Gastrointestinal problems in the immunocompromised host. A review for surgeons

As the immunocompromised patient population grows, the gastrointestinal surgeon is increasingly called upon to make complex diagnostic and therapeutic decisions. The surgeon should first identify the patient as immunocompromised and then categorize the probable degree of immunocompromise as mild, moderate, or severe. Mildly immunocompromised patients tend to present late and with minimal symptoms, but the disease entities are the same ones seen in the general population. Moderately and severely immunocompromised patients may also develop the usual surgical problems, but the differential diagnosis is expanded to include complications of the immunocompromised state or complications of the underlying problem which caused the immune compromise. The expanded differential diagnosis includes infections with atypical organisms, opportunistic neoplasms, neutropenic enterocolitis, complications of medications, and forms of biliary tract disease not seen in the general population. Advances in oncology, transplantation, and the treatment of AIDS, have extended the life expectancy of these patients and increased the immunocompromised population. Prompt appropriate operative therapy may be lifesaving when surgical complications develop.

Serum beta 2-microglobulin in chronic diseases of the pancreas

Elevated serum concentrations of beta 2-Microglobulin (beta 2-MG) has been reported in a variety of chronic diseases and solid tumors. We determined serum beta 2-MG concentrations in 140 subjects divided into five groups: group 1, 34 patients with proven chronic pancreatitis, 8 of whom were studied during a painful relapse; group 2, 40 patients with pancreatic cancer staged according to the Cubilla-Fitzgerald classification; group 3, 40 healthy subjects; group 4, 10 patients with digestive nonpancreatic carcinomas; group 5, 16 patients with benign digestive nonpancreatic diseases. Serum soluble interleukin-2 receptor (sIL-2R) was also determined in all patients with pancreatic diseases as an index of immune system activation. In addition, serum CA 19-9 was assayed in patients of groups 2 and 4, and C-reactive protein (CRP) of groups 1 and 5. Renal function, evaluated by serum creatinine determination, was normal in all subjects studied. Patients with pancreatic cancer and those with chronic pancreatitis had serum concentrations of beta 2-MG significantly higher than those of healthy subjects (p < 0.001 and p < 0.005, respectively). Patients with stage I and stage III pancreatic cancer had similar serum levels of beta 2-MG, and these concentrations were significantly lower than those of patients with stage II tumors (p < 0.002 and p < 0.05, respectively). In chronic pancreatitis patients, those studied during painful relapse of the disease had serum concentrations of beta 2-MG similar to those studied during clinical remission.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of new domestic foodstuffs in the treatment of digestive system diseases with food intolerance]

A clinical trial has been performed of the food Unipit-3 and Laktanal based on cow milk proteins subjected to enzymic hydrolysis, dia- and ultrafiltration. A preliminary immunochemical assay of the above products protein component and its testing in anaphylactic shock reaction in animals demonstrated low sensitizing activity of this protein. The results of the trial of the above hypoallergenic foods in patients with food allergy showed their good tolerance and therapeutic efficacy.

[The T- and B-immunity systems in patients with digestive organ diseases and exposure to internal radiation]

Results are reported of an immunological examination of 534 patients with digestive diseases and 130 healthy persons. 282 patients subjected to radiation effects showed a marked and persistent T-lymphocytopenia, B-lymphocytosis, reduction of the content of T-helpers, T-suppressors, dysimmunoglobulinemia characterized by reduction of IgG content and excessive IgA secretion. These changes were observed during the period of exacerbation and remission requiring the use of immunocorrective agents.

