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ObjectiveTumour-infiltrating lymphocytes (TILs) favour survival in human colorectal cancer (CRC). Chemotactic factors underlying their recruitment remain undefined. We investigated chemokines attracting T cells into human CRCs, their cellular sources and microenvironmental triggers.DesignExpression of genes encoding immune cell markers, chemokines and bacterial 16S ribosomal RNA (16SrRNA) was assessed by quantitative reverse transcription-PCR in fresh CRC samples and corresponding tumour-free tissues. Chemokine receptor expression on TILs was evaluated by flow cytometry on cell suspensions from digested tissues. Chemokine production by CRC cells was evaluated in vitro and in vivo, on generation of intraperitoneal or intracecal tumour xenografts in immune-deficient mice. T cell trafficking was assessed on adoptive transfer of human TILs into tumour-bearing mice. Gut flora composition was analysed by 16SrRNA sequencing.ResultsCRC infiltration by distinct T cell subsets was associated with defined chemokine gene signatures, including CCL5, CXCL9 and CXCL10 for cytotoxic T lymphocytes and T-helper (Th)1 cells; CCL17, CCL22 and CXCL12 for Th1 and regulatory T cells; CXCL13 for follicular Th cells; and CCL20 and CCL17 for interleukin (IL)-17-producing Th cells. These chemokines were expressed by tumour cells on exposure to gut bacteria in vitro and in vivo. Their expression was significantly higher in intracecal than in intraperitoneal xenografts and was dramatically reduced by antibiotic treatment of tumour-bearing mice. In clinical samples, abundance of defined bacteria correlated with high chemokine expression, enhanced T cell infiltration and improved survival.ConclusionsGut microbiota stimulate chemokine production by CRC cells, thus favouring recruitment of beneficial T cells into tumour tissues.

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Quality of surgical training in the era of resident duty-hour restrictions (RDHR) is part of an ongoing debate. Most training elements are provided during surgical service. As exposure to surgical procedures is important but time-consuming, RDHR may affect quality of surgical training. Providing structured training elements may help to compensate for this shortcoming.

Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects. From a prospective database of patients with LRYGB, we selected as primary cohort patients with non-closure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra- and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed. We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %. The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.

In the era of cost-constrained health care, optimal resource utilisation becomes fundamental in daily clinical practice. Currently, processes during surgery are poorly defined and workflows need to be scrutinised. This investigation aimed at identifying interruptions of surgical workflow and quantifying their impact on the duration of surgery and costs. Interruptions of surgical workflow were defined as microcomplications (MC) and divided into the following subgroups: communication-related (CR), instrument changes (IC), missing instruments (MI), instrument failure (IF), waiting for a senior surgeon (SS), anaesthesia-related (AR) and position changes (PC). Audio–video records of laparoscopic cholecystectomies were reviewed regarding type, frequency and duration of MC. Risk factors for MC were investigated in a multivariable linear regression analysis. The costs of MC due to intraoperative delay were calculated. Twenty audio–video records of laparoscopic cholecystectomies with a total duration of 28.9 h were reviewed. The median frequency of MC was 95 events/h with an overall duration of 452 min, corresponding to a delay of 15.6 min/h. Most frequent causes for MC were CR (32 events/h) and IC (54 events/h), leading to a total delay of 6.5 min/h for CR and 4.5 min/h for IC, respectively. MI and IF were less frequent (2.0 and 5.4 events/h), but single events lasted longer, resulting in a total delay of 1.4 min/h in MI and 2.1 min/h in IF. Intraoperative delays due to SS, AR or PC were rare. Multivariable regression analysis revealed previous abdominal surgery and cholecystitis as risk factors for a longer duration of MC (p= 0.004; p= 0.046). Based on OR minute costs of € 31.98, the delay due to MC led to additional costs of € 499/h. MC cause relevant intraoperative delay and increased costs. Step-by-step protocols for a laparoscopic cholecystectomy may lead to a reduction in MC and should be further evaluated.

Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20–30 % of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB. In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity. Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8 % after 12 months of follow-up evaluation and 45.1 % after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3 % after 12 months and 57.2 % after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8 %/54.3 % versus 64.1 % (p< 0.001 and <0.01) after 12 months and 45.1 %/57.2 % versus 70.4 % (p< 0.001 and <0.002) after 24 months. Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.

