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

The relationships of nutrients, routes of delivery, and immunocompetence

Malnutrition has marked consequences on surgical outcomes. Adequate nutrition is important for the proper functioning of all organ systems, particularly the immune system. Determination of the type and amount of nutrient supplementation and the appropriate route of nutrient delivery is essential to bolster the immune system and enhance the host's response to stress. Correct administration of immunonutrients could lead to reductions in patient morbidity following major surgery, trauma, and critical illness.

Beneficial immune modulatory effects of a specific nutritional combination in a murine model for cancer cachexia

The majority of patients with advanced cancer are recognised by impaired immune competence influenced by several factors, including the type and stage of the tumour and the presence of cachexia. Recently, a specific nutritional combination containing fish oil, specific oligosaccharide mixture, high protein content and leucine has been developed aimed to support the immune system of cancer patients in order to reduce the frequency and severity of (infectious) complications. In a recently modified animal model cachexia is induced by inoculation of C26 tumour cells in mice. In a pre-cachectic state, no effect was observed on contact hypersensitivity, a validated in vivo method to measure Th1-mediated immune function, after adding the individual nutritional ingredients to the diet of tumour-bearing mice. However, the complete mixture resulted in significantly improved Th1 immunity. Moreover, in a cachectic state, the complete mixture reduced plasma levels of pro-inflammatory cytokines and beneficially affected ex vivo immune function. Accordingly, the combination of the nutritional ingredients is required to obtain a synergistic effect, leading to a reduced inflammatory state and improved immune competence. From this, it can be concluded that the specific nutritional combination has potential as immune-supporting nutritional intervention to reduce the risk of (infectious) complications in cancer patients.

The role of psychosocial factors in the progression of hepatocellular carcinoma

The number of deaths per year from hepatocellular carcinoma (HCC) exceeds 250000, placing it sixth as the cause of death from cancer worldwide. The primary etiology of most cases of HCC in the US is hepatitis B and/or C. Extensive research has demonstrated that the relationship between hepatitis B infection and the progression to HCC is mediated by the immune system. A substantial, but unrelated literature, describes the relationship between psychosocial factors (e.g., stress, psychiatric morbidity), immune system reactivity, and disease progression in patients with cancer. However, the role of these factors in the progression of HBV-HCC has not been explored. An understanding of the relationship among virology, immunology, and behavior in the development and recurrence of HCC may provide alternative methods for secondary prevention of HCC (e.g., behavioral) until a vaccine and/or pharmacological treatments are developed, feasible, and affordable.

Lymphocyte subpopulations in patients with multiple primary tumors

BACKGROUND

Cancer patients with single tumors live longer today due to earlier detection and improved treatment methods. For this reason, the authors see more patients who develop a second primary tumor. The etiology of the second tumor can be the same as the first, whether treatment-induced or unknown. The prognoses of these patients usually depend on the behavior of the second tumor.

METHODS

The authors investigated the lymphocyte subset in 88 of the more than 750 patients listed in the tumor registry at their treatment center who had at least one carcinoma of the breast or colon and a second primary of the same or another site. Mononuclear cells were obtained from heparinized blood by the standard fractionation Hypaque gradient centrifugation technique. Helper and suppressor cells were identified by using three murine monoclonal antibodies: CD3 for mature T lymphocytes, CD4 for helper inducer cells, and CD8 for suppressor cytotoxic cells. T-cell subset distribution was evaluated with flow cytometry.

RESULTS

Most values of CD3, CD4, and CD4/CD8 were lower in patients than in healthy controls. The values of CD4 and CD4/CD8 were lower in patients who had a second tumor in the colon rather than in the breast.

CONCLUSIONS

As tumors in patients with a second primary sometimes recur or the patient develops a third primary, the authors are prospectively following their patients to see whether those with immunosuppression have a greater tendency to develop recurrent disease or a third primary.

Studies on functional status of circulating lymphocytes in unaffected members from cancer families

That the inheritance of mutations in tumor susceptibility genes alone cannot determine risk for developing cancer is now well accepted. Immune functions have long been recognized as one of the important risk modifying factors in this regard. In an attempt to develop a multiparametric approach to identify high risk individuals from cancer families, we have examined NK cell function in unaffected members from familial breast cancer families. We have also carried out a parallel study of T lymphocyte functions in these individuals. Our studies demonstrate a significantly lower NK cell activity in members from cancer families. T lymphocyte activity also showed a similar trend, with the unaffected members demonstrating a notably lowered T lymphocyte function. In addition the data from patients reveals differential sensitivity of NK and T lymphocyte function to the disease phenotype. Implications of these observations are discussed.

