Preoperative and postoperative immunological evaluation of patients with colorectal cancer

Innate immunity recovers earlier than acquired immunity during severe postoperative immunosuppression

Background: Postoperative immune suppression, particularly a loss of cell-mediated immunity, is commonly seen after surgery and is associated with worse outcome, i.e. delayed wound healing, infections, sepsis, multiple-organ failure and cancer recurrence. However, the recovery of immune cells focusing on differences between innate and acquired immunity during severe postoperative immunosuppression is not investigated. Methods: In this retrospective randomized controlled trial (RCT) subgroup analysis, 10 postoperatively immune suppressed patients after esophageal or pancreatic resection were analyzed. Innate and acquired immune cells, the expression of human leukocyte antigen-D related on monocytes (mHLA-DR), lipopolysaccharide (LPS)-induced monocytic TNF-α and IL-10 secretion ex vivo, Concanavalin A (Con A)-induced IFN-γ, TNF-α, IL-2, IL-4, IL-5 and IL-10 release were measured preoperatively (od) until day 5 after surgery (pod5). Recovery of immune cells was defined by a significant decrease respectively increase after a significant postoperative alteration. Statistical analyses were performed using nonparametric statistical procedures. Results: Postoperative alterations of innate immune cells recovered on pod2 (eosinophils), pod3 (neutrophils) and pod5 (mHLA-DR, monocytic TNF-α and IL-10 secretion), whereas alterations of acquired immune cells (lymphocytes, T cells, T helper cells, and cytotoxic T cells) did not recover until pod5. Peripheral blood T cells showed an impaired production of the T helper (Th) 1 cytokine IFN-γ upon Con A stimulation on pod1, while Th2 specific cytokine release did not change until pod5.Conclusions: Innate immunity recovered earlier than acquired immunity during severe postoperative immunosuppression. Furthermore, we found a more anti- than pro-inflammatory T cell function on the first day after surgery, while T cell counts decreased.

Regulating surgical oncotaxis to improve the outcomes in cancer patients

Excessive surgical stress and postoperative complications cause a storm of perioperative cytokine release, which has been shown to enhance tumor metastasis in experimental models. We have named this phenomenon "surgical oncotaxis". The mechanisms that underpin this process are thought to be excessive corticosteroid secretion, coagulopathy in the peripheral vasculature, immune suppression and excessive production of reactive oxygen species. Nuclear factor-kappa B (NFkB) activation plays a key role in these mechanisms. Minimally invasive surgical techniques should be used, and postoperative complications should be avoided whenever possible to lessen the impact of surgical oncotaxis. Furthermore, there may be a role for a small preoperative dose of corticosteroid or the use of free radical scavengers in the perioperative period. Recently, there has been a great deal of interest in omega-3 fatty acid, because it regulates NFkB activation. The use of multimodal treatments that regulate surgical oncotaxis may be as important as chemotherapy for determining the outcome of patients with cancer undergoing surgery.

Naringenin reduces lung metastasis in a breast cancer resection model

Metastasis is the main cause of death in cancer patients. To improve the outcomes of patients undergoing a surgery, new adjuvant therapies that can effectively inhibit metastases have to be developed. Studies have shown that flavonoid naringenin, a natural product that is mainly present in grapes and citrus, may contribute to cancer prevention. It has many advantages compared to traditional chemotherapeutic drugs, such as low toxicity. To determine whether naringenin can also inhibit metastases, a breast cancer resection model that mimics clinical situations was established. We found that orally administered naringenin significantly decreased the number of metastatic tumor cells in the lung and extended the life span of tumor resected mice. Flow cytometry analysis revealed that T cells displayed enhanced antitumor activity in naringenin treated mice, with an increased proportion of IFN-γ and IL-2 expressing T cells. In vitro studies further demonstrated that relief of immunosuppression caused by regulatory T cells might be the fundamental mechanism of metastasis inhibition by naringenin. These results indicate that orally administered naringenin can inhibit the outgrowth of metastases after surgery via regulating host immunity. Thus, naringenin can be an ideal surgical adjuvant therapy for breast cancer patients.

Surgery induced immunosuppression

Surgery and anaesthesia result in a variety of metabolic and endocrine responses, which result in a generalised state of immunosuppression in the immediate post-operative period. Surgery induced immunosuppression has been implicated in the development of post-operative septic complications and tumour metastasis formation. In addition the effectiveness of many treatments in the adjuvant setting is dependent on a functioning immune system. By understanding the mechanisms contributing to surgery-induced immunosuppression, surgeons may undertake strategies to minimise its effect and reduce potential short-term and long-term consequences to patients.

