Neoadjuvant treatment of hepatic malignancy: an oncolytic herpes simplex virus expressing IL-12 effectively treats the parent tumor and protects against recurrence-after resection

The objective of the study was to evaluate the utility of NV1042, a replication competent, oncolytic herpes simplex virus (HSV) containing the interleukin-12 (IL-12) gene, as primary treatment for hepatic tumors and to further assess its ability to reduce tumor recurrence following resection. Resection is the most effective therapy for hepatic malignancies, but is not possible in the majority of the patients. Furthermore, recurrence is common after resection, most often in the remnant liver and likely because of microscopic residual disease in the setting of postoperative host cellular immune dysfunction. We hypothesize that, unlike other gene transfer approaches, direct injection of liver tumors with replication competent, oncolytic HSV expressing IL-12 will not only provide effective control of the parent tumor, but will also elicit an immune response directed at residual tumor cells, thus decreasing the risk of cancer recurrence after resection. Solitary Morris hepatomas, established in Buffalo rat livers, were injected directly with 10(7) particles of NV1042, NV1023, an oncolytic HSV identical to NV1042 but without the IL-12 gene, or with saline. Following tumor injection, the parent tumors were resected and measured and the animals were challenged with an intraportal injection of 10(5) tumor cells, recreating the clinical scenario of residual microscopic cancer. In vitro cytotoxicity against Morris hepatoma cells was similar for both viruses at a multiplicity of infection of 1 (MOI, ratio of viral particles to target cells), with >90% tumor cell kill by day 6. NV1042 induced high-level expression of IL-12 in vitro, peaking after 4 days in culture. Furthermore, a single intratumoral injection of NV1042, but not NV1023, induced marked IL-12 and interferon-gamma (IFN-gamma) expression. Both viruses induced a significant local immune response as evidenced by an increase in the number of intratumoral CD4(+) and CD8(+) lymphocytes, although the peak of CD8(+) infiltration was later with NV1042 compared with NV1023. NV1042 and NV1023 reduced parent tumor volume by 74% (P<.003) and 52% (P<.03), respectively, compared to control animals. Treatment of established tumors with NV1042, but not with NV1023, significantly reduced the number of hepatic tumors after resection of the parent tumor and rechallenge (16.8+/-11 (median=4) vs. 65.9+/-15 (median=66) in control animals, P<.025). In conclusion, oncolytic HSV therapy combined with local immune stimulation with IL-12 offers effective control of parent hepatic tumors and also protects against microscopic residual disease after resection. The ease of use of this combined modality approach, which appears to be superior to either approach alone, suggests that it may have clinical relevance, both as primary treatment for patients with unresectable tumors and also as a neoadjuvant strategy for reducing recurrence after resection.     

Hemodynamic changes during displacement of the beating heart using epicardial stabilization for off-pump coronary artery bypass graft surgery

OBJECTIVE: To evaluate the hemodynamic alterations during off-pump coronary artery bypass graft surgery to determine the degree of impairment caused and the techniques to rectify them. DESIGN: Prospective, observational cohort study performed from January 2000 through September 2000. PARTICIPANTS: Patients (n = 500) with coronary artery disease undergoing multivessel off-pump coronary artery bypass graft surgery using the Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, MN). Unstable patients with ongoing ischemia were excluded from the study. INTERVENTIONS: All patients were monitored with radial artery and pulmonary artery catheters and continuous transesophageal echocardiography monitoring with a multiplane transducer. The perioperative requirement of an intracoronary shunt, inotropes, or an intra-aortic balloon pump was noted. The effect of the Trendelenburg position and fluids on hemodynamics was observed. The need for defibrillation and institution of emergency cardiopulmonary bypass were major endpoints to determine the inability of the patient to tolerate displacement of the heart. MEASUREMENTS AND MAIN RESULTS: Mean patient age was 59.3 +/- 11.6 years. There were 204 (40%) patients in the high-risk category; 54 (10.8%) patients had left ventricular ejection fraction <25%. The mean number of grafts was 2.7 +/- 0.8. Vertical displacement of the heart to access the lateral and inferior walls decreased the mean arterial pressure by 18 +/- 4% (p < 0.01), with a concomitant increase in central venous pressure of 66 +/- 18% (p < 0.001). The stroke volume and the cardiac index were reduced by 35.7 +/- 11% (p < 0.001) and 45 +/- 13% (p < 0.001). On transesophageal echocardiography, there was development of new regional wall motion abnormalities in 59.2% and a decrease in global left ventricular functions in 61.2%. The use of inotropes was highest during anastomosis on the posterior wall-78.4% compared with 21.9% for the anterior wall. An intra-aortic balloon pump was used in 55 (11.2%) patients, and 7 (0.71 %) patients had to be put on emergency CPB. The in-hospital mortality was 1.2%. CONCLUSION: Most patients had hemodynamic changes easily correctable by fluids and inotropes. Monitoring of left ventricular and right ventricular function by transesophageal echocardiography enhances safety of the procedure and is recommended. The use of the Octopus II tissue stabilizer proved to be a safe and versatile means to stabilize the heart during off-pump coronary artery bypass procedures, especially in high-risk patients.     

