Immunologic impairment in patients with non-lymphoid cancer: correlation with the tumoral stage, response to treatment and survival

Analysis of T-cell-receptor variable gene segment usage in peripheral-blood lymphocytes of advanced cancer patients

Advanced cancer patients generally display impaired T-cell immune functions. The underlying mechanisms are not well understood. The aim of this study was to analyze whether major alterations of TCR variable gene segment usage could be detected in the blood of these patients. Seventeen individuals with various malignancies were tested using PCR and a panel of V-gene-segment-sub-family-specific (V alpha 1-w29/V beta 1-w24) oligonucleotide primers. The results indicate that these cancer patient lymphocytes expressed most V alpha and V beta sub-family specificities, similarly to the lymphocytes of healthy donors (n = 10). This suggests that immunodepression in advanced cancer patients is not related to major deletions in their T-cell repertoires. We also compared the mean relative expression of each V-sub-family specificity of patients and healthy donors by quantitative densitometric analysis. We found significant differences in 4 V beta specificities (and no V alpha). Our analysis identified unique T-cell sub-sets putatively involved in the mechanisms leading to immunodepression in advanced cancer patients. Alternatively, the observed differences in terms of V beta specificity expression may reflect the host response against the tumor.

Contribution of monocytes to the decreased lymphoproliferative response to phytohemagglutinin in patients with lung cancer

Patients with lung cancer (LC) have a reduced T-cell proliferative response to phytohemagglutinin (PHA) compared with that of healthy individuals. This decreased response is a result of an inhibitory effect exerted by the monocytes as evidenced by: (1) a restoration to normal levels of the response to PHA when the peripheral blood mononuclear cells were depleted of adherent cells (AD) and (2) a dose-dependent inhibition of the response to PHA when the nonadherent cell population was co-cultured with increasing numbers of autologous AD cells. The addition of indomethacin to the cultures resulted in only a partial restoration of the response to PHA. Monocyte production of interleukin-1 from patients with LC in response to lipopolysaccharide was normal. These findings support the hypothesis that the AD cell population plays a major role in the low T-cell proliferative response to PHA in patients with LC. This suppressor effect is partially mediated by the prostaglandins released by the monocytes.

Serial immunological testing in patients with gastric cancer

Standard immunological parameters measuring non-specific cellular immune reactivity were determined in 175 patients with different stages of gastric cancer prior to surgery and during follow-up. Several tests measuring monocyte activity were also employed. The total number of T cells and their subpopulations Ta and T29o was unchanged except depression of T29o in stage IV. The blastogenic response of lymphocytes to PHA as assessed by stimulation of protein synthesis was only depressed in stage IV. In contrast the PHA-induced lymphokine production was increased in all patients but the differences were significant for stage III and IV. Monocyte Fc receptor expression was increased in stages II-IV, while nitro blue tetrazolium reduction and antibody dependent cellular cytotoxicity of monocytes was elevated in stage IV. The number of extractable monocytes was not increased. Longitudinal studies suggested that most of the parameters normalized during follow-up. No major long-term impact of chemoimmunotherapy (5-FU + BCG) on the immune parameters was observed except a transient increase in PPD reactivity approximately 1 year after commencement of treatment. In patients with stage III gastric cancer the increased occurrence of suppressor cells (mostly monocytes) and elevated cytostatic activity of monocytes was associated with a longer survival while the increased lymphokine production and Fc receptor expression were seen in the group of patients succumbing earlier. We concluded that most of the changes in immune parameters were seen only in advanced disease and paradoxically disappeared in the course of disease. The determination of monocyte activity seems to be a sensitive indicator of immune system dearrangements in earlier stages of cancer and a useful prognostic factor in gastric cancer.

