Recombinant interleukin-2 and adoptive immunotherapy alternated with dacarbazine therapy in melanoma: a National Biotherapy Study Group trial.

We evaluated adoptive cellular therapy with recombinant interleukin-2 (rIL-2) plus lymphokine-activated killer (LAK) cells alternating with sequential dacarbazine chemotherapy in 27 patients with metastatic melanoma. rIL-2 was given to the patients as a 5-day continuous-infusion priming cycle followed by 1 day of rest, 4 days of leukapheresis for in vitro LAK cell expansion, and then 4 1/2 days of continuous rIL-2 infusion in conjunction with reinfusion of LAK cells during the first 3 days of the continuous infusion. Two weeks later, patients received dacarbazine (1,200 mg/m2) chemotherapy. Two patients achieved complete remission, and five achieved a partial remission for a response rate of 26% (95% confidence interval = 12%-47%). Three patients had mixed responses. The partial and mixed responses were brief, ranging from 1 month to 6 months, whereas the two complete responses have been sustained for 13+ and 24+ months. There were no additive toxic effects except for thrombocytopenia, which delayed treatment in two patients. Alternating adoptive immunotherapy and dacarbazine chemotherapy appear to be reasonably tolerated by patients, but the response rate is not clearly better than that achieved with other rIL-2 regimens or with chemotherapy alone.

Activation and expansion of tumor-derived activated cells for therapeutic use.

We obtained tumor specimens from patients with cancer in an effort to activate and expand the tumor-infiltrating lymphocytes for therapeutic use. With the use of finely minced tumor preparations from eight different tumor types, recombinant interleukin-2, and lymphokine-activated killer cell-conditioned medium, lymphocytes were expanded in vitro. After 4 weeks, the tumor cells were virtually absent from the cultures. At this point, the lymphocytes were termed "tumor-derived activated cells" (TDACs). Over 90% of the TDACs from each of the different tumor types were T lymphocytes, and the percentage of cells expressing either CD4 or CD8 varied considerably from population to population. The lymphocytes showed specific cytolytic activity in melanoma and colon and renal cell carcinomas. Continued expansion and long-term growth of the TDACs, as well as maintenance of the cytolytic activity, were achieved by periodic stimulation of the TDACs with irradiated autologous tumor cells. In a clinical study of 28 patients with cancer, we generated a mean number of 1.2 X 10(11) TDACs in an average time in culture of 69 days. These TDACs were subsequently infused into the patients with cancer. TDACs appear to represent an important resource for biotherapy of patients with cancer.

Lymphocytes forming rosettes with sheep erythrocytes in metastatic pleural effusions.

Percentages of lymphocytes forming rosettes with sheep erythrocytes at 29 degrees C were determined in 10 cancer patients with metastases to the pleural cavity. Compared with normal controls, the patients showed a decreased proportion of rosette-forming cells (RFC) in the peripheral blood. The same patients had elevated levels of RFC in their metastatic pleural effusions. However, 2 patients with benign diseases had normal levels of RFC in their peripheral blood and pleural transudates. These observations suggested that in cancer patients some T-cells might migrate from the peripheral blood and accumulate in sites of tumor infiltration such as the pleural cavity.

Enhancement of human lymphokine-activated killer cell cytolysis and a method for increasing lymphokine-activated killer cell yields to cancer patients.

In a continued effort to make interleukin-2/lymphocyte-activated killer (LAK) cell therapy safer and more efficacious for cancer patients, we examined methods of increasing the yields of cells obtained as a final product for reinfusion. Previously, the major cell loss occurred in the Ficoll-Hypaque gradient separation procedure used before cell culture. Therefore, we investigated the necessity of this step. Leukapheresis procedures (n = 105) from 40 different cancer patients showed that the resultant cell product is predominantly mononuclear (lymphocytes and monocytes; greater than 97%) before the gradient purification step. The only cells observed to decrease in percentage as a result of the step were red blood cells (RBC: WBC ratio of 17:1 before purification to 1:3 after purification). Our study showed that the cytolytic potential of unpurified leukapheresis products against the LAK-sensitive line Daudi and the natural killer cell-sensitive line K562 was greater and that the patients received significantly more cells at times of reinfusion if the gradient separation step was eliminated. By additional experiments, we determined that autologous red blood cells enhance the generation of cytolytic LAK cells. This enhancement was greater if the red blood cells were in contact with the mononuclear cells during the time of cell culture. The elimination of the Ficoll-Hypaque purification step not only reduces the time and cost of the cell collection procedures, it also allows us to return to the patients greater numbers of cytolytic LAK cells following the activation period.

