95 PROSTAGLANDIN E1 FOR INTERRUPTED AORTIC ARCH IN THE NEONATE be used to maintain the SIR,-E-type prostaglandins in neonates with certain ductus arteriosus the of patency heart malformations.’ 2 The reported excongenital cyanotic perience has been exclusively in infants with right-heart obstructive lesions whose survival and arterial oxygen saturation depend on pulmonary blood-flow through a persistent ductus arteriosus.
This
case
seriously
illustrates its potential sick neonates.
as an
initial
D. J. RADFORD K. R. BLOOM F. COCEANI R. FARIELLO P. M. OLLEY
can
We have used prostaglandin E1(r.G.E,) in interruption of the aortic arch. In this malformation, blood-supply to the lower part of the body depends on persistence of the ductus arteriosus, and infants usually die of severe metabolic acidosis and cardiac failure as the ductus closes. If the patient can be maintained medically in a reasonably fit condition, surgical reconstruction of the aortic arch is now feasible.3 The use of the ductal muscle-relaxant effect of prostaglandins seems worthy of trial in this situation.4
After
normal pregnancy and delivery, the male infant 3.8kg and had an Apgar score of 8. A hare lip and subluxation of the left hip were noted, but he was apparently well and was discharged from hospital on the fifth day. On the ninth day he began to vomit and was readmitted. Transfer to our unit was arranged on day 10. a
weighed
approach to these
Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada MSG 1X8
INTRAPLEURAL B.C.G. TREATMENT OF EXPERIMENTAL LUNG TUMOURS
SIR,-Dr McKneally and his colleagues (Feb. 21, p. 377) reported beneficial effects in stage-i lung-cancer patients after postoperative intrapleural administration of B.C.G. Baldwin and I have shown that growth of solid tumours or malignant effusions in the pleural cavity of the rat can be controlled by intrapleural administration of the vaccine.’ In addition, lungtumour deposits can be suppressed by pulmonary infiltration with B.C.G., administered intravenously.23 In view of the clinical findings of McKneally et al. preliminary tests have been carried out to examine experimentally the effect on tumour growth in the lungs of B.c.G. given into the pleural cavity. B.C.G. TREATMENT OF LONG-TUMOUR GROWTH IN RATS
On examination, the baby was very ill with severe cardiac failure. The pulses in the left arm and both femorals were weak to palpation and systolic blood-pressures were 100 mm Hg in the right arm, 68 in the left arm, and 64 in both legs. Digoxin and diuretics were started. At cardiac catheterisation, angiography demonstrated complete interruption of the aortic arch. Flow to the descending aorta was through a patent ductus arteriosus and the left sub-
clavian artery arose from this lower segment. In addition, there was a ventricular septal defect and an atrial defect. The pressures were: right ventricle 100/14 mm Hg, main pulmonary artery 100/55, and descending aorta 55/45. During the procedure bicarbonate was given to correct metabolic acidosis. P.G.EI5 0.11 g/kg/min, was infused directly into the ductus arteriosus via a catheter positioned there from the venous side. Within 10 min, the pressure in the descending aorta rose from 55/45 to 72/46 mm Hg suggesting reopening of the ductus. Simultaneously, the pulmonary-artery pressure fell to 94/50
mm Hg. A cannula was left in the inferior sion continued at 0.03
and p.G.E1 infuthe reduced dose, Despite g/kg/min. the improvement in the general haemodynamic status of the patient was maintained and he began to pass urine. The systolic pressure in his legs remained around 65 mm Hg. However, he developed generalised seizures and eventually entered into status epilepticus. This was attributed to severe hypocalcaemia, and p.G.EI treatment was maintained while the status epilepticus was controlled with anticonvulsants and by correction of the hypocalcaemia. The heemodynamic improvement persisted during p.G.EI treatment, and at the age of 13 days surgical correction under deep hypothermia was scheduled. Unfortunately, the infant developed ventricular fibrillation as his chest was
vena cava
opened and he could not be resuscitated.
At necropsy, the patency of the ductus arteriosus was confirmed along with the interrupted aortic arch and ventricular septal defect.
