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IMPAIRED CELL-MEDIATED IMMUNITY IN HUMAN BRAIN TUMOURS
1389 75 +. In the tenth decade a survival of months or even weeks increases the liability to fracture. In 1961, 38-2% of women aged 65+ were aged over 75 years; in 1970, 394% were over 75. Similar rises in rates of hospital discharges in the age-group 65 + years are recorded for other degenerative diseases of old age-3-4% per year for vascular diseases of the central nervous system and 8 % per year for cerebral paralysis, between 1957 and 1967. In England and Wales1 and the U.S.A.2 mortality of old people from falls is so closely related to mortality from femoral fractures that they may be used to study secular trends. In Britain, there was an increasing mortality throughout this century until about 1958, except for an extraordinary remission in the decade 1940-50, and there has been a decline since 1958. Like Dr Burton and his colleagues, I have attributed secular changes in fracturemortality rates (presumably related to fracture incidence) to differences in ultraviolet radiation. But I related these to atmospheric changes at a much lower stratum of the atmosphere, much more closely related to the local human environment than the stratosphere-i.e., domestic coal smoke.3 18 Denmark Villas, Hove, East Sussex BN3 3TE.
Fig. 1—Effect of increasing P.H.A. concentration on stimulation ratio (mean ± S.E.) in patients and control subjects.
T. P. EDDY.
IMPAIRED CELL-MEDIATED IMMUNITY IN HUMAN BRAIN TUMOURS
SIR— Evidence suggests that cell-mediated immunity is depressed in patients with cancer, particularly in those with generalised metastases.4 This has been demonstrated by impaired cutaneous reactivity to ubiquitous antigens such as tuberculin, candida, and streptokinase/streptodornase.5,6 In addition, such patients show a decreased ability to dinitrochlorobenzene and dinitroto reject homografts, and their lymphocytes show depressed in-vitro The cause responses to phytohaemagglutinin (P.H.A.).7 of this anergy is unknown, although there is some evidence to implicate an immunosuppressive serum factor.8 Such a factor has been found in patients with cancer and also reported recently in patients with glioma.9 Patients with advanced malignancy and multiple metastases have the greatest degree of impairment of delayed hypersensitivity responses.1o Patients with brain tumour rarely have metastasis, and in early cases there is little systemic upset. The brain has been claimed to occupy a privileged immunological site.ll However, brain-tumour-specific antigens have been demonstrated and there is evidence that patients mount an immune response to the tumour.12-15 Indeed, histological examination has shown that the degree of lymphocyte infiltration in glioma is variable 16 and may correlate with survival. This implies that the strength of the immunological defences of the host to some extent become sensitised
to
fluorobenzene,6 have impaired ability
1. 2. 3. 4.
5. 6. 7. 8.
9.
10. 11. 12. 13. 14.
15. 16.
T. P. Br. J. prev. soc. Med. 1973, 27, 247. Iskrant, A. P. Am. J. publ. Hlth, 1968, 58, 485. Eddy, T. P. Nature, Lond. 1974, 251, 136. Eilber, F. R., Morton, D. L. Cancer, 1970, 25, 362. Hughes, L. E., MacKay, W. D. Br. med. J. 1965, ii, 1346. Southam, C. M. Cancer Res. 1968, 28, 1433. Whittaker, M. G., Rees, K., Clark, C. G. Lancet, 1971, i, 892. Glasgow, A. H., Nimberg, R. B., Menzoian, J. O., Saporoschetz, I., Cooperband, S. R., Schmid, K., Mannick, J. A. New Engl. J. Med. 1974, 291, 1263. Brooks, W. H., Netsky, M. G., Normansell, D. E., Horwitz, D. A. J. exp. Med. 1972, 136, 1631. Catalona, W. J., Sample, W. F., Chretien, P. B. Cancer, 1973, 31, 65. Medawar, P. B. Br. J. exp. Path. 1948, 29, 58. Brooks, W. H., Caldwell, H. D., Mortara, R. H. Surg. Neurol. 1974, 2, 419. Kumar, S., Taylor, G. Br. J. Cancer, 1973, 28, suppl. ii, 135. Wahlström, T., Linder, E., Saksela, E., Westermark, B. Cancer, 1974, 34, 274. Levy, N. L., Mahaley, M. S., Day, E. D. Cancer Res. 1972, 32, 477. Ridley, A., Cavanagh, J. B. Brain, 1971, 94, 117.
