Preoperative chemotherapy and sentinel lymphadenectomy for breast cancer.

BACKGROUND: Sentinel lymphadenectomy (SL) for breast cancer is becoming the standard of care for selected patients treated by experienced surgeons. One of the few contraindications for performing SL alone is prior chemotherapy (PC). There are, however, no data to support that PC interferes with the ability of the sentinel node to predict the presence of disease in the remaining axillary lymph nodes. The goal of this study was to determine the effect of PC on patients undergoing SL for breast cancer. METHODS: A multicenter trial was organized in 1997 to evaluate the diagnostic accuracy of SL in patients with breast cancer. Investigators were recruited after attending a course on the technique of SL. Technetium-99 and isosulfan blue were injected into the peritumor region and a gamma probe was used to aid identification of the sentinel nodes. The only exclusion criteria for entrance into the trial were palpable or suspicious axillary lymph nodes. A total of 968 patients were enrolled in the trial. Twenty-nine patients were treated with PC and compared with 939 patients not receiving PC. RESULTS: The overall, sentinel node identification rate for the PC patients was 93% (27 of 29) compared with 88% (822 of 939) for patients not treated with PC. There were no false negatives in those patients receiving PC compared with a 13% (25 of 193) false negative rate in those patients not receiving PC. The mean tumor size was 1.4 cm for the PC group and 0.6 cm for the remaining patients (P <0.005). The mean number of sentinel nodes found was 2.0 for the non-PC group and 2.5 for the PC group (not significant). As expected, a higher proportion of patients had positive axillary nodes in the PC group (52%, 15 of 29) compared with the remaining patients (21%, 200 of 939). CONCLUSION: In this small group of patients, PC did not adversely impact the false negative or identification rate. Most patients receiving chemotherapy have larger tumors and a higher chance of harboring metastatic disease but a significant group of these patients (48%) without metastases can potentially be spared an axillary node dissection.

Human T-cell-porcine endothelial cell interactions induce human Th1 cytokines and porcine activation markers.

BACKGROUND: Since the future of clinical transplantation will undoubtedly include xenotransplantation, there is a need to examine human anti-pig cellular reactions. The objective of this study is to use human anti-porcine mixed lymphocyte endothelial cell culture (MLEC) to investigate cell interactions, cross-species molecular compatibilities, and the induction of human cytokines and porcine activation markers. METHODS: Human peripheral blood mononuclear cells or enriched CD4+ T cells depleted of professional antigen-presenting cells were cultured with resting pig aortic endothelial cells in the absence of exogenous cytokines. T-cell proliferative responses were measured and PAEC were monitored for cell surface markers by flow cytometry. Culture supernatants were assayed for human TNF-alpha and IFN-gamma by ELISA. RESULTS: Human T cells proliferated strongly in response to PAEC (median stimulation index = 75), even in serum-free cultures. High levels of the human Th1 cytokines TNF-alpha (20-350 pg/ml) and IFN-gamma (200-3800 pg/ml) were detected only in cultures containing PAEC, with levels peaking on Day 4. CD4+ T-cell-enriched, APC-depleted responders maintained proliferative anti-PAEC responses and cytokine release. By Day 3, MHC Class II and VCAM expression was induced in 92-96% PAEC: mean fluorescence intensity (MFI) increased from 5 to 83 +/- 12 and 166 +/- 74, respectively, and MHC Class I was increased from MFI 31 to 965 +/- 269. CONCLUSIONS: These results indicate that MLEC is an excellent in vitro model in which to study human anti-porcine cellular responses. Human T cells are activated in response to direct antigen presentation by PAEC, which are also activated in this system. Specific cytokines, receptors, and adhesion molecules appear to cross the xenograft barrier and play a critical role in T-cell - PAEC interactions. Such interactions are likely to affect VEC activation and immune responses to porcine xenografts in vivo.

Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye.

OBJECTIVE: To determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99). SUMMARY BACKGROUND DATA: Sentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue. METHODS: Investigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region. RESULTS: Five hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the false-negative rate was consistently greater. CONCLUSIONS: This multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.

