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Detection of the anti-Hu antibody in the serum of patients with small cell lung cancerЧA quantitative western blot analysis.

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Detection of the Anti-Hu Antibody
in the Serum of Patients with Small Cell
Lung Cancer-A Quantitative Western
Blot Analysis
Josep Dalmau, MD,” Henry M. Furneaux, PhD,” kchard J. Gralla, MD,? Mark G. Kris, MD,?
and Jerome B. Posner, MD”
We looked for the presence of the anti-Hu antibody in the sera from 50 normal subjects; 44 patients with small cell
lung cancer, not associated with paraneoplastic disease; and 25 patients with small cell lung cancer associated with
paraneoplastic sensory neuropathy, encephalomyelitis, or both. Using the avidin-biotin immunoperoxidase method
and a highly sensitive quantitative Western blot analysis, the anti-Hu antibody was not detected in the 50 normal
human sera. Seven of the 44 patients with small cell lung cancer but no paraneoplastic syndrome had detectable levels
(average titer, 76 U/ml) of anti-Hu antibody on Western blot. These levels are significantly lower than the average titer
of the 25 patients who had small cell lung cancer and paraneoplastic sensory neuropathy or encephalomyelitis (average
titer, 4,592 U/ml). In the group with nonparaneoplastic small cell lung cancer (low anti-Hu titer) there was apredominance of women (5 women: 2 men), and all patients had “limited” disease when diagnosed. In the antibody-negative
group the sex ratio was 16 women to 21 men and 51% of the patients had “extensive” disease. None of the 7 patients
with a low-titer anti-Hu antibody developed a paraneoplastic syndrome by the time of writing. The anti-Hu antibody
appears, when present, to be a good marker for small cell lung cancer and, when present at high titer, for small cell
lung cancer associated with a paraneoplastic syndrome.
Dalmau J, Furneaux HM, Gralla RJ, Kris MG, Posner JB. Detection of the anti-Hu antibody in the serum of
patients with small cell lung cancer-a quantitative Western blot analysis. Ann Neurol 1990;27:544-552
Two paraneoplastic syndromes-sensory neuronopathy
(PSN) and encephalomyelitis (PEM)-are characterized by neuronal death and inflammatory infiltrates of
the neuraxis 11-41. In PSN the clinical symptoms and
pathological changes are most marked in the dorsal
root ganglia 11, 2). Neurological symptoms of PEM
include dementia (limbic encephalitis), cerebellar degeneration, brainstem encephalitis, or myelitis 11, 3,
41. PSN and PEM, which often occur together, are
associated with lung cancer, particularly small cell lung
cancer (SCLC), in about two of three instances 11, 21.
Patients who have these syndromes associated with
SCLC harbor a characteristic autoantibody in their
serum and spinal fluid called anti-Hu 15-91. The antibody identifies a protein antigen with molecular mass
of 35 to 40 kDa C61. This protein is expressed in the
nuclei of most neurons of the central nervous system
including the dorsal root ganglia, and in most or all
SCLC, but not in other normal tissues or other tumors
15, 6, 91 with the exception of a few cells in normal
bronchus and adrenal gland (unpublished results,
1989).
Our previous studies indicated that in patients who
had SCLC but no paraneoplastic syndrome, the autoantibody was not detectable even though the Hu antigen was expressed in the tumor 18, 101. Recent reports
from Grisold and colleagues 111-131 suggested that
autoantibodies against neuronal tissue (in particular
Purkinje cells) are found in 40% of patients with
SCLC independent of whether a paraneoplastic syndrome was present or not. N o attempt was made to
establish whether these antibodies were the same as
those characterized by Graus and colleagues 15, 61.
They concluded that in patients with SCLC, antineuronal antibodies are not markers of PSN and PEM.
To reconcile these disparate findings, we undertook to
restudy the question of the presence of antineuronal
autoantibodies in patients with SCLC using more sen-
From the Departments of *Neurology and tMedicine, Memorial
Sloan-Kettering Cancer Center and Cornell University Medical College, New York, NY.
