Lymphokine-activated Killer Induction and Its Regulation by Macrophages in Malignant Pleural Effusions

Mononuclear cells (MNC) from pleural effusions and peripheral blood of 18 patients with primary lung cancer with malignant pleural effusion were studied. Pleural and blood MNC generated lymphokine-activated killer (LAK) activity similarly when cultured for 4 days with an optimal concentration of interleukin 2 (IL-2). Highly purified lymphocytes (>98%) and monocyte-macrophages (>90%) were isolated by discontinuous Percoll gradient centrifugation from pleural and blood MNC. Pleural macrophages, as well as blood monocytes, showed significant augmenting effects on in vitro LAK cell induction from pleural and blood lymphocytes by IL-2. During daily intrapleural administration of IL-2, significant induction of LAK activity in vivo was observed after 3 days, but then this LAK activity in pleural MNC decreased almost to zero by day 15. Daily injections of IL-2 resulted in reduction in the up-regulation of LAK induction by pleural macrophages and also in increase in the levels of soluble IL-2 receptors in pleural effusions. These findings indicate that in vivo LAK induction of lymphocytes in malignant effusions by IL-2 may be regulated by macrophages in the effusions.     

Lymphokine-activated killer induction and its regulation by macrophages in malignant pleural effusions

Mononuclear cells (MNC) from pleural effusions and peripheral blood of 18 patients with primary lung cancer with malignant pleural effusion were studied. Pleural and blood MNC generated lymphokine-activated killer (LAK) activity similarly when cultured for 4 days with an optimal concentration of interleukin 2 (IL-2). Highly purified lymphocytes (greater than 98%) and monocyte-macrophages (greater than 90%) were isolated by discontinuous Percoll gradient centrifugation from pleural and blood MNC. Pleural macrophages, as well as blood monocytes, showed significant augmenting effects on in vitro LAK cell induction from pleural and blood lymphocytes by IL-2. During daily intrapleural administration of IL-2, significant induction of LAK activity in vivo was observed after 3 days, but then this LAK activity in pleural MNC decreased almost to zero by day 15. Daily injections of IL-2 resulted in reduction in the up-regulation of LAK induction by pleural macrophages and also in increases in the levels of soluble IL-2 receptors in pleural effusions. These findings indicate that in vivo LAK induction of lymphocytes in malignant effusions by IL-2 may be regulated by macrophages in the effusions.     

The immune response at the tumor site in lung carcinoma.

The local immune response to lung cancer was investigated by histologic and immunologic means. Distinctive patterns of stromal cellular reaction, characteristic for different histologic types of lung carcinoma, were recognized. The amount of cellular infiltration was highest in squamous cell carcinomas and lowest or nonexistent in oat cell carcinomas. Within the various histologic categories the well-differentiated tumors appeared to be accompanied by more reactive cells than the poorly differentiated ones; there was no relation between tumor necrosis and cellular infiltration. The plasma cells were distinctly associated with squamous cell carcinomas; their number in the stroma was proportionate to the degree of differentiation and the presence of keratin produced by the tumors. Eluates with a high content of immunoglobulins were recovered from pleural effusions and from solid lung carcinomas by dissociation of antigen-antibody complexes. These preparations reacted positively in indirect immunofluorescence tests with tissue cultures and with fresh suspensions of lung carcinoma cells, but not with tissue culture cells of most nonpulmonary tumors or with cell suspensions of normal adult and fetal lung. Similarly prepared fractions of noncarcinomatous pleural effusions did not react with lung cancer cells.     