Eddy,
Fig. 2-Scatter diagram of stimulation ratio of patients and control subjects. reflect on the overall prognosis. Clearly, it is important to know whether a brain tumour can depress cell-mediated immunity. We have studied several patients with malignant glioma, and compared their cell-mediated immune responses to those in patients with disseminated cancer or benign intracranial tumour, and healthy controls. Nine patients with malignant glioma and eight patients with benign intracranial tumour (three acoustic schwannoma and five meningioma) were studied. Eight were men and nine were women, and their ages ranged from 20 to 67 years. At the time of the study the patients were not receiving steroids or cytotoxic drugs, nor had they received radiation therapy. Five other patients with disseminated malignancy and cerebral or spinal metastases were also studied. Forty-nine healthy subjects served as controls
Peripheral-blood lymphocyte protein synthesis
was
measured by a modification of a whole-blood technique already described." Essentially, a 6 ml. venous bloodsample was collected into a syringe wetted by preservative17.
Pauly, J. L., Sokal, J. E., Tin Han. J. Lab. clin. Med. 1973, 82, 500.
1390 free heparin (1000 units per ml.) and diluted tenfold in culture-medium RPMI 1640 containing 100 units of penicillin and 50 (1.g. of streptomycin per ml., and tritiated leucine (specific activity 54 Ci per mmol) at a concentration of 0-5 mCi per ml. This suspension was dispensed in triplicate 3 ml. aliquots to upright tissue-culture tubes 16 x 125 mm. containing various dilutions of purified P.H.A. The tubes were cultured with and without autologous serum, or calf serum, for 22 hours. Then the cells were centrifuged and washed twice with 3% acetic acid, bleached with one drop of 30% hydrogen peroxide, heated at 85 °C for 20 minutes, and dissolved in 0-6 ml. of NCS solubiliser, resuspended in scintillation fluid, and counted for 10 minutes on a Hewlett Packard scintillation counter. The results (figs. 1 and 2) confirm that there is a conspicuous depression of cell-mediated immunity in disseminated neoplasia and show a definite, though less striking, depression in patients with glioma. The apparent depression of cell-mediated immunity in patients with benign intracranial tumour is not significant. In our preliminary study the effect of autologous serum on protein synthesis was not clearly and defined, a more detailed analysis with a larger group of patients would be necessary to elucidate this point. These results show that there is a definite impairment Of P.H.A. responsiveness in lymphocytes of patients with malignant glioma. The impairment of protein synthesis in these lymphocytes may be due to an intrinsic abnormality or to a humoral inhibiting factor in the serum. Further work on analysing this immune defect is in progress and may have important implications for management of intracranial tumour. We gratefully acknowledge the support of the Peel Medical Trust in performing this study. Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF.
D. G. T. THOMAS CATHERINE B. LANNIGAN P. O. BEHAN.
APHTHOUS ULCERATION, CROMOGLYCIC ACID, AND CELLULAR IMMUNE RESPONSE
SIR,-It has been reported that disodium cromoglycate (D.S.C.G.), a known inhibitor of IgE-mediated release of histamine1 and other substances in type-i immune reactions, conveyed in toothpaste, reduces the incidence of recurrent aphthous ulceration.’ In a double-blind trial of cromoglycic acid, the acid form of D.s.c.G., in topical tablet form, we found a significant reduction in the symptoms but not the incidence of recurrent aphthous ulcers.3 In view of the proposal that cell-mediated reactions may play a part in the pathogenesis of aphthous ulceration4 and of the effects of levamisole (a drug thought to modify the cellular immune response) upon aphthous ulceration,5 we determined the effect of D.S.C.G. upon in-vitro lymphocyte responsiveness.6 D.S.C.G. at 100 and 1000 µg. per ml. did not alter the in-vitro lymphocyte response of 6 individuals to a mitogen, P.H.A., and an antigen, P.P.D., as measured by lymphocyte transformation, production of -macrophage migration inhibitory factor, and lymphotoxin production. Both of these concentrations of D.S.C.G. were apparently non-toxic for the lymphocytes in culture. It seems possible that the c.G.A. in the trial was acting upon a second immune component of the ulceration, one giving rise to the pain in the middle of the ulcer life. This second immune phase may be associated with the reduction in the demonstrable 1. Assem, E. S. K., McAllen, M. M. Br. med. J. 1970, ii, 504. 2. Frost, M. Lancet, 1973, ii, 389. 3. Dolby, A. E., Walker, D. M. Br. J. oral Surg. (in the press). 4. Lehner, T. Oral Surg. 1972, 33, 80. 5. Symoens, J., Brugmans, J. Br. med. J. 1974, iv, 592. 6. Walker, D. M., Dolby, A. E. Int. Archs Allergy appl. Immun.
