Antigen solubilized from human leukemia: lymphocyte stimulation.

Soluble antigen was extracted with hypertonic (3 molar) potassium chloride from the malignant cells of seven patients with acute leukemia. The antigen and leukemia cells were used to stimulate autologous patients' and allogeneic normal donors' lymphocytes in mixed lymphocyte cultures. The lymphocytes of six patients showed significant blastogenic responses to autologous antigen. In contrast, the lymphocytes of only one of seven normal donors responded to the soluble antigens. Both patients' and normal subjects' lymphocytes responded to the intact leukemia cells. The use of these antigens should facilitate the study of specific tumor immunity in human leukemia.

Serial studies of immunocompetence of patients undergoing chemotherapy for acute leukemia.

Immunocompetence was followed serially for 1 yr from the onset of treatment in 55 adult patients with acute leukemia. The tests used were delayed hypersensitivity responses to a battery of five recall antigens (dermatophytin, dermatophytin 0, candida, streptokinase-streptodornase, and mumps) and in vitro lymphocyte blastogenic responses to phytohemagglutinin and streptolysin 0. There was a strong correlation between immunocompetence at the start of treatment and a good prognosis; 32/39 patients who subsequently entered remission were initially immunocompetent compared to 4/15 who failed to enter remission. In the complete remission group there was a decline in competence starting from 2 to 5 mo after the onset of treatment. In those who remained in remission for 1 yr, competence recovered at 6 mo and remained vigorous thereafter. In those who relapsed before 1 yr, the decline in competence occurred 1 mo before relapse and competence continued to decline progressively during the 1 yr follow-up period. These studies suggest that therapeutic approaches which restore immunocompetence or prevent its decline will improve both the remission rate and the remission duration of patients with acute leukemia.

Effect of BCG (Tice strain) on primary sensitization to 2,4-dinitrochlorobenzene and on established delayed hypersensitivity in human malignant melanoma.

Studies of primary sensitization and delayed hypersensitivity reactions to 2,4-dintrochlorobenzene (DNCB) and recall antigens were conducted in 71 patients with melanoma who were receiving BCG (Tice strain) immunotherapy by scarification. Similar studies were conducted in 32 control patients with melanoma who did not receive BCG. No significant differences were observed, in the various clinical stages, between patients receiving and those not receiving BCG, in terms of the frequency or intensity of primary sensitization to DNCB. Furthermore, there was no significant difference in delayed hypersensitivity to recall antigens between these groups of patients. The apparent discrepancy between the clinical benefit from BCG immunotherapy and its failure to stimulate certain parameters of cellular immunity in patients with melanoma is discussed.

Indomethacin-induced, monocyte-dependent restoration of local graft-versus-host reaction among cells from cancer patients.

Peripheral blood mononuclear cells from 16 of 17 cancer patients known to have a negative local graft-versus-host (GVH) reaction (T-cell function deficiency) were pharmacologically immunorestored by treatment with indomethacin. The restorative effect of the indomethacin was exerted directly on nonadherent lymphocytes. This process of desuppression required for its completion the presence of glass-adherent monocytes. The immune restorative effect of indomethacin in terms of local GVH reaction did not appear to be mediated by inhibition of prostaglandin synthesis. Pharmacologic immune restoration may be an important therapeutic modality in cancer patients.

Immunomorphological features of prognostic significance in Dukes' Class B colorectal carcinoma.

Histological slides of primary tumors and regional lymph nodes from 134 unselected patients operated on for colorectal carcinoma of Dukes' Class B were assessed semiquantitatively for the presence of perivascular lymphocyte cuffing in the muscular layers and pericolic/subserosal fat immediately subjacent to the tumors and for paracortical hyperplasia in the regional lymph nodes. These two immunomorphological features related significantly to each other (p less than 0.05), and their combined presence related signifcantly to favorable disease-free interval (p = 0.02) and to survival (p = 0.04), making possible the identification of a subgroup of approximately one-third of Dukes' B class patients with an estimated better than 85% chance for 5-year recurrence-free survival.

Fetal antigens in human leukemia.

