A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy.

METHODS

CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%.

RESULTS

Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2.

CONCLUSIONS

The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC.

CLINICAL TRIAL REGISTRATION

NCT04953962.

Two-site jumps in dimethyl sulfone studied by one- and two-dimensional 17O NMR spectroscopy

Polycrystalline dimethyl sulfone is studied using central-transition oxygen-17 exchange NMR. The quadrupolar and chemical shift tensors are determined by combining quantum chemical calculations with line shape analyses of rigid-lattice spectra measured for stationary and rotating samples at several external magnetic fields. Quantum chemical computations predict that the largest principal axes of the chemical shift anisotropy and electrical field gradient tensors enclose an angle of about 73°. This prediction is successfully tested by comparison with absorption spectra recorded at three different external magnetic fields. The experimental one-dimensional motionally narrowed spectra and the two-dimensional exchange spectrum are compatible with model calculations involving jumps of the molecules about their two-fold symmetry axis. This motion is additionally investigated by means of two-time stimulated-echo spectroscopy which allows for a determination of motional correlation functions over a wider temperature range than previously reported using carbon and deuteron NMR. On the basis of suitable second-order quadrupolar frequency distributions, sin-sin stimulated-echo amplitudes are calculated for a two-site model in the limit of vanishing evolution time and compared with experimental findings. The present study thus establishes oxygen-17 NMR as a powerful method that will be particularly useful for the study of solids and liquids devoid of nuclei governed by first-order anisotropies.

Development of a novel clinical biomarker assay to detect and quantify aggrecanase-generated aggrecan fragments in human synovial fluid, serum and urine

OBJECTIVE

Proteolytic degradation of aggrecan in articular cartilage is a hallmark feature of osteoarthritis (OA). The present study was aimed at developing a sensitive enzyme linked immunosorbent assay (ELISA) for the detection of aggrecanase-cleaved fragments of aggrecan in human serum and urine to facilitate the clinical development of aggrecanase inhibitors for OA.

METHODS

The BC3 monoclonal antibody that detects the ARGS neoepitope sequence in aggrecanase-cleaved aggrecan was engineered and optimized using complementarity determining region (CDR)-saturation mutagenesis to improve its binding affinity to the neoepitope. A sandwich ELISA (BC3-C2 ELISA) was developed using the optimized alpha-ARGS antibody (BC3-C2) as capture antibody and a commercially available antibody directed against the hyaluronic-acid binding region (HABR) of aggrecan as detection antibody. Aggrecanase-cleaved fragments of aggrecan present in in vitro digests, human cartilage explant culture supernatants and in human synovial fluid, serum and urine were detected and quantified using this ELISA.

RESULTS

The optimized antibody had a 4-log improvement in affinity for the ARGS containing peptide compared to the parental BC3 antibody, while maintaining the ability to not cross-react with a spanning peptide. The BC3-C2 ELISA demonstrated the ability to detect aggrecanase-cleaved aggrecan fragments in the native state, without the need for deglycosylation. This ELISA was able to measure aggrecanase-generated ARGS containing aggrecan fragments in human articular cartilage (HAC) explant cultures in the basal state (without cytokine stimulation). Treatment with an aggrecanase inhibitor resulted in a dose-dependent inhibition of ARGS neoepitope released into the culture supernatant. The ELISA assay also enabled the detection of ARGS containing fragments in human synovial fluid, serum and urine, suggesting its potential utility as a biomarker of aggrecanase activity.

CONCLUSIONS

We have developed a novel ELISA using an optimized ARGS antibody and have demonstrated for the first time, an ELISA-based measurement of aggrecan degradation products in human serum and urine. This assay has the potential to serve as a mechanistic drug activity biomarker in the clinic and is expected to significantly impact/accelerate the clinical development of aggrecanase inhibitors and other disease modifying drugs for OA.

