The immunology of cancer of the head and neck with particular reference to oral cancer

Prognostic value of circulating biomarker score in advanced-stage head and neck squamous cell carcinoma

BACKGROUND

Circulating biomarker (CB) is a convenient, emerging predictive tool for treatment response and outcomes in human cancers. Therefore, we examined the prognostic value of pre-treatment and early post-treatment CBs and their summated scores in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

This study prospectively included 310 consecutive patients who underwent definitive treatment for previously untreated advanced-stage HNSCC between 2010 and 2015. The CB score was determined by complete blood counts (CBCs) and blood chemistry before and 2 months after the treatment, and the number of abnormal CB was counted from 0 to 10. Univariate and multivariate analyses with Cox proportional hazards models were used to find factors associated with disease-free survival (DFS) and overall survival (OS).

RESULTS

Most CBC profiles were significantly changed at 2-months post-treatment compared with those at pre-treatment. Univariate analyses showed that hypoalbuminemia, leucocytosis, C-reactive protein, high CB scores (≥6), age, performance status and comorbidity and tumour site were significantly associated with DFS and OS (all P < 0.05). Both pre- and post-treatment CB scores were independent factors predictive of DFS and OS outcomes in the multivariate analyses (P < 0.05). High CB scores at pre-treatment were associated with 7-10-fold increased risk of unfavourable DFS and OS outcomes, and those at 2-months post-treatment were associated with 2 to 4-fold increased risk of poor survival outcomes (all P < 0.05).

CONCLUSIONS

CB scores at pre-treatment and early post-treatment are useful for predicting survival outcomes in patients with advanced-stage HNSCC.

Interferon-gamma and interleukin-10 production by mononuclear cells from patients with advanced head and neck cancer

OBJECTIVE

This study aims to evaluate the production of interferon-gamma and interleukin-10 by stimulated peripheral blood mononuclear cells isolated from patients with supraglottic laryngeal cancer before and after surgical treatment.

METHODS

Fourteen patients with advanced supraglottic laryngeal cancer were studied. Cultures of peripheral blood mononuclear cells isolated during the preoperative and late postoperative periods were stimulated with concanavalin A and Bacille Calmette-Guerin, and the supernatant concentrations of interferon-gamma and interleukin-10 were measured.

RESULTS

For non-stimulated cultures, the interferon-gamma levels produced by the preoperative period and the late postoperative period cultures were lower than the levels produced by the control group cultures. The interferon-gamma levels after stimulation with concanavalin A were higher in the late postoperative period cultures than in the preoperative evaluation cultures. Stimulation with Bacille Calmette-Guerin led to the production of similar levels of interferon-gamma and interleukin-10 by all cultures; thus, stimulation increased the levels of interferon-gamma produced by both the preoperative and postoperative cultures relative to the levels produced by the corresponding unstimulated cultures.

CONCLUSION

Patients with advanced supraglottic laryngeal cancer exhibit an in vitro deficiency in interferongamma secretion by mononuclear cells. Stimulated cells seem to recover this function during the postoperative period.

Effect of BCG stimulus on proinflammatory cytokine production in laryngeal cancer

BACKGROUND

Evaluate the production of TNF and IL-6 in the supernatant of peripheral blood mononuclear cell (PBMC) cultures of patients with supraglottic laryngeal cancer before and after surgical treatment.

MATERIALS AND METHODS

Adherent cell cultures were stimulated with LPS and BCG. Fourteen patients with advanced supraglottic laryngeal cancer were studied. Cytokine concentration was determined by ELISA in supernatants of mononuclear cell cultures.

RESULTS

In non-stimulated cultures, lower TNF cytokine levels were detected during the late postoperative (LP) period compared to control (P = 0.02). LP TNF and IL-6 levels were high in cultures stimulated with LPS compared with the preoperative period (PREOP) (P = 0.007; P = 0.008, respectively). Stimulation with BCG led to increased levels of TNF and IL-6 during the LP period compared to control (P = 0.001; P = 0.04, respectively).

CONCLUSION

BCG is able to modulate the immune response of patients with advanced supraglottic laryngeal cancer in vitro, increasing the secretion of TNF and IL-6 by macrophages during the postoperative period.

Effect of surgical treatment on lymphoproliferation in advanced supraglottic laryngeal cancer

OBJECTIVES

The capacity of cell immunity to act against tumor cells has been presented as a decisive influence in the prognosis of patients with cancer. The aim of this study was to evaluate lymphoproliferation in nonadherent peripheral blood cell cultures of patients with advanced supraglottic laryngeal cancer.

