Occurrence of hepatitis and hepatitis B surface in adult patients with acute leukemia D.H. COWAN,* MD, FRCP[C]; G.M. KOUROUPIS,f W-D. LEERS4 MD, PH D, FRCP[C], DIP BACT, CPH
antigen
D SC, M SC, FRSH, FRMS, CPH;
Summary: Fifty-eight adult patients with
acute leukemia screened at the onset of the disease for hepatitis B antigen (HBsAg) in the serum, and during the course of the disease for the development of hepatitis B. One patient had a positive test for HBsAg by the radioimmunoassay technique only at the time leukemia was diagnosed; this patient had received transfusions some years before. In six patients icteric hepatitis B developed; five recovered completely and one died of leukemia during the course of hepatitis. All patients in whom hepatitis developed had received transfusions as a part of supportive therapy for leukemia. The hepatitis risk for patients who received transfusions of blood found to be negative for HBsAg by counterimmunoelectrophoresis was 0.26% per unit of blood administered. Resume: Survenue d'hepatite et d'antigene de surface de I'hepatite B chez des malades adultes souffrant de leucemie aigue' Nous avons passe au crible des le debut de la maladie 58 malades adultes souffrant de leucemie aigue et cherche dans le serum de ces malades I'antigene de surface de I'hepatite B (HB8Ag) et au cours de I'evolution de la maladie, I'apparition de I'hepatite B. Chez un malade le test de l'HBsAg n'etait positif par la technique d'essai radtoimmunologique qu'au moment ou la leucemie etait diagnostiquee; ce malade avait recu des transfusions quelques annees auparavant. Chez six malades une hepatite B icterique survint; cinq malades ont gueri completement et le sixieme est mort de leucemie durant I'evolution de I'hepatite. Tous les malades qui ont souffert d'hepatite avaient recu des transfusions a titre de traitement de soutien pour la leucemie. Le risque d'hepatite chez les malades qui avaient recu des transfusions et dont le sang s'etait revele negatif pour HBsAg par contreimmunoelectrophorese a ete evalue a 0.26% par unite de sang transfuse. were
From the departments of medicine and medical microbiology, University of Toronto, The Ontario Cancer Institute, The Princess Margaret Hospital and The Wellesley Hospital, Toronto ?Professor, department of medicine, University of Toronto tVirologist, department of microbiology, The Wellesley and The Princess Margaret hospitals JChief, department of microbiology, The Wellesley and The Princess Margaret hospitals; assistant professor, department of medical microbiology, University of Toronto Reprint requests to: Dr. D.H. Cowan, Sunnybrook Medical Centre, 2075 Bayview Ave., Toronto, Ont. M4N 3M5
Since the initial observation of a "new" antigen in leukemia serum1 there have been a number of reports of an increased prevalence of hepatitis B surface antigen (HBsAg) in the serum of patients with leukemia.2"8 The populations and types of leukemia studied and the methods used for detec¬ tion of HBsAg have varied in these reports. Whereas most investigators have concluded that the occurrence of HBsAg in leukemic patients is related to previous blood transfusion, in at least one report the authors concluded that the increased prevalence of HBsAg was unrelated to the blood transfusion histories of the patients.8 These reports have not documented horizontal studies in a group of patients with leukemia. We previously reported on 14 patients with acute leuke¬ mia treated between July 1, 1970 and June 30, 1971.9 Four patients had a positive test for HBsAg; three of these died of fulminant hepatitis. All four had previously received blood transfusion and all had been treated with intensive chemotherapy. Because all patients with acute leukemia seen during that period were not tested for HB8Ag, and because tests were not carried out at the time leukemia was diagnosed, we were unable to comment on the overall prevalence of HBsAg in patients with acute leukemia, either at the time of diagnosis or during the course of the illness. Consequently, a prospective study was designed to deter¬ mine: (a) the frequency of positive HBsAg tests in patients with newly diagnosed acute leukemia, (b) the incidence of hepatitis associated with HBsAg during the course of acute leukemia, (c) the relation of HBsAg to the administration of blood transfusion products and (d) the course of HBsAgpositive hepatitis in patients with acute leukemia. This report documents the findings in 58 patients treated on an adult acute leukemia service. Methods and Tests
patients
for HBsAg
The methods used to detect HBsAg in this laboratory have been described in detail.10 In brief they are as follows: 1. The complement fixation test (CFT) was done by the method of Sever.11 If the titre was 1:8 or greater, the test was considered positive. The problem of anticomplementary activity was solved by treating the sera with fluoro-
carbon.10-12
CMA JOURNAL/MARCH 22, 1975/VOL. 112 693
2. Counterimmunoelectrophoresis (CIEP) was performed by the method of Gocke and Howe13 and modified as previously described.10 3. The radioimmunoassay (RIA) test was carried out by the two-step direct solid-phase radioimmunoassay technique as described by Miller and Mordecai14 and modified as previously described.15 RIA-positive sera that were negative by all other tests were treated as follows: Equal volumes of the serum sample and rabbit serum containing antibodies to HBsAg were mixed and left at room temperature for at least 1 hour. The sera were then retested for the presence of HBsAg by RIA. The absence of HBsAg in the repeated RIA test would confirm validity of the positive result. During the initial phase of this study, sera from the leukemic patients were tested by CFT only. Sera from most of these patients were stored and were subsequently re¬ tested by RIA and CIEP. After the introduction of RIA all sera from the leukemic patients were tested by all three
donors
tory.
were
screened
by the
CIEP method in
our
labora¬
All blood products administered to patients in this study free of HBsAg as tested by CIEP. One patient inadvertently received a leukocyte transfusion from a donor with hepatitis B antigen and subsequently developed hepa¬ titis B. In this report a unit of blood (red cells, platelets or leukocytes) refers to the blood or blood products obtained from a single donor. Statistical methods The chi-square test, with Yates's correction for continuity, was used for testing differences in the occurrence of hepa¬ titis B in patients with ALL and ANLL. The Wilcoxon rank test was used for testing differences in age and num¬ bers of transfusions in groups of patients. were
methods.
Results
Patient selection
Initial HBsAg screening In the initial HBsAg screening all 58 patients were tested by CFT but only 54 by CIEP and 41 by RIA because insufficient stored serum was available (Table I). Serum from 1 of the 58 leukemic patients was positive on RIA testing (confirmed positive); the CFT and CIEP gave negative results. This was a 68-year-old woman with ANLL who had received blood transfusions during mitral commissurotomy 13 years before this admission and also 10 days before the test for HBsAg. There was no history of hepa¬ titis and at the time of the initial test there was no clinical or biochemical evidence of hepatitis. Over the next 2 months results of liver function tests remained normal. The RIA test, repeated twice, remained positive; the CFT and CIEP remained negative, indicating a low HBsAg content in the serum. The patient died 6 months after presentation as a result of the leukemia. No autopsy was performed.
