Immunologic unreactivity in bladder cancer patients

Prognostic relevance of preoperative circulating CD8-positive lymphocytes in the urinary bladder recurrence of urothelial carcinoma

OBJECTIVE

Tumor-infiltrate lymphocytes (TIL) have been associated with favorable outcomes in various tumors including urothelial carcinoma (UC). There is little literature about peripheral blood lymphocytes (PBL). Our objective is to investigate the clinical significance and relevance of PBL on the outcomes of UC patients.

MATERIALS AND METHODS

Ninety UC treated patients at Chia-Yi Christian hospital were enrolled. Preoperative PBLs were collected and analyzed for the percentage of each subpopulation of lymphocyte using flow cytometry. The prognostic values were calculated by using Kaplan-Meier curve and Cox progression model for univariate and multivariate analyses, respectively. Furthermore, available tumor specimens from 27 patients were further analyzed for number of CD8(+) tumor infiltrating lymphocytes (TIL) using immunohistochemistry. The correlation between percentage of CD8+ PBL and number of CD8+ TIL was analyzed using a linear regression model.

RESULTS

The log-rank test showed that tumor location (urinary bladder vs. upper urinary tract), enrolled status (primary or recurrent), and CD8(+) PBL were significant prognostic indicators of recurrence (P values, 0.043, 0.039, and 0.018, respectively). Cox analyses showed that CD8(+) PBL was the sole independent prognostic indicator for recurrence-free survival (P = 0.048). The results using a linear regression analysis showed there was a reverse correlation between CD8(+) TIL and PBL (r(2) = 0.635, P < 0.0001).

CONCLUSIONS

In our investigation, preoperative CD8(+) PBL was an independent predictor for bladder recurrence. The percentages of CD8(+) PBL were reversely correlated with the number of TIL. Such findings may benefit in the decision for subsequent intravesical therapy after surgery.

Immunological studies of anergic patients

Sixty-one patients with a variety of different illnesses were studied with respect to skin test anergy and the presence of serum chemotactic inhibitors. In initial testing, 55% of the patient tests demonstrated negative skin test responses to all six test antigens. Sera from 65% of these anergic patients were capable of suppressing the migration of normal polymorphonuclear leukocytes toward chemotactic factors. Statistical analysis of the association of anergy and chemotactic inhibitory sera resulted in a P value of <0.0005. Chemotactic inhibitory sera were also capable of suppressing monocyte chemotaxis. No association of chemotactic inhibitory activity and lymphocytotoxic antibody or suppressors of mitogen-induced lymphocyte blast transformation were noted. In addition, T-cell populations in some anergic patients were studied by the erythrocyte-binding technique. Erythrocyte-binding lymphocytes in anergic patients were significantly suppressed when compared to normal controls, but not when compared to skin test-positive patients. The data presented here indicate a close parallel between skin test anergy and the presence of serum chemotactic inhibitory activity. The exact relationship is yet undefined but may indicate the involvement of chemotactic inhibitors as immunological regulators in the host during a variety of systemic illnesses.

Flow cytometric analysis of Th1 and Th2 cytokines in PBMCs as a parameter of immunological dysfunction in patients of superficial transitional cell carcinoma of bladder