Surgeons’ personalities have been described as different from those of the general population, but this was based on small descriptive studies limited by the choice of evaluation instrument. Furthermore, although the importance of the human factor in team performance has been recognized, the effect of personality traits on technical performance is unknown. This study aimed to compare surgical residents’ personality traits with those of the general population and to evaluate whether an association exists between their personality traits and technical performance using a virtual reality (VR) laparoscopy simulator.In this study, 95 participants (54 residents with basic, 29 with intermediate laparoscopic experience, and 12 students) underwent personality assessment using the NEO-Five Factor Inventory and performed five VR tasks of the Lap Mentor™ basic tasks module. The residents’ personality traits were compared with those of the general population, and the association between VR performance and personality traits was investigated.Surgical residents showed personality traits different from those of the general population, demonstrating lower neuroticism, higher extraversion and conscientiousness, and male residents showed greater openness. In the multivariable analysis, adjusted for gender and surgical experience, none of the personality traits was found to be an independent predictor of technical performance.Surgical residents present distinct personality traits that differ from those of the general population. These traits were not found to be associated with technical performance in a virtual environment. The traits may, however, play an important role in team performance, which in turn is highly relevant for optimal surgical performance.

Objective.To evaluate the feasibility of implementation of the refined window for routine antimicrobial prophylaxis (RAP) of 30-74 minutes before skin incision compared to the World Health Organization (WHO) standard of 0-60 minutes.Design.Prospective study on timing of routine antimicrobial prophylaxis in 2 different time periods.Setting.Tertiary referral university hospital with 30,000 surgical procedures per year.Methods.In all consecutive vascular, visceral, and trauma procedures, the timing was prospectively recorded during a first time period of 2 years (A; baseline) and a second period of 1 year (B; after intervention). An intensive intervention program was initiated after baseline. The primary outcome parameter was timing; the secondary outcome parameter was surgical site infection (SSI) rate in the subgroup of patients undergoing cholecystectomy/colon resection.Results.During baseline time period A (3,836 procedures), RAP was administered 30–74 minutes before skin incision in 1,750 (41.0%) procedures; during time period B (1,537 procedures), it was administered in 914 (56.0%; P< .001). The subgroup analysis did not reveal a significant difference in SSI rate.Conclusions.This bundle of interventions resulted in a statistically significant improvement of timing of RAP even at a shortened window compared to the WHO standard.

Operative Eingriffe am oberen Gastrointestinaltrakt (inkl. Pankreas) können zu einer Vielzahl postoperativer funktioneller und metabolischer Syndrome führen. Deren Kenntnis ist nicht nur für den behandelnden Chirurgen wichtig, sondern auch für den nachbehandelnden niedergelassenen Arzt. In den meisten Fällen stellt sich mit zunehmender Rekonvaleszenzzeit eine Besserung ein. Die Therapie solcher Syndrome erfolgt am besten in enger interdisziplinärer Zusammenarbeit (Allgemeinpraktiker, Chirurg, Gastroenterologe etc.) und beinhaltet physikalische, medikamentöse, interventionelle und letztendlich auch chirurgische Maßnahmen.

HYPOTHESIS The 50-hour workweek limitation for surgical residents in Switzerland has a major effect on surgical training, resident quality of life, and patient care. DESIGN Survey study. SETTING Residencies in Switzerland. PARTICIPANTS Surgical residents and surgical consultants. MAIN OUTCOME MEASURES An anonymous survey was conducted in Switzerland. Of 93 surgical departments contacted, 52 (55.9%) responded; of their 281 surgical residents and 337 surgical consultants, 405 (65.5%) returned a completed survey. RESULTS Residents and consultants indicated a negative effect of the 50-hour workweek limitation on surgical training (62.8% and 77.2%, respectively) and on quality of patient care (43.0% and 70.1%, respectively) (P &lt; .001 for both). Most residents and consultants reported that operative time (76.9% and 73.4%, respectively) and overall operating room experience (73.8% and 84.8%, respectively) were negatively affected by the work hour limitation. Only 8.1% of residents and 4.9% of consultants perceived the work hour limitation as beneficial to surgical training. Conversely, 58.4% of residents and 81.5% of consultants considered that residents' quality of life had improved (P &lt; .001). CONCLUSIONS Most surgical residents and surgical consultants perceive the work hour limitation as having a negative effect on surgical training and on the quality of patient care. Despite somewhat improved resident quality of life, the work hour limitation for surgical residencies in Switzerland appears to be a failure.Arch Surg. 2010;145(6):558-563--

