Immunological relevance of the tumor associated antigen (TAA) COA-1 in colorectal cancer (CRC)

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Background: Immunotherapy (IT) in CRC has often produced discouraging results. COA-1 is a new TAA recognized by CD4+ T cells from peripheral blood (PB) of a CRC pt; its immunogenic epitope is presented on the surface of tumor cells in association with DRβ1*1301 or *0402 HLA class II molecules. Our aim is verifying whether an immune response directed against COA-1 mediated by CD4+ T cells can be isolated from PB of CRC pts. To achieve a more efficient anti-tumor response a recognition of a specific antigen by both the CD4+ and CD8+ lymphocytes should be performed; so different epitopes deriving from the processing of the same antigen should be presented to the immune system in association with both class I and class II MHC molecules. We identified a list of COA-1 derived peptides with the calculated score for the binding to HLA-A2, the more common HLA class I molecule within the Caucasian population. A failure in generating COA-1 specific T cells was observed in stage I-II CRC pts. Methods: From Jan 04 to day PB samples from 36 CRC pts (14 stage III/ 22 stage IV) have been collected and the HLA typing has been performed. Pts. expressing HLA DRbβ*0402, HLA DRβ1*1301 or HLA-A2 have been selected to collect other blood drawns and verifying whether an immune response directed against COA-1 could be isolated from their PB. Results: 4 pts were positive for the expression of DRβ1*1301 and 2 for the expression of DRβ1*0402. PB lymphocytes have been in vitro stimulated with the COA-1 derived epitopes and tumor reactivity has been verified. An immune response directed to COA-1 was detected in the PB of these 6 pts; anti-COA-1 CD4+ T cells were in vitro isolated and their cytotoxicity measured by granzyme B release. 9 pts were positive for the expression of HLA-A2 and we are stimulating the lymphocytes isolated from these pts with 6 selected COA-1 derived peptides binding the HLA-A2. We observed specific CD8+ T cells for 2 peptides in 1 pt. Conclusions: Our data identify COA-1 like an immunogenic antigen that can evoke an anti-tumor immune response CD4+ mediated in CRC; the response correlates with disease progression. Experiments are ongoing to evaluate an immune response mediated by both CD4+ and CD8+ T cells. These results will determine whether COA-1 could be used for future protocols of IT in CRC.

No significant financial relationships to disclose.

High prevalence of vitamin D deficiency in premenopausal women with early-stage breast cancer

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Background: The use of bisphosphonates in the treatment of breast cancer is increasing for patients with metastatic and early-stage disease. Vitamin D deficiency may be a risk factor for breast cancer development and is very common in the northeastern US. Vitamin D deficiency appears to increase the risk of hypocalcemia following IV bisphosphonate therapy. The purpose of this study is to evaluate the prevalence of vitamin D deficiency following the initial diagnosis of breast cancer. Methods: We analyzed fasting morning blood from premenopausal women, from the northeastern US, diagnosed with stage I/II breast cancer. Bloods were obtained following curative surgery, and prior to initiating therapy. Serum was archived, stored at -70o and analyzed in batches in a research laboratory for 25-hydroxyvitamin D (25-OHD; Diasorin RIA), albumin-corrected calcium, phosphate, parathyroid hormone (PTH), markers of bone turnover, FSH, LH, estradiol and sex hormone binding globulin (SHBG). Information on demographic, clinical and tumor characteristics were collected and bone mineral density (BMD) was measured (Hologic 4500). Data were analyzed using SAS version 9. Results: We analyzed sera from 36 premenopausal women, none of whom were taking calcium or vitamin D supplements. The mean age was 42 (range 27–54). The mean serum 25-OHD was 22.6 ng/dl, (SD 7.4) and similar among all racial/ethnic groups. Only 4 patients met contemporary criteria for optimal levels (>30 mg/ml); 18 patients had levels between 20–30 mg/ml, 14patients had “insufficient” levels (<20 mg/ml), and 3 patients had “deficient” levels (<12). Serum 25-OHD was inversely associated with serum PTH and free estradiol, and directly associated with SHBG. There were no associations between serum 25-OHD and serum calcium, phosphate, bone turnover markers, or BMD. Conclusions: Suboptimal vitamin D levels are surprisingly common among premenopausal women with early stage breast cancer. The associations between serum 25-OHD, SHBG and free estradiol, suggest that serum levels of vitamin D binding protein may be influencing 25-OHD measurements. Serum 25-OHD should be measured and low levels supplemented before initiating adjuvant bisphosphonate therapy, as vitamin D deficiency may increase the risk of hypocalcemia.

