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

Are there overlapping clinical features between thoracic radiotherapy side effects and covid-19 pneumonia? Radiation pneumonitis outside the radiation ports: Three case reports

Respiratory involvement of COVID-19 infection, with presentations ranging from a mild flu-like illness to potentially lethal acute respiratory distress syndrome, is the main clinical manifestation in adults. Chest imaging shows a pictorial fashion of images due to the severity and stage of the disease, starting from focal nodular or mass-like opacities with air bronchogram to areas of ground glass consolidation or whited out lung. However, during the COVID-19 pandemic, CT findings could yield confounding reporting in the case of cancer patients previously treated with thoracic radiotherapy (tRT) due to atypical radiation pneumonitis occurring outside the radiation ports. Hypersensitivity pneumonitis and radiation-induced bronchiolitis obliterans organizing pneumonitis (RT-BOOP) are accounted for in this report.

Standard radiotherapy but not chemotherapy impairs systemic immunity in non-small cell lung cancer

Introduction: Advanced non-small cell lung cancer (NSCLC) is traditionally treated with platinum-based chemotherapy and radiotherapy. Since immunotherapy holds promise for treating advanced NSCLC, we assessed the systemic effects of the traditional therapies for NSCLC on immune cell composition and function.

Methods: 84 pulmonary adenocarcinoma patients, treated either with chemotherapy or radiotherapy, were studied. A prospective study of 23 patients was conducted in which the myeloid and lymphoid cell compartments of peripheral blood were analyzed. Changes in cell populations were validated in a retrospective cohort of 61 adenocarcinoma patients using automated differential counts collected throughout therapy. Furthermore, the functional capacity of circulating T cells and antigen-presenting cells (APC) was studied. Blood samples of healthy individuals were used as controls.

Results: In comparison to healthy controls, untreated adenocarcinoma patients display an elevated frequency of myeloid cells coinciding with relative lower frequencies of lymphocytes and dendritic cells. Standard chemotherapy had no overt effects on myeloid and lymphoid cell composition nor on T-cell and APC-function. In contrast, patients treated with radiotherapy displayed a decrease in lymphoid cells and a relative increase in monocytes/macrophages. Importantly, these changes were associated with a reduced APC function and an impaired response of T cells to recall antigens.

Conclusions: Platinum-based standard of care chemotherapy for NSCLC has no profound negative effect on the immune cell composition and function. The negative effect of prolonged low-dose radiotherapy on the immune system warrants future studies on the optimal dose and fraction of radiotherapy when combined with immunotherapy.

Late Relapse in Hodgkin's Disease: Report of Five Cases and a Review of the Literature

During the past 15 years the treatment of Hodgkin's disease (HD) with chemo/radiotherapy has been shown to appreciably improve the long-term prognosis of patients, even those with more advanced disease. In the past it was accepted that the probability of primary relapse 5 years after achieving complete remission (CR) was small and a 5-year disease-free period was sufficient to be considered as a cure. During the past 15 years, however, more data has been published relating to late relapses in these patients after an initial "cure" has been achieved. This report briefly examines our own experience with five patients initially "cured" who relapsed 5 to 11 years after achieving CR and also reviews recent literature on the subject. The phenomenon of late relapse has thus become a more important issue in the management of patients with HD.

Host antitumour immune responses to HIFU ablation

The ideal cancer therapy not only induces the death of all localized tumour cells without damage to surrounding normal tissue, but also activates a systemic antitumour immunity. High-intensity focused ultrasound (HIFU) has the potential to be such a treatment, as it can non-invasively ablate a targeted tumour below the skin surface, and may subsequently augment host antitumour immunity. In addition to thermal and cavitation effects, which act directly and locally on the tumour, there is increasing evidence linking systemic anti-tumour immune response to HIFU ablation. This may provide micro-metastatic control and long-term tumour resistance for cancer patients. The goal of this article is to review the emerging pre-clinical and clinical results suggesting that HIFU ablation may enhance host anti-tumour immunity, and to discuss its potential mechanisms. It is concluded that the systemic immune response induced by thermal ablation may play an important role in local recurrence and metastasis control after HIFU treatment.