Address correspondence to Dr Posner, Department of Neurology,
Memorial Sloan-Kettering Cancer Center, 127 5 York Ave, New
York, N Y 10021.
Received Aug 9, 1989, and in revised form Nov 14. Accepted for
publication Nov 15, 1989.
544 Copyright 0 1990 by the American Neurological Association
sitive immunohistochemical and quantitative Western
blotting techniques. O u r results indicate that although
the anti-Hu autoantibody can be detected at a low titer
in about 16% of patients with SCLC, a high titer is
almost always associated with paraneoplastic dysfunction.
Criteriah r the Presence o f the Anti-Hu Antibody
Positive anti-Hu antibody reactivity was defined as: (1) sera
that specifically stained neuronal nuclei at dilutions greater
than 1:500 (reactivity at lower dilutions, sometimes associated with glial staining, was considered nonspecific) and ( 2 )
sera that identify proteins of 35- to 40-kDa molecular mass
on Western blots of cerebral cortex neurons.
Materials and Methods
Serum was obtained from 44 patients (not previously
studied) with SCLC but no paraneoplastic syndrome (SCLCNP); 25 patients with SCLC associated with PSN or PEM
(SCLC-P) (6 patients [Patients 45, 46, 47, 54, 55, and 561
had been previously studied [8]); and 50 "normal" subjects
(blood bank donors who were not previously studied)
(Table). Lysates of SCLC cells (line NCI-N417) were prepared as previously reported [lo]. Neurons from the cerebral cortex were isolated as described by Blomstrand and
Hamberger [14].
Inmunohistochemistry
Cerebral cortex and cerebellum were obtained from neurologically normal individuals within 12 hours after death.
Pieces were embedded in optimal cutting temperature compound (Miles Inc, Elkhart, IN), snap frozen in isopentane
chilled by liquid nitrogen, and stored at - 70°C. Seven-kmthick tissue sections were sequentially incubated with 0.3%
hydrogen peroxide (to avoid endogenous peroxidase activity)
for 10 minutes, 10% normal goat serum (as a blocking
serum) (Cappel, West Chester, PA) for 15 minutes, serial
dilutions of the patient's serum overnight at 4"C, biotinylated
goat anti-human IgG (Vector Labs, Burlingame, CA) for 1
hour, and the Vectastain avidin-biotin complex (Vector Labs)
for 30 minutes at room temperature. The substrate staining
was developed with 0.05% diaminobenzidine tetrahydrochloride (Sigma, St Louis, MO), 0.5% Triton X-100, and
0.01 % hydrogen peroxide in phosphate-buffered saline solution.
Western Blotting
The protein content of SCLC homogenates and of crude
neuronal preparation of human cerebral cortex obtained at
autopsy from neurologically normal individuals was determined using the Bio-Rad Protein Assay (Bio-Rad, Richmond, CA). Samples were boiled in 0.0625 M Tris hydrochloric acid (pH 6.8), 2% sodium dodecyl sulfate, 0.001%
bromophenol blue, and 5% 2-mercaptoethanol for 10 minutes. Aliquots (1 mg) were electrophoresed on preparative
10% sodium dodecyl sulfate-polyacrylamide gel, and proteins were transferred to nitrocellulose as described by Towbin and associates 1151 and blocked with 5% blotto, 5% Dry
Carnation Milk (Carnation Company, CA) in PBS. The nitrocellulose sheets were then cut into strips and incubated
with the indicated amount of patients' sera (diluted in buffer
containing 1% bovine serum albumin/lO mM Tris hydrochloric acid {pH 7.41/0.9% sodium chloride/0.5% Triton
X-100) overnight at room temperature; washed 4 times for
15 minutes in the above buffer; incubated with iodine 125
(1125) protein A (0.1 pCi/ml) for 1 hour at room temperature; and after washing thoroughly, dried, apposed to Kodak
XAR5 film (Sigma), and exposed at - 70°C.