No significant financial relationships to disclose.

[Clinical guidelines for the management of gastrointestinal stromal tumors]

Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid progress at molecular and clinical level observed in the last few years, there is a need to review the current state of the art in order to delineate appropriate guidelines for the optimal management of these tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology, molecular biology and imaging, were invited to participate in a meeting to present and discuss a number of pre-selected questions, and to achieve a consensus according to the categories of the National Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117, CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib therapy are not well known, but they should include reduction in tumor size and disease stabilization, as well as reduction of tumor density on CT scan and metabolic activity on PET scan.

Treatment of gram-positive surgical sepsis: role of the oxazolidinones

Surgical sepsis is still too frequent (the thirteenth cause of death in the U.S.) with an estimated cost of 5-10 billion dollars. Since the early 1990s antibiotic resistance has become a serious public health problem, with a relevant increase in nosocomial gram-positive infections. The oxazolidinones, a new class of antibiotics acting on bacterial synthesis at a very early stage, were first commercialized in 1987, and linezolid was the first antibiotic in this class registered for clinical use. This new molecule has been shown to be effective in a variety of aerobic and anaerobic infections (both nosocomial and community-acquired), especially those due to gram-positive agents. Linezolid has complete bioavailability in parenteral and oral administration, is well tolerated and shows little toxicity, thus favoring a shortened hospital stay, improving the patient's quality of life and reducing social costs. Oxazolidinones may be considered the first choice in the treatment of resistant gram-positive infections.

Drug-induced modulation of carcinoembryonic antigen (CEA) expression in neoplastic cells from a patient with rectal cancer

Treatment with 5-fluorouracil (5-FU) or recombinant interferon-gamma (IFN), alone or in combination, was found to increase carcinoembryonic antigen (CEA) expression in several carcinoma cell lines. In this study we examined the in vitro effect of these agents on CEA expression of tumor cells, obtained from a patient operated for rectal cancer. The results showed that exposure of cancer cells to 5-FU or to IFN resulted in increased CEA levels in terms of percentage of CEA-positive cells and mean fluorescence values, as indicated by FACS analysis. However, drug combination did not induce CEA expression higher than that provided by single agents alone. Treatment with 5-FU or with IFN produced a reduction of the total number of viable cells. Moreover, Western blot analysis revealed that exposure of cancer cells to each drug was followed by a substantial increase of the total cellular CEA content. On the contrary, 5-FU in combination with IFN did not increase the expression of the antigen more than that obtained by single agents. Noteworthy, exposure of CEA-negative cells from adjacent normal rectal tissue to both agents alone or in combination, did not result in CEA induction. In conclusion, the present results suggest new approaches aimed at (a) increasing the sensitivity of diagnostic procedures based on detection of CEA-positive tumor cells; (b) facilitating the recognition of CEA-positive cancer cells by immune responses induced by anti-CEA peptide vaccines.

Flow cytometric DNA ploidy, p53, PCNA, and c-erbB-2 protein expressions as predictors of survival in surgically resected gastric cancer patients

In order to determine retrospectively the impact of some cytometric and immunohistochemical parameters on the overall survival of gastric cancer patients treated with surgery alone, paraffin-embedded tumor samples from 137 gastric carcinoma patients undergoing curative resection from 1987-1993 were analyzed by flow cytometry (FCM) and immunohistochemistry (p53, c-erbB-2, and PCNA expression). FCM-derived parameters were DNA ploidy and fraction of S-phase cells (SPF). Multiple regression analysis was applied to determine the prognostic significance of the conventional clinicopathologic findings together with the flow cytometric and immunohistochemical parameters on overall survival. When all parameters were entered simultaneously into the Cox regression model, stage and DNA ploidy (DNA index >1.35) clearly emerged as the only independent prognostic factors. When the stages were analysed separately, the independent prognostic factors resulted DNA ploidy in early stages (I-II) and grading in stage IIIA tumors. For stage IIIB tumors, no independent prognostic factor was found. These results indicate that the DNA ploidy pattern is a valuable predictor of survival in curatively resected gastric cancer patients, especially when less advanced tumors are taken into consideration.

