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[ RESEARCH 31, 420-426, April 1971] The Immunosuppressive Effects of Long-Term Combination in Children with Acute in Remission1

Luis Borella and Robert G. Webster Laboratories of Virology and Immunology, St. Jude Children 'sResearch Hospital, Memphis, Tennessee 38101

SUMMARY effects of prolonged maintained combination chemotherapy upon immunocompetence have not been investigated. The immunosuppressive effects of maintenance Knowledge of the immunosuppressive effects of long-term combination chemotherapy given for periods ranging from 8 combination chemotherapy is now urgently needed because of to 28 months to 20 children with acute lymphocytic leukemia the increasing number of prolonged remissions and potential in remission were investigated. There was depression of both 5-year among children with acute lymphocytic leukemia the primary production to the hemagglutinin antigen receiving this form of treatment (19). of the Hong Kong influenza virus and the anamnestic response This study was aimed at determining the to the neuraminidase of the same virus. The primary response immunosuppressive effects of long-term combination (hemagglutination inhibition) was affected to a greater extent chemotherapy in children with acute lymphocytic leukemia. than the secondary (neuraminidase inhibition) response. A Several unique features of this investigation were as follows. preferential depression of 2-mercaptoethanol-resistant (a) All patients were in remission and received the same hemagglutination inhibition (IgG) was also combination chemotherapy continuously for periods ranging observed. One-fourth of all acute lymphocytic leukemia from 8 to 28 months, (b) Patients and controls were patients had low serum IgG levels. In vitro transformation of immunized with the Hong Kong influenza virus prior lymphocytes was a poor index of immunocompetence. After 2 to the Hong Kong influenza virus epidemic. This permitted the years of continuous chemotherapy, children with low IgG and assay of the primary antibody response to one of the antigenic suppressed antibody production had normal response to determinants of the virus, the hemagglutinin, and the phytohemagglutinin. This initial study on the secondary antibody response to the other determinant, the immunocompetence of patients with leukemia undergoing neuraminidase (4, 23). (c) The effect of long-term long-term combination chemotherapy should provide a base chemotherapy upon 2 other parameters of line to establish correlations between immunological immunocompetence, lymphocyte response to PHA2 and parameters and infectious complications. serum immunoglobulin levels, was also determined and compared.

INTRODUCTION MATERIALS AND METHODS It has been stated that combination chemotherapy is Selection of Patients. Immunological studies were mandatory in the treatment of acute leukemia (10). performed in 20 children with acute lymphocytic leukemia Combination chemotherapy in children with acute and 22 nonleukemic children. All children with leukemia were lymphocytic leukemia at St. Jude Children's Research Hospital in complete remission during the entire period of has resulted in prolonged remissions and a 17% 5-year immunological evaluation. They were in the maintenance rate (9, 19). Continuous administration of immunosuppressive phase of the treatment, which consisted of daily 6MP, weekly has, however, increased the risk and severity of MTX, and Cyclo, and a 2-week course of VCR and (15). Several recent reviews discuss the effects of every 10 weeks (Table 1). They had this therapy for periods antineoplastic upon different stages of the immune ranging from 8 to 28 months. Another group of 22 children response in both animals and man (8, 13, 24). Studies in with acute lymphocytic leukemia that were not inoculated humans have been aimed at determining the degree of with the Hong Kong also received the same in patients receiving short-term courses of maintenance treatment for periods ranging from 4 to 26 single or combined (11-14, 22). However, the months. They were included in this study solely in an attempt to determine clinically whether during an epidemic of 1Supported by USPHS Center Grant CA-08480 influenza there was any difference in the incidence or severity from the National Cancer Institute, USPHS Research Grant AI-08831 of influenza-like illness between vaccinated and nonvaccinated from the National Institute of and Infectious , General children with acute lymphocytic leukemia. Research Grant RR-05584 from the NIH, and by ALSAC. 2The abbreviations used are: PHA, phytohemagglutinin; 6MP, All patients with acute lymphocytic leukemia had complete 6-; MTX, ; Cyclo, ; physical examinations, including white , differential, VCR, . and counts, weekly. The doses of antineoplastic drugs Received September 8, 1970; accepted December 3, 1970. were adjusted for each individual patient to maintain the white

