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Purpose: Gangliosides are tumor-associated antigens with many biologic functions, including complex interactions with cytokines and other modulators of the immune system. Serum total ganglioside level may be an ideal surrogate marker to predict tumor burden and response to treatment. Antibodies produced against tumor gangliosides may help predict survival. The purpose of this study is to determine whether the serum total ganglioside levels might predict the tumor burden in patients with soft tissue sarcoma, and whether the augmented anti-ganglioside immunoglobulin M (IgM) response might reflect the clinical outcome of these patients., Methods: Serum TG levels were measured in the cryopreserved sera by estimating lipid-associated sialic acids from 97 patients before surgical resection of soft tissue sarcoma and from 39 age- and gender-matched healthy volunteers. All sera were analyzed for IgM titers (expressed natural log) by enzyme-linked immunosorbent assay against eight gangliosides (GM1, GM2, GM3, GD3, GD2, GD1a, GD1b, and GT1b). Cox regression was used for univariate and multivariate analyses of the variables affecting progression-free and overall survival., Results: Serum TG levels were higher in soft tissue sarcoma patients than in healthy individuals (21.8 + 7.7 vs 16.1 + 2.7 mg/dL; P = 0.001). Larger tumors, high histologic grade, and more advanced stage of disease correlated with higher serum total ganglioside levels (P < 0.05). Anti-ganglioside titers to GM3, GD2, and GT1b were significantly higher in patients with soft tissue sarcoma, whereas anti-GD1a and GD1b titers were significantly higher in healthy subjects. The titers of antibodies against GM1, GM2, and GD3 in patients with soft tissue sarcoma were comparable to those of the healthy individuals. When compared with healthy controls, patients with low-grade tumors had higher titers of anti-GT1b, anti-GM3, and anti-GD2 antibodies, and patients with high-grade tumors had higher titers of anti-GT1b and anti-GD2 antibodies. These data suggest that the predominant gangliosides expressed by sarcomas may include GT1b and GD2. In addition, low-grade tumors may express an immunogenic species of GM3. On both univariate and multivariate analyses, augmented anti-GD1a IgM titers, age > 50 years, and retroperitoneal location were predictive of decreased overall survival, whereas augmented anti-GT1b titers were predictive of improved overall survival., Conclusions: Serum TG level may be a useful marker of tumor burden and response to treatment for soft tissue sarcoma. Anti-GD1a and anti-GT1b IgM titers predicted survival and may be of therapeutic and prognostic value in the management of soft tissue sarcoma.

One hundred eighty-three patients with advanced solid neoplasms were tested for their ability to react to four common skin test antigens (tuberculin PPD, streptokinase-streptodornase, mumps, and Monilia) and their ability to develop delayed cutaneous hypersensitivity (DCH) to 2, 4 dinitrochlorobenzene (DNCB). All patients were followed for at least 6 months or until death. Histologic tumor types studied were: melanoma (65), sarcoma (28), squamous cell carcinoma (23), and adenocarcinoma (67). The rate of progression of disease within 6 months of testing was lower in patients who had a positive response to a challenging dose of 50 mug of DNCB. Reactivity to recall antigens had no prognostic value except in patients with adenocarcinomas. Among patients with adenocarcinoma, those who reacted strongly to DNCB and one or more skin test antigens had the best prognosis, while those who were nonreactive to all had the worst prognosis (progression rate: 18% vs. 78%). Peripheral lymphocyte counts were related to the results of DCH to DNCB and skin tests. The preseence or absence of lymphocytopenia (count less than 1000/mm3) had prognostic value in patients who had positive skin test(s). In such patients, the disease progression rate was much higher in patients who were anergic to DNCB and who were lymphocytopenic (90% vs. 40%). These data suggest that DCH to DNCB, recall antigens, and peripheral lymphocyte counts are useful immunologic measurements in patients with advanced cancer. Although the prognostic value of each individual test is relatively limited, the predictive worth can be increased when multiple tests are employed. Pertinent findings reported in the literature are reviewed.