(in the press).
mast-cell content of the ulcers which occurs a few days after onset.’ It is not certain whether the two immune components are related, but if our hypothesis is correct new inhibitory compounds which both inhibit lymphocyte transformation as well as mast-cell degranulation8 are indicated in the treatment of aphthas. We are grateful to Fisons Ltd., Pharmaceutical Division, for financial support for the investigations. Welsh National School of Medicine, Dental School, Heath Park, Cardiff CF4 4XY.
D. M. WALKER A. E. DOLBY.
7. Dolby, A. E., Allison, R. J. J. dent. Res. 1969, 48, 901. 8. Assem, E. S. K. Int. Archs Allergy appl. Immun. 1973, 45, 708.
Obituary HERBERT VICTOR MORLOCK
M.C., M.D.Lond., F.R.C.P.
Dr H. V. Morlock, consulting physician to the London Chest Hospital and the Miller and Hampstead General Hospitals, died on May 18 at the age of 76. In the 1914-18 war, immediately after leaving school, he joined the Rifle Brigade, saw service in France, and was decorated with the M.c. on the field at the age of 19. He qualified M.B. from St. Bartholomew’s Hospital in 1924, and was elected to the staff of the first of his three hospitals at the age of 28. With the late Dr A. J. Scott Pinchin he spent some months in Vienna and on his return started the bronchoscopy clinic at the London Chest Hospital, using an instrument of his own design with a telescope for direct vision. This pioneer work, in which he was later joined by E. H. Hudson, established diagnostic bronchoscopy firmly in the hands of chest physicians and thoracic surgeons and was complementary to the work of H. P. Nelson on postural drainage for bronchiectasis. Some found his dynamic personality a little forbidding, but those who accepted this soon developed for him an admiration coupled with affection. There was about him an endearing streak of eccentricity. He habitually wore the old-fashioned style of dress of a consultant after most others had abandoned it, entirely in keeping with his basic philosophy that whatever you set out to do should be done properly. A story runs that at the beginning of the 1939-45 war patriotism impelled him to give up his Rolls and take to an Austin Seven, only to find that he could not sit in it with his top hat on unless the sunshine roof was open. The war affected him keenly; the arrival of the N.H.S. in 1948 even more so. Feeling that his initiative would be cramped, he withdrew to some extent. When he retired he transferred his boundless energy to riding and the hunting field. We shall cherish the memory of a man of character, a generous, warm-hearted colleague. He is survived by his wife, a son, and a daughter who is herself a doctor.
N. L. R. ANGUS NORMAN MacPHAIL M.C., M.D.Glasg., D.P.H.
Dr A. N.
MacPhail, formerly senior lecturer in medicine and general practice in the community of died on June 1 at the age of 60. University Leeds, He had retired last year owing to ill-health. Angus MacPhail qualified M.B. at Glasgow in 1937, subsequently graduating M.D. with commendation in 1951.
Fig. 1—Effect of increasing P.H.A. concentration on stimulation ratio (mean ± S.E.) in patients and control subjects.
T. P. EDDY.
IMPAIRED CELL-MEDIATED IMMUNITY IN HUMAN BRAIN TUMOURS
SIR— Evidence suggests that cell-mediated immunity is depressed in patients with cancer, particularly in those with generalised metastases.4 This has been demonstrated by impaired cutaneous reactivity to ubiquitous antigens such as tuberculin, candida, and streptokinase/streptodornase.5,6 In addition, such patients show a decreased ability to dinitrochlorobenzene and dinitroto reject homografts, and their lymphocytes show depressed in-vitro The cause responses to phytohaemagglutinin (P.H.A.).7 of this anergy is unknown, although there is some evidence to implicate an immunosuppressive serum factor.8 Such a factor has been found in patients with cancer and also reported recently in patients with glioma.9 Patients with advanced malignancy and multiple metastases have the greatest degree of impairment of delayed hypersensitivity responses.1o Patients with brain tumour rarely have metastasis, and in early cases there is little systemic upset. The brain has been claimed to occupy a privileged immunological site.ll However, brain-tumour-specific antigens have been demonstrated and there is evidence that patients mount an immune response to the tumour.12-15 Indeed, histological examination has shown that the degree of lymphocyte infiltration in glioma is variable 16 and may correlate with survival. This implies that the strength of the immunological defences of the host to some extent become sensitised
to
fluorobenzene,6 have impaired ability
1. 2. 3. 4.
5. 6. 7. 8.
9.
10. 11. 12. 13. 14.
15. 16.
