The past, the present and future of the OK-432 therapy for patients with malignant effusions

For the past 20 years, our group has treated over 400 cases of malignant effusion by the intraperitoneal injection of streptococcal preparation OK432 (OK-432 therapy) and has investigated extensively the antitumor mechanisms of this therapy. Prospective clinical data has demonstrated that the OK-432 therapy induced a definite reduction of the effusions in around 60% (responders) of cases and significantly prolonged the survival time in patients who responded well. In addition, a definite reduction of original tumor mass volume was found in around 20% of cases. We have shown that OK432-induced neutrophils, lymphocytes, and probably macrophages may play an important role in tumor cell destruction in ascites. Tumor necrosis factor alpha (TNF-alpha)-induced CD11b/CD18 expression on leukocytes and interferon-gamma (IFN-gamma)-induced ICAM-1 expression on tumor cells may play an important role in leukocyte-mediated tumor destruction. It has also been shown that OK-432 induces various cytokines, such as TNF-alpha, TNF-beta, IFN-alpha IFN-gamma, interleukin-1 (IL-1), IL-2, IL-6, IL-12, tumor growth inhibitory factor(s) (TGIF), and possibly unknown apoptosis-inducing factor(s). Some of these cytokines have been adduced as representing the antitumor activity. These data suggest that two pathways of antitumor activity, i.e., cell-mediated and cytokine-mediated, can be induced simultaneously in the peritoneal cavity. OK-432 therapy may be valuable in the management of patients with malignant effusions. Future clinical and basic research should contribute to further progress in OK-432 therapy.

Pleural disease and acquired immune deficiency syndrome

Patients with acquired immune deficiency syndrome (AIDS) do not frequently have pleural complications. However, pneumothorax is a troublesome complication of patients with AIDS. At some medical centres, more than 50% of patients with spontaneous pneumothorax have AIDS. Most patients with spontaneous pneumothorax and AIDS have Pneumocystis carinii infection and necrotic subpleural blebs. The pneumothoraces in these patients usually cannot be managed with tube thoracostomy alone. Patients who do not respond to tube thoracostomy are best managed with a Heimlich valve or with thoracostomy with stapling of blebs and pleural abrasion. Approximately 2% of human immunodeficiency virus (HIV)-positive individuals will have a pleural effusion. Parapneumonic effusions or empyema, tuberculosis and Kaposi's sarcoma are the three leading causes. P. carinii infection is frequently responsible for pulmonary infections, but is only occasionally responsible for a pleural effusion. Pleural effusions may also develop from non-Hodgkin's lymphoma (NHL). There is one relatively rare NHL that is associated with the Kaposi's sarcoma associated virus that produces a lymphoma confined to the body cavity.

Pleural effusion as a significant prognostic factor in non-small cell lung cancer

In non-small cell lung cancer (NSCLC), pleural effusion is a frequently observed complication, and often provides a treatment difficulties. The aim of this study is to evaluate prognostic significance of pleural effusion in patients with NSCLC.

MATERIALS AND METHODS

Seven hundred and eight untreated patients with NSCLC who were consecutively admitted to our department over a 20 year period up to December 1996, were analyzed using uni- and multivariate analyses.

RESULTS

Univariate analysis showed pleural effusion to be a significant prognostic factor for NSCLC, in addition to gender, stage, performance status(PS). Multivariate analysis proved pleural effusion to be one of the significant prognostic factors, especially in patients with poor PS.

CONCLUSION

Adequate palliative care to provide prolonged quality survival remains the primary goal of therapy for patients with poor performance status and pleural effusion until better treatments are developed.

Pleural cytologies in lung cancer without pleural effusions

BACKGROUND

Malignant pleural effusions significantly increase the stage of lung cancer with attendant worsening of prognosis. There is a paucity of literature evaluating malignant pleural lavage cytology in patients without pleural effusions. We propose to determine the incidence of malignant pleural cytologies in patients without pleural effusions who undergo curative resection for lung cancer and to identify any predictive risk factors for positive cytology.

METHODS

Seventy-eight patients underwent curative resection for lung cancer. Lavage was performed before lung manipulation and after resection and cytologically evaluated.

RESULTS

Twelve pneumonectomies, 64 lobectomies, and 2 wedge resections were performed on 40 men and 38 women with an average age of 65.7 years. Fourteen percent had positive lavage cytology before lung resection with an 11% (6 of 53) incidence in stage I. A significant correlation to adenocarcinoma compared with squamous cell was found (p = 0.03) but not to stage, T or N status, grade, pleural invasion, or preoperative transthoracic needle biopsy.

CONCLUSIONS

The incidence of positive pleural cytology in otherwise stage I patients is disconcertingly high. Positive cytology may be a prognosticator of a more aggressive tumor biology.