Identification of superior markers for polymerase chain reaction detection of breast cancer metastases in sentinel lymph nodes.

Sentinel lymph node biopsy (SLNB) is being evaluated in breast cancer patients to improve detection of metastases and to guide therapy with minimal morbidity. The use of reverse transcription-PCR analysis to increase detection of tumor cells in SLN of breast cancer patients is hampered by the lack of specific markers. In this study, seven markers were evaluated by reverse transcription-PCR for expression in human breast adenocarcinoma lines (BrCa) and in normal nodes from non-cancer patients. Two markers yielded exceptional results; mammaglobin and carcinoembryonic antigen transcripts were detected in 100 and 71% BrCa, respectively, and were absent from all normal lymph nodes. These markers will be used as components of a multimarker panel to evaluate sentinel nodes in an on-going, multicenter clinical trial.

Preclinical studies of allograft tolerance in rhesus monkeys: a novel anti-CD3-immunotoxin given peritransplant with donor bone marrow induces operational tolerance to kidney allografts.

A major challenge in clinical transplantation today is to design a practical and effective protocol for tolerance induction compatible with cadaver organ transplantation. A preclinical rhesus monkey kidney allograft model using immediate peritransplant anti-CD3 immunotoxin (anti-CD3-IT) and donor bone marrow (DBM) is shown here to induce operational tolerance with prolonged graft survival in the absence of chronic immunosuppressive drugs. Bone marrow harvested from the kidney donor was depleted of mature alloantigen-presenting cells and T cells by removing DR(bright) cells and CD3(bright) cells, respectively. In outbred, major histocompatibility complex-incompatible donor-recipient pairs with high pretransplant mixed lymphocyte response and cytotoxic T lymphocyte precursor activity, four of six allografts survived for periods of 120 days to >1.5 years. Graft acceptance after peritransplant treatment followed robust elimination of both peripheral blood T cells and lymph node T cells. In most recipients given anti-CD3-IT and DBM infusion, anti-donor immunoglobulin G responses were completely inhibited. Microchimerism was observed in all recipients studied, including those not given DBM, but levels of microchimerism did not correlate with graft survival. Anti-CD3-IT induction in combination with modified DBM protocols such as the depletion of mature T cells and DR(bright) antigen-presenting cells may offer new opportunities to improve clinical tolerance protocols beyond those attempted in the clinic to date. Overall, these results with anti-CD3-IT show promise for development of cadaver transplant tolerance induction.

The facilitating effect of one-DR antigen sharing in renal allograft tolerance induced by donor bone marrow in rhesus monkeys.

Infusion of donor bone marrow cells (DBMC), a long-standing, successful strategy for inducing tolerance in experimental rodent transplantation models, can promote long-term acceptance of life-sustaining renal allografts in rhesus monkeys with no maintenance immunosuppression. To investigate the immunological basis for heterogeneity in duration of long-term graft acceptance following infusion of the DR-/dim fraction of DBMC into RATG-treated rhesus monkeys, we examined the relationship of recipient-donor major histo-compatibility class I and II DR matching to the development of antidonor antibody-dependent cellular cytotoxicity (ADCC) and renal allograft survival. The findings indicate a requirement for sharing one DR allele to achieve long-term graft acceptance. The observed immunological consequence of DR sharing that correlated with functional graft tolerance in this model was the suppression of early antidonor ADCC+ IgG antibody responses. Significant associations were observed between graft survival and suppression of ADCC antibody (P < 0.0005), graft survival and DR sharing (P < 0.005), and DR sharing and suppression of ADCC (P < 0.02). Early antidonor ADCC antibody responses associated with failure to maintain graft tolerance and were most consistently directed to donor class I. The required one DR antigen sharing in DBMC-induced suppression of antidonor class I antibody suggests a restriction for recipient DR, implying critical regulation of a response to donor antigen presented on recipient cells. We hypothesize a DBMC tolerogenic mechanism in which presentation of donor class I peptide by a shared DR allele configuration allows a veto effect by DBMC. Thus DR sharing would allow DBMC veto cells to reduce clonal expansion elicited by both the direct and indirect antigen presentation pathways.