Continuous interleukin-2 and lymphokine-activated killer cells for advanced cancer: a National Biotherapy Study Group trial.

We conducted a multicenter, phase II trial of continuous-infusion recombinant interleukin-2 (rIL-2) and lymphokine-activated killer (LAK) cells. Patients had advanced cancer, measurable disease, and a good performance level. Treatment included a 5-day continuous infusion of 18 x 10(6) IU/m2/d of rIL-2 followed by 1 day of rest, 4 days of leukapheresis to collect cells for in vitro augmentation of cellular cytotoxicity, and 5 more days of rIL-2 infusion with reinfusion of LAK cells for 3 successive days. Therapy was repeated after 2 weeks. There were 117 patients enrolled: 63% were males, with a median age of 51 years. Eighty-two percent were managed in oncology units, and 18% were in intensive care units. Six patients died within 1 month of initiating therapy. In renal cell carcinoma, the response rate was one of 31 patients (3%), with a median survival of 10.7 months. In melanoma, the response rate was four of 33 patients (12%), with a median survival of 6.1 months. For all other histologies, response rate was three of 53 patients (5%), with a median survival of 7.4 months. All responders were asymptomatic when therapy was initiated. This trial confirms the feasibility of administering continuous rIL-2 and LAK cells outside the intensive care unit environment. Antitumor activity in melanoma was similar to that seen in multicenter trials of bolus rIL-2 and LAK cells. Activity in renal cell cancer was disappointing.

IL-2: a review of current knowledge.

A limiting factor in the use of T-cell therapy for cancer has always been the ability to expand T-cells, whether derived from the peripheral blood, spleen or tumor. The availability of r-IL-2 has confirmed the feasibility of expanding T-cells and LAK cells for clinical trials after confirmation of their anti-tumor activity in murine models. While the most promising results using IL-2/LAK cells have been in patients with melanomas and renal cancer, anti-tumor effects have been seen in patients with a wide variety of cancers, even those with bulky tumors. This form of adoptive cellular biotherapy has confirmed that an expanded and activated cell population using the cancer research laboratory can provide a method by which clinicians can effectively treat advanced cancer. In tumor biopsies, the infiltrating lymphocytes have been recognised and are known to be cytolytically active for many years. Using IL-2 stimulation of growth and an ongoing antigen stimulation (tumor cells), we have maintained selective killing of tumor cells. Accessing cells and various factors in the medium which support and enhance T-cell growth and activation are being defined. The role of antigen stimulation is also basic to further progress with this technology. Tumor cell chunks and cultures, nude mouse xenografts, or purified antigen all represent potential sources of repeated antigen stimulation. Thus, the components are now available to develop a broad attack on advanced cancer using this laboratory-based technology of tumor-derived activated cell (TDAC) stimulation, expansion and therapy. These approaches and preliminary results point to the dramatic change in technology which has allowed the cancer research laboratory to be a substantial component in new clinical approaches to cancer treatment. Laboratory scientists have become a major component in the design and conduct of clinical trials using adoptive biotherapy. These techniques are laboratory based and it is only with close and effective communication between the laboratory scientists and the clinician that rapid and effective translation of these technologies to the patient will occur (20).

Treatment-related mortality in 1000 consecutive patients receiving high-dose chemotherapy and peripheral blood progenitor cell transplantation in community cancer centers.