Long-term (5-11 years) follow-up of general immune competence in breast cancer. I. Pre-treatment levels with reference to micrometastasis

General immune competence was measured before treatment in 185 breast cancer patients. They were then followed for 5 to 11 years to determine its relationship to recurrence and its clinical value in predicting prognosis. The tests of immune competence used were immunoglobulins IgG, IgA, IgM, leucocyte counts, percentage and total lymphocyte counts and Mantoux and DNCB skin hypersensitivity tests. None of these tests was strongly predictive of recurrence on an individual basis, a finding similar to our results at 2 years. The longer period of follow-up now reported has provided no findings of unequivocal statistical significance, but suggests a biphasic host response to early tumours. The patients who developed recurrence within 5-11 years due to micrometastasis had higher lymphocyte counts in their preoperative assessment than patients who remained recurrence free. This suggests that small tumour volumes do not stimulate immunity and that large volumes depress it; tumours in between these groups are associated with higher levels. Examination of studies by a number of authors reveal parallel findings which have not been previously noted. It is not possible to confirm the significance of these findings from this study because of the heterogeneity of human breast cancer. However, if they indicate a general principle of a dynamic host-tumour interplay they have important implications for assessing immune competence at any single point of time and for the theory that cancer may arise during an anergic state. We hope that these findings will stimulate other workers to examine host-tumour interaction from this point of view.

Long-term follow-up of general immune competence in breast cancer. II. Sequential pre- and post-treatment levels: a 10 year study

Pre-treatment and sequential post-treatment (at 3 months, 6 months, 1, 2, 3, 4 and 5 years) examination of general immune competence was performed in 185 consecutive breast cancer patients. The patients were followed for 5 to 11 years to monitor the dynamic relationship between host immunity and cancer and to examine the effect of the treatment method. The tests of immune competence used were immunoglobulins IgG, IgA, IgM, leucocyte counts, percentage and total lymphocyte counts and Mantoux and DNCB skin hypersensitivity tests. Serum IgG and IgA showed no change relating to treatment method in recurrence-free patients; but IgG levels were higher when recurrent disease was imminent or established; IgM diminished (P less than 0.001) after treatment and this continued at 5 years in all patient groups. Simple lymphocyte counts showed the most interesting changes. They remained depressed for as long as 60 months following radiotherapy (P less than 0.01). After treatment by surgery, lymphocyte counts rose in patients without recurrence, but fell when systemic recurrence was imminent or established. This effect was not seen in patients with local recurrence only. There was no change in immune competence immediately before recurrence sufficient to be of clinical usefulness, but a low pre-treatment lymphocyte count with a steady rise after surgery carried a good prognosis. Similarly a high initial lymphocyte count with a fall after surgery was indicative of recurrence. Universal and prolonged depression of lymphocyte counts following radiotherapy was confirmed, and the effect was additive to that of tumour load in recurrent disease. Because of the large number of statistical calculations carried out, some of the apparently significant findings may be due to chance. However, the general trends emerging suggest that similar long-term studies, using the more sophisticated measures of lymphocyte function now available, might be rewarding.

Evidence in advanced cancer of an activated leukocyte state to explain the reversible defect in transmembrane signaling and leukocyte adherence inhibition to extracts of cancer

When leukocytes bind tumor antigen, a transmembrane signal induces the cascade of physiological changes that result in leukocyte adherence inhibition (LAI). Leukocytes from patients with early stages of cancer exhibited transmembrane potential (delta psi) changes and LAI when incubated with a cancer extract of the same organ and histogenesis, whereas leukocytes from patients with advanced cancer did not. The refractoriness was reversed by transiently raising intracellular cyclic AMP. LAI is produced by leukotrienes and leukocytes from patients with advanced cancer were refractory to leukotriene-induced delta psi changes which was also restored by raising intracellular cyclic AMP. Moreover, leukocytes could be made refractory to delta psi changes: leukocytes from patients with early cancer when preincubated with a breast cancer extract showed no delta psi change with a second exposure; and leukocytes from control subjects preincubated with leukotrienes showed no delta psi change with a second exposure. The responsive population of leukocytes in LAI to either the specific cancer extract or leukotrienes consisted of about 35 to 42% of the adherent leukocytes. The responsive leukocytes in advanced cancer were already nonadherent, accounting for the 39% increased nonadherence with the control extract. Raising cyclic AMP decreased nonadherence by 39%. The results suggest that leukotrienes and other chemoattractants released in vivo by immune cells binding tumor antigen have stimulated the changes in leukocytes in advanced cancer. However, the unresponsiveness seems to be because of appropriate expression of physiological changes triggered by antigen and chemoattractant stimuli.

