Proceedings: Cellular immunity in cured cancer patients

Immunotherapy: The Fourth Domain in Oral Cancer Therapeutics

Owing to high global prevalence, incidence and associated mortality, cancer of head and neck particularly oral cancer remains a cardinal domain for research and trials. Immune-modulatory therapies that employ patients own immune system for therapeutic benefits in oral cancer seems promising. The aim of this review is to gauge the potential of immunotherapy as fourth domain of Oral cancer therapeutics. Articles were searched using suitable search terms in MEDLINE and Google Scholar database to include clinical trials, meta-analyses, and research in humans/animals/cell lines published in peer reviewed journals. A total of 97 articles were included in this review. Literature has several studies and trials where different types of immunotherapies has been attempted but it is crucial to identify precise biomarkers of genome based targeted agents and to find parameters to select patients who might benefit from immunotherapy. Also further research is required to estimate predictive value of tumor mutational burden and mutational signatures so as to aid in personalized prediction of oral cancer therapeutic response.

Defective Function of Granulocytes in Patients with Cancer

Mobilization of granulocytes into a serum-filled chamber, histochemical nitroblue tetrazolium (NBT) reduction tests, and phagocytosis were performed in 11 patients with solid tumors treated with surgical excision and chemotherapy and in 22 untreated or surgically treated patients. The results revealed a decreased mobilization (p < 0.001) and an impaired capability of neutrophils to reduce NBT after stimulation (p < 0.05) in both groups of patients. The decrease in the values in the stimulated reduction of NBT was more pronounced in untreated patients than in treated ones. At the same time the phagocytic activity of neutrophils on Candida albicans, which was decreased (p < 0.01) in untreated patients, was normal in those who had been treated with chemotherapy. There were no distinctive correlations between circulating immune complexes and granulocyte function. We propose that this newly demostrated defect in neutrophil mobilization and low median C. albicans-stimulated NBT reduction contributes more in the evolution of the tumor than in the pathogenesis of infections and that chemotherapy seems to restore a better granulocyte function.

Nutritional Status and General Immune Competence in Patients with Head and Neck Cancer

Anergy to 2,4-dinitrochlorobenzene (DNCB) has been reported as a highly significant adverse prognostic immunological factor in several studies of patients with squamous cell carcinomas involving the head and neck. Patients with these tumours often present with concurrent nutritional deficiencies. This paper reports the findings of a prospective study into both the nutritional status and general immune competence of 53 such patients.

Analysis of the results has demonstrated a statistically highly significant positive correlation between nutritional status and both the delayed hypersensitivity response to DNCB, and the pretreatment total lymphocyte count levels. It is suggested that nutritional deficit may be a primary adverse prognostic factor in this disease group, with immunoincompetence a secondary phenomenon, and supporting evidence is presented. The consequent probable importance of nutritional status with regard to clinical trials, and the necessity for controlled studies to determine the possible beneficial effect of nutritional support on ‘cure’ rates, are discussed.

Effect of selenium on the immunocompetence of patients with head and neck cancer and on adoptive immunotherapy of early and established lesions

Supplementation with 200 microg/day of sodium selenite during therapy for squamous cell carcinoma (SQCC) of the head and neck, e.g., surgery, radiation, or surgery and radiation, resulted in a significantly enhanced cell-mediated immune responsiveness. The enhanced responsiveness was evident during therapy and following conclusion of therapy. In contrast, patients in the placebo arm of the study showed a decline in immune responsiveness during therapy. The results from studies on mice inoculated with SQCC cells expressing the receptor for interleukin-2 (IL-2) and supplemented with Se (2.00 ppm) indicated that Se significantly retards the clinical appearance of tumors; peritumoral injections of 2,000 IU of IL-2 resulted in 50% reduction in the size of established tumors and 72% of early tumors. The combined data suggested that local immunotherapy with IL-2 in hosts supplemented with Se may represent an effective modality of treatment for the prevention of recurrences at the site of conventionally treated primary tumors.

Immunologic dysfunction in cancer

The interactions between the tumor and its host are complex, and many aspects of the immune system appear to be adversely affected directly or indirectly by the presence of the tumor. Virtually all of the processes involved in immune induction and action have been implicated in the observed deficient response in tumor-bearing patients. Improved understanding and molecular analysis of the mechanisms underlying the escape of tumors from immune surveillance may lead to the development of novel strategies for the prevention of T-cell immunosuppression in cancer patients, the development of novel immunotherapeutic strategies, and potentially prevention of tumor progression or development.

