Preoperative cell-mediated immune status of gastric cancer patients

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Impaired cytotoxic T lymphocyte inductivity by dendritic cells derived from patients with hepatitis C virus-positive hepatocellular carcinoma

AIM

Peptide-based therapeutic vaccines are being developed. The aim of this study was to determine the feasibility of immunotherapy to hepatitis C virus (HCV)-positive hepatocellular carcinoma (HCC) by assessing the inductivity of peptide-specific cytotoxic T lymphocyte (CTL) by dendritic cells.

METHODS

The inductivity of CTL was characterized in six patients with HCV-positive HCC, and compared to seven healthy volunteers and six patients with chronic HCV hepatitis (control).

RESULTS

Peptide-specific CTL was comparably induced in controls, but not induced in any patients with HCC. To characterize this, the cytokine profile and the expression of surface molecules interacting between dendritic and T cells were evaluated. Among the cytokines, production of interferon (IFN)-gamma was found to be impaired and closely related to the results of CTL assays, while the expression of surface molecules showed no significant changes.

CONCLUSIONS

In HCV-positive HCC patients, CTL inductivity by dendritic cells is impaired. This may be related to the impaired production of IFN-gamma.

Epidemiology of infectious complications in cancer patients

Patients with underlying malignancies are at risk for a wide array of infectious diseases that cause significant morbidity and mortality. To develop a clear etiologic understanding of the infectious agents involved first requires a knowledge of the factors that predispose to infection. Neutropenia is clearly the single most important risk factor for infection in the cancer patient. However, a variety of both host and treatment-associated factors act together to predispose these patients to opportunistic infections. Approaching the individual malignancies with a knowledge of the underlying risk factors helps logically guide diagnosis and therapy. The astute clinician must also be aware of new and emerging infections in this patient population. As new pathogens are discovered and established pathogens become increasingly drug resistant, they will continue to present challenges for physicians caring for these patients in the years ahead.

Nutritional and immunologic evaluation of patients with gastric cancer before and after surgery

The main objective was to evaluate a patient's immunologic and nutritional status as a prognostic indicator of morbidity and mortality in patients with gastric cancer. A prospective clinical study carried out at the National Cancer Institute in Bogotá, Colombia. Our study group consisted of 40 patients with a diagnosis of gastric adenocarcinoma that was treated surgically. Blood samples were taken before and 5 d after surgery; mononuclear cell typing was done by flow cytometry allowing a bicolor analysis. Nutritional evaluation was obtained through measurement of albumin levels, average weight loss, and nutritional risk index (NRI). Half of the malignancies were localized to the middle and lower third of the stomach: stage I, 17.55%; stage II, 10%; stage III, 55%; and stage IV, 17.5%. Twenty subtotal gastrectomies, 11 total gastrectomies, 7 gastrojejunostomies, and 2 esophagogastrectomies with D1 and D2-D3 lymph node resection were performed. A postoperative morbidity of 22.5% and a mortality of 7.5% were observed. A preoperative cellular immunosuppression was identified, with a helper lymphocyte (CD4) to suppressor/cytotoxic lymphocyte (CD8) ratio of 1.38 normal value (NV > 1.5), which increased according to the stage of the disease. Patients who died presented with a significantly greater preoperative cellular immunosuppression than those who survived (P = 0.05). Postoperative mortality correlated significantly with hypoalbuminemia (P = 0.008). In those who died, weight loss was greater than in those who survived (P = 0.06). Patients with severe malnutrition had greater postoperative mortality according to the NRI. Severe preoperative cellular immunosuppression (CD4/CD8 < 1), hypoalbuminemia, weight loss, and severe NRI have a positive predictive value for mortality in patients with gastric cancer.