恶性胸腔积液来源树突状细胞对自体肿瘤 浸润性淋巴细胞的作用

 目的探讨恶性胸腔积液来源DCs（dentritic cells,DCs）对自体肿瘤浸润性淋巴细胞（tumor infiltration lymphocytes, TILs）增殖及杀伤肿瘤细胞能力的影响。方法用体外培养方法从16例肺癌患 者恶性胸腔积液来源分离单个核细胞,再用密度梯度离心辅以免疫磁珠分选细胞,用白细胞介素4（IL-4 ）、肿瘤坏死因子-α（TNF-α）、粒-单核细胞刺激因子（GM-CSF）等诱导出DCs,用流式细胞仪和电子 显微镜鉴定分离DCs;用IL-2、植物血凝素诱导同一患者胸腔积液单个核细胞中的TILs,用HEA-125磁珠分 选纯化肿瘤细胞,3H-TdR渗入法检测DCs对TILs增殖能力;MTT法检测TILs对肿瘤细胞杀伤活性。结果从肺 癌患者恶性胸腔积液单个核细胞中可诱导成熟DCs,电镜和光镜观察结果显示,这类DCs具有典型的DC形态 ,高表达HLA-ABC、HLA-DR、CD86,较高表达CD80、CD54,也表达CD83、CD1a。DCs可明显促进TILs增殖能 力（增加约1.7倍）。以TILs本身为对照,DCs激活的TILs对肿瘤细胞杀伤活性明显增加［从（31.80± 14.05）%提高到（51.89±13.27）%,P<0.05］。结论肺癌患者恶性胸腔积液单个核细胞中可诱导成熟DCs ,这种DCs可刺激自体TILs扩增,增加TILs杀伤肿瘤细胞的活性。     

癌性胸腹水抗癌药物敏感试验的研究

对５８例癌性腹水及２５例癌性胸水用ＭＴＴ法进行抗癌药物敏感试验。用临床常规方法收集胸腹水，并用肝素抗凝（１０ｕ／ｍｌ）；用不连续密度梯度离心去除渗出液中红白细胞，制成肿瘤单细胞悬液，进行药敏测试。同时观察到卵巢癌患者的实体瘤与腹水之间的肿瘤细胞存活率无统计学意义的不同，相关性较好。应用药敏结果进行胸腹腔给药治疗，效果较好，６０％～７０％患者胸腹水近期得到控制，这对于延长患者生命是有益的。     

Lymphocytes forming rosettes with sheep erythrocytes in metastatic pleural effusions.

Percentages of lymphocytes forming rosettes with sheep erythrocytes at 29 degrees C were determined in 10 cancer patients with metastases to the pleural cavity. Compared with normal controls, the patients showed a decreased proportion of rosette-forming cells (RFC) in the peripheral blood. The same patients had elevated levels of RFC in their metastatic pleural effusions. However, 2 patients with benign diseases had normal levels of RFC in their peripheral blood and pleural transudates. These observations suggested that in cancer patients some T-cells might migrate from the peripheral blood and accumulate in sites of tumor infiltration such as the pleural cavity.     

从恶性胸腔积液体外诱导成熟树突细胞

背景与目的:树突细胞(dendriticcells,DCs)具有激活初始T细胞、引发抗原特异性免疫反应的特性。本研究拟用体外培养的方法,从肺癌患者恶性胸腔积液中诱导出功能健全的DCs。方法:取16例肺癌患者胸腔积液500～1000ml,用密度梯度离心辅以免疫磁珠分选的方法,分离出DCs前体细胞,加入IL鄄4、GM鄄CSF、TNF鄄α诱导出DCs。用电镜和光镜观察培养的DCs,用流式细胞仪检测DCs的表面分子。将不同培养时间的DCs和肿瘤浸润性淋巴细胞(tumorinfiltrativelymphocytes,TILs)作混合淋巴细胞反应,了解DCs对TILs的激活作用。结果:在体外能诱导出恶性胸腔积液来源的功能健全的DCs,电镜和光镜分析表明,这类DCs具有成熟DCs的典型形态;当DCs体外培养到第48h时,表面分子的表达率与培养0h、24h、92h、192h的DCs比较相对较高;DCs可使TILs细胞扩增。结论:可从肺癌患者恶性胸腔积液中诱导具有成熟功能的DCs。     