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Table 1 extensively dialyzed against -buffered solution after Maintenance combination chemotherapy of children with acute treatment with 2-mercaptoethanol. lymphocytic leukemia in remission Criteria for Clinical Diagnosis of Influenza. The children in Immunological parameters were determined in 20 children with this study were vaccinated against Hong Kong influenza virus acute lymphocytic leukemia in remission receiving this maintenance treatment for periods ranging from 8 to 28 months. during the first 2 weeks of December 1968. Written parental consent was obtained in all cases. The Hong Kong influenza epidemic was first detected in the local community (Memphis, DoseDrug Tenn.) on December 20, 1968, reached a peak on January 10, Route6MPMTXCycloPrednisoneVCR5020200401.5P.O.p.o.(mg/sq m) 1969, and was over by January 31,1969. The following list of symptoms was considered for clinical diagnosis of influenza ori.v.p.o. virus during the epidemic period: , , ori.v.p.o.I.V.ScheduleDailyWeeklyWeeklyDaily myalgia, temperature over 38°, lacrimation, coryza, sore for 15Weekly weeksweekss every 10 throat, cough, hoarseness, , and . Since for 3day every 10 weeks identification of the virus was not attempted, we have used the term influenza-like illness rather than influenza to describe the infections. Siblings of leukemic children served as normal count between 2000 and 3000/cu mm. The control controls. group consisted of 22 children without neoplastic diseases seen In Vitro Stimulation of Peripheral Blood Lymphocytes with at the Nutrition and Metabolic Clinic for evaluation of growth, PHA. For avoidance of any interference from previous development, and nutritional status. The age of leukemic and immunization upon the response of peripheral blood control children ranged from 2 to 15 years and the median was lymphocytes to PHA stimulation, this test was performed at 5 years; 38 were female and 26 were male. least 6 months after influenza vaccination. The 13 patients Vaccine and Vaccination. Monovalent type A2/Aichi/2/68 evaluated were still in continuous complete remission and (Hong Kong variant) influenza virus vaccine prepared by zonal receiving the same uninterrupted combination chemotherapy. centrifugation (Zonomune) containing 800 chick cell Fifteen ml of venous blood were removed 7 days after the last agglutinin units/ml was obtained from , dose of MTX and Cyclo, mixed with 250 units of heparin, and Indianapolis, Ind. The vaccine was administered s.c. at the allowed to sediment for 2 hr at 37°in a 20-ml plastic syringe following dosage: for children over 10 years of age, 0.5 ml; for in a vertical position. The WBC-rich plasma was transferred to children 6 to 10 years old, 0.25 ml; and for children 3 months a sterile tube, and the cells were then cultured in glass tubes to 6 years old, 2 doses of 0.1 ml each at an interval of 2 weeks. according to the method described by Hersh and Oppenheim Viruses. The A2/Aichi/2/68 (Hong Kong) and the (14). Each culture contained 2 X IO6 WBC; 40 to 60% of A2(Tokyo/3/67 (Tokyo) strains of influenza virus were grown these were lymphocytes. Half of the cultures were inoculated in the allantois of 11-day-old chick embryos. The viruses were with 0.025 ml of PHA (Difco Laboratories, Detroit, Mich.). For concentrated by differential centrifugation and stored at 4° each patient and each determination, sets of 4 stimulated and with 0.1% sodium azide as preservative. 4 nonstimulated cultures were established. Three days after Titration of Antibodies to the Hemagglutinin and initiating the culture, 1.5 /uCi of thymidine-3H (Schwarz Neuraminidase Antigens of Influenza Virus. Blood samples BioResearch, Inc., Orangeburg, N. Y.) with a specific activity were obtained before vaccination and at weekly intervals of 3.0 Ci/mmole were added to each tube and the cells were thereafter for 4 weeks. To reduce the immediate suppressive incubated for an additional 18 hr. The cells were washed twice effects of chemotherapy, all blood samples were obtained 7 with 0.9% NaCl solution, and the nucleoproteins were days after the last and immediately before the next weekly precipitated with 3 ml of 5% trichloroacetic acid; 1 ml of injection of MTX and Cyclo and at least 4 weeks after the last bovine serum albumin (500 ßg)wasadded as carrier . dose of VCR and prednisone. The sera were stored at -20° The precipitates were taken up in 1.0 ml of NCS and treated with receptor-destroying to remove (Amersham-Searle, Chicago, 111.), mixed with 10 ml of nonspecific serum inhibitors (3) before serological assays were toluene-based scintillant, and counted in a liquid scintillation spectrometer. All these procedures were performed at 4°.The done. Hemagglutination inhibition tests were done in plastic trays (WHO type) with the use of 4 hemagglutinating doses of results were expressed as the relationship between PHA virus as described previously (7). stimulation in cultures from leukemic children over the PHA Neuraminidase assay was done with fetuin as substrate by stimulation in control cultures (Fig. 3). PHA stimulation was the method of Warren (25) except that the color was extracted defined as the ratio of cpm in cultures with PHA over the cpm into 1-butanol containing 5% (v/v) concentrated hydrochloric in cultures without PHA. In several cultures, the percentage of acid (1). Neuraminidase inhibition tests were performed as blasts per IO6 WBC was also calculated; there was a good previously described (26). agreement between PHA stimulation as determined by the Mercaptoethanol Treatment of Sera. Antisera were treated incorporation of thymidine-3H and blastic transformation with a final concentration of 0.1 M 2-mercaptoethanol as determined morphologically. described by Reisner and Franklin (20). The sera for Serum Immunoglobulin Levels. Serum immunoglobulin hemagglutination inhibition tests were first treated with concentrations were determined by a modification (6) of the receptor-destroying enzyme as described above, and the single radial diffusion method of Mancini e! al. (17). antisera used in the neuraminidase inhibition test were Quantitative immunodiffusion plates and standard sera were