Tumour marker CA 125 in patients with digestive tract malignancies

The serum levels of tumour marker CA 125 were measured in 162 patients with various digestive tract malignancies and in 155 patients with benign digestive tract diseases. The highest frequency of elevated CA 125 values (greater than 35 U ml-1) was found in patients with liver cancer (78%), but the level was equally often elevated in liver cirrhosis (78%). Two-thirds of the patients with biliary tract cancer had an increased CA 125 concentration, while four patients with benign biliary diseases had an elevated value. The serum level of CA 125 was elevated in only 20% of 60 patients with primary colorectal cancer, and in none of those with local disease (Dukes A or B). The CA 125 concentration seldom increased in patients with recurrent colorectal carcinoma. Twenty-three per cent of 44 patients with gastric cancer had an elevated CA 125 value. Two of 33 patients with benign colorectal and one of 68 patients with benign gastric diseases had an increased CA 125 concentration. The serum values of CA 125 showed no correlation with those of tumour markers alphafetoprotein (AFP), carcinoembryonic antigen (CEA) or CA 19-9. AFP was superior to the other markers in the diagnosis of liver diseases, while CA 19-9 showed the greatest accuracy in gastric diseases. In colorectal diseases, CEA had a higher sensitivity, but a lower specificity than CA 125 and CA 19-9. CA 125 and CA 19-9 had similar sensitivities for biliary tract cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of a new tumour marker CA 242 with CA 19-9, CA 50 and carcinoembryonic antigen (CEA) in digestive tract diseases

The levels of CA 242, a new tumour marker of carbohydrate nature, were measured in sera of 185 patients with malignancies of the digestive tract and of 123 patients with benign digestive tract diseases. High percentages of elevated CA 242 levels (greater than 20 U ml-1) were recorded in patients with pancreatic and biliary cancers (68%). The sensitivity was somewhat lower than that of CA 19-9 (76%) and CA 50 (73%). On the other hand, in benign pancreatic and biliary tract diseases the CA 242 level was less frequently elevated than the CA 19-9 and CA 50 levels. The serum CA 242 concentration was increased in 55% of patients with colorectal cancer. CA 242 detected more Dukes A-B carcinomas (47%) than CEA (32%), whereas CEA was more often elevated (71% vs 59%) in Dukes C-D carcinomas. CA 242 was slightly elevated (ad 41 U ml-1) in 10% of patients with benign colorectal diseases. CA 50 and CA 19-9 had lower sensitivities than CA 242 using the recommended cut-off values. When cut-off levels based on relevant benign colorectal diseases were used, the sensitivities of these markers were similar and somewhat higher than that of CEA. Less than half of patients with gastric cancer (44%) had an elevated CA 242 serum level. CA 242 is a promising new tumour marker, that may be of additional value in the diagnosis of pancreatic and biliary, as well as colorectal cancer, and may be useful in monitoring cancer patients after radical surgery.

Serum sialyl-Tn antigen levels in patients with digestive cancers

Serum levels of sialyl-Tn antigen (STN) were measured using a one-step radioimmunoassay kit in 257 patients with digestive cancers, 121 patients with benign digestive diseases, and in 64 healthy controls. With 45 U/ml regarded as the cutoff value, the positive rates of serum STN in digestive cancers were as follows: pancreas 40.0%, stomach 28.1, colon and rectum 27.8, biliary tract 25.0, liver 7.1, and esophagus 0%. In benign digestive diseases, the positive rate of STN was low (4.1%). In gastric and colorectal cancers, simultaneous measurements of STN and carcinoembryonic antigen (CEA) revealed that the positive rates of STN, CEA, and STN and/or CEA were 28, 42, and 55%, respectively. There was no significant correlation between STN and CEA in these cancers. STN may be a useful serum marker for digestive cancers, especially gastric and colorectal cancers.

[Candidal carriage and the development of invasive candidiasis of the organs of the digestive tract during experimental immunodepression]

After infecting healthy mice with Candida by their oral administration the fungi are rapidly eliminated from the digestive tract. In the animals, immunosuppressed by the injection of cyclophosphamide, the prolonged persistence of Candida in the digestive tract occurs, and the administration of Candida in considerable doses over prolonged periods in combination with the injections of high doses of immunosuppressing agents results in the development of profound invasive lesions, in some cases leading to the dissemination of the process.

Evaluation of a serologic marker, CA19-9, in the diagnosis of pancreatic cancer

STUDY OBJECTIVE

To determine the utility of the serologic marker CA19-9 in the diagnosis of pancreatic cancer in patients suspected of having a pancreatic disorder.