T lymphocyte function in patients with malignant biliary obstruction

The T lymphocyte function in 59 patients with malignant biliary obstruction undergoing pre-operative endoscopic drainage (group Ia, n = 24) or surgery (group Ib, n = 35) was evaluated by mitogen stimulation test with phytohaemagglutinin. The T lymphocyte function before endoscopic or surgical intervention was found to be impaired as compared with patients with gastric cancer (group II, n = 27) and with normal persons (group III, n = 19). Regression analysis showed a significant negative correlation between T lymphocyte function and the serum bilirubin level (correlation coefficient -0.3, P = 0.01) and a positive correlation with serum albumin level (correlation coefficient 0.34, P = 0.01) and serum transferrin level (correlation coefficient 0.45, P = 0.001). After 18 +/- 3 days of endoscopic biliary drainage, the T lymphocyte function of group Ia patients did not change substantially. At postoperative day 14, there were more patients in both groups Ia and Ib having deterioration of T lymphocyte function than those with improvement. The incidence of postoperative sepsis was found to be significantly higher in patients with deterioration than those with improvement of T lymphocyte function (18/31 vs 7/26, P = 0.036). It is concluded that endoscopic biliary drainage and surgery could not reverse the T lymphocyte dysfunction in patients with malignant biliary obstruction.

Results of surgery on 6589 gastric cancer patients and immunochemosurgery as the best treatment of advanced gastric cancer

Results of 6589 gastric cancer operations at the Department of Surgery, Seoul National University Hospital, from 1970 to 1990 were reported. About two thirds (76.6%) were advanced gastric cancer (stages III and IV). The 5-year survival rate of operated stage III gastric cancer was only 30.6%, with frequent recurrence. Conversely, cell-mediated immunities of advanced gastric cancer patients were significantly decreased. Therefore, to improve the cure rate and to prevent or delay recurrence, curative surgery with confirmation of free resection margins and systematic lymph node dissection of perigastric vessels were performed and followed by early postoperative immunotherapy and chemotherapy (immunochemosurgery) in stage III patients. To evaluate the effect of immunochemosurgery, two randomized trials were studied in 1976 and 1981. In first trial, 5-fluorouracil, mitomycin C, and cytosine arabinoside for chemotherapy and OK 432 for immunotherapy were used. The 5-year survival rates for surgery alone (n = 64) and immunochemosurgery (n = 73) were 23.4% and 44.6%, respectively, a significant difference. In the second trial, there were three groups: group I, immunochemosurgery (n = 159); group II, surgery and chemotherapy (n = 77); and group III, surgery alone (n = 94). 5-Fluorouracil and mitomycin C for chemotherapy and OK-432 for immunotherapy were administered for 2 years. The 5-year survival rate of group I was 45.3%, significantly higher than the 29.8% of group II and than the 24.4% of group III. The postoperative 1-chloro-2.4-dinitrobenzene test, T-lymphocyte percentage, phytohemagglutinin- and con-A-stimulated lymphoblastogenesis and the antibody-dependent cell-mediated cytotoxicity test showed more favorable values in the immunochemosurgery group. Therefore, immunochemosurgery is the best multimodality treatment for advanced gastric cancer.

Parenteral arginine infusion in humans: nutrient substrate or pharmacologic agent?

When given as a dietary supplement, arginine enhances lymphocyte mitogenesis and improves nitrogen balance. The purpose of this study was to evaluate arginine's ability to mediate these same effects when given as the sole nitrogen source with minimum additional calories. Thirty patients were randomized to receive 20 g/day arginine hydrochloride or a mixed amino acid solution (Travasol) by intravenous infusion for 7 days after abdominal operations. Mean patient age, body weight, gender ratios, and preoperative degree of weight loss were similar between groups. Mean plasma arginine and ornithine levels rose to 228 +/- 50 mumol/L and 191 +/- 76 mumol/L in the arginine group during infusion. Mean nitrogen balance was -8.8 g/day and -9.2 g/day in the arginine and Travasol groups, respectively. Mean lymphocyte stimulation indices to concanavalin A and phytohemagglutinin fell on postoperative day 1 in both groups. No significant differences in patterns of lymphocyte mitogenesis changes were noted between groups. The mean total number of circulating T cells increased in the arginine group at postoperative day 7. Thus, parenteral arginine infusion in postoperative patients provided comparable nitrogen balance to a balanced amino acid solution but did not increase peripheral blood lymphocyte mitogenesis. When arginine is given parenterally as the sole nitrogen source with minimal additional calories to postoperative patients, no enhancement of mitogen-stimulated lymphocyte proliferation could be demonstrated.

