Serum immunoglobulin levels in childhood Hodgkin's disease. Effect of splenectomy and long-term follow-up

A prospective study on antibody response to repeated vaccinations with pneumococcal capsular polysaccharide in splenectomized individuals with special reference to Hodgkin's lymphoma

BACKGROUND

Splenectomy is accompanied by a life-long risk of overwhelming postsplenectomy infection (OPSI), mainly caused by polysaccharide (PS) encapsulated bacteria such as Streptococcus pneumoniae. Despite extensive prophylactic efforts the mortality and morbidity rates remain high. The present study was based on a strategy with a predefined vaccination algorithm including repeated 23-valent pneumococcal vaccinations and monitoring of pneumococcal antibody levels. The antibody levels of splenectomized Hodgkin's lymphoma (HL) patients were compared with those patients splenectomized due to immune-mediated cytopenias [autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenic purpura (ITP)] and also individuals who were splenectomized because of trauma (TRAUMA).

METHODS

A total of 311 splenectomized individuals were included in this prospective study (208 HL; 15 AIHA; 60 ITP; 28 TRAUMA). Depending on their individual anti-PS antibody levels measured by enzyme-linked immunosorbent assay technique the patients were revaccinated with 23-valent pneumococcal PS vaccine up to four times in accordance with the predefined algorithm. For each vaccination occasion, serum was collected at vaccination, after 1 month +/- 2 weeks (peak), and after 1 year +/- 6 months (follow-up). Patient files, a national population-based database, and microbiological databases were checked for 124 HL patients to identify OPSI.

RESULTS

A significant response was recorded on primary vaccination as well as on two revaccination occasions for HL, AIHA/ITP, as well as TRAUMA patients. None of the variables age, gender, or time elapsed between splenectomy and first pneumococcal vaccination was found to be associated with mean PS antibody levels at prevaccination, peak or follow-up. No severe adverse events were reported. Amongst 124 clinically monitored HL patients, 10 OPSI were recorded in seven patients during the study period. One of these patients, a middle-aged female, died as a result of fulminant pneumococcal bacteraemia, which was her third OPSI during a 7-year period.

CONCLUSIONS

A significant response to pneumococcal PS vaccination was found in all three groups (HL, AIHA/ITP and TRAUMA) of splenectomized patients. Importantly, both primary and repeated vaccinations were safe. Until further knowledge is gained regarding the protective concentration of serotype-specific antibody concentrations we believe that the value of vaccination and frequent revaccination (every 1-5 years) in combination with education of patients and health care professionals and clinical monitoring is beneficial for these patients at risk for OPSI.

Structural and functional properties of membrane and secreted IgD

More than 35 years ago, study of an unknown immunoglobulin (Ig) in the serum from a myeloma patient led to the discovery of IgD. Subsequently, the finding that it also exists as a membrane-bound Ig stimulated a large number of studies during the 70s. Then, the interest on IgD shrank, largely because of the lack of known function of secretory IgD (secIgD) and of a stagnating knowledge of the functions of surface IgD. In the recent years, very significant advances followed the tremendous accumulation of data on the physiology of the B cell receptor, of which IgD is the major component, on the role of secIgD in normal and diseased individuals. This review, which is focused on human IgD but integrates data in the mouse and other species when needed, summarizes present data on the structure, synthesis and functions of both membrane and secIgD, IgD receptors and the involvement of IgD in various diseases, especially the hyperIgD syndrome.

Immunoglobulin levels and lymphocyte response to mitogenic stimulation in children with malignant disease during treatment and follow-up

Intensification of chemotherapeutic regimens has improved survival in childhood malignant disease. To characterize the impact of this intensified therapy on some aspects of the immune system, we have, in an unselected material of 220 children with malignant disease, investigated serum immunoglobulin levels and lymphocyte response at diagnosis and then subsequently during and up to 4 years after cessation of therapy. In leukemia and Hodgkin's disease, all immunoglobulin isotypes decreased during therapy. A profound depression of immunoglobulin M levels, lasting well after completion of therapy, was seen in all tumor types. The mitogenic response was attenuated in patients with leukemia at diagnosis but was rapidly restored after institution of therapy. Patients with solid tumors, particularly Hodgkin's disease, had a reduced mitogenic response during therapy. Thus these patients exhibit multiple immunological disturbances. The basis of the pronounced immunoglobulin M deficiency remains unclear.

Central nervous system infection in the compromised host

The possible causes of central nervous system infection in the compromised host are many. Careful consideration of the underlying defects in host defenses, the epidemiology of infection, and the clinical findings, however, can narrow these possibilities and focus diagnostic testing. Aggressive attempts at early diagnosis and therapy offer the potential for meaningful survival.