HYPOTHESIS Clinically apparent surgical glove perforation increases the risk of surgical site infection (SSI). DESIGN Prospective observational cohort study. SETTING University Hospital Basel, with an average of 28 000 surgical interventions per year. PARTICIPANTS Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery. MAIN OUTCOME MEASURES The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation. RESULTS The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P &lt; .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26). CONCLUSION Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.Arch Surg. 2009;144(6):553-558--

Objective.Research has shown 1.5 minutes of surgical hand antisepsis with alcohol-based hand rub to be at least as effective under experimental conditions as the 3-minute reference disinfection recommended by European Norm 12791. The aim of the present study was to validate the effectiveness of 1.5 minutes of surgical hand antisepsis in a clinical setting by comparing the effectiveness of 1.5- and 3-minute applications of alcohol-based hand rub (45% vol/vol 2-propanol, 30% vol/vol 1-propanol, and 0.2% mecetronium ethylsulphate).Design.Prospective crossover trial in which each surgeon served as his or her own control, with individual randomization to the 1.5-or the 3-minute group during the first part of the trial.Setting.Basel University Hospital, Switzerland.Participants.Thirty-two surgeons with different levels of postdoctoral training.Methods.We measured the bactericidal effectiveness of 1.5 minutes and 3 minutes of surgical hand antisepsis with alcohol-based hand rub by assessing the mean (± SD) log10number of colony-forming units before the application of hand rub (baseline), after the application of hand rub (immediate effect), and after surgery (sustained effect) so as to follow European Norm 12791 as closely as possible.Results.The immediate mean (± SD) log10reduction in colony-forming units (cfu) was 2.66 ±1.13 log10 cfu for the 1.5-minute group and 3.01 ±1.06 log10cfu for the 3-minute group (P= .204). Similarly, there was no statistically significant difference between the 2 groups with respect to the sustained effect; the mean ( ± SD) log10increase in bacterial density during surgery was 1.08 ± 1.13 log10cfu for the 1.5-minute group and 0.95 ± 1.27 log10cfu for the 3-minute group (P= .708). No adverse effects were recorded.Conclusion.In this clinical trial, surgical hand antisepsis with alcohol-based hand rub resulted in a similar bacterial reduction, regardless of whether it was applied for 3 or 1.5 minutes, which confirms experimental data generated with healthy volunteers.

Abstract: Background: Thoracic epidural analgesia (TEA) provides superior analgesia with a lower incidence of postoperative ileus when compared with systemic opiate analgesia in open colorectal surgery. However, in laparoscopic colorectal surgery the role of TEA is not well defined. This prospective observational study investigates the influence of TEA in laparoscopic colorectal resections. Methods: All patients undergoing colorectal resection between November 2004 and February 2007 were assessed for inclusion into a prospective randomized trial investigating the influence of bisacodyl on postoperative ileus. All patients treated by laparoscopic resection from this collective were eligible for the present study. Primary endpoints were use of analgesics and visual analogue scale (VAS) pain scores. Secondary endpoint concerned full gastrointestinal recovery, defined as the mean time to the occurrence of the following three events (GI-3): first flatus passed, first defecation, and first solid food tolerated. Results: 75 patients underwent laparoscopic colorectal resection, 39 in the TEA group and 36 in the non-TEA group. Patients with TEA required significantly less analgesics (metamizol median 3.0 g [0–32 g] versus 13.8 g [0–28 g] (p < 0.001); opioids mean 12 mg [±2.8 mg standard error of mean, SEM] versus 103 mg [±18.2 mg SEM] (p < 0.001). VAS scores were significantly lower in the TEA group (overall mean 1.67 [± 0.2 SEM] versus 2.58 [±0.2 SEM]; p = 0.004). Mean time to gastrointestinal recovery (GI-3) was significantly shorter (2.96 [±0.2 SEM] days versus 3.81 [±0.3 SEM] days; p = 0.025). Analysis of the subgroup of patients with laparoscopically completed resections showed corresponding results. Conclusion: TEA provides a significant benefit in terms of less analgesic consumption, better postoperative pain relief, and faster recovery of gastrointestinal function in patients undergoing laparoscopic colorectal resection.

