Multiple myeloma causes clonal T-cell immunosenescence: identification of potential novel targets for promoting tumour immunity and implications for checkpoint blockade.

Tumour-induced dysfunction of cytotoxic T cells in patients with multiple myeloma (MM) may contribute to immune escape and be responsible for the lack of therapeutic efficacy of immune checkpoint blockade. We therefore investigated dysfunctional clonal T cells in MM and demonstrated immunosenescence but not exhaustion as a predominant feature. T-cell clones were detected in 75% of MM patients and their prognostic significance was revalidated in a new post-immunomodulatory drug cohort. The cells exhibited a senescent secretory effector phenotype: KLRG-1+/CD57+/CD160+/CD28-. Normal-for-age telomere lengths indicate that senescence is telomere independent and potentially reversible. p38-mitogen-activated protein kinase, p16 and p21 signalling pathways known to induce senescence were not elevated. Telomerase activity was found to be elevated and this may explain how normal telomere lengths are maintained in senescent cells. T-cell receptor signalling checkpoints were normal but elevated SMAD levels associated with T-cell inactivation were detected and may provide a potential target for the reversal of clonal T-cell dysfunction in MM. Low programmed death 1 and cytotoxic T-lymphocyte-associated antigen 4 expression detected on T-cell clones infers that these cells are not exhausted but suggests that there would be a suboptimal response to immune checkpoint blockade in MM. Our data suggest that other immunostimulatory strategies are required in MM.

Phospho-flow detection of constitutive and cytokine-induced pSTAT3/5, pAKT and pERK expression highlights novel prognostic biomarkers for patients with multiple myeloma.

Identifying check points in cell signal transduction pathways has led to the development of new cancer therapies; however, relatively few studies have determined the diagnostic and prognostic significance of analysing phosphorylated signaling proteins in patient blood and bone marrow (BM) samples. This is the first comprehensive phospho-flow study of both constitutive and cytokine-induced pSTAT3, pSTAT5, pAKT and phosphorylated extracellular signal-regulated kinase (pERK) expression in malignant plasma cells of patients with monoclonal gammopathies. In diagnostic BM samples from 65 patients with multiple myeloma (MM), interleukin (IL)-6-induced pSTAT3 proved to be a new and independent prognostic biomarker for improved survival. When combined with the International Staging System, 6 subgroups demonstrated stratified median survivals from 9 to 72 months (χ(2)=34.3; P<0.0001). In contrast, constitutive expression of pSTAT3, pSTAT5, pAKT and pERK did not assist the differential diagnosis nor determine prognosis. High pSTAT3 expression was dependent on existing CD45 expression and pSTAT5 appeared to regulate IgG production. Phospho-flow cytometry could be used to screen for personalized therapy, although the lack of clinical significance of constitutive pSTAT3 levels suggests that pSTAT3 blockade may not be clinically relevant in MM. This study has revealed novel prognostic biomarkers and insights into the biology of signaling pathways in patients with MM.

Long-term survival in multiple myeloma is associated with a distinct immunological profile, which includes proliferative cytotoxic T-cell clones and a favourable Treg/Th17 balance.

Despite improved outcomes in multiple myeloma (MM), a cure remains elusive. However, even before the current therapeutic era, 5% of patients survived >10 years and we propose that immune factors contribute to this longer survival. We identified patients attending our clinic, who had survived >10 years (n=20) and analysed their blood for the presence of T-cell clones, T-regulatory cells (Tregs) and T helper 17 (Th17) cells. These results were compared with MM patients with shorter follow-up and age-matched healthy control donors. The frequency of cytotoxic T-cell clonal expansions in patients with <10 years follow-up (MM patients) was 54% (n=144), whereas it was 100% (n=19/19) in the long-survivors (LTS-MM). T-cell clones from MM patients proliferated poorly in vitro, whereas those from LTS-MM patients proliferated readily (median proliferations 6.1% and 61.5%, respectively (P<0.0001)). In addition, we found significantly higher Th17 cells and lower Tregs in the LTS-MM group when compared with the MM group. These results indicate that long-term survival in MM is associated with a distinct immunological profile, which is consistent with decreased immune suppression.

Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies.

