Burkhard Lehner

First experiences with negative pressure wound therapy and instillation in the treatment of infected orthopaedic implants: a clinical observational study

PurposeInfections associated with orthopaedic implants remain a serious complication. The main objective in acute infection control is component retention, whereas this option is usually not considered for chronic infections.MethodsThis multi-centre prospective, non-randomised observational study investigated one possible treatment option for implant retention in combination with negative pressure wound therapy with instillation (NPWTi). Thirty-two patients with an infected orthopaedic implant were analysed. Twenty-two patients had an acute infection (< 8 weeks after implantation) and ten patients had a chronic infection (> 8 weeks and < 36 weeks after implant placement). Polyhexanide was used as the instillation solution in 31 of the 32 cases.ResultsNineteen patients (86.4%) with an acute infection and eight patients (80%) with a chronic infection retained their implant at 4–6 months follow-up after treatment.ConclusionsOur study showed that NPWTi can be used as adjunctive therapy for salvage of acutely infected orthopaedic implants and may even be considered for early chronically infected implants.

CT-guided radiofrequency ablation of osteoid osteoma and osteoblastoma: Clinical success and long-term follow up in 77 patients

The purpose of this study was to retrospectively evaluate long-term success of CT-guided radiofrequency ablation (RFA) in patients with osteoid osteoma (OO) and osteoblastoma (OB) including tumors in critical locations. Eighty-one CT-guided RFA procedures were performed in 77 patients with OO (65 patients) and OB (12) including 6 spinal and 15 intra/periarticular tumors. Procedural techniques included multiple needle positions, three-dimensional access planning, as well as, thermal protection techniques. Long-term success was assessed using a questionnaire including, among others, several VAS (visual analogue scale) scores. All patients completed 3-6 months follow-up, overall response to the questionnaire was 64/77 (83.1%). Primary success rate was 74/77 (96.1%) of all patients. Retreatment with RFA in 3 patients resulted in a secondary success rate of 77/77 (100%). Long-term follow-up (mean, 38.5 months; range, 3-92) revealed a highly significant (p<0.001) reduction of all assessed limitation scores reaching normal or almost normal values. One major complication, a cannula break leading to a secondary short hospital stay, occurred. In conclusion, RFA is a safe and effective long-lasting treatment of OO and OB. Advanced procedural techniques aid treating tumors in critical locations and in the coverage of larger tumors. Besides night pain, RFA also greatly improves other factors negatively affecting the quality of life.

In vitro and clinical characterisation of a newcastle disease virus-modified autologous tumour cell vaccine for treatment of colorectal cancer patients

A virus-modified autologous tumour cell vaccine prepared from human colorectal cancer cells is described. After dissociation an average of 5 x 10(7) cells/g tissue were obtained from primary tumours and 9 x 10(7)/g tissue from metastases with an average viability of 72% and 51%, respectively. Following irradiation (200 Gy), inactivation of the proliferative activity of the cells was demonstrated by their degeneration in tissue culture and the absence of incorporation of 3H-labelled thymidine. One third of the cells were still metabolically active, as shown by the incorporation of 3H-uridine and a mixture of 3H-aminoacids. The dissociated cells expressed MHC class I and II antigens in a qualitatively similar way to tissue sections. Epithelium-specific antigens (detected by MAb HEA125) were expressed on an average of more than 75% cells of the suspension, while leucocyte-specific antigens (detected by MAb CD53) were expressed on an average of less than 25% cells. The vaccine was prepared by admixing the nonlytic strain Ulster of Newcastle disease virus (NDV) with the tumour cell suspension. The NDV adsorption at tumour cells was shown by electron microscopy. Clinically, the treatment with the vaccine was associated with an increased sensibilisation against autologous tumour cells, measured by DTH skin reactivity. First results in 23 patients with colorectal liver metastases who underwent curative liver resection followed by vaccination show a clear correlation between the induced increase of DTH skin reaction against autologous tumour cells and the recurrence-free interval. No correlation was found for DTH reaction caused by standard antigens (Mérieux test), NDV alone or autologous normal liver tissue. The results demonstrate the possibility of preparing immunogenic virus-modified autologous tumour cell vaccine from colorectal cancer tissue, which could be used for cancer therapy.