Immune complexes, serum proteins, cell-mediated immunity, and immune regulation in patients with squamous cell carcinoma of the head and neck

A collaborative study of the humoral and cellular immune status of patients with carcinoma of the Head and Neck (H&N) was conducted at the West Virginia University (WVU) hospital. In addition, blind-coded serum panels were supplied on H&N cancer patients being treated at the National Cancer Institute (NCI). Serum protein analysis of the WVU study groups revealed that at the pretreatment sampling, the alpha-1 acid glycoprotein (AGP), total complement, and IgA levels were significantly elevated. The AGP levels and total complement levels declined to normal levels in the post-treatment period, whereas the IgA levels remained elevated throughout the entire observation period. Levels of serum immune complexes (SIC) were measured in both the WVU and NCI H&N cancer populations using the polyethylene glycol (PEG) precipitation method. In both survey populations all cancer groups had significantly elevated levels of SIC when compared to any of the control populations. The SIC levels never returned to comparative normal values even in cases after successful treatment. A subpopulation of the WVU-H&N cancer study group underwent a short course of intravenous hyperalimentation prior to their treatment regimen. These patients demonstrated a transient decrease in their SIC levels as well as a concomitant increase in their in vitro cell-mediated immune (CMI) correlates. The analysis of in vitro CMI correlates of the WVU study group using both polyclonal mitogens and specific antigens demonstrated a significant depression in these parameters pretreatment and post-treatment. In addition, it was observed that the time course for elevation of selected serum proteins (i.e., IgA and SIC) correlated with concomitant drops in CMI activity. Investigations were also conducted into the effects of immune complex-rich serum fractions upon selected in vitro CMI correlates. Significant blockage of a normal donor leukocyte migration-inhibition assay was demonstrated. Also, a similar inhibition of the ability of normal human lymphocytes to form high affinity rosettes was accomplished with serum from H&N cancer patients.

Lymphocytopenia in high cancer risk population: evidence in automobile pattern makers

A total of 1454 automobile pattern makers were studied to determine the degree of lymphocyte reduction. These occupational workers have been known to be at high risk for colorectal cancer. As a group, pattern makers had significantly lower lymphocyte counts than the comparison group. The proportion of lymphocytopenia (less than 1500/mm3) in pattern makers was 26.2% as compared with 5.6% in the comparison group. Continuous monitoring of lymphocyte reduction in pattern makers may be worthwhile to evaluate whether these workers face a high risk for deficiency in lymphocytes in association with their risk for high rates of colorectal cancer.

Gastrointestinal cancer-associated antigen (GICA) in oral carcinoma

Gastrointestinal cancer-associated antigen (GICA) is detected by means of a monoclonal antibody in the serum and pathologic tissues of patients with gastrointestinal tumors. This article compares serum and salivary GICA and carcinoembryonic antigen (CEA) levels in 19 healthy control subjects, 17 patients with benign oral cavity lesions, and 11 patients with squamous cell carcinoma of the oral cavity. Serum CEA levels were similar in all three groups, whereas salivary CEA levels were higher in patients with squamous cell carcinoma than in the control subjects (p less than 0.001) and the patients with benign lesions (p less than 0.025). Serum GICA levels gave the opposite result and were significantly lower in squamous cell cancer when compared with control subjects (p less than 0.0001) and patients with benign lesions (p less than 0.02). Values of GICA in saliva of patients with oral cancer were also lower than in the control subjects (p less than 0.02). The possible significance of this difference between the two antigens is discussed.

Serum ferritin as a tumor marker in patients with squamous cell carcinoma of the head and neck

A double antibody enzyme immunoassay was used to measure serum ferritin levels in several different control and tumor-bearing populations collected from two institutions. The control groups consisted of normal volunteers, smokers, and Latter Day Saints. No statistically significant differences were noted in ferritin levels between pairs of these groups. Differences were noted among the normal groups when separated on the basis of age and sex, with higher ferritin levels in individuals older than 32 years of age and in men. By one-way analysis of variance, most control groups and subgroups were shown to have significantly lower levels (P less than 0.05) than the head and neck cancer group, with the exception of male smokers, who had levels comparable to male head and neck cancer patients. Serum ferritin levels were higher in head and neck cancer patients than in controls; however, there was no difference when compared with patients with other types of solid malignancies or when considering the anatomic site of the head and neck lesion. Ferritin levels were significantly (P less than 0.05) higher in patients with advanced (Stages III and IV) cancer than in those individuals with Stage I or II cancer. In patients with no evidence of clinical disease 5 years after treatment, the ferritin level had essentially returned to normal. In a group of head and neck cancer patients followed longitudinally, a significant decline in ferritin levels (P less than 0.05) was seen by 5 months after the completion of successful treatment. Furthermore, ferritin levels showed a tendency to increase or remain at high levels in patients with a poor prognosis and to decrease in those patients with a favorable prognosis, giving support to the contention that ferritin may prove to be a valuable tumor marker in head and neck cancer.