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula-4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.

Hyperthermia greater than or equal to 42 C is tumoricidal, apparently a function of absolute temperature and duration of heating. However, because the technology for producing safe and effective deep hyperthermia did not exist, there was virtually no data on the thermal death times of human cancers. The development of a fundamentally new radio frequency device that produces uniform hyperthermia to any depth without surface tissue injury has allowed preliminary testing of this hypothesis in 38 patients with advanced cancer. Temperature measurements were taken in tumors and normal adjacent tissues. Tumors were heated from 40 C to greater than or equal to 50 C, one to ten times (13-600 minutes). Serial tumor biopsies compared percent necrosis (total absence of nuclei) by type of therapy. Of 44 tumors evaluated (21 superficial, 23 visceral), 31 (70%) were heated greater than or equal to 42 C, 23 (52%) greater than or equal to 45 C, and 14 (32%) greater than or equal to 50 C, with virtually no normal tissue injury. Single, short duration hyperthermia at greater than or equal to 50 C resulted in 20-100% tumor necrosis, while lower temperatures had no effect. Two or three treatments at 45-50 C produced 70-100% necrosis, while lower temperatures produced less necrosis at more than twice the duration of heating. Multiple treatments produced increased necrosis at lower temperatures; however, at the same temperature duration, higher temperatures were most effective. These clinical results support the hypothesis that the observed necrosis is related to both temperature and treatment time and suggest that higher temperatures and longer durations of therapy are most beneficial.

Adjuvant chemotherapy with adriamycin (ADR) and high-dose methotrexate (HDM) with citrovorum rescue appears to hold promise for preventing recurrence of sarcomas following surgery. However, the effect of prolonged treatment with these agents on both in vivo and in vitro cell-mediated immunity (CMI) is unknown. To assess in vitro CMI, cryopreserved lymphocytes from 18 patients, collected before and at monthly intervals following initiation of biweekly ADR and HDM therapy, were tested simultaneously for stimulation to phytohemagglutinin, poke-weed mitogen, Concanavalin A, and pooled allogeneic lymphocytes by a micro-test technique. In vivo CMI was determined by serial skin-testing with 2,4,-dinitrochlorobenzene (DNCB). No significant overall change was noted for any of the in vitro lymphocyte function tests. DNCB skin test ratings, peripheral leukocyte counts and absolute lymphocyte counts did not change significantly during the study. Lymphocytes from a second group of patients were tested before, at 24 and 48 hours after HDM therapy. In vitro lymphocyte function tests were significantly depressed 24 hours following treatment, but returned to pretreatment levels at 48 hours. Long-term adjuvant ADR and HDM therapy does not appear to alter in vivo and in vitro CMI, although transient depressions were noted. The preservation of intact CMI may account in part, for the effectiveness of these agents as surgical adjuvants.

In order to assess the association of enhancement or suppression of humoral immune responses with cancer histology, sera from age and sex matched patients with sarcoma, melanoma and breast cancer and from normal donors were tested for natural antibodies in six serologic assays. Patients with melanoma were found to have a significantly higher level of antibody than the other groups tested. Antibody levels in patients with breast cancer were lowest.

A quantitative assessment of the effect of localized magnetic-loop hyperthermia on blood flow was performed in 12 human tumors using the 133Xe clearance method. Because blood flow in these tumors changed in response to needle injection, a physiologically based, one-compartment model was developed that included both a hyperemic and a steady-state component. In six tumors, changes in blood flow induced by heat were also observed. The ability of tumor vessels to respond dynamically to stress and the degree of response may be predictive of tumor heating capacity and subsequent therapeutic response.

