥35, and/or history of prior difficult intubation were randomized to undergo endotracheal intubation with either the RIFL or FOB. Induction was performed in usual manner, and intubation was performed by providers proficient with both airway devices after induction of general anesthesia. The primary outcomes measured were intubation success, time to intubation, number of attempts, and the need for airway assist maneuvers. The lowest observed oxygen saturation and airway trauma were also recorded.

RESULTS

A total of 41 patients were enrolled, with 20 randomized to each group and 1 withdrawal. Intubation was successful in all patients with both devices. The median time for successful intubation was significantly shorter in the RIFL group compared to the FOB group (49 vs. 64 seconds; P=0.048). Airway assist maneuvers were required in 2 (10%) intubations with the RIFL compared to 16 (80%) intubations with the FOB (P<0.001). There were no significant differences in lowest oxygen saturation or airway trauma.

CONCLUSION

The RIFL required significantly less time and fewer airway assist maneuvers for successful endotracheal intubation compared to FOB when used by experienced providers in patients with anticipated difficult airways.

Pulsing of dendritic cells with cell lysates from either B16 melanoma or MCA-106 fibrosarcoma yields equally effective vaccines against B16 tumors in mice

BACKGROUND AND OBJECTIVES

Dendritic cells (DC) pulsed in vitro with a variety of antigens have proved effective in producing specific antitumor effects in vivo. Experimental evidence from other laboratories has confirmed that shared antigens can be encountered in histologically distinct tumors. In our experiments, we set out to evaluate the immunotherapeutic potential of vaccines consisting of DC pulsed with MCA-106 fibrosarcoma or B16 melanoma cell lysates and to determine whether a cross-reactivity exists between the two tumors.

METHODS

DC were prepared from the bone marrow of C57BL/6 (B6) mice by culturing progenitor cells in murine granulocyte-macrophage colony-stimulating factor (GM-CSF). They were separated into three equal groups and were either pulsed with B16 melanoma cell lysates (BDC), pulsed with tumor extract from the syngeneic fibrosarcoma MCA-106 (MDC), or left unpulsed (UDC). DC were then used to immunize three groups of mice, with all mice receiving two weekly intravenous (IV) doses of 1 x 10(6) DC from their respective preparations on days -14 and -7. A fourth group of control mice were left untreated. On day 0, all mice were challenged with subcutaneous injections of 1 x 10(5) B16 and 1 x 10(5) MCA tumor cells, administered in the left and right thighs, respectively. After the inoculations, the mice were monitored closely with respect to tumor growth and survival.

RESULTS

The MDC mice developed specific cellular immunity directed against not only MCA-106 tumor cells, but also against B16 melanoma, as measured through chromium-release assays of splenocyte preparations, while remaining ineffective at killing both L929 fibroblasts and CT26 tumor cells. By day 30 after tumor inoculations, control mice manifested the largest B16 tumor volumes at a mean of 2185 mm3, followed by the UDC, MDC, and BDC groups at 92 mm3 (P=0.00008), 3 mm3 (P=0.000002), and 2 mm3 (P=0.00004), respectively. The survival data mirrored this pattern, with control animals displaying the shortest mean survival time (37.1+/-4.0 days), followed by UDC (44.8+/-6.6), MDC (56.2 +/-14.7), and BDC (56.4+/-18.3) animals. No significant differences were noted between MCA-106 and B16 cell lysate-pulsed DC vaccines with respect to their abilities to inhibit B16 tumor growth and to prolong survival. These findings were confirmed using a B16 pulmonary metastasis model. Likewise, vaccination with interferon-gamma gene-modified MCA-106 tumor cells was shown to be effective at protecting against a subsequent subcutaneous B16 tumor challenge in 3 of 4 mice observed.

CONCLUSIONS

These results demonstrate that immunization with antigen-pulsed DC confers cellular immunity, retards tumor growth, and prolongs the survival of tumor-challenged mice. The ability of MCA-106 cell lysate-pulsed DC vaccines to inhibit the growth of subcutaneous B16 tumors also suggests the presence of shared tumor-associated antigens between these two histologically distinct tumors.

Human dendritic cells, pulsed with either melanoma tumor cell lysates or the gp100 peptide(280-288), induce pairs of T-cell cultures with similar phenotype and lytic activity