Correlation between postoperative infections and long-term survival after colorectal resection for cancer

INTRODUCTION

Predicting long-term survival and cancer recurrence in patients with colorectal cancer is difficult because of the many factors that may affect the prognosis. This study investigated the prognostic significance of postoperative infections for patient outcome.

METHODS

From an electronic database we selected 192 patients undergoing elective radical surgery for Dukes' stage B and C colorectal adenocarcinoma. The five-year survival rates were analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were carried out to evaluate the potential prognostic variables using the Cox proportional hazard model.

RESULTS

Forty-three patients developed deep incisional or organ/space surgical site infections, while the remaining 149 were complication free. The two groups were comparable for baseline, surgical and histopathological characteristics. At univariate analysis, Dukes' stage and infections were negative prognostic factors, while peritumoral infiltration of lymphocytes and eosinophils and fibrotic tissue appeared as protective variables. However, multivariate analysis showed that only Dukes' stage (P = 0.048) and occurrence of postoperative infectious complications (P = 0.011) were independently associated with outcome. In patients with infectious complications, the survival rate was significantly lower than in patients without infections (log-rank = 0.0004).

CONCLUSIONS

The present results suggest the importance of evaluating other variables besides tumor stage in the prediction of long-term outcome. In prognostic studies more attention should be paid to postoperative infections.

Inflammatory response after abdominal surgery

Surgical manipulation of the gut elicits an inflammatory cascade within the intestinal muscularis that contributes to postoperative bowel dysmotility. A range of cytokines is sequentially released into the peritoneal fluid following abdominal surgery, their concentrations reflecting the magnitude of surgical trauma. The overproduction of inflammatory mediators might have detrimental effects on organ function and contribute to the enhanced risk of anastomotic leakage in the presence of sepsis. Specific cellular immune functions such as the microbicidal activity of peritoneal phagocytes are depressed after elective surgery, imposing a risk of infectious complications. Laparoscopic surgery decreases the local and systemic production of cytokines and acute-phase reactants, and better preserves peritoneal immunity compared with open surgery. As concluded from animal studies, the gas used for the pneumoperitoneum may possess substantial immunomodulatory activity.

Effect of laparoscopy on immune function

BACKGROUND

Laparoscopic surgery is believed to lessen surgical trauma and so cause less disturbance of immune function. This may contribute to the rapid recovery noted after many laparoscopic operations. Preservation of both systemic and intraperitoneal immunity is particularly important in surgery for sepsis or cancer and so an understanding of the impact of laparoscopy on immune function is relevant.

METHODS

Literature on immunological changes following laparoscopy and open surgery was identified from Medline, along with cross-referencing from the reference lists of major articles on the subject.

RESULTS AND DISCUSSION

Despite a few contradictory reports, systemic immunity appears to be better preserved after laparoscopic surgery than after open surgery. However, the local intraperitoneal immune system behaves in a particular way when exposed to carbon dioxide pneumoperitoneum; suppression of intraperitoneal cell-mediated immunity has been demonstrated in a number of studies. This feature may be clinically important and should be acknowledged when considering laparoscopic surgery in patients with malignancy or sepsis.

Suppression of cellular immunity by surgical stress

BACKGROUND

Suppression of cellular immunity is one of the host responses to surgical stress. In cancer patients this immunosuppression may accelerate the growth and metastasis of residual cancer cells, so it is desirable to restrict immunosuppression by surgical stress to a minimum. However, the extent and duration of immunosuppression caused by operations on gastrointestinal cancer, as well as the mechanisms involved, have not been determined.

METHODS

To clarify these points, we investigated immunocyte function and measured the blood levels of hormones, cytokines, and acute phase reactants from before to after operation in 20 patients with stage I gastrointestinal cancer.

RESULTS

In patients exposed to surgical stress, peripheral blood lymphocyte numbers and function were suppressed until at least 2 weeks postoperatively. This immunosuppression was mainly due to a decrease of helper-inducer T cells, cytotoxic T cells, natural killer cells, and interleukin-2 receptor-positive cells, as well as an increase of suppressor T cells. In addition, hypersecretion of cortisol and overproduction of immunosuppressive acidic protein were observed.