All patients with acute leukemia referred to the adult acute leukemia service of The Princess Margaret Hospital,
Toronto whose disease was diagnosed between July 1, 1971 and Dec. 30, 1973 were included in this study. Followup extended to July 31, 1974. There were 49 patients with acute nonlymphoblastic leukemia (ANLL) and 12 papatients with acute lymphoblastic leukemia (ALL). Three patients with ANLL did not undergo HBsAg tests; these patients survived for 1, 1 and 14 weeks and did not have any clinical evidence of hepatitis. The remaining 58 patients (46 ANLL and 12 ALL) form the basis for this report.
Treatment methods The treatment protocol for patients with ANLL has been reported in detail.16*17 In brief it is as follows: Remission induction and consolidation treatment consisted of 4-day courses of cyclophosphamide, cytarabine (Ara-C) and vin¬ cristine repeated at 2- to 3-week intervals (CAV protocol). Maintenance treatment with 1,3-bis (2-chloroethyl)-l-nitrosourea (BCNU) and cyclophosphamide was given at 8-week intervals. Patients whose condition failed to respond to the remission induction protocol were treated with a variety of chemotherapeutic agents. Several different regimens were used in the management of patients with ALL. The majority received prednisone and vincristine to induce remission. Consolidation therapy consisted of three 5-day courses of methotrexate given at 2- to 3-week intervals, then a 2-week reinduction course of prednisone and vincristine. This cycle was repeated three times, after which the patients were maintained on twiceweekly methotrexate. Most patients were treated by cranial irradiation and intrathecal methotrexate as prophylaxis against central nervous system leukemia. Patients whose condition failed to respond to induction therapy were treated with combinations of a variety of drugs, including
Ara-C, cyclophosphamide, vincristine, prednisone, 6-mer-
captopurine, L-asparaginase
and
daunomycin.
Transfusion practice Patients were transfused with packed red cells for ane¬ mia and platelet concentrates for severe thrombocytopenia. The red cells and platelet concentrates were provided by the Canadian Red Cross blood transfusion service, and during the study period all blood was screened for HBsAg by the CIEP method at the Toronto regional transfusion centre before release for transfusion.18 Some patients also received fresh leukocyte transfusions obtained by the IBMNCI Blood Cell Separator19 from volunteer donors. These 694 CMA JOURNAL/MARCH 22, 1975/VOL. 112
Follow-up In 6 (10%) of the initial group of 58 leukemic patients (1 of 12 with ALL and 5 of 46 with ANLL) icteric hepatitis with positive tests for HBsAg developed. In all cases all three tests for HBsAg were positive. Pertinent clinical data are summarized in Table II. The onset of hepatitis with positive HBsAg tests occurred from 21 to 64 weeks after the diagnosis of leukemia. Four patients (cases 1, 3, 4 and 6) were in their first complete remission, one (case 5) in an excellent partial remission and one (case 2) was being treated for a first relapse after a complete remission. All six patients had received transfusions. All but one patient (case 6) had received transfusions between 12 and 24 weeks before the onset of hepatitis; this patient had received no transfusions for 39 weeks before the onset of clinical hepatitis. One patient (case 2) inadvertently received HBsAg-positive blood in a leukocyte transfusion from a donor whose serum was positive by CIEP. The CFT and RIA determinations subsequently carried out on the donor's serum were also positive. Hepatitis was diagnosed in the recipient 10 weeks after the transfusion.
The clinical course of the hepatitis is summarized in Table III. In five patients (cases 1, 3, 4, 5 and 6) there was complete recovery, with return of results of biochem¬ ical tests to normal in 6 to 12 weeks. In these five patients all tests for HBsAg became negative in 9 to 17 weeks. One of these five patients (case 1) suffered a relapse of leukemia during the episode of hepatitis and died as a result of the leukemia shortly after recovery from hepatitis. The sixth patient (case 2) died with leukemia in relapse 5 weeks after the onset of hepatitis when the hepatitis was less severe; death cannot be attributed to liver failure. The hepatitis, however, did prevent the administration of ade¬ quate drug treatment for the leukemia and in this way may have indirectly contributed to the patient's death. In three patients (cases 3, 4 and 5) recovery from hepa¬ titis was followed by prolonged survival and in none did hepatitis recur. Results of the HBsAg tests remained nega¬ tive in two of these patients. In the other (case 5) they became positive again 9 months after recovery from hepa¬ titis; there were no associated liver enzyme abnormalities in this patient, who had received another series of trans¬ fusions (30 units) 4 months before the HBsAg tests became positive again. No HB antibody studies were performed. In the majority of patients in whom hepatitis did not develop, follow-up tests for HBsAg and liver function were not carried out as a routine. In 10 patients who lived at least 3 months after diagnosis of leukemia, repeat tests were Table II.Clinical data at onset of
done from 3 to 8 months after the diagnosis was made; none of the results was positive. It is, however, possible that if tests had been carried out as a routine on all patients who did not have symptoms or signs of clinical hepatitis, more positive results for HBsAg might have been obtained and cases of asymptomatic anicteric hepatitis might have been identified. Comparison of ''hepatitis'' and "nonhepatitis" groups To determine what factors may have influenced the de¬ velopment of HBsAg-positive hepatitis, we compared the six patients who had hepatitis ("hepatitis" group) with those who did not have hepatitis ("nonhepatitis" group). In no patient did hepatitis develop in less than 21 weeks after the diagnosis of leukemia; therefore, all "nonhepatitis" pa¬ tients who survived for less than 20 weeks were excluded from this comparison. Among the initial 58 patients who were tested for HBsAg there were 52 in whom hepatitis did not develop; of these 52, 4 (ANLL) were seen for opinion only and not followed, and 18 (ANLL) survived for less than 20 weeks. There remained 30 (19 ANLL and 11 ALL) "nonhepatitis" patients who survived for 20 to more than 147 weeks. Although the latent period from transfusion to the development of hepatitis may be as short as 30 days,20 we excluded all transfusions given less than 12 weeks before the onset of hepatitis and less than 12 weeks before death or the last follow-up date in the "nonhepatitis"
hepatitis
*ALL acute lymphoblastic leukemia. ANLL acute nonlymphoblastic leukemia. tCR complete remission. PR partial remission. JTwo series of transfusions, the first associated with initial remission induction and maintenance treatment, the second with treatment for first relapse. §lnadvertently given 1 unit of CIEP-positive leukocytes 10 weeks before onset of hepatitis. =
=
=
=
Table III.Clinical
of hepatitis Maximum values
course
Interval (wk) after onset of hepatitis To normal results of liver function To negative tests Subsequent course HBsAg 8 9 Full recovery from hepatitis. Died of leukemia 10 months after diagnosis, 12 weeks after onset of hepatitis.