Major trauma induces a dysregulation of immune response supported in parts by lymphocyte dysfunction. Controversial data about a shift within the T-helper cell subsets Th1/Th2 are reported.

Objective.To quantify the economic burden of in-hospital surgical site infections (SSIs) at a European university hospital.Design.Matched case-control study nested in a prospective observational cohort study.Setting.Basel University Hospital in Switzerland, where an average of 28,000 surgical procedures are performed per year.Methods.All in-hospital occurrences of SSI associated with surgeries performed between January 1, 2000, and December 31, 2001, by the visceral, vascular, and traumatology divisions at Basel University Hospital were prospectively recorded. Each case patient was matched to a control patient by age, procedure code, and National Nosocomial Infection Surveillance System risk index. The case-control pairs were analyzed for differences in cost of hospital care and in provision of specialized care.Results.A total of 6,283 procedures were performed:187 SSIs were detected in inpatients, 168 of whom were successfully matched with a control patient. For case patients, the mean additional hospital cost was SwF19,638 (95% confidence interval [CI], SwF8,492–SwF30,784); the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13–20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1–9.6 days). Differences were primarily attributable to organ space SSIs (n= 76).Conclusions.Ina European university hospital setting, SSIs are costly and constitute a heavy and potentially preventable burden on both patients and healthcare providers.

HYPOTHESIS High-volume surgeons and hospitals are more likely to perform laparoscopic procedures than open procedures for diverticular disease as compared with low-volume surgeons and hospitals. DESIGN Real-world analysis. SETTING United States community hospitals. PATIENTS Patients with primary International Classification of Diseases, Ninth Revision diagnosis codes for diverticulosis or diverticulitis and International Classification of Diseases, Ninth Revision procedure codes for laparoscopic or open sigmoidectomy were selected from the 1992 to 2001 Nationwide Inpatient Samples commercially available US databases. MAIN OUTCOME MEASURES The outcome variable was the likelihood of performing laparoscopic vs open sigmoid resection. The primary predictor variable was the annual caseload of sigmoid resections per surgeon and hospital. RESULTS The study population included 55 949 patients who were predominantly white (70.5%) with a mean (SD) age of 60.7 (14.7) years. Unadjusted and risk-adjusted odds ratios of performing laparoscopic sigmoidectomy were significantly higher for high-volume surgeons and high-volume hospitals. In fact, high-volume surgeons were 8.80 times more likely to perform a laparoscopic sigmoid resection compared with low-volume surgeons. Similarly, in high-volume hospitals, patients were 3.02 times more likely to undergo a laparoscopic sigmoid resection compared with patients who underwent surgery in low-volume hospitals. These clinically relevant differences remained statistically significant in subset analyses stratified by age (&lt;65 vs ≥65 years) and time of surgery (elective vs nonelective). CONCLUSIONS The findings of the present investigation based on data from large US nationwide databases provide compelling evidence that high-volume surgeons and hospitals are significantly more likely to perform laparoscopic surgery for diverticular disease compared with low-volume surgeons and hospitals. Based on recent studies showing clear advantages of the laparoscopic technique over the open counterpart, our results should be considered by both patients and physicians.Arch Surg. 2007;142:253-259--

Traumatic hemorrhage of the thyroid gland is a rare injury with few published case reports. Surgical and nonsurgical management have been advocated but there is no consensus of opinion.