Determination o f Anti-Hu Antibody
Titer-Quantitative Western Blotting
The titer of anti-Hu antibody in the sera of SCLC-P versus
SCLC-NP groups was determined by a quantitative Western
blot assay. Increasing amounts of sera were incubated with
nitrocellulose strips containing identical amounts of Hu antigen. Conditions were established in which the amount of
binding of IgG to the H u antigen was proportional to the
amount of IgG used. The amount of I 125 protein A bound
to the 35- to 40-kDa segment of the strip was taken as a
measure of antibody titer. The nonspecific binding (background) of IgG was measured by determining the amount of
I 125 protein A bound to the 35- to 40-kDa segment in a
strip that was incubated with normal serum. The area of the
nitrocellulose strip corresponding to the H u antigen was cut
out and 5 ml of scintillation solution (CytoScint, ICN Biomedicals, Inc) was added. The strip was counted in a liquid
scintillation counter. We defined a unit (U) of anti-Hu antibody as the amount of antibody that yields 10,000 cpm of
bound I 125 protein A. The normal serum value, which was
equivalent to 6 U, was subtracted from value for the amount
of bound protein on the 35- to 40-kDa segment of patients
with SCLC in whom there was a visible band. Counts of
patients without a visible band were always equal to or less
than background.
Medical records of the SCLC-NP group were reviewed for
evidence of neurological dysfunction suggestive of PSN or
PEM.
Results
Laboratory Findings
IMMUNOHISTOCHEMISTRY AND IMMUNOBLOTTING.
Only 1 of the 50 sera from normal subjects gave positive immunostaining. That staining was nuclear but not
confined to neurons, reacting also with glial cells and
nonneural tissues (liver and kidney), and was considered to be an antinuclear antibody (ANA). Western
blot analysis identified a 200-kDa band but was negative for the 35- to 40-kDa bands characteristic of H u .
All sera from the 25 patients with paraneoplastic neurological dysfunction (SCLC-P group) were
strongly positive by immunohistochemistry (see Table
1) and all identified a closely arranged set of bands of
35- to 40-kDa molecular weight when incubated with
blots of cerebral cortex neurons (Anti-Hu) (Fig lA,
lane 5). T h e sera of SCLC-P also reacted monospecifically with a 37-kDa band in immunoblots of an SCLC
cell line (see Fig lB, lane 5).
Specific immunohistochemical staining of neurons
was found in 9 out of 44 sera of patients with SCLCDalmau et al: Paraneoplastic Autoantibodies 545
'
Table I . Immunohistocbemistv and Western Blot Characteristics
Purkin je
Nuclei
Cytoplasm
Nuclei
Cytoplasm
Immunohistochemistry
Titer
-
-
-
+b
+
-
1 : 500
-
-
-
-
-
-
1:8,000
1 : 1,000
1 : 16,000
1:8,000
1: 8,000
1: 8,000
1: 1,000
1:4,000
1: 500
Cortex Neurons
Quantitative
Western Blot
(Units of
Anti-Hu/ml
of Serumy
50 normal
subjects
49 subjects
1 subject
44 patients
with SCLC-NP
35 patients
Patient no.
36
37
38
39
40
41
42
43
44
25 patients
with SCLC-P
Patient no.
45'
46'
47'
48
49
50
51
52
53
54<
55'
56'
57
58
59
60
61
62
63
64
65
66
67
68
69
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
++
-
-
-
-
-
-
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
-
-
-
1: 256,000
1:512,000
1:64,000
1:64,000
1:32,000
1:64,000
1: 16,000
1: 32,000
1: 16,000
1: 128,000
1:64,000
1: 128,000
1:32,000
1: 16,000
1: 128,000
1 : 128,000
1 : 128,000
1:8,000
1: 16,000
1: 16,000
1: 16,000
1:32,000
1:32,000
1 :8,000
1:8,000
-
(< 6)
119
(< 6)
(< 6)
109
119
86
17
13
69
7,194
20,521
8,003
13,264
2,093
4,046
794
450
596
5,641
3,053
13,146
4,319
3,120
11,157
4,948
8,589
288
505
897
72 1
209
582
379
306
"A unit of anti-Hu antibody is the amount of antibody that yields 10.000 cpm of bound I 125 protein A.
bDotted nuclear staining of neurons, glia, and extraneural tissues.
