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The Deans' Rural Primary Care Clerkship was developed through the collaborative efforts of South Carolina's two medical schools. The clerkship provides students an innovative learning experience in rural community medicine through the unique combination of learning opportunities with community-oriented primary care, continuous quality improvement, interdisciplinary health care teams, and cultural competency. Much of students' learning addresses current directives for population health training. The positive experience students are having in these rural, underserved South Carolina communities will help them better understand the rewards and challenges of rural, community-responsive health care.

This study quantitates the extent of heterogeneity of drug resistance in breast and ovarian cancers. Identification of drug-specific resistance in tumors from multiple sites provides information necessary to understand the unique biology of a patient's disease.Drug resistance to cisplatin, paclitaxel, and doxorubicin was measured in multiple synchronous or metachronous tumors using the extreme drug resistance (EDR) assay. The degree of resistance for each tumor was classified into one of three categories: low drug resistance (LDR), EDR, or intermediate drug resistance (IDR).When tested against cisplatin, 66% of primary ovarian cancers and their paired synchronous distant metastases (N = 88) shared the same resistance category, while 4% of the results were discordant (one site had EDR and the other site had LDR). Of the paired results for paclitaxel (N = 68), 54% were in the same resistance category, while 13% of the comparisons were discordant. Heterogeneity of drug response to cisplatin was also measured in primary ovarian cancers and paired recurrent tumors from 108 women. Median time to recurrence was 9.6 months. Only 55% of the paired results fell into the same resistance category, while 19% of the results were discordant. Drug resistance to doxorubicin was measured in primary breast cancers and paired synchronous metastases from 23 women: 74% of the paired results fell into the same resistance category, while 13% of the results were discordant. Metastatic sites had a slightly higher incidence of EDR than primary sites (26% and 17%, respectively). Heterogeneity of drug response to doxorubicin was then determined in primary breast cancers and paired recurrent tumors from 26 women with a median time to recurrence of 14.3 months. Only 52% of the paired results fell into the same resistance category, while 24% of the results were discordant.Heterogeneity of drug resistance for ovarian and breast cancer is a serious clinical problem encountered in administering chemotherapy for overt metastatic or recurrent cancers. The first step in managing this problem is to recognize that heterogeneity of drug resistance exists. Drug resistance tests may then help the physician avoid administering certain chemotherapeutic agents when a patient's metastatic or recurrent tumor is found to be resistant to those agents.

Cell surface gangliosides in human melanoma cell lines were modulated by pretreatment and adaptation to 6-thioguanine and 5-bromo-deoxyuridine. Chemo- and radiation sensitivities were compared in original cell lines and modulated cells by the human tumor colony-forming assay. Modulated cells showed decreased expression of cell surface GM2 and GD2 gangliosides. This reduction was correlated with increased resistance to bleomycin, vincristine, cisplatin and radiation treatment. These results suggest that cell surface GM2 and GD2 ganglioside expression in human melanoma cells is intimately associated with several cellular biological properties, such as drug or radiation sensitivity and cellular differentiation.

In the opinion of the authors, good medical practice demands the avoidance of ineffective therapies and good cancer chemotherapy generally demands the avoidance of inactive drugs. The authors present their viewpoint that randomized trials are not required to prove that physicians should not administer inactive drugs and that existing cell culture assays are acceptably accurate in identifying inactive drugs. They describe and advocate the use of two such tests to aid in choosing between different forms of therapy that would otherwise be equally acceptable in the absence of test information. Strengths, weaknesses, and applications of the assays are discussed.

Because both Rhodamine 123 (R123) and hyperthermia have been shown to be cytotoxic, we examined their effect, independently and in combination, on five different human malignant cell lines in vitro and on cultured melanoma cells grown intradermally in nude mice. The cell lines examined include two human melanomas, UCLA-SO-M14 and UCLA-SO-M21, the colon cancer cell line HT29, the human lung cancer cell line P3, and the human breast cancer cell line B231. R123 and hyperthermia, when used in combination, were found to be cytotoxic for these five different human malignant cell lines in vitro. The two agents together appear to enhance the cytotoxic effect of each alone, as documented by synergistic ratios ranging from 2.31 to 45 for the different cell lines. In the "nude" mouse model, animals were treated with a combination of R123 and hyperthermia (43 degrees C for 90 min). A statistically significant (P = 0.04) decrease in tumor growth rate was observed when compared with the rate of tumor growth in untreated animals. The results suggest a potential role for R123 in combination with hyperthermia in the treatment of malignant cells.