In vivo and in vitro observation of cellular immune parameters in squamous cell carcinoma of the oral cavity and its correlation with tumor load and prognosis

In vivo and in vitro observations of cellular immune response in 70 patients with squamous cell cancer of the oral cavity and in 40 age-matched normal controls, were made using delayed hypersensitivity responses to DNCB, PPD, and Candida albicans extract (Dermatophytin 'O'), absolute lymphocyte counts, absolute T-cell numbers, and PHA-induced lymphocyte blastogenesis reactions as parameters. The results were correlated with clinical stage, tumor size, lymph node involvement, tumor differentiation, lymphoreticular responses, and outcome during a one-year follow-up period. A significant degree of impairment of both in vivo and in vitro parameters was found in oral cancer patients compared to normal control. The impairment was more prominent in advanced stages. Lymph node involvement was associated with impaired dermal hypersensitivity to recall antigens as well as a reduced T-cell population and blastogenic response. Only delayed hypersensitivity response to DNCB, PPD, and Candida showed a correlation with histologic features such as tumor differentiation and lymphoreticular response. Although absolute lymphocyte counts and T-cell population were reduced in the primary stage of the disease, the functional capacity of isolated lymphocytes to undergo blast formation was retained. PHA-induced lymphocyte blastogenesis showed a significant impairment only when the tumor was well established and disseminated beyond its local confines. Delayed hypersensitivity responses to DNCB, higher T-cell counts, and blastogenic indices were associated with recurrence-free survival. Immunologic parameters provide prognostic information beyond the clinical stage of the disease. Therefore, it seems that a multiparametric in vivo and in vitro observation of cellular immune response may be useful as an indicator of clinical course and prognosis of patients with squamous cell cancer of the oral cavity.

Blood lymphocyte counts with subset analysis in operable breast cancer. Relation to the extent of tumor disease and prognosis

Blood lymphocyte counts and various lymphocyte subsets, as defined by rosette tests, were examined in breast cancer patients and correlated to the extent of tumor disease and prognosis. One hundred sixty-six patients tested before or shortly after surgery were included. It was observed that the frequency of E-rosette-forming lymphocytes correlated to the development of distant metastases (P = 0.007) and survival (P = 0.022). A high frequency of E-rosette-forming cells was associated with a poor prognosis. The well-known prognostic value of clinical tumor stage and axillary lymph node involvement was also confirmed. A possible relation between the tumor disease and other immune variables was indicated by the finding that the frequency of EAC-rosette-forming lymphocytes (mainly B-cells) was reduced in patients with relatively large primary tumors. This relation was most pronounced in patients without axillary node involvement (P less than 0.01). In addition, it was observed that the blood lymphocyte counts were significantly higher in patients with three or more tumor-involved axillary nodes than in those with zero to two (P less than 0.005). Our results seem to stand in contrast to the generally held view that low lymphocyte counts and a low proportion of E-rosette-forming cells in the blood are associated with a large tumor burden and a poor prognosis.

Immunoincompetence in cancer patients. Assessment by in vitro stimulation tests and quantification of lymphocyte subpopulations

The authors performed a variety of lymphocyte-stimulation tests and quantified several lymphocyte subpopulations in 73 healthy controls and 72 patients with advanced cancer who were no longer receiving anticancer therapy. As a group, cancer patients had fewer lymphocytes and helper cells, but a greater proportion of suppressor cells and Ia+ cells than controls. The ratio of helper to suppressor cells was lower in the cancer group. Uptake of 125I-uridine was markedly depressed in cancer patients in the face of stimulation with various plant lectins, foreign lymphocytes, and varicella-zoster antigen. There was little correlation between any of the stimulation tests and any of the lymphocyte subpopulation proportions or numbers. The two tests that were most frequently abnormally low among the cancer patients were percent lymphocytes and number of helper cells (81% each). The most frequently abnormal functional assay in patients was pokeweed mitogen stimulation (59%). Three separate statistical methods selected the combination of percent lymphocytes, percent Ia+ cells, percent suppressor cells, number of helper cells, and pokeweed mitogen stimulation as being the best predictors of cancer/immunoincompetent status. This study confirms the breadth of immunoincompetence in advanced cancer patients as defined by in vitro techniques. A smaller battery of tests can be useful in monitoring the immune status of such patients, especially during therapy with proposed immune modulators.

Immunology and oral cancer

This paper summarises the evidence for the involvement of the immune response in the development of neoplasia, discusses the immunological abnormalities found in patients with head and neck carcinoma, and outlines recent attempts at treatment of patients with head and neck carcinoma by modulation of the immune response (immunotherapy).

