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Total Lymphoid Irradiation
837
exposed to 17 fractions of 200 rad. The supradiaphragmatic and subdiaphragmatic fields were irradiated simultaneously and all the major lymph nodes, the spleen, and the thymus were within the radiation field. The skull, lungs, tail, and forelimbs were shielded with lead. Radiation was given to the mice
Total
Lymphoid Irradiation
TOTAL lymphoid irradiation (TLI) has been used for over 15 years to treat patients with Hodgkin’s disease or
non-Hodgkin’s lymphoma. This form of therapy is somewhat protracted since it is delivered in small doses (150-250 rad) over 3-4 months. Irradiation has usually been done through two ports-an upper, mantle, port and a lower inverted-Y port. The mantle port includes the supradiaphragmatic lymphoid areas (i.e., the cervical and axillary lymph nodes as well as the mediastinum). The subdiaphragmatic inverted-Y port includes the para-aortic iliac and inguinal nodes, as well as the spleen ifit has not been removed. Treatment usually begins with 4-5 fractions a week to the mantle port until 3500-4000 rad has been given, and then the inverted Y port is irradiated to the same level. Lately this therapy has generated considerable interest because it seems strikingly immunosuppressive. The peripheral-blood lymphocyte count of patients who have received this treatment has remained depressed for about two years, with T-cell levels staying low for even longer.Although lymphocytes from Hodgkin patients respond normally in the mixed-
lymphocyte reaction, TLI can abolish the response for 20 months or more, and delayed-hypersensitivity skin reactions are also inhibited. TLI has proved immunosuppressive in rodents and other species and, when it given to animals before bone-marrow transplantation, engraftment took place without subsequent rejection or graft-versus-host disease. SLAVIN and coworkers3,4 have done much experimental work with was
1
Kaplan HS. Hodgkin’s
disease. Cambridge: Harvard
2 Fuks Z, Strober S, Bobrove AM,
University Press,
anxsthetised animals at the rate of 5 fractions a week to a total of 3400 rad. This treatment caused a profound fall in the level of circulating lymphocytes and, although B lymphocytes began to rise after 2 weeks, the T lymphocytes remained undetectable for at least a month and were still reduced a year later. Lymphocytes from these animals responded poorly if at all to mitogens or allogeneic cells, and antibody production was severely depressed. Skin grafts from an H-2 disparate donor survived on these treated animals for about 50 days. It was clear from these experiments that the thymus needed to be included within the irradiation field since screening of the thymus reduced skin-graft survival to 18 days. Other experiments showed that this immunosuppression was probably due to a population of T suppressor cells.5TLI seems rather less effective in larger animals but prolongation of heart transplants has been seen in rhesus monkeys.6 These animals were given just 6 daily fractions of 100 rad each and were then grafted with an unmatched allogeneic heterotopic heart. Whereas three control animals rejected their hearts in 10-13 days, rejection was delayed in the irradiated monkeys until 29-50 days. Further prolongation (133-229 days) was seen in another group of 7 recipients that, along with irradiation, received 3 doses of antithymocyte globulin, although this globulin was not immuno-
suppressive on its own. A more lasting tolerance has been observed when TLI has been followed- by an injection of donor bone marrow (BM). When mice were treated this way about half accepted allogeneic skin grafts for more than 100 days.4 These animals proved to be stable chimasras, 50% of their peripheral-blood lymphocytes being of donor origin. The proportion of tolerant recipients could be increased to 9007o by increasing the number of bone-marrow cells given. The signs of graft-versushost disease (diarrhoea, hunch-back, ruffled fur, weight loss, and dermatitis) were never seen. These results were quite different from those in which whole-body irradiation had been given (1000 rad), since all these animals died within 11 days of irradiation or by 2 weeks if bone marrow had been grafted. Further experiments of this type showed that long-term engraftment of bone could be obtained after TLI even when the excluded, but that engraftment was unthymus successful if none of the supradiaphragmatic nodes marrow
was
1972.