Reduced mitogenic stimulation of peripheral blood mononuclear cells as a prognostic parameter for the course of breast cancer: a prospective longitudinal study

Immunosuppression has been often associated with the course of malignant diseases. In the present study, the proliferation of peripheral blood mononuclear cells (PBMCs) in response to mitogenic stimulation with phytohaemagglutinin (PHA) was assessed prospectively in 90 patients with stage I-III breast cancer. Whereas PHA-induced proliferation of PBMCs derived from patients with breast cancer preoperatively was significantly decreased when compared with data obtained in healthy control individuals (P < 0.001), the degree of the defect in PHA-induced proliferation of PBMCs depended upon the tumour burden as manifested by tumour size and axillary lymph node involvement (P < 0.003 in each case). PHA-induced proliferation of PBMCs dropped significantly in patients who received adjuvant chemotherapy consisting of cyclophosphamide, methotrexate and fluorouracil (CMF) after an observation period of 6 months (P < 0.01), but not in patients under adjuvant treatment with tamoxifen only. After an additional 6 months (i.e. 12 months after surgery), PHA-induced proliferation of PBMCs was similar in patients after adjuvant chemotherapy with CMF and in those receiving continued adjuvant tamoxifen treatment (P > 0.1), but in all patients still significantly decreased as compared with healthy controls (P < 0.001). When data obtained preoperatively and after 12 months were compared, it was found that out of 23 patients whose PBMCs had experienced a drop in their PHA-induced proliferation, 14 (61%) had developed metastatic disease within the subsequent 24 months (i.e. 36 months after surgery). In contrast, out of 59 patients whose PBMCs showed an increase in their PHA-induced proliferation within the first 12 months after surgery, only one (2%) presented with disease progression. We thus conclude that PHA-induced proliferation of PBMCs derived from patients with breast cancer depends upon the tumour load and is a good clinical predictor for the further course of the disease.

A biobehavioral model of cancer stress and disease course

Approximately 1 million Americans are diagnosed with cancer each year and must cope with the disease and treatments. Many studies have documented the deteriorations in quality of life that occur. These data suggest that the adjustment process is burdensome and lengthy. There is ample evidence showing that adults experiencing other long-term stressors experience not only high rates of adjustment difficulties (e.g., syndromal depression) but important biologic effects, such as persistent downregulation of elements of the immune system, and adverse health outcomes, such as higher rates of respiratory tract infections. Thus, deteriorations in quality of life with cancer are underscored if they have implications for biological processes, such as the immune system, relating to disease progression and spread. Considering these and other data, a biobehavioral model of adjustment to the stresses of cancer is offered, and mechanisms by which psychological and behavioral responses may influence biological processes and, perhaps, health outcomes are proposed. Finally, strategies for testing the model via experiments testing psychological interventions are offered.

A biobehavioral model of cancer stress and disease course

Approximately 1 million Americans are diagnosed with cancer each year and must cope with the disease and treatments. Many studies have documented the deteriorations in quality of life that occur. These data suggest that the adjustment process is burdensome and lengthy. There is ample evidence showing that adults experiencing other long-term stressors experience not only high rates of adjustment difficulties (e.g., syndromal depression) but important biologic effects, such as persistent downregulation of elements of the immune system, and adverse health outcomes, such as higher rates of respiratory tract infections. Thus, deteriorations in quality of life with cancer are underscored if they have implications for biological processes, such as the immune system, relating to disease progression and spread. Considering these and other data, a biobehavioral model of adjustment to the stresses of cancer is offered, and mechanisms by which psychological and behavioral responses may influence biological processes and, perhaps, health outcomes are proposed. Finally, strategies for testing the model via experiments testing psychological interventions are offered.

Impaired cytokine production in whole blood cell cultures of patients with gynaecological carcinomas in different clinical stages

The production of the cytokines IFN-gamma, IL-1-alpha, IL-2 and TNF-alpha was investigated in mitogen-stimulated, whole blood cell culture from 239 untreated patients with primary gynaecological carcinomas (breast, cervix, ovary, endometrium), and 191 healthy female controls. The cytokines were measured in the 4-day post-induction supernatants by a sensitive enzymoimmunological assay. In the blood cell cultures of all four groups of cancer patients, significantly lower values of IFN-gamma (P < or = 0.001), IL-2 (P < or = 0.01) and IL-1 alpha (P < or = 0.01) were found as compared to the controls, although lymphocyte and monocyte counts were almost identical. Grouping the tumour patients into different clinical stages we could show in the four groups of carcinomas a gradual depression of the cytokine production according to growing tumour burden.