Although arteriosus is
interruption
the relaxant action of P.G.E, on the ductus striking under hypoxic conditions,4 its use in of the aortic arch has previously been suggested.2
most
Elliott, R. B., Starling, M. B., Neutze, J. M. Lancet, 1975, i, 140. Olley, P M., Coceani, F., Bodach, E. Circulation, 1976, 53, 728 3 Goor, D A, Lillehei, C. W. Congenital Malformations of the Heart, p. 281 New York, 1975. 4 Coceani, F., Olley, P. M. Can. J. Physiol. Pharmac. 1973, 51, 220. 1. 2
I
i
I
*With respect to tumour injection. tFrom Wilcoxon non-parametric rank
i
i
test.
In these tests (see accompanying initiated by intravenous (i.v.)
were
I
table) pulmonary tumours injection of cells from two
syngeneically transplanted tumours in Wistar rats3-methylcholanthrene-induced sarcoma (Mc40A’) and an aminoazodye-induced hepatoma (D23’). Treatment was given by subcutaneous (s.c.) or intrapleural (i.pl.) injection of B.C.G. (Glaxo percutaneous vaccine B.P., 3x 107 viable units/mg moist weight of organisms, representing approximately 20% viability). In the first ten untreated animals survived for 16-23 days, all having to be killed because of extensive pulmonary tumour growth, but a single intrapleural injection of B.C.G. prolonged survival to 24-65 days. Similar results were obtained in two other tests, where the effect of intrapleural B.C.G. significantly prolonged survival, while s.c. injection of the vaccine had a smaller and less consistent effect. These preliminary findings may help to provide a rational basis for treatment of lung tumours by intrapleurally administered B.c.G., the indication being that this route is superior to distant injection. In addition, they provide an experimental model for screening other adjuvants, and for investigating the mechanism of action of intrapleural B.C.G. Previous studies, with subcutaneous tumour growths in rats, have demonstrated that tumour supression by regionally applied B.C.G. depends more upon local activation of host macrophages than upon general immunostimulation,4and further tests are in pro1. 2. 3. 4. 5.
Pimm, M. V., Baldwin, R. W. Int. J. Cancer, 1975, 15, 260. Pimm, M. V., Baldwin, R. W. Br J. Cancer, 1973, 27, 48. Baldwin, R. W., Pimm, M. V. ibid. 1974, 30, 473. Hopper, D. G, Pimm, M. V., Baldwin, R. W. Cancer Immun, 1976, 1, 143. Pimm, M. V., Hopper, D. G. Br. J. Cancer, 1975, 32, 241.
Immunother.
96 gress
to
examine the effect of
intrapleural
B.C.G.
in
macro-
phage depleted and immunosuppressed animals.
We believe that restoration of immune competence if possible, precede specific or non-specific treatment.
Cancer Research Campaign Laboratories,
University of Nottingham, University Park, Nottingham NG7 2RD
M. V. PIMM
Institute of Clinical Science and Research, Royal College of Surgeons in Ireland, Dublin, Eire
should,
ORLA BROWNE J. BELL P. D. J. HOLLAND R. D. THORNES
PLASMAPHERESIS AND IMMUNOSTIMULATION very interested in your editorial’ on the applications of plasmapheresis and in particular of its use by Hersey and his colleagues to remove serum blocking factors of cell-mediated immunity in patients with malignant melanoma. We have shown that T-lymphocyte activity can be enhanced in patients with malignant disease, including melanoma, by intravenous infusion of proteolytic enzymes (i.e., ’Brinase’2 and
SIR,-We
were
clinical
or by washing of lymphocytes removed by an I.B.M./N.C.I. continuous-flow cell separator.’ The enhancement of T-cell activity by these measures, however, lasts only
streptokinase3)
about four to seven days in advanced malignancy. The reblocking of activity, we presume, is due to serum blocking factors.