Hyperthermia greater than or equal to 42 degrees C is tumoricidal in vitro and in many animal models, although such temperatures have only recently been achieved experimentally in some human cancers. A recently developed radio frequency device that provides safe hyperthermia to any depth without surface tissue injury now permits evaluation of the effects of hyperthermia on advanced human sarcomas. Twelve patients with large sarcomas located intraabdominally [7], in the chest wall [2], proximal extremity [2], and the neck [1], were evaluated in this study. Tumor types include liposarcoma [3], rhabdomyosarcoma [2], leiomyosarcoma [2], neurofibrosarcoma [2], and one each malignant mesothelioma, undifferentiated sarcoma, and osteosarcoma. Intratumor temperatures greater than or equal to 42 degrees C were observed in all tumors, with virtually no normal tissue injury. Selective tumor heating greater than or equal to 45 degrees C occurred in 9/12 (75%) and greater than or equal to 50 degrees C in 6/12 (50%). One to five weekly treatments greater than or equal to 50 degrees C and ten daily treatments greater than or equal to 45 degrees C resulted in significant tumor necrosis and pain relief in some patients. Hyperthermia of advanced sarcomas is possible with little host toxicity and may be of potential therapeutic benefit.

Multimodality management of extremity skeletal and soft tissue sarcomas with preoperative intra-arterial Adriamycin and radiation therapy, radical surgical resection and postoperative chemotherapy or chemo-immunotherapy has resulted in preservation of a functional extremity in 13 or 14 patients. Seven of 8 patients with Stage IIIA and IIIB soft tissue sarcomas, managed with preoperative intra-arterial Adriamycin and radiation therapy, followed by en bloc soft tissue resection and 6 patients with bone sarcomas managed by preoperative treatment, followed by bone resection and replacement with cadaver bone allografts, remained free of disease from 4 to 34 months. The results of the combined modality approach were significantly better than the results obtained in patients managed by surgical resection alone, or by combination of operation with another single modality, both in terms of short term-recurrence free survival and salvage of a functional extremity.

Serial measurements of tumor-associated antigens in the urine of patients with sarcoma who received preoperative intra-arterial doxorubicin and radiation therapy were assayed by microcomplement fixation. Changes in urinary antigen titer as a result of therapy were compared to pretreatment samples and were correlated with clinicopathologic evidence of in situ tumor cell destruction. Of the 53 patients with sarcoma studied, 44 had clinicopathologic evidence of tumor destruction induced by the preoperative therapy, and all 44 had a fourfold or greater rise in the level of urinary antigens during the treatment period. The other nine patients had no evidence of tumor destruction and antigen titers remained unchanged. Results suggested that tumoricidal therapy released tumor-associated antigens which could be detected in urine by microcomplement fixation. This phenomenon may be useful for measuring the in vivo effectiveness of tumoricidal therapy on nonaccessible tumors.

We use pulmonary resection in patients with metastatic disease confined to the lungs when the primary disease is controlled, when the tumor doubling time of metastases is longer than 40 days, and when there is no evidence of metastases to other viscera. A staged bilateral thoracotomy should be performed when necessary. The size of the lesions and the number of lesions are not contraindications for resection. Pneumonectomy has been performed with gratifying long term results. Treatment in patients who have rapidly progressive metastatic lesions (tumor doubling time less than 40 days) or who have other metastatic disease must be considered experimental. Chemotherapeutic regimens used as adjuncts to pulmonary resection may produce extreme toxicity in this group of patients. This form of therapy must be administered and followed by experienced personnel in a medical center with facilities for close supervision.

Nonamputative limb salvage is possible for many patients with malignant skeletal or soft tissue sarcomas. Significant advances in pathology, radiology, chemotherapy, radiation therapy, and surgical and biomechanical techniques have contributed to a better understanding of these diseases, and have provided the necessary techniques to achieve local tumor control without amputation. Integration of diagnostic and treatment modalities has reduced local recurrence and improved overall patient survival. Preoperative (neoadjuvant) therapy permits assessment of the treatment effect and appears to significantly improve selection of effective postoperative adjuvant therapy. As overall patient survival has improved, efforts to increase local tumor control and to evaluate long-term functional stability of the salvaged extremity are now possible.