Impact of Dynamic 18F-FDG PET on the Early Prediction of Therapy Outcome in Patients with High-Risk Soft-Tissue Sarcomas After Neoadjuvant Chemotherapy: A Feasibility Study

Dynamic PET (dPET) studies with 18F-FDG were performed in patients with soft-tissue sarcomas who received neoadjuvant chemotherapy early in the course of therapy. The goal of the study was to evaluate the impact of early dPET studies and assess their value with regard to the therapy outcome using histopathologic data. Methods: The evaluation included 31 patients with nonmetastatic soft-tissue sarcomas, who were treated with neoadjuvant chemotherapy consisting of etoposide, ifosfamide, and doxorubicin. Patients were examined before the onset of therapy and after the completion of the second cycle. Histopathologic response served for reference and was available for 25 of 31 patients. Response was defined as less than 10% viable tumor tissue in the resected tumor tissue. The following parameters were retrieved from dPET studies: standardized uptake value (SUV); fractal dimension; 2-compartment model with computation of K1, k2, k3, and k4 (unit, 1/min); fractional blood volume; and influx according to Patlak. Results: The mean SUV was 4.6 before therapy and 2.8 after 2 cycles. The mean influx was 0.059 before therapy and 0.043 after 2 cycles. The mean SUV was 3.9 in the responders and 5.5 in the nonresponders before therapy. After therapy, responders revealed a mean SUV of 2.5, whereas nonresponders had a mean SUV of 3.5. We used linear discriminant analysis to categorize the patients into 2 groups: response (n = 12) and nonresponse (n = 13). The correct classification rate of the responders (positive predictive value) was generally higher (>67%) than that for the nonresponders. Finally, the combined use of the 2 predictor variables, namely SUV and influx, of each study led to the highest accuracy of 83%. This combination was particularly useful for the prediction of responders (positive predictive value, 92%). The use of the percentage change in maximum SUV led to an accuracy of 58%. Conclusion: On the basis of these results, only a multiparameter analysis based on kinetic 18F-FDG data of a baseline study and after 2 cycles is helpful for the early prediction of chemosensitivity in patients with soft-tissue sarcomas receiving neoadjuvant chemotherapy.

Nuclear relocation of STAT6 reliably predicts NAB2-STAT6 fusion for the diagnosis of solitary fibrous tumour.

Nuclear relocation of STAT6 has been shown in tumours with NAB2–STAT6 fusion, and has been proposed as an ancillary marker for the diagnosis of solitary fibrous tumours (SFTs). The aim of this study was to verify the utility of STAT6 immunohistology in diagnosing SFT.

Postoperative active specific immunization in curatively resected colorectal cancer patients with a virus-modified autologous tumor cell vaccine