Immunization of BALB/c male mice with human peripheral leukemic blasts effectively reduced the later formation of syngeneic fetal liver, but not bone marrow hematopoietic colonies in the spleen when these mice were lethally irradiated and challenged i.v. Fetal antigen was detected in 6 of 6 lymphocytic leukemic patients and in 4 or 8 myelocytic leukemia patients and was correlated with low cellular levels of sialic acid. A rabbit antiserum ot BALB/c 15-day fetal liver cells labeled only 0 to 2% of normal donor peripheral leukocytes in indirect immunofluorescence but reacted with 10 to 21% of leukemic peripheral blasts. Active disease bone marrow on the same patients gave 7 to 40% fluorescent cells. Two remission bone marrow smaples were negative and 1 had 44% fluorescent cells. Using this antiserum coupled to sepharose, affinity column separation of KCl extracts from mouse and human fetal liver and from chronic lymphocytic leukemia has produced 4 common protein bands (identifiable on polyacrylamide gel electrophoresis).

A phase I study of intracarotid artery infusion of cis-Diamminedichloroplatinum(II) in patients with recurrent malignant intracerebral tumors.

A phase I study of intracarotid cis-diamminedichloroplatinum was performed in 11 patients with intracerebral tumors (five glioblastoma, four melanoma, one meningeal sarcoma, and one lung carcinoma) progressing after radiation +/- chemotherapy. The internal carotid artery was temporarily cannulated by a percutaneous transfemoral approach. All patients received i.v. heparin, mannitol, and fluids; seven received dexamethasone, 50 mg i.v., twice the day before and the day of treatment. Intracarotid cis-diamminedichloroplatinum, 60 to 100 mg/sq m in 175 to 250 ml 0.45% NaCl solution with 1000 units heparin, was infused over 1 hr. Six patients received two or more courses (maximum of 6) at 2- to 8-week intervals. Gastrointestinal toxicity was mild to moderate. Ototoxicity was minor. Central nervous system (CNS) toxicity was focal, severe, permanent, and possibly due to embolus in one patient at 75 mg/sq m; focal and reversible in one patient at 100 mg/sq m; and generalized but reversible in one patient at 75 mg/sq m. Possible CNS toxicity was noted in two additional patients. Two patients with CNS toxicity developed permanent ipsilateral retinal toxicity, and one patients without CNS toxicity developed bilateral decreased visual and auditory acuity 2 weeks after his sixth treatment. Renal and hematological toxicity and orbital pain were mild. Response status included: early death, one; probable responses, six (2+ 4+, 6, 6+, 8, and 8+ months); stabilization, two (3+ and 4 months); and failure, two. We recommend cis-diamminedichloroplatinum (60 mg/sq m) every 2 to 4 weeks for Phase II studies. Severe CNS and retinal toxicity are possible.

Clinical pharmacology of 99mTc-labeled liposomes in patients with cancer.

The pharmacokinetics, organ distribution, and 24-hr urinary excretion of negatively charged 99mTc-labeled multilamellar liposomes, composed of dimyristoylphosphatidylcholine and dimyristoylphosphatidylglycerol in a 7:3 molar ratio, were studied in seven patients with cancer. The radiolabeled liposomes were administered i.v. in three doses: 150 mg/sq m of body surface area; 300 mg/sq m; and 450 mg/sq m of lipid. The dose of 99mTc was 4.8 to 7.6 mCi per patient. The plasma disappearance curve was biphasic (half-life alpha = 5.53 min, half-life beta = 289 min), suggesting a two-compartmental model of distribution. The calculated volume of distribution indicated considerable tissue retention of liposomes. This was confirmed by body imaging. Twenty-four hr after injection, liposomes were localized in organs rich in reticuloendothelial cells, i.e., liver [44.5 +/- 9.1% (S.E.)], spleen [25.5 +/- 7.7%], lung [14.5 +/- 4.9%], and bone marrow. Although the hepatic uptake accounted for more than 40% of the total uptake, the spleen retained liposomes at a higher density. Cumulative urinary excretion of radioactivity was 13.4 +/- 1.5% over 24 hr. Liposome administration was safe and devoid of any adverse side effects. The results provide a basis for the use of liposomes as potential target-specific and safe drug carriers in the treatment of pathological conditions that involve organs rich in reticuloendothelial cells.