Transitional cell carcinoma (TCC) is the commonest cancer of the bladder. Although majority of TCC can be diagnosed at an early stage and removed easily by transurethral resection of tumor (TURT), the management of this carcinoma is complicated due to frequent recurrences usually within 6 months to one-year period. An imbalance between the Th1 and Th2 immune responses has been attributed to immune dysregulation in various malignancies. The present study aims to evaluate the Th1 and Th2 balance in Peripheral Blood Mononuclear Cells of 41 TCC patients (20 recurrent and 21 non-recurrent) using flow cytometry. It also further assesses immunological and cellular factors influencing the anti-neoplastic activity of the TCC patients and in 21 normal healthy subjects in terms of their cytokine expression and various cell surface markers. The findings of the study revealed that the cell surface markers CD3+, CD4+ and CD8+ along with NK cells were found to be significantly lower in patients than healthy controls (p < 0.01). The mean percent expression of CD4+ was significantly lower in patients showing recurrence (23.9 +/- 9.84) as compared to patients with non-recurrence (31.1 +/- 12.27). The percentage of CD4+T-cells (mean +/- SD) producing IFN-gamma, IL-2 and TNF-alpha were statistically significantly reduced in patients (19.1 +/- 4.94, 52.3 +/- 20.86 and 12.8 +/- 4.49) as compared to healthy controls (23.3 +/- 3.67, 67.5 +/- 12.0 and 17.6 +/- 5.96 respectively), (p < 0.01, 0.018, 0.001). On the contrary, the mean levels of IL-4, IL-6 and IL-10 in patients (63.8+/-17.01, 60.4+/-14.79 and 65.7 +/- 14.84 respectively) were significantly higher as compared to healthy controls (24.4 +/- 8.77, 26.5 +/- 5.28 and 20.6 +/- 3.81 respectively), (p < 0.001). No statistically significant difference was observed in the cytokine expression between patients showing recurrence and non-recurrence. Patients with bladder cancer seem to develop a Th2 dominant status with a deficient type1 immune response. The lymphocyte evaluation along with cytokine measurement can provide a sensitive and valuable tool for evaluating the function of cell-mediated immunity in these patients and can also find application in therapeutic monitoring of bladder cancer patients as new targets for immunotherapy.

Immunotherapy with keyhole limpet hemocyanin: efficacy and safety in the MB-49 intravesical murine bladder tumor model

The antitumor activity and potential toxicity of a clinical-grade keyhole limpet hemocyanin preparation (KLH-Immune Activator; KLH-IA) were determined in the MB-49 intravesical murine bladder tumor model. Mice were immunized subcutaneously with KLH-IA two weeks prior to intravesical implantation of MB-49 tumor cells. Treatment consisted of intravesical KLH-IA (10 or 100 micrograms.) 1, 4, 7, 14 and 21 days after implantation. Control animals either were not immunized prior to tumor implantation and KLH-IA treatment, or were immunized with KLH-IA and treated with the vehicle. By 4 weeks after implantation tumor outgrowth in the treated groups was significantly decreased (p < 0.01, Fisher's Exact) relative to the control groups. Prior subcutaneous immunization was required to elicit antitumor activity of KLH-IA; thus, the mechanism of action is immune-mediated and not due to spurious interference with tumor implantation by intravesical instillations. Animals treated with a dissociated form of KLH exhibited decreased tumor outgrowth approaching, but not attaining, significance (p < 0.09, Fisher's Exact). A separate toxicity study in which KLH-IA was given subcutaneously (4 mg./kg.), intraperitoneally (40 mg./kg.), or intravesically (40 mg./kg.) disclosed no significant gross or histopathologic abnormalities except for mild-to-moderate papillary hyperplasia in all catheterized animals. These results establish the efficacy and safety of KLH-IA in mice and suggest that clinical trials for intravesical treatment of superficial bladder cancer may be warranted.

Keyhole limpet hemocyanin immunotherapy of murine bladder cancer

The current treatment of choice for superficial bladder cancer, bacillus Calmette-Guérin, has significant adverse side effects. We have compared two alternative immunotherapies--crude keyhole limpet hemocyanin (KLH) and Immucothel, a KLH modified for clinical use (Biosyn)--in an intralesional mouse model of bladder cancer (MBT2). Crude KLH required either immunization before tumor transplant or frequent intralesional therapy after transplantation to be effective. In addition, Immucothel required pre-immunization to be effective, and increasing the frequency and dosage of post-transplant immunization was not effective without pre-immunization. Preliminary investigations into the KLH-induced anti-tumor mechanism(s) suggest that natural killer cell activity may be involved. Both crude KLH and Immucothel appear to be effective immunotherapies of use in the treatment of transitional cell carcinoma.

Analysis of natural killer activity and natural killer cell subsets in patients with bladder cancer

In order to analyze the state of the natural resistance system of bladder cancer patients in vivo, we measured natural killer (NK) activity and NK cell subsets of peripheral blood lymphocytes (PBL) from 46 patients with bladder cancer and 25 age- and sex-matched healthy volunteers. The mean NK activity in patients with low-stage bladder cancer was similar to that in the controls, while NK activity in patients with high-stage bladder cancer was significantly depressed. The mean proportions of Leu7+ cells in patients with both low-stage and high-stage bladder cancer were significantly higher than that in the controls. The mean proportion of Leu11 a+ cells in patients with low-stage bladder cancer was similar to that in the controls, while in patients with high-stage bladder cancer it was significantly higher. This study demonstrates the abnormal immunological state of bladder cancer patients: namely, abnormalities exist not only in NK activity but also in the proportions of circulating NK cell subsets.

