Phase I and II trials of subcutaneously administered rIL-2, interferon alfa-2a, and fluorouracil in patients with metastatic renal carcinoma

PURPOSE

A phase I followed by a phase II trial utilizing rIL-2, IFN alpha, and 5-FU were conducted in patients with unresectable and/or metastatic renal cell carcinoma.

METHODS

Treatment consisted of: rIL-2 at 5.0 x 10(6) IU/m2 SQ on days 1-5 for 4 weeks, rHUIFN alpha-2a at 5.0 x 10(6) U/m2 SQ on days 1, 3, and 5 for 4 weeks, and 5-FU by IV bolus on days 1-5 during week 1. In the phase I study, patients were treated at varying doses of 5-FU: I-none, II-250 mg/m2, III-300, and IV 375. A phase II trial was then conducted utilizing the same schedule and maximum tolerated dose (MTD) for 5-FU.

RESULTS

Twenty patients were entered into the phase I trial. Dose-limiting toxicity included grade III nausea and vomiting, and one sudden cardiac death. The MTD for 5-FU was determined to be 300 mg/m2. In the phase II trial, a median of two cycles of therapy was administered to 25 evaluable patients. Toxicity was moderate and consisted primarily of fevers, chills, fatigue, nausea/vomiting, and anorexia. Grade IV thrombocytopenia, consistent with ITP, developed in one patient each on the phase I and phase II trial. Seven partial responses were seen among 25 patients treated in the phase II trial for a 28% (CI 12-49%) response rate.

CONCLUSIONS

The addition of 5-FU to rIL-2 and rHuIFN alpha-2a appears to increase the toxicity of this therapy. Randomized trials will be required to determine if efficacy is enhanced.

New approaches to HIV surveillance: means and ends. Summary report of conference held at Yale University, 21-22 May 1998, by the Law, Policy and Ethics Core, Center for Interdisciplinary Research on AIDS, Yale University

A system of HIV surveillance based on AIDS case reporting is no longer adequate to monitor the epidemic of HIV/AIDS in the U.S. We are now faced with the challenge of designing an effective system of HIV surveillance. The "New Approaches to HIV Surveillance: Means and Ends" conference emphasized that there are several alternatives, each with strengths and limitations. The CDC has recommended that all states adopt a system of HIV surveillance based on case reporting. Although it has not specified that such systems need be name-based, CDC appears to reward states that adopt name-reporting systems. The rationale for this stance should be reviewed and made explicit. Name reporting may be superior in some respects to a system of case reports based on unique identifiers (UIs), especially in its greater ability to link surveillance activities to follow up at the individual level. Neither a name-reporting nor a UI approach to case reporting would provide HIV incidence data. The only currently envisioned means of providing incidence data is statistical estimation based on "snapshot estimates" of HIV incidence in sample cohorts. Calibration of this new instrument for HIV incidence estimation against existing data or through field trials is of critical importance.

Interferon-gamma and CXC chemokine induction by interleukin 12 in renal cell carcinoma

Interleukin 12 (IL-12) is known to play an important role in the development of an antitumor response. Its activity has been shown to be dependent upon the intermediate production of IFN-gamma and the influx into the tumor of CD8 lymphocytes. In a murine model, tumor regression induced by IL-12 treatment correlated with IFN-gamma, IP-10, and Mig expression in the tumor bed and was abrogated by antibodies to both chemokines. Here we examined the effects of rHuIL-12 on IFN-gamma and CXC chemokine gene expression in patients with renal cell carcinoma (RCC) in an attempt to determine whether a similar series of molecular events leading to IL-12-mediated tumor regression in mice is also detectable in humans. As in the murine RENCA model, cultured RCC cells themselves could be induced by IFN-gamma to synthesize IP-10 and Mig mRNA. Explanted RCC produced IFN-gamma and IP-10 mRNA in response to IL-12 treatment, which was consistent with the finding that biopsied RCC tumors from IL-12-treated patients also variably expressed augmented levels of those molecules after therapy. Although Mig mRNA was present in the majority of biopsied tumors prior to treatment, both the Mig and IP-10 chemokines as well as IFN-gamma were induced in the peripheral blood mononuclear cells of IL-12-treated patients. Skin biopsies of IL-12-treated patients also all synthesized IP-10 mRNA. This study demonstrates that recombinant human IL-12 therapy of patients with RCC has the potential to induce the expression of gene products within the tumor bed that may contribute to the development of a successful antitumor response.