Splenic versus hepatic artery infusion of interleukin-2 in patients with liver metastases.

In an attempt to improve the therapeutic index of recombinant interleukin-2 (rIL-2) by generating or activating lymphokine-activated killer (LAK) cells and tumor-infiltrating lymphocytes (TIL) regionally and/or in situ, we randomly assigned 28 patients with liver metastases to receive rIL-2 by continuous infusion for 5 days via either the splenic artery or the hepatic artery. Clinically significant and lasting tumor regression was observed only in two of 28 patients (7%), one in each of the two treatment arms. The maximum-tolerated daily dosage of rIL-2 was 3 x 10(6) U/m2; beyond this dosage, toxicity was excessive. Peripheral LAK cell activity measured in vitro and clinical tumor regression did not correlate. This observation, coupled with the equal distribution of regressions between the two treatment arms, raises the possibility that tumor regression, rare though it may be in response to rIL-2 administration, is largely mediated by TIL activation and not by LAK cell generation.

Hepatic arterial infusion with floxuridine and cisplatin: overriding importance of antitumor effect versus degree of tumor burden as determinants of survival among patients with colorectal cancer.

Cisplatin (CDDP) was combined with floxuridine (FUDR) and delivered into the hepatic arteries of 29 patients as induction therapy for colorectal cancer metastatic to the liver. Mitomycin C and FUDR combination was substituted after progression or when response had peaked. Chemotherapy was delivered with an Infusaid pump (Infusaid Corp; Norwood, Mass; 14 patients), Medtronic programmable drug administration device (Medtronic, Inc, Minneapolis; two patients), or percutaneously placed catheters (13 patients). Complete disappearance of liver metastases was observed in four patients and 11 additional patients had a partial remission as determined by computed tomography (CT) scan and substantiated at times by angiography, for a total response rate of 52%. Response as determined by imaging techniques coincided with a concurrent decrease in carcinoembryonic antigen (CEA) and improvement in performance status. The severity of tumor burden was correlated with the response to therapy and survival. Among those patients who responded to arterial chemotherapy, differences in disease severity did not significantly influence survival. Median survival among responders with greater than 25% liver replacement by tumor was 14 months (P = .28), compared with 28 months for those patients with less than 25% liver replacement. In contrast, differences in tumor burden significantly affected survival among patients who failed to respond to chemotherapy; median survival among nonresponding patients with greater than 25% liver replacement was 4 months, compared with 8 months for those who had less than 25% liver replacement (P = .01). The presence of minimal extrahepatic disease at the time of initiation of intraarterial treatment did not seem to have a significant detrimental effect on survival. The study suggests that hepatic tumor response to arterial administration of CDDP and FUDR and mitomycin C and FUDR is clinically significant because it overrides the effect of tumor burden on survival among patients who have colorectal cancer with liver metastases and may offer effective palliation.

A phase I study of TNP-470 administered to patients with advanced squamous cell cancer of the cervix.

A Phase I study of the novel angiogenesis inhibitor TNP-470 was performed. Patients with inoperable recurring or metastatic squamous cell cancer of the cervix with evaluable disease, no coagulopathy, and adequate renal, hepatic, and hematological function were eligible. One course of treatment consisted of an i.v. infusion of TNP-470 over 60 min every other day for 28 days, followed by a 14-day rest period. The starting dose was 9.3 mg/m2. Eighteen evaluable patients were treated, with a median age of 48 years (range 27-55) and performance status Zubrod 1 (range 0-2). Grade 3 neurotoxicities consisting of weakness, nystagmus, diplopia, and ataxia were encountered in two patients receiving the 71.2 mg/m2 dose. An intermediate dose level of 60 mg/m2 was evaluated and found to be well tolerated by three patients. Only one patient experienced grade 3 nausea on the 60 mg/m2 dose level. No myelosuppression, retinal hemorrhage, weight loss, or significant alopecia were observed. One patient had a complete response, which continues for 26 months, and three patients with initially progressive disease stage had stable disease for 5, 7.7, and 19+ months. Other Phase I studies, including over 200 patients, were performed concurrently with this study. Based on this experience, the dose of TNP-470 recommended for further studies is 60 mg/m2 as a 60-min i.v. infusion every Monday, Wednesday, and Friday. Neurotoxicity was dose limiting, but appears to be reversible. Otherwise, the treatment was well tolerated. The drug may be active in squamous cell cancer of the cervix. Further studies of TNP-470 in squamous cell cancer of the cervix are warranted.