Xenogeneic immune RNA (I-RNA), extracted from the lymphoid organs of sheep or guinea pigs immunized with human tumor cells, mediated in vitro cytotoxic immune responses that were directed specifically against tumor-associated antigens of human tumor target cells. Normal human peripheral blood lymphocytes from healthy donors became markedly more cytotoxic for human tumor target cells after being incubated with I-RNA extracted from the lymphoid organs of animals that had been immunized with that particular tumor. Gastric carcinoma, malignant melanoma, and carcinoma of the breast were studied. Lymphocytes incubated with RNA from animals immunized with only complete Freund's adjuvant evidenced no increased cytotoxic activity. RNA extracted from the lymphoid organs of animals immunized with normal skin fibroblasts that were autologous to the immunizing tumor, when incubated with normal allogeneic lymphocytes, also mediated cytotoxic immune reactions against tumor target cells. These immune responses probably were directed principally against normal transplantation antigens. However, when lymphocytes that were autologous to the immunizing tumor and/or the tumor target cells were incubated with RNA from animals immunized with autologous normal fibroblasts, cytotoxicity did not increase. Only I-RNA extracted from donor animals specifically immunized with tumor cells mediated cytotoxic antitumor immune responses when incubated with autologous lymphocytes.

The immunologic effects of leukapheresis on cancer patients and three other groups of donors using the continuous-flow blood cell separator are presented according to the protocol described in the preceding article. Transient declines were noted in per cent T-lymphocytes of some, but not all, leukapheresed normal donors and cancer patients. These declines were comparable to the small declines observed in sham donors and the fluctuations in per cent T-lymphocytes noted in individuals who did not undergo leukapheresis. There were no changes in lymphocyte-mediated cytotoxicity to a melanoma cell line in 2 of 4 melanoma patients, while values in 2 patients fell by about one-half within 4 hours and returned to preleukapheresis levels by 24 hours. Release of macrophage migration inhibition factor by lymphocytes from all 4 cancer patients and 4 normal donors, in whom this parameter was studied, fell transiently and returned to preleukaphresis levels within 24 hours. Blastogenic responses of lymphocytes from cancer patients and normal donors to phytohemagglutinin (PHA) and in one way mixed lymphocyte reactions increased in several individuals and decreased slightly in others. There appears to be no significant immunosuppressive effects (within the parameters studied) of a single leukapheresis for lymphocytes on the blood cell separator, since changes in lymphocyte parameters were relatively minor, transient, and variable and, where studied, paralleled fluctuations observed in sham donors and individuals not undergoing leukapheresis.

Simple methods were developed for cloning human solid tumors; 68 percent of the tumors processed formed at least 30 colonies within two to four weeks. The accuracy of the clonogenic assay for predicting clinical response was determined in a prospective, correlative study. Eight-four patients had objectively measurable disease and had at least one course of chemotherapy. Tumor types included melanoma (33), lung (12), colon (7), breast (7), stomach (4), ovarian (12), sarcoma (7), and hepatoma (2). For patients whose tumors were sensitive in vitro to a particular drug, clinical response was seen in 21/25 cases (84 percent). Tumor resistance was found in 59 instances, and 54 patients (92 percent) had no clinical response to the same drugs. Associations between in vitro chemosensitivities and clinical course were highly significant.

Complement-dependent cytotoxic antibodies to common cell surface antigens of cultured melanoma cells were produced in guinea pigs. At appropriate dilution, melanoma antisera were cytotoxic only to melanoma target cells. Following absorption with pooled lymphoid cells, additional absorption with melanoma cells but not absorption with fibroblasts or carcinoma cells was found to remove all cytotoxic activity from melanoma antisera. Absorption with human fetal skin cells but not with autologous fetal visceral cells was found to remove cytotoxicity from melanoma antisera. Tissue type-specific antigens may be shared by human malignant melanomas and fetal skin of black racial origin (at 16 to 18 weeks of gestation). The methods may be useful in the production of xenogeneic antisera with "operational monospecificity" for common melanoma-specific antigens. Sera from 47 patients with malignant melanoma failed to evidence specific cytotoxicity for melanoma target cells.