NMP22: a sensitive, cost-effective test in patients at risk for bladder cancer

BACKGROUND

This study was designed to determine the clinical utility of NMP22 as a urinary marker for the early detection of transitional cell carcinoma (TCC) of the bladder in patients with hematuria or other indications for risk of malignancy. Its utility will be measured by sensitivity and specificity estimates as compared to cystoscopy. Since urine cytology is normally collected in this population of patients, it will also be analyzed and compared to cystoscopy.

MATERIALS AND METHODS

Each patient submitted a single voided urine which was stabilized with the NMP22 urine collection kit or preserved in the appropriate cytology medium for cytopathologic testing. All patients provided the urine samples before cystoscopic exam. Of the 146 patients, there were 43 patients with microscopic hematuria and 13 with gross hematuria. Other indications for cystoscopy included unexplained or medically refractory voiding. There were 8 patients with biopsy confirmed bladder cancer and 138 patients with benign conditions of the bladder.

RESULTS

The median NMP22 value for the bladder cancer malignancies was 27.8 U/mL (95% Confidence interval: 10.5-32.1 U/mL). The median NMP22 value for the benign conditions of the bladder was 3.25 U/mL (95% Confidence interval: 2.5-3.8 U/mL). The urinary NMP22 values from the bladder cancer group was statistically different (p < .000001 Mann-Whitney U test) than the NMP22 values in the benign conditions group. Using a reference value of 10.0 U/mL, the sensitivity of NMP22 was 100% with a specificity of 90%, while cytology had a sensitivity of 25% and a specificity of 100%. Due to its high negative predictive value, using NMP22 alone could have eliminated 124 cystoscopies with total savings ranging from $24,824 to $63,264 depending on the type of insurance carrier.

CONCLUSIONS

This study indicates that urinary NMP22 is a useful, cost-effective marker for the early detection of bladder cancer.

Interferon-gamma production by T lymphocytes from renal cell carcinoma patients: evidence of impaired secretion in response to interleukin-12

Interleukin-12 (IL-12) is a heterodimeric cytokine that enhances the cytolytic activity, proliferation, and interferon-gamma (IFN-gamma) production by T lymphocytes and natural killer cells, and has significant antitumor activity in a variety of murine tumor models. The induction of interferon (IFN)-gamma by IL-12 in tumor-bearing mice plays an important role in its antitumor activity. We therefore examined the effects of IL-12 on IFN-gamma production by T cells derived from patients with renal cell carcinoma (RCC), including freshly isolated tumor infiltrating lymphocytes (T-TIL), matched peripheral blood T cells (T-PBL), and RCC-specific TIL lines. IL-12 alone induced IFN-gamma secretion by T cells from normal individuals and appeared to act synergistically with either IL-2 or anti-CD3 antibody. In contrast, it failed to stimulate significant IFN-gamma secretion by T-PBL and T-TIL from RCC patients. This unresponsive state in T-PBL appeared selective because IFN-gamma was produced when cells were stimulated with either phytohemagglutinin or anti-CD3 antibody. Moreover, costimulation through the T-cell receptor (TCR)/CD3 complex or with IL-2 made T-PBL from RCC patients responsive to IL-12, possibly secondary to the upregulation of IL-12R (beta chain). A selective loss of IL-12-dependent production of IFN-gamma was also consistently observed in two of three established RCC-specific TIL lines. Although these cell lines did not respond to any concentration of IL-12, they did produce IFN-gamma after ligation of the TCR/CD3 or stimulation with IL-2, IL-12 also acted either syngeristically or additively with IL-2, anti-CD3 antibody, or autologous tumor cells to induce IFN-gamma production. The observed decreases in IFN-gamma production in response to IL-12 may have a negative effect on the development of T-cell immunity. The clinical importance of these findings during in vivo administration of IL-12 remains to be determined.