Monitoring of antimicrobial prophylaxis in general surgery

The incidence of infections in general surgery is related to different factors. Cost-benefit analysis of antimicrobic prophylaxis is positive, even though incorrect use may be even dangerous (development of resistance and/or superinfections, for instance). The authors report data on a study concerning a total of 316 patients divided into two series, who had antimicrobic prophylaxis before a surgical operation. 274 patients out of 316 (or 86.7%) had an ultra-short (one-shot-only) or short (<24 hours) prophylaxis, 42 (13.3%) standard (>24 hours). The operations performed were classified following class of contamination, i.e. I (clean), II (potentially contaminated), III (contaminated). Antibiotics used were ceftizoxime, cefepime, ceftriaxone, piperacillin and gentamicin in combination. A total of 16 postoperative infections was observed (5%); 11 of these 16 belonged to class III operations. Escherichia coli and Staphylococcus aureus were isolated in most of the infected wounds. The data confirm what is reported in the literature. The authors conclude that a preoperative single-shot 3rd or 4th generation cephalosporin reduces the incidence of wound infections in clean and clean-contaminated surgery.

Palliative treatment of extrahepatic bile ducts tumors

Extrahepatic bile duct (EHBD) tumors often become symptomatic in an advanced stage when curative resection is seldom possible. In a group of 111 patients, 7 (6.3%) received no treatment, 32 (28.8%) underwent non-operative biliary drainage (NOD), and 72 (64.8%) underwent surgical exploration. Radical resection was possible in only 25 cases (34.7%); 14 patients (19.4%) underwent a biliary digestive bypass (BDB), 15 (20.8%) received a transtumoral biliary prosthesis (TBP), and 18 (25.0%) an external biliary drainage (EBD). Average survival rates were: 6.5 months after BDB, 4.0 months after TBP, and 2.8 months after EBD. In a second group of 2,066 patients with primary and secondary malignant obstruction of the upper EHBD, treated with the insertion of a Carey-Coons transhepatic transtumoral biliary prosthesis, the average survival was 4.3 months. The early morbidity rate was 0.6%. Obstruction of the prosthesis occurred in 91 patients (4.4%), and the late morbidity rate was 3.6%. Although EHBD tumor treatment results are generally poor, surgical exploration should be performed in all patients with acceptable surgical risk, and without evidence of disseminated disease. When resection of the tumor is not feasible, we favor the use of a BDB or of a biliary prosthesis over that of an external drainage. In poor risk cases or cases with evidence of disseminated disease, we prefer the placement of an internal prosthesis (PTBD or endoscopic.

Immuno-chemotherapy of advanced colorectal cancer with alpha-2a interferon and 5-fluorouracil. Immunopharmacological studies

Twelve patients with metastatic colorectal cancer received alternating cycles of low immunomodulating doses of alpha-IFN + 5-Fluorouracil (5-FU) or 5-FU alone. Hematological, biochemical and physical evaluation showed that both treatment cycles were well tolerated. However, transient fever and moderate flu-like symptoms were observed following alpha-IFN administration. Treatment with 5-FU alone produced long-lasting inhibition of CD8+ T lymphocytes, but did not depress NK activity (NKA). Combined treatment with alpha-IFN produced a short-term increase of NKA and antagonized the effect of 5-FU on CD8+ cells on day 5 of the cycle. Parallel studies on in vitro models showed antiproliferative effects of 5-FU on PHA-stimulated MNC and confirmed the preferential inhibition of CD8+ cells. Pretreatment with alpha-IFN did not reverse the effect of 5-FU on CD8+ lymphocytes, but partially protected MNC from the toxic effects of the drug. This was presumably due to the cytostatic effects induced by alpha-IFN on MNC before exposure to the cycle-specific antineoplastic agent. This investigation suggests that alpha-IFN could play a positive role in immuno-chemotherapy of colorectal cancer through multiple mechanisms not entirely related to direct antitumor effects of the agent.