STUDY DESIGN

Fourteen patients with advanced supraglottic laryngeal cancer were studied prospectively. Lymphoproliferation was quantified by adding 3H-thymidine and measured in counts/minute using liquid scintillation spectrometry. Based on the ratio between stimulated and baseline cultures, the proliferation index was calculated before and 236 +/- 18 days after the surgery.

RESULTS

Lymphoproliferation was lower in patients than in healthy controls (P = .01) in the preoperative as well as in the late postoperative period (P = .006 and P = .02, respectively). However, there was no change from preoperative to late postoperative.

CONCLUSION

Pre- and postoperative results show that patients with advanced supraglottic laryngeal cancer present lymphoproliferation diminished before the surgery, and in the late postoperative period, there was no recovery of immune capacity evaluated by lymphoproliferation measurement.

Differential regulation of IL-2 and IL-4 in patients with tobacco-related oral squamous cell carcinoma

AIM

The aim of the study was to investigate the systemic immunity in terms of major lymphocyte subsets and the expression of IL-2 and IL-4 in T-cell subsets from peripheral blood of patients with tobacco-related intraoral squamous cell carcinoma.

METHODS

CD3+, CD4+ and CD8+ T-cell subsets and CD16+ CD56+ natural killer cells, and intracellular cytokines in T-cell subsets were determined by two-colour flow cytometry and confocal microscopy.

RESULTS

Oral cancer patients showed a significantly reduced (P < 0.001) CD3+ and CD4+ T-cell subsets with a lower CD4/CD8 ratio when compared with the normal controls. The frequency of CD3+ IL-4+ and CD8+ IL-4+ T cells were significantly higher (P < 0.001) while CD4+ IL-2+ were significantly lower (P < 0.02) in patients when compared with the normal controls. Late stage of the tumour was associated with reduced expression of IL-2 in both CD4+ (P < 0.05) and CD8+ (P < 0.03) subsets.

CONCLUSIONS

The tobacco-related intraoral squamous cell carcinoma seems to be associated with multiple systemic immune defects particularly, an impaired CD3+ and CD4+ T cells in the peripheral blood as well as a differential regulation of IL-2 and IL-4 in CD4+ and CD8+ T-cell subsets. The cytokine response in these patients seems to be skewed from protective Th1 to immunosuppressive Th2 type. Thus these patients could be ideal candidate for immunomodulation therapy.

Basic science advances in head and neck oncology: the past decade

Research advances over the past decade have led to a changing perception of the natural history of head and neck cancer. For instance, we now have the capacity to quantify and characterize various environmental carcinogens bound to mucosal DNA. These DNA adducts provide a quantitative measure of a disease process which exists long before clinically defined cancer is recognized. Similarly, histopathologically normal mucosa within head and neck cancer patients is currently known to express multiple genetic abnormalities including increased cellular DNA content, mutations in cell regulatory genes, as well as alterations in growth factors and their associated receptors. These subclinical events may, likewise, be associated with aberrant cellular proliferation and differentiation which provide a target for subsequent therapy. Disease invasion and metastases is now seen as a heterogenous process involving a complex of factors intrinsic to both the host as well as the cancer. Most significantly, advanced disease is not simply defined by its size and location. Rather, the progression of head and neck cancer is a dynamic process characterized by increasing genetic instability leading to an accumulation of critical mutational events. A biologic basis for resistance to treatment is thus being defined. Treatment strategies based on these laboratory advances are emerging and involve monoclonal antibody targeting, cytokines produced through recombinant molecular technology, and gene therapy.

Phorbol dibutyrate plus ionomycin improves the generation of cytotoxic T cells from draining lymph nodes of patients with advanced head and neck cancer

Fifty-one cervical nodes from 19 patients with advanced head and neck cancer were stimulated with phorbol dibutyrate and ionomycin (PDBu + Io) to determine the effect of such stimulation on the generation of cytotoxic T cells and whether this stimulation could bypass the need for autologous tumor stimulation. Lymphocytes stimulated with PDBu + Io demonstrated a sixfold greater in vitro expansion and significantly increased DNA synthesis. Whereas fresh lymphocytes displayed no cytotoxicity, stimulation with PDBu + Io and culture in interleukin-2 (IL-2) led to significant cytotoxicity equivalent to that of lymphocytes stimulated with autologous tumor and IL-2. T cells with the greatest cytotoxicity were generated from patients with nodal metastases. In patients with stage IV tumors, effector cells demonstrating greater lysis of natural killer-resistant targets (Daudi cells) were associated with higher rates of recurrence (50% versus 12%, respectively, p < 0.001). Stimulation with PDBu + Io augments growth and proliferation of lymphocytes from draining lymph nodes and preserves cytotoxicity without the need for autologous tumor. Excluding the need for antigenic stimulation by autologous tumor may prove useful in adoptive immunotherapy procedures.

