Galactoside-specific misletoe lectin modulates dexamethasone-induced apoptosis and glucocorticoid receptor level in Balb/c thymocytes.

The galactoside-specific plant lectin, Viscum album agglutinin-(VAA)-I has been shown to activate the natural immune system and modulate the maturation of thymocytes in vivo. However the mechanism of this immunobiological action is not yet understood. In our previous study we demonstrated the VAA-I-induced enhancement of proliferation and selection of thymocytes which inhibited the dexamethasone (DX)-induced thymocyte depletion. In this present work we investigated the effect of 1, 4 and 21 days of VAA-I treatment on DX-induced apoptosis of thymocytes in Balb/c mice. The number of early apoptotic cells was detected with Annexin V staining while the late apoptotic cells were identified according to their propidium iodide incorporation into DNA using flow cytometry. The expression of glucocorticoid receptor (GCR) in double-negative (DN), double-positive (DP) and CD4 or CD8 single-positive (SP) cell populations was assessed. The additive effect of lectin on DX-induced apoptosis of thymocytes consisted of two different actions of VAA-I and DX. One-day VAA-I treatment caused enhanced apoptosis in SP mature cells in contrast to the apoptotic effect of DX, which was mainly directed towards immature DN and DP cells. Treatment with 30 ng/kg VAA-I for four days elevated the GCR level (mean fluorescence intensity) in DP thymocytes. Lectin treatment for 21 days caused more than 20% elevation of GCR expression in all thymocyte subpopulations (DN, DP, CD4+ and CD8+). These results suggest that VAA-I may alter the sensitivity of thymocytes to glucocorticoids and this effect may play a role in the bell-shaped dose-response curve of lectin-induced immunological effects.

Activation of human neutrophils by the plant lectin Viscum album agglutinin-I: modulation of de novo protein synthesis and evidence that caspases are involved in induction of apoptosis.

The plant lectin Viscum album agglutinin-I (VAA-I) was recently found to modulate protein synthesis and to induce apoptosis in various cells of immune origin. We found that VAA-I induces de novo protein synthesis of metabolically 35S-labeled human neutrophils when used at low concentrations (< 100 ng/mL) but acts as an inhibitor at higher concentrations. Using both flow cytometry (FITC-Annexin-V/PI labeling) and cytology (Diff-Quick staining) approaches, we found that VAA-I could not modulate neutrophil apoptosis at low concentrations but could induce it in >98% of cells at 500 and 1000 ng/mL. VAA-I was also found to reverse the delaying effect of GM-CSF on neutrophil apoptosis and to inhibit GM-CSF-induced de novo protein synthesis. In contrast to GM-CSF, VAA-I does not induce tyrosine phosphorylation by itself and does not alter the GM-CSF-induced response. Among the inhibitors used, genistein, pertussis toxin, staurosporine, H7, Calphostin C, manoalide, BpB, quinacrine HA-1077, and z-VAD-FMK, only the latter (inhibitor of caspases-1, -3, -4, and -7) was found to inhibit VAA-I-induced neutrophil apoptosis as the percentage of apoptotic cells decrease from 98 +/- 1.3 to 54 +/- 3.2% (n=4). Furthermore, we confirm that caspases are involved in VAA-I-induced neutrophil apoptosis as we have observed the fragmentation of the cytoskeletal gelsolin protein that is known to be caspase-3-dependent. Such degradation was reversed by the z-VAD-FMK inhibitor. We conclude that induction of neutrophil apoptosis by VAA-I is a caspase-dependent mechanism that does not involve tyrosine phosphorylation events, G-proteins, PKCs, and PLA2. In addition, we conclude that at least caspase-3 is involved. Correlation between VAA-I-induced neutrophil apoptosis and VAA-I-induced inhibition of de novo protein synthesis is discussed.

Selective modulation of phosphatidylserine exposure on subpopulations of human peripheral blood lymphocytes by a plant lectin, Viscum album agglutinin (VAA)-I and its recombinant form (rVAA) in vitro.

