Effectiveness of pleurodesis for postoperative air leaks after lung resection

BACKGROUND

Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis using different materials and timing.

METHODS

We retrospectively reviewed 913 consecutive patients who underwent segmentectomy or lobectomy for non-small cell lung cancer between 2014 and 2021. Pleurodesis efficacy was assessed on the day of chest tube removal.

RESULTS

Eighty-six patients (9%) underwent pleurodesis for postoperative air leaks. Pleurodesis was performed on a median of postoperative day (POD) 5. Talc was the most frequently used material (n = 52, 60%), followed by autologous blood patches (n = 20, 23%), OK-432 (n = 12, 14%), and others (n = 2, 2%). No difference existed in the number of days from initial pleurodesis to chest tube removal among the three groups (talc, 3 days; autologous blood patch, 3 days; OK-432, 2 days; P = 0.55). No difference in patient background, except for sex, was observed between patients who underwent pleurodesis within 4 PODs and those who underwent pleurodesis on POD 5 or later. Drainage time was significantly shorter in patients who underwent pleurodesis within 4 PODs (median, 7 vs. 9 days; P = 0.004).

CONCLUSIONS

The efficacies of autologous blood patch, talc, and OK-432 would be considered comparable and early postoperative pleurodesis could shorten drainage time. Prospective studies are required.

Synergistic effect of OK-432 in combination with an anti-PD-1 antibody for residual tumors after radiofrequency ablation of hepatocellular carcinoma

BACKGROUND AND AIMS

Radiofrequency ablation (RFA) often results in incomplete ablation for medium-to-large and irregular tumors. To solve this clinical problem, we proposed a new treatment strategy of OK-432 in combination with an anti-programmed cell death protein 1 (αPD-1) antibody for residual tumors after incomplete RFA (iRFA) of hepatocellular carcinoma (HCC).

APPROACH AND RESULTS

The effect of OK-432 on immature dendritic cells (iDCs) was evaluated in vitro. A CCK-8 kit and ELISPOT were used to assess the killing effect of OK-432-induced CD8+ T cells in combination with an αPD-1 antibody on Hepa1-6 cells. We found that OK-432 significantly increased the maturation level of DCs, and OK-432-induced CD8+ T cells in combination with αPD-1 antibody significantly enhanced the function of CD8+ T cells. In the in vivo experiment, HCC model mice were treated with (1) pseudo iRFA + phosphate-buffered saline (PBS); (2) iRFA + PBS; (3) iRFA + OK-432; (4) iRFA + αPD-1; or (5) iRFA + OK-432 + αPD-1. We found that the combined therapy of OK-432 with αPD-1 antibody significantly increased the infiltration and function of CD8+ T cells and significantly decreased the number of FoxP3+ regulatory T cells in residual tumors after iRFA of HCC. Moreover, the smallest tumor volumes and the longest survival were observed in the triple combination treatment (iRFA+OK-432 +αPD-1 antibody) group compared with the other four groups.

CONCLUSIONS

The combined therapy of OK-432 with αPD-1 antibody induced a strong antitumor immune response, which significantly inhibited the residual tumors after iRFA of HCC. This concept may provide a new treatment strategy to increase the curative efficacy of RFA for medium-to-large and irregular HCCs.

AVAILABILITY OF DATA AND MATERIAL

The data of this study are available from the corresponding author on reasonable request.

[Algorithm of Therapy for Spontaneous Pneumothorax]

The initial treatment for the patient with primary or secondary spontaneous pneumothorax occupying less than 15% of the hemithorax is observation. And then the treatment with primary spontaneous pneumothorax greater than 15% of the volume of hemithorax is a simple thoracoscopic aspiration. However, the treatment with secondary spontaneous pneumothorax greater than 15% of the volume of hemithorax is tube thoracotomy. Conservative treatment for continuous air leakage with secondary spontaneous pneumothorax is instillation of a sclerosing agent( small amount of picibanil 3 KE). Surgical treatment for continuous air leakage with secondary spontaneous pneumothorax due to severe idiopathic pulmonary fibrosis (IPF) is intractable. We have experienced three cases in which surgical treatment is difficult in secondary spontaneous pneumothorax with underlying lung diseases. The first cases are a pneumothorax with a giant bulla or severe lung emphysema. Second cases are a pneumothorax with a fragile lung. Third cases are a pneumothorax with a hardened lung. We need devised surgical approaches to these cases.