BACKGROUND: Sleeve lobectomy and bronchoplasty are established alternatives to pneumonectomy for bronchial malignancies involving a main bronchus. However, potential bronchial anastomotic complications have deterred the general application of these types of resection. Some reports have contained a mixture of non-small cell lung cancer (NSCLC) and tumors of low-grade malignancy, making it difficult to assess the long-term results of these procedures as an alternative to pneumonectomy for lung cancer. METHODS: We retrospectively reviewed our experience with sleeve lobectomy and bronchoplasty for bronchial malignancies from January 1988 to September 1998 separating NSCLC (n = 58) from tumors of low-grade malignancy (n = 19). We compared the overall results between sleeve lobectomy and pneumonectomy (n = 142) performed for NSCLC over the same time interval. RESULTS: For NSCLC, after sleeve lobectomy, the operative mortality was 5.2% (3 of 58 patients) and the overall 5-year actuarial survival was 37.5%. After pneumonectomy, the operative mortality was 4.9% (7 of 142 patients) and the overall 5-year actuarial survival was 35.8%. For tumors with low-grade malignancy, there was no operative mortality after sleeve lobectomy or bronchoplasty and the 5-year actuarial survival was 100%. Major bronchial anastomotic complications occurred in 3 patients among the 77 patients who underwent sleeve resection. CONCLUSIONS: Sleeve resection can be performed with a low risk of bronchial anastomotic complication. The long-term survival after sleeve resection for NSCLC is similar to pneumonectomy. Excellent results are obtained after sleeve resection for low-grade malignancies.

Physiologic consequences of pneumonectomy. Consequences on the esophageal function.

Esophageal and upper gastrointestinal dysmotility occur after both pneumonectomy without pulmonary replacement and recipient pneumonectomy for thoracic organ transplantation. After pneumonectomy without pulmonary replacement, there is a shift of the esophagus to the side of pneumonectomy and disturbance of esophageal peristalis. After recipient pneumonectomy for thoracic organ transplantation, esophageal dysmotility and delayed gastric emptying are common. Injury of the vagal nerves, local ischemia, postoperative scarring of the esophagus and mediastinum, and disturbance of the autonomic nervous systems are the major causes of the abnormality. To reduce the incidence of esophageal dysmotility after pneumonectomy, every effort should be made during surgery to prevent direct injury of the esophagus or the vagal nerves.

The "H" graft: an alternative approach for performing minimally invasive direct coronary artery bypass.

OBJECTIVES: Minimally invasive direct coronary artery bypass permits arterial revascularization without cardiopulmonary bypass, potentially decreasing associated morbidity. The procedure is, however, technically challenging and associated with significant postoperative pain resulting from retraction through the small incision. METHODS AND PATIENT SELECTION: From December 1996 to April 1997, eight patients underwent grafting of the left anterior descending coronary artery by use of a short segment of right inferior epigastric artery attached proximally to the side of an in situ left internal thoracic artery. We have termed this procedure the "H" graft MIDCAB. RESULTS: No patients required intraoperative conversion to conventional bypass. No postoperative deaths or myocardial infarctions occurred. Six patients with normal renal function underwent postoperative angiography that demonstrated graft patency with rapid filling of the left anterior descending coronary in each case. Postoperatively clinical signs of acute ischemia were resolved or a normal exercise tolerance test was obtained in all patients. The median postoperative length of stay was 3 days. Rib spreading and chest wall retraction were not required in any procedure. CONCLUSIONS: The "H" graft procedure is an attractive alternative to standard minimally invasive bypass because of greater technical simplicity, the avoidance of internal thoracic artery harvest, and excellent visualization with no chest wall retraction.

Repair of right ventricular rupture complicating mediastinitis.

A treatment strategy for rupture of right ventricle complicating mediastinitis is presented. We used two strips of anterior rectus sheath to buttress the ventricular closure during femoral-femoral bypass.

Minimally invasive direct coronary artery bypass: our experience with 32 patients.

From January 1996 to May 1997, minimally invasive direct coronary artery bypass (MIDCAB) through a small anterior thoracotomy without cardiopulmonary bypass was completed in 31 of 32 patients (Male: Female=1.9:1, mean age=64.6 years, 11 (34.4%)>70 years). Twenty, five, and seven patients had one, two, and three vessel disease respectively. Twelve patients presented with unstable angina, seven had prior myocardial infarction, one had a pre-operative intra-aortic balloon pump, and four had prior coronary artery bypass grafting (CABG). Eight were diabetic, five had chronic obstructive pulmonary disease, and one was morbidly obese. Our newly developed coronary artery immobilizing and occluding device facilitated the coronary anastomosis. There were no post-procedure deaths, no peri-operative myocardial infarctions, and no strokes. One patient required intra-operative conversion to conventional CABG for an intramyocardial target vessel. Two patients had conversion after post-operative angiogram demonstrated incorrect target identification and early graft occlusion. Four patients had limited access graft revision (two kinks, one graft injury, and one haemorrhage). Thirty-one of the 32 patients were followed from 0.5 to 16 months and 30 reported no post-operative cardiac events (one required PTCA to another vessel). We conclude that MIDCAB is safe and effective.