[Lymphovenous anastomosis in severe ascites]

The authors dealt with 37 patients suffering from advanced liver cirrhosis with ascites. Eighteen patients out of them underwent Denver peritoneum-jugular shunt as a first choice procedure, the other 19 patients underwent lymphovenous anastomosis. The extremely advanced hepatic damage and the general conditions of these patients discouraged us to perform a portocaval shunt. In the 19 patients who underwent lymphovenous anastomosis we had no mortality rate. Two patients showed post-operative complications: 1 patient complained which hoarseness regressed in 5 months and the other patient suffered from a spleno-mesenteric-portal thrombosis with digestive hemorrhage from gastro-esophageal varices. In 6 patients out of 19 who underwent lymphovenous anastomosis, we did not obtain any immediate positive effects on ascites. In 4 patients, after 3 months, the ascites came back ingravescent and in the other 9 patients the positive effects on ascites were still evident after 1 year. Despite failure to obtain very comforting results, they suggest to employ this technique at any rate, as the first procedure, to make ascites more "manageable", because of its safety.

[The Denver peritoneojugular shunt. Current indications]

Personal experience of 31 patients suffering from intractable ascites due to advanced liver cirrhosis between 1978 and 1987 is reported. Seventeen patients were selected for a peritoneojugular shunt: in 3 patients the Le Veen shunt was performed and in 14 the Denver shunt was preferred. The high postoperative morbidity and mortality due to liver failure, DIC, hepatorenal syndrome, bleeding, sepsis and cerebral thrombosis is pointed out. Careful selection of patients to be submitted to this surgical procedure is essential because of the high morbidity due to ascites reinfusion. DIC has to be diagnosed as soon as possible and, when severe, the prompt interruption of the peritoneojugular shunt is mandatory.

Immunochemotherapy of advanced colorectal cancer with alpha-interferon and 5-fluorouracil. 1. Toxicological studies

Twelve patients with advanced colorectal cancer were subjected to alternating cycles of treatment with low immunomodulating doses of recombinant alpha-interferon (alpha IFN) + 5-fluorouracil (5FU) or with 5FU alone. Hematological, biochemical and physical evaluation of the patients showed that alpha IFN + 5FU cycles were well tolerated like 5FU alone, except for modest and transient fever following alpha IFN administration. At hematological nadir (day 15-18 of each cycle) lymphocytopenia and granulocytopenia were more pronounced during alpha IFN + 5FU than 5FU cycles. No difference was found for platelet nadir. At the beginning of each cycle complete leukocyte recovery was observed in all cases. Platelet recovery was also complete, although counts were higher after alpha IFN + 5FU than after 5FU alone. Clinical results showed 1 complete remission, 1 partial remission, 5 stable disease and 5 progressive disease. These data point out that low doses of alpha IFN can be safely associated with 5FU. However further studies are required to establish the possible therapeutic value of alpha IFN-mediated immunomodulation for immunochemotherapy of colorectal cancer.

Short-term prophylaxis with cefuroxime in colorectal surgery for cancer

A controlled study of short-term prophylaxis with cefuroxime was performed on a group of 52 patients with colorectal neoplasms who underwent elective surgery. The patients were divided into two groups, A and B. Group A received the antibiotic immediately before surgery, intraincisionally and immediately after the end of operation; group B was treated only postoperatively. Each patient received a total of 5,250 mg of cefuroxime. Wound sepsis was demonstrated in 11.5% of cases of group A and 23.0% of group B (P less than 0.01); another type of sepsis was observed in 34% of group A and 11.5% of group B (P less than 0.001). There was no difference in the operative mortality in the two groups.

Effects of intravenous erythromycin lactobionate in respiratory infections

The antibiotic erythromycin lactobionate given intravenously acts almost exclusively on Gram-positive bacteria. Even at high plasma and tissue concentrations there is an almost total absence of side-effects. It could be considered, therefore, as first choice in the treatment of patients with infectious respiratory diseases. Most of the 40 patients admitted to the present study were elderly and all had either acute or chronic and becoming acute respiratory disease. Their clinical symptoms and levels of phlogosis improved on treatment with erythromycin lactobionate without any interruption of therapy due to side-effects and toxicity. The absence of unfavourable pharmacological interactions further enhances the usefulness of the drug. In view of the excellent response to monotherapy with erythromycin lactobionate and the few groups of resistant bacteria found in those cases when it was possible to check, it was not considered necessary to investigate any synergistic association with other antibiotics. It can be concluded, therefore, that therapy with erythromycin lactobionate in patients with infective respiratory disease is favourable and patients show excellent tolerability.