Recombinant poxviruses expressing immunomodulatory molecules together with specific antigens represent powerful vaccines for cancer immunotherapy. Recently, we and others have demonstrated, in vitro and in vivo, that coexpression of CD80 and CD86 costimulatory molecules enhances the immunogenic capacity of a recombinant vaccinia virus (rVV) encoding different tumor-associated antigens. To further investigate the capacity of these vectors to provide ligands for different costimulatory pathways relevant in the generation of T cell responses, we constructed a recombinant virus (rVV) expressing CD40 ligand or CD154 (CD154rVV). Upon binding the CD40 receptor expressed on antigen presenting cells (APC), this molecule, physiologically expressed on activated CD4+ T cells, increases their antigen presentation and immunostimulatory capacities.Therefore, we evaluated the effects of CD154rVV infection on APC activation and its consequences on T cell stimulation. CD154rVV infection of autologous fibroblasts, monocytes, or iDC promoted the expression of a number of cytokines, including GM-CSF, TNF-α, and IL-15 in iDC. Most importantly, IL-12 p40 gene expression and protein secretion were induced by CD154rVV but not by wild-type VV (WT VV) in either CD14+ cells or iDC, and these effects could be blocked by anti-CD40 monoclonal antibodies. Furthermore, phenotypic characterization of CD154rVV infected iDC revealed enhanced expression of CD83 and CD86 surface markers as compared with wild-type vaccinia virus infection. As expected, VV infection triggered cytokines gene expression in cultures including APC and T cells from VV immune donors. However, cytokine genes typically expressed by T cell receptor triggered T cells such as those encoding IL-2 and IFN-γ, or T cell proliferation, were detectable to a significantly higher extent in CD154rVV infected cultures, as compared with WT VV.Activation of specific CD8+ T cells was then investigated using MART-1/Melan-A27–35 epitope as the model of tumor-associated antigen (TAA). In the presence of CD154rVV activated APCs, significantly higher numbers of specific cytotoxic CD8+ T cells were detected, as compared with cultures performed in the presence of WT VV or in the absence of virus.Taken together, these data indicate that functional CD154 expression from rVV infected cells promotes APC activation, thereby enhancing antigen-specific T cell generation. Such a recombinant vector might help bypass the requirement for activated helper cells during CTL priming, thus qualifying as a potentially relevant vector in the generation of CD8+ T cell responses in cancer immunotherapy.

A specific cellular immune response directed against a panel of three defined tumor-associated antigen (TAA) epitopes was induced in metastatic melanoma patients by a prime-boost strategy taking advantage of an innovative recombinant vaccinia virus as evaluated by quantitative assessment of cytotoxic T lymphocytes (CTLs) with corresponding specificity. The immunization protocol consisted of the administration of psoralen-UV-treated and replication-incompetent recombinant vaccinia virus encoding the three immunodominant HLA-A*0201-restricted epitopes Melan-A27-35, gp100280-288, and tyrosinase1-9 together with two costimulatory molecules, B7.1 and B7.2, in the context of systemic granulocyte-macrophage colony-stimulating factor (GM-CSF) treatment. Boosts were subsequently applied with corresponding synthetic nonapeptides and GM-CSF. Specific CTL induction was assessed by tetramer staining and CTL precursor (CTLp) frequency evaluation. Within 12 days of injection of the recombinant vector, cytotoxic T cell responses specific for engineered epitopes were detectable in three of three patients. During the vaccination treatment, antigen-specific CTLp frequencies exceeding 1:10,000 peripheral CD8+ T cells could be observed. Tetramer staining also revealed significant increases in specific CD8+ T cell numbers. We conclude that active specific antitumor vaccination can raise a concurrent and specific cellular immune response against a panel of molecularly defined antigens, thereby increasing the chance of an immune hit against neoplastic cells with heterogeneous antigen expression. Data from this study emphasize the potency of a recombinant vaccinia virus vector encoding multiple minigenes and costimulatory molecules in the context of exogenously administered GM-CSF. Clinical effectiveness of this immunologically active protocol should therefore be explored in appropriately selected groups of patients.

Fine needle aspiration cytology is the mainstay of the diagnostic work-up of solitary thyroid nodules. Together with the patient's history and the clinical findings, cytology determines the indication for surgery. The minimal intervention for a suspicious nodule consists of thyroid lobectomy. If a diagnosis of malignancy is established, then we recommend total thyroidectomy for all follicular lesions that are larger than 1·5cm and for high-risk papillary tumours. Near-total thyroidectomy may be appropriate for low-risk patients with papillary carcinoma in whom it is not intended to use radioactive iodine ablation. Whereas ipsilateral lymphadenectomy of the central (primary) compartment should routinely be performed, modified radical neck dissection is only indicated in evident nodal disease of the lateral (secondary) compartment(s). Patients with incidentally discovered differentiated thyroid carcinomas generally do not require complete thyroidectomy unless the tumours are larger than 1·5cm in diameter or nodal involvement is present. A detailed description of the surgical technique for thyroidectomy and lymphadenectomy is given and an overview of surgical complications is provided.