High-dose chemotherapy (HDC) with autologous peripheral blood progenitor cell (PBPC) is being increasingly utilized as a therapeutic modality for patients with chemotherapy-sensitive disease. Several published HDC regimens have become relatively widely used. The purpose of this analysis was to determine treatment-related mortality (TRM) following administration of five different HDC regimens in community cancer centers. A retrospective evaluation of 1000 consecutive patients with leukemia, non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma, sarcoma, ovarian cancer, or breast cancer who received one of five published HDC regimens followed by PBPC infusion over a 5-year period in community cancer centers was performed to determine TRM. Fifty-nine patients (5.9%) died within 100 days of PBPC infusion. Twenty-five patients (2.5%) died predominantly of causes related to disease progression. Thirty-four patients (3.4%) died of TRM, 15 patients (1.5%) died from infection and 19 (1.9%) died from regimen-related toxicities (RRT). In a logistic model, increasing age (P = 0.001) and lower numbers of CD34+ cells/kg (P = 0.003) were associated with an increased risk of 100-day TRM. High-dose cyclophosphamide, thiotepa, and carboplatin was associated with a lower risk of mortality than other regimens (P = 0.0001). High-dose chemotherapy and autologous PBPC support can be performed in community cancer centers with relative safety. Patient age, the type of preparative regimen and the number of CD34+ cells infused were important determinates of mortality.

High-dose chemotherapy with BUCY or BEAC and unpurged peripheral blood stem cell infusion in patients with low-grade non-Hodgkin's lymphoma.

Forty-nine patients with low-grade non-Hodgkin's lymphoma (NHL) received high-dose chemotherapy (HDC) with busulfan and cyclophosphamide (BUCY) or carmustine, etoposide, cytarabine and CY (BEAC) followed by unpurged autologous peripheral blood stem (PBSC) infusion. All patients had failed initial chemotherapy or progressed after an initial remission. Peripheral blood stem cells were mobilized with CY alone (n = 1), CY, etoposide (n = 19), or CY, etoposide and cisplatin (n = 29) followed by granulocyte colony-stimulating factor. Twenty-two patients received BU, 16 mg/kg, and CY, 120 mg/kg. Twenty-seven patients received carmustine 300 mg/m2, etoposide 600 mg/m2, cytarabine 600 mg/m2, and CY 140 mg/kg. Four patients (8%) died of non-relapse causes, two (9%) in the BUCY group and two (7%) in the BEAC group. Twenty-seven patients (55%) relapsed or progressed at a median of 9.4 months (2-38) from PBSC infusion. Ten patients who relapsed are alive a median of 31 months (range, 6-47) after relapse. The probabilities of relapse at 3.6 years for patients receiving BUCY or BEAC were 0.57 and 0.70, respectively (P = 0.92). Twenty-seven patients (55%) are alive at a median of 3.6 years (range, 1-5). The probabilities of survival at 3.6 years for patients receiving BUCY or BEAC were 0.58 and 0.55, respectively (P = 0.72). The probabilities of EFS at 3.6 years for patients receiving BUCY or BEAC were 0.36 and 0.28, respectively (P = 0.82). It was concluded that BUCY is an active regimen for the treatment of patients with low-grade NHL.

A phase I-II study of high-dose melphalan, mitoxantrone and carboplatin with peripheral blood stem cell support in patients with advanced ovarian or breast carcinoma.

The purpose of this study was to develop a high-dose chemotherapy (HDC) and peripheral blood stem cell (PBSC) regimen for treatment of patients with ovarian carcinoma that could be administered in an outpatient setting. Fourteen patients with advanced ovarian (n = 9) or breast (n = 5) carcinoma, who had failed conventional chemotherapy, were entered into a dose-escalation trial to determine the maximum tolerated dose (MTD) of carboplatin that could be administered with fixed doses of melphalan (160 mg/m2) and mitoxantrone (50 mg/m2). Twenty-five additional patients were included in a phase II trial at the MTD. Two of two patients had grade 4 severe regimen-related toxicities (RRT), one fatal, at a dose level of 1600 mg/m2. Two of 29 patients (6.9%) treated at the MTD (carboplatin, 1400 mg/m2) died of RRT. All three patients who died of toxicity had a calculated AUC for carboplatin >30 mg/ml/min. Thirty-one patients with ovarian cancer who had failed chemotherapy were treated, 24 at the MTD. Fourteen of 20 patients (70%) with ovarian carcinoma with evaluable disease achieved a CR and seven (35%) are alive disease-free a median of 20 months (range, 7-26). Five of seven patients with ovarian cancer who had failed chemotherapy but were rendered clinically disease-free following surgery survive without progression a median of 13 months (range, 9-19). Eight of 16 (50%) platinum-resistant and 4/12 (33%) platinum-sensitive patients with ovarian cancer survive disease-free.