胸腔积液中肿瘤坏死因子、癌胚抗原和神经元特异性烯醇化酶的检测及诊断价值研究

目的探讨检测胸水中肿瘤坏死因子（TNF-α）、癌胚抗原（CEA）和神经元特异性烯醇化酶（NSE）对胸腔积液的诊断价值。方法采用电化学发光酶免疫分析法检测59例结核性胸水和48例肺癌性胸水患者胸水中TNF-α、CEA和NSE水平。结果结核性胸水中TNF-α水平显著高于肺癌性胸水（P〈0.05）。肺癌性胸水中CEA和NSE明显高于结核性胸水（P〈0.01）。肺腺癌胸水中CEA升高最明显,非小细胞肺癌胸水中NSE升高最显著。联合检测CEA及NSE,诊断敏感度92.0%,准确度86.3%。结论检测TNF-α、CEA和NSE对结核性胸水和肺癌性胸水的诊断及鉴别诊断有较高的临床价值,联合检测胸水CEA和NSE可提高肺癌诊断敏感度。     

Vascular endothelial growth factor levels and induction of permeability in malignant pleural effusions.

Vascular endothelial growth factor (VEGF) is an important mediator of angiogenesis and vascular permeability. We hypothesized that malignant pleural effusions may contain high levels of VEGF protein as well as other cytokines implicated in these processes. Pleural effusions cytologically proven to be malignant were collected from 39 patients with various types of cancer, and VEGF, interleukin-8, and angiogenin levels in the effusions were determined by immunoassay. Negative controls were nonmalignant ascites and serum samples from healthy individuals. VEGF levels were significantly higher than those of control samples in pleural effusions secondary to breast, mesothelioma, and non-small cell lung cancer and when all malignant pleural effusion samples were pooled. Neither interleukin-8 nor angiogenin levels were elevated in malignant pleural effusions relative to the control samples. Vascular permeability, which was measured by using the Miles assay in nude mice, was increased proportionately with VEGF levels in the malignant pleural effusions; this increase in permeability induced by injection of recombinant VEGF or the malignant effusions was reduced by pretreating the mice with a VEGF receptor antibody.     

High level of vascular endothelial growth factor in hemorrhagic pleural effusion of cancer

Angiogenic cytokines, such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and angiogenin, are candidates for the induction of pleural effusions because they have been implicated in the induction of neovascularization, vascular permeability, and hemorrhage both in the inflammatory process and in tumor progression. Thus, we hypothesized that these angiogenic factors in effusion might be involved in the clinical manifestation of malignant pleural disease. We measured the levels of VEGF, bFGF, and angiogenin in pleural effusions and sera from 40 patients. Pleural effusions due to malignancy (1,350 pg/ml) contained significantly higher levels of VEGF than effusions due to inflammatory diseases (102 pg/ml; p = 0.034). Furthermore, hemorrhagic effusions showed significantly higher VEGF levels (1,942 pg/ml) than non-hemorrhagic effusions (202 pg/ml; p = 0.016) in malignant patients. In contrast, neither bFGF nor angiogenin were correlated with any clinical manifestation of pleural effusion. Immunohistochemical study revealed that malignant cells in the pleura were stained with anti-VEGF antibody. Our data suggest that VEGF secreted from tumor cells may be involved in the accumulation of pleural effusion in malignancy, and that increased levels of VEGF may induce hemorrhagic effusion.     

Intrapleural therapy with MDP-Lys (L18), a synthetic derivative of muramyl dipeptide, against malignant pleurisy associated with lung cancer