We found that the
use
of the cell
separator
alone without
washing of the lymphocytes enhanced T-cell activity in patients. We then demonstrated (unpublished) that simple mechanical agitation of blocked T cells from patients with malignant disease increases their capacity to bind sheep erythrocytes (E rosettes) and that the material shaken off the lymphocytes when incubated with normal control T cells inhibits their binding capacity: Cancer Breast
T cells (%) ’’Shakings’’ added to control T cells Before shaking After shaking Control (%) Reduced to (%)
Qaecum Lymphosarcoma
The T-cell
18 48 54
62 58 70 of healthy controls
50 74
35 67
70 unaffected
59
by shaking. Because of the blocking effect of serum factors on T cells in malignancy we subjected two patients with advanced malignant disease to plasmapheresis using the I.B.M. continuousflow cell separator, 2 litres of patient’s plasma being exchanged for a similar amount of fresh-frozen pooled human plasma. The patient’s T-cell counts rose from 30% to 58% (case 1) and from 34% to 75% (case 2) following the procedure. The serum blocking effect on control normal T cells fell appreciably immediately after plasmapheresis and remained at a low level in each case for about 4 weeks. Normal control T cells were incubated in patient’s serum for 30 min at 18°C. The serum blocking effect was then expressed as the percentage reduction in E counts
were
rosetting: % reduction in E rosetting Time
Before plasmapheresis After plasmapheresis: 1 wk 2 wk 3 wk 4 wk
Case 1
Case 2
(osteosarcoma)
(bronchogemc carcinoma)
34 7 3 4 2 22
50 24 17 18 16 15
Repeat plasmapheresis: 1 wk later 2 wk later Skin hypersensitivity
6 16 to dmitrochlorobenzene and was restored in both patients.
4 11
punfied protein derivative but streptokinase In these two cases the relatively small exchange of 2 litres was sufficient to produce a prolonged effect. If this experience is confirmed in a larger series of patients which we are now investigating then plasmapheresis could have a practical part to play in immunotherapy.
not to
ENHANCED ANTIBODY RESPONSES IN ACTIVE CHRONIC HEPATITIS
SIR,—We read the paper by Galbraith et al.’ with interest. We have done similar studies but our results differ in several respects. Galbraith et al. found a significant correlation between raised antibody titres to rubella and to measles and the possession of HLA-B8 in patients with HBsAg-negative chronic active hepatitis, but not in their relatives. We have studied antibodies to a variety of antigens including rubella and measles in individually matched HLA-B8 positive and negative subjects-mainly patients with HBsAg-negative chronic liver disease, including many with chronic active hepatitis-and found no correlation between HLA-B8 and any antibody titre except gluten.2 Furthermore, in a separate unpublished study of 33 patients with HBsAg-negative chronic active hepatitis we found no correlation between HLA-B8 and rubella or measles antibody titres. We were careful in our published study2 to match individually the HLA-B8 positive and negative subjects, especially for age, since we find in adult controls an inverse correlation between these antibody titres (notably rubella, P
This
case
seriously
illustrates its potential sick neonates.
as an
initial
D. J. RADFORD K. R. BLOOM F. COCEANI R. FARIELLO P. M. OLLEY
can
We have used prostaglandin E1(r.G.E,) in interruption of the aortic arch. In this malformation, blood-supply to the lower part of the body depends on persistence of the ductus arteriosus, and infants usually die of severe metabolic acidosis and cardiac failure as the ductus closes. If the patient can be maintained medically in a reasonably fit condition, surgical reconstruction of the aortic arch is now feasible.3 The use of the ductal muscle-relaxant effect of prostaglandins seems worthy of trial in this situation.4
After
normal pregnancy and delivery, the male infant 3.8kg and had an Apgar score of 8. A hare lip and subluxation of the left hip were noted, but he was apparently well and was discharged from hospital on the fifth day. On the ninth day he began to vomit and was readmitted. Transfer to our unit was arranged on day 10. a
weighed
approach to these
Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada MSG 1X8
INTRAPLEURAL B.C.G. TREATMENT OF EXPERIMENTAL LUNG TUMOURS
SIR,-Dr McKneally and his colleagues (Feb. 21, p. 377) reported beneficial effects in stage-i lung-cancer patients after postoperative intrapleural administration of B.C.G. Baldwin and I have shown that growth of solid tumours or malignant effusions in the pleural cavity of the rat can be controlled by intrapleural administration of the vaccine.’ In addition, lungtumour deposits can be suppressed by pulmonary infiltration with B.C.G., administered intravenously.23 In view of the clinical findings of McKneally et al. preliminary tests have been carried out to examine experimentally the effect on tumour growth in the lungs of B.c.G. given into the pleural cavity. B.C.G. TREATMENT OF LONG-TUMOUR GROWTH IN RATS