'Previously studied [S}.
SCLC = small cell lung cancer; NP = no paraneoplastic syndrome; P = associated with paraneoplastic sensory neuropathy or encephalomyelitis.
546 Annals of Neurology Vol 27 N o 5 May 1990
Fig I . (A)Immunoblots of cerebral cortex neurons reacted with
sera of patients with SCLC and no paraneoplastic syndrome
(lanes 1 through 4) and serum of a patient with SCLC who
had a paraneoplastic syndrome (lane 5). Lane 1: Serum of a
patient without anti-Hu antibody (amount of 1gG used, 40
pgl. Lanes 2 and 3: Sera of Patients 36 and 39 that are positive for anti-Hu antibody (amounts oflgG used, 40 and 46
pd. Lane 4: Serum of Patient 38, positive by immunohistochemisty but negative by Western blot quantitation (i.e., < 6
U of anti-Hulml of serum) (amount of IgG used, 40 pg).Lane
5: Anti-Hu-positive serum of a patient with paraneoplaitic
sensory neuropathy (amount of IgG used, 10 pgl. (B) lmmunoblots ofhomogenate ofan SCLC cellline (NCl-N417). Sera I
through 5 are the same as in Figure I A . Lane 6: Serum of a
n o m l subject. Sera that are anti-Hu positive (lanes 2, 3, and
5 ) display a 37-kDa band. Sera that are anti-Hu negative
(lanes 1 and 4) show several bands at different molecular
weights. SCLC = small cell lung cancer.
presence of the anti-Hu antibody (see Fig l A , lanes 2
and 3). The sera are usually not monospecific in that
they often react with other neural and tumor antigens
as well as with Hu. One serum with similar immunoreactivity to those with the anti-Hu antibody gave a
weaker banding pattern on Western blot analysis in
addition to the presence of other bands. Because the
quantitation was less than 6 U of anti-Hu antibody per
ml, we consider this serum to be negative for the presence of the antigen (see Fig IA, lane 4).
We next examined the reactivity of the 7 anti-Hupositive sera with extracts from an SCLC tumor cell
line. Three reacted with a band of 37-kDa molecular
mass (see Fig IB, lanes 2 and 3). The other 4 , with a
lower anti-Hu titer, did not identify a 37-kDa band.
N P (see Table 1). Eight were consistent with anti-Hu
reactivity in that there was nuclear staining that spared
the nucleoli, with a weaker staining of the cytoplasm
(Fig 2). Nuclei and cytoplasm of glial cells did not
stain. The same pattern of staining was found in Purkinje cells, granular cells, and basket and stellate cells
of the cerebellum. There was no selective staining of
Purkinje cell cytoplasm. Results were the same
whether the tissue was unfixed or fixed with cold
acetone. The serum of the ninth patient with SCLCN P (Patient 37) stained diffusely the cytoplasm of all
neurons but spared the nuclei.
In 7 of the 8 sera with neuronal nuclear staining H u
antigen was also recognized on Western blot analysis
of cerebral cortex neurons, fulfilling our criteria for the
The titer
of anti-Hu antibody in the sera of SCLC-P versus
SCLC-NP groups was determined by quantitative
Western blot.
Conditions were established in which the amount of
binding of IgG to the H u antigen was proportional to
the amount of IgG used (Fig 3). Anti-Hu antibody was
not detected in 50 normal human sera. The reactivity
of normal human sera with the nitrocellulose strip was
then used to determine the background in the assay
and to establish the limit of detection. This only comes
to 6 U of anti-Hu antibody/ml of serum. Assays of
SCLC-NP sera and SCLC-P sera were only quantified
if their reactivity was greater than twice the background. In patients with SCLC-P the average titer of
QUANTITATIVE WESTERN BLOT ANALYSIS.