SummaryActive specific immunotherapy was performed in a phase I study in 20 colorectal cancer patients after surgical resection of the tumor. An autologous tumor cell vaccine surface modified by Newcastle disease virus (NDV) was used, which showed the following characteristics. After mechanical and enzymatic dissociation of the tumor tissue an average of 5 × 107 cells/g tissue was obtained. According to trypan blue dye exclusion assay the average viability was 72%. Following irradiation (200 Gy) the inactivation of proliferative activity of the cells could be demonstrated by the absence of incorporation of3H-labelled thymidine. The cells were, however, still metabolically active as shown by the incorporation of [3H]-uridine and a mixture of3H-labelled amino acids. Epithelium-specific antigens (detected by mAb HEA125) were expressed on more than 75% cells of the cell suspension indicating a high amount of (epithelium-derived) tumor cells. In order to increase the immunogenicity of the tumor cells the suspended cells were infected by the nonlytic, apathogenic Ulster strain of NDV. The successful modification of tumor cells with NDV could be shown by electron microscopy. Three weeks postoperatively cells were thawed, virus-modified, and inoculated intradermally in the upper thigh. Several cell and virus concentrations were tested in each patient. As control, tumor cells without NDV, NDV alone and normal colon mucosa were used. The number of tumor cells ranged from 2 × 106 up to 2 × 107 cells and NDV concentrations from 4 to 64 hemagglutination units (HU) were tested. Sixteen patients responded with a delayed-type hypersensitivity (DTH) skin reaction to the vaccine. The best DTH reaction, measured 24 h following vaccination, was obtained using a vaccine consisting of 1 × 107 tumor cells and 32 HU NDV (median induration of 8 mm). Response to NDV alone was seen in 2 patients only (median induration of 3 mm); 12 patients responded to tumor cells (1 × 107) alone (median induration of 4 mm). Of 10 patients tested with normal colorectal mucosa, 4 responded with a median induration of 3.5 mm. DTH responses to the vaccine of 1 × 107 tumor cells and 32 HU NDV increased throughout the repeated vaccinations to a median induration of 9.5 mm at the end of the therapy. No severe side-effects in the course of the immunotherapy, except for mild fever in 4/20 patients, were observed. The results of our phase I study show that this type of autologous colorectal tumor cell vaccine is ready for a large clinical trial to prove its efficacy.

TERT promoter hotspot mutations are recurrent in myxoid liposarcomas but rare in other soft tissue sarcoma entities.

BackgroundRecently, recurrent point mutations in the telomerase reverse transcriptase (TERT) promoter region have been found in many human cancers, leading to a new transcription factor binding site, increased induction of TERT and subsequently to telomere maintenance. We determined the prevalence of TERT promoter mutations in soft tissue sarcomas of 341 patients comprising 16 entities and in 16 sarcoma cell lines covering 7 different soft tissue sarcoma types.MethodsThe sarcoma tissue samples were collected from the archives of the Institute of Pathology, University of Heidelberg and were composed of 39 myxoid liposarcomas (MLS), 61 dedifferentiated liposarcomas, 15 pleomorphic liposarcomas, 27 leiomyosarcomas, 25 synovial sarcomas (SS), 35 malignant peripheral nerve sheath tumors (MPNST), 40 undifferentiated pleomorphic sarcomas, 17 myxofibrosarcomas, 9 low grade fibromyxoid sarcomas, 10 cases of dermatofibrosarcoma protuberans, 31 solitary fibrous tumors (SFT), 8 extraskeletal myxoid chondrosarcomas, 9 angiosarcomas, 6 alveolar soft part sarcomas, 5 clear cell sarcomas and 4 epithelioid sarcomas. Sarcoma cell lines were obtained from the raising laboratories. A 193xa0bp fragment of the TERT promoter region covering the hot-spot mutations C228T and C250T was amplified, and direct sequencing of the PCR products was performed.ResultsTERT promoter mutations were detected in 36/341 sarcomas. They were highly recurrent in MLS (29/39; 74%) and were in the present MLS series not associated with the phenotype (myxoid vs. round cell variant), tumor grade, tumor site and patients’ median age or gender. In the remaining cases, TERT promoter mutations were found only in 7/302 sarcoma samples and confined to SFTs (4/31; 13%), MPNSTs (2/35; 6%), and SSs (1/25; 4%). Within the collection of sarcoma cell lines examined, TERT promoter mutations were detected in two MLS and in one of three MPNST cell lines.ConclusionsTERT promoter mutations are frequent in MLSs including their round cell variants, representing the most prevalent mutation identified in this sarcoma entity to date, and in a minor fraction of SFTs, MPNSTs and SSs. The majority of sarcomas are devoid of TERT promoter hotspot mutations. These data suggest that telomere maintenance through increased expression of telomerase plays an important role in the pathogenesis especially of MLS.