Immunobiologic staging of patients with carcinoma of the head and neck

For decades immunologic deficiencies have been documented in patients with carcinoma, and many investigators have attempted to utilize this information in determining prognosis more accurately. Determining prognosis more accurately would be most helpful with Stage III patients, since at present there are no useful guidelines as to which Stage III patients would benefit from aggressive surgery and/or radiation therapy and which would not. Assays of cellular immunity--such as skin testing, determining peripheral T-lymphocyte counts, and assessing lymphocyte reactivity--have achieved extremely limited clinical application. These assays are too expensive and/or too difficult to perform in the routine clinical setting. Total lymphocyte counts, however, are readily available in the clinical setting and can be helpful in determining prognosis. Other readily available clinical information, such as age and pretreatment serum immunoglobulin levels, can also be of value in determining prognosis. In this study, logistic regression was utilized to determine the prognostic implications of stage, age, and pretreatment total lymphocyte counts in 132 patients with carcinoma of the head and neck. Although each variable determined prognosis accurately less than 70% of the time, the stage, age, lymphocyte prognostic index (SALPI) accurately predicted outcome at 3 year follow-up 80% of the time (Pr. less than .0001). Discriminant function analysis was utilized to determine the prognostic implications of pretreatment serum immunoglobulins in 243 patients with head and neck carcinoma. A serum immunoglobulin prognostic index (SIPI) was derived which was based on the observations that elevated levels of immunoglobulin A (IgA) indicated a poor prognosis, while elevated levels of immunoglobulin E (IgE) and immunoglobulin D (IgD) indicated a favorable prognosis (Pr. less than .009). The SIPI was not as accurate as the SALPI in determining prognosis; however, when the indices were used simultaneously, concurring indices predicted the outcome of Stage III patients correctly 86% of the time.

Clear cell sarcoma and selective IgM deficiency: a case report

A case of clear cell sarcoma of tendons and aponeuroses and a co-existent IgM deficiency is reported. The tumor arose in the Achilles tendon with metastases to the skin, bone, and lymph nodes. The tumor, examined by light and electron microscopy, consisted of glycogen-containing clear cells with melanotic and amelanotic features. There was no detectable serum IgM. The IgA levels were normal and IgG levels were elevated. Peripheral blood lymphocytes contained a normal amount (4.5%) of IgM-bearing cells. Cultured mononuclear cells from the patient suppressed production of IgM by normal lymphocytes, suggesting a role of suppressor cells in the IgM deficiency. The co-existence of soft tissue sarcomas and immunoglobulin deficiency states is reviewed.

Comparison of the response to PHA and suppressor macrophage function in different age groups of cancer patients and healthy controls

The mitogenic response of peripheral blood lymphocytes was examined in 37 healthy individuals and in 44 patients with various malignant neoplasms. Tested individuals were divided into three major age groups (20-40; 40-60; and over 60 years of age). There was a significant decrease in Phytohemagglutinin (PHA) response with age in the normal controls, but no significant change with age was observed in the cancer patients. Comparison between the various age groups of cancer patients and their corresponding normal controls did not reveal a significant difference in mitogenic response of the young and middle age groups. However, the older cancer patients responded significantly better compared with their corresponding older normal controls. The reduced responsiveness of older normal controls was partially explained by a high activity of suppressor macrophages observed in this group. Reduction of the proportion of phagocytic cells improved their response to PHA. On the other hand, the activity of suppressor macrophages in the older cancer patients was much less prominent. These observations emphasize the importance of appropriate age grouping when immune function tests in cancer patients are compared with those performed in normal individuals and suggest the possibility of higher mitogen responsiveness in certain age groups of cancer patients.

Intravenous hyperalimentation. Effect on delayed cutaneous hypersensitivity in cancer patients

Effects of nutritional repletion with intravenous hyperalimentation (IVH) on sequential skin test reactivity were evaluated in 160 malnourished cancer patients undergoing chemotherapy (76 patients), surgery (49 patients), radiation therapy (20 patients) and supportive care (15 patients). In the chemotherapy group, 45 patients had negative reactions initially, and 25 patients (55%) had at least one skin test convert to positive in an average period of 19 days of IVH. In the surgery group, 23 patients (46%) were initially positive and remained positive, 13 patients (24%) converted from negative to positive, and 13 patients (30%) remained negative or converted to negative. Postoperative complications occurred in 25% of positive reactors, compared with 69% (p < 0.01) of negative reactors. In the radiation therapy group, the skin tests of six patients (30%) remained positive, three patients (15%) converted from negative to positive and the skin tests of nine patients (45%) remained negative. In the supportive care group, the skin tests of 73% of the patients either remained positive or converted to positive with IVH within an average period of 11 days of treatment. Nutritional therapy with IVH was associated with restored skin test reactivity in 51% of malnourished cancer patients undergoing oncologic therapy. Radiation therapy was generally immunosuppressive despite adequate nutritional repletion. In surgical patients, positive skin test reactivity correlated directly with a favorable response to operative therapy.

Carcinoma of the pyriform sinus: predictors of TNM relapse and survival

To determine predictors of TNM relapse and survival for 108 patients with epidermoid carcinoma of the pyriform sinus, the histopathologic features of tumor-related and host-related characteristics were correlated with primary and/or cervical nodal failure, distant metastases, and actuarial three-year survival. Patients in this study received preoperative irradiation and partial laryngopharyngectomy (PLP) or total laryngopharyngectomy (TLP) with en bloc radical neck dissection. Higher rates of local failure were observed in patients with keratinizing tumors (34 vs. 15%), with tumors having an "infiltrating" tumor-stromal interface (30 vs. 14%), with positive surgical margins in PLP or TLP specimens (30 vs. 16%), and with extranodal extension of tumor (39 vs. 22%). The development of distant metastases was significantly correlated with nonkeratinizing carcinomas (30 vs 11%, P = 0.02), and was observed more often in patients with positive lymph nodes (17 vs. 7%). Patients with negative surgical margins in PLP or TLP excision (50 vs. 21%, P = 0.01) survived significantly longer.