N2-[(N-acetylmuramoyl)-L-alanyl-D-isoglutaminyl]-N6-stearoyl-L-lysine (MDP-Lys (L18), romurtide) is a synthetic muramyl dipeptide derivative, and has immunomodulating activities including activation of cells of monocyte-macrophage lineage. We examined the effect of intrapleural instillation of MDP-Lys (L18) against malignant pleurisy associated with lung cancer. Six patients with cytologically-positive malignant pleural effusion (four with adenocarcinoma, one with small cell carcinoma and one with large cell carcinoma) were treated with single intrapleural instillation of MDP-Lys (L18) of 200 microg. Clinically, no reaccumulation of pleural effusion for at least 4 weeks was observed in four patients. No major side effects were observed. Total cell number elevated remarkably 4 h after instillation, and main increased population was that of neutrophils. Levels of chemotactic cytokines, such as interleukin (IL)-8, and monocyte chemotactic protein (MCP)-1 and levels of pro-inflammatory cytokines, such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta and IL-6, elevated in pleural effusion, and peak IL-1beta and IL-6 levels tended to be higher in clinical responders than non-responders. These results suggest MDP-Lys (L18) instilled by intrapleural route had a potential local immunomodulatory activity. Further study is warranted to further determine the critical factors which correlate with the clinical response.     

Evaluation of pleural fluid human epididymis 4 (HE4) as a marker of malignant pleural effusion

Pleural effusion is a commonly encountered problem in clinical practice, and pleural fluid analysis is usually the first step towards identifying the underlying etiology. Numerous studies have been published analyzing the potential utility of measuring biomarkers in pleural fluid as possible indicators of a malignant effusion; however, there are no studies that have examined the presence of human epididymis 4 (HE4) in pleural effusions. The aims of this study were to assess pleural effusion and serum concentrations of HE4 in patients with different types of pleural effusions and to evaluate the diagnostic performance of HE4 in detecting malignant pleural effusion. A prospective cohort study was carried out of 88 consecutive patients presenting with pleural effusions. The patients were divided into three groups: 22 patients with transudative effusions, 32 patients with non-malignant exudative effusions, and 34 patients with malignant pleural effusions. Blood and pleural fluid HE4 levels were measured using immunoassay. Both serum HE4 levels and pleural effusion HE4 levels were significantly higher in patients with malignant effusions than in patients with transudative or non-malignant exudative effusions. A pleural fluid HE4 cutoff value of 1,675?pmol/L was found to predict malignant pleural effusions with a diagnostic sensitivity of 85.3?% and specificity of 90.7?%. The current study reports a novel finding of increased serum and pleural fluid HE4 levels in patients with malignant effusions compared to non-malignant effusions. This finding has the potential to strengthen the diagnostic performance of tumor markers in detecting malignant pleural effusions.     

Pleural effusion in breast cancer. Thoracoscopy for hormone receptor determination

Metastatic breast cancer frequently presents as a malignant pleural effusion. Knowledge of the estrogen and progesterone receptor status of the tumor predicts response to hormonal therapy, but breast cancer tissue in the pleural space is not readily accessible for hormone receptor determination. Thoracoscopy was used in six breast cancer patients with pleural effusions; all but one had concurrent sites of metastases. In five of six women recurrent breast cancer in the pleural cavity was diagnosed by thoracoscopy, and in four sufficient tissue was obtained for receptor assay. All patients achieved excellent control of their pleural effusions through a combination of local sclerotic measures and systemic therapy. Thoracoscopy is a safe procedure that can be performed under local anesthesia and is useful to visualize the pleural space, not only for diagnosis but also for obtaining breast cancer tissue for hormone receptor determination.     

Up-regulation of pro-angiogenic factors and establishment of tolerance in malignant pleural effusions

Introduction

Malignant pleural effusions (MPEs) are a significant source of cancer morbidity and mortality. Currently there is no cure for MPEs and treatments only palliate the symptoms. The purpose of this study was to determine if there are differences in markers of angiogenesis and immune phenotypes between adenocarcinoma-induced MPEs and benign pleural effusions (BPEs).

Methods

Pleural effusions were collected from patients with MPEs and BPEs. Cells were isolated from effusions and characterized using fluorescent cell sorting (FACS). Pleural effusions were evaluated by ELISA for VEGF-A. An angiogenesis protein array was completed to compare protein expression in malignant and non-malignant effusions.