The method of the human tumor clonogenic assay and its clinical correlations have been reported here. True positive rate for predicting of sensitivity to cytostatic drugs has been characteristically low. Results of our studies indicate that discrepancy of in vitro and in vivo results in clinical trials with the tumor clonogenic assay may be due to therapeutic heterogeneity among tumor colony-forming units within a primary tumor and between primary tumor and metastases.

A rapid assay for in vitro chemosensitivity testing measuring [3H]thymidine incorporation has been developed. Results of this assay correlate highly with chemosensitivities determined by the soft-agar clonogenic assay. A correlative study was carried out on 219 solid tumor specimens to assess the ability of the rapid assay to predict clinical response to antineoplastic therapy. One hundred forty-two of 219 tumors (65%) yielded chemosensitivity data. Of these, 33 were evaluable for in vitro-in vivo correlations. In vitro sensitivity (greater than or equal to 80% inhibition of thymidine uptake) was associated with clinical response in 6 of 13 patients. In vitro resistance was associated with progressive disease in 20 of 20 patients. The rapid assay offers several advantages over the soft-agar clonogenic assay, including higher success rate, avoidance of clumping artifact, shorter time course (5 days), and very low false-negative rate. Further refinement may be necessary, but the rapid assay appears to have potential for individualizing solid tumor chemotherapy.

Evidence that xenogeneic immune RNA (I-RNA) mediated specific cytotoxic immune responses against human tumor-associated antigens was obtained from in vitro studies in two autologous melanoma systems. In these systems, malignant melanoma target cells, matching normal fibroblast target cells, lymphocyte effector cells, and melanoma and normal skin tissue used to immunize RNA donor animals were derived from the same autochthonous hosts. When incubated with autologous lymphocytes, I-RNA extracted from the lymphoid organs of donor animals immunized with melanoma tissue mediated immune reactions against autologous melanoma target cells in vitro. I-RNA from animals immunized with normal skin tissue from autochthonous hosts did not increase the cytotoxicity of autologous lymphocytes for autologous melanoma cells. Using autologous fibroblasts as target cells, we detected no increase in cytotoxicity when autologous lymphocytes were incubated with RNA from animals immunized either with melanoma tissue or normal skin tissue from the autochthonous host. By contrast, when allogeneic lymphocytes were used as effector cells, RNA extracted from animals immunized either with melanoma tissue or normal skin mediated cytotoxic immune reactions against melanoma target cells and normal fibroblast target cells derived from the same patient.

Selection and determination of the efficacy of antineoplastic agents has been dependent upon the trial and error method of observing measurable disease. Such methods subject the patient not only to loss of precious time but to needless toxicity if the drug is ineffective. The clonogenic assay, an in vitro assessment of tumor cell sensitivity to antineoplastic agents, has the potential for individualizing therapy. In this assay, tumor cells exposed to various drugs are cloned in soft agar. In the 16 primary and 24 metastatic pulmonary tumors tested with this technique, a growth rate of 80% was achieved. Fifty-five percent of the primary tumors and 60% of the metastatic lesions responded in vitro to one or more of the test drugs. There were twelve possible correlations between in vitro and in vivo results. In four of 12 assays, in vivo sensitivity was predicted and three of four patients demonstrated a clinical response. No drug that was inactive in vitro had activity in vivo. Prior knowledge of in vitro sensitivity may dictate a more aggressive surgical approach to pulmonary metastatic disease, whereas in vitro resistance would call for more conservative treatment. Just as with estrogen receptor status in breast cancer, data derived from the clonogenic assay may ultimately be of such import that thoracotomy would be warranted solely for the purpose of obtaining tissue for the assay.

A phase I clinical trial of immunotherapy with "Immune" RNA was undertaken fifteen months ago. Twenty-six cancer patients were treated with RNA extracted from the lymphoid organs of sheep immunized with either autologous tumor cells or allogeneic tumor cells of the same histologic type. Eighteen patients had gross disease and eight had minimum residual disease. RNA was administered weekly, intradermally, at doses up to 9 mg/week without any significant local or systemic toxicity. Four patients improved, thirteen achieved stability of disease or possible improvement, seven were treatment failures, and two are indeterminate. Lymphocyte-mediated cytotoxicity to allogeneic tumor target cells of the same histologic type were monitored in eleven patients. In seven patients, cytotoxicity increased after "Immune" RNA therapy; no change was observed in three patients; a decrease was noted in one patient. There appeared to be a possible correlation between cytotoxicity assessed in vitro and clinical response. There is some evidence that these responses may be specific for the particular tumor used to immunize the RNA donor.