(Improved, but (Remained + ve Hepatitis improved, but he died of leukemia 16 months remained abnormal.) to death.) after diagnosis, 5 weeks after onset of hepatitis. Full recovery from hepatitis. Died with leukemia in 10 relapse 33 months after diagnosis. Full recovery from hepatitis. Surviving in second CR 32 months after diagnosis of leukemia. Full recovery from hepatitis. Surviving in second PR 29 17 months after diagnosis. HB8Ag remained negative for 9 months, then became -f ve again without clinical or biochemical evidence of hepatitis 4 months after another 16.5
866
1040
12
12
series of transfusions. Full recovery from hepatitis. Surviving in first CR 15 months after diagnosis of leukemia.
?Serum glutamic pyruvic transaminase; normal value < 36 international units per litre. fSerum glutamic oxaloacetic transaminase; normal value < 32 international units per litre. CMA JOURNAL/MARCH 22, 1975/VOL. 112 695
group. The "corrected" number of transfusions and the pertinent clinical data for the "hepatitis" and "nonhepatitis" groups are shown in Table IV. There was no significant difference in the age of the patients in the two groups (P > 0.05). All patients, except for five in the "nonhepatitis" group, received intensive chemotherapy. In 1 of 12 patients with ALL and 5 of 24 with ANLL hepatitis B developed. These numbers are not significantly different (P > 0.05) and therefore there is no evidence to suggest that a patient in either diagnostic category is more susceptible to the hepatitis B virus. If one excludes the five patients with ANLL who did not receive chemotherapy, then in 1 of 12 patients with ALL and 5 of 19 patients with ANLL, hepatitis developed. These numbers are also not significantly different (P > 0.05). Finally, although patients in the "hepatitis" group received somewhat more transfusions than those in the "nonhepatitis" group, there was considerable overlap and no significant difference in the number of units given to each group (P > 0.05). Hepatitis B risk To determine the hepatitis B risk per unit of CIEPnegative blood, we totalled the "corrected" number of transfusions given to the patients who received CIEP-negative blood and who survived for at least 20 weeks. Five "hepatitis" patients (case 2 received leukocytes from a CIEP-positive donor and is excluded) received 288 units and 28 "nonhepatitis" patients (2 of 30 received no transfusions) received 1628 units. Therefore, five cases of hepatitis occurred in 33 patients who received a total of 1916 units of CIEP-negative blood; the hepatitis risk was therefore 5/1916 or 0.26% per unit of blood. Discussion and conclusions One of the 58 patients with newly diagnosed acute leukemia had a positive test for HB5Ag; in this instance only the RIA test was positive. The validity of the positive test was confirmed by the antibody absorption technique, and it is likely that the patient was a chronic HB5Ag carrier, possibly as a result of transfusions 13 years before. If only the CFT and CIEP methods had been used, no positive results would have been obtained in our series. In Toronto the Canadian Red Cross blood transfusion service found 325 of 212 622 (0.15%) units of blood from volunteer donors to be positive by CIEP.2' In other studies22.'26'27 the prevalence of RIA-positive donor units has varied between 1 and 4%. In Toronto a previous study on sera from CIEPnegative volunteer donors identified 8 of 606 (1.3%) to be positive by RIA.28 Therefore, in this small series we have no evidence to suggest that the prevalence of HB5Ag positivity is greater in patients with newly diagnosed acute leukemia than in the population at large. In contrast, after large numbers of transfusions had been Table IV-Comparison of "hepatitis" and "nonhepatitis" groups "Nonhepatitis" group "Hepatitis" group 30 6 No. of patients 16.69 (median, 30) 17.66 (median, 35) Age (yr) Diagnosis 11 1 ALL 19 5 ANLL Response to treatment 5(1 ALL, 4 ANLL) 21(10 ALL, 11 ANLL) Complete remission 1 (ALL) 1 (ANLL) Partial remission 3 (ANLL) Failure 0 5 (ANLL) 0 No treatment Total, 1628; range, Total, 745; range, "Corrected" no. of 0-232; median. 43* 7.457; median, 79 units transfused *Two patients received no transfusions. 696 CMA JOURNAL/MARCH 22, 1975/VOL. 112
administered, 6 of 58 (10%) of our patients later had icteric hepatitis with positive HB5Ag tests. If only those patients who lived for more than 20 weeks after the diagnosis of leukemia are considered, then in 6 of 36 (17%) hepatitis developed. It is, of course, not possible to rule out modes of HB8Ag transmission other than transfusion; however, the fact that in no patient did hepatitis develop less than 21 weeks after the diagnosis of leukemia and the start of transfusion suggests that the transmission of HB5Ag was most likely by means of blood transfusion. For one of the six patients in whom hepatitis developed it is known that the patient had received CIEP-positive blood 10 weeks before the onset of hepatitis. The other five patients had received CIEP-negative blood; however, it is well documented that hepatitis B can occur in recipients of blood found to be negative for HB.Ag by CIEP.M".27'29 The hepatitis B risk calculated from the 33 patients who received CIEP-negative blood was 0.26% (26/1000 units of blood). This figure is similar to those reported in other studies."."7'2' in which nonleukemic surgical patients received CIEP-negative blood with a hepatitis B risk that varied between 0.16 and 0.29% per unit of blood transfused. The similarity of these figures further supports the view that the occurrence of hepatitis B in patients with acute leukemia is directly related to blood transfusion. Further, it suggests that there is no increased susceptibility to the development of hepatitis B in patients with acute leukemia when compared with the nonleukemic population. It is more difficult to comment on the severity and course of hepatitis B in patients with acute leukemia as compared with nonleukemic patients. Although we did not screen our patients for anicteric hepatitis, the six patients in whom hepatitis B was diagnosed were all very ill; none died as a result of the hepatitis, although in our previous report9 three of four patients with HB antigenemia had died of fulminant hepatitis. One cannot rule out the possibility that either the leukemic state or the antileukemic therapy might be instrumental in increasing the severity of the infection. Hepatitis B is a definite hazard in patients being treated for acute leukemia. Blood transfusion products, necessary for the supportive treatment of these patients, should be screened with the most sensitive practical test, which at this moment we believe is the RIA technique. Such a group of patients would provide an ideal population to study prophylactic measures in the prevention of hepatitis B. This work was supported by grants from The Ontario Cancer Treatment and Research Foundation and the Medical Research Council of Canada. The statistical analysis was carried out by Mrs. Joan Reid of the department of special studies, Ontario Cancer Institute. The authors wish to thank Dr. B.P.L. Moore