Signal transduction abnormalities in T lymphocytes from patients with advanced renal carcinoma: clinical relevance and effects of cytokine therapy

Studies have demonstrated abnormalities of the CD3/T-cell antigen receptor (TCR) and pathways of signal transduction in T lymphocytes from animals and patients with advanced malignancy. Diminished expression of TCRzeta and p56(lck) that are associated with the TCR and reduced nuclear localization of RelA containing nuclear factor kappaB (NFkappaB) complexes have been noted. These defects have been described in T cells from patients with malignant melanoma, renal cell carcinoma (RCC), ovarian cancer, and colorectal cancer. Preliminary observations also indicate possible correlation with clinical variables such as stage in selected instances. To further characterize altered expression of TCRzeta, p56(lck), and impaired activation of NFkappaB, T lymphocytes were obtained from 65 patients with RCC, the majority of whom were receiving combination cytokine therapy [interleukin (IL)-2, IFN alpha-containing regimens] and 37 control individuals. In 29 of these patients, levels of TCRzeta and p56(lck) were determined by Western blots of T-cell lysates and semiquantitated using densitometry. Relative levels were then correlated with a series of clinical variables including response to therapy, performance status, survival, disease sites, age, and others. In another group of 28 patients (three individuals from the first group), the frequency of abnormal NFkappaB activation was studied using electrophoretic mobility shift assays after activation of T cells with phorbol myristate acetate/ionomycin or anti-CD3 monoclonal antibody. Changes in these signaling molecules during cytokine treatment were also investigated. TCRzeta and p56(lck) were detected in the peripheral blood T cells in 27 of 29 patients, and overall, reduced levels were noted visually in 12 of 29 (41%) and 13 of 29 (45%) individuals, respectively. When levels were semiquantitated using densitometry, significant decreases of TCRzeta (P = 0.029) and p56(lck) (P = 0.029) but not CD3epsilon (P = 0.131), compared with control levels, were found. In patients treated with IL-2/IFN alpha-based therapy, relative levels of TCRzeta increased significantly (P = 0.002) on day 15 of cycle one compared with the baseline. Correlations of TCRzeta or p56(lck) levels with response or disease variables, except for lower TCRzeta levels (P < 0.001) in the presence of bone metastases, were not found. Abnormal NFkappaB activation after stimulation with phorbol myristate acetate/ionomycin and/or anti-CD3 monoclonal antibody was found in 59% of patients (17 of 28) and was not accounted for by the advanced age of the study cohort. Activation of NFkappaB in peripheral blood T cells was inducible during cytokine therapy in four of six individuals who displayed impaired NFkappaB activity prior to therapy. Moreover, impaired activation of NFkappaB does not appear linked to a reduction of TCRzeta expression, because in five patients, normal TCRzeta levels were present although kappaB binding was not inducible. In the majority of patients with advanced RCC, peripheral blood T cells express TCRzeta and p56(lck), and in a subset, reduced levels of these TCRzeta associated molecules are seen that may increase during cytokine-based therapy. Abnormal activation of NFkappaB is also present in >50% of patients and may also revert to normal during IL-2/IFN alpha-based treatment. This alteration in NFkappaB activation occurred in the presence of normal expression of TCRzeta-associated signaling elements. The clinical significance of these findings remains unclear.

Impaired activation of NFkappaB in T cells from a subset of renal cell carcinoma patients is mediated by inhibition of phosphorylation and degradation of the inhibitor, IkappaBalpha

Activation of the transcription factor NFkappaB in peripheral blood T cells from patients with renal cell carcinoma (RCC) is compromised. This impaired signaling function results from a failure of RelA and c-Rel to translocate to the nucleus though normal levels of Rel proteins are present in the cytoplasm. We demonstrate here in a subset of RCC patients that the defect in NFkappaB activation is attributable to the absence of phosphorylation and degradation of the inhibitor IkappaBalpha. In patient T cells there was no stimulus dependent decrease in the cytoplasmic level of IkappaBalpha. Coimmunoprecipitation studies showed that RelA was in complex with IkappaBalpha and was not released after stimulation. Moreover, the phosphorylated form of IkappaBalpha detected in normal T cells after activation is absent in patient T cells. Additional experiments showed that soluble products from RCCs (RCC-S) can reproduce the same phenotype in T cells from healthy individuals. Supernatant fluid from cultured explants of RCC, but not normal kidney, inhibited the stimulus dependent nuclear translocation of NFkappaB without altering the cytoplasmic levels of RelA, c-Rel, and NFkappaB1. Phosphorylation and degradation of IkappaBalpha was also blocked by RCC-S. The mechanistic similarities between patient-derived T cells and normal T cells cultured with RCC-S suggest that the tumor-derived products may be the primary mediators of impaired T-cell function in this tumor system.