Utility of skin testing in nutritional assessment: a critical review

To evaluate the claim that delayed cutaneous hypersensitivity skin testing is useful in nutritional assessment of hospitalized patients, we reviewed the English language literature of the last 12 years. Although several hundred publications discussed delayed cutaneous hypersensitivity testing and nutritional status, only 15 provided new, objective data correlating these variables in hospitalized adults. Of these, only three provided age-matched control groups to control for antigen variability, lack of prior exposure, and other technical problems. The majority of reports took no account of diseases (cancer, immune disease, infection) or therapies (radiation, drugs, surgery) known to affect skin test response. In the reports specifying different degrees of malnutrition, the most important group, those with less than obvious malnutrition, were not abnormal by skin testing. Ten reports described serial skin testing during nutritional intervention. Non reported serially tested controls without nutritional intervention, important since serial testing alone can augment skin test response. Nonnutritional intercurrent therapy which might affect skin tests was seldom mentioned. In the few reports specifying that nutritional repletion was even achieved, repleted patients were not separated from unrepleted in subsequent analyses. No report examined skin testing for its predictive accuracy, cost/benefit ratio, or influence on outcome. Because of these problems in experimental design, the frequent lack of appropriate controls, and the low specificity of abnormal delayed cutaneous hypersensitivity responses, we conclude that the utility of skin testing in nutritional assessment remains unproved.

Evaluation of peripheral blood T lymphocytes in renal adenocarcinoma before and after surgical removal of the tumor

Peripheral blood T lymphocytes were studied in 24 untreated patients with renal adenocarcinoma, 80 per cent of whom had local extension of the tumor. T lymphocytes were evaluated with the total and the active rosette assays, and were further submitted to stimulation by a range of phytohemagglutinin concentrations in vitro. Controls were healthy volunteers tested on the same days as the patients. Total E-rosette forming cells were slightly decreased but the difference compared to controls was not significant. Active rosettes were normal. When present lymphocytopenia affected total E-rosette forming cells. The mean of the log-converted stimulation indexes was reduced significantly in the patient group only when a suboptimal concentration of phytohemagglutinin was used. Total E-rosette forming cells returned to normal 3 weeks postoperatively but lymphocyte reactivity did not improve and active rosette forming cells remained within normal range. Thus, only minor abnormalities of T lymphocytes were disclosed in this study, suggesting functional alterations rather than depletion. Our study confirms that a cancer operation may act as immunotherapy.

Inhibition of delayed hypersensitivity reaction in skin (DNCB test) by 8-methoxypsoralen photochemotherapy. Possible basis for pseudo-promoting action in skin carcinogenesis?

Fifty-five of a hundred and two subjects undergoing photochemotherapy with 8-methoxypsoralen and near ultraviolet showed an abnormally low or undetectable delayed cellular hypersensitivity reaction in the skin as judged by the dinitrochlorobenzene test. It is suggested that photochemotherapy may act as a pseudo-promotor by blocking an immunologically based control process in the skin so allowing the relatively rapid appearance of squamous skin tumours, documented elsewhere, in individuals whose skin already contains a population of potentially tumorous cells. Immune surveillance of a kind may thus operate in human skin. Impairment of delayed cellular hypersensitivity to dinitrochlorobenzene was more likely to occur with more intensive treatments and in patients with less skin pigmentation.

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.

Tumor-induced changes in T cell mitogen responses in rats: suppression of spleen and blood lymphocyte responses and enhancement of thymocyte responses

Concanavalin A (Con A) and phytohemagglutinin (PHA) responses of spleen and blood lymphocytes from tumor-bearing (TB) rats were found to be markedly depressed in 4 different models employing tumors of spontaneous origin. Removal of phagocytic cells from both spleen and blood lymphocyte suspensions led to a complete restoration of the responses, indicating that the decreased responses were not due to intrinsic defects in the lymphocytes. The reduction was shown to be due to the inhibitory effect of an increase in the percentage of phagocytic cells. In addition, TB induced an atrophy of the thymus and a decrease in the number of thymic lymphocytes, mainly due to severe lymphocyte depletion in the cortex. The cells that remained in the thymus exhibited increased responsiveness to PHA and Con A as compared to thymus cells from normal rats. Similar results were found in hydrocortisone acetate-treated rats, suggesting that TB leads to a decrease in nonresponsive, cortical corticosteroid-sensitive thymocytes.

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.