Immunocompetence, immunosuppression, and human breast cancer. III. Prognostic significance of initial level of immunocompetence in early and advanced disease

The prognostic significance of immunocompetence determined at diagnosis was analyzed in 158 operable breast cancer patients followed for 3--6 years, in terms of disease recurrence and of length of disease-free period (DFP) and in 52 patients with metastatic disease in terms of length of survival. In vitro lymphocyte stimulation by PPD and PHA were of higher predictive value with respect to probability of disease recurrence than in vivo cutaneous reactivity to PPD and DNCB. Conversely, length of DFP and of survival were found to correlate better with in vivo than within vitro parameters. Absolute number of peripheral blood lymphocytes (PBL) and percent of E-rosette-forming cells (E-RFC) proved devoid of prognostic value. Prognostic separation was best brought out upon analysis by integrated score of immunocompetence, comprising the four functional parameters. Probability of disease recurrence was 0.43 for all operable patients, as calculated by actuarial method 48 months postoperatively; it was 0.26 for optimal and 0.61 for suboptimal responders (P less than 0.0001). Separate analysis of Stage 1 (N0) and Stage II (N+) patients revealed prognostic segregation within each stage: probability of recurrence in Stage I was 0.06 for optimal vs. 0.41 for suboptimal responders (P less than 0.001) and in Stage II it was 0.45 vs. 0.79, respectively (P less than 0.01). These findings may prove valuable for a more selective patient allocation for post-mastectomy adjuvant therapy. Length of DFP was found inversely proportional to initial immunocompetence, with a mean of 23.5 months for good responders and 12.8 months for poor responders (P less than 0.01). Length of survival of metastatic patients was found to correlate with initial (pretreatment) levels of immunocompetence, mean survival being 29.5 months for those with preserved immune function and 12.3 months for the immunosuppressed (P less than 0.001). It was concluded that initial immunocompetence, determined by parameters of cell-mediated immunity, shows strong prognostic association with the subsequently observed course of human breast cancer.

Enzyme-linked immunosorbent assay for herpes simplex virus tumor-associated antigen

The antibodies against herpes simplex virus (HSV) tumor-associated antigen (TAA) in human sera were investigated by the enzyme-linked immunosorbent assay (ELISA). By combining the findings of antibody levels in many human sera, a significant level of discrimination between normal and cancer sera could be reached. Thus, 57 of 74 pathological sera had increased levels of antibodies against HSV-TAA antigen as compared to 26 of 512 normal sera. A significant correlation between the ELISA values and complement fixing (CF) and radioimmunoassay (RIA) values was also found. The results suggest that serodiagnosis with the ELISA test may therefore be of some use in the detection of specific antibodies against HSV-TAA antigen in sera of cancer patients.

Cellular immune deficiency in black patients with basal cell carcinoma

Skin cancer, the most common malignancy in white patients, is rare in black populations. Seventeen black patients have been diagnosed and treated for basal cell carcinoma in the past 20 years at the University of Mississippi Medical Center. Ten of them have died, six of various types of cancer. Of the seven living patients, one had two cancers at the time of study: a new basal cell carcinoma and generalized lymphoma. The majority of patients had some degree of mixed racial ancestry, with medium to light brown skin, a history of heavy sun exposure, and lesions appearing on the head or neck. Highly significant depression of cellular immunity was demonstrated in these patients by T-cell assay. Altered tumor surveillance is implied as an etiological factor in basal cell carcinogenesis in black patients.

Significance of tumour mass on T-lymphocyte levels in patients with gastrointestinal cancer

The relationship between tumour load and immunity in gastrointestinal cancer has been studied by sequential comparison in patients whose tumour has been removed and those whose tumour was found to be inoperable. Total lymphocyte count, absolute and percentage T- and B-lymphocyte counts, effect of papain on E-rosetting cell levels, and inhibitory effect of cancer sera on E-rosette formation by normal lymphocytes have been studied in 30 patients with stomach or colorectal cancer, and 10 control patients with benign gastrointestinal disease. The examination was done on each patient before and at regular intervals after operation up to 24 weeks. Operable cases, with removal of tumour load, showed a temporary fall in total lymphocyte count and T cell counts, which returned to normal by four weeks postoperatively. Inoperable cases (15 patients) showed a progressive fall in total lymphocyte count and a relatively greater depression of T cell counts, in parallel with increasing tumour mass. E-receptor blocking factor was demonstrated in the sera of cancer patients. This factor was related to tumour mass and presumably was of tumour origin, as it persisted in the inoperable group but disappeared by 12 weeks after tumour removal. The factor explained the excess depresion of T cells over total lymphocytes, but does not explain the continuing depression of total lymphocyte count in the cancer patients.