Growing evidence suggests that lectin-carbohydrate interactions are involved in the regulation of the balance between cell growth and programmed cell death. Viscum album agglutinin (VAA)-I is a galactoside-specific, type II ribosome-inactivating plant lectin. At concentrations less than 10 ng/ml, VAA-I has been shown to induce gene expression and secretion of proinflammatory cytokines as well as apoptosis in cultures of human peripheral blood mononuclear cells (PBMC). This study analyzes the effects of VAA-I and its recombinant nonglycosylated form (rVAA) on alterations of cell membrane permeability of cultured human peripheral lymphocytes (PBL) and on membrane exposure of phosphatidylserine characteristic of apoptosis. Analyses were performed by flow cytometry after staining with propidium iodide (PI) and/or with FITC-Annexin V/PI. After 24 h incubation of PBMC with 100 ng/ml VAA-I and rVAA, staining with supravital concentration of PI (20 microg/ml) for 1 h revealed no differences in percentages of PI-positive cells induced by the two forms of lectin (32.3% and 29.4%), but the exposure to 5 microg/ml PI for 15 min resulted in a significant difference: 35.1% and 8.0% after VAA-I and rVAA treatment, respectively. Kinetic analysis of membrane alterations showed mainly Annexin V positivity after 24 h, whereas after 48 h and 72 h incubation with 100 ng/ml VAA-I or rVAA loss of membrane integrity occurred, as demonstrated by PI staining. Similar to VAA-I, rVAA showed a higher binding affinity for monocytes and granulocytes than for lymphocytes. In cultures of PBL, the binding rank order of both lectins to lymphocyte subsets was NK, CD19+ > CD8+ > CD4+. The amount of Annexin/PI staining of PBL subsets corresponds to the degree of their binding capacity. In conclusion, present results demonstrate that VAA-I and its nonglycosylated recombinant form rVAA exhibit comparable effects on cell membrane alterations in the subsets of human PBLs.

[Mistletoe therapy from the pharmacologic perspective]. / Zukunft der misteltherapie aus pharmakologischer sicht.

Because of their cytostatic/apoptotic and immunomodulatory effects mistletoe extracts are often applied in tumour patients. Recent experimental data suggest that the mistletoe lectins Viscum album agglutinin (VAA)-I and -II are play an important role in the efficacy of mistletoe therapy. VAA-I and -II are members of the type-II ribosome-inactivating proteins. VAA-I has been shown to induce cytostatic effects in cultures of various eukaryotic cells in vitro. In 24-hour cultures of human peripheral lymphocytes, flow-cytometric investigations with propidium iodide (PI) in hypotonic buffer and quantitative assessment of DNA breaks with terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-digoxigenin nick end-labeling (TUNEL) assay were carried out; they revealed a dose-dependent VAA-I-induced apoptosis (lectin concentrations between 10 ng/ml and 1 microg/ml). In 24-hour cultures of peripheral blood mononuclear cells (PBMC), VAA-I in non-cytotoxic concentrations (1+/-10 ng/ml) induced mRNA expression and enhanced the secretion of proinflammatory cytokines. The stimulation of NK cells by VAA-I in vitro was enhanced in additive manner by the combination of VAA-I with IL-2 and IL-12. In culture of PBMC and bone marrow CD34+ cells coincubation of VAA-I with other haematopoietic growth factors induced a dose-dependent increase in clonogenic growth. In cancer patients the mechanisms of natural immunity, believed to be essential for their survival, are often significantly decreased. VAA-I and standardized mistletoe extracts are able to stimulate the cellular parameters of natural immunity with a bell-shaped curve of efficacy. Studies in animal models suggest that application of 0.5-3 ng/kg VAA-I twice a week is effective in sustaining the elevation of the number and activity of peripheral blood NK cells. These parameters often exhibit high intrinsic fluctuations, in healthy persons, however, blind crossover studies reveal an optimal lectin dose of about 0.5 and 1 ng/kg bw, suggesting a potential use of mistletoe preparations as a modulator of the natural immune system. Selective apoptotic effects of VAA-I may represent a novel approach for pharmacological manipulation of the balance between cell growth and programmed cell death. Appropriate combination of immunomodulatory and cytotoxic doses may open new clinical perspectives in the mistletoe therapy.

Effect of a recombinant lectin, Viscum album agglutinin on the secretion of interleukin-12 in cultured human peripheral blood mononuclear cells and on NK-cell-mediated cytotoxicity of rat splenocytes in vitro and in vivo.