Constitutive endothelial nitric oxide synthase gene expression is regulated during lung development.

Nitric oxide (NO), a potent vasodilator, is a free-radical gas synthesized from L-arginine by nitric oxide synthases (NOS). NO appears to have an important role in perinatal changes in pulmonary vascular resistance. We previously identified mRNA encoding the constitutive endothelial NOS (ceNOS) isoform in human pulmonary tissue. To begin investigating functions of this enzyme in perinatal pulmonary development, we measured ceNOS mRNA and immunoreactivity in the developing rat lung. With the use of RNA blot hybridization, abundant pulmonary ceNOS mRNA was detected during the late fetal and postnatal period. The highest levels were detected within 24 h after birth, and elevated mRNA levels persisted for 16 days. In contrast, much lower levels of ceNOS mRNA were found in adult rat lung. With the use of immunoblot techniques, ceNOS protein levels were found to be correlated with mRNA levels. To identify the pulmonary cell types expressing the ceNOS gene, in situ hybridization with a digoxigenin-labeled cRNA probe was performed on sections from lungs of 1-day-old and adult rats. In lungs from 1-day-old rats, ceNOS mRNA was detected in alveolar and serosal epithelial cells as well as in endothelial cells lining small and medium-sized blood vessels. In contrast, in adult lungs, ceNOS gene transcripts were detected in rare endothelial cells. These observations suggest that ceNOS gene expression is regulated during lung development and that ceNOS is available to participate in the postnatal reduction of pulmonary vascular resistance. ceNOS gene expression in nonendothelial cells in the neonatal rat lung suggests that NO may also contribute to nonvascular functions in the developing lung.

Prenatal hormonal therapy improves pulmonary compliance in the nitrofen-induced CDH rat model.

Neonates with congenital diaphragmatic hernia (CDH) experience a high mortality despite intensive medical and surgical management. The associated pulmonary hypoplasia is accompanied by an underlying biochemical deficiency that bears similarity to respiratory distress syndrome (RDS) in the premature newborn. Using therapies extrapolated from those used to treat RDS, the authors have previously shown correction of the immature pulmonary biochemical indices in the nitrofen rat CDH model. This study investigates the functional and histological outcome of prenatal hormone therapy on CDH rats. Compared with saline-treated CDH controls, dexamethasone-treated CDH animals achieved significant increases in lung distensibility (P = .0006) and functional residual capacity (P = .004); CDH rats treated with combined dexamethasone and thyrotropin-releasing hormone (TRH) showed improved functional residual capacity (P = .043) and alveolar stability (P = .025); CDH animals treated with TRH alone (TRH-CDH) showed no improvement in any parameter tested. Histologically, the lungs from dexamethasone- and dexamethasone-TRH-treated CDH animals showed changes that included narrow septal walls, increased air saccule size, and thinning of the pulmonary interstitium compared with the lungs of saline or TRH-CDH rats, which were developmentally arrested at the canalicular stage. Lung weights and lung weight-body weights ratios were similar in all CDH rats, confirming that treatment did not impair pulmonary growth. These results support the potential clinical use of prenatal pharmacological therapies to treat human fetuses with prenatally diagnosed CDH.

A methodological comparison of survey techniques in obtaining self-reports of condom-related behaviors.

To obtain more accurate accounts of sexual attitudes and practices, researchers must explore innovative ways to overcome the reluctance of individuals to disclose sensitive and perhaps incriminating information about themselves. The differences among selected modes of inquiry and survey techniques used to gather self-reports about sensitive contraceptive behaviors among young adults were examined in this study. Comparisons were made between the randomized response versus the direct-inquiry survey techniques and personal interview versus self-administered modes of inquiry relative to the reporting of sensitive condom-related sexual practices of 352 students at a large northeastern university. Findings indicated that the "controlled-choice" randomized-response technique was less effective in obtaining self-reports about condom-related practices than were direct-inquiry techniques. Recommendations for investigations are proposed.