Defective granzyme B gene expression and lytic response in T lymphocytes infiltrating human renal cell carcinoma

Granzyme B is a protein thought to play a pivotal role in the cytolytic functions of T cells. In view of this, the inducibility of this gene in freshly isolated T cells (T-TILs) infiltrating human renal cell carcinoma (RCC) in vitro was examined by using the reverse transcriptase-polymerase chain reaction (RT-PCR). A reduction in granzyme B messenger RNA (mRNA) expression in stimulated T-TILs from five of nine patients with RCC compared with autologous peripheral blood T cells was noted. The reduced expression was observed after multiple stimuli including anti-CD3 antibody, interleukin-2 (IL-2), and phytohemagglutinin (PHA). Because CD8+ T cells represent the predominant cytotoxic population, the ability of this cell population to express granzyme B mRNA after stimulation also was examined. When compared with CD8+ peripheral blood lymphocytes (T-PBLs) from patients with RCC and normal donors, the induction of granzyme B mRNA was reduced in CD8+ T-TILs. CD8+ T-TILs also had lower non-major histocompatibility complex (MHC)-restricted cytotoxic activity than did CD8+ T-PBLs against both Daudi cells and allogeneic RCC cell lines. These results show that in a subset of patients with RCC, depressed lytic activity of CD8+ TILs compared with CD8+ PBLs is present. Reduced granzyme B mRNA expression also was noted in selected patients.

Tumor-induced suppression of T lymphocyte proliferation coincides with inhibition of Jak3 expression and IL-2 receptor signaling: role of soluble products from human renal cell carcinomas

The proliferative capacity of T cells infiltrating human tumors is known to be impaired, possibly through their interaction with tumor. Here we demonstrate that soluble products derived from renal cell carcinoma (RCC-S) explants but not normal kidney can inhibit an IL-2-dependent signaling pathway that is critical to T cell proliferation. A major target of the immunosuppression was the IL-2R-associated protein tyrosine kinase, Janus kinase 3 (Jak3). RCC-S suppressed basal expression of Jak3 and its increase following stimulation with anti-CD3/IL-2. Jak3 was most sensitive to suppression by RCC-S; however, reduction in expression of p56(lck), p59(fyn), and ZAP-70 was observed in some experiments. Expression of other signaling elements linked to the IL-2R (Jak1) and the TCR (TCR-zeta, CD3-epsilon, and phospholipase C-gamma) were minimally affected. In naive T cells, RCC-S also partially blocked induction of IL-2R alpha-, beta- and gamma-chain expression when stimulating via the TCR/CD3 complex with anti-CD3 Ab. To determine whether RCC-S suppressed IL-2-dependent signaling, primed T cells were employed since RCC-S had no effect on IL-2R expression but did down-regulate Jak3 expression and, to a lesser degree, p56(lck) and p59(fyn). Reduction in Jak3 correlated with impaired IL-2-dependent proliferation and signal transduction. This included loss of Jak1 kinase tyrosine phosphorylation and no induction of the proto-oncogene, c-Myc. These findings suggest that soluble products from tumors may suppress T cell proliferation through a mechanism that involves down-regulation of Jak3 expression and inhibition of IL-2-dependent signaling pathways.