Arterial chemotherapy in the management of colorectal cancer: an overview.

We have discussed the role of arterial therapy in patients with various stages and types of colon cancer. Arterial therapy is probably not useful as an adjuvant therapy for Dukes' C colon cancer. It may, however, play a role among patients with incomplete resection of liver metastases (positive margins). A randomized trial is needed to determine the role of arterial therapy in patients who have undergone complete resection of liver metastasis. Arterial therapy does not seem justified for patients with recurrent pelvic tumors. For nonresectable liver metastases, hepatic arterial therapy induces a higher response rate than does intravenous treatment. It may also improve performance status and offer additional palliation to patients who have failed systemic chemotherapy. are refractory to systemic chemotherapy may be candidates for palliative hepatic arterial chemotherapy even out of the context of a clinical trial. Asymptomatic patients with nonresectable liver metastasis who are refractory to systemic chemotherapy should be enrolled in phase I-II arterial chemotherapy trials designed to identify optimal treatment regimens. Previously untreated asymptomatic patients wishing treatment may be enrolled in a new multi-institutional phase III trial being designed to compare contemporary systemic chemotherapy with less toxic arterial therapy and combined arterial and systemic therapy. Such a new trial will have to avoid any cross-over between arms to determine the true impact of arterial therapy on survival. Regional arterial chemotherapy tries to extract the "extra mile" from marginally active drugs that have a steep dose response curve by increasing tumor drug exposure. Increased drug concentrations in the tumor may be accomplished by means of the blood vessel-to-tumor concentration gradient. The technology to achieve such a gradient has involved percutaneous hepatic arterial catheters, implantable infusion pumps or ports, and external pumps. The most economic hepatic arterial delivery system for protracted arterial FUdR is an infusion pump. Despite good pharmacological rationale, an improved response rate, and good evidence for effective palliation in advanced disease, hepatic arterial therapy has not improved survival when compared with systematic intravenous treatment. Possible explanations include the following: (1) poor study design that allowed patients to cross over between arms: (2) inadequate arterial chemotherapy combination; (3) inadequate arterial chemotherapy schedule; (4) hepatobiliary toxicity levels that required cessation of hepatic arterial therapy and allowed the emergence of resistant tumor clones; and (5) systemic progression of disease. Only time will tell whether improved chemotherapy and the design of a new phase III trial will establish a beneficial role for upfront hepatic arterial therapy in asymptomatic patients with colon cancer metastatic to the liver.

Permanent slide preparations of T lymphocyte-sheep red blood cell rosettes.

Rosette formation between sheep erythrocytes (SRBC) and human thymus-derived lymphocytes (T cells) is used to monitor T cells in various human diseases. Rosettes are usually counted in a hemacytometer immediately after preparation. This paper reports a technique for permanently fixing and staining rosettes for serial and comparative studies, a procedure which has probably been less well standardized, less reproducibly performed, and less widely used than many investigators appreciate. The technique describedhas the advantages of providing distinct morphological identification of the rosette-forming cell and it produces a permanent mount for further reference.

Objective evaluation of local xenogeneic graft-versus-host reaction by computerized radioisotope imaging (CRI).