PIP: 352 students at a large American northeastern state university were randomly selected from intact college classes to rank 15 sensitive condom-related items. 257 students actually participated. 53% of the 257 students were women; 55% were non-health-related majors (education, policy, communications) and 45% were health-related majors (health education, health policy, nursing, family studies, and physical education). The subjects in the original sample were randomly assigned to distinct treatment groups: Group 1 (n = 76) self-administered direct inquiry, Group 2 (n = 76) self-administered randomized response, Group 3 (n = 100) face-to-face interview direct inquiry, and Group 4 (n = 100) face-to-face interview randomized response. Subjects in each group completed 15 items on a questionnaire concerning their condom-related practices. Perceived item sensitivity was assessed by a follow-up survey of 60 randomly selected subjects from the original sample. The subjects rated the sensitivity of each item on a 5-point scale anchored by extremely sensitive (5) through neutral (3) to extremely innocuous (1). 60% of the 15 survey items were given below average ratings with respect to sensitivity. Only 40% of the items received a mean rating above 3 (range = 2.7-3.8). The mean behavior score in the randomized response group (M = 4.1, standard deviation [SD] = 2.8) was significantly lower than the mean behavior for the two direct inquiry groups (M = 5.6, SD = 1.8, p or= .05). Subjects in the direct inquiry groups reported engaging in unprotected or socially stigmatized sexual behaviors more frequently than did subjects in the randomized response group. The controlled choice randomized response technique may be less effective than the conventional direct inquiry technique in obtaining self-reports of condom-related behaviors among college students. The direct inquiry methods are more suitable for populations such as college students who may not be threatened by sensitive survey inquiry.

Pulmonary hypoxia increases endothelin-1 gene expression in sheep.

The hypoxic pulmonary vasoconstrictor response (HPVR) is a physiologic mechanism for directing pulmonary blood flow to nonhypoxic regions of the lung. The mechanism of this response remains unclear. To investigate the role of endothelin-1 (ET-1), a potent vasoconstrictor produced by vascular endothelium, in HPVR an in vivo model of alveolar hypoxia was developed. When one lung in an anesthetized sheep was made hypoxic, the static ET-1 mRNA levels in lung tissue increased in proportion to the observed decrease in pulmonary blood flow (Qp) to that lung. With reversal of hypoxia, Qp and ET-1 levels returned to baseline. This relationship between alveolar hypoxia and ET-1 mRNA levels suggests a role for ET-1 in the local pulmonary response to hypoxia.

Accurate method to study static volume-pressure relationships in small fetal and neonatal animals.

We designed an accurate method to study respiratory static volume-pressure relationships in small fetal and neonatal animals on the basis of Archimedes' principle. Our method eliminates the error caused by the compressibility of air (Boyle's law) and is sensitive to a volume change of as little as 1 microliters. Fetal and neonatal rats during the period of rapid lung development from day 19.5 of gestation (term = day 22) to day 3.5 postnatum were studied. The absolute lung volume at a transrespiratory pressure of 30-40 cmH2O increased 28-fold from 0.036 +/- 0.006 (SE) to 0.994 +/- 0.042 ml, the volume per gram of lung increased 14-fold from 0.39 +/- 0.07 to 5.59 +/- 0.66 ml/g, compliance increased 12-fold from 2.3 +/- 0.4 to 27.3 +/- 2.7 microliters/cmH2O, and specific compliance increased 6-fold from 24.9 +/- 4.5 to 152.3 +/- 22.8 microliters.cmH2O-1.g lung-1. This technique, which allowed us to compare changes during late gestation and the early neonatal period in small rodents, can be used to monitor and evaluate pulmonary functional changes after in utero pharmacological therapies in experimentally induced abnormalities such as pulmonary hypoplasia, surfactant deficiency, and congenital diaphragmatic hernia.

Antenatal glucocorticoid corrects pulmonary immaturity in experimentally induced congenital diaphragmatic hernia in rats.

Congenital diaphragmatic hernia, a highly lethal condition, displays at term the pulmonary biochemical and morphologic immaturity characteristic of premature delivery. We hypothesized that antenatal glucocorticoid, now the standard treatment to prevent hyaline membrane disease in premature human beings, might correct the parameters of the pulmonary biochemical and morphologic immaturity in severe congenital diaphragmatic hernia. A total of 112 fetal rats with or without nitrofen-induced congenital diaphragmatic hernias from 34 pregnancies were treated antenatally with either saline or dexamethasone. Antenatal dexamethasone increased the lung disaturated phosphatidylcholine content, reduced the lung glycogen concentration, reduced the saccular septal thickness, and increased the mean saccular size and volume fraction of saccules in the lungs of rats with large congenital diaphragmatic hernia in comparison with similar rats not so treated. All differences were statistically significant. Antenatal glucocorticoid therapy was efficacious in treating rats with nitrofen-induced congenital diaphragmatic hernia. This encouraging finding warrants further investigation in a large animal model with surgically created congenital diaphragmatic hernia.