On examination, the baby was very ill with severe cardiac failure. The pulses in the left arm and both femorals were weak to palpation and systolic blood-pressures were 100 mm Hg in the right arm, 68 in the left arm, and 64 in both legs. Digoxin and diuretics were started. At cardiac catheterisation, angiography demonstrated complete interruption of the aortic arch. Flow to the descending aorta was through a patent ductus arteriosus and the left sub-
clavian artery arose from this lower segment. In addition, there was a ventricular septal defect and an atrial defect. The pressures were: right ventricle 100/14 mm Hg, main pulmonary artery 100/55, and descending aorta 55/45. During the procedure bicarbonate was given to correct metabolic acidosis. P.G.EI5 0.11 g/kg/min, was infused directly into the ductus arteriosus via a catheter positioned there from the venous side. Within 10 min, the pressure in the descending aorta rose from 55/45 to 72/46 mm Hg suggesting reopening of the ductus. Simultaneously, the pulmonary-artery pressure fell to 94/50
mm Hg. A cannula was left in the inferior sion continued at 0.03
and p.G.E1 infuthe reduced dose, Despite g/kg/min. the improvement in the general haemodynamic status of the patient was maintained and he began to pass urine. The systolic pressure in his legs remained around 65 mm Hg. However, he developed generalised seizures and eventually entered into status epilepticus. This was attributed to severe hypocalcaemia, and p.G.EI treatment was maintained while the status epilepticus was controlled with anticonvulsants and by correction of the hypocalcaemia. The heemodynamic improvement persisted during p.G.EI treatment, and at the age of 13 days surgical correction under deep hypothermia was scheduled. Unfortunately, the infant developed ventricular fibrillation as his chest was
vena cava
opened and he could not be resuscitated.
At necropsy, the patency of the ductus arteriosus was confirmed along with the interrupted aortic arch and ventricular septal defect.
Although arteriosus is
interruption
the relaxant action of P.G.E, on the ductus striking under hypoxic conditions,4 its use in of the aortic arch has previously been suggested.2
most
Elliott, R. B., Starling, M. B., Neutze, J. M. Lancet, 1975, i, 140. Olley, P M., Coceani, F., Bodach, E. Circulation, 1976, 53, 728 3 Goor, D A, Lillehei, C. W. Congenital Malformations of the Heart, p. 281 New York, 1975. 4 Coceani, F., Olley, P. M. Can. J. Physiol. Pharmac. 1973, 51, 220. 1. 2
I
i
I
*With respect to tumour injection. tFrom Wilcoxon non-parametric rank
i
i
test.
In these tests (see accompanying initiated by intravenous (i.v.)
were
I
table) pulmonary tumours injection of cells from two
syngeneically transplanted tumours in Wistar rats3-methylcholanthrene-induced sarcoma (Mc40A’) and an aminoazodye-induced hepatoma (D23’). Treatment was given by subcutaneous (s.c.) or intrapleural (i.pl.) injection of B.C.G. (Glaxo percutaneous vaccine B.P., 3x 107 viable units/mg moist weight of organisms, representing approximately 20% viability). In the first ten untreated animals survived for 16-23 days, all having to be killed because of extensive pulmonary tumour growth, but a single intrapleural injection of B.C.G. prolonged survival to 24-65 days. Similar results were obtained in two other tests, where the effect of intrapleural B.C.G. significantly prolonged survival, while s.c. injection of the vaccine had a smaller and less consistent effect. These preliminary findings may help to provide a rational basis for treatment of lung tumours by intrapleurally administered B.c.G., the indication being that this route is superior to distant injection. In addition, they provide an experimental model for screening other adjuvants, and for investigating the mechanism of action of intrapleural B.C.G. Previous studies, with subcutaneous tumour growths in rats, have demonstrated that tumour supression by regionally applied B.C.G. depends more upon local activation of host macrophages than upon general immunostimulation,4and further tests are in pro1. 2. 3. 4. 5.
Pimm, M. V., Baldwin, R. W. Int. J. Cancer, 1975, 15, 260. Pimm, M. V., Baldwin, R. W. Br J. Cancer, 1973, 27, 48. Baldwin, R. W., Pimm, M. V. ibid. 1974, 30, 473. Hopper, D. G, Pimm, M. V., Baldwin, R. W. Cancer Immun, 1976, 1, 143. Pimm, M. V., Hopper, D. G. Br. J. Cancer, 1975, 32, 241.