Induction, mobilization of peripheral blood stem cells (PBSC), high-dose chemotherapy and PBSC infusion in patients with untreated stage IV breast cancer: outcomes by intent to treat analyses.

We investigated the outcomes of patients with breast cancer undergoing induction chemotherapy, mobilization of peripheral blood stem cells (PBSC) and high-dose chemotherapy (HDC) with PBSC infusion. One hundred and fourteen patients with untreated stage IV breast cancer, with a median age of 46 years (range 24-62), were entered on a phase II trial consisting of; (1) doxorubicin, 5-flurouracil, methotrexate (AFM) x 4 courses at 2 week intervals; (2) cyclophosphamide (4 g/m2), etoposide (600 mg/m2), cisplatin (105 mg/m2) (CEP), filgrastim (6 micrograms/kg/day) and PBSC collection; (3) cyclophosphamide (6 g/m2), thiotepa (500 mg/m2), carboplatin (800 mg/m2), (CTCb) followed by PBSC infusion. All patients received AFM, 107 (94%) received CEP, 93 (82%) received CTCb and PBSC as per protocol and 99 (87%) ultimately received HDC and PBSC. There was one infectious death after AFM and all other deaths were associated with progressive disease. Fifty-two patients (46%) are alive, 21 (18%) without progression, at a median 31 months (range 22-47). The probabilities of survival and progression-free survival at 3.5 years were 0.40 and 0.17, respectively. All 62 patients with visceral disease and/or a prior history of doxorubicin adjuvant therapy have relapsed or progressed. We conclude that the sequential administration of AFM, CEP and CTCb followed by PBSC resulted in long-term PFS only in patients who were NED, had bone-only disease or had lymph node or soft tissue disease with or without bone disease. Other strategies, aimed at improving responses to initial therapy, improving HDC regimens and/or developing immunomodulatory therapies, will be necessary to improve PFS for patients who fail doxorubicin adjuvant or who have visceral disease.

High-dose chemotherapy and peripheral blood stem cell infusion in patients with non-Hodgkin's lymphoma: results of outpatient treatment in community cancer centers.

The outcomes for patients with non-Hodgkin's lymphoma (NHL) treated with high-dose chemotherapy (HDC) and peripheral blood stem cell (PBSC) infusion by practicing oncologists in community cancer centers in the United States were determined. Eighty-three patients with NHL, who had failed conventional chemotherapy, underwent mobilization of PBSC with chemotherapy and a recombinant growth factor in an outpatient facility. At a median of 40 days (range 26-119) after mobilization chemotherapy all received carmustine (300 mg/m2 x 1), etoposide (150 mg/m2 twice a day x 4 days), cytarabine (100 mg/m2 twice a day x 4 days) and cyclophosphamide (35 mg/kg x 4 days) (BEAC) followed by infusion of unmanipulated PBSC in an outpatient facility. The probabilities of treatment-related mortality, relapse/progression, overall survival (OS) and event-free survival (EFS) at 3 years for all 83 patients were 0.07, 0.57, 0.49 and 0.38, respectively. The probabilities of relapse/progression, OS and EFS at 3 years for 28 patients who had failed primary induction chemotherapy were 0.55, 0.42 and 0.38, respectively. The probabilities of OS and EFS for 27 patients in untreated first relapse were 0.52 and 0.44, respectively, as compared to 0.56 and 0.32, respectively, for 18 patients who had reinduction attempts prior to receiving mobilization chemotherapy (P = 0.81 for OS and 0.99 for EFS). No significant risk factors for the outcomes of TRM, relapse/progression, OS or EFS could be identified. These data demonstrate that approximately 40% of patients with NHL who have failed conventional chemotherapy become long-term disease-free survivors after mobilization chemotherapy, high-dose BEAC and PBSC infusion administered in an outpatient setting in community cancer centers, with the major cause of failure being relapse. Results obtained in this study are comparable to published data in similar patient populations receiving therapy as inpatients, suggesting that clinical trials involving well-tested HDC regimens can be carried out safely in this setting.