Tracking clinical trial accrual strategies and barriers via a Web-based screening tool

6586

Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) has developed a web based tracking tool to monitor screening of patients for clinical trial participation. The system is designed to collect data from multiple research sites throughout the geographically diverse group. The log blindly collects patient demographics, successful trial entry, and reasons for trial enrollment failure. Methods: Seven NCCCP sites utilized the log during the 60 day open accrual period for the Wake Forrest WFU 07–02–03 cancer control trial (chronic lymphocytic leukemia COLD- fX) in Novermber 2008 and December 2008. Results: 327 chronic lymphocytic leukemia patients were screened mostly by chart review. 162 (50%) were eligible for study entry. 45 (14%) entered the trial. 103 (31%) eligible patients declined entry. Of the 103, 72 (70%) did not wish to participate in research, 15 (15%) had travel constraints, 5 (5%) perceived excess toxicity, 9 (9%) gave no reason. 14 (3%) eligible had their physician decline entry. Overall, 28% of eligible patients entered the trial. 165 (50%) were trial ineligible. 82 (50%) for prior therapy, 30 (18%) for co morbid conditions, 10 (6%) missed an entry time requirement, 39 (24%) have incomplete data. Conclusions: The NCCCP trial screening log successfully captures real time clinical trial participation data from a diverse network of clinical trial sites. This data base will allow future analysis of individual clinical trial and site accrual barriers and empower strategies to increase trial participation.

No significant financial relationships to disclose.

Tricuspid valve group B streptococcal endocarditis after an elective termination of pregnancy

A patient developed fever, chills, and shortness of breath after an elective first trimester dilation and curettage. Blood cultures grew Group B streptococcus, and a transesophageal echocardiogram revealed a 2 x 2 cm vegetation on the tricuspid valve and global left ventricular hypokinesis. A 6-week course of parenteral antibiotics and vasodilator therapy resulted in resolution of the valvular vegetation as well as of the left ventricular dysfunction.

Hepatic arterial Fotemustine chemotherapy in patients with liver metastases from cutaneous melanoma is as effective as in ocular melanoma

AIM

Hepatic metastases from melanoma are associated with poor prognosis. Systemic chemotherapy and biological treatments remain unsatisfactory. This study investigated the impact of hepatic arterial chemotherapy in patients with ocular and cutaneous melanoma.

METHODS

In a retrospectively analysed observational study, 36 consecutive patients with hepatic metastases from ocular or cutaneous melanoma were assigned for surgical hepatic port-catheter implantation. Fotemustine was delivered weekly for a 4-week period, followed by a 5-week rest and a maintenance period every 3 weeks until progression. Overall survival, response and toxicity were analysed and compared.

RESULTS

After port-catheter implantation 30/36 patients were finally treated (18 with ocular and 12 with cutaneous melanoma). A median of 8 infusions per patient were delivered (range 3-24). 30% thrombocytopenia grade >or=3, 7% neutropenia grade >or=3 but no nausea or vomiting grade >or=3 were encountered. Nine out of 30 patients achieved partial remission, 10/30 stable disease; 11/30 patients were progressive. Median survival for all treated patients was 14 months. Partial remission and stable disease were associated with a survival advantage compared to progressive disease (19 vs. 5 months). No significant difference in survival was observed for ocular versus cutaneous melanoma. Serum LDH was a significant predictor of both response and survival.

CONCLUSIONS

Hepatic arterial Fotemustine chemotherapy was well tolerated. Meaningful response and survival rates were achieved in ocular as well as cutaneous melanoma. Careful patient selection in consideration of extra-hepatic involvement is crucial for the effectiveness of this treatment. Independent from the primary melanoma site, it is debatable if patients with highly elevated serum-LDH may benefit from this approach.

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis

BACKGROUND

Gastric cancer frequently spreads to the peritoneal cavity. Whether laparoscopy is useful in planning therapy remains controversial. The aim of this study was to investigate the value of laparoscopy and to develop a therapeutic algorithm.

METHODS

Six hundred and sixty consecutive patients with gastric cancer were included in this prospective observational study. The sensitivity of abdominal ultrasonography, computed tomography (CT) and laparoscopy for detecting peritoneal carcinomatosis was compared. The lesions were biopsied and classified as P1, P2 or P3 according to the recommendations of the Japanese Research Society for Gastric Cancer. Prognosis was determined according to the stage of peritoneal carcinomatosis and therapeutic procedure adopted.