The effect of distant malignancy upon quantitative cytologic assessment of normal oral mucosa

In 1962 Nieburgs et al. reported specific changes within cells taken from normal buccal mucosa, in those with malignant disease distant from the oral cavity. Few have attempted to confirm these findings. Given the potential application of the observations of Nieburgs et al., a quantitative investigation seemed necessary. Two groups were studied: 40 patients with malignant disease outside the oral cavity and 40 healthy patients attending for routine dental treatment. Both groups were matched for age and sex, with anemia excluded. Quantitative cytologic assessment of nuclear (NA) and cytoplasmic area (CA) and DNA distribution (using DNA cytophotometric study) were calculated from cells in normal buccal mucosal smears. No significant difference in NA (P = 0.28) was found between the two groups. However, a significant reduction in CA (P = 0.005) was found within the distant malignancy group. DNA distribution was invariably diploid. Previous studies on the effect of distant malignancy and nutritional deficiency have concentrated on examination of the nucleus, with exclusion of the cytoplasm. Important changes, such as the one reported, may therefore have gone unrecorded, particularly since oral smears have rarely been quantitatively assessed. The cause of this decrease in CA in distant malignancy patients is discussed with regard to the patients' nutritional state. The buccal smear may yet prove of value in assessing nutritional deficiency consequent to internal malignancy.

Long-term effects on the immune system following local radiation therapy for breast cancer. 4. Proliferative responses and induction of suppressor activity of the blood lymphocyte population

The long-term effect of local irradiation for breast cancer on the blood lymphocyte population was examined in 149 women who had been disease-free for 5-6 and 10-11 years. The patients were included in a clinical trial aiming at determining the value of pre- and post-operative irradiation (45 Gy) compared to surgery only. It was observed that the relative mitogen responses of lymphocytes to phytohaemagglutinin (PHA) and Concanavalin (Con A) and in a mixed lymphocyte culture (MLC) were significantly lower in irradiated compared to unirradiated patients at least a decade after treatment. The prolonged reductions of mitogen responses after irradiation could partly be due to an increased proportion of lymphocytes which may express suppressor function since the Con A-inducible suppressor activity of lymphocytes was significantly higher in irradiated compared to unirradiated patients.

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.

An immunohistological study of leukocyte localization in benign and malignant breast tissue

Using morphometric and immunohistological techniques, we investigated the distribution of T lymphocytes and subsets, B lymphocytes, macrophages and plasma cells in sections of human breast tissue. In normal lobules and ducts, leukocytes were found in greater density in the epithelium than in the stroma. The intra-epithelial cells consisted largely of suppressor/cytotoxic T lymphocytes with a smaller number of macrophages; inducer T cells were seen in only 1 out of 10 subjects and were present in very low numbers. In the stroma, there were roughly equal numbers of suppressor/cytotoxic cells, macrophages and plasma cells containing IgA or IgM. Small numbers of stromal inducer lymphocytes were seen in only 2 cases. Although the density of suppressor/cytotoxic cells in the epithelium was considerably greater than in the stroma, macrophages were present in roughly similar density in both locations. In carcinoma, the ratio of epithelial to stromal leukocyte density was reversed, due to a marked reduction in intra-epithelial cells and to an increase in those in the stroma. Between 10% and 30% of lymphocytes expressed activation markers in contrast to the normal breast in which virtually all were negative. Inducer lymphocytes were identified in 9/10 carcinomas. The possible relationship of inducer cells to breast carcinoma and pre-neoplasia is discussed and warrants further investigation. No alteration in stromal plasma cell numbers was observed.