CONCLUSIONS

Cellular immunosuppression by surgical stress was mainly due to an increase of lymphocyte subsets that depress cellular immunity coupled with a decrease of the subsets that promote it. Overproduction of cortisol and immunosuppressive acidic protein in response to surgical stress may play an important role in the development of immunosuppression.

Evaluation of multi skin test in colorectal cancer patients and effects of serum immunosuppressive factor and cytokine production of peripheral mononuclear cells

Decreased skin reactions using five kinds of recall antigens correlate d with the stage of colorectal cancer. Immunosuppressive factors in the serum (IS index) increased with the progression of the stage in cancer patients, but interleukin (IL)-I and IL-2 production in peripheral mononuclear cells (PBMC) did not correlate with the advance of the disease. In patients with low immunosuppressive factors, the score of skin reactions was significantly higher than that in patients with high immunosuppressive factors. Increased serum immunosuppressive factors seem to reduce skin reactions in the patients. Furthermore, significant difference in skin reaction score was observed between patients with high IL-1 production of PBMC and patients with low IL-1 production of PBMC. These results suggest that skin reaction might be controlled by serum immunosuppressive factors and IL-1 production of PBMC, and that the score of skin reaction using multirecall antigens is a useful parameter to learn the host immunity in colorectal cancer.

Immunosuppressive activity of sera from patients with colorectal and gynecological carcinomas as evaluated by impaired IFN-gamma, IL-1 alpha and TNF-alpha production of human peripheral mononuclear cells

The sera from patients with preoperative colorectal and gynecological carcinomas (ovarian and breast cancer) were investigated for their putative immunosuppressive activity (ISA). ISA was measured by determining the changes in the production of IFN-gamma, IL-1 alpha and TNF-alpha by human peripheral mononuclear cells (PBMC) from six normal donors. Phytohemagglutinin-stimulated PBMC were incubated with sera from patients with colorectal and gynecological carcinomas and healthy controls and in the 4-day post-inductional supernatants the cytokines were measured by an enzymoimmunological assay (ELISA). Sera from patients with carcinomas significantly decreased the IFN-gamma production as compared to the controls. In the cultures containing sera from patients with colorectal and ovarian but not breast carcinoma, significantly lower levels of IL-1 alpha and TNF-alpha were measured compared to the cultures with sera from healthy controls.

Impaired cytokine production in whole blood cell cultures of patients with urological carcinomas

The production of the cytokines interferon gamma (IFN gamma), interleukin-1 alpha (IL-1 alpha) and tumor necrosis factor alpha (TNF alpha) was investigated in the mitogen-stimulated whole blood cell culture media from 51 patients with urinary bladder carcinomas, 52 patients with renal carcinomas, 31 patients with prostatic carcinomas and 360 healthy controls. The cytokines were measured 4 days after induction by a sensitive enzymo-immunological assay. In the blood cell culture supernatants of the patients with urinary bladder carcinomas significant lower levels of IFN gamma (P < or = 0.001), IL-2 (P < or = 0.01) and TNF alpha (P < or = 0.05) were found as compared to the controls. Blood cells of patients with renal carcinomas had lower production of IFN gamma (P < or = 0.01), IL-2 (P < or = 0.001) and IL-1 alpha (P < or = 0.01), whereas the values of the total group of patients with prostatic carcinomas were not significantly different from those of the controls. Lymphocyte and monocyte counts were almost identical in the control and all tumor patient groups. When the patients with renal carcinomas and prostatic carcinomas were analyzed according to their different clinical stages we could show a gradual depression of the IFN-gamma levels, which was related to tumor burden.

The influence of the host on the course of gastric carcinoma

Immunoglobulins (Ig) and some complement components (C) were quantified in sera from patients with gastric carcinoma before surgery and at regular intervals during a 5-year follow-up. The preoperative concentrations of C1-INH and C4 were higher (P < 0.0005 and P < 0.005) and IgG lower (P < 0.0005) in 50 patients with recurrence than in 46 5-year survivors. The prognostic significant of C1-INH was superior to that of the extent of disease (F-values 37.1 and 26.1). The preoperative immune data classified 76% of the patients correctly as to recurrence and no recurrence. Also, the preoperative C1-INH concentration had a highly significant effect on time to recurrence of cancer (P = 0.0007), adjusting for age and disease extent. After surgery the mean IgG concentrations were within normal range and without difference between the two groups. On the other hand, the concentrations of C1-INH and C4 in the individual patients in both groups remained the same from before to after surgery and throughout the observation period (P = 0.34). Apparently, the serum levels of C1-INH and C4 do not reflect the bearing of cancer. We therefore suggest that these variables represent an independent immune state that is appropriate to the host. A comparison of our variables with those of healthy individuals seems to support this idea. This immune state has a significant influence on whether a resected gastric cancer will recur, and also on how soon recurrence may be manifest.