RESULTS

One hundred and ten (16.7 per cent) of 660 patients presented with synchronous peritoneal carcinomatosis. The sensitivity for detecting peritoneal carcinomatosis was 85 per cent for laparoscopy compared with 19 per cent for ultrasonography and 28 per cent for CT. Patients with P3 disease did not benefit from additional surgery compared with chemotherapy alone. Those with P1 carcinomatosis had improved survival rates after complete resection followed by chemotherapy.

CONCLUSION

Laparoscopy improves the detection and classification of peritoneal carcinomatosis, and offers patients with gastric cancer a more individualized and effective therapy.

Sildenafil citrate use and the incidence of nonarteritic anterior ischemic optic neuropathy

Nonarteritic anterior ischemic optic neuropathy (NAION) has been reported rarely in men after taking sildenafil or other phosphodiesterase 5 inhibitors for erectile dysfunction (ED). The incidence of NAION in men receiving sildenafil treatment for ED was estimated using pooled safety data from global clinical trials and European observational studies. Based on clinical trial data in more than 13,000 men and on more than 35,000 patient-years of observation in epidemiologic studies, we estimated an incidence of 2.8 cases of NAION per 100,000 patient-years of sildenafil exposure. This is similar to estimates reported in general US population samples (2.52 and 11.8 cases per 100,000 men aged >or=50 years). The data cited herein do not suggest an increased incidence of NAION in men who took sildenafil for ED.

[The question of surgical therapy for necrolytic migratory erythema, a cutaneous disease]

Necrolytic migratory erythema (NME) is a rare paraneoplastic dermatologic condition. Its underlying cause is usually a pancreatic islet cell tumour with marked glucagon secretion. The glucagonoma syndrome is characterised by pancreatic neuroendocrine neoplasm, NME, and diabetes mellitus. We present a case of glucagonoma syndrome in a 58-year-old woman with a history of recurrent cutaneous manifestations who was referred for surgical resection of a pancreatic neoplasm after the NME was finally diagnosed. We discuss diagnostic methods, differential diagnosis, and therapeutic management of this disease.

Amantadine in treatment of chronic hepatitis C virus infection?

SUMMARY

Treatment of chronic hepatitis C (CHC) continues to be an important and growing challenge. As the response rate to FDA-approved treatment improved over the past decade, we are facing increasing number of difficult-to-treat patients such as those who have failed prior anti-viral therapy. The role of amantadine in the treatment of CHC remains unclear. Studies thus far have produced conflicting results, and type II error could not be excluded. This review summarized results published in the literature from 1997 to 2003, and reviewed the existing questions and controversies regarding the use of amantadine. Current literature suggests that amantadine is ineffective as monotherapy. Amantadine increased the sustained virologic response of certain treatment naïve patients when used in combination with interferon, and may be effective as an adjunct to interferon-based combination therapy in some patients who have failed or relapsed on prior therapy. Factors such as small sample size, patient characteristics, and differences in treatment protocols including amantadine preparation and duration of therapy might explain the conflicting observations of various studies. Further investigations are needed to define optimal dosing and formulation of amantadine, and its appropriate role in management of CHC infection.

The bile acid-activated phosphatidylinositol 3-kinase pathway inhibits Fas apoptosis upstream of bid in rodent hepatocytes

BACKGROUND & AIMS

Bile acids differentially modulate hepatocyte injury in cholestasis. Although glycochenodeoxycholate (GCDC) induces Fas-mediated hepatocyte apoptosis, taurochenodeoxycholate (TCDC) simultaneously activates a phosphatidylinositol 3-kinase (PI 3-K)-mediated survival pathway blocking Fas apoptosis. In this study, the mechanisms by which the TCDC/PI 3-K survival signal disrupts Fas signaling were examined.

METHODS

Studies were performed in primary cultures of mouse hepatocytes and the bile-salt-transporting McNtcp.24 rat hepatoma cell line.