Immunother.
96 gress
to
examine the effect of
intrapleural
B.C.G.
in
macro-
phage depleted and immunosuppressed animals.
We believe that restoration of immune competence if possible, precede specific or non-specific treatment.
Cancer Research Campaign Laboratories,
University of Nottingham, University Park, Nottingham NG7 2RD
M. V. PIMM
Institute of Clinical Science and Research, Royal College of Surgeons in Ireland, Dublin, Eire
should,
ORLA BROWNE J. BELL P. D. J. HOLLAND R. D. THORNES
PLASMAPHERESIS AND IMMUNOSTIMULATION very interested in your editorial’ on the applications of plasmapheresis and in particular of its use by Hersey and his colleagues to remove serum blocking factors of cell-mediated immunity in patients with malignant melanoma. We have shown that T-lymphocyte activity can be enhanced in patients with malignant disease, including melanoma, by intravenous infusion of proteolytic enzymes (i.e., ’Brinase’2 and
SIR,-We
were
clinical
or by washing of lymphocytes removed by an I.B.M./N.C.I. continuous-flow cell separator.’ The enhancement of T-cell activity by these measures, however, lasts only
streptokinase3)
about four to seven days in advanced malignancy. The reblocking of activity, we presume, is due to serum blocking factors.
We found that the
use
of the cell
separator
alone without
washing of the lymphocytes enhanced T-cell activity in patients. We then demonstrated (unpublished) that simple mechanical agitation of blocked T cells from patients with malignant disease increases their capacity to bind sheep erythrocytes (E rosettes) and that the material shaken off the lymphocytes when incubated with normal control T cells inhibits their binding capacity: Cancer Breast
T cells (%) ’’Shakings’’ added to control T cells Before shaking After shaking Control (%) Reduced to (%)
Qaecum Lymphosarcoma
The T-cell
18 48 54
62 58 70 of healthy controls
50 74
35 67
70 unaffected
59
by shaking. Because of the blocking effect of serum factors on T cells in malignancy we subjected two patients with advanced malignant disease to plasmapheresis using the I.B.M. continuousflow cell separator, 2 litres of patient’s plasma being exchanged for a similar amount of fresh-frozen pooled human plasma. The patient’s T-cell counts rose from 30% to 58% (case 1) and from 34% to 75% (case 2) following the procedure. The serum blocking effect on control normal T cells fell appreciably immediately after plasmapheresis and remained at a low level in each case for about 4 weeks. Normal control T cells were incubated in patient’s serum for 30 min at 18°C. The serum blocking effect was then expressed as the percentage reduction in E counts
were
rosetting: % reduction in E rosetting Time
Before plasmapheresis After plasmapheresis: 1 wk 2 wk 3 wk 4 wk
Case 1
Case 2
(osteosarcoma)
(bronchogemc carcinoma)
34 7 3 4 2 22
50 24 17 18 16 15
Repeat plasmapheresis: 1 wk later 2 wk later Skin hypersensitivity
6 16 to dmitrochlorobenzene and was restored in both patients.
4 11
punfied protein derivative but streptokinase In these two cases the relatively small exchange of 2 litres was sufficient to produce a prolonged effect. If this experience is confirmed in a larger series of patients which we are now investigating then plasmapheresis could have a practical part to play in immunotherapy.
not to
ENHANCED ANTIBODY RESPONSES IN ACTIVE CHRONIC HEPATITIS
SIR,—We read the paper by Galbraith et al.’ with interest. We have done similar studies but our results differ in several respects. Galbraith et al. found a significant correlation between raised antibody titres to rubella and to measles and the possession of HLA-B8 in patients with HBsAg-negative chronic active hepatitis, but not in their relatives. We have studied antibodies to a variety of antigens including rubella and measles in individually matched HLA-B8 positive and negative subjects-mainly patients with HBsAg-negative chronic liver disease, including many with chronic active hepatitis-and found no correlation between HLA-B8 and any antibody titre except gluten.2 Furthermore, in a separate unpublished study of 33 patients with HBsAg-negative chronic active hepatitis we found no correlation between HLA-B8 and rubella or measles antibody titres. We were careful in our published study2 to match individually the HLA-B8 positive and negative subjects, especially for age, since we find in adult controls an inverse correlation between these antibody titres (notably rubella, P