Dendritic cells (DCs) pulsed with unfractionated tumor cell lysates or defined tumor peptides provide potent vaccines which elicit strong antitumor immunity. In this study, we generated DCs from the 2-h adherent progenitor cells obtained from the peripheral blood of melanoma patients. These DCs were able to capture biotinylated melanoma tumor cell lysates. We examined the efficacy of immunogens composed of DCs loaded either with the melanoma peptide gp100 [amino acids 280-288 (DC/gp100)] or with lysates from melanoma tumor cells (DC/lysates) in inducing cytotoxic T-cells from autologous PBLs of HLA-A2 melanoma patients. After four to five weekly stimulations of bulk PBLs with DC/gp100 or DC/lysates, the cultures were enriched with CD3+ T-cells and exhibited one of three phenotypic and functional patterns: (1) Predominant expression of CD8+ and MHC class I-restricted CTLs which displayed strong lytic activity against melanoma cells and T2 cells loaded with the gp100 peptide, (2) mixed CD4+/CD8+ phenotype and weak lytic activity, or (3) nonlytic and predominantly CD4+ cultures. Interestingly, T-cell cultures from each patient exhibited similar phenotypes and lytic activities whether the stimulant was DC/gp100 or DC/cell lysates. Our study demonstrates that DCs pulsed with soluble melanoma peptides or cell lysates are capable of inducing CD8+ CTLs from autologous PBLs of some, but not all, melanoma patients. The function and phenotype of the generated T-cell cultures are governed by DCs since both antigens (the gp100 peptide and melanoma lysates), when presented by a given DC preparation, induced similar T-cell cultures. In summary, it may be difficult to predict the nature of the cellular responses elicited by DC/tumor antigen vaccines from patient to patient.

A Phase I clinical trial of immunotherapy with interferon-gamma gene-modified autologous melanoma cells: monitoring the humoral immune response

BACKGROUND

Tumor cells transduced with cytokine genes provide immunogenic vaccines for cancer immunotherapy.

METHODS

A Phase I clinical trial was conducted for the specific active immunization of melanoma patients with interferon-gamma (IFN-gamma) gene-modified autologous melanoma tumor cells. Short term melanoma cultures were transduced retrovirally with the gene for human IFN-gamma. The genetically modified melanoma cells secreted biologically active IFN-gamma and showed enhanced expression of major histocompatibility complex class I and class II surface antigens. These cells were inactivated by irradiation (50 gray) and were cryopreserved for the vaccine. Twenty melanoma patients were enrolled in this clinical trial. The immunizations were administered in escalating doses once every 2 weeks for 3 months. The first and second injections consisted of 2 million cells, followed by 6 million for the third and fourth injections, and then 18 million for the fifth and sixth injections. The humoral immune responses of the patients were assessed by enzyme-linked immunoadsorbent assay, radioimmunoassay, and radioimmunoprecipitation.

RESULTS

Thirteen of the 20 patients completed the immunization protocol. Eight of these 13 patients showed a humoral immunoglobulin (Ig)G response against autologous and allogeneic melanoma cells. The other five patients either had no detectable antimelanoma antibodies or showed a weak IgG response that did not rise significantly above the preimmune level. All the sera contained low or undetectable levels of antimelanoma IgM antibodies. The IgG response increased progressively in titer during the course of immunization. The positive sera showed preferentially strong binding to melanoma cell lines and some cross-reactivity to nonmelanoma tumors. A 75-80 kD antigen on melanoma cells was immunoprecipitated by postimmune sera of 3 of the responding patients. Preimmune sera from these three patients and sera from other patients immunized with a standard nontransduced melanoma cell vaccine failed to precipitate this antigen. Two patients with significant increases in serum IgG had clinical tumor regression, and two additional patients with low serum IgG response had transient shrinkage of nodular disease during therapy.

CONCLUSIONS

These data suggest that gene therapy with IFN-gamma-transduced melanoma cells is safe and worthy of further investigation in patients with less advanced stage malignant melanoma. The ability to monitor changes in the humoral responses of the immunized patients has been demonstrated.

Eradication of melanoma pulmonary metastases by immunotherapy with tumor cells engineered to secrete interleukin-2 or gamma interferon

This study was undertaken to investigate the effectiveness of interleukin-2 (IL-2) and gamma interferon (gammaIFN)-modified B16 melanoma cells in the immunotherapy of established melanoma pulmonary metastases. The genes for IL-2 and gammaIFN were introduced retrovirally into B16 melanoma cells. Transduction with the gammaIFN, but not the IL-2, gene caused significant increases in the expression of major histocompatibility complex (MHC) antigens on B16-gammaIFN cells. The in vivo tumor-forming capacity of both IL-2- and gammaIFN-transduced B16 cells was drastically reduced when the cells were inoculated subcutaneously (SC) in syngeneic C57BL/6 mice. After intravenous (IV) inoculation, most of the B16-gammaIFN cells were rejected, but B16-IL-2 cells were relatively tumorigenic and formed pulmonary metastases. C57BL/6 mice bearing 4-day established parental B16 lung metastases were treated with B16 parental (B16P) unmodified cells, IL-2- or gammaIFN-modified B16 cells, or a combination of both transduced cells. Treatment consisted of a weekly intraperitoneal (IP) injection of one million irradiated (10,000 rad) tumor cells alone or in combination with exogenous IL-2 for a total of three to four injections. Immunotherapy with B16 parental or B16-IL-2 secreting cells caused a moderate reduction in the number of lung metastases. However, mice treated with gammaIFN-secreting B16 cells showed a significant reduction or complete elimination of lung metastases. There was no additive effect for combining both IL-2- and gammaIFN-modified tumor cells in the immunotherapy. Exogenous IL-2 (50,000-100,000 U/day for 3 days) caused a significant enhancement of the immunotherapeutic benefit of the vaccines. Moreover, mice treated with gammaIFN-modified B16 cells survived longer than the other groups. Twenty-five percent of these mice were tumor free and remained alive for an observation period of 4 months. The in vitro cytolytic activity of splenocytes in chromium release assays did not correlate in every case with the in vivo antitumor effect of the treatment. Our findings have implications for the use of cytokine-modified cells for immunotherapy and for evaluating the therapeutic benefit of this novel treatment.