Clinical significance of arginase in colorectal cancer

Arginase, a potent immune inhibitor, existed in much greater abundance in the cytoplasm of cancer cells than in normal cells. Serum arginase levels from 31 patients with colorectal adenocarcinoma were determined by using enzyme immunoassay (mean +/- standard error = 18.96 +/- 4.83 ng/ml) and showed to be significantly higher than levels from control subjects (n = 115, 3.09 +/- 0.22 ng/ml) (P less than 0.005). Surgical samples of 15 patients were individually homogenized and assayed by the same method and revealed that the arginase level in tissues with colorectal cancer was two times greater than the level found in normal mucosal tissues (1.74 +/- 0.31 micrograms/g tissue versus 0.77 +/- 0.09 micrograms/g tissue, P less than 0.005). However, the serum arginase levels in patients with colorectal cancer were independent of their carcinoembryonic antigen (CEA) levels (n = 27, arginase 11.81 +/- 1.88 ng/ml, CEA 17.31 +/- 4.24 ng/ml, r = 0.084, P = 0.666). The results suggested that serum arginase level can be a valuable criterion for preoperative evaluation and possibly postoperative follow-up study. It can also combine with CEA determination to intensify the clinical assessment for colorectal cancer.

Immunohistochemical assessment of splenic lymphocyte and macrophage subpopulations in patients with gastric cancer

In order to assess the effects of malignant tumors on the immune system, 25 spleens from patients with gastric carcinoma were studied by in situ immunohistochemical methods for lymphocyte subsets and cells of the mononuclear phagocyte system. Highly significant reductions of CD4+ T cells (P less than 0.001), Ki M2+ and Ki M-3+ MPS cells (P less than 0.02 and P less than 0.05), and a stage-dependent reduction of Ki 67+ B cell proliferation activity (P less than 0.05) were seen in spleens of patients with gastric cancer. These results, which were obtained by morphologic methods in a noninvolved lymphatic organ, reflect the systemic immunosuppressive and immunodepleting effects of malignant tumors that are probably mediated by tumor-associated cytokines.

Immune status in advanced upper gastrointestinal cancers

Thirty-eight cases of advanced upper gastrointestinal cancer were assessed for their immune status prior to any form of therapy. Cell-mediated immunity, as tested by absolute lymphocyte count, T-cell count and delayed cutaneous hypersensitivity reactions to purified protein derivative and phytohemagglutinin showed severe depression. Immunoglobulins A and M were elevated, while immunoglobulin G reduced. No correlation could be established between the immune status and the site of cancer or its extent, the performance status of the patients, or their response to chemotherapy.

Immunochemosurgery for gastric cancer

The effects of immunochemosurgery on 73 patients with stage III gastric cancer who were treated with radical subtotal gastrectomy followed by immunochemotherapy for 18 months during the 5-year period between 1975 and 1980 were compared to the effects of therapy on 64 patients with stage III gastric cancer treated with radical subtotal gastrectomy alone during the period between 1970 and 1980. For immunotherapy, picibanil (streptococcus pyogenes preparation) was intramuscularly given weekly, and for chemotherapy, either MFC (mitomycin-C, 5-FU, and cytosine arabinoside) regimen I.V. ten times followed by oral 5-FU or FME (5-FU and methyl-CCNU) regimen was given. The percentage of survivors who received postoperative immunochemotherapy compared to that of survivors who received surgery alone differed by approximately 15%. This difference was rather constant with more than 5 years of follow-up. The 5-year survival rate in the immunochemosurgery group was 38.1%, whereas that in the surgery alone group was 24.8%, which was statistically significant (p less than 0.01). Various immune parameter studies such as 1-chloro-2, 4-dinitrobenzene (DNCB) test, T lymphocyte count and percent, PHA- and concanavalin-A-stimulated lymphoblastogenesis, and antibody dependent cellular cytotoxicity (ADCC) activity showed more favorable data in the immunochemosurgery group than in the surgery alone group. The effects of early postoperative immunochemotherapy (immunotherapy from the fourth to fifth postoperative day, and chemotherapy from the eighth to tenth postoperative day) after radical gastrectomy seems to be superior to that of surgery alone for stage III gastric cancer. For stage I and II gastric cancer, radical gastrectomy and postoperative immunotherapy for 3 months would be the best treatment.