Tumor-associated antigens were demonstrated in concentrated and dialyzed urine of several sarcoma patients with large tumor burden. The antigens were detected by complement fixation using autologous and allogeneic sera from sarcoma patients. The antigenic activity in three patients who were studied sequentially disappeared after surgical ablation of tumor. In two of these three patients, the antigenic activity reappeared before tumor recurrence. The reactivity of the sarcoma sera to the urine could be abolished by absorption of the sera with human sarcoma cells but not by normal human liver cells, which indicates that the same antigen was present in the urine and on biopsy-obtained sarcoma cells. Urine from cancer patients with high tumor burden may be useful as a source of tumor-associated antigen. Further studies on the presence of these antigens in urine of sarcoma patients may lead to a method for detecting subclinical tumor recurrence.

One hundred eighty-three patients with malignant skeletal (83) or soft tissue sarcoma (100) were entered into the multimodality preoperative limb salvage protocol. Local recurrences were observed in 5 of 183 (2.7%). Six patients required amputation because of complications, and 13 patients died within 1 year from metastatic disease. There was no statistical difference in survival rates between a series of patients who had amputation and adjuvant therapy and patients treated by limb salvage and adjuvant therapy. Overall survival rates for patients with soft tissue sarcoma were 76%. Although the exact reason for the improved local control is not known, it is our belief that it is the result of the multidisciplinary therapy that destroys microscopic disease at the periphery of the primary tumor.

Surgical therapy has been the accepted method for management of most soft tissue sarcomas of the extremities, although it has been associated frequently with local treatment failure. Even when local control was achieved, over 50% of the patients with soft tissue sarcomas eventually developed and succumbed to distant metastases of their disease. Therefore, single modality therapy for soft tissue sarcomas by operation alone results in an unacceptably high incidence of treatment failure. Fortunately, new adjuvant treatment techniques have been developed that seem to have activity against these neoplasms. It is the purpose of this article to discuss our experience with a number of these techniques.

Intra-arterial infusion of Adriamycin (doxorubicin) has increasing clinical usage in various chemotherapeutic protocols for treatment of sarcomas and other tumors. This route of drug delivery is generally believed to provide better delivery of drug to the tumor than intravenous infusion. However, the differential delivery of drug to the tumor for the two methods has not been adequately described. An analytical model has been developed to investigate the hemodynamics of intra-arterial Adriamycin in terms of various parameters including location of injection; tumor site, resistance, and blood flow; relative resistances and blood flows in adjacent structures; and the pharmacokinetics of Adriamycin plasma concentration. A three-phase exponential model is fitted to experimental plasma concentration measurements and used in the formulation of equations describing tumor Adriamycin exposure. For typical values of tumor blood flow (4-20 ml/min/100 gr) and size (1,000 gm), it is estimated that with intravenous injection of Adriamycin the tumor is exposed to only 4-19% of the injected drug. Substantially higher doses of Adriamycin are delivered to the tumor by intra-arterial injection. Typically 3-4 times more drug flows through the tumor when injected into a major artery proximal to the tumor-feeding vessel, as into the common femoral artery for a sarcoma of the leg. With injection directly into a major tumor arterial feeding vessel, as much as 6 to 26 times the mass of drug is delivered to the tumor compared to a comparable intravenous injection.hus, smaller doses of drug should be required for tumorcidal activity and systemic toxicity of the drug may be reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-three of 36 (64%) lung cancer patients, 19 of 36 (54%) melanoma patients and 18 of 27 (66%) sarcoma patients tested in the leukocyte migration in agarose assay against soluble extracts of histologically similar tumors showed significant inhibition of leukocyte migration. Reactivity to extracts of dissimilar tumors was low. Sera of only 1/13 (7%) lung cancer patients, 2/19 (10%) melanoma patients and 7/21 (33%) sarcoma patients were inhibited by extracts of histologically dissimilar tumors. Only 7-9% of cancer patients reacted to paired extracts of normal tissue from the tumor donors. An average of 13% of sera from normal controls reacted to tumor extracts. Stage of disease and mode of therapy appeared to have little effect on overall reactivity in this assay, although the number of patients within the various categories was small for purposes of statistical analysis. The leukocyte migration in agarose assay shows a sensitivity and specificity to tumor-associated antigens comparable to that of the older capillary tube method in general use and may facilitate performance of migration inhibition. This assay may not be useful as a prognostic test due to the lack ofcorrelation with stage of disease and treatment modality. However, its high specificity and economical use of tumor antigen suggest applications in tumor antigen purification. The use of soluble tumor antigen preparations may make it possible to purify these antigens further to increase specificity and reactivity.