Tumor-induced suppression of T lymphocyte proliferation coincides with inhibition of Jak3 expression and IL-2 receptor signaling: role of soluble products from human renal cell carcinomas

The proliferative capacity of T cells infiltrating human tumors is known to be impaired, possibly through their interaction with tumor. Here we demonstrate that soluble products derived from renal cell carcinoma (RCC-S) explants but not normal kidney can inhibit an IL-2-dependent signaling pathway that is critical to T cell proliferation. A major target of the immunosuppression was the IL-2R-associated protein tyrosine kinase, Janus kinase 3 (Jak3). RCC-S suppressed basal expression of Jak3 and its increase following stimulation with anti-CD3/IL-2. Jak3 was most sensitive to suppression by RCC-S; however, reduction in expression of p56(lck), p59(fyn), and ZAP-70 was observed in some experiments. Expression of other signaling elements linked to the IL-2R (Jak1) and the TCR (TCR-zeta, CD3-epsilon, and phospholipase C-gamma) were minimally affected. In naive T cells, RCC-S also partially blocked induction of IL-2R alpha-, beta- and gamma-chain expression when stimulating via the TCR/CD3 complex with anti-CD3 Ab. To determine whether RCC-S suppressed IL-2-dependent signaling, primed T cells were employed since RCC-S had no effect on IL-2R expression but did down-regulate Jak3 expression and, to a lesser degree, p56(lck) and p59(fyn). Reduction in Jak3 correlated with impaired IL-2-dependent proliferation and signal transduction. This included loss of Jak1 kinase tyrosine phosphorylation and no induction of the proto-oncogene, c-Myc. These findings suggest that soluble products from tumors may suppress T cell proliferation through a mechanism that involves down-regulation of Jak3 expression and inhibition of IL-2-dependent signaling pathways.

Phase II trial of interleukin-2 and interferon-alpha in patients with renal cell carcinoma: clinical results and immunologic correlates of response

A phase II trial was conducted in patients with metastatic renal cell carcinoma, to assess the clinical efficacy and immunoregulatory effects of continuous-infusion recombinant interleukin-2 (rIL-2) (9.0 x 10(6) IU/m2/day on days 1-5, 8-12, 15-19, and 22-26) and subcutaneously administered recombinant human interferon-alpha 2b (rHuIFN alpha 2b) (10.0 x 10(6) U/m2/day TIW). Thirty-six patients with metastatic renal cell carcinoma, performance status of 0-1, and measurable disease who had not received prior rIL-2, rHuIFN alpha 2b, or chemotherapy were treated. Patients with CNS metastases, active infections, history of another malignancy within 3 years, and those requiring corticosteroids were ineligible. Cycles of rIL-2 and rHuIFN alpha 2b were administered in the outpatient department every 6-8 weeks in stable or responding patients until patient tolerance or a complete response were reached. Doses were modified for grade III or IV toxicity. Ancillary studies included three-color immunocytometric analysis of peripheral blood lymphocytes, repetitive tumor biopsies for immunohistologic analysis of infiltrating cells and proliferative responses of tumor infiltrating lymphocytes, and preliminary studies of changes in peripheral blood T-lymphocyte signal transduction molecules [T-cell receptor (TCR)-zeta, p56ick, p59fyn]. Thirty-six eligible patients were treated, with 6 of 36 patients (17%, 95% confidence interval 6-33%) responding (3 complete response, 3 partial response). In two of the partial responders, and in an additional three patients with either minimal tumor regression (one patient) or stable disease (two patients), surgical removal of residual disease was undertaken. The median survival of all patients was 14 months. The toxicity of this regimen was severe, but outpatient administration was possible in most instances. Immunoregulatory effects on T-cell subsets included increases in various CD3+ CD25+/- HLADr+/- subsets unrelated to response. Tumor biopsies before and/or during therapy were obtained in 17 patients, and no consistent alterations in the degree of T-lymphocyte or macrophage infiltrates could be detected. In a subset of patients, tumor infiltrating lymphocyte proliferative responses and levels of peripheral blood T-cell signal transduction molecules (TCR-zeta, p56lck, p59fyn) were investigated. Abnormalities were found in selected patients, which improved during rIL-2/rHuIFN alpha 2b therapy. This cytokine combination produces tumor regression in selected patients with metastatic renal cell carcinoma. Surrogate immunologic markers associated with response were not identified; however, preliminary studies demonstrate investigation of immune defects and their reversal with cytokine therapy is possible.