for his valuable comments and Miss Helen Cheetham and Mrs. Olive Lacey for typing the manuscript. References 1. BLUMBERO BS, ALma HJ, VIsNIcH S: A "new" antigen in leukemia sera. JAMA 191: 541, 1965 2. SLITNICK AT, LONDON WT, BLUMBERG B5, et al: Australia antigen (a hepatitis-associated antigen) in leukemia. J Nail Cancer Inst 44: 1241, 1965 3. BLUMBERG B5, SUTNIcK AT, THOMAS WT: Hepatitis and leukemia: their relation to Australia antigen. Bull NY Acad Med 44: 1566, 1968 4. SALZANO FM, BLUMBEIG B5: The Australia antigen in Brazilian healthy persons and in leprosy and leukemic patients. I Clin Pathol 23: 39, 1970 5. SumicK AT, LEVINE PH, LONDON WT, et al: Frequency of Australia antigen in patients with leukemia in different countries. Lancet 1: 1200, 1971 6. PALVA IP, RAUNJO V: Australia antigen in patients with leukemia in Finland. Lancet 2: 1159, 1971 7. KORczOwsKs R, HAUKOwsKI B, ZAJACKOwsKI J: Australia antigen in leukemias and lymphoreticular proliferative disorders in children. Pediatr Pol 47: 1065, 1972 8. KATZ L, EMaIL IA, ROKEE KR: The occurrence of hepatitis-associated antigen in a group of Canadian patients with leukemia. Can Med Assoc 1 107: 210, 1972 9. ABU-ZAHRA HE, COwAN DH, CLAaYssa AM, et al:
Occurrence
of
Australia antigen in patients with leukemia in Canada. Lancet 2: 375, 1971
0. KouRouPis GM, LEERS W-D: Radjoimmunoassay, complement fixation and counter-immunoelectrophoresis in the laboratory diagnosis of hepatitis-B. Arch Gesamte Vlrusforsch 43: 112, 1973 1. SEVER JL: Application of a microtechnique to viral serological investigations. J Immunol 88: 320, 1962 2. HUMMELER K, KItTLER A: Dissociation of poliomyelitis virus from neutralizing antibody. Virology 6: 297, 1958 3. Gocxa DJ, Howa C: Rapid detection of Australia antigen by counterimmunoelectrophoresis. J Immunol 104: 1031, 1970 4. MILLER PJ, MORDECAS BG: Evaluation of a solid-phase radioimmunoassay technique for the detection of hepatitis associated antigen. I Nuci Med 13: 454, 1972 5. Kouaous'ss GM, LEERS W-D: A rapid radioimmunoassay method for detection of hepatitis B antigen. Arch Gesamte Varusforsch 44: 370, 1974 6. ABU-ZAHRA H, CLARYSSE A, COWAN DH, et al: Treatment of acute myeloblastic leukemia in adults: remission induction with a combination of cyclophosphamide, cytarabine and vincristine. Can Med Assoc I 107: 1073, 1972 7. MANASTER J, COwAN DH, CusiTIs JE, et at: Maintenance of acute non-lymphoblastic leukemia remission with 1,3-Bis (2-chloroethyl)-1nitrosourea (NSC-409963) and cyclophosphamide (NSC-26271). Cancer Chemother Rep, in press 8. MOORE BL, MEADE D: Counter-immunoelectrophoresis for detection of hepatitis B antigen and antibody: a technique for large scale use. Can I Public Health 63: 453, 1972 9. FREIREICH El, JunsoN G, Lavne RH: Separation and collection of leukocytes. Cancer Res 25: 1516, 1965
20. GocaB DJ: A prospective study of posttransfusion hepatitis. JAMA 219: 1165, 1972 21. WRODEL DM, FEINMAN V. Bmss B, Ct al: Frequency of hepatitis B
antigen in blood donors. Can Med Assoc J 108: 570, 1973 22. GINSBERG AL, CONRAD ME, BANCROFT WH, et al: Prevention of endemic HAA-positive hepatitis with gamma globulin: use of a simple radio immune assay to detect HAA. N Engi J Med 286: 562, 1972 23. HoLLSNGER FB DREESMAN G, MoRRIsoN M, et al: Improved double
antibody-RIA (RIA-DA) methodology for detecting hepatitis B antigen (HB-Ag) and antibody (HB-Ab), in Abstracts of the Annual Meeting of the American Society for Microbiology, Philadelphia, April 23-28, 1972, p 213 24. HOLLINGER FB, AACH RD, GITNIcK GL, et al: Limitations of solid-
phase radioimmunoassay for HB-Ag in reducing frequency of posttransfusion hepatitis. N Engi J Med 289: 385, 1973 25. ALTER Hi, HOLLAND PV, PURCELL RH, et al: Posttransfusion hepatitis after exclusion of commercial and hepatitis-B antigen-positive donors.
Ann intern Med 77: 691, 1972 26. KORETz RL, KLAHS DR, RITMAN S. et al: Post-transfusion hepatitis in recipients of blood screened by newer assays. Lancet 2: 694, 1973 27. HOLLINGER FB, WERcH J, MELNICK JL: A prospective study indicating that double-antibody radioimmunoassay reduces the incidence of posttransfusion hepatitis B. N Engl J Med 290: 1104 1974 28. LEERS W-D, Kouaous'ss GM: Hepatitis B antig.n in screened blood units for transfusion in renal dialysis patients. Can Med Assoc I
110: 308, 1974 29. AACH RD, ALTER J, HOLLINUER FB, et al: Risk of transfusing blood containing antibody to hepatitis-B surface antigen. Lancet 2: 190, 1974
Retrospect Colloidal copper injections in malignant disease
in the course of a presidential address delivered before the Cardiff Medical Society on November 11th (Lancet, December 27th., 1924) Dr. E. E. Brierly, F.R.C.S.Ed., spoke highly of the value of a course of colloidal copper injections in conditions of inoperable carcinoma. He mentioned two cases of nodular growths in the breast with secondary glands in the axilla which were treated by him with intramuscular injections of colloidal copper; the glands and the growth disappearing after a course of injections extending a little over a year. Both patients are still alive and well, ten and seven years after the commencement of this treatment. A patient with a large scirrhus carcinoma of the breast had her breast removed and the axilla cleared in November, 1916. The supraclavicular glands on the same side were found to be enlarged when she was seen by him in February, 1918. Intramuscular injections of colloidal copper were given over a period of eight months. The glands disappeared and the patient is still alive and well. A patient, aged sixty-two, who gave a history of haemorrhagic vaginal discharge called him in on account of excessive flooding. Vaginal examination demonstrated the clinical signs of cancer of the cervix. Operation was refused, but consent was given for intramuscular injections of colloidal copper. After seven injections the haemorrhage and discharge had ceased, and the patient refused further injections. On examination the cervix was found healed and smooth. This patient died nine months later from a paralytic stroke. Among other cases mentioned he reports two cases of advanced and inoperable carcinoma of the rectum which had been treated by him. One improved and put on weight, but died in twelve months. The other received no benefit. Dr. Brierly referred to a case of inoperable cancer of the rectum treated by colloidal copper and selenium, reported by Lionel Norbury, in Proceedings of the Royal Society of Medicine, June, 1923. Dr. Brierly strongly urged the trial of colloidal copper after operations for cancer and in inoperable cases; emphasizing the need of perseverance in the treatment, even if signs of improvement were delayed until the patient was cured. - Editorial, Can Med Assoc J 15: 203, 1925
CMA JOURNAL/MARCH 22, 1975/VOL. 112 697
antigen
D SC, M SC, FRSH, FRMS, CPH;
Summary: Fifty-eight adult patients with