Unaltered immunocompetence in patients with non-disseminated breast cancer at the time of diagnosis

Immunologic parameters were examined preoperatively in 104 patients with breast cancer, staged according to the TNM classification and in 95 age-matched healthy women. The immunologic evaluation in the peripheral blood included lymphocyte and monocyte counts, determination of E-rosette-forming T-lymphocytes (SER+) and B-lymphocytes (MER+), T-lymphocyte subsets defined with monoclonal antibodies (Leu-1, Leu-2a, Leu-3a) and with lectin fractionation (soybean agglutinin), lymphocyte transformation test with phytohemagglutinin (PHA) and concanavalin A (ConA), and colony formation of T-lymphocytes in agar (T-lymphocyte colony-forming cells, [TL-CFC]). Two age groups (Group A: 30-50 years; Group B: 51-70 years) and the different tumor stages (Stage I-IV) were analyzed. Patients and controls did not differ in the absolute numbers of lymphocytes, T- and B-cells. In patients of Group B, the absolute number of monocytes was increased slightly in Stage II and III and significantly in Stage IV (P less than 0.05). Similarly, the lymphocyte response to PHA was significantly reduced in Stage IV Group B only (P less than 0.05). ConA-induced lymphocyte proliferation and TL-CFC capacity were not different in patients and controls. In the small number of patients and age-matched controls in whom T-lymphocyte subsets were determined, the absolute numbers of T-cells with helper or suppressor phenotype as defined with Leu-3a, Leu-2a, or lectin fractionation with soybean agglutinin were similar. This study demonstrates that in patients with early breast cancer (Stage I-III), immunocompetence as defined by either functional in vitro studies or surface marker analysis is not significantly altered at the time of diagnosis. In contrast, patients with advanced disease (Stage IV) show a significant increase in the absolute number of monocytes and a depressed PHA responsiveness of mononuclear cells.

Delayed cutaneous hypersensitivity, lymphocyte count, and blood tests in patients with breast carcinoma

General immunocompetence was examined in 125 patients with various stages of breast cancer. Tests include peripheral blood lymphocyte count, serum protein electrophoresis, quantitative immunoglobulins, CEA level, and delayed cutaneous hypersensitivity (DCH) reaction to six recall antigens (PPD, Monilia, mumps, Varidase, histoplasmin, and coccidioidin). About one third of the patients responded positively to each of the first four antigens, whereas 12% reacted to histoplasmin and 4% to coccidioidin. In this study, DCH to recall antigens had no prognostic value because the distributions of skin test reactivity were similar among patients with different stages of breast carcinoma. And among patients with similar stage of disease the relapse rates were similar for those who reacted and those who were anergic. But peripheral lymphocyte count had definite prognostic value because patients with advanced stage (group III/IV) and those who were anergic had significantly lower lymphocyte counts. Among patients with relatively early stages of breast carcinoma (group I/II), those who had higher lymphocyte count (greater than or equal to 2,000/mm3) had lower chance of having relapse up to 5 years after mastectomy.

The contribution of regional lymph nodes in the resistance against breast cancer: practical implications

Experimental evidence suggests that regional lymph nodes (RLN) are important in the initiation and possibly the maintenance of tumor immunity. "Negative" nodes denote strong tumor immunity and "positive" nodes low. The latter also serve as markers of systemic disease. From histological and immunological studies, and mostly from recent clinical studies in breast cancer, the following practical recommendations are made: (1) Clinically positive axillary nodes are best eliminated by surgery. (2) Resection of positive internal mammary nodes appears to increase survival of patients with central and inner quadrant lesions; however, destruction of these nodes by irradiation, although improving local disease control, may decrease survival. (3) Negative RLN should be preserved, as they appear to prevent lymph node metastases and stimulate systemic immunity. Only a small fraction of unresected RLN harboring micrometastases will ultimately develop palpable disease, and their elimination at that late phase yields the same results as when these nodes are treated prophylactically.

Characterisation of breast cancer infiltrates using monoclonal antibodies to human leucocyte antigens

Serial frozen sections from eleven patients with malignant breast tumours and five patients with benign disease were studied by indirect immunoperoxidase using a panel of mouse monoclonal antibodies to human leucocyte antigens. More infiltrating leucocytes were seen in tumour sections than those of benign conditions. A considerable proportion of the infiltrating cells were T cells, and more of these were of the suppressor/cytotoxic subset than the helper/inducer subset. The T cells were apparently not all activated as indicated by lower levels of staining with anti HLA-DR than anti-leucocyte antibody. Diffuse staining was sometimes seen with HLA-DR and T cell subset antibodies. Tumour cells did not stain or were only very weakly positive with anti HLA-A, B, C.