Superficial bladder cancer. Risk of recurrence and potential role for interferon therapy

Superficial bladder tumors--cancer in situ (CIS) and papillary transitional carcinoma of the bladder--are the most frequent presentations of bladder cancer, the second most common disease of the urethelial tract. These superficial tumors demonstrate a tendency to recur, either at the same stage and grade or as deeply invasive tumors. To some extent, the likelihood of tumor recurrence can be predicted, based on certain risk factors. Furthermore, the probability of recurrence can be altered through appropriate clinical interventions. A review of the literature, much of which is preliminary, suggests that interferon therapy for bladder cancer may modify the biologic behavior of this disease and provide clinical benefit for some patients.

Urinary tract infection in boys

Considerable literature exists regarding the evaluation and treatment of children with urinary tract infection yet little has been reported solely about boys. We reviewed retrospectively 83 boys who were seen after an initial urinary tract infection. Fever was the most common presenting sign (50 per cent) and the most common organisms encountered were of the gram-positive group of bacteria. Escherichia coli accounted for only 21 per cent of the infections. Of the boys 75 per cent (62 patients) had an anatomic abnormality, most commonly vesicoureteral reflux, although more than 25 per cent of our patients had obstructive lesions. Renal scarring was present in half and 58 per cent required early surgical intervention. Urinary tract infection seems to have a higher morbidity in boys and the finding of an atypical organism is to be expected. Based on our findings, we strongly recommend an excretory urogram and a voiding cystourethrogram as the minimal evaluation of boys following an initial urinary tract infection.

The predictive value of 2,-4, dinitrochlorobenzene skin testing in patients with bilharzial bladder cancer

A group of 40 patients with bilharzial bladder cancer underwent quantitative skin testing with dinitrochlorobenzene and purified protein derivative of tuberculin before radical surgery. Correlations were made between various clinical parameters, patient outcome, skin test results and pathologic changes in the resected bladder and draining lymph nodes. Striking associations between dinitrochlorobenzene responses and tumor stage, tumor recurrence and several specific parameters of lymph node stimulation were found, while no correlations were made with the pathologic grade, size or type of tumor, degree of schistosomal infestation or tumor bed inflammation. Purified protein derivative responses showed no correlation with any parameter examined. Patient outcome also showed a good correlation with tumor stage and draining lymph node reaction. These findings indicate that dinitrochlorobenzene skin testing as a presumptive test of cell-mediated immunity may represent a good predictor of clinical outcome in patients with bilharzial bladder cancer, and correlates well with draining lymph node stimulation.

Immunological profile of patients with transitional cell carcinoma of the bladder

The immunological profile of 58 patients with various stages of transitional cell carcinoma of the bladder was determined by using the local xenogeneic graft versus host reaction (GVHR) test, by skin testing with 3 recall antigens (candida, trichophyton, streptokinase-streptodornase) and by quantification of T-lymphocytes. Thirty-two patients with low grade low stage tumours (Group A) showed only a slight impairment of the immunological profile with a slight decrease in T-lymphocytes, 4.4% negative GVHR tests and 31.2% negative skin tests. Ten patients with highly invasive inoperable tumours (Group B) showed a severe impairment of the immunological profile with a significant decrease in T-lymphocytes, 100% negative GVHR and 80% negative skin tests. A marked improvement in the immunological profile was noted while comparing 9 patients who were examined within 6 months after cystectomy (Group CI) (severe decrease in T-lymphocytes 44.4% negative GVHR tests and 66.6% negative skin tests) with 7 patients who were examined 18 months or more after operation (Group CII) (slight decrease in T-lymphocytes 0% negative GVHR and 42.8% negative skin tests). Incubation of T-lymphocytes with a thymic hormone (THF) caused an increase in the extent of the graft versus host reaction in 10 out of 14 patients with low grade low stage bladder tumours. This may represent an improvement in the functional activity of the T-lymphocytes with a possible therapeutic use in the future.