Dalmau et al: Paraneoplastic Autoantibodies 547
Hu-positive serum were women, compared with only
16 of the 37 patients who had anti-Hu-negative
serum.
The second difference was that all of the patients
with anti-Hu-positive serum had “limited” disease
(i.e., the cancer was limited to lung and mediastinum
only), whereas of the patients with anti-Hu-negative
serum approximately 49% had limited and 51% had
“extensive” disease (i.e., cancer that had metastasized
beyond the mediastinum) (Fisher’s exact test 0.014, p
< 0.05). One of the 7 patients with anti-Hu-positive
serum and 4 of the 18 with anti-Hu-negative serum
subsequently developed more extensive disease.
None of the 44 patients had neurological disability
that could not be related either to metastases or to
effects of vincristine or cis-platinum on the peripheral
nervous system. There was no difference in this regard
between the two groups.
Fig 2. Section of human hippocampus from a normal individual
immunoreacted with anti-Hu-positive serum from a patient
with paraneoplastic sensoty neuropathy. The section has not been
counterstained. (A) There is prominent immunostaining of the
nuclei of neurons. ( x 40 before 19% reduction.) (B) Higher
power field shows neuronal nuclear staining and sparing of the
nucleoli. ( x 200 before 18% reduction.)
anti-Hu antibody reactivity was 4,592 U/ml (range,
209-20,521 U/ml) whereas in the SCLC-NP group
the average titer was 76 U/ml (range, 13-119 U/ml)
(see Table 1, Fig 4). N o overlap was found between
the titers of patients with SCLC-P and those of patients
with SCLC-NP.
Clinical Findings
Fifty sera were obtained from blood donors who were
assumed to be neurologically normal. The patients
with SCLC-NP were consecutive patients seen for
evaluation of SCLC at Memorial Sloan-Kettering Cancer Center. Table 2 compares the clinical findings in
the 7 patients whose serum was anti-Hu positive and
37 patients whose serum was anti-Hu negative. The
patients were similar in most respects but there were
two exceptions. Five of the 7 patients who had anti548 Annals of Neurology Vol 27 No 5
May 1990
Discussion
Autoantibodies, using techniques of either immunohistochemistry or immunoblotting, can be detected in
the sera of many normal persons [16, 171 and many
patients with a variety of neurological diseases 14, 18261. T o argue that a given autoantibody has clinical
significance, either as a marker of a neurological disease or as a factor in pathogenesis, requires that one
first establish both the sensitivity and the specificity
of the antibody for that disease. This is what we attempted in this and prior studies [8, 271. Our results
indicate that anti-Hu antibody is highly but not completely sensitive and specific as a marker for PSN,
PEM, or both, associated with SCLC.
First we consider how specific the autoantibody is as
a marker of cancer, specifically SCLC. The presence of
the anti-Hu antibody appears to be highly specific for
identifying a patient with a neurological disorder as
having a paraneoplastic complication of an underlying
SCLC {S]. There are a few exceptions. Jaeckle and
colleagues [28) reported a single patient with autoantibody-positive PEM in which autopsy failed to reveal an
underlying cancer. We identified 2 patients in whom
autopsy findings done in another center were negative
for cancer. We also identified 1 child in whom the
autoantibody was associated with paraneoplastic brainstem encephalitis and a neuroblastoma. Our three exceptions are drawn from a cohort of 39 patients who
had PEM, PSN, or both, associated with SCLC. Thus,
specificity appears to be at least 92%.