An assessment of neck node immunoreactivity in head and neck cancer

Current conventional forms of cancer treatment represent non-specific modalities that destroy not only cancerous but also non-cancerous tissue in an effort to totally eradicate the neoplasm. It was unknown in head and neck cancer whether a more specific form of treatment, as it relates to neck nodal disease, was advisable. The purpose of this investigation was to study the cervical node immunoreactivity in head and neck cancer patients as a means of determining their immunologic capabilities and thus provide information about the merits of specific vs. non-specific cancer treatment. The results demonstrated that lymphocytes arising from cervical nodes caused alterations in the tumor growth. There appeared to be no particular difference in immunoreactivity of lymphocytes arising from nodes located in different areas of the neck. The regional immune system of neck nodes in the head and neck cancer patient appears to be capable of mounting an immune response irrespective of the patient's tumor status. Usual measures of systemic immunocompetence failed to identify any patients with advanced stage disease and showed little correlation with the regional immunoreactivity. The regional nodal immunoreactivity also did not correlate with the size or the numbers of metastatic neck nodes. The results demonstrate that cervical neck nodes are capable of mounting an immune response to head and neck cancer and are not mere passive filters that are periodically involved with tumor emboli. These results support the need for the development of reliable treatments which are directed at tumor tissue only.

Efficacy of streptococcal preparation OK-432 for gastric cancer patients--comparison between intradermal and intramuscular injection

Nonspecific immunotherapy with OK-432, penicillin and heat treated lyophilized powder of Su-strain of streptococcus pyogens A3, was evaluated in patients with recurrent or unresectable stomach cancer to assess the relative benefit of the preparation administered by different routes. Comparative studies were made of the variation in immunological parameters, the survival rate and the incidence of adverse reactions in two groups of patients with uniform background factors: 24 receiving the preparation intradermally and 18 receiving intramuscular doses of the preparation. In for former group, no serious adverse reaction occurred but more marked improvement was achieved in various immunological parameters examined. The survival rate was significantly higher (P = 0.005) for patients receiving intradermal than those receiving intramuscular doses of the preparation. The results of the present study showed that the preparation is of greater value when it is administered intradermally than intramuscularly.

Lymphocyte subpopulations in gastric disease; effect of histamine and cimetidine on immunoregulatory T cell subsets

The numbers of T lymphocytes, helper and suppressor T lymphocytes, were measured in peripheral blood of 10 patients, 13 patients with gastric cancer and 20 normal controls. T lymphocyte subpopulations were enumerated by the use of monoclonal antibodies OKT3 (pan-T lymphocytes), OKT4 (helper/inducer lymphocytes) and OKT8 (cytotoxic/suppressor lymphocytes) in an indirect immunofluorescence technique. Furthermore, the possible pharmacological modulation of 10(-4) histamine and 10(-4), 10(-6) M cimetidine of T lymphocyte subsets was investigated. Lymphocyte subpopulations were found to range in normal values in patients with ulcer and chronic gastritis. A marked decrease of OKT3 and OKT8 positive lymphocytes was noted in patients with gastric cancer, whereas OKT4 lymphocytes from the three groups of patients to histamine and cimetidine resulted in no significant changes of lymphocyte subsets.

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.

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.

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.

Impaired cell-mediated immunity function in thyroid cancer

Immunological parameters were studied in 31 patients with thyroid cancer. Serum immunoglobulin levels, T and B cell percentages in peripheral blood, showed no significant difference as compared with those of control group. The blastogenesis with phytohemagglutinin P (PHA) was significantly reduced, especially, in those having larger tumor size or metastasis or in those over age 60. The positive rate of skin test with purified-protein-derivative (PPD) and Streptokinase-Streptodornase (SK-SD) was also markedly reduced. The impaired blastogenesis of lymphocyte and reduced positive rate of skin test in those cancer patients suggested that the cell-mediated immunity function, in spite of adequate count of T-cells, was impaired.

In vitro lymphocyte activity: its relation to the stage of gastric cancer

Lymphocyte activity of patients with gastric cancer and its relation to the stage of cancer were studied. PHA response of lymphocytes from patients with gastric cancer was decreased markedly even in early stage of cancer. The PHA-stimulated lympho-cytotoxicity was not impaired in all stages of the disease. Spontaneous lymphocyte-mediated cytotoxicity showed a tendency to decrease as the cancer stage advanced. The cytotoxic activity of the supernatants from lymphocytes cultured without PHA was significantly high in the advanced stage of gastric cancer.