Cellular immunity in bladder cancer patients

The leukocyte adherence inhibition test was used to evaluate the cellular immune status of 16 patients with a histological diagnosis of transitional cell carcinoma of the bladder. The reactivity of the leukocytes was measured against extracts of transitional cell carcinoma as well as renal cell carcinoma. The leukocytes of age and sex-matched control subjects, as well as patients with urinary tract infection, also were studied. The leukocytes of patients with transitional cell carcinoma were more reactive to extracts of transitional cell carcinoma. These results suggest that a response to tumor-associated antigens is present in transitional cell carcinoma patients.

Suppressive effects of regional lymph node cells and extracts of antibody-dependent cellular cytotoxicity

Lymphocytes from regional lymph nodes that drain tumors and extracts of such lymphocytes suppress antibody-dependent cell-mediated target cell lysis by effector cells from cancer patients and controls. In contrast, lymph node cells from control patients are not suppressive. Control extracts from normal lymphocytes and 2 immunologically inert tissues, muscle and kidney, exhibit some suppressive activity but significantly less than extracts from lymph nodes that drain tumors.

Levamisole in the treatment of non-invasive and invasive bladder cancer: a preliminary report

We have done a double-blind, randomized, controlled study on 37 patients with transitional cell carcinoma in which levamisole was used as an immune adjuvant in addition to the standard therapy for non-invasive and invasive bladder cancer. Levamisole is administered easily and is well tolerated, especially when compared to other immune adjuvants, such as bacillus Calmette-Guérin or Corynecbacterium parvum. Recall antigens, dinitrochlorobenzene reactivity and total lymphocyte count demonstrated little correlation to the initial stage of disease. Monocyte chemotaxis was increased significantly in patients receiving levamisole. Since our study is ongoing on data exist as yet to make any statement regarding the efficacy of levamisole in the treatment of bladder cancer.

Adenosine deaminase activity in patients with carcinoma of the bladder

Adenosine deaminase is an important enzyme in purine metabolism, and patients with abnormal lymphocyte and erythrocyte adenosine deaminase levels have been shown to have impaired immune competence. Since immune factors have been shown to be important in patients with transitional cell carcinoma of the bladder we studied adenosine deaminase activity in the hemic cells of 48 patients with this tumor. Lymphocyte adenosine deaminase levels were elevated in patients with transitional cell carcinoma and correlated with stage, activity, clinical course and tumor resection but not with tumor grade. Erythrocyte adenosine deaminase levels also were elevated in patients with transitional cell carcinoma but did not correlate with other disease parameters. Lymphocyte adenosine deaminase activity in patients with transitional cell carcinoma may be a sensitive indicator of disease activity and further studies may provide insight into the host-tumor relationship at the enzyme level.

Re-evaluation of hydrostatic pressure treatment for malignant bladder lesions

We reviewed 50 cases of bladder cancer treated with the hydrostatic pressure technique. Results were encouraging when 1) single or multiple papillary tumors were not located around the ureteral orifice, with a presumed depth of tumor infiltration within T2, I) there was no history of open operations, 3) there was observed activity of immunological surveillance, for example a positive reaction to a tuberculin test, and 4) management of anesthesia was satisfactory. Hydrostatic pressure therapy is not palliative treatment for far-advanced cases of bladder cancers but should be the first choice for new cases beyond the scope for transurethral operations and when indications in tumor and host condition are satisfied.

Commentary on the immunobiology of bladder cancer

This review is an attempt to integrate the conflicting studies that constitute the literature on immunobiology of bladder cancer and to indicate areas that need further investigation. It is clear that immune reactivity directed at antigens expressed on bladder cancer cells and general host immunologic competence decline with progressive tumor growth. This immunodepression correlates with patient prognosis, even within a given stage of disease. The mechanisms underlying this decline in host immune reactivity are poorly understood. A better understanding of these mechanisms may provide fundamental insight into the host-tumor relationship that possibly could be exploited for preventive, diagnostic and therapeutic purposes.