Effect of postoperative total parenteral nutrition (TPN) as an adjunct to gastrectomy for advanced gastric carcinoma

Clinical staging and immune reactivity were correlated in 39 patients who underwent gastrectomy for primary gastric cancer. Cellular immunity was depressed as the stage of cancer advanced, whereas humoral immunity was unaffected. Gastrectomy for advanced cancer in stage 3 and 4 suppressed cellular immunity. The cellular and humoral immune systems in relation to total parenteral nutrition (TPN) versus non-TPN were evaluated in 57 patients who underwent gastrectomy for stage 3 and 4 advanced cancer. Cell-mediated immunocompetence was restored in all 29 patients who received postoperative TPN, while serum immunoglobulins were unaffected by TPN. Improvement of impaired cell-mediated immunity was also obtained in patients treated with a TPN-5-FU combination as an adjunct to surgery. Treatment with TPN during 5-FU administration restored immunocompetence, increased tolerance for 5-FU and gave a satisfactory 3-year survival rate. There were significant differences in the 3-year survival rates of patients who underwent non-curative gastrectomy (54 per cent for TPN-5-FU v. 0 per cent for non-TPN-5-FU; P less than 0.05). It is concluded that TPN during chemotherapy as an adjunct to surgery leads to diminished morbidity, and possibly to prolonged survival time, in patients undergoing gastrectomy for gastric cancer. A possible mechanism responsible for the gratifying results of TPN treatment may be the increased tolerance for 5-FU resulting from improved nutrition and increased cell-mediated immunity.

Usefulness of clinical chemistry measurements in classifying patients with breast cancer

Laboratory measurements can be used to detect, classify, and monitor patients with breast cancer. This review covers in detail the clinical usefulness of carcino embryonic antigen, tissue polypeptide antigen, various glycoproteins, pregnancy-associated proteins, casein, lactalbumin, beta-2-microglobulin, ferritin, immunoglobins, acute phase proteins, placental-like alkaline phosphatase, liver-associated enzymes, glycosyltransferases, human chorionic gonadotropin, calcitonin, polyamines, and collagen breakdown products, in relationship to their diagnostic utility in patients suspected of having or known to have breast cancer. In addition, these authors assess the merits of various multivariate techniques using a number of clinical chemistry quantities in the same regard. Finally, the relative contribution of biochemical tests vs. the information values gained from "surgical pathology" data (number of positive nodes, number of negative nodes, and degree of anaplasia) is discussed.

The immune response to carcinoma of the colon in a rat model: a temporal study

Carcinoma of the colon was induced in rats by treatment with 1, 2-dimethylhydrazine (DMH). Macroscopic tumours were observed from eight weeks after commencing DMH injections and rapidly increased in mass to cause death of the animals between 20 and 27 weeks later. Tumour immunity was assessed by the gross parameters of body, spleen and mesenteric lymph node weight and by in vitro tests of lymphocyte antitumour cytotoxicity and leucocyte migration inhibition by tumour and normal colon homogenates. Immune responses were recorded in control (saline treated) and in tumour (DMH treated) rats. Body weight of the tumour rats paralleled that of control animals until tumours were well advanced. At this time tumour animal body weight was significantly less than that of control animals. Spleen weight and in vitro lymphocyte antitumour cytotoxicity were significantly greater in tumour than in control rats and were so found soon after macroscopic tumours were observed. Mesenteric lymph node weight and leucocyte migration inhibition did not change until late in tumour development, but at this time there was an immune response in tumour animals. The study showed that carcinoma of the colon induced in rats was associated with an antitumour immune response and that this change occurred soon after macroscopic tumours were present. In spite of this the animals died of their neoplasms.

DNCB reactivity and prognosis in 419 patients with malignant melanoma

Delayed cutaneous hypersensitivity to 2,3-dinitrochlorobenzene (DNCB) was tested in 419 patients with malignant melanoma to determine whether DNCB reactivity was associated with prognosis. At the time of definitive surgery, a positive DNCB test was seen in 82% of the patients in State I (regional lymph node histologically negative) and in 81% of patients in Stage II (regional lymph node positive). A positive DNCB test, obtained at the time of staging in patients with more advanced disease, was seen in 70% of patients in State III (metastases in, at most, on internal organ) and in 68% of patients in Stage IV (metastases in more internal organ). Using the chi 2 test, the trend of a decrease in DNCB reactivity from Stage I to Stage IV is significant (P less than 0.04). In regard to DNCB reactivity and prognosis, the following statistical differences (P less than 0.05) were obtained: In Stage II, the recurrence distribution for DNCB-positive patients is more favorable than for DNCB-negative patients (estimated median time to recurrence 16 vs. 7 months); the survival distribution again in Stage II was more favorable for DNCB-positive patients tha DNCB-negative patients (estimated survival time 31 vs. 18 months). When the group of State II patients was divided into subgroups with different prognoses (state of primary at the time of lymphadenectomy), a survival advantage was seen in all substages but was statistically significant (P less than 0.05) only in Stage II d (regional lymph node involvement diagnosed more than two months after resection of primary melanoma). The results of DNCB tests in patients with malignant melanoma correlate with stage of disease and, in Stage II, with prognosis.