Shoulder arthroplasty in nontraumatic osteonecrosis of the humeral head

Twelve patients (thirteen shoulders) treated with arthroplasty for nontraumatic osteonecrosis of the humeral head were prospectively evaluated. At a mean follow-up of 30.2 months (range, 14-49 months), shoulder function assessed by the Constant score improved from 18 (adjusted score, 24%) to 51 (adjusted score, 69%; P <.001). Patients older than 65 years obtained lower adjusted scores than patients younger than 65 years (P =.02). The radiographs at follow-up showed radiolucent lines in 2 patients with no evidence of implant migration. Progressive glenoid erosion was identified in 2 patients treated with hemiarthroplasty. The subjective assessment revealed good and excellent results in 4 of 13 patients (numeric rating scale [NRS] 1 and 2). Three patients were unsatisfied with the final outcome (NRS 5). All three patients had abnormal findings with regard to the glenoid, either preoperatively with subtotal destruction of the glenoid or postoperatively with glenoid erosion after hemiarthroplasty or radiolucency around the glenoid component after total joint replacement. Contrary to previously published retrospective studies, we recommend a more cautious prediction of midterm results, especially in patients older than 65 years.

Effect of Gemfibrozil on lipids, apoproteins, and postheparin lipolytic activities in normolipidemic subjects

The lipid lowering agent Gemfibrozil was tested in 8 normolipidemic subjects during a three-month intake. Plasma triglycerides decreased by 41% and Very Low Density Lipoprotein (VLDL) triglycerides decreased by 54%. The reduction of plasma cholesterol, less marked (by 10%), was due to a decrease of Low Density Lipoprotein by 20% while High Density Lipoprotein (HDL) increased up to 30%. The separation of HDL demonstrated that only HDL3 were increased. The determination of the apoproteins in plasma and lipoprotein fractions showed similar results with a decrease of apo B (by 20%) and an increase of apo A-I and apo A-II, mainly in the HDL3 fraction. Plasma postheparin lipolytic activities (PHLA) were not influenced by the therapy and no correlation was found between these activities and any of the plasma or lipoprotein lipids. The apo C-III/apo C-II ratio in VLDL decreased by 30%; however, no correlation was found between this ratio in plasma as well as VLDL and triglycerides. In addition, the Intra Venous Fat Tolerance Test did not demonstrate any improvement of the clearance of exogenous fat. The lipid lowering efficacy of Gemfibrozil, its collateral effects, and the possible mechanisms of action are discussed.

Genomic profiling reveals subsets of dedifferentiated liposarcoma to follow separate molecular pathways

With the aim to provide more insight into their biology, a series of 79 liposarcomas (LS) representative of all main subtypes was analysed for chromosomal imbalances using comparative genomic hybridization. Based on the genetic data, unsupervised hierarchical clustering unveiled two main LS clusters, each with two subclusters, one comprising three subsets. The first main cluster consisted of one larger subcluster, being characterised by gains/high-level amplifications of chromosomal subregions 12q13–q15, and exclusively included well-differentiated and dedifferentiated LS. A smaller subcluster was set apart on the basis of recurrent gains of 20q13 and 8q24, and mainly comprised pleomorphic and myxoid/round cell LS. The larger subcluster was subdivided into three subsets, one with nearly exclusive overrepresentations of 12q13–q15, the second with additional frequent gains of 1q21–q24, and the third with further recurrent overrepresentations of 6q22–q24, 20q13, and 12q24 and frequent losses of 13q14–q21 and 11q22–q23. While the first subset comprised both well-differentiated and dedifferentiated LS, the second and third subsets entirely included dedifferentiated LS. The second main cluster was characterised by recurrent overrepresentations of 5p13–p15, 1q21–q24, 1p12–p21, and 17p11.2–p12 and essentially comprised pleomorphic and myxoid/round cell LS. A separation of this second main cluster into two subclusters was based on additional gains on 22q13 and losses on 1q42–q43. Genomic profiling reveals genetically distinct subsets of dedifferentiated LS, which are clearly different from pleomorphic, myxoid/round cell, and, for some subsets, from well-differentiated LS. These data indicate that dedifferentiated LS follow separate tumourigenic pathways and that genetic analysis is important to unravel these differences.