Potent effector function of tumor-sensitized L-selectin(low) T cells against subcutaneous tumors requires LFA-1 co-stimulation.

OBJECTIVE: Animal tumor models have demonstrated that adoptive transfer of tumor-draining lymph node (TDLN) T lymphocytes can cure established tumors in many anatomic sites. However, subcutaneous tumors are relatively refractory and have required maximally tolerated doses of cells. The goals of this study were to determine whether a subset of TDLN T lymphocytes varying in expression of the cell adhesion molecule L-selectin (CD62L) had augmented therapeutic efficacy and to determine the co-stimulatory requirements for trafficking and anti-tumor effector function. STUDY DESIGN: TDLNs were recovered from mice bearing progressive MCA 205 fibrosarcomas, and the T lymphocytes were segregated into CD62L(low) and CD62L(high) subsets and activated ex vivo with anti-CD3 mAb and IL-2. Mice bearing established subcutaneous MCA 205 tumors were treated with activated T cell subsets and in some experiments with additional mAb against cell adhesion molecules. RESULTS: Adoptive transfer of as few as 5 x 10(6) activated cells cured mice bearing 3-day subcutaneous MCA 205 tumors initiated with 6 x 10(6) cells, and the tumors demonstrated a dense infiltrate of CD62L(low) cells. In marked contrast, adoptive transfer of 10 times as many T cells derived from the reciprocal CD62L(high) compartment had no effect on tumor growth. The effector function of the CD62L(low) T cells was clearly dependent on co-stimulation through the cell adhesion molecule LFA-1, because anti-LFA-1 mAb completely abrogated the anti-tumor reactivity of the transferred cells against subcutaneous tumors and inhibited tumor infiltration. In contrast, blockade of ICAM-1, VLA-4, or VCAM-1 had no inhibitory effect on the anti-tumor function. CONCLUSION: These studies demonstrate the high therapeutic activity of the CD62L(low) subset of tumor-draining LN T cells against subcutaneous tumors, a relatively refractory site, and confirm the essential role of LFA-1 for effector T cell function. SIGNIFICANCE: Identification of the phenotype and requirements for effector function of T lymphocytes sensitized to tumor antigens has implications for clinical trials of adoptive immunotherapy for head and neck carcinoma using a similar approach.

Primary radiation therapy for early glottic cancer.

OBJECTIVES/HYPOTHESIS: Early glottic squamous cell carcinoma can be effectively treated with either radiation or surgical intervention. We evaluated our experience treating early glottic cancer with primary radiation therapy and our vertical hemilaryngectomy (VHL) salvage experience. STUDY DESIGN/METHODS: Retrospectively, patient records between January 1986 and December 1994 were reviewed and 45 patients with early glottic squamous cell carcinoma who received full-course radiation therapy at the Cleveland Clinic Foundation were identified. RESULTS: Local control after radiation therapy was 80% overall, 87.5% for T1 lesions, and 75% for T2 lesions. Four patients underwent VHL for salvage after local recurrence; 1 was successfully salvaged with VHL. Five patients underwent total laryngectomy salvage after radiation therapy; all were successful. Only 1 of the 6 patients who were originally candidates for VHL before radiation therapy was successfully salvaged with the larynx preserved. CONCLUSIONS: Our local control rates using primary radiation therapy are consistent with prior published series, but voice sparing salvage is poor.

Effect of in vitro irradiation of donor larynges on cyclosporine requirements and rejection rates in rat laryngeal transplantation.

Total lymphoid irradiation is an acknowledged adjunctive immunosuppressant in whole organ transplantation in humans and animals. Local irradiation administered for a similar purpose is at best controversial. We evaluated in vitro donor larynx irradiation immediately preceding laryngeal transplantation as an immunomodulator. Each donor larynx was pretreated with 7.34 Gy of radiation in vitro. After transplantation, cyclosporine was administered in doses of 5 mg/kg per day, 2.5 mg/kg per day, and 1 mg/kg per day for trial lengths of 15 days and 30 days. Each of these 6 groups consisted of 10 rats per group. Earlier data have shown cyclosporine dosed at 5 mg/kg per day, without irradiation, administered for 1 month to have varied efficacy. Established histologic criteria were used to determine rejection patterns. All recipient rats survived the 15-day and 30-day trials. In all 10 rats receiving 5 mg/kg per day of cyclosporine for 15 days, the harvested transplanted larynges were viable without evidence of meaningful rejection (mild rejection). In 9 of the 10 rats receiving 5 mg/kg per day of cyclosporine for 30 days, the transplanted larynges displayed no meaningful rejection (mild rejection). In 9 of the 10 rats receiving 2.5 mg/kg per day of cyclosporine for 15 days, the transplanted larynges displayed no meaningful rejection (mild rejection). One rat receiving 2.5 mg/kg per day of cyclosporine for 15 days had a transplanted larynx that displayed moderate rejection. In all 10 rats receiving 2.5 mg/kg per day of cyclosporine for 30 days, the transplanted larynges displayed no meaningful rejection (mild rejection). At 15 days, 5 rats treated with 1 mg/kg per day of cyclosporine displayed mild rejection, 2 displayed moderate rejection, 2 displayed advanced to moderate rejection, and 1 displayed severe rejection. At 30 days, 4 rats treated with 1 mg/kg per day of cyclosporine displayed moderate rejection, 2 displayed advanced to moderate rejection, and 4 displayed severe rejection. We conclude that pretransplantation in vitro irradiation of donor larynges has immunomodulatory effects, allowing reduced cyclosporine immunosuppression with less rejection.