Furthermore, autopsy findings that are negative for
cancer must be viewed with caution. Anderson and
colleagues reported on a single patient with a paraneoplastic cerebellar degeneration associated with a
unique autoantibody in whom a 4-mm adenocarcinoma of the lung was found at autopsy E291. Since that
time we examined 2 patients with PEM and anti-Hu
autoantibody whose clinical evaluation for tumor was
B
Fig 3. (A) Lanes 1 to 5: Immunoblots of cerebral cortex neurons
reacted with serial dilutions (1 :1,000-1 :16,000) of serum
from a patient with small cell lung cancer and paraneoplastic
sensory neuropathy (SCLC-PI. Lanes 6 to 10: Immunoblots of
cerebral cortex neurons reacted with serial dilutions (1 :5001 :8,000) of serum from a cancer patient who was anti-Hupositive but had no paraneoplastic disease (SCLC-NP).(B)
Quantitation of anti-Hu reactivity of serum from a patient with
small cell lung cancer and paraneoplastic syndrome (SCLC-P)
compared with that of a cancer patient without paraneoplastic
syndrome (SCLC-NP).A unit of anti-Hu equals 10,000 cpm of
1-125 protein A bound to anti-Hu antibody (see text).
negative but who were found to have SCLC in hilar
and mediastinal lymph nodes. In one of them the primary tumor could not be found. Thus, even autopsy
findings that are negative for the presence of cancer do
not necessarily prove that the disorder is not paraneoplastic.
Next, we consider the specificity of the anti-Hu antibody as a marker of PSN or PEM. We identified 2
patients who presented with somewhat atypical neurological disorders, slowly progressive, mild sensory neuropathy, who were autoantibody negative and subsequently were determined to have SCLC. In at least one
of these patients the clinical findings were complicated
by a &platinum neuropathy. Patients with the Lambert-Eaton myasthenic syndrome (LEMS) associated
with SCLC usually do not harbor the anti-Hu antibody
although an exception has been reported 1301. Furthermore, patients with LEMS associated with cerebellar degeneration and SCLC may be negative for the
anti-Hu antibody 1271. There are no other reports in
the literature and we have not encountered a patient
with unequivocal PEM or PSN with SCLC who did
not harbor the autoantibody 181.
What about the patient with known SCLC who does
not have neurological disability? Our previous study
181, using a less sensitive technique, had indicated that
in those patients the anti-Hu antibody was not detectable. However, in the present study using the avidinDalmau et al: Paraneoplastic Autoantibodies
549
loo'ooo
h
E
--.
fn
c
.-
5
1,000
v
m
I
Fig 4. Anti-Hu titer (units of anti-Hulml of serum) of the
group with small cell lung cancer and paraneoplastic syndrome
(SCLC-P) compared with that of the cancer group without
paraneoplastic syndrome (SCLC-NP).Note that the scale in the
abscissa is logarithmic. There is no overlap between the levels in
patients with SCLC-NP (highest level, 119 Ulml) and in the
patients with SCLC-P (lowest level, 209 Ulnzl). Dotted line
shows the background level.
biotin immunoperoxidase method and a highly sensitive quantitative Western blot analysis, we found that
approximately 16% of patients, not included in previous studies, harbor the anti-Hu antibody. With their
low titer there is no overlap between the patients with
paraneoplastic syndromes and those without when the
titers are done by quantitative Western blotting. This
antibody is not present at low titer in normal subjects
nor does it appear to be present in patients who have
other cancers (with the exception of a neuroblastoma
as indicated). However, a thorough assay of sera from
other patients with cancer has not yet been carried out
using the highly sensitive methods described here.
Thus, the accumulated data indicate that the presence of anti-Hu antibody is a good marker for SCLC
and, when present at high titer, for SCLC associated
with a PSN, PEM, or both.
In evaluating the usefulness of autoantibodies as
markers of disease it is important to characterize the
antibody to the fullest extent possible. In practice, this
requires both histochemical and Western blot analysis.
We identified antineuronal antibodies with an immunohistochemical appearance identical to anti-Hu, but
with different Western blot patterns, in patients with
opsoclonus and carcinoma of the breast C3 11 and occasionally in other patients.
We are unable to explain the differences between
our findings and the results of Grisold and colleagues
C11-131. They examined 40 patients with SCLC, only
one of whom had a paraneoplastic syndrome [ll].
They did not identify the anti-Hu antibody but instead
reported antibodies directed against different morphological structures including nuclei and cytoplasm of
neurons or cytoplasm only, with the brightest immunofluorescence staining displayed by Purkinje cells.