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Downloaded from cancerres.aacrjournals.org on September 23, 2021. © 1971 American Association for Cancer Research. Luis Borella and Robert G. Webster obtained from Melpar, Inc., Falls Church, Va. All values RESULTS reported were from preimmunization sera. The results were compared with the curve of immunoglobulin concentrations of Hemagglutinin and Neuraminidase Antibody Levels after sera obtained from 50 normal children used as standard Vaccination of Normal and Leukemic Children with Hong reference in this hospital. There was agreement between Kong Influenza Virus. Buth groups of children in this study immunoglobulin levels in our control group and those reported received Hong Kong influenza vaccine before the onset of the by Buckley et al. (2). Immunoglobulins were considered low Hong Kong influenza virus epidemic in 1968. Therefore, this when the values were below the normal bounds for age a? was their first exposure to the Hong Kong influenza virus described by Buckley et al. (2). hemagglutinin. On the other hand, the neuraminidase on the

Table 2 The immune response of normal and leukemic children to influenza virus (A, /Hong Kong] Mean antibody titers of 20 children with acute lymphocytic leukemia and 22 nonleukemic children 4 weeks after immunization with the A2/Hong Kong influenza virus vaccine.

Leukemic children in remission Normal children

Test Prebleed Post vaccination" Prebleed Post vaccination

Hemagglutination inhibitionNeuraminidaseinhibition2.0b4.94.47.02.05.98.29.3

0 Antibody titers are expressed as mean Iog2/0.25 ml. Postvaccination sera were obtained 4 weeks after immunization. b The lowest level at which significant readings for influenza virus hemagglutination inhibition can be done.