Prognostic value of prechemotherapy skin tests in patients with metastatic breast carcinoma

Two hundred patients with metastatic breast cancer who were treated with combination chemotherapy and nonspecific immunotherapy with BCG or MER were skin tested prior to, and at regular intervals during the administration of chemotherapy with a battery of six antigens (Dermatophytin, Varidase, candida, mumps, PPD, and KLH). Delayed-type hypersensitivity responses to this battery of antigens were analyzed to assess whether they correlated with ability to respond to chemotherapy, length of survival, and a number of other host and tumor characteristics of known prognostic significance. Responsiveness to individual recall antigens or the number of positive skin test responses did not correlate with overall or complete response rates. The correlation did exist with KLH, a primary antigen. A positive response to two or more antigens correlated with a longer survival. Inability to mount a skin test response to any antigen correlated with poor survival. PPD conversions during serial BCG administration did not correlate with a better prognosis. Serial skin testing with a battery of antigens did not correlate with prognosis. Skin test responsiveness to the antigens used in this study did not correlate with the other pretreatment factors of prognostic importance such as tumor burden, absolute lymphocyte count, performance status, prior radiation therapy, menopausal status, and age. Therefore, responsiveness to skin testing with these antigens appears to be an independent prognostic variable and should be incorporated in the planning and analysis of systemic treatment programs in metastatic breast cancer.

Immunocompetence, immunosuppression, and human breast cancer. II. Further evidence of initial immune impairment by integrated assessment effect of nodal involvement (N) and of primary tumor size (T)

Comprehensive immune function by integrated score was assessed in 158 operable, 55 inoperable, and 52 metastatic breast cancer patients relative to 107 healthy controls. The score was derived from in vivo response to PPD and DNCB and in vitro lymphocyte stimulation by PPD and PHA. Proportion of E-RFC was significantly lower in patients than in controls but was not found to correlate directly with the above functional criteria. Fifty-one percent of the patients with early, operable tumors were shown to be at least partially immunosuppressed by integrated score achievement vs. 11% of controls. This proportion rises to 68% of inoperable and 89% of metastatic patients. Quantitative analysis by graded response revealed an additional, significant degree of immune impairment in the respective patient groups by all testing parameters. Depression of immune function in operable patients was not related to age nor influenced by surgery. Immunocompetence of patients with mammary dysplasia did not differ from controls. Increasing size of primary tumor (T) was not found to be matched by progressive degree of immunosuppression, excepting that associated with large T4 tumors. Patients with lymph node involvement (N+) were not significantly immunologically inferior to those without (N0) where the larger operable T2-3) tumors are concerned. In the smallest, T1 tumors, nodal involvement (N+) is accompanied by remarkable immunosuppression relative to T1N0 cases. This finding suggests a pre-existing immune defect inherent in T1N+ patients. It supports the hypothesis that the immunosuppression associated with early breast cancer is primary, patient related. Secondary tumor-induced depression of immune response characterizes advanced and metastatic human breast cancer.

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.

Recall skin-test antigens and the prognosis of stage I melanoma

Thirty-one patients with Stage I melanoma were studied with regard to their response to common skin antigens. Patients were divided into two groups, those who had surgery alone, and those who had surgery and BCG. The results were comparable. It was found that the disease-free interval was longer and the recurrence rate lower in patients who demonstrated cutaneous hypersensitivity to common antigens than in those who did not. Patients who had Clark's levels I and II lesions were more likely to be immunocompetent. The addition of BCG in the study did not appear to decrease the rate of recurrence, which seems to be related to the basic immunological status of the individual.