Veto cells in transplantation tolerance.

Advances in immunosuppressive management for transplantation have improved graft survival. However, lasting success will probably depend on the induction of donor-specific unresponsiveness, avoiding chronic immunosuppressive drug therapy and its debilitating side effects. Tolerance strategies have been developed in rodents, but applicability to human organ transplantation has not been achieved. We have established a preclinical allogeneic kidney transplant model in unrelated outbred rhesus monkeys and have investigated a tolerance-inducing strategy in which posttransplant administration of rabbit antithymocyte globulin and infusion of a subpopulation of donor bone marrow cells yields long-term graft acceptance in the absence of chronic immunosuppressive drugs. Recent studies of the immunological mechanisms by which induction and maintenance of transplant tolerance is achieved in this model are presented within the framework of a veto hypothesis.

A comprehensive definition of the major antibody specificities in polyclonal rabbit antithymocyte globulin.

The potent immunosuppressive action of rabbit antithymocyte globulin (RATG) in allotransplant recipients has been recognized for many years. Some of the antibody specificities and immunoregulatory effects of RATG have been described, but a comprehensive definition of RATG components has not been reported previously. In this study, we have identified 23 specificities that are consistent among different clinical RATG batches and represent the major antibody specificities in RATG. These specificities were defined by immunoprecipitation/gel electrophoresis and also antibody blocking/flow cytometry methods. Titration studies performed for semiquantitative analysis of RATG antibodies showed that the antibodies present in highest titer were directed to CD6, CD16, CD18, CD28, CD38, CD40, and CD58 (titer > 1:4000), most of which are not T cell-specific antibodies. In contrast, the RATG antibodies that persisted the longest in vivo in the plasma of rhesus monkeys transplant recipients are antibodies to CD3, CD4, CD8, CD11a, CD40, CD45, CD54, and class I. These antibodies, which are directed at signal transduction and adhesion molecules, were present during the early period of lymphocyte recovery. We suggest that the persistence of these antibodies in vivo is directly related to the prolonged anergy of circulating T cells after RATG treatment and to the unusual potency and complex tapestry of immunological effects in transplantation.

A role for transforming growth factor-beta in the veto mechanism in transplant tolerance.

We have studied the veto cell-mediated induction of transplant tolerance by allogeneic donor bone marrow cells and have achieved kidney allograft tolerance in a preclinical rhesus monkey model. Here we extend these studies to investigate the veto mechanism of CTLp suppression and the role of CD8 and TGF-beta in these events. Infusion of DR-/dim donor BMC into RATG-treated rhesus monkeys induced functional deletion of donor-specific CTLp and prolongation of kidney allograft survival, whereas depletion of the CD8+ subset from BMC ablated these effects. A role of CD8 in the veto effect was further implicated by rhesus MLR-induced CML experiments in which pretreatment of normal responder cells with MAb to MHC class I, the natural ligand of CD8, blocked the suppressive activity of allogeneic BMC. In addition, pretreatment of the BMC with anti-CD8 MAbs blocked strong veto activity significantly, suggesting that CD8 functions as an accessory or adhesion ligand. In contrast, anti-CD8 treatment significantly enhanced weak BMC-mediated veto activity, suggesting that CD8 might additionally serve as a signal transducer to increase veto activity, perhaps by the induction of cytokine release. The cytokine TGF-beta was studied because it has immunosuppressive properties that are shared by veto cells. Human TGF-beta, like BMC veto cells, inhibited MLR-induced CML in a dose-dependent manner, and anti-TFB-beta Ig relieved the BMC-mediated veto suppressive effect. Active TGF-beta was detected only in the supernatants of CML cultures containing BMC. Pretreatment of BMC with L-leucyl-leucine methyl ester (Leu-leu-OMe), which eliminates cytotoxic precursor and effector lymphocytes and monocytes, did not affect levels of active TGF-beta. In previous studies, the veto effect of BMC was also shown to be Leu-leu-OMe-resistant. Finally, treatment of isolated DR-/dim BMC cultures with anti-CD8 elicited TGF-beta secretion, whereas anti-CD2 or anti-CD3 had no effect. When isolated after stimulation with anti-CD8, only the CD8+ subset of DR-/dim BMC produced detectable levels of active TGF-beta. In summary, these studies demonstrate that CD8 functions as an immunoregulatory molecule in veto effects by freshly isolated rhesus BMC and suggest that CD8-ligand interactions may induce low-level secretion of TGF-beta to mediate or facilitate the veto mechanism of CTLp inactivation in a paracrine manner.