Prognostic value of pre-treatment lymphocyte count and T cell levels in localized bronchogenic carcinoma

In the patient with clinically localized bronchogenic carcinoma, the pre-treatment peripheral blood lymphocyte count and the thymus-dependent lymphocyte (T cell) level correlated with the prognosis of the tumor histology was either squamous cell, oat cell, or undifferentiated carcinoma. Patients whose pre-treatment lymphocyte count was less than 1,000/ml or whose T cell level was less than 750/ml either died or developed distant metastases by nine months after treatment of their localized tumor. By contrast, 55% of patients whose pre-treatment T cell level was greater than 750/ml were alive and without evidence of metastases nine months after treatment (P less than 0.02). Analysis of survival of these patients by the life-table method through the first post-treatment year further demonstrates the prognostic value of a low pre-treatment lymphocyte count or T cell level. The pre-treatment lymphocyte count and T cell level in patients with adenocarcinoma did not correlate with prognosis.

Immune monitoring protocol for patients with carcinoma of the head and neck. Preliminary report

Numerous investigators have observed a depression of cell-mediated immunity in patients with carcinoma of the head and neck using a variety of in vitro and in vivo assays. This report presents the data obtained when a group of head and neck cancer patients were evaluated for reactivity in an in vitro lymphocyte blastogenesis assay using polyclonal mitogens and specific antigens, numbers of peripheral blood T-lymphocytes, and levels of circulating immune complexes. Such an immunological monitoring protocol revealed a depressed reactivity of the cancer patients in the lymphocyte blastogenesis assay when compared to normal age-matched controls. We also observed that 75% of these patients had circulating soluble immune complexes in their sera before and after therapy. These preliminary data indicate that further research is needed to examine the potential role of soluble immune complexes in modulating the host's immune response.

Soluble immune complexes in sera from head and neck cancer patients: a preliminary report

With the recent demonstration of circulating immune complexes in a variety of malignant and nonmalignant diseases, we have examined the sera of head and neck cancer patients for evidence of soluble immune compleses. Using the Raji, cell test, we have shown that immune complexes are present in over 80% of the cancer sera examined as compared to less than 10% of normal control sera, and that these complexes persist following treatment of the patients by surgery or radiation therapy. These complexes may be acting as blocking factors which would account for the anergic state of these patients.

Relationship of cell-mediated cytotoxicity against melanoma cells to prognosis in melanoma patients

The cell-mediated cytotoxicity (CMC) of blood mononuclear cells against cultured human melanoma cells was measured in patients after surgical removal of localized melanoma, at a time when they were considered on clinical grounds to be free of melanoma. It was found that the distribution of CMC values against melanoma cells in melanoma patients was different from that in control subjects, and several sub-populations of melanoma patients were evident on the basis of these measurements. No difference in distribution of CMC values was found against non-melanoma cells, which suggested the changes were specific for melanoma. The proportion of patients with recurrence of melanoma was compared between the patient groups with low, normal or high CMC values against cultured melanoma cells after surgery. Analysis for periods extending to 2 years showed that patients with low CMC values after surgery had a significantly higher incidence of recurrence from melanoma than patients with normal or high CMC values. These results suggest there may be a sub-group of melanoma patients who have intrinsically low CMC against melanoma cells, and that this may be an important predisposing factor in the development of recurrent melanoma.

Changes in cell-mediated immunity in patients undergoing radiotherapy

The cell-mediated immune status of 147 patients who received radiotherapy was evaluated using in vitro tests (PHA, E-rosette and spontaneous blastogenesis) both before and 6 weeks after the end of radiation. All patients had verified malignancies, involving the bronchus in 29 cases, breast in 28, female genital system in 26, head and neck in 20 and bladder in 15. Patients suffering from bronchogenic carcinomas or malignancies of the head and neck showed a relative high degree of immune suppression. Our findings indicate a trend towards some improvement in PHA reactivity, as well as in as the percentage of E-rosette-forming cells after treatment, which is more noticeable in patients with pelvic or breast tumors. A relationship seems to exist between the tumor load and the immune status, which reverts to a normal pattern when the former is extinguished. Moreover, patients with poor clinical response display a profoundly depressed level of immune status without any improvement after treatment.

Correlations among serum protein-bound carbohydrates, serum glycoproteins, lymphocyte reactivity, and tumors burden in cancer patients

Levels of glycoprotein-associated carbohydrates (neutral hexoses, hexosamine, sialic acid and fucose) were determined in the serum of patients with either local, regional or metastatic cancer, patients clinically cured of cancer, and controls (smokers and nonsmokers). Total protein-bound carbohydrates were compared with levels of 17 normal serum glycoproteins, carcinoembryonic antigen (CEA), and with lymphocyte reactivity to phytohemagglutin (PHA). Tumor burden was directly related to protein-bound carbohydrate levels in patient groups. Levels of bound carbohydrates reflect the sum of all the changes in serum glycoproteins, but primarily changes in the acute-phase proteins (alpha 1-acid glycoprotein, alpha 1-antitrypsin, haptoglobin, ceruloplasmin) found in the alpha-globulin fraction of serum. Increases in protein-bound carbohydrates in tumor-bearers were not related to increases in CEA. Increased levels of the acute-phase proteins occurred in individuals with depressed in vitro lymphocyte reactivity to PHA. A significant positive correlation was found between lymphocyte reactivity and level of alpha 2HS-glycoprotein. The results suggest that serum protein-bound carbohydrates or glycoproteins may be of adjunctive value is assessing tumor burden and immune reactivity in cancer patients.