The applicability of a human tumor colony-forming assay to drug screening was investigated in terms of feasibility, validity, and potential for discovering new antitumor drugs. Feasibility was addressed in a pilot study during which basic methods, appropriate assay quality controls, and a standardized protocol for screening were developed. Considerable variability was noted in the availability and colony growth of different tumor types. The majority of the evaluable experiments utilized breast, colorectal, kidney, lung, melanoma, or ovarian tumors. For many tumor types, little evidence of growth was observed, or only rare specimens formed colonies. Colony-forming efficiencies ranged from 0.05 to 0.11% for the six most useful tumors listed above. A set of quality control measures was developed to address technical problems inherent in the assay. Testing of standard agents in the pilot study established that most of these agents could be detected as active. However, it also identified three assay limitations: compounds requiring systemic metabolic activation are inactive; medium constituents may block the activity of certain antimetabolites; and compounds without therapeutic efficacy may be positive in the assay. The assay categorized nontoxic clinically ineffective agents as true negatives with 97% accuracy. Of 79 compounds which were negative in the current National Cancer Institute prescreen (leukemia P388), 14 were active in the assay. Several demonstrated outstanding in vitro activity and are structurally unrelated to compounds already in development or in clinical trials. A subset of these active compounds were found to lack activity in a P388 in vitro colony-forming assay. This indication of differential cytotoxicity to human tumor cells makes this subset of compounds particularly interesting as antitumor drug leads. The demonstrated sensitivity to most standard agents, discrimination of nontoxic compounds, reproducibility of survival values within assays and between laboratories, and evidence of ability to identify active compounds which were negative in the in vivo prescreen suggest that the human tumor colony-forming assay may be a valuable tool for antitumor drug screening. However, because of technical limitations inherent in the current assay methodology, this must be confined to selected tumor types and limited to screening on a moderate scale.

Two technological problems limit the usefulness of chemosensitivity assays: low success rates (generally 30-60%); and the requirement for large numbers of tumor cells (5 X 10(5)/dish). To solve these problems, we developed a miniaturized, improved, nucleic acid precursor incorporation assay (MINI-assay). In this new assay, 0.3-1.5 X 10(5) tumor cells were plated in double-layer agarose in 16-mm wells of a Costar (No. 3524) 24-well cluster dish. After 72 h of incubation, 5 microCi [3H]thymidine were added to each well. After an additional 24 h of incubation, the trichloroacetic acid-precipitable material was collected and counted by liquid scintillation. We found that 280 of 351 (80%) human solid tumors gave evaluable chemosensitivity results. Labeling efficiency was optimum when the plating density was between 1.5 and 3 X 10(4) cells/well. Radioisotope uptake was less efficient in 35-mm Petri dishes and in the 7-mm wells. The MINI-assay was particularly suitable for small specimens (less than 1 g) and for tumor types that usually yield small numbers of viable tumor cells (19 of 30 breast cancers and 56 of 71 sarcomas were evaluable). The artifacts of colony counting (cell clumps, debris, clots) were also eliminated with this assay. With high evaluability rates, the requirement of fewer cells, a short duration (5 days), and ease of quantitation, the MINI-assay is widely applicable to chemosensitivity testing in human tumors.