Production of stable rabbit-mouse heterohybridomas: characterization of a rabbit monoclonal antibody recognizing a 180 kDa human lymphocyte membrane antigen.

Polyclonal rabbit antihuman thymocyte globulin (RATG) remains a key component of immunosuppressive strategies in transplantation. The human thymus immunization regimen that produces highly immunosuppressive RATG induces unique antibody specificities in the rabbit. Rabbit monoclonal antibodies (RAb MAbs) to human T cell antigens would be of value in the effort to investigate and reproduce the multiple specificities of RATG. We have fused mouse Sp2/0 cells with splenocytes from rabbits immunized with human thymus and have identified 52 rabbit-mouse heterohybridomas which secrete RAb MAbs directed against human lymphocyte surface antigens. The technical aspects of hybridoma isolation, stabilization and characterization are presented. Analysis by flow cytometry, preabsorption and immunoprecipitation suggests that RAb MAb 1A8 IgG may recognize LFA-1, one of the principal lymphocyte surface antigens recognized by RATG. The 1A8 antigen is 180 kDa and is expressed by 80-90% human PBL and thymocytes. LFA-1 and the 1A8 antigen exhibit 100% co-expression in two-color FACS analysis using four different murine anti-LFA-1 MAbs. 1A8 markedly inhibits the mitogenic response of lymphocytes to PHA, as do murine anti-LFA-1 MAbs. A combination of rabbit antilymphocyte MAbs may potentially reproduce the multiple specificities found in polyclonal RATG and lead to the production of a superior immunosuppressive clinical agent.

Preparation, characterization, and in vivo biodistribution properties of synthetically cross-linked multivalent antitumor antibody fragments.

Two new antibody forms of the general structure F(ab')n (n = 3 or 4) were prepared and tested in vivo as part of an ongoing search for antibody candidates with improved biodistribution properties for cancer immunotargeting applications. The novel multivalent antibody forms, called F(ab')3-x (tribody, 150 kDa, x = cross-linker) and F(ab')4-x (tetrabody, 200 kDa), were constructed through chemical cross-linking of Fab' subunits derived from murine CC49 IgG, a monoclonal antibody which recognizes the tumor-associated antigen TAG-72. Two new chemical reagents (trismaleimide 1 and tetramaleimide 2) were synthesized for use in cross-linking cysteine sulfhydryl groups present on the hinge region of Fab'. Homogeneous Fab' was prepared by mild reduction of F(ab')2 followed by selective reoxidation of interchain disulfide bonds, leaving a single hinge-region cysteine sulfhydryl group available for modification. For biodistribution studies, the parent F(ab')2 fragment was first radiolabeled via lysine amine modification using the isothiocyanate derivative of the 105Rh(BA-2,3,2-tet)Cl2 complex. Both new fragment forms were shown to retain antigen binding ability in vitro using a solid-phase immunoassay. Although isolated yields for F(ab')3-x and F(ab')4-x were low (18 and 4%, respectively), sufficient quantities were prepared for preliminary biodistribution studies in Balb/c mice and, in the case of F(ab')3-x, for a 5-day biodistribution study in tumor-bearing nude mice. A large proportion of the 105Rh-labeled F(ab')4-x was found to accumulate in the liver, possibly indicating an upper size limit for the in vivo use of cross-linked fragments. The biodistribution behavior of 105Rh-labeled F(ab')3-x in both Balb/c and nude mice was intermediate between that of IgG and F(ab')2 for all organs studied. Kidney localization was reduced, while blood circulation time and tumor accumulation were slightly increased, for the trivalent species compared with F(ab')2. The unique biodistribution profile of F(ab')3-x suggests the possible use of this multivalent fragment for in vivo tumor targeting applications.