Immune evaluation with skin testing. A study of testicular, prostatic, and bladder neoplasms

Fifty patients with testicular carcinoma, 45 with prostatic neoplasm, 84 with bladder carcinoma, and 13 with benign bladder papilloma were evaluated for skin reactivity to DNCB and other intradermal antigens. Correlation between pathologic staging and skin-test reactivity was sought. Reaction to DNCB among patients with testis tumors was more significantly depressed by chemotherapy than by the extent of retroperitoneal or distant metastatic disease indicating that skin testing as a means of following the course of disease or of predicting survival may be limited by alterations caused by chemotherapy. DNCB reactivity did not correlate with the prognosis for the different stages of disease, but follow-up studies of individual patient survival are needed for substantiation. Depression of DNCB reactivity exists among patients with prostatic carcinoma whether the disease is localized or widely metastatic. Only lengthy follow-up will determine if there is any correlation of reactivity with survival in individual patients. DNCB reactivity among patients with bladder tumors shows progressive reduction with increasing stage disease and lends support to the evidence suggesting immune deficiency in patients with bladder neoplasm.

Anergy and tryptophan metabolism in bladder cancer

The tryptophan loading test and cutaneous antigen test were done on 55 patients with various stages of bladder cancer. Patients with an abnormality of tryptophan metabolism showed a greater degree of unreactivity to cutaneous delayed hypersensitivity testing. Of the 23 patients with normal tryptophan metabolism 47 per cent were unreactive to 2 or 3 skin antigens. Of 13 patients with 1 abnormal tryptophan metabolite 62 per cent were unreactive to 2 or 3 skin antigens. Of 19 patients with 2 or more abnormal tryptophan metabolites 68 per cent were unreactive to 2 or 3 antigens.

Evaluation of renal masses including retrograde renal brushing

1. The evaluation of renal masses has become an increasingly important topic because of the increasing incidence of kidney cancer, the improved cure rate of renal carcinoma with the proper preoperative diagnosis, and the proliferation in renal mass diagnostic methodology. 2. A variety of benign entities can produce an abnormal renal mass with attendant difficulties in being distinguished from malignant neoplasms. Among these benign lesions are: simple renal cysts, polycystic kidneys, congenital variations in renal size and shape, segmental renal hypertrophy, renal infarcts, intrarenal hematomas, renal hamartomas, renal leiomyomas, renal adenomas, renal angiomas, renal fibrolipomatosis, hydronephrosis of a duplicated collecting system, renal abscesses, and xanthogranulomatous pyelonephritis. 3. Nephrotomography, nephrosonography (ultrasound), adrenalin renal arteriography, selective magnification renal arteriography, renal venography and cavography, lymphangiography, renal scintillation scanning, abnormal levels of enzymes in blood and urine, immunologic studies (circulating antibodies and tumor-associated antigens), percutaneous needle aspirations, and retrograde renal brushing have all increased the diagnostic accuracy of determining the etiology of renal masses. None of these diagnostic procedures is infallible. A judicious combination of procedures gives the most reliable diagnostic results. 4. A search continues for (a) chemical agent(s) or a chemical profile in the blood or urine which is (are) specific for renal carcinoma, but as yet this is an investigational area and not a practical clinical reality.

Immunostaging in carcinoma of prostate

Immunostaging is a new method of assessing patients immunologically before and after immunotherapy. Twenty-eight patients with adenocarcinoma of the prostate were immunostaged independently by two investigators. There was a positive correlation between both immunostagings. There was also a positive correlation between the patient's immunostage and the clinical stage of his cancer.