Effect of irradiation on cytokine production, MHC antigen expression, and vaccine potential of interleukin-2 and interferon-gamma gene-modified melanoma cells

Recent studies have shown that tumor cells transduced with interleukin-2 (IL-2) or interferon-gamma (IFN-gamma) genes stimulated a potent and specific antitumor immunity in experimental animals. For use as a human vaccine, tumor cells must be inactivated by irradiation to ensure the arrest of their growth. This study was undertaken to examine the effects of irradiation (10,000 rad) on the growth characteristics and vaccine potential of IL-2 and IFN-gamma-modified human melanomas and B16 murine melanoma. Irradiation caused cessation of cell growth and gradual reduction of cell number. Irradiated melanoma cells displayed 1.5 to 10-fold increases in the surface expression of MHC class I and/or class II antigens. The increases in MHC antigens persisted for 7-14 days postirradiation and then declined thereafter. Furthermore, IL-2- and IFN-gamma-transduced melanoma cells showed enhanced expression of the cytokine mRNA and increased cytokine secretion after irradiation. The effect of irradiation on the vaccine potential of the transduced cells was examined in C57BL/ 6 mice by prophylactic immunization and immunotherapy, and in nude mice by mixed transplantation assays. The irradiated, cytokine-transduced B16 cell vaccine was as or more effective than the unirradiated vaccine. These irradiated vaccines protected the animals against a challenging tumorigenic dose of B16 parental cells and suppressed the growth of 4-day-established B16 lung metastases. The ability of the irradiated IL-2-transduced human melanomas to inhibit the growth of admixed parental melanoma cells was retained but was less efficacious than unirradiated cells. The results suggest that irradiation does not abrogate the vaccine potential of IL-2- and IFN-gamma-transduced melanomas. These findings have implications for designing specific active immunotherapy protocols utilizing cytokine gene-modified tumor cells.

Unilateral spatial neglect recovery after sequential strokes

We describe a patient who had sequential strokes in both hemispheres with a severe unilateral spatial neglect after a first right-sided parietal infarct and abrupt disappearance of the neglect after a second left-sided frontal infarct. The first lesion involve the caudalmost right angular gyrus (area 39), whereas the second lesion involved the left frontal eye field (area 8) and surrounding cortex. Those two cortical areas are assumed to have a pivotal role in modulating both shifts of attention within extrapersonal space and saccadic eye movements through their connections with subcortical structures, in particular, superior colliculi and thalamic nuclei. Our case supports the existence of a distributed anatomic-functional network in subserving directed spatial attention.

RPE dysplasia with retinal duplication in a mutant mouse strain

An autosomal dominant mutation was produced by quadruple gonadal exposure of a male (C3H x 101)F1 mouse to 500 rad of X-irradiation. This mutation is maintained by the mating of affected heterozygous males to normal (C3H x C57B1)F1 females. Clinically apparent abnormalities were limited to the eyes and, in the affected adults, ranged from apparent anophthalmia to globes that were enlarged and exhibit large uveoscleral colobomas. Sequential evaluations of the embryogenesis of this condition have identified abnormal differentiation of the outer layer of the optic cup (presumptive retinal pigment epithelium-RPE) into a second layer of neural retina. The abnormality is identified as early as day 10 of gestation, during invagination of the optic cup and lens placode. The area of RPE dysplasia may be diffuse or regional with an abrupt transition from normal RPE and often demonstrates excessive and uncontrolled proliferation. The two symmetrical, apposed layers of photoreceptors fail to differentiate and begin to degenerate prenatally. Absence of normal RPE leads to failure of induction of adjacent choroid and sclera, resulting in a posterior segment consisting of a large neuroepithelial-lined cyst. Radiation-induced ocular malformations of this type have not been previously described. In addition, this model presents a unique opportunity to examine the processes leading to differentiation of a single, continuous epithelial layer into tissues as anatomically and functionally distinct as neural retina and RPE.