Impaired cytokine production in whole blood cell cultures from patients with colorectal carcinomas as compared to benign colorectal tumors and controls

Cytokine production was investigated in whole blood cell cultures from 74 patients with colorectal carcinomas, 20 patients with benign colorectal tumors, and 314 healthy controls. In the 4 day post induction supernatants the levels of IFN-gamma, IL-1-alpha, IL-2, and TNF-alpha were measured by a sensitive immunoassay. In the blood cell cultures of the patients with colorectal carcinomas significantly lower values of IFN-gamma (P less than or equal to .001), IL-1-alpha (P less than or equal to .001), and IL-2 (P less than or equal to .01) were found as compared to the patients with benign tumors and the controls, although total and differential leukocyte counts were similar in all three groups. A linear correlation between the levels of IFN-gamma and IL-1-alpha and the tumor stages could be shown. Our results suggest that a growing tumor burden may induce increasing immunological deficiencies as reflected by a decreasing cytokine production of the immune cells.

Orally administered streptococcal preparation, OK-432 augments the antitumor immunity of patients with gastric or colorectal cancer

A streptococcal preparation, OK-432, was orally administered at a dose of 5 KE to patients with gastric or colorectal cancer for 7-14 days before their operations, and its immunomodulatory effects on peripheral blood lymphocytes (PBL), regional node lymphocytes (RNL) and tumor infiltrating lymphocytes (TIL) were assessed. The group treated with OK-432 included 8 gastric and 6 colorectal cancer patients, and the control group included 8 gastric and 8 colorectal cancer patients. The NK cell activity of PBL was significantly augmented by the oral administration of OK-432, and the proportions of Leu 7+ and Leu 11+ cells in PBL also increased. The responses of PBL and TIL to autologous tumor extracts in the presence of interleukin-2 were enhanced after the oral administration of OK-432. The proportion of OKT8+ cells in PBL increased after treatment with oral OK-432, whereas the proportion in RNL significantly decreased. These results indicate that oral OK-432 affects NK and T cells and may augment the antitumor immunity of patients with gastrointestinal cancer.

Influence of surgery on the responsiveness of blood lymphocytes in patients with advanced cancer

The effect of surgery on peripheral blood mononuclear cell responsiveness to mitogens and suppressor cell (SC) activity assessed in a concanavalin A (ConA) assay were studied in patients with stage 0 and stage III-IV cancer. Patients were exposed to a similar surgical trauma the same type of anaesthesia, and to no pre- and early postoperative radio- or chemotherapy. A more pronounced postoperative decrease in the lymphocyte count, responsiveness to phytohemagglutinin (PHA) and ConA, and in the SC activity was found in the nonadvanced than advanced cancer group. These findings point to an impaired mobilization and distribution capacity of circulating lymphocytes in patients with advanced neoplastic disease.

Reversal of defective lymphoproliferation in postoperative patients with colon cancer

To establish a method for evaluation of immunological parameters in small blood samples, a whole blood technique was developed for the estimation of mitogen- or antigen-induced proliferation. Studies regarding cellular immunity in patients with colon cancer were done with 108 patients in all tumor stages, aged 32 to 80 years. They were studied before surgery and 10 days after operation. A group of 35 patients were further tested 3 months after surgical treatment. In patients with colon cancer the proliferative responses of peripheral blood lymphocytes to mitogens were significantly lower in comparison to healthy controls. These results were found when the response to concanavalin A, phytohemagglutinin, OKT 3, and pokeweed mitogen were analyzed preoperatively and 10 days postoperatively. There was no relation to the stage of disease. The marked reduction of mitogen responses was followed by a gradual return toward normal values 3 months after surgical resection of neoplastic growth in 80% of the patients. Our studies indicate that the defects were largely restored when testing was performed 3 months after operation. Using this result, it will be possible to perform long-term studies in order to establish if there is a correlation between the return to normal immune reactivity and the survival of individual patients.