T. P. Br. J. prev. soc. Med. 1973, 27, 247. Iskrant, A. P. Am. J. publ. Hlth, 1968, 58, 485. Eddy, T. P. Nature, Lond. 1974, 251, 136. Eilber, F. R., Morton, D. L. Cancer, 1970, 25, 362. Hughes, L. E., MacKay, W. D. Br. med. J. 1965, ii, 1346. Southam, C. M. Cancer Res. 1968, 28, 1433. Whittaker, M. G., Rees, K., Clark, C. G. Lancet, 1971, i, 892. Glasgow, A. H., Nimberg, R. B., Menzoian, J. O., Saporoschetz, I., Cooperband, S. R., Schmid, K., Mannick, J. A. New Engl. J. Med. 1974, 291, 1263. Brooks, W. H., Netsky, M. G., Normansell, D. E., Horwitz, D. A. J. exp. Med. 1972, 136, 1631. Catalona, W. J., Sample, W. F., Chretien, P. B. Cancer, 1973, 31, 65. Medawar, P. B. Br. J. exp. Path. 1948, 29, 58. Brooks, W. H., Caldwell, H. D., Mortara, R. H. Surg. Neurol. 1974, 2, 419. Kumar, S., Taylor, G. Br. J. Cancer, 1973, 28, suppl. ii, 135. Wahlström, T., Linder, E., Saksela, E., Westermark, B. Cancer, 1974, 34, 274. Levy, N. L., Mahaley, M. S., Day, E. D. Cancer Res. 1972, 32, 477. Ridley, A., Cavanagh, J. B. Brain, 1971, 94, 117.
Eddy,
Fig. 2-Scatter diagram of stimulation ratio of patients and control subjects. reflect on the overall prognosis. Clearly, it is important to know whether a brain tumour can depress cell-mediated immunity. We have studied several patients with malignant glioma, and compared their cell-mediated immune responses to those in patients with disseminated cancer or benign intracranial tumour, and healthy controls. Nine patients with malignant glioma and eight patients with benign intracranial tumour (three acoustic schwannoma and five meningioma) were studied. Eight were men and nine were women, and their ages ranged from 20 to 67 years. At the time of the study the patients were not receiving steroids or cytotoxic drugs, nor had they received radiation therapy. Five other patients with disseminated malignancy and cerebral or spinal metastases were also studied. Forty-nine healthy subjects served as controls
Peripheral-blood lymphocyte protein synthesis
was
measured by a modification of a whole-blood technique already described." Essentially, a 6 ml. venous bloodsample was collected into a syringe wetted by preservative17.
Pauly, J. L., Sokal, J. E., Tin Han. J. Lab. clin. Med. 1973, 82, 500.
1390 free heparin (1000 units per ml.) and diluted tenfold in culture-medium RPMI 1640 containing 100 units of penicillin and 50 (1.g. of streptomycin per ml., and tritiated leucine (specific activity 54 Ci per mmol) at a concentration of 0-5 mCi per ml. This suspension was dispensed in triplicate 3 ml. aliquots to upright tissue-culture tubes 16 x 125 mm. containing various dilutions of purified P.H.A. The tubes were cultured with and without autologous serum, or calf serum, for 22 hours. Then the cells were centrifuged and washed twice with 3% acetic acid, bleached with one drop of 30% hydrogen peroxide, heated at 85 °C for 20 minutes, and dissolved in 0-6 ml. of NCS solubiliser, resuspended in scintillation fluid, and counted for 10 minutes on a Hewlett Packard scintillation counter. The results (figs. 1 and 2) confirm that there is a conspicuous depression of cell-mediated immunity in disseminated neoplasia and show a definite, though less striking, depression in patients with glioma. The apparent depression of cell-mediated immunity in patients with benign intracranial tumour is not significant. In our preliminary study the effect of autologous serum on protein synthesis was not clearly and defined, a more detailed analysis with a larger group of patients would be necessary to elucidate this point. These results show that there is a definite impairment Of P.H.A. responsiveness in lymphocytes of patients with malignant glioma. The impairment of protein synthesis in these lymphocytes may be due to an intrinsic abnormality or to a humoral inhibiting factor in the serum. Further work on analysing this immune defect is in progress and may have important implications for management of intracranial tumour. We gratefully acknowledge the support of the Peel Medical Trust in performing this study. Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF.