Neutrophil function in cured cancer patients

Spontaneous and endotoxin-stimulated nitroblue tetrazolium (NBT) dye reduction was evaluated in 86 individuals cured of various types of solid malignancies and in 55 healthy adults. Oxygen consumption tests, at rest and during phagocytosis, were performed with polymorphonuclear leukocytes of 22 patients and 10 controls, chosen at random. The results revealed an impaired capacity of patients' neutrophils to reduce NBT. The decrease in the stimulated reduction values was more pronounced (p less than 0.0005) than in spontaneous values (p less than 0.01), and was also noticed in patients who had been treated by surgery alone and in those with a disease-free interval of 10 years or more. Oxygen consumption by patients' leukocytes was similar to that of controls. The present results, especially those of the endotoxin-stimulated NBT test, might reflect a neutrophil dysfunction in cured cancer patients. The nature of such an abnormality and its possible clinical implication are still obscure.

Phytohemagglutinin skin tests in cancer patients

Phytohemagglutinin (PHA) stimulates blastic transformation of normal lymphocytes in vitro and when injected intradermally produces a skin response histologically similar to a delayed hypersensitivity reaction. We investigated the skin test responses to PHA, mumps, candida, and varidase (SK-SD) and the PHA-induced lymphocyte transformation in patients with malignant neoplasms. Increased incidence of anergy to recall antigens and unresponsiveness to PHA skin testing was observed in patients with lymphoreticular malignancies but not in those with solid tumors. There was a direct correlation between skin test reactivity to at least one recall antigen and/or PHA and survival in lymphoma patients. This was true of both short and long terms survival in Hodgkin's disease and of survival at least through 42 months in non-Hodgkin's lymphomas. In vitro stimulation of lymphocytes with PHA did not correlate with PHA skin test reactivity. We conclude that PHA skin testing is a useful adjunct in the evaluation of patients with lymphoreticular malignancies.

Spontaneous rosette formation and rosette inhibition assays in patients with squamous cell carcinoma of the head and neck

Peripheral blood lymphocytes from patients with squamous cell carcinoma (SCC) of the head and neck were studied by spontaneous lymphocyte rosette and rosette inhibition (RI) assays prior to treatment. The patients were clinically staged and the results of the assays compared with the clinical stage of the disease. The percentage of T-lymphocytes as determined by the spontaneous lymphocyte rosette test was significantly lower (p less than .01) for the patient group when compared with a normal population. Patients with stage I and II disease did not differ significantly from controls. Individuals with stage III or IV disease, however, had significantly lower T-lymphocyte counts. The tumors were histologically graded as well, moderately well, or poorly differentiated SCC. Patients with poorly differentiated neoplasms had significantly lower T-cell counts. The RI assay (using horse anti-human thymocyte globulin to inhibit rosette formation) was abnormal in many of the patients but did not appear to be a more sensitive in vitro measure of cell mediated immunity in these patients. Performing both tests detected more patients with cellular immunologic incompetence than either one alone.

Abnormalities of the immune system in children with neuroblastoma related to the neoplasm and chemotherapy

Children with localized and metastatic neuroblastoma were studies to determine their immune status at the time of diagnosis and while they were receiving intensive intermittent chemotherapy; Investigations included leukocyte and differential counts, delayed hypersensitivity response, quantitative serum immunoglobulins, percentages of T and Fc receptor lymphocytes, PHA-induced mitogenesis, and antibody-and PHA-dependent cellular cytoxicity. Abnormalities related to the neoplasm at diagnosis were limited to depressed leukocyte and lymphocyte counts and increased concentrations of serum IgM in patients with metastases to bone marrow and other sites. No abnormalities were observed in those with localized tumors. Intermittent chemotherapy of metastatic neuroblastoma caused immunosuppression. Effects were most marked during five-day courses of chemotherapy; they included abrogation of DH and decreased leukocyte and lymphocyte counts and percentages of Fc receptor lymphocytes. Recovery of DH with partial recovery of leukocyte and lymphocyte counts was observed three weeks, later, prior to the next course, We conclude that both metastatic tumor and chemotherapy cause abnormalities of the immune system in children with neuroblastoma.