Combined antenatal thyrotropin-releasing hormone and low-dose glucocorticoid therapy improves the pulmonary biochemical immaturity in congenital diaphragmatic hernia.

The lungs of patients born with severe congenital diaphragmatic hernia (CDH) are biochemically and morphologically immature. Because antenatal glucocorticoid therapy can accelerate pulmonary maturation in premature neonates who have respiratory distress syndrome, we hypothesized that it may correct the pulmonary biochemical and morphological immaturity associated with CDH. We showed in previous experimental studies that antenatal low-dose dexamethasone improved the biochemical and morphological parameters of pulmonary immaturity in rats that had severe CDH. Somatic and pulmonary growth were inhibited with high doses of dexamethasone. In the present study, we examined the effects of antenatal low-dose dexamethasone and thyrotropin-releasing hormone (TRH), alone or in combination, on the pulmonary maturation in CDH. Combined antenatal low-dose dexamethasone and TRH significantly reduced mean lung glycogen concentration (P = .001), and increased mean disaturated phosphatidylcholine content (P < .005) to better than that observed with either therapy alone, without changing mean body or lung weight. Combined TRH and low-dose glucocorticoid as an antenatal therapy may reduce the morbidity and mortality of CDH.

Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection.

We received the clinical and pathologic features of 22 cases of papillary carcinoma of the thyroid that invaded the trachea and were treated by thyroidectomy and airway resection with or without reconstructive surgery over an interval of 16 years. We studied the fine relationships between lamina propria and lymphatics in the region between the isthmus of the thyroid and the trachea. The manner of invasion of papillary carcinoma of the thyroid was by blunt dissection along blood vessels and collagen fibers oriented perpendicularly to the tracheal lumen between cartilaginous rings. Although lymph node metastases were found in 14 patients (64%), we observed lymphangitic tumor in the tracheal mucosa in only three patients (14%). We devised a staging system for papillary carcinoma of the thyroid based on the extent of invasion of the trachea. Of the 11 patients with stage I, II, or III disease, none of six (0%) followed for 5 years died of thyroid cancer in the 5-year observation period; one patient in this group died later of thyroid cancer. Of the 11 patients with stage IV disease, five of seven (71%) followed for 5 years died of thyroid cancer in the 5-year observation period; one additional patient in this group died later of thyroid cancer.

A controlled randomized response technique.

The randomized response survey technique appears to be suitable for studies of sensitive sexual behaviors, particularly in AIDS-related research. However, existing methods provide only estimates of group statistics, not of individual information. Additionally, the popular "unrelated question" approach requires the knowledge of the parameters of the unrelated question. In this article, a variation of the unrelated-question method is suggested for use. Specifically, it is suggested that the unrelated question be one to which the response is known to be "yes." Through this "controlled" approach, the raw data become a direct linear transformation of the response to the sensitive question, and thus can be used directly in regression and other analyses at the individual score level. The estimation of the parameters for the unrelated question is not necessary and the hesitation to provide a "yes" response found in the "forced choice" method is minimized.

Biochemical immaturity of lungs in congenital diaphragmatic hernia.

Neonates with congenital diaphragmatic hernia (CDH) continue to have unacceptably high mortality rates. To better understand the associated pulmonary pathology we measured biochemical parameters of lung maturity in neonatal rats with or without congenital diaphragmatic hernia created by maternal feeding of a single dose of nitrofen on day 9.5 or day 11.5 of gestation. Lungs from neonatal rats with large CDH (n = 9, 5 right-sided, 4 left-sided) had a significantly lower lung weight (P = .0001), lung weight/body weight ratio (P = .0001), disaturated phosphatidylcholine (DSPC) per microgram DNA (P < .005), total DSPC (P = .0001), total DNA (P < .05), protein per microgram DNA (P < .05), and total protein content (P < .005) when compared with lungs from the litter mates without congenital diaphragmatic hernia (n = 10). The lungs of rats with hernia also had significantly higher DNA concentrations (P < .05) and glycogen concentrations (P < .05). These data demonstrate that lungs in neonatal rats with large CDH are biochemically immature. Treatment directed toward correcting the pulmonary biochemical immaturity of affected fetuses before birth may improve the prognosis for these babies.