The local xenogeneic graft-versus-host reaction (GVHR) assay has been used clinically to evaluate cellular immune competence and experimentally to monitor the immunomodulatory effects of several drugs. By employing a computerized radioisotope imaging (CRI) technique, we were able to perform the assay with smaller numbers of mononuclear cells (MNC) and to rid it entirely of any bias. Measuring the local GVHR by CRI compares well with the conventional measurement of the volume (correlation coefficient r = 0.619; P less than 0.001). A clear-cut distinction was documented between normal donors and cancer patients (P less than 0.001) when 10 X 10(6) or more MNC were used in the assay. This is an improvement over the previous, conventional testing of local GVHR which required injection of 20 X 10(6) MNC in order to achieve a similar resolution. The indications for the presence of immune competence have therefore been redefined using the local GVHR index as determined by CRI according to the scale of MNC injected. Thus, immunocompetence is considered present if the CRI index is greater than or equal to 1.2 for 10 X 10(6) MNC, greater than or equal to 2.0 for 15 X 10(6) MNC and greater than or equal to 2.6 for 20 X 10(6) MNC.

Elevated plasma thrombopoietic activity in patients with metastatic cancer-related thrombocytosis.

BACKGROUND AND PURPOSE: High platelet counts are occasionally seen in patients suffering from progressive malignant disorders. While granulocyte colony-stimulating factor (G-CSF) has been implicated in paraneoplastic leukemoid reactions, the stimulus for thrombocytosis is unknown. Our purpose in this study was to determine if plasma from cancer patients with thrombocytosis contains a factor or factors with thrombopoietic activity. METHODS: We tested the effects of plasma obtained from 5 individuals with advanced tumors and high platelet counts and from 4 patients with advanced cancer and normal platelet counts on megakaryocytic differentiation of two megakaryoblastic cell lines (Dami and HEL). Differentiation was evaluated by assessing the expression of the platelet-specific cell-surface antigens CD41 (HUPL-mI) and glycoprotein IIb-IIIa using an immunocytochemical staining score. In addition, plasma samples from 7 of the 9 patients and from 5 additional cancer patients with thrombocytosis were assayed for the levels of interleukin (IL)-3, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF, and IL-1 beta protein using an enzyme-linked immunosorbent assay (ELISA). RESULTS: Expression of platelet-specific cell-surface antigen was increased in HEL cells after exposure to plasma from all 5 of the cancer patients with thrombocytosis, and in Dami cells after exposure to plasma from 4 of the 5. Similar, but less significant, results were found when these cells were incubated with control combinations of recombinant GM-CSF plus IL-6 or of IL-3 plus IL-6. Platelet-specific cell-surface-antigen expression was not increased in HEL or Dami cells after exposure to the plasma from the 4 cancer patients with normal platelet counts or to normal control plasma. ELISA revealed elevated levels of IL-6 in the plasma from 4 patients with thrombocytosis (38, 40, 63, and 99 pg/mL). In addition, GM-CSF concentration was high in 3 of these 4 patients (33, 47, and 127 pg/mL), and the G-CSF level was elevated in 1 (543 pg/mL). IL-1 beta and IL-3 levels were undetectable. CONCLUSIONS: Our data suggest that the thrombocytosis observed in individuals with advanced malignant disease is mediated by a humoral mechanism. Levels of IL-6, GM-CSF, and G-CSF are elevated in some of these patients, but the plasma concentrations are generally lower than those required for in vitro induction of megakaryocytic differentiation. Plasma from patients with paraneoplastic thrombocytosis may therefore contain thrombopoietins that have not yet been identified, and which might have clinical usefulness.

Effective retreatment of patients with colorectal cancer and liver metastases.

Twenty-two patients with colorectal cancer and metastatic liver disease in whom systemic intravenous therapy with 5-fluorouracil previously had failed were given fluorodeoxyuridine and mitomycin C by hepatic arterial infusion. Ten of the 22 patients (45.4 percent) had a partial response and median survival of 14 months, as opposed to a median survival of six months among the 12 patients who did not have response to the treatment (p = 0.02). Hepatic arterial occlusion was effected in seven of the 10 patients who responded and in seven of the 12 nonresponding patients. Such manipulation of hepatic arterial blood flow did not have a significant effect on the survival duration in either group. Retreatment of patients with colon cancer and liver metastases by hepatic arterial infusion of fluorodeoxyuridine and mitomycin C can result in significant prolongation of survival in patients with response to this treatment.