Effect of steroidogenesis on ascorbic acid content and uptake in isolated adrenal cells.

Isolated adrenal cell preparation was used to investigate the relationship between ascorbic acid and steroidogenesis by two methods: (1) in vivo incorporation of exogenous [1-14C]ascorbic acid into endogenous ascorbic acid of adrenal by intraperitoneal injection of labeled ascorbic acid into rats and studying the depletion of labeled ascorbic acid under a variety of experimental conditions; and (2) study of the uptake of [14C]ascorbic acid by IAC in response to steroidogenic stimuli and various steroids. These studies demonstrate that: 1. IAC preparation by the trypsin digestion method results in almost total depletion of ascorbic acid from adrenal cells, i.e., ascorbic acid content of the cell preparation was less than 1% of the original ascorbic acid in quartered adrenal gland. 2. In spite of such a severe depletion of ascorbic acid, steroidogenesis in response to ACTH and dibutyryl cyclic AMP (dcAMP) is quite pronounced. 3. ACTH and dcAMP affect depletion of endogenously labeled ascorbic acid in IAC by a process that is both concentration- and time-dependent, but is independent of steroidogenic processes. 4. ACTH and dcAMP both inhibit the uptake of exogenous [1-14C]ascorbic acid, which is time-dependent but independent of the steroidogenic phenomenon. 5. The uptake of [14C]ascorbic acid by IAC is independent of extra-to-intracellular gradient of glucocorticoids or mineralocorticoids.

Midline granuloma.

A 34-year-old woman had a granulomatous ulceration of the nose that responded to radiation therapy. The limitation of the disease to the nose and the histologic findings were consistent with a diagnosis of midline granuloma, Stewart type. The relationship of midline granuloma to Wegener's granulomatosis is reviewed. In view of the uniform mortality that accompanies untreated midline granuloma, a correct diagnosis must be made so that radiation therapy can be promptly instituted.

Sequential treatment including high-dose chemotherapy with peripheral blood stem cell support in patients with high-risk stage II-III breast cancer: outpatient administration in community cancer centers.

The authors determined outcomes for patients with localized high-risk breast cancer undergoing sequential outpatient treatment with conventional-dose adjuvant therapy, chemotherapy, and growth factor mobilization of peripheral blood stem cells (PBSC) and high-dose chemotherapy (HDC) with PBSC support in community cancer centers. Ninety-six patients with stage II-IIIB noninflammatory breast cancer with 10 or more positive lymph nodes and a median age of 46 years (range, 22-60 years) were treated with: 1) doxorubicin, 5-fluorouracil, and methotrexate (AFM), four courses at 2-week intervals; 2) cyclophosphamide (4 g/m2) and etoposide (600 mg/m2) (CE), followed by filgrastim (6 microg/kg per day) and PBSC harvest; and 3) cyclophosphamide (6 g/m2), thiotepa (500 mg/m2), and carboplatin (800 mg/m2) (CTCb), followed by PBSC infusion. All 96 patients received AFM, 95 (99%) received CE, and 95 (99%) received CTCb with a median hospital stay of 12 days (5-34 days) for all phases of treatment. Sixty-nine patients (72%) are alive, 55 (57%) without relapse at a median follow-up of 53 months (range, 37-77 months). One patient (1%) died of acute myeloid leukemia and all other deaths were associated with recurrent breast cancer. The probabilities of event-free survival (EFS) at 4 years for patients with or without locally advanced disease were 0.37 and 0.69, respectively (p = 0.004), and 0.71 and 0.48 for patients who were estrogen/progesterone receptor (ER/PR) positive or ER/PR negative, respectively (p = 0.016). In multivariate analyses, locally advanced disease (relative risk, 2.3; p = 0.021) and ER/PR-negative hormone receptor status (relative risk, 2.2; p = 0.014) were the only adverse risk factors for EFS identified. Patients with zero, one, or two of these adverse risk factors had 4-year EFS of 0.80, 0.56, and 0.33, respectively. The sequential administration of AFM, CE, and CTCb followed by PBSC in an outpatient community setting was well tolerated in patients with high-risk stage II-III breast cancer. More intensive or more novel treatment strategies will be required to decrease relapses in patients who have ER/PR-negative tumors and/or have locally advanced disease.