Hong Kong influenza virus was not different from the LESS THAN neuraminidase on the preceding influenza viruses (4), and MEAN many of these children would have had experience with this antigen before vaccination. 12.0'ÒJenor Children with acute lymphocytic leukemia on long-term maintenance chemotherapy had a depressed immune response to the Hong Kong influenza virus vaccine. However, several differences were noticed between the antibody response to the •VL••• lo.oEtriij hemagglutinin and neuraminidase antigens (Chart 1, Table 2). (a) In the control children and children with acute lymphocytic leukemia, the mean preimmunization

8.0EÈK- • ••4 hemagglutination inhibition antibody titers were below the lowest dilution tested; in contrast, the mean Iog2 initial titers ».* V..:**"* to the neuraminidase were 5.9 in the normal children and 4.9 i—S in the acute lymphocytic leukemia group, (b) All control 6.0!5 •••NORMALCHILDREN.•••children responded to both antigenic determinants of the

.U"ALL"CHILDREN•*«4-+•.NORMALCHILDREN virus, but in the acute lymphocytic leukemia group, 5 and 2 patients failed to produce antibodies to the hemagglutinin and *UHI"ALL"CHILDREN•,«the neuraminidase, respectively, (c) At the peak of the 4.0Z)Z2 antibody response, the mean hemagglutination inhibition titer of patients receiving immunosuppressive drugs was at least 10-fold below that of the control group. The mean niW—,_0^1 neuraminidase inhibition antibody titer was depressed less than the hemagglutination inhibition response, and most of these children were producing neuraminidase antibodies in excess of 1:128 and as high as 1:2048. HEMAGGLUTINATION NEURAMINIDASE These results indicate that long-term combination INHIBITION INHIBITION chemotherapy depresses both the primary and secondary Chart 1. Hemagglutination and neuraminidase antibody titers after vaccination of normal and leukemic children with the Hong Kong immune response. Antibody production to the new influenza virus vaccine. The probability that the differences between hemagglutinin antigen of Hong Kong influenza was inhibited the groups with acute lymphocytic leukemia (ALL) and normal groups to a greater extent than the response to the antigenic may occur by chance alone is <0.001 for hemagglutination inhibition determinant present in influenza viruses from preceding years: and 0.001 for neuraminidase inhibition. the neuraminidase.