Immunocompetence, immunodeficiency and prognosis in cancer.

Immunocompetence and prognosis are related in solid tumors, malignant lymphomas, and acute leukemia. Among the parameters of immunocompetence vigorous delayed-type hypersensitivity responses to recall antigens or to primary immunization with Keyhole limpet hemocyanin, vigorous in vitro lymphocyte blastogenic responses to mitogens such as PHA, and relatively high B-lymphocyte levels, all correlate with a good prognosis. The spectrum of immune reactivity as measured by established delayed-type hypersensitivity to recall antigens and in vitro blastogenic responses to mitogens and antigens is similar in melanoma patients and their nontumor-bearing spouses. In melanoma, only patients with widespread inoperable metastatic disease show severe immunological deficiency and this is selective for certain antigens. There are highly significant differences in response to specific antigens when patients with melanoma and lung cancer are compared. Immunotherapy with BCG and C. parvum can boost immunocompetence as measured by recall DTH skin testing. However, the relationship between the initial immunocompetence and prognosis still holds in patients receiving BCG immunotherapy to prevent recurrence of melanoma. These data indicate that a broader survey of immunological reactivity in cancer patients is needed, that immunological testing is useful in cancer prognosis clinically, and that the results of immunological testing can be used to evaluate therapy and to indicate new pathways for improved treatment.

Arteriovenous carcinoembryonic antigen gradient: determination by selective angiography for localization of metastatic colorectal cancer.

Two colorectal carcinoma patients with elevated serum carcinoembryonic antigen (CEA) levels are discussed. In the first patient, metastatic disease in the left adrenal gland was diagnosed by computerized tomography scanning. A CEA concentration gradient between the left adrenal artery and the left adrenal vein was detected by selective sampling of the appropriate vessels. After adrenalectomy, the serum CEA level returned to normal. In the second patient, a CEA gradient between the hepatic artery and the left hepatic vein helped localize metastatic disease in the left lobe of the liver, before it became evident by any other means. We conclude that subselective angiography and sampling of serum for CEA levels could serve as an auxiliary method of detecting obscure metastatic colorectal carcinoma in patients with elevated levels of the antigen.

Arterial infusion of dacarbazine and cisplatin for recurrent regionally confined melanoma.

We treated nine patients who had metastatic malignant melanoma confined to one extremity (8/9) or the vulva (1/9) with arterial dacarbazine and cisplatin at respective doses of 800 and 90 mg/sq m. We percutaneously introduced catheters into the extremity or regional artery under fluoroscopy by the Seldinger technique, removed them at the end of the infusions, and repositioned them at four-week intervals for repeated treatment cycles. One patient achieved a complete remission, three patients had partial remissions, and five patients' disease was stable. The group median survival will exceed 19 months. Three patients with stable disease died 6, 18, and 19 months after treatment initiation, respectively. The toxic effects were primarily nausea and vomiting, pain in the infused extremity, and local erythema. Arterial dacarbazine and cisplatin offer a more effective and less toxic alternative to higher-dose single-agent arterial cisplatin for locally advanced malignant melanoma.

Immunotherapy of leukemia.

The data reviewed in this paper indicate that immunotherapy is effective in prolonging remission and survival in acute and chronic leukemia. The acute lymphocytic leukemias may or may not respond to immunotherapy and further work is needed in this area. No studies of immunotherapy in chronic lymphocytic leukemia have been done, but this will be an important area for investigation, since there is often profound immunodeficiency in this disease. The malignant lymphomas are another fertile area for this type of research, since they have a high response rate, tumor-associated immunodeficiency, and at least differentiation antigens if not tumor-specific antigens. The scientific basis for the use of immunotherapy in leukemia includes the demonstration of a relationship of rate and duration of remission and survival to immunocompetence, the demonstration of unique tumor-associated antigens on leukemia cells, and the demonstration of immune responses to these antigens which can be boosted by immunization. At the present time, active nonspecific immunotherapy with BCG and MER and active specific immunotherapy have been proved effective in acute myelogenous leukemia. Careful attention should be given to dose, schedule, route, and so forth. Other types of immunotherapy remain to be explored.