acute leukemia screened at the onset of the disease for hepatitis B antigen (HBsAg) in the serum, and during the course of the disease for the development of hepatitis B. One patient had a positive test for HBsAg by the radioimmunoassay technique only at the time leukemia was diagnosed; this patient had received transfusions some years before. In six patients icteric hepatitis B developed; five recovered completely and one died of leukemia during the course of hepatitis. All patients in whom hepatitis developed had received transfusions as a part of supportive therapy for leukemia. The hepatitis risk for patients who received transfusions of blood found to be negative for HBsAg by counterimmunoelectrophoresis was 0.26% per unit of blood administered. Resume: Survenue d'hepatite et d'antigene de surface de I'hepatite B chez des malades adultes souffrant de leucemie aigue' Nous avons passe au crible des le debut de la maladie 58 malades adultes souffrant de leucemie aigue et cherche dans le serum de ces malades I'antigene de surface de I'hepatite B (HB8Ag) et au cours de I'evolution de la maladie, I'apparition de I'hepatite B. Chez un malade le test de l'HBsAg n'etait positif par la technique d'essai radtoimmunologique qu'au moment ou la leucemie etait diagnostiquee; ce malade avait recu des transfusions quelques annees auparavant. Chez six malades une hepatite B icterique survint; cinq malades ont gueri completement et le sixieme est mort de leucemie durant I'evolution de I'hepatite. Tous les malades qui ont souffert d'hepatite avaient recu des transfusions a titre de traitement de soutien pour la leucemie. Le risque d'hepatite chez les malades qui avaient recu des transfusions et dont le sang s'etait revele negatif pour HBsAg par contreimmunoelectrophorese a ete evalue a 0.26% par unite de sang transfuse. were
From the departments of medicine and medical microbiology, University of Toronto, The Ontario Cancer Institute, The Princess Margaret Hospital and The Wellesley Hospital, Toronto ?Professor, department of medicine, University of Toronto tVirologist, department of microbiology, The Wellesley and The Princess Margaret hospitals JChief, department of microbiology, The Wellesley and The Princess Margaret hospitals; assistant professor, department of medical microbiology, University of Toronto Reprint requests to: Dr. D.H. Cowan, Sunnybrook Medical Centre, 2075 Bayview Ave., Toronto, Ont. M4N 3M5
Since the initial observation of a "new" antigen in leukemia serum1 there have been a number of reports of an increased prevalence of hepatitis B surface antigen (HBsAg) in the serum of patients with leukemia.2"8 The populations and types of leukemia studied and the methods used for detec¬ tion of HBsAg have varied in these reports. Whereas most investigators have concluded that the occurrence of HBsAg in leukemic patients is related to previous blood transfusion, in at least one report the authors concluded that the increased prevalence of HBsAg was unrelated to the blood transfusion histories of the patients.8 These reports have not documented horizontal studies in a group of patients with leukemia. We previously reported on 14 patients with acute leuke¬ mia treated between July 1, 1970 and June 30, 1971.9 Four patients had a positive test for HBsAg; three of these died of fulminant hepatitis. All four had previously received blood transfusion and all had been treated with intensive chemotherapy. Because all patients with acute leukemia seen during that period were not tested for HB8Ag, and because tests were not carried out at the time leukemia was diagnosed, we were unable to comment on the overall prevalence of HBsAg in patients with acute leukemia, either at the time of diagnosis or during the course of the illness. Consequently, a prospective study was designed to deter¬ mine: (a) the frequency of positive HBsAg tests in patients with newly diagnosed acute leukemia, (b) the incidence of hepatitis associated with HBsAg during the course of acute leukemia, (c) the relation of HBsAg to the administration of blood transfusion products and (d) the course of HBsAgpositive hepatitis in patients with acute leukemia. This report documents the findings in 58 patients treated on an adult acute leukemia service. Methods and Tests
patients
for HBsAg
The methods used to detect HBsAg in this laboratory have been described in detail.10 In brief they are as follows: 1. The complement fixation test (CFT) was done by the method of Sever.11 If the titre was 1:8 or greater, the test was considered positive. The problem of anticomplementary activity was solved by treating the sera with fluoro-
carbon.10-12
CMA JOURNAL/MARCH 22, 1975/VOL. 112 693
2. Counterimmunoelectrophoresis (CIEP) was performed by the method of Gocke and Howe13 and modified as previously described.10 3. The radioimmunoassay (RIA) test was carried out by the two-step direct solid-phase radioimmunoassay technique as described by Miller and Mordecai14 and modified as previously described.15 RIA-positive sera that were negative by all other tests were treated as follows: Equal volumes of the serum sample and rabbit serum containing antibodies to HBsAg were mixed and left at room temperature for at least 1 hour. The sera were then retested for the presence of HBsAg by RIA. The absence of HBsAg in the repeated RIA test would confirm validity of the positive result. During the initial phase of this study, sera from the leukemic patients were tested by CFT only. Sera from most of these patients were stored and were subsequently re¬ tested by RIA and CIEP. After the introduction of RIA all sera from the leukemic patients were tested by all three
donors
tory.
were
screened
by the
CIEP method in
our
labora¬
All blood products administered to patients in this study free of HBsAg as tested by CIEP. One patient inadvertently received a leukocyte transfusion from a donor with hepatitis B antigen and subsequently developed hepa¬ titis B. In this report a unit of blood (red cells, platelets or leukocytes) refers to the blood or blood products obtained from a single donor. Statistical methods The chi-square test, with Yates's correction for continuity, was used for testing differences in the occurrence of hepa¬ titis B in patients with ALL and ANLL. The Wilcoxon rank test was used for testing differences in age and num¬ bers of transfusions in groups of patients. were
methods.
Results
Patient selection
Initial HBsAg screening In the initial HBsAg screening all 58 patients were tested by CFT but only 54 by CIEP and 41 by RIA because insufficient stored serum was available (Table I). Serum from 1 of the 58 leukemic patients was positive on RIA testing (confirmed positive); the CFT and CIEP gave negative results. This was a 68-year-old woman with ANLL who had received blood transfusions during mitral commissurotomy 13 years before this admission and also 10 days before the test for HBsAg. There was no history of hepa¬ titis and at the time of the initial test there was no clinical or biochemical evidence of hepatitis. Over the next 2 months results of liver function tests remained normal. The RIA test, repeated twice, remained positive; the CFT and CIEP remained negative, indicating a low HBsAg content in the serum. The patient died 6 months after presentation as a result of the leukemia. No autopsy was performed.