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Table 3 virus from the year before (Tokyo/67) and to compare the Sensitivity of antibody to 2-mercaptoethanol kinetics of response to these 2 viruses following immunization Sera from children with acute lymphocytic leukemia and with the Hong Kong influenza virus vaccine. The results shown nonleukemic controls were obtained 4 weeks after immunization with in Chart 2 demonstrate that the sera of both children with the A¡/Hong Kong influenza virus and titrated before and after treatment with 2-mercaptoethanol. acute lymphocytic leukemia and control children had higher initial titers to the Tokyo/67 virus than to the Hong Kong 2-Mercaptoethanol-sensitive strain. In the control groups, the anti-Hong Kong sera0/sera tested hemagglutination inhibition Iog2 titer rose in the first 2 weeks from less than 2 to 8.5. In contrast, in the same group there with acute lymphocytic leukemia was only 1 Iog2 difference between the initial and the 2-week TestHemagglutination in remission9/15 children0/1 antibody titer to the Tokyo virus. This slight increase can be explained in terms of steric inhibition of hemagglutination by 8Ò antibodies directed against the neuraminidase antigen of Hong inhibition Neuraminidase 0/17Normal 0/18 Kong virus (23). Children with acute lymphocytic leukemia inhibitionChildren also had preimmunization titers to the Tokyo 67 strain; however, these were below the initial titers of the controls. A 0 The number of 4-week sera that had all antibody activity removed slight rise was also noticed around the 3rd week, but at 4 by treatment with 2-mercaptoethanol. All other 4-week sera had a less than 50% reduction in titer after 2-mercaptoethanol treatment. weeks they had returned to the preimmunization level. The size of the samples did not permit the measurement of These data show that most children had previous exposure neuraminidase inhibition and mercaptoethanol sensitivity in 4 of the to the Tokyo influenza virus and immunization with the Hong control sera. Kong virus failed to induce a true secondary response to the hemagglutinin antigen of the Tokyo virus. Susceptibility of Antibodies to 2-Mercaptoethanol. The Incidence of Influenza-like Illness in Vaccinated and above studies indicated a quantitative difference in antibody Nonvaccinated Groups of Normal and Leukemic Children. The incidence of influenza-like illness in normal and leukemic response. To determine whether or not prolonged chemotherapy also induced qualitative changes, the sera were groups of children receiving Hong Kong influenza vaccine is titrated before and after treatment with 2-mercaptoethanol. Although 2-mercaptoethanol sensitivity is not an absolute z KONG /68 /67p-i-^i— measure of the IgM response, the appearance of o1—mXzg 2-mercaptoethanol-resistant antibodies usually parallels the lO—iT7 9-t IgG response. •-P As shown in Table 3, only one-third of the children with :/ idyH* acute lymphocytic leukemia that responded to the hemagglutinin antigen had 2-mercaptoethanol-resistant szr-isUJIHONG -1-X hemagglutionation inhibition antibodies 4 weeks after 4-S^tHiJi-iiiiTOKYOi"*^! NORMAL CHILDREN immunization. Conversely, in the control group, all children CHILDREN11234 • LEUKEMIC had 2-mercoptoethanol-resistant hemagglutination inhibition —i¡AH antibody, and in all determinations the reduction in antibody titers following 2-mercaptoethanol treatment was less than 1234 WEEKS AFTER VACCINATION 50% of the total. On the other hand, in all 4-week sera from Chart 2. Kinetics of antibody response to the hemagglutinin antigen the children with acute lymphocytic leukemia and control of the Tokyo/67 and Hong Kong/68 influenza viruses. Points, mean of children, the antibodies against the neuraminidase antigen sera with titers higher than 2.0. were mainly 2-mercaptoethanol resistant. There was no difference in the amount of 2-mercaptoethanol-sensitive Table 4 neuraminidase inhibition antibodies between the children with Incidence of influenza-like illness in vaccinated and nonvaccinated acute lymphocytic leukemia and normal children. groups of normal and leukemic children These results indicate that prolonged chemotherapy Clinical diagnosis of influenza-like illness was made during the period inhibited the primary IgG antibody response to a greater of Hong Kong influenza epidemic in the local communitv according to extent than the primary IgM response. However, there was no the symptoms described in "Materials and Methods." detectable difference in the quality of the secondary response with illness to the neuraminidase antigen. As previously mentioned, the GroupLeukemic (total)2/2010/2213/51Percentage10.045.525.5 neuraminidase is not different from the enzyme on preceding influenza viruses. childrenin Kinetics of Antibody Response to the Hemagglutinin of the remissionLeukemic Tokyo and Hong Kong Influenza Viruses. In the interpretation childrenin vaccinatedNot remissionSiblings of the above results, we assumed that most of these children ofleukemic vaccinatedNo. had previous contact with influenza viruses from preceding childrenStatusVaccinated"Not years. Thus, it was important to determine whether they had preexisting antibodies to the hemagglutinin of the influenza ' Hong Kong influenza vaccine.

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TabJeS The relationship between serum immiitioglobulins and antibody response IgG, IgA, and IgM immunoglobulin levels were determined by quantitative immunodiffusion in the sera obtained from 20 children with acute lymphocytic leukemia and 22 nonleukemic children.

Serum immunoglobulins Antibody response

Patient Age (yrs) IgG (mg/100 ml) IgA (mg/100ml) IgM (mg/100 ml) HI Nl

Group 1: Immunized children with acute Ivmphocytic leukemia with low IgG

J. J. 3 375 30 60 L. C. 4 390 30 52 D.M. 4 375 45 T. S. 3 350 30 98 S.S. 12 370 74 46 Group 2: Immunized children with acute lymphocytic leukemia 15 patients 2-12 849(480-1200) 90(50-180) 60(27-105) 2/15° 1/15"