Phase 1/2 study of immunotherapy with dendritic cells pulsed with autologous tumor lysate in patients with refractory bone and soft tissue sarcoma

BACKGROUND

There are limited options for the curative treatment of refractory bone and soft tissue sarcomas. The purpose of this phase 1/2 study was to assess the immunological and clinical effects of dendritic cells (DCs) pulsed with autologous tumor lysate (TL) in patients with advanced bone and soft tissue sarcomas.

METHODS

Thirty-seven patients with metastatic or recurrent sarcomas were enrolled in this study. Peripheral blood mononuclear cells obtained from the patients were suspended in media containing interleukin 4 (IL-4) and granulocyte-macrophage colony-stimulating factor. Subsequently, these cells were treated with TL, tumor necrosis factor α, and OK-432. The DCs were injected into the inguinal or axillary region. One treatment course comprised 6 weekly DC injections. The toxicity, clinical response (tumor volume, serum interferon-γ [IFN-γ], and serum IL-12), and oncological outcomes were observed.

RESULTS

In total, 47 courses of DC therapy were performed in 37 patients. No severe adverse events or deaths associated with the DC injections were observed in the study patients. Increased serum IFN-γ and IL-12 levels were observed 1 month after the DC injection. Among the 37 patients, 35 patients were assessed for clinical responses: 28 patients showed tumor progression, 6 patients had stable disease, and 1 patient showed a partial response 8 weeks after the DC injection. The 3-year overall and progression-free survival rates of the patients were 42.3% and 2.9%, respectively.

CONCLUSIONS

Although DC therapy appears safe and resulted in an immunological response in patients with refractory sarcoma, it resulted in an improvement of the clinical outcome in only a small number of patients. Cancer 2017;123:1576-1584. © 2017 American Cancer Society.

Evaluation of the protective effect of methotrexate on OK432-induced liver injury in a rat model

Cholangitis-induced liver damage was created in rats by intraductal injection of OK432, a lyophilized incubation mixture of group A Streptococcus pyogenes of human origin. Oral, low-dose methotrexate (MTX) was given to one group to study its protective effect on liver injury. The liver histology was studied and semiquantitatively graded. The OK432-induced changes were compared with and without MTX therapy. The results revealed statistically significant higher grades of portal inflammation and sinusoidal infiltration in rats treated with OK432 compared to saline-treated controls. There was significant improvement in liver changes in the group treated with MTX compared to the untreated group. It could be concluded that oral, low-dose, pulsed MTX therapy caused significant improvement in cholangitis-induced liver damage in rats.

Lymph flow and lymph node metastasis in esophageal cancer

This paper delineates which lymph nodes should be dissected due to the high frequency of metastasis associated with different types of primarily lesions of the thoracic esophagus. In cancer involving the upper third of the esophagus (Iu), lymph flow was found to be primary from the superior mediastinal area to the cervical area; in that involving the middle third (Im), it was broadly distributed from the superior, middle, and inferior mediastinal region to the cervical and abdominal regions; and in that involving the lower third (Ei), it tended to extend from the inferior mediastinal region to the abdominal region, with single primary metastatic nodes also being noted in this area. The significance of the "top" nodes, namely, the nodes located along the right recurrent laryngeal nerve in the upper portion of the thorax, was also investigated, and it was confirmed that the prognosis for patients with metastases to both the top nodes and other nodes was unfavorable. An immunohistochemical study on mediastinal lymph flow using the anti-Su-Ps antibody demonstrated interactions between top nodes and cervical and/or thoracic nodes.

Inhibition of autoimmune diabetes in NOD mice with serum from streptococcal preparation (OK-432)-injected mice