DESIGN

Blinded study of frozen pedigreed serum samples collected at time of diagnostic evaluation with follow-up review at a mean of 8 years.

SETTING

A general university teaching hospital serving both primary and referral patient populations.

MEASUREMENTS AND MAIN RESULTS

Sera collected prospectively from 1978 to 1980 from 261 patients undergoing imaging studies of the pancreas (ultrasound, computed tomography, endoscopic retrograde cholangiopancreatography) for a variety of symptoms were assayed for CA19-9 levels, and the results were compared with earlier determinations of other potential markers for pancreatic cancer. In 54 patients ultimately shown to have pancreatic cancer, the CA19-9 assay showed a sensitivity of 70% with a median value of 349 u/mL (normal less than 70 u/mL) and range, 7.3 to 2,859,964 u/mL, whereas specificity of the marker in this population was 87%. The positive predictive value was 59%, and the negative predictive value was 92%. Results of CA19-9 testing in the small group of patients with definitive staging information showed no difference in sensitivity between patients with local/regional disease (n = 6) and those with distant metastases (n = 14), 50% compared with 71% (P = 0.613).

CONCLUSION

CA19-9 was found to be a more sensitive and specific marker of pancreatic cancer than other serologic markers and should be a useful test in the patient with suspected pancreatic disease.

[Immunologic reactions in surgical patients with concomitant diabetes mellitus]

Reactions of the cell and humoral immunity in 40 emergent surgical patients with concomitant diabetes mellitus were studied which manifested themselves as a transitory immune reactions without immunization. The operative intervention eliminating mutual aggravation was shown to improve the indices of the cell and humoral immunity.

Comparative effectiveness of the tumour diagnostics, CA 19-9, CA 125 and carcinoembryonic antigen in patients with diseases of the digestive system

Serum concentrations of CA 19-9, CA 125 and carcinoembryonic antigen (CEA) in 145 patients with gastrointestinal carcinomas and 89 with non-neoplastic diseases were determined to compare the clinical usefulness of these tumour markers. Significantly fewer positive cases were obtained with serum CA 19-9 (9%) and CA 125 (8%) tests than the CEA test (22%) (both p less than 0.05) in patients with benign diseases, while comparable sensitivities were achieved with the CA 19-9 (44%) test, the CA 125 (41%) test and the CEA test (47%) in those with a carcinoma. High incidences of raised concentrations of serum CA 19-9 and CA 125 were observed in case of cancer of the pancreas (CA 19-9: 87%, CA 125: 67%) and biliary tract (CA 19-9: 63%, CA 125: 48%). Combined tests of CA 19-9 and CA 125 revealed increments in the sensitivity (61%) and provided a higher specificity (87%) than that of the single CEA test (78%). These combined tests were most useful for a differential diagnosis of pancreatic carcinoma (97% positive) and biliary tract carcinoma (74%) from chronic pancreatitis (4%) and cholelithiasis (0%), respectively. Studies on the relations of clinical staging and serum concentrations of CA 19-9 and CA 125 revealed significant rises in cases of disseminated carcinoma. These results clearly show that serum CA 19-9 and CA 125 tests are most pertinent for diagnosing advanced carcinomas of organs in the digestive system.

Activated killer cell activity in lymph nodes

The activated killer cell activity of cells from the perigastric lymph nodes (LNC) in patients with gastric carcinoma or benign lesions was assayed in comparison with that of peripheral blood mononuclear cells (PBM). The cytotoxic activity induced by phytohemagglutinin (PHA) activation in LNC from patients with either carcinoma or benign lesions was significantly decreased as compared to that in PBM, although the ability to produce interleukin 2 (IL 2) in LNC was significantly increased. Therefore, the ability to generate cytotoxic cells after activation with IL 2 was examined, and decreased capacity in LNC was observed. In LNC, the proportion of OKT3+ cells was similar to that in PBM, with a prevalence of OKT4+ cells over OKT8+ cells. Also, the percentage of Leu-11+ cells was remarkably reduced. The results indicated that decreased levels of the activated killer cell activity, which might be partially attributable to the composition of lymphocyte subsets, existed in lymph nodes, and this might facilitate tumor metastasis to the regional lymph nodes.