Effect of IFN-gamma on the expression of MHC class I and class II antigens in a human malignant oral epithelial cell line

This study examined the expression of major histocompatibility complex (MHC) antigens in the KB human carcinoma cell line. MHC class I antigens (HLA-ABC and beta 2microglobulin) were constitutively expressed but not significantly enhanced by interferon-gamma (IFN-gamma). By contrast, MHC class II antigens were absent or expressed minimally on unstimulated KB cells, but DR and DP were significantly stimulated in a non-coordinated pattern (HLA-DR greater than -DP greater than -DQ) by IFN-gamma.

Inhibition of lymphokine-activated killer cell generation by blocking factors in sera of patients with head and neck cancer

Cytolytic activation of peripheral blood lymphocytes by recombinant interleukin-2 (rIL-2) in patients with squamous cell carcinoma (SCC) of the head and neck may be inhibited by serum blocking factors, and this could influence therapeutic efficacy. Peripheral blood lymphocytes from 21 patients with this disease and 17 controls were incubated with 10-1000 U rIL-2 for 6 days in supplemented complete medium (containing 10% fetal calf serum) or the same medium plus 10% autologous serum. After washing the effector cells, we determined their cytotoxicity against K562 and MDA1386, a lymphokine-activated-killer(LAK)-sensitive SCC cell line, using a 51Cr-release assay. Patient sera inhibited LAK-generated lysis of both MDA1386 and K562, while control sera from healthy persons inhibited LAK-generated lysis of MDA1386. The blocking activity of patient sera tended to be greater than that of control sera. The sera of patients with untreated or recurrent disease and those who were free of disease had equivalent inhibitory capacity. The serum blocking factor acted in a dose-dependent manner, and inhibition was overcome by increasing the dose of rIL-2. Levels of circulating immune complexes (measured by the C1q binding method) did not correlate significantly with inhibition. A clinical protocol of repeated plasma exchange in patients with advanced and recurrent squamous cell carcinoma of the head and neck allowed sequential study of one patients's serum before, during, and after treatments. Plasmapheresis removed serum inhibitory factors, albeit temporarily. The activity of serum blocking factors in patients with this disease can be modulated by increasing doses of rIL-2 and by plasma exchange. This modulation may be important to improving clinical response rates for patients undergoing immunotherapy.

An immunologic profile of young adults with head and neck cancer

Numerous reports have suggested, although never demonstrated, a suppressed immune defense mechanism as a contributing factor in the development of head and neck cancer in the young adult. Twenty-four previously untreated adults less than or equal to 40 years of age with squamous cell carcinoma were examined for lymphocyte function (natural killer cell activity and in vitro lymphocyte blastogenesis response to mitogens), total lymphocyte number and percentage of lymphocyte subsets, and humoral immune status (circulating IgA, IgG, and IgM). As compared with 33 healthy young adults, no significant immunologic deficit could be identified. On the contrary, the young adult cancer population had significantly increased lymphocyte numbers (P less than 0.05) and serum IgA, IgG, and IgM levels (P less than 0.001, respectively). These young cancer patients cannot be considered to be immunosuppressed. Alternative biologic mechanisms must be defined to account for the increasing incidence of head and neck cancer over the last decade among young adults in the United States.

Natural killer and lymphokine-activated killer cell-mediated cytotoxicity in patients with oral cancer

Peripheral blood lymphocytes (PBL) from untreated and treated oral cancer patients, lymph node lymphocytes (LNL) from metastatic (met) and nonmetastatic (non-met) lymph nodes, and tumor infiltrating lymphocytes (TIL) were tested for natural killer (NK) and lymphokine activated killer (LAK) cell cytotoxicity using appropriate targets in a short-term chromium release assay. The results showed that while both NK and LAK functions of PBL from oral cancer patients were comparable to those of normal healthy donors, the NK activity of metastatic and nonmetastatic LNL and TIL was highly compromised. On the other hand, potent LAK activity could be generated from all three lymphoid populations. Individual patients showing low NK activity displayed good LAK cytotoxicity, indicating that endogenous cells with low NK potential have adequate ability to respond to interleukin 2 (IL-2). LAK activity tested on autologous tumour targets revealed that TIL were the best source of LAK cells. followed by PBL and LNL.