Activated anti-tumor immunity in cancer patients after high intensity focused ultrasound ablation

T cell-mediated immune responses represent the main cellular antitumor immunity in cancer patients. Recent studies have shown that that both surgical procedure and radiation therapy could cause the functional suppression of lymphocyte-mediated cellular immunity. The purpose of current study is to evaluate whether high intensity focused ultrasound (HIFU) might change a systemic antitumor immunity, particularly T lymphocyte-mediated immunity in cancer patients. A total of 16 patients with solid malignancies were treated with HIFU. Among them, six patients had osteosarcoma (Enneking stage, II(B)4, III(B) 2), five had hepatocellular carcinoma (TNM stage, III 3, IV 2), and five had renal cell carcinoma (TNM stage, III 2, IV 3). Using flow cytometry technique, T lymphocyte and subset, B lymphocyte and natural killer cell (NK) in the peripheral blood were measured in these patients on the day before HIFU and 7 to 10 d after HIFU. The statistical significance of any observed difference is evaluated by Student's t-test. The results showed a significance increase in the population of CD4(+) lymphocytes (p < 0.01) and the ratio of CD4(+) /CD8(+) (p < 0.05) in the circulation of cancer patients after HIFU treatment. The abnormal levels of CD3(+) lymphocytes returned toward the normal range in two patients, CD4(+)/CD8(+) ratio in 3, CD19(+) lymphocytes in one and cytotoxic NK in one, respectively, in comparison to control values. It is concluded that HIFU could enhance a systemic antitumor cellular immunity in addition to local tumor destruction in patients with solid malignancies.

Effect of fractionated regional external beam radiotherapy on peripheral blood cell count

PURPOSE

The purpose of this study was to assess the need for obtaining weekly complete blood count (CBC) values and to identify the pattern of changes in CBC during regional conventional fractionated radiotherapy.

METHODS AND MATERIALS

A retrospective analysis of CBC data on 299 adult cancer patients who received definitive conventional radiotherapy to head and neck (n = 95), chest (n = 96), and pelvis (n = 108) was performed. Temporal patterns and magnitude of change in white blood cells, neutrophils, lymphocytes, and platelets during radiotherapy were examined.

RESULTS

There were statistically significant declines in all counts, albeit not clinically significant. Notable differences between disease sites were found. The greatest weekly interval change in counts occurred during the first week of radiotherapy for all groups of patients. The mean WBC nadir values during treatment were 5.8 for head & neck, 6.8 for chest, and 5.4 for pelvis. The nadirs for all counts occurred toward the middle-to-end of radiotherapy. Lymphocytes were found to be more sensitive to radiotherapy than other leukocyte subcomponents.

CONCLUSION

Our study suggests that weekly CBC monitoring is not necessary for all patients undergoing standard fractionated radiotherapy. Baseline blood counts may be used to determine an optimal schedule for monitoring CBCs in patients receiving conventional radiation alone. Reduced monitoring of CBC may result in significant financial savings.

Risk of second primary cancers after Hodgkin's disease by type of treatment: analysis of 2846 patients in the British National Lymphoma Investigation

OBJECTIVE

To analyse the risk of second primary cancers during long term follow up of patients with Hodgkin's disease.

DESIGN

Cohort study.

SETTING

The British National Lymphoma Investigation (a collaborative group of over 60 participating centres in Britain treating lymphomas).

PATIENTS

2846 patients first treated for Hodgkin's disease during 1970-87, for whom follow up was complete in 99.8%.

MAIN OUTCOME MEASURES

Second primary cancers; uniform pathology reviews confirmed the diagnosis of Hodgkin's disease and of second primary non-Hodgkin's lymphomas.

RESULTS

113 second primary cancers occurred. Relative risk of cancer other than Hodgkin's disease was 2.7 (95% confidence interval 2.3 to 3.3) compared with the general population, with significant risk of leukaemia (16.0(9.1 to 26.0)); non-Hodgkin's lymphoma (16.8(9.8 to 26.9)); and cancers of the colon (3.2 (1.4 to 6.2)), lung (3.8 (2.6 to 5.4)), bone (15.1 (1.8 to 54.7)), and thyroid (9.4 (1.1 to 33.9)). Absolute excess risk associated with treatment was greater for solid tumours than for leukaemia and lymphomas. Relative risk of leukaemia increased soon after treatment, reaching a peak after five to nine years. It was increased substantially after chemotherapy (27.9 (12.7 to 52.9)), combined treatment with radiotherapy and chemotherapy (21.5 (7.9 to 46.8)), and relative to number of courses of chemotherapy but was not significantly increased after radiotherapy (2.5 (0.1 to 14.1)). Relative risk of non-Hodgkin's lymphoma increased in the first five years after treatment and remained high but showed no clear relation with type or extent of treatment. Relative risk of solid tumours was less raised initially but increased throughout follow up and for lung cancer 10 years or more after entry was 8.3 (4.0 to 15.3). The risk of solid tumours increased after treatments including radiotherapy and after chemotherapy alone. The risk after chemotherapy increased significantly with time since first treatment.

CONCLUSION

The risk of solid cancer, not of leukaemia, is the major long term hazard of treatment for Hodgkin's disease, and this seemed to apply after chemotherapy as well as after radiotherapy. These risks of second cancers are important in choice of treatment and in follow up of patients, but they are small compared with the great improvements in survival which have been brought about by modern therapeutic methods for Hodgkin's disease.