A plant lectin, Viscum album agglutinin-I (VAA-I) has been shown to increase the number and cytotoxic activity of natural killer (NK) cells in animal models, but the mechanisms underlying these effects are poorly understood. We investigated the effects of the recombinant form of this lectin (rVAA) on secretion of interleukin (IL)-12 and on NK-mediated cytotoxicity against K562 target cells in cultures of human peripheral blood mononuclear cells (PBMC) as well as against YAC-1 target cells in cultured rat spleen cells. In 24-hour cultures of PBMC, 10 ng/ml plant VAA-I and 50 ng/ml rVAA induced significant increases in the secretion of total IL-12. Its biologically active heterodimeric form, p70, was also significantly induced by rVAA. Preincubation of PBMC or splenocytes for 48 h with rVAA in concentrations ranging between 10 pg/ml and 100 pg/ml resulted in moderate enhancements of NK-mediated cytotoxicity. However, coincubation of a low dose of rVAA (100 pg/ml) together with IL-2 and IL-12 (60 U/ml and 2 U/ml, respectively) led to additive stimulation of NK activity. In in vivo experiments, rVAA showed an enhancing effect on NK activity with a bell-shaped curve of efficacy. Forty-eight hours after a single intravenous injection of its most effective doses, 0.5 and 1 ng/kg, into Wistar rats, the NK cytotoxicity of splenocytes against YAC-1 targets doubled, and the frequency of large granular lymphocytes in peripheral blood showed 2.1- and 3-fold increases as compared to control animals. Twenty-four hours following these low lectin doses, the number of large granular lymphocytes was also significantly elevated. After 48 h, 0.5 ng/kg rVAA induced a significant augmentation in the percentage of peripheral Mac-1+ mononuclear cells, including activated monocytes and NK cells. The present results suggest that rVAA augments the secretion of an active form of IL-12 and potentiates the cytokine-induced NK activation. These effects of rVAA may be related to its stimulatory effects on MHC-unrestricted cytotoxicity in vivo.

Effects of a standardized mistletoe preparation on metastatic B16 melanoma colonization in murine lungs.

The immune response-modifying drug Lektinol is a mistletoe preparation which is standardized with respect to bioactive viscum album agglutinin, the most active component of mistletoe. The present study was designed to evaluate the antimetastatic effects of this preparation following intravenous injection of B16 melanoma cells into mice. The standardized mistletoe extract was administered intravenously in doses of 100, 1000 or 5000 microliters/kg (equivalent to 3, 30 or 150 ng/kg of viscum album agglutinin) once daily for three weeks. An inhibition of mean pulmonary metastatic colonization of 58 to 95%, as measured by the number of melanoma cells on lung tissue slides, and a significant decrease of percentage of bronchoalveolar lavage pigmented cells were observed. In addition, a correlation of this antimetastatic activity with cellular immune parameters was investigated. In lavage fluids from the tumor-bearing mice, there was a 5 to 6-fold significant increase in the percentage of MAC-1+ (CD11b/CD18) immunocompetent macrophages in comparison with cells from vehicle-treated animals. The percentages of double-positive immature CD4+8+ thymocytes were significantly increased in animals treated with the standardized mistletoe extract. There were no signs of treatment-related toxicity. The results of this study indicate that the standardized mistletoe extract shows antimetastatic activity against B16 melanoma lung colonization.

Lectin-induced increase in clonogenic growth of haematopoietic progenitor cells.

The galactoside-specific plant lectin, Viscum album agglutinin (VAA-I) increases cellular parameters of natural host defence. It also binds to a variety of haematopoietic cells, including progenitors. We investigated whether VAA-I has a stimulatory effect on haematopoietic progenitor cells. Peripheral blood progenitor cells from 7 healthy volunteers were cultured in a colony assay with VAA-I plus erythropoietin (EPO) and stem cell factor (SCF). At 50 pg/ml VAA-I induced a significant increase in the cytokine-dependent clonogenic growth (52% in median, p < 0.05). In another set of experiments purified CD34+ cells were isolated from the bone marrow aspirate of 4 patients with non-metastatic breast cancer using fluorescence-activated cell sorting. Binding to CD34+ cells was demonstrated by using directly fluorescence-conjugated VAA-I. Co-incubation with D-galactose significantly abrogated this effect. CD34+ cells were cultured in the presence of EPO, SCF, interleukin-3, granulocyte/monocyte colony-stimulating factor and granulocyte colony-stimulating factor. VAA-I alone had no measurable effect on the clonogenic growth of the isolated cells. However, at concentrations of 100 and 250 pg/ml VAA-I increased the cytokine-dependent proliferation and differentiation of CD34+ cells by a median of 75 and 85%, respectively. The results show that VAA-I binds to haematopoietic progenitor cells and has a co-stimulatory effect on their proliferation.