RESULTS

GCDC, but not TCDC, resulted in cytochrome c release demonstrating that TCDC blocked apoptosis upstream of mitochondria. In contrast, both GCDC and TCDC treatment resulted in Fas aggregation and recruitment of a dominant-negative FADD green fluorescent protein (GFP) and C360S procaspase 8-GFP to the plasma membrane. Despite recruitment of procaspase 8 to the plasma membrane by both bile acids, only GCDC resulted in increases of caspase 8 activity and Bid-GFP mitochondrial translocation. However, when PI-3K was inhibited with wortmannin or dominant-negative PI 3-K, TCDC-induced Bid-GFP mitochondrial translocation and cytochrome c release.

CONCLUSIONS

The TCDC/PI 3-K survival signal blocks Fas-mediated apoptosis by preventing caspase 8 activation and Bid mitochondrial translocation. Potentiation of this survival pathway in cholestasis has the potential to attenuate liver injury.

How short can courses be in lower respiratory tract infections?

Prospective clinical studies conducted over the last 10 years provide data on which to base decisions regarding the treatment of community-acquired pneumonia (CAP), including the need for hospitalization, optimal timing of the switch from intravenous to oral antibiotic therapy and the discharge of patients. Validated treatment algorithms, such as the classification of community-acquired pneumonia, now enable decisions to be made on which patients with CAP require hospitalization, as well as identifying those who will benefit from early switch therapy. Generally, unstable CAP patients are suitable candidates for early switch therapy, which consists of rapid initiation of 1 - 2 days' intravenous therapy followed by 5 days' oral therapy, with early discharge from hospital after the receipt of one or two doses of oral antibiotic. Studies with intravenous cefuroxime and followed by oral cefuroxime axetil suggest this regimen is both effective and well tolerated as rapid switch therapy, and has the potential to reduce overall healthcare costs and improve patient satisfaction.

Behçet's syndrome with left ventricular aneurysm and ruptured renal artery pseudoaneurysm

A 21-year-old man with Behçet's syndrome presented with both a left ventricular aneurysm and a left renal artery pseudoaneurysm. After successful embolization of the ruptured pseudoaneurysm, the patient underwent successful repair of the left ventricular aneurysm. Although multiple aneurysms have been reported previously, we believe this to be the first reported case of both a ventricular aneurysm and a renal artery pseudoaneurysm afflicting a patient with Behçet's syndrome.

Mature T lymphocyte apoptosis--immune regulation in a dynamic and unpredictable antigenic environment

Apoptosis of mature T lymphocytes preserves peripheral homeostasis and tolerance by countering the profound changes in the number and types of T cells stimulated by diverse antigens. T cell apoptosis occurs in at least two major forms: antigen-driven and lymphokine withdrawal. These forms of death are controlled in response to local levels of IL-2 and antigen in a feedback mechanism termed propriocidal regulation. Active antigen-driven death is mediated by the expression of death cytokines such as FasL and TNF. These death cytokines engage specific receptors that assemble caspase-activating protein complexes. These signaling complexes tightly regulate cell death but are vulnerable to inherited defects. Passive lymphokine withdrawal death may result from the cytoplasmic activation of caspases that is regulated by mitochondria and the Bcl-2 protein. The human disease, Autoimmune Lymphoproliferative Syndrome (ALPS) is due to dominant-interfering mutations in the Fas/APO-1/CD95 receptor and other components of the death pathway. The study of ALPS patients reveals the necessity of apoptosis for preventing autoimmunity and allows the genetic investigation of apoptosis in humans. Immunological, cellular, and molecular evidence indicates that throughout the life of a T cell, apoptosis may be evoked in excessive, harmful, or useless clonotypes to preserve a healthy and balanced immune system.

Molecular genetic studies in lymphocyte apoptosis and human autoimmunity

Using a genetic approach, we have studied the molecular basis of human autoimmunity with special emphasis on a disease that is due to defective lymphocyte apoptosis. Recently, we and our collaborators have found that the autoimmune/lymphoproliferative syndrome (ALPS), an inherited disease of children comprising marked lymphoid hyperplasia and autoimmune manifestations, is due to abnormalities in the CD95 gene that cause defective lymphocyte apoptosis. Our recent investigations have shown that the mutations in most families with ALPS cause either global or local changes in the structure of a cytoplasmic portion of the molecule called the 'death domain'. These death domain alterations impair binding of the adapter protein FADD/MORT1 and result in a failure to activate apoptotic caspases after CD95 (Fas/APO-1) cross-linking. Mutations in apoptotic caspases may also contribute to the pathogenesis of ALPS in individuals that have no CD95 gene mutations.