All patients with acute leukemia referred to the adult acute leukemia service of The Princess Margaret Hospital,
Toronto whose disease was diagnosed between July 1, 1971 and Dec. 30, 1973 were included in this study. Followup extended to July 31, 1974. There were 49 patients with acute nonlymphoblastic leukemia (ANLL) and 12 papatients with acute lymphoblastic leukemia (ALL). Three patients with ANLL did not undergo HBsAg tests; these patients survived for 1, 1 and 14 weeks and did not have any clinical evidence of hepatitis. The remaining 58 patients (46 ANLL and 12 ALL) form the basis for this report.
Treatment methods The treatment protocol for patients with ANLL has been reported in detail.16*17 In brief it is as follows: Remission induction and consolidation treatment consisted of 4-day courses of cyclophosphamide, cytarabine (Ara-C) and vin¬ cristine repeated at 2- to 3-week intervals (CAV protocol). Maintenance treatment with 1,3-bis (2-chloroethyl)-l-nitrosourea (BCNU) and cyclophosphamide was given at 8-week intervals. Patients whose condition failed to respond to the remission induction protocol were treated with a variety of chemotherapeutic agents. Several different regimens were used in the management of patients with ALL. The majority received prednisone and vincristine to induce remission. Consolidation therapy consisted of three 5-day courses of methotrexate given at 2- to 3-week intervals, then a 2-week reinduction course of prednisone and vincristine. This cycle was repeated three times, after which the patients were maintained on twiceweekly methotrexate. Most patients were treated by cranial irradiation and intrathecal methotrexate as prophylaxis against central nervous system leukemia. Patients whose condition failed to respond to induction therapy were treated with combinations of a variety of drugs, including
Ara-C, cyclophosphamide, vincristine, prednisone, 6-mer-
captopurine, L-asparaginase
and
daunomycin.
Transfusion practice Patients were transfused with packed red cells for ane¬ mia and platelet concentrates for severe thrombocytopenia. The red cells and platelet concentrates were provided by the Canadian Red Cross blood transfusion service, and during the study period all blood was screened for HBsAg by the CIEP method at the Toronto regional transfusion centre before release for transfusion.18 Some patients also received fresh leukocyte transfusions obtained by the IBMNCI Blood Cell Separator19 from volunteer donors. These 694 CMA JOURNAL/MARCH 22, 1975/VOL. 112
Follow-up In 6 (10%) of the initial group of 58 leukemic patients (1 of 12 with ALL and 5 of 46 with ANLL) icteric hepatitis with positive tests for HBsAg developed. In all cases all three tests for HBsAg were positive. Pertinent clinical data are summarized in Table II. The onset of hepatitis with positive HBsAg tests occurred from 21 to 64 weeks after the diagnosis of leukemia. Four patients (cases 1, 3, 4 and 6) were in their first complete remission, one (case 5) in an excellent partial remission and one (case 2) was being treated for a first relapse after a complete remission. All six patients had received transfusions. All but one patient (case 6) had received transfusions between 12 and 24 weeks before the onset of hepatitis; this patient had received no transfusions for 39 weeks before the onset of clinical hepatitis. One patient (case 2) inadvertently received HBsAg-positive blood in a leukocyte transfusion from a donor whose serum was positive by CIEP. The CFT and RIA determinations subsequently carried out on the donor's serum were also positive. Hepatitis was diagnosed in the recipient 10 weeks after the transfusion.
The clinical course of the hepatitis is summarized in Table III. In five patients (cases 1, 3, 4, 5 and 6) there was complete recovery, with return of results of biochem¬ ical tests to normal in 6 to 12 weeks. In these five patients all tests for HBsAg became negative in 9 to 17 weeks. One of these five patients (case 1) suffered a relapse of leukemia during the episode of hepatitis and died as a result of the leukemia shortly after recovery from hepatitis. The sixth patient (case 2) died with leukemia in relapse 5 weeks after the onset of hepatitis when the hepatitis was less severe; death cannot be attributed to liver failure. The hepatitis, however, did prevent the administration of ade¬ quate drug treatment for the leukemia and in this way may have indirectly contributed to the patient's death. In three patients (cases 3, 4 and 5) recovery from hepa¬ titis was followed by prolonged survival and in none did hepatitis recur. Results of the HBsAg tests remained nega¬ tive in two of these patients. In the other (case 5) they became positive again 9 months after recovery from hepa¬ titis; there were no associated liver enzyme abnormalities in this patient, who had received another series of trans¬ fusions (30 units) 4 months before the HBsAg tests became positive again. No HB antibody studies were performed. In the majority of patients in whom hepatitis did not develop, follow-up tests for HBsAg and liver function were not carried out as a routine. In 10 patients who lived at least 3 months after diagnosis of leukemia, repeat tests were Table II.Clinical data at onset of
done from 3 to 8 months after the diagnosis was made; none of the results was positive. It is, however, possible that if tests had been carried out as a routine on all patients who did not have symptoms or signs of clinical hepatitis, more positive results for HBsAg might have been obtained and cases of asymptomatic anicteric hepatitis might have been identified. Comparison of ''hepatitis'' and "nonhepatitis" groups To determine what factors may have influenced the de¬ velopment of HBsAg-positive hepatitis, we compared the six patients who had hepatitis ("hepatitis" group) with those who did not have hepatitis ("nonhepatitis" group). In no patient did hepatitis develop in less than 21 weeks after the diagnosis of leukemia; therefore, all "nonhepatitis" pa¬ tients who survived for less than 20 weeks were excluded from this comparison. Among the initial 58 patients who were tested for HBsAg there were 52 in whom hepatitis did not develop; of these 52, 4 (ANLL) were seen for opinion only and not followed, and 18 (ANLL) survived for less than 20 weeks. There remained 30 (19 ANLL and 11 ALL) "nonhepatitis" patients who survived for 20 to more than 147 weeks. Although the latent period from transfusion to the development of hepatitis may be as short as 30 days,20 we excluded all transfusions given less than 12 weeks before the onset of hepatitis and less than 12 weeks before death or the last follow-up date in the "nonhepatitis"
hepatitis
*ALL acute lymphoblastic leukemia. ANLL acute nonlymphoblastic leukemia. tCR complete remission. PR partial remission. JTwo series of transfusions, the first associated with initial remission induction and maintenance treatment, the second with treatment for first relapse. §lnadvertently given 1 unit of CIEP-positive leukocytes 10 weeks before onset of hepatitis. =
=
=
=
Table III.Clinical
of hepatitis Maximum values
course
Interval (wk) after onset of hepatitis To normal results of liver function To negative tests Subsequent course HBsAg 8 9 Full recovery from hepatitis. Died of leukemia 10 months after diagnosis, 12 weeks after onset of hepatitis.