Results

FACS analysis demonstrated lower accumulation of cytotoxic T-cells and significantly higher accumulation of monocytes, dendritic cells, mesothelial and tumor cells in MPEs compared to benign pleural effusions. MPEs were found to have 77-fold higher VEGF-A levels compared to BPEs. The angiogenesis protein array demonstrated elevated levels of pro-angiogenic factors VEGF-A, CXCL4 and MMP-8, and low levels of pro-inflammatory cytokines IL-8, MCP-1, and TGF-β1 in MPEs.

Conclusions

MPE is biased toward a Th2 dominant state. There is an increase in expression of VEGF-A and other pro-angiogenic factors in MPE. These data suggest there is a role for anti-angiogenesis therapy in patients with MPEs.     

Regulatory T cells and cytokines in malignant pleural effusions secondary to mesothelioma and carcinoma

Immunotherapy against a variety of malignancies, including pleural-based malignancies, has shown promise in animal models and early human clinical trials, but successful efforts will need to address immunosuppressive factors of the tumor and host, particularly certain cytokines and CD4(+) CD25(+) regulatory T cells (Treg). Here, we evaluated the cellular and cytokine components of malignant pleural effusions from 44 patients with previously diagnosed mesothelioma, non-small cell lung cancer (NSCLC), or breast cancer and found significant differences in the immune profile of pleural effusions secondary to mesothelioma vs. carcinoma. Although a high prevalence of functionally suppressive CD4(+) CD25(+) T cells was found in carcinomatous pleural effusions, mesothelioma pleural effusions contained significantly fewer CD4(+) CD25(+) T cells. Activated CD8(+) T cells in pleural fluid were significantly more prevalent in mesothelioma than carcinoma. However, there is clear patient-to-patient variability and occasional mesothelioma patients with high percentages of CD4(+) CD25(+) pleural effusion T cells and low percentages of CD8(+) CD25(+) pleural effusion T cells can be identified. Mesothelioma pleural effusions contained the highest concentrations of the immunosuppressive cytokine transforming growth factor (TGF)-beta. Thus, the contribution of cellular and cytokine components of immunosuppression associated with malignant pleural effusions varies by tumor histology and by the individual patient. These results have implications for the development of immunotherapy directed to the malignant pleural space, and suggest the need to tailor immunotherapy to overcome immunosuppressive mechanisms in tumor environments.     

Performance of the mucinous-like carcinoma-associated antigen in serous effusions.

The mucinous-like carcinoma-associated antigen (MCA), a new tumour marker, was dosed in 150 serous effusions. The levels of MCA were measured by means of an enzyme immunoassay (EIA). Ninety-seven were pleural effusions, 49 were peritoneal effusions and 4 were pericardial effusions. Thirty-five effusions were caused by breast carcinoma, 19 by ovarian carcinoma, 17 by pulmonary carcinoma, 19 by various cancers, while 60 effusions turned out to be of non-neoplastic origin. The results were considered in comparison with the cytologic examination, and the data obtained were also elaborated in terms of sensitivity, specificity, predictive value and test efficiency. The EIA showed satisfactory statistical parameters principally regarding ovarian metastatic cancer. On the other hand, less satisfactory results were extrapolated on breast and lung cancers. Even if further studies are necessary, for example to compare MCA with other seric tumour markers, this experience suggests that MCA could be a satisfactory tumour marker in the diagnosis of metastatic ovarian effusions.     

Clinical evaluation of four tumor markers in malignant and benign pleural effusions.

Total sialic acid (TSA), lipid-bound sialic acid (LSA), ferritin and carcinoembryonic antigen (CEA) were evaluated in 55 patients with malignant pleural effusions and in 32 patients with benign (exudative) pleural effusions. No significant differences were found in the pleural fluid TSA, LSA and ferritin levels between malignant and benign conditions. CEA levels in malignant effusions were significantly higher than those in benign effusions (43.13 +/- 72.8 ng/ml versus 2.6 +/- 5.56 ng/ml, p less than 0.01). At a cut-off level of 5 ng/ml, 60% of the patients with cancer showed elevated pleural fluid CEA levels. The specificity and diagnostic accuracy of CEA in distinguishing malignant from benign pleural exudates were both very high (91% and 71% respectively). Therefore, of the four markers investigated, only CEA could be a valuable tool in the detection of pleural malignancy.     