al. Long term effects of radiation on T & B lymphopatients with Hodgkin’s disease JClin Invest 1976; 58: et
cytes in peripheral blood of 803. S, Strober S, Fuks Z, Kaplan HS. Long term survival of skin allografts in mice treated with fractionated total lymphoid irradiation. Science 1976; 193: 1252. 4 Slavin S, Strober S, Fuks Z, Kaplan HS. Induction of specific tissue transplantation tolerance after fractionated total lymphoid, irradiation in adult mice: Long term survival of allogenic bone marrow and skin grafts. J Exp Med 1977; 146: 34. 3. Slavin
I, Slavin S, Strober S. Induction and mechanism of tolerance to bovine serum albumin in mice given total lymphoid irradiation (TLI). J Immunol 1978; 121: 1400. 6. Bieber CP, Jamieson A, Raney A, et al. Cardiac allograft survival in rhesus primates treated with combined total lymphoid irradiation and rabbit antithymocyte globulin. Transplantation 1979; 28: 347-50. 5. Zan-Bar
838
irradiated. Irradiation of the thymus alone was also ineffective. Very similar results have been obtained with rats,7 and there are now reports that TLI and BM grafting has been successfully accomplished in dogs, monkeys, and baboons. In 1979 SLAVIN and his colleagues reported the successful engraftment of five mongrel dogs.s The mantle field was exposed to 2800-5400 rad and the abdominal field to 3000-3800 rad. This lower field encompassed the whole of the abdomen and pelvis, the kidneys alone being shielded. The radiation was delivered 4 or 5 times a week, at doses of 100-200 rad, and the whole course lasted 4-5 months. Marrow from dogs of a different sex and red-blood-cell type was infused at a dose of about 1 x 109 cells/kg within 48 h of the last radiation dose. 2 of the 5 dogs became stable BM chimaeras and during 14-months of observation no evidence of graft-versus-host disease was seen. In other experiments TLI and bone-marrow transplantation has been used to prepare beagles for a kidney transplant.9 The dogs were treated with daily fractions of 125 rad TLI to a total dose of 2500-2700 rad and transfused with DLA-incompatible bone marrow immediately afterwards. Two days later a kidney was grafted from the same donor. During a short follow-up period no rejection of the kidney or graft-versus-hostdisease was seen in the recipient. Other attempts, however, have not been so successful. In a paper delivered to the Transplantation Society in June, 1980, RAFF et al. 10 reported substantial lymphoid chimsrism in only 2 of 41 dogs that received bone marrow. 26 dogs went on to receive kidney allografts from the bone-marrow ,donor but most of these were rejected quite rapidly; only the 2 chimxric dogs retained their kidney grafts for any period. At the same meeting the group from Stanford presented their results of heterotopic heart transplantation in dogs given 1800 rad of TLI and donor bone marrow. 4 dogs rejected their heart grafts within 84 days but when antithymocyte globulin and azathioprine were administered in addition, survival times were longer.’’MYBURGH has tried much shorter courses of TLI for suppressing rejection of liver and kidney transplants in baboons. 11,13 He reports prolonged survival of kidney transplants in baboons given just three doses of 200 rad to the torso in one week, with bone-marrow and kidney grafting one month later. were
7.
8
Slavin S, Reitz B, Bieber CP, Kaplan HS, Strober S. Transplantation tolerance in adult rats using total lymphoid irradiation Permanent survival of skin, heart and marrow allografts. J Exp Med 1978; 147: 700-07. Slavin S, Gottlieb M, Strober S, et al. Transplantation of bone marrow in outbred dogs without
9
histocompatibility barriers after total lymphoid irradiation. Transplantation 1979; 28: 359-61. Raaf J, Bryan C, Monden M, et al. Bone marrow and renal transplantation in canine recipients prepared by total lymphoid irradiation. Transplant Proc (in press). Gottlieb MS, Koretz SH, Bieber CP, et al. Organ transplantation in mongrel dogs using total lymphoid irradiation (TLI). Transplant Proc (in press). Myburgh JA, Smit JA, Browde S, Hill RRH. Transplantation tolerance in primates following total lymphoid irradiation and allogenic bone marrow injection. I. Orthotopic liver allografts. Transplantation 1980; 29: 40-04. Myburgh JA, Smit JA, Hill RRH, Browde S. Transplantation tolerance in primates following total lymphoid irradiation and allogenic bone marrow transplantation. II Renal allografts. Transplantation 1980; 29: 405-08. major
10. 11. 12.