Immunomodulatory effects of Viscum album agglutinin-I on natural immunity.

In 24 h cultured human peripheral blood mononuclear cells, treated with various (1 microgram/ml to 1 ng/ml) concentrations of Viscum album agglutinin-I, quantitative assessment of DNA breaks labelled with terminal deoxynucleotidyl transferase revealed a dose-dependent Viscum album agglutinin-I-induced apoptosis above a lectin concentration of 10 ng/ml. After 24 h incubation of peripheral blood mononuclear cells with non-cytotoxic concentrations of Viscum album agglutinin-I (10 and 1 ng/ml), messenger (m)RNA expression and secretion of a panel of cytokines were evaluated by reverse polymerase chain reaction and by enzyme-linked immunosorbent assay (ELISA), respectively. The lectin induced expression of interleukin-1 alpha, interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, interferon-gamma, granulocyte-monocyte colony stimulating factor and interleukin-10 genes, but no expression of interleukin-2 or interferon-gamma production could be detected. In addition, cellular components of the natural immune system (such as monocytes and granulocytes) bound Viscum album agglutinin-I molecules to a higher degree than lymphocytes. To establish the modulatory potency of Viscum album agglutinin-I on the natural immunity of human subjects, four randomized, double-blind crossover trials were performed on healthy volunteers. In contrast to the significant lectin-induced increases in number and activity of natural killer cells observed in animal models, in the first and second trial human healthy individuals showed no significant differences between their natural killer responses following an injection of lectin-enriched preparation or saline. Due to considerable intrinsic fluctuation of these parameters, a third and fourth double-blind trial with freshly isolated Viscum album agglutinin-I was performed using a more rapidly detectable parameter, the priming of granulocytes. Here, significant lectin-induced increases were found.

A natural immunity-activating plant lectin, Viscum album agglutinin-I, induces apoptosis in human lymphocytes, monocytes, monocytic THP-1 cells and murine thymocytes.

A galactoside-specific plant lectin, Viscum album agglutinin-I (VAA-I) with protein synthesis-inhibiting properties, has been shown to be cytotoxic in various eukaryotic cells, in vitro above a 10 ng/ml concentration. Noncytotoxic concentrations of VAA-I induced mRNA expression and enhanced secretion of proinflammatory cytokines in cultures of human peripheral blood mononuclear cells. In an animal model VAA-I has been shown to stimulate natural killer cells and granulocytes. In this study, human peripheral blood lymphocytes (PBL), human peripheral blood monocytes (PBM), murine thymocytes and human monocytic THP-1 cells were incubated for 24 h in the presence of various concentrations of VAA-I. The apoptotic effect of VAA-I was analyzed by flow cytometry following staining of the apoptotic nuclei in the cells with PI in hypotonic buffer and quantitative detection of DNA breaks were analyzed by the terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick end-labeling (TUNEL) assay. In cultures of all types of investigated cells, a dose-dependent VAA-I concentrations above 10 ng/ml in PBL and at 1 ng/ml VAA-I concentration in PBM, thymocytes and THP-1 cells, a lectin-induced increase of the apoptotic nuclei was observed. In 24-hour cultures of PBL and thymocytes, the ratios between apoptotic and nonapoptotic cells were enhanced 10 times and 8 times, respectively, by 100 ng/ml VAA-I compared to the negative control. The concentration of 100 micrograms/ml VAA-I only caused necrosis. The isolated A chain of the VAA-I induced apoptosis in PBL and thymocytes. In the culture of PBL the isolated B chain of the VAA-I was not effective indicating that cytokine induction by VAA-I is probably not involved in its apoptotic effect. On CD4+8+ thymocytes, VAA-I resulted in a reduced expression of CD8+ molecules that could be related to a loss of volume and increase of density, both characteristic features of apoptosis.