Hodgkin's disease in children. A ten-year experience in South Africa

Twenty-seven children with Hodgkin's disease were treated with MVOPP (mustine, Velban [vinblastine], Oncovin [vincristine], procarbazine, prednisone) combination chemotherapy. All 11 children with Stage I or Stage II disease achieved complete remission and no relapses have occurred between 34 and 179 months of continuous follow-up. Of the 16 children with Stage III or Stage IV disease, two with partial remission and three nonresponding patients died with a median survival of 18 months. The remaining 11 (68%) achieved complete remission. Of these, 6 (55%) have relapsed with a median remission duration of 36 months; five have been retreated with MVOPP, and one with total nodal irradiation, and all achieved second complete remission. Three of the children have died of Hodgkin's disease, with a median survival of 55 months; one child died of acute myeloblastic leukemia while in remission; and one child remains disease-free off all therapy at 165 months; the sixth child treated with total nodal irradiation is disease-free at 166 months. The initial complete remission has been sustained in all 11 children with Stage I or Stage II Hodgkin's disease, suggesting that combination chemotherapy is an alternative to radiotherapy as the initial form of treatment in this group of individuals.

Involved field (IF) irradiation with or without chemotherapy in the management of children with Hodgkin's disease

The present policy at Memorial Sloan Kettering Cancer Center (MSKCC) of treating children with Hodgkin's disease [HD] is as follows: involved field (IF) irradiation only (3,600 rad) for Stages IA and IIA; IF irradiation (2,400 or 2,000 rad) combined with multidrug chemotherapy (MDP) protocol for all other stages. A somewhat higher recurrence rate is accepted for Stages IA and IIA in view of the good salvage rate for these recurrences and in view of side effects of more aggressive types of radiation treatment. One hundred forty-two patients with HD, 2-19 years of age, were treated at MSKCC between 1970 and 1981; 98 of these were treated according to the present policy (SP group), and 44 (NP group) were treated differently. All SP patients underwent staging laparotomy. The follow-up time was 12 to 146 months with a median of 65 months; two patients were lost to follow-up. For the SP group, all stages, 10-year disease-free survival is 77%, and 10-year survival is 93%. By comparison, in the NP group 10-year disease-free survival is 64%, and 10-year survival is 80%. The disease-free survival of SP patients in Stages IA and IIA treated with IF radiation alone is 72%, and survival is 95%. The disease-free survival of SP patients in advanced stages treated with combined radiation and chemotherapy is 87%; the salvage rate of recurrent disease in these stages is poor. The survival was apparently better (P = 0.07) in the SP group as compared to the NP group. All 6 patients of the SP group who died had a nodular sclerosing type of HD. None of the patients in the SP group have developed secondary malignancies, and no severe bone growth retardations or late effects to other organs were observed. In our opinion, IF irradiation alone might at present be suitable treatment for children in Stages IA and IIA of Hodgkin's disease, and addition of IF radiation with low doses of MPD improves the survival of patients in advanced stages.

A prospective study of the changes in immune status following radiotherapy for Hodgkin's disease

In a prospective study, immune status was measured in 23 previously untreated patients with Hodgkin's disease Stage I-IIIA. Assessments of immunologic capacity were performed at diagnosis and repeated after staging laparotomy and after radiotherapy. The immune status was measured using delayed-type hypersensitivity tests to common recall antigens, the number of T- and B-lymphocytes in the peripheral blood, in vitro lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes, and serum levels of immunoglobulins. Skin reactivity was not significantly affected by either the staging laparotomy with splenectomy or the radiotherapy. Absolute T-lymphocyte count increased after splenectomy (P less than 0.025) and decreased after radiotherapy (P less than 0.005 compared to postsplenectomy values). In vitro lymphocyte responsiveness after splenectomy was comparable to the initial presenting level and diminished after radiotherapy (P less than 0.005). Serum levels of IgM were lowered after radiotherapy (P less than 0.05) while the fall was not significant after splenectomy. Three months after radiotherapy, lowest mean T-cells percentages were noted, but the responses to mitogens were significantly higher than those obtained immediately after treatment (P less than 0.01). While the reduction in the proportion of the T-lymphocytes persisted for 18 months, the mean lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes increased on follow-up. Apart from a severe impairment of the immune status following radiotherapy, this study also shows the existence of significant repair mechanisms during the follow-up period.