13.
graft-versus-host disease using total lymphoid irradiation. Transplantation
1979; 27: 139-42. Strober S, Kaplan H, Howard RJ, Sutherland DER. Transplantation tolerance across
Grafting four months after irradiation was also successful if 200 rad of "booster" irradiation was given each month up to the time of grafting. Single doses of irradiation (300, 400, or 500 rad) on their own were rather less effective. Animals treated with the fractioned regimen acquired suppressor cells that could inhibit both donor-specific and donor-non-specific mixed-lymphocyte culture responses.’4 A few transplant centres have begun to use TLI for preparing certain patients for kidney transplantation. The largest experience has been obtained in Minnesota, and NAJARIAN presented to the Transplantation Society his results with 15 patients who had all previously exhibited strong immunity by rejecting kidney transplants or becoming highly sensitised after blood transfusions. 15 All but one of the patients had a splenectomy after which they received lymphoid irradiation, 100-125 rad, weekly to a total of 2500-4000 rad. The patients then received a crossmatch-negative cadaveric kidney transplant, 4 also receiving donor bone marrow. Although the follow-up is still short, only one kidney has so far been lost from rejection. So TLI seems to have an exciting future, particularly as a means of preparing patients for bone-marrow transplantation. It seems to be safer than conventional whole-body irradiation and much less likely to be followed by graft-versus-host disease. In kidney transplantation its place is not so clear but the Minnesota experience suggests that it can be useful in strongly sensitised patients. If MYBURGH’s results in baboons hold true for man then much shorter courses of TLI may be sufficient to condition patients successfully, which would make TLI a practical regimen for clinical transplant centres.
Parenteral Nutrition in the Newborn a Time for Caution TWELVE years ago WILMORE and DUDRICK’ described how, with total parenteral nutrition (TPN), they had been able to sustain normal growth in an infant. Since then TPN has been much used by neonatal surgeons: in babies with gastrointestinal anomalies the benefits far outweigh the hazards. Lately there has been a trend towards total (or supplementary) parenteral nutrition in another group of babies - those of very low birthweight (VLBW). In these babies the benefits of parenteral nutrition are less impressive. What are the pros and cons? For early TPN several arguments are offered. The first is based on the difficulties of establishing feeding in these babies under 1500 g,2 and the harm which JA, Hill RRH, Myburgh JA, Browde S. Transplantation tolerance in primates after total lymphoid irradiation and allogenic bone marrow injection III Lymphocyte responsiveness and suppressor cell activity. Transplantation 1980; 30: 107-10 15. Najarian JS. Total lymphoid irradiation. Transplant Proc (in press). 1. Wilmore DW, Dudrick SJ. Growth and development of an infant receiving all nutrients exclusively by vein. JAMA 1968; 203: 860. 2. Wharton BA, Bower BD. Immediate or later feeding for premature babies? Lancet 1965; ii: 969-72. 14. Smit
exposed to 17 fractions of 200 rad. The supradiaphragmatic and subdiaphragmatic fields were irradiated simultaneously and all the major lymph nodes, the spleen, and the thymus were within the radiation field. The skull, lungs, tail, and forelimbs were shielded with lead. Radiation was given to the mice
Total
Lymphoid Irradiation
TOTAL lymphoid irradiation (TLI) has been used for over 15 years to treat patients with Hodgkin’s disease or
non-Hodgkin’s lymphoma. This form of therapy is somewhat protracted since it is delivered in small doses (150-250 rad) over 3-4 months. Irradiation has usually been done through two ports-an upper, mantle, port and a lower inverted-Y port. The mantle port includes the supradiaphragmatic lymphoid areas (i.e., the cervical and axillary lymph nodes as well as the mediastinum). The subdiaphragmatic inverted-Y port includes the para-aortic iliac and inguinal nodes, as well as the spleen ifit has not been removed. Treatment usually begins with 4-5 fractions a week to the mantle port until 3500-4000 rad has been given, and then the inverted Y port is irradiated to the same level. Lately this therapy has generated considerable interest because it seems strikingly immunosuppressive. The peripheral-blood lymphocyte count of patients who have received this treatment has remained depressed for about two years, with T-cell levels staying low for even longer.Although lymphocytes from Hodgkin patients respond normally in the mixed-
lymphocyte reaction, TLI can abolish the response for 20 months or more, and delayed-hypersensitivity skin reactions are also inhibited. TLI has proved immunosuppressive in rodents and other species and, when it given to animals before bone-marrow transplantation, engraftment took place without subsequent rejection or graft-versus-host disease. SLAVIN and coworkers3,4 have done much experimental work with was
1
Kaplan HS. Hodgkin’s
disease. Cambridge: Harvard
2 Fuks Z, Strober S, Bobrove AM,
University Press,