We have recently reported that systemic and chronic administration of recombinant tumour necrosis factor alpha (TNF-alpha), as well as streptococcal preparation (OK-432), inhibits development of insulin-dependent diabetes mellitus (IDDM) in NOD mice and BB rats, models of IDDM. In this study we examined whether serum containing endogenous TNF induced by OK-432 injection could inhibit IDDM in NOD mice. Treatment twice a week from 4 weeks of age with OK-432-injected mouse serum, which contained endogenous TNF (75U), but not IL-1, IL-2 and interferon-gamma (IFN-gamma) activity, reduced the intensity of insulitis and significantly inhibited the cumulative incidence of diabetes by 28 weeks of age in NOD mice, as compared with the incidence in non-treated mice (P less than 0.01) and in mice treated with control serum (P less than 0.02). This inhibitory effect of the serum was diminished, although not significantly, by neutralization of serum TNF activity with anti-mouse TNF antibody. In the mice treated with the serum from OK-432-injected mice, Thy-1.2+ or CD8+ spleen cells decreased (P less than 0.01) and surface-Ig+ (S-Ig+) cells increased (P less than 0.05), whereas the proliferative response of spleen cells to concanavalin A (P less than 0.01) and lipopolysaccharide (P less than 0.05) increased. The results indicate that the inhibition by OK-432 treatment of IDDM in NOD mice was partially mediated by serum factors including endogenous TNF.

Langerhans cell density and activity in mouse skin and lymph nodes affect herpes simplex type 1 (HSV-1) pathogenicity

Langerhans cells are epidermal antigen-presenting cells that function by taking up antigens in the skin, migrating to the lymph nodes, where they are designated interdigitating cells, and triggering the immune response. The role of interdigitating cells (IDC) was investigated in a murine model of herpes simplex virus-1 infection in the skin. The number of IDC in the lymph nodes began to increase on the first day following infection and reached a peak three days p.i. Low titers of infectious virus were recovered from the fraction of lymph node cells that consisted of 60-80% IDC at one day p.i. Lymph node cells that were obtained from mice immunized with HSV-1 proliferated in vitro in response to viral antigens but did not respond to mock antigens. When mice were immunized with HSV-1 inoculated into skin that had been depleted of Langerhans cells, this in vitro proliferative response was abolished. Thus, the present results suggest that Langerhans cells function in the immune defense of the skin against HSV-1 infection by transporting the virus to the peripheral lymph nodes where an immune response is initiated. Injection of the immunomodulator OK-432 into the footpad skin caused a local increase in the number of Langerhans cells in the epidermis and led to an increased migration of dendritic cells to the lymph nodes. Under these conditions, a decrease in HSV-1 pathogenicity was noted. These observations indicate that the pathogenicity of herpes simplex virus type 1 in the skin is affected by Langerhans cell density and activity in the epidermis and the lymph nodes.

Adoptive immunotherapy by pantropic killer cells recovered from OK-432-injected tumor sites in mice

A murine malignant ascites model with BAMC-1 tumors was established previously, which was cured completely by five consecutive i.p. injections of OK-432. We have found that peritoneal mononuclear cells from these animals contained antitumor effector cells which could destroy nonspecifically a variety of tumor cells in vitro. They were tentatively called pantropic killer cells (PKCs). The present study was essentially designed to show the antitumor effectiveness of the PKCs in vivo by the use of an adoptive immunotherapy model. The growth of BAMC-1 tumors transplanted s.c. 5 days earlier was significantly suppressed by passive transfer of 5 x 10(6) to 2 x 10(7) PKCs induced by injection of OK-432 into BAMC-1 bearing donor mice, while more than 1 x 10(8) immune spleen cells from the same donors treated with OK-432 were required to achieve the similar effects. Furthermore, if the tumor-bearing recipients were pretreated with 180 mg/kg of cyclophosphamide 1 h before the adoptive transfer, even 5 x 10(6) PKCs could induce complete regression of the tumors transplanted 5 days earlier. This protocol made it possible even to achieve the complete regression of larger tumors (9-10 mm in diameter) in recipients transplanted 12 days earlier. The PKCs were, as expected, able to cure not only BAMC-1-bearing animals but also Meth-A-bearing mice. As effector cells for adoptive immunotherapy, therefore, the PKCs induced by OK-432 seem to be as effective as, if not better than, lymphokine-activated killer cells expanded in vitro by culturing tumor infiltrating lymphocytes with interleukin-2. Although the study on surface markers of PKCs did not unequivocally discriminate these from lymphokine-activated killer cells, the present findings are considered significant indicating that a potent biological response modifier such as OK-432 can induce pantropic killer cells which are extremely effective in destroying various tumor cells in vivo. One of the advantages of OK-432 therapy over lymphokine-activated killer cell therapy, therefore, is that the former does not require the tedious and time-consuming in vitro procedures which are essential for the latter.