Extent and diversity of inflammatory cell infiltrates in squamous cell carcinomas and basal cell epitheliomas of the head and neck

Using monoclonal antibodies reactive with Langerhans' cells (LCs), macrophages, and T cell subpopulations, the density and proportions of cells of the immune system of the normal oral mucosa were determined immunohistochemically, and compared with findings in oral squamous cell carcinomas (SCC) and basal cell epitheliomas (BCE). In normal oral epithelia, the dominant cell type was the LC, positive for CD 1, and expressing HLA-DR antigens (DR+). Many intraepithelial cells were lymphocytes of the suppressor/cytotoxic phenotype (CD 8+), which was also the most prominent cell type in the normal mucosal stroma. Significant differences were observed for the content of CD 8-, OKM 1-, and CD 4-positive cells in the epithelium of normal oral mucosa, SCC, and BCE, and for the amount of CD 1-positive Langerhans cells in the connective tissue of the different groups of tissues. When CD 4/CD 8 ratios were calculated, differences between SCC and BCE became most evident. A CD 4/CD 8 ratio greater 0.5 was seen to be characteristic for BCE. Thus, in contrast to the striking preponderance of suppressor/cytotoxic lymphocytes (CD 8+) in SCC, BCE showed typically almost balanced numbers of suppressor/cytotoxic (CD 8+) and helper/inducer (CD 4+) lymphocytes. This finding further underlines the biological differences recognized between these most common neoplasias of the head and neck.

Pharyngeal carcinoma and natural killer cell activity

An evaluation of natural killer cell activity was performed in 42 patients with pharyngeal carcinoma. Compared with age- and sex-matched control subjects, the cancer patients expressed significantly lower cytotoxicity against K562 target cells (68 +/- 8 lytic units versus 99 +/- 8 lytic units, p less than 0.01), with 52 percent of the patients expressing deficient activity (below 1 standard deviation of the mean activity of the control population). The probability of deficient activity was greater in these patients than observed in patients with cancer of other head and neck sites. Although natural killer cell activity was lower in patients who drank alcohol or had nodal metastases, no single clinical factor was predictive of deficient cytotoxic response. Prospective longitudinal evaluation (mean = 12 months) of these pharyngeal cancer patients demonstrated that deficient natural killer cell activity measured before treatment identified a population with a significantly increased risk for the development of distant metastases. Distant metastases developed in 7 of 18 patients (39 percent) with deficient natural killer cell activity. In contrast, none of the 16 patients with normal natural killer cell function had evidence of distant disease at last follow-up (p less than 0.01). Deficient natural killer cell activity exists in patients with pharyngeal cancer and is an independent marker for the subsequent development of distant metastases.

Phenotypic identification of mononuclear cells in oral premalignant lesions and cancer by monoclonal antibodies

To explore the nature and importance of mononuclear cells of different phenotypes in oral premalignant lesions and oral cancer, we studied biopsy specimens from 21 oral red and/or white lesions (6 hyperkeratosis, 3 mild dysplasia, 4 severe dysplasia and 8 squamous cell carcinoma), using monoclonal antibodies and avidin-biotin-peroxidase complex staining. Peripheral blood samples (PB) from 4 normal subjects and 5 reactive lymph nodes (LN) were used as controls for the technique. T11-positive cells were the predominant phenotype (74-78%) in all cases examined. The T4/T8 ratio in severe dysplasia was significantly lower than that in mild dysplasia (p less than or equal to 0.05). These observations support the hypothesis of a role for cellular immune responses in oral premalignant lesions and oral cancer. The predominance of T cells may represent the local expression of immunity against antigens (viral or other). The decreased T4/T8 ratio observed in severe dysplasia may represent a transitory stage of local immunosuppression, which may be of critical importance for the progression into carcinoma. Phenotypic variations in mononuclear cell infiltrates in these conditions could be diagnostic value.

Gastrointestinal cancer-associated antigen (GICA) in oral carcinoma

Gastrointestinal cancer-associated antigen (GICA) is detected by means of a monoclonal antibody in the serum and pathologic tissues of patients with gastrointestinal tumors. This article compares serum and salivary GICA and carcinoembryonic antigen (CEA) levels in 19 healthy control subjects, 17 patients with benign oral cavity lesions, and 11 patients with squamous cell carcinoma of the oral cavity. Serum CEA levels were similar in all three groups, whereas salivary CEA levels were higher in patients with squamous cell carcinoma than in the control subjects (p less than 0.001) and the patients with benign lesions (p less than 0.025). Serum GICA levels gave the opposite result and were significantly lower in squamous cell cancer when compared with control subjects (p less than 0.0001) and patients with benign lesions (p less than 0.02). Values of GICA in saliva of patients with oral cancer were also lower than in the control subjects (p less than 0.02). The possible significance of this difference between the two antigens is discussed.