Improvement of in vitro mitogen proliferative responses in non-Hodgkin's lymphoma patients exposed to fractionated total body irradiation

Patients with non-Hodgkin's lymphomas who failed to respond to chemotherapy were treated with low dose fractionated total body irradiation (TBI). Prior to during and after scheduled therapy, their clinical status was evaluated and peripheral blood studies were performed to enumerate EAC and E rosetting cells and to measure proliferative responses to mitogens. Peripheral blood abnormalities were present prior to TBI using these in vitro assays. Patients who obtained clinical remissions following therapy had restoration of mitogen progressive disease had no change in their ability to proliferate in response to mitogens. Normalization of EAC and E rosetting profiles often occurred regardless of clinical response. These data indicate that low dose fractionated TBI produces clinical and in vitro detectable immunological changes. Furthermore, they show that improvement in mitogen responsiveness correlates best with good clinical responses.

Overview on new immunologic markers for diagnosis of cancer

There is a large and increasing number of tumor-associated markers which can be detected immunologically and which may be useful for detection, diagnosis and monitoring of cancer. These include cell surface antigens and other components specifically associated with tumor cells, ectopic hormones, and normal materials which are produced in increased amounts by or in response to the tumors. Some of these markers are only antigenic in heterologous species, whereas others are reacted to by the tumor-bearing host. The major current problem is to determine which of these markers may be applied to practical problems of immunodiagnosis.

Immunology, tumor markers, and breast cancer

Although our knowledge of immunologic processes in breast cancer is still inadequate, many preliminary studies described here may yield valuable information after long-term patient follow-up. At present, there is no specific tumor marker diagnostic of breast cancer, but markers such as CEA, ferritin, immune complexes, and specially estrogen receptors have strong potential as prognostic indicators. As a group, breast cancer patients, as do those with other malignancies, demonstrate reduced immunologic capacity, therefore assays of nonspecific immune function may not be relevant. Assays of "specific" reactivity to breast tumor antigens, however, warrant further investigation as clinical tools. Application of immunotherapy to breast cancer is relatively recent and few trials have more than preliminary data. Determination of estrogen receptors should be included in future clinical immunotherapy protocols so that true evaluation of immunologic responses may benefit, hopefully, from our awareness of the endocrine milieu.

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.

In vitro assessment of immunocompetence in patients with malignant melanoma

Ninety-four patients with malignant melanoma and 96 healthy controls were tested for lymphocyte proliferative capacity in a microblastogenesis assay. Each lymphocyte sample was assayed for incorporation of (3H)thymidine after stimulation with PHA, PWM, Con A (two doses), PPD, and allogeneic lymphocytes (MLC). MLC was the only assay that revealed a substantial and significant difference between the melanoma patients and controls. Almost all assays showed lower values in patients with more advanced disease. However, it was not possible to accurately predict clinical outcome from data obtained from in vitro immunocompetence tests. These results indicate the relatively limited clinical usefulness of assays of lymphocyte proliferative capacity in melanoma patients.

The relative proliferation index as a more sensitive parameter for evaluating lymphoproliferative responses of cancer patients to mitogens and alloantigens

Lymphocyte proliferation (LP) assays were performed in microculture using the T-cell mitogens phytohemagglutinin (PHA) and concanavalin A (Con A); the T + B cell mitogens, pokeweed mitogen (PWM) and staphylococcal phage lysate (SPL); and a pool of allogeneic stimulating leukocytes in one-way mixed leukocyte cultures (MLC) in lung and breast cancer patients and normal individuals. The resultant data were expressed in three different ways: (1) as mean counts per minute (CPM) of tritiated thymidine incorporation; (2) as a stimulation index (SI) and (3) as a relative proliferation index (RPI). The RPI is defined as the ratio of net CPM (nCPM) in experimental cultures with stimulant (E) minus medium control cultures (C) of a test individual to the mean nCPM of three or more normal individuals examined in the same assay on the same day. These expressions were then compared for their ability to discriminate between LP responses in cancer patients and normal individuals. The RPI value and selected cut-off values gave the most sensitive measure for the determination of depressed proliferative responses. These analyses demonstrated that lung carcinoma patients were depressed to PHA (50%), MLC (47%), PWM (43%) and Con A (40%). To a lesser degree, breast carcinoma patients were also depressed to MLC (36%), PHA (31%), PWM (27%) and Con A (19%). Our data indicate that the use of the RPI in the analysis of LP response represents an improved method for detecting impaired response of lymphocytes to general mitogens and alloantigens which can consistently reveal immunosuppression in many cancer patients and may be useful for serial monitoring of individual patients.