Biosynthesis, processing, and secretion of M and Z variant human alpha 1-antitrypsin.

The Z genetic variant of human alpha 1-antitrypsin (alpha 1AT) is associated with decreased serum alpha 1AT levels, hepatic inclusion bodies, and an increased risk of lung and liver disease. We studied the biosynthesis, processing, and secretion of normal and Z variant alpha 1AT in cell-free translation systems, reconstituted in vitro processing systems, and in the Xenopus oocyte secretory system. Human liver mRNA was prepared from normal subjects (PiMM) and from individuals homozygous for alpha 1AT deficiency (PiZZ). Cell-free translation resulted in the synthesis of 49,000-Da preproteins with a 23-amino acid signal sequence. The genetic variants were synthesized at comparable levels and could be distinguished on the basis of charge. The majority of the amino acids in the ZZ signal peptide were identified and found to be the same as those comprising the MM signal sequence. These proteins were co-translationally processed with similar efficiency by dog pancreas microsomes, producing 52,000-Da glycoproteins which were completely translocated across the endoplasmic reticulum membrane. When the human liver RNA preparations were injected into Xenopus oocytes, both of the alpha 1AT variants were synthesized intracellularly and alpha 1AT was detected in the medium of all oocytes injected with MM RNA. However, the Z variant accumulated within the microsomal vesicles of the cell and was undetectable or present at decreased levels in the medium. We conclude that the single amino acid substitution in the Z variant of alpha 1AT does not affect its synthesis or co-translational processing but that it strongly affects its transport from the rough endoplasmic reticulum through the secretory pathway.

Biosynthesis and processing of rat alpha 1-antitrypsin.

Various biosynthetic forms of rat alpha 1-antitrypsin (alpha 1AT) have been isolated by immunoprecipitation of in vitro and in vivo synthesized products. Rat alpha 1AT is synthesized in a rabbit reticulocyte system as a 45,000-Da preprotein with a 23-amino acid signal sequence. The majority of the amino acids in the signal sequence have been identified and resemble the signal peptides of other secretory proteins with respect to the abundance and positions of hydrophobic amino acids. Evidence from the translation of rat liver RNA in the presence of dog pancreas microsomes, from the translation of rat liver polysomes, and from tunicamycin-treated rat hepatocytes established that cleavage of the signal peptide of pre-alpha 1AT results in the formation of a 42,000-Da protein, the polypeptide backbone of mature alpha 1AT. A 50,000-Da glycoprotein is immunoprecipitated from translations programmed with rat liver microsomes or with rat liver mRNA and dog pancreas microsomes. Cotranslational glycosylation of alpha 1AT appears to occur in a stepwise fashion since three glycosylated forms of alpha 1AT (approximately 45,000, 47,000, and 50,000 Da) can be detected in polysome translations. These proteins are susceptible to cleavage by endo-beta-N-acetylglucosaminidase H and are digested to the same product, indicating that they have identical polypeptide chains. Two intracellular forms of alpha 1AT were detected in cultured rat hepatocytes, a 50,000- and a 52,000-Da protein; only the larger protein was immunoprecipitated from the medium of these cells. Digestion with endo-beta-N-acetylglucosaminidase H indicated that the 50,000-Da protein is a core glycosylated processing intermediate, whereas the 52,000-Da protein, which comigrated with purified serum alpha 1AT, appears to contain complex carbohydrate sidechains. When glycosylation was inhibited by incubation of hepatocytes with tunicamycin, a nonglycosylated 42,000-Da protein was immunoprecipitated from the cells and the culture medium, indicating that glycosylation of alpha 1AT is not essential for its secretion.

Role of the H-2 complex in preimplantation mouse embryo development.

The H-2 complex was found to influence early mouse embryo development. Slow development was shown to be associated with the H-2k haplotype. By the use of congenic strains, it was clearly demonstrated that gene(s) in the H-2 complex affect the time of the first cleavage division and the rate of subsequent preimplantation development