Surgical management of the severely displaced supracondylar fracture of the humerus in children

We reviewed 44 children with a widely displaced supracondylar fracture of the humerus (Gartland grade III) treated with primary open reduction and cross pinning. The average age was 8 years and the mean delay in presentation was 34 h. Comminution of the medial supracondylar pillar was seen in 57% of the cases. After treatment, the range of the elbow motion was restricted in eight patients. Cubitus varus was not seen. There was no deep infection or myositis ossificans. Post-operatively, five children had a temporary nerve palsy. According to Flynns' criteria, 42 patients had a satisfactory outcome.     

Replication-competent herpes virus NV1020 as direct treatment of pleural cancer in a rat model

OBJECTIVE: Innovative treatments are needed for metastatic disease involving the pleura. NV1020 is a novel, multimutated, replication-restricted herpes simplex virus under investigation for its ability to selectively kill tumors by means of direct cell lysis. This study examines NV1020 in a rat model of pleura-based lung cancer. METHODS: Cytotoxicity and viral proliferation were evaluated in vitro by exposure of the human non-small cell lung cancer cell line A549 to virus. NV1020 was also tested in an in vivo pleura-based cancer model established by injecting 1 x 10(7) A549 cells into the thoracic cavity of nude rats. Intrapleural treatments (1 x 10(7) viral particles) were given 3 hours or 3 days after tumor injection to model treatment of microscopic or macroscopic disease (n = 8-9/group). Tumor burden was assessed at 5 weeks. NV1020 infection and dissemination within the thoracic cavity was determined by means of immunohistochemistry. RESULTS: In vitro, at multiplicities of infection (viral particles per tumor cell) of 0.01, 0.1, and 1.0, cell killing of A549 by NV1020 was 66%, 90%, and 97%, respectively, at 7 days after infection. Viral burst occurred by day 2. Intrapleural treatment was effective for both the microscopic (P <.001) and macroscopic (P <.05) in vivo tumor models. Virus was detectable by means of immunohistochemistry in tumors but not in adjacent normal intrathoracic tissues. CONCLUSIONS: NV1020 is not only highly cytotoxic to the human lung cancer line A549 in vitro but can be delivered in a clinically relevant fashion to safely and effectively treat pleura-based tumor in vivo in a rat model.     

Does gender difference influence outcome?

BACKGROUND: Recent laboratory studies have demonstrated that immune responses differ between male and female rodents, and some clinical studies have suggested gender differences regarding incidence and mortality from sepsis. The differences appear because of both deleterious testosterone and beneficial estrogen effects; clinical trials of testosterone blockage and/or estrogen administration for male subjects have been suggested. We evaluated the effect of gender on various outcomes in trauma patients. METHODS: Trauma patients over a 52-month period were identified from the trauma registry. Early deaths were excluded. Outcomes included mortality, pneumonia (> or = 10 colony-forming units/mL in bronchoalveolar lavage effluent), acute respiratory distress syndrome, bacteremia, ventilator days, and intensive care unit and hospital length of stay. Patients were stratified by injury mechanism, gender, age (assuming women < or = 40 were premenopausal and those > 50 were postmenopausal), and injury severity. RESULTS: There were 18,133 patients identified, and 544 were excluded because of early death. There were 12,756 (73%) men and 4,833 (27%) women. There were no outcome differences after penetrating injury with respect to gender and age group. There was a survival advantage for women < or = 40 in the Injury Severity Score 16 to 24 group, but these patients had statistically less severe injury. Overall, men tended to have more infectious complications, but women had lower survival in the face of infection. Logistic regression did not identify gender as an independent predictor of mortality. CONCLUSION: Although there was a survival advantage for women in subgroup analysis, there was no overall difference in mortality. Women with pneumonia, however, had a higher mortality than men. Further understanding of potential mechanisms is necessary before hormonal manipulation studies.     

Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited

BACKGROUND: Patients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass. METHODS: All patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality. RESULTS: Eighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8, < 0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells, p = NS), hospital days (17.9 vs. 19.1, p = NS) and mortality (10% vs. 9%, p = NS) were similar. CONCLUSION: NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.     