The potential of subtype-selective neuronal nicotinic acetylcholine receptor agonists as therapeutic agents

Neuronal nicotinic acetylcholine receptors (NAChRs) are pentameric ligand-gated ion channel receptors which exist as different functional subunit combinations which apparently subserve different physiological functions as indicated by molecular biological and pharmacological techniques. It is possible to design and synthesize novel compounds that have greater selective affinities and efficacies than nicotine for different NAChRs, which should translate into different behavioral profiles and therapeutic potentials. Examples of NAChR agonists studied are nicotine, SIB-1508Y, SIB-1553A and epibatidine. These compounds have different degrees of selectivity for human recombinant NAChRs, different neurotransmitter release profiles in vitro and in vivo and differential behavioral profiles. Preclinical studies suggest that SIB-1508Y is a candidate for the treatment of the motor and cognitive deficits of Parkinson's disease, whereas SIB-1553A appears to have potential as a candidate for the treatment of Alzheimer's disease. Epibatidine has a strong analgesic profile, however the ratio between pharmacological activity and undesirable effects is so low that it is difficult to envisage the use of this compound therapeutically. Nicotine has a broad profile of pharmacological activity, for instance demonstrating activity in models for cognition and analgesia. As for epibatidine, the adverse effects of nicotine severely limits its therapeutic use in humans. The discovery of subtype-selective NAChR agonists such as SIB-1508Y and SIB-1553A provides a new class of neuropsychopharmacological agents with better therapeutic ratios than nonspecific agents such as nicotine.

Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical College of Wisconsin Lung Transplant Group

OBJECTIVE

To determine the utility of CT-determined main pulmonary artery diameter (MPAD) for predicting pulmonary hypertension (PH) in patients with parenchymal lung disease.

DESIGN

Retrospective review of right-heart hemodynamic data and chest CT scans in 45 patients.

SETTING

Tertiary-referral teaching hospital and VA hospital.

PATIENTS

Between October 1990 and December 1995, 36 patients referred for evaluation of parenchymal lung disease or possible pulmonary vascular disease were found to have PH, as defined by mean pulmonary artery pressure (mPAP) > or =20 mm Hg. Nine control patients (mPAP <20 mm Hg) were also identified (4 from hospital records search, 5 after evaluation for possible PH).

RESULTS

CT-determined MPAD was 35+/-6 mm in patients with PH and 27+/-2 mm in control subjects. In our group of patients, MPAD > or =29 mm had a sensitivity of 87%, specificity of 89%, positive predictive value (PPV) of 0.97, and positive likelihood ratio (LR) of 7.91 for predicting PH; in the subgroup of patients with parenchymal lung disease (n=28, PH and control subjects), MPAD > or =29 mm had a sensitivity of 84%, specificity of 75%, PPV of 0.95, and positive LR of 3.36 for predicting PH. The most specific findings for the presence of PH were both MPAD > or =29 mm and segmental artery-to-bronchus ratio > 1:1 in three or four lobes (specificity, 100%). There was no linear correlation between the degree of PH and MPAD (r=0.124).

CONCLUSIONS

CT-determined MPAD has excellent diagnostic value for detection of PH in patients with advanced lung disease. Therefore, standard chest CT scans can be used to screen for PH as a cause of exertional limitation in patients with parenchymal lung disease. Because CT is commonly used to evaluate parenchymal lung disease, this information is readily available.

Individual beta cells within the intact islet differentially respond to glucose

Insulin production by the pancreatic islet is tightly coupled to the concentration of blood glucose. The mechanism by which glucose controls proinsulin biosynthesis in beta cells is poorly understood. Analysis of insulin gene expression in individual cells within whole, living islets using adenovirus gene transfer and direct observation of insulin promoter-directed green fluorescent protein activity indicates that beta cells are functionally heterogeneous. An increase in glucose concentration not only stimulates expression within individual beta cells, but unexpectedly acts to increase the total number of positive cells. The net islet response to a given glucose stimulus reflects an integrated action of beta cells with individually differing behaviors. This additional level of functional complexity may provide new insights into the pathophysiology and treatment of diabetes mellitus.