The axes of rotation of the thumb interphalangeal and metacarpophalangeal joints

The axes of rotation of the thumb interphalangeal and metacarpophalangeal joints were located using a mechanical method. The interphalangeal joint axis is parallel to the flexion crease of the joint and is not perpendicular to the phalanx. This offset of the axis with respect to the phalanx explains the ulnar deviation and pronation that occurs with flexion of the interphalangeal joint. The metacarpophalangeal joint has 2 fixed axes: a fixed flexion-extension axis just distal and volar to the epicondyles, and an abduction-adduction axis related to the proximal phalanx passing between the sesamoids. Neither axis is perpendicular to the phalanges. All physiologic motion for these joints occurs about the axes. These are the mechanical axes of the joints through which the muscles and external forces act. Knowledge of their location should help in constructing prosthetic joints and in planning reconstructive surgery such as tendon transfers.

The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

Anti-glomerular and anti-tubular basement membrane nephritis in a renal allograft recipient with Alport's syndrome

A 28-year-old deaf, white man with a clinical diagnosis of Alport's syndrome since 4 years of age experienced renal failure, fever, and mental status changes suggestive of vasculitis following his first cadaveric renal transplant; these symptoms and changes resolved after removal of the allograft. Immunohistological stains demonstrated intense linear deposition of IgG and C3 in glomerular and tubular basement membranes in the absence of glomerular crescents. One year later, a second renal transplant led to similar symptoms. A biopsy was performed 14 days after engraftment, which demonstrated intense linear deposition of IgG in glomerular and tubular basement membranes, but cellular crescents were not present. A serologic profile was ordered to evaluate the patient further for vasculitis, and during the evaluation, circulating anti-glomerular basement membrane and anti-tubular basement membrane antibodies were identified by indirect immunofluorescence microscopy (titer, > 1:320). An open biopsy specimen obtained during repair of a renal laceration demonstrated a crescentic glomerulonephritis with immunohistologic findings identical to those of previous biopsies. Anti-glomerular basement membrane nephritis should be suspected in any patient with Alport's syndrome in whom progressive renal failure develops following renal transplantation. Detection of anti-glomerular basement membrane/anti-tubular basement membrane antibodies will assure the diagnosis, and early initiation of plasmapheresis may be helpful to prevent further renal damage.

Prevention of thromboembolism in spinal cord injury: role of low molecular weight heparin

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are major causes of morbidity and mortality in patients with acute spinal cord injury. Our preliminary studies indicated that low molecular weight heparin (LMWH) was significantly more effective than standard heparin in preventing these complications. We have now extended these studies by screening an additional 122 patients and treating 60 who met predefined criteria with LMWH in a dose of 3,500 anti-Xa U given subcutaneously once daily for 8 weeks. All patients were examined daily at bedside and had regularly scheduled venous ultrasonography; those with abnormalities had confirmatory venography and lung scans. Postmortem examinations were conducted in those who died. Forty completed the trial without incident, 6 had DVT (4 proximal and 2 distal), 1 had a fatal PE, 1 had postoperative bleeding requiring discontinuation of the LMWH, 10 were transferred or discharged, and 2 died of respiratory failure. The percentage of patients free of thrombosis or bleeding after 8 weeks of treatment was 85.9 +/- 5.0% standard error of mean (SEM). Thirty-three patients entered a follow-up observation period of 4 weeks without thromboprophylaxis; 2 weeks into this period 1 had a proximal DVT and 1 had a fatal PE; the course of the remainder was uneventful. We conclude that LMWH compares favorably with standard heparin in preventing venous thromboembolism, and is associated with significantly less bleeding. Eight weeks of prophylaxis seems adequate for most patients.

Stenting of proximal venous obstructions to maintain hemodialysis access

PURPOSE

The purpose of the study was to evaluate the efficacy of stenting central venous obstructions in patients dependent on hemodialysis to preserve or restore central venous patency and allow for continued hemodialysis from the affected side.

METHODS

Twenty-five self-expanding (17) and balloon-expandable (8) stainless steel stents were deployed in 19 patients with end-stage renal disease and central venous stenosis or occlusion. Nineteen lesions were treated: 11 subclavian and eight innominate. Twenty-two stents were initially implanted.