(Improved, but (Remained + ve Hepatitis improved, but he died of leukemia 16 months remained abnormal.) to death.) after diagnosis, 5 weeks after onset of hepatitis. Full recovery from hepatitis. Died with leukemia in 10 relapse 33 months after diagnosis. Full recovery from hepatitis. Surviving in second CR 32 months after diagnosis of leukemia. Full recovery from hepatitis. Surviving in second PR 29 17 months after diagnosis. HB8Ag remained negative for 9 months, then became -f ve again without clinical or biochemical evidence of hepatitis 4 months after another 16.5
866
1040
12
12
series of transfusions. Full recovery from hepatitis. Surviving in first CR 15 months after diagnosis of leukemia.
?Serum glutamic pyruvic transaminase; normal value < 36 international units per litre. fSerum glutamic oxaloacetic transaminase; normal value < 32 international units per litre. CMA JOURNAL/MARCH 22, 1975/VOL. 112 695
group. The "corrected" number of transfusions and the pertinent clinical data for the "hepatitis" and "nonhepatitis" groups are shown in Table IV. There was no significant difference in the age of the patients in the two groups (P > 0.05). All patients, except for five in the "nonhepatitis" group, received intensive chemotherapy. In 1 of 12 patients with ALL and 5 of 24 with ANLL hepatitis B developed. These numbers are not significantly different (P > 0.05) and therefore there is no evidence to suggest that a patient in either diagnostic category is more susceptible to the hepatitis B virus. If one excludes the five patients with ANLL who did not receive chemotherapy, then in 1 of 12 patients with ALL and 5 of 19 patients with ANLL, hepatitis developed. These numbers are also not significantly different (P > 0.05). Finally, although patients in the "hepatitis" group received somewhat more transfusions than those in the "nonhepatitis" group, there was considerable overlap and no significant difference in the number of units given to each group (P > 0.05). Hepatitis B risk To determine the hepatitis B risk per unit of CIEPnegative blood, we totalled the "corrected" number of transfusions given to the patients who received CIEP-negative blood and who survived for at least 20 weeks. Five "hepatitis" patients (case 2 received leukocytes from a CIEP-positive donor and is excluded) received 288 units and 28 "nonhepatitis" patients (2 of 30 received no transfusions) received 1628 units. Therefore, five cases of hepatitis occurred in 33 patients who received a total of 1916 units of CIEP-negative blood; the hepatitis risk was therefore 5/1916 or 0.26% per unit of blood. Discussion and conclusions One of the 58 patients with newly diagnosed acute leukemia had a positive test for HB5Ag; in this instance only the RIA test was positive. The validity of the positive test was confirmed by the antibody absorption technique, and it is likely that the patient was a chronic HB5Ag carrier, possibly as a result of transfusions 13 years before. If only the CFT and CIEP methods had been used, no positive results would have been obtained in our series. In Toronto the Canadian Red Cross blood transfusion service found 325 of 212 622 (0.15%) units of blood from volunteer donors to be positive by CIEP.2' In other studies22.'26'27 the prevalence of RIA-positive donor units has varied between 1 and 4%. In Toronto a previous study on sera from CIEPnegative volunteer donors identified 8 of 606 (1.3%) to be positive by RIA.28 Therefore, in this small series we have no evidence to suggest that the prevalence of HB5Ag positivity is greater in patients with newly diagnosed acute leukemia than in the population at large. In contrast, after large numbers of transfusions had been Table IV-Comparison of "hepatitis" and "nonhepatitis" groups "Nonhepatitis" group "Hepatitis" group 30 6 No. of patients 16.69 (median, 30) 17.66 (median, 35) Age (yr) Diagnosis 11 1 ALL 19 5 ANLL Response to treatment 5(1 ALL, 4 ANLL) 21(10 ALL, 11 ANLL) Complete remission 1 (ALL) 1 (ANLL) Partial remission 3 (ANLL) Failure 0 5 (ANLL) 0 No treatment Total, 1628; range, Total, 745; range, "Corrected" no. of 0-232; median. 43* 7.457; median, 79 units transfused *Two patients received no transfusions. 696 CMA JOURNAL/MARCH 22, 1975/VOL. 112
administered, 6 of 58 (10%) of our patients later had icteric hepatitis with positive HB5Ag tests. If only those patients who lived for more than 20 weeks after the diagnosis of leukemia are considered, then in 6 of 36 (17%) hepatitis developed. It is, of course, not possible to rule out modes of HB8Ag transmission other than transfusion; however, the fact that in no patient did hepatitis develop less than 21 weeks after the diagnosis of leukemia and the start of transfusion suggests that the transmission of HB5Ag was most likely by means of blood transfusion. For one of the six patients in whom hepatitis developed it is known that the patient had received CIEP-positive blood 10 weeks before the onset of hepatitis. The other five patients had received CIEP-negative blood; however, it is well documented that hepatitis B can occur in recipients of blood found to be negative for HB.Ag by CIEP.M".27'29 The hepatitis B risk calculated from the 33 patients who received CIEP-negative blood was 0.26% (26/1000 units of blood). This figure is similar to those reported in other studies."."7'2' in which nonleukemic surgical patients received CIEP-negative blood with a hepatitis B risk that varied between 0.16 and 0.29% per unit of blood transfused. The similarity of these figures further supports the view that the occurrence of hepatitis B in patients with acute leukemia is directly related to blood transfusion. Further, it suggests that there is no increased susceptibility to the development of hepatitis B in patients with acute leukemia when compared with the nonleukemic population. It is more difficult to comment on the severity and course of hepatitis B in patients with acute leukemia as compared with nonleukemic patients. Although we did not screen our patients for anicteric hepatitis, the six patients in whom hepatitis B was diagnosed were all very ill; none died as a result of the hepatitis, although in our previous report9 three of four patients with HB antigenemia had died of fulminant hepatitis. One cannot rule out the possibility that either the leukemic state or the antileukemic therapy might be instrumental in increasing the severity of the infection. Hepatitis B is a definite hazard in patients being treated for acute leukemia. Blood transfusion products, necessary for the supportive treatment of these patients, should be screened with the most sensitive practical test, which at this moment we believe is the RIA technique. Such a group of patients would provide an ideal population to study prophylactic measures in the prevention of hepatitis B. This work was supported by grants from The Ontario Cancer Treatment and Research Foundation and the Medical Research Council of Canada. The