Dysfunction of monocytes in Hodgkin's disease by excessive production of PGE-2 in long-term remission patients

The candidacidal activity and the production of oxygen radicals by monocytes were investigated in untreated and long-term remission patients with Hodgkin's disease (HD). Both groups showed a decreased candidacidal function of monocytes with a chemiluminescence (CL) response significantly lower and delayed with respect to normal controls. Indomethacin at 1 microgram/ml corrected the monocyte deficiency increasing the CL response to normal values and normalizing the kinetics in the untreated patients. However, in patients in remission, the peak was delayed and followed by a significant increase in the production of oxygen radicals compared with untreated patients. A direct linear correlation was found between the percentages of lysed Candida and maximum CL peak of stimulated monocytes. When prostaglandin E2 (PGE-2) levels, measured in supernatants of cultured mononuclear cells, were plotted against the percentages of killed Candida, an inverse linear correlation was found. Therefore, monocytes from HD patients have a dysfunction in the generation of oxygen radicals and a decreased candidacidal activity associated with excessive production of PGE-2. Indomethacin can correct the oxidative metabolism in the untreated patients while in apparently "cured" patients the disorder persists.

Hodgkin's disease: subsequent primary cancers in relation to treatment

A consecutive series of 2,999 patients, diagnosed with Hodgkin's disease (HD) between 1950 and 1979, was assembled from the records of the Birmingham and West Midlands Cancer Registry and followed to the end of 1984. Cohort analyses of subsequent primary cancers among 1,976 patients, surviving one or more years (mean follow-up 6.7 person-years), were carried out in relation to overall treatment by radiotherapy (RT), chemotherapy (CT) or both modalities (CT + RT). Over all sites a 50% increase in risk, relative to the West Midlands population, was found [observed (O) = 65; relative risk (RR) = 1.5; P less than 0.01]. Among patients treated by CT (with or without RT) a significant increase in acute and non-lymphocytic leukaemias was found (O = 6; RR = 30.0; P less than 0.001). The excess risk was of the order of 1 per 1000 patient-years and the cumulative risk was 1.2%. Among solid tumours increased risks, which might be attributable to RT, occurred in the lung (O = 15; RR = 1.6; P less than 0.05), breast (O = 9; RR = 2.2; P less than 0.05) and bone (O = 2; RR = 20.0; P less than 0.01). The excess of skin cancers (O = 13; RR = 2.9; P less than 0.01) occurred mainly within 10 years of treatment with CT. The follow-up period is still insufficient to determine the long-term effect on the incidence of solid tumours with long latent periods from multiple-agent CT which became more frequently used in the early 1970s. A sub-set of these data was analysed over all treatments and the results were contributed to an international study co-ordinated by the International Agency for Research on Cancer, Lyon.

Immunologic profile in patients with Hodgkin's disease in complete remission

Mononuclear cell subsets in peripheral blood, in vitro production of interleukin-2 (IL-2) and gamma interferon (IFN gamma), spontaneous cell-mediated cytotoxicity (SCMC) and circulating levels of Type I IFN, neopterin, beta-2 microglobulin (B2-M), immunoglobulins and complement fractions were studied in 33 patients with Hodgkin's disease (HD) in complete remission. The mean percentages, but not the absolute numbers, of T-lymphocytes expressing pan-T markers (OKT11, OKT3, ER, E-AET R) were significantly decreased compared with control values. Furthermore, patients showed a selective loss of OKT4+ cells, as well as increased percentages and numbers of Leu7+ and OKIa+ lymphocytes, and of OKM1+, LeuM2+, and LeuM3+ cells. OKT4+ cell depletion was a characteristic of patients with shorter time since beginning of remission as well as of those with nodular sclerosis (NS), mixed cellularity Hodgkin's disease (MC-HD), and systemic symptoms at diagnosis. Multifactorial statistical analysis carried out to investigate the effect of disease characteristics and the time since remission began on peripheral mononuclear blood cell (PMBC) subsets showed that histologic condition was the single best predictor of T-cell pool or OKT4+ cell subset size. Time since remission duration and other disease-related factors determined differences in the percentages, but not in the absolute numbers, of T-cell fractions. In addition, neither the disease features nor the time since remission duration determined significant differences in the absolute number of non-T-mononuclear cells in the various patient groups. Patients displayed decreased in vitro synthesis of IL-2 and IFN gamma. The values of SCMC, Type I IFN, neopterin, B2-M, immunoglobulins, and complement fractions did not differ greatly from those of controls.