RESULTS

Stent deployment was successful in all cases and immediately remedied the underlying cause of venous hypertension. Follow-up at up to 17 months revealed three deaths from unrelated causes, one occlusion at 3.25 months, and three restenoses at 16 days, 2.5 and 5 months, respectively, with successful implantation of three additional stents for a primary central patency rate of 68% (+/- 14%) and secondary central patency rate of 93% (+/- 7%).

CONCLUSIONS

Stenting of subclavian and innominate venous stenoses and occlusions effectively corrected the underlying lesions responsible for disturbed hemodynamics and, in most cases, prolonged available hemodialysis access from the affected side. Stents seem to be valuable adjuncts in the management of failing hemodialysis access due to central venous stenosis or occlusion.

Ultrasound Guided Balloon Angioplasty: What is its Role?

A modified angioplasty catheter has been developed which can be guided-into position with duplex ultrasound. This reduces the risks of ionizing radiation and contrast agents and uses a modality familiar to the vascular surgeon. This catheter was tested successfully in a canine model for safety, accuracy and therapeutic efficacy. Following FDA approval, clinical trials in humans were initiated. This paper describes the preliminary results with use of this device in humans.

Reduction of plantar pressure with the rigid relief orthosis

The rigid relief orthosis was developed to protect vulnerable sites on the plantar surface of the insensitive foot against reulceration by providing both a nonyielding relief under the healed lesion site and a total contact fit. Clinically, the rigid relief orthosis has been effective in protecting the foot against the trauma induced by the repetitive mechanical stress of walking. This study used both the Hercules and F-Scan pressure transducer systems to measure pressure at the first metatarsal head in three orthotic treatments. Both measurement systems recorded significant reductions in pressure at the first metatarsal head with the rigid relief orthosis, establishing a quantitative rationale explaining its clinical effectiveness. Significant pressure differences were also recorded at the secondary sites of the heel, midfoot, and third metatarsal head.

Reliability of torque range of motion: a preliminary study

The clinical reliability of torque range of motion (TROM) has not been tested. This preliminary review was performed to determine the intra- and interrater reliability of TROM. The proximal interphalangeal joints of the index and middle fingers of 14 normal subjects, 56 digits, were tested by applying extension forces of 200 g, 400 g, 600 g, and 800 g. Data were collected using both the hand-held Haldex orthotic gauge with the dial goniometer (manual) and the cantilever-beam force transducer and electrogoniometer (digital) as testing instruments. The testing order of digits, sides, and devices was randomized and tested separately by three different test teams. Results of the analysis of variance showed a significant difference of the means between raters at all force levels (p < 0.0001) and between instruments at 600-g and 800-g forces (p < 0.01). The Pearson product-moment correlation coefficient test, used to test the consistency, resulted in moderate consistency of measures of intrarater reliability between trials, and between instruments used (digital and manual). Intraclass correlation coefficients (ICCs) were calculated with results that were nearly identical to those of the Pearson. Intrarater reliability was in more consistent agreement at the 600-g and 800-g levels. There was significantly high agreement between the tests of tester B, compared with moderate correlations of the tests of testers A and C.

Transcutaneous ultrasonography can be used to guide and monitor balloon angioplasty

PURPOSE

Percutaneous balloon angioplasty is an accepted technique for the treatment of short segmental stenoses of the iliac and superficial femoral arteries. Some surgeons have not embraced this technique because of lack of training, unfamiliarity with radiologic equipment, or poor-quality fluoroscopy equipment in the operating room. A new technique, ultrasound-directed balloon angioplasty, enables the vascular surgeon to guide the catheter and evaluate the progress of the procedure without the use of radiographic imaging.

METHODS

The new catheter is integrated externally into a standard duplex scanner. A spherical brass bead positioned on the catheter shaft in the middle of the balloon is covered with a piezoelectric material. This omnidirectional receiver is connected through a wire to a catheter interface system, which allows the exact position of the balloon to be represented on the screen of a duplex unit. The catheter is advanced under visual control with use of the scanner.