In vivo and in vitro observation of cellular immune parameters in squamous cell carcinoma of the oral cavity and its correlation with tumor load and prognosis

In vivo and in vitro observations of cellular immune response in 70 patients with squamous cell cancer of the oral cavity and in 40 age-matched normal controls, were made using delayed hypersensitivity responses to DNCB, PPD, and Candida albicans extract (Dermatophytin 'O'), absolute lymphocyte counts, absolute T-cell numbers, and PHA-induced lymphocyte blastogenesis reactions as parameters. The results were correlated with clinical stage, tumor size, lymph node involvement, tumor differentiation, lymphoreticular responses, and outcome during a one-year follow-up period. A significant degree of impairment of both in vivo and in vitro parameters was found in oral cancer patients compared to normal control. The impairment was more prominent in advanced stages. Lymph node involvement was associated with impaired dermal hypersensitivity to recall antigens as well as a reduced T-cell population and blastogenic response. Only delayed hypersensitivity response to DNCB, PPD, and Candida showed a correlation with histologic features such as tumor differentiation and lymphoreticular response. Although absolute lymphocyte counts and T-cell population were reduced in the primary stage of the disease, the functional capacity of isolated lymphocytes to undergo blast formation was retained. PHA-induced lymphocyte blastogenesis showed a significant impairment only when the tumor was well established and disseminated beyond its local confines. Delayed hypersensitivity responses to DNCB, higher T-cell counts, and blastogenic indices were associated with recurrence-free survival. Immunologic parameters provide prognostic information beyond the clinical stage of the disease. Therefore, it seems that a multiparametric in vivo and in vitro observation of cellular immune response may be useful as an indicator of clinical course and prognosis of patients with squamous cell cancer of the oral cavity.

Cell-mediated immune status in patients with squamous cell carcinoma of the oral cavity

Sixteen untreated patients with squamous cell carcinoma of the oral cavity were tested for in vitro immune status in comparison with the normal healthy donors. The parameters investigated were total leukocyte and lymphocyte counts, percentages and absolute counts of T- and B-cells in circulation, subsets of T-cells identified by the Fc receptors, phytohemagglutinin (PHA), and mixed lymphocyte culture (MLC) responses, natural killer (NK) and antibody-dependent cellular cytotoxicity (ADCC) activities, and circulating immune complexes (CICs). Eight of these patients were retested 3 to 6 months after surgery. The results showed that there was an increase in leukocyte and lymphocyte counts, an increase in the percentage and absolute number of B-lymphocytes, an increase in the percentage of T-gamma cells, suboptimal PHA and MLC responses, normal NK and ADCC activities, and increased levels of CICs in untreated oral cancer patients. In the postoperative stage, except for a reduction in leukocyte and lymphocyte counts, other abnormalities remained unchanged. The CICs in treated patients correlated with the tumor load in that in three patients showing recurrence, the CIC level remained elevated, whereas in patients without evidence of the disease the CIC level was either low or comparable to the upper normal limits.

Humoral immune responses to adenoviruses, herpes virus type 1, and Candida albicans in sera of dental patients with oral neoplastic and periodontal diseases

Levels of immunoglobulin class-specific antibodies as determined by solid phase radioimmunoassays to herpes simplex virus type 1 (HSV-1), human adenovirus types 5, 21, and 31 and to Candida albicans in sera from untreated healthy dental patients were not significantly different from levels of these antibodies in sera from untreated dental patients with benign oral tumors, oral carcinoma, or periodontal disease. These results show that higher levels of immunoglobulin class-specific antibodies to HSV-1, the three adenoviruses, or Candida albicans are not a consistent finding in sera from patients with oral cancer when comparisons are made with healthy patients and patients with other oral diseases.

Oral carcinoma: evidence for viral oncogenesis

Since early this century, when Rous (1911) first demonstrated the association of a tumour (chicken sarcoma) with a transmissible agent, evidence has accumulated on possible associations between viruses and various neoplasms. There is now conclusive evidence linking some RNA viruses (Temin, 1972) and DNA viruses (Rapp, 1973) with tumours in animals--including sub-human primates (Leading article, 1982). Indeed, a serious complication of hepatitis B infection in man is now recognised to be hepatocellular carcinoma. (Editorial, 1982). The evidence association other viruses with human neoplasms is not unequivocal but there are strong associations between, for example, herpesviruses and some human malignant neoplasms (Klein, 1972; Rapp, 1973; zur Hausen, 1975).