Clinical response of liver metastases treated by high-dose intraarterial chemotherapy (HDIAC) delivered via the hepatic artery was predicted by a modification of the human tumor colony-forming assay (HTCFA) originally described by Hamburger and Salmon [Science (Wash. DC), 197:461-463, 1977. In a first set of experiments, the immediate clinical response to HDIAC was determined in 12 patients with colorectal liver metastases. Biopsies were taken immediately before and after HDIAC, and cells were plated in the HTCFA. Three patients received intraoperative 4-epidoxorubicin and another 9 received mitomycin C by 15-min intraarterial infusions. Sensitivity in the HTCFA was defined as 50% inhibition of colony formation in tumors exposed to the chemotherapeutic agent, compared to the untreated controls. Clinical response was accurately predicted by the HTCFA in 11 of 12 cases. Eight patients had a regression of disease following HDIAC treatment with mitomycin C, as evidenced by either greater than 50% reduction in carcinoembryonic antigen serum level (7 patients) or regression of tumor by computed tomography scan (1 patient). Three patients had no evidence of clinical response to epidoxorubicin, and their tumors were resistant to epidoxorubicin in the HTCFA. One tumor was sensitive to mitomycin C in the HTCFA, but serum carcinoembryonic antigen in the patient continued to increase following HDIAC. The HTCFA was also performed on untreated biopsies following incubation in vitro with the drug used for HDIAC. Results correlated with clinical response in all 12 cases. In a second set of experiments, the HTCFA was used to predict the long-term clinical response to HDIAC of 30 patients with liver metastases. One patient had breast cancer metastases, one patient had carcinoid liver metastases, 4 had liver metastases of malignant melanoma, and 24 patients had colorectal liver metastases. All 21 of the patients whose tumors were sensitive in vitro had clinical response, while 6 of 9 patients predicted by the HTCFA to be resistant had no clinical response. Our results demonstrate a high correlation between the HTCFA and clinical response.

In order to assess the value of the clonogenic assay for predicting clinical response to dimethyl-triazeno-imidazole-carboxamide (DTIC) plus hyperthermia (42 degrees C), the responses of patients with measurable disease, who received combined therapy, were compared with assay results. The clonogenic assay was used independently to determine in vitro sensitivities of 53 melanomas to DTIC, with and without hyperthermia. Separate cell suspensions were incubated for 1 hour with DTIC at 37 degrees C and at 42 degrees C. In vitro sensitivity was determined by inhibition of colony formation in a double-layer agar system. Three of the 53 (6%) melanomas were sensitive to DTIC at 37 degrees C, 13 of the 53 (25%) were sensitive to 42 degrees C hyperthermia alone, and 22 of the 53 (42%) were sensitive to DTIC at 42 degrees C. Nine patients were treated with DTIC, plus hyperthermia, to the areas of their melanoma metastases (one pulmonary, four hepatic, and four subcutaneous). In five patients, the clonogenic assay results predicted positive tumor sensitivity to combined therapy, and 4 of the 5 had objective tumor regression. Tumors were resistant in vitro for four patients, and all had disease progression during treatment. Statistical analysis suggested that some responses were due to synergism of the combination of heat and drug, whereas others were due to an additive effect. The apparent direct correlation between in vitro tumor cell sensitivity to DTIC at 42 degrees C and actual clinical response to chemotherapy, plus hyperthermia, in this limited trial, has been encouraging. The clonogenic assay and in vitro evaluation of drug-heat interaction may prove helpful for selecting those patients in whom hyperthermia should be used as an adjunct to chemotherapy, and may help determine the most effective drug/heat scheduling. Further trials with other malignancies and other chemotherapeutic agents are warranted.

The cytotoxic activities of three new synthetic catechol analogues, beta-[(p-hydroxyphenyl)amino]alanine (Compound 1), N delta-(p-hydroxyphenyl)ornithine (Compound 2), and N delta-(m-hydroxyphenyl)ornithine (Compound 3), were determined against 10 human melanoma and 5 nonmelanoma cell lines. Activities of L-DOPA and 3,4-dihydroxybenzylamine were also measured. Dose-response curves were obtained and concentrations in micrograms/ml required to give 90% inhibition of colony formation (IC90) were calculated. Using a cutoff IC90 of less than 2.5 as a definition of activity. Compound 2 was active in 6 of 10 melanoma and 0 of 5 nonmelanoma cell lines while both Compound 1 and L-DOPA methyl ester were active in 1 of 10 melanomas and 0 of 5 nonmelanomas. Compound 3 was inactive in all cell lines and all IC90 values exceeded 100. 3,4-Dihydroxybenzylamine was active in 3 of 8 melanomas and 1 of 5 nonmelanomas. Regression analysis of IC90 values for Compound 2 and tyrosinase levels in the 15 cell lines yielded a correlation coefficient of 0.93 (P less than 0.001). By contrast, a similar analysis for 3,4-dihydroxybenzylamine gave a correlation coefficient of 0.17 (P greater than 0.05). Spectrophotometric data indicated that Compounds 1 and 2 were oxidized by tyrosinase to quinones. Cytotoxic activity was blocked by the tyrosinase inhibitor phenylthiocarbamide. Since the rates of activation of Compounds 1 and 2 were identical, the higher activity of Compound 2 was probably due to its higher lipophilicity and greater intracellular accumulation. Compounds 1 and 2 exhibited greater potency and selectivity against malignant melanoma than did the natural product L-DOPA methyl ester.