Therapeutic efficacy of Th1 and Th2 L-selectin--CD4+ tumor-reactive T cells.

OBJECTIVE: To evaluate the cytokine secretion profile and therapeutic efficacy of Th1 CD4+ L-selectin-tumor-draining lymph node lymphocytes in the treatment of murine pulmonary metastases. STUDY DESIGN: Prospective, murine in vivo and in vitro study. METHODS: B6 mice were injected bilaterally subcutaneously with MCA 205 sarcoma cells to initiate tumor growth. Eleven days later, tumor-draining inguinal lymph nodes were harvested. Single-cell suspensions were prepared and fractionated using magnetically activated cell sorting. Sorted CD4+ L-selectin-lymphocytes were activated with anti-CD3 monoclonal antibody for 48 hours either alone to give a Th1 phenotype, or in the presence of interleukin (IL)-4 and anti-interferon-gamma (alpha-IFN-gamma) monoclonal antibody to elicit a Th2 phenotype. Activated cells were then expanded for 3 days in IL-2. Resulting cells were used to treat 3-day pulmonary metastases. Enzyme-linked immunosorbent assay and intracellular fluorescent-activated cell-sorter (FACS) scanning were used to evaluate the cytokine secretion profiles of these cells. RESULTS: Activated and expanded L-selectin- CD4+ T cells demonstrated a Th1 cytokine profile and excellent antitumor efficacy. In contrast, L-selectin- CD4+ lymphocytes activated in the presence of IL-4 and alpha-IFN-gamma monoclonal antibody demonstrated a Th2-like profile and significantly (P < .05) poorer antitumor efficacy. CONCLUSIONS: The cytokine environment during the activation of tumor-draining lymph nodes can influence the therapeutic efficacy of activated L-selectin-, CD4+ T cells. Cell mediated, Th1-dependent immunity appears to play an important role in mediating tumor regression. Culture conditions promoting Th2 cells resulted in T cells associated with diminished antitumor efficacy.

Snoring, obstructive sleep apnea, and surgery.

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, with or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction with contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity. Nonetheless, tracheostomy can be lifesaving and remains an option for patients with severe OSA with serious associated cardiovascular complications, who cannot tolerate CPAP, and for whom other interventions are ineffective or unacceptable. Effective surgical treatment of snoring has been accomplished with UPPP and LAUP. LAUP is less invasive, less morbid, more cost-effective, and better tolerated and is likely the most appropriate procedure for debilitating symptomatic snoring. Currently, LAUP is not recommended for the treatment of OSA, despite some efficacy in patients with mild OSA. Exclusion of OSA in patients undergoing LAUP for snoring is important.

Girdling effect of nonstimulated cardiomyoplasty on left ventricular function.

The precise hemodynamic effects of latissimus dorsi cardiomyoplasty have not been well characterized. We prospectively studied 11 mongrel dogs using a rapid ventricular pacing model of congestive heart failure. Six dogs received a nonstimulated left latissimus dorsi cardiomyoplasty wrap, and 5 control dogs were paced only. Two-dimensional transthoracic echocardiography was performed on all dogs at baseline and then weekly for 4 weeks. Measurements obtained included left ventricular diameters, lengths, volumes, and ejection fractions. Progressive left ventricular enlargement, increase in volumes, and worsening ejection fractions developed in both groups. However, less left ventricular dilatation and higher ejection fractions were seen in dogs that received a cardiomyoplasty wrap. A nonstimulated cardiomyoplasty wrap significantly attenuated the degree of left ventricular enlargement, increase in left ventricular volumes, and decrease in ejection fraction in a rapid pacing model of congestive heart failure. Apart from its effect on systolic augmentation with a stimulated muscle wrap, cardiomyoplasty may have an important "girdling" effect on the left ventricle that prevents dilatation and deterioration of left ventricular function.

Aortic valve replacement using a continuous suture technique.

The continuous suture technique has been proposed as an alternate method for aortic valve replacement (AVR). Advantages include a decreased ischemic and bypass time. Despite reports of a low incidence of perivalvular leak, wide use of the continuous suture technique has not been adopted. This report reviews our experience with the continuous suture technique. From January 1984 through November 1991, 181 consecutive patients underwent AVR using the continuous suture technique. The mean age was 61 years (range 6 to 88 years). Diagnoses included pure aortic stenosis (AS) in 41%, aortic insufficiency (AI) in 31%, and a combination of AS and AI in 28%. Fifty-six patients underwent isolated AVR and 125 underwent AVR combined with other procedures. The overall early mortality was 5.5%. Early mortality for isolated AVR was 0% (0/56) and was 8.0% (10/125) for those undergoing concomitant procedures. Late mortality was 4.7% in a mean follow-up of 30 months (range 1 to 86 months). The incidence of perivalvular leak was 2.3% (4/171 operative survivors). Perivalvular leak was mild in two, and moderate in two; none required reoperation. Perivalvular leak developed only in patients whose suture line was not reinforced with glutaraldehyde treated pericardium. The continuous suture technique is a quick and effective method for AVR and results in a low incidence of perivalvular leak.