Production of factor(s) that render polymorphonuclear leukocytes cytostatic from spleen cells stimulated with a streptococcal preparation, OK-432

We previously reported the augmentation of tumor cytotoxicity of polymorphonuclear leukocytes (PMN) by in vivo administration of a streptococcal preparation, OK-432 (S. Watabe et al., J. Natl. Cancer Inst., 72: 1365-1370, 1984). The present study was undertaken to elucidate the mechanisms of the phenomena. Mouse and rat spleen cells were stimulated in vitro with OK-432. The culture supernatants from the stimulated spleen cells (OK sup) contained factor(s) that rendered mouse and rat PMN cytostatic [neutrophil activating factor (NAF)]. The stimulation of spleen cells with a small dose of OK-432 (0.05 micrograms/ml) resulted in the production of maximum NAF, and NAF was produced soon (12 h) after OK-432 stimulation. NAF was partially inactivated with 60 degrees C 30-min treatment, and completely inactivated with 100 degrees C 10 min. NAF was sensitive to pH 2 treatment. The treatment of PMN with OK sup for 5 min at 37 degrees C was sufficient to induce cytostatic activity of PMN. That OK sup contained gamma-interferon and recombinant gamma-interferon showed NAF activity indicate that gamma-interferon is a NAF in OK sup.

[Definition of tumor-necrosis factor and its production mechanism]

There is significant evidence that the macrophage plays a critical role in the host's defense against neoplasia. Tumor-necrosis factor was recognized by Carswell et al. during a study of the antitumor activity of serum from mice infected with BCG and subsequently injected with endotoxin. The same procedure was applied to rabbits in order to obtain serum containing tumor-necrosis factor (TNF). Sera from these mice and rabbits contained a factor that induced hemorrhagic necrosis of certain mouse sarcomas in vivo and had cytotoxic effects on mouse and human tumor cells in vitro. Sera from mice and rabbits singly treated with BCG or endotoxin did not have these properties. Other agents such as C. parvum, OK-432, lentinan or zymosan, that cause hyperplasia of reticuloendothelial system and increase sensitivity to endotoxin lethality, could substitute for BCG in priming for TNF release. However, the use of P. acnes as a priming agent was the most effective and lipopolysaccharide from gram-negative bacteria appeared to be unique in its ability to elicit TNF release. TNF is a protein with a molecular weight, ranging from 40,000 to 60,000 that has both tumor necrotizing activity in vitro and tumor killing activity in vitro. It is relatively stable to heating at up 70 degrees C. This result indicated that both in vitro and in vitro activities of mouse and rabbit TNF are a property of one and the same molecule. TNF is thought to be produced by macrophage and is distinguished from the other know macrophage products in serum containing TNF. TNF is cytotoxic to several but not all tumor cell lines. Its most interesting feature is that it reportedly dose not affect any non-transformed cell types, implying that it somehow recognizes transformed cells.

Immunotherapeutic response of concanavalin A-bound L1210 vaccine enhanced by a streptococcal immunopotentiator, OK-432

Immunotherapeutic response to concanavalin A (Con A)-bound L1210 murine leukemic vaccine and immunopotentiators was examined in histocompatible animals bearing a small burden L1210 leukemic cells. When combined with Con A-bound vaccine, a streptococcal immunopotentiator, OK-432 (NSC B116209), prepared from Streptococcus pyogenes, was potent in antitumor therapy and resulted in a number of cured animals. Administration of either Con-A-bound vaccine or OK-432 alone did not produce any beneficial effect on leukemic animals. The enhanced therapeutic response was dependent on the effectiveness of the dose and timing of the administration of OK-432 when given after vaccination. Combined modality of Con A-bound L1210 vaccine and OK-432 was not effective in animals bearing P388 murine leukemic cells, which indicates specificity of therapeutic response. In enhancing the therapeutic potency of Con A-bound leukemia vaccine, pyran copolymer (NSC 46015) was as effective as OK-432, whereas Bacillus Calmette-Guérin and Corynebacterium parvum were far less effective. When combined with OK-432, therapeutic response to Con A-bound L1210 vaccine was much greater than response to glutaraldehyde-, mitomycin C-, or Vibrio cholerae neuraminidase-treated L1210 vaccine.