A prospective study of the changes in the immune status before, during, and after multiple-agent chemotherapy for Hodgkin's disease

In a prospective study, immune status was measured in 20 previously untreated patients with Stage III and IV Hodgkin's disease. Assessments of immunologic capacity were performed at diagnosis and repeated after eventual staging laparotomy and after multiple-agent chemotherapy. The immune status was measured using delayed-type hypersensitivity tests to common recall-antigens and in vitro lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes. Immunoglobulin levels were determined on each point of assessment. In untreated patients, the disturbances in the cell-mediated immunity had no predictive value with respect to the chance to achieve a complete remission. During chemotherapy the mean value of the unstimulated culture in responders increased, whereas it decreased in nonresponders (P less than 0.05 between both groups). After treatment, the proliferative capacity of lymphocytes in vitro was severely affected, while the reactivity to skin tests improved. Chemotherapy also reduced the IgM level, irrespective of the performance of splenectomy. Thirteen patients achieved a complete remission after chemotherapy. In this group, measurements of immunologic capacity were continued. The patients showing a relapse did so despite gradual improvement of delayed-type hypersensitivity and the lymphocyte responsiveness to phytohemagglutinin in vitro.

Late infections following splenectomy in Hodgkin's disease

Here 145 reported post-splenectomy infections in 115 patients with Hodgkin's disease are reviewed. Such infections can occur at any age (median age 19.8 years) and the interval from splenectomy to the infection is quite variable (median 21.9 months). Most infections are present clinically as pneumonia, septicemia, meningitis, or a combination thereof, with the most common offending organism being pneumococcus. The infection can be fulminant and even fatal. It is recommended that the spleen should only be removed when essential. A staging laparotomy and splenectomy seem justifiable only in cases of Hodgkin's disease where a change of staging would lead to a change of planned therapy. Prophylactic penicillin should be administered at least for 3 years and possibly indefinitely since post-splenectomy infections can occur many years later. Pneumococcal vaccine should also be given before any chemotherapy or radiotherapy is initiated. Prompt and aggressive treatment should be given when post-splenectomy infection is diagnosed.

The in vivo effect of a thymic factor (thymostimulin) on immunologic parameters of patients with untreated Hodgkin's disease

The in vivo effect of a calf thymus extract (thymostimulin, TS) on the E-rosetting capacity, PHA blastogenic response, serum migration inhibitory activity (LIF) and skin reactivity to recall antigens was evaluated in 19 untreated patients with Hodgkin's disease. In patients the mean percentage of peripheral blood lymphocytes forming E-rosettes increased from 47 to 55.7% (P less than or equal to 0.001; normal: 58.9). The mean PHA stimulation index rose with all three concentrations tested but did not reach normal values. Serum LIF was positive in only one patient prior to treatment with a mean LIF for all patients of 0.75 (P less than or equal to 0.005). Skin tests were positive in ten patients (52.6%) prior to therapy and 18 patients following therapy (94.7%; P less than or equal to 0.05). Thymostimulin, in vivo, appears to return immunologic competency to a population of untreated patients with Hodgkin's disease.

Efforts to explain spontaneous regression of cancer

After a study of the 176 cases (Everson and Cole) of spontaneous regression of cancer and recent progress in immunology, the author is convinced stimulation of the immune process is the most important factor in S.R. of cancer. Stimulating factors are numerous including bacterial products, enzymes, infections, hormones, trauma, etc. Of the 176 cases reported by Everson and Cole, 71 (40%) were associated with some type of operative trauma. Since the effective anticancer agent interferon is an important protective agent (especially antiviral) in the human body, this product could readily play an important role. Immunoglobulins appear to be possible factors. The blocking and unblocking agents of the Hellströms and associates support this supposition. Elimination of carcinogens appears important, considering the remarkable disappearance of cancer of the bladder in 12 of 13 patients having diversion of the urine from the bladder to the colon by transplantation of the ureters from the bladder to the colon. Innumerable antigens unknown to us at the present time could act as stimulants to our immune system, and thus cause regression of cancer. Hormonal factors must obviously be considered, but the author is doubtful that they exert an important role.

Hodgkin's disease: pathology and pathogenesis

The pathogenesis of Hodgkin's disease has been the subject of intensive investigation for nearly a century. Numerous lines of inquiry have been pursued and the resulting quantity of literature on the subject attests to the enigmatic nature of the disease. Periodically, it becomes prudent to review progress in the study of a disease such as this, in light of recent methodologic and conceptual advances. By so doing, a more integrated view of the disease process may emerge, thereby guiding future research endeavors. The present report is undertaken to explore, in depth, recent advances in the study of the pathology and pathogenesis of Hodgkin's disease. Contemporary classifications, clinicopathologic and epidemiologic studies, cellular and humoral derangements, and the controversial nature of the Reed-Sternberg cell are considered.