Group 3: Nonleukemic. immunized controls

22 patients 2-12 1037(670-1450) 124(60-200) 64(30-130) 0/22 0/18 0 Absence of hemagglutination antibodies/total tested. b Absence of neuraminidase antibodies/total tested. shown in Table 4. The incidence of illness in nonvaccinated leukemia children was 45.5% and in vaccinated leukemic children it was 10%, a figure below the incidence of illness in normal children (25.5%). The incidence of influenza-like illness in the vaccinated leukemic group of children was significantly lower than in the nonvaccinated group of leukemic children: p = 0.01 by the X2 test. However, since evaluation was solely on clinical grounds and no virus isolation was attempted, these results suggest only that the Hong Kong influenza vaccine reduced the incidence of influenza in children with acute lymphocytic leukemia in remission. Relationship between Serum Immunoglobulins and Antibody Response. The levels of serum IgG, IgM, and IgA were determined to investigate whether or not there was a correlation between the effects of long-term chemotherapy upon serum immunoglobulins and antibody response. As shown in Table 5, one-fourth of the children receiving 15 19 21 25 27 29 immunosuppressive drugs had low serum IgG. Four of these 5 TIME IN COMBINATIONCHEMOTHERAPY(Months) patients also had low IgA. Three of these 5 children had no Chart 3. The relationship between the response of lymphocytes from hemagglutination inhibition antibodies to the Hong Kong virus children with acute lymphocytic leukemia to in vitro stimulation with vaccine. On the other hand, only 2 of the 15 children with PHA and the duration of treatment. The method used to determine acute lymphocytic leukemia who had normal levels of PHA response in cultures from patients and controls is described in the immunoglobulins failed to produce hemagglutination text, o, children with no hemagglutination inhibition antibody inhibition antibodies. These results indicate that long-term response. Three of them had low IgG. combination chemotherapy may depress serum IgG and IgA. The lack of apparent effects upon IgM may be related to the given without interruption for 17 to 28 months had any effect previously described prolongation of IgM antibody response to upon this in vitro response and whether there was any the hemagglutinin-antigenic determinant of the influenza virus. correlation between PHA stimulation and duration of Response of Peripheral Blood Lymphocytes to PHA maintenance therapy or antibody production. In all children Stimulation. The response of peripheral blood lymphocytes to who received continuous combination chemotherapy at the PHA is nonspecific. On the other hand, it has been correlated time of testing, the PHA response was similar to the controls with other in vitro specific immune responses and has been (Chart 3). In half of these patients, the incorporation of shown to be markedly depressed by immunosuppressive drugs thymidine-3H into peripheral blood lymphocytes was above (14). We investigated whether combination chemotherapy that of the controls. There was no correlation between blastic