An improved method for testing human tumors against chemotherapeutic agents was developed. Drug effects were quantitated in the thymidine incorporation assay (TIA) by measuring inhibition of deoxyribonucleic acid (DNA) synthesis by the proliferating cell population following exposure to anticancer drugs. Results were obtained within five days. A total of 480 out of 568 tumors received were evaluable for an overall growth rate of 85 percent. Even small biopsy specimens could be successfully grown. In 126 correlations with clinical response, the TIA had a prediction accuracy for sensitivity of 51 percent and a prediction accuracy for resistance of 97 percent. Because it is rapid, has a high growth rate, and is not subject to clumping and other cellular artifacts, the TIA represents a significant improvement over colony counting assays for predicting drug effects in human tumors.

Allogeneic immune RNA (I-RNA), extracted from the peripheral blood lymphocytes of patients putatively cured of cancer, mediated cytotoxic immune reactions that apparently were directed specifically against human tumor-associated antigens. I-RNA was extracted from the peripheral blood lymphocytes of patients with various types of cancer. Patients selected had not been previously sensitized to HL-A or other normal transplantation antigens or to blood group antigens. Normal human peripheral blood lymphocytes were incubated with these allogeneic I-RNA preparations and tested for cytotoxicity against human target cells in vitro. Allogeneic I-RNA mediated cytotoxic immune reactions only against tumor target cells of the same histologic type as the I-RNA donor. I-RNA's extracted from peripheral blood lymphocytes of melanoma patients mediated cytotoxic immune reactions only against melanoma cells. Similarly, only I-RNA's extracted from the lymphocytes of patients with colon cancer mediated cytotoxic immune reactions against colon carcinoma cells, and only I-RNA's from the lymphocytes of breast cancer patients mediated immune reactions against breast cancer target cells. Allogeneic I-RNA extracted from peripheral blood lymphocytes of cancer patients possibly mediated specific cytotoxic immune reactions that were directed against common tumor-associated antigens shared by human tumors of similar histologic type.

The human tumor colony-forming assay was used to compare chemosensitivity among tumor cells within a primary tumor, between primary tumor and metastases, and between different metastases. No significant differences in cloning efficiency were found in any of the three comparison studies. However, considerable differences in chemosensitivities were observed between different parts of the same tumor and between the primary tumor and metastases. Two different parts of the same tumor were comparably assayed for nine primary tumors. In nine paired samples which allowed in vitro drug sensitivity testing, there was no satisfactory correlation of sensitivity to cytostatic drugs. Cell suspensions were prepared from 28 primary tumors and from metastases taken from the same patient. In 14 paired samples which formed sufficient colonies for determination of drug effect, the data showed no satisfactory correlation of chemosensitivity between a primary tumor and its metastases. Both tumor samples from different metastatic sites of the same patient formed sufficient colonies in seven of eight instances. In the seven paired samples, there was strong association of chemosensitivity (p less than 0.005). The results indicate that the reported discrepancies of in vitro and in vivo results in clinical trials using the tumor colony-forming assay for predicting resistance or sensitivity to cytostatic drugs may be due to therapeutic heterogeneity among tumor colony-forming units within a primary tumor and between a primary tumor and its metastases.

Melanoma-associated antigens (MAA) were isolated and their functional immunologic properties were evaluated. Spent fetal calf serum-free culture media and 3-m KCI extracts of cultured human melanoma cells grown in this medium were used as antigen sources. Ultracentrifugal flotation on KBr was used to separate MAA and HLA antigens present in the extracts or spent culture media; thus interference by histocompatibility antigens was prevented in subsequent tests of tumor antigenic activity. MAA purified in this manner retained their immunologic functions as evidenced by their ability to produce delayed cutaneous hypersensitivity reactions in patients with melanoma, specifically combine with antimelanoma xenoantibody, and elicit production of functionally specific xenoantibody. Possible structural differences between HLA antigens and MAA were considered in evaluation of the data.