Efficacy of multiagent herpes simplex virus amplicon-mediated immunotherapy as adjuvant treatment for experimental hepatic cancer

OBJECTIVE: To evaluate the use of herpes simplex viral (HSV) amplicon vectors for production of tumor vaccines and to determine if such vaccines expressing combinations of immunostimulatory agents may be effective in the treatment of experimental liver cancer. METHODS: A hepatic metastatic tumor model using CT-26 colorectal cancer in syngeneic Balb/C mice was utilized. Tumor vaccines were produced by brief (20 minutes) exposure of irradiated tumor cells to herpes amplicon vectors carrying the transgene for RANTES, B7.1, or GM-CSF. The antitumor efficacy of vaccination using tumor cells secreting GM-CSF (single agent) or a combination of RANTES/B7.1/GM-CSF (multiagent) was tested. The effect of 60% hepatectomy or T-cell depletion was also tested in this model. RESULTS: In vitro assays confirmed high-level cytokine or costimulatory molecule production by cells transduced with amplicons. Antitumor efficacy was observed with single-agent or multiagent treatment. Without hepatectomy, immunization with single-agent or multiagent vaccine therapy appears equivalent. When administered in the setting of hepatectomy, multiagent regimens produced a higher cure rate than single-agent therapy (50% vs. 12.5%, =.03). Animals treated with GM-CSF alone had an average nodule count of 40 +/- 19 ( <.006 vs. Hep control 232 +/- 30), while animals treated with multiagent therapy had an average nodule count of 11 +/- 7 ( <.0004 vs. control). CD4 and CD8 lymphocyte blockade abrogated observed efficacy, confirming a lymphocyte-mediated response. CONCLUSIONS: Tumor vaccines produced using HSV amplicon-mediated gene transfer may be useful in the treatment of liver malignancies. In the setting of hepatectomy, multiagent vaccine therapy offers an advantage over single-agent therapy. These data encourage consideration of such HSV-based neoadjuvant immunotherapy for treatment of liver malignancies.     

Effects of reduction of renal mass on renal oxygen tension and erythropoietin production in the rat

BACKGROUND: It is well known that the anemia of chronic renal failure is associated with a blunted erythropoietin response. However, it is not clear why this response is blunted. Oxygen tension is an important regulator of erythropoietin production and release, but the effect of reduced renal mass on renal tissue oxygen tensions is currently unknown. METHODS: A computer-based simulation was used to determine how alterations in filtration fraction might impact on renal tissue oxygen tensions. In addition, direct measurements of oxygen tension with needle electrodes were employed, as well as conventional physiological measurements and ELISA measurements of plasma and tissue erythropoietin concentrations in rats subjected to 5/6th nephrectomy. RESULTS: Remnant kidney rats had 39% and 52% decreases in tissue and plasma erythropoietin concentrations, respectively, that correlated with 73% increased oxygen tensions in both cortex and outer medulla in the remnant kidney (all P < 0.01). Estimations of filtration fraction were decreased by approximately 36% in the rats bearing remnant kidneys. CONCLUSIONS: Higher oxygen tensions were observed in the remnant kidneys. We suggest that higher oxygen tensions are caused by a decrease in filtration fraction, and that these higher tissue oxygen tensions result in decreased renal erythropoietin production and anemia.     

Expression of proinflammatory and proangiogenic cytokines in patients with head and neck cancer.

Altered immune, inflammatory, and angiogenesis responses are observed in patients with head and neck squamous cell carcinoma (HNSCC), and many of these responses have been linked with aggressive malignant behavior and a decrease in prognosis. In this study, we examined the hypothesis that HNSCC cells produce cytokines that regulate immune, inflammatory, and angiogenesis responses. We identified important regulatory cytokines in supernatants of well-defined and freshly cultured HNSCC cell lines by ELISA and determined whether these cytokines are detected in tumor cell lines and tissue specimens by immunohistochemistry. The serum concentration of the cytokines and cytokine-dependent acute phase inflammatory responses (i.e., fibrinogen, C-reactive protein, and erythrocyte sedimentation rate) from patients with HNSCC was determined, and the potential relationship of serum cytokine levels to tumor volume was analyzed. Cytokines interleukin (IL)-1alpha, IL-6, IL-8, granulocyte-macrophage colony-stimulating factor (GM-CSF), vascular endothelial growth factor (VEGF), and basic fibroblast growth factor were detected in similar concentration ranges in the supernatants of a panel of established University of Michigan squamous cell carcinoma (UM-SCC) cell lines and supernatants of freshly isolated primary HNSCC cultures. Evidence for the expression of IL-1alpha, IL-6, IL-8, granulocyte-macrophage colony-stimulating factor, and VEGF in HNSCC cells within tumor specimens in situ was obtained by immunohistochemistry. In a prospective comparison of the cytokine level and cytokine-inducible acute-phase proteins in serum, we report that cytokines IL-6, IL-8, and VEGF were detected at higher concentrations in the serum of patients with HNSCC compared with patients with laryngeal papilloma or age-matched control subjects (at P < 0.05). The serum concentrations of IL-8 and VEGF were found to be weakly correlated with large primary tumor volume (R2 = 0.2 and 0.4, respectively). Elevated IL-1- and IL-6-inducible acute-phase responses were also detected in cancer patients but not in patients with papilloma or control subjects (at P < 0.05). We therefore conclude that cytokines important in proinflammatory and proangiogenic responses are detectable in cell lines, tissue specimens, and serum from patients with HNSCC. These cytokines may increase the pathogenicity of HNSCC and prove useful as biomarkers or targets for therapy.