Defective in vitro immunoglobulin production in response to pokeweed mitogen in patients with Hodgkin's disease pretreatment and in remission

In vitro production of IgG and IgM from peripheral blood lymphocytes and B-cell enriched fractions was assessed in a group of Hodgkin's disease (HD) patients and normal controls using pokeweed mitogen (PWM) stimulation. Our studies demonstrated a significant (P less than 0.01) reduction in the absolute number of helper (OKT4 positive) T cells and a significant alteration in the helper/suppressor T-cell ratio (0.89 +/- 0.15) compared to normal (1.83 +/- 0.31). Results from PWM stimulation experiments demonstrated that HD patients produced significantly lower IgG (P less than 0.01) and IgM (P less than 0.01) levels than controls. Synthesis of IgM but not IgG induced by PWM was subnormal after addition to patient B-cell cultures of autologous irradiated T cells or allogeneic irradiated normal T lymphocytes. Irradiated T cells from HD patients were as effective as normal T cells in helping PWM induced IgG and IgM synthesis by normal B cells. Our results suggest that in HD impaired circulating B-cell function is partly due to T-suppressor cell activity and furthermore that B-cell subpopulations producing different immunoglobulin isotypes may either be defective or vary in their susceptibility to T-cell suppression.

Five-year survival in Hodgkin's disease. The prospective value of immune status at diagnosis

Immune status was measured in 47 previously untreated patients with Hodgkin's disease. For all patients, a 5-year follow-up was established. Immunologic capacity was measured by delayed-type hypersensitivity tests to common recall-antigens; enumeration of T- and B-lymphocytes in the peripheral blood; in vitro lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes; and serum levels of immunoglobulins. Compared with healthy controls, skin reactivity was decreased in the patients (P less than 0.05), but was not a prognostic marker with regard to survival. Total lymphocyte counts and the numbers of T- and B-cells did not differ between surviving and deceased patients. Decreased in vitro lymphocyte responsiveness to phytohemagglutinin and impaired responding capacity of patients lymphocytes in the mixed lymphocyte culture (MLC), used as markers, were a poor prognostic sign (P less than 0.001). The relevant clinical parameters with regard to 5-year survival were age, stage, and B symptomatology (P less than 0.005). The prognostic information supplied by age plus responding capacity in the MLC exceeded the predictive value of any combination of clinical parameters. Lymphocyte stimulation to pokeweed mitogen and antigens, stimulatory capacity of patients' lymphocytes in mixed lymphocyte cultures, the spontaneous DNA-synthesis, and immunoglobulin levels, did not provide prognostic information. The use of mixed lymphocyte cultures in staging patients with Hodgkin's disease may refine the prognostic information supplied by age, stage, and symptomatology.

Abnormal immunoregulation in remission Hodgkin disease

Peripheral blood mononuclear cells from 11 patients with remission Hodgkin disease and 20 normal controls were incubated with irradiated allogeneic lymphocytes in one-way mixed lymphocyte cultures. Simultaneously, modified assays were performed by adding supplemental irradiated PBM, T lymphocytes, or adherent cells autologous to the responders. Baseline allogeneic responsiveness of patients and controls was not different. However, significant suppression (p less than .01) was demonstrated when the cultures were supplemented with patient mononuclear cells or adherent cells, an effect not found with similar supplemental cells from controls. Conversely, T-cell supplementation of control cultures produced more than twofold increases in proliferation but significantly less augmentation in the patients' cultures (p less than .01). T-cell subset analysis in six patients showed decreased helper: suppressor cell ratios. Hodgkin disease patients have adherent suppressor cells, which persist during remission, as well as a defect in T-cell helper function.

Long term effects on the immune system following local radiation therapy for breast cancer. I. Cellular composition of the peripheral blood lymphocyte population

Local radiation therapy for breast cancer depletes the blood of various subsets of lymphocytes. Previous studies showed that the recovery is still incomplete at 30 months. To further elucidate the recovery we examined blood lymphocyte counts of 138 disease-free women and various lymphocyte subsets in 102 of these patients. These patients, 5-6 and 10-11 years earlier, had entered a clinical trial in which preoperative irradiation (45 Gy) was evaluated against postoperative irradiation (45 Gy) or surgery only. Patients who had undergone surgery only served as controls. Total lymphocyte counts of the irradiated patients were still significantly reduced 10-11 years after treatment. This reduction was mainly attributable to a subnormal level of T-cells as determined by the monoclonal antibody Leu-1 and the ability to form rosettes with sheep erythrocytes, whereas the number of non-T cells, expressing C'3 receptors, did not differ significantly from the controls. Within the T-cell population a subset with helper/inducer phenotypes, detected by Leu-3a antibodies, was significantly reduced even 10-11 years after irradiation. T-cells with suppressor/cytotoxic phenotypes, stainable with Leu-2a antibodies, however, had already recovered 5-6 years after irradiation. The duration of the radiation induced reductions of different lymphocyte subsets may be related to the physiological turn-over of the cells or a changed distribution of cells in the body.