statistical analysis was carried out by Mrs. Joan Reid of the department of special studies, Ontario Cancer Institute. The authors wish to thank Dr. B.P.L. Moore for his valuable comments and Miss Helen Cheetham and Mrs. Olive Lacey for typing the manuscript. References 1. BLUMBERO BS, ALma HJ, VIsNIcH S: A "new" antigen in leukemia sera. JAMA 191: 541, 1965 2. SLITNICK AT, LONDON WT, BLUMBERG B5, et al: Australia antigen (a hepatitis-associated antigen) in leukemia. J Nail Cancer Inst 44: 1241, 1965 3. BLUMBERG B5, SUTNIcK AT, THOMAS WT: Hepatitis and leukemia: their relation to Australia antigen. Bull NY Acad Med 44: 1566, 1968 4. SALZANO FM, BLUMBEIG B5: The Australia antigen in Brazilian healthy persons and in leprosy and leukemic patients. I Clin Pathol 23: 39, 1970 5. SumicK AT, LEVINE PH, LONDON WT, et al: Frequency of Australia antigen in patients with leukemia in different countries. Lancet 1: 1200, 1971 6. PALVA IP, RAUNJO V: Australia antigen in patients with leukemia in Finland. Lancet 2: 1159, 1971 7. KORczOwsKs R, HAUKOwsKI B, ZAJACKOwsKI J: Australia antigen in leukemias and lymphoreticular proliferative disorders in children. Pediatr Pol 47: 1065, 1972 8. KATZ L, EMaIL IA, ROKEE KR: The occurrence of hepatitis-associated antigen in a group of Canadian patients with leukemia. Can Med Assoc 1 107: 210, 1972 9. ABU-ZAHRA HE, COwAN DH, CLAaYssa AM, et al:
Occurrence
of
Australia antigen in patients with leukemia in Canada. Lancet 2: 375, 1971
0. KouRouPis GM, LEERS W-D: Radjoimmunoassay, complement fixation and counter-immunoelectrophoresis in the laboratory diagnosis of hepatitis-B. Arch Gesamte Vlrusforsch 43: 112, 1973 1. SEVER JL: Application of a microtechnique to viral serological investigations. J Immunol 88: 320, 1962 2. HUMMELER K, KItTLER A: Dissociation of poliomyelitis virus from neutralizing antibody. Virology 6: 297, 1958 3. Gocxa DJ, Howa C: Rapid detection of Australia antigen by counterimmunoelectrophoresis. J Immunol 104: 1031, 1970 4. MILLER PJ, MORDECAS BG: Evaluation of a solid-phase radioimmunoassay technique for the detection of hepatitis associated antigen. I Nuci Med 13: 454, 1972 5. Kouaous'ss GM, LEERS W-D: A rapid radioimmunoassay method for detection of hepatitis B antigen. Arch Gesamte Varusforsch 44: 370, 1974 6. ABU-ZAHRA H, CLARYSSE A, COWAN DH, et al: Treatment of acute myeloblastic leukemia in adults: remission induction with a combination of cyclophosphamide, cytarabine and vincristine. Can Med Assoc I 107: 1073, 1972 7. MANASTER J, COwAN DH, CusiTIs JE, et at: Maintenance of acute non-lymphoblastic leukemia remission with 1,3-Bis (2-chloroethyl)-1nitrosourea (NSC-409963) and cyclophosphamide (NSC-26271). Cancer Chemother Rep, in press 8. MOORE BL, MEADE D: Counter-immunoelectrophoresis for detection of hepatitis B antigen and antibody: a technique for large scale use. Can I Public Health 63: 453, 1972 9. FREIREICH El, JunsoN G, Lavne RH: Separation and collection of leukocytes. Cancer Res 25: 1516, 1965
20. GocaB DJ: A prospective study of posttransfusion hepatitis. JAMA 219: 1165, 1972 21. WRODEL DM, FEINMAN V. Bmss B, Ct al: Frequency of hepatitis B
antigen in blood donors. Can Med Assoc J 108: 570, 1973 22. GINSBERG AL, CONRAD ME, BANCROFT WH, et al: Prevention of endemic HAA-positive hepatitis with gamma globulin: use of a simple radio immune assay to detect HAA. N Engi J Med 286: 562, 1972 23. HoLLSNGER FB DREESMAN G, MoRRIsoN M, et al: Improved double
antibody-RIA (RIA-DA) methodology for detecting hepatitis B antigen (HB-Ag) and antibody (HB-Ab), in Abstracts of the Annual Meeting of the American Society for Microbiology, Philadelphia, April 23-28, 1972, p 213 24. HOLLINGER FB, AACH RD, GITNIcK GL, et al: Limitations of solid-
phase radioimmunoassay for HB-Ag in reducing frequency of posttransfusion hepatitis. N Engi J Med 289: 385, 1973 25. ALTER Hi, HOLLAND PV, PURCELL RH, et al: Posttransfusion hepatitis after exclusion of commercial and hepatitis-B antigen-positive donors.
Ann intern Med 77: 691, 1972 26. KORETz RL, KLAHS DR, RITMAN S. et al: Post-transfusion hepatitis in recipients of blood screened by newer assays. Lancet 2: 694, 1973 27. HOLLINGER FB, WERcH J, MELNICK JL: A prospective study indicating that double-antibody radioimmunoassay reduces the incidence of posttransfusion hepatitis B. N Engl J Med 290: 1104 1974 28. LEERS W-D, Kouaous'ss GM: Hepatitis B antig.n in screened blood units for transfusion in renal dialysis patients. Can Med Assoc I
110: 308, 1974 29. AACH RD, ALTER J, HOLLINUER FB, et al: Risk of transfusing blood containing antibody to hepatitis-B surface antigen. Lancet 2: 190, 1974
Retrospect Colloidal copper injections in malignant disease
in the course of a presidential address delivered before the Cardiff Medical Society on November 11th (Lancet, December 27th., 1924) Dr. E. E. Brierly, F.R.C.S.Ed., spoke highly of the value of a course of colloidal copper injections in conditions of inoperable carcinoma. He mentioned two cases of nodular growths in the breast with secondary glands in the axilla which were treated by him with intramuscular injections of colloidal copper; the glands and the growth disappearing after a course of injections extending a little over a year. Both patients are still alive and well, ten and seven years after the commencement of this treatment. A patient with a large scirrhus carcinoma of the breast had her breast removed and the axilla cleared in November, 1916. The supraclavicular glands on the same side were found to be enlarged when she was seen by him in February, 1918. Intramuscular injections of colloidal copper were given over a period of eight months. The glands disappeared and the patient is still alive and well. A patient, aged sixty-two, who gave a history of haemorrhagic vaginal discharge called him in on account of excessive flooding. Vaginal examination demonstrated the clinical signs of cancer of the cervix. Operation was refused, but consent was given for intramuscular injections of colloidal copper. After seven injections the haemorrhage and discharge had ceased, and the patient refused further injections. On examination the cervix was found healed and smooth. This patient died nine months later from a paralytic stroke. Among other cases mentioned he reports two cases of advanced and inoperable carcinoma of the rectum which had been treated by him. One improved and put on weight, but died in twelve months. The other received no benefit. Dr. Brierly referred to a case of inoperable cancer of the rectum treated by colloidal copper and selenium, reported by Lionel Norbury, in Proceedings of the Royal Society of Medicine, June, 1923. Dr. Brierly strongly urged the trial of colloidal copper after operations for cancer and in inoperable cases; emphasizing the need of perseverance in the treatment, even if signs of improvement were delayed until the patient was cured. - Editorial, Can Med Assoc J 15: 203, 1925
CMA JOURNAL/MARCH 22, 1975/VOL. 112 697