The role of interventional radiology in the management of intra- and extra-peritoneal leakage in patients who have undergone continent urinary diversion

PURPOSE

To assess how radiologic intervention altered the hospital course of patients undergoing continent urinary diversion.

METHODS

Thirty-seven consecutive patients with bladder cancer invading the muscular layer were treated with total cystectomy and construction of a continent urinary reservoir. Eleven of 37 patients suffered early and late anastomotic leakage; six had prolonged extraperitoneal leakage at the urethroenteric anastomosis, three had prolonged intraperitoneal pouch leaks, and two had delayed ureteroenteric leaks. Seven of these patients required radiologic intervention.

RESULTS

Intervention in the form of drainage catheter manipulation (n = 4), percutaneous nephrostomy (n = 4), or ureteral stent placement (n = 2) resulted in cessation of leakage without surgical intervention in all seven patients. Intraperitoneal pouch leaks were more difficult to control than extraperitoneal leakage and required longer drainage intervals.

CONCLUSION

Interventional radiologic procedures played a key role in the management of continent urinary diversion complications, obviating the need for repeat surgical intervention in all instances.

Hamartomatous malformation of the left ventricle associated with sudden death

We describe unusual left ventricular cardiac lesions in a 17 year old boy who died suddenly during exertion. These consisted of two grossly evident regions of deficient myocardium, containing cavernous spaces which represented exaggerated intertrabecular regions of the left ventricular cavity. Dense fibro-elastotic tissue was deposited around these spaces along with a variable admixture of mature adipose tissue, fibrous tissue and blood vessels. The etiology of these presumably congenital developmental abnormalities is obscure. The lesions most probably represent a hamartomatous malformation, which is a poorly documented pathological entity.

Identifying the mental health needs of children living in families with AIDS or HIV infection

The present article highlights the mental health needs of children living with loved ones who have AIDS or HIV infection. In addition the article describes an intervention program which is being developed to meet the needs of the children and their families. Children who live in families affected by AIDS and HIV infection, like children who live with other life-threatening illnesses, are vulnerable to psychological distress. They experience numerous separations from parents, changes in the nature and predictability of emotional nurturing, concerns about loss, disruptions in routine and contact with peers, and economic hardship. AIDS and HIV infection present the additional stressors that stem from discrimination, stereotyping, and social ostracism. Finally, many families living with AIDS or HIV infection are disenfranchised, living under the pall of poverty and substance abuse. The intervention program described is being implemented in an urban community mental health clinic to meet the diverse mental health needs of the children living in these families. Preliminary implications of the program are discussed so as to begin a dialogue with other agencies who are challenged to meet the needs of this heterogeneous population.

Transesophageal echocardiographic assessment of pulmonary venous flow after single lung transplantation

Transesophageal echocardiography was used to evaluate pulmonary venous flow velocity and pulmonary venous diameter of both the transplanted and native lungs in six single lung transplant recipients. Mean pulmonary venous velocity (50 +/- 10 versus 27 +/- 8 cm/sec) and pulmonary venous diameter (1.39 +/- 0.16 versus 0.98 +/- 0.18 cm) were significantly greater in the transplanted lung than in the native contralateral lung. An index of allograft perfusion, QD-transesophageal echocardiography (pulmonary venous velocity x pulmonary venous diameter), correlated highly with previously measured technetium 99m-labeled macroaggregated albumin quantitative lung perfusion studies (r = 0.94). A pressure gradient in pulmonary venous flow velocity across the left atrial anastomosis was detected in two patients (8 and 12 mm Hg). Analysis of previous resting supine and upright incremental hemodynamic exercise testing showed no significant differences in these two patients with respect to maximum oxygen uptake, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, or pressure-flow relationships. Therefore these left atrial anastomotic gradients did not appear to adversely affect the pulmonary vascular response to incremental exercise. Transesophageal echocardiography may be an invaluable technique in the expedient evaluation of cardiac function and allograft perfusion after lung transplantation.