D. G. T. THOMAS CATHERINE B. LANNIGAN P. O. BEHAN.
APHTHOUS ULCERATION, CROMOGLYCIC ACID, AND CELLULAR IMMUNE RESPONSE
SIR,-It has been reported that disodium cromoglycate (D.S.C.G.), a known inhibitor of IgE-mediated release of histamine1 and other substances in type-i immune reactions, conveyed in toothpaste, reduces the incidence of recurrent aphthous ulceration.’ In a double-blind trial of cromoglycic acid, the acid form of D.s.c.G., in topical tablet form, we found a significant reduction in the symptoms but not the incidence of recurrent aphthous ulcers.3 In view of the proposal that cell-mediated reactions may play a part in the pathogenesis of aphthous ulceration4 and of the effects of levamisole (a drug thought to modify the cellular immune response) upon aphthous ulceration,5 we determined the effect of D.S.C.G. upon in-vitro lymphocyte responsiveness.6 D.S.C.G. at 100 and 1000 µg. per ml. did not alter the in-vitro lymphocyte response of 6 individuals to a mitogen, P.H.A., and an antigen, P.P.D., as measured by lymphocyte transformation, production of -macrophage migration inhibitory factor, and lymphotoxin production. Both of these concentrations of D.S.C.G. were apparently non-toxic for the lymphocytes in culture. It seems possible that the c.G.A. in the trial was acting upon a second immune component of the ulceration, one giving rise to the pain in the middle of the ulcer life. This second immune phase may be associated with the reduction in the demonstrable 1. Assem, E. S. K., McAllen, M. M. Br. med. J. 1970, ii, 504. 2. Frost, M. Lancet, 1973, ii, 389. 3. Dolby, A. E., Walker, D. M. Br. J. oral Surg. (in the press). 4. Lehner, T. Oral Surg. 1972, 33, 80. 5. Symoens, J., Brugmans, J. Br. med. J. 1974, iv, 592. 6. Walker, D. M., Dolby, A. E. Int. Archs Allergy appl. Immun.
(in the press).
mast-cell content of the ulcers which occurs a few days after onset.’ It is not certain whether the two immune components are related, but if our hypothesis is correct new inhibitory compounds which both inhibit lymphocyte transformation as well as mast-cell degranulation8 are indicated in the treatment of aphthas. We are grateful to Fisons Ltd., Pharmaceutical Division, for financial support for the investigations. Welsh National School of Medicine, Dental School, Heath Park, Cardiff CF4 4XY.
D. M. WALKER A. E. DOLBY.
7. Dolby, A. E., Allison, R. J. J. dent. Res. 1969, 48, 901. 8. Assem, E. S. K. Int. Archs Allergy appl. Immun. 1973, 45, 708.
Obituary HERBERT VICTOR MORLOCK
M.C., M.D.Lond., F.R.C.P.
Dr H. V. Morlock, consulting physician to the London Chest Hospital and the Miller and Hampstead General Hospitals, died on May 18 at the age of 76. In the 1914-18 war, immediately after leaving school, he joined the Rifle Brigade, saw service in France, and was decorated with the M.c. on the field at the age of 19. He qualified M.B. from St. Bartholomew’s Hospital in 1924, and was elected to the staff of the first of his three hospitals at the age of 28. With the late Dr A. J. Scott Pinchin he spent some months in Vienna and on his return started the bronchoscopy clinic at the London Chest Hospital, using an instrument of his own design with a telescope for direct vision. This pioneer work, in which he was later joined by E. H. Hudson, established diagnostic bronchoscopy firmly in the hands of chest physicians and thoracic surgeons and was complementary to the work of H. P. Nelson on postural drainage for bronchiectasis. Some found his dynamic personality a little forbidding, but those who accepted this soon developed for him an admiration coupled with affection. There was about him an endearing streak of eccentricity. He habitually wore the old-fashioned style of dress of a consultant after most others had abandoned it, entirely in keeping with his basic philosophy that whatever you set out to do should be done properly. A story runs that at the beginning of the 1939-45 war patriotism impelled him to give up his Rolls and take to an Austin Seven, only to find that he could not sit in it with his top hat on unless the sunshine roof was open. The war affected him keenly; the arrival of the N.H.S. in 1948 even more so. Feeling that his initiative would be cramped, he withdrew to some extent. When he retired he transferred his boundless energy to riding and the hunting field. We shall cherish the memory of a man of character, a generous, warm-hearted colleague. He is survived by his wife, a son, and a daughter who is herself a doctor.
N. L. R. ANGUS NORMAN MacPHAIL M.C., M.D.Glasg., D.P.H.
Dr A. N.
MacPhail, formerly senior lecturer in medicine and general practice in the community of died on June 1 at the age of 60. University Leeds, He had retired last year owing to ill-health. Angus MacPhail qualified M.B. at Glasgow in 1937, subsequently graduating M.D. with commendation in 1951.