We examined over 40 patients using the more sensitive immunoperoxidase method and we did not iden-
Table 2. Clinical Characteristics of the Patients without Paraneoplastic Disease (SCLC-NP Groupj
Variable
Anti-Hu Negative (n = 37)
Anti-Hu Positive (n = 7)
Mean age (range)
Sex (ratio)
Mean time of follow-up (range)
Stage of disease at diagnosis
60 yr (41-80)
16F, 21M (1: 1.3)
5F, 2M (2.5 : 1)
Chemotherapy
Neurological complications
Stage of disease at last follow-up
Survival at last follow-up
8 mo (1-25)
19 (51%) extensive
18 (49%) limited
37 (100%)
9 brain metastases (24%)
8 iatrogenic (22%)
1 meningeal carcinoma (3%)
1 spinal metastasis (3%)
23 (62%) extensive
14 (38%) limited
30 (81%) alive
"Not present at initial evaluation.
SCLC-NP = small cell lung carcinoma without paraneoplastic disease.
550 Annals of Neurology Vol 27 No 5 May 1990
58 yr (38-68)
6 mo (5-10)
0 (0%) extensive
7 (100%) limited (p < 0.05)
7 (1005%)
1 brain metastases (14%)a
2 iatrogenic (29%)
1 (14%) extensive
6 (86%) limited
6 (86%) alive
tify the autoantibody they reported. We began dilutions at 1:50, which should have identified their
autoantibody. Furthermore, we did not find any difference in the immunostaining whether the tissues were
unfixed or fixed with cold acetone as Grisold and associates reported 1121. They did not report data on
Western blotting analysis.
Patients with this autoantibody-associated paraneoplastic neurological syndrome may provide a unique
opportunity to investigate the relationship between the
immune system and primary cancer. All SCLC from
tissues so far examined expressed the Hu antigen (irrespective of whether the tumor tissue was from an
individual with or without a neurological symptom).
Therefore, the central question is why some individuals with SCLC made no detectable immune response,
a partial immune response, or a profound immune response. The current consensus of tumor immunologists is that tumor cells use a variety of mechanisms to
evade surveillance by the immune system. One mechanism that has been studied in particular detail is
the selective suppression of major histocompatibility
(MHC) class I gene expression 1321. It would therefore be interesting to examine the expression of MHC
class I genes in tumor tissue from the SCLC-NP and
SCLC-P groups.
Two clinical observations are of interest. The first,
though it does not reach statistical significance, is the
predominance of women in the group with anti-Hupositive serum but without paraneoplastic disease.
This finding is in accord with the female predominance
in patients with paraneoplastic disease {S] and in autoimmune disorders in general. The other clinical feature
is the preponderance of limited stage disease in the
anti-Hu-positive patients without paraneoplastic disease. Several observers of paraneoplastic syndromes
have commented on the relative indolence of the cancer in patients with paraneoplastic disorders. The problem in determining the truth of this observation is that
most patients with paraneoplastic syndromes present
with the neurological disorder, thus allowing for earlier
identification of the cancer, when it may still be localized. The absence of paraneoplastic syndromes in
the patients with SCLC whose serum was positive for
anti-Hu antibody eliminates this bias, and the finding
that their disease is more limited than that of antiHu-negative patients suggests that in some fashion
the antitumor immune response protects against the
spread of the disease.
Dr Josep Dalmau is supported, in part, by funds granted by the
“Fondo de InvestigacionesSanitaria de la Seguridad Social, Instituto
Nacional de la Salud. Ministerio de Sanidad y Consumo,” Madrid,
Spain. This work was supported in part by National Institutes of
Health grant NS 26064 (Dr Posner) and American Cancer Society
grant PDT-359 (Dr Furneaux).
We are grateful to Leslie B. Tyson, RN, and Lisa M. Potanovich,
RN, for securing the serum samples from the oncology patients, and
to E. Rosa and E. Wong for the excellent technical assistance.
Presented in part at the annual meeting of the American Neurological Association, New Orleans, September 24-27, 1989.
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