anxsthetised animals at the rate of 5 fractions a week to a total of 3400 rad. This treatment caused a profound fall in the level of circulating lymphocytes and, although B lymphocytes began to rise after 2 weeks, the T lymphocytes remained undetectable for at least a month and were still reduced a year later. Lymphocytes from these animals responded poorly if at all to mitogens or allogeneic cells, and antibody production was severely depressed. Skin grafts from an H-2 disparate donor survived on these treated animals for about 50 days. It was clear from these experiments that the thymus needed to be included within the irradiation field since screening of the thymus reduced skin-graft survival to 18 days. Other experiments showed that this immunosuppression was probably due to a population of T suppressor cells.5TLI seems rather less effective in larger animals but prolongation of heart transplants has been seen in rhesus monkeys.6 These animals were given just 6 daily fractions of 100 rad each and were then grafted with an unmatched allogeneic heterotopic heart. Whereas three control animals rejected their hearts in 10-13 days, rejection was delayed in the irradiated monkeys until 29-50 days. Further prolongation (133-229 days) was seen in another group of 7 recipients that, along with irradiation, received 3 doses of antithymocyte globulin, although this globulin was not immuno-
suppressive on its own. A more lasting tolerance has been observed when TLI has been followed- by an injection of donor bone marrow (BM). When mice were treated this way about half accepted allogeneic skin grafts for more than 100 days.4 These animals proved to be stable chimasras, 50% of their peripheral-blood lymphocytes being of donor origin. The proportion of tolerant recipients could be increased to 9007o by increasing the number of bone-marrow cells given. The signs of graft-versushost disease (diarrhoea, hunch-back, ruffled fur, weight loss, and dermatitis) were never seen. These results were quite different from those in which whole-body irradiation had been given (1000 rad), since all these animals died within 11 days of irradiation or by 2 weeks if bone marrow had been grafted. Further experiments of this type showed that long-term engraftment of bone could be obtained after TLI even when the excluded, but that engraftment was unthymus successful if none of the supradiaphragmatic nodes marrow
was
1972.
al. Long term effects of radiation on T & B lymphopatients with Hodgkin’s disease JClin Invest 1976; 58: et
cytes in peripheral blood of 803. S, Strober S, Fuks Z, Kaplan HS. Long term survival of skin allografts in mice treated with fractionated total lymphoid irradiation. Science 1976; 193: 1252. 4 Slavin S, Strober S, Fuks Z, Kaplan HS. Induction of specific tissue transplantation tolerance after fractionated total lymphoid, irradiation in adult mice: Long term survival of allogenic bone marrow and skin grafts. J Exp Med 1977; 146: 34. 3. Slavin
I, Slavin S, Strober S. Induction and mechanism of tolerance to bovine serum albumin in mice given total lymphoid irradiation (TLI). J Immunol 1978; 121: 1400. 6. Bieber CP, Jamieson A, Raney A, et al. Cardiac allograft survival in rhesus primates treated with combined total lymphoid irradiation and rabbit antithymocyte globulin. Transplantation 1979; 28: 347-50. 5. Zan-Bar
838
irradiated. Irradiation of the thymus alone was also ineffective. Very similar results have been obtained with rats,7 and there are now reports that TLI and BM grafting has been successfully accomplished in dogs, monkeys, and baboons. In 1979 SLAVIN and his colleagues reported the successful engraftment of five mongrel dogs.s The mantle field was exposed to 2800-5400 rad and the abdominal field to 3000-3800 rad. This lower field encompassed the whole of the abdomen and pelvis, the kidneys alone being shielded. The radiation was delivered 4 or 5 times a week, at doses of 100-200 rad, and the whole course lasted 4-5 months. Marrow from dogs of a different sex and red-blood-cell type was infused at a dose of about 1 x 109 cells/kg within 48 h of the last radiation dose. 2 of the 5 dogs became stable BM chimaeras and during 14-months of observation no evidence of graft-versus-host disease was seen. In other experiments TLI and bone-marrow transplantation has been used to prepare beagles for a kidney transplant.9 The dogs were treated with daily fractions of 125 rad TLI to a total dose of 2500-2700 rad and transfused with DLA-incompatible bone marrow immediately afterwards. Two days later a kidney was grafted from the same donor. During a short follow-up period no rejection of the kidney or graft-versus-hostdisease was seen in the recipient. Other attempts, however, have not been so successful. In a paper delivered to the Transplantation Society in June, 1980, RAFF et al. 10 reported substantial lymphoid chimsrism in only 2 of 41 dogs that received bone marrow. 26 dogs went on to receive kidney allografts from the bone-marrow ,donor but most of these were rejected quite rapidly; only the 2 chimxric dogs retained their kidney grafts for any period. At the same meeting the group from Stanford presented their results of heterotopic heart transplantation in dogs given 1800 rad of TLI and donor bone marrow. 4 dogs rejected their heart grafts within 84 days but when antithymocyte globulin and azathioprine were administered in addition, survival times were longer.’’MYBURGH has tried much shorter courses of TLI for suppressing rejection of liver and kidney transplants in baboons. 11,13 He reports prolonged survival of kidney transplants in baboons given just three doses of 200 rad to the torso in one week, with bone-marrow and kidney grafting one month later. were
7.