Perfluorochemical reperfusion yields improved myocardial recovery after global ischemia.

Reperfusion injury remains a limiting factor in extending ischemic storage time for human heart transplantation. In this study, initial myocardial reperfusion with an oxygenated perfluorochemical (Fluosol) was investigated as a means of limiting such injury. Neonatal piglet hearts were arrested with crystalloid cardioplegia, excised, and stored for 12 hours in saline solution at 0 degrees C. Initial reperfusion (10 minutes) was either with whole blood (n = 6), unmodified perfluorochemical (n = 8), or aspartate/glutamate-enriched perfluorochemical cardioplegia (n = 6), and was followed by an additional 40 minutes of whole blood perfusion. Functional evaluation was then completed, and left ventricular biopsy specimens were taken. A control group (n = 7) was evaluated without an intervening period of ischemia. At a left ventricular end-diastolic pressure of 9 mm Hg, hearts stored in whole blood cardioplegia developed a left-ventricular stroke work index of 3.8 +/- 2.3 x 10(3) erg/g (mean +/- standard error of the mean). Under the same conditions, perfluorochemical-reperfused hearts achieved a stroke work index of 14.6 +/- 1.3 x 10(3) erg/g, significantly greater than that of the whole blood group (p < 0.001). Stroke work index for hearts reperfused with aspartate/glutamate-enriched perfluorochemical cardioplegia was 19.8 +/- 1.6 x 10(3) erg/g, significantly increased over that of the nonenriched perfluorochemical group (p < 0.01) and not different from values obtained in controls (19.2 +/- 0.8 x 10(3) erg/g).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantification of flow through an interatrial communication. Application to the partial Fontan procedure.

The partial Fontan procedure has become an accepted alternative for the high-risk candidate. Creation of a small right-to-left shunt will lower the systemic venous pressure and improve systemic cardiac output while maintaining an acceptable systemic arterial saturation. However, because of variations in patient size and postoperative transpulmonary gradient, proper sizing of the residual defect is difficult. We have therefore conducted a series of experiments on a model that simulates the blood flow across interatrial defects of varying sizes at several pressure gradients. We used porcine blood to develop guidelines for the sizing of the residual defect. Our results demonstrate a linear relationship between flow and pressure gradient across all hole sizes tested. In addition, there was a linear relationship between atrial septal defect size and flow at each pressure gradient. Our data show that the Gorlin formula predictions overestimated flow by 10% to 40%. It is evident from these data that relatively small changes in the size of the atrial septal defect or in the pressure gradient result in significant changes in flow. Therefore we advocate the use of an adjustable interatrial communication such as the snare-controlled adjustable atrial septal defect for patients undergoing partial Fontan procedures.

Perfluorochemical reperfusion limits myocardial reperfusion injury after prolonged hypothermic global ischemia.

The ability of an oxygenated perfluorochemical (Fluosol) to limit myocardial reperfusion injury following global hypothermic ischemic insult was investigated. Neonatal piglet hearts were arrested with cold crystalloid cardioplegia and stored for 12 hours in 2 degrees C saline. Reperfusion was carried out using an isolated, blood-perfused, working heart preparation. Hearts were initially reperfused (10 minutes) with either whole blood (WB, n = 6), unmodified perfluorochemical (PFC, n = 8), or aspartate/glutamate-enriched perfluorochemical cardioplegia (PFC+, n = 6), prior to institution of whole blood perfusion, functional evaluation and left ventricular biopsy. A control group (C, n = 7) was evaluated without an intervening period of ischemia. At a left ventricular diastolic pressure of 9 mm Hg WB hearts developed a left-ventricular stroke work index (SWI) of 3.8 +/- 2.3 x 10(3) erg/g (mean +/- standard error of the mean). Under similar conditions, PFC-reperfused hearts achieved a SWI of 14.6 +/- 1.3 x 10(3), significantly greater than that of WB (p less than 0.001). SWI for PFC+ hearts was 19.8 +/- 1.6 x 10(3), significantly increased over that of PFC (p less than 0.01), and not different from values obtained for C (19.2 +/- 0.8 x 10(3)). In addition, PFC-reperfused hearts demonstrated superior maintenance (p less than 0.05) of ATP (2.08 +/- 0.16 umole/g), compared to WB (1.50 +/- 0.19), while preservation of ATP in PFC+ hearts (2.99 +/- 0.12), was significantly increased over that of PFC (p less than 0.001), and not significantly different from that for C (2.68 +/- 0.17).(ABSTRACT TRUNCATED AT 250 WORDS)