Investigations of cellular parameters to establish the response of a biomodulator: galactoside-specific Lectin from Viscum album plant extract.

Injections of non-toxic doses of purified galactoside-specific lectin from the Viscum album plant (VAA-I) caused significant changes in the cellular host defense system in animal models. To establish the immunomodulatory potency of VAA-I on human subjects, four randomized double blind crossover trials were performed on healthy volunteers. In the first and second trials using either older (storage over 8 months at 4°C) or freshly (application immediately after production) isolated lectin enriched preparation from mistletoe extract by ultrafiltration with known VAA-I content, the effect of lectin on the number of CD 3+, CD4+, CD 8+, CD 16+/56+ cells, natural killer cytotoxicity and frequency of large granular lymphocytes was tested in peripheral blood of nine and eight individuals, respectively. In comparison to the significant increase in the number of peripheral lymphocytes observed in balb/c mice, human healthy individuals showed no significant difference between their responses after lectin enriched preparation and saline treatment. Due the considerable intrinsic fluctuation of these parameters in placebo control and the assumption that a change in immunomodulatory potency of VAA-I in lectin enriched preparation depends on aging, a third and fourth double blind trial, in this case using freshly isolated VAA-I from plant, were performed on six and eight healthy volunteers, respectively. In these studies an other more rapidly detectable parameter, the priming of polymorphonuclear (PMN) leukocytes, was monitored. In both studies, 5 h after lectin injection, significant enhancement in priming of circulating PMNs was found compared to the placebo response.

A plant lectin derived from Viscum album induces cytokine gene expression and protein production in cultures of human peripheral blood mononuclear cells.

A plant lectin from Viscum album (ML-I) has been shown to increase the number and cytotoxic activity of natural killer cells and to induce antitumor activity in animal models. However, the mechanisms underlying the effects of ML-I on natural host defenses are unknown. After 24 h incubation of peripheral blood mononuclear cells in the presence of 10 and 1 ng/ml of ML-I, mRNA expression and secretion of a panel of cytokines were evaluated by reverse polymerase chain reaction and by ELISA, respectively. The lectin induced expression of interleukin (IL)-1 alpha, IL-1 beta, IL-6, tumor necrosis factor-alpha, interferon-gamma, granulocyte-monocyte colony-stimulating factor and IL-10 genes but no expression of IL-2 and IL-5 genes could be detected. Regarding cytokine secretion, IL-6 and TNF-alpha production was induced by 10 ng/ml ML-I. On the other hand, IL-10 secretion was only stimulated by 1 ng/ml lectin. No production of IFN-gamma or, as expectable, IL-2 could be detected. In addition, ML-I increased the percentage of HLA-DR+ T lymphocytes in vitro. In tests performed on whole blood, monocytes and granulocytes bound the fluorescence-conjugated ML-I molecules to a higher degree than lymphocytes. Expression of IL-1 beta and IFN-gamma genes could also be observed upon ML-I stimulation of nonadherent cells. These results suggest that lectin-sugar interactions on the cell surface of immunocompetent cells can induce cytokine gene expression and protein synthesis.

Improvement of DNA repair in lymphocytes of breast cancer patients treated with Viscum album extract (Iscador).

We investigated alteration in DNA repair during therapy with an immunomodulator. 14 patients with advanced breast cancer were treated parenterally with Iscador, an extract of Viscum album (mistletoe). As a parameter for measurement of DNA repair the incorporation of (3H) thymidine into DNA of unstimulated lymphocytes after ultra violet light (UV) damage was taken. The DNA repair values in the patients were very low before treatment and on day 1: on average 16% of those in a healthy control population. Values started to increase on day 2 and on days 7-9 were on average 2.7 times higher than before treatment. 12/14 patients showed an improvement in repair. The values of spontaneous DNA synthesis were not altered during the treatment. We suggest that the increase of DNA repair could be due to a stimulation of repair enzymes by lymphokines or cytokines secreted by activated leukocytes or an alteration in the susceptibility to exogenic agents resulting in less damage.

Increased secretion of tumor necrosis factors alpha, interleukin 1, and interleukin 6 by human mononuclear cells exposed to beta-galactoside-specific lectin from clinically applied mistletoe extract.