Effect of cutaneous and digestive colonization in the induction of anti-Candida albicans antibodies: experimental study

Candida albicans colonization induces antibodies, which must be taken into account in the serological diagnosis of candidiasis. In order to determine the degree of this effect, an experimental study in rabbits free of specific anti-Candida antibodies by cutaneous and digestive inoculation has been carried out. The evolution of humoral response was studied over 8 weeks by indirect immunofluorescence (IIF), direct agglutination (DA), counterimmunoelectrophoresis (CIE) and double diffusion (DD). The cutaneous colonization detectable by culture was maintained until the second week in 70% of the animals and the presence of antibodies detectable by IIF and DA was observed after the 2nd week. The highest antibody titre by IFF and DA was 1/64, and was reached in the 5th week, with a tendency to drop in the following weeks. Precipitins were only detected by CIE in 15% of the animals in the 7th week. Elimination of yeast in stools continued only in 20% of the animals in the 2nd week of the experiment. Antibodies were detected by IIF and DA after the 2nd week, with the highest titres detectable by IFF in the 5th week. Precipitant antibodies detectable by CIE appeared in 15% of the animals in the 8th week.

[Alpha-chain disease]

The pathological and clinical features of alpha-chain disease, its immunological diagnosis, the structural abnormalities of the abnormal immunoglobulin A compared with those of proteins of gamma and mu heavy chains diseases, the course of the disease and its present treatment, the epidemiological factors involved and their influence on pathogenesis and finally, the relationship with the "Mediterranean abdominal lymphoma" or IPSID are successively described. The stress has been placed on the latest data which refine but no not modify the first description of the disease. In the same way as studies on the synthesis and structure of proteins in heavy chain diseases will provide new data on the biosynthesis of normal immunoglobulins, so the elucidation of sequential events leading from a plasmocytic stage reversible by antibiotic therapy alone to a highly malignant immunoblastic stage should improve our knowledge of the genesis of human lymphomas.

[Evaluation of the measurement of serum carcinoembryonic antigen (CEA) levels using monoclonal antibody]

We measured serum carcinoembryonic antigen (CEA) levels in 164 cancer patients, 153 patients with benign diseases and 45 healthy controls using monoclonal antibody and compared CEA levels by monoclonal antibody (m-CEA) with those by polyclonal antibody (p-CEA). There was a good correlation between m-CEA and p-CEA, especially in cancer patients. The positively of m-CEA was almost the same as that of p-CEA in cancer patients. But, false-positive cases by m-CEA were less common than by p-CEA in non-cancerous patients. Thus, the measurement of m-CEA was not less useful than that of p-CEA.

A more specific, simpler radioimmunoassay for carcinoembryonic antigen, with use of monoclonal antibodies

A solid-phase, two-site monoclonal antibody radioimmunoassay for carcinoembryonic antigen in serum or plasma has been developed. Two monoclonal antibodies are used: 3d6, which is immobilized on polystyrene beads, reacts with high-molecular-mass CEA; the other, C4, with apparently restricted reactivity toward gastrointestinal tract and mammary carcinomas, is labeled with 125I. The assay consists of incubating 0.2 mL of serum both with 3d6-coated beads and 125I-labeled C4 at room temperature for 18 h. The CEA standard is calibrated against WHO international standard (73/601). Advantages of this assay include: (a) no heat or acid pre-treatment of samples; (b) linear response over a wider functional range, 0 to 150 micrograms/L, requiring fewer calibration points; and (c) no interference by glycosaminoglycans. Average inter- and intra-assay reproducibilities (CVs) are less than 10%; analytical recovery of CEA was 94 to 107%. CEA of less than 0.5 micrograms/L can be detected. The mean concentration of CEA in serum from healthy individuals is 0.97 (SD 1.18) micrograms/L; only 3% of the sera tested had concentrations greater than 3.0 micrograms/L. On comparing this assay with a polyclonal RIA, we found similar assay sensitivity for colorectal carcinoma but fewer false-positive results for sera from patients with benign liver and bowel diseases.