Peripheral blood lymphocytes and skin fibroblasts from 12 cancer patients were infected with Epstein-Barr virus (EBV) or SV40 virus. The EBV-transformed lymphoblasts and SV40-transformed fibroblasts were grown as continuous cell lines and expressed the same histocompatibility antigens as tumor cell lines established from the same cancer patients. Sera from 350 melanoma and 195 sarcoma patients were tested for antibody reactive with membrane antigens on three of these tumor cell lines (two melanomas and one sarcoma) by immune adherence (IA) and indirect immunofluorescence (IMI) assays. Antibodies to HLA and other non-tumor-related antigens were completely removed from the most reactive sera by quantitative absorption with 4 x 10(7) lymphoblasts or 10(7) transformed fibroblasts autologous to the tumor target cells. These paired cell lines were used to monitor humoral immune responses in melanoma and sarcoma patients receiving allogeneic tumor cell vaccines.

Because there is evidence for an active immunologic response against sarcoma, a clinical trial of adjuvant immunotherapy using bacillus Calmette-Guérin (BCG) and tumor cell vaccine was begun. Eleven of 18 patients with localized soft tissue sarcoma who received immunotherapy are free of disease, compared to only 5 of 15 treated by operation alone who are free of disease. Furthermore, immunotherapy also prolonged the median disease-free interval from 7.3 months to 15 months in the patients who experienced recurrence of their disease.

Retroperitoneal sarcoma, regardless of the histopathologic grade of malignancy, has a high incidence of local recurrence that is usually fatal. Surgical resection is mandatory and resectability may be improved by a midline transabdominal approach. However, even with total tumor excision, recurrence is high. A preliminary study, combining resection and preoperative adriamycin, found to be effective for established disease, suggests potentially improved prognosis. Further clinical trials employing combined with adjuvant chemotherapy are warranted.

This study describes the development of an enzyme immunoassay (EIA) to quantitate antigen in the urine of sarcoma patients and compares its results with those of the authors' previously reported complement fixation assay. Three populations were studied for the presence of urinary antigen by EIA: (1) sarcoma patients who developed metastatic disease after resection of their primary tumor; (2) sarcoma patients who remain clinically disease-free two years after resection of their primary tumor; and (3) normal volunteers with no history of malignant disease. EAch group consisted of nine individuals. None of the urines from normal volunteers and none from sarcoma patients who remained free of disease for two years had elevated antigen titers detectable by EIA. However, all nine patients who developed pulmonary metastatic disease ahd significantly elevated levels of antigen in their urine prior to clinical evidence of disease recurrence. The day-to-day fluctuations in antigen titer detectable by EIA tended to parallel the levels detected by the complement fixation assay. However, EIA detected a significant elevation in antigen titer one to four months earlier than the complement fixation assay in four of the patients in whom disease recurred.

Urine samples from patients with solid tumors and from donors without malignant disease were concentrated and tested for the presence of tumor-associated antigens. In the complement-fixation assay using serum from a source autologous with the source of the urine, 87.4% of cancer patients were positive, while only 6.9% of control donors were positive. When serum from an allogenic source was used, 94.7% of cancer patients and 35.1% of control donors were positive. Absorption of a cancer patient's serum with autologous tumor cells removed antibody activity to autologous and allogeneic urine samples. Normal lymphocytes, skin, or muscle-cell suspensions were ineffective as absorbents. The excretion of antigen into urine is dependent upon the presence of tumor. Surgical removal of tumor resulted in cessation of antigen excretion. The urine remained antigen-negative as long as the patient remained disease-free. The antigenic activity was heat-stable and comprised molecules of greater than 1,000,000 daltons which could be dissociated into smaller molecular weight active fractions by treatment with 6 M urea.