Nonspecific immune determinants in the patient with unresectable gastrointestinal carcinoma

Assays of immune function (recall skin tests to microbial antigens; total circulating lymphocytes, T-cells, B-cells; lymphocyte blastogenesis with PHA, Con A, and pokeweed mitogens; and serum immunoglobulins IgA, IgM, IgG) were obtained in 408 patients with unresectable gastrointestinal carcinoma. The overall patient population, in comparison to normal controls, was characterized by reduced response to recall skin tests, reduced total lymphocyte and T-cell counts, reduced lymphocyte blastogenesis assays, increased B-cell counts and increased IgA and IgM. Significant immunosuppression was associated with prior radiation or chemotherapy, and with impaired patient performance status. There was no apparent correlation between extent of clinically evident malignant disease and immune function within this patient population. No assay of immune function matched the prognostic value of the more readily available and less expensive determinations of performance status, serum alkaline phosphatase, or SGOT. Only reactivity to recall skin tests had a significant correlation to patient survival independent of performance status. Among patients with little or no disability, only intensity of skin test reactivity correlated significantly with survival; and among those with greater disability, there was correlation only with proportion of skin tests positive. The combination of candida and streptokinase antigens provided the best recall skin test survival correlation. Adding a third, fourth, or fifth antigen did not add to prognostic value. From an overall standpoint, the immune determinants which we studied do not appear to provide useful additions to the evaluation of the patient with unresectable gastrointestinal cancer.

Evaluation of nutritional indices as prognostic indicators in the cancer patient

The nutritional and immunological status of 140 malnourished cancer patients who were to receive intravenous hyperalimentation (IVH) were evaluated prior to treatment with IVH and chemotherapy (CMX), surgery or radiation therapy (XRT). Subsequently, these indices were correlated with responses to treatment. Cell-mediated immunocompetent (CMI+) patients (41%) had lost an average weight of 10 +/- 2.2 lbs., while cell-mediated immunoincompetent (CMI-) patients (59%) had lost an average weight of 31 +/- 2.5 lbs. (p less that 0.05). Total lymphocyte count (TLC) averaged 1290 +/- 250 cells/mm3 in CMI+ patients and 900 +/- 140 cells/mm" in CMI- patients (p less than 0.05). Serum albumin concentration (SA) was 3.6 +/- 0.06 g/dl in CMI+ patients and 3.3 +/- 0.05 g/dl in CMI- patients (p less than 0.05). In the CMI+ group, 49% had a positive response to CMX, whereas only 27% of the CMI-group responded to CMX (p less than 0.01). In the surgery group, 88% of the CMI+ patients, but only 65% of CMI- patients, had uncomplicated postoperative recovery periods. Although nutritional repletion with IVH was undertaken in all patients, those patients with initial CMI- responses had greater body weight loss, lower SA and TLC and either a decreased response to CMX or an increase in postoperative morbidity and mortality when compared with patients who initially had CMI+ responses.

Change of macrophage migration inhibitory factor: possible indicator for postoperative prognosis

Sixty three cancer cases who received minimum of the removal of the main tumor constitute the subjects of the present study. Macrophage migration inhibitory factor (MIF) of peripheral blood lymphocytes was studied using extirpated autochthonous tumor tissues as antigen and guinea-pig peritoneal exudative cells as indicator cells immediately before the operation and the fourth postoperative week. The results indicated that in those cases of relatively early stage, i.e. Stages I and II, whose tumor was believed to have been removed completely, MIF turned negative in 7/9 (77.8 per cent) after the operation, while in others with advanced cancer of Stage IV in which the tumor bearing tissue was probably not completely removed, MIF turned positive in most cases (13/17: 75.6 per cent) postoperatively, even though it was negative before the operation. In the cases of Stage III with cancer progressed to an intermediate degree, in about half of the cases (7/11: 63.6 per cent) MIF turned negative after the operation and in the other half (7/10: 70 per cent) MIF became positive postoperatively, suggesting that for MIF to persist the presence of certain amount of tumor tissue is necessary.