Pleural disease in patients with AIDS

Patients infected with HIV are at risk of developing a variety of infectious and malignant pleuropulmonary disorders. The three most common causes of AIDS-related pleural effusions are parapneumonic effusions or empyemas, tuberculosis, and Kaposi's sarcoma. However, the relative frequency of these conditions varies from series to series as well as from one region of the world to another. Pneumocystis carinii is a common pulmonary pathogen in AIDS, but it is rarely the cause of a pleural effusion. By contrast, P. carinii infection is strongly associated with the occurrence of spontaneous pneumothoraces. Pleural complications in AIDS are often difficult to treat and contribute significantly to the high morbidity and mortality of the syndrome. Recent progress in antiretroviral therapy as well as improved supportive care should lead to better survival rates in AIDS in the near future. Unfortunately, this progress may be associated with a growing number of patients with AIDS-related diseases, including the pleural complications discussed here.

Massive pleural effusion as isolated manifestation of metastatic spread of salivary adenoid cystic carcinoma

Adenoid cystic carcinoma is a low-grade malignant neoplasm that arises preferentially in the major and/or minor salivary glands. While it has a tendency to spread locally, distant metastases have been described occasionally. This case report describes a patient with a massive pleural effusion as primary manifestation of metastatic adenoid cystic carcinoma. This is a very uncommon, yet treatable, occurrence.

Granulocyte-macrophage colony-stimulating factor augments lymphokine-activated killer activity from pleural cavity mononuclear cells of lung cancer patients without malignant effusion

The role of recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) in augmentation of lymphokine-activated killer (LAK) cell induction by interleukin-2 (IL-2) from pleural cavity mononuclear cells (PCMNCs) was examined in sixteen patients with resectable primary lung cancer not associated with malignant effusion. None of the patients had received any anticancer therapy prior to this study. Incubation of PCMNCs of patients without malignant effusion with GM-CSF for 4 days in the presence of IL-2 resulted in a significant increase in LAK activity against natural killer-resistant Daudi cells. This result was obtained by using the 4 h 51Cr-release assay. PCMNCs and blood mononuclear cells (BMNCs) were harvested simultaneously from pleural cavity lavage fluid and peripheral blood in lung cancer patients. The LAK activity developed from PCMNCs and BMNCs following incubation with IL-2 for 4 days, but the LAK activity from PCMNCs was significantly lower than that from BMNCs (P < 0.05). Incubation of PCMNCs with GM-CSF augmented the LAK activity from PCMNCs to a level as high as that from BMNCs. These results suggest that the combined use of GM-CSF with IL-2 may result in augmentation of LAK activity developed from PCMNCs of lung cancer patients without malignant effusion.

Pleural malignancies including mesothelioma

Malignant mesothelioma is caused almost exclusively by occupational exposure to asbestos. During the past few years, however, increasing evidence has mounted that background exposure to asbestos could be sufficient to cause mesothelioma. Treatment of malignant mesothelioma remains a big problem. Some new approaches are on their way, and the most exciting ones are local immunotherapy in very early cases. Some success has been reported with local interferon treatment. As for treatment of metastatic pleural disease, the main purpose is symptomatic relief of dyspnea caused by fluid accumulation. The best way to achieve a lasting palliation is pleurodesis, and the most common way to do this, is by chemical means. The drug of choice in the United States has for many years been tetracycline, but since injectable tetracycline is no longer available, some substitute must be found. The substance that will "win" is not yet clear, but the two leading contestants are talc and doxycycline. Bleomycin also has its supporters, and a dark horse is quinacrine, which although not easily available in the United States, has been used in many European centers for decades.

Intrathoracic complications of malignancy and its treatment

Obstruction of the superior vena cava is seldom a true emergency and should not be treated without an adequate tissue diagnosis. For patients who are poor operative risks for invasive procedures, percutaneous biopsies of mediastinal masses under ultrasound guidance have resulted in a high diagnostic yield. Superior vena caval syndrome secondary to thrombosis is increasing as venous access devices are used more commonly, and it is important that the catheter should be positioned well down in the vena cava to prevent thrombotic complications. Talc remains the best agent to achieve sclerosis of the pleural cavity, but doxycycline and minocycline are also quite effective replacements for tetracycline, which is no longer available. Radiation-induced pneumonitis and esophagitis continue to limit the total dose and the field that may be administered within the thoracic cavity. As combined modality treatment programs are developed and as doses of chemotherapeutic agents and radiation are both intensified, steps must be taken to ensure that the added toxicity of such treatment can be justified by a significantly superior outcome.

EFFECTS OF MALIGNANT EFFUSIONS ON THE MITOTIC INDEX OF L STRAIN MOUSE CELLS GROWN IN TISSUE CULTURE

By employing a clone of L strain mouse fibroblasts (L(E)) which does not exhibit cell clumping and lysis (cytolytic antibody reaction), it was possible to screen for the presence of growth-regulating factors in human sera and effusions, exclusive of an antigen-antibody reaction. Under conditions of the test a mitotic index greater than 20% indicated the presence of a growth-promoting factor.A total of 11 pleural effusions was tested. Four of the eight malignant effusions possessed a growth-promoting factor, while none of the three non-malignant effusions or the one sample of human umbilical cord serum possessed such a factor. Overnight storage of the unfiltered effusions at 5 degrees C. resulted in complete loss of the growthpromoting activity.

Radioactive gold in malignant effusions

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