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Downloaded from cancerres.aacrjournals.org on September 23, 2021. © 1971 American Association for Cancer Research. Immunosuppression in Acute Leukemia transformation or thymidine-3 H incorporation and either the suggested that, during an epidemic of influenza, children with length of treatment or hemagglutination or neuraminidase leukemia in remission may be protected by prompt inhibition antibody response. Thus, the in vitro response of immunization. However, a definitive answer should wait for peripheral blood lymphocytes to PHA was not affected by and prospective studies with systematic virus isolation. cannot be used as a sensitive parameter of the Serum IgG was depressed in one-fourth of the children with immunosuppressive effects of long-term chemotherapy. leukemia in remission. This is in agreement with our own unpublished observation of low levels of serum IgG in a larger DISCUSSION group of patients treated with the same chemotherapy protocol. The apparent discrepancy with other reports of The major aim of this study was to determine the effects of normal IgG levels in patients with leukemia in remission can be long-term combination chemotherapy upon explained by the shorter duration of the maintenance phase or immunocompetence in children with acute lymphocytic by differences in schedule in those studies (16, 18). In leukemia in remission. At the time of this study all patients the report of McKelvey and Carbone (18), the were in continuous complete remission and receiving immunoglobulin levels were determined only in the first 7 maintenance chemotherapy for periods ranging from 8 to 28 months of the maintenance phase. The patients studied by months. Kiran and Gross (16) received various treatments, but only 1 Long-term chemotherapy with a combination of 6MP, or 2 drugs were used simultaneously. In our study, 3 of the 5 MTX, Cyclo, VCR, and prednisone depressed the antibody children with low IgG failed to produce hemagglutination response to the hemagglutinin and neuraminidase antigens of inhibition antibodies. These 2 parameters of severe the Hong Kong influenza virus. Antibodies to the immunosuppression in the same individuals may indicate hemagglutinin determinant were inhibited to a greater extent genetic hypersusceptibility to chemotherapy or minor than antibodies to the neuraminidase. individual differences in drug dosage. Results from this and other studies (4, 23) indicate that the In vitro lymphocyte transformation has been used as a hemagglutinin antigen of Hong Kong influenza virus was a new sensitive and reproducible way of evaluating the antigen in 1968 and distinct from the hemagglutinin antigen immunocompetence of circulating lymphocytes. Intensive on the influenza virus in the preceding years. However, the combination chemotherapy with 6MP and MTX completely neuraminidase on Hong Kong influenza virus was identical abolished transformation after 3 days of treatment (14). with the neuraminidase antigen on the influenza viruses that However, our study conclusively shows that combination were current in the preceding years. therapy given continuously for more than 2 years does not We can conclude that this maintenance combination affect the response of peripheral blood lymphocytes to PHA. chemotherapy inhibited both the primary and the secondary Since we were more intrested in the long-term than in antibody response. However, the primary response was more immediate effects of this treatment, the samples were obtained affected than the anamnestic response. These effects may vary 7 days after the last weekly doses of Cyclo and MTX. with other antigens and different routes of inoculation. Therefore, the immediate suppressive effects of these drugs All the drugs used in this maintenance phase have been were not measured since a substantial recovery of the shown to depress the primary immune response in animals and lymphocytes may occur as soon as 3 days after stopping a man (8, 12, 22). Previous studies in man had been designed, short-term course of combination chemotherapy (14). however, to determine the immunosuppressive effects of single The use of combination chemotherapy has increased the (11, 12, 22) or combined antimetabolites (12) given in duration of continuous complete remission and the 5-year cure short-term courses. Hersh et al. (12) and Santos (22) had rate (9, 19). However, serious infections threatened the life of reported that 6MP given in a weekly total dose of 1.5 to 10 these patients during the prolonged maintenance phase of g/sq m depressed the primary response to tularemia, Vi, and treatment. At this institution, children with acute leukemia in pneumococcal antigens. Similar inhibition of antibody remission have died mainly of nonbacterial infections not production was obtained with Cyclo given i.v. at a dose of 7 preceded by granulocytopenia (15). This study provides an mg/kg for a period of 7 consecutive days. These weekly doses initial profile on the effects of this long-term chemotherapy were approximately 7 to 10 times higher than the maintenance upon the immunocompetence of these children. Currently, the dosage of this study. Thus, significant differences in dosage, levels of secretory immunoglobulins and IgA antibodies and schedule, and duration of treatment prevents any fruitful the response of peripheral blood lymphocytes to hemocyanin comparison between the results from this and previous studies. (5) are also under investigation. These data are now being used In animals treated with 6MP, the suppression of IgG in the clinical follow-up of these children with acute antibodies led to a prolongation of the IgM response (21). The lymphocytic leukemia in remission with the hope to establish important concept of the feedback control of IgM production definitive correlations between these parameters of by IgG antibodies is based on these experimental data. Santos immunocompetence and incidence and severity of infections. reported that in 5 patients treated with 6MP the anti-Vi antibody activity was present only in the 19 S fraction of their REFERENCES sera (22). In our study, children receiving combination chemotherapy also showed a preferential suppression of IgG 1. Aminoff, D. Methods for the Quantitative Estimation of antibody response, but only to the primary stimulation with jV-Acetyl-neuraminic Acid and Their Application to the the hemagglutinin antigen. The clinical information obtained Hydrolysates of Sialomucoids. Biochem. }., 81: 384-392, 1961.

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Downloaded from cancerres.aacrjournals.org on September 23, 2021. © 1971 American Association for Cancer Research. The Immunosuppressive Effects of Long-Term Combination Chemotherapy in Children with Acute Leukemia in Remission

Luis Borella and Robert G. Webster

Cancer Res 1971;31:420-426.

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