The relationship between in vitro tumor stem cell sensitivity and in vivo antitumor efficacy using 13 active antineoplastic agents was examined by means of the intraperitoneal P388 mouse leukemia system. The doses, which produced a 50% increase in life span after one, five and nine days of treatment, were all significantly correlated with the in vitro concentration producing a 70% reduction in colony formation during a seven-day continuous drug exposure. The five-day correlation was the best, followed by nine days and one day. Correlations were not improved by corrections for either in vitro drug stability or toxicity (LD50). The highly significant correlations observed in this simple retrospective analysis provide a basis for the development of more sophisticated models for the prediction of in vivo results from in vitro data.

Ribonucleic acids extracted from specifically sensitized lymphoid cells (I-RNA) have been shown to transfer specific immunoreactivity to normal non-immune lymphoid cells. Evidence for the transfer by I-RNA, of immune responses to tumor-associated antigens of animal and human neoplasms, in vivo and in vitro, is reviewed. Results obtained in our laboratory and in other laboratories indicate that xenogeneic, allogeneic and syngeneic I-RNA extracts mediate specific cytotoxicity to tumor cells, in vitro, and mediate transplantation resistance and tumor rejection responses in vivo. Our results suggest that I-RNA preparations fail to elicit immune responses directed against "self" antigens. By contrast, I-RNA's directed against "non-self" tumor-associated antigens appear to induce lymphocytes to effect specific anti-tumor immune responses. The mechanisms responsible for the failure of I-RNA to initiate immune responses against "self" antigens are not known at present and demand investigation. Preliminary results of a clinical Phase I trial of immunotherapy with xenogeneic I-RNA in selected cancer patients are reviewed. I-RNA might offer promise as a new modality for the immunotherapy of human cancer.

The clinical usefulness of the soft agar colony-formation assay of in vitro chemosensitivity developed by Hamburger and Salmon is limited by long turnaround time (2-3 weeks), low success rate for small specimens, and clumping artifacts that can lead to erroneous predictions of resistance (false-negative errors). An improved technique was developed for measuring in vitro growth by incorporation of tritiated thymidine that can be performed in 5 days. With this rapid assay, 819 tumors were processed, with an overall success rate of 59.3%. This result compared favorably to the overall success rate of 58.2% for 1591 colony-formation assays because more small specimens could be submitted for the rapid assay. Melanoma and ovarian cancer specimens grew particularly well (76% and 75% successful, respectfully). Sixty-five correlations of in vitro and in vivo responses are available to date. None of 30 tumors, predicted to be resistant in vitro responded to chemotherapy clinically. Patients whose tumors were predicted to be sensitive in vitro had a 43% clinical response rate. The assay appears to be particularly accurate for predicting clinical resistance to chemotherapy, possibly because clumping artifacts do not occur in this system and peak achievable plasma concentrations of chemotherapeutic agents can be used. Optimal in vitro drug concentrations and culture conditions are still being defined, and improved success rates are being seen with more recent specimens. The introduction of this technique underscores the fact that in vitro chemosensitivity tests must continuously evolve to maximize their clinical application.

We found that human malignant melanoma cells had varying thermal sensitivity and that some exhibited natural thermal resistance, a heretofore unrecognized phenomenon. Samples of 73 melanoma cell suspensions were heated at 42 degrees C for 1 hour before plating in the soft agar clonogenic assay or the thymidine assay for proliferating cells. We observed greater than 75% cell kill after hyperthermia in 39 (53%) tumors. Native thermal resistance was apparent in 17 (23%) tumors and growth enhancement in 17 (23%) at this temperature and exposure time. We postulated that prostaglandin, known to protect stomach mucosa against thermal injury, has a role in stabilizing the tumor cell membrane exposed to heat. Three melanoma cell lines known to be thermosensitive were heated to 42 degrees C without and with exogenous prostaglandin E2 (PGE2). The survival of colony-forming cells was increased in all three lines in the presence of 30 microM PGE2. A naturally thermoresistant cell line was exposed to 1 microgram/ml indomethacin for 24 hours before hyperthermic treatment. The survival of colony-forming cells was significantly decreased compared to cells not treated with indomethacin. The addition of 30 microM of exogenous PGE2 to indomethacin-treated cells reestablished thermal resistance. These preliminary data suggest that some tumor cells synthesize prostaglandins to render the cell thermoresistant. Treatment with indomethacin blocks prostaglandin synthesis and induces thermosensitivity. These discoveries may have important clinical applications for hyperthermia treatment of human cancers.