Prognostic value of host immunocompetence in urologic cancer patients

To evaluate the prognostic significance of host immunocompetence in urologic cancer patients, the subsequent clinical course of 95 patients was determined a year after skin testing with dinitrochlorobenzene. A close correlation was demonstrated between dinitrochlorobenzene reactivity and prognosis among 38 transitional carcinoma patients. Of 19 patients with impaired reactivity 13 had tumor recurrences and 11 of these died of cancer within 1 year. Only 5 of 19 patients with normal dinitrochlorobenzene reactivity had recurrences and none died during the same interval. Although not statistically significant, similar results were observed among 10 renal cell carcinoma patients of whom 3 of 5 with impaired dinitrochlorobenzene reactivity had tumor recurrences, while 4 of 5 with normal reactivity remained free of tumor. One testis tumor patient with impaired dinitrochlorobenzene reactivity died of cancer, while 3 of 4 with normal reactivity remained free of tumor. Similarly, 1 patient with carcinoma of the penis with impaired dinitrochlorobenzene reactivity died of cancer, while 2 of 3 with normal reactivity remained free of tumor. In contrast, reactivity to dinitrochlorobenzene did not correlate with the clinical course of 38 prostatic carcinoma patients. Ten of 19 patients with normal dinitrochlorobenzene reactivity and 9 of 19 with impaired reactivity were dead or had symptomatic recurrences within 1 year, while 9 of 19 with normal reactivity and 10 of 19 with impaired reactivity were either free of tumor or asymptomatic. However, a trend toward a correlation between dinitrochlorobenzene reactivity and tumor progression was observed among patients not receiving endocrine therapy. The differences with respect to the prognostic significance of host immunocompetence between transitional carcinoma patients and those with prostatic carcinoma may be explained by fundamental differences in the biologic properties of these tumors, especially the endocrine sensitivity of prostatic carcinoma.

Cellular immunity in neoplasia. Antigen and mitogen responses in patients with bronchiogenic carcinoma

Cellular immune responses of patients with histologically confirmed lung carcinoma were assessed in vivo using cutaneous response and in vitro with a microlymphocyte blastogenic transformation (LBT) assay. In addition, correlation of the cutaneous response with the migration inhibitory factor (MIF) assay and LBT response was examined. The results indicated that cutaneous responses seen in patients with cancer of the lung were consistently lower than similar responses in normal controls (p less than 0.001). Similarily, the percentage of positive cutaneous responses seen with patients included in this study was lower than the frequencies reported by others. Stimulation of cells from lung cancer patients by PHA-M was also depressed when compared to similar lymphocytic responses in normal volunteers (p less than 0.001). The correlation between cutaneous response to tuberculin and the in vitro assays was high. The few instances of disparity demonstrate the need to utilize more than one assay in evaluating cellular immune functions. These data would support the work of others that indicate a depression of cellular immunity in advanced malignancy.

Study of local and systemic effects of intravesical BCG

Defects in cell-mediated immunity have been implicated as one of the underlying causes for the appearance and progression of neoplasms. One approach toward correcting these defects employs immune potentiators for the purpose of stimulating cell-mediated immunity. BCG is the immune potentiator which has been used most frequently in the experimental and clinical situation. A preliminary study directed toward ascertaining the local histologic changes and systemic serum response to BCG injection in the dog bladder was undertaken in anticipation of its possible application in the treatment of bladder neoplasm. Local response was predictable and was associated with low morbidity. The appearance of serum precipitin bands to culture filtrates of Mycobacteria tuberculosis strains strongly suggests systemic absorption and reaction to BCG administered intravesically.

Studies on the immune status of patients with renal adenocarcinoma

Thirty-one patients with renal carcinoma were divided into 3 groups according to the stage of the disease and evaluated with skin tests to determine cell-mediated immunity and an in vitro chemostaxis assay to measure monocyte function. The patients demonstrated a significant defect in monocyte function, that is the ability to undergo chemotaxis when compared to healthy controls and patients with non-neoplastic disease (p less than 0.001). The defect tended to be more severe in patients with advanced disease. Improvements in monocyte function occurred following nephrectomy in patients with localized disease. The patients were skin tested with recall antigens and dinitrochlorobenzene to determine the presence of a delayed cutaneous hypersensitivity response. Croton oil was used to evaluate the non-specific inflammatory response. These studies indicate that a defect exists in cellular immunity as well as the inflammatory response. Patients with advanced disease tend to be unresponsive to these skin tests while those with localized disease are more likely to react to dinitrochlorobenzene and croton oil.

Skin testing in genitourinary carcinoma: 2-year followup

Compound 2,4 dinitrofluorobenzene was used to sensitize 115 patients with genitourinary cancer to test their ability to be immunized with a newly encountered antigen. In general, patients in whom a cutaneous hypersensitivity response did not develop were more likely to have advanced stage tumors than patients whose immunocompetence was intact. A 2 to 3-year followup showed that patients with impaired cell-mediated immunity were more likely to undergo disease advancement than patients of similar stage whose immunity was normal. Unfortunately, these results cannot be extrapolated for application to a given patient.