Active specific immunotherapy targeting tumor-associated antigens (TAA) requires reagents of high immunogenicity and safety. To address this issue, we constructed a recombinant vaccinia virus carrying a minigene insert encoding the HLA-A2.1-restricted MART-1/Melan-A27-35 melanoma TAA (rVV-M). To facilitate the entry of the antigenic epitope into the endoplasmic reticulum, a sequence coding for adenovirus E3/19K leader peptide was added. This rVV-M was made replication-incompetent by treatment with psoralen and UV light. Infection with rVV-M rendered HLA-A2.1 EBV-transformed lymphoblastoid cells sensitive to the cytotoxic effects of HLA-class-I-restricted, MART-1/Melan-A27-35-specific cytotoxic T lymphocytes (CTL). The capacity of rVV-M to generate HLA-A2.1-restricted MART-1/Melan A-specific CTL was demonstrated from tumor-infiltrating-lymphocyte (TIL) cultures and from healthy donors' peripheral-blood mononuclear cells (PBMC). MART-1/Melan-A27-35-specific CTL were generated from TIL after 2 weekly stimulation courses. Infection with rVV-M elicited a higher CTL response than addition of exogenous peptide, whereas, when a similar protocol was used to stimulate PBMC of healthy donors, significant and specific cytotoxic activity could be observed only upon rVV-M infection but not upon exogenous peptide addition. All CTL generated upon rVV-M stimulation were also able to efficiently kill melanoma cell lines expressing both MART-1/Melan-A and HLA-A2.1. In addition, TNF-α production could be induced in rVV-M-stimulated CTL upon co-culture with COS-7 cells transiently transfected with MART-1/Melan-A and HLA-A2.1 genes. This safe and highly immunogenic reagent could be of use in TAA-targeted clinical immunotherapy. Int. J. Cancer 71:491-496, 1997. © 1997 Wiley-Liss Inc.

We constructed recombinant vaccinia viruses (recVV) encoding the human T-cell costimulatory molecules B7-1 and B7-2. To abrogate the vaccinia virus transcription termination signal for early genes, the cDNA of B7-1 had to be modified by a T through C sense mutation at position 766. Upon infection with replication incompetent and noncytopathic recVV, several tumor cell lines as well as cultured human fibroblasts expressed the costimulatory molecules. All these cells were capable of providing effective costimulation for proliferation of resting CD4+T-cells after infection with recVV encoding B7 molecules. The costimulatory effect could be blocked with CTLA-4 IgG fusion protein, the soluble ligand for B7. RecVV-induced overexpression of B7 on syngeneic EBV-transformed lymphoblastoid B-cells was able to costimulate the proliferative response of CD4+memory cells against VV antigens. The possibility of easily engineering a variety of human cells using recVV encoding human B7 molecules holds implications for the future design of vaccination strategies.

We prospectively evaluated 31 patients with invasive breast cancer. Preoperative positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (18F-FDG) for detection of axillary lymph node metastases was compared with the histopathologic status of the sentinel lymph node (SLN). Sensitivity of PET imaging was 43%, specificity and negative predictive value were 94 and 67%, respectively. The smallest metastasis detected by PET measured 3 mm in diameter. The results of this study suggest that detection of small axillary lymph node metastases is limited by the currently achievable spatial resolution of PET imaging. Selective axillary surgery in breast cancer patients based on 18F-FDG PET is yet not possible.

Colorectal cancer (CRC) infiltration by cells expressing myeloperoxidase (MPO) or CD8 positive T lymphocytes has been shown to be independently associated with favorable prognosis. We explored the relationship occurring between CD8+ and MPO+ cell CRC infiltration, its impact on clinical-pathological features and its prognostic significance in a tissue microarray (TMA) including 1,162 CRC. We observed that CRC showing high MPO+ cell infiltration are characterized by a prognosis as favorable as that of cancers with high CD8+ T cell infiltration. However, MPO+ and CD8+ CRC infiltrating cells did not synergize in determining a more favorable outcome, as compared with cancers showing MPOhigh/CD8lowor MPOlow/CD8highinfiltrates. Most importantly, we identified a subgroup of CRC with MPOlow/CD8lowtumor infiltration characterized by a particularly severe prognosis. Intriguingly, although MPO+ and CD8+ cells did not co-localize in CRC infiltrates, an increased expression of TIA-1 and granzyme-B was detectable in T cells infiltrating CRC with high MPO+ cell density.