8
Slavin S, Reitz B, Bieber CP, Kaplan HS, Strober S. Transplantation tolerance in adult rats using total lymphoid irradiation Permanent survival of skin, heart and marrow allografts. J Exp Med 1978; 147: 700-07. Slavin S, Gottlieb M, Strober S, et al. Transplantation of bone marrow in outbred dogs without
9
histocompatibility barriers after total lymphoid irradiation. Transplantation 1979; 28: 359-61. Raaf J, Bryan C, Monden M, et al. Bone marrow and renal transplantation in canine recipients prepared by total lymphoid irradiation. Transplant Proc (in press). Gottlieb MS, Koretz SH, Bieber CP, et al. Organ transplantation in mongrel dogs using total lymphoid irradiation (TLI). Transplant Proc (in press). Myburgh JA, Smit JA, Browde S, Hill RRH. Transplantation tolerance in primates following total lymphoid irradiation and allogenic bone marrow injection. I. Orthotopic liver allografts. Transplantation 1980; 29: 40-04. Myburgh JA, Smit JA, Hill RRH, Browde S. Transplantation tolerance in primates following total lymphoid irradiation and allogenic bone marrow transplantation. II Renal allografts. Transplantation 1980; 29: 405-08. major
10. 11. 12.
13.
graft-versus-host disease using total lymphoid irradiation. Transplantation
1979; 27: 139-42. Strober S, Kaplan H, Howard RJ, Sutherland DER. Transplantation tolerance across
Grafting four months after irradiation was also successful if 200 rad of "booster" irradiation was given each month up to the time of grafting. Single doses of irradiation (300, 400, or 500 rad) on their own were rather less effective. Animals treated with the fractioned regimen acquired suppressor cells that could inhibit both donor-specific and donor-non-specific mixed-lymphocyte culture responses.’4 A few transplant centres have begun to use TLI for preparing certain patients for kidney transplantation. The largest experience has been obtained in Minnesota, and NAJARIAN presented to the Transplantation Society his results with 15 patients who had all previously exhibited strong immunity by rejecting kidney transplants or becoming highly sensitised after blood transfusions. 15 All but one of the patients had a splenectomy after which they received lymphoid irradiation, 100-125 rad, weekly to a total of 2500-4000 rad. The patients then received a crossmatch-negative cadaveric kidney transplant, 4 also receiving donor bone marrow. Although the follow-up is still short, only one kidney has so far been lost from rejection. So TLI seems to have an exciting future, particularly as a means of preparing patients for bone-marrow transplantation. It seems to be safer than conventional whole-body irradiation and much less likely to be followed by graft-versus-host disease. In kidney transplantation its place is not so clear but the Minnesota experience suggests that it can be useful in strongly sensitised patients. If MYBURGH’s results in baboons hold true for man then much shorter courses of TLI may be sufficient to condition patients successfully, which would make TLI a practical regimen for clinical transplant centres.
Parenteral Nutrition in the Newborn a Time for Caution TWELVE years ago WILMORE and DUDRICK’ described how, with total parenteral nutrition (TPN), they had been able to sustain normal growth in an infant. Since then TPN has been much used by neonatal surgeons: in babies with gastrointestinal anomalies the benefits far outweigh the hazards. Lately there has been a trend towards total (or supplementary) parenteral nutrition in another group of babies - those of very low birthweight (VLBW). In these babies the benefits of parenteral nutrition are less impressive. What are the pros and cons? For early TPN several arguments are offered. The first is based on the difficulties of establishing feeding in these babies under 1500 g,2 and the harm which JA, Hill RRH, Myburgh JA, Browde S. Transplantation tolerance in primates after total lymphoid irradiation and allogenic bone marrow injection III Lymphocyte responsiveness and suppressor cell activity. Transplantation 1980; 30: 107-10 15. Najarian JS. Total lymphoid irradiation. Transplant Proc (in press). 1. Wilmore DW, Dudrick SJ. Growth and development of an infant receiving all nutrients exclusively by vein. JAMA 1968; 203: 860. 2. Wharton BA, Bower BD. Immediate or later feeding for premature babies? Lancet 1965; ii: 969-72. 14. Smit