New approaches in the diagnostic procedure of malignant pleural effusions

The content of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (Ca 19-9), carbohydrate antigen 15-3 (Ca 15-3) and the expression of LewisY related carbohydrate antigens in benign and malignant pleural effusion were determined. These included 35 malignant pleural effusions: 13 breast cancers, 12 lung cancers (6 squamous cell carcinomas, 5 adenocarcinomas and 1 microcytoma), 2 mesotheliomas, 1 epithelioma, 1 kidney cancer, 1 hepatocarcinoma, 1 colon carcinoma, 3 lymphomas, 1 osteosarcoma and 9 benign pleural effusions. We showed that pleural fluid content of CEA, Ca 19-9 and Ca 15-3 were higher in malignant than in benign effusions. However CEA levels in squamous lung cancers were very high in both serum and pleural fluids whereas its levels were only slightly above the cut-off in breast cancers and in lung adenocarcinomas. Serum and pleural fluid Ca 15-3 values were higher in breast and in lung cancers with the highest values in the patients with breast cancer. Furthermore, the LewisY related carbohydrate antigens, evaluated by the reactivity of the cell extracts to MAb B3, were expressed only in breast cancers. These data suggest that pleural fluid content of CEA, and Ca 15-3 associated with the immunoblotting of cell extracts with MAb B3 appear to be very useful to improve the diagnosis of malignant pleural effusions.     

Pulmonary surfactant protein A in pleural effusions.

Pulmonary surfactant protein A (SP-A) is known to be a major phospholipid-associated glycoprotein in pulmonary surfactant, which is specific to the lung. Immunohistochemically, expression of SP-A in tumor tissues is found in approximately 50% of patients with lung adenocarcinoma but not in the other histologic types of lung cancer of metastatic lung tumors. In this study, the SP-A content of pleural effusions was determined using an enzyme-linked immunosorbent assay. These results showed that approximately 40% of patients with lung adenocarcinomas (27 of 67) had high levels of SP-A (greater than 500 ng/ml) in their pleural effusions. By contrast, patients with other histologic types of lung cancers, adenocarcinomas of different primary sites, and tuberculosis had low levels of SP-A in their pleural effusions. The determination of SP-A in malignant effusions will contribute to distinguishing primary lung adenocarcinoma from adenocarcinomas of miscellaneous origin.     

The Role of Vascular Endothelial Growth Factor in the Pathogenesis, Diagnosis and Treatment of Malignant Pleural Effusion

Malignant pleural effusions (MPEs) are a significant source of cancer-related morbidity. Over 150,000 patients in the United States suffer from breathlessness and diminished quality of life due to MPE each year. Current management strategies are of mostly palliative value and focus on symptom control; they do not address the pathobiology of the effusion, nor do they improve survival. Further elucidation of the pathophysiological mechanisms, coupled with the development of novel treatments such as intrapleural chemotherapeutics targeting this process, has the potential to greatly improve the efficacy of our current management options. Vascular endothelial growth factor-A (VEGF-A) has been implicated as a critical cytokine in the formation of malignant pleural effusions. Elevated levels of VEGF produced by tumor cells, mesothelial cells, and infiltrating immune cells result in increased vascular permeability, cancer cell transmigration, and angiogenesis. Therefore antiangiogenic therapies such as Bevacizumab, a monoclonal antibody targeting VEGF-A, may have a potential role in the management of malignant pleural effusions. Herein we review the pathogenesis and potential treatment strategies of malignant pleural effusions, with a focus on angiogenesis and antiangiogenic therapeutics.