More advanced colonic cancer among smokers

Clinical records of 392 patients with adenocarcinomas of the colon were reviewed. Tumors identified in smokers had been diagnosed more often at an advanced stage. In comparison with tumors identified in nonsmokers, those of smokers were much less likely to be Modified Dukes' Stage A (3.9% versus 12.2%) (P less than 0.001), less likely to be Stage B (30.1% versus 39.0%) or Stage C (23.3% versus 26.8%), and nearly twice as likely to be Stage D (42.7% versus 22.0%) (P less than 0.001). The duration of symptoms before diagnosis was similar for smokers and nonsmokers. Age-corrected, 2-year and 5-year survivals were similar for smokers and nonsmokers after correction for the more advanced disease of smokers at diagnosis. The association between smoking and tumor stage was independent of age, sex, tumor location, and date of diagnosis. These observations suggest that environmental stresses may be able to modify tumor-host interrelationships. Smoking-associated changes seem most likely to reflect alterations in host immune anti-tumor defenses.

Effect of colon tumor development and dietary fat on the immune system of rats treated with DMH

We examined the effect of dietary fat and colon tumorigenesis on the morphology and function of the rat mesenteric lymph node (MLN) and spleen at two stages of tumor development. Male Sprague-Dawley rats were fed semipurified diets of varying fat content (5% mixed fat, 24% beef fat, 24% corn oil, or 24% Crisco) and treated for five weeks with either the colon carcinogen 1,2-dimethylhydrazine (DMH) or the vehicle (saline). Animals consuming high-fat diets had an increased incidence of splenic follicular and germinal center hyperplasia. Carcinogen treatment had no significant effect on the histological morphology of the spleen. MLN morphology was not dramatically affected by either diet or DMH treatment. At this time period, the splenic lymphocyte transformation response induced by concanavalin A (Con A), phytohemagglutinin, or pokeweed mitogen was significantly depressed in the group fed 24% corn oil (vehicle-treated) and in the DMH-treated groups fed 5% fat compared with the vehicle-treated group fed 5% fat. In contrast, the MLN transformation response was elevated in the group fed 24% Crisco. DMH treatment did not significantly influence the MLN response. Four months after carcinogen or vehicle treatment, at the point of colon tumor development, no statistically significant differences were seen in the splenic or MLN blastogenic responses of DMH- or saline-treated animals. Splenic natural killer cell cytotoxic activity was also not significantly affected by dietary fat, carcinogen treatment, or tumor development.

Adjuvant treatment of colorectal cancer. Current status and concepts

Colorectal cancer is the second leading cause of cancer mortality in the United States, causing approximately 50,000 deaths per year. The overall prognosis and results of treatment have not changed impressively over the last three decades. Half of all the patients who undergo curative surgery finally succumb to locoregional or metastatic recurrence of their disease. Recent clinical research has been aimed at adjuvant therapeutic measures to improve survival after curative surgical resection. For rectal cancer, combined postoperative chemotherapy and radiation therapy have been shown to reduce the overall relapse rate and improve disease-free survival. Further studies of adjuvant treatment for rectal cancer are needed to evaluate the optimal radiation schedule and limit the side-effects of the treatment. Adjuvant treatment of colon cancer must still be regarded as unsettled. Since liver metastases are the most common unfavorable outcome of colon cancer, ongoing trials using liver-directed treatment (perfusion, irradiation) should be followed with interest. The lack of proven efficacy and the side-effects of these treatments strongly favor the inclusion of an observation-only control group in trials for adjuvant treatment of colon cancer. Unfortunately, there is as yet no proven significant benefit from immunotherapy as an adjuvant therapy for colorectal cancer, but further basic and clinical studies will be of great interest in this field.

Stage-related correlations between immunoglobulins and complement components in preoperative sera from patients with gastric carcinoma

Immunoglobulins A, G and M and complement components C3, C4 and C1-INH were quantitated in sera taken preoperatively from 168 patients with gastric carcinoma. The values were grouped according to stages (pTNM). The concentrations of C4 and C1-INH increased with advancing stage of disease and were above normal mean values in all stages. The concentration of IgG was below the normal mean value among all the patients and with the lowest concentration in stage III. Concentrations of IgA and C3 were above normal means but without significant relation to stages. There was a positive correlation between the concentrations of IgG and C1-INH in sera from patients with stage IV carcinoma, while the same correlation was negative in stages I-III. Although the results varied among the patients within each stage, the profiles of immunoglobulin and complement concentrations are of value in the preoperative staging of the disease.