Tumor-associated antigens (TAA) excreted into the urine of sarcoma patients can be detected by the complement-fixation assay. The authors prospectively measured TAA levels in the urine of 50 sarcoma patients postoperatively to determine whether reappearance of antigen in the urine would be predictive of disease recurrence. Twenty-five patients developed recurrence of their disease in the postoperative period, and 24 (96%) had reappearance of antigen in the urine 10.1 +/- 9.2 months prior to clinical evidence of recurrence. Of the 25 patients who remained disease free (mean follow-up, 48 months), 23 of 25 (92%) were urinary-antigen negative at last follow-up, although 8 patients had transient elevations of urinary TAA early in the postoperative period. Results indicate that postoperative measurement of urinary TAA in sarcoma patients permits selection of a subset of individuals at high risk for the development of recurrence. This knowledge can be of assistance in the postoperative management of these patients.

Urine samples obtained from patients with histologically proved melanoma and sarcoma were analyzed for the presence of tumor-associated antigens by complement fixation and enzyme immunoassay. Also, serum samples obtained during 24-hour urine collection from these patients were analyzed for circulating immune complexes by the complement consumption method and by the K562 radiometric assay. Of 36 cancer patients who were positive for urinary antigen (UA) by both assays, 28 (78%) were also positive for CIC in the two assays, six (17%) were positive in one of the two CIC-detection assays, and two (5%) were negative in both assays. Of 24 patients that were negative for CIC in both assays, ten (42%) were also negative for UA in both assays, i.e., complement fixation and enzyme immunoassay; 12 (50%) were negative by one of the two assays; and only two (8%) exhibited UA by both assays. This relationship was more striking for melanoma than sarcoma patients. In a melanoma patient whose samples were studied sequentially during his thermochemotherapy, the fluctuations in CIC and UA were parallel. These results suggest that excretion of tumor-associated antigen into urine is not an isolated phenomenon; rather, immune complex deposition in kidneys appears to cause glomerular damage which may allow the passage of the antigens into the urine.

Thirty-eight patients with locally recurrent soft-tissue sarcomas of various histologic types and grades but with no evidence of distant metastases were studied. Twenty-five patients had more than one local recurrence. Most primary lesions had been initially treated by simple or "wide local" excision with removal of little or no surrounding normal tissue. The most common site for recurrence was the extremity. Sixteen patients received preoperative intra-arterial Adriamycin (30 mg/day X three days) and radiation therapy (3500 R over ten days) followed by wide resection of the recurrence and the previous operative field. Tumor-free margins were confirmed microscopically. There were no subsequent local recurrences in this group. In five patients, no preoperative therapy was used, and the resection was incomplete because of proximity to vital structures. In these patients, postoperative radiation therapy and chemotherapy could not prevent continued local tumor progression. Amputation for control of local recurrence was necessary in only three patients. the remaining patients underwent either resection alone or resection in combination with postoperative radiation and/or chemotherapy. Life-table analysis of these 38 patients shows an unexpectedly high predicted five-year survival of 76% (87% for patients whose local recurrence could be completely resected). This high salvage rate clearly justifies aggressive treatment of patients with local recurrences alone and warrants attempts to salvage functional extremities.

A microcytotoxicity test has been used to detect a factor cytotoxic for human sarcoma cells; the factor was found in serums from 70 percent of sarcoma patients, 58 percent of their family members, and 8 percent of serums from normal blood donors. This cytotoxin is an antibody against a common cell surface sarcoma antigen since it is specific for sarcoma cells, is complement dependent, and is extractable with the globulin fraction of serum.