RESULTS

The system has been used to perform balloon angioplasty on 21 lesions (16 superficial femoral, 3 iliac, 2 popliteal arteries) in 17 patients. Procedures in 16 patients were performed percutaneously; in an additional patient bilateral angioplasties were performed during operation. The balloon was successfully positioned in each case with use of ultrasonography alone; each procedure was confirmed by use of angiography. Angioplasty was accomplished in 16 (76%) of 21 with the ultrasound-guided catheter alone. Supplemental use of a high-pressure balloon or atherectomy device was necessary in five patients.

CONCLUSIONS

This technique records physiologic and anatomic data in real time so that the progress of the angioplasty can be monitored. In three patients the inadequacy of the initial angioplasty was recognized by a persistent velocity increase but not by angiography. As a result corrective measures were taken. This new procedure allows vascular surgeons to use equipment with which they are familiar, reduces the risk of ionizing radiation and contrast nephropathy, and permits the monitoring of the angioplasty with hemodynamic parameters.

Healing rates of plantar ulcers in leprosy and diabetes

Comparison was made of wound healing time in a consecutive series of leprosy and diabetic patients with plantar ulceration. In the leprosy group, 66 of 70 (94%) ulcers healed in a mean time of 42.7 (+/- 36.1) days, and in the diabetic group, 75 of 80 (94%) ulcers healed in a mean time of 39.7 (+/- 32.1) days. Analysis of all healed ulcers using a general linear model found wound depth (p < 0.03), and wound diameter (p < 0.05) significantly related to ulcer healing time. Diagnosis, healing devices (cast, splint and cut-out sandal), age and sex were not significant. In diabetic subjects a regression model including depth, diameter and age explained 36% of the variation in healing time. A meaningful regression model was not found in leprosy patients.

The axes of rotation of the thumb carpometacarpal joint

Two axes of rotation of the carpometacarpal (CMC) joint of seven cadaver thumbs were located using an axis finder. The flexion-extension axis is located in the trapezium and the abduction-adduction axis is in the first metacarpal. These axes are fixed, are not perpendicular to each other or to the bones, and do not intersect. Motion of the first metacarpal on the trapezium can be defined by these two axes. Understanding of the movements of the basal joint of the thumb is essential to the study of its function and reconstruction.

Methods of treating plantar ulcers

The purpose of this article is to describe the indications, precautions, and fabrication techniques for orthotic devices the authors use to facilitate the healing of plantar ulcers. The methods of fabricating and applying three types of orthotic devices developed by the staff at the Gillis W Long Hansen's Disease Center--walking casts, walking splints, and cutout sandals--are described. Patient examples are given for each of the methods. These techniques, in conjunction with patient education and the use of special footwear, provide clinicians with procedures they can use to aid in the healing of plantar ulcers secondary to leprosy, diabetes, or other neuropathic conditions.

Treatment of acute vascular occlusions with intra-arterial urokinase

This study reviewed 57 patients with 71 vascular occlusions treated with urokinase from 1985 to 1988. Of these patients, 89% were candidates for urgent surgery. Total clot lysis was achieved in 73% of cases. The success rate rose with increasing experience (p less than 0.05), and recent occlusions had more favorable outcomes than older ones (p less than 0.05). The length and type of occluded conduit (graft or vessel), age, sex, other medical conditions, and concurrent use of heparin had no influence on success. Of 18 cases successfully lysed and not subjected to any adjunctive therapy directed at the cause of occlusion, 9 (50%) reoccluded within 1 to 88 days (mean: 25 days). Cases successfully treated with thrombolysis and surgery or dilation of the causative stenosis had poor 1-year patencies: 17%, 20%, and 55% for vein grafts, prosthetic grafts, and native arteries, respectively. With additional urokinase treatments, surgical operations, and percutaneous procedures, 1-year patencies were 22%, 45%, and 65%, respectively.

Salvage surgery for renal cell carcinoma

Complete surgical excision of solitary metastatic lesions in renal cell carcinoma has been reported to be associated with improved survival. An analysis of 65 outpatients undergoing excision of metastatic renal cell carcinoma is reviewed. In our series there was no significant difference among patients with solitary versus those with multiple metastasis. The overall 5-year survival was considerably lower than previously reported. We recommend that only patients with good performance status, who are participating in protocols with biological response modifiers, could potentially benefit from surgical removal of metastatic lesions.