Clinical application of continuous infusion of recombinant interleukin-2.

While preclinical studies suggest a steep dose-response relationship for the anti-cancer effect of recombinant interleukin-2 (rIL-2), translation of dose-intense rIL-2 to humans can be complicated by known toxicities, including hypotension, capillary leak phenomena and fluid retention. In an attempt to develop a manageable approach to dose-intense rIL-2, we have employed a continuous infusion schedule, 18 X 10(6) IU rIL-2/m2/day for five days. This treatment results in marked biological effect, and continuous infusion of rIL-2 alone or in conjunction with lymphokine-activated killer cells can result in complete remission of metastatic renal carcinoma. Treatment with continuous infusion tumour necrosis factor at 60 micrograms/m2/day for three days prior to rIL-2 may be of possible benefit in isolated cases of colon and lung carcinoma, but has not appeared to produce results superior to rIL-2 alone. Addition of tumour-infiltrating lymphocytes has been of benefit in selected cases of melanoma. The most promising combination of biological agents may be rIL-2 in conjunction with alpha-interferon. Ongoing studies involving subcutaneous alpha-interferon during continuous infusion rIL-2 suggest clinical synergy with acceptable toxicity.

Low affinity E-rosette formation by the human K cell.

Human T lymphocytes were separated into two subsets on the basis of relative affinity for sheep red blood cells (E), and these T cell fractions were examined for cytotoxic reactivity against antibody-sensitized Change liver cells (ADCC). High affinity E-rosette-forming cells (E-RFC) (55 +/- 6% of peripheral blood mononuclear cells), capable of rosette formation despite elevated temperatures of incubation (29 degrees C) and a limited concentration of E, contained few antibody-dependent cytotoxic cells (K cells). In contrast, low affinity E-RFC (23+/-7% of mononuclear cell suspensions) requiring cool temperatures of incubation (4 degrees C) and an excess of E to form rosettes, were highly enriched for ADCC activity. The majority of K cells exhibited low affinity interactions with E. T cells in thymus, tonsil, and lymph node formed high affinity E-rosettes and exhibited little reactivity in ADCC. Only peripheral blood and spleen contained easily identified low affinity E-RFC and anti-body-dependent cytotoxic cells. The proportion of low affinity E-RFC in the peripheral blood of normal subjects correlated closely with reactivity in ADCC, making it possible to predict cytotoxic potential for the E-rosette pattern. These data indicate that the human K cell may belong to a previously unappreciated but functionally important subset of thymic dependent mononuclear cells.

Relationship of human natural lymphocyte-mediated cytotoxicity to cytotoxicity of breast-cancer-derived target cells.

Mononuclear cells from 115 individuals were tested in a 4-h chromium release assay against two breast-cancer-derived cell lines, G11 and MCF-7, and a myeloid line, K-562, shown previously to be sensitive to natural cytotoxicity. These data were analyzed in a manner designed to detect hyperreactivity against the breast cell lines relative to the level of reactivity against K-562. A high proportion of breast cancer patients were found to be relatively hyperreactive against G11 (12/18 or 67%) and against MCF-7 (10/18 or 56%). Fibroadenoma patients were very similar to the normal females, with 0/11 hyperreactive to G11 and 1/11 (9%) to MCF-7. However, several normal males (7/17 or 41%) were hyperreactive to G11 but not to MCF-7 (2/17 or 12%). Colon cancer and lung cancer patients were also more hyperreactive to G11, 4/8 or 50% and 4/6 or 67%, respectively, than they were to MCF-7, 1/8 or 13% and 1/6 or 17%, respectively. Only fibrocystic patients resembled the breast cancer patients, with some but not as many individuals being hyperreactive to G11 (3/8 or 38%) and to MCF-7 (2/8 or 25%). With another group of individuals reproducibility of the method was demonstrated, with only 1/14 or 7% of normal females and 12/17 or 70% of breast cancer patients being hyperreactive to G11. Thus, natural cytotoxicity toward K-562 can be related to breast cancer-associated cytotoxicity toward MCF-7 in a way that distinguishes a majority of breast cancer patients specifically from other groups of individuals.