Value of lymphocyte reactivity induced by phytohemagglutinin in the treatment of malignant diseases

An improved micromethod for evaluating in vitro lymphocyte blastogenetic activity, a modification of the method of Park and Good, is devised and used in 111 stomach cancer, 34 colorectal cancer, and 22 breast cancer cases. Follow-up information on the lymphocyte blastogenetic activity levels was available in 28 stomach cancer patients after the clinically complete removal of the tumor. In 16 patients with early stomach cancer the lymphocyte blastogenetic level did not differ greatly from a control values from healthy volunteers. However, in 66 advanced stomach cancer cases, statistically lower levels were encountered. After the complete removal of the tumor in 28 stomach cancer patients, the lymphocyte blastogenetic values rose postoperatively. The lymphocyte blastogenetic levels in patients with curative colorectal cancer or curative breast cancer were significantly higher than those patients with non-curative tumors.

The effects of therapeutic irradiation on lymphocytes and immunity

The lymphocytotoxic effect of therapeutic irradiation may lead to immune depression. The significance of such effects is yet to be determined in many malignancies, especially in light of the persistant immune depression in many "cured" patients. The present review examines the effects of age, type of cancer, and stage of disease as well as the results of immune parameters following radiation therapy. Factors to be considered in both the analysis of present day data and in future studies are also reviewed.

Cellular hypersensitivity in patients with adenomatous hyperplasia and adenocarcinoma of the endometrium

Cellular hypersensitivity was studied in patients with adenomatous hyperplasia and adenocarcinoma of the endometrium with the use of dinitrochlorobenzene (DNCB) skin tests and inhibition of leukocyte migration by homologous and autologous tumor antigen. Inhibition of leukocyte migration by homologous endometrial carcinoma antigen was found in two of five patients with adenomatous hyperplasia and eight of 11 patients with endometrial adenocarcinoma. A comparable degree of inhibition was found with autologous antigen. DNCB skin reactions were found to be strongly positive in patients with adenomatous hyperplasia, and a lesser degree of reactivity was observed in patients with endometrial adenocarcinoma. No correlation was found between leukocyte migration tests and DNCB reactions, and no correlation was observed between these tests and the age of the patient, clinical stage of disease, or histologic grade of the tumor.

Immunocompetence, immunosuppression, and human breast cancer. I. An analysis of their relationship by known parameters of cell-mediated immunity in well-defined clinical stages of disease

General immune competence was examined 255 breast cancer patients, including 104 operable, 44 locally advanced/inoperable, and 44 with demonstrable metastatic dissemination, all at the time of diagnosis, as well as 63 disease-free long survivors; this was compared with that of 100 normal controls. The parameters employed were PPD and DNCB skin testing, lymphocyte response to PHA mitogen, E-rosette formation, and lymphocyte number. Significant patients, with only 31% showing optimal and 25% showing minimal levels of immune function, as compared with 70% optimal and 2% minimal function in controls. Immune competence was not affected by metastatic involvement of regional lymph nodes. In patients with early, occult metastatic dissemination (as determined in retrospect), the degree of immune competence was found to be identical to that of patients who did not develop disease dissemination. Remarkably, this early phase of tumor spread is not accompanied by immune impairment, such as is evident in clinically demonstrable metastatic disease and, to a lesser degree, in advanced local and regional disease. Since tumor dissemination preceded impairment of general immunocompetence, it emerges as the cause rather than the result of immunosuppression. Long disease-free survivors, who had postoperative irradiation 5-12 years previously, were shown to have a notably low level of immune competence. Lymphocyte response to PHA stimulation was found to be impaired in the earlier stages of disease, while skin DHR was still well maintained; in advanced disease both parameters tend to correlate as total immunologic impairment ensues. The sequence of immunologic events leading up to immunosuppression with disease progress is discussed.

Impaired general cell-mediated immune functions in vivo and in vitro in patients with nasopharyngeal carcinoma

General cell-mediated immune (CMI) functions in NPC patients were investigated by the in vivo Mantoux and in vitro lymphocyte response to PHA assays. Thirty-eight (50%) of 76 untreated NPC patients were hyporesponsive in the Mantoux assay compared to 27 (25%) of 110 control patients. Forty-three (65.2%) of 66 untreated NPC patients also showed lymphocyte hyporesponsiveness to PHA compared to 15 (15.5%) of 97 control patients. Combined deficiencies were observed in 35 (42.2%) of 83 NPC patients compared to only 2 (3.3%) of 61 control patients. No difference in the frequency of immunodeficiency was observed between "early" and "late" disease patients. CMI functions of treated "remission" NPC patients were found to be impaired to the same extent as those of untreated NPC patients.

The long-term effect of radiotherapy on the immune status of patients cured of a gynecologic malignancy

The long-term effect of radiotherapy on the immune system were evaluated in 52 patients cured for a gynecologic malignancy from 3 to 15 years. Eighty-seven percent of the patients had no depression in cell-mediated immunity as determined by delayed hypersensitivity reaction to DNCB. The absolute lymphocyte count, as well as the circulating immunoglobulins (IgA, IgG, IgM), were within the normal range. Thus, there were no significant changes in cell-mediated immunity and circulating immunoglobulins several years after radical wide-field radiotherapy.