A beta-galactoside-specific lectin from proprietary mistletoe extract, recently reported to exhibit immunomodulatory potency in vivo (T. Hajto, K. Hostanska, and H J. Gabius, Cancer Res. 49: 4803-4808, 1989), induced increased secretion of tumor necrosis factor alpha, interleukin 1, and interleukin 6 in cultures of human peripheral blood mononuclear cells. The enhancement of secretion, determined independently by bioassays and enzyme-linked immunosorbent assay-based quantitation, was caused by selective protein-carbohydrate interaction, as revealed by the strict dependence on the presence of the carbohydrate-binding subunit of the specific lectin-binding sugar as well as anti-lectin antibodies. Increased cytokine levels in serum of patients after injection of optimal lectin doses corroborated the in vitro results. Thus, these data provide an explanation for the increases in cellular parameters of the host defense system in vivo, which presents a further step toward their potentially beneficial clinical exploitation in standardized regimens.

Modulatory potency of the beta-galactoside-specific lectin from mistletoe extract (Iscador) on the host defense system in vivo in rabbits and patients.

Proprietary extract of mistletoe (Iscador) that has federal approval for clinical application can exhibit immunomodulatory capacity. However, the nature of this responsible substance has still remained elusive. To validate the hypothesis that specific lectin-carbohydrate interactions at least participate in eliciting immunomodulation, the modulatory efficiency of the major beta-galactoside-specific mistletoe lectin (ML I) from the clinically applied extract on selected immunological parameters was monitored "in vivo" in rabbits. Injections of nontoxic doses of the purified lectin or even only of its carbohydrate-binding subunit (0.25-1.0 ng/kg) into rabbits yielded significant increases in natural killer cytotoxicity, frequency of large granular lymphocytes, and phagocytic activity of granulocytes. In the clinically relevant situation, changes in these parameters were also determined in cancer patients after extract (Iscador) injection s.c. as well as i.v., emphasizing the potential relevance of the lectin. Comparative analyses of the changes in the selected parameters following injection of extract with normal lectin content as well as of extract, selectively depleted of lectin, into healthy volunteers corroborated this inference. Lectin depletion by affinity chromatography was highly specific and did not affect any other substance in the extract. Remarkably, contamination by endotoxin has been rigorously excluded in each applied specimen. These results encourage detailed elucidation of lectin action on various parts of the tumor defense system "in vitro" with the long range goal of achieving progress in the treatment of cancer through immunological strategies, exploring selective mediatory lectin-carbohydrate interactions.

Immunomodulatory effects of iscador: a Viscum album preparation.

The immunomodulatory effects of Iscador (a mistletoe, Viscum album extract) were investigated. After a single intravenous infusion of Iscador several immunological parameters in the peripheral blood of breast cancer patients were examined. Parallel with neutrophilia, and with an increase of juvenile neutrophils, a significant enhancement of phagocytic activity of granulocytes was shown. After short decreases during the first 24 h, significant increases in natural killer (NK) and antibody-dependent cell-mediated cytotoxicity (ADCC) activities as well as augmented levels of large granular lymphocytes were observed. These NK/ADCC responses followed a kinetic pattern similar to that after treatment with alpha-interferon described by others. Further significant increases in mitogenic responses to phytohemagglutinin and concanavalin A were observed.

Natural killer and antibody-dependent cell-mediated cytotoxicity activities and large granular lymphocyte frequencies in Viscum album-treated breast cancer patients.

20 breast cancer patients received a single intravenous infusion of Iscador, a mistletoe (Viscum album L.) extract. Natural killer (NK) and antibody-dependent cell-mediated cytotoxicity (ADCC) activities as well as the number of large granular lymphocytes (LGL) were investigated in their peripheral blood at various times. Six hours after the start of the infusion, significant decreases and 24 h later, significant increases in NK/ADCC activities and LGL frequencies were observed. These responses followed a kinetic pattern similar to that which has been described by others to occur after treatment with interferon.

Frequency of large granular lymphocytes in peripheral blood of healthy persons and breast cancer patients.

The frequency of large granular lymphocytes (LGL) in the peripheral blood of healthy persons (n = 56) and breast cancer patients (31 cases with stage-I and -II disease and 42 cases with stage-III and -IV disease) was studied. The frequency of LGL in peripheral blood was significantly depressed in cancer patients, and particularly in patients with advanced breast cancer.