Ranitidine and somatostatin. Their effects on bleeding from the upper gastrointestinal tract

In a randomized, double-blind placebo-controlled clinical trial, the effect of ranitidine was compared with the effect of somatostatin in the control of massive gastrointestinal tract bleeding. Ninety-six patients completed the study. Rates of continuing bleeding and death, incidence of surgery, and blood transfusion requirements were not significantly different in the three treatment groups. Eighteen of the 96 patients presented with a visible vessel at endoscopy. In this group the percent of patients with continuing bleeding, mean transfusion requirements, and mortality were significantly higher than in patients without a visible vessel. Seven patients with a visible vessel underwent surgery and six survived; 11 patients underwent conservative measures and eight died. Ranitidine and somatostatin do not seem to alter the clinical course of patients with upper gastrointestinal tract hemorrhage.

Hepatic staging in operable breast cancer: a reappraisal from a prospective study

A consecutive series of 100 patients affected by breast cancer and referred for surgical treatment were studied for the eventual spread of the tumour to the liver (echography, carcinoembryonic antigen [CEA], hepatic enzymes). Hepatic echography was positive in five cases: two also had bone and skin metastases at the time of diagnosis, and one was a case of remastectomy (these three patients died rather quickly of the disease); the remaining two patients are free of the disease 24 months after surgery and thus should be considered false-positive cases. Hepatic enzymes were not significant. The same was true for CEA except in nine cases with levels much greater than 20 ng/ml (six of these had early local and/or distant metastases). It is concluded that the usefulness of routine hepatic echography before locoregional treatment of breast cancer is rather limited. CEA much greater than 20 ng/ml may be useful prognostically.

Combined ultrasounds and CEA in preoperative assessment of hepatic metastases from gastrointestinal malignancies

A consecutive series of 100 patients affected by gastrointestinal malignancies entered a prospective controlled study of liver metastases performed by ultrasound echography, CEA, hepatic enzymes (only alkaline phosphatase (AP) was found to be somehow significant). Laparotomic inspection and palpation were taken as objective control of ultrasound scan. Eighteen out of the 100 patients showed diffuse hepatic metastases at surgery (all controlled histologically). Hepatic echography correctly diagnosed liver metastases in 15 out of these 18 patients (= 83.8% sensitivity); two more cases (hepatic fibroangiomas) were interpreted as metastases (= 89.9% specificity). CEA-RIA assay was pathologic (greater than 10 ng/ml) in all of the 18 patients with liver metastases; 21 out of the 82 without liver metastases were CEA positive (difference of mean values statistically significant at P less than 0.01). The only significant hepatic enzyme was AP, which was pathologic in 12 out of 18 patients with liver metastases. The comparative evaluation of the three tests showed that ultrasound scanning missed three cases of diffuse hepatic metastases, which, however, were CEA positive, while AP could not help to correct such misdiagnosis.

[The value of echotomographic data in mesenteric cysts]

The Authors report a case of chylous mesenteric cyst of great size in an adult patient. They stress the diagnostic value of roentgen and sonographic findings that are determinant for a correct preoperative diagnosis. Sonography is the most important diagnostic tool; it leads to identification and localization of the mass; moreover it gives other important information about its physic composition. The various pathology that have a similar sonographic relief are discussed and differential diagnostic characters are referred.

[Rupture of the transplanted kidney]

Five cases of kidney grafts followed by rupture are described. The explanation of the syndrome accompanying such an occurrence is deduced from personal observations as well as from literature data. As a matter of fact, the aetiopathology of this syndrome cannot be with an isolated cause, for several multifactorial immunological and non-immunological components may be involved.

[Arteriovenous fistulas for hemodialysis. Experience in 366 cases]

The surgical techniques adopted in performing 366 a-v fistulas for hemodialysis in 346 patients over ten years' experience are presented. A survey of the results obtained is then made as well as the evaluation of the same, based upon functional and clinical parameters. The technical details sometimes adopted, the occlusions and the principles drawn out for personal experience in this field are described.

Intraoperative assessment of mitral valve function

Clinical, echocardiographic, hemodynamic, and angiographic data can usually assess the preoperative status of the mitral valve quite accurately. However, there is need for an intraoperative method to observe the dynamic function of the mitral valve, particularly after an open commissurotomy, or to determine the efficacy of a valvoplasty. Our experience with more than 250 mitral annuloplasties has led to the development of a safe method for direct observation of the mitral closure mechanism using the left ventricular vent and a slight modification of the usual cardiopulmonary circuit.